Reflective Listening by Xavier Amador

All the passages below are taken from Xavier Amador’s book, “I am Not Sick I Don’t Need Help!” It is 10^th Anniversary Edition of 2010-12.

In my LEAP seminars, I always ask, “Why would anyone want to listen to you if he felt you had not first listened to him? Quid pro quo.”

This important psychological principle–which is the cornerstone of my method for breaking an impasse–is far from new. More than 2,000 years ago, the Roman poet Publilius Syrus said, “We are interested in others when they are interested in us.”

Psychologists who are expert in conflict resolution and marriage and family therapy have written about this fundamental principle for decades. Dale Carnegie, author of the 70-year-old best-seller How to Win Friends and Influence People writes, “Philosophers have been speculating on the rules of human relations for thousands of years, and out of all that speculation, there has evolved only one important precept. It is not new. It is as old as history. Zoroaster taught it to his followers in Persia twenty-five hundred years ago. Confucius preached it in China twenty-four centuries ago. Jesus taught it among the stony hills of Judea nineteen centuries ago. Jesus summed it up in one thought–probably the most important rule in the world: “Do unto others as you would have others do unto you.”

More recently, the authors of Getting to Yes, The 7 Habits of Highly Effective People, Good to Great, How to Argue and Win Every

Time and other insightful observers of human relations have all emphasized this same fundamental principle of persuasion. But despite the ancient lineage and popular dissemination of this simple and logical truth, it is too often overlooked when we are lured into an “I’m right, you’re wrong” situation and end up thrashing around like a fish caught on the end of a line, certain that if we try just hard enough (i.e., speak more loudly or repeat our position once again), we will win. And sometimes we do succeed in bending the other person to our will, but not without doing some damage. Listening with genuine curiosity and respect is the key to not getting stuck in this trap and opening the other person to caring about your opinion.

It was 7:30 a.m. and morning rounds had begun on the ward where I worked as an attending psychologist. The entire day shift was seated in a circle around the room. Doctors, nurses, social workers and assorted students were, or soon would be, repeating this ritual on inpatient psychiatric wards all over the country.    a

The chief of the unit, a psychiatrist, called the meeting to order and then Marie, the head nurse, took over. She began by reviewing how each patient had fared the night before. When she came to Samantha, a 40-year-old single woman with chronic schizophrenia, she paused and sighed before beginning. “Samantha Green, stable on six milligrams of Risperdal. She slept well last night and is ready for discharge today. Jo Anna,” she asked the senior social worker, “do you want to fill everyone in on the discharge plan?”

“Sure. It’s a real gem,” responded Jo Anna sarcastically. “Samantha is going back to her parents’ house and has an outpatient appointment with her doctor set for a week from today. Mr. and Mrs. Greene are picking her up at noon and she’s walking out the door with a one-week supply of medication.”

“You don’t sound too pleased with the plan,” I commented.

“It’s nothing personal,” she replied, knowing that Samantha and her parents also had an appointment with me for a family meeting. “The plan is all right–it’s Samantha I’m not pleased with! She paused, and then added, “Look, we all know what’s going to happen. Call me cynical, but I’ll bet you ten dollars she stops taking her medication before the end of the month and she’ll be back here before you know it. She needs long-term hospitalization, not another trip through the revolving door.”

Samantha had been admitted to the hospital four times in the past year. Each episode of illness had been triggered when she secretly stopped taking her medication. Her parents would notice her talking to herself and start to worry that she was not taking her pills. Her mother would then ask if this was so, and Samantha would invariably deny it, even though she had not taken them for weeks. By the time the truth came out, it was usually too late and she needed to be hospitalized.

To my ears, Jo Anna’s lack of faith in Samantha, her parents, and in me was neither cynical nor insulting. Given Jo Anna’s experience and perspective, she would have been foolish to expect anything more than she did. However, if Jo Anna had known what I knew, she might have shared my optimism for Samantha and her family.

I knew why Samantha didn’t want to take psychiatric drugs. It had taken some effort to uncover the true reasons, but with that knowledge and a good idea of what Samantha wanted out of life, I knew I could help her stay on her medication, in treatment, and out of the hospital. But Jo Anna and the rest of the hospital staff hadn’t learned what I had, because they were focusing on other things.

In the climate of managed care and increasing advances in drug therapies for serious mental illness, mental health professionals working in hospitals have become increasingly specialized. Psychiatrists evaluate health and symptoms and order medications. Psychologists working on inpatient wards typically perform psychological assessments and, less often, do therapy. Nurses dispense medications, monitor patients’ health and safety, and provide education about the treatments received. Social workers evaluate the patients’ discharge needs and make arrangements for outpatient treatment and residence. As a psychologist working with the seriously mentally ill, I know a good deal about the medications used to treat the disorder but I don’t prescribe them. My job is different–understanding the person and how the illness has affected his sense of self and goals is one of my areas of focus. And that is why I was optimistic about stopping the revolving door Samantha was stuck inside.

Unlike the others, I knew how Samantha experienced being ill and what she thought about the drugs we were “pushing” on her. I also had a clear understanding of what it was she wanted out of life, and that knowledge had helped me to get her to agree to a trial of the medication as an outpatient. Unlike the other times she’d been hospitalized, she was not agreeing to take the medicine to placate us so she could get out–she was agreeing to continue (for a time) to see if it could help her achieve one of her goals. In other words, I had been doing a lot of listening, and what I had learned gave me a foothold with Samantha and reason to have hope.

Building a Treatment Agreement

The cornerstone of building a treatment agreement that will work and outlast your direct involvement is cut from the quarry of your loved one’s sense of who she is, what she believes she is capable of doing, and what she wants out of life. Unless you know its shape, color, texture, and strength, you will be unable to build on this foundation. Each stone you lay will topple and fall to the ground unless you have listened and learned about her experience of these things. Specifically, you want to ask about

her:

• beliefs about having a mental illness
• experience and attitudes about medication
• concept of what she can and cannot do
• hopes and expectations for the future

In the next three chapters, I will show you how to put your knowledge of these areas to practical use. But before we get there, you have to know your loved one’s answers to each of these questions. And, because serious mental illness often changes the way people communicate with one another and what each person wants to talk about, there are some common pitfalls you’ll need to avoid. The best way to do that is by learning how to use reflective listening.

Reflective Listening

We all know how to listen. But I’m not talking about “everyday listening.” I’m talking about reflective listening, which is very different.

When you’re doing it right, you’re asking a lot of questions. You sound like a journalist conducting an interview.

Reflective listening has, as its sole purpose, understanding what the other person is trying to convey and then communicating that understanding back without commenting or reacting in any way. It is an active, rather than passive process–your role is purely that of a listener who wants to get it right. When you’re doing it right, you’re asking a lot of questions. You sound like a journalist conducting an interview.

I’ll give you an example of how and why something that seems so simple doesn’t come naturally.

All my life, people have told me I am a naturally good listener. As a psychotherapist, I pride myself on my ability to listen and understand other people’s experience. But everything I thought I knew about listening was put to the test the first few times I tried to converse with people in denial about having a serious mental illness.

I was 23 years old when I took a job as a psychiatric technician (a.k.a. nursing aide) on an inpatient psychiatric ward at the University of Arizona Medical Center. My brother Henry’s first psychotic episode had occurred less than a year before, and despite his rambling speech and crazy ideas, I could still understand him. My experience with my brother had given me a lot of confidence. I have listened to many bizarre things, I thought. I can do this.

As a psychiatric technician, I was responsible for assessing, among other things, how agitated, depressed, elated, suicidal or dangerous my patients were. I was also charged with determining whether my patients were following the prescribed treatment plan. Every conversation had a hidden agenda.

