TCPR: How did you become interested in patients who aren’t aware they have problems?
Dr. Amador: I’m a psychologist, and I have a brother who has schizophrenia, so I’ve seen this play out firsthand and learned from a lot of the mistakes I made as a family member. From that experience, I got involved in research on anosognosia, the neurologic syndrome that renders a person unable to understand that they have an illness. This led to a book for the public, I Am Not Sick, I Don’t Need Help!, which I’ve kept updated over 25 years, and a communication strategy called LEAP that I developed with the late Aaron Beck.

TCPR: How does LEAP work?
Dr. Amador: The LEAP strategy is designed to help us reach, engage with, and form alliances with people who do not understand that they have serious mental illness. It stands for: Listen actively without judgment; Empathize and normalize; Agree—look for areas where you agree; and Partner. All these tools are focused on meeting the person where they’re at. When someone believes there is nothing wrong with them, I have to gain their trust. That involves a very different approach than teaching and psychoeducation. It’s quite the opposite, actually.

TCPR: What happens if we take a commonsense approach and try to educate the patient about their illness?
Dr. Amador: You’re going to lose them. If you say to someone, “You clearly have a psychotic disorder,” they hear an outlandish insult. It compromises the therapeutic alliance. Without trust, without the patient feeling respected and unjudged, we won’t get buy-in for anything we’re offering—especially powerful psychiatric medications.

TCPR: What else can go wrong?
Dr. Amador: Don’t frame the work around symptom management. “I’m here to help you with your symptoms” is a loser from the start—because they don’t know they have symptoms. What you say instead is: “I’m here to see if I can help you with your goals.” In your mind, you think of ways to link their goals to the symptoms you’re targeting, but you don’t discuss that explicitly.

"It’s a losing proposition to say, ‘I’m here to help you with your symptoms’—because patients with anosognosia don’t know they have symptoms. What you say instead is: ‘I’m here to see if I can help you with your goals.’" - Xavier F. Amador, PhD

TCPR: Suppose their goal is to get out of the hospital.
Dr. Amador: Then I’d say, “I have some ideas. Would you like to hear them?” With LEAP, we ask permission before giving opinions. Most people say yes. Then: “I know you’ve told me you don’t need medication. Nevertheless, if you took medicine, we’d probably be able to get you out more quickly. Would you be open to that?”

TCPR: What other goals do they name?
Dr. Amador: Love and work—getting a job, having relationships, having friends. Sometimes, though, the goals reflect their delusions: “I want the FBI to leave me alone,” or “I want to be one with God.”

TCPR: And how do you handle a delusional goal with LEAP?
Dr. Amador: You don’t avoid it. You reflect it back: “What I’m hearing you say is that you want the FBI to leave you alone—did I get that right?” Then they’ll often ask, “Do you agree with me? Are you taking my side?” With LEAP, you have tools for that. You can delay: “I promise I’ll answer your question about the FBI—but first, can you tell me more about how this hospitalization happened?” You ask permission to delay. Most people agree.

TCPR: And if they don’t agree?
Dr. Amador: If they press for your opinion, you give it with the three A’s: Apologize, Acknowledge your fallibility, and Agree to disagree. It might sound like: “You’ve asked whether I believe the FBI is surveilling you. I want to apologize—I could be wrong. I don’t see it the same way you do. I hope we don’t have to argue about it, and I could be wrong. What’s important is that you’re not alone in dealing with this.” Saying “I could be wrong” doesn’t make someone more delusional. But it does create space for them to feel respected.

TCPR: Are there other times you’ll use the apology tool?
Dr. Amador: Yes—apologize for participating in an involuntary admission. Apologize for prescribing medication the person didn’t want. “I’m sorry I felt the right thing to do was to prescribe this. I know you’ve told me you don’t need it.” What you’ll often get back is appreciation for the humility: “Thank you for saying you’re sorry.”

TCPR: LEAP starts with “L” for Listening actively without judgment. What are you listening for?
Dr. Amador: You’re listening for their goals, their desires, and their emotions. If they have delusions, you’re listening for the emotions that spring from those delusions—whether it’s the fear from paranoid beliefs, the grandiosity, or the loneliness and isolation of knowing that everyone around them thinks they’re sick when they know they’re not. These are normal human feelings, and LEAP treats them that way.

