How can I develop a written safety plan for a patient at risk of self‑harm?

Developing a Written Safety Plan for Patients at Risk of Self-Harm

Create a collaborative, written safety plan that includes six core components: warning signs, internal coping strategies, social supports, professional crisis resources, means restriction, and reasons for living—this intervention reduces suicidal behavior by approximately 43% compared to usual care. 1

Core Components of an Evidence-Based Safety Plan

1. Warning Signs and Triggers

• Document specific thoughts, images, mood changes, or situations that precede suicidal crises (e.g., "feeling hopeless about the future," "intrusive thoughts about death," "conflict with family members") 1, 2, 3
• Include behavioral indicators the patient recognizes as early warning signals (e.g., social withdrawal, increased substance use, sleep disturbance) 1, 4

2. Internal Coping Strategies

• List concrete activities the patient can do independently without contacting others (e.g., "take a walk," "listen to music," "practice deep breathing," "watch a favorite show") 1
• Identify healthy distractions that have worked previously to suppress suicidal thoughts 3, 4

3. Social Support Contacts

• Name specific people and their contact information whom the patient can reach out to for distraction or support (not necessarily to discuss suicidal thoughts) 1
• Include friends, family members, or trusted individuals who provide emotional connection 2, 3

4. Professional Crisis Resources

• List the patient's mental health provider with direct phone number and after-hours contact information 1
• Include crisis hotline numbers (National Suicide Prevention Lifeline: 988), local emergency services (911), and nearest emergency department address 2, 3, 4
• Provide clear instructions for reaccessing emergency services if symptoms worsen 3

5. Means Restriction Plan

• Document removal of all firearms from the home—this is mandatory, as firearm access doubles suicide risk and patients consistently find ways to access "locked" weapons 2, 3, 4
• Specify that all medications (prescription and over-the-counter) must be locked away and controlled by a responsible adult 2, 3
• Address access to other lethal means (e.g., sharp objects, ligature points, toxic substances) and document restriction strategies 1, 2
• Verify that a responsible adult has agreed to enforce these restrictions 2, 4

6. Reasons for Living (Optional Enhancement)

• Include personalized reasons the patient identifies for wanting to live (e.g., children, pets, future goals, religious beliefs) 1
• This component may strengthen engagement but is not essential for basic safety planning 1

Implementation Process

Collaborative Development

• Create the safety plan WITH the patient, not FOR the patient—collaborative development is essential for effectiveness 1, 2
• Complete the plan during a single session when possible, typically 20-45 minutes 1
• Use simple, concrete language that the patient understands and can remember during crisis 1

Format and Accessibility

• Provide the plan in written format on a wallet-sized card or single sheet of paper 1
• Give copies to the patient, family members, and document in the medical record 2, 3
• Ensure the patient knows where to find the plan during a crisis (e.g., in wallet, on phone, on refrigerator) 1

Follow-Up Contact

• Implement periodic caring communications (phone calls, text messages, or postcards) for at least 12 months after plan creation 2, 4
• These contacts significantly reduce suicide attempts and deaths 1

Critical Pitfalls to Avoid

What NOT to Do

• Never use "no-suicide contracts" or "safety contracts"—these have zero proven efficacy and may damage therapeutic engagement 1, 2, 3, 4
• Do not use coercive language like "you can't leave until you promise not to hurt yourself"—this encourages deception and undermines trust 2, 3, 4
• Do not create a safety plan for patients who cannot engage in the discussion due to severe agitation, psychosis, or persistent intent to die—these patients require psychiatric hospitalization instead 1, 2, 3
• Do not assume the plan alone is sufficient—it must be paired with ongoing mental health treatment and close follow-up 2, 4

Common Mistakes

• Creating overly complex plans with too many steps that patients cannot remember during crisis 1
• Failing to verify means restriction, particularly underestimating patient access to "secured" firearms 2, 3, 4
• Neglecting to involve family members or responsible adults in the plan 2, 3
• Not scheduling immediate psychiatric follow-up before discharge from emergency settings 1, 2, 4

Special Populations

Home-Based Telepsychiatry

• When developing safety plans via telehealth, obtain the patient's physical address and location for emergency services 1
• Obtain explicit consent for contacting community resources in emergencies 1
• Avoid home-based safety planning if serious safety concerns exist or if the family refuses to participate in the safety plan 1

Pediatric and Adolescent Patients

• Interview adolescents separately from caregivers to facilitate honest discussion, while explaining confidentiality limits 1
• Obtain collateral information from parents, as adolescents frequently minimize symptom severity 1, 4
• Emphasize to families that the highest risk for reattempt occurs in the months immediately after an initial attempt 1, 4

Evidence Base

The safety planning intervention demonstrates a relative risk of 0.57 for suicidal behavior compared to usual care (43% reduction), with a number needed to treat of 16 1. Studies show significant reductions in hospitalizations (69% decrease in inpatient days) and increased use of appropriate crisis resources after safety plan implementation 5. However, safety plans do not significantly reduce suicidal ideation, so other evidence-based treatments (cognitive-behavioral therapy, dialectical behavior therapy, or pharmacotherapy) are needed to address underlying psychiatric symptoms 1, 2.