Dr. Amador Cambridge Talk on Helping People W/ Mental Illness

good evening and welcome my name is Tom Martin and I am a board member of the Cambridge Middlesex affiliate of the National Alliance on Mental Illness before I introduce our speaker tonight I have a couple of announcements Namie as many of you know is a membership organization of individuals and families working to support and advocate for those with dealing with mental illness and the associated stigma around that we welcome any of you who would like to join with us in this effort information on Nami which has the Cambridge affiliate other affiliates across the state the state office in the National Organization is located on tables outside the hall I would also like to note that national mental illness Awareness Week starts on October 7th this was declared this week was declared by Congress in 1990 and so we usually try to have a program every year at this time to really highlight that mental illness Awareness Week it gives me great pleasure to introduce dr. Amador for many in this audience he really needs no introduction dr. Amador is a teacher lecturer and author basic Columbia University and the creator of the lis program and without further ado please help me welcome dr. Amador Larry and thanks to Nami Cambridge for bringing us all together tonight I'm going to talk about something that is very important to me from a professional perspective I'll tell you a little bit about my professional background so you have some sense of how I come to you tonight the body of experiences but also it's very personal I had a brother with schizophrenia who really is the one who gave me the title for this talk and for the book by the same name I'm not sick I don't need help how many of you in the audience have heard someone that you love or someone that you're caring for is a health care professional say I'm not sick I don't need help look around everybody and keep your hand up this saves me showing you a lot of research slides good for those watching this at home every hand went up I don't think any hand didn't go up this is a very very common problem I will talk about how how common it is in just a moment but just briefly a little bit about about myself I started out working as a nurse's aide back in 1982 and I was working in an inpatient psychiatric ward an emergency room later with the Tucson Police Department doing crisis work and one thing that I saw over and over again is that we would work really really hard to help people with schizophrenia bipolar disorder schizotypal of course psychotic illnesses that affect really well over four million Americans if you combined them all we'd help them get well we'd help them to stop hearing voices perhaps if they were suffering from grandiose or paranoid delusions to stop responding to or even believing those delusions through medication through support through psychoeducation all sorts of services we discharge them from from the hospital sometimes meeting them in a crisis situation on the street bringing them to an emergency room getting them into the hospital getting them from our perspective well and what do you think would happen they'd come back back then in the early 80s we used to call you miss eclis used to call patients like that frequent flyers today people refer to them I'm sorry back then we call them revolving door patients today the the euphemism is frequent fliers none of them really capture the tragedy of repeated relapse when someone relapses it there's some evidence that it may in fact be toxic to the to the brain that's not conclusive but certainly there's no question that it it's it's disruptive to the individual to the family to the person's attempts at recovery recovering a life with relationships with work whether it's paid work or volunteer work or returning to school so I come I come to this problem really from a very personal and professional perspective I want to start with the personal perspective and I'm going to talk to you about leaf it's a program that really grew out of my relationship with my brother Henry poor insight affects relationships whether you're a healthcare provider or a family member it affects your relationship so I want to talk about my relationship with my brother before I do so I have a sense of who's in the room how many are family members of somebody with one of these illnesses okay most hands going up how many are health care providers I'm seeing about a third of the room also healthcare providers any consumers in the room anyone ever been treated for mental illness I have good so not good sorry but good that you got help and I'm glad I got help I saw about forty five hands go up any law enforcement in the room I saw at least one police officer trying to sneak beverage in where are you raise your hand Dave that's not I do I hope she comes back in she was going to bring coffee in but somebody busted her hi am I asking about law enforcement because our law enforcement community often times have become the first responders the people who are filling the gaps in our health care system so this is a great group we're the stakeholders were these so-called patients were the family members who are trying to help our loved ones with the health care providers and we even have law enforcement here there's others as well but those are the main stakeholders let me talk about my brother and me about our relationship and how this problem of poor insight and how I handled it affected our relationship this is a picture of Henry and and me when we immigrated to Cincinnati Ohio from Cuba after the Revolution our father had been killed in in the Cuban Revolution that's a long story and we don't have time for it here but Henry being 8 years older than me was much more than a brother he was in many respects like an older sorry like a father a father figure he taught me how to ride a bicycle how to throw a baseball he taught me the value of insight and self-confidence he was a very self-confident popular talented young man throughout his life really up until the onset of his illness who was very well liked had girlfriends had jobs went to university but was always really humble and was one of those people who always when he had problems with other people would ask himself what did I do you know he really was a self-reflective insightful person and I'd like to think I picked up on some of that although some people would say I didn't I'm some of those qualities of self-reflection that's Henry looking in the window if you haven't figured it out and me driving our first car as 64 comment I think it was pretending to drive it we were very very close he would tell you if you were alive today and I I'll touch briefly on on his death it's not really relevant to the talk but it is in a way relevant to this whole notion of how lack of insight affects relationships he lost my train of thought there whenever I talk about is that that makes me pause for a moment he didn't die from his illness just so you know it was from an accident but it was a very telling event the way in which he died it said a lot about his character we were very oh what I was going to say is if he were alive today he would tell you javi is my hobby my little brother he call me javi for Xavier yeah he's my best friend and Henry was my best friend when he became ill in 1981 I was a senior in college and Henry was 29 he'd actually been ill for about five years we just didn't know it he'd withdrawn a lot of negative symptoms negative symptoms for those of you who don't know are things like an inability to express emotion a very kind of flat effect not using gestures the person seems to just not care about much anhedonia a loss of interest in things loss of motivation these are some of the negative symptoms we saw on my brother and we misinterpreted as being lazy not trying and it created tension in our family with my parents my stepfather my mother and and Henry and me and others first psychotic episode 1981 hearing voices delusional believed our mother was the devil her eyes were laser beams he would show me the lacerations on his arms there were no lacerations but he would show me what he saw which were actual you know cuts in his arm from my mother's laser beams and he got hospitalized I was elected to be the family member to deal with Henry because I was the quote psychologist in the family for those of you who remember if you went to college your senior year in college just because I was studying psychology I didn't know I was doing I certainly wasn't wasn't a psychologist but Henry and I were very close which is probably probably the other reason I was elected to to try and engage him I begged him to go to the hospital I tried to describe his symptoms we were all seeing he was disheveled he didn't smell good he was talking out loud to his voices he had these delusions he said no there's nothing wrong with me you're the crazy one not me leave me alone how do you think I got him to the hospital anyone hmm police now how did you guess that if ESP experienced I asked the same question in the Netherlands a couple of months ago I asked the same question in Turkey eight months ago I asked the same question in Taiwan about nine months ago and in San Diego just a couple of months ago and always I get the same answer I had to call the police to get my loved one to the hospital so poor insight recession affects relationships he would not go he could not go is really how I think about it today and I could not turn the other way he was getting sicker and sicker and more and more a danger to himself I won't go into all the details so he goes to the hospital he gets well he gets treatment gets well from our perspective he's not talking to his voices he's not delusional he's not paranoid he promises to go to the outpatient partial hospitalization program but it was called back then take his medicine except a psychiatrist a social worker and we came home after our family meeting he had been in the hospital for weeks Anki imagine a four week hospitalization nowadays or lucky if we could for days but for weeks he was there he came home where do you think I found his bottle of anti-psychotic medication you all read my mind this is a really phenomenal again all over the world over this country I asked the question I get the same answer we have a common experience here in this room and anyone who has a loved one or a patient or a client with these illnesses that doesn't understand they're ill these are the behaviors we see my reaction to it makes a big difference my reaction to do to it was to confront the denial I thought it was denial so I fished his bottle of I think it's a generic drug now haloperidol it's the first anti-psychotic after Thorazine and I picked it out and I said you