Safety plans people actually use
A plan written for someone, in clinical language, listing a number they will never ring, is a documentation exercise. Written with them, it is an intervention — and it takes the same twenty minutes.
Safety plans are among the better-evidenced things in this field and among the most poorly executed. A plan written for someone, in clinical language, listing a crisis line they will never ring, is a documentation exercise. A plan written with them, in their words, is an intervention.
The difference is not effort. It is roughly the same twenty minutes, spent differently.
Why generic plans fail
Consider the standard version: "Patient advised to contact the crisis team or attend A&E if her mood deteriorates. Given crisis line number. Advised to use coping strategies."
Four problems, and they are fatal ones.
- It requires the person to recognise deterioration at the moment when their judgement is least reliable.
- It names no coping strategy, so at 2am there is nothing to remember.
- It assumes they will ring a stranger at the worst moment of their life, which most people will not.
- It changes nothing about the environment, which is the part with the best evidence behind it.
Would this plan be usable by this person, at 2am, alone, distressed, without you? If any part requires them to be calmer or more insightful than they will be, it will not survive contact with the crisis it was written for.
The six parts
The structure below follows the widely used safety planning approach, ordered from what the person can do alone to what requires other people. That order matters: it means the plan does not depend on anyone else being available.
- Warning signs — how they know things are getting worse
- What they can do alone — internal coping strategies
- People and places that help — distraction, not disclosure
- People they can tell — those they would actually ring
- Professional contacts — named, with numbers, and when to use each
- Making the environment safer — the practical changes agreed today
Warning signs, in their words
Start here, because it is the part they know best and the part clinicians most often supply for them.
"Thinking back to the last time things got difficult — what was the first sign?"
"What do you notice before things get bad? What might your family notice?"
"Is there something you find yourself doing when you are struggling?"
Write down what they say, not your translation of it. "Stops answering his phone and starts cleaning at night" is a warning sign. "Social withdrawal and disturbed sleep" is the same information rendered useless to the person it belongs to.
What they can do alone
The critical constraint is that these must work without anyone else, because the moment the plan is for is often a moment when nobody is available.
"What has helped, even a little, when you have felt like this before?"
"Is there anything that reliably gets you through an hour?"
Take what they offer, however unclinical. Walking the dog, a specific programme, a shower, driving, a particular album. Specificity is what makes it retrievable later; "distraction techniques" is not something anyone remembers at 2am.
Strategies built on physical discomfort — holding ice, snapping a band, cold water — are still occasionally suggested. They substitute one form of self-directed pain for another and reinforce the pattern rather than interrupting it. There is no shortage of better options, and the person usually knows several already.
Who they will contact
Two separate lists, and conflating them is a common error.
People and places for distraction — where the person can be around others without having to explain anything. A sibling's house, a café, a place of worship, a gym. Nothing needs to be disclosed for these to help.
People they can tell — those they would actually ring and say they are struggling. Ask directly: "Who would you actually call? Not who should you call — who would you?" The honest answer is sometimes nobody, and that is itself an important finding which changes the rest of the plan.
Where someone is named, ask whether they know they are on the plan. A supporter who has not been told is a plan with a gap in it.
Making the environment safer
Restricting access to means has some of the strongest evidence in suicide prevention, and it is the part most often left out because it is uncomfortable to raise.
Raise it plainly and practically, framed around what can be changed today.
"Is there anything at home that you have thought about using?"
"Would you be willing for someone else to look after that for a while?"
"Who could hold your medication, and how much should be at home at once?"
Record the action agreed — who is holding what, what has been removed, how medication will be dispensed — rather than cataloguing methods in the notes. The action is what matters and what can be checked at review.
Professional contact
Name the service, give the number, and say when to use which. "Contact services if needed" is not a plan; it is a sentence.
Three practical points that materially raise the chance the plan is used.
- Save the numbers into their phone during the appointment. A number on a leaflet in a coat pocket does not exist at 2am.
- Say what happens when they ring — who answers, what they will be asked, how long it takes. Fear of the unknown stops more calls than reluctance does.
- Distinguish urgency levels. Which number for a difficult evening, which for an emergency, and when to go straight to A&E or call 999.
A worked plan
Synthetic, and written in the person's register rather than a clinical one.
How I know things are getting worse. I stop answering my phone. I start cleaning the flat at night. I stop eating properly.
What I can do on my own. Take Rosie out, even just around the block. Put the snooker on. Have a shower and get dressed even if I am not going anywhere.
Where I can go. My sister's, she is ten minutes away. The café on the high street in the mornings.
Who I can tell. My sister Angela — 07xxx xxxxxx. She knows about this plan and has agreed to call me every evening this week.
Making things safer at home. Angela is keeping my medication and will bring a week at a time. I have agreed to give her the spare set of keys to the garage.
Who to ring. Crisis line, saved in my phone as CRISIS — for a bad evening. Duty number for the team, weekdays. 999 or A&E if I cannot keep myself safe. All three are now in my phone.
What I am working towards. Getting back to work in the spring.
The last line is not decoration. Asking what the plan is for gives it a purpose beyond survival, and the answer is frequently the most quotable thing in the assessment.
Recording it in the note
The clinical record does not need the whole plan verbatim, but it needs enough that a colleague can see what was agreed and check it at review.
Safety plan written together and a copy given to her; she has photographed it. Her sister Angela will call daily this week, has agreed to hold the medication and dispense weekly, and is aware of the plan. Crisis line and team duty number saved into her phone during the appointment. She has agreed to hand over the garage keys. Discussed with the duty consultant. Housing referral submitted today. Review in five days, sooner if Angela is concerned.
Notice what is absent: no risk rating, no score, no low/medium/high. NICE guideline NG225 advises against those, and this paragraph conveys considerably more about what to worry about and what to check than any of them would.
Two practical additions. Make sure the person leaves with a copy in a form they will still have — a photograph on their phone beats a folded sheet. And put a review date in the plan itself, because a safety plan is a snapshot of one conversation and stops being accurate the moment circumstances change.
Common questions
What should a safety plan include?
Six parts: the person's own warning signs, what they can do alone, places and people that offer distraction, people they would actually tell, professional contacts with numbers and when to use each, and practical changes that make the environment safer. Ordered so the early steps do not depend on anyone else being available.
Why should a safety plan use the person's own words?
Because they have to retrieve it while distressed. 'Stops answering his phone and starts cleaning at night' is recognisable to the person it describes; 'social withdrawal and disturbed sleep' is the same information rendered unusable. A plan written in clinical language belongs to the clinician, not the patient.
How do I raise restricting access to means without causing distress?
Plainly and practically, framed around what could change today: whether anything at home has been thought about, whether someone else could look after it for a while, who could hold medication and how much should be at home at once. Record the action agreed rather than cataloguing methods in the notes.
Should a safety plan include a risk rating?
No. NICE guideline NG225 advises against stratifying risk into low, medium or high, and against using scales to predict suicide or self-harm. A specific plan describing what was agreed, with whom, and when it will be reviewed conveys far more than a rating and says what to do about it.
How often should a safety plan be reviewed?
It is a snapshot of one conversation and stops being accurate as soon as circumstances change. Put a review date in the plan itself, and revisit it whenever something material changes — housing, a relationship, medication, or the availability of the people named in it.