Communicating with a Loved One Who Has a Mental Illness

Communicating with a Loved One Who Has a Mental Illness[1]
Ingrid Waldron, NAMI PA, Main Line[2]

 I.  Communication is a two-way process. – Why and How to Listen Well

Communication begins with good listening. Good listening helps you to better understand your loved one and helps him or her to feel heard and understood. Over time, good listening will allow you to

  • gain valuable insight into the experiences and motivations of your loved one
  • improve your relationship with your loved one and increase his/her willingness to hear what you have to say
  • break through the isolation experienced by many people with severe mental illness.

Guidelines for Listening to Someone Who Has a Mental Illness

  • Practice reflective listening. Listen with the goal of understanding. Reflect back what you have heard and ask whether you have understood your loved one accurately. Ask questions so you can understand your loved one’s experiences and point of view. Communicate your understanding and empathy. Remember that if your loved one feels that you care enough to listen and understand his/her point of view, this will probably help to motivate him/her to be willing to listen to you.
  • It will help if you can be curious to learn more about your loved one, focus your attention on understanding your loved one, and put all your other agenda items aside for the time being. Although you are eager to accomplish helpful changes for your loved one, you will be more effective in helping your loved one if you postpone any advice or suggestions until your loved one feels heard and understood and asks for your opinion.
  • Even if you disagree with the person’s interpretations of reality, try to understand his/her experiences, point of view, hopes, fears, and beliefs about him/herself and his/her situation. Your goal is to understand his/her reality from his/her point of view even if he/she is psychotic (out of touch with reality).
  • Avoid reactive listening. Listen to understand, rather than thinking about how you can argue back or convince the person to change his/her wrong beliefs. Avoid interrupting, criticizing or giving advice. Even if your loved one criticizes you, let it be. Recognize that criticisms and blame generally come from the illness and typically have little to do with you personally. Remember that a mentally ill person may have anosognosia (the inability to perceive the mental illness or neurological deficit) and/or delusions (fixed beliefs that do not change in response to evidence to the contrary), so arguing about what is real will not be useful.
  • To listen well, you will want to be reasonably calm. It may be challenging to cope with your loved one’s pain, anger, criticism and/or blame. You will be better able to help your loved one if you can maintain some emotional distance so you do not drown in his/her pain. To stay calm, you may find it helpful to do deep breathing if you start to get upset while you are listening.
  • You may need to set limits on when, where and how long you can listen. Try to choose a time and place when your loved one wants to talk and you will be able to focus your attention on listening well. When you can’t listen well any more, say something like “I’m sorry. I know you probably have more to say, but I need to take a break now.” This type of limit setting helps to make it safe for you and your loved one, and will help you to remain calm as you listen.
  • These guidelines provide helpful general advice, but individuals and situations differ, so you will need to learn what works best in your situation and develop modified guidelines that work well for you and your loved one.

Some Suggested Responses to Use During Reflective Listening

This list offers multiple versions of a basic reflective listening response (since variety can help to make the responses seem less artificial), followed by several types of suggested alternative responses to get more information or express empathy. You will need to figure out which responses work best in various situations with your loved one.

  • If I heard you correctly you said … Did I get that right?
  • If I understand you, you’re telling me that … Is that right?
  • So, I hear you saying … Did I get that right?
  • Let me see if I have this right. Are you saying that …?
  • Let me see if I am following you. … Is that right?
  • So, (person’s name), tell me if I have this right. …
  • So, if I heard you right, you see yourself as … or you see the situation as …

Is that right?

  • I hear you saying “…”. Can you tell me more about that?

or Can you help me understand that?

or some other follow-up question to learn more

  • If I understand you correctly, … I can understand why you feel/want …

or I would feel the same way if I were in your situation.

or How do you feel about that?

  • A follow-up question to learn more about something your loved one has said or an expression of empathy (with the understanding of what your loved one has said implicit rather than explicitly reflected)
  • Nonverbal responses (e.g. nodding your head), sometimes best without any verbal response (As with the verbal responses, you will need to figure out which ones work best in which situations; e.g. sometimes your loved one may appreciate eye contact and other times eye contact may make your loved one uncomfortable.)

 Additional Advice

  • If you are just beginning to use reflective listening with your loved one, you may want to begin by saying something like “Today, I’m going to try something a little different. I’m going to try to understand how you really feel and what you really want by listening very carefully to what you have to say.” If necessary, you may want to apologize for not listening in the past.
  • If your loved one doesn’t want to talk to you, his/her verbal and nonverbal cues may help you figure out what circumstances will encourage him/her to communicate. You may find that your loved one is more willing to talk if you can reduce the intensity of the interaction (e.g. by not making eye contact or by talking while engaged in a joint activity) or your loved one may be more willing to talk with someone else (e.g. another family member or friend).
  • Identify and deal with your fears that make it hard for you to listen to what your loved one with mental illness has to say.
  • Find some way to process the emotions that come up while you are listening to your loved one with mental illness. For example, seek out someone who can listen well to you as you process these emotions.
  • In general, take good care of yourself so you will be able to stay well and cope with the long-term stresses of having a loved one with severe mental illness. We encourage you to take advantage of the helpful programs offered by NAMI (NAMI.org) and other similar organizations.

