05 Crisis Care and Safety

Recognize a crisis

A behavioral health crisis occurs when distress, behavior, or immediate circumstances overwhelm a person’s usual ability to cope. It may involve suicidal thoughts, self-harm, severe agitation, psychosis, intoxication, trauma, or an acute medical problem.

The immediate priorities are to protect life, reduce danger, listen without judgment, and connect the person with appropriate care. Do not assume that unusual or agitated behavior is purely psychiatric: new confusion, injury, intoxication, or illness may require urgent medical assessment.

Assess immediate safety

Begin by checking for immediate danger to the person or others, serious injury, overdose, or a medical emergency. If danger is imminent or urgent medical care is needed, contact emergency services—911 in the United States—and follow local procedures. If it is safe, stay with the person until help arrives; do not put yourself or others in danger.

Use a calm, direct, respectful approach. Introduce yourself, explain what you can do, and ask what the person needs right now. Listen more than you speak. Brief questions can clarify the situation, such as “What happened?” and “What would help you feel safer right now?” Ask directly about immediate safety, including thoughts of suicide or harming someone else when indicated. Do not promise secrecy; explain that you may need to involve others to help keep people safe.

Assess suicide risk

For a clinical suicide assessment, SAFE-T organizes the work into five steps:

1. Identify risk factors.

2. Identify protective factors.

3. Ask directly about suicidal thoughts, plans, behavior, and intent.

4. Determine risk and intervention using clinical judgment.

5. Document the assessment and plan.

Ask about prior attempts or self-injury, recent stressors, substance use, access to lethal means, and available supports. Protective factors matter, but they do not automatically cancel acute risk. Reassess if the person’s condition or circumstances change; a checklist or risk category cannot predict an individual’s behavior with certainty.

De-escalate safely

Agitation can have many causes and does not by itself prove that someone intends violence. When the setting is safe, use the least coercive approach that can meet the person’s needs.

• Keep your voice low and your words brief; allow time for the person to respond.

• Have one person speak while others reduce noise, give space, and move bystanders away.

• Respect personal space and keep a clear path to the exit. Avoid sudden movements, crowding, arguing, threats, or touching without permission.

• Acknowledge feelings without endorsing unsafe actions. For example: “I can see this feels frightening. I’m here to help us find a safe next step.”

• Offer simple, realistic choices and explain what will happen next.

• Set clear, respectful limits on unsafe behavior. If danger escalates, withdraw to safety and summon trained help.

In healthcare settings, assessing possible medical causes and de-escalating may need to happen at the same time. Physical restraint or seclusion is not a substitute for listening or assessment. Use them only when permitted by law and policy, by trained staff, and when necessary to address immediate danger.

Respond to self-harm

If someone has self-harmed, assess injuries and arrange medical care as needed. Ask whether the self-harm was intended to cause death; do not assume either that it was or that it was not a suicide attempt.

If the person may act soon, has begun an attempt, or cannot remain safe, stay with them if it is safe to do so. Reduce access to dangerous items only when this can be done safely, and obtain emergency help. In the United States, call or text 988 for crisis support; call 911 for immediate danger or an urgent medical emergency.

Create a collaborative safety plan

A safety plan is a practical, personalized set of steps to use when distress or suicidal thoughts increase. Develop it collaboratively in clear language, including specific names, places, and contact details where possible. A common plan has six parts:

1. Warning signs: Thoughts, feelings, situations, or behaviors that signal a crisis may be building.

2. Internal coping strategies: Safe activities the person can try on their own.

3. Social distractions: People or places that offer connection or a break from distress.

4. People to ask for help: Trusted individuals the person can contact directly.

5. Professional and crisis support: Clinicians, urgent care or emergency services, and crisis lines such as 988 in the United States.

6. Making the environment safer: Collaborative steps to create distance from items or circumstances that could be used for harm, with help from a trusted person when appropriate.

Review how and when to use the plan, discuss obstacles, and arrange follow-up or a warm handoff to care. A safety plan is not a promise or contract to avoid self-harm, and it does not replace emergency care when danger is immediate.

• De-escalation