Risk & Crisis Drills
The Safety Plan
Before we begin
Welcome. This is the first crisis drill, the safety plan. Not a talk you give and not a symptom you elicit, but a crisis you steer, safely, honestly, and with the person rather than at them.
A safety plan is not a risk assessment. The task usually forbids a history, a mental state, and questions about past treatment. Your whole job is to build, collaboratively, a short personal emergency guide, in the person's own words, that they will actually use when the thoughts get strong, and to reduce their access to the means. Their words, on paper, read back.
Two habits carry every crisis drill. Keep them close.
One. Secure safety before you assess, and say what you are doing. In a crisis you make the room safe before you take a history. The seat nearest the door is yours, the alarm is within reach, the means are removed, and you check who else is at risk. And you narrate it calmly, so the person is steadied by it, not alarmed.
Two. Honest and collaborative first, coercive only when safety demands it. You are straight about the limits, what you cannot keep confidential, what powers exist, and why. You work with the person as far as you safely can, and you reach for compulsion only when the risk leaves no safer option. You would rather do this with them than to them.
Ready. Let us walk in.
What this drill looks like
Picture the door. On it is a task card. It says, near enough, this.
Formulate a safety plan with this person to manage their suicidal thoughts when they occur, and discuss strategies for managing those thoughts. Do not take a history, do not examine the mental state, and do not ask about previous treatments.
You are in a clinic or an emergency department. The person may be someone who left before they were seen, rising suicidal thoughts and little trust. An examiner sits silent in the corner.
Here is the shape of it. Agree the task and the collaboration. Then the plan itself, warning signs, their own coping, people and places, who they will tell, the professional and crisis resources, and above all the means. Then read it back, check they believe it, and safety-net a follow-up.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the collaboration
You do not open with a history. You open by naming what today is, and is not, and by making it theirs.
Say something like this.
I am not going to go through everything again today. I would like us to write a plan together, in your words, for the next time it gets bad. Is that all right.
That single sentence sets the frame, protects you from sliding into a risk history, and hands the pen to them. A safety plan is like a personal emergency guide, and it only works if the words in it are theirs.
Check. Shall we meet the person. Let us.
Who is in front of you
Her name is Chloe. Her suicidal thoughts have been rising, she came to the emergency department and left before she was seen, and she has come back guarded and half-expecting to be processed rather than helped.
She does not want the whole story dragged out again. She will engage if you make it plain that today is about a plan she owns, not an interrogation. She knows, if you ask gently, what the first warning sign feels like, what has helped her before even a little, and what is at home that frightens her. She has not laid this out in order. It comes if you make it safe and collaborative.
That is your patient. Now every move is made with Chloe, her words on the page, not yours.
Check. Let us take the moves, one at a time.
The plan, step by step
Each step is one question, then you write the answer in her words. Trigger, decode, move, words, check.
4.1 - Warning signs
Trigger. She needs to catch the crisis early, before it peaks.
Decode, kept in your head. The plan begins with her own earliest signal, a thought, a feeling, a situation, so she can act while she still can.
The move. Ask how she knows it is starting, and write the exact words down.
How do you know it is starting. What do you notice first, a thought, a feeling, a situation.
Check. Warning sign captured in her words. Move on.
4.2 - Her own coping first
Trigger. Before other people, what can she do alone.
Decode, kept in your head. Internal coping, the things that have helped even a little, plus simple grounding and a store of reasons to live, a hope box or a crisis bank.
The move. Ask what has helped before, and suggest grounding, breathing, distraction, and a hope box of good memories and reasons.
What have you done before that helped even a little, on your own. Could we add some grounding, or a box of things that remind you why you keep going.
Check. Internal coping and a hope box noted. Move on.
4.3 - People and places
Trigger. Isolation is when it is most dangerous.
Decode, kept in your head. People to be around, and places to go, that break the isolation without her having to disclose anything.
The move. Ask who she could sit with, or where she could go just to be near people.
Who could you sit with, or where could you go, just to be around people, even without talking about it.
Check. People and places noted. Move on.
4.4 - Who she will actually tell
Trigger. One real person she would confide in.
Decode, kept in your head. Not who she should tell, but who she actually would. Write the name and the number in the plan.
The move. Ask who she would truly tell, and write the number down there and then.
Who would you actually tell. Can I write their name and number here, in the plan.
Check. A real confidant, with a number, on the page. Move on.
4.5 - The professional and crisis resources
Trigger. When her own steps are not enough.
Decode, kept in your head. The ladder of help, the crisis team, the general practitioner, the Samaritans on one one six one two three, the non-emergency line, the emergency services, the emergency department, a crisis cafe, and third-sector groups. Continued mental health support stands even if she declines medication or therapy.
The move. Offer the whole ladder, and write the numbers in.
Shall we add these. The crisis team, your doctor, the Samaritans on one one six one two three, the emergency services if it feels like an emergency, and a crisis cafe where you can just be with people. You can keep being seen by us either way.
Check. The crisis ladder written in, with numbers. Move on.
4.6 - Reducing the means, the part that saves lives
Trigger. The method she thinks of when the thoughts are strongest.
Decode, kept in your head. Making the means harder to reach, tablets held by someone else, weekly dispensing, one packet at a time, is the single most protective thing in the plan. Do not skip it.
The move. Ask, gently, what is at home, and how to make it harder to reach in the moment.
What is at home that you think of. Who could hold your tablets for now. How would you feel about weekly dispensing, or one packet at a time.
Check. Means restriction agreed and written in. This is the life-saver. Move on.
4.7 - Safe tonight, and read it back
Trigger. The plan exists. Now the immediate question, and the ownership check.
Decode, kept in your head. Whether she is safe to go home with this today, and whether, when you read it back, she believes it. A plan she does not believe is not a plan.
The move. Ask the safe-tonight question, then read the whole thing back to her and check she owns it.
Right now, today, are you safe to go home with this. Let me read it back to you. Do you believe it. Keep it in your phone.
Check. Safety today established, plan read back and owned. Move on.
The traps that fail this drill
Half the marks are in avoiding the traps. Say the trap in your head, and step around it.
5.1 - Sliding into a risk history
The commonest failure. The task forbids a history, yet the pull to ask before, during and after is strong. Every time you feel it, come back to the plan. You are building a tool, not taking a story.
5.2 - Writing your plan, not theirs
A plan in your words, full of services you chose, is a leaflet. A plan in her words, with her people and her coping, is a lifeline. Hand her the pen, use her phrases, and put her name and number in, not just yours.
5.3 - Skipping the means
A plan with warning signs and phone numbers but no means restriction has missed the one intervention that most reduces death. Always ask what is at home and how to make it harder to reach.
5.4 - A plan never read back
If you never read it back, you never learn whether she believes it, and belief is the whole point. Read it aloud, watch her face, and ask, do you believe this.
Check. Name the trap you avoided. That is the mark.
The close
Close in four small movements.
One. Read it back, in her words.
Let me read the whole thing back to you, so we know it is yours.
Two. Check she believes it.
Do you believe this would help. Is there anything in it you would change.
Three. Make it reachable.
