Journal of Contextual Behavioral Science 20 (2021) 101–107

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Journal of Contextual Behavioral Science

journal homepage: www.elsevier.com/locate/jcbs

Practical Innovations

The empowerment plan: Enhancing the safety plan with a CBS approach to
repertoire expansion
Jonathan H. Weinstein a, *, Emily B. Kroska b, Robyn D. Walser c
a
VA Hudson Valley Health Care System & Department of Psychiatry & Behavioral Sciences, New York Medical College, USA
b
Department of Psychological and Brain Sciences, University of Iowa, USA
c
National Center for PTSD, Dissemination and Training Division, Bay Area Trauma Recovery Clinic, Department of Psychology, University of California, Berkeley, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Safety planning is an essential tool for helping those considering suicide stay safe, and it is best practice for
Suicide prevention assisting veterans who are in crisis. Further elaboration on this tool, as well as integration of empirically sup­
Safety planning ported therapeutic interventions, may lead to greater engagement and possibility for change. Stanley and
Relational frame theory
Brown’s safety plan (2012) has been implemented in the Veterans Health Administration Medical Centers (VA)
Acceptance and commitment therapy
and is considered the standard of care for suicidal behavior in veterans, a population with a well-documented
Veterans
Crisis intervention vulnerability to suicide. The unique characteristics of a CBS-informed safety plan (supplemented with compo­
nents of Relational Frame Theory), or Empowerment Plan, is contrasted with Stanley and Brown’s approach.
Increasing specificity with RFT provides the clinician with sets of targeted interventions to empower the patient,
providing the CBS therapist with skills to enhance safety planning. The goal is to identify multiple ways to
amplify meaning and associated action into awareness, thus, connecting the veteran with reasons and motivation
to live. The key elements of a transdiagnostic, process-focused approach to safety planning are delineated. A
description for creating a CBS-informed single-session safety plan is provided.

Suicidality is regarded as a transdiagnostic process, as it is not spe­
cific to one disorder or syndrome. Suicidal behavior is universal, wide­
spread, and poorly predicted (Chiles, Strosahl, & Roberts, 2018).
Though base rates of completed suicide may be low when compared to
other causes of death, base rates of suicidal behavior are at an all-time
high (CDC, 2020). Suicide is a concern for many former members of
the U.S. military, many of whom receive care at the United States
Department of Veterans Affairs (VA). In 2017 the VA released a report
showing the suicide rate for veterans to be 1.5 times the rate of
non-veteran adults, adjusting for age and sex (U.S. Department of Vet­
erans Affairs, 2019). Additionally, veterans treated for depression at VA
hospitals between 1999 and 2004 had elevated suicide risk the first 3
months post-discharge, a rate that is 5 times that of the overall base rate
of depressed veterans seeking treatment (Valenstein et al., 2009) and 54
times the rate of the general US population (Luxton, Trofimovich, &
Clark, 2013).
Low treatment engagement is an added cause for significant concern,
given that the first 90 days following a suicide attempt are the riskiest
time for a subsequent attempt (Hunt et al., 2009; Monti, Cedereke, &
Öjehagen, 2010). In one study, 60% of veterans receiving VA treatment
dropped out after one week of post-discharge care (Stanley et al., 2018).
Of those who did not drop out at one week, 38% terminated care within
three months (Stanley et al., 2018). Limited engagement in
post-discharge treatment, in addition to elevated risk, not only creates
substantial barriers to prevention, but limits intervention efforts as well.
The onset of suicidal behavior and attempts also may create barriers
to intervention, with nearly half of patients reporting that the interval
between first suicidal thought and suicide attempt was less than 10
minutes, and 80% acted within 30 minutes or less (Deisenhammer et al.,
2009), making timely screening and evaluation difficult at best. Taken
together, veterans have a poor record of treatment engagement, are at
higher risk, and have greater acuity for a behavior that is often impulsive
and sometimes fatal. For this reason, a single-session intervention is
gaining recognition as a public health strategy and supports the
importance of an of collaboratively developed prevention plan.
1. Safety planning
A recommended preventive intervention for suicide is the safety plan
– a written document formed in partnership with the patient. The safety

* Corresponding author. VA Hudson Valley Healthcare System, Montrose, NY, 10548, USA.
E-mail address: jonathan.h.weinstein@gmail.com (J.H. Weinstein).

