Lesson · Clinical practice

Crisis, Suicide Assessment and Treatment Planning

What should a counselor do first? This lesson teaches the order of clinical priorities: recognizing a crisis, asking directly about suicide, building a safety plan, completing an intake and writing a treatment plan with measurable goals, evidence-based interventions and progress measures.

Safety firstSafety plan builderRisk and protective factorsSMART goalsLesson plan20-question check

Content note: this lesson discusses suicide. If you or someone you know is struggling, call or text 988 (U.S. Suicide and Crisis Lifeline) or go to the nearest emergency room. Outside the U.S., contact your local emergency number.

Start here

What is a crisis?

A crisis is a person's response to an event that overwhelms their usual coping. The event may be a loss, violence, a disaster or a sudden change; what makes it a crisis is how the person perceives and copes with it. Crisis counseling is short-term, active and focused on safety and stabilization.

Step 1–2

Assess and connect

Assess safety and lethality first. Build rapport quickly with calm, clear, nonjudgmental communication.

Step 3–4

Define the problem and feelings

Identify the main problem and the event that triggered the crisis. Listen actively and validate emotions.

Step 5–6

Explore options and plan

Explore coping strategies and supports the person has used before. Make a concrete, short-term plan together.

Step 7

Follow up

Arrange follow-up contact and referrals. Roberts' seven-stage model summarizes these steps.

Ask directly

Suicide risk assessment

Asking about suicide does not plant the idea; it opens the door to help. Ask clearly: "Are you thinking about killing yourself?" Then explore the pieces below. No single factor predicts suicide well, so counselors assess the whole picture and focus on what can change today.

What to ask about

Ideation: frequency, intensity, duration
Plan: method, time, place
Intent: how much the person intends to act
Means: access to firearms, medications or other methods
History: past attempts, self-harm, family history
Current state: hopelessness, agitation, substance use, insomnia
Protective factors: reasons for living, connections, faith, children, future plans

Tools and actions

Screen with a validated tool such as the Columbia Suicide Severity Rating Scale (C-SSRS) or the Ask Suicide-Screening Questions (ASQ).
Follow up any positive PHQ-9 item 9.
Build a safety plan and counsel on lethal means safety.
For imminent risk, do not leave the person alone; follow emergency procedures and state law.
Document what you asked, what you learned and what you did.
Avoid "no-suicide contracts"; research supports crisis response and safety planning instead.

Practice

Risk factor, warning sign or protective factor?

Risk factors raise long-term risk. Warning signs suggest risk right now. Protective factors buffer risk. Sort each item.

Build it together

Safety plan builder

The Stanley-Brown Safety Planning Intervention is a short, written plan the client and counselor create together. It is supported by research and is used in emergency departments, clinics and schools. Practice here with the example or a fictional client.

Getting the whole picture

The intake interview

Presenting problem

Why now? Onset, duration, severity and what the client has tried. Use the client's own words.

History

Mental health, medical, substance use, trauma, family, education, work, legal and developmental history.

Mental status exam

Appearance, behavior, speech, mood and affect, thought process and content, perception, cognition, insight and judgment.

Culture and context

Use the DSM-5-TR Cultural Formulation Interview: how the client defines the problem, its causes, supports and preferred help.

Diagnosis builds on intake. See the DSM-5-TR Guide for how clinicians reach a diagnosis.

From assessment to action

Writing a treatment plan

A treatment plan turns assessment into a shared map. It lists problems in the client's words, long-term goals, measurable short-term objectives, the interventions the counselor will use, how progress will be measured and when the plan will be reviewed.

SMART objectives

Specific: what exactly will change?
Measurable: how will we know?
Achievable: realistic for this client now
Relevant: tied to the client's goals and culture
Time-bound: by when?

Not SMART: "Feel less depressed." SMART: "Reduce PHQ-9 from 18 to below 10 within 12 weeks, and walk 20 minutes three days a week."

