C.R.I.S.P. (Crisis Recovery Individualized Support Plan)
Psychological crises in our lives usually don't happen in a flash. It isnt like dropping off of a cliff. It is usually a more gradual process. Normally, it takes time for our mind to reach a crisis point. Often, we are unaware that we are spiraling down into a crisis until it is too late (point "C" on the chart) and we have reached a full-blown crisis (point "D" on the chart). Then we have to struggle for quite a while to claw our way back up out of the crisis. Wouldn't it be nice if we could apply, earlier (point "B" on the chart) in the process, some of those things (the numerous point "Es" on the chart) that helped us recover from a crisis? Maybe we could even find a way to take those things that helped us recover and use them to help keep us from developing a full-blown crisis.
It is said that any change (either good or bad) produces stress. It is also true that anyone can develop a full-blown crisis if they are stimulated with too much stress. One of the key ingredients to a personal support plan is to develop ways to cope with the stresses of life before they accumulate into too much stress and lead to a crisis.
Essentially, a personal support plan reflects in writing our examined thoughts and those things we believe will be useful or not very useful in coping with the stressors in our lives. It reflects our understanding of our personal trigger events and it represents our plan for coping with those events in the future. It reflects our understanding that we are often the last to notice (even with heightened awareness of potential trigger events) that we are heading toward a crisis. It reflects our understanding of the need for a support system of friends, family, peers, co-workers, supervisors and others who will be able to point out to us that we are displaying early warning signs and that we should pay attention to what is happening if we want to avoid a full blown crisis.
Every personal support plan will necessarily be different. Different events will be identified as triggers. Different things will help or hinder each person. What we choose to happen based upon past experience and thoughts about the future will create the course for our actions. Each person has different levels of support. Some may have greater support from family and others may find that friends provide the most objective feedback. At different times of day different levels of support are necessary and so we need friends we can call upon morning, noon and night and even in the wee hours of the morning. We will have different levels of trust amongst our friends. Some of us find interaction with co-workers most rewarding while others are more trusting of a roommate, a neighbor, someone from the same church or neighborhood, etc. It will be different for each individual.
There are a couple of basic assumptions at work in order for the tool of a support plan to perform properly. The first assumption is that you want to avoid reaching a full-blown crisis. A second assumption that may or may not be true is that you want to avoid being locked-up in a hospital as a way to deal with your crisis. A support plan can serve as a useful document for you. It will be for your reference only because, you alone are responsible for your mental health. If you want accommodations from others, then you must take it upon yourself to ask for and negotiate for these accommodations.
To develop a personal support plan, I ask you to look back and remember the different steps of any of your own previous crises. Remember when life was cruising along fairly normally? Thats point "A" on my chart. First, I ask you to identify when things first started going bad. That would correspond to point "B" on my chart. Some typical responses Ive heard are as follows:
working and caring for others too much
eating too much or too little
worrying too much
lack of concentration
short temper and agitation
returning to your addiction
thoughts of harming yourself
not trusting yourself or others
feelings of worthlessness
giving yourself mixed messages
feelings of hopelessness
feelings of helplessness
feelings of emptiness
As you remember these first steps, it is important that you notice which of these things are signs that you are perhaps headed for a crisis. If any of these is a sign, then you need to be alert to watch for those signs and if you have trouble noticing these things in yourself, then you need to have trusted others who can help you to watch for these signs. This is an important first step awareness that you are heading toward a potential crisis. If you are aware, then you can do something to change the course of your heading and produce a different outcome other than a crisis.
Other leading questions I use early in the process of developing support plans are:
As stated previously, you must first reach a level of conscious awareness that you may be on a path toward a crisis. The previous set of questions is designed to not only produce that level of awareness, it is also designed to allow for the fact that you may not be consciously aware when you are displaying these signs. At point "A" on my chart, you are not having any difficulty. At point "B" things are starting to become difficult and it is at this point that you need to be aware of a possible impending crisis and apply steps to change your course.
If you reach point "C" it is often too late to change or alter the course of your crisis because by then you are often spiraling too steeply out of control and headed for your personal "bottom" at point "D". The ideal time to be aware of your difficulties is between point "A" and point "B". This is where you need to train your support system (friends, family, neighbors and trusted others in your life) to help you identify in a non-threatening way that you could be headed for a crisis.
You need to train your support people to be helpful and to assure that they dont make matters worse. You also need to select support people who will be supportive. A family member who treats you as if nothing you ever do will be good enough would not make a good support person. The last thing you need is someone who whines or harps on you in a negative way or someone who always sees everything you do in terms of symptoms.
You need people you trust who will give you honest feedback with dignity and respect in a way you will be able to hear. You need people who understand the idea of support and who know what is appropriate at what time. Sometimes we need a pat on the back, a hug, a caress or a cuddle. Other times we might need to, metaphorically, be whapped upside the head with a two-by-four or be given a good swift kick in the ass. We need support people who know the difference, who are not afraid to do the right thing and who know us well enough to be able to do the right thing at the right time.
