My friend has severe mental health issues and I don't know what to do.
November 5, 2009 4:13 PM   Subscribe

Help me decide the best plan of attack with a friend who has very severe mental health issues.

One of my oldest and closest friends has severe mental health issues that consist of anger, depression, anxiety, and paranoia among many other things. She is quite smart and has her masters degree. She can't hold down a job, because she can't get along with her co-workers and there is always some sort of drama. She has a history of self-mutilation and has threatened to kill herself multiple times, and was involuntarily committed once, and voluntarily committed a second time.

I live across the country from her, but I try to be the best friend I can, available when she needs to talk, and as supportive as I can even though there's only so much I can do, and I try to keep some distance from the situation because of the insanity.

Her behavior has been escalating and I think I'm going to try to push her to do something inpatient until she can really get herself better. But, I'm wondering if anyone has had any experience with a situation like this.

She has state health insurance, and seems like she has gotten very little help. Her behavior has continued to escalate, and I'm worried that the situation will end in suicide. She doesn't speak to her family and she has another close friend that feels the same way I do. She is married and it seems like their marriage is in a bit of trouble and he has just emotionally distanced himself from the situation.

Has anyone dealt with a situation like this, and how did you handle it? Is there any hope? It seems like she's constantly on and off new medication and nothing really helps. I feel like there is a careful balance of being a good friend and getting too involved in a very messy and complicated situation.
posted by hazyspring to Human Relations (18 answers total) 5 users marked this as a favorite
As someone with bipolar, I can only say that your friend's health is her own responsibility. If she's seeing a psychiatrist, which I'm assuming she is because she's been on medication, then her mental health issues are between her and her psychiatrist. The "on and off medication" is part and parcel of being mentally ill - no one knows what will work until they find something that works. Even then, some will go off a medication that works because of side effects. If she's not seeing a psychiatrist, then you can suggest that she try again, but it's really up to her.

Being a friend to someone with MI is tough, I know. I've been on both sides of that fence. It's very tempting to want to take care of her, but in the end, only she can do that. Inpatient is for people who are a danger to themselves or others, if that's what you feel she is, then yeah, suggest she might call the ER. But if she's seeing a shrink and they haven't committed her, then it might not be that desperate of a situation.

I wouldn't push her towards anything - it may have the opposite affect. Make a suggestion if you feel strongly enough, but don't push it. That's what I would suggest...
posted by patheral at 4:51 PM on November 5, 2009 [3 favorites]

I'm interested in seeing the responses, as I'm going through a similar situation with someone I know. Let's call him or her Friend A.

Echoing what patheral said above, an anecdote. Recently I was discussing Friend A's situation with someone who does not know Friend A (let's call him Friend B), his response to me was to the point: "Friend A's mental health is not your responsibility." At the moment I thought Friend B was being a bit harsh, but perhaps not.

Best of luck to you, and to your friend.
posted by chez shoes at 5:08 PM on November 5, 2009

I sure hope the Straightener shows up in this thread to give his advice, he is always is spot on.
When I was in a similar situation, I contacted the good folks at, who gave me the name of mental health professionals in the area where my loved one was located. We arranged for the local police to perform a 'mental health check' home visit, which the situation necessitated, but may not be relevant to your case. In any event, getting in touch with local mental health care providers ended up being essential to providing assistance. Good luck, I know how hard this is to care about someone suffering, and to be so far away.
posted by msali at 5:13 PM on November 5, 2009

I have admittedly very little experience with this sort of thing; I had a friend that had serious issues and had voluntarily committed himself, and two other friends that were involuntarily committed.

That said, I would like to note a few key things:

1. Take any talk of suicide seriously. If you are unsure of what to do, call a counselor or suicide hotline and ask.

2. Your friend will probably not experience much improvement until she decides that she is responsible for and capable of improving her own situation. The fact that she voluntarily committed herself is a good sign. Depending on the nature of your relationship, she may take this idea more seriously if you yourself are confident in it.

3. Keeping some distance is appropriate. This is her fight, and getting too involved in it (which is all too easy to do if this is someone you feel close to) could undermine her taking responsibility for herself. Being there to listen can be constructive; attempting to solve anything may not be. If you can, converse as equals, trying to remove from your mind any thoughts you might have of taking care of her.

It seems like she's constantly on and off new medication and nothing really helps.

