An Open Trial of a Suicide Safety Planning Group Treatment: “Project Life Force”

Abstract

In 2008, the Department of Veterans Affairs mandated that clinicians oversee the construction of a Suicide Safety Plan for every patient who is identified as “high risk” for suicide. While the Suicide Safety Plan is a mandated “best practice,” there are currently no recommended guidelines for its augmentation in a group setting. To address this gap, a novel group intervention, “Project Life Force,” (PLF; a 10-session manualized psychotherapy), was developed and piloted. Results indicate high feasibility and acceptability. Exploratory analysis revealed statistically significant decreases in suicidal thoughts/behaviors, depression, and hopelessness. Feedback from Veterans and PLF therapists is also discussed. Despite some limitations (e.g. small sample size) exploratory results suggest that PLF may be a promising treatment for Veterans with suicidal symptomology.

INTRODUCTION

The prevention of suicide, and treatment of those at greatest risk, remains a national priority for both civilians and Veterans. The Department of Veterans Affairs’ (VA) most recent suicide publication reported that Veteran suicide deaths exceeded 6,000 each year from 2008 to 2017 and most recently occurred at a rate 1.5 times greater than that of non-Veterans, after adjusting for sex and age (Department of Veterans Affairs, 2019). Despite the launch of the National Strategy for Preventing Veteran Suicide, and the VA’s implementation of extensive services nationwide to Veterans at high-risk, there is continued concern regarding the lack of progress in lowering suicide rates in this population (Department of Veterans Affairs, 2019). These statistics highlight the urgent need for the development of additional suicide prevention strategies, rehabilitation, and recovery-based interventions for Veterans experiencing suicidality (Kemp & Bossarte, 2012).

Creating a Suicide Safety Plan is a critical component of suicide prevention services at the VA. The VA Suicide Safety Plan is a prioritized, sequentially written list of coping strategies, and sources of support, developed collaboratively with patients and their clinician, to mitigate suicide risk after hospitalization for suicidal ideation, attempt, or self-harm (Stanley & Brown, 2012; Stanley, Brown, & Von Bergen, 2008). The patient takes the safety plan home for his/her use during (or at the onset of) suicidal crises. The plan instructs one to: recognize personal warning signs of suicide; use internal coping strategies; engage social contacts that can serve as a distraction from suicidal thoughts; contact family members or friends who may help resolve a crisis; provide contact information for VA professionals to help; and plan how to make the immediate environment safer (Stanley et al., 2018).

Research suggests that creating a safety plan is an effective intervention for individuals at increased risk for suicide and can decrease suicidal behavior (Miller et al., 2017; Stanley & Brown, 2012; Stanley et al., 2018). Multiple augmentations of the safety plan, such as its use in a smart phone application, also suggest statistically significant decreases in suicidal thoughts and behavior (Melvin et al., 2019). However, there are few recommended guidelines or mechanisms for refinement of the Suicide Safety Plan in Veteran populations beyond its initial development (Stanley et al., 2018).

At present, there is a paucity of literature on manualized outpatient group treatments for suicidal individuals (Jobes, Wong, Conrad, Drozd, & Neal-Walden, 2005; Johnson, O’Connor, Kaminer, Jobes, & Gutierrez, 2014; Rings, Alexander, Silvers, & Gutierrez, 2012). Dialectical Behavior Therapy (DBT) includes a group component in its comprehensive approach, but discussion of suicidal urges, thoughts and behaviors is discouraged in the group setting. The paucity of recently published literature on group approaches for suicidal individuals is surprising given the numerous advantages of group treatment that include: (1) diminishing social isolation and increasing social support, a protective factor against suicide (Rings et al., 2012); (2) its cost effectiveness and maximizing staff time; (3) the peer movement among those who have experienced suicidal crises is strong and growing; and (4) Veterans and military service members are used to working with a team approach to problems.

PROJECT LIFE FORCE

“Project Life Force” (PLF) aims to fill this gap in research and clinical interventions as a manualized, weekly 90-minute psychotherapeutic group treatment lasting 10-weeks coinciding with the time frame for enhanced monitoring of Veterans identified as “high-risk.” As a helpful adjunctive treatment, with close communication and feedback to the Veteran’s primary outpatient mental health team, PLF proposes to enable Veterans with acute suicidality to more effectively implement steps of the safety plan. The primary purpose of PLF is to enhance the meaningfulness and personalization of the safety plan with the necessary guidance in emotional regulation, interpersonal/friendship and distress tolerance skills.

