Therapists Spill: The Books I Turn to on a Difficult DayIn my practice I have seen several clients with schizophrenia. In that time I have noticed that a good majority of the therapy and psychoeducation is also needed for the family and loved ones of the person with schizophrenia. I cannot tell you how many times I hear pleas from family members that they just want to know how to help, communicate, understand and engage with their loved one but cannot find enough resources or help. The purpose of this article is to offer some understanding of the cycle of schizophrenia as well as “do’s” and “don’ts” of how to help your loved one.

Responding to Beliefs or Hallucinations

Often times your loved one with schizophrenia will express to you beliefs and ideas that are difficult for you to believe. This may come in the form of feeling they are being followed, watched, or persecuted. Our first instinct is to tell them that it’s not true or real. However, when we do this it is likely to only agitate the person or leave them feeling alone in what they are experiencing.

When someone feels this way they may began to distance themselves reducing your opportunity to help. Typically when any of us are told we are wrong about something we tend to stick to the idea more and become more passionate about proving others wrong. So don’t tell your loved one with schizophrenia that what they are saying is not true. Instead, let them know you understand that they are hearing that or experiencing that (because they are). This may not be real but it is real to them and it is happening, it’s just not happening to you. You don’t have to agree with them though or feed into it. Let them know you believe them but you’re struggling to know if the information they are receiving is true or correct. The goal here is to listen without agreeing or arguing. Don’t challenge their thoughts as this could lead to defensive thinking (just like anyone with or without schizophrenia).

You may be thinking, “So how can I help? I cannot just let them follow these beliefs and stand by and do nothing.” You’re right! While you should probably not challenge their thoughts you can encourage and guide them to challenge their own thoughts. Ask them what other explanations they feel could explain an event that happened. Ask them to think of a simpler explanation.

For example: let’s say they express someone is trying to send them messages through TV shows. Validate their feelings and then ask them if there are any other explanations without dismissing their current explanation. Let them know you are not disregarding their reasoning or belief but that you should also explore other reasons such as some shows have common themes, when we expect to see something we see it everywhere, etc. Therapy is a great place to start this type of challenging of intrusive thoughts setting you up for more reception from your loved one when you try it at home.

If trying to guide them to challenge the thought is not working that’s OKAY. You can focus on showing empathy for what they are feeling due to the hallucination or belief. Ask them how they are feeling and coping and let them express their feelings. Just like you would for anyone going through a difficult time. Remember, to them this is real and it is affecting them. Sometimes the best thing we can do for someone is just be there for them and let them talk about their feelings.

Decreasing Urgency or Intensity

Through my years of working with individuals with schizophrenia I have noticed that hallucinations or beliefs will often lead them to feeling they need to complete a certain action. These may include purchasing a plane ticket to somewhere, signing up for something, etc. Our natural instinct is to try and stop them or talk them out of it. However, telling anyone “no” only reinforces their need or desire to do it.

So how can we stop them from following through on something that could harm them or cause more distress? Listen to them and validate their feelings and then attempt to have them put it off, reschedule the plan for later, take their time, etc. For example. If they insist on purchasing a ticket to another country because they feel they need to solve a problem over there, ask them if they can wait until they can take the time off of work appropriately so they don’t lose their job or if they can plan it out more and purchase the ticket with you later.

Just like anyone if we feel others are with us and not trying to stop us we will be more open to them. This can also decrease the intensity of the need and urgency they are feeling to follow through on the action. It will not stop the desire but it can decrease the intensity and buy some time until they can see their therapist or be assessed.

Important note: If the person appears to be a danger to themselves or others then hospitalization will need to occur until the desire for the action passes or their medications may need to be adjusted. However, if we are being realistic and attempting to have a functioning life as a schizophrenic we do not want to hospitalize for things that are not a danger. A therapist, psychiatrist, police officer, or judge can help you with making this decision. The goal is of course safety but we are also thinking long term and helping the individual through these moments and empowering them to work through them as well.

Medication

Medication is (in this therapist’s opinion) the first step towards help. Medication helps put someone in a position where they can better challenge intrusive thoughts. In this therapist’s experience I have not seen symptoms completely disappear from medicine (that does not mean it does not happen though) so it’s important to understand your expectations. However, the medication seems to help calm down the intensity and intrusiveness of the hallucinations or thoughts. This frees up mental energy to better challenge the beliefs. So while medication is the first step, the individual should also be gaining therapeutic techniques to identify symptoms of schizophrenia, accepting their diagnosis, and working on coping skills.

Giving Credit for Therapeutic Work

When I have a client who has accepted their diagnosis and is actively trying to disengage from auditory hallucinations and challenge intrusive paranoid thoughts they are able to recognize that the medication helps but so does the hard work they put it. When they feel others are only giving credit to the medication this can become hurtful and frustrating. Our first instinct when someone begins to show a flare up of symptoms is to ask, “Are you on your medication?”, but we should avoid saying it so bluntly. This could agitate the person and make them feel as if they have no control — it is only the medication.

Remember to let them know you know how hard they are working to disengage from the voices or challenge their thoughts. Ask them how that is going lately and if they feel they are struggling. Then ask about their medication. Make sure the person feels you are checking on them and not just the medication.

Acceptance and Relapse

The acceptance of schizophrenia for an individual and for their loved ones is a difficult and long process. Just like someone with a substance abuse problem it is not an easy to accept diagnosis. There will be phases and ups and downs of acceptance. Someone a person with will acknowledge the diagnosis and the importance of their medication. Other times they will not.

There is likely to be instances of medication non-compliance — stopping meds. I know it’s hard but this is the process, so it’s better to prepare yourself for this cycle. It’s a difficult journey for both the individual and the loved one, and it’s highly recommended for the loved one to also engage in their own therapy or support group. The more help you can get the better you’ll be able to help your loved one. Plus, you also deserve to be heard and validated.

For a go to guide see the chart below of “do’s and don’ts”. Remember there is help and there is hope!

Do’sDon’ts
Let them know you know they are experiencing it but you’re not sure if it’s correct or true information Don’t tell them it’s not real- to them it is happening
Listen without agreeing or arguing, but using empathy for what they are feeling due to the hallucinationDon’t  challenge their belief when they are intense
Attempt to have them put off or reschedule the plan for later, take their time, refocus themDon’t tell them “no” when they insist of doing something caused by their hallucination (fly somewhere, sign up for something, etc.)
Medication is necessary but it’s not a cure all, they also will need to work at not engaging with the voices or challenging paranoid thinkingDon’t tell them it’s only their medication that helps and disregard their efforts
Prepare for relapses of getting off medicationDon’t expect relapses not to happen