She may have been misdiagnosed. One of my friends selectively hid some of her symptoms of bipolar disorder from her therapist, because she really wanted to believe that she was merely depressed (for her, bipolar disorder was a deeper kind of "crazy" that she found unacceptable). This strategy seemed to work for a time; to outside observers it just looked like none of her medication was working. Eventually, she had a psychotic episode (which can happen in people with bipolar disorder) and the jig was up.

If she herself complains about the ineffectiveness of her meds, and again depending on the nature of your relationship, you may be able to suggest to her that she get re-evaluated.

But again, try not to get sucked in. This woman is an adult.
posted by Jpfed at 5:14 PM on November 5, 2009 [1 favorite]

You can encourage her your friend to seek inpatient treatment at this point, but there are a few things to consider:

1. Hospitalizations are traumatic. The only two reasons to go into the hospital are (a) being unsafe and (b) needing to make a real change. For that to work, the patient has to be personally committed to it. She needs to have a sense of agency, of knowing she can take charge of her life. If she doesn't have that, all the doctors in the world won't be able to help her.
2. Most hospitalizations are very short, too short to really help in the long-term. The only way hospitalization can help is by (a) stabilizing the patient temporarily, (b) trying to fix any serious medication problems, and, most importantly, (c) coming up with a long-term plan for the patient after her release.
3. Medicare and Medicaid don't pay for everything, unfortunately. Things may be better in your friend's state, but most patients leave hospitals with huge bills that they can't pay. Especially if they're incapable of working.

I would recommend that you help your friend look into intensive outpatient and/or partial hospitalization programs. There are some that are five days a week, six hours a day -- like a job. Others are only a few days a week, a few hours a day. All of these programs tend to focus on getting people back on their feet by giving them tools they can use to cope and by helping to shape real plans for recovery. The problem is that it's very hard to get someone who is suffering from acute mental illness to those programs, though. The patients who attend need support systems, they need transportation, and most of all they need hope. If you think your friend is a serious danger to herself right now, by all means try to get her to go into the hospital. But remember that hospitalization is not a solution in itself. She needs a plan for getting back on her feet, and she needs to believe that it's possible for her to do so.

Another thing to consider is that, from the other side of the country, you may not be in a position right now to tell exactly how badly she is faring. Do you have common friends who are closer to her geographically? (Do you get along with her husband, for example?) What do the people who are around her on a daily basis think?

Finally, how do you think she would take the suggestion that she go into a hospital? Would she be so angry that she would cut off contact with you? You should be careful about how you frame your suggestion. You might try saying something neutral like, "It sounds like you need more support than you're getting right now." That way she can lead the discussion -- the patient should always be in charge of her own care if it's at all possible. Of course you can contribute ideas, do a bit of research for her, but if she thinks you're all, "OMG, you are totally crazy," she won't be able to hear your advice. Make sure that anything you say comes off as concerned and not accusatory.

Good luck.
posted by brina at 5:14 PM on November 5, 2009

For those who advocate doing nothing....please do something.In our city a local businessman, loved and wellregarded by all who knew him, started showing symptoms of paranoia. Long story short, he just killed his wife, his two teenaged children, and himself.

Yes, he was an adult, and yes he was responsible for himself. I do think some of his friends tried to help him but probably weren't really sure what they should do. My boss, who is a trained therapist, feels that probably people weren't sure what to do about the warning signs, and that also the fear of stigma entered into the equation.

To the poster: All I can say is if she acts as if she could be in imminent danger of harming herself (or others) please, please, please contact mental health professionals, or worst case scenario, the police. Yes, hospitalization is traumatic (I know this from experience) but there are worse things.
posted by St. Alia of the Bunnies at 5:33 PM on November 5, 2009 [3 favorites]

You, yourself, should NAMI up.
posted by jgirl at 5:54 PM on November 5, 2009

the story is fairly vague, so it's a bit hard to know what is actually going on. however, one thing that comes to mind is that sometimes a "mentally ill" person is wanting us to become involved in a drama. If we refuse, they might implicitly or explicitly give the "world is going to end" response, but almost always they end up just moving on to someone else who is more interested in that drama. That doesn't mean you shouldn't call the police if the person says she is going to kill herself, but might suggest that hopping on a plane yourself as the rescuer isn't going to solve her problem.
posted by peter_meta_kbd at 6:02 PM on November 5, 2009

These previous answers may help.
posted by mkb at 6:02 PM on November 5, 2009

For those who advocate doing nothing....please do something.In our city a local businessman, loved and wellregarded by all who knew him, started showing symptoms of paranoia. Long story short, he just killed his wife, his two teenaged children, and himself.

