Dr. Amador NCBH Keynote Speech

living our keynote speaker this morning Javier Amador urges us to see individuals with serious mental illness for who they are not for their illness dr. Amador is a psychologist author professor executive coach even a reality star and his credentials are impressive I see others out there watch Bethenny on TV I'm not the only one I think he does a great service in fact to show a woman on TV high-powered and successful still needing support and help and I think that's good for all of us and good for our profession however it isn't strictly dr. Amador's impressive professional credentials that bring him here today it's also his personal experience his brother Henry has schizophrenia as an 18 year old Amador was often angry with Henry he doesn't do anything he won't even try he complained about his brother Amador later learned that he was making the same mistake as millions make around the world he was confusing the illness for the person in his first book I'm not sick I don't need help dr. Amador teaches us how to partner and engage those who we care about who are mentally ill and in his latest book I'm right you're wrong now what he applies the same strategies to salary negotiations to disagreements with partners and colleagues and even to challenging job assignments he encourages us to leap to listen to empathize to agree and to partner this morning we look forward to making the leap please join me in warmly welcoming dr. Amador thank you good morning I gave Linda a little bit of trouble this morning because I've been outed as being a therapist on a reality show it's not on any of my websites and those of you who like the Talking Heads there's that song how did I get here I have no idea still but I do feel actually proud of that work that's a whole other story and that's not why I'm here today I'm here to talk about something that I've heard many times I'm sorry I didn't realize my slide was up could we get the monitor to also have the slides please my monitors thank you how many of you in the room have heard someone with a diagnosis of mental illness say I'm not sick I don't need help could you raise your hands real high look around the room please look around the room please you just saved me a lot of data slides I it's a joke you know it's not a joking matter in fact a consumer came up to me prior and wanted to talk to me he'd seen me years ago my work has been used to advocate for involuntary commitment laws and my work has been used to advocate for the abolishment of involuntary commitment laws I think that'll be clear to you by the end I'll say at the outset anytime I've been involved in an involuntary commitment it's heartbreaking I don't want to do it in my mind it is absolutely a measure of last resort I want to get that out right now and it's to save lives but we're gonna talk a little bit more about that mostly we're going to talk about how do we engage people in treatment how do we get people who who have a firm belief that lasts for years that nothing is wrong with me I don't need your help has my brother used to say javi my nickname was javi you you've been brainwashed by their psychiatrist there's nothing wrong with me you're the sick one how many of us are family members in the room of somebody with mental illness quite a few of us how many of us are consumers I'm also a consumer I'm not going to talk about that today but I am okay thank you insight and and what is insight really it's just agreement do I agree with the other person about the problem I think they have effects relationships relationships with health care providers unfortunately with the criminal justice system and we've talked about involuntary commitment briefly but also families it devastates families schizophrenia alone we're talking about three million families bipolar disorder even more let me tell you briefly about Henry we came from Cuba in the early 1960s we were refugees our father had been killed tortured and killed during the Cuban Revolution we were really in dire straits in many ways our mother courageously got her four children out and my older brother Henry who you see in the slide looking through the window the big smile on his face looked look after me and looked over me that's me driving the car it's our first car in Cincinnati Ohio and Henry was more than an older brother he was like a father and he was someone I really looked up to a very humble person very popular always had friends girlfriends jobs school in 1981 my mother was fortunate to remarry we had a wonderful stepfather he unfortunately died young and at that point Henry's symptoms really kind of flared up he was hearing voices he was paranoid he was delusional he wouldn't go to the hospital was right after my father's death our stepfathers death and I I really appealed to him in every way I could think of even with guilt you know we're dealing with too much please go to the hospital he wouldn't go anyone want to guess how I finally got him into the hospital as a family member as my beloved older brother who was my older brother do you know how I got him in the hospital just shattered out anyone if you want to guess police and if you've ever been in that situation it is a horrible situation to be in unfortunately for the next seven years of our relationship I called the police on my brother a lot I'm not proud of it I'm also not apologetic because it really was a life-or-death situation for many reasons I want to say one more thing about my brother's character you'll hear me talk about him in the past tense because he died four years ago some people may not be aware of that because people come up and ask me how's Henry doing Henry died very happy and a happy part in the point in his life he had a volunteer job that was meaningful he lived in a house that he really enjoyed and felt valued as a human being he had a girlfriend he was getting on a city bus and he noticed a woman behind him struggling with her groceries the police told me this they have a video of it from the bus I of course haven't looked at it he stepped off the bus and he's handing her grocery bags to her this is how kind this man was when somebody who had diabetes and was non-compliant with his treatment had lost control of his car went into a diabetic shock and ran onto the sidewalk he died committing an act that was so central to his character an act of kindness so I say all this for a very specific purpose I called the