https://doi.org/10.1016/j.jcbs.2021.03.004
Received 22 July 2020; Received in revised form 21 December 2020; Accepted 3 March 2021
Available online 9 April 2021
2212-1447/Published by Elsevier Inc. on behalf of Association for Contextual Behavioral Science.
J.H. Weinstein et al.
plan creates multiple layers of behavioral alternatives to suicide and is
generally implemented in times of crisis (Stanley & Brown, 2012). When
developed with veterans presenting to the emergency room, the safety
plan resulted in a 45% reduction in suicidal behaviors during the
following six months when compared to those who did not form a safety
plan (Stanley et al., 2018). Stanley and Brown’s (2012) safety plan is the
standard of care for suicidal behavior in veterans (The Joint Commis­
sion, 2019; US Department of Veterans Affairs, 2018).
Stanley and Brown’s (2012) safety plan includes 6 collaborative
steps. The plan is designed to provide the veteran with behaviors that
disrupt suicidal behavior and provide an ascending support over time,
depending on the outcome of the prior step. The steps include recog­
nizing warning signs (e.g., thoughts), developing internal coping stra­
tegies (e.g., distracting, exercising), engaging in social situations to
distract from the crisis, calling on supportive family members or friends,
seeking professional supports (e.g., crisis line, therapist), and making
the environment safe (e.g., remove weapons). The veteran is encouraged
to start with the first step and move to the next if the first fails to
interrupt the suicidal behavior. Multiple possibilities are generated for
each step, and likelihood of engagement is explored by assessing ob­
stacles and problem-solving. The VA guidelines indicate that any vet­
eran who is at-risk for suicide should complete a safety plan. Risk is
determined by clinical judgment or by a predictive model based on
algorithmic analysis of VA medical records (McCarthy et al., 2015).
Safety plans may be employed in an emergency, outpatient, or inpatient
setting.
2. Towards a CBS-informed safety plan
Given that suicidal behavior transcends diagnostic categories,
Contextual Behavior Science (CBS) might offer additional possibilities
for enhancing the quality of safety planning by clarifying the function of
the suicidal behavior in context. This allows for interventions that are
not overly focused on the form of a behavior (Hayes, 2016) such as the
content of a suicidal thought or a particular emotion. Instead, focusing
on the function of the behavior, escape from aversive experiences (see
Walser et al., 2015 for example of relationship of experiential avoidance
to suicidal ideation), becomes the target of the safety plan as an inter­
vention. As an experiential therapy, ACT addresses suicidal behavior by
reducing experiential avoidance (Hayes, Strosahl, & Wilson, 2012). That
is, for the veteran struggling with suicidal ideation, she can choose to
make immediate behavioral changes based on processes of openness,
awareness, and engagement without the content of her thoughts needing
to change before engaging in values-based action.
Several trials have applied ACT with success in the context of co­
morbid depressive symptoms and suicidality (Barnes, Borges, Smith, &
Bahraini, 2019; Ducasse et al., 2014; Walser et al., 2015). In an
acceptability and feasibility trial examining ACT as an intervention for
acute suicidal crisis in hospitalized veterans, Barnes et al. (2019) found
treatment was well-tolerated despite its condensed and more intense
application, and retention rates remained high, with more than 75% of
the participants completing the intervention. Most veterans reported
that they would continue to participate in the intervention following
discharge were it available (Barnes et al., 2019). In an open trial,
Ducasse et al. (2014) found that outpatients suffering from Suicide
Behavior Disorder (SBD; see American Psychiatric Association, 2013)
treated with ACT had significant reductions in suicidal ideation as
measured by the Columbia-Suicide Severity Rating Scale (C-SSRS; Pos­
ner et al., 2011). The treatment was found to be acceptable, and
depression and anxiety decreased, while functioning increased and im­
provements were maintained at 3-month follow-up (Ducasse et al.,
2014). Finally, veterans undergoing ACT for depression showed de­
creases in suicidal ideation as acceptance increased across time, with the