Keep it in your phone, and a copy somewhere you will see it. It is yours.
Four. Safety-net a date.
I will see you on Thursday, and the crisis team is there in between. You are not leaving here without a plan and a date.
The two habits, again
Carry these two out of the room.
One. Secure safety before you assess, and say what you are doing. In a crisis you make the room safe before you take a history. The seat nearest the door is yours, the alarm is within reach, the means are removed, and you check who else is at risk. And you narrate it calmly, so the person is steadied by it, not alarmed.
Two. Honest and collaborative first, coercive only when safety demands it. You are straight about the limits, what you cannot keep confidential, what powers exist, and why. You work with the person as far as you safely can, and you reach for compulsion only when the risk leaves no safer option. You would rather do this with them than to them.
The thread of this drill is one line. Their words, on paper, read back, with the means made harder to reach, and never a history in a plan.
Do those two things and this crisis is yours to steer.
De-escalating Agitation and Aggression
Before we begin
Welcome. This is the de-escalation drill. Not a talk you give and not a symptom you elicit, but a crisis you steer, safely, honestly, and with the person rather than at them.
An agitated or aggressive patient is a crisis of safety first and psychiatry second. You secure the environment and yourself, you de-escalate with your voice before any medicine, you offer oral before injected, and you keep rapid tranquillisation and seclusion as last resorts. And you hold one warning in your mind throughout, that answering agitation by simply giving more antipsychotic is how a patient ends up rigid and febrile.
Two habits carry every crisis drill. Keep them close.
One. Secure safety before you assess, and say what you are doing. In a crisis you make the room safe before you take a history. The seat nearest the door is yours, the alarm is within reach, the means are removed, and you check who else is at risk. And you narrate it calmly, so the person is steadied by it, not alarmed.
Two. Honest and collaborative first, coercive only when safety demands it. You are straight about the limits, what you cannot keep confidential, what powers exist, and why. You work with the person as far as you safely can, and you reach for compulsion only when the risk leaves no safer option. You would rather do this with them than to them.
Ready. Let us walk in.
What this drill looks like
Picture the ward. A nurse has called you. A patient is agitated, pacing, and has become aggressive, sometimes after being stopped from leaving. You may be speaking to the patient, or advising the nurse.
Here is the shape of it. Your safety and the environment first. Verbal de-escalation. Find the trigger. Rule out a physical cause. Offer oral medication. Rapid tranquillisation only if de-escalation fails, by protocol, with monitoring. Seclusion last of all. Then debrief.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and your own safety
You do not open by confronting. You open by making the space safe and lowering the temperature.
Before a word, position yourself. The seat nearest the door is yours, the alarm within reach, remove anything that could be thrown or used as a ligature, give space, reduce noise and crowding, and let one person, you, do the talking.
Then, calmly.
I can see you are really upset, and I want to understand what has happened and help. I am not going to crowd you. Shall we sit, and you tell me what is going on.
Check. Space made, one voice, calm. Let us take the moves.
Who is in front of you
His name is Mr Stephen. He has a psychotic illness and several past admissions, and he became aggressive when staff stopped him leaving the ward, which to him confirmed that they were in league against him. He threw hot coffee and tried to swing a chair.
He is frightened as much as angry, and the anger has a reason inside his beliefs. He settles if he is listened to and not challenged, and escalates if he is cornered or argued with. He is not, at this moment, a puzzle to be solved but a temperature to be brought down.
That is your patient. Now every move lowers the temperature before it does anything else.
Check. Let us take the moves, one at a time.
The moves, in order
Each move is trigger, decode, the move, the words, then a check. The order is the safety.
4.1 - Verbal de-escalation
Trigger. He is agitated but still talking.
Decode, kept in your head. While he will talk, words are safer than anything. Acknowledge the feeling, do not argue the belief, offer choices, keep your voice low and slow.
The move. Name the feeling, offer small choices, never dispute the delusion.
I can see how frightening this feels. I am on your side here. Would it help to sit by the window, or to have a drink while we talk.
Check. Talking maintained, feeling acknowledged, belief not challenged. Move on.
4.2 - Find the trigger
Trigger. Something set this off.
Decode, kept in your head. Environmental and interpersonal triggers, noise, crowding, being stopped from leaving, a frightening belief, often drive the agitation, and removing the trigger often settles it.
The move. Ask what happened just before, and address the trigger where you can.
What happened just before this started. Was it being stopped from leaving, or something someone said.
Check. Trigger identified and, where possible, eased. Move on.
4.3 - Rule out a physical cause
Trigger. New or sudden agitation is not always psychiatric.
Decode, kept in your head. Delirium, hypoglycaemia, intoxication, withdrawal, pain and hypoxia all present as agitation. Miss them and you sedate a sick body.
The move. Screen quickly for a physical cause before reaching for a psychiatric explanation.
Before I assume this is the illness, let me check, any fever, confusion, pain, missed meals, or anything he has taken or stopped.
Check. Physical causes screened. Move on.
4.4 - Offer oral before injected
Trigger. De-escalation alone is not settling him.
Decode, kept in your head. If medication is needed, offer it, and offer it by mouth first, a sedating oral option such as lorazepam or olanzapine, with the choice left to him where possible.
The move. Offer oral medication as help, not punishment.
Would you take something now to help you feel less wound up. We can do it as a tablet, your choice.
Check. Oral offered first, collaboratively. Move on.
4.5 - Rapid tranquillisation, by protocol
Trigger. He is extremely agitated, de-escalation and oral have failed, and he is a risk to himself or others.
Decode, kept in your head. Only now, rapid tranquillisation by the hospital protocol, intramuscular lorazepam with or without an antipsychotic, with close monitoring of temperature, pulse, blood pressure and oxygen afterwards.
The move. Use it as the reserved step, and monitor vitals after.
To the nurse. If verbal de-escalation and oral medication have not worked and he remains at risk, we follow the rapid tranquillisation protocol, and we monitor his vitals closely afterwards.
Check. Rapid tranquillisation reserved and monitored. Move on.
4.6 - Seclusion, and the debrief
Trigger. Even medication has not contained the risk, or afterwards, once he is settled.
Decode, kept in your head. Seclusion is the last resort, used lawfully and briefly. And afterwards, a debrief matters, for him and for the staff who were assaulted.
The move. Reserve seclusion, then debrief both the patient and the staff.
Seclusion only if nothing else keeps everyone safe, and briefly. And afterwards we talk it through with him, and check the nurse is all right.
Check. Seclusion reserved, debrief planned. Move on.
The traps that fail this drill
Half the marks are in the traps. Say the trap and step around it.
5.1 - Crowding and cornering
Standing over him, blocking his exit, several staff closing in, all escalate. Give space, keep his exit open, one person talks. Your body language de-escalates before your words do.
5.2 - Arguing the belief
Disputing the delusion in the heat of it is fuel. You acknowledge the fear without agreeing the belief is true and without calling it false. Understanding, not debating.
5.3 - The agitation-so-more-drug trap
The dangerous reflex. He is agitated, so the antipsychotic dose is pushed up fast, and rigidity and fever follow. If a patient given repeated antipsychotic becomes stiff, hot and confused, think of the neuroleptic malignant reaction and stop, do not give more.
