BITES: A Framework for Safety Planning and Understanding Mental Health Warning Signs

Mental health crises often appear sudden from the outside. A person may seem to be managing, then reach a point where their distress becomes intense, their behavior changes, or staying safe becomes difficult.

For the person experiencing the crisis, however, there are often warning signs along the way. The problem is that those signs may be subtle, difficult to describe, or only recognizable after the situation has passed.

A safety plan is intended to help identify those signs before a crisis reaches its most dangerous point. Established safety planning models begin by asking someone to recognize the thoughts, images, moods, situations, and behaviors that indicate a crisis may be developing. A complete plan then identifies coping strategies, supportive environments, people who can help, professional resources, and steps for making the environment safer.

In my clinical work, I noticed that identifying warning signs can still be difficult. Asking someone, “What are your triggers?” or “How do you know you are getting worse?” may produce a vague answer, especially when the person has never slowed the experience down enough to examine it.

That led me to develop BITES, a framework for exploring five areas that often change as emotional distress begins to build:

Behaviors, Images, Thoughts, Emotions, and Sensations.

BITES is not a replacement for a full safety plan or professional risk assessment. It is a way to make the warning-sign portion of safety planning more specific, personal, and easier to recognize before someone reaches the peak of a crisis.

Why Recognizing Warning Signs Can Be So Difficult

People do not always experience a clear moment when they realize a crisis has begun. The movement from manageable distress to serious risk may happen through a series of smaller changes.

Sleep becomes inconsistent. A person starts withdrawing. Their thoughts become more rigid or hopeless. Their body remains tense. They repeatedly imagine a feared outcome. Activities that usually help no longer feel accessible.

Each change may seem insignificant by itself. Together, they can form a recognizable pattern.

The challenge is that people often evaluate their distress only by its most intense expression. They notice the panic attack but overlook the irritability, poor sleep, physical tension, and repetitive thoughts that appeared earlier. They remember the moment they felt unsafe but not the gradual withdrawal and emotional numbness that preceded it.

Safety planning becomes more useful when it captures the full sequence rather than only the final stage.

The Stanley-Brown Safety Planning Intervention similarly emphasizes recognizing personal warning signs early so that someone knows when to retrieve and begin using the plan. Those warning signs are meant to be individualized because the same crisis will not look identical in every person.

BITES provides a structure for finding that individual pattern.

B: Behaviors

Behaviors are the things a person begins doing more often, less often, or differently as distress increases.

Some behavioral changes are visible to other people. Someone may isolate, stop answering messages, miss work, cancel plans, pace, argue more frequently, or abandon routines that usually provide stability. Other changes are more private, such as spending hours scrolling, staying in bed longer, neglecting meals, using substances more often, or repeatedly checking something connected to the source of distress.

The important question is not whether a behavior appears dramatic. The question is whether the behavior represents a meaningful change from the person’s usual pattern.

For example, spending an evening alone may be restorative for one person. For someone else, abruptly cutting off contact and refusing support may signal that their mental health is deteriorating. The behavior only makes sense when placed in context.

It is also useful to examine the function of the behavior. Isolation may reduce immediate social pressure while increasing hopelessness over time. Staying constantly busy may prevent difficult emotions from surfacing while also producing exhaustion. Reassurance seeking may offer brief relief but strengthen anxiety when certainty never lasts.

Identifying behaviors helps make distress observable. Instead of relying only on the broad feeling that something is wrong, the person can begin noticing specific actions that signal the need to use the safety plan.

I: Images

Mental images are often overlooked during safety planning, even though they can carry significant emotional intensity.

Some people experience distress primarily through words and thoughts. Others experience flashes, memories, imagined scenes, or vivid pictures of what they fear might happen. A person may repeatedly picture a relationship ending, imagine being rejected, replay a painful interaction, or see mental images connected to trauma, disappearance, death, or escape.

An image is not automatically the same as an intention. People can experience unwanted or frightening mental imagery without wanting to act on it. However, changes in the frequency, vividness, emotional impact, or controllability of those images can provide important information about escalating distress.

Images can also affect the body before the person has consciously identified what they are feeling. A mental picture may lead to panic, shame, anger, numbness, or an immediate urge to withdraw. When the image goes unnoticed, the emotional reaction may seem to come from nowhere.

