While awareness around mental health issues has increased over recent years, it can still be really difficult to recognize a mental health crisis in the people closest to us. The crisis may arise gradually, which can make it hard to notice the changes (just like we don’t notice a person’s hair getting longer when we see them every day). And many people feel ashamed about their mental health-related struggles, and will work hard to hide them, even from those closest to them.
Below are some signs that someone may be experiencing a mental health crisis. Keep in mind that none of these signs necessarily means the person is having a crisis; rather, they serve as cues to pay attention and get more information.
One of the common signs of mental health struggles is noticeable withdrawal from a person’s normal activities. Types of withdrawal include:
- Staying in the person’s room
- Not going out with friends
- Not answering texts
- Avoiding family gatherings like meals
- In school-age children, not wanting to go to school
These types of withdrawal could reflect the low energy, motivation, and engagement that are typical of depression, or the fear and avoidance that are common with high anxiety. They could also reflect other struggles that make the person want to hide.
Alcohol and Other Substance Use
Changes in a person’s consumption of alcohol or other substances (especially marijuana) can be a sign of an underlying mental health issue. Look for changes like:
- More frequent use, such as starting to drink most nights of the week
- Greater volume when using, like drinking to the point of slurred speech
- Using substances alone, like smoking marijuana alone in one’s room
Alcohol and other substances are often used to ease the pain of depression or trauma, or to blunt feelings of anxiety. Problematic patterns of use might also reflect a tendency toward addiction. Be especially vigilant if there’s a history of substance use problems in your family.
Having Experienced a Major Life Stress
While not a sign in the true sense, stressful life events are one of the best predictors of mental health struggles, including depression, posttraumatic stress, problems with alcohol, or excessive anxiety. Life stress comes in many forms, including:
- Losing one’s job
- Having health difficulties
- Being in a car accident
- Struggling in school
- Loss of a relationship, including divorce
- Being assaulted or mugged
- Death of a loved one
- Financial difficulties
- Being bullied
It’s not uncommon for a person to experience a delayed reaction to a stressful life event. For example, some people who survive a major trauma like being assaulted may experience posttraumatic stress disorder (PTSD) “with delayed expression,” meaning the condition is not fully present until at least 6 months after the trauma.
Stresses that continue for a long time, like chronic health struggles or long-term unemployment, often have a cumulative effect. For this reason, a person may seem to be doing surprisingly well as they face enormous challenges. However, our bodies and minds will start to struggle as the stress wears on, and our nervous systems are continually on high alert. Plan to check in regularly to see how a loved one is doing.
It can also be hard to recognize someone’s reactions to a major stressor when that stressor also affects you. For example, if you’re dealing with the stress of a recent move, you might not be as aware of how this major life disruption is affecting a family member. At these times we may need to deliberately remind ourselves to check in with those around us to see how they’re doing.
Struggling to Fulfill Obligations
You might notice that the person you’re concerned about has been missing work more often, or missing deadlines, or not turning in papers and other assignments. They may be less on top of their responsibilities at home like doing the dishes or taking out the trash. They could be missing scheduled appointments or struggling to be punctual.
Often a person might have an explanation for each lapse that seems reasonable—they couldn’t submit their paper in time because the website was down, or they missed a morning appointment because they set their alarm for PM instead of AM. Follow your instincts if you sense there’s something deeper that accounts for the struggles you’re seeing, and keep in mind the overall pattern you’re noticing.
Lack of Self-Care
When a person is having major life difficulties, basic self-care is often one of the first things to go. The person might stop bathing regularly, to the extent that they have a noticeable body odor or look disheveled. They might also stop taking care of their teeth. If they’re accustomed to paying attention to how they dress, they might start wearing the same sweat suit every day.
You might notice a change in the person’s food choices: whereas they might have eaten mostly healthful foods in the past, now they’re surviving on fast food or sugary snacks. They might also stop exercising. Unfortunately these changes can worsen the person’s condition, as poor diet and lack of exercise are linked to worse well-being, which in a vicious cycle can perpetuate poor self-care.
Change in Outlook
Some of the subtler changes you might notice are in the way the person sees the world. They may have become more pessimistic or cynical, and quick to see the worst in other people. Instead of seeing the world through rose-colored glasses, they have mud-colored glasses. You might notice a difference in tone in your interactions with them, and a shift in how they see themselves, the world, and other people.
One particular change in outlook to pay attention to is when someone expresses a lack of hope that things will get better. It’s hard to overstate the importance of hope, and it can be completely dispiriting to lose it. Examples of statements to listen for include:
- “I just don’t see things ever improving.”
- “I feel like giving up.”
- “I don’t know why I even try—nothing ever works out.”