5.4 - Jumping to the needle
Reaching for an intramuscular injection before de-escalation and oral options is both unsafe and poorly marked. The order is the safety, verbal, then oral, then injected, then seclusion.
Check. Name the trap you avoided. That is the mark, and the patient's safety.
The close
Close in four small movements.
One. Confirm safety, present tense.
Right now, is everyone safe, the patient, the staff, and anyone nearby.
Two. State the order you followed.
We de-escalated, we found the trigger, we ruled out a physical cause, we offered oral, and we held medication and seclusion in reserve.
Three. Address the staff.
How is the nurse who was assaulted, and does the team need a debrief.
Four. Plan forward.
We review his medication and his triggers, and put a plan in place so this is less likely to happen again.
The two habits, again
Carry these two out of the room.
One. Secure safety before you assess, and say what you are doing. In a crisis you make the room safe before you take a history. The seat nearest the door is yours, the alarm is within reach, the means are removed, and you check who else is at risk. And you narrate it calmly, so the person is steadied by it, not alarmed.
Two. Honest and collaborative first, coercive only when safety demands it. You are straight about the limits, what you cannot keep confidential, what powers exist, and why. You work with the person as far as you safely can, and you reach for compulsion only when the risk leaves no safer option. You would rather do this with them than to them.
The thread of this drill is the order itself. De-escalate before you medicate, medicate by mouth before by needle, and never answer agitation by simply giving more of the drug.
Do those two things and this crisis is yours to steer.
The Request to Self-Discharge
Before we begin
Welcome. This is the self-discharge drill. Not a talk you give and not a symptom you elicit, but a crisis you steer, safely, honestly, and with the person rather than at them.
A patient admitted informally after a serious attempt now wants to leave. The temptation is to reach straight for the Mental Health Act. You do the opposite. You start with why he wants to go, right now, and you let the plan he describes for afterwards become your risk assessment. You weigh his capacity conversationally, you screen the risk to others, and only then do you state your plan and your reason for it.
Two habits carry every crisis drill. Keep them close.
One. Secure safety before you assess, and say what you are doing. In a crisis you make the room safe before you take a history. The seat nearest the door is yours, the alarm is within reach, the means are removed, and you check who else is at risk. And you narrate it calmly, so the person is steadied by it, not alarmed.
Two. Honest and collaborative first, coercive only when safety demands it. You are straight about the limits, what you cannot keep confidential, what powers exist, and why. You work with the person as far as you safely can, and you reach for compulsion only when the risk leaves no safer option. You would rather do this with them than to them.
Ready. Let us walk in.
What this drill looks like
Picture the ward, in the small hours. A task card, near enough, this.
This patient agreed to an informal admission after a near-fatal attempt, and now, shortly after arriving, wants to self-discharge against advice. Perform a risk assessment and explain your management plan to him.
Here is the shape of it. Understand why now. Hear his plan for after he leaves. Weigh his capacity in conversation. Screen the risk to others. Then state your plan, and your reason, holding powers only if the risk demands it.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, not the Act
You do not open with detention. You open with curiosity about the leaving itself.
Say something like this.
I can see you want to leave, and it is the middle of the night. Help me understand what is pulling you out of here right now, so we can think it through together.
His answer, where he is going and what he means to do, is the richest risk assessment you will get, far better than a checklist. Let him talk before you mention any legal framework.
Check. Shall we meet the person. Let us.
Who is in front of you
His name is Mr Johnson. He came in informally after a near-fatal hanging, and now, at four in the morning, he wants out. He does not think he is mentally ill, he thinks the admission was a mistake, and he says his life is genuinely not worth living.
He wants to leave to go and collect his children from his estranged wife, and take them home. He calls this his last chance, and he does not know what he will do if they will not come, though he says that if this fails, life is definitely not worth it. That plan, a hopeless man collecting children from an ex-partner in the middle of the night, is the whole risk assessment, if you let him describe it.
That is your patient. Now every move is made through his plan, not through the statute book.
Check. Let us take the moves, one at a time.
The moves, in order
Each move is trigger, decode, the move, the words, then a check.
4.1 - Why now
Trigger. He is set on leaving this minute.
Decode, kept in your head. The urgency and the timing carry the risk. Four in the morning, straight after admission, is not a considered decision, it is a driven one.
The move. Explore the why and the now, without judgement.
Why tonight, and why this minute. What has changed since you agreed to come in.
Check. The driver behind the urgency understood. Move on.
4.2 - His plan for after
Trigger. He has somewhere to go and something to do.
Decode, kept in your head. The plan he describes is the risk assessment. Where, who, what he will do, and what he will do if it fails.
The move. Draw out the whole plan, especially the if-it-fails.
If you leave now, where will you go, and what will you do. And if it does not go the way you hope, what then.
Check. The full plan, including the failure branch, elicited. Move on.
4.3 - Weigh capacity conversationally
Trigger. You must know whether he is deciding capacitously.
Decode, kept in your head. Capacity is decision-specific and time-specific. Rather than reciting the four elements, walk him through the weighing, the good of leaving now, the difficulty of it, the alternative.
The move. Weigh it aloud with him, which assesses capacity without a recital.
What is good about leaving right now. What might be hard about it, getting home safely, not having seen a senior doctor, no plan yet. If you waited until morning, what would you lose.
Check. Capacity assessed through the weighing, understanding, retaining, weighing, communicating. Move on.
4.4 - Risk to others
Trigger. His plan involves other people, including children.
Decode, kept in your head. A hopeless man collecting children in the night can carry a risk to them as well as to himself. This is hard to assess accurately, so you name that difficulty out loud.
The move. Ask, gently, about thoughts of harm to others, linked to the thoughts of ending his own life.
When you feel there is no point, do those thoughts ever include the children, or anyone else. I have to ask, because I want everyone safe.
Check. Risk to others, including the children, screened, and its uncertainty named. Move on.
4.5 - State the plan, and the reason
Trigger. You have the picture and must act.
Decode, kept in your head. Now, and only now, you state your plan and your reason. If the risk is high, he stays, detained if necessary. If it is lower, an urgent crisis team, clearly justified.
The move. Be honest and plain about what you recommend and why.
Given what you have told me, I do not think it is safe for you to leave tonight, and I will explain the options, including staying under the Act if we cannot agree, because keeping you safe tonight matters more than anything.
Check. Plan and reason stated, holding power reserved for high risk. Move on.
The traps that fail this drill
Half the marks are in the traps.
5.1 - Leading with the Act
Open with the Mental Health Act and you turn a conversation into a standoff, and you skip the risk assessment his plan would have given you. The Act comes at the end, as a reasoned last resort, not the opening move.
5.2 - Reciting capacity
Listing understand, retain, weigh, communicate at him is a checklist, not an assessment. Weigh the decision with him, in his own situation, and the capacity shows itself.
5.3 - Missing the risk to others
Focus only on his suicide risk and you miss the children he means to collect. In any self-harm plan that involves other people, screen the risk to them, and say how hard it is to be sure.
