Writing a Safety Plan

DeeDee newWhen I started creating a Wellness Journal awhile back, I found I didn’t have some of the “required” ingredients on hand, including a Safety Plan and a Wellness Plan. Fortunately, plans can be developed as needed, right?

I started with a little research and quickly learned that there are a number of different contracts and plans meant to improve accountability and interventions in mental health crisis situations. I ended up putting together a Help Contract (which acknowledges that my husband sometimes knows better than I, and promises that I’ll accept help) and a Suicide Prevention Contract as separate free-standing commitments. They were easy to adopt almost as I found them, with very little personalization required.

“Plans are nothing; planning is everything.” Dwight D. Eisenhower

But the Safety Plan, that clearly needed some consideration and effort. The focus of a Safety Plan is on intervening in crisis situations; it lays out the plan of action for times when things get rough. That’s separate from a Wellness Plan, which sets up ongoing medical and behavioral management plans.

Plan Ahead by New York City Department of Transportation, CC BY-ND 2.0

Plan Ahead by New York City Department of Transportation, CC BY-ND 2.0

My therapist and I discussed the idea of a Safety Plan. He thought it was a good idea, and after a couple rough patches that got nasty quite quickly, I felt like it was a good idea too. I found a few templates and examples, and then sort of created my own by mashing up the most useful (for me) elements of them together. Actually writing it, however, was no easy task.

Pondering what to do if you totally flip out is something of a downer, if you know what I mean. As is thinking about exactly the behaviors that mean it’s time for someone else to start making decisions. I don’t relinquish control easily, even when I’m not in any condition to make rational decisions, but writing my own instructions means there’s a level of grudging acceptance because I wrote them this way for a reason.

It wasn’t a quick project, either. I didn’t try to avoid the discomfort by completing it as quickly as possible, but instead let it stew a little – making sure that I was doing it thoroughly, thoughtfully, and honestly. After about two months of slow processing and a little effort here and there, the final document includes contact information for all of my regular medical care team (plus my husband, of course) and facility preferences, as well as indicators of symptoms and appropriate interventions.

Reviewing the plan makes it glaringly obvious to me that depression is a much bigger problem than mania. But even more apparent is how much I depend on my husband to help me through rough times. If I really went off my rocker, he’s the one who would have to call my supervisors and let them know I need extended sick leave. If I’m not sleeping and am getting way too wound up, he’s the one who is supposed to remind me that I shouldn’t be drinking, not even a little bit. Providing this kind of support is a nontrivial thing to ask someone to do. I’m a lucky girl to have such a supportive partner!

I emailed the final draft of my Safety Plan to my therapist. He said it looks good, covers a number of different situations, and hopefully we’ll never have to use it. Well, actually, I did use it already, so I guess we’ll just hope I don’t have to use it again

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Purpose

This document establishes responses to emergency situations when my decision-making capacities are compromised. It is meant to improve my accountability, and help others know when to intervene and how to help.

Care Team

Husband: Mr. Chickadee

Medication management: Nurse Nycta, NPP

PCP: New Nurse, NP

Individual therapy: Hippie Dude, LCSW-R

DBT group: Leader #1, PhD & Leader #2, LCSW-R

Preferred Facilities

Emergency: 911; Great Hospital ER

Psych ER: Psychiatric ER (walk-in 24-hour)

Inpatient psychiatric ward: Great Hospital Inpatient Psychiatry (by referral from PER, ER, MDs, etc.)

Pharmacy: Rite Aid #00000

Current Medications

My current medications and supplements are kept in my top left desk drawer and the left bottom shelf of my desk organizer. Spare/discontinued meds are kept in the psychedelic box in the linen cupboard.

My current medications & dosages are listed in the front of the red binder stored in the bin to the right of my desk. They are also available from MedicAlert (800-625-3780; member ID ########).

My Rx history since late 2008 is in the blue binder to the right of my desk, and in ~/Dropbox/Health/RxRecords.xlsx. My labs, gene testing results, and other patient records are also in the blue binder.

I have no known drug allergies, but have sensitivities to epinephrine and codeine. Should hospitalization be required, intake needs to receive a copy of my medication sensitivity testing results (CYP2D6 ultrarapid metabolizer, CYP2C9 poor metabolizer).

