“I Am Not Sick I Don’t Need Help!” by Xavier Amador, PhD

Subtitle: How to Help Someone with Mental Illness Accept Treatment

Recommended to me by: a friend with a mentally ill relative

This is a book about how to communicate better with people with mental illnesses involving psychosis like schizophrenia or bipolar disorder. The focus is on getting people to accept psychoactive drugs when they don’t believe they are ill.

Rather than assuming non-compliant patients are immature, defensive, stubborn, or oppositional, Xavier Amador documents that poor insight into being mentally ill is a symptom of being ill itself. People carry their self-image from before becoming ill and don’t update it to match their new reality. Anosognosia is the official diagnosis for lacking self-awareness of a disability.

He also presents research that early and consistent use of medications leads to better long-term outcomes than longer periods of untreated psychosis. My intuition says that there may be correlation rather than causation there.

Rather than arguing with someone about whether they are ill and need medications, Amador proposes the LEAP protocol: Listen, Empathize, Agree, Partner. Listen to what the person has to say, ask questions to clarify, and reflect it back, even if it is delusional. Empathize with the underlying emotions. Find places of agreement. Partner to meet common goals, such as avoiding repeated hospitalizations. Be an ally rather than an adversary. Recognize the person’s autonomy.

Reflective listening can be difficult when we have an urgent agenda, especially when we believe someone is delusional. It’s easy to believe we are listening reflectively while being patronizing instead, which undermines all attempts at creating an alliance.

  1. Make it safe – Apologize for past attempts at coercion and indicate an intention to listen. It will take time to rebuild trust.
  2. Know your fears – Many people fear worsening or joining in delusions if they are not immediately contradicted.
  3. Stop pushing your agenda – Drop attempts to be in control. The agenda is to listen and learn.
  4. Let it be – Don’t fan the flames of conflict. Don’t try to impose order on disordered thinking.
  5. Respect what you’ve heard – Reflect back without comment or criticism.
  6. Find workable problems – Find out how they see their problems, and help them address them.
  7. Write the headlines – Listen for what is most important, and underlying themes.

Delay giving opinions, especially about whether the person has a mental illness and needs drugs. Say things like, “I’ll answer that, but first I want to hear more about how you’re feeling.” When giving an opinion, Apologize, Acknowledge, Agree. Apologize for having an opinion that may be hurtful to hear. Acknowledge that it is only an opinion and could be wrong. Agree to disagree. Above all, acknowledge that the person is in charge of their own body and will be making the final decisions about taking meds when not in the hospital.

Recommended for the respectful communication skills, with the caveat that this book emphatically advocates for meds, with one brief paragraph about the benefits of intensive therapy instead.

Available at Powell’s Books.

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