When your mentally ill loved one is in denial
Save your breath and try LEAP instead
Tanya, the woman who has called in promptly at 9 am to the National Alliance on Mental Illness (NAMI) Sacramento Helpline, is upset. “My daughter won't listen to me. She won't admit there's anything wrong! She's completely in denial! Do you know someone who can help us do an intervention? She is doing crazy things like she drove to LA and got arrested for stalking some movie star. She says he loves her and wants her to have his baby. She's never even met him. She needs help but she won't go!” Tanya is now crying.
We hear stories like this every day on the Helpline. About 40% of the calls we get are from individuals with a mental health condition (we refer to these callers as peers or consumers). The other 60% are almost all from family members. I will refer to these callers as natural supporters from here on out because family in this context includes a broad array of folks from parents, siblings, and adult children to coaches, therapists, and neighbors. A natural supporter is someone who is in a position to offer support and willingly does so.
These natural supporters frequently want to talk about how their loved one is “in denial,” which means that their person won’t admit that something is wrong and refuses to seek treatment. These natural supporters often complain that the peer ignores the negative impacts of their behavior even when they are in jail or the hospital as a result of a crisis. Sometimes these callers are really angry. Some are afraid. Most of the time they are frustrated that this person they thought they knew well has turned into a stranger who won’t listen to them. Some people have shown their loved one a video of them behaving strangely or raging, and the peer says it’s not real or doesn’t react at all. It’s as if they can’t even see it. The natural supporters universally report that they are unable to convince the person of their point of view or to seek help, and they have been unable to stop the person from destroying their life.
This is not denial. This is anosognosia (an-uh-sug-no-see-uh), a symptom of serious mental illness, which is an inability to accurately perceive one’s behavior as bizarre, dangerous, or out-of-character. Some people describe anosognosia as having a lack of insight into one’s illness. The person with the mental health condition is literally unable to perceive their behavior accurately. You can’t convince them their perceptions are wrong no matter what you do. They can total their car in a solo crash going 100 mph on a residential street and be taken to jail as a result and still refuse to accept “responsibility.” Instead, they will tell you a story about how it was another driver’s fault or that the CIA was tailing them and they had to get away. As far as you can tell, they honestly believe their own explanation in defiance of the facts.
About 50% of people with bipolar disorder, schizophrenia, and schizoaffective disorder (schizophrenia and a mood disorder combined) experience anosognosia. The condition varies from mild to severe and can vary in intensity over time. It might only be a problem during acute episodes or persist even when other symptoms improve.
As you might imagine, severe anosognosia leaves the peer completely unable to understand the consequences of the unusual behavior caused by their illness and they are unable to tell that they are ill. The result is that they don’t seek or refuse treatment and frequently come to believe they are being persecuted because bad things happen to them when they are doing nothing to justify those bad things, things like jail, bankruptcy, divorce, or the loss of custody of their children. They may get very angry and confrontational when they are deprived of something like the right to use a parent’s car or find themselves being evicted because of problematic behavior. Interventions like the one Tanya wants to do are likely to backfire and alienate the peer, sometimes permanently. Arguing with them, trying to confront them, or trying to pressure them into accepting their diagnosis and the need for treatment will almost always provoke an angry response. Their brain is telling them they are fine just like your brain is telling you you are fine. Would you believe you weren’t fine if someone else told you you were crazy and you couldn’t perceive that anything was wrong?
Milder manifestations may still make the person unlikely to seek treatment or to choose to stop treatment when stable. The person might tell you that it was just a one-time thing (even though it has happened more than once) or that other people were overreacting. It may lead them to discount the severity of their symptoms when they are once again stable. For example, this happened to me. When my mania flipped into a mixed episode (a state where you have the driven energy of mania but feel depressed), I believed I was evil and felt the urge to kill myself. Except for my first psychotic break when I had no insight (you can read about that incident here. I retained enough insight to resist those urges with the help of binge eating and other self-harm. But once the mixed episode was over, I discounted the severity of the episode. While I did seek some treatment, I did not disclose to my doctors and therapists just how severe my symptoms actually were until I was very, very sick, forty years after my first episode at age 19.
When a natural supporter asks what to do, we tell them about the work of Dr. Xavier Amador. He is the author of the book “I am not sick, I don’t need help.” He also has a You Tube video of his TED Talk that you can find here, and videos on his website that demonstrate his technique for working with someone who is living with anosognosia. It is called LEAP, which stands for Listen, Empathize, Agree, and Partner. Dr. Amador is a clinical psychologist whose brother has schizophrenia with significant anosognosia. He was successful, over time, in getting his brother to go on medication despite the fact that his brother didn’t believe there was anything wrong with him. That led Dr. Amador to write the book and share his technique with others.
In a nutshell, LEAP entails the natural supporter listening empathetically to the peer and affirming their feelings without blaming the situation on their illness or engaging with any delusions they may have. The natural supporter strives to get their loved one to agree that there is a problem they are both interested in solving—for example that the peer keeps having to go to the hospital when he doesn’t want to. The peer hates being locked up. (For some insights into why this might be true, see my post on Involuntary Holds.) The natural supporter dislikes experiencing episodes that result in their loved one being locked up. Together, they agree that getting locked up is a problem they each would like to solve without agreeing on the reason for the problem. The natural supporter doesn’t insist that the peer “admit” they are mentally ill as a prerequisite for seeking a solution together. The solution might be taking medication or something else. Together they develop a plan or Partner together to come up with a solution.
LEAP takes persistence and skill. If you have someone in your life who is “in denial” like this, consider watching the videos on the LEAP Institute website and investing in the book. You might also want to find a NAMI family support group online or in person near you. Many NAMIs, like ours, have online meetings now so even if you don’t have a NAMI in your county, you can find a meeting in your time zone to attend. We also have an eight-week program called Family to Family that covers types of mental illness, typical treatments, crisis planning, self-care, and communication tips. Most NAMI affiliates offer both. Go here to find the NAMI near you.
If you have tried using the LEAP method, tell us about your experience in the comments. If you’ve found some other way that worked for you, share your story. And, if you liked what you read, please scroll down and hit the heart button and re-stack with a comment so other folks can find me. If you want to get my posts every Thursday in your inbox, hit subscribe.
Your clear and concise explanation of this little-understood condition is most appreciated!
It’s interesting to read your insight and the LEAP method. However, it’s very difficult to put into practice when you add in all the complicating factors, such as a very broken system that is incapable of handling a loved one’s complexities with urgency. I’ve seen it fail my mother and brother.