74 | Top to Tap - World Suicide Prevention Day 2025 Special

Progress to Practice 

This World Suicide Prevention Day 2025 Special episode explores the three critical mindset shifts that bring suicide prevention from concept to care.

First, the shift from prediction to prevention — moving beyond static categories of “low, medium, high” risk to dynamic, forward-focused conversations that anticipate what lies ahead.

Second, the shift from past to future — learning from history but ensuring time is spent preparing for the immediate days and weeks where safety can truly be shaped.

Third, the shift from deficits to assets — not only naming what is wrong, but reconnecting people to their strengths, values, and relationships that hold them in distress.

Together, these shifts are woven into a deeper transformation: from TOP (The Only Professional) to TAP (Together As Partners). Relational safety grows not through control, but through shared responsibility, dignity, and connection.

This special episode also reflects on Creating Hope Through Action — a new song released on 10 September 2025 to mark World Suicide Prevention Day. Inspired by the idea that hope lives in small, shared actions, the song invites us all to consider how we can nurture hope for ourselves and for others.

We close by setting the stage for the next episode, where we’ll explore the four guiding tasks of the STEPS model: Step, Source, Span, and Scenario — practical anchors for turning mindset into method, and hope into action.

Connect with Assoc Prof Manaan Kar Ray on Linkedin
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Transcript

Welcome back to Protect, Season 4 episode 9. Top to Tap.

In this episode, we take the next step: moving from concept to practice. Up to now, we’ve explored STEPS as a framework, as a way of understanding how suicidal distress weaves itself into someone’s life. But frameworks alone aren’t enough. What matters is how they come alive in the room between two people.

That’s where relational safety begins.

Relational safety isn’t just about preventing immediate harm. It’s about creating a foundation where both the present and the future can feel survivable. It’s built through genuine curiosity, mutual respect, and a willingness to acknowledge the depth of another person’s pain. When someone feels seen in this way, they are more able to take part in their own recovery.

And to foster that, we as clinicians must face a shift in mindset. We need to move from thinking of ourselves as The Only Professional — what we call the TOP stance — to working Together as Partners, or TAP.

Think of clinical practice like an iceberg. Above the waterline, maybe thirty percent is visible: the questions we ask, the forms we fill, the interventions we offer. But beneath the surface lies the bigger mass—our beliefs, assumptions, values, even our unmet needs. It’s these hidden mindsets that often shape our practice more than we realise.

In a TOP mindset, the clinician stands as the expert: diagnosing, categorising risk, writing the care plan. That has its place, but it also positions the person in distress as a passive recipient of care. It risks stripping them of self-determination at precisely the time they most need to feel agency.

By contrast, TAP invites us into partnership. Yes, we bring our professional expertise. But the person in distress brings the wisdom of lived experience — knowledge of their triggers, their strengths, their fears, their survival strategies. TAP says: both voices matter. And it’s in that shared space that relational safety is built.

As we record this episode, it’s World Suicide Prevention Day—September 10—where we remember not only the lives lost to suicide, but also redouble our commitment to ending stigma and crafting systems of care that offer genuine belonging. The shift from TOP to TAP—moving from the clinician as sole holder of responsibility to walking alongside as partners—not only restores agency to the person in distress, but also reflects the spirit of this day and its 2025 theme: Creating Hope Through Action. It’s a reminder that every step we take toward partnership builds hope—and through that hope, we honour those whom we’ve lost.

Let’s hear how this plays out.

Ari’s Story – First Encounter

Ari is twenty-five. She has been carrying the echoes of her attempt for several months. Discharge brought her back into daily life, but not back into safety. The question that hums in the background of every day is simple, but heavy: Will I make it through?

In the traditional TOP frame, her first meeting with a clinician might unfold like this. The clinician begins by telling Ari that their priority is to ensure her safety. They explain that, given her attempt earlier this year, the best course of action is to keep her under a high level of observation.