My very first admission evaluation was with Barbara, a 42-year-old woman who was in the throes of a grandiose delusion and irritable manic episode. She was talking a-mile-a-minute about her power to read minds, her supernatural abilities, the alien implant in her brain that had given her these powers, and the fact that she didn’t need to be in the hospital. And she was very angry about being there.

With a bright red, hospital-issued clipboard on my knee, I diligently started with the list of questions that were printed neatly in rows on the evaluation form. “Can you tell me why you came to the hospital?”

“Can you tell me why you came to the hospital?” She mimicked me with disdain, effectively humiliating me for being a rookie.

I quickly countered, trying to recover my composure. “I am sorry. You were brought here by your husband. That’s right, isn’t

it?”

“I am sorry. You were brought here by your husband. That’s

right, isn’t it?” she echoed sarcastically.

Stating the obvious, I said, “It sounds like you don’t want to talk right now. I am sorry, but I have to get through these questions.” I pleaded with her, despite the fact that I was feeling even more humiliated and was also starting to get angry.

“I don’t give a shit about your f-king questions!”

“I’m sorry, but I really do need to get through these questions.”

“Grow up, little boy. You better realize who you’re dealing with here. You don’t know what you’ve gotten yourself into and you are in way over your head. Way over your head. Maybe I’ll have your head. I could, you know. It’s as easy as snapping my fingers or blinking an eye or squashing the wings of a butterfly!” She shouted in rapid fire before bursting into hysterical laughter.

My agenda was moot, my face a bright shade of red. I know, because she made a point of telling me as I was excusing myself and trying to walk–not run–out the door. I was scared and angry. I went to the nurses’ station and plopped down next to Nancy, the charge nurse.

“You got that done fast,” she said incredulously.

“Not really. I didn’t get much done at all.” 

“She wouldn’t answer your questions?”

“No. All she did was mimic my every word and threaten me.” “Threaten you?!”

“Not exactly. At least not in reality. She was threatening me with her God-like delusional powers.”

“Well, it seems like she may not be able to answer these questions right now. What did you learn about her from just sitting in the room?”

“Well, she’s angry and doesn’t want to be here. She’s in denial. She’s manic, irritable, and grandiose. And she doesn’t want to talk to me. Maybe someone else should give it a shot.”

“No. She’s your patient. I just gave her some medicine–give her a couple of hours to calm down a little, then try again. Only this time, don’t bring in the admission form. Start by asking her if there’s anything she would like to say. Let her talk about why she thinks she shouldn’t be here and see where it goes. Ask her questions about that. That seems to be where she’s at. Look for an opening to tell her you’re sorry she’s here.”

“God knows I’m sorry she’s here!” I said, joking, and feeling better.

I saw the wisdom in Nancy’s advice. I followed her suggestions and ultimately learned quite a bit about Barbara. But it took putting my agenda on the back burner for me to listen to what she was feeling about being forced to be a “mental patient” in a psychiatric hospital. As a result, I was able to get my form filled out. Some questions were not answered, but the essentials were covered. (I will tell you more about Barbara later. But for now, I want to focus on the other elements of reflective listening.)

To do it right, you have to drop your agenda. Your only goals are to understand what your loved one is saying and to convey that understanding.

It’s hard to listen reflectively in the face of all the distracting “noise” of psychosis, especially if you are pursuing an agenda and trying to follow a timetable. To do it right, you have to drop your agenda, as I did with Barbara. Your only goals are to understand what your loved one is saying and to convey that understanding.

     This is very hard to do at first, but it’s not impossible and actually gets quite easy once you “unlearn” your natural bad habits. Reflective listening is a skill and, as with any skill, once you know the basic principles, all you need to do is practice to get it right. To start, here are seven guidelines for reflective listening:

Seven Guidelines for Reflective Listening

1. Make it Safe

2. Know Your Fears

3. Stop Pushing Your Agenda 

4. Let it Be

5. Respect What You’ve Heard 

6. Find Workable Problems 

7. Write the Headlines

1. Make it Safe

During the first few years he was ill, Henry never wanted to talk to me about the medicine he was prescribed. He didn’t feel safe. As you will learn later on, my brother and I argued a lot for many years, going round and round on the issue of whether or not he was sick and needed to take medicine. This happened because we got into what I call the denial dance, which creates pessimistic expectations about talking.

Let me tell you about one of my first experiences with this.

My brother had just come home from the hospital and was doing well. The medication obviously helped him, but within a day of his getting home, I found it in the garbage can. Naturally, I asked him why he’d thrown it out.

“I’m okay now,” he explained. “I don’t need it anymore.”

This ran counter to everything he was told in the hospital, so I made a point of reminding him. “But the doctor said you’re probably going to have to be on this medicine for a rest of your life. You can’t stop taking it!”

“He didn’t say that.”

I countered with, “Sure he did! I was at the family meeting, remember?”

“No, he said I had to take it while I was in the hospital.” “Then why did he give you a bottle of pills to take home?”

I argued, trying to prove him wrong.

“That’s just in case I get sick again. I’m fine now.” 

“No, that’s not what he said.”

“Yes, it is.”

“Why are you being so stubborn? You know I’m right!” I said.

“It’s my business. Leave me alone.”

“When you got sick it became everyone’s business. And besides, I’m worried.”

“You don’t have to worry about me. I’m fine.”

“You’re fine now, but you won’t be if you don’t stay on the medicine.”

“That’s not what the doctor said!” 

“Then let’s call him and I’ll prove it!”

“I don’t want to talk about it! Just leave me alone,” he said as he walked away.

With every dose of “reality” I tried to give him, Henry countered with more denials. And with every go-round, we both became angrier and angrier. I thought he was being stubborn and immature. My accusations and threat to prove him wrong made him even angrier and more defensive. My natural instinct to confront his denial was completely ineffective and only made things worse. We got caught in a cycle of confrontation and denial that pushed us further apart and, not surprisingly, left my brother feeling that it was not safe to talk with me about these issues. The end result of conversations like this was that he walked away. The dance always ends in avoidance.

Henry said it best after one of our early arguments. “Why should I talk about this? You don’t care about what I think. You’re just going to tell me I’m wrong and need to see a shrink!”

It wasn’t until I was in training to become a psychologist that I finally understood that my brother wasn’t simply being stubborn. Armed with more knowledge and experience, I reflected on how I had talked to him and realized I had played a big role in getting him to stop talking and start sneaking (e.g., when he secretly threw his medicine in the garbage while claiming he was still taking it).

I made him feel unsafe. He knew that if he said he wasn’t sick and didn’t need medication, I was going to argue with him. Sometimes I did it gently, but as the years wore on and he became what mental health workers call a “frequent flyer,” I was often harsh in my confrontation of his denial. Once, I even planned an intervention involving several family members and Henry’s social worker. We all, gently but powerfully, told him he was in denial. One by one we told him he had schizophrenia and needed to take psychiatric drugs to get better.

Now imagine if that happened to you (assuming you do not have schizophrenia, which was exactly Henry’s point of view). Imagine that this conversation followed on the heels of dozens more like it. Would you really be interested in explaining, once again, that there was nothing wrong with you and you didn’t need medicine? No. Better to walk away or, if you can’t, shut up and pretend to agree in order to get the conversation over with quickly.

“I am sorry for not listening to you. I understand why you don’t want to talk about this anymore.”

So how do we make it safe to talk? First, set aside a special time. It can be over a cup of coffee, a walk, on top of a Ferris wheel! Anywhere. What matters is how you introduce the conversation.