TCPR: The “E” in LEAP—Empathizing and normalizing—what does that look like?
Dr. Amador: First, a warning: Don’t be afraid of it. Clinicians often hesitate to empathize with a delusion because they fear they’re colluding with it or making it worse. That’s not how delusions work. If I say, “Given what you’re telling me about the CIA, I think I’d be scared and angry too,” I’m not reinforcing a delusion—I’m validating the emotion. Validation builds trust, and trust opens the door to treatment offers. Normalizing is a key part of empathy: “I would feel the same way.” And when they’re frustrated with you, you say: “You know what? If I were in your situation, I’d be frustrated with me too. I think anyone would be.”

TCPR: Next is “A” for Agreeing.
Dr. Amador: Yes, agreeing and finding common ground. When you find it, make it explicit: “Don’t we both agree that it would be a good thing if your parents weren’t always bothering you about medication?” Then write it down—with the person’s input and editing. It becomes a visual anchor, a concrete area of alignment between the two of you. You’re going to lean on those agreements when you make treatment offers.

TCPR: Do you ever find symptoms to agree on?
Dr. Amador: Yes. Even if they deny having an illness, they may agree they need help with insomnia, fatigue, or agitation: “I can’t stop pacing.” Also hypervigilance, worry, somatic symptoms, and concentration problems: “I can’t read, I can’t watch a movie.” Or loneliness: “Nobody believes me.” These are your entry points. You don’t say, “This medication will treat your hallucinations.” You say, “This may help you cope with the stress you’re under. It could make you more resilient—more effective, given everything you’re dealing with.” Don’t say “calm”—people who believe they’re under threat can’t afford to be calm. “Effective” and “resilient” land differently.

TCPR: Tell us about the “P” in LEAP—Partnering.
Dr. Amador: Partnering is when you make the treatment offer, pulling those areas of agreement out of your back pocket: “We agreed that you’re not sleeping, you’re pacing, and you’re exhausted. I have something I think could help you handle that more effectively.” But sometimes you don’t need the areas of agreement. If the relationship is strong enough, people will consider your offer simply because they trust you and feel respected by you. You can say, “I know you don’t want this, but I can’t help offering it.”

TCPR: What if they agree intellectually but never follow through?
Dr. Amador: We’re in a marathon, not a sprint. You also need to “look both ways before you leap,” by which I mean assess the emotional climate before making a treatment offer. If you’re feeling impatient, or the person is angry or agitated, it’s not the time. This is almost never resolved in one conversation.

TCPR: What are common fears clinicians have about using this approach?
Dr. Amador: That they’ll make the delusions worse. That they’ll be seen as liars when the person discovers they weren’t agreeing with them after all. That they’re not doing their job if they’re not offering treatment immediately. These fears are understandable, but they’re unfounded. The approach doesn’t worsen delusions, and being honest about disagreement while staying empathic actually deepens the alliance.

TCPR: Does anosognosia ever go away?
Dr. Amador: Some patients may temporarily be unaware that they have an illness. We see that in mania, acute psychosis, intoxication, and delirium. But if the anosognosia has gone on for more than six months in schizophrenia, it’s probably not going away. Longitudinal studies looking two years out find that in the overwhelming majority of patients who have lacked insight for that long, the poor insight continues—even when hallucinations, delusions, and thought disorders improve with medication (Phahladira L et al, Schizophr Res 2019;206:394–399). It tends to be stable in most patients. It’s a lot like negative symptoms: Flat affect and other negative symptoms tend not to improve with medication, and anosognosia is similar.

TCPR: Should we be concerned about underlying neurological disorders when we see anosognosia?
Dr. Amador: No more than we would be when we encounter psychosis generally. It doesn’t signal a significant neurological condition any more than delusions or hallucinations do—though neurological conditions can produce these symptoms. That’s why we often do brain imaging during first episodes, to rule out lesions. But anosognosia itself isn’t a soft sign of neurological disorder. It tells us there’s frontal lobe dysfunction present, correlated with mania and psychosis.

