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Book Forum: Mental Illness and Its Boundaries   |    
I Am Not Sick, I Don’t Need Help! Helping the Seriously Mentally Ill Accept Treatment: A Practical Guide for Families and Therapists
MARY V. SEEMAN, M.D.
Am J Psychiatry 2002;159:513-513. doi:10.1176/appi.ajp.159.3.513
View Author and Article Information
Toronto, Ont., Canada

By Xavier Amador, Ph.D., with Anna-Lisa Johanson. Peconic, N.Y., Vida Press, 2000 (originally published in 1959), 239 pp., $17.95 (paper).

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This is a guidebook primarily meant for families of severely and persistently mentally ill patients who don’t realize that they are ill, don’t want to seek treatment, and, once discharged from involuntary hospitalization, are not likely to continue in treatment. The author has had personal experience of this at home with his brother. He has also had professional experience with it, being at the forefront of a scientific approach to the study of insight or recognition/acknowledgment of illness. Unfortunately, such patients form a substantial proportion of those with illnesses like schizophrenia, which means that, no matter how our treatments for these conditions improve, only a minority will ever take full advantage of them. This, perhaps above all else, is the tragedy of schizophrenia and related disorders. It is one thing to develop treatments aimed at eradicating delusions and hallucinations. It is another to develop treatments aimed at improving the recognition that beliefs so fervently held and constantly confirmed by the most minute of everyday events are, in fact, "figments of one’s imagination," nightmares conjured in waking life by a disorder of the brain.

Families will welcome this book; indeed, it receives well-deserved endorsements from many highly respected mental health professionals. It even provides a web site through which families and others can write in and have their questions answered—an innovative and useful extra to the information provided.

For therapists, the conversational style and heavy use of dialogue seem less immediately helpful, although there are some very useful tips for enlisting a reluctant patient’s cooperation. These include the following: 1) Set aside the time to listen. 2) Agree on an agenda (even if it ends up being agreeing not to have an agenda). 3) Understand the patient’s own beliefs about himself or herself and the illness. 4) Don’t react (with shock, surprise, dismay, fear, disappointment, disbelief, etc.). 5) Let chaos be (if the patient can stand it, so can you). 6) Echo what you’ve heard. 7) Write it down. Another helpful recommendation, for therapist and for family member, is to convey empathy for the many frustrations, fears, discomforts, and desires (perhaps unreasonable) that the patient expresses. This includes normalizing the psychotic experience as much as possible when the oddness of it seems to be a source of humiliation. There are times, of course, when the patient does not want the experience normalized because the one saving grace is the feeling of being specially selected for the harrowing things he or she is being subjected to. Grace notes on the general theme are learned through experience, but the basics are well covered in this primer. I will be recommending it to the families of my patients.

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