5.4 - Letting a driven decision stand
A hopeless man leaving at four in the morning for a last chance is not making a considered choice. Do not mistake insistence for capacity, and do not let the fear of confrontation override the risk.
Check. Name the trap you avoided. That is the mark.
The close
Close in four small movements.
One. Acknowledge his wish.
I understand how much you want to be with your children, and I am not dismissing that.
Two. State the plan and reason plainly.
I do not think it is safe to leave tonight, because of what you have told me you might do, and I would rather keep you safe than let you take that risk alone.
Three. Offer the collaborative path first.
Stay tonight, see a senior doctor in the morning, and let us make a plan about your children safely and properly.
Four. Be honest about the last resort.
If we cannot agree, I may have to use the Act to keep you safe, and I would tell you before I did. I would much rather do this with you.
The two habits, again
Carry these two out of the room.
One. Secure safety before you assess, and say what you are doing. In a crisis you make the room safe before you take a history. The seat nearest the door is yours, the alarm is within reach, the means are removed, and you check who else is at risk. And you narrate it calmly, so the person is steadied by it, not alarmed.
Two. Honest and collaborative first, coercive only when safety demands it. You are straight about the limits, what you cannot keep confidential, what powers exist, and why. You work with the person as far as you safely can, and you reach for compulsion only when the risk leaves no safer option. You would rather do this with them than to them.
The thread of this drill is one line. Not the Act first, but why now, and the plan he describes for afterwards is the risk assessment.
Do those two things and this crisis is yours to steer.
Assessing Capacity to Refuse Treatment
Before we begin
Welcome. This is the capacity drill. Not a talk you give and not a symptom you elicit, but a crisis you steer, safely, honestly, and with the person rather than at them.
A patient is refusing a treatment, often after an overdose, and someone wants them detained. Your task is to assess capacity properly, presume it, test the four elements for this decision at this time, and be clear about the crucial line, the Mental Health Act lets you treat a mental disorder, not force a medical treatment for the physical consequences of one. Where a person lacks capacity in an emergency, it is the Mental Capacity Act and best interests, or common law, that let you act, not the section paper.
Two habits carry every crisis drill. Keep them close.
One. Secure safety before you assess, and say what you are doing. In a crisis you make the room safe before you take a history. The seat nearest the door is yours, the alarm is within reach, the means are removed, and you check who else is at risk. And you narrate it calmly, so the person is steadied by it, not alarmed.
Two. Honest and collaborative first, coercive only when safety demands it. You are straight about the limits, what you cannot keep confidential, what powers exist, and why. You work with the person as far as you safely can, and you reach for compulsion only when the risk leaves no safer option. You would rather do this with them than to them.
Ready. Let us walk in.
What this drill looks like
Picture the emergency department. A task card, near enough, this.
This patient has taken an overdose and is refusing the treatment for it, and the medical team, or a relative, want you to detain her. Discuss the management, assess her capacity, and advise on the lawful way forward.
Here is the shape of it. Presume capacity. Find out what has already been tried. Test the four elements for this specific decision. Separate the mental disorder from the physical treatment. Reach for the right legal route. And assess it jointly with the medical team.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the presumption
You do not open by deciding she lacks capacity. You open by presuming she has it, and by understanding the refusal.
Say something like this.
I am not here to force anything on you. I would like to understand how you are seeing this, and to make sure that whatever you decide, you are deciding with the full picture. Can we talk it through.
And before you assess her, find out what the team has already done to keep her there, and what has helped, because her ambivalence, staying so far, is itself information.
Check. Shall we meet the person. Let us.
Who is in front of you
Her name is Ms Foster. She has taken a large overdose, she has done so before, and she is now refusing the treatment that would protect her. The medical consultant is anxious and wants a clear plan, and a relative is pressing for her to be sectioned on the spot.
She is ambivalent, she has let the staff persuade her to stay this far, which tells you the door is not fully closed. Whether she can refuse depends not on how alarming her choice is, but on whether she can understand, retain, weigh and communicate this decision, now.
That is your patient. Now every move tests the process of her decision, not its wisdom.
Check. Let us take the moves, one at a time.
The moves, in order
Each move is trigger, decode, the move, the words, then a check.
4.1 - Presume capacity, and understand the refusal
Trigger. She is saying no.
Decode, kept in your head. Capacity is presumed until shown otherwise, and the refusal has a reason. Hear it before you test it.
The move. Ask why she is refusing, without arguing.
Help me understand why you do not want the treatment. What is worrying you about it.
Check. The refusal heard, capacity presumed. Move on.
4.2 - Understand and retain
Trigger. Does she grasp the situation.
Decode, kept in your head. The first two elements, can she understand the information about treatment and non-treatment, and hold on to it long enough to decide.
The move. Give the information plainly, then ask her to tell it back.
Can you tell me, in your own words, what could happen if you have the treatment, and what could happen if you do not.
Check. Understanding and retention tested. Move on.
4.3 - Weigh, and communicate
Trigger. Can she use the information to decide.
Decode, kept in your head. The other two elements, can she weigh the risks and benefits against her own values, believe the team is acting in her interest, and communicate a reasoned choice.
The move. Ask her to reason it out, and to give her decision.
Knowing all that, how are you weighing it up. Can you tell me the reasons for the choice you are making.
Check. Weighing and communication tested. All four elements now assessed for this decision. Move on.
4.4 - Separate the mind from the poisoned body
Trigger. Someone wants the Mental Health Act used to force the physical treatment.
Decode, kept in your head. The pivotal point of law. The Mental Health Act authorises treatment of a mental disorder. It does not authorise forcing the antidote or the blood tests for the overdose itself. Those need capacity, or the Mental Capacity Act and best interests, or common law in an emergency.
The move. State the distinction clearly to the team.
To the medical team. The Mental Health Act would let us treat her mental illness. It does not let us force the treatment for the overdose. If she lacks capacity for that decision, we act in her best interests under the Mental Capacity Act, or common law in an emergency.
Check. The mental-disorder versus physical-treatment line drawn. Move on.
4.5 - The joint assessment and the safe holding
Trigger. A decision has to be made now, with the medical team.
Decode, kept in your head. Capacity here is assessed jointly, the medical team giving the physical treatment, you assessing the mind. And if she lacks capacity and tries to leave, common law justifies keeping her safe in the moment, especially given past large overdoses.
The move. Agree a joint assessment and a lawful safe holding.
Let us assess her capacity together, you and I, and if she lacks it and tries to leave, we can lawfully keep her safe while we act in her best interests. I will come to the department now.
Check. Joint assessment and lawful holding agreed. Move on.
The traps that fail this drill
Half the marks are in the traps.
5.1 - Confusing incapacity with disagreement
A person can make an unwise choice, even a dangerous one, and still have capacity. Capacity is about the process of deciding, not the wisdom of the outcome. Do not declare incapacity simply because you disagree.
5.2 - Using the Act to force the antidote
The commonest legal error. The Mental Health Act treats the mental disorder, not the poisoned body. Reaching for a section to justify the overdose treatment is wrong, and the marks are for saying so.