Specifically, PLF teaches skills that target: (1) aggression and impulsivity, (2) medication and treatment adherence, (3) emotion regulation strategies to alleviate psychological distress and hopelessness, (4) reducing access to means, and (5) asking for support and help. PLF is augmented with modules about strengthening friendships, education pertaining to suicide risk, suicide means reduction, and suicide prevention mobile applications (Luxton, June, & Kinn, 2011). The group format allows Veterans to learn from each other, offers social support, and mitigates the sense of isolation and loneliness that has been associated with suicide (Van Orden, Cukrowicz, Witte, & Joiner, 2012). Specific session content is described in more detail in Table 1.

TABLE 1.

Project life force session outline.

Session number and focus		Skill covered
1	Introduction, psychoeducation about suicide, safety plan step #5 – crisis numbers, meet local suicide prevention coordinators	Crisis management skills Urge restriction
2	Safety plan step #1 – identification of warning signs	Emotion recognition skills
3	Safety plan step #2 – internal coping strategies	Distress tolerance and coping skills
4	Safety plan step #3 – identifying people to help distract	Making friends skills
5	Safety plan step #4 – sharing safety plan with Family	Interpersonal effectiveness and asking for help skills
6	Safety plan step #5 – professional contacts	Skills to maximize treatment efficacy and adherence
6	Safety plan step #6 – making the environment safe	Means restriction, psychoeducation about methods
7	Improving access to the safety plan	Use of safety planning mobile apps
8	Physical health management	Skills to maximize physical health and wellbeing
9	Building a positive life	Building reasons for living
10	Recap/Review	Recap, sharing of safety plans
11	(Add on session if required)	Dealing with a suicide death of a group member

Each PLF session’s format includes: (1) a brief check in and follow up pertaining to use of the safety plan, (2) homework review, (3) teaching of new material and skill, (4) in-class practice of the skill, including role plays, and (5) assignment of homework/outside practice/development of the safety plan. Due to the growing evidence base of the effectiveness of these skills groups offered in more flexible frameworks, including dropin (Denckla, Bailey, Jackson, Tatarakis, & Chen, 2015), PLF has an open-group format, with new members joining at any session throughout the 10-week cycle. This permits members to join at any time, allowing for immediate access to the intervention to accommodate the need for expeditious safety planning for these higher risk Veterans. As the PLF program runs continuously, Veterans who join after session one, can cover missed material in the next cycle.

PLF differs from many skill-based treatments in the direct discussion of suicidal symptoms in session and fostering of relationships between group members. The principle of openly discussing suicide is always in the context of manualized skills, coping and management, rather than emphasizing details of suicidal experiences. Through these direct discussions, the group members help the suicidal Veteran better manage the situation through application of the safety plan steps and skills. Members recognize they are not alone with their feelings, and the act of helping one another builds support and connection. Members often place other group members on their safety plan as someone to call for distraction and/or when feeling suicidal. Through discussing aspects of suicidality openly, the clinician can also use experiences the Veterans’ share as applicable examples for how to use aspects of the manual and the safety plan in everyday life.

PLF is one of the first outpatient manualized suicide prevention group interventions to date and has direct VA and military relevance as psychotherapy groups are a standard treatment modality in both settings. The group format allows for Veterans to assist other group members with transportation, supplied meals, advice and support. To help prepare Veterans for these added responsibilities of intra-group member actions, group material included rules and during the “building friendships” session emphasis was placed on the need to recognize one’s limits in their ability to support others. In addition, participants are reminded to reach out to one of the group leaders if they feel overwhelmed with another Veteran’s situation.

Along with these rules and procedures, all group members in PLF must be suicidal to join the group. Prior research suggests that homogeneous groups are crucial to avoiding the drawbacks of discussing aspects of suicidal crises openly in a group (Horwitz, 1978). If everyone in the group is struggling with suicidal symptoms, discussions around these topics serve to mitigate loneliness, foster connection and are less likely to be triggering (Horwitz, 1978).