Exploring imagery allows the person and clinician to ask more specific questions. What keeps replaying? Is the image based on a memory, a feared future, or an urge? Does it feel unwanted or comforting? Does it increase the desire to escape, disconnect, or take action?

These distinctions matter because vague questions about “negative thoughts” may miss an important part of the person’s internal experience.

T: Thoughts

Thoughts are often the most familiar part of mental health conversations, but they still require more detail than simply labeling them positive or negative.

During periods of escalating distress, thoughts may become more absolute, repetitive, self-critical, or hopeless. A person may begin thinking, “I cannot handle this,” “Nothing will change,” “I ruin everything,” or “People would be better off without me.” They may feel trapped between choices or become convinced that the current pain will continue indefinitely.

These thoughts often feel believable in the moment because emotional intensity narrows perspective. A temporary problem can begin to feel permanent. One painful interaction can appear to confirm every negative belief a person has about themselves.

The purpose of identifying these thoughts is not to argue with someone during a crisis or demand that they think positively. A safety plan needs to remain usable when the person’s ability to reason flexibly may already be reduced.

Instead, recognizing the thought can become a signal: “When my thinking becomes this absolute, I need to use my plan.”

Thoughts can also reveal the meaning a person is assigning to the situation. Two people may experience the same event and react differently because one interprets it as a temporary setback while the other experiences it as proof of rejection, failure, or permanent loss.

Understanding that meaning helps make the safety plan more responsive to the actual source of distress.

E: Emotions

People commonly associate crisis with sadness or fear, but emotional warning signs can take many forms.

Hopelessness, shame, anger, guilt, humiliation, panic, grief, loneliness, resentment, numbness, and feeling trapped may all be relevant. Some people become emotionally overwhelmed, while others become unusually detached or calm.

That emotional shutdown can be easy to misread. A person who was visibly distressed may suddenly appear composed because they feel disconnected, exhausted, or resolved rather than because the risk has passed.

It is important to identify both the emotion and the change in intensity. A person may experience anger frequently without being in crisis, but a sudden increase in rage, shame, or despair may signal that the situation is becoming more dangerous. Another person may notice that the absence of emotion is the stronger warning sign.

Emotions also tend to interact. Anger may be covering fear. Shame may follow panic. Loneliness may intensify hopelessness. Emotional numbness may develop after the person has felt overwhelmed for too long.

Naming these shifts gives the person more than one opportunity to respond. They do not have to wait until they feel completely unsafe. The plan can begin when familiar emotional markers first appear.

S: Sensations

The body often recognizes distress before the person can put the experience into words.

Physical sensations may include tightness in the chest, a racing heart, nausea, trembling, heat, heaviness, restlessness, dizziness, shallow breathing, numbness, pressure in the head, or the feeling of being disconnected from the body.

Someone may initially say, “I do not know what I was feeling,” while being able to describe that their chest was tight, their face felt hot, or their entire body became heavy. Those sensations provide an entry point for understanding what was happening.

Sensations are particularly important because they can be mistaken for evidence that something catastrophic is occurring. A racing heart may lead someone to believe they are losing control.

Numbness may create fear that they are no longer connected to reality. Severe exhaustion may reduce the person’s ability to access coping strategies even when they know what those strategies are.

Recognizing bodily warning signs allows coping to begin earlier. Grounding, paced breathing, temperature changes, movement, rest, sensory regulation, or contacting another person may be more effective before physiological arousal reaches its highest level.

The specific response depends on the person. The goal is not to create a generic list of coping skills. It is to connect the person’s actual bodily warning signs with strategies they are realistically able to use.

Looking at the Whole Sequence

The five BITES areas are interconnected.

A stressful event may trigger a mental image. The image activates a thought. The thought produces shame or panic. The emotion changes the person’s body. The physical discomfort then contributes to withdrawal, impulsivity, reassurance seeking, or another behavior.

The sequence can also begin in a different place. Poor sleep may produce physical exhaustion, which lowers emotional tolerance. Irritability may lead to conflict, which strengthens self-critical thoughts and mental images of rejection. The resulting shame may then increase isolation.

There is no single correct order.

The value of BITES is that it helps slow the sequence down enough to recognize where intervention may be possible. A person may not be able to prevent every trigger, but they may learn that chest pressure, repeated images of a recent conflict, and the urge to stop responding to others are early signals that they need support.