5.3 - Skipping the four elements
Declaring capacity present or absent without testing understanding, retention, weighing and communication, for this decision, is an assertion, not an assessment. Walk all four.
5.4 - Assessing alone
Capacity in the emergency department is a joint task with the medical team who are giving the physical treatment. Reassure the anxious consultant, and assess together, rather than handing back a single line.
Check. Name the trap you avoided. That is the mark.
The close
Close in four small movements.
One. State the capacity verdict, for this decision.
For this particular decision, right now, I judge that she does, or does not, have capacity, and here is why.
Two. Name the lawful route.
So the lawful way forward is her own consent, or best interests under the Mental Capacity Act, not a section for the overdose itself.
Three. Reassure the team and the relative.
I will come to the department, we will assess together, and we will keep her safe lawfully in the meantime.
Four. Keep the door open.
And I will keep talking with her, because she has stayed this far, and that ambivalence is something to work with.
The two habits, again
Carry these two out of the room.
One. Secure safety before you assess, and say what you are doing. In a crisis you make the room safe before you take a history. The seat nearest the door is yours, the alarm is within reach, the means are removed, and you check who else is at risk. And you narrate it calmly, so the person is steadied by it, not alarmed.
Two. Honest and collaborative first, coercive only when safety demands it. You are straight about the limits, what you cannot keep confidential, what powers exist, and why. You work with the person as far as you safely can, and you reach for compulsion only when the risk leaves no safer option. You would rather do this with them than to them.
The thread of this drill is two lines. Capacity is about the process, not the outcome, and the Act treats the mind, not the poisoned body.
Do those two things and this crisis is yours to steer.
Explaining Detention under the Mental Health Act
Before we begin
Welcome. This is the detention-explanation drill. Not a talk you give and not a symptom you elicit, but a crisis you steer, safely, honestly, and with the person rather than at them.
You have to tell someone that they are being, or may be, detained. The failure is to lead with section numbers and legal machinery. Instead you explain, in plain words, why, what it means for them, what their rights are, and that it is a framework to keep them safe and get them well, reviewed and time-limited, not a punishment and not a prison.
Two habits carry every crisis drill. Keep them close.
One. Secure safety before you assess, and say what you are doing. In a crisis you make the room safe before you take a history. The seat nearest the door is yours, the alarm is within reach, the means are removed, and you check who else is at risk. And you narrate it calmly, so the person is steadied by it, not alarmed.
Two. Honest and collaborative first, coercive only when safety demands it. You are straight about the limits, what you cannot keep confidential, what powers exist, and why. You work with the person as far as you safely can, and you reach for compulsion only when the risk leaves no safer option. You would rather do this with them than to them.
Ready. Let us walk in.
What this drill looks like
Picture the room. A task card, near enough, this.
This patient needs to be detained for assessment or treatment of a mental disorder. Explain to them what is happening and why, address their concerns, and outline their rights.
Here is the shape of it. Why, in plain words. What it means for them. Which framework, briefly and without jargon. Their rights. Reassurance. And an invitation to ask.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, plain and honest
You do not open with a section number. You open with honesty and warmth about why you are worried.
Say something like this.
I want to be honest with you about something, and I would rather you heard it from me plainly. I am worried about how unwell you are and about your safety, and I think you need to stay in hospital for now, even though I know that is not what you want.
Check. Shall we meet the person. Let us.
Who is in front of you
In front of you is someone frightened, often angry, who does not believe they are ill, and who hears the word detained as the word prison. They may feel betrayed, or trapped, or that this proves the conspiracy they already fear.
What they need is not a lecture on the law but a person being straight with them, telling them why, what will actually happen, and what say they still have. The tone carries this station as much as the content.
That is your patient. Now every move is plain, honest, and on their side.
Check. Let us take the moves, one at a time.
The moves, in order
Each move is trigger, decode, the move, the words, then a check.
4.1 - Why, in plain words
Trigger. They want to know why this is happening to them.
Decode, kept in your head. The grounds, an illness, a risk to themselves or others, a need for assessment or treatment, and no less restrictive way to keep them safe, said as human reasons, not legal tests.
The move. Give the why as care, not as a charge.
The reason is that you are unwell in a way that is putting you at risk, you need proper assessment and treatment, and there is no safer way to do that right now than here.
Check. The why given plainly. Move on.
4.2 - What it means for them
Trigger. They imagine the worst, indefinite, locked away.
Decode, kept in your head. What it actually means, a stay in hospital for assessment or treatment, reviewed regularly, time-limited, with leave possible as they improve.
The move. Describe the reality, which is far less frightening than the fear.
In practice it means staying here so we can assess and treat you. It is reviewed regularly, it does not go on indefinitely, and as you get better we can look at time out and going home.
Check. The reality described. Move on.
4.3 - The framework, briefly
Trigger. You must name the legal basis, without drowning them.
Decode, kept in your head. Whether it is for assessment or for treatment, in one plain sentence. The number matters less than that they understand the purpose.
The move. Name it once, in purpose terms, and move on.
This is a legal framework that allows us to keep you here to assess, or to treat, your illness. I can write down the details for you, but the point of it is simply your safety and your treatment.
Check. Framework named in plain purpose terms. Move on.
4.4 - Their rights
Trigger. They feel powerless.
Decode, kept in your head. The rights that restore some control, the right to appeal to a tribunal, an independent advocate, a nearest relative involved, a second opinion, and the right to have all this explained.
The move. Give the rights clearly, as things they can use.
You have real rights here. You can appeal against this to an independent panel, you can have an advocate whose only job is your voice, your nearest relative can be involved, and you can ask for a second opinion. I will make sure you get these in writing.
Check. Rights given, control partly restored. Move on.
4.5 - Reassure, and invite
Trigger. The word prison still hangs in the air.
Decode, kept in your head. The plain reassurance, this is not a punishment and not a prison, it is treatment, and you are on their side, and an open invitation to ask.
The move. Separate this from prison, and open the floor.
This is not a punishment, and it is not prison. It is treatment for an illness, and I am on your side in it. What questions do you have for me.
Check. Reassurance given, questions invited. Move on.
The traps that fail this drill
Half the marks are in the traps.
5.1 - Leading with section numbers
Opening with the section and its subsections is jargon that frightens and alienates. Lead with why, in human words. The number is a detail you can write down, not the message.
5.2 - Sounding punitive
A cold, procedural tone makes detention feel like a sentence. Warmth, honesty and being visibly on their side are marked as hard as the facts.
5.3 - Omitting their rights
Detention without explaining the appeal, the advocate, the nearest relative and the second opinion leaves the person powerless, and it fails the station. Rights are not optional.
5.4 - Arguing them out of their illness
This is not the moment to debate whether they are ill. Acknowledge you see it differently, keep the focus on safety and treatment, and do not turn the explanation into an argument.
Check. Name the trap you avoided. That is the mark.
The close
Close in four small movements.
One. Restate the why, gently.
The whole reason for this is your safety and getting you well, nothing else.
Two. Hand them their rights.
Here is the information on your rights, the appeal, the advocate, and the second opinion, in writing.
Three. Reassure on time and review.
