Outpatient Therapy: Creating Practical Safety Plans
Safety planning in outpatient therapy requires concrete, actionable strategies that clients can use during moments of crisis. This article presents twelve evidence-based techniques for building effective safety plans, drawing on insights from mental health professionals who specialize in suicide prevention and crisis intervention. Each strategy offers practical steps that therapists can teach and clients can implement when they need support most.
Partner and Message a Trusted Ally
A safety plan is only as effective as the client's willingness to use it. That's why co-creation—not prescription—is essential.
Principles of Effective Co-Creation
Collaborative Language I ask, "What has helped you stay safe before?" Their lived experience holds wisdom no textbook provides.
Keep It Simple Overly complex plans get ignored during crisis. I aim for 4-5 concrete, accessible steps.
Make It Visible I encourage clients to photograph it or save it on their phone—a plan buried in a drawer won't help at 2 AM.
Rehearse It Together We walk through the plan in session. Practice builds muscle memory.
One Element I Always Include: "One Person, One Text"
The element I never omit is identifying one trusted person the client can contact with one pre-written text message.
Why this works:
Reduces Barriers During crisis, composing a message feels overwhelming. A pre-drafted text like "I'm struggling tonight. Can you talk?" removes cognitive load.
Combats Isolation Knowing someone specific is "on call" fights the loneliness that fuels suicidal ideation.
Creates Accountability Clients often say, "I didn't want to let them down"—that connection becomes protective.
Clinical Takeaway
Safety plans work when they're personalized, practiced, and portable. The "one person, one text" element bridges crisis and connection—often making the difference between isolation and intervention.
Write Your Own After-Drink Truth
I've sat with clients who were fine in session and then texted me at 10pm in crisis - so this question hits close to home. The gap between sessions is where relapse most often lives, and a safety plan only works if the person actually reaches for it in that moment.
The one element I always include is what I call "thinking the drink through" - written out in their own words, in advance. Not my words. Theirs. What happens after that first drink? Where does it take them specifically? Their relationship, their kids, their job. When it's in their handwriting and it's visceral and personal, it's harder to dismiss at 11pm when the urge hits hard.
I had a client who kept relapsing in the hours after work - that was her window. We mapped it exactly and replaced it with a gym session straight from the office, so she never walked through her front door during her danger zone. That one routine change, written into her plan, broke the pattern.
The co-creation part is non-negotiable. If I hand someone a plan, they'll leave it in the car. If they built it, they own it. I ask: what has worked for even five minutes before? We start there.
Designate a Housing Anchor Space
With over 30 years in social services and leading LifeSTEPS across 36,000 affordable homes--where we've sustained 98.3% housing retention for vulnerable residents like those with mental health challenges--I've co-created countless safety plans tailored to real-life housing risks.
We start between-session planning by having clients list their top two risk triggers tied to daily routines, like isolation in seniors aging in place, then match them to on-site resources they control.
One element I always include: A "housing anchor" step--designating a specific communal space in their building as a safe retreat, pre-approved by management. This works because it's instantly accessible without leaving home.
In one case with formerly homeless individuals, this anchor space facilitated peer check-ins that de-escalated nighttime anxiety, keeping them stably housed.
Add Scheduled Exercise to Regain Control
As a clinical psychologist and Board-approved supervisor with experience in acute psychiatry at Monash Health, I've spent years helping clients navigate complex trauma and high-risk emotional crises. My background in psychological resilience research helps me co-create safety plans that are grounded in evidence-based practice and clinical oversight.
I prioritize "Control" by helping clients set actionable, short-term goals that provide immediate agency when they feel powerless between sessions. We use "Structure" as the glue for these plans, implementing specific timetabling to create a predictable routine that stabilizes the client during periods of instability.
One element I always include is "Movement," specifically 30 minutes of moderate-intensity exercise. Since high-risk states often involve a manifest "slowing down" of the mind and body, physical exertion is a proven tool to mitigate symptoms and provide a necessary circuit breaker for the nervous system.
Recall Personal Reasons to Stay Alive
My approach is to collaborate with the client to convert the safety plan from a standard clinical form of documentation into an individualized guide to surviving. Together, we will create a detailed plan based on each client's individual triggers and what an actual crisis looks like for them. The safety plan should be grounded in the client's real life environment and is also a reflection of available resources. Finally, the plan must be accessible, and therefore it will include a decision about where the safety plan will be kept, such as a physical copy in a bedside table or a digital copy on a cell phone.
An additional piece I incorporate into the safety plan is a list of "Reasons for Living" or an "Anchor List," which are connections to the present and future. This list is helpful when there is an immediate, intense emotional crisis and the cognitive portion of the brain is difficult to access because the client is in a fight-or-flight response. Having a specific list of reasons to live that the client can refer to in that moment will provide them with a transitional tool that allows them to reconnect with their reason for being before things spiral out of control.
Build a Tiered Support Contact List
In order for a safety plan to be usable when there is an increased risk between sessions, I ensure that it is concrete, simple, and individualized. We create the safety plan together through a process of collaborating during a time of calmness and practicing the steps, so that moving from recognizing a crisis to taking action feels automatic rather than an agonizing decision. I describe the plan as a "support bridge" as opposed to a "contract for safety," which helps limit the feelings of shame around reaching out for support. This distinction in language enhances a partnership mentality, where the safety plan is viewed as a tool for their health and wellbeing rather than a document merely for the purpose of satisfying a professional.