Ari listens, but when she speaks, her words are laced with frustration: she says she feels like she is no longer in control of her own life. The clinician responds by reaffirming that, for now, most of the decisions will need to be made by the care team.

This exchange might keep Ari safe for a while, but it risks silencing her. She becomes contained, not connected — treated as an object of risk rather than a person with agency.

Now picture the same moment through the TAP stance. This time, the clinician acknowledges how tough things have been and tells Ari that her insights are really important in working out what will help. They ask what might make her feel safer and more in control.

Ari pauses, then admits she doesn’t know exactly. But she says that perhaps having some say in her care plan could help, because it feels like everything has been taken out of her hands.

The clinician agrees and suggests that they work together to shape a safety plan that reflects what Ari feels would be most helpful.

Here, the tone changes. Ari is no longer spoken about; she is spoken with. Her experience isn’t filed away; it is folded in. She begins to see herself not only as someone at risk, but as someone with a role in her own recovery.

In the Team Room

Later, Ari’s care team gathers — a psychiatrist, a psychologist, a nurse, and a couple of junior staff. The air in the room carries a familiar tension: the weight of responsibility.

Traditionally, the mindset has been that the team must carry it all. They decide, they hold responsibility, and if something happens, it is on their shoulders. That mindset may sound noble, but in truth it is crushing. Because even if Ari is followed up weekly, that amounts to perhaps an hour — one hour out of 168 in the week. Who holds the other 167 hours?

The psychiatrist names it plainly. “It cannot be us. Those hours belong first to Ari herself. Then, to her family and friends. To her GP. To her wider circle of support. If we believe we can somehow maintain her safety through all those hours, we deceive ourselves. And we burn out.”

This is the humility TAP asks of us. It shifts the question from “Who is responsible?” to “Who is responsible for what, when, where, and how?” If we cling to the first question, it always circles back to the clinician — I am responsible. But that is not true, and pretending otherwise makes care less safe in the long run.

In a TAP stance, Ari is recognised as the captain of her own vessel. She cannot outsource the steering of her ship — nor should she. What she can do is invite others to crew alongside her. The family may take responsibility for certain supports, friends for others. The GP plays their part, and so does the mental health team. Each thread is distinct, but together they strengthen the weave.

One of the junior staff reflects on the difference. “With TOP, we try to control the risk. Ari has little say. With TAP, she is invited in. She begins to feel like a partner, not a passenger. Yes, that means we need to be careful not to overwhelm her, but it also means she is more likely to tell us when she’s struggling — instead of hiding it until it escalates.”

The nurse nods, adding: “Even on an inpatient ward we can’t keep watch every second. Responsibility has to be shared. It’s about prudent risk — about equipping Ari to carry her safety when we’re not in the room. That’s not abandoning her. That’s preparing her for the long run.”

This is the essence of the shift. TAP is not about abdicating responsibility. It is about redistributing it, naming clearly who does what, and when, and how. It turns safety from a solitary task into a collective craft. It stops clinicians from carrying a burden they cannot realistically hold, and it stops patients from being treated as powerless.

In Ari’s case, this clarity is life-giving. When she hears that her voice matters in shaping her plan — when she sees that the team, her family, and her friends all have parts to play — she begins to feel less like a problem to be managed and more like a person reclaiming her life. And for her clinicians, it brings relief. They are no longer asked to hold the impossible. They are asked to hold their part — and to do it well.

This redistribution of responsibility is what operationalises the shift from TOP to TAP. And it sets the stage for the three practice changes that follow: moving from prediction to prevention, from past to future, and from deficits to assets.

From Prediction to Prevention

This brings us to the first of three practice shifts: the move from prediction to prevention.

For decades, suicide prevention has leaned on prediction. We tick boxes. We sort people into categories: low, medium, high risk. It feels structured, even scientific. But here’s the hard truth: prediction doesn’t save lives.

