from The Introduction

In my private practice, too, this has been a frequent query. And in social settings, I am often approached by someone who, in a low tone, poses the same question. I came to see that a need existed, and the seeds for this book were planted.

When you are worried about someone in your life, someone whose life is in a downward spiral, you may be struggling with this same quandary. You may have tried to help and been rebuffed; or you've helped and things did get better for a while, but now you see the old patterns reemerging. Maybe you haven't said anything because you don't know what to say or fear a negative response ("Are you telling me I'm crazy?") if you suggest a mental health professional might be helpful. Are these problems beyond your capacities as a friend, spouse, colleague, or relative? What can you do?

If you have reached this point with a loved one, a roommate, a friend--the point where you know he or she has problems beyond your ability to remedy and it's time for professional help--I'm glad you're here. This book will give you the understanding and tools to help your friend get what is so obviously needed--a consultation with a mental health professional.

As a psychiatrist in practice for twenty-five years, I meet with people who have concerns just like yours. They want to help someone, but they aren't sure whether to get involved, how to get involved, or how to help. During my years in practice, I have not only helped people with their own mental health problems but also coached caring people who want to know how to help a troubled friend or relative.

When I recall dramatic mental illness stories in the media, I am repeatedly struck by how often friends and family had observed the person become increasingly troubled, knew that this was abnormal, figured something was wrong in that person's mental life, but didn't say anything, do anything, or consult with anybody else about what they were seeing. The silence in these onlookers has always struck me as deafening. A caller to one radio show after the Tucson massacre where Congresswoman Gabrielle Giffords was shot described how her own son had a psychotic break at age eighteen. Later, when she spoke to his friends, they confessed they had seen the emergence of hallucinations and delusions in her son for a couple of months, but never told his parents, or anyone else. He was showing things to his friends that he was able to hide from his family, but those friends said nothing. I had to write this book because I came to understand that one of the major missing pieces in approaching people with psychiatric problems is the efforts of friends and loved ones in directing them toward treatment. Those efforts are sometimes not even attempted or, if attempted, are ineffective. It is often left to the legal, medical, or mental health systems to get people into treatment. Those systems are quite imperfect. In contrast, family and friends are some of the most powerful forces in people's lives, and they can sometimes have far more effective (and benign) influence in getting people into treatment.

What stops most people who want to help is not knowing how to begin to talk to a troubled person. It's awkward. The person's responses can be sharp and rejecting. And so many areas are unfamiliar--where to turn for help, how to access resources that are already in place, how to learn about mental illness and its treatment, how to use legal mechanisms that can help people get treatment, how to link up with organizations that can help guide and support the process. Most people know how to help a friend who has discovered a lump in her breast. Call your doctor right now and get in for an exam and mammogram! In contrast, very few people know how to approach a friend or relative with an emotional problem. In this book, you will learn why it is vital to get beyond that awkwardness and be able to start the conversation. To say, Can we talk?

. . . .

This book is divided into two sections. The first four chapters provide the background to help you understand why you might have come to need a book like this. These chapters help you focus on your primary goal: getting the troubled person to seek a professional psychiatric evaluation. The last six chapters are a step­by­step practical guide to accomplishing that goal. If you are in a hurry to use the “how­to” portion of this book, you can go directly to chapter 5 and come back later to the first section.

1. •Chapter 1 helps you to see when it’s time for profes­sional evaluation—when things have become too serious for your efforts alone, and a threshold has been crossed. Your reluctance to get involved is squarely addressed, and you are encouraged to overcome your own natural resistance.
   

2. •Chapter 2 demonstrates that mental problems are widespread, and it discusses the consequences of untreated mental disorders.
   

3. •Chapter 3 reviews many possible reasons why the troubled­other hasn’t sought treatment on his or her own—hence your need to help.
   

4. •Chapter 4 clarifies the core goal of this book: the ini­ tial professional evaluation of the troubled person. I review what happens in the mental health evaluation, some of the available treatments, and who best to do the evaluation. I will also give you tips about how to find an appropriate professional.
   