know why aren't you taking this and he said I'm not sick I don't need it so what you promise you take it he said well I I needed it then but I don't need it now and that started seven years of arguing you know that you're sick in him saying no you're the crazy one that's like I used to say the psychiatrist had brainwashed me and there's always an element of truth to any delusion but not that I was brainwashed but I certainly had really been trained to think of approaching him in a certain way which was with the medical approach which is you have a diagnosis here's the prognosis here's the treatment take your medicine and this next picture which is the cover of the book I was talking about best describes our relationship it's not much of a relationship is it during the first seven years of his illness when we had no relationship he or it was an adversarial relationship a lot of fighting he was homeless for a while he left the house in anger he was hospitalized about four times a year okay almost 30 times perhaps more than 30 times I lost count so hospitalized a lot most of the time I'd say about a third of the time actually involuntarily and the majority of the time voluntarily I put that in quotes I say voluntarily because I would or the police officer by my side would say to him you can sign or the psychiatrist in the emergency room you can sign yourself in or we're going to admit you in volunteer early so you practice common sense and he signed himself in but he wasn't a voluntary patient he never understood that he had a mental illness during this time I was training to become a psychologist I started picking up some skills which I'm going to give you more than an introduction I'm hoping we'll have some time to practice some of those skills that that became the leap program and the first thing I learned was to shut up stop telling my brother he was sick to shut up and start listening pardon the harshness but I I needed to hear it said to me that way I was talking to his supervisor about a patient and I said hey can I talk to you about my brother and I'll never forget this and he said once you just shut up about this seven years you've been telling it me sick is it has it made a difference no what's the result he hates me I mean we went from that relationship to no relationship so I not only stopped telling if he was mentally ill I promised him I would never again tell him he was mentally ill so now what is where does that leave me right well we're going to come back we're going to come to that we're going to take a little detour in a moment before we get to what do you do if you're not going to be arguing with the person and by the way that one of the definitions of insanity is you keep doing the same thing over and over and over again expecting a different result I was insane for those seven years right keep that in mind as I try to teach you some different ways of approaching people whatever relationship look like the last 18 years of his life well in the last 18 years of his life I stopped telling him he was mentally ill I started listening to his goals his desires I engaged with him with a really different way of communicating let him take the lead I convinced them to take a long acting therapy a long-acting injectable treatment so when he missed an appointment I knew it and I could talk to him and he was hospitalized one time in 18 years voluntarily and this is what our relationship looked like you know the love that we have always had was always there but it was buried beneath years of arguing over whether he was mentally ill or not so if you leave here tonight with nothing but that please consider if you've been trying for three six nine months three six ten years to convince a loved one or a client or a patient they're mentally ill and they either overtly say you know you're wrong or they become very docile and submissive and you keep thinking I don't think they're being honest with me about taking the medicine in other words they've gained common sense I'm not going to tell my doctor what I really think because if I tell her or him what I really think I'm going to get another lecture about being mentally ill if you're seeing that you might want to consider doing things differently it took me a long time to get there the 911s is in the news all the time poor insight in schizophrenia and bipolar disorder is very very common I'm using the term denial in quotes for a reason I'll get to it in just a moment this is a picture of Margaret Mary Rae does anybody remember who Margaret Mary Rae was Margaret Mary Rae many of you know as David Letterman's stalker this is many years ago now but we still remember her and it's really sad that her legacy is that she's remembered really because of a symptom of her mental illness she had the delusion that she was married to the late night television host David Letterman she would be in his in his Greenwich Connecticut mansion when he came home she took his car once she got lots of jail time never got treatment never got consistent treatment she died like many many people with these illnesses died she died from suicide now I don't say people commit suicide in the context of serious mental illness I think the research shows that my experience has convinced me that suicide is a consequence of the brain disorder not a knowing and voluntary decision and one's life so I don't like to use the phrase you know Margaret Mary committed suicide rather she died from suicide never understanding never believing she was mentally ill ended up in our criminal justice system like so many people now we don't know the details but I must have had 20 interview requests after the shooting in Colorado and then what do we learn this is somebody who was in treatment for schizophrenia we don't know the details yet so I'm not going to infer anything more than that but these are so common these stories the first case I ever worked on was that of Ted Kaczynski this is Ted graduate graduating from high school on the left on the right is when he was arrested I never forget seeing that picture of his arrest and thinking this kind of looks like he probably is mentally ill I was one of six experts that diagnosed him with paranoid schizophrenia the judges own expert agreed with all of us Ted wanted to fire his attorneys because he said I'm not sick and I am NOT going to let you present evidence of a mental illness that I don't have even though he understood that that was probably the only evidence that would have saved his life because he had a journal where he described the bombings for those of you who don't remember the Unabomber who has a name Ted we don't remember Ted's story Ted was turned in by his brother David once David recognized the manifesto that that Ted got published after one of his terrorism threats long before 9/11 tecna's insky had shut down our airline system for a day and if you remember that because he threatened to bomb the airlines again 25 years the FBI couldn't find them it took his brother took a family member to to really stop the tragedies that his mental illness was causing not only murder but maiming people and terrifying people but it was mental illness it is mental illness the judges own expert agreed with us this is not one of those battle of the experts stories and the government once the judges expert agreed made a deal and said you know rather than seeking the death penalty which is what they were doing to settle the case because they probably would have had a harder time getting the death penalty so you know we look at the headlines and unfortunately that story gets out a lot more than all the other wonderful stories about my brother's 18 years of recovery when he died he had a girlfriend he had part-time volunteer work he had an amazing routine that included going to a clubhouse and spending time with people with serious mental illness even though from Henry's perspective he didn't have a serious mental illness but they were his friends you know all those stories of engaging people in treatment who understand their ill and those who don't understand their ill don't usually make it to the headlines but those are just some illustrations and everywhere I go I'll often pull stories from the local press because this is this is everywhere it is not unique to Cambridge to Massachusetts or the United States so I have a question for you for you all about denial of illness would you agree with me that denial impairs common sense judgment about the need for treatment if you agree with me if the answer is yes raise your hand or say yes say yeah yeah okay I completely disagree if I come over here and take the perspective of Ted Kaczynski Margaret Mary ray Henry Amador my brother and the countless patients that I've treated over the years who don't understand they're ill it's common sense to refuse treatment then put it to you a different way if you do not have diabetes you're certain you don't have diabetes let's forget about how you got to that certainty that you are certain you don't have it would you inject yourself with insulin raise your hand anyone and not one hand is going up why not you don't need it it could hurt you couldn't it what else so in your mind you're certain that you don't have it but why else wouldn't you inject yourself with insulin one more what I haven't heard that one before okay I'll ah I hope so what else it hurts what else hmm fear fear of what what would happen if you injected yourself with insulin anyone here medically minded you worry about contaminated needles but what else you could die thank you that's the answer I was looking for I'm sorry you could get hurt insulin shock you'd go into insulin shock the reason I wanted to elicit that particular answer along with you don't need the insulin it could hurt you it could actually kill you is because that's what I've heard from my patients over the years about antipsychotic medications they hurt me I don't need them they cause the symptoms anyone hear these kinds of reasons for not taking medicine it could kill me they're addictive is another thing we hear so if you don't understand you're ill if you don't believe you're ill it is actually common sense to refuse treatment right so you have to find another reason to accept treatment not it's not because you understand you're ill I've been using the word denial are we dealing with denial we're not in most instances we're dealing with another symptom of these brain disorders right the brain is used for many things perceiving thinking making judgments also assessing our own state of well-being and in fact what we're probably dealing with is a syndrome symptom rather called Annis Ignacio this is a very hard word to say I didn't coin the term this was coined by a Hungarian psychiatrist in 1919 