One of the components I always include in the safety plan is a detailed contact list that includes both professional crisis lines and trusted personal contacts. These supporting contacts enable the client to significantly reduce the effort required to identify who to call when they are feeling overwhelmed. When someone is in crisis, it can be difficult to make decisions, and having a pre-verified list of names and numbers reduces the period of isolation the client experiences. Using a tiered approach ensures that if one person is not available, the client has a pre-determined backup support ready, reducing the feeling of being completely alone at a time of crisis.
Restrict Means to Create Protective Delay
When clinical risk increases, safety planning continues to be a structured approach for addressing the comfort and safety of the individual through an assessment of their environment as well as what they can do if they find themselves in trouble. I build the safety plan with the client by identifying warning signs, both internal feelings and external situations, where they can recognize the point at which they need to transition from normal behavior to safety behaviors. We make sure the plan is written in the client's own words so they feel ownership over it and are more likely to use it when they are in a heightened state. This allows the client to be the focal point of their own safety while the therapist provides the framework within which the plan will work.
One component I always include is a section of the safety plan that addresses limiting access to harmful objects or substances in the home. By doing this, we create a physical layer of protection that does not hinge solely on the client's emotional state or willpower at the time. By creating distance in both time and space between an urge to harm themselves and their ability to act on it, we increase the likelihood that the intervention will work. This distance gives the emotional surge time to peak and pass, allowing the client time to use their grounding skills or reach out for support before acting on the urge.
Prioritize Proven Skills First
When a client's risk rises between sessions, I co-create a safety plan by keeping it simple, specific, and tied to what the client can realistically do in the moment. We focus first on stabilization, using concrete skills like distress tolerance and emotion regulation so the plan supports present-moment safety rather than relying on willpower. I ask the client to help choose the steps and wording, then we practice the plan in session so it feels familiar under stress. One element I always include is a short, prioritized list of coping skills the client has already used successfully, because it reduces decision fatigue and helps them act quickly when things escalate.
Start with Immediate Reset Step
Across our nationwide virtual therapy network, we have found that a safety plan is only effective if it is completely frictionless to access during a spike in distress. A static PDF gets lost, so co-creation for us means building the safety plan directly into a secure, mobile-friendly patient portal that the client co-designs with their therapist. The one element our top clinicians always include is a highly specific 'micro-action' placed right at the top of the plan, such as a localized somatic grounding technique or a link to a specific familiar song. By prioritizing an immediate, accessible physical reset before listing crisis hotlines, we see a much higher utilization rate of the plan itself.
Use a Verbatim Risk Script
I'm Efrat Gotlib, LCSW--Clinical Director of Therapy24x7 in Midtown Manhattan--where we do depth-oriented psychodynamic work with high-achieving professionals, and risk planning often has to fit real executive lives without turning into a "worksheet no one opens." I also consult with ISMHO on keeping clinical depth in digital/hybrid care, which matters a lot between sessions.
When risk rises, I co-create the plan by treating it like an "internal-world map," not a checklist: what *exactly* changes in you right before things tip (thought pattern, body state, relational fantasy, the urge to disappear, the compulsion to prove something). In a case like "Sarah" (a hypervigilant clinician), the danger wasn't just workload--it was the unconscious caretaker identity that made stopping feel morally wrong, so the plan had to target that moment of compulsion.
One element I always include because clients actually use it: a short, verbatim "risk-script" they can copy/paste to me (or to their own notes) when language collapses--something like, "I'm escalating. I'm not safe with myself tonight. My mind is doing the all-or-nothing thing. I need containment." It reduces the shame/friction of having to explain, and it captures the *pattern* (internal architecture) in the exact moment it's active.
Then we tighten it with one boundary that matches their psychology--e.g., if their risk spike is driven by perfectionistic collapse after a work interaction, the plan includes a pre-decided "no processing after X pm" rule (not as a hack, but as protection from the repetitive unconscious trial). That's wellness in the psychodynamic sense: fewer reenactments, more internal safety.
Apply a Focus Shift Technique
Safety planning serves primarily to provide individuals with a sense of safety, security, and comfort during times of extreme distress when they are unable to see a therapist.
At those moments in time, anxiety causes the brain's "danger detection" system to become locked into a perpetual state of "fear."
In order to disrupt this process, a "shift your focus" technique has been used within the context of the safety plans.
Clinical observation suggests that by giving a person a structure upon which to rely while under extreme amounts of stress, an individual will refrain from acting out in obsessive/compulsive ways.
Thus, safety plans serve as a neurologic equation for freedom.
By viewing safety planning as such, it provides clients with the ability to consider applying the skills they learned through utilization of their safety plans towards shifting their dependency on short-term means for reducing anxiety (coping) to long-term, clear mental thought processes.
Carry a Practiced, Pocket-Sized Crisis Card
A safety plan that lives in a drawer is useless. The plans that actually function in a crisis are co-created in the session, practiced aloud before the client leaves, and fit on a single card the client physically carries. Three things need to be on it: who to call (a specific person, not a general list), what to do with the body (one concrete grounding action, not a menu. Cold water on the face, feet flat on the floor, something specific to that client), and the one sentence that has historically interrupted the spiral for them. That last one has to come from the client, not from me. I ask them to think back to a moment when they pulled back from the edge and identify what they said to themselves or what shifted. That sentence belongs on the card. The reason co-creation matters clinically is that a plan the client helped build is one they feel agency over. A plan handed to them is something that happened to them. When the crisis arrives, agency is what gets the card out of their pocket.
Natalie Buchwald, LMHC, Founder & Clinical Director, Manhattan Mental Health Counseling (manhattanmentalhealthcounseling.com)
