Q & A: Expressed Emotion and Schizophrenia

A reader writes:

I have a friend, let's call him X, who refuses to communicate with me now because I keep telling him he should be on medication to help him with his paranoia. I'm pretty sure X hears voices and he also is quite sure that Jesus speaks to him personally. He won't go to therapy. Any advice or insight would be welcome. Thanks!

First of all, you can't put yourself in the place of a trained mental health professional.

Be that as it may, I think from your letter that you recognize that X may suffer from schizophrenia, a disorder that drastically affects cognitive functioning. You budding therapists out there may know by now that that means we don't do any rational cognitive therapy in this case.* What it means in plain English for everyone else is that you don't try to reason with a person who has difficulty reasoning, as is often characteristic of persons with schizophrenia.

You can and should contact X's family, tell them of your suspicions, ask them to help X get help. You said he is high functioning, so they may be in denial and may have little control over X and his compliance to treatment. But you never know until you ask.

As a friend you can remain supportive and caring. That may seem like no big deal, but it is a tremendous deal, and it translates into avoiding "expressed emotion," and telling others to do that as well.

"Expressed emotion" in this context is anger. People with schizophrenia are extremely sensitive to stress, and conflict/anger is stressful. We protect loved ones who suffer from this disorder by avoiding any criticism, sarcasm, argument, loud noises, yelling, even angry facial expressions, decisions, demands, bad news when in their presence.

You can also ask X what he's thinking. If he says voices speak to him and to no one else, then ask him what the voices are saying. If the words he's hearing in his head scare or stress him, he might confide in you. It might be a relief to tell you about them. He might get to a point where he really wants help. He's scared. Then you're there to take him in to see a psychiatrist. Skip right to a medical doctor with a person who has schizophrenia if at all possible.

Being supportive and non-conflictual is the best way to help someone who says they don't want help. Persons who suffer from mental illness who are mistrustful of the health care system have a right to be afraid. It is terrifying to them. They have to trust you or someone else, like a physician or a therapist, to the degree that they will confide their fear before there is a possibility of lowering resistance. If a sick person is in enough psychic pain, he might reach out for relief.

You may be that person who gets to hear how bad it really is for X. Then it is in your court to somehow reel him in. Until he's there, meaning until X really is in tremendous psychic pain and is willing to talk about it, all you'll get is denial and social withdrawal.

You want him to get help before he hurts himself or someone else. Not every person with schizophrenia is dangerous, but that's not your call to make. So if you really are friends with X or someone with this disorder, without seeming too invasive, hearing the thoughts is pretty important, and attending to them without being conflictual or demanding is the objective.

You want to ask him directly (gently) if he ever feels like hurting himself or anyone else. In that case, you really have some convincing to do, and might have to bring in either the police or a mental health professional who will help you bring him to a hospital. Sometimes the police are actually well-trained for this kind of thing.

And good luck.

*Studies have shown, according to F.D., that cognitive therapies are used successfully as an adjunct when drug therapies have successfully stabilized patients with schizophrenia.

Friends, if you have any other suggestions, by all means comment below. But...
I'm not encyclopedic, certainly, and don't pretend to know everything. I just want to be helpful generally, not to advise in particular cases. These are merely guidelines. Please consult appropriate mental health and legal professionals with problems when you think they might help.

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