Development of Manual

The PLF manual was developed by Marianne Goodman, MD, with feedback from the coauthors. The manual is organized into 10 distinct sessions, each addressing elements in the safety plan, in a manner that permits it to become a ‘living document,’ with meaningful significance rather than “just words on paper.” Yalom and Leszcz (2005) identified 12 therapeutic factors attributed to group therapy: group cohesiveness, altruism, universality, interpersonal learning (input), catharsis, instillation of hope, interpersonal learning (output), identification, family reenactment, self-understanding, guidance, and existential factors. The PLF manual facilitates these 12 factors, as described throughout the following section.

The 80-page manual was developed to address the themes uncovered in qualitative interviews of Veteran’s usage of their Suicide Safety Plan (Kayman, Goldstein, Dixon, & Goodman, 2015). Each session corresponds to a step of the plan with skills identified to maximize the use of that step. Additional sessions on physical wellbeing, accessibility of the safety plan with a mobile application, and reasons for living, were added to the curriculum.

Each session was pilot tested on Veterans who provided assessment of the overall acceptability and specific suggestions regarding manual content and presentation of the material. Revisions were made throughout the treatment. Sessions were piloted a minimum of five times and edited based on Veteran and study therapist feedback forms. These surveys included space for open-ended feedback and two questions on a 5-Point Likert Scale about the session’s helpfulness and their comfort using their safety plan.

Overall, the PLF manual establishes the four main goals presented to Veterans in the first session: (1) teaching important information about suicide prevention; (2) adding detail to, personalizing, and maximizing the efficacy of an individual’s safety plan; (3) providing skills and techniques relevant to safety planning enabling more effective coping; (4) increasing a sense of connection to others, including the Veteran’s treatment team and the VA. Veteran subjects were introduced to the project with a coordinated overview of how each session will address the Suicide Safety Plan’s specific elements, which is reviewed again in session #1. Group rules are established during the initial session, as well as reiterated when each new member is integrated into the group at any point during the 10-week cycle. Group rules include, confidentiality, missing sessions, sharing information at each individual’s own comfort level, which are highlighted throughout the PLF cycle. As the PLF manual facilitates increased dialog and greater insight during the course of the treatment, patients are reminded of the necessity of these established group rules.

AIMS FOR PILOT PROJECT

The aims of this pilot study were to finalize the PLF manual and perform an open trial. The PLF manual was considered finalized when PLF group member satisfaction ratings plateaued and feedback after each session identified no new concerns.

Specific aims of the pilot included:

1. Evaluate feasibility of key components including: ease of implementation, recruitment, attendance/treatment retention,

2. Assess treatment satisfaction using satisfaction ratings of the PLF intervention assessment from the Veteran and PLF therapists on individual session content and overall intervention,

3. Use exploratory analyses to preliminarily assess effectiveness of PLF in reducing suicidal ideation/behavior, depression, and hopelessness.

METHODS

This open trial was conducted at the James J. Peters VA Medical Center (Bronx, NY). Data was collected from December 2015 to February 2018. Participants were recruited using recommendations of inpatient attending physicians and Suicide Prevention Coordinators.

Participants

The inclusion criteria included: Veterans aged 18 through 89, recently discharged from inpatient hospitalization for suicidality (requiring the creation of a safety plan), ability to give informed consent, and tolerate group psychotherapy. The exclusion criteria were: refusing to participate in group format, inability to communicate in English, and a psychotic disorders diagnosis.

To examine feasibility of participation, retention and dropout in PLF, attendance was tracked by measuring the number of sessions, and specific sessions, each Veteran attended. Based on “adequate” completion of published group interventions (e.g. McCracken, Sato, & Taylor, 2013) our predetermined criteria for retention was defined as participants attending at least 75% of the sessions. With the streamlining of content during the development of the project from originally 12 sessions to only 10 sessions, we modified our retention criteria to 70% of sessions as to not have anyone need to attend a half session (5%). Therefore, completers attended ≥7 sessions.

Outcome Measures

The primary outcome, suicidal ideation, was measured using The Columbia Suicide Rating Scale (C-SSRS; Posner et al., 2011) which provides a count of prospective or treatment emergent suicidal ideation and behaviors. This tool has been used in many treatment trials and is often considered the gold standard for assessing suicidality (Madan et al., 2016).