proportion of patients without suicidal ideation increasing from 44.5%
at baseline to 65% at follow-up (Walser et al., 2015). This limited
research has indicated that suicidality can be reduced with ACT, and in
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Journal of Contextual Behavioral Science 20 (2021) 101–107
some cases, in limited time intervals (e.g., a single inpatient stay).
Randomized trials investigating ACT to decrease suicidal ideation spe­
cifically are needed to demonstrate efficacy as compared to a control.
The three studies noted above are promising concerning ACT and its
capacity to address a suicidal behavior. Indeed, the ability to deliver
effective and brief interventions during a suicidal crisis is of utmost
importance in addressing the growing public health problem that is
suicide. Brief interventions that may prove useful are beginning to
emerge. For instance, in a randomized trial with depressed adults, three
single-session group ACT interventions were compared to examine how
much is enough to treat depression (Kroska, Roche, & O’Hara, 2020), a
diagonsis often highly associated with suicidal behavior. Findings
indicated that all intervals (90 minutes, 3 hours, 6 hours) reduced
depressive symptoms (Kroska et al., 2020). Similar single-session
intervention trials with suicidality are needed.
3. Constructing a CBS-informed safety plan
Relational Frame Theory (RFT) is the behavioral analytic theory of
human language underlying ACT. Increasing specificity of the safety
plan with RFT may provide targeted interventions to enhance the safety
plan. The unique characteristics of a CBS- and RFT-informed safety plan
are contrasted with Stanley and Brown’s (2012) approach (see Table 1).
The Empowerment Plan extends beyond changing the form of prob­
lematic behaviors to behaviors which function to augment veteran’s
sense of purpose, meaning and motivation.
An important first step in establishing these enhancements is the
clinical context inherent to safety planning. The patient experiencing
suicidal ideation is likely to be reminded of feelings or thoughts asso­
ciated with pain of such magnitude that suicide seems like a reasonable
strategy to escape these thoughts and feelings (Cole-King, Green, Gask,
Hines, & Platt, 2013). Avoidance of such reminders and any associated
context is likely to be maintained by negative reinforcement, and as
such, avoidant behavior may become more pervasive. Also inherent in
the clinical context is the role of the clinician, who both wishes to
support the patient but also must take steps to ensure patient safety.
What follows is a six-part safety plan informed by RFT and CBS.
Throughout the six steps clarified in the section below, a patient
example will be used to demonstrate the process. The example is a
combination of the authors’ clinical experiences across different settings
to protect confidentiality. Also added is an example in the form of a
blank Empowerment Plan (Fig. 1).
Henry is a 38-year-old divorced Veteran. He has presented to his
local VA hospital with reports of suicidal ideation with intent and
means. He denied specific plan but noted method of suicide as loaded
firearm stored in an unlocked gun safe in his home. Henry reported that
he was feeling high levels of stress related to a recent job loss, fear about
an ongoing custody dispute with his ex-partner, and memories of losing
his father to suicide when the patient was young. He reported a history
of a prior suicide attempt within the last year following his divorce. He
currently uses alcohol and tobacco as a way of avoiding intense emo­
tions, memories, urges, and thoughts.
3.1. Step 1a: recognizing warning signs from a CBS-informed perspective
The first step in safety planning is to help patients recognize and
name the specific warning signs indicative of the patient’s experience of
a crisis (Matarazzo, Homaifar, & Wortzel, 2014; Stanley & Brown,
2012). Stanley and Brown’s approach does not offer guidance to the
clinician as to how this might be done. From a CBS-informed perspective,
this can be done by deictically framing questions to expand the veteran’s
awareness of I-Here-Now (Villatte, Villatte, & Hayes, 2016):
• If I were you just as you were beginning to get upset, what sensations,
memories, emotions, or thoughts would I be having?
• What was important to you then? What is important to you now?
J.H. Weinstein et al. Journal of Contextual Behavioral Science 20 (2021) 101–107