- “It’s pointless—things are never going to get better.”
- And of course, “I feel so hopeless.”
While none of these statements in itself indicates a crisis, they’re worth paying attention. Loss of hope can lower our willingness to seek help and to invest our energy in activities and relationships that can help us feel better. Hopelessness is also an almost universal experience for those who attempt suicide. That’s not to say that most people who feel hopeless try to end their lives—they don’t—but the risk goes up greatly when hopelessness is high.
HOW YOU CAN HELP
So what can you do for a loved one if you know or suspect they’re in a crisis?
Don’t Go It Alone
First, consider consulting with someone who also knows the person well—another family member, for example, or a mutual friend. Let the person know what you’ve observed and what your concerns are, and invite them to share anything they might have noticed. It can be hard to know how to respond to a possible crisis, so teaming up with someone else if often a good idea.
While it’s important to protect the person’s privacy as much as possible, at some point safety concerns take priority. So while you honor your loved one’s need for privacy, share as much information as you need to describe why you’re concerned.
Approach the Person You’re Worried About
Whether or not you consult with someone else, discuss your concerns with the person you’re worried about (assuming there’s no obvious reason not to). Pick a time that’s mutually convenient (unless the person keeps putting you off), and describe what you’ve seen in as non-judgmental terms as possible, and then invite them to respond. The goal is to let them know that you want to be helpful if necessary, and to work together as a team.
For example, you might say, “I’ve noticed lately that you’re drinking every night of the week, and usually having several drinks at a time. It seems like a big change from how things used to be, and I’ve been worried about you. How are you doing?” This description is more likely to invite a positive and collaborative response than something like, “You’re drinking too much lately, and it’s going to get you in trouble. What’s the deal?”
These conversations are often not easy to have, so be prepared for a range of responses; for example, the person might:
- Express genuine bewilderment, if the person feels like they’ve been doing fine
- Get irritated, perhaps because your concern feels unwarranted, or because it’s well-placed
- Validate your concerns and tell you more about how they’ve been
- Get defensive, perhaps as a result of feelings of shame
Expect Some Amount of Shame
The issue of shame is very important, because it so often accompanies psychological difficulties, and often prevents a person from being open about their struggles. Shame might be especially prominent when a person isn’t meeting their obligations and is already feeling guilty about it; drawing attention to it and letting them know you’ve noticed can amplify that sense of guilt and shame. They may also feel ashamed if they’re engaging in behaviors they’re not proud of, like problematic alcohol use, and may interpret your concern as condemnation. Express as clearly as you can that you love and support them regardless of what the struggles might be.
Mind Your Own Anxiety
Be aware of your own anxiety about the person’s well-being. When we’re worried about someone, we might bring an unhelpful energy to our conversations with them. For example, we might become angry if the person isn’t immediately forthcoming, making them even less likely to share openly. It’s unrealistic to expect we’ll be perfectly calm, of course, but simply recognizing our own anxiety about the situation can help us to manage it more effectively.
Discuss How You Can Help
If there is a crisis, discuss with the person how they would like you to help. Options can include:
- Providing a listening ear as often as they like
- Helping them come up with a self-directed plan to address the crisis if professional assistance isn’t required
- Brainstorm other resources that might be helpful, like Alcoholics Anonymous meetings for a person dealing with alcohol use disorder
- Providing practical assistance, like taking over some responsibilities to free up time for them to pursue treatment
- Researching psychotherapists or other professionals who could be helpful
- Accompanying them to appointments if they want
What If They Don’t Want Help?
Just because someone is having a crisis doesn’t mean they’re ready to receive help. Keep the following principles in mind if they refuse to seek help:
- Stay as calm as possible. Meeting their anger with your own will probably lower rather than raise the likelihood that they get help.
- Take the long view. Just because they’re not ready and willing to seek help now doesn’t mean they won’t be. This principle assumes there isn’t an emergency, such as the risk of imminent self-harm.
- Stay supportive. Make sure the person knows that your love and fundamental positive regard aren’t dependent on whether they get the help you think they need.
- Remember that the ultimate decision is theirs. It’s extremely hard to watch someone we care about not getting help that may be available. Watch out for thoughts like, “They have to get help,” or, “I have to convince them to get help.” The best you can do is encourage them to take care of themselves. Even with children it’s good to make them feel included in the decision-making process.
- Take care of yourself. You may need extra support during your loved one’s crisis. Seek out the company of those you’re closest to, and don’t hesitate to seek therapy if you think it might help. A therapist who knows you well can probably offer guidance on how to manage your loved one’s crisis.
If you believe your loved one is a serious threat to themselves or someone else, take them to the nearest emergency room or call 911.