Unknown Unknowns

I’ve been thinking about anosognosia, or lack of insight into one’s mental illness. I see a lot of coexisting mental illness and addiction occurring in some of the people I encounter at my local drop-in center. If mentally ill people don’t believe they have an illness then they’re not going to believe that they have an addiction either. Addiction is a mental illness, but many people that have only an addiction experience denial, not lack of insight into their condition. Denial is different. Many addicted people minimize their problems. People who are seriously mentally ill and experience anosognosia don’t minimize their condition. They experience the incapacity to even minimize their problem. They flat out don’t believe it.
There’s an article in the New York Times that addresses “everyday anosognosia” There will always be unknown unknowns for everyone. The article says the more aware we are of this predicament the smarter we are. Anosognosia in mentally ill people is not a matter of how intelligent they are. Researchers hypothesize that it comes about by right frontal lobe damage. It’s similar to stroke victims who have right frontal lobe damage. It has nothing to do with intelligence. Stroke victims with this condition retain much of their native intelligence in spite of their belief that the left side of their body isn’t paralyzed.
Even in the chapter “How It Works” in the Alcoholics Anonymous text it mentions people with “grave mental and emotional disorders” can recover if they have the capacity to be honest. The AA text also mentions that there are those who are incapable of being honest with themselves and that they are not at fault. They were born that way. Mentally ill people who have coexisting addiction who don’t believe that they are mentally ill are going to have the same lack of insight into their addiction. The ones who have both conditions at my local drop-in center are more likely to be homeless. I think many of the people at my AA group know this, but to me they seem callous towards the clients at the drop-in center where I volunteer. Maybe it’s because they know that the people with anosognosia have little chance of becoming sober. I’ve spoken to members of my AA group about this organization. They don’t seem to understand that there are also people at the drop-in center who don’t have substance abuse problems and others that have insight and are trying to address their addiction. My friends at my AA group write all of them off. My bipolar group understands. They donate items and food to the drop-in center. There are people at the drop-in center who will never recover because of their lack of insight, but they need compassion, not the judgment and dismissal I see at my AA home group. I guess this happens because the chapter in the AA text “Working with Others” says not to waste your time with someone who does not want help. The text says to move on to someone who does want to recover.
A psychologist named Dr. Xavier Amador has discovered a way to get some people with anosognosia to take medication. Dr. Amador emphasizes developing a non-judgmental approach in your relationship to a client or loved one. He developed a form of therapy that finds common ground on goals rather than trying to talk someone into believing that they are mentally ill. This article provides advice for family members on how to repair and change the relationship with a mentally ill loved one.
Dr. Amador’s approach is derived from a type of therapy called motivational interviewing. “It is an empathic, supportive counseling style that supports the conditions for change. Practitioners are careful to avoid arguments and confrontation, which tend to increase a person’s defensiveness and resistance.”
Some consider these therapies as coercive. Some of the side effects of psychotropic medications are horrific. That’s a choice and not the case with anosognosia. To people with anosognosia, it’s logical to not take medication. People who have mentally ill relatives seem to think medication will solve their loved ones problems. I know from my experience and from other mentally ill people that in spite of medications improving their condition they don’t make your condition symptom free. It’s always there no matter how much better your functioning improves with medication.
After being misdiagnosed myself I understand why someone would not want treatment. Not all noncompliance has to do with anosognosia. There are many reasons why people refuse to take psychotropic medication. Some can’t accept the stigma that comes with mental illness. They don’t like the side effects. They don’t like big PHaRMA, the pharmaceutical lobby of the drug companies.
Maybe Dr. Amador’s approach and motivational interviewing are coercive, but families of mentally ill people suffer a lot when their relative is ill. They are desperate. The medications, however, aren’t magic pills. Their relative may function at a much higher level, but the symptoms never completely go away. The medications are crude tools. There is so much we don’t know about the brain.