In This Chapter
Being prepared for psychiatric emergencies
Recognizing signs of an impending crisis
Watching for suicide risks
Knowing what to do if your loved one disappears
Handling arrests
A psychiatric crisis is a frightening event for everyone — the individual, family and friends, sometimes even the community at large. A psychiatric crisis handled poorly can quickly turn dangerous for the person with schizophrenia or others around him.
Just like the Boy Scouts motto suggests, being prepared is key to coping with any crisis. Having a plan not only allows you to act quickly and appropriately, but also helps minimize stress for everyone involved. In this chapter, we help you prepare for psychiatric emergencies — from psychotic breaks and attempted suicide to disappearances or arrests. We also show you how to recognize signs of possible crisis early and show you how to cope effectively to end the crisis, with a good resolution, as quickly as possible.
Accepting Crises as Part of Schizophrenia
Life may seem to be going along well; your loved one is improving on medication and coping reasonably with life. Then a crisis occurs. You wrack your brain wondering if you should’ve seen this coming, and feel like you could have done something to prevent it.
But the reality is that schizophrenia is not only a chronic disorder, but also a cyclical disorder, characterized by periods of relative well-being that are interrupted by relapse (a severe worsening of symptoms that interferes with a person’s functioning). The same type of waxing and waning of symptoms also occurs with other chronic medical disorders, such as arthritis and asthma; even some cancers are seen as chronic diseases that relapse and remit.
Mental health crises — which can be a sudden worsening of symptoms, or a more gradual change that eventually reaches the point where the person with schizophrenia is out of control and/or can’t function — are not uncommon and can’t always be prevented, although their frequency and severity can be minimized.
Relapse can occur for a variety of different reasons. The cause of relapse may be apparent at one time and a complete mystery at another. Often, more than one factor contributes to the relapse.
The most common cause of relapse is stopping medication. Either people stop taking medication on their own, or they’re advised to stop by a doctor (perhaps because of intolerable side effects). Other potential triggers include the following:
Susceptibility to stress in the environment: Stressful interpersonal or living situations — such as annoying roommates; the threat of eviction or loss of housing; or conflicts with friends, family members, employers, or clinicians — can exacerbate symptoms.
Medications failing to work as well as they once did: The reasons for this situation are still unknown, but it does happen.
Laxness in taking medications regularly: People with schizophrenia may forget a dose here or there, just as people may do when taking a prescribed course of antibiotics. This is especially true when they’re feeling better and forget that “feeling good” is probably due to the medication.
Complexity of medication schedules: People with schizophrenia may have to take multiple drugs with different dosing schedules. Following these schedules consistently may be particularly difficult.
Unwillingness to adhere to the regimens prescribed by doctors: It’s common for people to experiment, taking more or (usually) less medication than prescribed.
Costliness of medications: New medications that are still under patent are especially expensive. The medications often become unaffordable because of insurance limitations or lack of insurance.
Alcohol and/or other drug abuse: A relapse of a co-occurring substance-abuse problem can precipitate a downward spiral. For example, the person may be unable to stay on medication due to eviction or arrest.
Discouragement, depression, or stress: If someone feels hopeless or overwhelmed, she may neglect many aspects of staying healthy, including taking medication.
Psychiatric crises can also crop up spontaneously, without any identifiable cause, just as part of the disease. When this happens, it’s especially frustrating to people with schizophrenia, their relatives, and clinicians who have done everything humanly possible to keep the illness at bay.
The disappointment and frustration associated with relapse is often exasperating for families when the person who is ill doesn’t believe or refuses to admit that he is sick. He may instead blame everyone else for what’s happening to him. This situation makes it difficult to convince the person that he’s sick and needs help. It may also cause friends and family members to question their own behavior, wondering whether they have, in fact, caused or contributed to the crisis.
As a friend or family member of someone with schizophrenia, you have to keep your own emotions on an even keel and not fall prey to the idea that you’re somehow responsible for a deteriorating situation. Realizing that relapse is a possibility and recognizing the first signs of it, can help you remind your loved one that he needs to be seen by his doctor.
Anosognosia is the technical term used when an individual has no insight into or awareness of his own illness.
Many people with schizophrenia need to be taught by their clinicians to recognize the warning signs of relapse. In a perfect world, the person in crisis would recognize that she needs help and seek it herself or ask you to intervene. Frankly, this doesn’t often happen because, as the illness worsens, awareness and insight — that the illness is causing the disordered behavior — tends to disappear.
