Contrary to a popular old saying, what you don’t know can hurt you terribly.  So I want to dedicate this blog post to providing some “Jewels of Rules” to families of people who have a mental illness.

After reading Liza Long’s blog post and watching her interview with Erin Burnett on CNN a couple of weeks ago, I can say – in an admittedly cheesy paraphrase of Ms. Long’s blog post title – “I am a psychiatrist who has spent his career trying to prevent mothers from becoming Adam Lanza’s Mother.”  You may recall that in her blog post, “I Am Adam Lanza’s Mother,” Ms. Long wrote from her heart about her son “Michael’s” occasionally life-threatening episodes of rage and hostility towards her. She honestly expressed her feelings about these episodes, the difficulty of parenting “Michael,” and the complicated mix of emotions she has about him and his threats of violence.  She pointed out in her CNN interview that “97% of the time, he is just the sweetest, brightest, kindest, most articulate child…” but the other 3% of the time – when he is having a threatening or violent episode – life with him is difficult, stressful, frightening and intolerable.  At one point in the interview Ms. Burnett asked her if pulling a knife on her and threatening to kill her was  “normal behavior” for her son.  Her answer was frightening, but sadly, not unusual:  “That’s the scary thing,” she said, “ the extent to which we had normalized that behavior…” And she concluded that, “I have to face up to the fact that I have a sick son, and we need help.”

I have intentionally taken a couple of weeks to think about this interview and Liza Long’s blog post, and the firestorm of debate that has raged in the blogosphere and elsewhere in the wake of it all – particularly in light of my last blog post.  Obviously, I stand by my factually correct statements in that last post that people with mental illness are far less violent than most people estimate; that they are no more likely to become violent than are people without a mental illness; and that mentally ill people are actually much more likely to be victims of violence than perpetrators.  Facts are facts, inconvenient though they may be in the context of a particular discussion.

But it’s also a fact that sometimes mentally ill people do become violent.  And when they do – as people like Lanza, Seung-Hui Cho, Jared Lee Loughner and others keep reminding us – the results can be devastating to individuals, families, communities, and literally the entire nation.  This fact shouldn’t be overlooked or minimized, any more than it should be exaggerated or overgeneralized. As far as I’m concerned, Liza Long is to be commended for having the courage to speak up and express what countless other mothers and families are feeling, because so many of them are silently suffering in the same way that she and “Michael” have been suffering.  These quotes I came across from families’ posts on The Huffington Post are as chilling as they are heartbreaking:

• “[Her mentally ill brother] chased my sister and I around the house with a butcher knife, he would push my sister on her tricycle down the drive way into the house,”

Or…

• “[Her mentally ill little girl] would be fighting me, biting me, scratching me. One time I had to lock her in the bathroom so she would not hurt herself — once she fell asleep, she woke up as if it was a new start to the day … and it was like nothing ever happened and I also pretended it was a new day and a new start.”

Or, most horribly…

• “Until my son stabbed his loving father 52 times in a schizophrenic delusion, no one listened…”

Let me be clear: there is absolutely no excuse in 21^st century America for an individual or a family to be in a situation in which “no one listens” until a man is stabbed 52 times by the mentally ill son that he loved dearly but was unable to help.  For my part, I’ve spent my professional career making sure that when patients or families under my care were at risk for this kind of horror, if no one else was listening, I was.  For that reason, I’ve learned that there are far too many families who suffer in this way.  And I’ve been able to help some of them make some simple changes in their attitudes and actions that give them at least a chance to decrease the risk of their mentally ill loved one hurting someone in a violent episode.

So now, it’s time for me to share 7 basic “Jewels of Rules” for minimizing the risk of violence by a mentally ill loved one – right here on this blog:

Jewel-of-a-rule #1:      Remember, “Safety First” isn’t just a glib slogan, it’s a lifestyle imperative for anyone living with and caring for a person with a mental illness.  Start incorporating this concept into your way of thinking. It needs to become automatic, second nature.

Jewel-of-a-rule #2:      In the wake of the horrible massacre in Newtown, CT and many other incidents like it, if you haven’t done so already, cut through the denial and get real.  Yes, a horrible incident like this could happen to you – yes, you, too!  Yes, your loved one could conceivably do something terrible.  So pull your head out of the sand and start safeguarding your well-being and that of your loved one and your entire family.