Secondary outcomes included suicide related constructs including depression and hopelessness. Depression was measured with the Beck Depression Inventory-II (BDI-II; Beck, Steer, Ball, & Ranieri, 1996), which consists of 21-items related to symptoms of depression and is scored based on a Likert scale. Widely used in adults and adolescents, it has high internal consistency (Cronbach coefficient α = 0.92; Beck et al., 1996). Lastly, the Beck Hopelessness Scale (BHS; Beck & Steer, 1988) measured levels of hopelessness and beliefs about the future. The BHS is a 20-item self-report measure with true-false items. Adequate reliability and concurrent validity data exist for this measure (Metalsky & Joiner, 1992).

Procedure

Approval was obtained from the James J. Peters VA Medical Center Institutional Review Board (IRB) and the Research and Development Office. Following written informed consent, Veteran participants were assessed in-person at baseline and immediately post intervention. These time points were specifically selected to collect information on the creation of the plan (baseline) and after acute symptom stabilization (10-weeks).

Data Analytic Approach

To identify feasibility of participation, retention, and dropout in PLF, number of sessions was analyzed with descriptive statistics including frequencies, means, modes and ranges. The same descriptive statistics were used to assess clinician feasibility preparation and supervision time allocated to the intervention. For acceptability of PLF, two items pertaining to overall satisfaction on feedback surveys from all group participants in attendance were evaluated via the same descriptive statistics using a 5-Point Likert scale.

Although the small sample size precludes sufficient statistical power for null hypothesis testing, for the purposes of exploring the clinical data, a series of statistical tests were run to assess change in primary and secondary outcomes over the course of the treatment. Calculations were performed in the statistical software R (R Core Team, 2018). Outcome data from the C-SSRS measured on ordinal scales were analyzed using paired Wilcoxon tests (Hollander & Wolfe, 1973) to compare pre/post values. Presence of preparatory acts (yes/no) was examined with an exact McNemar’s test, for paired binary data (Fay, 2010). We found no evidence for missing not at random (MNAR), and due to the small sample size, only the results for the complete case analysis (e.g. subjects with both pre-and post-intervention scores), were presented in the results. To examine outcomes on the BDI and BHS, a multivariate analysis of variance (MANOVA) was used to assess for within group differences in these suicide-related clinical outcome measures. We then used follow up univariate analyses for individual outcomes. All analyses were run including and not including missing data.

Data missingness was inspected for the full sample, by timepoint, separately for each outcome. As displayed in Figure 1, 31 subjects completed the baseline and initiated this open pilot trial, while 24 completed the intervention, only 20 completed post treatment assessments. Therefore, this study had a 23% dropout. Before analyzing the data, participants were separated into three groups: (1) completers (attending at least seven groups); (2) partial-completers (attending at least one group); (3) lost to study prior to baseline assessment.

Figure 1.

CONSORT flow diagram.

RESULTS

Sample Characteristics

A total of 45 of the targeted 50 subjects signed consent, of which 31 completed baseline assessments and were included in the sample analyzed. See Table 2 for demographic and clinical characteristics of study participants. All demographic and diagnostic information was self-reported by participants. Diagnosis was then confirmed via the participants’ medical chart.

TABLE 2.

Demographic and clinical characteristics of study participants.

	Mean (SD)		Range
Age (years)	46.43 (11.83)		25–66
		%
Sex; Male		78.4
Race; White/ Caucasian		32
Race; Black/African American		38
Race; Asian		3
Race; Multi-racial		3
Not otherwise Specified		24
Ethnicity; Hispanic		54
Diagnosis
Major depressive disorder		70.27
Post-traumatic stress disorder		56.76
Substance abuse disorder		27.02
Any anxiety disorder		21.61
Bipolar disorder		10.81
Borderline personality disorder		27.02

Completers vs. Partial Completers

There were 24 completers, seven partial completers, and 14 Veterans lost to study prior to the baseline assessment (see Figure 1: CONSORT Flow Diagram). Five of the partial-completers were lost to study and the team was unable to reach or persuade participants to come in for post treatment assessments. The additional two partial-completers were withdrawn after they both moved out of state. Unfortunately, subjects who dropped out of treatment did not fill out the follow up assessments and therefore, beyond the two participants who moved away, the reasons for remaining dropout (n = 5) are unknown. To compare baseline presentations between the completers and partial completers regarding age, education level, depression, and suicidality a series of t-tests were run. There were no significant between group differences (all ps >0.05). To compare baseline presentations of sex, ethnicity, race, marital status and employment, chi-squares tests for independence were run. These tests did not identify any significant differences between the completers and partial completers (all ps < 0.05).