police when Henry got sick he was hearing voices he was paranoid he was terrified and he was terrifying got him to the hospital he got better I was as far as I was concerned he got better he came home where do you think I found his bottle of anti-psychotic medication anyone how do you all know that dear VSP right I'm not joking about this problem but I think sometimes humor is important because these are tragic situations okay you all know that because you've been there because this happens to lots of people I took the bottle out and I said Henry what happened why aren't you taking your medicine and he says I was sick before I'm fine now leave me alone and what happened next what happened to our relationship is best described I think by this picture on the face of the book that Linda mentioned does that look like much of a relationship to you now for seven years we argued you're sick no I'm not you need medicine no I don't and I won't go into the details of his history why the illness threatened his life but it did and and I did end up having to call the police on my own brother which was traumatic for him and and it was not inconsequential to me and and to our family the last 18 years of our life this is what our relationship looked like of his life our life together that's Henry holding me I love looking at his hands on me and how did we get there part of how we got there is through leap Henry really helped me develop this program because I was highly motivated to get my relationship back with my brother I was highly motivated to engage him in treatment because I saw from my perspective how much better he was denial of illness unfortunately is in the news a lot by the way does anyone know that it was AMA bin Laden was killed okay so make sure sorry turn the TV on for three seconds this morning and I'm not if you want to get the details it's there it's just have used to work for NBC as a news consultant years ago and what gets covered sometimes is upsetting to me including this story do you know who this is Margaret Mary ray is known as David Letterman's stalker I'm friends with her daughter who's sitting in the front she was in her mid-20s when I met her after Margaret Mary died from her illness what do I mean by that anyone real loud please suicide I don't like to say people with serious mental illnesses commit suicide the science my experience tells me that this is a symptom of the illness it's a consequence of the illness not being engaged with people whether it's therapy whether it's going to club houses a consumer peer counselor on medication not being engaged in treatment and in recovery is a major risk factor for suicide what's the rate I call it the mortality rate let's talk about it like we do other medical illnesses I loved this I didn't know about this program to to name the unmarked graves you know why should it be different in schizophrenia people are people and whether the diseases of the disease of the brain or disease that we treat in oncology why don't we call it what it is the mortality rate mortality rate by suicide and schizophrenia alone is 1 out of 10 people 1 out of 10 people so this is a life or death illness for many people I've known people who have died from suicide bipolar disorder the rates even higher depression of course we all know about it she never got treatment I mention her because she died from suicide she ended up being criminalized she ended up in our criminal justice system as many people do who do not who we do not engage in treatment let me put it that way Ted Kaczynski is another example like John Nash brilliant mathematician like John Nash professor of mathematics like John Nash has paranoid schizophrenia unlike John Nash he got disengaged from his community and disengaged from treatment and ended up in a cabin in Montana mailing bombs because of his paranoid delusions unfortunately this is what the press covers there are some good documentaries out there you're going to see some of them some others have been involved in recently talking about hope recovery and the the positive stories of schizophrenia so I don't mean to be a downer but I do want to really emphasize what has been now nearly a 30-year history I've worked in emergency rooms with police departments on crisis teams inpatient psychiatric wards and in community mental health facilities I've worked in the whole range and the consequences of not being in treatment do oftentimes result in interfacing with police suicide homelessness and I think most importantly a lack of a opportunity to recover from this illness so I have a question for the for the room and you're gonna have a chance to ask me questions don't worry thank you raise your hand if you agree with me denial of illness impairs common sense judgment about the need for treatment you've got a diagnosis of schizophrenia or bipolar who agrees with me you raise your hand looks like most of you okay I disagree completely I'm gonna step over here and take the perspective of the person with the illness who does not believe he's ill it is common sense to refuse treatment in fact it's unwise to take treatment for an illness you don't have often times how many of you raise your hand would inject yourself with insulin if you did not have diabetes raise your hand please I don't see a single hand thanks for the lights why anyone why not it could hurt you you don't need you don't need it it could actually be a form of poison you could die from it from insulin shock right so do you hear this do you hear this from your staff do you hear this from the consumers you're working with I don't need this medicine it's it's dangerous but are we talking about denial we're not how many of you know this word could you raise your hands now we're near as many as I would like I'm gonna go quickly through this the word is Anna signo Xia it's a syndrome that is mediated by frontal lobe function that results in unawareness of illness first described by Babinski a neurologist working in France in 1919 to describe people with neurological deficits for example paralysis who are unaware that they were paralyzed when I started my research in 1989 my brother had been ill for eight years and I looked at the literature and there were ten studies now I already had eight years of experience with her brother and working as a nursing staff on a crisis team emergency rooms and I'm like why can't why are there only ten studies about lack of insight so rather than