Baseline Wellness

  • Alert and functional within 30 minutes of waking
  • Sleeping approximately 7 – 8 hours/night
  • Normal level of engagement in work and leisure activities
  • Generally optimistic and rational
  • Good sense of humor, laughs and smiles easily

Depression Symptoms

  • Disrupted sleep patterns, always tired
  • Very slow to wake, never fully alert
  • Cognitive & physical slowing, reduced verbal skills
  • Sharp decline in productivity
  • Significant increase in anxiety, pessimism
  • Loss of interest, hopelessness
  • Crying – persistent, uncontrollable
  • Clingy, seeking reassurance
  • Nonfunctional/non-responsive/semi-catatonic

Interventions for Depression

  • Crying for 2+ days:
    • Take the day off
    • Call/email Hippie Dude for appt
  • Severe symptoms for 5+ days
    • Take 2-3 days off
    • Call/email Hippie Dude for appt
    • Call Nurse Nycta for emergency appt
  • Self-injury ideation
    • Tell Mr. Chickadee
    • Call/email Hippie Dude for appt
    • Tell Nurse Nycta at next appt
  • Self-injury
    • Tell Mr. Chickadee immediately
    • Dr. or Mr. Chickadee calls Hippie Dude on cell for emergency appt
    • Dr. or Mr. Chickadee calls Nurse Nycta for emergency appt
    • Evaluate taking leave or checking into Good Hospital
    • Mr. Chickadee removes knives, razors, & extra meds
  • Suicidal ideation
    • Tell Mr. Chickadee
    • Dr. or Mr. Chickadee calls Hippie Dude & Nurse Nycta for emergency appt
    • Evaluate taking leave or checking into Good Hospital
    • Mr. Chickadee removes knives, razors, & extra meds
  • Actively suicidal (have a plan)
    • Tell Mr. Chickadee and/or Hippie Dude immediately
    • Admission to Psych ER
    • Mr. Chickadee notifies Hippie Dude & Nurse Nycta of admission
    • Mr. Chickadee informs supervisors that I need sick leave
  • Suicide attempt
    • 911 or ER
    • Mr. Chickadee notifies Hippie Dude & Nurse Nycta of admission
    • Mr. Chickadee informs supervisors that I need sick leave

Self-injury history of cutting and burning; prior suicide attempts by cutting.

Mania Symptoms

  • Sleeping less than 5 hours/night for 2+ consecutive nights
  • Starting or agreeing to many new projects
  • Excessive, impulsive spending
  • Unusually talkative, sociable, physically active
  • Irritability, ranting, aggressive driving
  • Failure to record mood scores 3+ consecutive days (while on the grid)
  • Significant increase in alcohol consumption (3+ servings, 2+ nights)

Interventions for Mania

  • Under 5 hours sleep/night for 2+ consecutive days
    • Tell Mr. Chickadee
    • Stick to sleep schedule; use melatonin
    • Take breaks from overstimulating situations
    • Take Ativan before social events
    • Limit caffeine to 2 servings in AM
    • Limit alcohol to 2 servings (if no Ativan taken)
    • Stay offline as much as possible; save emails and blog posts as drafts
    • Avoid new projects, commitments, purchases
  • Under 3 hours sleep/night for 5+ consecutive days
    • Skip ADD meds
    • Take Ativan, not alcohol – no alcohol at all
    • Call Nurse Nycta for emergency appt
    • Call Hippie Dude for next available appt
    • Mr. Chickadee verifies adherence to interventions above

In an Emergency

If I am unable to conduct my own affairs, Mr. Chickadee has power of attorney and is authorized to make all decisions on my behalf; he knows my preferences. Under no circumstances is ECT permitted.

© DeeDee and A Canvas Of The Minds 2013. Unauthorized use and/or duplication of this material without express and written permission from this blog’s author and/or owner is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to DeeDee and A Canvas Of The Minds with appropriate and specific direction to the original content.

