Transcript How to Convince Someone to Get Psychiatric Help

CALVIN: I think we should go see him, Beth. - Dr.
Berger.
BETH : What?
CALVIN: I think we could all go and see him together.
BETH: What does he know about me, about this
family? I've never even met him.
CALVIN: Exactly. That’s the point. Wouldn't it be easier
if we all talked about it? In the open.
BETH: About what? What are we gonna talk about? I
don't want to see any doctors or counselors. I am me.
This is my family. And if we have problems, then we will
solve those problems in the privacy of our own home,
not by running to some kind of specialist every time
something goes wrong...
“Breaking Bad”
QuickTime™ and a
DV/DVCPRO - NTSC decompressor
are needed to see this picture.
“Komrad on Call”
ARN
“Sunday Rounds”
NPR
Last night, your adult daughter was at your house
for dinner, as she always is on Tuesdays. But she
was short tempered and rude. You’ve watched as
over the last few months she has become more and
more irritable. Lately, she arrives with a bottle of
wine and drinks most of it before dinner is served.
The next day, when she calls to thank you for
dinner, she appears to have forgotten how rude she
was, and never apologizes. This morning she didn’t
call. Now you and your husband are worried that
your daughter is abusing alcohol. You’ve tried to
talk to her about her drinking, but she explodes.
Now you’re afraid to say anything because her
temper is close to the boiling point.
A close friend of yours is acting strangely. You
and she have a longstanding lunch date every
other Tuesday, but lately she’s been canceling at
the last minute. When you call her at the office,
the receptionist tells you that she’s not in. You
ran into her husband at the grocery store and he
told you that she hasn’t been sleeping well and
she’s been missing days at work. You don’t know
whether she has lost interest in your friendship,
whether she’s having an affair, or whether she’s
having emotional problems and needs help.
Your brother called and suggested you keep your living room curtains
closed because “they might be watching.” “Who is watching?” you ask
him. “The people in the red cars; I saw three of them on my way home
today, and they all had license plates beginning with the number three. I
think they’re watching people who have three kids, like you.” This
conversation only adds to the worries you have had about him, like
noticing that he isn’t changing his clothes very much and it seems to be a
long time since he took a shower. At the last family dinner with your
parents, he came late, seemed very uncomfortable, and left abruptly.
“THIS PERSON NEEDS MORE
HELP
THAN I KNOW HOW TO GIVE”
“I NEED SOME PROFESSIONAL
ADVICE ABOUT HOW TO
HANDLE THIS PERSON”
“I’M NOT SURE
HE’S GOING TO
BE OK”
Caring Friend?
Supportive Hair Stylist?
Mental Health Professional?
"When the only tool you have is a hammer
you tend to see every problem as a nail."
-Abraham Maslow
10 signs
(APA + HHS + WHO)
•
•
•
•
•
•
•
•
•
•
Marked personality change
Strange or grandiose ideas
Excessive anxiety
Prolonged depression, crying or apathy
Extreme moods--highs and lows
Marked changes in eating or sleeping patterns
Talking, or repeatedly thinking about, suicide
Abuse of alcohol or drugs
Excessive anger, hostility or violent behavior
Inability to cope with problems and daily activities
• i.e. problems functioning at work, school, or home
Komrad’s
additional signs
• Making others suffer or feel scared
• Problems caring for or regulating one’s self
• Something very traumatic happened
• After the breakup of a longstanding, significant
personal relationship
THE 3-DIMENSIONS OF MENTAL LIFE
A Change from Baseline
Lisa Nowak
Why Didn’t This Person
Get Help on Her Own?
•
“Just do it” : the myth of totally free-will (“Nike Nation”)
•
“I’m not sick” : anosognosia
•
“People will reject me; I’ll get in trouble” : stigma
•
“It’s no big deal” : denial
•
“Psychiatry is bull-----” : misinformation
•
“It takes too long” : the culture of the “Maalox Moment”
•
“You can’t make me” : double-edged sword of civil rights
•
“It’s physical, not mental” : mind-body duality
•
“I can’t afford it” : financial and access barriers
The Goal
An Initial Evaluation
“Diagnosis is half the cure”
--Hippocrates, 325 B.C.
Prognosis
Diagnosis
Therapeutics (Treatment Plan)
Getting Started
Can we talk?