complain and moan I got involved in a study this is part of the dsm-4 field trials and what we found back then is that of 221 people with schizophrenia all around this country five different sites first episode first episode see it's a friend and people with chronic illness a real mixed group about 40% were aware and essentially close to 60% were unaware moderate unawareness means I'm definitely not sick but I consider I can consider the possibility maybe I am this finding has now been replicated hundreds of times we now have close to 300 findings in the literature what's the headline from the research literature this is something that's common that affects about half of all people with schizophrenia and bipolar disorder and especially in schizophrenia it tends to be stable over time it does not improve with treatment now there are many consumers at least one and a half million if you trust the research in our country who know they're ill who are advocates who I've worked with doing advocacy work for myself and in other other settings and then there's the other group over a million a million and a half Americans who don't understand they have schizophrenia and they don't for years that finding is very well replicated they're also unaware of signs and symptoms of the illness and believe it or not if they have the movement disorder tardive dyskinesia so they have the pill rolling movements or the perioral grimacing you can ask the person do you see that you have difficulty controlling your movements and studies find that about 50% of people with this movement disorder who also have schizophrenia don't know it so there's lots of problems with illness awareness that don't have to do with feeling stigmatized by the illness and in denial what's the biggest problem with oral antipsychotic medications anyone what's that side-effects compliance let's put it in a different way I hate the word compliance but you're right people don't take them people do not take them now my brother promised me over and over again in the hospital he would take the medication what was he doing he was lying to me I thought he was stubborn I thought he was immature I thought it was irresponsible of Henry to lie to me and mom how could he do that to us especially after our stepfather had died everything she was going through I mean can you see the 18 year old the 20 year old remember how close we were and Henry would say I'll take the medicine I'll take the medicine I'll take the medicine he'd come home and he throw it away well he was doing what I would do if I was wrongfully locked up and thrown into a hospital that is that was his reality that is reality of at least one and a half million people in our country 50 to 75% of people with schizophrenia don't take their medicine at all or take sub-optimal doses within seven to ten days of starting someone on medication seven to ten days one out of four are off the medication half four off after a year and up to 75% after two years let's flip the question around who's taking a medication reliably only a third of our people with schizophrenia I don't know about you but that's not acceptable to me and that's why I started looking for ways not only first to engage my brother and frankly first to just repair the relationship but also to see if I could engage him and meeting with somebody I don't care if you take medicine Henry I promise I started stumbling on some of the techniques I'm going to tell you about I promise I will never again tell you you're mentally ill I made him that promise in 1988 I think it was and I never told him again unless he begged me for my opinion then I apologize look I'm sorry I kind of still think you are but let's not argue about it and I've helped him to find reasons to stay in treatment and me and people like you people like the staff that are working in your and your treatment centers so I don't use the word compliance very much I used to work used the word adherence as of last week only I was in the Netherlands speaking about this and we had a discussion with a much smaller group than this one and we realized in our discussion it's about collaboration that's really what I'm looking for show up even if you're not going to take medicine come to the program come have relationships with us and then if we can't engage a person who needs medicine into accepting treatment all the better top predictor if you look at all the research is of who will take medication and take it reliably at 33% I showed you his insight and earlier I'm a consumer again I won't get into the details now but I'd be happy to talk about it afterwards with anyone but I wasn't denial at first I once that denial was broken through accepted treatment various forms of treatment and I'm grateful and the thing I learned about myself in terms of the mental illness that I'm vulnerable to I've never lost that knowledge what's the other predictor anyone of who will take medicine and stay in treatment reliably anyone family support thank you everyone always says that I supported my brother I i sat on the edge of his bed hours at a time trying to understand him not very well but really mostly trying to teach him about the illness that he was certain he didn't have remember the picture I showed you of the book cover that's what my family support did and I know there's family members out there and I and I talked to many over the last 11 years who went through the same thing that our family went through which is is this trauma of losing a loved one not only to the illness but to this unwinnable debate about being sick or not but you're on the right track if I look at the research and I have what what matters is an alliance most of this has been done with therapeutic alliance with therapists of all kinds but also it translates into family work I'm not going to show you any of our research but we have some research on this it's a relationship with someone who listens to you without judgment so when Henry says I don't need medicine I say okay so you're telling me as you don't need medicine I didn't used to do that when somebody I'm working with tells me about the alien transmitter her brain I say so that's your biggest problem is that what you're saying yes that's listening not only without judgment but with respect I'm respecting that person's point of view now a lot of people worry well then how are we gonna get that person to you know show up for an appointment or take medicine because