working with Charcot in France Charcot who had trained Freud his name the sect this neurologist rather was Babinski you may have heard of the Babinski reflex he scraped the bottom of the foot and the toes curl up same same neurologist and he described patients for example who were paralyzed in one side of their body and they didn't know it now I did a one-year neurology rotation at Beth Israel Hospital in New York City and I saw this I saw much more than this I saw a woman who was blind due to cortical damage to her occipital lobes and she didn't know she was blind unbelievable conversations I tried to show her that she was blind and she would accuse me of turning the lights off in her room when she would bump into things it's a very very severe unawareness we're going to come back to this how many of you have heard this term before raise your hand wonderful more than half so things are getting better there's a big gap between science and knowledge public knowledge and professional knowledge when I started my research career in 1989 actually was in 85 but as an independent researcher I was involved in the revision of the DSM so this is I can't do math 1989 is how many years ago 14:00 I wish I think it's why Matt I think it's 20 23 years ago or something yeah and we developed a scale my colleagues and I just to measure insight back then I just want to give you some perspective very quickly back then when I was interested in this in this subject because it might experience with my brother and with so many patients I was trying to help who kept coming back to kept throwing away their medication who kept fighting with their family members I looked at the research and I found almost nothing there were about 10 studies only 10 studies looking at this big problem and and they suggested that a majority of people had problems with insight so we started doing research we also published guidelines for doing research today there were close to 300 studies so during the course of my career we've gone from 10 studies to close to 300 and I want to tell you about one of the earlier studies the first one that that we did just looking at how common the problem is because it's been replicated over and over again just as an illustration this was the dsm-4 field trial study we looked at people who were in their first episode people who were sick for 10 years 20 years 30 years all over the country into international sites what we found was that basically nearly 60 percent were moderately to severely unaware these first two on the left slices of the pie right 32 percent were unaware and 25 percent were moderately aware only 40 percent were aware they had any kind of problem a nervous condition schizophrenia we gave them credit for awareness if they said things like I've had a nervous breakdown we also saw that there was a lot of unawareness of signs and symptoms of the illness those findings have been replicated over and over and over again in there's 300 studies roughly 300 studies in the last 23 years turns out is an interesting bit of research I just share with you there's other problems with insight or awareness turns out that if you look at people with schizophrenia who have tardive dyskinesia that movement disorder that the older medications in particular can cause they don't know it so they don't see that their arms are doing this or that they have perioral grimacing they can look in a mirror you can do a rating scale and that's what these investigators did why would half of all patients with schizophrenia not see a movement disorder it's not starting to sound like denial when I first read this research starting to sound like something very different but again here's the headline this is a very well replicated finding in the scientific literature now for the last 20 plus years that approximately half - more than half of our patients with schizophrenia we find this also in bipolar disorder don't believe they're ill and the unawareness goes on for the lifetime of the illness some people do develop true insight it's very rare or true awareness I'm going to start using the terms awareness and unawareness now right because denial suggests that you actually know something that you're just suppressing the knowledge when you're unaware you're really just unaware okay what's the problem with antipsychotic medications what do you think I'm going to say about that side-effects well you can change the dose or switch medications and usually resolve that problem what would you say is the biggest problem yes patients take them every day in somebody else okay yes they don't work well enough for some people the response rate hovers around 70% for four pretty good symptom management and about forty to fifty percent with a very good response so I might disagree that they don't work very well for a minority but they work fairly well for symptoms right they're not they're not the Silver Bullet but they're an important part of the treatment right yes so the problem is I'm going to paraphrase and tell me if I'm right basically that that there's a lot of variability that people respond to the medication is differently depending on how they metabolize this is such a big problem it's so right in front of you that no one's said it yes thank you they don't take them they people with schizophrenia schizoaffective bipolar and related disorders do not take the medication so we can do all the efficacy studies in the world the FDA can approve these medications for these conditions but if no one's taking the medications they're useless right how bad is the problem this study finds that between 50 and 75 percent of people with schizophrenia exhibit complete or partial non adherence in any given time just look cross-sectionally at the population or big samples of people on these drugs think about that number 50 to 75 percent if you're only taking some of the medication what happens when you only take some of your antibiotics you don't get well which is what people do poor adherence is a problem across a range of medical disorders but in fact comparative studies find that it's far worse actually in people with schizophrenia and bipolar disorder than it is in other medical conditions I hear this all the time well you know poor adherence or quote compliance is a problem with all sorts of prop issues and medical conditions like hypertension yes people forget to take their pills but nowhere near as much as this nowhere near as high and the consequences aren't the same when somebody with hypertension or heart disease forgets to take their medication they don't end up in jails and prisons or dying from suicide or homeless consequences are very different so this is a big public health problem in a very tragic problem in my view for those of you in the room for our prescribers prescribed medication if your patients are like most people with schizophrenia I'm just going to talk about schizophrenia now within seven to ten days of writing your prescription only one out of four will be taking the medication within a year half of the people you've written that prescription for will likely be off the medication within two years three out of four so we have really a major problem here in medications indicated if medication is helpful most people with these illnesses like my brother don't take them for good reason if you take their perspective they're certain they're not ill so why should they take them so what do we do it could be that they're feeling better that's not what's predicting these numbers I'm going to come to that in just a moment that is certainly one thing that does happen people feel better and they say okay I don't want to take the medication anymore but let's talk about what predicts good adherence okay the biggest predictor if you look at all the research on this of who will take medication and take it reliably is guess what awareness of being ill most of the studies still use the word insight I don't like insight because it makes it sound like we're studying denial or not it's the absence of a symptom the absence of Annis Ignacio could you try repeating it after me once one more time I know sick nausea very good reason I'm doing that is that people will tell me I was talking to colleagues about that symptom but I can never say the word it's really enough I wish I could give it a new name if you have trouble pronouncing anise Ignasi I just say unawareness the unawareness symptom and if you don't believe it's a symptom yet I'm going to provide you with some more information and you can decide for yourself so if you know you're ill one of the best top two predictors if you look at all the research all the reviews of studies meta analyses for those of you who know about research and meta-analysis is actually taking 50 60 even more studies and re analyzing all the data and pulling it together and they find if you know you're ill and you have schizophrenia you're likely to take your medication reliably you're in that mine or minority that 25% that takes the medication reliably but we have a problem because we know that half of our are people with schizophrenia don't take don't believe they're ill and bipolar disorder so what's the other predictor do you think of who takes medication reliably so if they have a relationship with somebody who they care about my brother Henry had a relationship with me and he loved me very much and he cared about me and we had seven years of fighting and anger and a paranoia on both our parts I wrote a column for schizophrenia magazine where I talked about violence and how I used to lock the door at night when he was psychotic and how I how ashamed I felt locking the door against my own brother who had raised me but protected me so that it doesn't fit with my experience and certainly not what the research shows you're on the right track though yes good communication with someone you love okay I like that I think you're heading closer to my next bullet point whether it's right or wrong you'll decide anyone else before I go there here okay being listened to you've read my book right yeah okay not anyone who's read the book communication and Trust with the provider you actually hit upon it most of the research show has been done with therapists caseworkers and prescribing psychiatrist nurse practitioners so most of the research is in that area so that's what we can talk about but I can tell you that there's additional research not as much it can be a family member it can be a police officer of a wonderful story if we have time of a police officer in in Dobbs Ferry who got somebody into treatment whose family convinced this police officer to do conference calls with me to learn how to use some of the leap communication tools to convince this young man to get into treatment because