It's statements like this that lead to misunderstandings about the mentally ill. Just because someone is "showing signs of paranoia" does NOT mean that they will kill themselves or anyone else. That's a blanket statement that perpetrates the stigma of being mentally ill. Because of my bipolar (before I found the right medication), I also suffered through periods of extreme paranoia, and I was NEVER a danger to anyone other than myself - and even then that was iffy. As you can see, I'm still alive and well.

Nearly everyone here has advised the OP to suggest to her friend that she seek treatment if the OP feels her friend is a danger to herself or others. Hospitalization exists for that purpose. However, I want to reiterate that the only person who is responsible for her friend is her friend. NAMI can help, her psychiatrist can help, friends can help, but she's the only one that can take charge of her own mental health.
posted by patheral at 6:42 PM on November 5, 2009

It's tough to be in your situation. You're a good friend for wanting to help. Friends, family connections, and relationships that can hold up against the pressures of mental illness and instability are priceless and few.

That said, you're really doing all that can right now. Patheral said it already, but I'll second that your friend's health is her responsibility. All you can do is make suggestions based on what you observe, don't judge her, and try not to over extend yourself to her (because you'll burn out too fast if she leans on you for long distance support multiple times a day).

Contact a third party if your friend's life is in danger. If she has the means and a plan to harm herself, you can call the police in her area and report your concerns. They'll do a welfare check on her, which just means they'll stop by and see if she needs a ride to the hospital.

Also, take care of yourself after episodes of taking care of her. It can be really draining to provide over the phone support to someone with MI and erratic behavior. The better you take care of yourself, the more help you'll be to her.

I hope your friend gets better soon.
posted by dchrssyr at 8:12 PM on November 5, 2009

It's okay to be honest about suicide, to ask "Do you think you might hurt yourself?" If the answer is yes, call the police. Stay in touch, express concern and love, listen. Encourage your friend to get good nutrition, get sunshine and exercise, take prescribed meds and go to a therapist.
posted by theora55 at 8:28 PM on November 5, 2009

For those who advocate doing nothing....please do something.In our city a local businessman, loved and wellregarded by all who knew him, started showing symptoms of paranoia. Long story short, he just killed his wife, his two teenaged children, and himself.

It's statements like this that lead to misunderstandings about the mentally ill. Just because someone is "showing signs of paranoia" does NOT mean that they will kill themselves or anyone else.

Yeah, I have an anxiety disorder that hangs out with clinical depression. I've been through bouts of pretty intense paranoia and I've never even gone one one single killing spree. So pardon me if I take exception with the notion that something as broad as exhibiting signs of paranoia is all the evidence needed to "do something" about someone.

But whatever. OP, it's commendable that you want to reach out to your friend during this clearly difficult time for her. However, if you get sucked in to her personal drama, it could have a negative impact on your OWN state of mind - in which case you're not going to be able to cope very well with helping her out. She needs to see a therapist, find a medication (or combination of medications) that works for her, and hopefully reconnect with her spouse, who really should be her primary support right now, not you. There's little you can do beyond encouraging her towards those things - barring emergency intervention if you think she's in IMMEDIATE danger of hurting herself.

If you do happen to think she's in danger of hurting herself, I'd strongly recommend AGAINST calling the cops - as there doesn't seem to be any evidence (that you've mentioned) of her being remotely dangerous to anyone besides herself, and she's in a vulnerable position right now anyway. Large men with guns whose jobs rely on very good intimidation tactics are the last things a depressed, anxious person needs to deal with. If she threatens suicide, call for an ambulance to her address. If she starts talking about hurting herself in a non-suicidal way, call your mutual friend and have them take her to an emergency room.
posted by ellehumour at 11:00 PM on November 5, 2009

Look, I've been a mental health consumer myself, so I didn't say what I said lightly. Most folks with these issues are NOT violent but since most people aren't trained to know what to look for, the few that are....I mean, at the very least they should have locked up this guy's guns since he shot out a dang window of his house in his upscale neighborhood the day before!!!!
posted by St. Alia of the Bunnies at 3:44 AM on November 6, 2009

My friend is not violent towards others, she's violent towards herself. She has tried to kill herself and also refused to eat, so those are the reasons she's been in the hospital.