we're going to win not on the strength of our argument for why they should be in treatment we're gonna win on what the strength of our relationship and that person knows I think they should be in treatment I think would be helpful to them the last time I talked to my brother in person I talked to him just a couple days before his death I said Henery people always ask me has your brother developed insight and I say well Henry says he has schizophrenia I said so what do you think and he said Oh javi you know I have schizophrenia and he had a great sense of humor I said come on what do you really think he says now I'm fast-forwarding it was a longer conversation we were driving back from this dinner and and and he says no I don't I don't have it I said yeah I didn't think you did no but he knows I think he does I could say that he has no doubt at that moment I said so why are you taking that he was taking along acting a Prolixin first generation antipsychotics I can talk about it it's generic I don't even know I don't even know who makes it I don't even know who makes it but they're not giving me any money as far as I know and he went from four to five hospitalizations in that a year most of them unfortunately sadly for him and for our family compulsory treatments too in the last 18 years of his life when he was on a long-acting depo one hospitalization big difference when he missed an appointment I got a phone call because he gave permission for me to be in contact I'd call him up hey how many what's going on talk about it and I rally with his caseworker and we'd convinced him to go and get treatment so what he said to me in this car in this last conversation face face to face conversation when I asked him why do you take medicine he says well I take it for you you know I know you worry about me and mom and pops now who were mom and pops they were the people that ran the residence he lived in you didn't even call them by their first names Betty and James he called them mom and pops relationships I was co-chair of the last revision of the DSM for text revised how many of you have the gray version of this book where your staff has it if you have the red please throw it out we were asked Michael flam and I to serve as kind of like scientific review chairs to serve as sort of journal editors all the text was revised in the red version of the book you have Nancy Andreasen view of prevalence gender differences associated features you know all the text around the criteria which we use to train people which you use to train your staff and and to learn and the APA felt it should be something that reflects scientific consensus so Michael and I got a group of experts from around the world together and asked them to propose changes based on scientific data as you know based on evidence-based information about the disorders so on page three or four and I bet there's very few of you since very few of you knew the word anise Ignacio unfortunately it's a big gap between science and practice it's our fault it's why I left my full-time career as a professor at Columbia University in the medical school doing research to go work at Nami and then do other work with other advocacy organizations was because I realized the research we needed clinicians family members and consumers was not getting translated it was not getting to the front lines so we reviewed the research with this panel of experts and they actually went further than I thought they would here's what's in the DSM that's under the associated features section and I'm working with the work group now to revise the text I'm not a part of the DSM committee this is another conversation it's a little complicated but let me just highlight a few things a majority of individuals with schizophrenia have poor insight evidence suggests in this part of obviously emphasized that poor insight is a manifestation of the illness itself rather than what denial rather than a coping strategy rather than stubbornness rather than immaturity these are the things I used to sadly think about my brother at the time when I was a young man I was a young man at one time I remember that it may be comparable to the lack of awareness of neurological deficits seen in stroke termed what can you say it with me once one more time class a no sig no SIA and no sig no SIA go Bravo thank you why am i doing that because it's it's a tongue twister no one can say it and if we can't say it we can't talk about it we can't educate each other what this is a symptom it's called a symptom did you know this was a symptom I mean that's what the research is showing that's what I believe and I'm not gonna get into the data and the details now because I want to get into leap and how do we engage people but it predisposes the person to non compliance with treatment big surprise you don't think you're ill of course you're not going to take a pill and it's been found to be predictive of higher relapse rates increased number of involuntary hospitalizations poor psychosocial functioning poor course of illness quality of interpersonal relationships a lot of measures that we think of as measures of recovery work school having meaningful activity also are worse in individuals who don't have insight now please remember this because a lot of people say well it's the minority of people even after they've heard me speak please remember it's half of the people we're trying to care for one half 1.5 million at least in this country with schizophrenia and I'm not talking about the related disorders and the rates are the same schizoaffective bipolar it's not rare first patient I ever evaluated with anise Ignazio as the neurologist Babinski described it almost 100 years ago was paralyzed in the left side of his body I asked him can you move he had a frontal lobe damage and posterior damage to his brain after his stroke I asked him can you move your arm I knew he couldn't but I was evaluating his insight or his is what and a sig knows yeah thank you last time I'll do it maybe and I said can you move your arm he said sure he had a week to learn he was paralyzed we used to have to restrain him in his bed because he tried to get out and he'd fall to the floor he doesn't move his arm and I asked him what happened actually we did this three times the last time he said I don't want to tell you I said why and he said I you're gonna think I'm crazy and I reassured him that I'd do my best not to think and he said well I