I Am Not Sick I Don't Need Help! How to Help Someone with Mental Illness Accept Treatment

by Xavier Francisco Amador

Many people with bipolar disorder and schizophrenia think of their illness as something that comes and goes.

The results of recent studies indicate unequivocally that about 50% of all people with these disorders don’t believe they’re ill and refuse to take the medications that have been prescribed for them.

The results of recent studies indicate unequivocally that about 50% of all people with these disorders don’t believe they’re ill and refuse to take the medications that have been prescribed for them.

Our results showed that nearly 60% of the patients with schizophrenia, about 25% of those with schizoaffective disorder, and nearly 50% of subjects with manic depression were unaware of being ill.

In other words, when the patients enrolled in our study were asked whether they had any mental, psychiatric, or emotional problems, about half answered “no.” Usually the “no” was emphatic and followed by sometimes bizarre explanations as to why they were inpatients on a psychiatric ward.

Whereas

Whereas the majority of patients with depression and anxiety disorders actively seek treatment because they feel bad and want help, these individuals, by contrast, were unaware of having a serious mental illness.

Unlike people with depression and anxiety, they never complained about “symptoms” because they didn’t have any. Indeed, their main complaint was usually feeling victimized by their family, friends, and doctors who were pressur...

In addition, a significant percentage of those we studied were also unaware of the various signs of the illness they “suffered” from despite the fact that everyone around them could readily recognize the symptoms (e.g., thought disorder, mania, hallucinations, etc.).

The unawareness we were documenting was severe and pervasive (i.e., patients were unaware of their diagnosis and unable to see even the most obvious signs and symptoms of their illness).

Rather, his poor insight into having an illness and into the benefits of treatment was clearly another symptom of the disorder itself.

Rather, his poor insight into having an illness and into the benefits of treatment was clearly another symptom of the disorder itself.

Research shows that getting seriously mentally ill persons into treatment early, and keeping them there, is very important. According to the new research, whenever someone with serious mental illness has another episode, the long-term prognosis worsens.

our hesitation as a society to infringe on the individual rights and freedoms of our fellow citizens as a major obstacle to providing the seriously mentally ill with the medical treatment they need.

What the three studies described above make clear is that when we ignore the problem, it not only doesn’t go away—it gets worse. We must address the twin problems of poor insight and medication refusal if we want our loved ones to have the best possible chance of recovery.

Regardless of which aspects of insight are being measured, most studies find that the more aware a seriously mentally ill person is of his illness and of the benefits of treatment, the better his prognosis.

Patients with better insight have shorter periods in a hospital and have fewer hospitalizations overall.

The researchers concluded that individuals with poor insight are likely to have more problems remaining in a course of treatment regardless of whether it involves drugs or psychotherapy.

The authors concluded that an inability to see oneself as ill seems to be a persistent trait in some patients with schizophrenia and one that leads to commitment.

Their neuropsychological deficits have left their concepts of self—their beliefs about what they can and cannot do—literally stranded in time. They believe they have all the same abilities and the same prospects they enjoyed prior to the onset of their illnesses. That’s why we hear such unrealistic plans for the future from our loved ones.

When one’s conception of who one is gets stranded in time, one can’t help ignoring or explaining away any evidence that contradicts it.

When one’s conception of who one is gets stranded in time, cut off from important new information, one can’t help ignoring or explaining away any evidence that contradicts it. As a result, many chronically mentally ill persons attribute their hospitalizations to fights with parents, misunderstandings, etc. Like neurological patients with anosognosia, they appear rigid in their unawareness, unable to integrate new information that is contrary to their erroneous beliefs.

In a sense, this belief was stranded in George’s brain, disconnected from his visual senses and left unmodified by the stroke he had suffered. He was operating under beliefs that were linked to his past self rather than his current self.

Our brains are built to order, and even help construct, our perceptions.

In other words, poor insight was related to dysfunction of the frontal lobes of the brain rather than to a more generalized problem with intellectual functioning.

The research discussed above, and other newer studies that link poor insight to structural brain abnormalities, lead us to only one conclusion. In most patients with schizophrenia and related psychotic disorders, deficits in insight and resulting non-adherence to treatment stem from a broken brain rather than stubbornness or denial.

In the chapters that follow, you will learn how to evaluate the nature and severity of the awareness deficits your loved one has, and to devise a plan for helping him compensate for these deficits.

You don’t have to agree with his reality—the “realness” of his experience—but you do need to listen and genuinely respect it.

My colleagues and I have helped many patients accept treatment for a wide range of problems they feel have nothing to do with mental illness: e.g., to relieve the stress caused by the conspiracy against them; to help them sleep; to get their families “off their back”; to lower the volume on the voices being transmitted by the CIA, etc.

Listen-Empathize-Agree-Partner (LEAP) method

The cornerstone of LEAP is reflective listening. It is also the one feature of the method that immediately turns down the volume on everyone’s anger, builds trust, and mends fences.

Listen Reflective listening is a skill that needs to be cultivated—it

Empathize The second tool for your tool belt involves learning when and how to express empathy.

Agree Find common ground and stake it out.

If you have been using reflective listening and empathy, your loved one is going to feel that you are an ally rather than an adversary, and getting answers to such questions will be a lot easier than it may sound.

At this point in the process you will know the motivations your loved one has to accept treatment (e.g., “sleep better,” “feel less scared,” “get a job,” “stay out of the hospital,” “stop people from bothering me about being ill,” etc.) that may have nothing to do with the belief he or she has a mental illness.

Partner Forming a partnership to achieve shared goals

It’s hard to listen reflectively in the face of all the distracting “noise” of psychosis, especially if you are pursuing an agenda and trying to follow a timetable. To do it right, you have to drop your agenda, as I did with Barbara. Your only goals are to understand what your loved one is saying and to convey that understanding.

Listen for the feelings behind the words and reflect back the emotion. When you understand the underlying emotions, you will discover what the person cares about most and what motivates him.

Very likely, the person you are listening to reflectively and without judgment will make the mistake of thinking you believe what he is telling you (about not being sick, not needing medications, or the CIA conspiracy). He may ask you to help him catch the CIA in the act or talk to his parents so he can go off medications since you seem to agree he doesn’t need them.

let me introduce you to two new tools: The Delaying Tool and the Three A’s For Giving Your Opinion that will allow you to use reflective listening without falling prey to these traps.

I promise I’ll tell you whether I think you are sick. But first, if it’s OK with you, I would like to hear more about _________. Would that be all right?

I promise to answer your question about whether you should stop taking medicine. Before I do, I want you to know that I think your opinion about this is far more important than mine. So can you tell me all the reasons why you want to do that?

You can say something like, “After listening to you, I have a much better picture of your views on this. Can I tell you what I think?”

the way you deliver your opinion will determine whether it throws more fuel on the fire or continues to douse the flames.

The “three A’s” are apologize, acknowledge, and agree.

I’m not suggesting you apologize for the opinion you’re about to offer (e.g., “Yes I think you may have bipolar disorder…”), but for the feelings it might engender. You’re not saying you’re sorry you feel this way, but rather that you’re sorry that what you have to say may make him or her feel upset.

When you do apologize, just be sure that you don’t use the word “but,” as in, “I apologize if this is going to upset you, but, I think…” I mentioned this before but want to emphasize it here again because it is so important. People who are in a disagreement typically stop listening when they hear the word “but.”

Rather, you need to acknowledge that you’re not infallible and you might be wrong—even though you clearly don’t think so.

“I hope we can just agree to disagree on this. I respect your point of view and I won’t try to talk you out of it. I hope you can respect mine.”