Assessing Safety and Urgent Risks in Psychological First Aid

Why safety assessment comes first

In Psychological First Aid (PFA), “safety” is not a vague feeling—it is a rapid, practical check for immediate threats to life, health, or physical security. Your goal is to decide, within minutes, whether the situation can be supported with PFA or whether urgent intervention is needed (medical care, emergency services, security, or a higher level of mental health response). A good safety assessment is brief, observable, and repeatable: you scan the environment, check for urgent risk indicators, ask direct questions when needed, and take clear action if risk is present.

1) Practical safety scan of the environment

A 30–60 second “STOP” scan

• S — Surroundings: crowds, noise, traffic, unstable structures, weather exposure, fire/smoke, weapons, aggressive animals, broken glass, sharp objects, substances on the ground.
• T — Threats: active conflict, escalating arguments, people shouting, security/police activity, ongoing violence, visible intoxication, someone blocking exits, harassment.
• O — Options: nearest exits, safe routes, well-lit areas, staff/security points, first aid station, public phones, where you can move to reduce risk.
• P — Privacy: can you speak without being overheard? Is the person being filmed? Are bystanders crowding in? Can you create a small buffer?

Step-by-step: moving to a safer setup

1. Pause and orient: take one breath, look around, identify the nearest exit and the nearest safe “anchor” (staff desk, security, clinic, well-lit open area).
2. Reduce exposure: if safe, guide the person a few steps away from hazards (traffic edge, broken glass, loud crowd). Use simple directions: “Let’s step over here where it’s quieter.”
3. Create space: position yourself at an angle (not blocking them), keep an open path to exits, and avoid cornering. If others are crowding, ask for space: “Please give us a little room.”
4. Check immediate needs: visible injuries, breathing difficulty, faintness, extreme cold/heat exposure, or inability to stand may require medical attention before any conversation.
5. Re-scan: safety is dynamic. Re-check if the crowd shifts, someone approaches, or the person’s state changes.

Quick environment checklist (use mentally)

2) Urgent risk indicators (what requires immediate action)

Urgent risk indicators are signs that the person (or others) may be in immediate danger. You do not need to “diagnose.” You need to recognize red flags and escalate appropriately.

A. Suicide risk / self-harm risk

• Direct statements: “I want to die,” “I’m going to kill myself,” “There’s no point.”
• Indirect statements with urgency: “Soon you won’t have to worry about me,” “I can’t do this anymore.”
• Access to means: pills, weapon, rope, high ledge, moving traffic.
• Recent attempt or self-harm injuries (fresh cuts, burns) or disclosure of a recent attempt.
• Severe hopelessness, agitation, or inability to commit to short-term safety.

B. Violence risk (harm to others)

• Threats to harm a specific person or group.
• Possession of a weapon or searching for one.
• Escalating agitation, clenched fists, pacing, intense paranoia, command-like statements (“They deserve it”).
• History disclosed of recent violent acts, or others report imminent threats.

C. Severe intoxication or overdose risk

• Unable to stay awake, repeated vomiting, slow/irregular breathing, bluish lips, confusion that worsens.
• Extreme agitation, overheating, chest pain, seizures.
• Mixing substances (alcohol + sedatives/opioids) or unknown ingestion.

D. Medical red flags (treat as urgent)

• Chest pain/pressure, severe shortness of breath, signs of stroke (face droop, arm weakness, speech difficulty).
• Seizure, fainting with injury, uncontrolled bleeding.
• Severe allergic reaction (swelling of lips/tongue, wheezing).
• Head injury with confusion, repeated vomiting, or worsening headache.

E. Disorientation / inability to care for self

• Does not know who/where they are, cannot state basic facts, appears delirious.
• Wandering into danger (traffic, extreme weather), unable to keep themselves safe.
• Severe neglect risk: no safe place to go, cannot access food/water/meds, cannot care for dependents.

