communication

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 biblio.com.

Subtitle: The Individual vs. Society

Recommended to me by: David Mitchell

David and I were discussing disclosure vs. silence, and he recommended this book. Rather than addressing the issue in a personal way, the book analyzes Japanese language and culture to address it in a more global way. None of it was immediately applicable, although it is validating to read that everyone struggles with the same issues, across cultures.

The first section analyzes Japanese word pairs that are essential to that culture. Omote and ura mean public, open, or spoken vs. private, hidden, or unspoken. They require each other, the way words require silence to surround them.

Tatamae and honne refer to the formal rules and public face of a group, vs. the unspoken rules and private opinions. Again, there must always be both, public harmony and private dissent. Even when someone intends to fully disclose their heart, the essence remains unspoken.

The second section addresses humans in society and analyzes several different stories.

The third section addresses secrets in the context of mental illness, charm, and love.

I was taken aback by the gratuitous subtle (all stories center on men) and overt (“effeminate” as an insult) sexism in a book published in 1986.

At the end of the book, my sense was that most of the message was unspoken, and I would have to study it in depth to understand the underlying points.

Available at biblio.com.

Subtitle: The Art of Powerful Non-Defensive Communication

A decade ago, this book, and a one-day workshop on Powerful Non-Defensive Communication (PNDC), helped me get out of an abusive relationship. My copy disappeared, probably on loan to someone, and I just replaced it. This is an edited review I wrote for Survivorship back then.

This communication technique focuses on good boundaries, emphasizing that we can only control our own words and actions, not anyone else’s. On each re-reading, I notice different helpful details. The book is carefully and clearly organized, with section headings for each new idea, lots of example stories, and a review of key points at the end of each chapter.

Part I describes the “War Model,” Sharon Ellison’s name for the combative communication style we learn to call “normal” in our culture. Defensiveness is a natural outgrowth of war-like communication. Six defensive modes are described – the three main strategies of surrender, flight, and fight, with passive and active sub-strategies for each. The passive modes seek to protect oneself, while the active modes seek to damage the other person. The six modes are

• Surrender-Betray (passive)
• Surrender-Sabotage (active)
• Withdraw-Escape (passive)
• Withdraw-Entrap (active)
• Counterattack-Justify (passive)
• Counterattack-Blame (active).

Part II describes the three primary conversational tools of Powerful Non-Defensive Communication (PNDC): curious and innocent Questions, open and direct Statements, and protective and firm Predictions. Each tool is described in detail, with many suggested formats and examples.

Questions
Non-defensive questions are used to clarify assumptions, and to learn information about the other person’s position. They also ask the other person to stop and think. Sometimes a single neutral, gentle, curious question can shift years of negative interactions.

One example tells about a couple where the man repeatedly accused the woman of being late, even though she was generally ready on time and met her commitments. They had fought about this for years. One day, the woman asked, “Is it my pacing that leads you to think I’ll be late?” The man stopped, blinked, and said, “You know, you are usually on time.” She tended to get ready at the last minute, while he tended to prepare in advance, and this was the first time the man had noticed that she did regularly succeed in pulling it all together.

Statements
Non-defensive statements are vulnerable, direct, subjective, and descriptive. They include all relevant elements of one’s own experience, even when some of the elements are contradictory.

One example tells of a divorced woman who no longer wished to invite her ex-husband to Thanksgiving dinner, but continued to do so because he had a tendency to withhold her alimony check whenever there was a conflict. One year, she chose to state to him that she did not want to invite him, and that she had continued to invite him through fear of the consequences, and that she did not want her alimony check to be delayed. Much to her surprise, he did not show up for dinner, and the next alimony check was on time.

Predictions
Non-defensive predictions are protective, foretelling, neutral, definitive and double-sided. The intent is to communicate the consequences of both sides of a choice, rather than to coerce one side or the other. Two types of predictions are described in detail: Limit-Setting Predictions, which identify one’s own responses based on the other person’s choices, and Challenge-Choice predictions, which identify outside consequences to the other person’s choices.

An example of a limit-setting prediction is “If you are not ready when it is time to leave for the play, I will drive my own car, and you can join me later. If you are ready on time, we can drive together and enjoy each other’s company.”

An example of a challenge-choice prediction comes from the owner of a printing company, who found that customers often argued with him about color choices, and then blamed him when the results were poor. He started making the prediction, “If you use too many colors, then, based on my experience, this logo will be less crisp and you will not be satisfied with the outcome. If you use fewer colors, it will be more crisp, and I think you will be pleased.”

The section on predictions includes a detailed discussion about how to devise and implement predictions, including strategies for handling negative reactions from people unaccustomed to encountering clear boundaries.

Highly recommended if you want new tools to communicate well.

Available at bookshop.org.