Research from the UK, where every suicide is formally counted and reviewed, has shown us just how poor we are at it. Even with decades of data, even with careful risk tools, we get it wrong most of the time. In fact, four out of five suicides occur in people we had not labelled as “high risk.” Think about that: 80% of the time, the prediction fails.

And even when we label someone as “low risk,” how much comfort does that really give? Ari herself is proof of this. She can wake up in the morning and feel steady, only to receive a letter in the afternoon — a rejection, a conflict, a painful reminder — and within hours the ground has shifted. Risk is not a category. It is a current. It ebbs and flows like weather. To try to predict it with accuracy is like trying to forecast lightning.

That is why we need a shift. We must stop treating risk as a fixed label, and start seeing it as a continuum that changes over time. And once we do that, the goal is not prediction. The goal is prevention.

With Ari, that sounds different in the room. Instead of saying, “Given your history, you’re high risk,” the clinician says, “As you return to daily life, Ari, what situations do you think will be most difficult? What moments feel most likely to pull you under? And how can we plan for those times together?”

Ari pauses, then admits: “When things pile up — especially if work or family feels overwhelming — I worry I won’t cope. That’s when the thoughts get loud again.”

Now the focus shifts. Instead of labelling Ari with a score, the conversation builds a plan. If those moments come, what can she reach for? Who can she involve? What practical steps can stop thoughts from hardening into action? This is prevention in action: not prediction of catastrophe, but preparation for possibility.

And prevention requires us to think about risk in more nuanced ways. We consider longitudinal risk — how Ari’s risk has fluctuated over weeks and months. Has she reached her worst point, or has she begun to turn a corner? We weigh the unaddressed risk — what vulnerabilities remain, even after safety planning. We notice the cross-sectional risk — how Ari’s current situation compares to others we see in similar settings: is she safer now at home than some who need inpatient care, or does she need more? And then we come to the clear and imminent risk — the here-and-now dangers that require immediate action, where safety planning must go further.

Taken together, these layers give us a living picture. Not a static label, but a dynamic map. They remind us that our job is not to predict who will die, but to prepare for how life can be carried safely forward.

In the team room, the reflection is clear. Instead of asking, “Who is responsible for Ari’s safety?” the question becomes, “Who is responsible for what, when, where, and how?” And in that weaving, Ari herself has a place. So do her family, her peers, her GP, her clinicians. Each has a thread in the net. Each has a role to play in prevention.

From Past to Future

The second practice shift we need to make is moving from past to future.

Think about the way most of our assessments go. We sit with someone for fifty minutes, and forty-five of those minutes are spent on the past. What happened last week? What symptoms showed up? What side effects have you had? What was your last attempt like?

The past matters. It gives us context. It helps us see patterns. But if that’s all we focus on, we end up with a beautifully detailed reconstruction of yesterday — and very little preparation for tomorrow.

With Ari, this pattern was obvious. Early in her follow-up, every session circled back to the attempt, the trauma, the triggers. She could recite the story almost by heart. And while those details gave her clinicians a sense of her history, Ari would leave the room with no new clarity about what to do if the same pain surged again tonight.

What was missing was the pivot. Not discarding the past, but deliberately carving out space for the immediate future — the next few hours, the coming night, the week ahead.

When her clinician finally made that turn, the tone shifted. Instead of only asking, “What’s happened since we last met?” they asked, “Ari, as you think about the next few days, what worries you most? What feels like it could pull you under?”

Ari paused, then said quietly, “Honestly, the evenings. That’s when the noise in my head gets loudest. I can get through the day when people are around, but once I’m alone, it’s harder.”

That answer opened the door to prevention. Together they began sketching a simple but powerful micro-plan. If evenings grew heavy, Ari would message her flatmate. If her sleep broke for more than two nights, she’d text her GP and call her sister before things spiralled. If a panic wave came, she’d lean on her grounding routine — five breaths, five senses, five minutes outside — before deciding her next move.