Risk level shorthand (for quick decisions)

• High/imminent: clear intent + plan + means; active violence; severe medical symptoms; unconscious/overdose signs; cannot maintain basic safety.
• Moderate: thoughts of self-harm without plan/means; escalating agitation; intoxication but responsive; confusion but stable vitals.
• Lower (still monitor): distressed but oriented, no threats, no medical red flags, can follow simple safety steps.

3) How to ask direct, respectful safety questions

When red flags appear—or when you are unsure—ask clear, direct questions. Use a calm tone, simple words, and a nonjudgmental stance. Avoid euphemisms. Direct questions do not “put the idea in someone’s head”; they clarify risk so you can help.

Principles for safety questions

• Ask permission when possible: “Can I ask you a couple of safety questions?”
• Be specific and brief: one question at a time.
• Normalize the check: “I ask everyone this when they’re feeling overwhelmed.”
• Match the moment: if the person is highly agitated, keep questions short and focus on immediate safety.
• Do not debate or challenge: you are gathering information, not persuading.

Sample phrases: suicide and self-harm

• “Sometimes when people feel this overwhelmed, they think about hurting themselves. Are you thinking about hurting yourself right now?”
• “Have you had thoughts about ending your life?”
• “Have you thought about how you would do it?”
• “Do you have access to what you would use—like pills, a weapon, or something else?”
• “Have you tried to hurt yourself recently?”

Sample phrases: violence risk

• “Are you feeling like you might hurt someone else?”
• “Is there anyone you’re thinking about harming?”
• “Do you have anything on you that could be used as a weapon?”
• “What would help you feel safe enough to not act on those urges in the next hour?”

Sample phrases: intoxication/medical risk

• “Have you taken anything today—alcohol, pills, or drugs? What and how much?”
• “Are you having chest pain, trouble breathing, or feeling like you might pass out?”
• “Did you hit your head or fall?”
• “Do you have a medical condition like diabetes, seizures, or heart problems?”

Sample phrases: disorientation and self-care

• “Can you tell me your name and where we are right now?”
• “Do you know what day it is?”
• “Do you have a safe place you can go today?”
• “Is there someone you trust we can call to be with you?”

How to respond to “yes” without judgment

• “Thank you for telling me. I’m glad you said it out loud.”
• “I’m here with you. We’re going to focus on keeping you safe right now.”
• “Because your safety matters, I need to bring in additional help.”

4) What to do if risk is present

When urgent risk is identified, your priorities are: (1) immediate safety, (2) rapid escalation to appropriate services, (3) supportive presence, (4) clear handoff with key facts. Do not promise secrecy if someone is at risk of serious harm.

Immediate actions (the “SAFE” steps)

1. S — Secure the setting: move away from hazards; position near exits; reduce crowding; if violence risk is present, prioritize your own safety and seek security/police.
2. A — Activate help: contact emergency services/onsite medical/security according to your setting. If you are not the designated responder, alert the designated lead immediately.
3. F — Facilitate supports: involve trusted supports (family, friend, supervisor, community leader) if it increases safety and the person agrees when possible; consider privacy and potential harm from certain contacts.
4. E — Escort/Stay: stay with the person when appropriate and safe until help arrives; if you must leave, ensure a responsible person stays and the person is not left in danger.

Decision tree 1: environment safety

Is there an immediate physical danger (traffic, violence nearby, fire, unstable structure)?  ── Yes ──> Move to safer location if possible + activate security/emergency help. Do not delay.  ── No ──> Can you create basic privacy and a clear exit route?  ── No ──> Relocate a short distance or enlist staff to manage crowd.  ── Yes ──> Proceed to urgent risk indicators and direct questions.

Decision tree 2: suicide/self-harm risk

Did the person express suicidal thoughts or self-harm urges?  ── No ──> Continue monitoring; reassess if cues change.  ── Yes ──> Ask about plan and access to means.  Do they have a plan AND access to means OR recent attempt OR cannot commit to short-term safety?  ── Yes (high/imminent) ──> Call emergency services/onsite crisis team now. Stay with person. Reduce access to means if safe.  ── No (moderate) ──> Involve trusted support, arrange urgent professional evaluation, create a short-term safety plan for the next hours, and do not leave them alone if risk escalates.

