Crisis Safety Plan: When a family member has Borderline Personality Disorder

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Develop a Family Crisis Safety Plan

Part I: Preventing Crisis and Controlling Potentially Explosive Situations

Information adapted from the National Alliance on Mental Illness (NAMI) Family Resource Guidebook

NAMI.org

Preventing Crises

According to NAMI, sixty-five percent of the individuals discharged from psychiatric hospitals now receive primary care and support from their families; so, it is likely at some time the family caregivers will experience a crisis situation with their ill family member. Both parties need to learn how to recognize that a crisis might be coming, what actions can be taken, and what supports can be put into place.

A full-blown crisis situation can result because no prior planning has been done. Seldom if ever does a person suddenly lose total control. Studies show that 70% of people with mental illness can pick up on their own early warning signs of crisis; 96% of their loved ones can identify those same signs. Both parties must know what to look for.

It is important that all family members understand what the expectations are within the family unit. Limits for the family and individual boundaries can give everyone a sense of safety and empowerment within the home and family unit. For more information on setting limits and boundaries please review this information:Communicate Boundaries and Limits

Learn to trust your instincts! It is during the early stages that a full-blown crisis can sometimes be averted. If you sense deterioration in a relatives mental condition, try to discuss with that person how he is feeling:

Validate their feelings and normalize those feelings. Ask validating questions like "what do you think would help right now?" Contact a predetermined person or professional to speak with them and give advice on any next steps that are needed.

Consider if any of the following may apply to the situation:

• Are the appropriate medications still being taken?

• Are recent events or activities too stressing?

• Are sleep patterns changing?

• Is there ritualistic preoccupation with certain activities?
  
  
• Are unpredictable outbursts, unusual agitation, or paranoia a problem?

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Families and people with mental illness can learn to recognize trouble spots and stressors in the environment. If we observe the potential for a situation to deteriorate ask to revisit the conversation after you have had time to think about the problem being presented, request being made, or complaint.  Have all family members move to a predetermined safe location by using a code word everyone has knowledge of.

Family Code Word________________________________________________

Predetermined safe location_________________________________________

Predetermined person name/#_______________________________________

Controlling a Potentially Explosive Situation

If the ill individual is in danger of self injury, if behavior is frightening, or if the ill person is threatening people, it is important to take immediate action: call a crisis center. Remember, the patient is probably terrified and your primary task is to help the patient regain some control. Accept the fact that the patient is in an "altered reality state."

It is imperative that you remain calm.  Below is a "what to do" list to use during a full-blown crisis.

1. Don't argue with the ill person that what he/she is seeing, hearing, or feeling is unreal. Assure the person that you understand what his/her are experiencing is real to him/her and you want to help.

2. Don't threaten. It may be interpreted as a power play and increase fear or encourage assaultive behavior.

3. Don't argue with other family members as to how to treat the situation. This creates more confusion.

4. Don't touch or have continuous eye contact with the patient. Don't turn your back on him/her.

5. Comply with reasonable, safe requests from the patient. This provides the patient with an opportunity to regain some of the control.

6. Don't block the doorway (However, try to keep yourself between the patient and an exit.)

7. Remember, do call the police if the person is violent. Most important, explain to police the details of the situation before they arrive so they will be prepared: i.e., how long the crisis has gone on; is the person suicidal; how has the person been violent; are there guns in the house; does the patient have a weapon of any kind.

8. Most importantly, understand that this illness is not your fault, nor is it the fault of the person in crisis. Mental illness is a biochemical disorder of the brain. It must be treated with the same attitude as a physical illness.

Crisis agency name/#_____________________________________________

Treatment team contact info:_______________________________________

It is important to put together a crisis management team before a crisis occurs.  See Part II Develop a Family Crisis Safety Plan

Our objective is to better understand the struggles our child faces and to learn the skills to improve our relationship and provide a supportive environment and also improve on our own emotional responses, attitudes and effectiveness as a family leaders

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Develop a Family Crisis Safety Plan

Part II: Steps to Follow During a Crisis and Putting Together a Crisis Management Team

Information adapted from the National Alliance on Mental Illness (NAMI) Family Resource Guidebook

NAMI.org

Putting Together a Crisis Management Team

Sixty-five percent of the individuals discharged from psychiatric hospitals now receive primary care and support from their families; so it is likely at some time the family caregivers will experience a crisis situation with their ill family member. Both parties need to learn how to recognize that a crisis might be coming, what actions can be taken, and what supports can be put into place.

Traditionally, most mental health services are "agency centered." Each agency-home health care (with psychiatrist/nurse/social worker), crisis service (with clinician, crisis support persons), mental health agency (with more psychiatrists, therapist, community support worker), and school (teacher, Special Education, social worker, principal) have set up their own plan. The more agencies, the more plans. Imagine trying to understand which agency has what plan? Who in each plan is responsible for what tasks? When should the parent and ill person use which plan? Now, add to this problems in communication, comprehension, memory, stress tolerance especially when you are in the midst of a psychiatric crisis!

