Many people also feel ashamed about their mental health-related struggles, and will work hard to hide them, even from those closest to them. It may be especially easy for them to hide their struggles when our contact with them is only by text or Zoom.
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; instead, 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. This may be difficult to gauge since most activities are now off-limits anyway. Types of withdrawal can include:
- Staying in the person’s room
- Not being in touch with friends
- Not answering texts
- Avoiding mealtime
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 Abuse
Changes in a person’s consumption of alcohol or other substances (especially marijuana) can be a sign of an underlying mental health issue. Increased alcohol use is widespread during this pandemic, which can make it challenging to know if there’s really a problem. 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
- Drinking more than others are (e.g., finishing a six-pack of high-alcohol beer during a Zoom happy hour, when others are having one or two drinks)
- Using substances alone, like smoking marijuana solo in one’s room
Recent Major Stresses
This is a stressful time for everyone, but more so for some than others. While not a sign of a mental health crisis by themselves, stressful life events are one of the best predictors of mental health struggles, including depression, posttraumatic stress, problems with alcohol, or excessive anxiety. Likely recent stresses might include:
- Losing their job
- Having had COVID
- Family members having had COVID
- Working in high-risk occupations, like public transportation
- Caring for those with COVID
- Losing their business
- Financial difficulties
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 a life-threatening illness 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, your loved one may seem to be doing surprisingly well as they face enormous challenges. However, our bodies and minds eventually struggle as the stress wears on, and our nervous systems are continually on high alert. Plan to check in regularly to see how they’re doing.
It can also be hard to recognize someone’s reactions to a major stressor like a pandemic when that stressor also affects you. For example, if you and your family member are both facing financial hardship, you might be less aware of how this strain is affecting them. 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 is less on top of their responsibilities at home, like doing the dishes or taking out the trash. If they’re still employed, they might be missing work more often, or missing deadlines. Students might not turn in papers and other assignments. They could be missing scheduled video conferences or showing up late.
Lack of Self-Care
When a person is having major life difficulties, basic self-care is often one of the first things to go. They might stop bathing regularly, to the extent that they have a noticeable body odor. They might stop taking care of their teeth. They may also wear the same dirty sweat pants and T-shirt every day, and look more disheveled than can easily be explained by the COVID situation.
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 stop exercising. Their sleep patterns may also have deteriorated.
Unfortunately these changes can worsen the person’s condition, as poor diet and lack of exercise are linked to worse well-being, which can perpetuate a vicious cycle of poor self-care. Consider any changes in the context of the person you know and in relation to other signs you’re seeing, since the majority of people seem to have changed their standards of self-care during the pandemic.
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. Granted, the world has changed dramatically in the past few months. So consider how the person tends to respond during very challenging periods.
Pay attention in particular if someone expresses a lack of hope that things will get better. While it may be hard to feel hopeful right now, most of us believe that at some point, the situation will get better. It’s hard to overstate the importance of hope, especially in these dark times, 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.”
- “This world doesn’t have anything to offer me.”
- “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 to. 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. While most people who feel hopeless don’t try to end their lives, hopelessness greatly increases the risk.
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 close friend. Let the person know what you’ve observed and what your concerns are, and invite them to share anything they might have noticed if they’ve had contact with the person. It can be hard to know how to respond to a possible crisis, especially in the middle of a pandemic, so teaming up with someone else can be 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 your concerns.
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 as non-judgmentally as possible what you’ve seen. Then invite them to respond. The goal is to let them know that you want to be helpful, 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. Are you an alcoholic?”
These conversations are rarely easy, so be prepared for a range of responses. For example, the person might:
- Express genuine bewilderment, if they feel like they’ve been doing fine
- Get irritated, perhaps because your concerns feel unwarranted—or because they’re right on target
- Validate your concerns and tell you more about how they’re doing
- 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 opening up 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 excessive alcohol use, and may hear condemnation in your concern. Express as clearly as you can that you love and support them regardless of what they’re struggling with.
Mind Your Own Anxiety
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
- Brainstorming other resources that might be helpful, like Alcoholics Anonymous meetings (probably virtual) 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 an imminent risk of self-harm.
- Stay supportive. Make sure the person knows that your love and fundamental positive regard don’t depend 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. I know this from personal experience. Watch out for thoughts like, “They have to get help,” or, “I have to convince them to seek treatment.” 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.