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 symptoms of psychosis and even more difficult to disregard what your senses are telling you.  

Over time, you can develop communication strategies 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 an overarching principle. This resource provides a few ideas for families to consider trying. 

Note: 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 resources to support emergency planning and family safety. 

Here are a few key concepts:  

Develop trust  

The most important initial outcome from careful conversations is trust. Trusting people are more willing to collaborate. Telling someone what to do or giving “or else” ultimatums can make them defensive. Defensive people tend to stop thinking and put up walls, so they don’t even hear you—let alone trust you. When people sense fear that can also shut down a conversation; make sure you are grounded and calm before you ask if it’s a good time to talk. 

Always begin by doing your best to create a safe space emotionally and physically. Keep your eyes and voice soft and your body relaxed and a safe distance away, with your arms passive (not crossed) and without pointing fingers. Strive to remain curious and avoid giving directions or telling someone what you think they should do. Whenever possible, use the phrase “tell me more,” or ask if there’s anything they want to add to what they’ve already said.  

Changing the way you communicate takes time and practice, but helps 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. SMI often comes with delusions, hallucinations, and extreme 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. Likewise, you cannot convince someone that they have a mental illness if their symptoms include anosognosia, a neurological symptom that blocks self-awareness of illness. Instead of insisting they believe you, try to show that you believe them when they say they are experiencing something. 

A trusting connection develops 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. And I’m having a different experience.” You might ask for more information about their experience: “How do you feel about what you see?” Showing that you care and are curious about their feelings can help you connect emotionally without requiring you to judge their perspective as valid or invalid.  

If your unwell loved one is convinced that they are not experiencing psychosis, don’t try to change their mind. Instead, ask about what is bothering them. They might express concern about sleep problems, fears, anxiety, or just generally feeling down. Listen to what they share so you can reflect your concern and interest in helping them find a way to feel the way they want to feel, do the things they wish to do, and get things they want more of in their life. 

Ask for permission to share your ideas  

If there is an opportunity to have a meaningful dialogue, ask their permission to have a chat. Maybe offer a favorite snack or beverage 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?”  

Try to avoid sounding like a salesman. For example, if you want your loved one to get a job, stop telling them what a great deal it would be if they got a job and made their own money. Instead ask about their hopes and dreams. Reinforce the value of those, and ask if they have a pathway in mind to get there. Try phrases like this: “I’m curious if getting a job at a craft store now might help you get started on your dream of becoming a sculptor?” 

Rephrase directives as questions  

Instead of being confrontational or adversarial, start with curiosity to uncover where their concern is focused. For example, instead of saying, “You need to clean this place up,” think of a way to ask something open-ended, such as, “What do you like most about your living space?” Always check your tone to avoid sarcasm and make sure you focus on their agenda, not your own.  

If your loved one opens up, make sure they know you are listening and hearing what they say. If they tell you they like their bed, for example, ask if they like slipping into the covers when the bed is freshly made. You might even say that’s something you enjoy. Your reflections might land on another question: “What do you think you might do?” If their answer naturally glides toward action and you’re up to it, you can make a gentle offer, “It sounds like you’re inspired to do some cleaning up. Is there a way I might help you get started, or do you prefer that I leave you to it?” 

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 (i.e. money, their own car or apartment, a relationship, etc.). Always keep in mind that change starts where they want to be, not where you want them to be. 

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). 
• Bob Krulish, nationally certified trainer, author of “When Screams Become Whispers,” and “The Ableing Shift” (theableingmovement.com).  
• 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).