Small flags. Small actions. Small people she could call on.
Simple moves, but moves that turned foresight into safety.

And this isn’t just about Ari. It’s about our practice as a whole.

On the ward, nurses often ask about the last 24 hours before approving leave: “Did you sleep? How are you feeling today?” Those questions matter. But what about the leave itself? Rarely do we ask: “What do you expect might happen in the next six hours? What challenges might you face overnight? If those challenges come, what will you do?”

Vignette – Ari Preparing for Overnight Leave

Take Ari again, but this time on the ward. She has been stabilising, and the team agrees she’s ready for her first overnight leave. The standard questions come: “How have you been feeling today? Did you sleep last night? Any distress in the last 24 hours?” Ari answers honestly — she’s managed better, her sleep has improved, and nothing acute has flared.

On paper, she looks ready. But then the nurse shifts the frame: “Ari, what about tonight? When you’re home, what do you expect might be difficult? What will you do if the thoughts return when the house is quiet?”

Ari pauses. “Evenings are hardest. If I wake at 2 a.m., it can spiral quickly.”

Together, they sketch a mini-plan for just that scenario. If sleep fragments, she will try her breathing routine first. If she can’t settle, she’ll call the ward phone before the thoughts snowball. If panic peaks, she’ll come back early rather than waiting until morning. The plan is small, practical, and focused on the hours ahead — but it transforms the leave from a gamble into a guided step.

This is the shift in action: not just asking how Ari was yesterday, but preparing for what tonight might bring.

The same blind spot shows up in community care. A case manager might spend an entire hour reviewing what happened in the week gone by, but never ask what’s coming in the week ahead. Yet that’s where prevention actually lives — on the near horizon.

This is where the distinction between types of risk helps us sharpen our lens.

• Longitudinal risk tells us how Ari’s distress has shifted over time — her baseline, her worst point, and whether she’s turned a corner. That history matters, but it doesn’t tell us what happens tomorrow.
• Cross-sectional risk compares her to others at a similar point — someone in the community with GP support versus someone requiring inpatient care. That helps with placement, but not with the next panic wave.
• Unaddressed risk is what remains even after a safety plan — the vulnerabilities we haven’t yet solved. That helps us know where the gaps are.
• But what really matters in the here-and-now is clear and imminent risk — the immediate scenarios that could tip Ari from ideation into action. And those are only revealed when we dare to ask about the future.

That’s why the shift from past to future is essential. If we stop at the history, we do endless risk assessment but very little risk management. If we turn toward the horizon, we can actually modify the risk that lies ahead.

Back in the team room, the psychiatrist put it bluntly: “The past tells us why the cloth tore. But prevention only happens when we ask how it might fray tomorrow. Are we leaving enough space in our sessions for that? Are we really asking what could happen next week, or what might bridge the ideation–action divide again?”

The psychologist added, “The past informs the map. But the future decides the route.”

That’s the essence of this practice shift. We don’t discard the past — we honour it. But we make sure the horizon gets equal time. In practice, it sounds like: “When you picture the next seven days, where are the pinch points?” Or: “If Thursday night unravels, what’s the first thing you’ll try?”

For Ari, those questions mattered far more than another re-telling of her attempt. They gave her a sense of agency today. They reminded her that safety isn’t just about surviving yesterday’s pain — it’s about preparing for tomorrow’s challenges.

This is the shift from past to future: learn from yesterday, but tool up for what’s around the corner.

From Deficits to Assets

The third shift changes not just the practice, but the emotional temperature of care. It’s the move from deficits to assets.

For centuries, psychiatry — and medicine more broadly — has been deficit-focused. Symptoms cluster into syndromes, syndromes lead to diagnoses, diagnoses demand treatment. The underlying posture has been: something is broken, and we must fix it. That mindset trains us to be fixers, engineers of distress. But here’s the problem: when we sit only in the “what is wrong” frame, we generate more heat than light. We leave people like Ari feeling smaller, more helpless, and less in control. And helplessness, we know, is one of the roots of suicidal ideation.

