Sample Text from Chapter 3
PROBLEMS FACED BY ADVOCATES
3. Consumer Crisis—Suicidal, Psychotic, Violent Behavior
On a crisis scale of 1 to 10, you want to stop the progression of a crisis when you are at the low end of the scale and relapse signs have just begun. After one or two sleepless nights, when feelings of paranoia are present or voices are breaking through, etc.— activate your Crisis Intervention Plan if you have one. If you do not have one, call the medical provider and create one.
As you start moving up on the crisis scale, the illness takes over more and more. As you may already know, the illness during crisis has a life of its own and crisis reversal or intervention may not be possible without hospitalization. It is likely that both the advocate and consumer want to avoid hospitalization so that is your common ground.
If the crisis is escalating to a point where the person is a danger to themself or others, call the crisis line or take the person to the Department of Mental Health, Crisis Services Center, or emergency room. In some areas, you must call the police or sheriff if you are unable to get the person to help. Give copies of the Medical and Symptom History Summary (see Appendix 1) and the Medication History Record (see Appendix 3) to anyone in a position to obtain or provide help. Be sure to tell the law enforcement officers, crisis workers, and medical providers if the person in crisis is a danger to themself and/or a danger to others and/or gravely disabled and unable to provide for their food, clothing, and shelter. These are legal terms that will be informative to the medical provider and may help the person get medical treatment. There is voluntary hospitalization when a person wants help and involuntary hospitalization when a person needs help but does not want it and might be a danger to themself or others if they do not get treatment.
The rate of suicide is high for people with mental disorders. A 2003 NAMI publication titled “Do you care for someone who’s at risk of suicide? It’s more common than you think” states that :
- “Every 42 seconds someone attempts suicide.”
- “Every 18 minutes someone in America commits suicide.”
- “Up to 90% of all persons who commit suicide suffer from a treatable, severe mental illness.”
- “People suffering from schizophrenia have a particularly high risk for suicide with nearly half attempting suicide at some point during their lifetime.”
- “Research suggests that the risk is even higher for people diagnosed with schizoaffective disorder, an illness in which there are both severe mood swings (mania and/or depression), and some psychotic symptoms of schizophrenia. Suicide risk is also increased among individuals with substance abuse disorders and people suffering from chronic depression.”
Suicide can be prevented with medication, counseling, and social support. Early treatment is essential to saving lives. For more information, contact the American Foundation for Suicide Prevention, Suicide Prevention Action Network, and NAMI. See Appendix 7, Selected Resources. The Bloch book mentioned in Appendix 8, Selected Bibliography has important coping strategies for dealing with suicidal thoughts and feelings. We can provide love and support but we cannot keep them alive. They must choose life.
Surprisingly, some social workers and medical providers do not recognize suicidal ideation (thinking or talking about suicide) and suicide attempts as medical emergencies. You may encounter a crisis worker or social worker telling a person in the hospital who has just made a very serious suicide attempt to just sign a contract that they won’t hurt themself and they can be released. They may say to you “Well, they say they are not suicidal now so there is no reason to hold them.” If the social worker is going to release them and you know the person is still suicidal, you may want to get outside help. Call NAMI and write a letter such as the one found in Appendix 5.
Psychosis can be part of Bipolar Disorder, Depression, Schizoaffective Disorder, and Schizophrenia. When someone is psychotic, call the crisis line or go to the Crisis Center, Department of Mental Health, or hospital. Write the recent behavioral symptoms down and make multiple copies. Give one copy to the crisis worker, one to the hospital, one to the regular medical provider, and keep copies for yourself and others. As many of us know, a person who is psychotic can pull it together for a period of time long enough to convince a medical provider that they are fine (and maybe inform them that the advocate is the one who is sick). Hopefully the letter will give the crisis worker and medical provider enough information so they will get help for the person in crisis. You will also want to give them a copy of the Medical and Symptom History Summary (Appendix 1) and the Medication History Record (Appendix 3).
