24/7 Suffolk County Mobile Crisis Team, Inc.

What To Do In A Crisis

Most families reported that a crisis or psychotic episode - that is, a severe break with reality - occurred a few months to a year after they began to notice unusual behaviour. Some said, however, that the crisis occurred with little or no warning.

During a crisis episode, your relative will exhibit some or all of the following symptoms: hallucinations, delusions, thought disorder, and disturbances in behaviour and emotions. Families who have been through these psychotic episodes warn that no amount of preparation can fully protect you from the shock, panic, and sickening dread you will feel when your relative enters this stage of schizophrenia. Understand also that your relative may be as terrified as you are by what is happening: "voices" may be giving life-threatening commands; snakes may be crawling on the window; poisonous fumes may be filling the room. You must get medical help for your relative as quickly as possible, and this could mean hospitalization. If your relative has been receiving medical help, phone the doctor or psychiatrist immediately. Ask which hospital you should go to and for advice about what to do.

Guidelines that May Help You In Crisis

DO'S - Try to remain as calm as possible. Decrease other distractions; turn off the television, radio, etc. If other people are present, ask them to leave the room. Talk one at a time. Try saying, "let's sit down and talk," or "let's sit down and be quiet." Speak slowly and clearly in a normal voice. Make statements about the behaviour you are observing: "You are afraid/angry/confused. Please tell me what is making you afraid, etc." Avoid patronizing, authoritative statements such as "you are acting like a child," or "you'll do as I say, young lady." Repeat questions or statements when necessary, using the same words each time. Don't rephrase the question in the hope that this will make it clearer. Allow your relative to have personal "space" in the room. Don't stand over him or her or get too close. Understand that too much emotion on your part can upset your relative further.

DON'TS - Don't shout. If your relative appears not to be listening to you, it may be because other "voices" are louder. Don't criticize. Your relative cannot be reasoned with at this point. Don't challenge your relative into acting out. Avoid continuous eye contact. Don't block the doorway. Don't argue with other people about what to do.

It is far better, if possible, to have your relative go to the hospital voluntarily. If you do not think your relative will listen to you, see if a friend can talk the person into doing so. Some have found that presenting their relative with a choice seemed to work. "Will you go to the hospital with me, or would you prefer that John take you?" Such an approach may serve to reduce the person's feeling of helplessness. Offering choice, no matter how small, provides some sense of being in control of the horrible situation in which they find themselves.

Families warn that sometimes a psychotic episode will involve violence. In such situations, there will be no time to talk calmly to your relative, or to phone the doctor or psychiatrist to ask for advice. Because your relative is in an altered state of reality, he or she may try to act out the hallucination - for example, shatter a window. Your relative may threaten to harm him or herself, to hurt you, or to damage property. One mother said that her son kept yelling that God was ordering him to kill her. In such situations, you must do whatever is necessary to protect yourself and others (including the ill person) from physical harm. It may be that the wisest course is to leave the premises. The alternative might be to secure your relative in a room while you phone or go for help. Such an action, however, would be advisable only under extreme circumstances. In such charged situations, probably your only choice is to phone the police. It may be unwise to drive your relative to the hospital by yourself: do so only if someone else can go with you.

Police Involvement

Families who have been through this agreed that they were hesitant to call the police. They felt that they were treating their relative as a criminal, and that they were giving up and abandoning the person, however, in some situations they had no other choice. Many families discovered that the statement, "I am calling the police," calmed their relative. It let the person know that his or her behaviour would not be tolerated. One father said that the sight of the police uniform helped to defuse the situation. But another father, disagreeing with this tactic, warned that because his daughter was paranoid, seeing a police officer in her home was like waving a red flag and infuriated her further. Remember to trust your instincts: you know your relative better than anyone else and have a better chance of judging how he or she may respond to different tactics.

When you phone the police, explain that your relative is in urgent need of medical help, and that he or she has been diagnosed as having schizophrenia (if this is the case). Briefly describe what your relative is doing - making threats, damaging property - and state that you need police assistance to get your relative to a hospital. Make sure that the police know whether your relative is armed, and whether or not there are accessible weapons in the home.

