Ask Directly, Then Build the Plan

Daniel, 22 · admitted four days ago

Admitted with a severe depressive episode after his partner left. Sertraline was started on day one and increased two days ago. There is a shotgun at his father’s farm where he stays at weekends, and one previous attempt three years ago that nobody in the family talks about. You are sitting with him now. Tick only what you have actually established — and notice how few ticks it takes to change what you must do in the next ten minutes.

What the interview found

What is working in his favour

Build the safety plan with him

A safety plan is written with the person, in their words, and it is a sequence of things to do — not a promise to refrain. Choose one item for each step. Six of the twelve options are traps.

The picture right now

No score predicts suicide. This meter reflects acuity and what it obliges you to do next; it does not stratify a person into safe. Structured tools such as the Columbia protocol or the Ask Suicide-Screening Questions organise the interview and are widely mandated — they support it, they never replace it, and a low total never overrides your clinical judgement or the person’s own words.

The plan you built

Fill the six steps and check them. Each choice gets its reasoning — including the six that look caring and are not.

Ask it in plain words

Ideation“Are you having thoughts of killing yourself?”Not “you’re not thinking of doing anything silly, are you?” — which tells the person the correct answer, signals your discomfort and shuts the door.

Plan“What have you thought about doing?”Keep the same tone you used for the sleep question. A change of voice tells the person they have frightened you.

Means“Do you have access to that — a firearm, medication, a vehicle, a rope?”Ask about firearms explicitly and by name. This is the question most often skipped and the one that most changes what happens next.

Intent and timing“Have you decided when? How close have you come? What has stopped you so far?”“What has stopped you” finds the protective factors and the ambivalence in the same breath.

History“Have you ever tried before?”A previous attempt is the single strongest predictor of a future one, and it is frequently absent from the chart because nobody asked.

Protective“What keeps you here? Who would you call?”These answers become steps three and four of the safety plan, in his words rather than yours.

Language commits you to a stance. A person died by suicide or attempted suicide. Never “committed” — the phrase carries the residue of crime and sin, and the people who have lost someone hear it. Never grade an attempt as failed or successful, and never call one a gesture. Ambivalence is almost universal: the person in front of you usually wants the pain to stop rather than wanting to be dead, and it is that ambivalence you are working with.

De-escalation always comes before restraint

Stage	What you see	What you do
1 · Anxiety	Pacing, jiggling, shorter sentences, cannot settle to anything	Supportive. Notice it out loud, ask what would help right now, offer a real choice — a quiet room, a walk, food, a phone call, a PRN.
2 · Defensive	Rising volume, refusing to sit, testing the limit, challenging staff	Directive. Short sentences, low and slow voice, name what you observe, state the limit once, give two acceptable options. Only one person speaks.
3 · Risk of harm	Clenched fists or jaw, invading space, fixed staring, sudden silence after agitation	Safety. Two arm’s lengths, no cornering, keep your own exit clear, reduce people, noise and light, call for help early, offer medication before hands.
4 · Tension reduction	Exhaustion, tears, shame, sleep	Repair. Re-establish the relationship, debrief with the person and the team, and find the de-escalation opportunity that was missed.

What escalating too fast costs. Meeting stage-one restlessness with a directive limit, or stage-two loudness with hands, produces the incident you were trying to prevent — and a person who has been restrained on your unit remembers it for the whole admission and often for years. Honour every option you offer; a broken promise here is remembered longer than the restraint.

If restraint or seclusion becomes unavoidable. Emergency use only, for imminent risk of harm, after less restrictive measures have failed — never for punishment, staff convenience or short staffing. A licensed independent practitioner must order it and there is no PRN or standing order for behavioural restraint. Face-to-face evaluation within 1 hour. Time limits: 4 hours for adults 18 and over, 2 hours for ages 9 to 17, 1 hour under age 9, renewed only after re-evaluation. Monitor continuously with documented attention to circulation, skin, respiratory status, range of motion, hydration, nutrition and toileting. Release at the earliest safe moment, and debrief afterwards — restraint is a traumatic event, and the debrief is where the missed opportunity is found.