If you’ve had arguments in the past, you need to apologize and acknowledge that you made your loved one feel unsafe. You can say something like, “I am sorry for not listening to you. I understand why you don’t want to talk about this anymore.” And then normalize his reaction to you by saying something like, “If I were in your shoes, I would feel the same way.” When you apologize for jumping in with your opinion (which I call reactive listening) and admit you would feel the same way he does, you make it safe to talk.

But there’s more. You have to promise not to do it again. “I want to hear more about why you hate the medicine and I promise I won’t do anything but listen and try to get a better understanding of your view on this. I promise not to give my opinion.”

You might be thinking, “Wait a minute! How can you help someone in denial if you are not going to tell him the truth? Don’t you have to help him see the problem and the solution?” Yes, you do. But not yet …and not in the way you think.

Advice is a funny thing. It can be perceived as either welcome or unwelcome, disrespectful, insensitive, and patronizing. What determines how the advice will be received? Here’s an example.

Women who have been pregnant often complain about how complete strangers walk up to them and give them unsolicited advice. Sometimes it’s humorous; usually it’s irritating. But almost always, they ignore the free advice because it was uninvited and felt intrusive.

And yet, every woman I have talked to about this experience admits that she had at least one friend or relative whose counsel she sought and listened to. That’s the difference between solicited and unsolicited advice. Advice that has been requested carries far more weight than unwelcome advice. So, when you promise to not give your advice because your main goal is to listen and learn, you gain instant credibility. And I guarantee, as strange as this may sound, that you will be asked for your opinion far sooner than you would like.

So apologize for not listening well enough, promise you will listen without comment, and keep the promise. To succeed, you will need to discover why you have been afraid to listen in this way, because if you don’t, the same fears that kept you from reflective listening in the past will trip you up going forward.

2. Know Your Fears

Whenever I teach reflective listening to a new group of people I am reminded how much more similar than different we all are. On the outside, all sorts of differences jump out at me–the man in the business suit sitting near the one in the “Guns Don’t Kill People, People Kill People!” T-shirt and torn jeans; the large, loud woman and the meek, diminutive one. People of all shapes, sizes, religions, races, and politics come to LEAP seminars because they all have a deep desire to help a loved one who is in denial. They also have the same fear about taking that first step, the fear that, “I will make it worse if I listen the way Dr. Amador says I should.”

During these seminars, I define reflective listening just as I did above. Then I ask for a volunteer. Recently, I did this role-play with Gwen in Halifax, Canada. Her job, as I explained it to her, was simply to listen to me as I role-played a delusional patient, and then reflect back what she had heard.

She looked confident as I began the role-play. Speaking fast and sounding very angry and scared, I said, “Look, Gwen, I am not sick, there’s nothing wrong with me. I’m not taking that medicine because it will kill me. It’s poison. If you want to help me, then help me with the people upstairs.”

“What about the people upstairs?” she asked, without reflecting back what I had just said.

“Every night at eight o’clock, they walk across the floor of their apartment to the bathroom. I hear them flush the toilet and I know what they’re doing! I’m no fool! They’re communicating with the group that’s trying to kick me out of my apartment. They’re the same people who have been trying to kill me!”

Gwen, who had been nodding as I explained the problem, answered, “So it sounds like the people upstairs are disturbing you. They’re making a lot of noise?”

Seeing that she was done, I asked the audience, “Did Gwen reflect back what I said?” Immediately numerous hands shot up. One after the other, they described how she had not. “They saw what Gwen could not see in the moment–although she had responded in the form of a question, as I had recommended, she had not reflected back a single thing I had said. The closest she came was mentioning that I was “disturbed” by the people upstairs. In fact, however, I wasn’t disturbed. I was scared and angry and it had nothing to do with their being “noisy” neighbors. The noise didn’t bother me–it was their use of the toilet as a signaling device that had me upset!

The audience was able to see that she had not reflected back what I had said, but they didn’t do much better themselves when several of them tried their hand at it. Like Gwen, they omitted mentioning the “crazy” facts. The closest anyone came was acknowledging that the toilet flushing was a signal to the other people in the building who wanted “me” evicted. But they all avoided talking about my denial, my belief that the medicine was poison, and the stranger, more paranoid delusions (the conspiracy of fellow tenants who were planning my murder).

After reassuring my volunteers that I used to make the same mistakes with my brother before I learned reflective listening, I modeled the correct way to do it. Playing the role of the listener now, I said, “So, Xavier, tell me if I got this right. You’re not sick and don’t need to take the medicine. What’s worse, the medicine is poison. And the thing you want my help with has to do with your neighbors. Every night at eight o’clock, your upstairs neighbors walk into their bathroom and flush the toilet to signal other people in the building. These are the same people who have been trying to kick you out and also kill you. Do I have that right?”

Not even halfway through saying this, I could see several people squirming in their seats, shaking their heads, and frowning. “I know that many of you are very uncomfortable with what I just said. What makes you so uneasy?”

“You’re reinforcing the denial!” one man practically shouted.

“You can’t tell this guy his medicine is poison. He’ll never take it!” Gwen added.

“What else worries you?” I asked the group.

“You worsened the delusion; now you’re going to get drawn into it. He’s going to want you to do something about his neighbors,” another man offered. A woman, who I knew to be a social worker, raised her hand. “This goes against everything I was taught. You can’t collude with a delusion like that. You’ll reinforce it!”

I turned to the group. “Was anyone feeling okay about what I did?” An elderly woman in the front row raised her hand.

“I thought it was fine,” she said. “He’s going to want to talk with you because you are talking about what’s important. He doesn’t believe he’s crazy and thinks people are trying to kill him, for gosh sake!”

“So why do you think the rest of them are so uncomfortable with my reflecting all that back to him?” I asked.

She slowly turned around to look at the audience, then, turning to face me again, she said simply, “They’re chicken,” and sat back down. After the laughter subsided, I thanked my unexpected accomplice and elaborated on her wise observation.

When you’re facing someone who rigidly holds irrational beliefs, you gain nothing by disagreeing.

First, I never agreed with his beliefs about being sick, the medicine, or the paranoid ideas. By prefacing and ending my statements with questions (“Tell me if I got this right” and “Do I have that right?”), I was free to use my patient’s own words. In no way did I challenge his beliefs. Why should I? He’s delusional!

Rather, I showed him, through my actions, that I wanted only to listen to him and understand. I have never talked anyone out of a delusion and, to my knowledge, I have never talked anyone into one either. The point is, when you’re facing someone who rigidly holds irrational beliefs, you gain nothing by disagreeing. More importantly, you lose that person’s willingness to talk about the problem.

There are, however, a few pitfalls you have to watch out for. One is when the person asks, “So it sounds like you agree with me. Do you?” Or the flip side of the same coin: “Why are you acting like you believe me? Actually, these questions offer an important opportunity, which I’ll talk about in the following chapter. For now, I ask that you trust me–and for the time being, focus on uncovering what your fears are.

3. Stop Pushing Your Agenda.

I know your agenda is to help someone you’re worried about. And you have specific ideas about how the help should come. But because the person in denial is already expecting unwelcome advice for a problem he doesn’t believe he has, you need to keep this agenda to yourself!

When reflectively listening, the only stated agenda you should have is your desire to listen and learn. When a person trusts that you will not pontificate about what he should and should not be doing, he will be more apt to agree to talk about certain “hot” topics (e.g., his refusal to seek professional help).

