Here's the thing about safety plans; they are hard to broach with the mentally ill person. Often the mentally ill person does not believe that their illness is bad enough to warrant such a measure. The truth of the matter is, we often do not know how our loved one will respond when we decide to approach them.
While creating a safety plan can seem extremely straight forward and black and white, the mentalities behind the safety plan are muddied and loaded with emotional quicksand. I began asking DH for a safety plan 14 months before he actually followed through and created his safety plan.
Here's another thing about safety plans: You, the healthy supportive family member or spouse, CANNOT create and execute the safety plan for your loved one. It is that simple. Think about the way a person must be motivated to begin a healthy life style weight loss plan. You cannot make that decision for another person to choose to be healthy and choose a healthy life style. This decision is not yours to make when it is a decision that will best suit someone else. They have to choose it. They have to live by it. They have to execute it. You cannot control the life of another. This is coming from someone, yours truly, who has major control issues. The reality is, if YOU create and execute the safety plan, the mentally ill person, will NOT follow it. It was not theirs. They do not trust it. When they are in fits of paranoia, they will believe it to be a conspiracy document drafted to execute their demise.
So, how do you compel your loved one to draft and execute a safety plan? I wish I had a clear cut, "one size fits all" answer. I do not. What I can tell you is that when it came to DH and myself, I eventually got to an ultimatum situation. Marriage is based on give and take, sacrifice and generosity, push and pull. Marriage is a constant balance of compromise and holding your ground. I know, without a doubt, the potential results of not having a safety plan in place for our mental health situation within our home. I know the severity of our situation. I know what I will and will not accept and agree to when it comes to tolerance in my marriage, my home and my personal emotional barometer. Mind you, it has taken over 15 years to learn these critical factors about myself and my living environment. Based on these real life lessons, I knew then and I know now that an ultimatum of my marriage itself was the only way to get DH to execute a proper and solid safety plan. Our marriage is contingent on a few major factors and while I love DH with every ounce of my soul, always have and I always will, he MUST be held accountable and he MUST put forth his share of maintaining his health as much as he possibly can within his capacity. Some of the contingencies of our marriage are those of a mental health safety plan, maintaining proper mood stabilizing medication and physician appointments and clear communication with each other as to mental health status check-ins. Here is the kicker - I HAD to get to the point within myself that if these things were not done, I was willing to walk away. Walk away from everything. Everything we had built, everything we had experienced. Everything we ever could be as a couple, united in love, goals and dreams. I had to know within myself that if these contingencies were breached, if my boundaries were crossed; for the health of myself and my children, I could not stay, despite how much I love him. It took me a LONG, LONG time to get to that point. Over 15 years, to get to that point to have the confidence and strength to hold my ground, draw the line and not waiver as to what I need. In personal conversations, marriage counseling sessions and actions of my own, DH came to a clear understanding of my position and the choice was his to make. Would he finally follow through with a mental health safety plan or would he not and risk that I actually meant what I said and would he lose me? Would I lose him?
This was one of the most frightening times of my life. I did not know what he would choose, any more than DH knew what I would choose. We could not read the minds of each other. My Self-Worth Monster screamed at me in the mirror. My Self-Worth Monster worked fervently trying to convince me that I was not worth the effort and no one would make such hard decisions on my behalf; convincing me that the person I am is not worth the effort DH should have to make. My Self-Worth Monster chanted spells of worthlessness, spells forcing me to believe how undesirable and unattractive I am in both physical and inner-self form. Fear of everything surrounded me. Spells repeated in my mind of my inability to survive on my own - should it come to that - and pounded in my head how selfish I was for forcing someone I knew was ill into such a drastic ultimatum. For 14 months, my Self-Worth Monster screamed at the audacity of my asking for a safety plan and hinging my entire marriage on a few sheets of paper that DH really didn't think was that big of a deal. My Self-Worth Monster chanted relentlessly in my head "Are you really going to risk your marriage, your livelihood and HIS LIFE over a few sheets of typed up paper? You KNOW he is suicidal. You KNOW if you leave him, he COULD kill himself? Is that what you are willing to do, all over a stupid plan that he has made clear he doesn't want to do?" My Self-Worth Monster crippled me to exhaustion.
