Suicide/self-harm risk & safety planning
Learning objectives
- Use a structured screen, such as NIMH's Ask Suicide-Screening Questions (ASQ) toolkit, and explain that a screen is not a full assessment.
- Ask directly about suicidal ideation, plan, intent, and recent behavior.
- Build a collaborative safety plan and counsel on means safety.
- Document the risk formulation and the handoff.
- Name 988 or the local crisis resource, and follow local emergency policy when danger is immediate.
Learn
NIMH publishes a free ASQ toolkit for medical settings (NIMH Ask Suicide-Screening Questions (ASQ) Toolkit). A positive screen is a reason to stay with the person and complete a clinical evaluation under your policy. It is not a diagnosis and it does not by itself set a disposition.
Ask in plain language about thoughts of suicide, a plan, intent, and what has happened recently. Collaborative safety planning usually covers warning signs, ways to cope, people to contact, professionals to contact, making the environment safer, and reasons for living. Means-safety counseling is specific: which method is available, and what the person will do to put time and distance between themselves and that method. Do not promise that a plan removes risk.
The handoff names who was told, what the plan is, and when follow-up happens. In the United States, SAMHSA 988 Suicide & Crisis Lifeline is the 24-hour Suicide & Crisis Lifeline. If someone is in immediate danger, follow your emergency policy rather than handing them a number and leaving.
Standards: Uses NIMH's free ASQ screening toolkit for medical settings, NIMH suicide-prevention guidance, APA's Psychiatric Evaluation of Adults guideline, and SAMHSA's 988 Lifeline for follow-up. Sources: NIMH Ask Suicide-Screening Questions (ASQ) Toolkit, NIMH Suicide Prevention, APA Clinical Practice Guidelines, SAMHSA 988 Suicide & Crisis Lifeline.
Practice
Behavioral Skills Training:
- Instruct the screen questions and the parts of a safety plan.
- Model a calm, direct question about suicide, then a pause for the answer.
- Rehearse in triads: an ED patient who says they cannot go on; an inpatient who has been saving medication; a primary-care partner calling about a positive screen.
- Feedback on whether the ask was direct, whether means safety was concrete, and whether anyone was left alone against policy.
Simulate
Interprofessional simulation: a nurse starts the screen, a social worker drafts the safety plan with the person, and a psychiatrist reviews the formulation. Security joins only if local policy calls for it. Debrief what was asked, what was missed, and whether the handoff would let the next clinician continue the plan.
Measure
| Skill | Observed? |
|---|---|
| Asks directly about thoughts of suicide | ☐ |
| Asks about plan, intent, and recent behavior | ☐ |
| Stays with the person when risk is acute, following local policy | ☐ |
| Completes a collaborative safety plan with warning signs, coping steps, and contacts | ☐ |
| Discusses means safety in concrete terms | ☐ |
| Documents the formulation and the handoff | ☐ |
| Names 988 or the local crisis resource | ☐ |
| Does not treat the screen as a complete assessment | ☐ |
Set your own mastery threshold, for example all safety items plus most others. Reassess at one month.
Further reading
- NIMH, NIMH Ask Suicide-Screening Questions (ASQ) Toolkit.
- NIMH, NIMH Suicide Prevention.
- APA, APA Clinical Practice Guidelines (including evaluation of adults).
- SAMHSA, SAMHSA 988 Suicide & Crisis Lifeline.
- Stanley B, Brown GK. Safety Planning Intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012.