Communication Tips

Communicating with someone with SMI often requires skill and patience.
Here are key tips and places to go for further training.

How do I talk to a loved one who cannot see that they need treatment? 

When someone you love cannot see what you see — due to altered perceptions, delusions, or paranoia — figuring out how to talk with them may be confusing, frustrating, and scary. First, please give yourself grace: it’s difficult to know what to say and how to say it. Second, give your loved one grace: it’s difficult to navigate a world that is altered by their symptoms, and even more difficult to disregard what your senses are telling you. 

Over time, you can develop communication strategies for working with your loved one that can improve your relationship and maybe even inspire change. A clinical approach called motivational interviewing is the basis. Asking instead of telling is the overarching principle. This resource provides a few ideas for families to consider trying when their loved ones are fairly stable.

Please note that these strategies, though they can be employed in any conversation, aren’t a substitute for acute care or intervention when a person is in crisis or severely symptomatic, especially if there is a safety concern. TAC provides an article to support planning for emergencies.

Here are a few key concepts: 

Develop trust 

The most important initial outcome from careful conversations with your loved one is to start building trust. Trusting people are more willing to collaborate. Telling someone what to do or giving “or else” ultimatums likely will make them defensive. Defensive people tend to shut down. They stop thinking and put up a wall so they cannot even hear you. Collaboration then becomes impossible. This may not happen overnight, but it can be your goal to increase mutual trust over time. 

Avoid telling your loved one they are wrong or “crazy” 

Do not try to talk someone out of their ideas or beliefs — even if they believe things that you know aren’t real or are impossible. Common symptoms for SMI include delusions, hallucinations, or paranoia. By definition, a delusional belief will persist no matter what evidence is presented. Persisting with delusional beliefs is not stubbornness, but rather part of the illness itself. Trust comes from listening, reflecting what you’ve heard, and finding points of agreement. You don’t have to agree that there is an alien sitting in the living room, but you can say, “I believe you that you see an alien on the couch. I can’t see it, though.” You might ask how they feel about it, “Are you afraid of the alien, or does it seem friendly?” This might help you connect about an emotion or a feeling without any need to agree or disagree about what is really on the couch. 

Ask for permission to share your ideas 

If there is an opportunity to have a meaningful dialogue with the person you are hoping to support, ask their permission to have a chat. Offer tea, coffee, or a snack to help them feel comfortable and cared for. Then ask what’s on their mind, and other open-ended questions that give them a choice of what to talk about. Be prepared to listen, reflecting now and then to show that you hear what they are sharing. If there is something you want to say, ask permission: “May I offer something that I think might be helpful?” 

Rephrase directives as questions 

Instead of saying, “You need to get a job,” think of a way to start a conversation with a question. Ask something open-ended, such as, “What do you want more of in your life?” If your loved one is willing to open up, make sure they know you are listening and hearing what they say. If they tell you that what they want more of is money, for example, you might respond with something like: “You want more money? I hear that! So many things I want I need more money for.”  Your reflections might land on another question: “What would you spend money on if you had more of it?” This will feel less adversarial and can help you to have a better idea of what the other person is thinking about or where their concerns are focused. 

Allow time for rest

Be sure to honor the stamina of your loved one for having a meaningful conversation. Remember that by asking questions you are helping them access their brain’s frontal cortex— the part of the brain that solves problems and makes plans. The brain uses about 20 percent of the body’s calories. The frontal cortex is the biggest calorie guzzler, so it’s tiring to hang out in deep conversation or thinking.  

Through thoughtful discussions, over time, you may be able to help your loved one see that help/medication/treatment is a road they might explore. Help them draw their own conclusions about how that choice might connect to what they want more of (money, their own car or apartment, a relationship, etc.)  

Resources for training and more information 

The ideas in this resource are not a prescription and offer just a flavor of how motivational interviewing can create more possibilities for helping someone make changes. Please refer to these professional resources for more information and training opportunities: 

• LEAP Institute, founded by Dr. Xavier Amador, author of “I Am Not Sick. I Don’t Need Help!” (leapinstitute.org).
• University of Washington Spirit Lab, Cognitive Behavioral Therapy for psychosis (CBTp) training for family caregivers (uwspiritlab.org).
• Motivational Interviewing Network of Trainers (MINT) (motivationalinterviewing.org). 
• Bob Krulish, nationally certified trainer, author of “When Screams Become Whispers” (bobkrulish.com).