When the police arrive, those families who have been through this experience warn that you must be prepared for a variety of responses. Some police forces have specially trained officers who know how to handle psychiatric emergencies. Some police officers have little knowledge of, or experience in dealing with, this sort of crisis. Some officers may be extremely sympathetic, while others may be quite unhelpful. You might be asked by the police to lay a charge. You should think very carefully of the implications of doing so. Know too that your own attitude or emotional state may be a factor in conditioning police reaction. In your record, document everything that happens when you phone the police: note how long it took for someone to respond to your call; note the officers' names and badge numbers; note briefly how they treated you and how they handled the situation.

Once in your home, the police will try to assess the situation and decide what should be done. While the police are present, you may have the chance to phone your relative's doctor or psychiatrist to ask for advice. Inform the police if you have been advised by the doctor to take your relative to a particular hospital.

After the police have the information they need, they may take your relative to a hospital emergency department. It is the responsibility of the police to report all relevant information to the doctor. They are usually required by law to stay with your relative until an assessment is carried out. If you have not been able to go with the police to the hospital - although you should go if at all possible - ask the police to phone you back and let you know what has happened. We recommend that you speak directly to the doctor; the emergency head nurse should be able to help you get in touch. You will want to find out if your relative has been admitted to the hospital, and whether or not treatment is being given. Find out the name of the admitting physician. Record all of this information.

Hospital Admission and Mental Health Legislation

Admissions in all provinces and territories are governed by the mental health legislation in effect in each area. Although there are significant variations between the different Acts, all make a distinction between voluntary and involuntary admission (in Quebec called "cure fermee" or "closed treatment"). Voluntary admission is usually based upon a request from the prospective patient together with a recommendation from his or her physician. Involuntary admission is one that occurs without the patient's consent. Such a decision rests on an assessment of the seriousness of the patient's condition.

In many jurisdictions, although the language used may differ, involuntary admission is the result of a conclusion that the person is suffering from a mental disorder and is a danger to him or herself, or to others. Some jurisdictions allow involuntary admission without evidence of dangerousness, if it is established that substantial deterioration in the person's health will occur if the person is not treated immediately. In some, the application for such an admission must be supported by examinations by two physicians. In others, the certificate of admission must be signed by a physician other than the one signing the application.

An explanation of the legal situation may be provided to you by a health care professional. If not, ask for one. Other possible sources of information are a local SSOC chapter or another family self-help group in your area. Useful brochures on mental health legislation may be available from your provincial or territorial health department, or you might consider obtaining a copy of the relevant legislation from the publications office of the province or territory.

In crisis situations, you might normally expect your ill relative to be admitted, if not voluntarily, then involuntarily. However, this may not be the case. Your relative may refuse to be admitted, and the medical examination may not result in an assessment that would support involuntary admission. If you are not able to be at the hospital, it is possible that your relative may be allowed to leave before you are notified. If your relative is not admitted, families who have been through the experience recommend strongly that you consider other possible courses of action, including, in some circumstances, leaving your relative on his or her own. Without the alternative of returning home, the hospital may appear to be a safe haven to the ill individual.

Emergency Planning

1. Contributing families recommend strongly that you have an emergency plan ready for crisis episodes.

2. Have handy a list of phone numbers for: the police, the doctor, the psychiatrist, and an emergency centre for psychiatric admissions.
3. Ask your relative's doctor or psychiatrist ahead of time which hospital to go to in case of an emergency.
4. Know which family members and friends your relative may trust more than others in an emergency.
5. Find out whom you can phone for support at any time of the day or night.
6. If applicable, decide who will take care of other children.
7. Consider explaining the situation ahead of time to your local police department to get advice about what to do.
8. Know that the crisis situation may be less frightening to your relative if the emergency procedure has been explained and is anticipated.

Public Health Agency of Canada

Schizophrenia: A Handbook for Families

http://www.phac-aspc.gc.ca/mh-sm/pubs/schizophrenia-schizophrenie/chpt06.htm