Without that awareness, the person may only recognize the crisis after their options already feel limited.

From Warning Signs to an Actionable Safety Plan

Identifying BITES is only the beginning. Awareness without an action plan may help someone understand the crisis but still leave them unsure what to do next.

A complete safety plan should translate warning signs into specific actions. The established six-step model includes recognizing warning signs, using internal coping strategies, identifying people and settings that offer distraction, identifying people who can provide direct support, listing professionals and crisis services, and making the environment safer.

The plan should answer practical questions such as:

• Which BITES signals mean I should begin using the plan?

• What can I safely do on my own at the earliest stage?

• Where can I go so that I am less isolated?

• Who can provide distraction without needing the full explanation?

• Who can I tell directly that I am becoming unsafe?

• Which therapist, crisis service, or emergency resource will I contact?

• What needs to change in my environment to reduce access to danger?

• What could prevent me from using the plan, and how can that barrier be addressed now?

  
  

A plan that says “use coping skills” or “call someone” may be too vague during an actual crisis. The person should know which coping strategy, which person, which number, and what they are going to say.

Specificity reduces the amount of decision making required when concentration and judgment may already be affected.

Safety Planning Should Be Collaborative

A safety plan should not be handed to someone as a worksheet and treated as complete.

The process requires conversation. The clinician and client need to identify warning signs in the client’s own language, evaluate which strategies have actually helped, discuss barriers, and make sure the plan is accessible when needed.

This collaborative approach matters because safety is personal. One person may regulate through quiet and reduced stimulation, while another becomes less safe when left alone. A crowded public place may provide helpful distraction for one client and intensify panic for another.

A useful plan reflects the person’s needs, environment, relationships, culture, abilities, and available resources. That emphasis on individualized care is consistent with the mission of In Situ Counseling & Coaching, which centers self-awareness, client empowerment, and personalized intervention rather than treating people as interchangeable problems.

The plan should also be reviewed over time. Warning signs change. Relationships change. Phone numbers change. Coping strategies that once worked may become less effective, while new sources of support may become available.

A safety plan is a living document, not a form that should disappear into a file after one conversation.

BITES Beyond Immediate Crisis

Although I developed BITES with safety planning and risk prevention in mind, the framework can also help people understand other patterns of emotional and behavioral escalation.

Someone managing panic may identify avoidance behaviors, catastrophic images, fearful thoughts, intense anxiety, and rapid heart rate. A person struggling with anger may notice pacing, images of confrontation, thoughts about disrespect, resentment, and heat through the face and chest. Someone trying to interrupt a trauma response may recognize withdrawal, intrusive imagery, beliefs about danger, fear or numbness, and physical disconnection.

The framework does not diagnose the experience. It organizes it.

That organization can help people recognize that their reaction is made up of several connected parts rather than one overwhelming and uncontrollable event. It also helps identify where different interventions may be useful.

A thought may require examination. A sensation may require regulation. An image may need grounding or trauma-focused treatment. A behavior may need interruption, replacement, or additional support.

Understanding the parts creates more places where change can begin.

Recognizing the Pattern Before the Peak

Safety planning works best before a crisis.

That sounds obvious, but many people do not create a plan until they are already overwhelmed. At that point, remembering coping skills, evaluating options, and deciding whom to contact can become much harder.

BITES helps create a clearer picture of the road leading toward the crisis. The person can begin recognizing, “When these behaviors, images, thoughts, emotions, and sensations start appearing together, I am moving into a period when I need to act.”

That awareness does not guarantee that every crisis will be prevented. Safety planning cannot eliminate all risk, and a framework cannot replace clinical judgment, emergency intervention, or ongoing treatment.

What the framework can do is increase the chance that distress will be noticed earlier, communicated more clearly, and connected to an action before the person feels completely trapped.

The goal is not merely to know that someone is struggling. The goal is to understand how their struggle develops and what can help interrupt the pattern while more choices are still available.

In Situ Counseling & Coaching offers therapy for adults, teens, and couples throughout Illinois. Safety planning, warning-sign identification, and ongoing assessment can be incorporated into treatment based on each client’s needs.

If you or someone you know is experiencing suicidal crisis or emotional distress in the United States, call 988, text 988, or use the 988 Lifeline online chat. If someone is in immediate physical danger, contact emergency services or go to the nearest emergency department.