this young man trusted this this officer it can be anyone and what's the nature of the relationship it's it's a relationship with somebody who listens to you without judgment well that sounds easy dad I'm not mentally ill you and Mom are the crazy ones the problem is that you're trying to poison me and kill me how do you listen to that and not react and not judge it how do you respect that person's point of view sounds crazy right you can do it I'm going to teach you I'm going to show you a few few techniques a few tools but it's vitally important if someone really feels are being poisoned by their parents if somebody really feels really believes they don't feel they are certain but the CIA is watching them and so they want to put paint all the windows in the house black I'm working with a family where the mother has barricaded all the doors creating a really dangerous situation with furniture because of the people who are against the family and trying to steal their valuables there's so many stories in this room right how do you respect that person's point of view without agreeing with it without making it worse right we're going to talk about that I'm going to show you some some some some tools and that relationship is with someone who not only listens to you without judgment not only respects your point of view but you know that that person thinks you'd benefit from treatment how do you get there this is by the way the most important point this is what leap is aiming to do it's to build a trusting respectful relationship where my opinion that the person ought to consider my recommendations starts to matter because I have first listened to their reality their convictions and I haven't dismissed them I haven't told them they're crazy I haven't told them they're wrong I used to tell my brother when all he said he said all I need is a girlfriend a job and go back to school why isn't that crazy I want those things I thought it was I thought it was a part of the term but you know I was young and didn't understand stigma very well and I used to say to and that's crazy Henry you're putting the cart before the horse you got to get well before you going to get any of those things I changed my tact and it changed our relationship and it changed his ability to accept treatment and and it wasn't just me it was also his treatment team so what causes poor insight my training was psychoanalytic originally in the 80s and we heard and read lengthy case descriptions of how this is psychotic denial as defensiveness this person really knows deep down inside he just won't what admit it so almost like it's almost like interrogating a prisoner isn't it just admit it you know you're mentally ill that's how it feels when I've talked to people who have been on the other side of this and they say I feel like I'm being interrogated by my doctor by my caseworker by my family members did you take your medicine etc we've done studies other people have done studies we can measure how defensive somebody is believe it or not there are some pretty good measurements of how defensive somebody's personality is and when you look at those measures and correlate it to the measures of illness awareness does the person understand they're ill they don't correlate very well so that's not proof but it certainly suggests that that's not what's predicting unawareness it's not defensive miss people with or without mental illness get defensive everybody does so we'll deal with defensive miss but that's it you gotta understand the root of the problem because if it's defensive 'no sand denial you'll do what i did for seven years with my brother henry and keep doing it you try to break through the denial and break through that barrier of denial so that he gets to the knowledge that he has deep down inside well guess what it's not there not if it's antacid nausea and not if it's unawareness there is no knowledge of being L as implausible as that sounds so we've looked at other things I'm going to jump over this and and get right to neuropsychological deficits in in 1991 my colleagues and I at Columbia University working in the skits research unit wrote a paper at where we reviewed the literature and there was only about a dozen studies back in 91 and we said look this is a big problem a little bit of research out there shows this is a huge problem it impacts course of illness hospitalization risk of suicide inability to accept treatment right why aren't we studying this and then we set out guidelines for measurements and and then people started doing research and one of the first studies and we also proposed the idea that maybe this is a symptom of the brain disorder like what one more I didn't hear you very good and no sig no SIA and the field jumped on this we've about fifty studies now showing links to neuro psychological dysfunction brain imaging showing a reduced white matter in the in the frontal cortex all sorts of findings that point to among other things primarily executive dysfunction I'm not going to review those slides because I want to get to practical communication tools and listen if if this feels in any way offensive like I'm saying that someone's belief they're not ill is just a symptom I hope you'll give me the benefit of the doubt my goal here is not to diagnose anybody from the stage I can't do that and and opinions do matter and if anything that's what the whole focus of leap is whether it's a symptom the truth or something in between understanding and respecting somebody's opinion about their life and themselves is the first step to a relationship and without a relationship there is no treatment there is no recovery in 1999 Michael Flom of University of Iowa and I were asked by the American Psychiatric Association to chair the revision of the text in the DSM is anybody not know what the DSM is okay the DSM is the Diagnostic Manual that that every mental health professional uses in this country and and in many countries worldwide so it's it's our diagnostic Bible if you will and dr. flomm and I were asked to make the text reflect science not opinion right this is not the diagnostic criteria this is everything around it the book is this big there's a lot of Education in the book like how common is is the disorder what are the Associated features that you'll see so this is a of putting together a team of experts from around the world around this country and sending them at that time I think it was about 60 articles on lack of awareness and asking them to put together a proposal what should we say in the DSM about poor insight right at that time we were still using the term and here's what they came up with the majority of individuals with schizophrenia have poor insight regarding the fact that they have a psychotic illness evidence meaning research evidence suggests that poor insight is a manifestation of the illness itself it's a little wordy right but it's a symptom of the illness or a sign of the illness rather than a coping strategy like denial it may be comparable to the lack of awareness of neurological deficits seen in stroke termed anise Ignacio thank you this is an important symptom this is what this peer review process concluded this symptom they're calling it a symptom for 14 years 13 years now this has been recognized as a symptom and you'll still talk to experts even experts at the American Psychiatric Association who are talking about denial even though in their book I'm not a member of the APA cuz I'm a psychologist even though in you know I'm saying it's their book the peer review process indicates that this is a symptom I'll come back to this in a minute but let's just read what what the consensus was this symptom predisposes the individual to the very first thing that this group found was non-compliance with treatment and we've known that for 25 years 30 years and it's also been found to be predictive of higher relapse rates increased number of involuntary hospital admissions a poor course of illness and among the thing is measured here under poor course of illness quality of relationships with loved ones are poor inability to work return school poor functioning and a poor course of illness so this is a very important symptom just unawareness of illness and in the dsm-5 there will be I believe more language about this and that's even stronger but we'll see what the process ends up with because there's a lot of controversy with the dsm-5 so let's talk about anis Ignacio real real quick because we're really close to talking about using some communication tools to engage people in treatment who don't understand they're ill or even people who do understand they're ill how can we communicate with them more respectfully and not judge judging them and give our opinions in a way that's respectful but first let's talk about anis Ignasi the first patient that I evaluated I'll never forget this is a man who had suffered a stroke about five days before I saw him he was awake he was alert when I interviewed him I knew he was paralyzed on the left side of his body yet hemiparesis and the stroke affected also the frontal lobes of his brain not just the motor area for those of you who know about strokes so it also affected executive dis functioning I asked him can you move your arm he said sure no problem okay he did move his arm I asked him what happened and he said and I just didn't feel like it and it's interesting at that moment I had my first connection to my brother I remember sitting at the edge of his bed for hours a few years into his illness trying to show him his symptoms of illness not unlike this neurological patient I was trying to show this man that he was paralyzed I asked him to move his arm he couldn't move it and what does he say I just don't feel like it I was trying to show my brother his impairment I said Henery he used to work he used to have friends used to have girlfriends in the last three years you haven't you haven't done any of those things don't you think something's wrong right I'm trying to show him teach him he has impairments deficits and do you know what he said to me I just don't feel like it same exact thing and the worst part for our relationship as I believed him I remember feeling angry and like he wasn't motivated and I had a deal with my mother crying and complaining about Henry that he's not trying and it was a really vicious cycle because I didn't understand but let's go back to this neurological patient so I asked him actually did this three times but I'm just going to tell you the last two times so I asked him to move his arm he said he didn't feel like it I asked him could you try one more time please I was in training and I said my grade depended on it I'm sorry healing to him as a young trainee because he didn't want to do it he