Safety planning to prevent suicidal self-directed violence among veterans with posttraumatic stress disorder: Clinical considerations

Veterans with posttraumatic stress disorder (PTSD) are at elevated risk for engaging in suicidal self-directed violence (S-SDV). Safety Planning has been widely implemented in the Veterans Health Administration to prevent S-SDV; however, limited guidelines exist regarding considerations for Safety Planning with veterans with PTSD. In this article, we discuss clinical considerations to guide health care providers in customizing each step of Safety Planning for veterans with PTSD. Proposed considerations include challenges establishing an appropriate baseline (Step 1); risky behaviors and substance use (Step 2); PTSD-related avoidance, beliefs, distrust, and isolation (Steps 3 and 4); stigma and distrust of providers and institutions (Step 5); and hypervigilance, safety beliefs, firearms, substances, and numbing (Step 6). Strategies for addressing these are provided for each step of the Safety Plan, such as delineating trauma-related warning signs, anticipating avoidance, and incorporating PTSD-related resources. In addition, methods of implementing the Safety Plan into evidence-based PTSD treatments disseminated within the Department of Veterans Affairs (e.g., cognitive processing therapy, prolonged exposure therapy) are discussed. Continued examination of Safety Planning in veterans with PTSD, including empirical investigation, is needed.