Table 1 Table 1 (continued )

Comparison of Stanley and Brown’s (2012) safety plan and empowerment plan. Safety Plan (Stanley Empowerment Plan Examples of
Safety Plan (Stanley Empowerment Plan Examples of & Brown, 2012) Empowering
& Brown, 2012) Empowering Questions
Questions
of avoidance. bathroom floor,
Step 1: Warning Signs Discuss willingness what about tiling
Elicit examples of Step 1a: Use perspective If I were you just as alternative gives you the
warning signs (e. Recognizing taking to as you were response, noting same feeling?
g., agitation, warning signs understand and beginning to get that this is not a How did you
hopelessness). validate the upset, what ‘solution’ in that it handle your tiling
Note emotions, patient’s current sensations, eliminates the problem? Are
thoughts, internal memories, internal experience, there any
behaviors. experiences. Note emotions, or but a potentially similarities with
avoidance thoughts would I more workable this moment?
behaviors or the be having? What behavior.
urge to avoid. was important to Step 2d: Other Integrate openness, How can holding
Cultivate awareness you then? What is internal coping awareness, and an ice cube
of internal important to you engagement within become a
experiences, and now? What do the newly mindfulness
begin to introduce you say to established exercise? How
approach, rather yourself when behavioral can meditation
than avoidance, of you catch responses. and/or prayer
internal yourself wanting help you explore
experiences. a feeling to go your values?
away? Step 3: Social Contacts
Step 1b: From Observe, describe, When was Identify sources of Step 3: Social Identify sources of What are
emotions to and then seek to another time you social support contexts meaning, purpose, examples of
values connect to values. had this feeling? who may help to and connection. Use activities you’ve
Explore the message How long has this distract from the deictic framing to enjoyed or felt
being conveyed by feeling been with crisis. reference the you- purposeful?
emotions regarding you? What does there-then. Identify Where are some
one’s values to this feeling “say” past or future places you like to
transform the to you about the instances where go with others?
function of painful future or past? Is meaning or What kinds of
internal something connection were events are you
experiences. important experienced. List looking forward
missing? Was both people and to? What are
something contexts that may some activities
important taken facilitate you would like to
from you? Is connection and plan?
something about meaning.
to be taken from Step 4: Family or Friends
you? Seek help from Step 4: Valued Identify people who The last time you
Step 2: Using Internal Coping Strategies family members others the patient values. had a moment of
Increase the Step 2a: Explore the If this feeling or friends who Collaboratively connection with
number of Hierarchical workability of didn’t have to go may be able to assess the another person,
behaviors a framing avoidance and away for you to offer support or workability of what were you
person could use potential do something help to alleviate involving close doing? Who are
to engage in alternative really important, the crisis. others in crisis and some people you
distraction responses to what would that expressing can do things
during a crisis. internal be? If you can’t vulnerability. with? Who are
Distraction experiences. do everything you looking
should facilitate Cultivate that’s important forward to
decreased willingness toward to you right now, seeing? Who has
distress. and awareness of is there some helped you in the
Examples: internal smaller step that past?
holding ice cube experiences. would move you Step 5: Professional Supports
in hand to change in the right Contact healthcare Step 5: Identify the Who do you
temperature, direction? providers, hotline Seeking contexts in which trust? When have
vigorous Step 2b: Gather information What are you supports, or seek professional seeking professional you felt safe?
exercise, Temporal about the veterans’ good at? When emergency care. support support is When have you
watching framing strengths and were you good at necessary. Facilitate felt relieved or
television interests. Using it? What makes noticing of the supported?
perspective taking you curious? function of such
(i.e., past- or future- When has there behavior and
oriented), collect been a time when reinforce reasons
information about you felt that way? for living.
values. In doing so, What do you Step 6: Making the Environment Safe
assess the veteran’s notice now as we Limit access to Step 6: Clarify sources of Where have you
ability to track are talking about means. Make Connecting meaning as related felt safe? What
changes in that time in the specific plans to values with to actions taken to helps make an
experiences across past? remove access to actions to limit ensure safety and environment feel
time. firearms, lethal means limit means. right to you?
Step 2c: Use metaphor to If the way you are medications, or Encourage What steps can
Analogical explore feeling right now other methods. intentional, values- you take to make
framing unworkability of were a problem based choices your home or
avoidance and costs in tiling the regarding limiting other
means. Facilitate environment a
(continued on next page)

