Key terms on this page (6)
- Suicidal ideation
- Thoughts of suicide, from a passive wish to be dead to active thoughts with a method, intent or plan.
- C-SSRS
- The Columbia Suicide Severity Rating Scale, a free structured interview and screener for suicidal thoughts and behavior.
- Safety plan
- A written, prioritized list of steps and contacts a client can use in a crisis, made collaboratively.
- Lethal means safety
- Reducing access to firearms, medications and other means during a period of risk, done with the client.
- Mobile crisis team
- Trained behavioral health staff who come to the person in crisis, often dispatched through 988 or a county line.
- Involuntary hold
- A short, state-authorized detention for psychiatric evaluation when someone is a danger to self or others. Rules vary by state.
Asking the question
The hardest part for most new clinicians is the first sentence. Euphemisms (“You’re not thinking of doing anything silly, are you?”) invite a no. Ask in plain words, in a calm voice, and then wait:
“Sometimes when people feel as low as you’re describing, they think about killing themselves. Have you been having thoughts like that?”
If the answer is yes, your job is not to talk them out of it in that moment. It is to understand: what the thoughts are like, how often they come, whether there is a method, intent or plan, what they have done before, and what has kept them alive so far. Thank them for telling you.
Assessing risk with a structured tool
A structured tool keeps you from skipping questions when you are anxious. One of the most widely used is the Columbia Suicide Severity Rating Scale (C-SSRS), which is free and comes in a short screener and longer versions. In plain language, the screener moves from a wish to be dead, to active thoughts, to thinking about a method, to intent, to a plan, and then asks about any suicidal behavior. Each yes tells you to ask more.
A full risk assessment also weighs:
- Risk factors
- Longer term
A previous attempt, a mental health or substance use condition, chronic pain or illness, access to firearms, family history of suicide, isolation.
- Warning signs
- Right now
Talking about wanting to die or being a burden, looking for means, withdrawing, giving things away, sudden calm after deep distress, increased drinking or drug use.
- Protective factors
- What holds
Reasons for living, people they love, responsibility for children or pets, faith or values, engagement with care, hope that things can change.
Then you and your supervisor form a judgment, not a score: how serious is the risk right now, what is driving it, and what would lower it. That judgment decides the response.
Level 1: Thoughts, no plan or intent
- What you might hear
- Passive wishes to be dead or fleeting thoughts, no plan, no intent, strong reasons for living.
- Typical response
- Safety plan, means counseling, more frequent sessions, supervisor informed, documented.
Level 2: Thoughts with some planning
- What you might hear
- A method in mind, some intent, or recent warning signs, but able to agree to a plan.
- Typical response
- All of the above, plus same-day supervisor consultation, firm lethal means steps, closer follow-up, and possibly a mobile crisis team or a higher level of care.
Level 3: Intent and a plan, or recent behavior
- What you might hear
- Clear intent, a plan, access to means, or a recent attempt or preparatory act.
- Typical response
- Don’t leave the client alone. Supervisor now. Arrange an emergency evaluation: mobile crisis or the emergency room, with family support if safe.
Level 4: Immediate danger
- What you might hear
- An attempt in progress, a weapon present, or the client leaving to act.
- Typical response
- Call 911. Stay on the line, stay with the client if it’s safe, then inform your supervisor.
Building a safety plan together
The Stanley-Brown Safety Planning Intervention is a widely used model. You build it with the client, in their words, during the session, so that it is theirs and they can use it at 2 a.m. without you. It is not a promise and not a contract. It is a list of steps that get more active as the crisis grows.
Safety plan · invented example for “J.”
Step 1: Warning signs
What thoughts, feelings, situations or behaviors tell you a crisis may be starting?
Lying awake past 2 a.m.; thinking “everyone would be better off”; skipping dinner.
Step 2: Internal coping strategies
Things you can do on your own to take your mind off the problem.
Walk the dog around the block; cold water on my face; the breathing app.
Step 3: People and places that distract
People and social settings that help you feel better, without talking about the crisis.
The coffee shop on 5th; texting my cousin about football; the climbing gym.
Step 4: People I can ask for help
Family or friends you can tell that you are struggling.
My sister (number); my friend from work (number).
Step 5: Professionals and crisis lines
Who to call when the steps above aren’t enough.
My therapist’s clinic (number, hours); 988 by call or text; the nearest emergency room (address).
Step 6: Making the environment safer
Steps to reduce access to lethal means.
My brother keeps the gun at his place for now; pharmacy blister packs, one week at a time.
Step 7: Reasons for living (optional)
What matters most to you and is worth living for?
My daughter’s soccer games. Seeing the ocean again.
Spend real time on step 6. Putting time and distance between a person and lethal means, especially firearms, is one of the most effective things you can do. Ask directly whether there are guns in the home, and work out with the client who could store them temporarily and where. Ask about stockpiled medications too.
988, mobile crisis and the emergency room
988 is the national Suicide and Crisis Lifeline. Since July 2022, anyone in the United States can call or text 988, or chat at 988lifeline.org, and reach a trained crisis counselor. Veterans can press 1 to reach the Veterans Crisis Line. Put 988 in every safety plan, and know how it connects in your area.
SAMHSA describes a full crisis system as someone to contact (988 and crisis lines), someone to respond (mobile crisis teams that come to the person) and a safe place to be (crisis stabilization units and receiving centers, not only emergency rooms). What exists near you varies a lot by county. Your practicum site will know; ask in your first week.
Call 911 when there is immediate danger to life. If you do, tell the dispatcher it is a mental health crisis, and ask whether a crisis-trained officer or team is available.
