If you are reading this article, it is probably because you have a serious problem. You are trying to reach someone with an addiction or a serious mental illness, such as schizophrenia or bipolar disorder, who is in “denial” and refusing treatment and relapsing. Or, if they’re in treatment, they’re dropping out again and again. You’ve tried various strategies that haven’t worked and you’re seeking information about how you can help your loved one get help.
We are not alone. I use “we” instead of “you” because I have met countless families just like my own—and yours—estranged from a loved one who has no clue they have mental illness or addiction.
During the first few years of my brother Henry’s schizophrenia (before I went to graduate school to become a clinical psychologist), I often thought he was being immature and stubborn. Asked about what his plans were after being discharged from yet another hospitalization, he ritually answered, “All I need to do is get a job. There’s nothing wrong with me.” His other stock answer was, “I am going to get married.”
Both desires were natural and understandable, but unrealistic given his recent history, the severity of the illness, and his refusal to accept treatment. Someday, perhaps, he would realize his desires, but it was very unlikely unless he was actively involved in the treatment recommended by his doctors.
It was exasperating to talk to Henry about why he wasn’t taking his medication—having limited experience with the illness, the only reason that I could think of for his adamant refusal was that he was being stubborn, defensive, and, to be frank, a pain in the rear. And, for myself, it was only after I started working in the field, and met many more people with serious mental illness, that I stopped giving such theories much credence. It just never made sense to me that the pervasive unawareness and odd explanations given by people like my brother could be explained simply as having an immature personality or a lack of love.
But you don’t have to take my word for it. Let’s look at the research for a more objective answer to the question of what causes poor insight and refusal to accept treatment.
Poor insight and why your loved one refuses treatment
I have considered two main causes of poor insight in seriously mentally ill persons. First, it could stem from defensiveness—after all, it makes sense that someone who is seriously ill would be in denial about all the potential and promise for the future that has been taken by the disease. However, while everyone gets defensive from time to time and some people are more prone to denial than others, studies show that “everyday” defensiveness is not responsible for the gross deficits in insight that are so common in these patients.
The second possible cause is that poor insight into the illness stems from the same brain dysfunction that is responsible for other symptoms of the disorder.
When patients with schizophrenia were studied to examine whether performance on neuropsychological tests predicted the level of insight into their illness, the results showed a strong association between the two. Of particular note is the fact that this correlation was independent of other cognitive functions, including IQ. 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.
Taken together, these results strongly support the idea that poor insight into illness and resulting treatment refusal stem from a mental defect rather than informed choice.
The finding that poorer insight is significantly correlated with frontal lobe dysfunction (and reduced grey matter in the frontal lobes) has been replicated many times by various research groups. Repeated replications by independent researchers are infrequent in psychiatric research, so the fact that various researchers have found essentially the same thing speaks to the strength of the relationship between insight and the frontal lobes of the brain.
Anatomical brain differences and poor insight :
There is also an emerging body of literature linking poor insight in schizophrenia and other psychotic illnesses to functional and structural abnormalities in the brain, usually involving the frontal lobes. Studies have found differences in the brains of schizophrenia patients who have insight, or awareness of their illness, compared to those who do not.
Three of these studies included individuals with schizophrenia who had never been treated with medication, discounting the hypothesis that these brain differences resulted from treatment.
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.
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