When you recognize that the person with schizophrenia no longer has insight, get help — and don’t allow her to persuade you that nothing is wrong.
Being Prepared Before a Crisis Occurs
Many crises can be averted or resolved quickly when you work collaboratively with the person’s psychiatrist or other clinician. This is where being prepared ahead of time really pays off. In this section, we help you make sure you’re ready to act quickly and effectively in a crisis:
Keeping essential information in a central location
When you’re in the middle of a crisis, you don’t want to have to search frantically for phone numbers, medical information, insurance cards, and other essential scraps of paper. Instead, keep all the information you need in one convenient location, preferably in a bound notebook near a telephone at home or in your personal address book. It should be readily accessible and easy to find when you need it.
Here’s the information you want to have at hand:
A list of the names, titles, and phone numbers of your loved one’s treatment team so everyone in the household has access to them, including the person with schizophrenia: This includes the names of the psychiatrist, psychologist, social worker, psychiatric nurse, other clinicians or peer counselor; the name of the person’s case manager; and contact information for how each of these professionals can be reached during working hours and off-hours in an emergency.
The phone number of the local hospital emergency room and local crisis services
The phone number of a friend or family member who understands and can help
The phone number of the local police department
Your loved one’s diagnosis and the approximate date when she was last seen by a clinician
A list of all the medications (psychiatric and any other) the person with schizophrenia is taking, including the names of the drugs, their dosages, and their frequency
A succinct history of the medications your loved one has taken in the past, along with notes about what worked, what didn’t, and any adverse reactions
History, if any, of alcohol and/or other drug abuse and its treatment
Any pertinent information about the person’s physical health
Be sure to update these lists as medications and service providers change.
Although the field of medicine is moving toward electronic medical records to enable consumers (and often their doctors) to have access to their personal health information on the Internet no matter where they are, the reality is that some systems can’t “talk” to others, and communication between one provider and another may not be as timely or reliable as it should be.
If possible, purchase a password-protected USB flash drive on which you can store your loved one’s electronic medical record. This empowers consumers and families to maintain control of their own information and always have it accessible in an emergency, whether at home or away. At the very least, keep hard copies of all clinician visits, pertinent lab results, and previous hospital-ization records.
A USB flash drive is a portable hard drive, about the size of your thumb, that plugs into any computer’s USB port. You can find these drives in places like the big-name office supply stores or computer stores. A small 1GB drive can be had for less than $20; drives with greater capacity will run you closer to $75 or more (and there are numerous options at prices in between). Look for one with a metal loop attached, so you can put it on your keychain and always have it handy.
Surveying crisis resources before you need them
The best time to learn about crisis resources is before you need them, when your loved one is stable. These resources include mental-health inpatient, outpatient, and crisis programs (alternatives to hospitalization) in the community such as:
Mobile outreach teams (trained teams of professionals who conduct clinical assessments and provide services wherever patients are located, at home or in the community)
Crisis response teams (mental-health professionals who can come to your home in the event of a psychiatric emergency, much like a volunteer ambulance corps might come in the event of an injury or heart attack)
Assertive Community Treatment (ACT) programs, which use multidisciplinary professional teams to provide comprehensive, round-the-clock services to clients in the comfort of their own homes and in the community
Hospitals
Local law enforcement programs intended to divert people from jails
Although all facilities sound wonderful in their brochures, in reality, some may be ill-equipped to handle a person with serious psychiatric issues, may not offer after-hours admitting services, or may not take your insurance — or any insurance at all. When possible, phone or visit these programs in person and speak to the staff to find how they may be able to help during a crisis and to get a feel for the facility or program and whether you would feel comfortable having them provide care for your loved one.
Some of the best sources of up-to-date information on facilities in your area are members of local affiliates of the National Alliance on Mental Illness (NAMI; a national membership organization of families providing education, support, and advocacy), who have vast experience and are willing to share their expertise. Professionals who work with your loved one may also be knowledgeable about community resources.
Also be sure to contact your local public mental health authority (county or city) to find out about the range of crisis services they offer. They’re usually listed in the Yellow Pages under government agencies. Depending on where you live, there may be publicly funded mobile outreach services, short-term crisis residential services, consumer-operated safe houses (shelters), and hot lines that can help.
Because crisis stabilization services aren’t available everywhere all the time, hospitalization is often a necessity of last resort.