Agreeing on an agenda is easy if you follow the lead of the person in denial. This is how I was finally able to engage Barbara. What she wanted to talk about was how furious she was for being forced into the hospital when she wasn’t mentally ill. If the person you’re trying to talk to is upset about having to take medicine, ask him about his feelings, not about the medicine or your belief that he should take it. You can say, “I’d like to understand why you hate taking your medicine. Would you mind talking with me about that? I promise I won’t pressure you or bug you–I really just want to understand how you feel about it.”

Try it once with any hot topic and see what happens.

4. Let it Be.

If the discussion turns into an argument and you feel the denial dance coming on, stop! If your loved one becomes accusatory, saying something like, “You don’t care about me, all you’re thinking about is yourself,” just let it be. Don’t fan the flames.

Sometimes mental illness creates “thought disorder,” making it especially difficult for others to follow the person’s train of thought. It’s annoying and frustrating. When talking with someone who has thought disorder, or disorganized speech, be careful that you don’t inadvertently impose order on the chaos, because usually you will get it wrong. In other words, let it be and focus on listening differently instead of on trying to impose order. Listen for the feelings behind the words and reflect back the emotion. When you understand the underlying emotions, you will discover what the person cares about most and what motivates him.

5. Respect what you’ve heard.

When you make it a point to communicate your understanding of what you’ve just heard without reacting to it, you convey your respect for the other person’s point of view. You also deflate anger. When you echo what you’ve heard without comment or criticism, you stop the denial dance dead in its tracks. Think of it this way: Would you really be interested in hearing the opinion of someone you’ve been arguing with if you felt he or she hadn’t listened to your views?

6. Find Workable Problems.

Everyone in denial or with anosognosia, knows he has at least one problem. The problem is you and everyone else who is telling him he needs help!

He will have other problems you can uncover as well. Understanding how the person in denial sees himself and his beliefs about what’s not working in his life is the key to unlocking the isolation and building a relationship with someone who recognizes he is in trouble and needs help. A relationship with someone who can lead him to that help is the only way he’ll find it as long as he is unaware of the illness.

Consequently, you first need to learn what he thinks the problem is. How does he define it? And what does he say he needs to fix it? Without understanding what he thinks is wrong and needs to change, you will be powerless.

For example, my brother never agreed that he had schizophrenia, but he did think that being forced into a psychiatric hospital again and again was a big problem. I couldn’t have agreed with him more. Once you find a problem you can work on together (e.g., Henry and I agreed that avoiding another hospitalization was a good thing), you have common ground and leverage. It is also vital that you find out what he wants out of life–in the short term and long term–without being judgmental. You need to find out what it is that is most important to him.

7. Write the Headlines

I started out by telling you that to do this right, you need to approach your loved one the way a journalist would. That means not only asking questions without injecting your criticism or other opinions, but also discovering a theme and figuring out what the “headlines” are. So, after a conversation in which you’ve been reflectively listening, think of the front page of a newspaper and literally write down the headlines. If you can, write them down in front of the person (I will give you examples of how to do this later), so that you know you are both on the same page about what’s important to him.

So what are the “headlines”? The headlines are the problems the mentally ill person believes he has (not the problems you say he has) and the things that motivate him to change (those that are most important to him). Ultimately you are going to work together on the problem as he defines it, but link it to the help you believe he needs. And you will do this by harnessing what motivates him.

To illustrate these listening guidelines, I offer the following two examples from families I have worked with. The first is a good example of how not to listen while the second provides an excellent lesson on how to do it right. Both examples are drawn from my work supervising therapists in training on an inpatient psychiatric ward. Because my students typically bring video tapes of their sessions with families to our supervision meetings, I can comment on both the therapist and the family members’ listening skills. 

Ineffective Listening

It was 3 o’clock and Dr. Brian Greene, a second-year resident in psychiatry, was meeting with Matt Blackburn and his parents. Matt is the 26-year-old man who lives at home with his parents I first told you about in Chapter 1.

As you may recall, he was admitted to the hospital believing he was a close confidant of the U.S. President. He also believed that God had chosen him as His special messenger to world leaders, that the CIA was trying to assassinate him, and that his mother was trying to sabotage his mission (this last belief was not entirely delusional).

When he was admitted to the hospital, he was also hearing voices and had thought disorder (rambling disconnected thoughts strung together so that when he spoke it was often difficult to make sense of what he was saying). After two weeks of treatment at Columbia, his speech was more cogent and the voices had quieted down a bit thanks to the medication he had received. He still had the same delusional beliefs, but the drugs helped relieve the pressure he felt to act on them (e.g., go to Washington to meet with the President).

The meeting was called by Dr. Greene to discuss what Matt would do after being discharged from the hospital. “Mr. Blackburn, Mrs. Blackburn,” Brian said to each as he shook their hands, “Please come in and have a seat.” Matt was already seated at the end of a long table in the patient dining room.

His mother circled the table to reach her son and bent down to give him a kiss. Mr. Blackburn immediately sat down in the nearest chair, which was also the farthest from Matt, and started asking questions of Dr. Greene. “I know we’re supposed to be talking about Matt’s discharge, but don’t you think he needs to stay here longer? I don’t think he’s ready to come home yet.”

“There’s really nothing more we can offer him here, Mr. Blackburn,” Brian answered. (In truth, it probably would have helped Matt to stay another week, but his insurance had run out.)

“Well, I don’t think he’s ready and neither does his mother!”

“Hold on,” Mrs. Blackburn said, “I didn’t say that exactly. Of course, we want you to come home,” she said, directing her last comment to Matt. “We’re just worried about what’s going to happen next.”

Seizing the opportunity, Brian began. “Matt has an appointment later this week with a doctor in our outpatient clinic. He has enough medicine with him to last until that appointment, and the hospital’s day program has accepted him. He can start there as soon as the doctor has seen him.”

“This is exactly what I was afraid of,” said Matt’s father to his wife. Then he turned to face Brian and added, “I don’t want to be negative, Dr. Greene, but he’ll never go to that appointment and he won’t go to this day program you’re talking about. He doesn’t think there’s anything wrong with him. We need a better plan than this. Matt won’t take his pills and he doesn’t like hanging around the people in these programs. He says they’re all crazy!”

“Matt, what do you have to say about all this?” Brian rightly asked.

 He responded loudly, while looking down at the table. “I said I’d go. I’ll go!”

“That’s what you promised us before, Matt,” said his father in a kinder tone. “But when we get home, you disappear into your room and you don’t go anywhere.”

“It’s different this time. I’ll go! I just want to get out of here and get a job and my own place.”

“Are you sure you’ll go?” his mother asked, looking worried. “Yeah, Mom, don’t worry, I’ll go. I really will. Okay?”

Matt’s father didn’t look convinced, but his mother and doctor looked, if not convinced, at least relieved by what they had just heard.

Let’s review the seven listening guidelines I gave above.

1. Did They Make It Safe?

Brian and Matt’s family did set aside a special time to talk but did not make the conversation “special” in the way I described above. There was no acknowledgment of their differing views and no apology for previous attempts to convince Matt he was in denial and mentally ill. No one explained that he or she wanted only to hear Matt’s views on the discharge plan. And no promise was made to refrain from giving unsolicited advice.

Instead, the old argument was immediately raised by his father and the battle lines drawn. The result was that Matt got defensive and then did what you and I would have done had we, like Matt, been through this a hundred times before. He lied and said he would go to the appointment. He lied to get his parents and his doctor off his back and to get released from the hospital.

2. Did They Know Their Fears?

On the surface, Matt’s father and mother both appeared to be in touch with the fear they felt going into this conversation. But they were not. They were aware of their fear that their son would continue his career as a “frequent flyer” or revolving-door patient-but they had no awareness of the specific fear they had about this conversation, which was that they would make things worse if they didn’t make their views known once again.

