By Mark Nathanson
“I don’t know where to turn. My son, James, is 35 and has been diagnosed with schizophrenia and bipolar disorder. He is using drugs—I know he is from the dazed look that he gets in his eyes. He is drinking too. The last time he was hospitalized on a psychiatric unit he was violent in our house. He punched my younger son in the face. They kept him for three days and released him back home. He wasn’t much better. He was referred to a program for substance users and mental health problems. He refused to go after one appointment so they closed his case. We are worried about him and don’t have an answer. He sleeps all day when my husband and I leave the house for work; he has no motivation to get a job, and he is on that computer all the time. Can you put him in the hospital for a few months and force him into treatment? You can’t let him go on this way.”
Does the story above sound familiar? This situation occurs frequently, leaving parents, family members and loved ones with unanswered questions, fear and anger. As a psychiatrist I wrestle with these crises daily—what can be done? How and where can families get help? What are realistic expectations of the mental health system today, and what are the legal, financial and programmatic limitations?
Our mobile crisis team commonly hears desperate pleas like the one from James’ mother. Often people incorrectly believe that persons with mental illness or substance use problems can be involuntarily admitted to a psychiatric ER, housed in psychiatric institutions for months or have treatment forced on them.
The reality is that having a mental illness or a problem with addiction to drugs or alcohol is not the criteria that mental health crisis teams use to involuntarily remove a person from the community to a mental health treatment facility. The criteria in New York and most other states is “dangerousness to self or others.” Yet, interpretation of this varies widely in the area of mental health treatment. For example, dangerousness to self may include the inability to meets one’s basic need for food, shelter or health care.
James continues to decline, according to his mother. He rarely showers, has no interest in leaving the house and rants at all hours of the day. The neighbors have called the police several times, but nothing was done.
When people are brought to the hospital for a psychiatric evaluation in the psychiatric ER, or CPEP (Comprehensive Psychiatric Emergency Service), chances are they will be held only for days or, at most, a few weeks. Federal and state funding through Medicaid and Medicare continues to shift the place of care away from the hospital and into the community. This may be hard to understand if your family member is released back home much sooner than you had hoped.
Having a mental illness, such as schizophrenia or bipolar disorder, does not mean that a person can be forced into treatment or even taken to the ER for evaluation. And, like in the case of James, parents may be frustrated because treatment for substance and alcohol use disorders requires voluntary consent. At its core, addiction is accompanied by strong denial and little, if any, interest in treatment. Typically the substance abuser will respond to requests from the family in the following ways: “I don’t have a problem. I can stop anytime.” They might try to turn the situation around, stating to a parent, “You are the one with mental illness—being around you is what is making me drink more.”
So what can a family do? In New York City an in-home crisis evaluation by a mobile crisis team begins by calling 1-800-LIFENET. The team asks the person making the referral questions to determine if the situation is a crisis or requires an immediate 911 call. Mobile crisis teams do not respond immediately as in a severe emergency; the teams have 24 to 48 hours to attempt to visit the client. However, if someone is an imminent risk to themselves or others, 911 must be activated. Families may be reluctant to call 911 out of fear of how their loved one might react.
If we consider the family in crisis as existing in some stable state, the goal of crisis intervention is to shake up that stability and change behaviors. The family might need to make difficult decisions regarding their role in the situation. For example, James’ mother gives him free room, board and spending money. His father doesn’t speak with him, and when he does, they argue. James has no incentive or motivation to change. The family might request some monthly payment for rent, food or even, most difficult, ask him to leave the home. “But if I do that,” his loved one might say, “James will end up in a shelter or homeless.” So, how do families find support in such tough situations?
This is where NAMI can help. A family counselor can educate families and loved ones about their role in helping the individual improve, without setting up a situation that prevents independence. NAMI is a great starting place to get advice, meet others in the same situation and find support in making hard decisions. NAMI has meetings throughout the country and can be easily accessed by visiting www.nami.org, calling 800-950-NAMI or emailing firstname.lastname@example.org.
Mental health crisis situations can be frightening for everyone involved. Families often feel helpless, like they are fighting a complex system. However, help is available if one understands the resources. Families can play a role in getting treatment for loved ones, even if doing so requires tough choices. Support is available through counseling services and NAMI to assist. Don’t give up on a loved one. See the person, not the illness, and let them know that you care about them even when you are frustrated.
Dr. Mark Nathanson is the attending psychiatrist on the Mobile Crisis Unit at NYC Health and Hospitals/Mt. Sinai at Elmhurst Hospital in Queens, NY. He is a well-regarded clinician, educator and program developer in the areas of geriatric mental health, emergency and crisis psychiatry and elder abuse issues.
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