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J.H. Weinstein et al.
Table 1 (continued )
Safety Plan (Stanley Empowerment Plan Examples of
& Brown, 2012) Empowering
Questions
flexible, values- safer and
driven responding healthier one?
to internal How can I store my
experiences. medications and
firearms to
increase safety?
Deictic framing offers specificity of the patient’s experience in the
context preceding the suicide attempt. It connects private even­
ts—thoughts, feelings, sensations, images, urges, and memories – to a
sense of importance or meaning. For example, it might also be asked:
• Why would it be important for you to have some awareness of your
experience of struggle when you are suffering?
• How important is it for you to have agency when you are in pain?
The rationale is that with awareness comes the possibility of choice.
With choice comes the possibility of empowerment. The possibility of
empowerment is enhanced by explicitly linking willingness, as a choice,
to awareness of internal experiences.
3.2. Step 1b: getting from emotions to values
If the veteran’s awareness of pain, suffering, or struggle is discussed,
emotion is more likely to be expressed. This can be extraordinarily
helpful to the clinician in completing the first step. In the context of
safety planning, emotions felt and expressed during the interview can
“open the door” to other occasions when the emotion was experienced.
Alternatively, rather than reflecting on the past, what they presently
value can be explored, even if that value might be at risk now or at risk in
the future (see Table 1).
The clinician and veteran can explore the emotions expressed in the
present to find what was valued by the veteran in the past when he felt
that same emotion. When Henry describes mourning the sudden loss of
his father, he is reminded of the grief he is feeling now associated with
the recent suicide of his closest friend. This sense of loss might point to
something valued about his relationship with his father that was also
notable with respect to his other losses. This sense of loss might point to
values of connection and care in his relationships. For the clinician, their
experience of the patient in the haze of a powerful emotion may result in
therapy strategies that prioritize coping rather than what Henry values.
In most mainstream settings, the clinician might attempt to help the
veteran manage, alleviate, or control emotions by addressing the con­
tent of those memories as an opportunity to perform some sort of coping
skill rather than addressing the root cause. From a CBS-informed
perspective, values can be explored as the psychological context asso­
ciated with his memories, emotions, and other related private events.
3.3. Step 2a: expanding behavioral repertoires with hierarchical framing
in therapy
Step two of safety planning encourages the collaborative develop­
ment of coping strategies the patient can use without contacting another
person. From a CBS perspective, the present moment work in Step One is
an initial introduction to approaching distress rather than avoiding it.
When patients can see the cost of not changing, they can learn to
observe, describe, and track consistency of actions with values (Villatte
et al., 2016). As awareness is facilitated, patients acquire flexibility to
select values-consistent behaviors, rather than behaviors that function to
reduce pain. For example, when discussing use of substances, it may be
that veterans engage in behaviors that are incongruent with values, such
as interpersonal conflict or impulsive behavior. Instead, veterans can
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Journal of Contextual Behavioral Science 20 (2021) 101–107
learn to choose discomfort, even emotional pain, in the service of
something larger and more important, (e.g., delivering the funeral eu­
logy for a beloved friend). Working to cultivate the veteran’s willingness
to feel distress as a means for behaving consistently with values is part of
this process. The prior work from Step One with present moment pro­
cesses can be used to approach their distress. Table 1 lists several
questions with this function under Step 2a.
Actions framed as part of a meaningful life, potentially facilitate
satisfaction from engaging the action rather than the consequent. Values
set the occasion for development of values-consistent behavior. Con­
necting Henry’s memory of losing his father with the importance of that
relationship may: 1) transform the function of the sadness associated
with the memory and 2) allow for more flexible responding to that
memory with behaviors, including responses that are inconsistent with
avoidance of internal experiences associated with the memory.
Previously tried coping strategies may helpfully function to de-
escalate emotions. However, there are drawbacks to control or
distraction-oriented coping strategies when examining the function and
consequences. Ignoring or suppressing emotions has been associated
with numerous negative mental health outcomes (Gross & John, 2003).
Useful information provided by emotions in the moment likely goes
neglected. Distraction limits experiential learning and potentially sub­
verts information that may shed light on values.
3.4. Step 2b: expanding behavioral repertoires with temporal framing
Deictic frames are built around three important distinctions in
perspective: I versus you, here versus there, and now versus then. The
latter distinction in perspective relates to now versus some other time, or
temporal framing, and can be particularly useful in safety planning. If
the purpose is to assess for and discover unknown strengths, capabilities,
and opportunities to practice resilience, this set of questions gathers
information about a veteran with high-risk behavior rather quickly (see
step 2b in Table 1) and reveals what the veteran does when their
behavior is not solely under aversive control. Talents and interests are
explored, framing present treatment needs in the service of new possi­
bilities. Exploring these questions invites unique qualities to be appre­
ciated about the veteran.
3.5. Step 2c: expanding behavioral repertoires with analogical framing
By developing a sense of the veteran’s interests, strengths, and past
successes, the clinician can explore potential future behaviors through
analogical framing. When a familiar context is used to reframe the
present struggles, the dominance of antecedent aversive stimulus con­
trol may lessen. Though the history does not change, it exerts less in­
fluence on the present and allows for more flexible behavioral
responding. This is most likely in a context where the veteran has
experienced some level of efficacy or competence. A more specific
example of analogical framing might include something with which the
veteran has personal or professional experience. For example, if Henry
has a history of working with his hands to build homes, Table 1 offers a
guide for sample questions that might be asked. Analogical reframing
removes the struggle from its traditional context and offers instead a
metaphorical context wherein the veteran has experienced greater suc­
cess and is therefore more likely to think creatively and flexibly.
Metaphor is a form of analogical framing that elucidates the un­
workability of avoidance behavior in response to internal experiences.
Metaphor allows for formation of verbal connections between a
described experience and the patient’s experience, and when done
effectively, provides the “right amount of distance” from which the
patient can take a new perspective on internal experiences, responses,
and the workability of different behaviors (Foody et al., 2014). For
example, a metaphor of quicksand may be used to explore the un­
workability of avoidance, noting that the more one struggles with in­
ternal experiences, the more trapped in those experiences they become.
J.H. Weinstein et al. Journal of Contextual Behavioral Science 20 (2021) 101–107