This is reviewed regularly and does not go on indefinitely, and we work towards home as you recover.
Four. Stay alongside.
I am still your doctor in this, and I will keep explaining anything that is not clear.
The two habits, again
Carry these two out of the room.
One. Secure safety before you assess, and say what you are doing. In a crisis you make the room safe before you take a history. The seat nearest the door is yours, the alarm is within reach, the means are removed, and you check who else is at risk. And you narrate it calmly, so the person is steadied by it, not alarmed.
Two. Honest and collaborative first, coercive only when safety demands it. You are straight about the limits, what you cannot keep confidential, what powers exist, and why. You work with the person as far as you safely can, and you reach for compulsion only when the risk leaves no safer option. You would rather do this with them than to them.
The thread of this drill is one line. Plain words before section numbers, and it is a framework to keep them safe and well, never a punishment and never a prison.
Do those two things and this crisis is yours to steer.
Risk to Others and the Duty to Protect
Before we begin
Welcome. This is the duty-to-protect drill. Not a talk you give and not a symptom you elicit, but a crisis you steer, safely, honestly, and with the person rather than at them.
A patient is expressing thoughts of harming another person. The crisis is to assess the risk honestly and to handle confidentiality with integrity. You never promise secrecy you cannot keep. You elicit the drivers, the target, the means and the disinhibitors, you weigh the protective factors, and where a specific person is in danger you are honest that you cannot keep it confidential, and that you will tell them before you tell anyone else.
Two habits carry every crisis drill. Keep them close.
One. Secure safety before you assess, and say what you are doing. In a crisis you make the room safe before you take a history. The seat nearest the door is yours, the alarm is within reach, the means are removed, and you check who else is at risk. And you narrate it calmly, so the person is steadied by it, not alarmed.
Two. Honest and collaborative first, coercive only when safety demands it. You are straight about the limits, what you cannot keep confidential, what powers exist, and why. You work with the person as far as you safely can, and you reach for compulsion only when the risk leaves no safer option. You would rather do this with them than to them.
Ready. Let us walk in.
What this drill looks like
Picture the room. A task card, near enough, this.
This patient has expressed thoughts of harming another person. Assess the risk to others and outline your management.
Here is the shape of it. The history of violence. The current drivers in the mental state. The specific target. The means and planning. The disinhibitors. The protective and situational factors. Then the honest handling of confidentiality, and the plan.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, honest from the first
You do not open by promising secrecy, and you do not open with alarm. You open warmly, and you set the honest frame early.
Say something like this, and be ready to say the confidentiality line the moment a target appears.
Thank you for talking to me. Most of what we discuss stays between us. The one thing I cannot keep private is if someone is in real danger, and if that comes up, I will always tell you before I tell anyone else. With that understood, tell me what has been happening.
Check. Shall we meet the person. Let us.
Who is in front of you
In front of you is a man whose illness is turning outward. A belief that someone is persecuting him, or a voice pushing him, and a particular person in his mind. He may have stopped his medication, and he may be drinking.
He is frightening and frightened at once, and whether he acts depends on the target, the means, the disinhibitors, and what has held him back so far. Your honesty about confidentiality is what keeps him talking rather than shutting the door.
That is your patient. Now every move assesses the danger while keeping faith with him.
Check. Let us take the moves, one at a time.
The moves, in order
Each move is trigger, decode, the move, the words, then a check.
4.1 - History and current drivers
Trigger. Past violence, and a belief or voice pushing him now.
Decode, kept in your head. The strongest predictor is past violence, and the acute driver is in the mental state, a persecutory belief or a command voice.
The move. Ask about the worst time before, and what is pushing him now.
Have you ever hurt anyone, or come close. Tell me about the worst time. And now, is there a belief, or a voice, pushing you towards it.
Check. History and current drivers elicited. Move on.
4.2 - The target
Trigger. A person in his mind.
Decode, kept in your head. Whether there is a specific, identifiable target, and whether he knows where they are, changes everything, including your duty.
The move. Ask directly who, and whether he knows where they are.
Is there someone in particular you feel this way about. Do you know where they are.
Check. Target identified or excluded. This gates the duty. Move on.
4.3 - Means and planning
Trigger. Intent hardening into a plan.
Decode, kept in your head. Whether he has thought about how, and whether he has the means, marks the move from thought to plan.
The move. Ask about method and access.
Have you thought about how. Is there anything at home you would use.
Check. Means and planning screened. Move on.
4.4 - Disinhibitors
Trigger. Drink, drugs, and stopped medication.
Decode, kept in your head. Alcohol, substances and non-adherence lower the threshold and raise the risk sharply.
The move. Ask about substances and medication.
How much are you drinking or using. Are you still taking your medication.
Check. Disinhibitors screened. Move on.
4.5 - Protective factors, weighed
Trigger. Something has stopped him so far.
Decode, kept in your head. A protective factor guards against a specific risk for a specific time. Name what has held him back, and what would remove it.
The move. Ask what has stopped him, who else is in the home, and whether children are there.
What has stopped you so far. Who else is in the house. Are there any children there.
Check. Protective and situational factors weighed, not just listed. Move on.
4.6 - The honest handling of confidentiality, and the plan
Trigger. A real, specific danger to a named person.
Decode, kept in your head. Now the duty is engaged. You are honest that you cannot keep this private, you tell him before you tell anyone else, and you act, admission, often under the Act, medication restarted, sometimes as a long-acting injection, and the people who need to know are informed.
The move. State the confidentiality limit plainly, then the plan, doing it with him.
Because you have told me someone is genuinely at risk, I cannot keep that between us, and I am telling you first, as I promised. I think you are unwell and this is treatable, and I need to keep you and them safe, which may mean staying in hospital. I would rather do this with you than to you.
Check. Confidentiality handled with integrity, plan stated, safety secured. Move on.
The traps that fail this drill
Half the marks are in the traps.
5.1 - Promising confidentiality you cannot keep
Telling him at the outset that everything is private, then breaking it, destroys trust and fails the station. Set the honest limit at the start, and hold to it, telling him before you tell anyone else.
5.2 - Not pinning the target
A general talk of anger without asking who, specifically, and whether he knows where they are, misses the very thing that decides the risk and the duty. Always seek the specific target.
5.3 - Listing protective factors
Reading off protective factors without saying what each guards against and what would remove it is not a risk assessment. Weigh them. A partner protects only while present, a wish to see children only until they refuse.
5.4 - Going behind the patient
Informing others without telling him first is dishonest and unsafe for the therapeutic relationship. The rule is simple, you tell him before you tell anyone else.
Check. Name the trap you avoided. That is the mark, and someone's safety.
The close
Close in four small movements.
One. Name the illness driving it.
I think you are unwell, and the illness is driving these thoughts, and that means we can treat them.
Two. State the plan.
We need to keep you, and the person you have named, safe, which may mean admission and restarting your treatment.
Three. Honour the confidentiality promise.
Where someone is at real risk, I cannot keep it between us, and I am telling you first, as I said I would.
Four. Stay with him.
I would rather do this with you than to you, and I will keep you informed at every step.
The two habits, again
Carry these two out of the room.