Also, most community hospitals lack a sufficient number of crisis beds resulting in long waits in the emergency room or transfers to other facilities. Knowing what’s available at each of your area hospitals can make the difference in the quality of care your loved one gets in a crisis. Consider the following:
Make sure the hospital is an in-network provider, participates in your relative’s insurance plan, or accepts patients with Medicaid.
Find out if the hospital’s behavioral healthcare program is accredited by the Joint Commission (www.jointcommission.org). In that way, you can be assured that the facility meets certain standards. (Although this is desirable, you may not always have a Joint Commission-accredited hospital in your area.)
Make sure that the hospital has psychiatric beds. Some hospitals don’t have these beds. If your loved one winds up in such an emergency room, she’ll likely be sent elsewhere, wasting time.
Ask about the number, demographics, and diagnoses of the psychiatric patients. If your loved one is in his 80s, you probably wouldn’t want him on the same unit as young people with dual diagnoses. On the other hand, if your loved one is an impulsive teenager, you may not want her to be on a mixed-sex ward.
Find out who supervises the unit. Because medication is one of the mainstays of inpatient treatment, ideally the person supervising the unit will be a competent psychopharmacologist (an expert in psychiatric medications).
Inquire about the visiting policies for patients and whether those hours will make visiting convenient for you.
Find out about the smoking policies if your loved one is addicted to nicotine.
Ask whether your loved one will be able to go outdoors during his stay if it extends more than a few days.
Check with other people who know the hospital about the competence of the physicians who will be taking care of your loved one.
If your loved one doesn’t speak English or is of a racial/cultural minority, make sure that the staff is linguistically and culturally sensitive. Ask
whether translators are available when needed.
Ask if you can visit the hospital beforehand, to see its facilities. Don’t be surprised if staff isn’t welcoming about families visiting a facility beforehand. Typically, they’re trying to protect the confidentiality of the patients who are there so your visit may be restricted to certain times or certain areas of the facility.
Most important: Find out about the hospital’s policies about communicating with families. Do they see them as part of the problem or part of the solution? Will they allow you to provide information? Will the hospital be willing, with the patient’s permission, to share information with you?
Proprietary services on the Internet, like HealthGrades (www.health-grades.com), provide information on individual hospitals and their doctors. Hospitals are rated, with information about their costs, patient volumes, and safety record. You can also find out about doctors, their training, certification, length of time in practice, and whether they’ve been subject to any disciplinary actions.
Recognizing the Signs That Something Is Wrong
The signs of a beginning recurrence of schizophrenia may or may not be obvious. The onset may be insidious, developing over a long period of time; other times it appears suddenly, seemingly out of the blue. Alerting yourself to the most common early signs that all is not well can help avert a crisis.
Noticing a downward spiral
The signs of an acute psychiatric crisis can’t be missed, but symptoms that appear gradually may be easily overlooked or explained away, unless you’re aware that they may represent an impending crisis. Many of these signs are also characteristic of the negative symptoms of schizophrenia (described in Chapter 3), and it can take an attentive eye to recognize the subtle differences between your loved one’s “normal” behavior and an increase in negative symptoms.
Confidentiality policies: Separating fact from fiction
In 1996, the U.S. Congress passed the Health Insurance Portability and Accountability Act (HIPAA), a lengthy and complex law that regulates and protects the sharing of all health (including mental-health) information. Many people don’t fully understand the provisions of the law, and some professionals use it as a handy excuse to deny all communication with families. (Additionally, independent of HIPAA, some policies established by mental-health programs are even more restrictive than the federal law.)
The ethical standards of conduct of many mental-health professions (such as psychology, psychiatry, and others) also uphold patient confidentiality in therapeutic relationships. But if a patient is at imminent risk of harming herself or others, clinicians have a duty to inform appropriate individuals, including the family.
In the case of patients with schizophrenia, practitioners need to be sensitive to the ways in which disclosure, with the patient’s permission, can actually benefit treatment. As a general rule, with explicit permission from the patient (usually in writing), clinicians can share relevant information with the family. If the patient is deemed incompetent, the patient’s permission isn’t necessary if the family member has legal authority to make medical decisions on behalf of the patient.
