- Hi, I'm Dr. Tracey Marks a psychiatrist
and I make mental health education videos.
Today I'm answering a viewer question
about how to get a friend or family member
to get help for their mental problem.
Here's Hector's question.
Hi, Dr. Marks my wife was diagnosed with bipolar 1 disorder
but she is not getting treatment for it.
This is really taking a toll on our marriage,
how can I approach her to get the help she needs?
Thank you, Hector for your question.
I have to preface this by saying
there's not a one answer fits all for this question.
The specifics of what you actually say or do depend
on circumstances like how much impairment
does the illness cause?
How much insight do they have into their illness?
How accepting are they of their illness?
You can have someone who doesn't accept
that they have an illness at all,
despite being very functionally impaired.
Or you could have a person that accepts
that they have an illness,
but doesn't take their medication consistently
because they don't think that they always need it.
So this person doesn't appreciate the need for consistent
treatment, but at least they've gotten as far as accepting
that they need some kind of treatment.
These are just a few of the factors
that guide you on how to handle this.
And even then what works for one person
may not work for another.
So that's the disclaimer here
and that's the reason there isn't much information
online about exactly what to do,
because there isn't this one thing that everyone can do.
But here's some general principles
that can guide you for your particular situation.
So let's go back to Hector's question.
His wife has bipolar disorder,
and she's not getting treatment.
I'll assume that means that she hasn't seen a doctor
or she's gone in the past,
but she's currently on no medication for it.
Bipolar disorder is an illness that can cause a person
to become psychotic, either when they're manic
or when they're depressed.
But usually those are temporary states.
That matters because when the person is not psychotic,
you can have a rational conversation about their illness.
This is in contrast to a psychotic illness
like schizophrenia, or even delusional disorder,
where the main problem is that the person has trouble
differentiating between what's real
and what's not real.
With those conditions, you're not going to be able
to argue the person out of their psychosis
or convince them using logic that they need help.
So here are some suggestions for the person
who is not experiencing a break from reality.
Giving the person an ultimatum does not work well,
like, if you don't get help, I'm leaving you.
The person may grudgingly go to see a doctor
or therapist but if their heart isn't in it,
it's not gonna go far.
So a different approach would be to meet the person
where they are with whatever pain points they have.
So Hector's wife has bipolar disorder,
and she should be having some degree of suffering.
Maybe she's having trouble sleeping,
maybe she's at risk of losing her job.
If she has children, maybe she can't keep up with them
and feels like a bad mom.
Once you identify these things that bother her
focus on getting help, because of the impact
that these problems have on both her and the family.
You're not trying to get her into getting help
you're just trying to help her see beyond herself,
that you're interested in helping her reduce
all of these negative impacts.
For example, a depressed mother who can't get out
of bed may be motivated to get help
so that her children won't suffer
or won't see her in that state.
Similarly, with your marital relationship,
instead of focusing on what she's doing
to turn you away, you could focus on how her suffering
hurts you and how you really hate
to see her not doing well.
You're trying to show compassion for her pain
because you love her and you want her to feel better,
sleep better and be able to work and so fourth.
Suppose her hypomania is manifesting as anger,
and she's snapping at everyone.
Usually when people are like this,
they feel bad about the fact
that they can't control themselves
and everything makes them angry.
This isn't the kind of entitlement rage that comes
from a personality disorder.
This is having very little frustration, tolerance,
and being unable to control your emotions
due to a mood disorder.
So the person usually has some regret about the fact
that they can't stand you.
So in this case, instead of fighting back with her
because you're sick of her stuff,
a different approach is to show compassion
for that irritability.
So let's role play and say I'm you.
Instead of saying, "you wouldn't be yelling at me
if you take your medication like you're supposed to."
Instead, I could say, "I hate that all these things
that I do irritate you.
It pains me to see you upset like this all the time.
I really wish you would consider getting help
or to take your medication so you won't feel as bad."
Now what I've just said applies
more to the situation of someone who recognizes
that they have an illness, but doesn't wanna get treatment.
If your loved one has gotten treatment,
but is now inconsistent with it,
before hounding them about why they're not taking
their medication or seeing the therapist,
you need to do a little work
to understand why they're not adhering
to the treatment.
It could be because the medication
has a bunch of side effects.
If the last medicine that your wife
took made her gain 50 pounds,
she may not wanna take that medication again.
In this case, you'll need help from your doctor or therapist
or some other source educating you and your wife
on other treatment options.
Also, in this case, instead of focusing on the pain points
as a reason to get treatment,
you focus on the benefits that she experienced
by being treated in the past.
You wanna help her get her eyes on the prize.
So when her symptoms start to return,
help her remember how much better she felt
when she was sleeping,
getting her work done when her mind wasn't racing.
Another thing that can drive non-compliance with treatment
is people forgetting what it was like
when they were doing so poorly.
I did a video talking about this phenomenon
called bipolar disorder and the imposter syndrome.
It was about people who felt like they were faking
their illness, because when they were well,
they just couldn't relate to how they were feeling
when they weren't doing well.
So they conclude, I must have been faking it.
