After assessing the presence of risk

Safety planning is a collaborative, person-centred process that supports people to navigate periods of distress and suicidal thinking⁴³. Its purpose is to strengthen the patient’s safety, agency and connection, and to help them identify what might support them when their distress escalates. Whether a patient’s suicidal thoughts are vague or intense in nature, a safety plan can help to contain distress and offer ideas to improve their mental health.

Importantly, a person might not be assessed as at risk during one consultation, but may be at risk in a subsequent consultation.

Effective safety planning acknowledges that risk can ebb and flow, and that plans need to be flexible enough to adapt to changed circumstances.

In general practice, safety planning needs to be:

• dynamic and revisited over time, not conducted as a single conversation
• tailored to the patient (ie with consideration of their identity, culture, preferences, capacity, circumstances, and so on)
• relational, grounded in empathy and trust
• practical, focusing on what the person is willing and able to use.

Safety planning is most pertinent when:

• you believe the risk of suicide is serious
• someone is ambivalent about living or dying.

Safety planning may occur:

• during a longer mental health consultation
• across multiple shorter appointments
• informally during routine care
• as part of crisis follow-up or review.

Early in the discussion, it can be helpful to ask:

• “Would it be okay if we talked about what might help when things feel overwhelming?”
• “What would make this conversation feel useful for you?”
• “Have you ever tried a plan like this before? What worked or didn’t?”

The way you introduce and discuss safety planning is critical: evidence consistently shows that kind, compassionate, empathetic and non-judgmental conversations reduce shame, increase disclosure and strengthen therapeutic alliance⁴⁴. Asking directly about suicide does not increase risk but is, in fact, associated with reduced distress when done respectfully. In other words, it should feel like something done with the person, not to them.

Therefore, questions about safety planning need to be designed to be kind, compassionate, empathetic and person-centred, and should not dismiss or invalidate the person’s thoughts.

To implement best practice person-centred communication:

• validate the person’s experience without normalising suicidal behaviour
• avoid rushed or overly procedural questioning
• use curiosity rather than interrogation
• check in with patient every now and then about how they are feeling about the questions.

Consider alternatives to the term ‘safety planning’

Because some people might find the term ‘safety planning’ to be clinical, restrictive or associated with loss of control, consider using alternative phrases, such as:

• “a plan for tough moments”
• “support and healing plan”
• “a staying-safe plan”
• “a support and coping plan”
• “a communication plan in case things get worse”.

Remain flexible about completing a detailed plan, as some people may not be able to complete a full plan in one sitting, or at all. Partial plans, brief check-ins, or a single agreed next step are still meaningful.

Having collaborative conversations about potential means of suicide is a key evidence-based component of suicide prevention. These conversations need to:

• be respectful and practical
• identify ways of keeping the patient’s immediate environment safe by reducing or eliminating their access to potentially lethal means
• help the patient be aware of and avoid stressful or upsetting situations.
• with the consent of your patient, include a family, friend or carer in safety planning. They can provide valuable insights and an outside perspective to help make the plan realistic and helpful.

Working with a patient to develop a safety plan involves curious, compassionate questioning and discussion, rather than the completion of a checklist. The process needs to be collaborative and consider the patient’s individual circumstances and preferences.

Frame your questions appropriately:

• Ask open-ended questions (ie questions that can’t be answered with a Yes or No, or other one-word answers) that will help your patient think about what has helped them in the past, what feels realistic now, and what support they might need if distress escalates.
• Ask questions that invite reflection rather than demand solutions.
• Adapt questions, based on the patient’s circumstances.
• Make the prompts relational and strengths-based, such as:
  • “What are the things you do that help you feel calmer or more in control?”
  • “Are there strengths or abilities you’d like us to build into your safety plan?”
  • “What has worked for you in the past that we should include?”
• Allow space for the patient’s story, values and lived experience.

Avoid rushing or being prescriptive:

• Take a break from asking questions if the patient seems overwhelmed.
• Don’t feel that the plan has to be completed in one sitting. It can be developed gradually, revisited regularly, and adjusted as circumstances change. Even identifying one or two helpful strategies or contacts can be a meaningful and protective step.

