Faculty of Psychiatry, Johns Hopkins University, University of Maryland, and Sheppard Pratt Health System, Baltimore, Maryland.
Throughout the 1990s and early 2000s, I hosted a national radio show on psychiatry that went coast to coast in the U.S., with 40 million listeners. During these radio talk shows callers would commonly ask for advice on how to convince troubled loved ones to get psychiatric help. I would brainstorm with people on the air about what attempts they had made to achieve this as they struggled with a family member who was often quite mentally ill.
This developed into a specialty in my practice, and people from around the country started to consult me about a relative or close friend who was clearly having significant emotional and/or behavioral problems, to see how they might be convinced to enter psychiatric treatment. So, doing these consultations with families struggling with a troubled loved one became a specialty for me throughout the last 25 years of my practice. Eventually, I put everything I had learned into this book, You Need Help!. You can click on the image or link below to learn more about the book on Amazon.com.
Many colleagues have found it useful to recommend this book to their patients who are worried about someone in their lives, hoping to get that person the same kind of mental health treatment that has been helpful to them.
Here is a summary of the key ideas in the book.
Note: POC “person of concern”—the troubled person you are trying to help.
Editor: I have substituted the words “loved one” for POC.
Step 1: Before you begin
Know the signs that the loved one’s problem is serious enough to need professional help.
What makes a problem serious enough to require a professional evaluation?
Figure out why you are getting involved, and why it’s worth it. Look at your motivations and the benefits.
Understand why the loved one may have avoided getting professional help so far.
Focus on the goal: getting the loved one to have a professional mental health evaluation. That is the sole goal that this book aims for—getting an evaluation.
Step 2: Choose a time and place
Plan in advance on a special time and place to speak, to listen, and to discuss the problem with the loved one.
Avoid discussing the problem at defensive times, family gatherings, holidays, special events, in the midst of, or right after an argument.
Approach the loved one when everyone is sober.
Speak with the loved one face-to-face, not by letter, phone, or email.
Select an emotionally neutral place where the loved one doesn’t feel trapped.
Acknowledge upfront that the loved one might be hurt by this discussion.
Focus on how you feel affected by the loved one in your discussion.
Focus on your caring, concern, and love as your point of departure in your approach.
Step 3: The first approach
Let the loved one know you are listening, and not just telling him what to do.
Try to make the loved one feel that it is safe to talk. There are several ways to do this.
If you feel unsafe, have another person present when you talk with the loved one.
Be prepared to tolerate the loved one’s anger at your concern, but don’t let that discourage you.
Let the loved one have some mixed feelings; he doesn’t have to totally agree at first. This is more of an ongoing process than a one-time effort.
Persist; keep coming back. Don’t give up because you tried discussing getting an evaluation once, and they weren’t interested.
Focus on specific behaviors that you have observed, without using jargon (e.g. “It’s hard on the kids when you wash the dishes for over 2 hours,” rather than, “I’m worried about the OCD-way you wash the dishes.”)
You don’t have to figure out what’s wrong with the loved one, just communicate that something is the matter and that a professional can help figure out what, if anything, is the problem.
Acknowledge to the loved one that you don’t have the power yourself to completely help him; you need an experienced, trained person to help him too.
Be prepared to ask the loved one to get help for YOUR sake, because YOU need more help to support him.
Ask the loved one to get an evaluation as a “gift” to you.
If you have benefited from your own treatment, share that with the loved one.
Ask the loved one to consider a single, one-time visit at this time; just an “evaluation,” not a commitment to “treatment.”
Make the appointment for the loved one, or help him to make it, and go along.
Step 4: Gathering your allies
Talk with the loved one’s personal physician or other primary care provider about the problem and the need for a psychiatric evaluation. That provider might even be able to provide treatment.
Consider including in your effort a close sibling, dear friend, or clergy with whom the loved one has a relationship.
Even before approaching the loved one, attend a support group meeting for families and friends, like the National Alliance on Mental Illness (NAMI.org). Hear the experience and advice of others who have done this.
Educate yourself about psychiatric problems by reading through memoirs and movies.
Before approaching the loved one, consult with a psychiatrist or other mental health professional yourself about the problem and how to approach the loved one.
If you are already getting mental health treatment, let your own treater help you approach the loved one.
Step 5: Beyond persuasion to coercion
If a person is rational, persuasion can work, if not, then it may be necessary to engage in “therapeutic coercion”—creating consequences that can result in steering the loved one towards getting an evaluation. These techniques are particularly useful in the context of a family, most commonly helpful to parents of an adult child who may be suffering from symptoms of mental illness, but refusing evaluation and treatment.
Accept that logic doesn’t always work.
Understand how friends and family can sometimes have more power than any professional or agency.
Consider that with privileges come responsibilities; in this case, responsibility for the loved one to get help for mental health problems.
Use the powers of giving or taking away privileges to influence the loved one to get professional help.
Your relationship with the loved one is important. In serious situations, be prepared to put the relationship at stake, if necessary.
In rare instances, you may even need to withdraw the privilege of providing a residence for the loved one. You’ll need a lot of support and guidance if it comes to that.
Consider using the power of a group, and gather others for an “intervention.”
Be prepared to deal with those who might be “enablers.”
Step 6: “Hardball”: Involuntary evaluation
The book includes a useful “flow chart” for how typical involuntary mental health processes work.
Determine if the loved one is dangerous to self or others.
Determine if the danger is imminent.
Know the legal process in your community for involuntary evaluation in the face of immediate dangers.
If mobilizing the legal steps for involuntary evaluation, SHOW UP at each and every step.
When describing the loved one’s situation to authorities, share the most serious behaviors you have seen. Don’t hide the worst of it, even if it’s embarrassing.
If the loved one is hospitalized, you may have to close your home to his return until he is better.
If the loved one is eligible, consider the VA system.
Do not be intimidated by fear of damaging the relationship. Not acting can do more damage than acting to mobilize involuntary evaluation.
If the loved one is already in legal trouble, use that as an opportunity to have the court require psychiatric evaluation and treatment as an outpatient.
If the loved one is in jail, help to mobilize the psychiatric treatment resources in that facility.
If the loved one does not have a legal problem, you may have to initiate one; then ask the court to require evaluation and treatment as a legal consequence.
Understand how the legal system treats mental illness and substance abuse differently.
Protect your own safety and that of children.
Remove firearms if possible and safe.
Step 7: Continuing your support
If you are successful at getting the loved one to agree to an evaluation, your job is not over.
Recognize that a crisis isn’t necessarily a catastrophe; it is often an opportunity for positive change.
Do not accept that “nobody changes unless they really want to.”
Try to go to the initial evaluation with the loved one and ask specific questions of the professional.
If there is treatment going forward, continue giving your input to the treater, even after the evaluation.
Support the loved one to stick with treatment after it begins.
Be prepared that changes in the loved one with treatment may produce changes in you; be prepared to respond to that in yourself and in your relationship with the loved one.
Consider the possibility that you might benefit from treatment, or your relationship with the loved one might benefit from treatment.
If you don’t succeed in getting the loved one evaluated now, don’t give up. There may be a better chance of succeeding later, with further developments.
Dr. Komrad’s key points are available as a handout that could be shared with patients and others provided that no attempt is made to alter the document. Click HERE to download the handout.
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