This publication was funded by the U.S. Department of Health and Human Services (DHHS), Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services (CMHS), and prepared by Mary Ellen Copeland, M.S., M.A., under contract number 99M005957. Acknowledgment is given to the many mental health consumers who worked on this project offering advice and suggestions.
The opinions expressed in this document reflect the personal opinions of the author and are not intended to represent the views, positions, or policies of CMHS, SAMHSA, DHHS, or other agencies or offices of the Federal Government.
All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, DHHS.
For additional copies of this document, please call SAMHSA's National Mental Health Information Center at 1-800-789-2647. Originating Office Center for Mental Health Services Substance Abuse and Mental Health Services Administration 5600 Fishers Lane, Room 15-99 Rockville, MD 20857 SMA-3720 07/2003
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Developing a Wellness Toolbox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Daily Maintenance Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Triggers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Early Warning Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
When Things Are Breaking Down or Getting Worse. . . . . . . . . . . . . . . . . . 7
Crisis Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Using Your Action Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Further Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
This booklet contains information, ideas, and strategies that people from all over the country have found to be helpful in relieving and preventing troubling feelings and symptoms. The information in this booklet can be used safely along with your other health care treatment. You may want to read through this booklet at least once before you begin working on developing your own action plans for prevention and recovery. This can help enhance your understanding of the entire process. Then you can go back to work on each section. You may want to do this slowly, working on a portion of it and then putting it aside and revise it on a regular basis as you learn new things about yourself and ways you can help yourself to feel better.
Charles G. Curie, M.A., A.C.S.W.
Substance Abuse and Mental Health
Bernard S. Arons, M.D.
Center for Mental Health Services
Do you experience feelings and symptoms that are upsetting, that keep you from being the way you want to be and doing the things you want to do? Many people who have troubling emotional, psychiatric, or physical symptoms have made great advances in learning how to do things to help themselves get well and stay well. One of the most frustrating stages of recovering your health is when you realize that you can do many things to help yourself stay well but you can't figure out a way to do them regularly. It is easy to forget simple things that you know, especially when you are under stress or when your symptoms are beginning to flare up. The action plans for prevention and recovery described in this booklet were devised by people who experience emotional or psychiatric symptoms. They developed ways to deal with their need for structure in their lives that actively support their health. The plans are simple, low-cost, and can be changed and added to over time as you learn more and more. Anyone can develop and use these plans for any kind of health concern.
People using this system report that by being prepared and taking action as necessary, they feel better more often and have improved the overall quality of their lives dramatically. One person said, "Finally, there's something I can do to help myself."
To develop this plan, the only materials you need are a three-ring binder, a set of five tabs or dividers, and lined three-hole paper. Before you begin working with the tabbed sections, you will create a resource list to keep in the beginning of your binder. This section is called the Wellness Toolbox. In it you identify and list the things you use to help yourself feel better when you are having a hard time. Some of them are things you know you must do, like eating healthy meals and drinking plenty of water; others are things you could choose to do to help yourself feel better. You can also list things you would like to try using to keep yourself well or to help yourself feel better. You will refer to this list for ideas when you are developing the tabbed sections of your plan.
You can get more ideas for your Wellness Toolbox by noticing the good things you do as you go through your day, by asking your friends and family members for suggestions, and by looking into self-help resource books. Write down everything, from really easily accessible things, like taking deep breaths, to things you only do once in a while, like getting a massage. This is a resource list for you to refer back to when you are developing your plans. Your Wellness Toolbox works best for you if you have enough entries so you feel you have an abundance of choices. Just how many entries you have is up to you. If you feel positive and hopeful when you look at the list, then you have enough. You can continue to refine your Wellness Toolbox over time, adding to your list whenever you get an idea of something you'd like to try, and crossing things off your list if you find they no longer work for you.
Once you've gotten your Wellness Toolbox underway, insert it into your notebook. Then, insert your five tabbed dividers, with several sheets of paper after each tab and a supply of paper at the end of the notebook.
On the first tab write "Daily Maintenance Plan." If you haven't already done so, insert it in the binder along with several sheets of paper.
On the first page, describe yourself when you are feeling all right. If you can't remember, or don't know how you feel when you are well, describe how you would like to feel. Make it easy. Make a list. Some descriptive words that others have used include: bright, talkative, outgoing, energetic, humorous, reasonable, argumentative. Now when you aren't feeling very well you can refer back to how you want to feel.
Some people use their plans to make a list of their dreams and goals, too. If you think you would find it help ful, make a list of goals you could work toward. You can write down far-fetched goals or more easily achievable ones. It is really helpful to remember your goals and dreams so you always have something to look forward to. Then, you can identify steps to take to achieve them and incorporate these small steps into your daily maintenance plan.