The effort of thinking this process through well in advance is beneficial because, if there is no one in your life that you trust enough at this time to let you know when you are having difficulty, then you need to get out and cultivate more friendships and develop this type of personal support. It takes time and effort to develop, train and maintain this level of a support system. Studies have shown that mental health clients are generally more impoverished in their social relationships. This means that well often have to work harder to seek out and develop an effective support system but, it is well worth it in the end.
Once you reach conscious awareness, either by yourself or with the aid of others, you must think about how to change the path you are on and this can be done in a couple of ways. The first way is to think of good things you can do and have done that have helped you to feel better. Some of these thing are the "Es" in my chart and can and should be applied at point "B" instead of waiting until sometime after reaching point "C" or "D". Some typical responses might look like these:
going to the ocean or a beach
talking with someone who has been through the same experience
sitting in a rocking chair
doing the hokey pokey
getting a massage
trying to think positive/have a positive outlook
going back to basics
staying at home
walking the dog
staying away from negative people
talking with non-judgmental listeners
good safe sex
It is interesting to note that, when Ive done this exercise with groups of mental health clients, in neither this nor the previous section did any of the mental health consumer responses include reference to their medications. They neither identify the medications as a sign that they might be getting worse nor did they identify the medications as something they might use to get better. This is fairly typical of the type of responses consumers have when approached regarding these issues and there is a fair degree of concurrence with reports from around the country in the research and other literature.
As a flip side to the good things that you might try, it's also helpful to identify those things that can make matters worse so that they can be avoided. This is useful in helping to avoid progressing from point "B" to point "C" or "D". Things which are typically identified are:
criticizing self and others
low self esteem
thinking "I can fix it"
holding it in
not getting enough sleep
eating too much or not enough
These things are not only things that can contribute to making matters worse, they can also hinder the healing process or stunt the growth process.
There is sometimes an assumption that when you are in the midst of your personal crisis (point "D" on the chart) that you lack the ability to perceive the reality around you. This is false. Most of the time it is an instance of, "just because I'm banging my head on the table doesn't mean that I don't know I'm banging my head on the table." I may have a very high level of awareness but, believe I'm helpless to behave otherwise. It is the understanding that even at our worst, we retain a level of conscious awareness that prompted this next question. I ask why you stopped getting worse (when you hit your personal "bottom" at point "D" on the chart) and started getting better and what helped you when you were at your very worst. These are some of the "Es" on my chart. Some typical answers are:
stopped doing drugs
thinking about those you'd leave behind
Note that from the deepest, darkest, most isolated depression or psychosis (point "D"), not one person mentioned medications as being useful or helpful. In fact, the connection that best helped people back to reality and a stable, fairly calm life was the caring, human connection. This little exercise is useful in a number of ways. First, it points out that despite some professionals who assert that drugs are the answer, consumers find otherwise. It also demonstrates the importance of self-help and peer support that often provide that much needed caring, human connection in a way that is safe and non-threatening. Even though I personally found no assistance from being locked in a hospital, I did sometimes find folks who were willing to connect with me as a person. Sometimes those folks were staff but more often, the human connection came from other clients.
As final steps, I ask you to do a couple of things. First, I want you to think about situations that might cause stress or other reactions that could put you in danger of heading into crisis. Consider various locations such as at school, at work or at home and consider different people whether strangers, bosses, family or others. Think about every conceivable situation you can imagine from getting bad news from a friend at 3 a.m. to a devastating earthquake.
Finally, I introduce the idea that no one has too many friends. If you get bad news from one friend at 3 a.m., do you have another friend you can turn to? Also, do you have still another friend you can turn to if your second friend is away on vacation? It is necessary to not only build a support network but you must also maintain it. How do you know if your friends really are or will be available for you at 3 a.m.? Have you tested your network? Is it reciprocal? Can your friends count on you too? What about on the job? Can you get away long enough to make a phone call if you are having a bad day? Are you assertive enough with your boss to ask for the space to make such a call? Is your 3 a.m. friend or your friend from work still available? Maybe if they were available six months ago, their situation has changed and they are no longer available.
After challenging you to look very hard at your situation and to give it a great deal of thought and to brainstorm together, I then ask you to simply write down your plan and to share it with one other person. Write down the things that can and do make things worse for you. Write down the things that have worked before to help you feel better. Write down new ideas of things to try. Keep adding to your list and then use it! Share this list with at least one other person so that if youre feeling overwhelmed, someone else can remind you that you have things that you can do to help and point out what some of those things are. I ask you to keep a copy of your plan with you at all times and to figure out how best to use and maintain it.