Focus on being collaborative, rather than prescriptive.

• Focus on what is realistic for the patient:
• Focus on what the patient is willing and able to do, especially on difficult days.
• Prioritise relationship-building as well as practical strategies.

Acknowledge that capacity and risk can change over time.

Having developed a nuanced, comprehensive understanding of this patient’s suicide risk, you are able to work collaboratively with them to develop an appropriate plan. The plan can include:

• safety planning
• increased monitoring
• referral to specialist services
• involvement of supports (with consent)
• crisis intervention.

Maintaining a transparent and empathetic approach during each conversation helps preserve trust and reinforces the therapeutic relationship as a central component of effective care.

An effective safety plan will address the following information.

Early warning signs

When the patient is aware of changes in their thoughts, moods and behaviour that might signal a developing crisis, it means they can act earlier, which helps to reduce further risk.

Warning signs could include:

• moods such as sadness, anxiety and irritability
• thoughts involving hopelessness, helplessness, and self-criticism
• behaviours such as drinking more alcohol than usual, avoiding social situations, and arguing more often with friends and loved ones.

To help the patient identify warning signs, you could ask:

• “When things start to feel harder, what do you usually notice first?”
• “Are there particular thoughts, feelings or situations that signal you need extra support?”
• “How will you know when you should use your safety plan?”
• “What are some of the difficult thoughts, feelings or behaviours that you experience leading up to a crisis?”

Creating a safe environment

To help the patient understand how they can create a safe environment, you could ask:

• “When people are feeling overwhelmed, access to certain items can increase their risk. Would it be okay if we talked about what might help keep you safe?”
• “Are there any specific situations or people that you find stressful or triggering, or that contribute to your suicidal thoughts?”
• “What things do you have access to that might be used in a suicide attempt?”
• “How can we develop a plan to limit your access to these things and avoid these situations?”

Strategies to limit access

Strategies to limit access could include:

• temporary changes to medication access (eg removing the medication, asking someone else to manage the patient’s access to the medication)
• removing glass, knives and blades that might be used to cause harm
• having a support person remove or secure firearms and other weapons.

Strength-based reasons for living

Some commonly asked questions that ask for significant answers (such as “What’s the best thing about living?”) can feel invalidating or burdensome when someone is experiencing suicidal ideation. However, developing a list of things that bring them joy and meaning, or something to look forward to, can help to change their focus, so consider framing the question so they can think of concrete everyday examples.

To help the patient identify their strengths-based reasons for living, you could ask:

• “Who or what brings strength, meaning, or connection to your life?”
• “When you’ve felt even a little better in the past, what helped?”
• “What gives you hope or purpose, even when things feel heavy?”
• “Are there moments, people or experiences that have mattered to you?”
• “Is there anything you’d miss if you weren’t here?”
• “What reminds you of who you are and what keeps you strong?”

Actions the patient can do for themselves

Identify enjoyable activities (eg watching a favourite movie, listening to their favourite music, spending time on a hobby) and internal coping strategies (eg breathing and relaxation exercises, going for a walk, doing yoga or other exercise) that a patient can do without involving or contacting anyone else. They should be simple, realistic and achievable, and the list should not be overwhelming.

These activities and strategies can help to regulate the patient’s emotions, reduce distress, change the focus of their thinking, and distract them from suicidal ideation, potentially preventing a further escalation into crisis.

Connection and community networks

Just being around other people can help distract the patient from suicidal thoughts. This could be as simple as spending time with friends and family, spending time with mob, yarning with family or Elders, attending cultural activities or Men’s/Women’s groups. Socialising can also include activities that don’t require much talking or engagement (eg watching TV together) or going somewhere where there are other people (eg coffee shop, park, place of worship, meeting group).

You could also discuss with the patient whether there is anyone they would like to include to support with their safety planning. The family, friends and carers of your patient know them well and can offer valuable insights into safety planning. This may include being able to identify what has worked well before, answering questions your patient may be unable to, and offering valuable insights to improve the safety plan.