On the next pages, describe those things you need to do every day to maintain your wellness. Use your Wellness Toolbox for ideas. Writing these things down and reminding yourself daily to do them is an important step toward wellness. When you start to feel "out of sorts," you can often trace it back to "not doing" something on this list. Make sure you don't put so many things on this list that you couldn't possibly do them all. Remember, this is a list of things you must do, not things you would choose to do.
On the next page, make a reminder list for yourself of things you might need to do. Check the list each day to ensure that you do those things that you need to do sometimes to keep yourself well. You'll avoid a lot of the stress that comes from forgetting occasional but important tasks.
That's the first section of the book. Cross out items if they stop working for you, and add new items as you think of them. You even can tear out whole pages and write some new ones. You will be surprised how much better you will feel after just taking these positive steps on your own behalf.
Triggers are external events or circumstances that may produce very uncomfortable emotional or psychiatric symptoms, such as anxiety, panic, discouragement, despair, or negative self-talk. Reacting to triggers is normal, but if we don't recognize them and respond to them appropriately, they may actually cause a downward spiral, making us feel worse and worse. This section of your plan is meant to help you become more aware of your triggers and to develop plans to avoid or deal with triggering events, thus increasing your ability to cope and staving off the development of more severe symptoms.
Write "Triggers" on the second tab and insert several sheets of paper. On the first page, write down those things that, if they occur, might cause an increase in your symptoms. They may have triggered or increased symptoms in the past. It may be hard to think of all of your triggers right away. Add triggers to your list whenever you become aware of them. It is not necessary to project catastrophic things that might happen, such as war, natural disaster, or a huge personal loss. If those things were to occur, you would use the actions you describe in the triggers action plan more often and increase the length of time you use them. When listing your triggers, write those that are more possible or sure to occur, or which may already be occurring in your life.
On the next page, develop a plan of what you can do, if a trigger come up, to comfort yourself and keep your reactions from becoming more serious symptoms. Include tools that have worked for you in the past, plus ideas you have learned from others, and refer back to your Wellness Toolbox. You may want to include things you must do at these times, and things you could do if you have time or if you think they might be helpful in this situation.
If you are triggered, and you do these things and find they are helpful, then, keep them on your list. If they are only somewhat helpful, you may want to revise your action plan. If they are not helpful, keep looking for and trying new ideas until you find the most helpful. You can learn new tools by attending workshops and lectures, reading self-help books, and talking to your health care provider and other people who experience similar symptoms.
Early warning signs are internal and may or may not arise in reaction to stressful situations. In spite of your best efforts to take care of yourself, you may begin to experience early warning signs, subtle signs of change that indicate you may need to take further action. If you can recognize and address early warning signs right away, you often can prevent more severe symptoms. Reviewing these early warning signs regularly helps you to become more aware of them. Write "Early Warning Signs" on the third tab and insert several more sheets of paper in your binder.
On the first page, make a list of early warning signs you have noticed in yourself in the past. How do you feel when you know you are not feeling quite right? How did you feel just before you had a hard time in the past or when you noticed that your habits or routines changed?
If you want to, ask your friends, family members and other supporters for early warning signs that they've noticed. On the next pages, develop an action plan for responding to your early warning signs, referring to your Wellness Toolbox for ideas. Some of the things you list may be the same as those you wrote on your Triggers Action Plan. If you notice these symptoms, take action while you still can.
Again, if you use this plan and it doesn't help you feel better, revise your plan or write a new one. Use your Wellness Toolbox and other ideas from workshops, self-help books, your health care providers, and other people who experience similar symptoms.
In spite of your best efforts, your symptoms may progress to the point where they are very uncomfortable, serious, and even dangerous. This is a very important time. It is necessary to take immediate action to prevent a crisis or loss of control. You may be feeling terrible and others may be concerned for your wellness or safety, but you can still do the things that you need to do to help yourself feel better and keep yourself safe.
Write "When Things are Breaking Down," or something that means that to you, on the fourth tab. On the first page, make a list of symptoms that indicate to you that things are breaking down or getting much worse. Remember that symptoms and signs vary from person to person. What may mean "things are getting much worse" to one person may mean a "crisis" to another. Your signs or symptoms might include-
On the next page, write an action plan that you think will help reduce your symptoms when they have progressed to this point. The plan now needs to be very direct, with fewer choices and very clear instructions.
As with the other plans, make note of the parts of your plan that work especially well. If something doesn't work or doesn't work as well as you wish it had, develop a different plan or revise the one you used-when you are feeling better. Always look for new tools that might help you through difficult situations.