Involuntary holds vary by state
Every state allows a short involuntary hold for psychiatric evaluation when a person is a danger to themselves or others, and some add a person who can’t care for their basic needs because of a mental illness. The state decides who can start a hold, the criteria, how long it lasts and what rights the person has. In many states only police, physicians or specially designated professionals can initiate one, so as a trainee you will almost certainly not be the person who does.
Most clients at risk don’t need a hold. Voluntary options, a safety plan with close follow-up, or a voluntary emergency evaluation keep more of the client’s dignity and trust, and should be considered first whenever they are safe.
Your first crisis as a trainee
No program expects a student to manage a suicidal crisis alone, and no good supervisor wants you to try. The single most important step is the phone call. Here is the order most trainees work in. Check the steps off as you read them, or use it to rehearse with a classmate.
Your first crisis, step by step
0 of 10 checked
Nothing here is saved or sent. Your site’s written protocol comes first.
Writing it down
If it isn’t documented, from a legal point of view it didn’t happen. A risk note shows what you asked, what you learned, how you reasoned and what you did. Here is an invented example in DAP format (more on note formats in documentation and notes):
Sample risk note · invented, de-identified
- Data
- Client (J., 34) reported increased hopelessness since job loss two weeks ago. When asked directly, endorsed thoughts of suicide “most nights” for one week, with thoughts of overdosing on stored medication. Denied intent to act and denied a specific plan or timeline. No past attempts. C-SSRS screener: yes to items 1–3, no to 4–6. Lives with partner; identified daughter as main reason for living. No firearms in the home (confirmed with client).
- Assessment
- Active ideation with method, without intent or plan, in the context of acute stressor and depressive symptoms. Protective factors: daughter, partner, engagement in treatment, future orientation. Risk judged moderate; does not currently meet criteria for emergency evaluation. Consulted with supervisor (Dr. R.) by phone during session; supervisor agreed with plan.
- Plan
- Completed Stanley-Brown safety plan with client; client has a copy on phone. Client agreed for partner to hold stored medications, pharmacy to dispense weekly; client to call the clinic by end of day to confirm. Reviewed 988 and emergency room. Increased sessions to twice weekly; next session in two days. Will repeat C-SSRS screener at next session.
Myths worth dropping
Myth
“Asking about suicide gives people the idea.”
Actually
It doesn’t. Asking directly is protective and often a relief to the client.
Myth
“A no-suicide contract protects the client and me.”
Actually
It doesn’t replace assessment, and it isn’t recommended. A collaborative safety plan does far more.
Myth
“People who talk about it won’t do it.”
Actually
Many people who die by suicide told someone first. Every disclosure deserves a full assessment.
Next · Step 15
Documentation and notes
How to write progress notes in SOAP, DAP and BIRP, build a treatment plan, show medical necessity, and keep records that hold up years later.
Questions people ask
Does asking about suicide put the idea in someone’s head?
No. Research has repeatedly found that asking directly about suicide does not increase suicidal thinking, and it often brings relief. Ask plainly: “Are you thinking about killing yourself?”
What is the C-SSRS?
The Columbia Suicide Severity Rating Scale, a free, structured set of plain-language questions developed at Columbia University. Its short screener asks about wishes to be dead, suicidal thoughts, method, intent, plan and recent suicidal behavior, and many clinics, hospitals and schools use it so that everyone asks the same questions.
What is a safety plan, and is it the same as a no-suicide contract?
No. A safety plan, such as the Stanley-Brown Safety Plan, is a written, step-by-step list the client makes with you: their warning signs, coping strategies, people and places that help, who to call, how to make their surroundings safer, and reasons for living. A no-suicide contract only asks the client to promise not to act, and is not recommended as a substitute for assessment and planning.
When should I call 988 or 911?
A client, or anyone, can call or text 988 or chat at 988lifeline.org for crisis support at any time. Many areas connect 988 to mobile crisis teams. Call 911 when there is immediate danger to life, such as an attempt in progress or a weapon present.
Can a therapist put a client on an involuntary hold?
It depends on the state and the role. Involuntary holds are set by state law, which decides who can start one, the criteria and how long it lasts. In many states only police, physicians or specially designated professionals can initiate a hold. In California, for example, a 5150 hold allows up to 72 hours of evaluation and treatment. Trainees almost never initiate holds; they call their supervisor.
Sources
Checked 28 October 2026. Crisis services and hold laws differ by state and county; your site’s protocol and your supervisor come first. This page is education, not clinical or legal advice.
- 988 Suicide and Crisis Lifeline — Call or text 988, or chat online, 24 hours a day; Spanish text and chat; administered with SAMHSA.
- SAMHSA, 988 Suicide and Crisis Lifeline — The federal program behind 988, launched 16 July 2022.
- Veterans Crisis Line (VA) — Veterans and their families dial 988 then press 1, or text 838255.
- SAMHSA, National behavioral health crisis care guidance (2025) — Someone to contact, someone to respond, a safe place to be; mobile crisis and stabilization services.
- Dazzi, Gribble, Wessely and Fear, Does asking about suicide and related behaviours induce suicidal ideation? (Psychological Medicine, 2014) — Systematic review: asking about suicide did not increase suicidal ideation.
- The Columbia Lighthouse Project, C-SSRS — The Columbia Suicide Severity Rating Scale, free screener and full versions, with training.
- Stanley and Brown, Safety Planning Intervention — The steps of the Stanley-Brown Safety Plan and the official template.
- California Welfare and Institutions Code section 5150 — California’s 72-hour hold for evaluation and treatment; who may initiate it.
- ACA, AAMFT, NASW and APA ethics codes — Duties to protect clients at risk and to practice within competence, which is why trainees consult.