Anticipation of potential future scenarios and appropriate planning are essential to relapse prevention. Many of the consumers spoken with in the consultations had plans that incorporated maintaining their wellness and preventing relapse. However, these were rarely developed in partnership with service providers and were not comprehensive. Plans tended to evolve in an ad hoc way, with people learning over time through their own experiences and those of other consumers what types of activities help them to prevent a relapse.
- It's a process. It's trial and error. You do all these things to try and distract yourself. Over time you know what works, you get an understanding of the illness. It's a balance of a whole lot of things that you learn to do. —Consumer
- I am a person with a disability. I have a psychiatric disability. I continuously work at having an overall plan for my psychiatric wellbeing. I also have daily plans and strategies. I believe in planning ahead as much as I am able to. —Moe Armstrong, Speaking Out
- Lists are important in terms of what do I have to do today. Do I have to go and have a coffee with someone or do I have to go and exercise. Just like everybody else does, it's just that the consequences of what can happen if you don't maintain your mental health can be a lot more severe. —Consumer
Planning and goal setting are not new concepts and have been well developed in the chronic illness management literature. For example, figure 4 presents a diagram of the illness management action process as applied in other chronic illnesses. These processes are equally valid for mental and physical illnesses, and the mental health field has much to gain from examining the chronic illness management field (see Von Korff , Glasgow & Sharpe 2002).
People at increased risk of relapse also need emergency or crisis plans, detailing what needs to be done if they become acutely unwell. During an acute episode, the ability of someone to make decisions is often taken away from them. It is essential, therefore, for consumers to be proactive and make these decisions when they are well. Decisions regarding the care of children and pets can be particularly distressing for people experiencing an acute episode, but planning ahead for such emergencies can help ensure that the decisions of consumers themselves are upheld, rather than what a service provider might deem appropriate or practical at the time.
- I've got one on the fridge – there's a map of how to get to the hospital, my case manager's number, the things I need to have looked after if I am away for awhile – like looking after my cat. If I get out of control he [my flatmate] can grab that, he knows all my current contacts and he can put it all in place. He knows it's what we agreed and he doesn't have to worry that he's doing the wrong thing because it's what I've put down. —Consumer
- Many times it's happened to me, and to my staff, where someone's in the midst of a full-blown psychotic experience and we'll pull out their wellness plan and they'll say, "You bastards have learned how to make my signature!". —Psychosocial rehabilitation services provider
- I've never stopped searching to get well. It's that thing of if you want something, you just keep searching, searching, searching, searching. So I don't see it as luck: I see it as you just keep going until you find the technique, you find the book that works, you find the medication that works. It took seven years for me to find the right medication to keep me stable, and without that I couldn't have done CBT, I couldn't have done support groups. So, whether that's luck or whether it's persistence. —Consumer
That to me is the crux of the whole matter, the system treats the problem and not the person ... they don't see the person they only see the problem and fixing it and they don't do a very good job. —Consumer
Relationships and communicationEssential to effective planning is good communication, between all the parties involved—the consumer, their family and carers, clinical service providers, rehabilitation and support services. Awareness and planning are based on openness, trust and communication. Wellness and relapse plans need to be explicitly negotiated with the other people involved who need to be aware of their roles and agree to their part in the process. For example, family members are often an important aid to undertaking a symptom or reality check. However, for this to work both the consumer and the family member have to agree to this arrangement and make clear the expectations and boundaries.
- I know it's ok to do this because it's what we've agreed. Earlier on there was lots of conflict because I would say I thought there was something going on and he would get really angry with me. But over time, he's realised that I am his best barometer. He knows that I can tell when he can't and now we talk about it and he trusts me to let him know when he's not well. It has made a big difference, but it has taken a long time to get to this. —Family member
Furthermore, it is necessary to regularly revise and revisit relapse prevention plans and this requires long-term ongoing relationships. Life situations are constantly changing, and all the consumers and carers contacted during the consultations emphasised the "learning process" and the "always changing" nature of the factors related to ongoing mental health. Relapse prevention plans will soon be outdated if they are not regularly reviewed and updated; these are not static documents, but rather dynamic tools for the recovery process and must be responsive to changing life circumstances and developmental needs.
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Figure 4. Illness self-management action process (Glasgow et al 2003)
Text version of Figure 4Figure 4 illustrates the illness self-management process as 5 actions which are linked in a cycle:
- Advise - Provide specific information about health risks and benefits of change
- Agree - Collaboratively set goals based on patient's interest and confidence in their ability to change the behaviour
- Assist - Identify personal barriers, strategies, proglem-solving techniques and social/environmental support
- Arrange - Specify plan for follow-up (eg visits, phone calls, mailed reminders)
- Assess - Beliefs, behaviour and knowledge
- List specific goals in behavioral terms
- List barriers and strategies to address barriers
- Specify Follow-up Plan
- Share plan with practice team and patient's social support