Picking the Right Time & Place
Don’ts
• the middle of the night
• when intoxicated (you or the other)
• at family gatherings or special events
• when arguing, or right afterwards
• by email, text, facebook, or mail
Do’s
• prepare the way: create some anticipation
•
designate a “special time” in advance
• ask to be listened to and taken seriously
• find a place that is emotionally neutral
• if feeling unsafe, find a semi-public place
How to talk the talk
Remember the goal:
an evaluation
Tools
•
empathy and psychological visibility
•
uncritical listening
• accept and acknowledge that this is uncomfortable
• state the importance of preserving the relationship
• deploy the theme of love and concern up-front
•
be prepared to tolerate anger without getting defensive
•
•
allow for mixed feelings
emphasize pain and/or dysfunction,
•
not words like “crazy” or “abnormal”
• describe the thoughts, feelings, and behaviors of
concern
Tools 2
• use “me” and “I” statements
admit your own pain
admit your own powerlessness
admit your own need for help
•
•
•
•
don’t suggest a diagnosis
ask for an evaluation as a gift to you, or children
share your own treatment experience
this may take some time, and a few tries
The Pitch
• a one-time evaluation (maybe starting
with the primary care provider)
• offer to make the appointment
• ask if you can go along, even just to sit in
the waiting room
• offer to pay
Using Allies
“Breaking Bad”
QuickTime™ and a
DV/DVCPRO - NTSC decompressor
are needed to see this picture.
Key Allies
• Siblings, key family, or friend
• Primary care provider
• Clergy
• A support group (NAMI: maybe the first thing to
try!)
• A psychiatrist or other professional to guide you
• Books, memoirs, and movies
• Your own mental health provider
MARK S. KOMRAD M.D.
Adult Psychiatry
222 Bosley Avenue
Suite A-3
Towson, MD 21204
Diplomate of the American Board
(410) 494-4411
of Psychiatry and Neurology
Fax: (410) 510-1119
Distinguished Fellow of the American Psychiatric Association
[email protected]
Clinical Assistant Professor, University of Maryland
www.komradmd.com
Instructor in Psychiatry, Johns Hopkins
Charlie, you asked me to write to you and share some thoughts about
our work together so far. As you know, most of our sessions have been
about how to cope in your marriage, which is very stormy. You have
often expressed some distressing feelings such as helplessness,
hopelessness, fear, anger, and concern for the effect that the
relationship is having on the children. I, too, have had some concerns
about the children’s mental health and the effect that this turbulent
relationship might be having on them. The original reason you came to
consult me was because of depression and anxiety. Though I am doing
my best to help those problems, I have come to realize that there is only
so much I can do to help you with medications and our therapy
sessions. Much of your depression is related to your stress, specifically
related to how your marriage is going . . . . .
From Persuasion to Coercion
The Power of the Family
Non-therapeutic Coercion
Reason
Reason
Persuasion
Coercion
1968
Privileges
Rights
Responsibilities
• cellphone
• computer and internet access
• car, gas, insurance
• $ subsidies
• vacations
• residence
GIVING
TAKING AWAY
Rewards
Consequences
better for
Extroverts
better for
Introverts
• Professional planning/facilitation
• Who will be there?
who is most influential?
who is most enabling?
•
•
•
•
•
Prepare what each will say
Prepare the goal ahead of time
Consensus on goal (anticipate the enabler)
Have a Plan B
Debrief afterwards
Involuntary
Evaluation
Phase 1
Call the Police, OR
Go to the local courthouse to
Initiate an order for involuntary
psychiatric evaluation
Order is not granted
Order is granted
Police pick up the person
and go to the ER
Doctor and possibly another
mental health professional
evaluates the patient to
determine if the criteria for
involuntary treatment are met
Criteria are met
Phase 2
A person is involuntarily admitted
to nearest psychiatric inpatient
unit (often in the same hospital
as the ER, sometimes
elsewhere)
The person can be forced to stay
in the hospital a certain minimum
number of days (differs by state)
Criteria are not met
Wait for the criteria for
“dangerousness” to be met.
Meanwhile, keep working
earlier steps in this book
The treatment team decides that
the patient can be offered an
option of becoming a “voluntary”
admission, before the minimum
days expire
Offer is not made
or patient refuses to
sign as “voluntary”
Offer is made
and patient accepts
becoming “voluntary”
The patient gets well enough to
leave before the minimum days
expire
Gets well
Does not get well
Phase 3
The patient does not recover
soon enough and a Civil
Commitment Hearing is
convened where a judge reviews
(often very strictly) if the criteria
for involuntary retention in a
psychiatric hospital is met
Judge decides
criteria
are not met
Judge decides
criteria are met
Phase 4
Inpatient treatment continues
Accepts
medication
Patient improved and
discharged from hospital
Refuses
medication
Clinical and legal procedures
initiated to give medication
involuntarily
Tips for Optimizing
Outcomes
• know the process in your community
• put the “worst face” on the story
• show up at each step
• close your home if necessary
• if the person is in legal trouble--use it!
• if there isn’t a legal problem--consider initiating one
“Crisis”
Opportunity
Danger