Identifying and responding to symptoms early reduces the chances that you will find yourself in crisis. It is important to confront the possibility of crisis, because in spite of your best planning and assertive action in your own behalf, you could find yourself in a situation where others will need to take over responsibility for your care. This is a difficult situation-one that no one likes to face. In a crisis, you may feel as if you are totally out of control. Writing a clear crisis plan when you are well, to instruct others about how to care for you when you are not well, helps you maintain responsibility for your own care. It will keep your family members and friends from wasting time trying to figure out what to do for you. It relieves the guilt that may be felt by family members and other caregivers who may have wondered whether they were taking the right action. It also insures that your needs will be met and that you will get better as quickly as possible.
You need to develop your crisis plan when you are feeling well. However, you cannot do it quickly. Decisions like this take time, thought, and often collaboration with health care providers, family members and other supporters. Over the next few pages, information and ideas that others have included in their crisis plans will be shared. It can help you develop your own crisis plan.
The crisis plan differs from the other action plans in that it will be used by others. The other four sections of this planning process are implemented by you alone and need not be shared with anyone else; therefore you can write them using shorthand language that only you need to understand. However, when writing a crisis plan, you need to make it clear, easy to understand, and legible. While you may have developed other plans rather quickly, this plan is likely to take more time. Don’t rush the process. Work at it for a while, then leave it for several days and keep coming back to it until you have developed a plan you feel has the best chance of working for you. Once you have completed your crisis plan, give copies of it to the people you name in this plan as your supporters.
On the fifth tab write "Crisis Plan" and insert at least nine sheets of paper. This crisis plan sample has nine parts to it, each addressing a particular concern.
Write what you are like when you are feeling well. You can copy it from Section 1, Daily Maintenance Plan. This can help educate people who might be trying to help you. It might help someone who knows you well to understand you a little better, for someone who doesn't know you well-or at all-it is very important.
Describe symptoms that would indicate to others that they need to take over responsibility for your care and make decisions on your behalf. This is hard for everyone. No one likes to think that someone else will have to take over responsibility for his or her care. Yet, through a careful, well-developed description of symptoms that you know would indicate to you that you can't make smart decisions anymore, you can stay in control even when things seem to be out of control. Allow yourself plenty of time to complete this section. Ask your friends, family members, and other supporters for input, but always remember that the final determination is up to you. Be very clear and specific in describing each symptom. Don't just summarize; use as many words as it takes. Your list of symptoms might include-
In this next section of the crisis plan, list these people who you want to take over for you when the symptoms you listed in the previous section arise. Before listing people in this part of your plan though, talk with them about what you'd like from them and make sure they understand and agree to be in the plan. They can be family members, friends, or health care providers. They should be committed to following the plans you have written. When you first develop this plan, your list may be mostly health care providers. But as you work on developing your support system, try to add more family members and friends because they will be more available.
It's best to have at least five people on your list of supporters. If you have only one or two, when they go on vacation or are sick, they might not be available when you really need them. If you don't have that many supporters now, you may need to work on developing new and/or closer relationships with people. Ask yourself how best you can build these kinds of relationships. Seek new friends by doing things such as volunteering and going to support groups and community activities. (See Making and Keeping Friends a Mental Health self-help booklet in this series)
In the past, health care providers or family members may have made decisions that were not according to your wishes. You may not want them involved in your care again. If so, write on your plan, "I do not want the following people involved in any way in my care or treatment." Then list those people and why you don't want them involved. They may be people who have treated you badly in the past, have made poor decisions, or who get too upset when you are having a hard time.
Many people like to include a section that describes how they want possible disputes between their supporters settled. For instance, you may want to say that if a disagreement occurs about a course of action, a majority of your supporters can decide or a particular person will make the determination. You also might request that a consumer or advocacy organization become involved in the decision making.
Name your physician, pharmacist, and other health care providers, along with their phone numbers. Then list the following-
There may be particular treatments that you like in a crisis situation and others that you would want to avoid. The reason may be as simple as "this treatment has or has not worked in the past," or you may have some concerns about the safety of this treatment. Maybe you just don't like the way a particular treatment makes you feel. Treatments here can mean medical procedures or the many possibilities of alternative therapy, (such as injections of B vitamins, massages, or cranial sacral therapy). In this part of your crisis plan, list the following-
Describe a plan for your care in a crisis that would allow you to stay where you like. Think about your family and friends. Would they be able to take turns providing you with care? Could transportation be arranged to health care appointments? Is there a program in your community that could provide you with care part of the time, with family members and friends taking care of you the rest of the time? Many people who would prefer to stay at home rather than be hospitalized are setting up these kinds of plans. You may need to ask your family members, friends, and health care providers what options are available. If you are having a hard time coming up with a plan, at least write down what you imagine the ideal scenario would be.
Describe the treatment facilities you would like to use if family members and friends cannot provide you with care, or if your condition requires hospital care. Your options may be limited by the facilities available in your area and by your insurance coverage. If you are not sure which facilities you would like to use, write down a description of what the ideal facility would be like. Then, talk to family members and friends about the available choices and call the facilities to request information that may help you in making a decision. Also include a list of treatment facilities you would like to avoid-such as places where you received poor care in the past.