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17 thoughts on “Writing a Safety Plan

  1. What a courageous woman you are. Most people just wanna forget about the whole thing, but Dr. Chickadee takes the bull by the horns, and publishes it too, so that other people struggling with illnesses might be able to take a cue from you and work out their own emergency plan.
    On another note, I’m sure you know how immensely fortunate you are to have Mr. Chickadee in your life and on your team. Kudos to both of you for being, well, you.

    • Thanks, Soul! It wasn’t my idea of a fun task, and I sure didn’t want to do it, but it had become obvious that I can’t figure out how I or anyone else should react when I get to be all mentally wobbly, and that it can get bad very fast. Having my therapist ask a couple of times if it was time to consider inpatient admission was enough to make me think it would be a good idea to set up the “rules” for what situations merit that sort of intervention.

      But yeah, not fun.

  2. This is a great plan, and you are indeed lucky to have such a wonderful, supportive husband to help you stick to it. I have had such plans in the past, when I had people who could help. But I have no people now, so I don’t know how to have a plan now. It is great you worked on this with such patience and honesty. I hope you don’t have to use it, though!

    • There’s always potential to bring new people into your life, right?

      What my therapist stressed over and over while I was working on it is that it had to start with me taking responsibility to let others know I needed help. So even if it’s just your own list of your doctors, nearby emergency facilities, and a list of your own rules for taking care of yourself, that’s still a good starting place. It makes you think about what kind of responsibility you need to take for your own health care, and really consider who can help you out, whether or not that includes friends, family, coworkers, doctors, etc.

      I’ve also seen versions of safety plans that had friends who had committed to be available in crisis and their phone numbers, so an earlier intervention step would be calling those people. I wouldn’t mind adding that to mine, but there aren’t more than one or two friends that I’d even consider calling when in that state of mind, so I left it out.

  3. Can I plagiarize this? My therapist was nagging me for a plan on Monday and I’m too disinterested to create one. (Hey, doesn’t that mean I’m really in need of one right now? 🙂 )

    • By all means, take it and run! I posted it so that there’s another template available to check out. But it’s not so useful if you don’t customize it pretty heavily for your own sets of indicators and interventions.

  4. Did I put you off of having ECT?! If so, I’m really sorry – maybe it could help you?

    Excellent plan. You should go in to the mental health field. You’re an expert. Well done for taking such time and effort to make this plan.

    Feel good x

    • Oh no, it wasn’t you put me off ECT. I just think the risks are unacceptable for me – potential memory problems could be even more disabling for me than severe depression. If I did have memory problems from ECT that interfered with being able to work, that would be more upsetting and depressing to me than almost anything else. So I don’t think that ECT is a good option for me. That could change someday, but I rather doubt it.

      • Gotcha. I also hope you won’t have to get to the point of doing ECT.

        Feel good.

  5. It’s very obvious that a lot of effort and self-examination went into this plan. It is extremely helpful to have, I’m sure, because it spells you out to a T. Those looking at you/talking to you that know you will recognize any deviation from the norm, and to have an action plan in place shows how much you care about your own well-being. I applaud your courage in sharing this with us.

    • It was really hard to decide at what the “rules” should be for this. A lot of people would say that I should see the doc right away as soon as things start going off. But I know that whatever state of upset often doesn’t last, so giving it a couple of days to make sure that it’s really something that needs attention is actually more appropriate most of the time – for me, that is. Fortunately, by making that call myself, no one else will have to.

      • You definitely know you best, with Mr. Chickadee and your doctors right there as second. As long as you’re all in agreement, then nobody can say that you’re in the wrong. You know you best. Who is anyone else to judge? Every person, every situation is different. Keep up the good work – and keep up writing; I love reading it.

  6. Thank you so much for sharing this, it’s really useful information. Mind if I re-blog it? I definitely think this is something I should do (though I’ll admit I kind of dread it) … just in case. Best to be safe.

    • By all means, go ahead and reblog!

      Yes, it was a task I dreaded too. But it’s something of a relief to know that I’ve set myself up a safety net.

  7. I can see why you took your time over that. Not only are you having to think for yourself but for everyone else who you interact with on a daily basis, and those who will be responsible for looking after you. And as you said, having to think about the symptoms and the situations to be able to write the plan in the first place.

    I wish you luck in not needing to use this again, but also I wish you luck in sticking to it if you do need to use it.

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