If something happens and triggers her, she can easily become suicidal again. But, I don't think she's there at this moment.

I appreciate everyone's advice, and I think the comments above illustrate the fine line between getting too involved, and helping someone too much, especially if they really don't want to help themselves. That is precisely the dilemma I have had.
posted by hazyspring at 5:09 AM on November 6, 2009

Dchrssyr has it, the only thing I would add is that the way for someone with a severe mental illness to prevent mental health crisis hospitalizations is to maintain some type of outpatient treatment regimen where they are engaged with professionals who are going try to help them prevent that necessity. Inpatient hospitalizations are really only for crisis situations and the experience can often be a rough one depending on the quality of inpatient facilities near your friend so while on the one hand you want to take the necessary steps to intervene if your friend is saying she's going to kill herself at the same time you don't want to talk her into voluntarily committing herself when that's not absolutely necessary. That's why these decisions are best made by the consumer with the input of a treatment team that is familiar with them.

She has state health insurance, and seems like she has gotten very little help.

There are a couple possiblities, here. One is that she's actually not getting very good help because she's on medical assistance and the community mental health system that serves Medicaid clients is very spotty in terms of service quality. This is why "call NAMI," while well intentioned, is sort of a useless suggestion; unless the person answering the phone at NAMI happens to know which agencies are currently providing quality services in the city where your friend lives (they probably won't) then it's really a crap shoot. What makes things even more difficult is that these providers' reputations are constantly in flux as they turn over staff; good providers tend to become bad providers overnight, and vice-versa. So there's a distinct possibility she's not thriving because she's not getting good services, and there is even a possibility that if she lives in a small town with only a single mental health service provider she can't get good service at all. That's sad, but that's the reality of the system as it exists right now for the mentally ill poor.

Another possibility, as suggested above, is that she is not really fully engaging in treatment though she gives you the impression that she is. She may not be taking her medication at all, though she tells you she does, or she may not be taking it as her doctor is directing. Her attendance at outpatient therapy sessions may be spotty, or nonexistent. It's not possible to tell from what you posted how much you know about this, which isn't surprising, because you're on the other side of the country.

Yet another possibility is that she is receiving quality treatment but she hasn't been able to zero-in yet on a therapy that works for her. Psychiatry is not an exact science and sometimes people have to cycle through an array of medications before finding a combination that works for them. Perhaps she is somewhere in this process, and maybe she will find something that works for her.

Really, the best you can do for her is be a friend, a source of love, support and encouragement. You're not a mental health professional and your ability to impact this domain of her life from a distance is minimal.
posted by The Straightener at 5:39 AM on November 6, 2009 [4 favorites]

It sounds like you're really scared by your friend's behavior, and you feel helpless because she's not listening to reason. She doesn't seem to be helping herself and you care for her, so when she hurts herself, it hurts you.

What can you do? You can take care of yourself, in whatever way helps you center yourself and feel more accepting.

I don't suggest pushing her to do anything--you don't know what works for what she has and inpatient treatment might not be right at this point.

As an example, some experts on borderline personality disorder have found that inpatient treatment is NOT helpful and does NOT prevent suicide. Ditto with medications. They really don't help very much. But most people, when faced with someone who is cutting themselves, depressed, moody, impulsive, would say--put them on meds, or put them in a hospital. And they would push for that, even if it wouldn't really help.

Now, obviously, that is not the end-all-be-all of research on that issue, and I am not diagnosing your friend.

But I hope this example illustrates why you suggesting or pushing a certain form of treatment is not really appropriate.

Best of luck.
posted by kathrineg at 10:27 AM on November 6, 2009

And, again, I am not diagnosing her with borderline personality disorder, but if she does have it or you think she has it, don't go and read the online stuff that says she is hopeless or will inevitably kill herself. That is not a given, and a lot of people with borderline personality disorder simply get better as they get older, even without consistent treatment; they generally don't kill themselves until later adulthood despite their multiple suicidal threats, gestures, etc. So another example of how the popular literature or the popular conception of a certain mental illness can sometimes be very, very wrong.
posted by kathrineg at 10:33 AM on November 6, 2009

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