Although she did it more gently than her husband, Matt’s mother also laid down the battle lines. She wanted her son to stay in the hospital longer. She made it very clear she thought he was still very sick. Both parents, and Dr. Greene for that matter, felt compelled by their fears to once again tell Matt, as if hearing it once again would make a dent in his denial, that he was ill and needed professional help. And yet, all three knew that Matt was not going to follow up with the clinic appointment.

They could have talked about that with Matt directly. But to do that they would have had to make it safe for him to talk, not let fear rule the conversation and stop pushing their agenda.

3. Did They Stop Pushing Their Agenda?

Matt was about to leave yet another hospitalization, and his parents and doctor knew he would not follow through with their recommendations because he never had before. But that didn’t stop the three of them from pushing their hopeless agenda anyway.

Dr. Greene wanted to communicate the details of the post-hospital treatment plans and “seal the deal” so to speak (even though he admitted to me later that he knew Matt would never follow through with the plan as it had been presented to him). Matt wanted to leave the hospital and was willing, if that’s what it took, to take medicine for the time being. How long he was willing to stay on the medicine was never determined because Matt did not trust his doctor or parents enough to be forthcoming and reveal what his true feelings were. Mr. Blackburn openly predicted that his son would stay on the medicine for less than one week while Brian naively hoped that Matt would be willing to follow doctor’s orders for months to come.

Mr. Blackburn was pursuing an agenda, which was trying to convince Brian to hold Matt in the hospital longer. And although Mrs. Blackburn was focused on the same agenda, she was preoccupied with her guilt and with not wanting to hurt or anger Matt.

What was Matt’s agenda? No one asked, so we really don’t know, although I found out later.

4. Did They Let It Be?

Matt was not offering his opinion or saying he would not take his pills. At least not directly. So there was little in the meeting for his doctor and parents to react to. But his parents were reacting to things Matt had said and done in the past. His father was angry from the start, not only because the hospital was discharging his son, whom he felt was too ill to come home, but also because he didn’t believe Matt was telling the truth. When Matt said he’d go to his appointment and take his medicine, his father reacted essentially by calling him a liar (“That’s what you promised us before, but when we get home you disappear into your room and you don’t go anywhere.”). Although more subtle, Matt’s mother also reacted to his reassurances with disbelief.

5. Did They Respect What They’d Heard?

No one echoed back to Matt what they understood him to be saying. Matt’s views on whether he was ill and needed treatment were not respected. There was at least one missed opportunity. When Matt said, “This time is different,” his doctor or parents could have replied, “So, Matt, I want to understand. You’re saying this time is different. Is that right?” If such a question had been asked, not with anger or sarcasm, but with genuine curiosity, Matt would have answered yes, his defenses would have dropped a notch, and he would have told them something very important. This time really was different for him. He truly did not want to come back to the hospital ever again, certainly not the way he had this time (his parents had called the police, who brought him to the hospital against his will).

And if they had echoed back what they heard and Matt had felt they truly understood, a problem they all shared could have been identified. They could have worked together to keep him out of the hospital.

From Matt’s perspective, his parents were the reason for his hospitalization. From theirs, it was the mental illness. But they all agreed that no one wanted him to end up in the hospital again (even the insurance company would have agreed to that). This was a missed opportunity to help Matt drop his defenses and turn down the volume on everyone’s anger.

Let me give you a feel for what I am talking about. Brian was Matt’s doctor, and I was Brian’s supervisor, so sometimes I met with the two of them together. During one of these meetings, Matt had described the terror he felt when the police brought him to the hospital. He had never felt so scared before and he never wanted to feel that way again. And he had grown tired of being hospitalized again and again. I asked him why he thought his parents had called the police, and he answered, “Because they think I’m sick.”

“But that doesn’t tell me why they would put you through this.”

“They think I’m sick and need to be in the looney bin, that’s why.”

“Let me ask the question differently. What’s motivating them to do this to you? Do they hate you?”

“No.”

“Do they want to hurt you?”

“I don’t know. I don’t think so.”

“Then why would they call the police on their son?” 

“They’re afraid, I guess.”

“Matt, let me see if I have this right. Your parents called the police to bring you to the hospital against your will, not because they hate you or want to hurt you, but because they’re afraid. Do I have that right?”

“Yeah. That’s it.”

“What are they afraid about?”

“They’re afraid I’ll get hurt.”

“Now, I know you disagree with them on this, but before we talk about that, let me see if I am following you so far. Your parents were afraid you would get hurt so they wanted you in the hospital to keep you safe. Is that right?” He nodded. “What does that tell you about how your mom and dad feel about you?”

“They love me.”

“So you have a big problem here, don’t you? How do you convince your parents to stop throwing you in the hospital? I mean, you can’t convince them to stop loving you, can you?”

“No,” he said smiling.

“Then what?”

“I can’t convince them there’s nothing wrong with me. You guys have all brainwashed them!” We both laughed at his reminder that people like me–doctors–were at the root of his problem.

“No. And they can’t convince you that you’re sick. So there you are. What could you work on together?”

“I guess reassuring them so they don’t get scared and call the police.”

“How can you do that?”

“There’s nothing I could do to convince them.”

“Nothing?”

“Well, no …not nothing. I could take the medicine.”

“But if I understand you, you’re not sick. Why would you take medicine if there’s nothing wrong with you?”

“To keep them off my back!” he said laughing.

This conversation, though valuable, would have been priceless had Matt had it with his parents. But because they were afraid and unable to echo what they heard, they missed a chance to find common ground with their son and work on the problem they all agreed Matt had (i.e., hospitalizations against his will were bad). By redefining the problem so that it was no longer about the question of whether or not he was sick and needed help, and clarifying that he knew his “misguided” parents were motivated by love, Matt could have translated the impossible problem he had into one that was workable.

6. Did They Find Workable Problems?

When it came to defining the problem, Matt, his parents, and Dr. Greene were talking apples and oranges. Matt saw the problem as his parents, the police who listened to them, and the shrinks who had convinced his mother and father he was ill. His parents and Dr. Greene saw the problem as Matt’s being stubborn, immature, and defensive–he was not taking any responsibility for the illness he clearly had. On the other hand, Matt and I had easily found at least one workable problem. We agreed that the only problem anyone would be willing to work on with him was how to keep him out of the hospital.

Identifying a problem we could work on together opened up a way for us to work as allies rather than adversaries. After his parents left, I briefly met with Matt and Dr. Greene and said: “Well you know it’s your choice, Matt. You know what I think, and I can’t force you to do something you don’t believe in. I wouldn’t want to do that even if I could, unless, of course, you were in danger, which you’re not in right now. I respect your right to make this decision for yourself. I know you told Dr. Greene and your parents that you would stay on the medicine. But if you change your mind, and if I had to guess I’d guess you will since you don’t believe you’re sick, I hope you will pay close attention to what happens next. It’s your life. Don’t just have an opinion about the medication–prove to yourself whether your opinion is right or wrong.”

“I already said I’d take the pills!” he responded defensively, probably because I was implying that I didn’t believe the reassurances he’d given Dr. Greene and his parents.

“Okay, I will take you at your word. But I have to say that if it were me, I wouldn’t take the medicine.” Seeing that Brian looked mortified by what I had just said, I asked him, “Dr. Greene, do you have something to say? You look like you might have a different view on this.”

“Well, I don’t think you really meant that if you were in Matt’s shoes you wouldn’t take the medicine.”

“That’s exactly what I meant.” Brian frowned and seemed to be searching for words when Matt saved him by asking me, “So, you don’t think I need the drugs?”

