crisis-protocols.md

Crisis Protocols

Universal crisis response procedures that apply across suicide-screening, depression-screening (Item 9), and trauma-screening.

Immediate Response Protocols

When Crisis is Identified

1. Stay with the person - Do not leave them alone
2. Ensure immediate safety - Remove access to means of self-harm if possible
3. Activate emergency response if needed - Call 988, 911, or emergency services
4. Document thoroughly - Record all assessments, interventions, and decisions

Crisis Severity Levels

Level 1: Low Imminent Risk

• Passive ideation without plan or intent
• Good protective factors present
• Willing to engage in safety planning
• Response: Safety plan, close follow-up, refer for treatment

Level 2: Moderate Risk

• Active ideation with some plan but low intent
• Mixed protective factors
• Ambivalent about safety
• Response: Consider higher level of care, same-day mental health evaluation, safety plan, remove means

Level 3: High Imminent Risk

• Active ideation with plan and intent
• Access to means
• Poor protective factors
• Recent attempt or aborted attempt
• Response: Immediate emergency evaluation, do not leave alone, call 988/911, likely hospitalization

Level 4: Acute Emergency

• Attempt in progress or just occurred
• Severe self-harm
• Psychotic features with command hallucinations
• Response: Call 911 immediately, provide first aid, do not leave alone

Safety Assessment Procedures

Core Assessment Questions

1. Ideation: Are you thinking about hurting yourself or ending your life?
2. Plan: Do you have a plan for how you would do it?
3. Intent: Do you intend to carry out this plan?
4. Means: Do you have access to [method mentioned]?
5. Timing: When are you thinking about doing this?
6. Previous attempts: Have you tried to hurt yourself or end your life before?
7. Protective factors: What keeps you from acting on these thoughts?

Risk Factors to Assess

Immediate Risk Factors:

• Current suicidal ideation with plan and intent
• Recent suicide attempt or self-harm
• Access to lethal means
• Acute intoxication
• Severe hopelessness or agitation
• Command hallucinations to harm self

Elevated Risk Factors:

• History of suicide attempts
• Mental health diagnosis (depression, bipolar, psychosis, PTSD)
• Substance use disorder
• Recent significant loss or trauma
• Social isolation
• Chronic pain or serious medical illness
• History of abuse or trauma

Protective Factors:

• Strong therapeutic relationship
• Reasons for living
• Responsibility to others (children, pets)
• Religious or cultural beliefs
• Positive coping skills
• Access to support
• Future-oriented plans

Documentation Requirements

Crisis Contact Documentation Template

**Crisis Assessment - [Date/Time]**

**Presenting Concern:** [Brief description of crisis]

**Safety Assessment:**
- Suicidal ideation: [Yes/No - describe]
- Plan: [Yes/No - describe]
- Intent: [Yes/No - describe]
- Means access: [Yes/No - describe]
- Homicidal ideation: [Yes/No - describe]

**Risk Factors Present:**
- [List all applicable risk factors]

**Protective Factors Present:**
- [List all protective factors]

**Risk Level:** [Low/Moderate/High/Acute Emergency]

**Interventions Implemented:**
- [List all actions taken]
- Emergency services contacted: [Yes/No - when/who]
- Means restriction: [What was done]
- Safety plan developed: [Yes/No]
- Consultation: [With whom]

**Disposition:**
- [Released with safety plan / Referred to emergency dept / Hospitalized / Other]
- Follow-up plan: [Specific details]

**Clinician:** [Name/Credentials]
**Supervisor Consulted:** [Name/Time - if applicable]

Required Documentation Elements

1. Verbatim statements - Document exact words used by person in crisis
2. Clinical reasoning - Explain basis for risk determination
3. Consultation - Document any supervisor or peer consultation
4. Notification - Document family/emergency contacts notified (with consent or as permitted)
5. Follow-up plan - Specific, concrete next steps with timeframes

Crisis Resources

National Crisis Lines

988 Suicide & Crisis Lifeline

• Phone: 988 (call or text)
• Website: 988lifeline.org
• Available 24/7, free, confidential
• Spanish: Press 2
• TTY: Use preferred relay service or dial 711 then 988

Crisis Text Line

• Text HOME to 741741
• Available 24/7, free, confidential
• Website: crisistextline.org

Veterans Crisis Line

• Phone: 988, then press 1
• Text: 838255
• Chat: veteranscrisisline.net
• Available 24/7 for veterans, service members, National Guard, Reserve, and families

Trevor Project (LGBTQ+ Youth)

• Phone: 1-866-488-7386
• Text START to 678678
• Chat: thetrevorproject.org
• Available 24/7 for LGBTQ+ young people