The result is confusion and chaos for families and patients who are already exhausted. All too often the ill person is labeled difficult or non-compliant, among other things, because he/she didnât follow everyoneâs plan correctly. In reality, it is probably not the person who has failed but all the confusing plans.

This is why we present a "person-centered" plan: a plan designed around the patient's needs and strengths and involving any agency or provider who can best support the particular needs of the person. It encompasses all the different degrees of full-blown crisis situation.

Pre-Crisis Directive. Prepare a folder that includes the patient's:

• Name, address, phone number (and caregivers)

• Diagnosis, psychiatric history medication dosages

• General medical history (diabetes, heart problems, very important!)

• Treatment preferences: i.e., patient's choice of hospital, doctor, type of restraint (if necessary), choice to use ECT (if necessary)

• A phone list of: the crisis team, doctors, emergency room, police, ambulance service, and any other services you may need.

Crisis management will likely take the most time, the most collaboration/cooperation and it can involve the most people. It is also the most critical and can literally save someone's life. Make sure you have plenty of time to plan and all the relevant participants are at the planning table.

Input from anyone who has close contact may be helpful at this point. This is where the plan really starts to formalize. Other team members - friends, clergy, support people, crisis workers, teachers, therapists, doctors, case managers-- may recognize other signs and can be brought into the process. In addition to the person with the mental illness, family and friends, it is imperative to have those professionals at the planning table as you begin to put the intervention plan on paper.

Involved providers may have access to funding for services and support that you may need to put this plan together. You will also need them all to "buy into" the plan.

All of this must be documented. All involved providers must be informed. Each must agree to the plan, sign their agreement and receive a copy of what they have agreed to.

In the chaos of a full-blown crisis situation remember even the simplest information can be difficult to communicate.

Have an information sheet with the following written on it:

• Crisis service number

• Local hospital number

• Local police number

• Your psychiatrist's number

• YOUR name address, telephone number

• Names and numbers of a support person, case manager, therapist or counselor

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Next, in a folder ready to go, have your family member's name, age, mental health diagnosis history, "other" medical diagnosis, medication(s) and dosage and information on the treating psychiatrist and family physician. It's best to have several copies of this information on hand. It can be given to mental health workers, ambulance personnel, police and emergency room staff to avoid repeating information.

A good preplan also includes preferences and decisions concerning the following items. If it is decided that the ill person must undergo voluntary or involuntary admission to a hospital:

Who is the best choice for transporting Johnny to a hospital, the parents, an ambulance, the police, or friends? How can you plan for these options in advance? If parents transport Johnny, will they need help getting Johnny safely from the car to the hospital? If parents need to arrange for child care for other family members, what are the options: parents, in-laws, siblings, neighbors? If the police, ambulance, and ER staff are involved, their roles must be clearly predetermined, written into the plan, agreed to and signed by their appropriate representative.

Hospital care: List the hospitals in order of preference. Include the patient's preferred form of restraint and/or medication for sedation (when and if necessary). Always consider the worst case scenario given past experience with the patient, and create needs-based interventions.

It is imperative that carers have a clear understanding of which service provider to contact to meet a specific need, what will happen when that service provider is contacted, and how this service will be funded.

For help with putting a crisis management team together a good place to begin might be with the patient or family's therapist and/or psychiatrist or case manager.  It is also highly important to contact your local authorities and ask about their policies for responding to 911 calls from families dealing with mental illness.  For example:  What action will be taken if I call because my child is a danger to self and others? Where will my child go if she is removed from my home?  Who will transport her? What other agencies will you contact? Also consider how calling 911 responses can differ depending on your location.  For example, you may live in an area where the county responds to a 911 call and your child attends school where the city would respond to a 911 call.  :)o not assume that the results of an emergency call would be the same. Know for sure.

The crisis plan is not a tool to be used for power or control, nor is it intended as punishment. It should never be used as a threat. It is not a "quick fix." A crisis plan is a management strategy to help keep your ill family member safe. It is like a job description: you know what your responsibility is and what your co-workers responsibilities are before you begin. The plan should be in written form, outlining what steps would be done by whom.

The purpose is to teach new coping skills to those involved, help prevent a full-blown crisis, and pre-plan all necessary supports and interventions. It must be flexible enough to be used in a home setting, in the community, at school, at the grocery store-- wherever the crisis may occur. Thorough, proactive planning clearly organizes the chaos of crisis.