did not want to do it he was getting really kind of frightened looking so he agrees he can't move his arm I asked him what happened and he didn't want to tell me so I had to keep reassuring him you know it's okay you know whatever the reason is you couldn't move your arm you know I'm not going to judge you I forget what I said so many years ago like 1987 I think 88 and he finally said you've done something to my arm when I asked him what he thought I did he said either we we had put something in the IV that paralyzed the arm which actually would be impossible because it's an IV so go all over his body would paralyzed everything or that I had somehow restrained it with with straps right so this is a very very severe lack of awareness of in his case neurological deficits paralysis the belief that he can move his arm that he's not ill that he doesn't have these deficits persisted despite the evidence didn't I show him evidence and he explained away the evidence with confabulations that's a technical term and when my brother said to me I don't feel like getting a job or having friends or a girl or a girlfriend it not only contradicted things he said at other times but I really think it was a confabulation that as I tried to point out the ways in which he was wrong and I was right that he was sick what it triggers is him trying to find some explanation well it must be that I just don't feel like it not a conscious process it's a brain reflex right give a tell a story and say oh wait wait wait it didn't happen that way you ever do that that's a confabulation it's a memory gap and you and as you're telling the story you fill the memory in with with the confabulation that's an everyday confabulation I've had the the privilege and and and the luxury because it gives me an understanding I wouldn't have had otherwise of interviewing probably oh well over a thousand people with unawareness of illness so I have a really good sense and working in clinical practice with people that's who get referred to me who don't understand they're ill for four decades I want to give you a little feel for what it's like to have this first question is anyone in the room currently married okay I need a volunteer you don't have to be happily married just married can I pick on you yeah would you mind walking to this microphone over here for a second and tell everybody your first name only pleased Cecile Cecile and Cecile how long is it that you've been married third evil 30 years 30 years I'm going to ask people not to laugh please and I'm going to ask for your patience because I was going to pick Cecile even if she didn't volunteer actually I did please don't laugh actually I did pick you didn't I yes ha what's the name of the man that you believe you're married to Jack Jack if you have children together yes that's what I understand how many five five children and I put again ask everyone's patience we'll try to do this very quickly are you here with anybody Cecile yes who you here with my sister and your sister raise her hand um I think she had to leave because she was getting dry eyes that's interesting yeah so she's not here no I think she may have gotten cold feet cuz your sister and I spoke before this um when she heard that Nami was sponsoring this top she wanted you to come did you want to come to this yeah bring her - she bring you we agreed to come together right and she contacted me because it turns out that you're not in fact married - his name is Jack right in fact I have right here in front of me something like seven restraining orders filed against you to stay away from Jack and his kids how many kids is it that you believe you have a jack five five right actually Jack and his wife have three children is what the papers say here so you you appear to have a delusion you're smiling and taking the seriously my heart is really beating yeah alright I'm sorry to do this in such a public place but your sister is really really worried about you because Jack and his wife have lost all patience and they are going to press charges the next time you call show up or try to contact their children would you like to see the restraining order second yes give you evidence have a look now I'm going to step out of the role play okey for those of you who are wondering this is a role play okay but let's take let's take close to it though okay you look at that have you seen restraining orders before no I haven't so you wouldn't know what they look like yeah okay yeah those really are restraining orders they are absolutely legitimate restraining orders you page through them okay and you see them you give them back to me now that you've seen these does that make you question if maybe I'm telling you the truth that you're not married to Jack it would make me wonder a little bit but it would make you wonder yeah really yeah if they've had a who proposed to who in my marriage yeah Jack proposed I never happened that's what you're telling me I could convince you with six pieces of paper that maybe that didn't happen no oh no I just want to be sure talking about the same thing remember the birth of your five children I love them yeah I didn't happen okay yeah that would be hard to believe here's the problem we have we have very limited time here we need to keep this moving and I apologize is a very unorthodox way to do an intervention I don't typically believe in interventions the Cecile's family was really really really worried and frantic because she's about to get arrested and lose are you working right now no that's my understanding as well that she's not been able to work and but she's about to lose her freedom she's about to get arrested because she won't stop calling Jack and Jack's family and kids so the good news is there is a police officer waiting outside with an ambulance and we're able to transport you to a hospital we have a bed for you would you go No why not because I don't believe you I I have a lot of evidence that I'm would you like to call Jack sure pick up the phone and call Jack let's pretend okay hello are you calling or me you're calling me and I'm Jack hello hi hi jack I've got some problems here so send you to jail but we will don't call here again I agree to this one phone call click that really happened your husband's voice on a real phone just said that to you does that change anything well it would change how I feel inside I'd be crushed but I still have wedding pictures and all kinds of stuff phurba in our home you can't go there you can't go there ok you need to leave the room right now I'm sorry so we can get on with this and and there is an officer waiting just out I walk you to her if you like and she'll escort you now you haven't done anything to endanger anybody or now that you're not a danger to anybody else or yourself so she can't force you to go so shall we either walk you to your car or at the very least she's going to walk you out of the building and she'll show you the ambulance and you can make a decision for yourself ok are you ready to go oh yeah you have your bag here or I have a purse here ok so let's just do that real quickly so we can get on with the presentation ok stop right there Cecile and I walk out and there is a police officer yeah and there is an ambulance when you get to the door that the officer is really nice and she says ma'am why don't you go get some help the doctor seems to really be worried about you your sister was out here a few minutes ago she was crying she left because she didn't want to stay here for the intervention why don't you go and get help what do you think you'll do I guess I'll go and get help because of all this oppression what are you gonna get help for well I'm just gonna try to make you stop convincing me that this is true so you're going to get help for the interpersonal conflicts that you're in not Burger Mental Illness no mental illness no so you go to the hospital and the doctor says I see these restraining orders I heard from dr. Amador and from your sister who called earlier I know dr. ometer is not your treating doctor but but he was willing to help your sister out your family out and and I heard from this man who you've been stalking and his family and they seem like really nice people we'd like to admit you are you up for that no okay well we can't keep you against your will all right so you know sign yourself out AMA that means against medical advice so you sign yourself out na what do you go yeah I would go home she goes like home what happens to her she's arrested now she's in the criminal justice system he just violated a restraining order the judge gives you a choice to seal you can go we would you know we're coming up in a weekend okay we can't do it your arraignment till Monday you can spend the next four or five days in jail or you can go to the hospital and get treatment what's your choice I need to know right now my dockets full man hospital then okay this case is adjourned I will wait two weeks for a report from the from the hospital and thank you to the public defender you may leave the courtroom so you leave you go to the hospital they offer you anti-psychotic medication do you take it yeah so you don't take it so the doctor and nurses work with her for three four or five days and they finally sit down with they're very sincerely with a lot of compassion and say to seal if you won't take your medicine we're going to tell the judge and they're going to end up back in front of the judge soon and likely heading towards jail for violating the restraining orders are you sure you won't take this medicine then I'm going to take it and she takes an anti-psychotic medication she's a compliant patient she's a hearing to the medication it's really important to us for us to give the report to the judge that you've developed some insight and that you'll accept our recommendations for treatment when we discharge you in two weeks can you can you accept that maybe you have a delusional disorder maybe it's schizophrenia is what we think it is and accept our referrals and I'm going to say yes to get out of the hospital okay so we give that report to the judge she says yes she's on probation and what do you do when you leave the hospital you've been able to talk to your kids or Jack the entire time you've been in the hospital I mean you talk to your sister and friends and other family members and they all are saying what I'm saying what are you doing to leave the hospital after two weeks I wouldn't have any place to go I don't think I will I go back to my house again go back to her house her judgment is incredibly poor you get her and you'd get arrested again Wow do you see how this happens let's fast forward six years do you think you might eventually learn to not go back to the house yes because you spent