Inclusion of family, friends and carers in the development of a safety plan also means they understand the plan and can encourage adherence or support with key actions in the plan when the patient is outside of formal care settings.

To help the patient identify their connections and networks, you could ask:

• “Who helps you to feel good when you socialise with them?”
• “Where can you go and be around other people in a safe environment?”
• “Among your friends and family, who do you feel you could talk to when you’re having suicidal thoughts?”
• “Who do you feel you could contact to support you during a suicidal crisis?”

Professional supports and services

A safety plan needs to clearly outline:

• who the patient can contact
• when and how to do so
• what to do if their GP is unavailable.

To help the patient identify their professional supports and services, you could ask:

• “Which services could you turn to for support?”
• “What health professionals can you involve in your treatment plan?”

A safety plan can be written on paper, in the clinical record, or in secure digital tools such as websites or apps. When choosing the format, be guided by what will be the most accessible, acceptable and useful for this patient, particularly if they are distressed.

Although many people find apps and online tools convenient and easy to use, they are not suitable for everyone. Some people might prefer a handwritten plan, a brief summary documented in the clinical notes, or a verbal plan reinforced at each follow-up. What matters more than the actual format is that the plan feels personally meaningful, usable in moments of distress, and easy to revisit and revise.

Using digital tools

Digital tools, such as the BeyondNow suicide safety planning app, might be useful for patients who will appreciate easy, on-demand access to their plan via their phone or other device. Using these tools, patients can review their coping strategies, their support contacts and the steps to take when their distress increases. They can also share parts of their plan with trusted people or health professionals if they choose.

Make sure you:

• are familiar with commonly used tools so you can confidently explain the options, including their benefits and limitations
• remain flexible if it looks like a patient might prefer an alternative approach, including a non-digital plan.

When considering the use of these tools:

• assess whether a digital format is appropriate for this patient, based on their needs, preferences, literacy, access to technology, cultural safety and other individual considerations
• find out if your patient is comfortable using technology when they are distressed
• discuss privacy, data storage and confidentiality in clear, plain language
• clarify that apps are in addition to care, and do not replace professional and relational support
• emphasise that the plan belongs to the patient, and that sharing details of their plan is always their choice
• always offer non-digital alternatives.

Whether your patient is at immediate risk of harm or not, be assertive in initiating appropriate aftercare and follow-up to prevent gaps in their mental health care. For example, you could do one or more of these, as appropriate:

• schedule one or multiple follow-up appointments to:
  • review their situation and suicide risk
  • develop a Mental Health Treatment Plan (MHTP) or Social and Emotional Wellbeing (SEWB) plan
  • conduct some FPS sessions, if you are an eligible Focused Psychological Strategies (FPS) provider
• refer the patient to an appropriate service:
  • if you’ve already prepared an MHTP/SEWB, refer them to an allied health professional, as appropriate, and follow up with your patient to make sure they have arranged appointments
  • refer the patient to an e-mental health resource, and follow up with your patient to make sure they have arranged appointments
• schedule some activities (eg choosing a small task to complete, arranging a yarn with someone they know, or writing or journalling), for the patient to complete before you see them next, or before they have an appointment with an allied health practitioner
• provide them with some psychoeducation, explaining and normalising their mental health condition/issue
• if the patient has consented to include a family member, friend or carer in their safety plan, talk to them about scheduling appointments, adherence to safety planning, assisting with referrals or paperwork, and/or providing emotional support.
• be proactive:
  • send a follow-up text message to remind the patient about their next appointment with you, or to encourage them to make a follow-up appointment
  • suggest brief check-in appointments or phone calls
  • contact and coordinate with allied health providers and community supports.

A safety plan should be regularly reviewed to ensure its effectiveness, especially after changes in the patient’s circumstances or mental state. At a follow-up appointment, you should ask your patient:

• How often have you needed to use the safety plan?
• What was the most helpful part of the plan?
• Were there anything about it you found difficult or unhelpful?
• What could we change to make it more useful?

Consider modifying the action plan if there are new or changed circumstances, particularly if the patient’s risk of suicide is higher.

Always give your patient hope, because with the right treatment and support, most people will be able to manage their illness and live a normal life.