Outcome Analyses

Feasibility and Acceptability

Initial data on PLF participants suggest high levels of feasibility and acceptability. For the feasibility issue of clinician time needed for the intervention, an average of 2 hours a week per PLF clinician was required totaling four hours per session. Levels of retention were good, 77% of Veterans (n = 24) enrolled into the pilot met our criteria of retention, 7 of 10 sessions. In fact, these 24 individuals completed all 10 sessions. The group attendance data suggests that if the Veteran completed the first three sessions, they also complete the entire treatment course (e.g. 10/10 sessions of the intervention).

In addition to baseline and post assessments, all participants (e.g. completers and partial-completers) across all sessions completed a brief acceptability survey soliciting feedback after every group session. There were two 5-Point Likert questions about: (1) satisfaction/helpfulness of the day’s session and, (2) comfort with safety plan use usage. Over all feedback forms, across sessions, Veterans (partial completers and completers) indicated high satisfaction with individual PLF sessions with a 4.74 average. As the treatment was progressively refined over the three years of PLF based on feedback received from the Veterans, it is worth noting that there was a positive trend in responses to these questions. See Figure 2 for a visual display of the average responses to two acceptability questions by year of treatment.

Figure 2.

Average response to acceptability questionnaire by year of treatment.

Exploratory Outcome Analyses

While the small sample size precludes sufficient statistical power for confirmatory null hypothesis testing, to explore the clinical data, a series of statistical tests were run.

Primary Outcome—Suicidal Ideation.

On the C-SSRS, there were significant decreases in suicidal ideation symptom severity (V = 136.0; p< 0.001), frequency of suicidal thoughts (V= 110.5; p = 0.027), and duration of suicide ideation (V = 115.0; p = 0.002). Deterrents stopping participants from wanting to die or act on suicidal thoughts significantly increased (V = 108.0; p= 0.005). As measured by the C-SSRS, there were neither actual attempts nor aborted attempts during the course of the study. However, one participant did have two interrupted attempts between baseline and post assessment. There were no deaths by suicide during the duration of the study.

Secondary Outcomes: Depression and Hopelessness.

After visually inspecting the distributions for outlier values using box plots and finding none, skewedness, kurtosis statistics were examined. All clinical variable met assumptions for normal distributions. Multiple regression techniques were used for estimating missing data points and analyses were run including and not including missing data without differences in patterns of findings.

A MANOVA was conducted to examine within-subject differences across BDI and BHS pre/post treatment due to assumptions of normal distribution being met and a matrix correlation suggesting higher order relations were present (e.g. post assessments correlated at a rate higher than 0.50). The MANOVA showed significant difference in pre-post suicide-related clinical variables (Pillai’s Trace-.505, F(3,21) = 7.13, p < 0.05. η²=0.51). See Table 3 for means and the standard deviations of the two suicide-related measures.

TABLE 3.

Descriptive statistics of outcome measures.

	Mean	Std. Deviation	N
BDI baseline	35.29	9.63	24
BDI post	23.94	12.65	24
BHS baseline	13.04	5.34	24
BHS post	9.95	5.82	24

A series of univariate follow-up tests of within group differences for each of the two suicide related outcome measures found significant pre-post differences in depression (F(1,23)=16.29, p < 0.05), and hopelessness (F(1,23)=5.86, p < 0.05).

DISCUSSION

Despite rising suicide rates in both civilian and Veteran populations, suicide treatment research has been hampered by a paucity of empirical treatment studies due to the inherent risk and challenges of studying these patients. However, suicide safety planning has emerged as a helpful intervention (Stanley et al, 2018) and is gaining traction as a mandated clinical practice in multiple health care settings. PLF aims to further enhance safety planning with targeted skills to help participants implement each of the steps and use technological aids to make the safety plan more accessible. The intervention is manualized with structured content and handouts. The group format is instrumental to the design and fosters hope, support and motivation.

PLF targeted the highest risk Veterans, those being discharged from the hospital, on the high-suicide risk list or experiencing an exacerbation of suicidal thinking. The open-group format provided maximum flexibility, facilitating hospitalized individuals to enter the group immediately upon discharge as well as ability to pick up missed sessions in the next round. As a consequence of this format, some members reviewed the steps of the safety plan out of order, but this was not a concern for our group participants, who all entered the group with an initial safety plan that was enhanced during the PLF program. Additionally, with an open-group format, developing group cohesion can be more challenging when there are multiple revisions to group membership in a short period of time. However, in most sessions the majority of group members had attended previous sessions so there was continuity of the group process. The beginning of each session is dedicated to introductions of new members, such that each Veteran knows the name and background of the other group members. Veterans who held seniority by having attended more PLF group sessions at times served as role models for newer members, who were more symptomatic.