Now, I am not telling you that you have to do the same thing I have done. Your situation could be entirely different from mine. Your solution to getting your loved one to create their own safety plan, or take their medication, or see a mental health doctor regularly could be on a completely different plane. You could simply ask your loved one to complete your requests and they could willingly oblige in a heart beat. Perhaps your loved one doesn't even know you want this from them. Again, there is no "one size fits all" answer. You know your loved one. I do not. You already know how to compel your loved one to get them to complete a mental health safety plan, take their medication or see their doctor, even if you don't know that you already know how. The reason you know this is because you are already in a relationship with this person. You already know what makes them tick. You already know what works and doesn't work for smaller, less intrusive, less demanding things. Use your skills, use your knowledge and use your understanding of your circumstances to come to the best method for the health of yourself and your loved one. Your method lies somewhere between two linear points of either:
You are a key player in providing constructive criticism and editing of the safety plan. It is your job to oversee what is being put in the plan, how feasible and realistic the plan is, and how readily your loved one recognizes the warning signs of mania episodes and depression episodes. When I said you could not create the safety plan, that does not mean you cannot assist. You can provide blank templates for your loved one to fill in with honesty and candidness. You can ask your loved one's mental health provider to orchestrate a meeting where everyone discuses things verbally before writing it down. You can ask a trusted family member or friend to help encourage your loved one to complete a safety plan for the benefit of you and family members. You want your loved one to be transparent with himself or herself and with you.
One of the things I did not realize for quite some time was a critical factor that held DH back from completing the safety plan. The Medical Power of Attorney portion of the plan was a huge barrier. It frightened DH that anyone could have so much power, including me - a person he explicitly trusts, to admit him into a mental health facility on a whim. After many counseling sessions, I came to understand that it deeply frightened him if we were to get into a couple's fight and he made me angry enough, I would lock him up and throw away the key. Here is a critical thing for you AND your loved one to understand: no one can just slam another person into a mental health hospital without just cause and proper evaluation. As I listened to DH, I came to an understanding of his fears and apprehensions. I would never want to give someone that much control either! DH began to realize that a mental health directive gives another person temporary, not permanent, but temporary decision making powers when he is incapacitated either by a manic episode, a depressed episode or a medication malfunction episode. That if he is not of sound mind to make a decision to voluntarily enter into a mental health facility, I can make the decision to admit him on his behalf. I cannot just take him somewhere and say "Here, take him!" I MUST consult with his psychologist and/or psychiatrist first. They must make a proper medical authorization, even if it is after hours at 3:00 am, they must medically approve of my decision to admit him. When DH fully understood these factors, he was much more willing to complete a safety plan and consider a medical power of attorney directive for the sake of our marriage, for the sake of our health as a couple and for the sake of his health as an individual. It took us 14 months to figure out that this was the biggest wall that was blocking the safety plan from being completed.
A generalized Power of Attorney for Health Care can be found by clicking on this hyperlink. This document has been provided by the American Bar Association and was prepared by The Commission on Law and Aging American Bar Association. This document must be modified to fit your specific needs. Pay particular attention to part 5 on page 4.
In addition, an estate planning and wills contract attorney can help you draft your own personal medical directive that will be much more customized for your specific needs.