Fig. 1. Empowerment plan.

The workable behavior is to maximize contact with the quicksand and
stop struggling, helping one to rise to the top, rather than be swallowed
by the quicksand. Notably, this does not eliminate the quicksand or
reduce contact with it, but allows for a more workable outcome (Hayes,
Barnes-Holmes, & Roche, 2001).
3.6. Step 2d: other forms of internal coping that can accommodate
additional functions
Lists of coping skills can be enhanced through elaboration using
typical CBS-informed processes. Willingness, awareness, and engage­
ment amplify coping skills and increase effectiveness. For example,

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listening to uplifting music or holding an ice cube can be utilized as a
mindfulness exercise, rather than a form of distraction. The focus is
shifted from distraction to changes and transitions in present moment
awareness. Mindful walking, meditation, and prayer can be an explo­
ration of values. Helping the veteran to elaborate on these themes can
become part of the Empowerment plan.
3.7. Step 3: social contexts
Traditional safety planning suggests listing people and social settings
that supply distraction from distress “where socializing occurs natu­
rally” (Matarazzo et al., 2014; Stanley & Brown, 2012). From a
CBS-informed perspective, helping veterans rediscover meaning and
purpose in relationships is the goal. CBS-informed interventions hold
meaning and purpose as direct intervention targets. It is important to
understand the veteran’s social support system when engaging the
veteran in these possibilities.
If challenged with a lack of or failing social support, Table 1 suggests
how clinicians can ask about meaningful connections using deictic
framing. The information can be used to further develop these connec­
tions. The questions emphasize behavior that occurred in another time
and place with another person (a You-there-then relation). This type of
questioning emphasizes how the use of past experiences in safety plan­
ning can now assist in motivating future behavioral action.
Deictic framing may also be useful in identifying potential sources of
support and future actions:
• What are you doing when you feel a sense of connection?
• Where are you when you feel connected to others?
• How is it to talk about this right now?
Moving from the present to the future, deictic framing can identify
continued sources of social support. For some who have difficulty
imagining a different future, they might be asked to imagine a universe
free from their current constraints or an alternate universe (Strosahl,
2015).
• In an alternate universe free of these constraints, what might you
want to be important?
• What might become important if you were free to choose?
3.8. Step 4: family or friends who May offer help
In traditional safety planning, when distraction and other forms of
coping are unsuccessful in alleviating the crisis, patients are encouraged
to seek help from family members or friends (Stanley & Brown, 2012).
Traditional safety planning acknowledges the risks this may pose and
suggests that clinicians should weigh the pros and cons with patients
before including a family member or friend in the plan. The interper­
sonal theory of suicide suggests that these ratings are warranted (Van
Orden et al., 2010). They cite two factors: (1) the patient’s perceived
sense of being a burden to others and (2) a thwarted sense of belonging.
These two factors suggest a range of reasons patients may give for not
seeking help from loved ones and friends. Additionally, emotions of guilt
and shame may play a similar role. For example, Henry could seek
support from his sister when he’s fighting the urge to drink, but the last
time he tried that he woke up her family and he still feels guilty about
the incident. The likelihood that a conversation with a friend or family
member might inspire private events in the form of aversive thoughts,
feelings, sensations, images, and memories, may suggest targets for
intervention, rather than functioning as a respite. From a CBS-informed
perspective, safety planning might include returning to earlier steps to
clarify how a patient’s relationships (or lack thereof) might be impli­
cated in the present predicament.
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Journal of Contextual Behavioral Science 20 (2021) 101–107
3.9. Step 5: professionals and agencies to contact for help
The standard model for safety planning supports maintaining a list of
mental health professionals and other providers who can provide sup­
port to the veteran in case of a mental health crisis (Stanley & Brown,