some time in jail the second time by the way and you learn to say things like I have schizophrenia I'll take the medicine maybe you take it or maybe you empty the capsules maybe you hide them right maybe you're like 75% who don't take it or take only some of it right unless you're on a long-acting treatment would you after those six years of not being able to reach your children not being able to reach Jack finally come to terms with this denial and understand that you're mentally ill and that you were never married to Jack and never had five children I guess I'd give it up out of being worn out you'd give what up the idea that I was married so let me ask you again are you telling us that if we this is hypothetical five six years down the road you think with those experiences you would come to believe that the proposal that Jack made to marry you the courtship never happened now okay yeah see it's interesting at one level you're saying yeah I've come to believe a mentally ill in a way I think it's a wish probably okay you'd like to think that you could be convinced you I'm not get nothing in the world that I'm going to be able to show you prove to you that you were never married to Jack and you didn't have your five children with him is there no let's go ten years down the road no but you may behave in ways that make it look like you know you're a patient with schizophrenia mm-hmm to get along to just get on with life you can move on yeah and it's an incredibly lonely place right let me ask you briefly this is a roleplay you immediately offered and thank you very much can we thank her and you don't have to answer if you don't want to but you I was going to ask you did you have any emotion emotional reaction you started out by saying your heart was racing yeah what were you feeling well I was feeling what if someone told me that everything I believed wasn't true I just did so what were you feeling as I was doing that to you like I was having my life taken away what about some emotions betrayal like why would Jack not take a phone call from me why does he have say as another wife was this Kevin crying himself to sleep you know all these things it didn't make any sense I mean mainly like parts of me were dissolving parts of you were dissolving yeah we opened it up to other people did you want to add any other feelings you were having okay thank you very much thank you hence the seal when you leave please call Jack okay I don't know where your kids are after all home or not but call the ones who aren't at home right anybody else what were you feeling it is you put yourself in cecile shoes any emotions yes total fear what else good paranoia right and she started to talk about it like why would he be doing this what else anger anger at who anger at me um do you know how hard I worked to get my degree and how hard I work to help I'm trying to help this damn woman you're angry at me so this is a little bit of the things that we go through as healthcare providers I used to get angry actually I wouldn't say that loud but I feel it like you know what it's Friday I've worked a 70 hour week in the hospital and I got another person doesn't think they're ill anger at me anger at Jack anger at her sister right any other feelings really bad about herself yeah yeah yes terror loss of her identity the way you were saying you would that was the primary thing it seemed like you were experiencing hmm loneliness yeah and what's the feeling usually linked to loneliness feeling emotion sadness I hear that a lot anybody feel sadness in her shoes okay let's stop there I want to move forward from this very lonely frightened sad experience I've tried to have us have together and it's just a role play this is what so many people with unawareness of illness with NSTIC knows yet feel this is the position they're in the world is against them they're all alone with the truth of their reality that nobody agrees with and the people who love them most are often their worst enemies myself being that that person for seven years with my brother not because we want to be enemies we're trying to help I was trying to help her but look at the emotions look at the feelings I was I was eliciting that's just a flavor of what it's like let me say one more thing the belief that you're not ill that solid so like paper it's not malleable okay it's that solid folks you can't change it in somebody with unawareness which turns out to be when someone says they're not sick for three six months and years and they don't it's a symptom my brother blasts face-to-face conversation I had with him six months before his death I asked them Henry people always ask me do you believe you're ill and he laughed he's at all Harvey I got schizophrenia just like Cecile learned to say I said now Henry come on it's you and me I was driving him back to his to his home after a family dinner I was visiting him in Arizona actually was about to move to New York to live near me and our mother had passed away nine months before so I was asking him this and he laughed and said yeah I've got schizophrenia I said Henry it's you and me come on what I mean do you really I mean if you do it that's okay with me and say that's great that's okay with me but that's certainly not what you told me before and he said now I don't there's nothing wrong with me I said yeah I thought that's that's what what you would say see I didn't say that I thought that's what you think I said I thought that's what you would say it's more respectful communication subtle but it's more respectful then I said why do you take your your I can talk about it's a generic drug Prolixin shots why why are you doing that well you and mom-and-pops think I should do it mom and pops are Betty and James who ran the board and care he lived in I tried to get him into some really really really nice supervised supported housing situations and he would sabotage it and leave every time because he wanted to live with Betty and James who were two people who loved him so what was my brother saying in shorthand he took medication for 18 years because of what relationships and one of the things that I say over and over again is I never won on the strength of my argument that he was mentally ill and needed treatment just like I will never win with Cecile on that argument on the proof I want him the strength of my relationship but I respected him I didn't judge him I conveyed frankly the kind of love if you're a professional you can still do that you can still be your patient your clients friend people who say I can't I was trained never to be friends with my patients that's inappropriate that's crossing boundaries and the analogy I use is anyone have friends at work yeah that you don't invite home for the holidays or family vacations right you have boundaries with your friends at work we can be friends with our patients with our clients and if you're a parent you can be friends with your son or daughter by the way especially if they're an adult and you can still be the parent yeah that's what we're looking for is to create those those relationships so when dealing with a nest egg nausea the doctor knows best approach isn't going to work because there's no collaboration collaboration is a goal it's not a given right I can't expect Cecile to be grateful or receptive or adherent to my advice right what I can expect is that she'll be frustrated and angry suspicious and not take my advice not take medication not accept housing not accept programs and either overtly refuse or learn to secretively refused to do that one quick word because I I just wouldn't feel right if I didn't talk about this both the research and my clinical and personal experience very clearly in my view point to long-acting therapies as being indicated for for those people who don't believe they're ill and actually for others I call them long-acting therapies why in the world the only company in the u.s. that launched a new generation anti-cycling therapy shows ads with needles in it with daisies coming out of it and focuses on the needle needle needle needle and I consult to that company and I when I first saw that ad I said please don't run that and focus on the injection why are we focusing on the injection that's not what's important what's important is it's long-acting and we have 100% confidence if the person is taking it we know which changes our interactions with the person if you look at the research and there's more than this compared to oils only 17% on average tend to drop out of a long-acting therapy that's 83% on it the numbers flip and it's common sense where my brother would miss an appointment which is rare I had permission to be contacted and I would get get on the phone and I would just have a chat with him and I wouldn't call him to say why didn't you go to your appointment he would eventually just tell me I didn't go to my appointment is that the reason you're calling I said well yeah it's the timing of the reason what's wrong are you are you okay I didn't push it oh oh I know you really get worried about me if I don't take it that's how it works it's like a smoke alarm for health care providers when you do if you're a psychiatrist especially you've got your 15 minutes of fame with your patient once a month or once every three months you don't have to ask them so are you taking the medication how much are you taking you already know you can start talking about things that matter to the person so how you feeling what's going on with your friend Darrell you were telling me about or your boyfriend or the job that you've been trying to get it these therapies actually change the relationship by eliminating the suspicion and the humiliation if you ever checked to see if somebody swallowed a pill very humiliating imagine I'm working with Cecile inpatient unit Cecile takes the pill which open your mouth please all right lift up your tongue please do it right now lift up your tongue okay thank you now to drink a little water thank you how'd that feel you're laughing but how did it feel yep humiliating right that's gone when you use long-acting therapies they improve relationships actually people don't usually talk about that so if you with leap or any other method convince someone who's not taking medication who needs it the premises the person would benefit from it to take medication please look into research long-acting therapies and there's more coming becoming available soon so we have more choices yes I'm going to stick with schizophrenia right now but yes it to the extent that the antipsychotics that are used in other mental illnesses form yes yeah I'm going to skip over this in the interest of time how much time do we have left we're good but basically if you look at what works this is 20 years of research