One of the best tools for maintaining your mental health is a simple one; that is, to give to others in need. When we are down, we often feel as if we have nothing valuable to contribute but, there are always those who are worse off. We can, by sharing ourselves with others, be stronger and more confident and thus, less needy for ourselves. Its hard to wallow in and focus on our own miseries if our attention is focussed on others. Sometimes, this focus outside of ourselves can provide a mini-vacation from our troubles. However, use this technique with caution. This can become addictive and eventually, you will have to face up to and deal with your own problems. Also, beware of the trap of giving to others so much that there is nothing left for you. All of these fundamentals are more than adequately spelled out in great detail in any twelve step program. This is not a plug for any twelve step program but, a recognition that they do have some very good principles upon which they are based and they have a proven track record of success using these principles.
CONTEXT OF SUPPORT PLAN
Originally, the development of a personal support plan as a tool for dealing with personal crisis situations occurred in the context of an eight to ten week training. The intensive training was allegedly for the purpose of training a class of twenty mental health consumers to work in the mental health field. Therefore, a significant portion of the class is devoted to assuring that students are fully aware of how the mental health system operates. This serves three primary purposes. First, it is good training for those who actually do go on to work in the mental health field. Second, it provides people with the personal resources they might need for their own purposes or for their friends. Third and most important, it demystifies an area of peoples lives where they have tended to have a great deal of interaction without much knowledge. Medical literature is rife with examples of how knowledge equates to power which in turn equates to personal empowerment that leads to hope and healthful growth in the face of great medical adversity. Unfortunately, this practice is not as common in psychiatry as it is in general medical practice.
Next, the class is trained in a variety of modalities in active listening, conflict resolution and other basic human interaction skills. The training consists of didactic presentation of material, supported by generally simple handouts and reinforced by role play in the classroom with many in the class participating and critiquing each other to sharpen the skills. Further discussions and repetition of the process many times helps to assure that students are better equipped to cope with their interactions with others in general.
The class is also challenged from the first day to make their own decisions. Often this is the most important thing I do in the class to lead to personal empowerment. I challenge people to dream, to imagine, to hope, to aspire, to conceive of a single tiny forward step in a positive direction toward any goal, no matter how lofty. All too often, this is the one piece of people's humanity that they have lost - probably because of the nature of their interaction with the mental health system and how that system views people with what the system calls mental illness.** Once I have awakened people's souls to the world of possibilities, they are able to perceive the world anew - like a child with all the hope of potential lying ahead. This is true empowerment. I don't create it. I merely tend the garden in the hope that the seeds will miraculously sprout. But, the essence of empowerment was always there within the heart of the seed.
Through these and various other methods, I create an atmosphere that is contagious with growth and hope. Failure is allowed and we cherish the growth opportunities that failure offers. From our shared failures and successes, we find the nurturing that we need to move forward with strength and courage and hope that was lacking prior to the training. We discover each other and we grow stronger as we realize we are not alone and that we need never be alone again. Others have been where we have been and have emerged as strong or stronger and therefore, we can too. That is truly our hope.
So, what is the context of the support plan as a personal crisis tool? It is but a single step in a personal process of growth that becomes expedited by a very special training that helps people put support as a basic human need in place as a proper priority in their lives. Without the context of this training, the support plan may not work as well because, it may lack the contextual meaning that provides the proper basis for building a true network of supportive people around ones self. However, it is my belief that the support plan can still provide a basis for helping people to help themselves.
SUPPORT PLANNING FOR CLIENTS GOING TO WORK FOR THE MENTAL HEALTH SYSTEM
Supervisors of clients working for the mental health system often don't understand just what a support plan is and how it's supposed to work. They think we should be able to have a plan in which they can call the workers' therapist or psychiatrist if they believe the worker is demonstrating "symptoms" on the job. However, they usually wouldn't know a worker's symptom from a normal person having a bad day at work. That is part of why it is important that training staff be there to support our students when they get worse from these sorts of judgmental micro-oppressions** working on them day after day. We need our students to feel confident and sure in the face of adversity not, paralyzed with fear and hopelessness in the face of being "just another consumer."
Its always sort of amazed me that so-called "normal" people can have a "bad" day. They can have an "off" week or even a "down" month. However, if youre a mental health client (past or present) then you are judged as having "symptoms" if you experience "normal" feelings and have "normal" reactions. A so-called "normal" person can get angry or sad. They can laugh and even cry at times. However, once labeled as a mental patient, you are no longer allowed these "normal" reactions to life. Too much sadness or crying gets interpreted as "depression" and too much anger or laughing gets interpreted as "mania." Everything we think, do and say gets interpreted through a "mental illness" filter which disempowers us and prevents us from ever living a "normal" life free of the stigma of our experiences.