One. Secure safety before you assess, and say what you are doing. In a crisis you make the room safe before you take a history. The seat nearest the door is yours, the alarm is within reach, the means are removed, and you check who else is at risk. And you narrate it calmly, so the person is steadied by it, not alarmed.
Two. Honest and collaborative first, coercive only when safety demands it. You are straight about the limits, what you cannot keep confidential, what powers exist, and why. You work with the person as far as you safely can, and you reach for compulsion only when the risk leaves no safer option. You would rather do this with them than to them.
The thread of this drill is one line. Never promise a confidentiality you cannot keep, pin the target, weigh what holds him back, and tell him before you tell anyone else.
Do those two things and this crisis is yours to steer.
Command Hallucinations
Before we begin
Welcome. This is the command-hallucinations drill. Not a talk you give and not a symptom you elicit, but a crisis you steer, safely, honestly, and with the person rather than at them.
A voice is telling a patient to do something, often to harm himself or someone else. The danger is not in the presence of the voice but in what it commands, whether he has acted on it before, whether he can resist it, and whether a delusion makes obeying it feel compulsory. You elicit all of that, and you weave in the target and the means, before you decide the risk.
Two habits carry every crisis drill. Keep them close.
One. Secure safety before you assess, and say what you are doing. In a crisis you make the room safe before you take a history. The seat nearest the door is yours, the alarm is within reach, the means are removed, and you check who else is at risk. And you narrate it calmly, so the person is steadied by it, not alarmed.
Two. Honest and collaborative first, coercive only when safety demands it. You are straight about the limits, what you cannot keep confidential, what powers exist, and why. You work with the person as far as you safely can, and you reach for compulsion only when the risk leaves no safer option. You would rather do this with them than to them.
Ready. Let us walk in.
What this drill looks like
Picture the room, perhaps after an incident. A task card, near enough, this.
This patient hears voices that tell him to do things, and there has been, or may be, harm. Assess the command hallucinations and the risk they carry.
Here is the shape of it. Establish the voice. Then the command itself. Then whether he has obeyed before. Then whether he can resist. Then the belief that makes obeying make sense. Then the target and the means. Then the risk decision.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the cue
You do not open by asking about commands. You open wide about the voices, and hook onto what they tell him to do.
Say something like this.
You have mentioned hearing voices. Can you tell me about them. Whose voice, and what sort of things do they say to you.
Then, the moment he mentions being told to do something, you follow it, warmly and without alarm, because the command is where the danger lives.
Check. Shall we meet the person. Let us.
Who is in front of you
His name is Leon. He is unwell, and he has assaulted someone. He says he could hear that person's voice in his head telling him to hurt him, and a neighbour's voice commanding him to attack people.
The voices do not merely comment, they instruct, and he has already acted on them once. Whether he acts again depends on how compelling the command is, whether he feels he must obey, whether a belief ties the voice to a threat, and who and what is within reach. He will tell you, if you ask each piece plainly and without recoiling.
That is your patient. Now every move walks the chain from the voice to what it drives.
Check. Let us take the moves, one at a time.
The moves, in order
Each move is trigger, decode, the move, the words, then a check.
4.1 - Establish the voice
Trigger. He hears a voice.
Decode, kept in your head. Whose, how many, and in what person, second person to him or third person about him, before you get to what it says.
The move. Locate and identify the voice.
Whose voice is it. Do you recognise it. Does it speak to you, or about you.
Check. The voice located and identified. Move on.
4.2 - The command itself
Trigger. The voice instructs, it does not merely comment.
Decode, kept in your head. The exact content of the command carries the risk. General instructions differ from a specific order to harm a specific person.
The move. Ask precisely what it tells him to do.
What does it actually tell you to do. Give me the exact words, if you can.
Check. The command captured in his words. This is where the danger lives. Move on.
4.3 - Past compliance
Trigger. He may have obeyed before.
Decode, kept in your head. Past compliance is the strongest predictor of future compliance. Ask whether he has ever acted on it, and what happened.
The move. Ask directly about acting on the voice before.
Have you ever done what it told you to do. What happened when you did.
Check. Past compliance established. A history of obeying is a major risk. Move on.
4.4 - Ability to resist
Trigger. How much control does he have.
Decode, kept in your head. Whether he can resist the command, and what helps him resist, separates a distressing symptom from an imminent danger.
The move. Ask whether he can resist, and what helps.
When it tells you to do something, are you able to resist it. What helps you not to obey.
Check. Ability to resist gauged. Move on.
4.5 - The belief that compels obedience
Trigger. A delusion may make obeying feel compulsory.
Decode, kept in your head. A congruent delusion, that the voice has power over him, or that obeying will avert a catastrophe, or that the target is a genuine threat, turns a command into a compulsion.
The move. Ask what he believes will happen if he obeys, or does not.
Do you feel you have to obey it. What do you believe would happen if you did not. And do you feel the person it names is really a threat to you.
Check. The compelling belief elicited. A command plus a congruent delusion is high risk. Move on.
4.6 - The target, the means, and the decision
Trigger. The command names or implies a victim.
Decode, kept in your head. Whether there is a specific target and the means to reach them completes the risk picture, and the risk decision, admission and treatment, follows.
The move. Weave in the target and means, then act.
Does it tell you to harm anyone in particular. Do you know where they are, and is there anything you would use. Given all this, I need to keep you and others safe.
Check. Target and means screened, risk decision made. Move on.
The traps that fail this drill
Half the marks are in the traps.
5.1 - Stopping at the voice
Eliciting that there is a voice and moving on misses the whole risk. The command, the past compliance, the resistance and the compelling belief are the assessment. Finding the voice is only the start.
5.2 - Not asking about past compliance
Whether he has obeyed the voice before is the single most important predictor. Never leave it unasked.
5.3 - Assuming a command means he will act
A command he can resist, with no congruent belief and no target, is far less dangerous than one he feels compelled to obey against a named person. Weigh resistance, belief and target, do not react to the word command alone.
5.4 - Missing the mood or the driver
Command voices can sit within a depression, a mania or an intoxication, each changing the treatment. Do not assess the command in isolation from the illness driving it.
Check. Name the trap you avoided. That is the mark.
The close
Close in four small movements.
One. Reflect it back.
So you are hearing a voice that tells you to do things, and at times you have felt you had to obey it, and that must be terrifying.
Two. Name it as illness, treatable.
These voices come from an illness, and the illness is treatable, and the voices can be quietened.
Three. State the safety plan.
To keep you and others safe while we treat this, I think you need to be in hospital, and we will start medication that helps with the voices.
Four. Stay with him.
You are not in trouble with me. You are unwell, and I am going to help you, and I will explain each step.
The two habits, again
Carry these two out of the room.
One. Secure safety before you assess, and say what you are doing. In a crisis you make the room safe before you take a history. The seat nearest the door is yours, the alarm is within reach, the means are removed, and you check who else is at risk. And you narrate it calmly, so the person is steadied by it, not alarmed.
Two. Honest and collaborative first, coercive only when safety demands it. You are straight about the limits, what you cannot keep confidential, what powers exist, and why. You work with the person as far as you safely can, and you reach for compulsion only when the risk leaves no safer option. You would rather do this with them than to them.