review that these authors did it's in the American Journal of Psychiatry I'm very sorry the slides have been cut off at the bottom of the slide is our website and I'll give it to you at the end of the talk where you can if you register at the website you'll get free chapters from the book I'm not sick three free chapters you'll get subscriptions gets a premium magazine you'll get access to there's videos and things there's lots of free resources there so I hope you'll go there and and have a look I think you can actually look at the free videos without registering too if you don't want to give your information but these authors looked at 20 years of studies and they basically found that psycho education was common in clinical practice but it typically didn't do anything in terms of helping people become more engaged in treatment so imagine I sense the seal to a group with a bunch of people with schizophrenia and she comes out is that going to make her more likely to take her medication no you know and my brother said when he came out of his first psycho education group I'm not going back why not they're all sick how did you know that now you're reading Henry's mind and he's dead that's scary I mean it's pretty weird right because it's common experience because the person doesn't believe they're ill since I was so light about Henry's death let me just say something quickly that how my brother died I'm here to very rich in meaningful life by his own account and that of others especially the last five years he was living with Betty and James he was working part time for James for free and doing light construction he was also volunteering it at this church sweeping every morning he got up and went to the Mexican restaurant ran run by my friends Marcela and Sandra Davila who are my angels and Henry's angels who would give Henry big hugs and kisses feed him and then give him the five dollars I sent to them that's he but he didn't go there for the for the money he loved Sandra and in Marcela and then unknown to me unbeknownst to me he went to another restaurant around the corner in downtown Tucson called Phil's cafe now I found out about this because after he died I got a phone call from Phil's cafe asking if their daughter Phil and his wife asked if their daughter Jacqueline could sing and my brother's funeral I didn't know if this was a three I was torn up I was a mess at the time and and I just said yes and then afterwards I thought what if this is like a two-year-old or a three-year-old I had no idea it's a 17 year old a young woman who was unbelievably talented I actually have it recording it is beautiful and she really sang about her relationship with my brother and how positively he had impacted on her I learned so much about his life that I didn't know at his memorial after going to Phyllis cafe he would take the bus back to the clubhouse then hit the clubhouse to take the bus back to his neighborhood he had gotten on the city bus noticed a woman behind him with groceries struggling he stepped off the bus and he said you go ahead and he was handing her her bags when and this is really incredible the ironic a man with diabetes who was not apparently managing his diabetes insulin dependent diabetes went into a diabetic episode and became unconscious and drove onto the sidewalk and ran my brother down but my brother died doing what being Henry being the man who I lost when he used to say I'm not sick and I would argue with them I forgot who he was to his court and to his court he was kind gentle guy you know even the moment of his death I mean it's amazing that's not that's not a random thing that's how he lived his life compassionate kind guy very responsible and I used to think I'm sorry I'm being emotional this is five years ago now almost four and a half years ago actually I'm not sorry I just means I love them right I still do but the thing about Henry is that he had a lot of compassion and I used to accuse him of not caring about his family I don't know if any of you have done that don't be hard on yourselves now that you understand I hope that this is a symptom because would you ever tell somebody to stop hallucinating just cut it out don't you know what your hallucinations are doing to mom why not because they can't stop and once I understood that Henry couldn't stop saying I'm not sick boy it just freed me up and it freed us up you know and I and I still and I saw him again for who he really was so it's a very powerful piece of information let's talk about leap briefly and let's practice a couple of the tools in the time we have left okay and I'm looking at my time keeper when do you want me to break okay leap was first developed the predecessor to lead was called mate for medication adherence and insight therapy doesn't exist anymore but I mentioned it because it was developed by Aaron Beck and myself Aaron Beck is the person that some of you may know is the father of cognitive therapy he invented cognitive therapy and still does research in and promotes its use in all sorts of psychotic illnesses what I discovered in when we had a grant from the National Alliance for research on schizophrenia and depression was that anybody could do the kinds of things we were teaching and I really developed a simpler version of mate called leap it stands for listen reflectively without judgment right while conveying respect remember that slide earlier about what predicts adherence empathize very strategically around those feelings that Cecille has that leave her isolated and alone and disconnected my god it must be so frightening for you to not be able to see your children and wonder what Jack why Jack would do this are you frightened are you angry about it I would be too she's nodding yes that's what leap sounds like now that sounds kind of dangerous to some people doesn't that sound like I'm agreeing agreeing with her delusions I'm not and we'll come back to this in just a moment I'm giving you the overview first what you do is you focus on the areas of agreement at CAA and lead what do we agree on staying out of the hospital let's see if we can convince you not to see Jack because all that's been doing for the last six years is getting you in trouble over and over and over again right I know you want to see them but can we agree or not if we can't agree that's okay but can we agree that that's a goal that we could work on since you're court-mandated to meet with me anyway let's do something with our time she's nodding yes so maybe this is hypothetical but it's very I'm drawing from experience and then we partner on that that's the P in leap now this book I'm right you're wrong now what is written for all sorts of situations not just dealing with persons with serious mental illness because what's happened is over the last 12 years we've trained trained tens of tens of thousands of people we have an all-day lead training we now have trainings online and people will come up to me and say hey I own a business I want you to know I've been doing this in my business would you come and consult with us family therapy parents with their kids and so after doing a lot of interviews and consultations the I'm right you're wrong now what book is a is a description of those experiences this has published four years ago in 2008 by Hyperion so if you want to get a broader picture of lead what I really love about about this book it's it's endorsed by a United States Ambassador who says is exactly what we do in international diplomacy it's endorsed by to business best-selling business writers this is what you do in business by a family therapist by a director of a cognitive therapy Institute I mean it's really it's it's it's really wonderful and you know what I didn't invent any of this it's one of the first things I say in the book these are timeless simple psychological truths that we put together into an easy kind of toolkit so let's talk about that toolkit all right the very first tool is listening reflectively now you came in here with all sorts of tools the same tools I had with my brother imagine that either you have a tool belt or a tool box and half of that tool belt or tool box are filled with those other tools trying to educate cecile that she's ill giving her the evidence telling her what her options are now the other side is empty let's fill it with some some other tools reflective listening is simply this I listen to the purpose to the person with the purpose of reflecting back what they told me so I can find out what first of all if I understood them correctly and I can also convey through my active reflective listening that I don't judge or disrespect what they're saying so the goal is simply reflect back what the person said don't add your two cents it sounds pretty simple right so who would like to try it first okay would you mind coming up here and I'm going to need you to use the microphone I'm sorry so I'm going to ask volunteers who are up close like our first volunteer or volunteers who are able to safely run and have signed the waiver that if you get injured in the auditorium you won't sue the library what's your name Richard okay Richard I'm going to go right into a role play of a patient of mine a real a real guy yeah Richard you want to help me then understand something I'm not mentally ill I don't need these damn medicines you can help me with the people upstairs every night they flush the toilets to communicate with those people who are trying to kill me how can I help you okay good was that reflecting back anything that I said no what did you do instead tried to sell it the problem very good so one of the first three most common mistakes is you responded you reacted instead of reflected you didn't absorb it reflected back but you know we're laughing but he did a nice thing didn't he he's trying to help me right but it's such a simple tool why didn't what couldn't you do it I'm sure you're intelligent enough I'm guessing you are nobody gets this right during a full league training we'll spend half an hour doing this we'll do it 15 times before somebody gets it right I forgot about that and just wanted to solve a problem yeah what want to try it again now that we have reviewed it so just reflect it back okay you want to help me even understand something I'm not mentally ill I don't need these damn medicines you can help me with the people upstairs I know what they're doing every night they flush the toilet to communicate with those people who are trying to kill me okay so let me see if I got this right people upstairs flush the toilet every night and they're in communication with people that are trying to kill you yes beautiful nice job right okay and thank you for making the other common mistake which is you left out two of the other most