CALVIN : I think we should go see him, Beth. - Dr. Berger. BETH : What?

2. CALVIN: I think we shouldgo see him, Beth. - Dr. Berger. BETH : What? CALVIN: I think we could all go and see himtogether. 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 talkabout? I don't want to see any doctors orcounselors. 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... 

3. “Breaking Bad”

4. “Komrad on Call” ARN “Sunday Rounds” NPR

5. 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 threekids, 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.

10. “THIS PERSON NEEDS MORE HELP THAN I KNOW HOW TO GIVE” “I NEED SOME PROFESSIONAL ADVICE ABOUT HOW TO HANDLE THIS PERSON” “I’M NOT SURE HE’S GOING TO BE OK”

11. Mental Health Professional? Caring Friend? Supportive Hair Stylist?

12. "When the only tool you have is a hammer you tend to see every problem as a nail." -Abraham Maslow

13. 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

14. 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

15. FEELINGS THOUGHTS BEHAVIORS THE 3-DIMENSIONS OF MENTAL LIFE

16. A Change from Baseline Lisa Nowak

17. 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

18. The Goal An Initial Evaluation

21. Prognosis Therapeutics (Treatment Plan) “Diagnosis is half the cure”--Hippocrates, 325 B.C. Diagnosis

22. Getting Started

23. Can we talk? Picking the Right Time & Place

24. 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

25. 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

26. How to talk the talk Remember the goal: an evaluation

27. 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

28. 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

29. 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

30. Using Allies

31. “Breaking Bad”

33. 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

34. MARK S. KOMRAD M.D. Adult Psychiatry 222 Bosley Avenue Suite A-3 Towson, MD 21204 Diplomate of the American Board (410) 494-4411 of Psychiatry and Neurology Fax: (410) 510-1119 Distinguished Fellow of the American Psychiatric Association mkomrad@me.com Clinical Assistant Professor, University of Maryland www.komradmd.com Instructor in Psychiatry, Johns Hopkins 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 . . . . .

35. From Persuasion to Coercion • The Power of the Family

36. Non-therapeutic Coercion

38. Persuasion Reason Coercion Reason

39. 1968

40. Responsibilities Privileges Rights • cellphone • computer and internet access • car, gas, insurance • $ subsidies • vacations • residence

41. GIVING TAKING AWAY

43. 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

44. InvoluntaryEvaluation

45. Wait for the criteria for “dangerousness” to be met. Meanwhile, keep working earlier steps in this book Call the Police, OR Go to the local courthouse to Initiate an order for involuntary psychiatric evaluation Order is not granted Phase 1 Order is granted 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 Criteria are not met Criteria are met Phase 2 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)

46. Offer is not made or patient refuses to sign as “voluntary” The treatment team decides that the patient can be offered an option of becoming a “voluntary” admission, before the minimum days expire The patient gets well enough to leave before the minimum days expire Gets well Does not get well Offer is made and patient accepts becoming “voluntary” 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 Judge decides criteria are not met Phase 3 Judge decides criteria are met Phase 4 Inpatient treatment continues Clinical and legal procedures initiated to give medication involuntarily Refuses medication Accepts medication Patient improved and discharged from hospital

47. 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

49. Opportunity “Crisis” Danger