Interview: How to effectively communicate with a person with mental illness?

Talking to your loved one without being critical or judgemental can help them recover better

White Swan Foundation

There's evidence to show that effective communication with a person with mental illness helps in better recovery. However, caregivers may sometimes find it challenging to communicate with a person who has severe mental illness. In a chat with Poornima BV of White Swan Foundation, Dr Aarti Jagannathan, assistant professor, NIMHANS, gives some simple, easy-to-follow guidelines for effective communication.

What are the common mistakes caregivers make in communicating with persons with mental illness? 

Caregivers often have low expectations from the person with mental illness. Their tone, tempo and attitude could sometimes be alluding to the idea that you, as the person with mental illness, are not able to do what most others possibly can. That, again, comes from their lack of knowledge and proper understanding of mental illness.

Some caregivers may continue being in denial about the person's illness, while others believe that they are motivating the person to improve by being critical and judgmental. Sometimes, if the caregiver continues to be critical for a long period of time, it may actually worsen their condition or lead to relapse. There is evidence to show that negative expressed emotions can lead a person with mental illness to relapse. Negatively expressed emotions have a negative impact while positively expressed emotions have a positive impact on the person's mental health.  

What does expressed emotion mean? 

Expressed emotion is the style of communication that the family follows when talking to the person with mental illness. It involves five components, any or multiples of which could be reflected in the communication styles of the family members: criticality, hostility, over-involvement, positive regard and warmth. The first three are negative expressed emotions and the last two are positive expressed emotions. 

How do negatively expressed emotions affect recovery? 

Research conducted by George Brown has revealed that criticism, hostility and emotional over-involvement, like many other environmental stressors, have the strongest link to relapse and readmission. Influence of expressed emotion has been found to be a major predictor of relapse in schizophrenia.  

What problems do persons with mental illness face in terms of understanding what the caregiver expects? 

They can only understand simple, step-by-step communication as they are already confused in their thoughts. They are also sensitive to others' emotions. Persons with schizophrenia, who sometimes have hallucinations, first need to come to terms with their own condition and know what's happening to them. So, it's difficult for them to sometimes understand what's happening around them. It is, therefore, important that our communication is simple, step-by-step and slow. Being warm to the person by displaying acts of kindness and empathy, accompanied by positive regard and appreciation of the little efforts that they make, can have a positive impact. 

Are these guidelines addressed to all kinds of mental illnesses or is it specific to anything in particular? 

These are generic guidelines, but for persons diagnosed with schizophrenia and dementia, the caregivers need to break down the communication further, in order to reach out to the person. 

Are these problems in understanding also linked to the person's cognitive abilities? 

Poor social cognition could probably be a cause. But whether it is poor social cognition in persons with mental illness that leads to high negative expressed emotions in caregivers or whether high negative expressed emotions have an impact on the symptoms and poor social cognition in persons with mental illness, is still open to debate. 

What can caregivers do if the person with mental illness refuses to take medicines? 

Caregivers need to have patience. They also need to be creative in their communication with persons with mental illness - persuading them, motivating them and being innovative in their approach. They need to negotiate and have some kind of behavioral contract with them – they could perhaps say, "Just like I have my medicine, you too can have your medicine". The caregiver can explain to them the importance of having medicines and the consequences of not taking them. They could explain that just as medicine can control high blood pressure, it can also help treat mental health conditions. 

What would your advice be to caregivers who are finding it difficult to communicate effectively? 

I would say it's very important to have positive regard for their loved one. It's also important not to talk for them - you need to make them feel respected and involved in the decision-making process. This would, in turn, enable them to participate more actively in day-to-day activities. 

Are there any tips you would like to give caregivers? 

1. Avoid speaking on the person's behalf. If there is a pause or delay before they communicate, wait for them to respond.  

2. Avoid talking about complex emotional topics in their presence, especially in times of crisis. Avoid detailed conversation - they may find it confusing.  

3. Avoid assuming what they are thinking about, their wants or needs, even before they say so. Speak only for yourself. Listen to what they say, even if you do not agree with it.  

4. If you cannot understand their communication, ask them to speak more clearly. Do not try to discover the hidden meaning by yourself.  

5. Be appreciative of the person's positive behavior and support them when they are having a difficult time.  

6. Avoid vague or unclear statements as these are difficult for them to interpret and understand.  

7. Avoid generalized comments such as, "He is useless", "She can never do anything right" etc.

8. Only one family member should speak at a time, as it is difficult to listen to two people at the same time. This will also help increase respect towards the person with mental illness.  

9. Talk with the person with mental illness and not about them. This reduces negative emotions like hostility and criticism in them. 

10. Every family member should get an equal opportunity to talk. If the person with mental illness feels pressurized to speak, you can assure them by saying that it is ok if they do not speak but if they wish to, the others would keep quiet and listen. 

White Swan Foundation