That mindset actually is a huge driver
of people not continuing to take medication
because they just don't believe that they were sick
or don't remember what it was like.
So in this case, you don't wanna throw in her face
how bad she was.
Instead, when things start to slip
you wanna remind her of how this has happened before
and she did get better.
You wanna focus on the positive end points
and the path to those end points is treatment.
What if your loved one is psychotic
and doesn't recognize that they have an illness?
This is the most difficult situation to deal with
because you can't have a rational conversation
with them about their concerns.
Usually people who hear voices will recognize
that something's not right.
But the person who's delusional
believes that their delusions are true.
I still think you could try focusing on the pain points.
And this is what I do if someone is forced
to see me by their family, but doesn't believe
that they have an illness.
Often people who are delusional
or bothered by the delusions may feel anxious,
and they may not be sleeping or they may be very fearful.
So the focus of treatment becomes about helping them
with their anxiety or fear response it's not about debating
about the delusion it's about helping them
with how they're beliefs affect them.
But that is just the starting place
to get them through the door to see a doctor.
If that person can somehow be convinced
to take anti-psychotic medication,
they could get to the point where they recognize
and appreciate that something happens to them
that makes them think things that they don't think
when they're not on medication.
So even if they don't believe
that they have a psychiatric illness,
they still may like the fact
that the medicine helps them not be anxious
about all these things that they believed.
The second part of the story is compliance with medication.
If the person doesn't believe they have an illness,
they may eventually stop taking the medication
and become delusional again.
Even though ultimatums are not a good way to motivate
someone to get treatment
sometimes you have to use contingencies
to get someone to stay on medication.
Setting up these contingencies works best
when the person is well enough to understand them.
So for example, if you have a family member
who can't work because of their illness,
and you're supporting them financially,
to continue to get your support,
they have to stay on their medication.
That's the most common example.
But there are other if then scenarios,
that you could create depending on the dynamics
of your situation.
And this usually boils down to how much support
you're giving the person.
But it can also be related to contact.
If this is a family member that you see
on a semi-regular basis and this person
stops taking their medication
and becomes verbally abusive,
you could let them know that contact with you
is contingent on them either being in treatment,
or containing the behaviors.
And if the person wants to be around you enough,
they can do whatever they need to do
to be able to contain whatever behaviors are objectionable.
Now you may say, "how can a delusional person
know how to contain their delusions?"
They don't contain their delusions.
They contain the behavior that they engage in
because of their delusions, even if they don't agree
that they have a delusion.
So for example, let's say you have an aunt
with a psychotic illness.
And you can always tell when she's not taking her medicine,
because she accuses you of poisoning your children.
You could say something to her like
"auntie, it hurts me when you say this,"
she may jump in and say, well, then you need to stop."
"Hear me out.
This is really important and I'm only gonna say
this one time."
You also wanna bring up the hurt,
because you wanna couch what you're saying
in a way that makes her feel less defensive
by focusing on how her behavior affects you.
That makes it less threatening
because now you're identifying yourself
as the weak link here because you're hurt.
"So let me continue.
It hurts me when you talk this way.
And I know that you don't say these things
when you take your medication,
I'm not going to come around you,
if you continue to speak to me like this,
it really is not my business whether or not
you take your medication.
But I'd like you to so that I can continue
to see you."
With this kind of statement, you're trying to make it clear
that she's the one in control of the outcome.
You're not trying to be judgmental
about her being on medication or not.
But taking medication gets this result
and not taking medicine gets this result.
And she knows what she needs to do
and the decision that she needs to make,
depending on the kind of result that she wants.
This kind of confrontation can easily deteriorate
into an ugly back and forth.
"You don't know me, who are you to tell me
this and that any other."
When this happens you take the broken record approach
and have a can statement that you can say over and over.
In this case, it could be something like,
"okay auntie, these are my conditions.
I'm sorry, I won't get a chance to see you."
"You think you're gonna keep me from seeing my grand niece?"
"These are my conditions.
I'm sorry, I won't get a chance to see you."
Now, in the heat of the moment,
it can be hard to be calm like this.
The way to make it easier is to practice,
anticipate how things can play out
and have your condition statement ready,
and your broken record response ready.
And then everything else after that you just walk away.
So as you can see, there's not one answer on how to handle
dealing with a family member who won't get treatment.
But here are the takeaways, for the person
who won't get treatment or return to it focus
on the pain points and encourage them
to get help for the pain points.
For the person who's already been in treatment,
but is not following through
focus on the positive end points of treatment.
These would be the things that would improve
with treatment.
You also want to understand what things
are like for them and what their objections are.
At first you wanna listen compassionately,
and not challenge them on their objections.
People need to feel heard when they're suffering
and especially when the solution
to their suffering causes them more suffering.
So then it's about offering support and engaging
in a partnership with them to see
how together you can find a workaround.
That is, how can you find treatment that's tolerable
and gets them to those positive end points.
For the person who doesn't appreciate
that they even have an illness,
you may need to use contingencies
to get them to follow through with treatment.
Thanks for watching.
See you next time.