“I didn’t say that. What I said is that if I were you, I wouldn’t take them after I leave the hospital. Matt, you don’t believe you have a mental illness and you feel strongly you shouldn’t be taking medicine for an illness you don’t have. That sounds like common sense to me. Who would take pills if they didn’t think they needed them? What would be the point? If I believed those things I wouldn’t be planning on taking the medicine when people were no longer looking over my shoulder. If I were in your shoes, I would say what it took to get out of here and then follow my own compass. Isn’t that really where you are? You can tell me and you will still go home today. It won’t change a thing.”

“I would never do that,” Matt said facetiously, a smile spreading across his face. I smiled back as we both recognized and shared the truth of what he would do once the door closed behind him.

“Hypothetically then, if you do stop taking the medicine, ask yourself these three questions: What stays the same? What gets worse? What gets better? Write it down like we’ve been doing while you were here. You know what I mean?”

“Yeah. The pluses and minuses.”

“Exactly. So you know what I’m talking about?”

“Yeah. It’s my life. I hold the key and it’s up to me to decide.”

“Right. Now, you’ve decided you really don’t want to take the medicine, right?”

“Yeah,” he admitted sheepishly. “But I will anyway. Everyone wants me to, so I will.”

“Well, I don’t know if everyone wants you to, but you know my opinion. I hope that you will. But if you decide to stop, I want you to know I respect that this is your life and your right.”

“Yeah, but you’ll think I’m stupid.”

“No, I won’t. But I might think you made a bad decision if you made an uninformed decision.”

“You’re the doctor, you would know.”

“That’s not what I meant. You are in the best position to be the expert on this issue. Be a scientist. Think of this as an experiment. Collect the data. Don’t jump to conclusions one way or the other. Just pay attention to what happens when you’re not taking the medicine. Ask people you trust how you seem when you’re off medicine. Think you’d be interested in doing that?”

“I don’t know. I already know the answer.”

“Well, it seems everyone else already thinks they know the answer, too, and most of them disagree with you. Here’s your chance to prove them wrong.”

“I’ll try to keep an open mind.”

“That’s all I’m suggesting. Anything else you want to talk about before we stop? Any feedback for me?” 

“No, I guess not.”

“Well, good luck.” I stood up, extended my hand, and added, “I hope I never see you again.”

“Same here,” Matt replied. We both laughed as we shook hands. If I saw Matt, it would be because he was back in the hospital. Keeping him out of the hospital and in his life was something we both wholeheartedly agreed upon.

7. Did They Write the Headlines?

No one appeared to pay attention to the headlines, much less write them down. Of course, writing down what Matt had to say would have been awkward in this situation because his doctor and parents had never practiced this technique with him. It’s true that Brian often took notes during their sessions, but they were almost entirely about symptoms he was observing. He rarely recorded Matt’s subjective experience of the problem (his parents, the police, and the “shrinks”) or statements that revealed what was important to him, what motivated him (staying out of the hospital, getting a job and a place of his own). But it would have been easy to ask, “Is it all right with you if I write down what you’re telling us is most important to you?”

Effective Listening

Dr. Ivan Kohut, a third-year resident in psychiatry, was meeting with Vicky, the 45-year-old woman with manic depression you heard about in Chapter 2. Her husband Scott was also present. Vicky had spent the last two weeks in the hospital following a manic episode during which she took her two children on a three-day “road trip” to Mount Desert Island National Park in Maine.

The first night of the trip was especially disturbing because Scott had no idea where his family had gone until Vicky called him at 11:00 p.m. to explain that she wanted their children to experience the same spiritual awakening she was having. God had instructed her to take them to the top of Cadillac Mountain because it was the highest point on the East coast, and had told her that once they were there, he would come to them.

Having gone through two previous manic episodes with Vicky over the course of their marriage, Scott figured out what was happening much more quickly than he had in the past. During the phone call, he begged her to come home, but she refused, and when he told her he thought she was becoming sick, she abruptly hung up the phone. Scott immediately called the police in the area she had phoned from, but they told him there wasn’t much they could do except to “keep an eye out for her car.” They suggested he call the National Park Headquarters in Maine.

With the help of Vicky’s psychiatrist, Scott was able to convince the park rangers to intercept his wife when she arrived. He then flew up to Maine, and after much cajoling and threats of commitment, he got her agreement to return to New York and go to the hospital.

From both Scott’s and Vicky’s perspective the drive back was nightmarish. The children, as children often do, were unconsciously running interference by misbehaving. Their fights and tantrums, together with Vicky’s rapid-fire speech and grandiose proclamations, made for an excruciatingly long drive home.

After greeting the couple, Ivan sat down and began by asking, “What would the two of you like to talk about today? I have two things I’d like to put on our agenda. How about you, Vicky?”

“When do I get out of here? That’s the only thing I’d like to talk about.”

“Okay. Scott, how about you?”

“Well, I have the same question. And I also want to talk about her medications.”

“Anything else? Either of you?”

“No,” Vicky answered quickly.

Scott thought a minute, then said, “I suppose not. Maybe more will occur to me as we talk.”

“Good. My two agenda items are similar,” said Ivan. “I want to report on how I think Vicky is doing and then ask her how she feels about the discharge plan. So that’s basically three items: One, when does Vicky get out of here; two, my view on how she’s doing, and three, Vicky’s opinion of the plan we put together for after she leaves. If it’s okay with the two of you, I’d like to get the second item out of the way first.”

Vicky and Scott both nodded their approval.

Addressing Vicky, Ivan said, “I think you are doing much better than when we first met two weeks ago. Back then you were sleeping about two to four hours a night, your thoughts were racing, your speech was pressured, you were euphoric, extremely irritable, and you had some unusual thoughts about God and supernatural abilities you felt he had given you. Right now your sleep is back to normal, your thoughts aren’t racing, and your speech isn’t pressured. You don’t need me to describe your mood. How would you describe your mood over the last week?”

“Kind of constricted. I’m not as happy and I don’t get irritated so easily. I’m not depressed.”

“Do you miss the happy feeling?”

“You know I do, Dr. Kohut! Wouldn’t you?”

“Absolutely.” Noting the smile on her face, he added,

“But it looks to me like you can still feel happy. It’s the extreme happiness, the high, that’s gone. Yes?”

“That’s true,” she answered.

“So, in a nutshell, I think you’re ready to go home the day after tomorrow.”

Vicky looked surprised. “Why didn’t you tell me that this morning when we met?”

“I suppose you don’t remember, but I told you I had to discuss it with the team first. I wanted everyone’s input. We generally make these decisions by consensus, and the consensus is that you’re much improved and can go home. Scott, any opinion about this?”

“Not really. I expected it. I see that she’s getting back to normal. But I guess I’m not clear on what happens next. What can we do to keep this from happening again?”

“Good segue to the last item on our agenda–what happens next with respect to your treatment.” Ivan addressed Vicky once again. “I’d like to see you in the clinic once a week for the next couple of months, and then maybe drop down to once a month. I don’t want to change anything about the medication you’re taking right now. I’d like to see how you do over the next couple of weeks, then re-evaluate and discuss if we should make any adjustments. What are your thoughts about what should happen next?”

Vicky laughed and asked, “Does it really matter? Everyone thinks I should stay on medication.”

“Of course, it matters!” Scott replied, a little irritated and

defensive.

“You’re the boss here, even if it doesn’t seem that way now,”

Ivan added.

“What are you talking about?” asked Vicky.

“I am talking about the fact that what your husband and I think you should do doesn’t amount to a hill of beans compared to what you think you should do. If you believe that the medications have done their job and want to stop taking them, you will. I can’t stop you and neither can your husband.”

