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...
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“Breaking Bad”
“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.
“I NEED SOME PROFESSIONAL ADVICE ABOUT HOW TO HANDLE
THIS PERSON”
“THIS PERSON NEEDS MORE HELP THAN I KNOW HOW TO GIVE”
“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
THOUGHTSBEHAVIORS
FEELI
NG
S
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.
DiagnosisTherapeutics (Treatment Plan)
Prognosis
Getting Started
Picking the Right Time & Place
Can we talk?
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
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“Breaking Bad”
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
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 . . . . .
MARK S. KOMRAD M.D.Adult Psychiatry
222 Bosley AvenueSuite A-3
Towson, MD 21204
Diplomate of the American Board
(410) 494-4411 of Psychiatry and Neurology
Fax: (410) 510-1119Distinguished Fellow of the American Psychiatric Association
[email protected] Assistant Professor, University of Maryland
www.komradmd.com Instructor in Psychiatry, Johns Hopkins
From Persuasion to Coercion
The Power of the Family
Non-therapeutic Coercion
Reason PersuasionReason Coercion
1968
• cellphone
• computer and internet access
• car, gas, insurance
• $ subsidies
• vacations
• residence
Privileges ResponsibilitiesRights
RewardsConsequence
s
better for Extroverts
better for Introverts
GIVING TAKING AWAY
• 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
InvoluntaryEvaluation
Call the Police, ORGo to the local courthouse toInitiate an order for involuntary psychiatric evaluation
Wait for the criteria for “dangerousness” to be met. Meanwhile, keep working earlier steps in this book
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
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)
Order is granted
Order is not granted
Criteria are not met
Criteria are met
Phase 1
Phase 2
The patient gets well enough to leave before the minimum days expire
The treatment team decides that the patient can be offered an option of becoming a “voluntary” admission, before the minimum days expire
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
Inpatient treatment continues
Offer is made and patient accepts
becoming “voluntary”
Offer is not made or patient refuses to sign as “voluntary” Gets well
Does not get well
Judge decidescriteria are met
Judge decidescriteria
are not met
Clinical and legal procedures initiated to give medication involuntarily
Refuses medication
Patient improved and discharged from hospital
Accepts medication
Phase 3
Phase 4
Tips for OptimizingOutcomes
• 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
Danger
“Crisis”
Opportunity