What if instead we saw ourselves not as fixers, but as enablers? Not creators of assets, but reconnectors. Ari already has strengths, values, relationships, and hopes — they’ve simply become obscured by the fog of suffering. Our task is not to invent them, but to shine a light on what’s still alive. That’s where safety lives for the longer run.

Take Ari in one of her therapy sessions. Early on, the conversation circled endlessly around symptoms: the panic waves, the sleeplessness, the hopelessness. Each box ticked, each deficit noted, but Ari left feeling like a catalogue of what had gone wrong. The risk was recorded, but the energy in the room was heavy, static, draining.

Then the clinician tried a different tack. Instead of asking, “Why can’t you cope?” they asked, “When you do cope, even a little, what’s different?”

Ari hesitated. Then she said, “On the days when I go for a walk and take my camera, I feel a bit more human. I notice small things — the way light falls on leaves, or the shape of clouds. It doesn’t fix everything, but it makes me feel like me again.”

That answer was a thread. The clinician picked it up. They wove it into the plan: Ari would take short walks three times a week with her camera, even if just around the block. They added another thread: her younger cousin, who’d always looked up to her. A weekly check-in call where Ari could be the mentor again, not the patient. And another: the pride she once felt in her art projects, which she had abandoned. Together they planned a simple goal — finish one sketch by the end of the month, not to prove anything, but to remember what her hands could make.

These weren’t distractions. They were footholds. Protective factors disguised as ordinary routines. Each one reminded Ari that she was more than her pain — that she had agency, dignity, and strengths worth drawing on.

And here’s the thing: this approach doesn’t just help Ari. It helps us as clinicians too. If we imagine we are solely responsible for safety, we set ourselves up for burnout. Think about it: even with weekly follow-up, we might spend one hour with Ari out of 168. Who carries the other 167? Ari does. Her family. Her friends. Her GP. Perhaps her support worker. If we don’t recognise that, we not only exhaust ourselves — we make the system unsafe, because we fail to prepare Ari for the hours when we are not there.

That’s why shifting from deficits to assets is so important. It clarifies who holds what. It gives Ari back the dignity of risk and the right to practise safety in her own life. And it gives us, as practitioners, the humility to see our place: not as captains of her ship, but as navigators alongside her.

In Ari’s team meeting, the nurse put it plainly: “If I only see her for one hour a week, she’s carrying herself for the other 167. Assets are how we help her carry those hours.”

The psychiatrist added: “We’re not the whole story. Friends, cousins, photography, walks, music — these are not extras. They’re the fabric of her life. If we don’t weave them in, we’re left holding a rope that frays the moment we let go.”

So the questions we ask begin to change. Not “What’s the matter with you?” but “What matters to you?” Not “What is broken?” but “What still holds?” Not “Why can’t you cope?” but “When you do cope, what makes that possible — and how can we make more of it?”

This is the shift from deficits to assets. It doesn’t deny risk — it reframes safety as something built from the person’s own life, values, and relationships. It moves us from fixer to enabler, from I-know-best to I-walk-with-you. And it embodies the larger mindset shift from TOP to TAP.

Because when we cast light on assets instead of heat on deficits, Ari isn’t reduced to a diagnosis. She becomes, once again, the captain of her own ship.

Bringing the Three Shifts Together

When these shifts come together — prediction to prevention, past to future, and deficits to assets — the stance in the room changes. Safety is no longer imagined as something held solely by the professional. Instead, it becomes a shared craft. Responsibility is clarified: not “Who is responsible?” but “Who is responsible for what, when, where, and how?”