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Develop a Family Crisis Safety Plan

Part III: Post Crisis-Evaluations, Hospitalization and Release Plans

Information adapted from the National Alliance on Mental Illness (NAMI) Family Resource Guidebook

NAMI.org

Post Crisis

Now that the crisis is over and your family member is safe, either at home or in an alternative setting, everyone needs to recuperate. It is okay to cry, to feel angry, stressed out, relieved and a whole host of confusing feelings. Take the day off take the phone off the hook, and do something special for yourself.

Next, understand and accept that what you did was necessary. Acting to keep your relative safe is the highest form of love, even when it may involve force and hospitalization. Your relative may be angry at you for calling the police or the crisis team, but at least he/she will still be around to express it.

Your ill family member will also need time to recover from this crisis episode. At no other time is this member and the rest of the family so totally "out of sync." Each is suffering from post-crisis slump. Families must back off. Lower their expectations of the patient. Recognize that you are dealing with a biological illness which strains your loved one's physical and psychological systems to the maximum. It may take weeks or months for a good recovery.

The final step in recovery is for the team to meet and evaluate the pan. How did it go? What worked? What didn't? This should be a blame-free time when team members cannot blame each other for mistakes. Focus on how to make needed improvements and evaluate the plan.

Emergency Evaluation and the Law

 If the ill person meets the criteria for dangerousness the crisis worker will arrange for a physician or a psychiatrist to confirm the assessment and contact the local sheriff's department to transport the ill person to a hospital for further evaluation and possible admission.

At the hospital, the person will again be evaluated, this time by a psychiatrist or other mental health professional, using similar criteria as used earlier. If the evaluation indicates the ill person meets criteria for involuntary hospitalization, the person will be retained at the emergency room until an involuntary hospital bed can be found and a "blue paper" processed.

At any time during this rather complex process, if the ill person is found (by doctors or the court) to not meet the specific criteria for involuntary commitment, he/she may be returned to the community, and referred to voluntary outpatient treatment. A person can be held for 72 hours under the blue paper until a court hearing can determine continued commitment or immediate discharge.

For a mentally ill person in crisis and refusing treatment, but not in immediate danger of hurting him/herself or others, it is possible to petition the Family Court for a "non emergency involuntary hospitalization." Relatives, friends, family doctors or mental health workers may execute a petition declaring that they feel the person should be committed and the reasons for their opinions. If your family member has been part of a community service provider's treatment program, the therapist or caseworker may be asked to testify at the hearing.

The most common means of getting a person in crisis admitted to a hospital is by calling a doctor for an assessment and referral. However, if the ill person refuses to go to the hospital, the next option is to call the community crisis team (emergency services). If from conversation with the caller the crisis team determines that an on site evaluation is justified, they will arrange to meet the ill person at a general hospital emergency room at your home, or any other safe community location. Often your family member will voluntary accept treatment eliminating the involuntary admission process.

The purpose of the hearing is to determine whether the ill person meets the criteria stated above. The person must be mentally ill by clinical standards and meet the criteria of dangerousness to self or others. (See also Hospitalization)

Hospitalization

Hospitals may be needed for emergencies (be sure to keep the number for emergency crisis services available), for voluntary hospitalization, or for involuntary hospitalization and/or commitment. If the choice is private care rather than through the community mental health program, there are several things to consider.

Private insurance may cover a short hospitalization. Check carefully to see how much of the cost is covered; most policies have very limited coverage for mental health or psychiatric illness. Check with your insurance company about continuing your son's or daughter's coverage after the age when coverage generally stops (usually 19, if the person is not attending college); it may be possible to continue coverage past that age on a parent's policy.

Medicaid may cover hospitalization expenses if there is no private insurance coverage. Personnel from the community service provider and/or the Department of Human Services may be able to assist you with an application for Medicaid.

Some Community Mental Health Centers have an alternative arrangement for individuals in crisis, such as "crisis beds" which are used to provide care in the acute episode while avoiding hospitalization.

Admission Procedures:

Voluntary Hospitalization

If a person needs to be hospitalized, voluntary admission is always the preferable route. If the person with a mental illness can participate in the hospitalization, the outlook is much brighter. When payment is made by an HMO (Health Maintenance Organization), insurance, or by the family or patient, the admission process is usually straightforward and decisions concerning need are determined by the patient's doctor and the admitting staff.

Hospitals have individual arrangements regarding admitting patients covered by Medicaid and/or Medicare. The admissions staff at each hospital will advise voluntary patients and/or their families about patient eligibility and unique restrictions or procedures.

Involuntary Hospitalization

The involuntary hospitalization of a person with mental illness is a complex process designed to provide treatment in the least restrictive environment and to protect the civil liberties of persons with mental illness. Sometimes families are witnesses to the serious and rapid deterioration of a family member, and become fearful that the ill person may die, or never really recover. Our instinct is to protect our ill family member by getting them the medical help they need before decompensating and becoming seriously psychotic.