2012). Crisis support hotlines are typically included in this list of re­
sources. In addition to the Veteran’s Crisis hotline, adding a second
hotline or texting service not associated with the VA that is both
confidential and anonymous provides an additional level of support to
veterans who are reluctant to contact the VA. This is useful for veterans
who have had past negative experiences with mental health care or at a
particular VA. This allows the veteran to seek emergency support
without surrendering agency until they are ready for a higher level of
intervention. The inclusion of specific mental health provider’s contact
information gives the veteran an option to seek out crisis support.
3.10. Step 6: making the environment safe
Suicide attempts that include a firearm are far more likely to result in
completed suicide than tries by other means (Elnour & Harrison, 2008).
As providers, a final step in the safety plan is to work with veterans to
limit access to lethal means, including surrendering weapons to close
others, placing weapons in a locked or off-site location, limiting quan­
tities of medication available for dispensation, or providing Naloxone
and appropriate training to patients and close others (Barber & Miller,
2014). However, in countries where firearms are legal, these weapons
may have meaning or significance for the veteran or gun owner. For
veterans, this may be especially true. Whether firearms are a safety
signal, a symbol of strength or freedom, or a means of self-protection,
the role of a clinician is to validate this meaning while prioritizing
safety. A CBS-informed approach to safety planning may ask patients to
hold both the meaning of firearms and a desire to be alive simulta­
neously, while encouraging intentional choice in moments of pain.
Though the presence of a firearm could serve as a safety signal, the
absence of a firearm could, too, serve as a safety signal if a patient be­
lieves that he cannot keep himself safe if the firearm is near. Encour­
aging flexible responding to these thoughts, rules, and the associated
strong emotions is paramount in creating a new values-based behavioral
repertoire.
4. Discussion
If safety planning reduces risk, the future of suicide prevention
research includes investigations of the mechanisms by which risk is
reduced, moderating variables of outcome, and identification of key
predictors of therapeutic outcomes. Investigating CBS-informed pro­
cesses may well become a key determinant of this effort. It is important
to investigate the functional outcomes associated with the Empower­
ment plan, as well as the symptoms and suicidal behaviors of interest.
The questions of what patients do after the intervention, as well as how
they do it, are of great interest in showing the incremental utility of the
Empowerment plan.
Future studies might seek to answer overall questions concerning
safety planning. Further investigation of the Empowerment plan, in
comparison to the safety plan, would be a first gateway to understanding
and potentially alleviating the suicide crisis. These investigations would
also be useful in informing existing policy in VA concerning suicide,
perhaps supporting future rollout of the Empowerment plan.
Of additional interest is the quality of the developed safety plan from
both the client and therapist perspectives, at least one study of this kind
is currently underway (Goodman et al., 2020). Relevant to RFT, one
might posit that the types of frames used in safety planning may play a
key role in predicting outcomes. If experiential avoidance is conceptu­
alized as a key process in suicide, examinations of the mediating role of
experiential avoidance in treatment gains are essential. Finally, of in­
terest is whether extensive training in ACT and/or RFT is needed to
J.H. Weinstein et al.
implement a CBS-informed Empowerment plan versus a traditional
safety plan.
In conclusion, developing empirically supported, brief interventions
for suicidal behavior is a top priority. With the goal of reducing suici­
dality in veterans and the global population broadly, it is posited here
that purpose and meaning is one such enhancement. The Empowerment
plan offers a CBS-consistent pathway toward this end.
Disclosures
The authors report no financial conflicts.
Declaration of competing interest
Given their role as an Editorial Board Member, Kroska E.B. had no
involvement in the peer-review of this article and had no access to in­
formation regarding its peer-review. We have no financial or other
conflicts of interest related to this manuscript.
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