In the training, we give people a shot of self-esteem but, that shot cannot immunize people against a lifetime of second-class treatment as some joke experiment for their supervisors to laugh at behind their backs and to sabotage at every opportunity. We need to be in there with the mental health director's sanction (with or without his/her understanding) on a regular basis in order to give booster shots as needed and to keep an eye out and to gently educate the supervisors on how to be better supervisors and better people without so much bias against our folks. We don't yearn for confrontation. We only want the chance to gently as possible help everyone involved to give this thing the best possible opportunity for success. Otherwise, the support plan will just be another one of our harebrained ideas that didn't quite cut it. I don't want us to be set up for failure
**A Rant from Pat on Spirituality and Madness
Spirituality and Madness
I've written before, albeit some time ago about a concept known as micro-oppression. Simply put, it's small little insults to our spirit which build and accumulate into a larger loss of a sense of self. For example, no therapist in their right mind (sorry, no pun intended) would walk up to a client and proclaim, "I'm the expert and you're JUST the patient so, I know what's best for you!" However, in many little subtle, smaller and almost imperceptible ways, this and similar attitudes bombard mental patients hundreds, perhaps thousands of times a day. These little micro-oppressors do not attack in visible ways. They are not gross enough to leave bruises or visible wounds. However, the cumulative effect is an attack on our human spirit which leaves us feeling exhausted and with a diminished feeling of self-esteem and self-worth.
The first step to battle back against this sort of spiritual oppression is to first acknowledge or become aware that it's happening. This awareness has to happen on different levels. First, one must be aware of the oppression that is directed at you from those outside of yourself. You must become aware that others are oppressive even if they are not aware of their own sense of superiority with which they batter you. You must also overcome the strictly biological notions of psychiatry and acknowledge your spiritual self in order to know the level within yourself upon which these attacks are being waged. The awareness of these notions is what I think of as consciousness-raising. Consciousness raising has been a part of the battle for human rights and dignity in all of the visible rights movements of recent history including women's rights, civil rights and disability rights.
Once you've gained this awareness, you can then fight back. With a heightened sensitivity to the oppressions you can move them to the realm of substance by confronting them as they occur in the present. It creates a heightened sense of self to recognize and confront oppression. It strengthens the spiritual self to counteract this constant battering.
The danger of not fighting this oppression or acknowledging it is that one's self may be lost. This is seen often in institutionalized patients. I used to think that the system was the problem and that if we could only tear down the bars and the walls of the institutions we could free folks from oppression. I watched folks who'd been in day treatment for many years. They sat around drinking coffee and smoking cigarettes. To counteract this, I started drop-in programs and folks came to the drop-ins and guess what they did? They sat around and drank coffee and smoked cigarettes. It was then that I realized that the bars and walls which need to be broken down are not with the institutions or the system but rather, within people's own minds.
A few years ago, on CNN (Cable News Network) they showed some scenes from the war in Bosnia. The shelling was advancing on a mental institution and all the staff had fled. There were no locks and the doors and windows stood wide open. There was no heat and no food or water yet, the patients mulled around not quite knowing what to do. The institution had become their life and their identity and without the institution and its' direction of their lives, the patients had no more sense than a horse running back into a burning barn. Quite simply, the patients had been brainwashed into a sense of helplessness, hopelessness and dependency.
In Oakland, California, a locked facility to help transition folks to the community from a state hospital was in operation for six months with all the expertise of the staff aimed at helping folks be able to eventually live in the community. After six months, staff agreed that several of the patients were ready to move to the community and asked those patients where they'd like to go. Much to the exasperation of the staff, the patients responded that they'd like to return to the state hospital. In one blinding flash of insight, one of the staff suggested that they contact the Alameda County network of mental health clients (the local self-help organization). Folks from the client network took the patients out of the hospital and showed them different possibilities including living in one's own apartment. Finally, the patients "got it." Up until then, they'd been so oppressed that it was like they had been brainwashed. They couldn't even imagine the possibilities other than a state hospital institution. Individual freedom was tragically unimaginable prior to the intercession of self-help, peer-support folks.
To facilitate the freedom of folks who have been under the oppressive influence of the system, reveal the world of possibility to them. Show them the DSM and reveal the lies of its labels. Show folks how to confront by example. Show folks the lies of the drug companies and gather up the research which demonstrates the placebo effect and shows the strength of alternatives to the drugs. Allow folks the freedom to feel their feelings including anger and help the consciousness raising process. Help folks to connect with self-help peer networks and to join with others and to know that there's hope. Help folks to join with others and to celebrate where-ever they are on life's journey and to choose their own path. Help folks to again be able to find within them our innate human ability to dream and then help them to believe in their dreams and to pursue them with hope and vigor. Help folks to know that there are other and better ways of living life to it's fullest and that they need not be limited by any diagnosis or perceived handicap. Give the gift of freedom and life by getting involved with others and you'll find yourself in a richer and better place in your own life. Free your own and others spirits and know true freedom from madness.