important things omission leaving things out that we are uncomfortable reflecting back it's very common so reacting or responding and then leaving things out now you don't have to reflect back every single thing the person says but at least hit the important ones I'm going to ask you take a seat let's ask for another quick ball they get a free copy of your book yes you did thank you see I reacted I did not reflect your wish it was your question whether you would get a free copy of the book for volunteering I understand you okay that's reflective blessing okay can you get to the microphone quickly I'm so sorry about the and then we're going to we're going to move on to why people don't do this what's your name that Valerie I'm going to start while you're making your way to the to the microphone listen carefully and people complain there's too much emotion so let me take that element out of this now I'm going to do it quietly and slowly Valerie you want to help me please understand something not mentally ill I don't need these damn medicines it can help me with the people upstairs they're communicating with you people who are trying to kill me they're using the toilet to communicate okay so you don't need to take these medicines and there are people upstairs communicating to you that they're trying to kill you my god they're not they're admitting it to me at all okay so they are flushing the toilet trying to kill you no they're communicating with other people with that toilet they're all part of the conspiracy of the people who are trying to kill me okay keep going no you're I like what you're trying to do here um if you want to go further I guess that's all I thought okay stop thank you very good but you also made the common mistake of omitting things right and you let me start with a very subtle omission you said you don't need the medications he didn't say that I don't need the damn medicines you're not really capturing what I said to him is you really don't need these medicines how many might even have said you don't need these damn medicines you know he was adamant about it it's a subtle thing but you left out some really big items you know what they were anyone or let's start with you in fairness one I know you don't okay let me just tell you there's seven elements to this roleplay Wow only seven that's a lot what are the limits of short-term memory everyone no five plus or minus two right so you should be able to is it seven no it's only five yeah five actually in this role play I'm not sick I don't need this damn medicines if you want to help me you can help me with the people upstairs for flushing the toilet to communicate with the people who are trying to kill me there's only five elements what did she leave out anyone I'm not sick that she said you reflected back that I don't need the damn medicine it's fantastic what else did she leave out people are flushing the toilet she got there to communicate as a form of communication it's called a delusion of reference it's hard to reflect back delusions you can take your seat thank you by the way thank you get out have to leave out so we can wrap what right that she that this young man wanted my help and when I do this I don't usually do it this way I'll do ten role plays so people can really experience it and see Wow when you listen you think you get it but until you try it you don't so here's what it sounds like Javier if I understood you correctly let's just slow down you seem really upset would that be okay I just want to make sure that I'm following you I had to calm them down a little bit you're not mentally ill you don't need these damn medicines you'd like me to help you with these people who are trying to kill you it's the people using the toilet to communicate with each other is that right it's really easy to do anyone uncomfortable with that and why yes why what and why did I agree with them reiteration is not agreement right why are you uncomfortable because it sounded like I was agreeing was I agreeing No if I just listen and try to interjecting in an interest of time and so people can hear and understand and tell me if I get it wrong my son's delusions it sounds like I'm tacitly I think you were going to say agreeing with them or supporting it or encouraging it encouraging and making it worse anyone here ever talk anybody out of a delusion you cannot talk somebody further into it and there's research on that so letting someone make the mistake that you might agree with them doesn't make things worse it only makes things worse if you lie and say you agree when you don't okay and why are we doing this it should be the other question people are starting to have because we want to have a communication where the person feels their point of view is respected and not judged and I'm going to give my opinion about treatment to this guy which I did right you don't need the medicines right yeah I get that if I were you I'd be pretty angry about everybody telling you to take the medication I have an angry dr. Amador you know I'd be angry too I did all that with him well what do you think you think I'm mentally ill what did I do i delayed answering that question as long as possible and then when I gave it my answer I used one of the leap tools where you convey your opinion in a very respectful humble way I'll show you and then we're going to wrap it up but we're listening especially to delusions if the person has them to the beliefs about not being ill and most importantly what they want this young man wanted me to help him with the people who are trying to kill him and when I reflected this back so you're not sick you don't need medicine you'd like me to help you with these people who are trying to kill you he said would you write a letter to the co-op board saying I'm not mentally ill because they're trying to kick me out because he was banging on doors at 3:00 in the morning 2:00 in the morning confronting people now what did I do you know this is why we don't reflect because we worry that we're going to be asked to do something we can't do we worry we're going to make it worse that's your worry right we were worried about injuring the therapeutic alliance because it makes it sound like we believe them and that we're being dishonest of what happens when they find out that we don't with there's only seven communication strategies or tools you can do this lots of people are doing this so I just wanted to give you a flavor for it delaying your opinion is for two purposes to get the person to ask for your opinion an opinion that's been asked for carries more weight than an opinion that has been given without being asked for how many women in the room have been pregnant and gotten free advice from strangers in the street okay and how did that feel did ever feel intrusive yes did ever feel I'm beginning yes has ever feel disrespectful and yet each of you probably had a woman who you trusted who you went to for help and advice a mother a sister a grandmother and his advice you considered if not followed about the pregnancy what's the difference in one case you had a relationship but in in the other case you didn't but the other big difference is you asked so that's why we delay we delay very respectfully I promise I'll answer your questions to seal about Jack we work together and she asked me are you married my marriage Jack do you believe me but if it's all right with you I'd like to talk more with you about staying out of jail would that be okay and I asked permission I put her in charge that's giving you a flavor for how you can delay honestly and with respect and then when you give your opinion we call it the three A's apologize acknowledge your foul ability you could be wrong and agree to disagree Cecile you've asked me several times about Jack and I'm sorry this might be hurtful now she already knows what I'm going to say might be hurtful to you and I could be wrong I don't know everything I'm comfortable saying that I don't see it the way you see it I wish I did I truly wish I saw it I just I don't want to be one of those people that argues with you about Jack I'd rather focus on all those areas that we agree on one of the leap tools is apologizing and I would apologize do you see how different that is than saying what I said to her when I was sitting in that chair before I'm creating a relationship where I'm really respecting her and not judging her and I start to encourage her to maybe take some medication to help her deal with her anxiety or heart was racing whatever the problems are that she describes I'm always looking to empathize and normalize her experience I'd feel the same way you're feeling so you agree with me I'm married well I promise I'll tell you what I think but if it's all right with you I just want I'd like you to stay here with your feelings if I were in your position I'd be really lonely and angry too you see how you can mix up the tools right and we're always focusing on those problems that we can agree on and when we disagree agree to disagree and we set goals that we partner on like taking the medication so you get a night's rest accepting this referral to this residence so that you can you can stay out of jail you know or something perhaps less coercive than that there's lots of things you can agree on so I'm going to end here and just summarize the seven lead tools listen empathize agree partner delaying I touched on giving your opinion slowly giving it with respect and sprinkling your dialogue with with apologies yeah I'm sorry that I think differently than you do I wish I agreed with you is what is the most powerful apology I'm going to jump ahead and we'll skip over this this is just about some trainings that happened in Turkey believe it or not we had 15 psychiatrists come over and ended up training about 600 people I think in Turkey psychiatrists and family members but since it wasn't shown on the bottom I'm sorry I will throw it up this is the website where there are free videos there's there's other courses as well and there's free literature that you can get on leap so all this stuff I skipped over quickly at the end is there in depth there's an hour and 20 minute leak training I did in Copenhagen that's free on this website so if this seems like something that might be helpful to you I hope you'll you'll have a look and certainly it's all in the book as well but you have to buy the book except for the volunteers so thank you very much for your attention I saw you I'm not gonna take any questions now here you

Channel: The LEAP Institute

Views: 62,641

Rating: 4.7956777 out of 5

Keywords: schizophrenia, mental illness, Xavier Amador, NAMI, LEAP Institute, Medicine (Field Of Study)

Id: bnbOizw_zS0

Length: 97min 37sec (5857 seconds)

Published: Sat Mar 23 2013