The thread of this drill is one line. Finding the voice is not the finding. The command, the past compliance, the ability to resist, the compelling belief, and the target are the risk.
Do those two things and this crisis is yours to steer.
Safeguarding a Child at Risk
Before we begin
Welcome. This is the safeguarding drill. Not a talk you give and not a symptom you elicit, but a crisis you steer, safely, honestly, and with the person rather than at them.
A parent's illness may be putting a child at risk, through a delusion involving the child, through neglect, or through a command. The crisis is that the child's safety comes first, above the therapeutic relationship and above confidentiality. Your very first move is to find out where the children are right now and who is with them, and you act, openly and with the parent where you can, because a parent's love does not protect a child from a psychotic belief.
Two habits carry every crisis drill. Keep them close.
One. Secure safety before you assess, and say what you are doing. In a crisis you make the room safe before you take a history. The seat nearest the door is yours, the alarm is within reach, the means are removed, and you check who else is at risk. And you narrate it calmly, so the person is steadied by it, not alarmed.
Two. Honest and collaborative first, coercive only when safety demands it. You are straight about the limits, what you cannot keep confidential, what powers exist, and why. You work with the person as far as you safely can, and you reach for compulsion only when the risk leaves no safer option. You would rather do this with them than to them.
Ready. Let us walk in.
What this drill looks like
Picture the room. A task card, near enough, this.
This parent is acutely unwell, and there are concerns for the safety of their children. Assess the risk to the children and outline your management.
Here is the shape of it. Where are the children right now. The nature of the risk. Access and opportunity. The parent's insight. Then the duty to act, openly, and the safeguarding referral, with the child's safety first.
Check. Does the shape make sense. Good. Let us find the opening.
The opening, and the very first question
You open with warmth, but the very first risk question, before anything else, is where the children are and who is with them.
Say something like this.
Before anything else, can I ask, where are your children right now, and who is with them at this moment.
Everything else in the station can wait behind that answer. A child unsupervised with an acutely unwell parent, or with no one, is the emergency inside the emergency.
Check. Shall we meet the person. Let us.
Who is in front of you
Her name is Angela. She is acutely psychotic, and she believes that aliens, or a malign force, want to take her children to experiment on them. She has kept them off school and barricaded the doors to protect them.
She loves her children, and that is exactly the trap, because her love is now being expressed through a terrifying delusion. The children may be safe with a grandmother, or they may be behind the barricade with her. She is not neglecting them out of indifference, she is endangering them out of a false belief, and her love will not override it. Only finding out where they are, and acting, will keep them safe.
That is your patient. Now every move puts the children's safety first, done with Angela where possible.
Check. Let us take the moves, one at a time.
The moves, in order
Each move is trigger, decode, the move, the words, then a check.
4.1 - Where are the children now
Trigger. The single most urgent unknown.
Decode, kept in your head. Their present location and supervision. A child alone with an acutely unwell parent is an immediate safeguarding emergency.
The move. Establish location and supervision before anything else, and confirm it is safe now.
Where exactly are they at this moment, and who is with them. Is that person well, and are the children safe right now.
Check. Present location and supervision established. This comes first, always. Move on.
4.2 - The nature of the risk
Trigger. The illness touches the children.
Decode, kept in your head. How the illness endangers them, a delusion that involves them, neglect from being too unwell to care, or a command to harm.
The move. Explore how the illness bears on the children, gently.
Tell me about your worries for the children. Do your beliefs, or any voices, involve them in any way.
Check. The nature of the risk to the children understood. Move on.
4.3 - Access, opportunity and neglect
Trigger. Risk is about what could actually happen to them.
Decode, kept in your head. Whether the children are exposed, whether basic care, food, warmth, school, medicine, is breaking down, and whether anyone else can step in.
The move. Ask about their daily care and who else is available.
How are they managing day to day, are they eating, sleeping, getting to school. Is there family who could help care for them right now.
Check. Exposure, neglect and available support assessed. Move on.
4.4 - The parent's insight
Trigger. Does she see the danger her belief creates.
Decode, kept in your head. Whether she can hold, even a little, that she is unwell, which shapes how much she will work with you, but does not change the duty.
The move. Gently probe insight, without arguing the belief.
Is there any part of you that wonders whether being so unwell and exhausted might be affecting how you are seeing things, and what is best for them.
Check. Insight gauged. It shapes the approach, not the duty. Move on.
4.5 - The duty to act, openly
Trigger. The children are at risk from the illness.
Decode, kept in your head. The child's safety overrides confidentiality and the therapeutic relationship. You make a safeguarding referral, you involve social care and the team, and you do it openly with the parent where you can, and regardless where you must.
The move. State the duty honestly, framed around keeping the children and her safe, and act.
Because the children's safety has to come first, this is one thing I cannot keep private. I am going to make sure they are safe and cared for while you get well, and I would like to do that with you, and to get you the treatment you need. I am telling you what I am doing at every step.
Check. Duty stated, referral made, done openly. The children are the priority. Move on.
The traps that fail this drill
Half the marks are in the traps.
5.1 - Not asking where the children are
The commonest and most serious failure. In any station where an unwell parent has children, the first risk question is where they are right now and who is with them. Everything else waits behind that.
5.2 - Reassured by a parent's love
She clearly loves them, so surely they are safe, is exactly the wrong reasoning. A psychotic belief expresses itself through the parent's love and overrides it. The barricade is love, and it is also the danger.
5.3 - Promising confidentiality
A child's safety cannot be kept confidential. Do not promise secrecy, and do not delay the safeguarding referral to preserve the therapeutic relationship. Be open that the children come first.
5.4 - Delaying the referral
Treating the parent while leaving the safeguarding for later fails the children. The referral and the arrangements for the children happen now, alongside her treatment, not after it.
Check. Name the trap you avoided. That is the mark, and a child's safety.
The close
Close in four small movements.
One. Confirm the children are safe now.
First and most important, the children are safe and cared for as we speak.
Two. Name the illness, and the treatment.
You are acutely unwell, and this is treatable, and you will recover, often very well.
Three. State the safeguarding, openly.
I am making sure the children are looked after while you get well, and I am telling you exactly what I am arranging.
Four. Keep her in it.
This is not about taking your children from you, it is about keeping them safe while you get better, and I will help you every step.
The two habits, again
Carry these two out of the room.
One. Secure safety before you assess, and say what you are doing. In a crisis you make the room safe before you take a history. The seat nearest the door is yours, the alarm is within reach, the means are removed, and you check who else is at risk. And you narrate it calmly, so the person is steadied by it, not alarmed.
Two. Honest and collaborative first, coercive only when safety demands it. You are straight about the limits, what you cannot keep confidential, what powers exist, and why. You work with the person as far as you safely can, and you reach for compulsion only when the risk leaves no safer option. You would rather do this with them than to them.
The thread of this drill is one line. Where are the children right now, a parent's love does not protect a child from a psychotic belief, and a child's safety cannot be kept confidential.
Do those two things and this crisis is yours to steer.