If you are dealing with a psychotic episode at home alone and the person is raging but not physically violent, you do not have to listen. You can say that you do not want to listen to that and ask them to go into another room to do it; and maybe even suggest they speak into a tape recorder. That may seem better than talking to the wall or yelling louder so you will hear. An early sign of psychosis for some people seems to be turning against the people they are closest to.
Never accept violent behavior. Always consider your own safety and get away from a person who is or is about to be, dangerously out of control. Call the police or sheriff and let the person go to jail. Inform the law enforcement officer of the person’s mental illness and medications; and say they need a psychiatric evaluation and medical treatment. Give them a copy of the Medical and Symptom History Letter. Work with the jail medical people if the person needs medical treatment and provide useful medical information to them. Press charges if you must to get court ordered medical compliance and anger management classes. It is a great act of love to stop someone’s out-of-control violent behavior and to get them the medical help they need. Set your limits firmly before violent behavior erupts by saying something like “If you become violent, I will call the police/sheriff and file charges. I am afraid of you when you are violent and I will act to protect myself.” Get a Restraining Order if you have to. If the person lives with you, either do not let them come back or tell them if they want to come back they must agree to all or some of the following: take medication, not use drugs or alcohol, go to therapy, anger management class, and Alcoholic Anonymous or Narcotics Anonymous groups if that is appropriate.
4. Consumer Living at Home
Sometimes it works for a consumer to live at home and sometimes it does not. If it is not working, and especially if someone has an untreated mental disorder, consider filling out applications to get the consumer on the waiting lists of low income or other apartments. It can take months (even years) to get in, and one can reapply if they are not ready. Plan to give or get the person the support they need to make it in their own apartment. You can gradually teach them what they need to know. Consider joining with others (e.g., NAMI members, church members) to start a Supported Living House. Hire someone to come in and cook dinners. Residents can fix their own breakfast and lunch. Ask someone at the Department of Mental Health if a case manager can visit the home periodically. Families can work out among themselves the number of visits needed and what skills you might teach the residents of the home.
I have come to believe that a parent cannot take a disabled adult child to their ultimate level of independence. Take them as far as you can and then let someone else take them to the next higher level of independence.
5. Dual Diagnosis: Mental Illness and Substance Use Disorder
It is fairly common for people suffering from mental illness to self-medicate with alcohol and/or drugs and to deny both the mental illness and substance abuse problem. It is often said that depression underlies substance abuse problems. So, you wonder if an antidepressant or a mood stabilizer would help someone with a dual diagnosis to recover. Getting them to seek a diagnosis and treatment can be difficult. Even if the person will agree to get help, it is hard to find an integrated treatment program where both the mental illness and substance abuse can be addressed simultaneously. Residential drug and alcohol treatment programs are important but some diminish the importance of psychiatric medication for people with mental illness. Call your local Department of Mental Health or Public Health, or Alcohol and Other Drug Programs to find out all possible recovery programs and if any have an integrated treatment program. Alcoholics Anonymous and Narcotics Anonymous are important components of recovery and a mood disorder support group could help too.
“Drug-induced psychosis” is a term you might hear. Some people seem to think a drug induced psychosis is a one-time event if the person quits using drugs. It seems to me that a more common experience is for drugs to trigger a lifetime of mental illness and psychotic episodes. You can ask if an antipsychotic medication will help the person become more stable. Once the person is stable, you can sort out with the medical provider if this is a one-time occurrence.
Some medical providers will not treat a mental illness until the person is clean (from drugs) and sober for some period of time. If the illness is undiagnosed, it would be hard to sort illness symptoms from substance abuse symptoms. If the consumer has a diagnosis, the medical provider may treat the mental illness.
If you know you have mental illness in your family, counsel your children and grandchildren when they are young about never using drugs that can trigger a lifetime of mental illness. I have heard countless stories of drugs such as LSD, marijuana, methamphetamines, and mushrooms triggering psychotic episodes. Many people never seem to recover to the point of functioning as they did prior to using those drugs.