I am not Charlie Sheen’s psychiatrist. I haven’t examined him, so I won’t diagnose him. But since he has turned himself into a kind of public laboratory of psychopathology, I want to explain how I would treat him, if he were my patient.
First of all, Sheen would already be in a locked psychiatric unit. I would have committed him. He has admitted that he only very recently attempted to become sober, and he has not presented evidence that he has maintained that sobriety—by, for example, routinely being tested for illicit drugs on a random basis (with no notice). While drug use itself is no reason that he should be deprived of his freedom and treated against his will, the fact that he has been violent toward others while using drugs is certainly reason enough. During 2006, Sheen reportedly pushed and threatened to kill his wife at that time, Denise Richards. During 2009, his third wife Brooke Mueller called 911 to report that he had held a knife to her throat (leading to Sheen being placed on probation). During October of this year, a porn star locked herself in a Plaza Hotel bathroom while Sheen destroyed hotel property. Most recently, Mueller obtained a temporary restraining order against him for threatening to behead her.
Homicidal ideation—whether in the setting of drug use or not—is ample reason for a person to be hospitalized psychiatrically against his will.
In addition, Sheen is, according to his own statements, incompetent to make rational decisions and “unable to care for himself”— another justification for his involuntary hospitalization. He has stated his belief that cocaine cannot kill him because he has animal blood in his veins—an entertaining statement, perhaps, but one that (taken at face value, which it must be by a psychiatrist who hears it) means that he may actually believe that he can use (per his own report) 7 grams of cocaine with medical impunity. This is a fixed and false (i.e. delusional) belief that can lead to his death.
After I hospitalized Sheen involuntarily on a locked psychiatry unit, I would instruct the nursing staff to search his belongings to make certain he had not smuggled drugs onto the unit and to then monitor him for signs of drug withdrawal. I would be suspicious of anything he might tell me about when he stopped using one or another drug because substance dependent people have (sadly) a habit of lying—even to their doctors, even after they say they want help.
With Sheen safely on the unit I would conduct an extensive interview with him to attempt to diagnose which psychiatric disorder(s) he suffers from. Among the possibilities would be (and I am certainly not diagnosing him now, because I have not interviewed him): Polysubstance dependence (cocaine, alcohol or other substances); bipolar disorder (often characterized by symptoms like pressured speech, hypersexuality, irritability and grandiosity) and narcissistic personality disorder (including symptoms like grandiosity and lack of empathy for others).
If Sheen’s symptoms were found to be due to an episode of mania (the “high” phase of bipolar disorder, or flipside of depression), then I would suggest that he consider using one or more psychiatric medications to bring his thinking toward equilibrium. He might also be offered medication to help him sleep and to decrease his irritability.
During Sheen’s first days on the psychiatric unit, I would encourage his family members to consider obtaining “substituted judgment” over his medical and financial decisions, rendering him incompetent. I would do this based on the way in which his recent actions have led to the termination of his parental rights, to a restraining order being filed against him and to him having lost a lucrative job.
Yet, all this would be only a beginning. The harder and more important work would be helping Sheen achieve insight into whatever has fueled his addiction to drugs, his escape into hypersexuality, his violence and his relentless pursuit of fame. I would be guided by my belief that those who feel most vulnerable deploy the most extensive emotional defenses (like distracting oneself with chaotic relationships and shiny material possessions). I would remind myself that it is often feelings of being unloved or unlovable which lead a person to assert he is superior to others. I would wonder whether publicizing his potency on national television and attacking women physically might actually reflect very deep questions he could harbor about his virility.
I would be determined to help Sheen understand that everything he has been running from—including his weaknesses and traumas and losses in life (yes, losses, not wins)—is actually the raw material for him to connect with himself and with others. I would help him understand that what he has suffered through defines him at least as much as what he has enjoyed. I would remind him that he can have no true friends who do not know the depths of his soul, and that, having been desperately treading water, he might not know these depths himself, yet need not fear them.
I would help him see that in admitting powerlessness over alcohol and drugs that he could find a much more powerful way to live—recognizing his need for real and genuine concern from others and his capacity to demonstrate real and genuine concern for others.
In the end, I would have him understand that his greatness is not that he is indestructible, but that he is mortal, hanging from the same thread that the rest of us hang from, connected to us and to all fragile human beings by the miracle of human empathy. I would help him understand that he should not protest against his weaknesses and shortcomings, but forgive himself for them and seek to strengthen himself, by facing them. Then, perhaps, he would know real stability, real courage, real faith, real truth and would feel wedded to our shared reality.
If we succeeded, Sheen might emerge from temper tantrums and flights of ego more in-keeping with childhood into self-possession. Then, over time, he might not need medications or legal restrictions on his rights. He might become competent again.
But, I’d keep drug testing him for as long as he remained my patient. I’d never trust him to tell the truth about whether he had used or not. And I wouldn’t leave a child alone with him, again, for a long, long time.
Dr. Keith Ablow is a psychiatrist and member of the Fox News Medical A-Team. He is a New York Times best-selling author, and co-author, with Glenn Beck, of the book "The 7: Seven Wonders That Will Change Your Life". Dr. Ablow can be reached at firstname.lastname@example.org
Keith Ablow, MD is a psychiatrist, and was host of the nationally-syndicated "Dr. Keith Ablow Show." He is a former member of the Fox News Medical A Team.