“ N o Estoy Enfermo ! No Necesito Ayuda! ”

1. “No Estoy Enfermo!No Necesito Ayuda!” Ayudando a las personas con enfermedades mentales serias a aceptar tratamiento. VIII Simposium Abordajes Psicoterapéuticos De Los Trastornos Psiquiátricos Cordoba, Spain, 27 March 2009 Xavier Amador, Ph.D. Columbia University E-mail: xa1@Columbia.edu www.LEAPInstitute.org

2. Poor Insight and relationships

3. “Denial” of Illness in the News Poor insight into schizophrenia and bipolar disorder is so common… … news stories involving such persons appear nearly everyday.

4. “Denial” of Illness Impairs common-sense judgment about the need for treatment… But are we dealing with denial? “Anosognosia”

5. Unawareness of Mental Disorder Xavier Amador, Nancy C. Andreasen, Scott Yale & Jack Gorman, Archives of General Psychiatry, 51(10):826-836, 1994 Unaware 32.1% Aware 40.7% Moderately Unaware 25.3% DSM IV Field Trial Study N = 221 patients with schizophrenia

6. Clinical Significance of Poor Insight Poor Insight is associated with: • “Noncompliance” with treatment & services • Involuntary/compulsory admissions • Poorer course of illness • Criminal behavior & violence:

7. Insight and Adherence Awareness of being ill (insight) is among the top two predicators of long-term medication adherence. What is the other top predictor? Relationship with someone who: • Listens to you without judgment. • Respects your point of view. • Believes you would benefit from treatment.

8. DSM-IV-TRTMSchizophrenia & other psychotic disordersXavier Amador & Michael Flaum, Co-Chairs Page 304, American Psychiatric Association,2000

9. Anosognosia is similar • Very severe lack of awareness. • The belief persists despite conflicting evidence. • Confabulations are common.

10. When dealing with anosognosia, or poor insight: The “doctor knows best” approach does not work, because collaboration is a goal not a given. DO NOT expect: Gratitude Receptiveness Compliance DO expect: Frustration and anger Suspiciousness Overt and secretive “non-compliance”

11. Anosognosia Treatment options Long-acting injectable medications. But how do you convince someone to accept? Motivational Interviewing and cognitive therapy

12. LEAP The Listen-Empathize- Agree-Partner (LEAP) Approach (Based on MAIT, Xavier Amador, Ph.D. and Aaron T. Beck, M.D.) 2000 2007 2008

13. Double blind, randomized, controlled study of LEAP: a psychotherapy designed to improve motivation for change, insight into schizophrenia and adherence to medication. Céline Paillot, Ph.D. Ray Goetz, Ph.D. Xavier Amador, Ph.D. University Paris X, France, New York State Psychiatric Institute, Columbia University Teachers College In Press Schizophrenia Bulletin Presentation at International Congress on Schizophrenia Research, San Diego California, April 2009

14. The Problem with Antipsychotic Medications From 50% to 75% of patients with schizophrenia exhibit full or partial non-adherence to pharmacological treatment (Rummel-Kluge, 2008). Approximately 33% reliably take medication as prescribed (Oehl, 2000). Within 7-10 days of medication initiation 25% are noncompliant, up to 50% after a year and up to 75% after two years (Keith & Kane, 2003). Poor adherence found to be associated with serious negative outcomes.

15. Methods 54 patients diagnosed with schizophrenia were included in a six month repeated measures outpatient study. Patients were randomly assigned to either the experimental (LEAP) or control (Roger’s) therapies and were blind to group assignment. All patients received long acting injectable antipsychotic medications. Blinded assessments: Insight into schizophrenia, attitudes toward treatment and motivation to change. All assessments were made by a rater blinded to group assignment.

16. Conclusions • Compared to the control psychotherapy, LEAP: • maintained compliance to injectable antipsychotics. • improved motivation to take medication. • increased insight in specific areas. • improved attitudes toward treatment.

17. Listen Reflectively to: Delusions Anosognosia Desires Listen-Empathize-Agree-Partner

18. How to delay giving your opinion: • “I promise I will answer your question. If it’s alright with you, I would like to first hear more about ________. Okay?” • “I will tell you what I think.I would like to keep listening to your views on this because I am learning a lot I didn’t know. Can I tell you later what I think?” • “I will tell you.I want you to know that I think your opinion is more important than mine and I would like to learn more before I tell you what I think. Okay? Listen-Empathize-Agree-Partner

19. When you finally give your opinion use the 3 A’s APOLOGIZE “I want to apologize because my views might feel hurtful or disappointing.” ACKNOWLEDGE FALLIBILITY “Also, I could be wrong. I don’t know everything.” AGREE  ”I hope that we can just agree to disagree. I respect your point of view and I hope you can respect mine.” Listen-Empathize-Agree-Partner

20. Empathize Strategically express empathy for: delusional beliefs desire to prove “not sick!” wish to avoid treatment Normalize the experience Listen-Empathize-Agree-Partner

21. Agree Discuss only perceived problems/symptoms Review advantages and disadvantages of treatment Reflect back and highlight the perceived benefits AGREE TO DISAGREE Listen-Empathize-Agree-Partner

22. Partner Move forward on goals you both agree can be worked on together. Listen-Empathize-Agree-Partner

23. Directions for 2009 and 2010 LEAP Institute goals American Journal of Psychiatry Proposal for Anosognosia subtype: Xavier Amador, Ph.D., Celso Arrango, M.D. and Michael First, M.D. Schizophrenia Bulletin Special Edition 2009 Editors: Xavier Amador, Ph.D & Anthony David, M.D. - Review of efficacy of adherence therapies - Updated review of brain imaging studies - Updated review of frontal lobe findings - DSM V: Anosognosia subtype will be proposed Listen-Empathize-Agree-Partner