Hiding behind the law, some clinicians and hospital employees cite the risk of fines and jail terms if they divulge information to anyone but the patient. In truth, as long as a patient doesn’t object, a health practitioner can share information about a patient with family members. Many times, clinicians fail to ask patients
their preferences and assume they don’t want their families involved (which isn’t always the case). Instead, they should discuss the importance of family involvement and support. Even if the patient voices an objection, the doctor isn’t prohibited from listening to families who can provide vital information about the patient, his illness, and prior treatments.
In some cases, the law is taken to such an extreme that some hospitals are unwilling to put telephone calls through when a relative calls and asks to speak to a patient, not wanting to reveal that the person is hospitalized there. To eliminate any confusion, you might ask your loved one to write a note giving her permission for a doctor to speak to you or for a hospital to release information. (See Chapter 7 for more information on advance directives.)
Regardless of any policy prohibitions against sharing patient-specific information, professionals have an ethical responsibility to share nonconfidential “educational” information — such as information about psychiatric disorders and their treatment, community resources, tips for coping, and information about the availability of NAMI groups and meetings in the community.
Although your loved one may not want a relative — including you — to know all the intimate details of his life, he may want them to know the name of his disorder, its symptoms, its treatment, the expected course, warning signs of relapse, and how they can know if he might be at risk of hurting himself or others. You may need to remind your loved one (and his clinician) that family members and friends can be an important source of support and encouragement on a person’s journey to recovery.
Some signs that may indicate a gradual decline include
Becoming increasingly withdrawn (not interacting or speaking with others) Losing interest in eating or eating excessively
Becoming irresponsible about self-care routines such as washing and dressing
Spending more and more time asleep or in bed Severe mood changes
Spotting the signs of an acute crisis
Symptoms of an acute exacerbation of illness are much more noticeable — and frightening — than the subtle signs that may precede it. These are also the so-called positive symptoms of schizophrenia (see Chapter 3).
A person in acute crisis may
Feel threatened and become hypervigilant
Hear voices when no one is speaking (known as hallucinating)
Become suspicious and frightened that someone or some group wants to hurt him (known as being delusional)
Become agitated
Say things that don’t make sense
Pace incessantly, or be unable to sit still
During a crisis, it’s easy to let emotions escalate as your fears take hold. However, it’s extremely important that you maintain a calm demeanor when speaking to your loved one with schizophrenia. Even if that person is acting belligerent, threatening, or isn’t listening to you, it does no good to yell, argue with, or provoke the individual in any way. Instead, your goal should be to diffuse the situation and get help as quickly as possible to protect the patient, yourself, and anyone else who is present. To achieve that, you need to maintain a positive relationship with the person, reassuring him, building his confidence, and letting him know that you’re there for him when he feels frightened and out of control.
Calling for Professional Help
If your loved one is in no immediate danger when a crisis begins, the best course of action is to seek immediate medical advice from the person’s own psychiatrist or other clinician.
Although only a physician can prescribe medication (except in a few states where psychologists have prescribing privileges), psychiatrists are often overextended and hard to reach, especially if crises occur after hours, on holidays, or on weekends.
Other mental-health professionals often have better luck contacting the psychiatrist than family members or consumers have, or they may be able to render their own help.
Even if you can’t reach your loved one’s own doctor, typically another doctor will be covering her practice. Other times, you may have to contact a clinic or crisis center where no one is familiar with your family member.
If you’re dealing with an unfamiliar clinician, identify your relation to the person with schizophrenia, and be prepared to describe what unusual behaviors or symptoms the person with schizophrenia is experiencing. You’ll also need to know the name of the person’s doctor, when your loved one was last seen, his diagnosis or diagnoses, and current treatments. (See “Keeping essential information in a central location,” earlier in this chapter, for the kind of information to have on hand before a crisis.)
With the information you provide, the clinician will be able to suggest a course of action for you to take. This might include
Changing medications or changing the dose of one or more medications
Making an appointment for the person to be seen at a clinic or private office as soon as possible
Recommending a visit to the emergency room of your local community hospital
Making arrangements for admission to a psychiatric hospital or a general hospital with psychiatric beds
Some other course of action based on the patient and family’s needs and the available community resources
Calling the police if the clinician feels the person is dangerous to himself or others
Knowing Whether Hospitalization Is Necessary
Although images from old topics and movies may have you very concerned about the possibility of hospitalization for your loved one, rest assured that the scary images of the past no longer represent modern psychiatric facilities. In
fact, the images portrayed in old movies (like The Snake Pit) actually helped reform them.
