Participants emphasized the value of receiving suggestions, guidance, and emotional support from the system, especially when they experienced overwhelming emotions, uncertainty, or difficulty practicing parts of their safety plan.

Across interviews, participants shared that they were interested in having automated decision aids that informed them about professional, supportive people or organizations they could ask for help if a crisis was escalating. For instance, W1-P2 noted how professional connections offered by the system can be helpful, “If the automated system recognizes signs of imminent suicidality in me, if it said something like, ‘I’m noticing that you’re deep in crisis’ or ‘I’m noticing that you’re having some pretty intense warning signs. Would you like to be connected to a trained crisis counselor?’” Participants further expressed the need for the system to inform a decision regarding when they should actually contact supportive individuals. W2-P9 described that, “I can imagine it maybe prompting you to talk to someone. For example, if you’re working on this tool, and you’re expressing that you’re kinda struggling right now, and you need a resource, or you to need some kind of help. I wonder if it could prompt you to have you reach out to this friend yet.”

Participants also valued prompts that fostered idea generation or brainstorming of coping strategies. Participants noted that this would be especially useful when building lists of warning signs, safe, trusted others to contact, and coping skills. The process of brainstorming needed to feel individualized based on the participants’ own experiences. As W2-P9 imagined that, “I guess that’s what I’m trying to say is if it were to suggest things based on your own experience it could kind of guide you through that process of identifying what you’re experiencing.” To accomplish this, 1 participant emphasized the importance of open-ended, reflective prompts that could elicit meaningful input and encourage deeper engagement:

Another element of self-guided digital safety planning that participants thought would be useful to personalize was generating example messages one could send to trusted others if they needed a distraction or help staying safe. Contacting trusted others for distraction and help is a key step in the safety planning process. However, knowing what to say to these individuals to elicit the required distraction or help can be difficult in a crisis state. Therefore, participants noted that having example messages or scripts they could adapt or use would be helpful for initiating difficult conversations about STB (eg, disclosing distress to a trusted other). When the interviewer asked whether the participant was interested in modifiable example text messages for reaching out, “How much would you be interested in language suggestions that you could then modify? Texts that you could then modify like, ‘Here is how to start a conversation with somebody that you were wanting to. Here’s a text message with some example language for how to open a conversation around this.’” Participant W2-P5 responded, “Yeah, I’d be interested in something like that. Sure.” Some participants reflected on the utility of a system suggesting script language that could facilitate help-seeking. Participant W2-P9 stated, “It could give you that prompt to reach out to someone, and then it could optionally offer a prompt. Cause that could be definitely helpful for sure.”

Participants emphasized the importance of personalizing the delivery of automated affirmations following the completion of safety planning sections, particularly when they felt unsure about how to complete certain parts of the safety plan. One participant, W1-P3, shared that when generating aspects of the safety plan, they are often uncertain. Having automated affirming messages could build self-confidence and suicide-related coping confidence: “there are some things in there that I can’t even answer right now cause I don’t even have the answers to. So, like I was just thinking maybe something that could be there that’s kind of like, ‘Oh, it’s okay. Don’t panic yet,’ kind of like a little reassurance…maybe just trying to relieve some pressure.”

Other participants explained that system-initiated positive affirmations could help alleviate the burden of reaching out for help, further reinforcing help-seeking as a continuous, positive habit:

Participants emphasized the importance of receiving personalized, trustworthy, and relevant coping resources from the system, spanning crisis helplines, online tools, and other external coping resources.

Participants shared that they wanted a digital SPI to automatically identify and provide them with lists of localized resources based on the user-provided location information. Localized resources were viewed as useful because they are more accessible and may offer services that are more relevant to individuals’ needs based on their location. As 1 participant explained:

This participant highlighted a desire for the system to automatically tailor mental health resources based on their geographic information. They shared how regional resources could enhance the relevance of the services for individuals who experience STB, as well as help them prepare more effectively for moments of distress by providing knowledge of the available, geographically tailored mental health service infrastructure.

