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September 25 - September 29, 2016
“I’m sorry because this might hurt your feelings. I want you to know I could be wrong. I don’t know everything, but yes, I think you might have schizophrenia. I hope we don’t have to argue about this—I respect your opinion on this and I hope you respect mine. Let’s just disagree on this.”
“Should you take the medicine? I’m sorry I feel this way and I could be wrong, I just hope we can agree to disagree on this. Yes, I think you ought to try it for at least a few months and see how it goes.”
When you feel empathy and convey it, your loved one will likely feel understood and respected. When you convey that you understand how your loved one is feeling, his or her defensiveness will decrease and openness to your opinion will increase.
Also, by asking questions instead of commenting on what she had to say (e.g., “What you’re planning isn’t realistic…”), I learned what was important to Dolores, what was uppermost on her mind, and how she was feeling. I created a window of opportunity, which I later used to discuss what role, if any, she felt treatment might play in what she wanted to accomplish (i.e., staying out of the hospital and working on Wall Street).
Only give your opinion when it has been asked for. An opinion that has been asked for carries more weight than an unsolicited opinion. It is important to avoid or delay giving your opinion.
Apologize — “Before I tell you what I think about this, I want to apologize because it might feel hurtful or disappointing.” Acknowledge fallibility — “Also, I could be wrong. I don’t think I am, but I might be.” Agree to disagree — “And, I hope that we can just agree to disagree on this. I respect your point of view and I will not try and talk you out of it. I hope you can respect mine.”
When defenses have been lowered and your loved one appears receptive to hearing your views: 1. Normalize the experience (“I would feel the same were if I was in your shoes.”). 2. Discuss only perceived problems/symptoms (Statements such as, “I can’t sleep at night because I’m constantly on guard. I am so afraid that they’re going to come and hurt me,” describe insomnia and paranoia stemming from a delusion. However, the words insomnia and delusion never need to be used in your discussions). 3. Review perceived advantages and disadvantages of treatment (whether rational or irrational). 4.
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“How did the psychologist find his wife who was lost in the woods? He followed the psycho-path.” —Henry Amador, October 1997—
Certain situations are “no-brainers” and almost always warrant commitment. Obvious among these are those situations in which someone is obviously about to hurt himself or someone else. In fact, being harmful to oneself or others is the most common legal standard for committing someone to a hospital against his will.
But, although most therapists are not currently trained this way, an exacerbation of a serious mental illness (e.g., psychotic decompensation) is good cause to breach confidentiality so that you can speak with others who care about your patient. If the limits of confidentiality are clear up front (“If you become sick and it affects your good judgment, I will need to inform your family to get their help”), there is no ethical dilemma.
Ideally, my order of preference is to: 1) Go together to the ER; 2) Call a mental health crisis team or an assertive community treatment team; or if all else fails, 3) Call the police and ask for officers from the department’s Crisis Intervention Team (CIT).
Don’t speak in absolute truths like, “I had to do this. I had no other choice.” Instead say, “I felt I had to do this, I felt I had no other choice.” Emphasize that your values and love led you to do what you did, not that you were “right” to do it.
In other words, the techniques I’ve been teaching you are not aimed at getting the person who is mentally ill to gain insight into being ill; they are directed specifically at getting him to find reasons to accept treatment despite what he believes.
We know today, right now, that building a respectful and trusting relationship is the key to helping someone with poor insight accept treatment for mental illness.
LEAP is partly based on Rogers’s conception of the transformative power of “actively listening” to patients:
In short, LEAP utilizes the following tools and principles from the three therapies: From Rogers’s Client-Centered Therapy: Reflective listening as the foundation for creating an alliance. Central to this technique is a complete lack of judgment—no opinion about what is being said is given unless it has been asked for (preferably many times over). From Cognitive Therapy: The collaborative stance, setting an agenda and cost benefit analyses. From MI: The patient remains the final arbiter of the change process. Ambivalence about change is explored. And perhaps most importantly, internal and
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