Action Planning for Prevention and Recovery

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Introduction
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.”

Action plans for prevention and recovery work because they—
 are easy to develop and easy to use
 are individualized. You develop your plan for yourself. No one else can do it for you; however,
you can reach out to others for assistance and support
 improve your ability to communicate effectively with your family members and health care providers
 directly address the feelings, symptoms, circumstances, and events that are most troubling to
you with plans to respond to them
 renew your sense of hope that things can and will get better, and that you have control over your
life and the way you feel

Developing a Wellness Toolbox
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. Some ideas for your Wellness Toolbox might be—

 eating three healthy meals a day
 drinking plenty of water
 getting to bed by 10:00 p.m. (or at a good regular time for you)
 doing something you enjoy–like playing a musical instrument, watching a favorite TV show, knitting,
or reading a good book
 exercising
 doing a relaxation exercise
 writing in your journal
 talking to a friend on the telephone
 taking medications
 taking vitamins and other food supplements

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.

Daily Maintenance Plan
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.

Feeling Well
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.

Dreams and Goals
Some people use their plans to make a list of their dreams and goals, too. If you think you would find it helpful, 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.

Daily List
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. Following is a sample daily maintenance list—

 eat three healthy meals and three healthy snacks that include whole grain foods, vegetables,
and smaller portions of protein
 drink at least six 8-ounce glasses of water
 get exposure to outdoor light for at least 30 minutes
 take medications and vitamin supplements
 have 20 minutes of relaxation or meditation time or write in my journal for at least 15 minutes
 spend at least half an hour enjoying a fun, affirming, and/or creative activity
 check in with my partner for at least 10 minutes
 check in with myself: “how am I doing physically, emotionally, spiritually?”
 go to work if it’s a workday

Reminder List
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. Write “Do I Need To?” at the top of this page and then list things such as—

 set up an appointment with one of my health care professionals
 spend time with a good friend or be in touch with my family
 do peer counseling
 do some housework
 buy groceries
 do the laundry
 have some personal time
 plan something fun for the evening or weekend
 write some letters
 go to support group

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
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.

Identifying Triggers
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. Some examples of common triggers are—

 the anniversary dates of losses or trauma
 frightening news events
 too much to do, feeling overwhelmed
 family friction
 the end of a relationship
 spending too much time alone
 being judged, criticized, teased, or put down
 financial problems, getting a big bill
 physical illness
 sexual harassment
 being yelled at
 aggressive-sounding noises or exposure to anything that makes you feel uncomfortable
 being around someone who has treated you badly
 certain smells, tastes, or noises

Triggers Action Plan
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. Your plan might include—

 make sure I do everything on my daily maintenance list
 call a support person and ask them to listen while I talk through the situation
 do a half-hour relaxation exercise
 write in my journal for at least half an hour
 ride my stationary bicycle for 45 minute
 pray
 play the piano or work on a fun activity for 1 hour

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
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.

Identify early warning signs
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? Your early warning signs might include things such as—

 anxiety
 nervousness
 forgetfulness
 inability to experience pleasure
 lack of motivation
 feeling slowed down or speeded up
 being uncaring
 avoiding others or isolating
 being obsessed with something that doesn’t really matter
 displaying of irrational thought patterns
 feeling unconnected to my body
 increased irritability
 increased negativity
 not keeping appointments
 changes in appetite
 restlessness

If you want to, ask your friends, family members and other supporters for early warning signs that they’ve noticed.

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. The following is a sample plan for dealing with early warning signs—

 do the things on my daily maintenance plan, whether I feel like it or not
 tell a supporter/counselor how I am feeling and ask for advice. Ask him or her to help me figure
out how to take action
 peer counsel at least once each day
 do at least three, 10-minute relaxation exercises each day (simple exercises described in many
self-help books that help you relax through deep breathing and focusing your attention on certain
things)
 write in my journal for at least 15 minutes each day
 spend at least 1 hour involved in an activity I enjoy each day
 ask others to take over my household responsibilities for the day

(I also might, depending on the circumstances)
 check in with my physician or other health care professional
 read a good book
 dance, sing, listen to good music, play a musical instrument, exercise, go fishing, or fly a kite

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.