II. Expressing Yourself Effectively

  • When you want to initiate a conversation on a challenging topic, try to choose a time when you are both calm and a time and place where you will not be interrupted. Speak calmly.
  • Use brief, concise sentences (since a person with mental illness may have trouble processing). Allow time for your loved one to process what you have said and respond.
  • Be thoughtful about how you describe a problem. Aim to present a problem in a way that your loved one can hear without triggering emotional reactions that preclude reasonable discussion.

– Use “I statements”.
– Describe a specific behavior that is of concern.
– Avoid attributing the behavior to character flaws or assumed motivations.
– Avoid terms such as “always” and “never”.

For example, to improve your chance of having a useful conversation, say “I get very worried when you are gone for several days and I don’t know where you are.” instead of “I’m so upset! You are always so inconsiderate. You never think about my feelings.”

  • If you want to propose a change, try to focus on a single specific proposal. Think about your loved one’s motivations and how you can present your proposed change in a way that will appeal to his/her motivations (e.g. offer some thing, activity or privilege he/she wants or appeal to his/her self-image or concern for other family members). Be flexible in considering alternative solutions that may be a better compromise that meets the most important needs of each person.
  • It is important to recognize that most problems or issues are not resolved in a single conversation. Instead it usually takes a long series of conversations with reflective listening and empathy to accumulate the understanding and build up the trust needed to solve problems. In addition, change usually takes time and occurs gradually. Before a person makes a significant change, there usually is a substantial period when his/her thinking is changing as he/she becomes more open to the possibility of change and begins to think about how he/she might change. Even after behavior begins to change, there will probably be relapses (think about your own efforts to increase exercise, improve your diet, stop smoking, etc.).

Additional Advice

In order to identify changes that you can make to increase your success in communicating, it can be helpful to think about the differences between occasions when communication has been relatively successful vs. times when communication has failed.

  • Were there differences in the physical setting (e.g. location, your relative positions, any other ongoing activity, other people present)?
  • Were there differences in your emotional state or your loved one’s emotional state?
  • Were there differences in the topic or topics you discussed – e.g. were you discussing a single specific topic, a broad topic, or multiple topics?
  • Were there differences in your communication strategies (e.g. asking questions, expressing empathy, criticism, or presenting a proposal)?

If you can identify differences between occasions when communication was successful vs. unsuccessful, this may help you identify approaches that you can use to increase your rate of success. For example, one person found that conversations in semi-public venues like a restaurant were more successful and another person recognized that conversations generally did not go well in the car. A third person found that communication was generally unsuccessful if either or both participants were upset and if the conversation covered multiple topics; she and her daughter agreed to make prearranged appointments to discuss a single specific topic and/or find a solution for a single problem; this resulted in much calmer and more constructive conversations.

III. LEAP[3]

LEAP is an effective system for communicating and collaborating to solve problems with a loved one who has a mental illness. Briefly, LEAP includes the following sequence:

Listen: Listen to try to understand what the person is telling you about him/herself and his/her experiences. Reflect back what you have heard, without your opinions and ideas.
Empathize: Empathize with how the person feels about his/her experiences and symptoms (without necessarily agreeing with his/her view of reality; e.g. “That sounds scary. Do you feel frightened?”).
Agree: Find areas of agreement, especially goals you both want (e.g. to stay out of the hospital)
Partner: Collaborate to work toward agreed upon goals.

Specific advice includes:

  • During the listening phase, use the approaches described in the first section. Also, do not give your opinion unless asked; even when asked, delay giving your opinion as long as possible, promising to give your opinion later, after you have learned more and understood what your loved one has to say. If possible, postpone responding to any requests that you do something; say something like “We can discuss that later, but first I need to understand more about what you are thinking and feeling.” If you have listened well and built up understanding, you are more likely to be able to provide your input in a way that your loved one will be able to hear. If your loved one is actively soliciting your input and has come to trust you, he or she is much more likely to listen to your input with interest.
  • The agree step should be based on understanding what your loved one wants and figuring out at least one goal that you both want. This does not mean pressuring your loved one to agree to what you want.
  • In the partner step, you may want to work with your loved one to:

– identify one or two specific goals within the overall goal(s) you have agreed on
– identify specific steps toward achieving this goal
– agree on what each of you will do to carry out these steps
– perhaps agree on a time frame for carrying out the first steps.

IV. Recommended Resources

[1] Available at https://namipamainline.org/info-resources/advice-coping-with-smi/; click on “Communicating with a Loved One Who Has a Mental Illness” (updated June, 2014)

[2] I am indebted to I Am Not Sick, I Don’t Need Help! by Xavier Amador for many of the ideas in this presentation and to Carolyn Ballinger, Ellen Berman, Bruce Fay, Judy Green, Loran Kundra, and Aita Susi for helpful input and suggestions.

[3] LEAP is a registered trademark®. LEAP was developed by Dr. Xavier Amador. Additional information is available in the recommended resources listed on the next page.

[4] This book is very helpful, but it may be useful for you to be aware of the following caution. The examples given in the book generally include skillful professional interpretations and problem solving and appear to make significant progress in a short time. In our experience, we rarely replicate this type of success, but over time we can substantially help our loved ones with lay reflective listening and empathy skills.

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