So all this begs the question, what is actually IN a safety plan? Well, you can do internet searches for templates and images. You can ask your health professional for a packet he or she might have on hand or, if you are intuitive enough, you could even try to create fill in the blanks document from scratch (I wouldn't recommend it - chances are you already have too much on your plate). Regardless what way you go, you need to make sure the safety plan meets some basic elements. This includes:
1. Triggers (physical, mental, and emotional) of Mental Episodes Identified;
2. Beginning Symptoms of Manic Episodes Identified;
3. Beginning Symptoms of Depressive Episodes Identified;
4. Beginning Symptoms of Medication Malfunctions Identified;
5. People of Trust that the Mentally Ill Individual May Call on in Crisis Situations Including Contact Information Identified (these are people besides you who live outside of your home);
6. Intervention Measures that the Mentally Ill Individual Approves of Ahead of Time;
7. Agreed Upon Qualifying Factors that Warrant a Medical Evaluation and Admittance to a Mental Health Facility; and,
8. A Medical Mental Health Power of Attorney Directive.
Additional information may be included, but the above items ought to be incorporated into the core safety plan.
I have created a Safety Plan Template for your use if you need it. This is patterned after DH's safety plan (all specifics removed) that he created on his own. I do not know what resources he used to make his plan as he presented it to me during one of our couples therapy appointments.
You must know, going over this plan with your partner or loved one will not be easy if your loved one is open and honest. Appreciate and understand this. You want this to be uncomfortable now so you can address symptoms and actions later. You could see things in this plan that make your skin crawl and your heart race with fear and trepidation. Your partner could put things in there like "when I am starting to get manic [or depressed - two separate categories] I want to... "sleep all the time", "spend all our money and get more credit cards", "start another small business", "flirt with members of the opposite sex", "watch porn on the internet", "have an affair", "run away", "kill myself ", "wreck my car", "buy a new car", "start a fight", "punch someone out", "gamble our mortgage at the casino", "get drunk", "get high", and the list can go on and on. It is one thing to hear your partner mutter these things, exclaim them in fits and get through those intense moments. It is quite another to have these words permanently affixed on paper in black and white Times New Roman font. This will be uncomfortable for you and your partner. This will be hard. It is supposed to be hard. You must maintain your composure. You must understand that your partner is making himself as vulnerable as he possibly can to protect himself from himself. You cannot become angry, irate or fight at the candidness of your partner. You cannot tear him down when he is trying to construct what you have asked him to build. This openness, this honesty, this vulnerability is going to be the foundation of the building blocks of trust you will formulate between each other. Once you know what his or her tendencies are, you can ask the on-point questions. When you begin to notice that he or she is off, You can look directly in their eyes and say "You seem out of sorts today. Are you thinking about ... [insert the tendency you are noticing here: gambling, starting a fight, spending money, stepping outside of the marriage]? What can I do to help? Would you like to go for a walk like you have listed on your plan? Or go to the movie theater and see the new release that just came out?" The important thing here is to look past the behavioral tendencies that are racing through your loved one's mind; it is important to not overreact and it is important to apply an intervention measure you have previously agreed upon based on the severity of the episode. If you do not feel you can handle the episode on your own, call a trusted person named on the safety plan to help you. You can and should constructively help your partner through their weak states. We are all human. In a healthy relationship, even the mentally ill help us healthy people through our weak moments. Weak moments of hard days at work.Weak moments of stress. Weak moments of being overwhelmed with obligations of duties and responsibilities. Our mentally ill partners can be incredibly strong for us when we are weak and we must do the same thing for them.
Putting off a safety plan only hurts you, your loved one and your relationship in the long run. There are times when we have to do the things we have to do so we can do the things we want to do. Love yourself enough, love your partner or family member enough, love and respect your relationship enough to insist on a safety plan. As a unit, you will grow closer. You will grow stronger and you will come to deeper understandings of each other more than you ever thought possible. Trust me on this one. While the preparation and execution of a safety plan may seem overwhelming and daunting, approach it in small pieces. It does not have to be done in one sitting. Help where you can and compel your loved one to choose to execute the plan. We all have boundaries. Unhealthy relationships cross over into each others' boundaries all the time. Establish your boundaries so your loved one can establish their boundaries in return. A safety plan lifts the burden of you, the caregiver, and gives personal freedom and personal relief to both you and your mentally ill loved one.
~Elizabeth~
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