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
Planning is what empowers people with mental illness to make the decisions they choose, rather than have decisions made for them. Planning needs to be undertaken when the consumer is relatively well and able to make such decisions. It needs to be undertaken on several levels: daily plans, wellness plans, relapse and crisis plans.
    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
People with mental illness may need daily plans to ensure that they undertake the everyday activities they need to keep them well and prevent relapse. These plans may involve behavioural tailoring to ensure that maintenance medications are taken. They may also involve prompts to ensure that symptom and reality checks are undertaken. Plans need to be comprehensive and ensure that protective factors such as exercise, sleep and social activities are undertaken, and that risk factors like stress are minimised or effectively coped with.
    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
More general wellness plans are also required. These identify the risk and protective factors that are currently impacting on mental health, and the actions to be taken in response to them. Relevant risk and protective factors need to be identified for all the domains—environmental, physical, social and emotional. Relapse plans tend to focus on reducing stress and stressful activities, sleeping and eating properly, exercising, and making social contact with other people. However, goals for change and growth also need to be determined, as well as the facilitators and barriers to attaining these goals. Top of page

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
This doesn't guarantee that all will be trouble-free during a future episode, but does generally act to empower consumers in crisis situations.
    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
Related to planning are self-will, responsibility and perseverance. Many people in the consultations, as well as their families and carers, noted the need for hard work and persistence in order to stay well. Persistence is required to achieve goals and to maintain the activities needed to prevent relapse (such as maintenance medication and exercise). It also entails a realisation that relapse prevention is something that you can do yourself: that your recovery is your own responsibility and that waiting around for services to provide the answers to your problems or for a miracle cure is not the way to get well and stay well (Walsh 1996). Furthermore, services must support self-will and responsibility rather than encourage dependence. Larry Davidson (2004) maintains that the statement, "You can do it - we can help", captures the approach that services need to adopt to support self-determination and recovery.
    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
An effective relapse prevention plan will tailor the development of awareness, acceptance and planning to each person's unique needs, taking into account their age, personal circumstances, level of insight, cultural background, and experience of mental illness. It is not appropriate for services to inflexibly impose a standardised 'relapse plan'; rather, it is essential to routinely make sure that all the factors that may prevent relapse for a particular individual are comprehensively but sensitively considered.

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 communication

Essential 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
Both formal and informal relationships are important. Family members and carers are highly motivated to build trusting relationships and have frequent contact and opportunities to do so. However, service providers can be less willing to take the time to invest in relationship development and good communication. This is somewhat surprising given the level of evidence attesting to the importance of the therapeutic relationship in terms of positive outcomes (Horvath & Greenberg 1994). Trust and effective communication between service providers and consumers and their families and carers are fundamental to good continuing care, but something that is generally elusive in the mental health care system.

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)

Refer to the following list for a text equivalent of figure 4. Illness self-management action process

Text version of Figure 4

Figure 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
The 5 actions are connected (via a double-headed arrow) with a central oval which contains steps in establishing a personal action plan:
  1. List specific goals in behavioral terms
  2. List barriers and strategies to address barriers
  3. Specify Follow-up Plan
  4. Share plan with practice team and patient's social support