Emergency Services

911

• Use for immediate medical or safety emergencies
• Suicide attempt in progress
• Severe self-harm
• Immediate danger to self or others

Emergency Department

• For urgent mental health crises
• When safety cannot be ensured in outpatient setting
• When involuntary hospitalization may be needed

Mobile Crisis Teams

• Many areas have mobile crisis response
• Can assess in community settings
• Alternative to police response in some areas

Escalation Pathways

Decision Tree for Crisis Response

Crisis Identified
    ↓
Is person in immediate danger?
    ↓ YES → Call 911, stay with person, ensure safety
    ↓ NO
    ↓
Can safety be ensured in current setting?
    ↓ YES → Develop safety plan, arrange close follow-up
    ↓ NO
    ↓
Is person willing to go to emergency evaluation?
    ↓ YES → Arrange transport, contact emergency dept
    ↓ NO
    ↓
Does situation meet criteria for involuntary evaluation?
    ↓ YES → Contact crisis team/police for evaluation
    ↓ NO → Continue safety planning, increase monitoring

Consultation Requirements

ALWAYS consult with supervisor/senior clinician when:

• High or acute risk level identified
• Considering emergency department referral
• Involuntary commitment being considered
• Unsure about risk level
• Complex case with multiple risk factors
• Your own emotional response interferes with judgment

Document all consultations including:

• Who was consulted
• When consultation occurred
• Recommendations received
• Decisions made

Safety Planning

Elements of a Safety Plan

A safety plan should include:

1. Warning signs - Personal signs that crisis may be developing
2. Internal coping strategies - Things person can do without contacting others
3. Social contacts and settings - People and places that provide distraction
4. People who can help - Family, friends who can be contacted for support
5. Professionals to contact - Therapist, crisis line, emergency services with specific numbers
6. Means restriction - Specific steps to limit access to lethal means

Safety Plan Template

Available in suicide-screening skill: skills/suicide-screening/references/safety-planning.md

Means Restriction

Firearms:

• Remove from home if possible
• Store at gun range, with family member, or law enforcement
• If must remain in home: locked safe, ammunition separate, someone else controls key/combination

Medications:

• Remove excess or dangerous medications
• Give to family member or pharmacy
• Blister packs or pill organizers (someone else controls)
• Weekly pickup from pharmacy

Other means:

• Remove ropes, belts, sharp objects if specific plan identified
• Lock up household chemicals
• Car keys removed if carbon monoxide plan

Special Populations

Children and Adolescents

• Involve parents/guardians unless safety concerns
• School notification may be required
• Age-appropriate language for safety planning
• Increased supervision requirements

Older Adults

• Assess medical comorbidity
• Evaluate capacity for safety planning
• Consider caregiver involvement
• Higher lethality of attempts

Individuals with Psychosis

• Assess for command hallucinations
• May require immediate hospitalization
• Antipsychotic medication may be urgent
• Reality testing may be impaired

Substance Use

• Assess current intoxication level
• Increased impulsivity when intoxicated
• May need detox before full assessment possible
• Substance removal is means restriction

Legal and Ethical Considerations

Duty to Protect

Clinicians have a duty to protect individuals from self-harm, which may include:

• Warning family members (with or without consent in emergency)
• Involuntary emergency evaluation
• Hospitalization
• Breaking confidentiality when necessary to protect life

Documentation and Liability

• Document thoroughly and contemporaneously
• Record clinical reasoning for all decisions
• Consult when uncertain
• Follow organizational policies
• Know your state's involuntary commitment laws

Confidentiality Limits

Crisis situations may require breaking confidentiality:

• Inform person of confidentiality limits at outset
• Break confidentiality only to extent necessary
• Document reason for disclosure
• Inform person of disclosure when safe to do so

Self-Care for Clinicians

After Crisis Response

• Debrief with supervisor or peer
• Process your own emotional reactions
• Recognize secondary trauma
• Take breaks when possible
• Use consultation and support

Recognize Your Limits

• Not all crises can be prevented
• You cannot control another person's choices
• Seek supervision when feeling overwhelmed
• Professional support is essential for this work

References

• 988 Suicide & Crisis Lifeline: 988lifeline.org
• Suicide Prevention Resource Center: sprc.org
• American Association of Suicidology: suicidology.org
• Zero Suicide Framework: zerosuicide.edc.org

Related Documents

• skills/suicide-screening/references/risk-assessment-protocol.md - Detailed suicide risk assessment
• skills/suicide-screening/references/safety-planning.md - Complete safety planning procedures
• skills/depression-screening/references/item-9-safety-protocol.md - PHQ-9 Item 9 specific guidance