Not everyone in crisis needs inpatient hospitalization today; outpatient management may be all your loved one needs. The next sections describe the options of hospitalization and outpatient care.
The decision to hospitalize
When does your loved one need to be hospitalized rather than treated on an outpatient basis? The short answer: when she needs to receive 24-hour care in a more protected and secure environment (which may or may not be locked) than you can provide or when medical treatment requires 24-hour monitoring and observation.
Here are some examples of when hospitalization is necessary:
When a person needs to be protected (he’s dangerous to himself, he’s dangerous to others, or his judgment is so impaired that he can’t be responsible for himself)
When the patient would benefit from close observation of symptoms and side effects in a controlled setting (for example, during an acute relapse)
When the patient needs intensive medical oversight (to rapidly switch medications, to withdraw from illegal drugs, to assess or treat medical complications)
When the patient would benefit from intensive therapeutic programming (that is, behavioral modification)
When the family can no longer handle care on their own or they need some respite from providing care and supervision
When there is an acute drug overdose (whether prescribed, over-the-counter, or illicit drugs)
Even though you think your loved one may be an imminent danger to herself or others, it may be difficult to have her hospitalized involuntarily if she doesn’t agree with you and refuses to be evaluated. In many cases, professionals must witness the behavior themselves — but often, they may be willing to accept information you provide.
Involuntary commitment laws are complicated and vary from state to state. Depending on where you live, you or a mental-health professional may need to call the police to transport your loved one to a hospital or file a petition seeking an involuntary psychiatric evaluation. You may be able to contact your local mobile crisis service to bring your loved one to a psychiatric emergency room. To find out about your state commitment law, its standards, and what you need to do in the event of an emergency, contact your local mental-health department or go to www.treatmentadvocacycenter.org/ LegalResources/Index.htm.
What to bring with you for hospital admission
Sometimes, hospitals will allow you to arrange for a scheduled admission screening. Other times, you may be required to show up at the emergency room and wait. Either way, these are some of the things you may want to bring with you:
Insurance cards from Medicaid or any third-party insurers
A written summary (no more than a couple of pages long) that includes information about your loved one’s current medications, a brief list of her current symptoms, a brief history of her medications, what worked, and what didn’t
Information about any health problems your loved one has or had — treated or untreated
Outpatient provider information (to assure that the treating team has access to prior information about the patient and to facilitate continuity of care after discharge)
Contact information for the family
Generally, at least two people should accompany the individual to the hospital so one of them can drive and the other can provide support to the person with schizophrenia and assistance to the driver, if necessary.
Alternatives to hospitalization
If your family member isn’t a danger to himself or others, outpatient care may be all he needs to get through a crisis — which can help avoid the stigma of a first hospitalization or the demoralization that often results because of a subsequent one. Some of the alternatives that may prevent or avoid hospital-ization include
More intensely supervised outpatient care: Checking in with a doctor or case worker more frequently to provide crisis support and monitor or adjust medication.
Injectable medication (generally an antipsychotic or sedative medication) administered at a physician’s office or in an emergency room
Mobile outreach teams: See “Surveying crisis resources before you need them,” earlier in this chapter.
ACT programs: See “Surveying crisis resources before you need them,” earlier in this chapter.
Crisis housing: A short-term residential alternative to hospitalization that offers intensive crisis support.
Partial hospitalization: A program in which patients continue to live at home but spend a certain number of hours in a hospital setting, either during the day or at night.
Assisted outpatient treatment (AOT): Also called outpatient commitment, AOT may be an option for people who are consistently unwilling to take medication and, as a result, are unable to live safely in the community. Forty-two states permit the use of this type of court-ordered treatment, although it’s used more infrequently than you might think. For more information on AOT, contact your state mental-health authority (see the appendix) or go to www.psychlaws.org/BriefingPapers/BP4.htm.
Reducing the Risk of Suicide
The risk of suicide for individuals with schizophrenia is estimated to be 50 times higher than that of the general population. In fact, it is the most common cause of premature death for people with the disorder. (Over 90 percent of Americans who kill themselves have a mental disorder.)
In some cases of suicide among people with schizophrenia, the suicide is considered unintentional — a product of delusional or disturbed thinking. More often, suicide among this group is linked to severe depressive symptoms. That shouldn’t be surprising considering all the losses associated with schizophrenia — financial, education, vocational, and social.