“Then why am I here? I don’t feel like the boss.”

“That’s because you lost a lot of control when the bipolar disorder you have flared up. It caused you to do things that worried a lot of people and motivated them to take control away from you. But now you’ve got the illness under control again and you’re back in the driver’s seat.”

“If that’s true, then I don’t want to take these drugs for more than a month or two.”

“So, if I understand you, you don’t want to take these drugs for more than two months at the most. Right?” 

“Yes.”

Scott interrupted. “Wait a minute! That’s how she got into this mess in the first place. Every doctor she’s seen, including you, has told us she will very likely have to stay on these medications for the rest of her life.”

“If she doesn’t want to have another flare-up, yes, that’s true. That is my opinion. Also, the medications will help to keep her from becoming depressed again. I’m not contradicting myself. I’m saying something else. It’s Vicky’s choice, not yours or mine. But the choices you make,” he added, looking at Vicky, “will have consequences.”

“You make it sound so ominous,” she replied.

“I think the consequences of stopping your treatment will be very negative. You know what my professional recommendation is and what your last psychiatrist felt. You know what your husband and your family would like. But what you believe is what you will ultimately do. And I have to respect that. But I am curious about one thing. Why don’t you think you will need the medications? Just this morning you told me they’ve been very helpful over the past few weeks. Were you just ‘yessing’ me or did you really mean it?”

“I meant it. They’ve done their job. But I’m better now.” 

“So you see yourself as cured of bipolar disorder.”

“Well, I’m not sure I have manic depression. But whatever was going on, yes, the medications helped calm me down. So, yes, the problem is solved. Why would I want to be on these drugs for the rest of my life when the problem doesn’t exist anymore?”

“So what you’re saying,” Ivan began, “is that you had some kind of problem, not manic depression, that the drugs helped you with. And now that the problem is solved, you don’t want to keep taking the medication. Right?”

“Right.”

“Want my opinion on what you just said?”

“I already know it.”

“Actually, it may surprise you.”

“Shoot.”

“What you propose is certainly possible,” Ivan said to the couples’ surprise. “How about we make a deal. If you decide, six months from now, that you still want to go off your medications, we can give it a try. But I won’t have any part of it if we’re not meeting regularly.”

“Why would you do that? You already told me you think I have to stay on these medications forever.”

“Because your opinion is the only one that ultimately determines whether or not you stay in treatment. I am willing to work with you to prove what you believe even though I don’t believe it. I have only two requirements: that you see me regularly, and that you keep a daily diary during the time we’re lowering your dosages.”

“Why a diary?”

“So you have a record of how you were thinking and acting during the time your medication was lowered. It will also help you to pay attention to the consequences, not only for you but for your family.”

“I would be willing to do that,” Vicky replied.

“Okay, then let’s write the deal down so we all remember. You will stay on the medications for another six months. If at that time you still want to discontinue the drugs, we do it together,” he said aloud as he wrote down his words. Then he added as an afterthought, “I’d like to include Scott in some of those meetings as well if that’s okay.”

“Sure,” she answered.

“And if we go that route, you will keep a daily diary. We can talk more about what I’d like you to record–cross that bridge when we come to it. Do I have it right? Is this what we agreed to?”

“Yes,” both Vicky and Scott replied.

1. Did They Make It Safe?

Did Ivan make it safe for Vicky to talk? Yes. He made it clear that he wanted to hear Vicky’s views on the treatment and was actually reluctant to tell her his views, which she already knew. She understood she could talk about her belief that she was not sick and didn’t need medicine without her doctor contradicting her. She also knew that Ivan would keep her husband from jumping down her throat. Ivan made it clear that her opinion was the only one that really mattered at the moment. It was more important than his and Scott’s opinion.

2. Did They Know Their Fears?

Scott got nervous and went on the attack for a moment when Ivan acknowledged, without argument, Vicky’s desire to stop taking the medicine. Otherwise, Scott did a great job of listening passively as his wife and doctor discussed her views on the problem and what she needed. In previous meetings, Ivan had worked with Scott to help him recognize where he was powerless and where he had power. Where he was powerless was in convincing his wife she had manic-depression and needed to be on medication for the rest of her life. He hadn’t succeeded in four years, and Ivan helped him to recognize what was obvious–he wasn’t going to suddenly succeed now by continuing the argument. Where he had power was in repairing their relationship so that she would feel he was once again her ally, on her team, and that they were working on the same problems together.

Ivan was clear about his fears and understood that he had nothing to lose by listening to Vicky’s views. He knew he would not harm her by allowing her to be honest, by not contradicting her views without her permission (he always asked her if he could give his opinion before he gave it), and by actively listening.

3. Did They Stop Pushing Their Agenda?

Not only did they agree on an agenda, but over the course of their conversation Ivan repeatedly checked back with Vicky and her husband to ensure that there wasn’t anything else either of them wanted to talk about. The main agenda was understanding Vicky’s views and working with how she experienced all this.

4. Did They Let it Be?

Ivan did not react emotionally to Vicky’s statement that she wanted to stop taking medication. Neither did Scott, except during the one brief moment when his fears caught him off guard. Neither Ivan nor Scott jumped in with their opinions to refute Vicky’s statement that she was no longer ill and planned to stop taking the medication. They let her opinions stand. They respected her point of view. When Ivan did offer his opinion, he empowered Vicky by first asking if it was okay with her for him to tell her what he thought.

5. Did They Respect What They Heard?

Ivan did this repeatedly, often rephrasing things Vicky had said to ensure that he “got it right.” He prefaced his reflective statements by indicating that he just wanted to be sure he understood her correctly (“Let me see if I got this right?”), used her words without comment or criticism, and then asked her if he’d understood correctly. He acknowledged that he understood and genuinely respected her point of view.

6. Did They Find Workable Problems?

Vicky felt that the medications were a short-term treatment, like antibiotics for an infection, rather than a long-term treatment, like insulin for diabetes. The good news is that Vicky had some insight, though nowhere near as much as her family and doctor would have liked. She understood that the drugs helped her when she had symptoms but didn’t understand that the drugs could prevent the symptoms from returning when she was feeling well.

Although Ivan understood that statistically it was highly unlikely she could stop without getting sick again, there was a very, very small chance that she could. He also understood that until the day Vicky “owned” the treatment, until she found a reason that made sense to her to stay on the medicine, she never would. Her problem, which he was willing to help her with for the time being, was taking the medicine. But he would work with her on this only if she stayed in therapy with him, allowed Scott to come to some of the sessions, and took responsibility for tracking what happened when she stopped taking the medicine.

By agreeing to work with her on the problem as she defined it, he kept her in therapy and on the medication for a longer period of time than if he had insisted the treatment was “a life sentence,” as she had once described it. He also laid the foundation for her discovering reasons to continue in treatment.

7. Did They Write the Headlines?

Ivan not only wrote down what they had agreed to do about the medications but asked permission to do so before starting. This was important because it emphasized Ivan’s wish to collaborate rather than pontificate. By asking, he also underscored that Vicky would be in charge after she left the hospital. He wasn’t afraid to acknowledge his own powerlessness.

By doing that, he reminded Vicky that the choice to continue treatment was hers, as was the responsibility for the consequences that would follow her decision. The “headlines” were that she wanted off the medications and that she understood they helped her when her thoughts were racing, when she wasn’t sleeping, and when she got tired out (these were the things she saw as problems even though she didn’t think she had an illness).