Decision tree 3: violence risk

Is there a credible threat to harm others or a weapon present?  ── Yes ──> Prioritize your safety. Increase distance. Alert security/police/emergency services immediately. Do not attempt to physically disarm.  ── No ──> If agitation is rising, seek additional staff support, keep space, maintain clear exit, and continue assessment.

Decision tree 4: medical/intoxication red flags

Any medical red flags (chest pain, severe breathing trouble, seizure, overdose signs, unconsciousness, stroke signs)?  ── Yes ──> Call emergency medical services immediately. Provide basic first aid within your training.  ── No ──> If intoxicated but stable, keep them observed, prevent wandering into hazards, and arrange safe transport/support.

How to contact emergency services (what to say)

Use calm, concrete facts. Avoid long stories. A simple structure is: Where + What + Who + Weapons/medical + What’s happening now.

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• “I’m at [location]. I’m with an adult who said they are going to kill themselves and has access to pills. They are awake and here with me. We need urgent assistance.”
• “I’m at [location]. A person is threatening to hurt someone and may have a weapon. I’m at a safe distance. Please send police/security.”
• “I’m at [location]. Possible overdose—person is very drowsy and breathing is slow. Please send an ambulance.”

Involving trusted supports (how to do it respectfully)

When it is safe and appropriate, supportive people can reduce risk and help with follow-through. Ask the person who feels safe to contact, and be mindful that some relationships may increase danger.

• “Who is someone you trust who could come be with you right now?”
• “Would you like me to call them, or would you prefer to call on speaker with me here?”
• “Is there anyone you do not want contacted because it could make things worse?”

Staying with the person: practical do’s and don’ts

• Do: keep a calm voice; maintain a safe distance; keep exits accessible; reduce stimulation; offer water if appropriate; use short sentences; repeat key points.
• Do: if self-harm risk is high, encourage moving away from means (e.g., step back from ledge) using collaborative language: “Let’s take two steps back together.”
• Don’t: physically restrain unless you are trained and it is required for immediate safety; don’t argue about reasons to live; don’t shame, threaten, or lecture.
• Don’t: promise confidentiality when serious harm risk is present. Use: “I can’t keep this secret because I want you safe, but I will be respectful about who we involve.”

Documenting key facts for handoff (brief and objective)

Write down only what is needed for continuity of care and safety. Stick to observable facts and direct quotes. Avoid interpretations.

• Time and location: when/where you met.
• Presenting concern: what prompted contact.
• Direct quotes: e.g., “I’m going to end it tonight.”
• Risk details: plan, means, timeframe, recent attempts, threats to others, weapons, intoxication, medical symptoms.
• Actions taken: who you called, who arrived, any supports contacted, any movement to safer location.
• Current status at handoff: calm/agitated, oriented/disoriented, alone/not alone, injuries noted.

Example handoff note (template)

Time/Place: 18:40, community center lobby.  Reason: Person tearful, stated “I can’t go on.”  Safety scan: Moved to quiet corner near exit; no immediate environmental hazards.  Risk indicators: Reported suicidal thoughts; stated plan to take “a lot of pills” tonight; access confirmed (pills at home). No weapons on person. No chest pain/SOB.  Actions: Called emergency services at 18:47. Stayed with person; contacted trusted friend (with consent) who arrived 18:55.  Status at handoff: Awake, crying, cooperative, oriented to name/place; agreed to wait for responders.

Calm, clear, nonjudgmental language bank

• “I’m going to focus on your safety first.”
• “I’m going to ask a few direct questions so I can get you the right help.”
• “Thank you for being honest with me.”
• “Because there’s a risk of serious harm, I’m going to involve emergency help now.”
• “You’re not in trouble. We’re trying to keep you safe.”
• “Let’s take this one step at a time—right now, we wait together.”