Communicating with a Loved One Who Has a Mental Illness

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

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

Successful communication begins with good listening.  Over time, good listening will allow you to:

  • gain valuable insight into the experiences and motivations of your loved one;
  • help him to feel heard and understood, which usually will increase his willingness to hear what you have to say.

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 to improve your understanding of his experiences and point of view.
    • Express empathy for what he is feeling.
  • 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 her if you postpone any advice or suggestions until she feels heard and understood and asks for your opinion.
  • Even if you disagree with his interpretations of reality, try to understand his experiences, point of view, hopes, fears, and beliefs about himself and his situation. Your goal is to understand his reality from his point of view even if he is psychotic (out of touch with reality).
  • Avoid reactive listening. Listen to understand, instead of thinking about how you can argue back or convince the person to change her wrong beliefs. Avoid interrupting, criticizing or giving advice. Even if she 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.
  • 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 approaches that work well for you and your loved one.

Some Suggested Responses to Use During Reflective Listening

You can say:

  • Let me see if I have this right. Are you saying that …?
  • I hear you saying … Did I get that right?
    or Can you tell me more about that?
  • If I heard you correctly, you said that … Is that right?
    or I can understand why you feel/want …
    or How do you feel about that?

You can use nonverbal responses (e.g. nodding your head).  You will need to figure out which responses work best in which situations.  For example, 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 appropriate, you may want to apologize for not listening in the past.
  • If your loved one doesn’t want to talk to you, you may find that he/she is more willing to talk if you can reduce the intensity of the interaction (e.g. 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).

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.  Think about what would be the best setting for a conversation with your loved one; in some cases, it will be best to choose a time and place where you will not be interrupted, but in other cases your conversation may be more successful in a semipublic venue like a restaurant.
  • When you speak:
    • Use a calm tone of voice and speaking style.
    • Use brief, concise sentences (since a person with mental illness may have trouble processing input).
    • 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 won’t trigger 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. Also, behavioral change usually takes time and occurs gradually. Before a person makes a significant change, there usually is a substantial period when her thinking is changing as she becomes more open to the possibility of change and begins to think about how 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.).
  • It is often more effective to focus on creating a positive, supportive environment, instead of dealing with problems after they arise.

III. Our emotions affect how we communicate.

  • To listen and communicate well, you will need to be calm.  You will probably find it challenging to cope with your loved one’s pain, anger, criticism and/or blame.  You will be better able to help him if you can maintain some emotional distance so you do not drown in his pain.  To stay calm, you may find it helpful to do deep breathing if you start to get upset while listening.
  • Identify and deal with any anger or fears you may have about your loved one with mental illness.  Even when you don’t talk about your negative emotions, your nonverbal expression of these emotions may upset your loved one, which may exacerbate her illness.
    • To reduce your anger, it may help to remember that your loved one’s difficult behavior is usually a symptom of her mental illness rather tan unkind, thoughtless, or manipulative behavior that she could stop if she would only try to change her behavior.
    • Find some way to process the emotions you experience as you communicate with your loved one with mental illness.  For example, seek out someone who can listen well to you as you process these emotions.
  • 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 (https://namimainlinepa.org/support/; https://www.nami.org/Find-Support) and other similar organizations.

IV. 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 himself and his experiences. Reflect back what you have heard, without your opinions and ideas.
Empathize: Empathize with how the person feels about 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.

Additional advice includes:

  • During the listening phase:
    • Use reflective listening (see section I)
    • 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 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.

V. Recommended Resources

NAMI resources include:

LEAP resources are available at https://leapinstitute.org/home, including videos (https://leapinstitute.org/free-leap-vids) and I Am Not Sick, I Don’t Need Help! by Xavier Amador (available in paperback for $22 or Kindle edition for $10).[4]

Mental Health First Aid provides useful guidelines for helping someone with depression, panic, psychosis, problem substance use, etc. (https://mhfa.com.au/cms/guidelines).  A Guide for Caregivers of People with Mental Illness is available at https://mhfa.com.au/sites/default/files/MHFA_carers_guidelinesA4.pdf.

[1] Available at https://namimainlinepa.org/communicating-with-a-loved-one-who-has-a-mental-illness/  (updated April, 2019)

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

[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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