A collaborative tool created with the patient — warning signs, internal coping, contacts, professionals, means restriction. Better than "no-suicide contracts."
Encounter card
Setting
Every patient with current or recent suicidality, especially before discharge from any clinical setting and at psychiatric encounters when risk emerges.
Opening move
Build the plan collaboratively, ideally in writing. Six elements: (1) warning signs, (2) internal coping, (3) social distractions, (4) people to ask for help, (5) professional contacts, (6) means restriction.
Sample language
"I'd like to make a plan with you for when things get hard. Not a contract — a tool you can use."
"What are the warning signs that tell you things are getting worse?"
"What's helped you get through hard moments before — what could you do on your own?"
"Who could you call or be with if things felt urgent? Friends, family, sponsor?"
"Who would you reach out to professionally — me, crisis line, ED?"
"Let's talk about access to means — what could we put out of reach for now?"
Listen for
Specificity of warning signs. Realistic coping strategies. Genuine vs nominal social supports. Patient ownership of the plan. Resistance to means restriction (a key signal).
Common pitfalls
Using "no-suicide contracts" (no evidence they work; may worsen). Making the plan for the patient rather than with them. Generic plan that doesn't match the patient. Skipping means restriction. Not giving the patient a copy.
Red flags / escalate: Patient cannot generate any warning signs, coping strategies, or supports — suggests severe hopelessness, dissociation, or non-engagement that warrants higher level of care.
Documentation
Safety plan in chart and copy given to patient. Means restriction plan specifically documented.
Safety plans work because they make help-seeking concrete in the worst moment, when problem-solving capacity is lowest.
Warm grey-tinted clinical notebook page, burnt orange accent. The six elements of safety planning — warning signs, internal coping, social distractions, people, professionals, means restriction. Margin clusters on each.
Safety planning is the structured tool that replaced the older "no-suicide contracts" — and the change is well-grounded. Contracts have no evidence of efficacy and may worsen outcomes through false security and shame when broken. Safety plans work by making help-seeking concrete in the worst moment, when the patient's problem-solving capacity is lowest.
The six elements structure the plan. First: warning signs — specific to this patient. What does this patient feel, think, or do when crisis approaches? "When I can't stop crying" or "When I start thinking my family would be better off without me" or "When the voices get louder." The patient's own words.
Second: internal coping — what helps without involving others. "Going for a run," "calling my dog," "watching specific movies," "deep breathing." The patient's track record of what has actually worked.
Third: social distractions — people and places that help even without discussing the crisis. "Going to the coffee shop," "calling my sister to chat about her kids." Engagement that interrupts the spiral without requiring crisis disclosure.
Fourth: people to ask for help — specific names and numbers for crisis support. "Call my best friend, Sarah, 555-1234." "Tell my husband what's happening." Not generic "talk to someone"; specific people the patient has identified and ideally informed in advance.
Fifth: professional contacts — me, crisis line, ED. "Call my psychiatrist at 555-5678. After hours, 988 crisis line, or go to ED."
Sixth: means restriction — non-negotiable. What does this patient have access to, and how can it be restricted during crisis periods?
Build it collaboratively, in writing, ideally in the patient's own handwriting or printed for their wallet. The plan they wrote is the one they'll use. Pre-printed forms with generic items don't get used; the personalized plan does. Update at every visit where crisis is on the table.
Means restriction deserves specific time in the conversation; the next concept covers it in more detail.
Building the plan with the patient rather than for them — collaborative authorship makes it usable. Margin notes on the moves.
The anchor
Safety planning is a collaborative tool with six elements — warning signs, internal coping, social distractions, people, professionals, means restriction. Better than "no-suicide contracts" because it makes help-seeking concrete.
The means restriction conversation as central to safety planning — not optional. Sample scripts. Margin clusters on common scenarios.
Prove it
A patient with chronic suicidality has multiple "no-suicide contracts" in her chart. She's here after another attempt. How do you proceed with safety planning?