In summary, listening is an active process. It involves asking many questions and not reacting to what you are hearing. You should think of yourself as a scientist trying to unravel a mystery. Your task is to gain a clear idea of what your loved one’s experience of the illness and treatment is. Once you know how he experiences the idea of having a mental illness and taking psychiatric drugs, you will have acquired vital knowledge you need in order to build a treatment agreement.

The Danger of Listening Reflectively

Very likely, the person you are listening to reflectively and without judgment will make the mistake of thinking you believe what he is telling you (about not being sick, not needing medications, or the CIA conspiracy). He may ask you to help him catch the CIA in the act or talk to his parents so he can go off medications since you seem to agree he doesn’t need them.

I touch on this problem at various points in this book–it’s why most people are afraid of reflective listening–but let me introduce you to two new tools: The Delaying Tool and the Three A’s For Giving Your Opinion that will allow you to use reflective listening without falling prey to these traps. I will talk about these both again later, but let me lay it out for you here concisely.

The Delaying Tool

You want to delay giving your opinion about controversial topics (delusions, desire to not take medicine, etc.) for as long as possible to preserve the alliance you are building, delay the hurt your answer will cause, and perhaps most importantly, shift the locus of control to the person who is asking for your opinion. After all, when you give it, he has no one to blame for hearing your point of view but himself, especially if you have delayed giving it because you have been genuinely reluctant to do so.

So, in terms of learning to LEAP, the longer you are able to delay giving your opinion, the more the other person will have experienced you as respecting his and, therefore, the more obligated he will feel to respect yours (or at least hear you out). If he has to solicit it, the more in control he will feel and the less defensive he will be when he hears it. The harder he has to work for it, the more it will matter when you finally do give it. For these three reasons, your opinion will have more weight.

When you delay, try the following: first honor the question by promising to answer, attempt to change the topic and ask permission to do so. Here are some examples that include all three elements (the promise, the diversion and the request for permission to change the topic):

• I promise I’ll tell you whether I think you are sick. But first, if it’s OK with you, I would like to hear more about_____. Would that be all right?
• I will answer your question about the CIA. Can I ask you to give me some more details about what happened last night first? Would that be OK?
• You’ve asked me many times whether I think you’re delusional. I promise to answer, but if it’s OK with you, before I tell you what I see, could you tell me more about____?
• I promise to answer your question about whether you should stop taking medicine. Before I do, I want you to know that I think your opinion about this is far more important than mine. So can you tell me all the reasons why you want to do that?

The “A” Tools for Giving your Opinion

Sometimes, even after you’ve listened and empathized, the other person won’t ask you what you think. This is rare in my experience, and if it happens to you, I want you to consider two possibilities. One is that you have not used the tools you’ve learned as effectively as you could. . .and the other is that the person likes talking so much that he simply isn’t interested in what you have to say. If it’s the latter, you can ask if he or she would be interested in hearing your perspective. You can say something like, “After listening to you, I have a much better picture of your views on this. Can I tell you what I think?”

I’ve never heard of anyone who has used the listening and empathy tools receiving a “no” in answer to this question, and I don’t believe you will either. But whether you have been asked for your opinion repeatedly and delayed giving it, or you have had to offer it because the person doesn’t ask, despite being cooled down and feeling listened to and respected, the way you deliver your opinion will determine whether it throws more fuel on the fire or continues to douse the flames. If you want to get past the impasse, there are three new tools you now need to add to your tool belt. I often use all three of them together, but sometimes you need only one or two to get the job done. I call these my “A” tools–it makes them easier to remember and they are powerful tools you can use whenever you’re arguing or negotiating. I like to think of these tools as soft, like felt or a goose-down pillow. Sometimes I think of them as airbags. In other words, they are tools that help to soften the blow and save lives–or at least relationships.

The “three A’s” are apologize, acknowledge, and agree.

APOLOGIZE

Apologizing may be the last thing you think you need or want to do at this point. After all, the other person has been asking you (probably more than once) what you think. You’re only doing what she’s asked. In fact, you may think that if you need to apologize for anything it would be for having delayed so long–but that’s not the way it works.

Keep in mind the reason you delayed in the first place: because you’re aware that when you do give your opinion, it’s likely to damage the trust you’ve so carefully been building. When you finally admit that you still don’t agree, the other person is likely to be disappointed, to feel somehow betrayed, and to get angry all over again. So what you need to indicate is that you understand all this and apologize, because you do truly wish what you believe didn’t make her feel that way.

I’m not suggesting you apologize for the opinion you’re about to offer (e.g., “Yes I think you may have bipolar disorder…”), but for the feelings it might engender. You’re not saying you’re sorry you feel this way, but rather that you’re sorry that what you have to say may make him or her feel upset. What you might say is something like, “Before I tell you what I think about this, I want to apologize because what I think might feel hurtful or disappointing.”

Understanding that difference ought to make the process easier for you. If you still feel unable to apologize, you’re probably still too angry, and you need to take a few deep breaths, step back–if only for a moment–and think about why you’re doing this in the first place.

When you do apologize, just be sure that you don’t use the word “but,” as in, “I apologize if this is going to upset you, but, I think…” I mentioned this before but want to emphasize it here again because it is so important.

People who are in a disagreement typically stop listening when they hear the word “but.” It’s as if you had pushed a button on a remote control and shut off their hearing aid. Not only are they incapable of hearing you–but the most likely outcome is that you’ll just revert to “butting” heads all over again.

ACKNOWLEDGE

What is it that you need to acknowledge? Certainly not that you still think you’re right (although, ultimately, that’s more or less what you’re going to be saying). Rather, you need to acknowledge that you’re not infallible and you might be wrong–even though you clearly don’t think so. (And you’re riot going to say that!) So, after you apologize, say something like, “Also, I could be wrong about this. I don’t know everything.”

When you do that, you are, first of all, indicating that you are flexible. If you can be flexible, you’re more likely to trigger some flexibility in the other person. If you’re rigid and dogmatic, you’re equally likely to trigger that. Remember that LEAP is all about giving in order to get.

Acknowledging that you could possibly be wrong is also a way to convey respect because you are not insisting that you are wise and the other person is ignorant. It’s the same principle Benjamin Franklin wrote about in his autobiography:

“I made it a rule to forbear all direct contradiction to the sentiment of others, and all positive assertion of my own. I even forbade myself the use of every word or expression in the language that imported a fix’d opinion …for these fifty years past no one has ever heard a dogmatical expression escape me.”

If it worked for Benjamin Franklin, who broke many seemingly insurmountable impasses, it can work for you.

AGREE

I’ve already said that you’re not going to be agreeing with the other person’s opinion. So what is this about?

Here, you’re going to ask her to agree that you disagree. In other words, you’ll be indicating that you respect her opinion and hope that she’ll respect yours. “I hope we can just agree to disagree on this. I respect your point of view and I won’t try to talk you out of it. I hope you can respect mine.”

Using the “three A’s” is far easier than it might appear at first glance. When my brother Henry asked me if I thought he had schizophrenia, I said: “I’m sorry because this might hurt your feelings. I want you to know I could be wrong. I don’t know everything, but yes, I think you might have schizophrenia. I hope we don’t have to argue about this–I respect your opinion on this and I hope you respect mine. Let’s just disagree on this.”

Did you see any or all of the “three A’s”?

Here is a shorter example. “Should you take the medicine? I’m sorry I feel this way and I could be wrong, I just hope we can agree to disagree on this. Yes, I think you ought to try it for at least a few months and see how it goes.”

The point is to be genuinely humble, help the person save face, and preserve the relationship you’ve been building. Remember, you will win on the strength of your relationship rather than on the strength of your argument. [70-112]