Crisis Stage Plans
During the Crisis Stage you are so far outside of your comfort zone that you are overwhelmed by the challenges you face because your ability to think clearly and cope is impaired. It is a particularly dangerous time because one's judgement is severely affected, possibly putting your safety and/or the safety of others in jeopardy. During this stage it would seem unthinkable to begin a process that will ultimately lead to Bipolar IN Order. The primary objective when you are in crisis is to lower the flow of energy and information so that you can return to your comfort zone allowing you to function and grow again. However, having a team, a plan and tools in place beforehand can be an invaluable help to successfully dealing with the crisis stage.
You should have a Crisis Plan in place long before you find yourself in a Crisis Stage that you couldn't avert. The plan's only goal is to end the crisis in the shortest time possible and get the appropriate help to do so. If there is an existing Life Plan in place that you have been working towards, it should be put on hold with the knowledge that there is a future worth hanging on to. The immediate decision when entering Crisis Stage is to implement your crisis plan by pulling together your team (family member, friend, therapist and/or psychiatrist) to determine how to help you work best towards getting the crisis to end the fastest way possible.
Plan To Recognize The Crisis
The first and most important assessment in a crisis is the recognition that you are in Crisis Stage. To help you do this, it is wise to determine what your crisis stage looks like in advance. Ask yourself, your family member, friend, and/or team members, "What does my Crisis look like? What are the signs that a crisis is beginning to brew?" Write everything down and keep it where you can find it so you can reference it, if you think you may he heading for a crisis stage, and get help early, before you become overwhelmed.
Sometimes, the first person to assess that there is a crisis may not be yourself. It might be that a family member, a friend, or a therapist is the first one to recognize that you have entered crisis. This is less likely if the crisis is a severe depression. In that case, you are likely to realize that your depression is overwhelming your ability to cope. If your behavior out in the community seems to be endangering yourself or others, the police might be the ones called upon to identify the nature of the crisis, but hopefully you have done a Crisis Recognition Assessment in advance and can avoid this scenario.
Generally the next step is the formal crisis assessment, when a crisis professional will do a focused assessment (focused on your immediate symptoms and needs, not a complete in depth assessment with a full history) that tends to identify a working diagnosis, rule out any medical causes of a crisis, assess for the best level of care and develop a crisis plan. The working diagnosis will be something like: depression, or psychosis, or bipolar mania. This working diagnosis can then guide the early intervention and identify appropriate medications and other treatments.
Most people who enter crisis don't need to be hospitalized, but some definitely do. The factors that go into making an assessment of the appropriate level of care include the presence or absence of family or a friend's support, the severity of the crisis (how overwhelmed the person is by their symptoms and experiences), past experiences of crisis and how those have turned out, the person's level or awareness of their condition and willingness to engage in outpatient treatment, and the presence or absence of other problems, such a substance use. All of these factors together help to determine what the appropriate level of care is: in patient care, partial hospitalization, or some type of outpatient care. This Level Of Care Assessment is an essential one.
If you are admitted to the hospital, there will likely be a more thorough assessment done by the inpatient doctor, but in general, the full, in depth, assessment doesn't take place until you get into outpatient treatment.
All other Bipolar IN Order assessments need to wait until the person has entered managed stage and the crisis is over. Any assessment other than a crisis assessment during crisis will likely be an over-reaction to the crisis and not indicative of the real underlying condition.
Suspend All Other Plans
Crisis Stage is not the time for creating or working on a Life Plan for the future. In fact, if you're in the midst of the most severe crisis, you may not be able to do much if any planning at all. You may have to rely on the guidance of professionals. The part of your Life Plan specific to crisis would best be called a Crisis Recovery Plan.
The key elements in the plan are writing down, in advance, what the triggers are that cause you to begin entering a crisis, what the behaviors and subjective experiences are that indicate that you are either entering a crisis or in a crisis, who should be your crisis companion, and what other sources of support you have. You should include what types of treatments you have had experience with that seem to have worked the best, if you have been in crisis previously. The previously mentioned Crisis Recognition Assessment is part of the Crisis Recovery Plan.