think you've done something to my arm that's why I can't move it he thought that we have put something in the IV like your re something to paralyze his arm or maybe we had restrained it so it's a very severe lack of awareness isn't it how can you not know you're paralyzed and the belief that nothing is wrong continued even though I showed him three times and confabulations are common his confabulations were for example I've done something to his arm he's trying to explain what he knows to be true in his mind and his heart and and and why that those beliefs are so different from what he's seeing with his own eyes he can't move his arms so it must be something else is happening I'd like to give you a feel for this I think it's really important I've had the opportunity to do interviews with many many people with schizophrenia and bipolar disorder where I get to say your family's not gonna find out what you really think your doctor your nurse your caseworker won't find out what do you really think do you think you're sick because what happens is we often hear what we want to hear people without insight will tell us what we want to hear so that they get more freedom less supervision they would do this the same things I would do or you would do so I need a volunteer for a moment you don't have to come up here preferably somebody closer to how many of you in the in the first half of the room are married could you raise your hand you you don't have to be happily married it's okay okay can can I pick on you right there and the yellow sweater you can stay there can someone bring her a microphone quickly let's see how fast you can run did you go to go good this morning now you don't have to run I'm sorry what's your first name I'll repeat it out loud Susan okay Susan how long bring the microphone is Susan up here second third row how long is it that you've been married 1977 so no 35 36 35 36 years and do you have please don't applaud because there's something going on here and I hate to do this in the room especially in a room this large but Susan people have asked me to to help you you're here with a friend sitting next to you is that correct yes yeah we talked earlier didn't we yeah I love how people play along with me we didn't talk earlier but no seriously who what's the first name of the man that you believe you've been married to all right Jeffrey what is it Jeffrey Jeffrey Susan you're not married to Jeffrey Linda has about seven restraining orders that we can show you signed by Jeffrey yeah I understand you believe do you believe you have children I was I got the clinical history correct yes yeah how many children is it that one yeah well Jeffrey and his wife and his three children are terrified and are tired of your stalking him I can show okay folks could you also not joke for a moment I want to move on I don't have a lot of time and we want to get Susan some help would you look at the restraining orders would you be willing to look at them would you believe that you're not married to Jeff to Jeffrey if you saw bears okay would you like to call him sure let's calm right now she calls them Oh answer hello uh hi is this Susan yes yes yes honey I know it's her it's the last time I promise Susan I know where you are I know the doctors trying to help you do not call here again if you call here again we will call the police that really happened that really just happened okay do you believe you're married to Jeff yes who do you trust other than Jeff that you could talk to about this hmm you asked is this a co-worker next to you yes you asked her she says the same thing Susan we arranged with the National Council to get dr. Amador to do an intervention please don't laugh please please please please it's really serious she's lost a lot in her life because she continues to think she's married to Jeff hotel security is waiting for us over there if you could let them in we have a bed available for you that's the wonderful news we'd like you to get some help I have to continue with this presentation okay would you be willing to to go with them and go to a hospital no you've just talked to Jeff I've offered to show you restraining orders you've talked to your friend here on your cell phone and you still believe you're married to Jeff yes anyone else in your family that you trust hmm did I would talk to ya my daughter so you talked to the girl who you think is your daughter how old is she she's 23 so we have allowed her to speak with you and she says please leave us alone your daughter just said that to you would you go get some help would you please turn over the microphone and go with the security and go to the hospital not willing they know okay well we need if we could have the security guards come forward we're gonna remove you okay because we need to continue okay it's a little heavy-handed and I apologize for that now we imagine what happens do you go peacefully uh I probably go peacefully okay and you get out there what do you do try to explain myself again you do what I would try to explain myself again I would not go willingly and they said well ma'am you've done nothing wrong you're not a danger to anybody you know we just need you off the premises so where do you go to your car do you have a car here yeah what do you drive to a hotel okay and where do you live where do I actually live but in Minneapolis so you fly back to Minneapolis where do you go home police meet you at the door nobody will open the door you're taken to a mental health diversion court the judge says there's a restraining orders I don't want to send you to jail you can go to jail and be charged with violating these restraining orders or you can go to the hospital what do you want to do my options are Jail in the hospital yes yes ma'am probably the hospital okay you go to the hospital you get admitted they offered you medication do you take it I'm not willingly no okay well we're gonna have to if you don't we're gonna give you two weeks but we're gonna have to send you back to court if you don't take the medicine what do you think you might do I probably take it okay we'd like to reassure the judge that you're going to stay on the medicine do you understand that you have a delusion about Jeff we'd like to discharge you to a really good act team that we have in a community mental health center I would say I understand that you think that I have a delusion about Jeff okay we're gonna need to keep you a lot longer than