If a person with schizophrenia is expressing hopelessness or suicidal thoughts, making suicidal threats, getting rid of her prized belongings, or putting her affairs in order, these behaviors and suicidal thoughts should be taken seriously. No suicidal threat or gesture should ever be ignored; people who talk about or threaten suicide are at high risk for following through.
Although there is no typical suicide victim, some of the factors that increase the risk of suicide include
Being male
Having a mental disorder Engaging in substance abuse
Having suffered recent losses Being impulsive
Having attempted suicide in the past or a family history of suicide Having access to firearms
If a person is considering suicide, you can take certain precautions to decrease the risk:
Remove dangerous objects (guns, knives, or other sharp objects).
Take responsibility for the person’s medication supply and only provide a dose at a time.
Explicitly ask the individual if he is contemplating suicide.
Give the person the opportunity to talk about her feelings; don’t simply dismiss them. Try not to provoke a confrontation.
Explain that the person is important to you and that his suicide would be a painful loss to you rather than any type of relief.
Make it clear you want to help and ask the person to promise not to attempt suicide for a certain period of time.
Explain that depression and suicidal thinking are part of his illness, that schizophrenia is treatable, and that you want to make sure he gets professional help as soon as possible.
Your loved one may be willing to allow you to make an appointment with a mental-health professional for her. (Generally, a person who has attempted suicide or is considered suicidal can be hospitalized involuntarily.)
If you can’t reach a mental-health professional in your community, contact the National Suicide Prevention Hotline at 800-273-8255. The hot line will route your call to the crisis center closest to you that has trained suicide counselors available 24 hours a day, to provide advice to individuals who are suicidal and to their families.
Dealing with Local Law Enforcement
You may think the last thing you need is the local police knowing all your family business. However, when a loved one has schizophrenia, family privacy often goes out the window, and you become much better acquainted with local law enforcement than you ever expected to be.
The best time to get acquainted is before a crisis occurs. Call or visit your local police department and make personal contact before you end up meeting in the middle of a chaotic situation. Explain your loved one’s illness and determine, in the event of an emergency, how you should contact law enforcement and what information they’ll need. You may be surprised and touched at the compassion law enforcement officers have when they understand the situation you’re in.
When to call the police
Some family members have told us that “calling the police on a family member” has been the most difficult thing they’ve ever had to do. In an emergency, you may have no alternative but to contact the police or call 911 if your loved one with schizophrenia is suicidal, acting threatening to others, has been assaultive, or has a weapon. Be prepared to explain the situation and clearly state that the person has a history of mental illness. Tell the police about the events that precipitated the crisis.
With increased efforts to properly train law-enforcement personnel, they’ve become more informed about mental illness. Police officers will not generally arrest an individual with schizophrenia unless an actual crime has been committed. Police often provide assistance, in fact, in transporting the person with schizophrenia to a hospital or other facility.
What to do when a person with mental illness is arrested
The phone rings, and it’s the local police department. An officer tells you that your loved one with schizophrenia has been arrested for a nuisance crime (perhaps urinating on someone’s lawn, touching a stranger, or picking up something from a store counter without paying).
Although people with mental illness are more often victims rather than perpetrators of crime, people with mental illness often get into trouble with the law because of symptoms of their mental disorder — lack of judgment, impulsivity, and inappropriate behavior.
If you get a call saying your loved one has been arrested, do the following:
Find out where the person is being held.
If you can, try to prevent the arrest by explaining that your loved one has a mental illness and ask the officer to help you get psychiatric care at an emergency room in lieu of arrest.
If the person has already been arrested, ask the police if they can drop the charges. If they won’t, see if they’ll release your loved one if you assure them that she’ll appear in court.
If your loved one is being arraigned, be sure to attend the arraignment hearing and tell the defense attorney who you are. Provide specific information about the person’s psychiatric illness and treatment needs. See if you can get the charges lowered or dismissed to avert her being jailed.
For some nonviolent individuals with mental illness who are not diverted from arrest or pretrial detention, some communities have established mental-health courts to allow these defendants to participate in court-supervised treatment designed and implemented by a collaborative team of criminal justice and mental-health professionals. For more about mental health courts, go to www.ojp.usdoj.gov/BJA/grant/mental health.html.
If your loved one is jailed, assure that she’s safe while in custody. The risk of suicide is very high during the first day or two. State the facts plainly: Explain that your loved one has schizophrenia and you’re afraid she might try to kill herself.
Engage a defense attorney to work with you and your loved one.