TCPR: Is anosognosia common in other psychiatric disorders, besides schizophrenia?
Dr. Amador: It’s most common in the schizophrenia spectrum disorders and bipolar disorder, particularly bipolar I disorder with psychosis. There’s also an emerging body of research suggesting we may be dealing with anosognosia in substance use disorders as well (Raftery D et al, Addict Behav 2020;111:106549). The research in schizophrenia implicates executive dysfunction, frontal lobe dysfunction, and prefrontal cortex dysfunction—even anatomical abnormalities—in predicting who lacks insight. Researchers in the substance use field are finding similar results, which makes sense because many abused substances impair frontal lobe functioning. That may be at the root of the denial we encounter in those disorders too.

TCPR: Does anosognosia present differently in bipolar disorder?
Dr. Amador: Yes. It tends to wax and wane more—during the depressive phase, a patient may develop some awareness that they have an illness (Depp CA et al, J Affect Disord 2014;152–154:250–255). So it’s a bit more responsive to the illness course than in the schizophrenia spectrum, where it tends to remain stable. We don’t see it much in bipolar II, mainly bipolar I.

TCPR: Are there other symptoms that cluster with anosognosia?
Dr. Amador: Working memory problems frequently co-occur with anosognosia. That means trouble remembering what was communicated moments ago, along with impaired problem-solving. These are all manifestations of the same frontal lobe and executive dysfunction that underlies anosognosia (Nair A et al, Schizophr Res 2014;152(1):191–200).

TCPR: Does it also predict a more severe course of illness?
Dr. Amador: Yes, and there’s been substantial research on this. In the associated features sections of both the DSM-IV-TR and the DSM-5, which I worked on, we note that anosognosia is the number one predictor of nonadherence to treatment—more than side effects, more than any other factor studied. It also predicts more involuntary hospitalizations, more hospitalizations overall, poorer course of illness, and poorer psychosocial functioning (Rose B and Harvey PD, CNS Spectr 2024;30(1):e24). It’s arguably one of the most clinically important symptoms to evaluate.

TCPR: Any thoughts on long-acting injectables (LAIs) versus oral medications in this population?
Dr. Amador: The research is abundantly clear that LAIs are adhered to far better than oral medications (Tiihonen J et al, JAMA Psychiatry 2017;74(7):686–693). But beyond that, when someone is on an LAI, I only need to have conversations about the next injection once a month, every two months, or even twice a year—depending on the formulation. Each time, I can use LEAP: “I know you’re reluctant. I could be wrong. I think this will help you be more effective given what you’re going through. We’ll talk about the next one when we get there.” There’s another practical benefit: If someone misses their appointment, we know immediately they’re off medication. I discovered my brother was off his medications by finding the pill bottle in the trash. I’d much rather have a missed appointment than that discovery, because the conversation is completely different. Instead of saying, “Why was this bottle in the trash?” you can say, “I noticed you missed your appointment—are you okay?”

TCPR: Is LEAP something that both families and professionals can use?
Dr. Amador: Absolutely. We teach families, mental health care professionals, general practitioners, and criminal justice professionals—police officers, EMTs, and even over 300 judges who run mental health diversion courts. It’s for anybody who interacts with and wants to help someone with serious mental illness.

TCPR: Any tips for involving families?
Dr. Amador: Introduce them to the concept of anosognosia. At www.leapinstitute.org, under Resources, there are free videos and a TEDx Talk with over half a million views. Families say it transforms their relationship with their loved one. It changes everything to understand that the person isn’t being defiant or difficult—that they genuinely cannot perceive their illness due to a neurological process. We teach families to stop teaching and start listening.

TCPR: What if the patient is an adult and won’t allow family involvement?
Dr. Amador: One practical HIPAA note: If you don’t have a release, you can still listen to the family and explain your approach. You can describe how you work without disclosing patient information. That’s not a HIPAA violation—and it prevents the family from misinterpreting the patient’s claim that you “agreed” with them.

TCPR: Thank you for your time, Dr. Amador.