Seek Treatment
Treatment, when you're in a crisis will most likely be guided by a professional's working diagnosis. In order for that working diagnosis to be as accurate and useful as possible, it is very helpful for you to not only provide as much information as you can to the professional but to also allow and encourage your crisis professional to talk to trusted family or friends who can provide additional information.
Treatment might entail medication, therapy and addressing any medical issues that may have contributed to the episode. This list is not comprehensive and will likely be added to by your attending doctor.
Safety Companion or Care Team
The first and most important task when you are in the Crisis Stage is to make sure that you and those around you are safe. The main focus is to slow down the flow of energy and information and to help you to stop the feeling that everything is urgent or dangerous. During this stage, it is common to feel that those around you don't understand what is happening to you and you feel very alone, which has the potential to further fuel the crisis. For this reason, it is imperative to have chosen, in advance, a person to be your safety companion and/or a care team who you trust to support you through this stage. A crisis companion or a care team provide you with another perspective about what is going on. Having a crisis companion/team is essential because the nature of Crisis Stage is that it distorts how you perceive things. It makes all of the problems that you're wrestling with seem both huge and urgent. Your crisis companion/team can help you identify what the real issues are and which ones are nothing to be concerned about at this time. In a crisis, what is most important is to have, one, two, or at most three other people who can guide you because it is easy to get overwhelmed and confused if you are listening to too many voices.
How do you select a safety companion or team? Usually the best guide is your past experience with the people in your life; people whose opinions you respect, trust, and who have your best interests at heart. Some possible choices could be a family member, close friend, therapist or psychiatrist. It is important to choose these people long before there is a hint of a crisis because once you begin to go into Crisis Stage, your perspective on some of your relationships may become distorted. If you do not plan ahead, you will probably make inappropriate choices when trying to piece together a team while in the throes of a crisis, and you might not even consider having one at all by then.
Once you have identified your safety companion/team, you should have a conversation with them that goes something like this: "There may be a time when I'm in a crisis. That means that I may not always see things as clearly as I have in the past. I will need help to see things from a different perspective while I'm in that state so I can make appropriate choices. I don't need you to tell me what to do, but I do need you to tell me how you see things. I promise that I will do my best to listen to your perception and thoughts about what is going on."
Medication
When you are in Crisis Stage, your psychiatrist's and care team's main goal is to slow down the flow of information and to help you get rest. To do this in the fastest way possible, medication or a combination of medications are often the first tools used to help you return to a state where you can begin to cope again. There are numerous medications that are used to treat bipolar disorder and your doctor will make the determination of which should be used based on your symptoms and history. It is important that you keep a current list of ALL medications and doses available in your wallet and a copy with your family member. The list should also include any prescribed by your family doctor and any over-the-counter medications.
Psychotherapy
In a crisis, therapy needs to focus on the essentials. In fact, much of emergency psychiatry is about trying to help patients get some sleep to allow the brain's natural healing abilities to reduce the overload. For many people, a sleeping medication may be necessary to get to sleep when everything seems urgent and overwhelming. For others relaxation techniques or meditation techniques may allow them to go to sleep. One challenge is convincing yourself that going to sleep is really just as important as whatever else it is that you feel you must do instead. Sometimes, everything else seems so important that going to sleep seems like a waste of time. In a crisis, much of the feeling of importance is being generated by overactivity inside the brain and a good night's sleep may allow a new perspective.
Other basics are very important including re-establishing some kind of daily routine, eating well, and avoiding self-medicating.
Your body has natural rhythms that help to maintain the good working order of all of its systems and integrate them so that the complex process of going to sleep, which involves many changes in body systems, can take place. These are called Circadian rhythms. Circadian means roughly once a day, and that "roughly" is important. Your body has a number of internal clocks to coordinate the daily rhythm. Each of these clocks is a little bit off of the 24-hour a day rhythm. Think of it as a very bad wristwatch that needs to be adjusted every day. The daily adjustments and synchronization of these clocks takes place because of certain routines. For instance, every day you should be exposed to light at roughly the same time of day. However, in our complicated and fast-paced world, these adjustments may not happen. You may be exposing yourself to light very late at night, you may sleep through morning, etc. When daily rhythms are off, the mood rhythms get dysregulated, as well. To help the body and brain find healing and balance, focusing on stabilizing daily rhythms is very important to resolving the crisis that develops in bipolar.