Stay in touch with the mental-health staff at the jail to make sure that your loved one’s release is planned in advance. It’s common for people to be released from jails without proper planning. You want to make sure that your loved one is linked to appropriate community mental-health services before her release.
People with schizophrenia should always carry some form of identification with a phone number for a relative or case manager in case of an emergency.
Mentally Ill and Missing
It isn’t uncommon for people with schizophrenia to disappear suddenly in an attempt to escape their problems or to search for a better life. This situation is a nightmare for families who realize their loved ones are unable to take care of themselves and fear for their safety. There are steps you can take to find your loved one, however, so don’t panic — but take appropriate action as quickly as possible.
Your first step will probably be to call the police, but keep in mind that they won’t be able to take any immediate action. After three days, your loved one can be placed on an “endangered adult” list that’s compiled by the FBI and sent out over a national alert.
While you’re waiting, there’s plenty you can do on your own. For example, you can:
Contact NAMI. NAMI provides support and guidance for families of missing persons. You can reach them at 800-950-6264.
Develop your own one-page “missing person” flyer, with a picture and description of your relative, and put it everywhere you can think of.
NAMI suggests posting the flyers the following places:
• Houses of worship
• College campuses
• Community health centers
• Banks
• Hospitals
• Public libraries
• Mass transportation centers
• Free meal sites
• The Red Cross
• The Salvation Army
• Homeless shelters
• Social security offices
• Social service agencies
A family we worked with was reunited with their relative when his picture was noticed on a bulletin board by an alert nurse in a hospital emergency room.
With the ease and speed of electronic communications, you can develop such a flyer and rapidly circulate it to everyone you know and to facilities in the community. You may also want to call the local newspaper to see if it would be willing to run a story about your missing relative.
Alert friends and relatives that your loved may show up in their area looking for a place to stay. If you haven’t been upfront with friends and relatives about what’s happening with your loved one up to this point, now is the time to start.
Contact all your loved one’s known hangouts and alert regular staff to call you if your loved one comes in.
Make yourself accessible day and night. Always have a cellphone with you and make sure the number is displayed on your flyers.
Advance Directives: Helping People Decide for Themselves
Healthcare power of attorney is a well-known and often-used tool in general healthcare — it’s a written legal document that enables another person you name (known as your proxy) to make decisions on your behalf if you’re unable to make them independently.
Psychiatric advance directives (PADs) for mental-health decision-making are a specific type of healthcare power of attorney that allows patients who are well (competent) to express how they want to be treated if they become ill again, generally as a result of a recurring mental illness like schizophrenia.
In Canada, PADs are called Ulysses contracts.
PADs are based on the idea that someone who was hospitalized in the past, perhaps involuntarily, may have definite preferences about the treatments he wants to have (or not have) next time around. For example, your loved one may realize that medication is helpful even if he’s opposed to it when he no longer has insight into his schizophrenia. Conversely, he may not want a certain medication to be used against his will because he found the side effects intolerable.
Generally, your loved one shares his PAD with his psychiatrist or other primary clinician, or another person he trusts to serve as his healthcare agent. Depending on where your loved one lives, the state may or may not require him to appoint an agent. Having a PAD in place accomplishes the following:
It ensures that the healthcare provider — and whoever else your loved one gives copies of the document to — knows his preferences.
It facilitates an open dialogue between your loved one and his clinician about future care.
It can prevent potential disagreements between your loved one and concerned family members or physicians around the use of medication.
It can prevent court battles over involuntary treatment.
It can help prevent relapse, by encouraging timely treatment before emergencies occur.
It can specify directions for the care of the person’s minor children in the event that he’s incapacitated, which can be very comforting to a parent who has schizophrenia.
In the following situations, PADs are not followed:
If the treatment requests in the PAD aren’t feasible or acceptable If the PAD conflicts with emergency procedures If the PAD is outside the law
The National Resource Center on Psychiatric Advance Directives (www.nrc-pad.org) provides information about how to craft a PAD and offers state-specific information and forms. Also, the Bazelon Center for Mental Health Law has a fact sheet on advance directives that provides information and resources(www.bazelon.org/issues/advancedirectives).
Every state has a federally funded protection and advocacy (P&A) system that can advise you about the laws in your own state or refer you to a lawyer who can. To find the contact information for your state P&A, visit the Web site of the National Disability Rights Network (www.napas.org) or call 202-408-9514.