In general, participants emphasized the importance of comprehensive and diverse resource provision within a self-guided digital safety planning tool that offers users information about services across different levels of need, spanning crisis resources, emergency care, and everyday well-being support. Participants valued crisis resources such as crisis helplines and text lines, noting that the intervention system could automatically organize and present the relevant resource to reduce cognitive burden during moments of distress. Other participants expressed interest in noncrisis supports such as warmlines, which extend care beyond crisis moments and promote overall well-being while fostering ongoing everyday support. In addition, some participants stressed the need for clarity about available resources, particularly emergency care. For example, W1-P1 noted confusion about emergency care options and what to expect, explaining, “it’s sad, I should know more about this [emergency departments]…with the place where you end up staying for like a week when stuff goes really shitty.”

Rather than relying on fixed schedules or uniform approaches, participants preferred tools that gave them a choice over when, how, and how much to engage, especially during moments of emotional overwhelm or executive dysfunction. Participants expressed a desire to set their own latency for responding—the time allowed for a user to respond to a message or prompt within the intervention before the system automatically advances. Participants shared that, especially as it related to a text message–delivered intervention, variation in energy levels and motivation could become a barrier to meaningful engagement in creating a digital safety plan. By controlling the response latency allowed, participants could adjust the message or prompt cadence according to their energy and motivation levels. One participant noted the ability to respond depending on a user’s motivation or energy level. As W2-P7 articulates, “with text messages you have more of a choice with how long it takes for you to respond, and whether you do respond.” Others echoed this idea and described that a substantial message latency could be especially helpful for supporting continued motivation to use the intervention. As W2-P8 put it, “...letting the system know you need more time...my first thought was one day needs to pass, but I can see the benefits of eight hours. I feel like that seems like it’s enough time for maybe something to happen in between those messages for a response.”

Relatedly, participants had varied preferences for the cadence of safety planning. Some preferred completing safety plans in 1 sitting, offering a sense of closure and continuity, while others appreciated the option to work through it section by section across multiple days. As W1-P4 explained, comorbid symptoms made long tasks difficult, so they desired the option to break safety planning into smaller, less overwhelming segments.

On the other hand, another participant expressed a preference for completing safety planning all at once:

W2-P7 viewed the creation of a safety plan as a task that was difficult or aversive in some fashion and preferred to complete the safety plan within a short time frame. Some participants valued the efficiency of safety planning in a single sitting, reinforcing the need for customizable pacing options that accommodate individuals’ preferred working styles and diverse needs.

Finally, participants identified the need to set the timing of messages to align with their own mental state, context, and vulnerability windows. Participants cautioned that poorly timed prompts sent when individuals were unavailable (eg, during class or low-energy periods) could be ineffective and intrusive. Participants stressed the importance of matching system outreach to user readiness and mental state. As W2-P9 pointed out, “I think random prompts might be challenging and less effective…for example, if I’m in class, or if I’m just in a place where I don’t have a lot of mental energy, or I am struggling that day, that’s not the best time to try and write that sort of thing.” Demonstrating the importance of the timing of prompts, 1 participant suggested that users should be able to identify high-risk times, such as evenings or periods of anticipated isolation, so the system can check-in with them during those vulnerable moments. As W1-P4 put it, “If there was some way to have set times when you know you’re likely to be alone like, for example, in the evening…and then maybe it could check up on you in those times.”

Participants wanted the ability to actively refine, reorder, and organize the content of their safety plans over time. When thinking about organizing their safety plans, participants shared that changing the order of content was helpful, allowing them to prioritize the most effective coping strategies or key contacts at the top so that essential information remains easily accessible during high-stress moments. As W1-P2 stated, “I think it’s important to think about that when I’m developing the safety plan. And to put that at the beginning so that when I’m really in crisis, I don’t need to read through the whole plan.”

Though less well represented among participants, 1 participant expressed interest in visual customization. This included naming the system, customizing the appearance of intervention messages, and adding meaningful images.