thank you let's just stop there thank you dude actually before we stop what this was a roleplay but what were you feeling anything besides confused I was feeling a sense of how do I hang on to my identity right I kind of hang on to what I believe to be true right do you feel lonely if this is really a yeah I could start to feel lonely yeah could you ever be convinced you're not married to Jeff and that you don't have a daughter nope anything convince you ten years of hospitalizations for this that's hard to say at this moment but anyone think you could be convinced even with 10 years of hospitalizations of something like this I don't think so I couldn't but this is hypothetical that's the nature of anis Ignasi a-- for mental illness right and why would Jeff participate with me why would all these people participate with me what's your theory Susan I don't know I'd have to think long and hard on that one it's going on for over a year's a year later you're talking to me I'm your therapist on her case right sorry somebody must have deluded him probably she's sounding kind of delusional and paranoid right yeah how could she get dr. Amador the National Council her her friend and colleague or this man this man's daughter how could a judge you know you're not sounding well Susan right how do we engage Susan in treatment any last comments before I release you to go call I'm good to be released thank you very much look folks here's what happens for many years I would write in medical records especially on an inpatient ward patient developed insight discharged with prescription follow-up appointment next Tuesday ok what I was hearing remember this morning this morning but half an hour ago what I was hearing was common sense like Susan like me I people will tell us what we want to hear to give them their dignity and their freedom back and I used to be angry at my brother for lying to me why did you lie to me at the family meeting in the hospital and I'm ashamed of that and I shouldn't feel too guilty it was ignorance I didn't know about Anna signo Zia and most of you didn't know about it and I hope if you doubt me you'll go and do some research on it go to our website go to other websites go to the NIH website don't get caught up in the controversy a please look at the science first about how we use this information so when working with someone like Susan when dealing with aniseed nausea for poor insight the doctor knows best approach isn't going to work is it I can't expect her to be grateful receptive or when she gets out of the hospital adherent or collaborative to take her medicine what I can expect is that she's going to be frustrated and angry probably suspicious and she starts to develop theories about how this happened and non-compliant not taking the medicine she'll stop overtly refusing it because when she does bad things happen to her so she'll start to hide it how many of you have found pills or your staff have found pills and trash bins lots of you how many under mattresses okay it's a horrible situation for the person with the illness who's being pushed into treatment what works to engage people motivational interviewing developed for working with people with substance abuse disorders has has begun to be looked at as a means of engaging people in treatment who don't believe they're ill this is a review of 20 years of research and I don't know if bill is in the room building we used to have offices next to each other hey Bill good to see you although interventions and family therapy programs relying on psycho education bills major contribution to our field we're common in clinical practice they were typically ineffective let me explain quickly what their focus was was in improving adherence or engagement in taking medicine this review okay I think psychoeducation can work with people who don't believe they're ill but you have to engage them in the psychoeducation certainly family psychoeducation is tremendously helpful there's I have no question about that but with these people these investigators found was that those programs that actually improved the person's engagement or adherence or compliance in treatment were those that use motivational techniques leadmon the first book came out in 2000 I was asked to write it by family members because they heard me speaking about Anna's agnosia I've been speaking about Anna stick nausea since 1994 and only about a hundred hands went up in this room it's humbling it's very humbling it's not your fault it's it's I think it's the fault of the system what does it stand for listening reflectively to build a bridge for example to someone like Susan it's a very lonely place that she's going to end up if this really happened to her so I want to listen to her complaints about what happened to her that fateful day in May in San Diego and I want to respect remember that earlier slide about how do we engage people in treatment I want to not judge and respect her story empathize with her you must be angry you must be furious to be sitting here with me another mental health worker if that's what she says look for where we agree what do you want I don't want the police in my life I don't want to be in the hospital I want more freedom I like my husband back well I can't help you with your husband do you believe I have a husband I'll come back to that we'll talk about how to deal with that but we look for areas where we agree and we part that I'm anxious I'm not sleeping I'd like friendship friends again I've lost all my friends because of this there's all sorts of things that we can agree on and partner on so I want to give you a quick feel for how this is different this is not straight motivational interviewing so those of you who know motivational interviewing will see there's some differences here this was first developed by Aaron Beck and myself you know dr. Beck as the father of cognitive psychology and dr. Beck and I had a grant at Columbia where Bill MacFarlane and I both used to work and and we were doing an inpatient study if you can read the acronym it's mate stands for medication adherence and insight therapy and what I discovered very quickly is the people with the least experience including non professionals who were volunteers that we were teaching mate to learned it really quickly people with experience like me psychiatrists social workers psychologists had a really difficult time because they had to unlearn the the medical model approach