Jewel-of-a-rule #3:      If your loved one is threatening violence towards you, your family, and/or himself, do not hesitate to call the police (via 911). You don’t need to wait until you are 100% certain that he’s going to act on the threat. (Let’s face it, if you wait until you’re that certain, it may turn out that you waited far too long!)  Just a slight concern that he may act on a threat is enough for you to take action to prevent that threat.  Remember, always err on the side of safety.  And here’s a “critical corollary” to this rule:

If you and your family ever find yourselves in that unfortunate situation (in which your mentally ill loved one is threatening violence) the psychiatrist is not the first person you should call to help you at that moment.  When your loved one is wielding a weapon, or in some other way seriously, imminently threatening to harm you, himself, or someone else, that is not the time for a therapy session.  Your psychiatrist’s effort (or your own effort) to “talk him down” is not what you need in that situation.  You need to neutralize the threat of violence.  Get the weapon away from your loved one without him hurting himself or anyone else, and then get your loved one physically under control so that he is unable to hurt anyone.  If you can’t do it, you’ve got to call someone who can – quickly and safely.  Sometimes, this may require the kind of physical restraint of the person that seems so utterly distasteful and upsetting to many of us that we don’t even want to consider it. But remember:

• If done properly, getting your loved one physically under control provides the best chance of making sure that no one – including your mentally ill loved one himself – will be harmed; and

• The consequences of failing to take this step can be disastrous beyond words – far more distasteful than tussling with your loved one to keep him from hurting himself or you.

Jewel-of-a-rule #4:      Don’t have guns or other potentially lethal weapons in your home or in any location that your mentally ill loved one can access – period.  If you don’t have lethal weapons now, don’t get any.  If you have them, get rid of them.  This is not a politically-motivated, gun-control-advocate kind of statement.  It is simply common sense advice that works. Fail to heed this advice, and you could pay with your life – like Adam Lanza’s mother did.  It doesn’t matter that she had a hobby as a target shooter.  She can’t have any hobbies now.  And that fact can only be viewed as an awful tragedy, regardless of where you stand on the “gun-control debate.”

Jewel-of-a-rule #5:      Do not develop a “tolerance” for violence or threats of violence. The “Safety First” principle from #1 above means that no amount of unconditional love for your mentally ill loved one should lull you into tolerating threatening or violent behavior.  Unconditional love for your mentally ill family member (which you absolutely should have, don’t get me wrong) means that you’ll do whatever is necessary to prevent him from becoming an Adam Lanza or a Seung-Hui Cho, and to prevent yourself from becoming an “Adam Lanza’s Mother.”

Jewel-of-a-rule #6:      Assume that if one threatening or violent episode has occurred, others will follow, sooner or later, unless something definitive and effective is done. By that I mean something that enhances your loved one’s treatment; or prepares you and your family to protect yourselves; or addresses stressors in your household or in your loved one’s life that may be leading to violent or threatening episodes; or – preferably – all of the above.  But never be resigned to simply “tolerating” threatening or violent behavior.  (This was the mistake that Liza Long realized she had been making.  Her blog post, in part, was her “wake-up declaration” that she’s going to take steps to correct that mistake.) Left alone, threats and/or violence by a mentally ill person typically get worse, not better.  Even the most effective interventions and treatment usually succeed only in decreasing the risk of further violence, not eliminating it.  Prudent families never fully “let their guard down.” Remember, most mental illnesses are chronic, potentially recurrent illnesses that are treatable and controllable – ideally, for long periods of time – but not usually curable.

Jewel-of-a-rule #7:      If you’re ever in the situation in which your mentally ill loved one is hospitalized, make sure you know your role.  You are NOT simply the loving family member who should passively and unquestioningly accept whatever the hospital staff routinely offers or tells you.  You are an active, paying consumer of health care for your loved one — health care which, if inadequate or ineffective, can cost you dearly.  You need to see it that way.  And it’s with that spirit that you need to advocate for your loved one when she is in the hospital being treated.  Demand to meet with the treating psychiatrist.  Demand a thorough explanation – in terms you can understand – of each and every medication that your loved one is prescribed, and of each and every treatment modality and other aftercare plan that is provided or recommended for your loved one.  Satisfy yourself that the plan for your loved one’s discharge makes sense, is doable and does not have “holes” in it. “Holes” – such as a dangerously long period of time between your loved one’s discharge from the hospital and her first outpatient follow-up appointment – can put you, your loved one or your family at risk.  Demand a thorough, coherent discussion of contingency plans that you and your family members can follow if, despite the hospital stay, your loved one once again becomes threatening and/or violent.  The plan should include detailed, easy-to-follow instructions that make it clear how you can keep yourself, your family and your loved one safe and unharmed, and how you can quickly access a return to emergency level care for your loved one.

This list of “Jewels of Rules” isn’t necessarily an exhaustive list.  There may be other measures that people have discovered – hopefully not “the hard way.”  Feel free to comment on this post.  Together, we can do something – right here on this blog – that might help someone who’s struggling with this.  I refuse to be a silent observer of horrible incidents like the Sandy Hook Massacre, and neither should you.  Sure, it took place more than two weeks ago. But it will never be “too late” or “no longer topical” to discuss ways to help individuals and families dealing with mentally ill loved ones.  Too many families have been suffering for too long.  And it’s not going to magically stop happening.  We’re going to do something about it, by sharing knowledge and ideas.

Dr. Steve