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mental health mondays :: crisis management

something that doesn't get discussed a great deal in the world of mental health is the idea of the psychiatric emergency. perhaps that's because our concept of an emergency is predicated on the assumption of physical danger. if you cut yourself and are bleeding, you have a limited amount of blood and therefore a limited amount of time before you die. the closer you get to the end of that hourglass, the worse your situation will be and so we know that we must immediately seek help in order to stop the bleeding.

mental health doesn't work that way. you don't have a fixed amount of sanity that can leak out your ears. viewed traditionally, a mental crisis can't be a life-or-death situation, except that we all know perfectly well that it can be, because suicide and [rarely] homicide are deadly outcomes that can result from a mind in the throes of panic, depression, psychosis or mania. the trick is figuring out if a person is close enough to their breaking point to warrant immediate intervention.

first of all, we need to come up with at least a semi-working definition of what would constitute a psychiatric emergency. this article is written by an american lawyer specifically on the topic of when hospitals or health care workers can justify giving treatment without the consent of the patient. that's a whole separate issue, but i think that there's something to be gleaned from the point to which he returns on several occasions: an emergency implies the threat of imminent physical danger. so let's take that as a working definition. 

if you have been thinking of hurting or killing yourself, that in itself warrants either a call to a crisis line [hint: if you've had problems with depression, keep the numbers of such hotlines somewhere you can easily find them at any time] or a visit to an emergency room. don't fall into the trap of over-analyzing, or justifying inaction by saying that it's not a "real" emergency. people who are severely depressed have a deep-rooted feeling that they are unworthy, or that they are incapable of dealing with "normal" problems because they are bad/ weak/ stupid, etc. serious thoughts of self-harm are absolutely a good enough reason to seek immediate help.

trying to help with someone else's mental illness is trickier, but again, take guidance from the idea that a successful resolution to the situation is one in which no one gets hurt. try to keep a cool head and pay careful attention to what you're hearing and seeing.

first off, dispense with the myth that people who talk about committing suicide don't actually do it. in fact, talking about contemplating suicide is possibly the biggest red flag when it comes to suicide. if someone tells you that they've thought about it, you need to take it seriously.

second, remember that there's a fine line between trying to make someone feel better and prolonging the problem. i'm not saying that you shouldn't try to cheer someone up by making them laugh, or letting them talk about their problems, keeping a cool head and expressing sympathy [although you'll probably want to avoid saying certain things], but remember that major depression is not cured through a friendly night out. you'll be a better friend if you're aware of your own limitations.

that's all well and good for people who might hurt themselves, but how can you tell if someone is seriously thinking of hurting others? it's extremely difficult and, frustratingly, there's not a lot of great research on when to take someone seriously when they express the desire to hurt others, specifically or in general. i did find this primer on dealing with psychiatric emergencies that can offer some help. it's intended for clinicians, but some of the material is applicable to the general public as well.

keep in mind that, while you might want to stop someone from hurting others, you need to protect yourself as well. someone who is obviously agitated, pacing, has tensed muscles or other signs of imminent aggression is not someone you should be approaching without extreme caution, if at all. if you know someone who has threatened or hinted at a plan to attack others and you believe those threats need to be taken seriously, that does not mean that you have to stop the person yourself. seek help.

in terms of resources, there are suicide hotlines, as mentioned above, but it is also perfectly sensible to go to a hospital. all hospitals are capable of dealing with mental illness, but if you have access to a place that deals specifically with those issues, it's always best to go with the experts. many mental health facilities have emergency wards just like regular hospitals and they are very used to dealing with any problems on the psychiatric spectrum.

i could get into a very long discussion about how access to proper health care, delays in providing regular, non-emergency treatment, the stigmatization of mental illness and other factors conspire to create emergencies in the field, but that's another post. another long, depressing post. for now, let's just say that we've established two golden rules of managing a mental health emergency:

  1. do no harm
  2. know your limits

and i sincerely hope that you don't have to put them to use any time in the near future.

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