so that's why I developed lead it is for family members it's for all sorts of health care professionals whether you're a CEO a case worker a nurse a doctor I don't care we've taught this to police departments to help with de-escalation and engaging the person with you we've taught this even even to corrections officers because so many of our friends and family and clients with mental illness are in our jails and prisons right Los Angeles County Jail still is the largest inpatient facility for people with serious mental illness and that's because I think as a field where we're not holding on to so many of the people who don't believe they're ill and we look for where we agree and we partner on that I'm never gonna agree with Susan about being mentally ill but we could agree on other things you all know this strategy but let me give you a feel for it and let me not diminish what you've done in the past think of a tool belt when I was five years old I wanted to be Batman for Halloween I was he was cool because he wasn't a superhero in the sense of having super natural powers like Superman he was just a regular guy with a really cool back utility belt remember that on one side of your belt whether it's a bat utility belt or a tool belt I don't care or all the things we've learned right how to do a good psychosocial history make a diagnosis communicate that to the patient and their family etc make recommendations prescribe treatments on the other side I'd like you to just sort of imagine some other tools leap is not to replace what we already do it's to augment to help people like Susan if this really had happened to her to help people like my brother Henry and the one and a half million people in this country with this problem so listening reflectively let me just give you a feel for this I need a volunteer all you need to do can we have two microphones up front please one on each aisle here I'm gonna keep it in the middle because of time constraints all I need you to do is to reflect back just respect and don't judge what my patient said to me this is a real person I worked with who would like to try right here okay if you had training and motivational interviewing no great thank you and you can stay right there what's your first name you can stand though that'd be nice if people could see you Michael I'm sorry Michael Michael you want to help me sure okay then understand okay I'm not mentally ill I don't need these damn medicines what I need help with are the people upstairs who are flushing the toilet to communicate with the assassins okay all he has to do it sounds easy reflect back what I said let me do this every time Michael you want to help me you understand something I'm not mentally ill I don't need these damn medicines you could help me with the people upstairs who are flushing the toilet to communicate with the assassins what would you like me to communicate to them okay stop there was that reflective listening not you guys don't help them Michael was that reflective listening now you've had a hint about 2,000 people just told you now you did a very nice thing it's on this side of your tool belt you tried to engage me with right he's reacting to what I said you might write a third time sure I'm gonna do it without the effect Michael you want to help me then you have to understand I'm not mentally ill I don't need these damned medicines what I would like your help with are the people upstairs who are flushing the toilet to communicate with the people who are trying to kill me with the people upstairs the ones trying to kill you okay so you believe me I believe you believe good another form of reacting another common mistake Thank You Michael and he's drawing he just drew a line in the sand remember everybody laughed when I said to Susan so you believe have been married to this man and I asked you to stop laughing because I was trying to create as much reality as we could in the context of a roleplay I believe you believe I used that for years and when I started talking to people you know in a less threatening way I found out that they felt very very pushed back by that it's like drawing a line in the sand and saying I'm on this side you're on that side should we give somebody else a chance quickly thank you Michael thank you for right here in yellow come microphones right here please this woman here in the yellow this nameless person what's your first name Vicky you want to help me you have to understand something okay I'm not mentally ill I don't need these damn medicines I need help with the people upstairs okay you can help me with that they're flushing the toilet to communicate with the people who are trying to kill me so what you're saying is that you're not mentally ill you just want somebody to believe that it's the people upstairs that are creating the problem nobody believes me and I understand what you're saying because it's your feeling as if nobody's listening to you okay stop there you're starting to react now you're starting to interpret you started to do reflective listening quite nicely and thankfully you made the second most common mistake is you left out a number of things there were really three very important things to him I was asking you for something I've been this three or four times now so you want me to go upstairs and talk to the ice very well done we don't reflect back things like that because we're afraid of where we'll lead right right what else did you not reflect back let's give one last person a chance cuz I'm running out of time which oh you can you guys are handling the microphones you want to try it anyone okay whoever said that where are you could you give me a microphone what's your first name please Michael yeah so you don't want to take your medications let me go through it for everybody so Michael understand something I'm not mentally ill I don't need these damn medicines you can help me with the people upstairs who are flushing the toilet to communicate with the people who are trying to kill me okay so you want my help with people upstairs yes trying to communicate with others that are trying to kill you're not trying they are communicating they are communicating with using the toilet yes and you don't want to take the medications and you're not mentally I don't something I don't want to take it I don't need the medicine okay you don't need the medicine stop there thank you there's a nice job thank you I'm sorry I'm rushing you