As seen in Psychology Today.
This is an ongoing series that offers guidance to friends and family who are worried that someone they know may harm themselves or others. In the first part of the series, which was posted on May 7, I provided information about how widespread the mental health crisis in the United States is, noted the differences between mentally unhealthy individuals and individuals with mental illnesses, and offered some guidance as to how to take the initiative when confronting someone who you feel may be a danger to themselves. In this post, I will discuss the importance of treatment for individuals with severe mental illnesses and provide details as to how to broach the subject of either seeking initial treatment or continuing with a treatment regimen. The following two posts will discuss the process of hospitalizing an individual with a mental illness and examine of some of the laws that govern this process.
These posts are being published throughout May to honor Mental Health Awareness Month.
It is important to remember that individuals with severe mental illness are not inherently violent or dangerous. If treated, most can lead productive lives. Treatment typically involves medication and counseling. In some cases, it may require infrequent and brief hospitalizations.
If untreated, the picture is not so rosy.
When individuals with severe mental illness stop taking their medication or avoid treatment entirely, they become more prone to psychosis. Psychosis is a symptom and not a disorder itself. It can affect individuals with a wide range of conditions, such as schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, Parkinson’s disease, Alzheimer’s disease, and substance abuse problems, among others. When a person is suffering from psychosis, it is known as a psychotic episode. During these episodes, an individual may lose contact with reality to a varying degree. They may behave in a disorganized fashion, speak in an incoherent manner, or neglect their personal hygiene. Some may become a whirlwind of activity; some may engage in extremely risky or dangerous behavior; some may entertain delusions; some may experience hallucinations; some may express feelings of extreme paranoia.
When an individual is having a psychotic episode, they typically do not realize that they are acting strangely or that they are suffering from either delusions or hallucinations. To many individuals with severe mental illness, the delusion or hallucination is a part of their reality. It is not something they recognize as artificial, nor is it something they can be “snapped out of.”
The inability to recognize the artificiality of one’s delusions is extremely common, and this lack of insight into one’s condition is known as anosognosia—a neologism that combines the Greek for without (a-), disease (nosos), and knowledge (gnōsis). It affects between 57 and 98 percent of patients with schizophrenia. While it is less common in patients with major depression, bipolar disorder, or schizoaffective disorder, it is still frequently observed. Poor insight does not only mean that they are unaware that they have an illness; it may also mean that they do not recognize the signs or symptoms of the illness, the negative consequences that arise because of the illness, or the need to treat the illness.
When one does not believe that they have a problem, they will not seek treatment. The reasoning is simple: One does not try to solve problems that do not exist. Similarly, individuals who have recently been released from the hospital with medication may stop taking it once they feel better. Once again, the reasoning is simple: Only sick people take medication; I am no longer feeling sick; therefore, I don’t need medication. In either case, a lack of medication can cause a patient’s condition to deteriorate, thereby increasing the possibility of a major psychotic episode.
The Potential for Violence
If an individual is in the midst of a psychotic episode and has lost touch with reality, then the likelihood that they will commit a violent act does increase. This is not an easy thing to admit, as it can increase the stigma facing individuals with mental illnesses, but it does highlight the need for intervention and treatment. More importantly, such a broad statement needs to be understood as containing a great deal of nuance, as there are numerous other factors involved in determining if an individual suffering from psychosis will become violent. Some factors include an individual’s socioeconomic status, family history, personal stressors due to a major life event such a divorce or the death of a loved one, or abuse of drugs or alcohol.
To account for many of these variables, a team of researchers at the University of Oxford compared rates of violence among schizophrenic patients and their unaffected siblings. The study, which took place in Sweden, found that people with schizophrenia were 1.6 times more likely to be convicted of a violent crime than their non-schizophrenic siblings and more than twice as likely as the general population. When the researchers accounted for concomitant substance abuse problems, they found that schizophrenic patients who abuse drugs or alcohol are four times more likely to be convicted of a violent crime than the general population, and that those who do not are only 1.2 times more likely to do so. A similar study, also conducted by an Oxford research team examining data from Sweden, found that the rate of conviction of violent crimes was 5 percent among bipolar patients without substance abuse problems, 5 percent among their unaffected siblings, and 3 percent among the general population. When bipolar patients abused drugs or alcohol, that number rose to 21 percent—a fourfold increase.
Concomitant substance abuse problems are a key indicator that an individual with a major psychiatric disorder will become violent. Alcohol and other drugs impair judgment and make individuals more impulsive. They also tend to exacerbate paranoia, grandiosity, and hostility even in individuals without mental illnesses. Perhaps most important of all, psychiatric patients with substance abuse problems frequently do not adhere to treatment plans, thereby increasing the likelihood that they will suffer a psychotic episode.
The Need for Treatment
Maintaining a treatment regimen is absolutely integral to keeping a friend or loved one with a severe mental illness from harming either themselves or others. Additionally, keeping individuals with severe mental illnesses from self-medicating with drugs and alcohol is yet another key step in promoting their wellbeing.
For those who have yet to be diagnosed or who are resistant to the notion that they need medication and treatment, however, this is far easier said than done. If, for example, a person is suffering from a persecutory delusion, they may feel as though an individual or group of individuals are conspiring to get them. Consequently, they may be unwilling to go to a hospital due to the fear that this will leave them vulnerable to the conspirators. Similarly, they may be unwilling to take medication out of fear that it could have a deleterious effect. They may even become upset that you have even suggested the possibility that they need help.
In instances such as these, you may want to argue with them or systematically pick apart their delusions in the hope that they will realize that they are sick and snap out of it. Unfortunately, this is not going to happen. Instead, it will likely drive them away and make them more isolated and hostile to the idea of treatment. Remember, the delusion is a part of their reality.
An even worse tactic is to trick them into going to the hospital or to involve the police if they are not threatening themselves or others. If you do feel as though they are an immediate danger to themselves or others, however, you should call 911. Should this happen, inform the police dispatcher that the individual has a mental illness and request a mobile crisis team.
Provided you do not feel imminent danger, your primary focus should be on establishing a firm bond based on trust. To do so, you need to listen to and respect what they are going through. This does not mean that you should enable them or give credence to their delusions; rather, you need to demonstrate your capacity for empathy and show them that you can understand their situation. Once they begin to open up, once they see you as a person who loves and cares about them rather than someone who wants to browbeat them into taking medication, they may be more willing to acknowledge your concern. Once the conversation ceases to be about whether or not they are sick and becomes about your worry for their wellbeing, they will likely become more willing to either see a mental health professional for a diagnosis or continue with medication they have already been prescribed.
In the third post in this series, I will focus on what to expect when you take a friend or loved one to the hospital to be evaluated by a mental health professional.