Reflections About Safety, Part 2: Safety Plans and Legal Documents

April 21, 2022 / Mental Health

by Diana Spore, PhD, MGS, and Steven G. Stone, MA

This is the second part of a four-part series about safety.

Part 1 in this safety series provided you with the patient’s perspective, laying the groundwork for what will be discussed next. What may be needed to feel and stay safe?

This part addresses what needs to be in place to ensure that someone with mental health concerns who also has safety concerns feels “safe” with reaching out for help. Instead of finding support, many people have found that openly revealing their feelings and fears – even to mental health professionals – can backfire. However, it’s possible to find a sense of self-empowerment, control and agency if you develop plans of action, including legal documents, before sharing that you feel unsafe or are facing a crisis situation.

Safety Plans

People can feel unsafe because of internal factors, like their own thoughts or feelings, or because of external factors. Those external factors could be related to stigma, discrimination, impending evictions and risk of homelessness, other housing-related issues, unhealthy relationships with family members and significant others, domestic violence, being stalked and more.

While they were not written specifically for those who receive mental health services or those with psychiatric disabilities, the Adult Advocacy Centers has created two safety planning resources:

As noted in the first guidebook, “Safety planning is a tool to help you think about what your responses would be in an unsafe situation.”

“A safety plan can help you stay safe,” the guidebook continues. “Your plan will list things that work for you in your specific situation.” These guidebooks walk you through a set of important questions help you develop a safety plan.

For example, the questions ask you to consider what being safe means to you and to identify individuals you trust and write down their contact information. You are asked whether or not you have sufficient privacy so that you can contact those people if needed. The guidebooks also provide room for you to list contact information for local organizations or agencies (such as an emergency shelter), in addition to calling 911 if you are dealing with lack of safety and need help immediately.

It is particularly useful for mental health consumers or those with psychiatric disabilities to think through another question in these guidebooks:

“What can I do to cope when I am in a stressful situation?”

These guidebooks suggest having a “safe word” to alert trusted others if you need help because you don’t feel safe where you are.

In addition to securing support and resources from others, it is important to set things in place to ensure your own safety. You need to be able to set boundaries (including with mental health professionals), have safe spaces in your home, engage in self-care and connect with those who have similar lived experiences. These suggestions were shared with Diana Spore (co-author of this blog) during a writing group session that she facilitated with participants who were facing significant life challenges.

Self-Empowerment by Creating Psychiatric Advance Directives (PADs)

Psychiatric advance directives (PADs) are legal documents in which you can note your wishes, in advance, for mental health care in the event that you are unable to speak for yourself or are identified as incapacitated. You can identify a proxy who will speak on your behalf, with the expectation that he or she will follow your wishes to the extent that is legal and practicable.

PADs offer the opportunity for you to express your wishes about what you want to be done, what matters the most to you, in terms of mental health care and crisis interventions. This is relevant for either being hospitalized by personal choice or by force. For example, do you have preferences about which hospital you are admitted to? Are there any drugs that you would prefer not to receive or any drugs that you cannot tolerate?

For more details about PADS, read the AACs’ blog from April 16, 2021, “The significance and meaning of National Healthcare Decisions Day.” A key quote from the blog:

“PADs are tools for self-empowerment, for demonstrating insight over what is needed for you to recover and remain well, and for having strong relationships with healthcare providers. You are the expert on yourself, and your voice must be heard while you are able to express yourself well. Along the way, you will reveal thoughtfulness, knowledge about self-care, and an awareness of the things that may work against you becoming well or improving markedly.”

Ideally, you should have your PAD in a place that is easy for you to access, especially if you are facing a safety threat. This is highly recommended, once again, from the perspective of a person who has been traumatized (Diana Spore, co-author of this blog).