When Things Are Breaking Down or Getting Worse
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—

 feeling very oversensitive and fragile
 responding irrationally to events and the actions of others
 feeling very needy
 being unable to sleep
 sleeping all the time
 avoiding eating
 wanting to be totally alone
 substance abusing
 taking out anger on others
 chain smoking
 eating too much

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.

Some ideas for an action plan are—
 call my doctor or other health care professional, ask for and follow his or her instructions
 call and talk for as long as necessary to my supporters
 arrange for someone to stay with me around the clock until my symptoms subside
 make arrangements to get help right away if my symptoms worsen
 make sure I am doing everything on my daily check list
 arrange and take at least three days off from any responsibilities
 have at least two peer counseling sessions
 do three deep-breathing relaxation exercises
 write in my journal for at least half an hour
 schedule a physical examination or doctor appointment or a consultation with another health
care provider
 ask to have medications checked

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.

Crisis Planning
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.

Part 1 Feeling well
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.

Part 2 Symptoms
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—

 being unable to recognize or correctly identify family members and friends
 uncontrollable pacing; inability to stay still
 neglecting personal hygiene (for how many days?)
 not cooking or doing any housework (for how many days?)
 not understanding what people are saying
 thinking I am someone I am not
 thinking I have the ability to do something I don’t
 displaying abusive, destructive, or violent behavior, toward self, others, or property
 abusing alcohol and/or drugs
 not getting out of bed (for how long?)
 refusing to eat or drink

Part 3 Supporters
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.

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 decisionmaking.

Part 4 Health care providers and medications
Name your physician, pharmacist, and other health care providers, along with their phone numbers. Then list the following—

 the medications you are currently using, the dosage, and why you are using them
 the medications you would prefer to take if medications or additional medications became necessary—
like those that have worked well for you in the past—and why you would choose those
 the medications that would be acceptable to you if medications became necessary and why you
would choose those
 the medications that must be avoided—like those you are allergic to, that conflict with another
medication, or cause undesirable side effects—and give the reasons they should be avoided.

Also list any vitamins, herbs, alternative medications (such as homeopathic remedies), and supplements you are taking. Note which should be increased or decreased if you are in crisis, and which you have discovered are not good for you.

Part 5 Treatments
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—

 treatments you are currently undergoing and why
 treatments you would prefer if treatments or additional treatments became necessary and why
you would choose those
 treatments that would be acceptable to you if treatments were deemed necessary by your support
team
 treatments that must be avoided and why

Part 6 Planning for your care
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.

Part 7 Treatment facilities
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.

Part 8 What you need from others
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—

 listen to me without giving me advice, judging me, or criticizing me
 hold me (how? how firmly?)
 let me pace
 encourage me to move, help me move
 lead me through a relaxation or stress reduction technique
 peer counsel with me
 provide me with materials so I can draw or paint
 give me the space to express my feelings
 don’t talk to me (or do talk to me)
 encourage me and reassure me
 feed me nutritious food
 make sure I take my vitamins and other medications
 play me comic videos
 play me good music (list the kind)
 just let me rest

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—

 buying groceries
 watering the plants
 feeding the pets
 taking care of the children
 paying the bills
 taking out the garbage or trash
 doing the laundry

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—

 forcing you to do anything, such as walking
 scolding you
 becoming impatient with you
 taking away your cigarettes or coffee
 talking continuously

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.”

Part 9 Recognizing recovery
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—

 when I am eating at least two meals a day
 when I am awake for six hours a day
 when I am taking care of my personal hygiene needs daily
 when I can carry on a good conversation
 when I can easily walk around the house

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.

Using Your Action Plans
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.

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