SchizophreniaConnection is pleased to present an interview Dr. Xavier Amador, who discusses the thorny dilemma of how to convince someone who doesn't believe he has schizophrenia to accept treatment. Dr. Amador is an internationally sought-after speaker, clinical psychologist, professor at Columbia University in New York City, and author of eight books.
Dr. Amador's expertise has made him a regular contributor to the Today Show and a featured guest on ABC Good Morning America, Prime Time Live, CBS This Morning, NBC Nightly News, 60 Minutes, CNN-Dateline, ABC's World News Tonight, Fox News, New York Times, Wall Street Journal, USA Today and many others.
Dr. Amador is a consultant to numerous companies and government agencies including the National Institute of Health and Department of Justice.
His forensic cases include the Unabomber, PFC Lynndie England, Elizabeth Smart kidnapping, and Zacarias Moussaoui trials. Dr. Amador has over 25 years experience working with adults, families and couples. He lives in New York. www.XavierAmador.com
Christina Bruni interviews. The following is the first of the two-part series.
SC: Talk about anosognosia; what it is, and what causes it. Can it be prevented?
XA: Research shows that about 50 percent of persons with schizophrenia (about 1.5 million in the U.S.) do not know they have an illness, and this unawareness does not improve with education, time, or treatment. I purposely did not use the term "denial" in the previous sentence because this problem is not denial. Denial is a coping strategy, a way we deal with painful knowledge. People in denial know something deep down inside (unconsciously), but they lie to themselves about it. But the research indicates that this is not what we are dealing with when, after months and years of evidence, the person still does not believe she or he is ill. What we are dealing with here is anosognosia (AH-no-sog-NO-sia)-a neurological syndrome that leaves patients unaware that they are ill.
According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), "A majority of individuals with schizophrenia lack insight ... Evidence suggests that poor insight is a manifestation of the illness itself, rather than a coping strategy ... comparable to the lack of awareness of neurological deficits seen in stroke, termed anosognosia."
As co-chair of the last revision of the DSM-IV text on schizophrenia, I was asked to propose changes that would better reflect scientific consensus. Every change considered had to be peer-reviewed by other scientists. The quote above reflects scientific consensus in the field (as of 1999) that poor insight is common in schizophrenia and is linked to executive (or frontal lobe) dysfunction. In the seven years since this update in the DSM, many new studies have replicated this finding.
If you believe that the person you are trying to help has anosognosia for schizophrenia, rather than denial, then you should not say that this person "refuses to acknowledge he is ill." That would be like accusing someone of refusing to stop being delusional or hallucinating! We don't do that because we understand that these are symptoms of the disorder and not the person's choice. Armed with this knowledge and some additional research, you can become much more effective at convincing someone who has anosognosia—someone with poor insight—to accept treatment and services.
We don't know if anosognosia can be prevented, but if it is anything like the other common symptoms of schizophrenia then early intervention and consistent treatment—both medicine and psychotherapy (psycho-social supports and cognitive therapy) should make a difference.
SC: Tell us about the foundation of your book, "motivational interviewing," its purpose, and why it's effective.
XA: Motivational Interviewing has been around for more than 25 years. It is well studied and proven to be effective in helping people with substance abuse problems accept treatment for their addiction. More recently it has been shown to be very effective in persons with schizophrenia who do not believe they are ill. For example, in 2002, the American Journal of Psychiatry published a review by Dr. Annette Zygmunt and her colleagues of studies published over a 20-year period that were aimed at improving medication adherence in schizophrenia. The researchers found that "...although interventions and family therapy programs relying on psychoeducation were common in clinical practice, they were typically ineffective [with respect to improving adherence to treatment]... Motivational techniques, [on the other hand] were common features of successful programs." By "motivational techniques" the authors meant the main elements of Motivational Interviewing.
Relying on the same evidence base reviewed by Dr. Zygmunt and her colleagues, Dr. Aaron T. Beck (the father of cognitive psychology) and I developed a form of MET we called Medication Adherence and Insight Therapy (MAIT) for an inpatient research study of people who have serious mental illness. At the time (mid-1990s), we taught this method only to therapists. But I realized almost immediately that anyone could learn the specific communication skills and strategies we were teaching.
I came to believe that you don't need an M.D., M.S.W., or Ph.D. to use this therapy effectively. So I developed a lay-friendly version that can be learned by anyone, not just mental health professionals. The result was the Listen-Empathize-Agree-Partner (LEAP) method.
Over the past ten years, since the publication of the first edition of my book "I am Not Sick, I Don't Need Help!" How to help someone with mental illness accept treatment (Vida Press, 2007 see www.VidaPress.com), I have taught LEAP to tens of thousands of people across the country and overseas. Although the focus of LEAP workshops was to show family members and health providers how to convince someone with serious mental illness to accept treatment, people at every seminar have commented on the usefulness of this method across a range of problems. That has been my experience as well. So whether or not you believe your loved one has anosognosia for mental illness or simple denial of illness, LEAP can help.
The method has proven so popular and useful that my latest book I am Right, You're Wrong, Now What? Break the impasse and get what you need (Hyperion, 2008; see www.XavierAmador.com) shows readers how to use LEAP with all kinds of denial, teenagers, spouses and in business.
SC: How does LEAP work?
XA: LEAP is very different than other conflict resolution strategies because it shows you that the best way out of an impasse—as in the "You're sick!" "No I'm not!" variety—is to shut up, step aside, and use your opponent's own argument to win your case.
I remember the worst fight I had with my best friend growing up. We were eleven years old building a fort in the woods behind my house. We disagreed about some aspect of our grand design—I can't even remember what—and got into a shoving match. I was shouting "Stop it!" and pushing him. He was shouting "YOU stop it!" and shoving back harder. We went back and forth like this several times and were about to come to blows when I just stepped aside and he stumbled forward and fell down hard. By the time he stood up and brushed himself off he was laughing. I forgot my own anger and laughed with him.
LEAP shows you how to not push back when you argue and instead use your opponent's momentum to move him to where you want him. It leaves you both feeling like friends again, if not laughing together about the fight.
SC: Do you feel the techniques outlined in I Am Not Sick, will possibly be able to help someone who has refused for MANY YEARS to take his meds?
XA: Absolutely. In fact these are usually the people who ask to consult with me and who have sent me e-mails after reading the book and finding it helpful. The reason is because LEAP focuses first and foremost on the strength of your relationship with the person you have locked horns with rather than on the strength of your argument for why they should believe they are mentally ill. It focuses on building trust, mutual respect and as a result, making your opinion something the person you've been arguing with starts to value. And your opinion will never again be—if you are following LEAP faithfully—"you're sick". Instead your opinion will be focused on linking treatment and services to those things the other person wants (e.g., housing, work, money, a boyfriend or girlfriend).
SC: Robin Cunningham, a blogger at SchizophreniaConnection, maintains that although the first psychotropic he was on didn't alleviate or halt his positive symptoms, the fact that he was on the medication prevented any further deterioration of his brain functionality. Are there studies that support this? If not, do you believe that the meds do have a protective effect when it comes to functionality, even if a person has symptoms while on the drugs?
XA: I agree with Robin's view. I have seen this first hand. But to my knowledge the evidence is still anecdotal as studies that can answer this question more definitively are very hard to do (longitudinal studies examining brain functioning and treatment). Nevertheless, several are underway as I write this and we may have more solid answers in the next ten years or so. We do know that early and consistent treatment leads to the best outcomes for the majority of people with the illness. So it stands to reason that Robin's view is correct.
Up next, Dr. Amador discusses techniques for dialoging with your loved one or friend.