Match evidence to the problem

Depression: CBT, behavioral activation, interpersonal therapy
PTSD: prolonged exposure, cognitive processing therapy, EMDR
OCD: exposure and response prevention
Panic and phobias: exposure-based CBT
Substance use: motivational interviewing, CBT, medications for opioid or alcohol use disorder
Bipolar disorder and psychosis: medication plus psychoeducation, family work and coordinated care

Measurement-based care

Repeat brief measures (PHQ-9, GAD-7, PCL-5) every few sessions.
Review scores with the client and adjust the plan if progress stalls.
Measurement-based care improves outcomes and catches clients who are getting worse.

Clinical judgment

What comes first?

Licensure exams often list several good actions. Choose the one that addresses the highest risk first.

Watch and read

Videos and recent research

Videos and peer-reviewed articles published in 2016 or later. Links need an internet connection.

Videos

The bridge between suicide and lifeKevin Briggs · TED2014

A retired patrol officer on listening, asking directly and staying present with people in crisis.

Why we all need to practice emotional first aidGuy Winch · TEDxLinnaeusUniversity · 2014

Caring for psychological injuries such as loneliness and rejection before they become crises.

Peer-reviewed articles

Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the Safety Planning Intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894–900.Safety planning with follow-up calls cut suicidal behavior by about half.https://doi.org/10.1001/jamapsychiatry.2018.1776
Nuij, C., van Ballegooijen, W., de Beurs, D., Juniar, D., Erlangsen, A., Portzky, G., O'Connor, R. C., Smit, J. H., Kerkhof, A., & Riper, H. (2021). Safety planning-type interventions for suicide prevention: Meta-analysis. The British Journal of Psychiatry, 219(2), 419–426.Safety planning-type interventions reduce suicidal behavior.https://doi.org/10.1192/bjp.2021.50
Bryan, C. J., Mintz, J., Clemans, T. A., Leeson, B., Burch, T. S., Williams, S. R., Maney, E., & Rudd, M. D. (2017). Effect of crisis response planning vs. contracts for safety on suicide risk in U.S. Army soldiers: A randomized clinical trial. Journal of Affective Disorders, 212, 64–72.Crisis response planning outperformed no-suicide contracts.https://doi.org/10.1016/j.jad.2017.01.028
Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., Musacchio, K. M., Jaroszewski, A. C., Chang, B. P., & Nock, M. K. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 143(2), 187–232.Single risk factors predict suicide only weakly, so assessment must look at the whole person and focus on safety.https://doi.org/10.1037/bul0000084
Lewis, C. C., Boyd, M., Puspitasari, A., Navarro, E., Howard, J., Kassab, H., Hoffman, M., Scott, K., Lyon, A., Douglas, S., Simon, G., & Kroenke, K. (2019). Implementing measurement-based care in behavioral health: A review. JAMA Psychiatry, 76(3), 324–335.Routine outcome measurement improves care when it is used to adjust treatment.https://doi.org/10.1001/jamapsychiatry.2018.3329

For instructors

Lesson plan preview: Safety first, then the plan

A ready-to-teach lesson with a suicide-assessment role-play, safety planning practice and a treatment plan workshop.

Quick check

Test your understanding

Twenty questions. More practice in Counselor Exam Prep.

Sources

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
Bryan, C. J., Mintz, J., Clemans, T. A., Leeson, B., Burch, T. S., Williams, S. R., Maney, E., & Rudd, M. D. (2017). Effect of crisis response planning vs. contracts for safety on suicide risk in U.S. Army soldiers. Journal of Affective Disorders, 212, 64–72.
Franklin, J. C., et al. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 143(2), 187–232.
Lewis, C. C., et al. (2019). Implementing measurement-based care in behavioral health: A review. JAMA Psychiatry, 76(3), 324–335.
Nuij, C., et al. (2021). Safety planning-type interventions for suicide prevention: Meta-analysis. The British Journal of Psychiatry, 219(2), 419–426.
Posner, K., Brown, G. K., Stanley, B., et al. (2011). The Columbia–Suicide Severity Rating Scale. American Journal of Psychiatry, 168(12), 1266–1277.
Roberts, A. R. (2005). Crisis intervention handbook: Assessment, treatment, and research (3rd ed.). Oxford University Press.
Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264.
Stanley, B., et al. (2018). Comparison of the Safety Planning Intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894–900.

For education and training. Follow your agency's crisis procedures, your state's laws and clinical supervision. In a crisis in the U.S., call or text 988.