but again in the common mistakes are to omit things that make us uncomfortable we worry about feeding the delusion here's how I would do it and by the way for those of you who think there's so much to remember you don't have to reflect everything back just what's important to the person right and you know the limits of short-term memory there's only five elements to what he said some people say there's too much to remember and I did it five times I'll do it in a room and I'll do it 15 times and people still leave out this patient wants me to help them with the people who are trying to assassinate them this person does not need medicine here's how I'd reflect it back Javier if I understand you you sound just slow down for a second I can use empathy for a second you sound upset but let me just see if I understand you're not mentally ill you don't need these medicines you'd like me to help you with the people who are using the toilet to communicate with the people are trying to kill you is that right yes and I'm not asking it in an incredulous way I'm just reflecting it back now why why don't we do that when I have time I usually ask people and you know when we reflect back delusions and the beliefs around the NSTIC nausea which for what you're not mentally ill and you don't need the medicine the fear is were making those things worse remember the definition of a delusion it's a fixed false belief anyone here talk to anybody out of a delusion no you're not going to talk them further into it there are some issues about therapeutic alliance but if you focus on what the person wants what did this person want he wanted my help why not reflect that back the reason we don't reflect that back is we fear that we're going to be asked to do something we can't do or we fear that if we let the person think we believe them we're being dishonest if you use leap you're being honest you never lie and pretend you believe what the person believes but you don't go out of your way to tell them you disagree the goal is to first respect and empathize with Susan's experience it must have been terrible what happened to you are you angry about it yes I would be too right when she asked me well will you help me get my husband back i delay giving her that information this is one of the other leap tools how do i delay my honor the question Susan I promise I'll answer your question now I try to move her away from it because I know what she wants we've talked about her desires but if it's a right with you I would like to first hear more about how you got in the hospital maybe how we could stop this cycle from continuing then I asked her permission would that be okay Tim Beck and I talked about this a lot give the locus of control to the person okay I think I have to wrap this up two other examples I'll tell you what I think and it's honoring the question but I'd like to keep listening to your views on this because I'm learning a lot I didn't know can I tell you later I'm asking permission I'll tell you but I believe your opinion is more important than mine when I said this to somebody about medication estab it you're the doctor I said you have like seven PhD because he had a sense of humor but then I said your opinions more important when you leave here you'll use your common sense your good judgment to decide whether or not you're going to take medicine it's up to you not up to me right and when you give your opinion I like to apologize I'm sorry Susan this might hurt your feelings I might be wrong acknowledge my own fallibility I hope we can agree to disagree I think I'd like to focus on keeping you out of the hospital keeping you from getting arrested right can we can we talk about that right now I don't want to become one of those people that argue with you about whether you're married or not would that be all right with you I'm asking permission you see how it works and I'm empathizing with those things that isolate her from other people and normalizing the experience I'd feel exactly the way you feel if I were in your shoes right and then looking again for those areas where we agree and that means the things that she perceives as problems talking about medication if it's relevant and reflecting back the the advantages of it if there are any for her she may not think there are my brother's case he took it because I wanted him to and other people in his life he care about wanting him to but always agree to disagree and then finally you move forward on goals you both can agree can be worked on together right can I have one more minute is there time or no since we started late I'm looking at you no I got it one minute okay very quickly I just want to tell you something about what what's happened with leap over the last 11 years I can't say yes to all the invitations we've trained faculty and I want to just give you a quick picture of what we're doing now these are 15 they sent this slide to me I don't usually animate slides like this 15 psychiatrists came from Turkey a year and a half ago to New York to be trained to use leap it's a two-day program and it's called the therapeutic alliance program I love the name and from I think it was April to June of last year they trained it's now over 500 physicians but it was 350 over 200 nurses and 50 family caregivers we're doing lead trainings all over Europe New Zealand China less so in the US recently for some reason but I want to just point out that it involves a lot of role playing a lot of learning these tools and this is really what I wanted to focus on that after only two days of training 95% rated these physicians these trainers as excellent it's not hard to do it's not hard to learn you could there's free videos on our website you don't have to go to a training you don't have to Train trainers look at the free videos if you want the book they have it here and if it's not leap than some other form of motivational interviewing last comment would you recommend this to your colleagues these are psychiatrists this is what they found 97% said said yes it's just another set of tools to help us become the friends of our patients again and and to work together with them to engage them in treatment thank you for your participation very much patience

Channel: The LEAP Institute

Views: 9,179

Rating: 4.8117647 out of 5

Keywords: Schizophrenia, Mental Health, Training, Help, Mental Illness

Id: GF3ilo2mxX0

Length: 56min 5sec (3365 seconds)

Published: Mon Apr 01 2013