by Tom Pyle
I Am Not Sick; I Don’t Need Help! How To Help Someone With Mental Illness Accept Treatment. By Xavier Amador, Ph.D. New York: Vida Press, 2010. 249 pages.
Over 6 million Americans suffer from severe mental illness. Incredibly, 50% of these who do believe they don’t. Clinically speaking, they do not have “insight” into their diseases. They experience what is technically called anosognosia. Previously thought to be a deliberate act of denial on the part of a patient, anosognosia is today considered to be caused by a neurological deficit, probably in the frontal lobe of the brain. Its presence is a symptom of the brain disorder, not a subconscious or willful psychological state.
Anosognosia can cause myriad problems for loved ones, their families, and society as a whole. A lack of insight results in treatment refusal. How could it not? Anyone who thinks they are not sick would understandably refuse treatment for what they do not acknowledge. Treatment refusal leads to medications non-compliance, which in turn can lead to more florid delusions or hallucinations. Personal hygiene can deteriorate. Isolation can increase. Especially when someone with a severe mental illness lacks insight also abuses street drugs or alcohol, there is a heightened potential for violence in a small percentage of cases.
How can family members cope with a loved one lacking insight? How can they get a loved one needed help if the loved one doesn’t acknowledge the need for help? Many family members in the maelstrom know the frustration of getting an oppositional loved one to do what might be good for them, at least as the family members perceive. Those in the earlier stages of their psychodysseys may feel particularly stressed by the apparent futility of talking a loved one out of his delusions or into a treatment for an illness he refuses to believe he has.
In his classic work, I’m Not Sick; I Don’t Need Help!, clinical psychologist and Columbia University professor Xavier Amador proposes a simple technique. It is called LEAP, for Listen, Empathize, Agree, and Partner. “Listen” means listening without commenting, disagreeing, or arguing. It is based in reflective listening, in which the listener drops his or her own agenda and redoubles efforts to understand the loved one, whatever his psychological idiosyncrasies. “Empathize” means displaying genuine emotion even when relating to a loved one’s delusions. “Agree” means agreeing as a neutral observer, acknowledging that the loved one has personal choice and responsibility for his decisions. “Partner” means undertaking with the loved one to achieve shared goals.
The LEAP technique is an amalgam of three therapies. From Carl Rogers’ client-centered therapy is drawn the concept of reflective listening without judgment or opinion. From Aaron Beck’s Cognitive Therapy come the ideas of collaboration, agenda setting, and cost-benefit analysis. From William R. Miller and Stephen Rollnick’s Motivational Interviewing derives the emphasis on the loved one keeping the locus of control for personal change.
Amador’s approach is elegant in its simplicity. It is also authentically based in Amador’s lived experience as younger brother to the late Henry Amador, a man with schizophrenia. (The evidently deep love Amador felt for his brother is itself an inspiration for other family members with loved ones in similar circumstances.) I Am Not Sick; I Don’t Help!, now in its 10th anniversary edition, is a classic text in the field of treatment of schizophrenia, an invaluable navigation tool for all families in the maelstrom of severe mental illness.