2. 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...

3. “Breaking Bad”

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

5. AUGUST 28

6. 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.

11. “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”

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

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

14. 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

15. 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

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

17. A Change from Baseline Lisa Nowak

18. 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

19. The Goal An Initial Evaluation

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

23. Getting Started

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

25. 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

26. 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

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

28. 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

29. 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

30. 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

31. Using Allies

32. “Breaking Bad”

34. 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

35. 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 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 mkomrad@me.com Clinical Assistant Professor, University of Maryland www.komradmd.comom Instructor Instructor in Psychiatry, Johns Hopkins

36. From Persuasion to Coercion The Power of the Family

37. Non-therapeutic Coercion

39. Reason Persuasion Reason Coercion

40. 1968

41. cellphone computer and internet access car, gas, insurance $ subsidies vacations residence PrivilegesResponsibilitiesRights

42. RewardsConsequences better for Extroverts better for Introverts GIVINGTAKING AWAY

44. 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

45. Involuntary Evaluation

46. Call the Police, OR Go to the local courthouse to Initiate 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

47. 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 decides criteria are met Judge decides criteria 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

48. Tips for Optimizing Outcomes 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

50. Danger “Crisis” Opportunity