An Interview With Xavier Amador, Ph.D. - Part Two
In our continuation of the Dr. Xavier Amador interview, the esteemed psychologist gives some suggestions for how to dialogue with a loved one or friend who lacks awareness that he has schizophrenia.
SC: In the New York Times, there was a recent article about Ely Lilly's new drug breakthrough that targets glutamate in the brain. Could you comment on this? It appears that this drug improves cognition. Do you feel that this drug will possibly "cure" anosognosia?
XA: I am very excited that psychopharmacology researchers and industry are finally looking at trying to treat anosognosia-improve insight. I think we will make advances in this area and some preliminary evidence suggests we may already have done this. But it's too soon to point to a particular compound. Still, I am very excited about the possibilities in the very near future.
SC: How many people are affected by anosognosia? Why is it that some patients lack insight, but others ARE aware they have an illness? If someone goes two or three years, or more, without treatment after his first episode, will that increase the chances of the patient getting anosognosia?
XA: As I mentioned earlier, about 50 percent of all persons diagnosed with schizophrenia worldwide have anosognosia for mental illness. Like other symptoms of schizophrenia, anosognosia can wax and wane-there are good days and bad days. That often confuses clinicians and family members because they think they are dealing with denial so if the person says one day "I see that I am sick" everyone around them expects that "insight" to stick. But it's not denial so moments of awareness usually disappear over time in those persons with anosognosia-just like someone who suffers from delusions can have periods when the delusions are not so severe...but then the delusions come back as strong as ever.
SC: Empirical studies show that early intervention leads to a better outcome for people who have a psychotic break. Does early intervention prevent anosognosia? Comment on the benefit of early intervention.
XA: I believe it does and there is data to support the notion that early and consistent treatment over the course of two years or longer is associated with increases in insight.
SC: Obviously, even if better drugs come on the market, if they don't target or halt anosognosia, a person still won't take them, even if the drugs are touted as better than the old ones. Have you heard of any new drugs in the pipeline that would counter anosognosia?
XA: I have seen one study each suggesting Clozaril and Risperdal CONSTA have improved insight. But both studies are preliminary and need to be replicated. I am eager to see attempts at replication and also the results of studies of new drugs in the pipeline.
SC: Give us some suggestions for how a family member could "couch" what he says, to influence a loved one to take the meds.
XA: Don't offer your opinion unless it's asked for. If the person never asks then ask if you can share your opinion. For example, say "Would you mind if I told you what I think might help you with the problem you've been describing?" Perhaps the problem that was being discussed was the conspiracy against the person or insomnia. When the person says yes, use the three A's to give your opinion that medicine might be useful for the problem in question (not because the person is mentally ill).
Here's how it works:
At some point, when you feel the time is right, you want to give your opinion. Research shows that a special kind of relationship can influence someone's willingness to take medicine. That relationship is one in which the mentally ill person feels that his opinion is respected, trusts the other person, and believes that this other person thinks taking medicine is a very good idea. Well, now is your chance to give your opinion. But, for the same reasons you should delay giving it, do it with humility and while empowering the person you are trying to help. Never give your opinion without first using what I call the three A's:
"Before I tell you what I think about this, I want to apologize because it might feel hurtful or disappointing."
"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."
This, too, comes quite easily once you practice it a few times. Try it out with someone in a role-play before using it with the person you are trying to help. Practice it in other situations. It will disarm the person you are about to disagree with when you say something like, "I am sorrybecause my answer might upset you and I realize I could be wrong. I just hope we can agree to disagree. I think _________________." Don't use the word "but" as in, "But, I think..." People who are in a disagreement typically stop listening when they hear the word "but."
If the person gets defensive after you give your opinion, don't argue. Just apologize for disagreeing. You might even say something like, "I wish I felt differently so we didn't have to argue about this." But I have found that by the time I give my opinion when using LEAP, I rarely encounter defensiveness.
SC: If a person is on medication and it's not working, what could you tell him?
XA: If you go to a movie and it's a bomb-a complete waste of your time and money-do you stop going to movies? Some medications, maybe many medications, won't be right for you. The same holds true for psychotherapy which I highly recommend. Like a bad movie they will make you sorry you went (in this case to fill the prescription or to the therapy appointment). But the research is clear-some people may not respond to many medications before finding the one that works for them and there's no way to predict which medication will work for which person. So hang in there, try and be patient and most of all, try and be hopeful because you do have reason to hope. For some the period of trial and error can last longer than for others. But for most, the pay-off in finding the right medication and psychotherapist can be life transforming.
SC: On that note, thank you for taking the time to speak to with us. You've given us a goldmine of useful information.
XA: You're welcome.