Periodically, most often prompted by crisis, mental health pops up in our cultural conversation. Pundits point out the obvious flaws in our care system, medical professionals speak of conflicting and vague diagnostics, and some families share heart wrenching personal tales. This flurry of post-crisis activity is actually a microcosm of the complex issues of mental health care: People state the obvious, others admit to the complexity and the people in need are suffering.
Family members (and by ‘family’ we mean everyone who shares love) are often in the direct line of fire of mental illness. Their lives can be upended by the illness of a loved one and their every moment consumed with pursuing effective care. It is those closest to someone ill who will witness and be subjected to troubling behaviors. And unless the ill person is a minor or the behaviors so blatantly outrageous, it is difficult to judge when it’s appropriate to intervene and to what extent. We are a culture that holds personal freedom and autonomy in the highest regard. And while we like to tell people what to do with their lives in the abstract, we shrink from doing so in reality. We don’t want to unnecessarily offend and even if we did, it’s difficult to know what to say or do. It might be helpful to think of behaviors and approaches categorically.
Danger to self or others – There’s no wiggle room here. Our society has agreed that impending physical harm trumps personal freedom. While the “danger to self or others” definition is meant to be applied in crisis, the philosophy applies more universally. When asking ourselves; “Is it time to seriously intervene?” we can use this statement as a guide. It is time to move on from nagging and/or cajoling a family member to eat when you see/feel that their weight loss is dangerous. If someone is driving when drinking, passing out and/or injuring themselves when drinking, they are a danger. If someone cannot get out of bed and has vulnerable people in his/her care he/she is a danger. The question to ask when making this judgment is; “Is someone going to get hurt?”
In crisis is probably the most common presenting challenge. There is no immediate danger but instead a person who is simply not well. For the most challenging mental illnesses (i.e., schizophrenia, bi-polar, personality disorders) a state of crisis is a common occurrence. For people faced with depression or anxiety, crises can be one-offs or few and far between. Depression is a real and debilitating illness, it should not be confused with sadness. Being sad is prompted by incident: a death, a world event, a hormonal event all can trigger sadness. Of course these events can also trigger depression. The key is how long is the darkness lasting and has it changed the very nature of the individual? The same is true for anxiety. When a response to real and present danger morphs into sustained hyper-vigilance it is not serving the individual well.
Intervention – Erase any image you might have of corralled family members confronting someone while shakily holding index cards. It’s a powerful scene for television and movies but is flat out surreal in real life. If there are other caring people who can assist in getting the person in need appropriate care, so be it. But folding chairs and prepared statements are not necessary. If the person is in crisis (danger to self or others) they need immediate professional assistance. If someone has demonstrated a desire to hurt themselves or others they can and should be hospitalized and treated until they are stable. If the person in crisis is compliant you can take them to an emergency room yourself. If they are violent the police will help them to the hospital. *Note: It is best to assume that each and every threat of harm is valid. There is nothing to gain from assuming someone is crying wolf. If nothing else the emergency room staff will become more familiar with the person in crisis and be able to provide more specific care with each return trip.
For people not in crisis, intervention can be a hairy and anxiety provoking business. Every situation, relationship and individual is different. There are no universal guidelines on what to do, but there are some pretty clear guidelines on what not to do. Do not make it easy for someone to not get help. Do not take on the role of amateur therapist. Do some research and find a therapist in the right price-range (any doctor’s office, school, women’s health clinic, or divorce attorney will have referrals.) When the individual seeks to emote or purge have a contact number on hand and take full responsibility; “I want to help in a meaningful way, I’m your friend/family but not a therapist.” If an individual refuses professional help do not abandon them but do not engage in the fiction (i.e., “it’s just a phase, the season, pesticides, politics, etc.) Keep in mind that they are not entirely themselves and may not be the most reliable narrator. Bring them into the world (perhaps kicking and screaming.) Do not sit by their side and watch television. Go for a walk; remind them of the world they’re missing out on. Do not lose sight of the goal of professional help. Do not give up until you’ve exhausted every argument and yourself.
Someday we will treat mental health as we do dental or physical health. Blame and shame will dissipate and systemic effective care will be available to all. Family (in all its definitions) will always be at the front, but in time they will have proper support. There simply is no sane alternative.