We’re not alone
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.
What is anosognosia?
Anosognosia is a condition where someone is either unaware of their own serious mental illness or addiction, or they are unable to understand their condition accurately. For people with schizophrenia or bipolar disorder, for example, anosognosia is the main reason for them refusing to accept treatment.
Trying to educate a person with anosognosia for their mental illness is like telling someone with psychosis to stop hallucinating. Education and the evidence we supply does not work. (Well, it does work to make the person angry with us.)
It turns out that the research indicates that establishing a trusting relationship imbued with respectful and nonjudgmental communication is the way to go. This works to help people who do not understand they are ill accept treatment. It helped that to happen with my brother Henry and with countless others.
Changing how you approach your loved one’s refusal to accept treatment
In my experience, it is often easy to change an adversarial relationship into an alliance and long-term engagement in treatment. It takes focused effort, but it isn’t hard to do once you learn the main lessons. The hardest part is putting aside your preconceptions and remembering that no amount of arguing has previously changed your loved one’s opinion.
My best advice to you is to stop trying to convince your loved one they are ill. When you accept your powerlessness to convince them, you will begin to open doors you didn’t even know existed. Remember, if you had truly succeeded in convincing your loved one they have a mental illness, you would not be reading this article.
The first step, therefore, is to stop arguing and start listening to your loved one in a way that leaves them feeling that their point of view—including their delusional ideas and the belief that they are not sick—is being respected.
If you can relate to your loved one in this way, you will be much closer to becoming their ally and working together to find the reasons they may have to accept treatment—even though they are not sick. You don’t have to agree with their reality—the “realness” of their experience—but you do need to listen and genuinely respect it.
4 steps to helping your loved one accept treatment: The (LEAP) method
The result of my research and that of colleagues at Columbia University in New York was the Listen-Empathize-Agree-Partner (LEAP) method.
Whether or not you believe your loved one has anosognosia for mental illness or addiction, or simple denial of their illness, LEAP can help you get your loved one to accept treatment.
Step 1: Listen
Reflective listening is a skill that needs to be cultivated—it doesn’t come naturally to most people. To succeed, you will need to learn to really listen and not react to what your loved one feels, wants, and believes. Then, after you think you understand what you are told, you need to reflect to them, in your own words, your understanding of what you just heard.
The trick is to do this without commenting, disagreeing, or arguing. If you succeed, your loved one’s resistance to talking with you about treatment will lessen and you will begin to gain a clear idea of their experience of the illness and the treatment they don’t want.
When you know how your loved one experiences the idea of having a mental illness, addiction, and/or taking of psychiatric drugs, you will have a foothold you can use to start moving forward. But you will also need to know what their hopes and expectations are for the future, whether or not you believe they’re realistic.
If you can reflect back an accurate understanding of these experiences, hopes, and expectations, your loved one is going to be much more open to talking with you. More importantly, they’re going to be much more open to hearing what you have to say.
Step 2: Empathize
The second tool for your tool belt involves learning when and how to express empathy. If there were a moral to each technique, the one for empathizing would go something like this: If you want someone to seriously consider your point of view, be certain they feel you have seriously considered theirs. Quid pro quo. That means you must empathize with all the reasons your loved one has for not wanting to accept treatment, even those you think are “crazy.”
You especially want to empathize with any feelings connected to delusions (such as fear, anger, or even elation, if the delusion is grandiose). But don’t worry—empathizing with how a particular delusion makes one feel is not the same as agreeing that the belief that it is true. This may seem like a minor point, but, as you will see, the right kind of empathy will make a tremendous difference in how receptive your loved one is to your concerns and opinions.
Step 3: Agree
Find common ground and stake it out. Knowing that what you want for your loved one is something they do not want for themselves can make it seem as if there is no common ground. You want them to admit they’re sick and accept treatment. They don’t think they’re sick, so why in the world would they accept treatment for an illness they don’t have?
To avoid coming to an impasse, you need to look closer for common ground and for whatever motivation the other person has to change. Common ground always exists, even between the most extreme opposing positions. One area you both can almost certainly agree upon is wanting the relationship to be conflict free, wanting the relationship to be better.
The emphasis here is on acknowledging that your loved one has personal choice and responsibility for the decisions they make about their life. When you use the Agreement tool, you become a neutral observer, pointing out the various things you do agree upon.
If invited, you can also point out the positive and negative consequences of decisions your loved one has made. That means refraining from saying things like, “See, if you had taken your medication, you wouldn’t have ended up in the hospital.” Or, “If you hadn’t been high you would not be in the trouble you’re in.”
Your focus is on making observations together—identifying facts upon which you can ultimately agree.
Step 4: Partner
If you have been using reflective listening and strategic 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. When you put aside your agenda for the time being, you can find a great deal of common ground. For example, if the answer to the question about what happened after the medicine was stopped was, “I had more energy but also I couldn’t sleep and got scared,” you can agree with that observation without linking it to having a mental illness.
At this point in the process, you will know some of the motivations your loved one has to accept treatment (such as “sleep better,” “feel less scared,” “get a job,” “stay out of the hospital,” “stop my family from bothering me,” etc.). These may be reasons that have nothing to do with the belief that they have a mental illness.
You will know what your loved one’s short- and long-term goals are because you will have talked about them together. And, with this knowledge, you will now be able to present the idea that medication might help them to achieve their goals. I can’t emphasize this enough—your suggestions should have nothing to do with the notion that your loved one has a mental illness.
Relationships that are respectful and nonjudgmental lead to acceptance of treatment
Finally, whenever you find areas of agreement and you talk about them together, you’re strengthening the relationship. Research shows that when you talk about things you agree on, you’re usually speaking in a respectful and nonjudgmental way. And when you have a relationship with someone that is marked by mutual respect and lack of judgment, it turns out that’s one of the best predictors of who will accept treatment and stay with it long-term.
In other words, relationships that are respectful and nonjudgmental lead to acceptance of treatment. To sum all this up: We don’t win on the strength of our argument (for why the person is ill and needs treatment), we win on the strength of our relationship.
About the author
Last updated or reviewed on February 28, 2023