W1-P4 highlights that visual customization, while less widely discussed, could further enhance ownership and individualization of the system.

This study aimed to identify key decision points in self-guided digital safety planning and examine how personalization and customization allocate autonomy and decision authority across these points. Participants identified 3 classes of decision points: system-driven personalization, user-driven customization, and interactions between automated guidance and user control. These classes aligned with 3 primary domains of the 5W1H framework. Decisions about what support is delivered were primarily associated with system-driven personalization, including tailored suggestions, prompts, affirmations, and resources. Decisions about when intervention occurs were primarily associated with user-controlled timing, pacing, and responsiveness. Decisions about how users participate and exert control included customization of safety-plan content and layout, as well as the ability to authorize, modify, or decline system-initiated actions. The remaining dimensions, who the system is responding to, where the user is situated, and why the user authorizes or resists an action, functioned as contextual conditions that shaped these decision points across domains rather than as separate categories. This structure highlights how personalization and customization jointly allocate control between users and systems during moments of suicidal distress.

The what domain concerns the content and resources the system should tailor or provide. Participants in the study emphasized the importance of systems automatically providing core safety planning support, particularly crisis resources, coping suggestions, and guidance that can be accessed without requiring complex decision-making during distress. Consistent with prior digital SPIs, participants valued immediate access to crisis resources and individualized coping strategies [36-38]. Our findings extend the existing literature by specifying that the selection and tailoring of crisis resources based on factors such as geography, passively sensed data that might suggest a crisis state, and potential relevance represent a central decision point where systems may be well suited to personalize support and present relevant information to users while remaining nondirective. Critically, decisions about what is most relevant are conditioned by the context of who the user is at any specific moment, for example, their behavioral state or where they are located, which determines the relevance of crisis resources.

Within this system-level scope, participants highlighted several forms of supportive content that should be personalized. One form of content that participants wanted personalized was reflective prompts. Reflective prompts within a self-guided digital SPI could be designed to help users generate individualized content, increase awareness of symptoms, and identify personalized coping resources. Reflective prompts are commonly supported in DMHIs through free-text engagement [14,39,40]. Prior work has used open-ended reflective prompts that invite and incorporate user-generated input, which supports the personalization of safety plans [39]. Additionally, participants emphasized the value of system-generated example outreach messages. Users of DMHIs benefit from social support features [41,42], and modifiable preprogrammed messages [43] have the potential to reduce cognitive and emotional barriers to social outreach—a protective factor for suicide prevention. These preferences point to specific content decisions that may be well suited for system-level personalization, particularly when the goal is to ease cognitive and emotional demands without directing user behavior during a crisis.

The when domain concerns message timing, response latency, and whether safety planning occurs in 1 session or across multiple interactions. Participants emphasized the need to consider when the system intervenes. Timing decisions shaped whether participants imagined that they could engage with prompts and safety planning tasks given momentary cognitive and emotional capacity. Noting that readiness to engage varies across contexts due to dynamic cognitive and emotional states (the who dimension of the 5W1H), participants expressed a preference for flexibility in when prompts are delivered and how much time is allowed for response. This preference aligns with prior digital suicide prevention research indicating that effective intervention should identify moments of individual vulnerability and receptivity to optimize timing of intervention components, ensuring that interventions are delivered when users are both in need and willing to engage [11]. Specifically, Bentley et al [38] showed that monitoring real-time suicide risk to dynamically guide the delivery of intervention components increased subsequent use of coping strategies, illustrating that when to intervene is inseparable from who is being monitored. Timing decisions, therefore, need to be personalized to an individual’s momentary state.

Beyond moment-to-moment prompting, participants identified the pacing of safety plan completion as a distinct temporal decision point that shaped both effort and engagement. Some preferred completing safety planning in a single session, while others favored distributing tasks across multiple interactions based on attentional and emotional resources. Although prior reviews [41] found that fully unsupervised, self-paced digital interventions may show weaker clinical effects than supervised, clinician-paced models, our findings suggest that pacing itself may be a design decision that can structure and scaffold user effort at key moments, especially in crisis contexts, when cognitive load and capacity may change rapidly.