Balancing the need for treatment of a very ill person with one's civil rights is one of the greatest challenges of our law. Equally, one of the greatest challenges a family may ever face is having a family member committed with dignity and love and without destroying family relationships and the self-esteem of the ill person.

Commitment is not easy, but it often must be attempted. There are times when a family member has no other choice but to proceed with the process.

Application

The statues allow that a law enforcement officer, health officer or other person may make application when they believe that a person is mentally ill and dangerous, i.e. poses a likelihood of serious harm. This person also states the grounds for this belief.

Next a licensed physician or psychologist, stating he/she has examined the person and, in his/her opinion, the person is mentally ill and poses a likelihood of harm, must certify this observation.

The application and certificate (a "blue paper" must then be endorsed by a judge or complaint justice, who authorizes that the person thought to be mentally ill may be taken into custody and transported to the facility designated in the application.

Judicial Procedure and Commitment

Application is made by the head of the hospital upon the certification of yet another physician or psychologist. Once filed with the court, release or discharge can only be made by petition from the head of the hospital or guardian, parent, spouse or next of kin and granted by the court.

The hearing must be held no later than 15 days from the date of the application. The court causes notice of hearing to be sent to the proposed patient's next of kin. For good cause, a continuance of up to 10 days may be granted.

The court orders an examination by two examiners, either licensed physicians or licensed psychologists. The patient has the right to choose one of the examiners. If the reports of the two examiners are to the effect that the person is not mentally ill or does not pose the likelihood of serious harm, the court orders discharge without a hearing.

The person shall have the opportunity to be represented by counsel.

Judicial Hearing

The hearing is conducted in as informal a manner as possible. The person, the applicant, and others required to be present have the opportunity to testify and cross-examine. The State is represented by the Attorney General's Office. It must be proven that the person is mentally ill and that his/her recent actions and behavior poses likelihood of serious harm. It must also be proven that inpatient hospitalization is the best means for treatment and that the hospital, through its treatment plan, has the ability and means to treat. The patient maintains the right to refuse treatment even after commitment. This procedure does not determine the person's competency.

Commitment

Upon making the finding, the court may order commitment up to 4 months in the first instance and not to exceed one year in subsequent hearings.

Hospital Treatment Program

As soon as possible after admission to a hospital or treatment program, family members should make an appointment with the treatment team to discuss the following:

• What is the diagnosis? Please explain.

• What is the treatment plan?

• What are the specific symptoms about which are you most concerned? What do they indicate? How are you monitoring them?

• What medication is the patient getting? Is the response what was hoped for? What side effects should be watched for?

• Has the doctor or nurse discussed with the patient the diagnosis, medications, and the treatment plan?

• How often can we meet to discuss progress?

• What is the aftercare plan when the patient is released from the hospital?

The patient must give consent before a staff person can release any information, including the person's presence in the hospital. Ask to have your relative sign an authorization for release of information. If your relative does not want certain information released, the form can specify which information may be released.

Release Plan

Before leaving the hospital, your ill relative and family should expect:

• Assistance securing appropriate housing such as group homes, supervised apartments, independent living, and community care homes.

• Assistance in applying for appropriate public benefits such as general assistance, medical assistance and Social Security income.

• Assistance in the orderly transfer to community based mental health services, such as timely psychiatric medication reviews, supportive counseling, and a case management system of coordinated care and treatment which provides a network or services through an identified program and staff.

After Hospitalization

Serious mental illness is a long term condition; families should plan ahead even if they are fortunate enough to have to deal with only one or two episodes. Families who have lived with mental illness for a long time often describe how carried away they were at the time of the first episode, and how they sometimes imprudently committed themselves to expensive treatment in expectation of a cure that was never to be realized.

Remember, the most expensive care is not necessarily the best! Money will not buy back the health of your loved ones. Private care is not necessarily better than public. What most patients do need is continued medical therapy, a safe, stable place to live, a chance to develop or relearn social skills, and someone who cares about them. The best place to look for comprehensive services over a long period of time is through the local community mental health provider. If such services do not seem to be available to your family member, contact your local affiliate. The members may be able to help you.

Day Treatment and Partial Hospitalization Programs

Day treatments are a component of the community resources for people with mental illness. Clients who have progressed along the road to recovery work within a group format to increase their understanding of their illness and improve their skills. The programs are staffed during the day and sometimes in the evening hours. Day treatment provides education on topics which include mental illness, medication and its side effects, money management, nutrition, leisure and social skills, job seeking, interpersonal communication, and self-esteem.

Partial Hospital programs provide a more supportive and structured environment for clients who are experiencing a period of instability. These programs offer more intensive psychotherapy groups as well as skill-building techniques. It's called partial hospitalization because it is offered by hospital staff, on hospital ground, but participants do not reside at the hospital.