5. •Chapter 5 helps you consider the timing—good times to approach the troubled­other, and times you want to avoid. Also, the chapter helps you think about the right place.
   

6. •Chapter 6 helps you with the opening pitch, that is, how to begin to talk about the problem one­on­one. The chapter suggests effective communication strategies that have a chance of “getting to yes.”
   

7. •Chapter 7 is useful if the private communications of chapter 6 are ineffective. You are encouraged to think of allies who might join you in the effort and how to mobilize their influence.
   

8. •Chapter 8 steps up the pressure further, moving from talk to action, spelling out approaches to “therapeutic coercion.” I will show you how to use the power inherent in your relationship to channel the person toward that all­important initial evaluation. Although very powerful, these measures have the potential for conflict, and you may be tempted to avoid them. Yet, it is failure to engage the troubled­ other at this level that often accounts for failure to get that professional evaluation, which might open the door to proper treatment. I will fortify your resolve and skill in using these more challenging approaches, should they be necessary.
   

9. •Chapter 9 is for situations that are acute and dangerous, where the softball approaches of the previous chapters are either ineffective or too slow. Here you will learn how to utilize the systems society has in place for involuntary evaluation of acutely men­ tally ill people. This chapter also considers your personal safety and the safety of children.
   

10. •Chapter 10 gives tips about what to do after the goal of evaluation is reached. If you can attend the evaluation, this chapter suggests how to most effectively use your presence, how to connect and stay connected with the care provider, and how to support the ongoing treatment of your person of concern. It raises the consideration of professional help for you, should you need it. This chapter also addresses the possibility that, in spite of everything you have tried, you may still have an unexamined or untreated per­ son with continuing psychiatric symptoms on your hands. What then?
    

11. •The appendix, called “The Seven Steps,” summarizes the book’s recommended process and methods for convincing a loved one to get help, as well as offering further steps to take should you run into resistance. You can use this list as a handy reference guide while putting the different suggestions from this book into practice.
    

12. •The resources sections list sources for further infor­ mation and ways to find               professional help.
    

I encourage you to read this book from beginning to end, and then return to the chapters that are relevant as you progress in your efforts to help your friend or loved one. It is possible that you are facing a very urgent situation in which the person you are trying to help is in danger, either because of the threat of suicide or violent behavior. There may not be time to read this entire book right now. Chapter 6 offers suggestions for approaching the subject of suicide with your loved one and resources for additional support. Chapter 9 will help you get rapidly acquainted with how to mobilize the authorities to assist in a suicidal or violent situation. You can also call the National Suicide Prevention Lifeline at 1­800­273­TALK or visit them online at www.suicidepreventionlifeline.org for expert advice.

Numerous studies have confirmed my own clinical observations: compared to other health problems, psychi­ atric problems can cause some of the worst suffering; and not just to those people who have a mental illness, but to those people who live and work with the mentally ill. This book will offer solutions to that suffering. You Need Help includes stories of real, suffering people and those who struggle to help them. You will read examples of conversations you can initiate with your loved one, friend, or  colleague. My hope is that reading this book will help you bring well­being and sanity to the life of the troubled person and to your own life as well. This book will give you hope and comfort that something can be done and that you can be instrumental in bringing about positive change.

What a person with a mental disorder really needs is you. Why you? Because you have a relationship with this person. You care about him or her. Your caring may have many faces: you may love him, you may have to raise children together, you may have to work together, you may share a loyalty that comes from experience or blood, you may have known each other for years, you may have great respect for him, he may have helped you in the past, you may have promised another person to care for him. Whatever the reason, enough caring exists for you to have picked up this book. That means that the other person cares about you in return—cares about your opinions, your feelings, and your ideas. Maybe the other’s ability to experience that caring is dimmed by the mental problem itself. But, somewhere, behind the symptoms, an ember of a relationship with you still glows—an ember of warmth you can reach.

Hippocrates, the ancient Greek father of medicine, wrote, “Sometimes doing nothing is the best remedy.” You’ve tried that remedy, and it has failed. You are now more than ready to access other remedies that are avail­ able in our time, more than two thousand years later. Turn the page. You can start learning how, right now.