Describe what your supporters can do for you that will help you feel better. This part of the plan is very important and deserves careful attention. Describe everything you can think of that you want your supporters to do (or not do) for you. You may want to get more ideas from your supporters and health care professionals.
Things others could do for you that would help you feel more comfortable might include-
Include a list of specific tasks you would like others to do for you, who you would like to do which task, and any specific instructions they might need. These tasks might include-
You may also want to include a list of things that you do not want others to do for you-things they might otherwise do because they think it would be helpful, but that might even be harmful or worsen the situation. These might include-
Some people also include instructions in this section on how they want to be treated by their caregivers. These instructions might include statements such as "kindly, but firmly, tell me what you are going to do," "don't ask me to make any choices at this point," or "make sure to take my medications out of my top dresser drawer right away."
In the last part of this plan, give your supporters information on how to recognize when you have recovered enough to take care of yourself and they no longer need to use this plan. Some examples are-
You have now completed your crisis plan. Update it when you learn new information or change your mind about things. Date your crisis plan each time you change it and give revised copies to your supporters.
You can help ensure that your crisis plan will be followed by signing it in the presence of two witnesses. It will further increase potential for use if you appoint and name a durable power of attorney-a person who could legally make decisions for you if you were not able to make them for yourself. Since power of attorney documents vary from state to state, you cannot be absolutely sure the plan will be followed. However, it is your best assurance that your wishes will be honored.
You have now completed your action plans for prevention and recovery. At first, you will need to spend 15-20 minutes each day reviewing your plans. People report that the morning, either before or after breakfast, is the best time to review the book. As you become familiar with your daily list, triggers, symptoms, and plans, you will find the review process takes less time and that you will know how to respond without even referring to the book.
Begin with Section 1. Review the list of how you are if you are all right. If you are all right, do the things on your list of things you need to do every day to keep yourself well. Also refer to the page of things you may need to do to see if anything "rings a bell" with you. If it does, make a note to yourself to include it in your day. If you are not feeling all right, review the other sections to see where the symptoms you are experiencing fit. Then follow the action plan you have designed.
For instance, if you feel very anxious and know that it is because one of your triggers happened, follow the plan in the triggers section. If there weren't any particular triggers but you noticed some early warning signs, follow the plan you designed for that section. If you notice symptoms that indicate things are breaking down, follow the plan you developed there.
If you are in a crisis situation, the plans can help you realize it so you can let your supporters know they should take over. However, in certain crisis situations, you may not be aware or willing to admit that you are in crisis. This is why having a strong team of supporters is so important. They will observe the symptoms you have reported and take over responsibility for your care, whether or not you are willing to admit you are in a crisis at that time. Distributing your crisis plan to your supporters and discussing it with them is absolutely essential to your safety and well-being.
You may want to take your plan or parts of your plan to the copy shop to get a reduced-size copy to carry in your pocket, purse, or glove compartment of your car. Then you can refer to the plan if triggers or symptoms come up when you are away from home.
People who are using these plans regularly and updating them as necessary are finding that they have fewer difficult times, and that when they do have a hard time, it is not as bad as it used to be and it doesn't last as long.
Substance Abuse and Mental Health Services Administration (SAMHSA)
Center for Mental Health Services
Web site: www.samhsa.gov
SAMHSA's National Mental Health Information Center
P.O. Box 42557
Washington, D.C. 20015
1 (800) 789-2647 (voice)
Web site: www.mentalhealth.samhsa.gov
Consumer Organization and Networking Technical Assistance Center
P.O. Box 11000
Charleston, WV 25339
1 (888) 825-TECH (8324)
(304) 346-9992 (fax)
Web site: is currently offline
Depression and Bipolar Support Alliance (DBSA)
(formerly the National Depressive and Manic-Depressive Association)
730 N. Franklin Street, Suite 501
Chicago, IL 60610-3526
Web site: www.dbsalliance.org
National Alliance for the Mentally Ill (NAMI)
(Special Support Center)
Colonial Place Three
2107 Wilson Boulevard, Suite 300
Arlington, VA 22201-3042
Web site: www.nami.org
National Empowerment Center
599 Canal Street, 5 East
Lawrence, MA 01840
Web site: www.power2u.org
National Mental Health Consumers' Self-Help Clearinghouse
1211 Chestnut Street, Suite 1207
Philadelphia, PA 19107
1 (800) 553-4539 (voice)
(215) 636-6312 (fax)
e-mail: firstname.lastname@example.org Web site: www.mhselfhelp.org
Resources listed in this document do not constitute an endorsement by CMHS/SAMHSA/HHS, nor are these resources exhaustive. Nothing is implied by an organization not being referenced.