For Ari, that shift is felt in very practical ways. Instead of being categorised as “high risk” or “low risk,” she is invited to prepare for the future: planning for evenings when the noise in her head grows loud, or rehearsing small steps she can take if tomorrow feels overwhelming. Instead of endlessly re-telling the story of her attempt, she is supported to imagine what next week might hold and how to face it. And instead of being reduced to symptoms and diagnoses, she is reconnected with the strengths that have always been part of her: her creativity, her values, her capacity for connection.

This is not just good for Ari — it is good for us as clinicians. We cannot carry all 168 hours of someone’s week when we only see them for one. Believing otherwise is a recipe for burnout and a false promise of safety. What we can do is walk alongside Ari, helping her clarify her role, her family’s role, her community’s role, and our role as part of her care team. That clarity distributes responsibility in a way that is sustainable, and it gives Ari back the dignity of risk — the right to practise safety in her own life, to fail and learn, to stumble and rise again.

These shifts do not mean we ignore the past or minimise deficits. Of course we need to know Ari’s history. Of course we need to recognise her vulnerabilities. But if we spend all our energy looking backwards or cataloguing what is wrong, we leave no space for new beginnings. The heart of prevention lies in the horizon: in anticipating challenges, strengthening assets, and preparing for the moments when risk will fluctuate.

And at the core of this way of working are values. Not just Ari’s values — though reconnecting her with what gives meaning, joy, and direction is central — but ours as well. Values like curiosity, compassion, humility, and hope. These values remind us that our task is not to fix but to enable; not to control but to collaborate; not to silence but to listen.

When we practise in this way, relational safety stops being an idea and starts becoming something you can feel in the room. Conversations become kinder and more candid at once. Plans become specific, shared, and realistic. Ari is not just kept safe for a moment, but equipped for the long run.

Closing Reflections – World Suicide Prevention Day Special

So where does this leave us?

Today we’ve explored the mindset shifts that sit at the heart of relational safety. We’ve seen why moving from TOP to TAP — from The Only Professional to Together as Partners — matters not only for the people we serve but also for us as practitioners. We’ve seen why prediction must give way to prevention, why the past must be balanced with the future, and why deficits must be held alongside assets.

These shifts are not small adjustments. They reshape the whole stance we take in the room. They restore dignity, agency, and the right to hold responsibility for one’s own life. They protect us, as clinicians, from carrying an impossible burden. And most importantly, they lay the ground for safety that is real, relational, and sustainable.

But mindset alone is not enough. It needs to find form in practice. And that’s where we’ll turn next. In our next episode, we’ll look at four guiding tasks within the STEPS model itself:

• Step — locating where the person is in the model, whether FABRIC, THREAD, NEEDLE, TIP, MEND, or FLOW.
• Source — uncovering the emotional pain at the heart of their distress.
• Span — tracing how their risk ebbs and flows over time, from worst points to turning points.
• Scenario — imagining the future together, planning for both stable and fluid risks.

These four lenses will help us anchor the shifts we’ve talked about today into daily practice, turning posture into method, and good intentions into tangible steps.

And yet, this episode is more than another chapter in our series. It is our World Suicide Prevention Day special. Earlier this week, on the 10th of September, we released a song — Creating Hope Through Action. The song is our reminder that hope is not abstract. It is something we can nurture for one another through the choices we make, the questions we ask, and the threads of connection we hold onto.

Three years ago, when this podcast began on 6 January 2022, we set out to share a single message: that relational safety saves lives. Across these episodes, we’ve returned to that theme again and again. But today it felt right to bring it together — because the shifts we’ve named are not just clinical strategies. They are acts of hope.

So as you listen on this World Suicide Prevention Day, let this episode stay with you. Remember that hope is not fragile. It is actionable. It is created when we walk together as partners, when we make room for futures that feel survivable, when we see not only the deficits but also the assets that keep people tethered to life.

This is why today’s episode is special. It honours the lives we have lost. It holds space for those still struggling. And it reminds us that all of us, in our conversations, in our care, in our communities, can play a part in creating hope through action.