As for immediate safety concerns, your proxy can serve as your first line of defense in speaking with the police, emergency squad personnel, landlords and hospital staff in certain circumstances. To be best able to serve in this role, it is essential that you have a strong and mutually respectful relationship with your proxy. This includes being open about sharing information about your mental health status, safety concerns, and your fears when they arise, not delaying until they are snowballing and become overwhelming.

Your proxy should be contacted immediately if you are transported to an emergency room for psychiatric reasons or to a psychiatric unit/hospital. Ideally, you should have your PAD at your fingertips (e.g., in your purse or another bag) so you can immediately provide it to hospital or emergency squad personnel. However, personnel are REQUIRED to ask you if you have PADs in place before you are admitted to receive mental health care.

Concluding Comments

In short, this blog emphasizes the following:

To confront and deal with safety threats, it is important to be well-informed and prepared.
Develop your safety plan or have someone assist you in doing so.
Create PADs or a mental health power of attorney document, selecting a proxy that you trust and can count on to follow your wishes, within legal parameters.
Retain healthy social connections, engage in self-care, and select a mental health professional you want to work with if the need arises. Be sure it’s someone who you can trust and is committed to shared decision-making.

By setting plans in motion, you retain a sense of control over what you are facing, are empowered, and remain in the driver’s seat.

Diana Spore is an advocate for individuals facing mental health challenges and those who are living with dementia, a writer/editor, and a mental health consumer in recovery. Spore received her Master’s degree in Gerontological Studies from Miami University (Ohio), and earned a PhD in Human Development and Family Studies, with a concentration in aging, from Penn State. She completed postdoctoral training at Brown University. Spore’s areas of expertise include mental health and aging, mental health recovery and trauma-informed care, medication optimization, long-term care, caregiving, and psychotropic drug use and inappropriate drug use among older adults. She is a former Board member of the Mental Health and Recovery Board of Ashland County (Ohio; MHRB). She was Editor-of-Chief of TAPESTRY OF OUR LIVES, an anthology of works created by individuals in recovery, a project that was done under the auspices of the MHRB. Spore served as Project Lead for a “Writing for Recovery” initiative, MHRB, and engaged in all aspects of the project, which has resulted in sustained spin-off efforts. Diana Spore has expertise in creative writing, writing for recovery, journaling for caregivers, legacy writing, and advocacy writing.

Steve Stone is Executive Director Emeritus of the Mental Health & Recovery Board of Ashland County Ohio. He retired in 2020 after serving as the executive director of the county mental health board for 18 years. He was the primary author of “Our Human Community” and served as a counselor, administrator, and advocate in the community behavioral health system for over 40 years.

Mr. Stone holds a Bachelor of Arts in religion/education and a Master of Arts in pastoral counseling and psychology from Ashland Theological Seminary. He received his clinical training at the Cleveland Psychiatric Institute and Case Western Reserve University. In addition, he completed extensive post-graduate studies in Public Policy and Social Change at Union Institute and University. He completed the Mental Health Executive Leadership Program at Case Western Reserve University and is an approved Mental Health Mediator.

Steve was licensed as a Professional Clinical Counselor with a Supervisory endorsement in 1989 and maintained a private counseling practice in Ashland for 15 years. Mr. Stone has served as the director of a not-for-profit community behavioral health agency and directed a mental health program for a county juvenile court. In addition, he has been an adjunct faculty member at Ashland University and Franklin University.

Steve has been an active member of his community in Ashland, Ohio, since moving there in 1979. He is the co-founder of the Annual Pat Risser RSVP Recovery Conference, past-president of the Rotary Club of Ashland and past-chair of the Leadership Ashland Advisory Council. He is currently on the board of North Central State College, where he served as board chair for two years and has served on a number of other community and non-profit boards. In addition, Steve is on the Board of Directors of the Academy of Violence and Abuse, an international healthcare organization whose mission is to address the long-term health effects of violence and abuse and to prevent their occurrence. Steve and his wife Marilyn have two adult sons and three grandchildren and live in rural Ashland County.