The how domain concerns how users structure the safety plan and retain authority over system actions. This study identifies user control as a class of decision points in self-guided digital safety planning, specifying where authority should remain with users rather than be assumed by the system. Participants’ preferences for user-controlled decision points reflect young adults’ preferences for self-reliance and autonomy [8,9] (ie, the why in the 5W1H) and suggest that customization functions as a structural response to the motivational barriers that can limit engagement with support. Participants described customization operating at multiple levels. At the interface level, users valued the ability to adjust visual presentation and layout, including reordering safety plan components so that the most salient strategies or contacts are immediately accessible during distress. Similar forms of visual and structural customization have been implemented in prior SPI tools and are associated with good usability [18,44].

The why domain concerns the conditions under which users are willing to authorize or resist system-initiated actions. Participants consistently emphasized that automated personalization in digital SPIs should remain contingent on explicit and revisitable user authorization, reflecting a preference for systems that function as decision aids rather than autonomous actors. This preference aligns with prior work showing that autonomy-related orientations shape help-seeking among young adults, with stronger preferences for self-reliance associated with lower intentions to seek formal mental health support [9]. More broadly, engagement with DMHIs depends on perceived fit as well as autonomy-, privacy-, and confidentiality-related considerations [24].

Building on this foundation, the present findings highlight the importance of integrating system-level and user-level decision points to support both adaptiveness and user control. While prior reviews suggest that personalization and customization can independently promote engagement, usefulness, and perceived relevance [18,24], our results highlight how they function together. Participants described wanting systems that could automatically detect warning signs and generate appropriate suggestions, such as proposing outreach to identified contacts during periods of heightened risk. These system-level decision points were expected to reduce the burden by supplying timely, personalized guidance during distress. At the same time, participants consistently emphasized that such actions should only occur with explicit user permission and the ability to override or revise system behavior.

This interplay underscores that effective digital SPIs must balance automation with user authority, embedding decision points that allow users to retain control over high-stakes actions while still benefiting from adaptive support. This design orientation aligns well with mixed-initiative interaction between users and computer automation [45] and with guidelines for human-AI interactions [46], which conceptualize control as dynamically shared between users and systems depending on contextual uncertainties, tasks, and user capacities. Within this framework, personalization reduces cognitive and emotional load by proactively generating relevant content, while customization preserves agency by enabling users to authorize, modify, or decline system-initiated actions. Importantly, participants viewed this balance as dynamic, requiring systems to support the ongoing renegotiation of control as needs and contexts change. Our findings suggest that at certain key decision points, there must be an integration of automated and user-controlled decisions.

These findings suggest 3 design implications for self-guided digital suicide prevention interventions. First, digital suicide prevention interventions should incorporate multistage pacing options, allowing users to complete suicide prevention activities (eg, safety planning tasks) either in a single session or across multiple interactions, based on momentary capacity and context (addressing the when domain). Prior research on self-guided DMHIs demonstrates that allowing users to progress at their own speed, rather than following a rigid timeline, supports overcoming barriers to engagement by accommodating fluctuations in emotional and cognitive resources [47,48]. Second, designers should implement structured customization, in which users exercise meaningful control within system-designed, constrained options to preserve agency while preventing excessive complexity or burden (addressing the how domain). This can be executed by allowing the users to select their preferences from a list of system-provided options [20]. For instance, users can choose their preferred visual content from a list. Third, systems should adopt adaptive but permissioned automation (addressing the what, who, and where domains). While automated personalization can reduce burden, such automation should be mediated through explicit user consent and ongoing opportunities for adjustment. Decision points related to permissions, such as contacting emergency resources or notifying trusted individuals, should be revisitable and require clear user consent before action.