Our PLF preliminary open label study was noteworthy for evidence of feasibility acceptability, and initial positive pilot data. As 77.4% of subjects who completed a baseline assessment attended all ten sessions, we achieved our apriori definition of treatment retention, which required 70% of subjects attending seven or more sessions. Additionally, we learned that 90% of subjects, who participate in three or more sessions, will complete all 10 sessions. Treatment dropout and lack of follow up assessments limited our ability to understand the impact of treatment on the few individuals lost to follow up. Retained subjects rated the treatment favorably and all participants regardless of retention status made improvements to their safety plans. The group focus was found to be particularly beneficial as a motivator and support network.

Since PLF therapists spent an average of 2 hours per week per clinician on the group it also seems this group would be feasible for clinicians to run. PLF is always run with two facilitators so one facilitator can run the group if the other therapist is required to leave with a PLF member to manage acute symptomatology. However, this never occurred throughout this pilot study. When needed, PLF facilitators were in contact with the Veteran’s treatment team to alert them of any high-risk behaviors. Otherwise, individual work was not encouraged as PLF is meant to be adjunctive to individual clinical care. Outcome data on suicide ideation, hopelessness and depression is preliminary given the small sample size and significant drop out rates, but in the correct direction and in support of the need for a larger adequately powered study.

Limitations

There are several limitations of this study. The first is the small sample size of this pilot study making inferential tests problematic. The sample size was selected for feasibility, not for hypothesis testing. Therefore, all data presented is non-hypothesis testing and was done for exploratory purposes. While underpowered for small effect sizes, exploratory inferential analyses on clinical variables still provide useful information regarding patterns in the data. However, even when studies find large effects, inferential results such as these should be viewed as exploratory and preliminary in nature due to difficulty replicating results within small samples. Additionally, due to its developmental focus, the study lacked a control group, which limits our ability to know whether treatment improvements were due to PLF or was a benefit of standard care. Future studies should use an adequately powered randomized clinical trial methodology. Secondly, treatment dropout and lack of follow up assessments (n = 5) limits our ability to know the impact of treatment on these individuals. While it is possible that individuals stopped participating due to a worsening of their symptoms, it is also feasible that Veterans improved and no longer wanted to discuss suicidal symptoms in depth. We are aware of logistical complications, geographical moves and competing commitments that were factors discovered by chart review. Future work in this area may consider telehealth formats to addresses these obstacles. However, a more thorough assessment of treatment dropouts is clearly indicated.

Additionally, due to the open study design, the assessors were not blind and knew the participants were receiving the intervention, which may have biased data collection. The study excluded individuals with schizophrenia due to concerns with paranoia and thought disorganization that may impact the group process. This intervention may have limited generalizability beyond Veterans seeking VA care. Civilians, as well as Veterans receiving their care in non-VA facilities, may respond differently to PLF. For many Veterans, their military experience was conducted in units with an emphasis on teamwork and helping one another, as exemplified by the motto “no man left behind,” and therefore may respond more favorably to PLF than civilians. Current pilots of PLF in civilian populations are currently underway to address this question.

Despite these important limitations, PLF had many strengths: (1) one of the only manualized outpatient group treatments for suicidal individuals that further develops and maximizes the evidence-based strategy of suicide safety planning, (2) the PLF intervention capitalizes on group support, is cost-effective and efficacious, which can be easily implemented throughout the VA and possibly civilian health care settings with potential for widespread implementation and impact, and (3) delivered in a group context offering support which may catalyze interest in the development of other group-based interventions. It should also be noted that this group intervention was adjunctive to regular mental health treatment, which facilitated better engagement with each Veteran’s primary mental health team and provided for a multidisciplinary team approach

CONCLUSION

This first open label trial for PLF, a manualized, 10-session, novel group intervention combining safety planning and skills targeting high risk suicidal Veterans demonstrated feasibility, acceptability and promising exploratory outcome results. Next steps include an adequately powered randomized clinical trial, which is currently underway.