What are the key things to attend to in order reestablish normal circadian rhythms? Interpersonal and Social Rhythm Therapy, IPSRT, is a type of therapy that has been developed to help people with bipolar that can help us understand these key rhythm stabilizers. IPSRT focuses on the time in the morning when you wake up, the time when you get your first exposure to bright light (which is usually being outdoors), the time when you have your first social interaction (which doesn't have to be meaningful in order to help stabilize your daily rhythm), when you start "work" which might involve school or other productive activities and getting to sleep at roughly the same time each night. Each of these important daily activities help to stabilize your circadian rhythm so focusing some attention on making these take place at the same time every day is helpful and will lead to improved mood.
Meditation and Relaxation
It is helpful to think about relaxation techniques and meditation at the same time. Although obviously meditation is much more than relaxation, almost all of the Western medical techniques used for relaxation training derive from the Ayurvedic traditions of medicine that have their roots in meditation practice. From that standpoint, relaxation therapy is a subset of meditation.
You may be helped if you have established a solid meditation routine already, but even then it may be nearly impossible to do during crisis. It is foolish to think that you can wait until crisis to start learning how to meditate. You may need to give up the practice temporarily and switch to easier relaxation techniques.
Listening to relaxing music, massage, walking in nature, or any other activity that tends to relax you can be a powerful tool during crisis. It would help immensely to have a list of tools already thought out. This should be a part of your Crisis Plan.
Finding Value
Right in the middle of the financial free fall that ended the first decade of the 21st century, there was a fascinating piece that was aired on NPR's "All Things Considered". It was a story about an economist in Texas who studies what is call "behavioral economics", which is, broadly speaking, the interface between psychology and economics. She was interested in studying the effects of feeling out of control. The piece involved two aspects:
First was the demonstration of the powerful effect the feeling of being out of control of how our brain functions has on us.
The second was the suggestion that, even in the midst of very difficult and turbulent times, there are techniques that can help us to cope with our sense of loss of control.
To demonstrate the first aspect, the economist did an experiment that looked at the impact of loss of control. Basically what she did was to show people pictures that were ambiguous. In other words there was the possibility that some people in the group would interpret the pictures in different ways. It was not surprising to find that those who were feeling a loss of control tended to perceive those pictures in ways that were consistent with that mood but what was even more surprising was that what they reported seeing was a different picture. In other words, as far as their conscious awareness was concerned, feeling out of control tended to change the experience of what they actually saw as well as their perception of those pictures. Of course the importance of people finding "meaning", or "understanding" in life has been a subject of discussion by psychologists for decades. But it is useful to remember when one is in a crisis that one is probably not even seeing things in the same way that one would see them if one wasn't in a crisis.
For the second aspect, the economist used an experiment that was equally illuminating. She had studied the effect of an intervention to try to increase people's sense of control even in the midst of a situation that they didn't have the ability to change. She was able to demonstrate that by focusing peoples' attention on their values, asking them to reflect on those values and define them in as clear a way as possible, people actually experienced a reduction in the distorted perceptions that came from loss of control. In other words, even in the midst of a situation that may be "hopeless", we do have the ability to exert some control by focusing on and embodying in our lives our core values and beliefs.
The final technique in our discussion in this section is an exercise to focus on your values to help you live more fully in a way that is consistent with those values, even in the midst of a situation that may be hopeless and out of control. Healthy boundaries are necessary for a healthy life and healthy relationships.
Crisis Recovery Plan
Crisis means that you are in a severe breakdown where you are an immediate threat to yourself or others. You will be going to the hospital and your choices may be frustratingly limited. That is why these worksheets and agreements are critical.
It is important to fill out your agreements when you are well. It is important not to sign away your self determination, but it is also important to agree to trust certain individuals whom you can ask to take on short-term decisions about your state. They can help you get the care you requested in advance, if ever you cannot make that effort or decision for yourself and are in a true crisis.
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