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The Myth of Denial: Why People With Mental Health Disorders Refuse Treatment
Treating mental health disorders is an investment that pays off fourfold or more, research shows. Among the many benefits of mental health treatment are increased productivity, reductions in substance abuse and medical issues, and lower rates of homelessness and poverty. But not everyone can access the treatment they need. An estimated 30 to 80% of people with mental health disorders do not receive treatment at all.
There are many barriers facing people who need mental health treatment, from practical concerns like work and family obligations to problems finding and paying for the right type of treatment. Perhaps the most significant obstacle is refusal of treatment by the person with mental illness. Loved ones often call this “denial” and get frustrated by the person’s seeming unwillingness to address the problem. But in many cases, it isn’t denial at all.
Rather, it could be issues such as:
Many people with mental health conditions don’t know that they have a disorder or don’t understand the nature of their illness. This lack of awareness, also called anosognosia, is a medical issue that impacts the functioning of the brain. Symptoms of anosognosia affect an estimated 50% of people with schizophrenia and 40% of people with bipolar disorder. With anosognosia, it is common for perceptions to vary over time. Sometimes the person realizes they have an illness, other times they do not.
Instead of looking at mental illness, people tend to attribute their problems to the circumstances in their lives or to a recent setback, financial problems or physical illness, even when those reasons don’t fully explain their symptoms. If someone has never been treated before, especially in the early phases of bipolar disorder, depression or schizophrenia, they’re going to try to make sense out of their symptoms or come up with a rational explanation for why this is happening to them. For example:
- Someone with depression might say, “I wouldn’t feel this way if my job was going better, or if my spouse loved me more.”
- A person in a manic phase of bipolar disorder may say, “Well, I’m just in a creative period. I’m exhilarated by the work I’m doing.”
- With paranoid schizophrenia, part of the illness is for people to think that others are plotting against them. They don’t believe they are ill; rather, the problem is with others.
Psychiatric illnesses affect motivation, problem-solving, decision-making and planning functions in the brain, making it difficult to address a problem even when there’s some awareness it exists. Many people with bipolar disorder have state-dependent memory, which means they may not recall manic episodes well. How much do patients with certain disorders remember if they haven’t slept well? Much like an alcoholic who doesn’t remember how much they drank or how they behaved because they blacked out, people with certain mental health disorders may not have access to their memory and other high-order brain functions.
Fear of stigma
There are still prevalent beliefs that people with mental illness are dangerous, defective, weak, flawed or lazy. This stigma prevents people who realize they may have a problem from getting help for fear of judgment and concerns about how being labeled could impact their career, relationships and lives. Three out of four people with a mental health disorder report that they have experienced stigma.
Concerns about treatments
People may resist getting help because treatment has unpleasant side effects. The two most common complaints are sexual dysfunction and weight gain. Side effects may lead people into the arms of drugs of abuse that override these symptoms. For example, methamphetamines may override sexual dysfunction and weight gain and opiates can depress appetite. Other people may feel uncomfortable with the changes treatment could bring. For example, people with bipolar disorder may miss the high-energy mania phases once medication stabilizes their moods.
Lack of efficacy of medications
Part of the problem, particularly for those with depression, is that the benefits of medications have been over-sold. Clients have expectations that medication will solve their problem but the truth is their efficacy is limited. Only about 30% of patients go into remission and about 60-70% improve a bit, which leaves 30-40% that don’t improve at all on the medication. With subsequent treatment (e.g., using a higher dose of medication or augmenting treatment with a secondary medication or other approach) the improvement rate can increase to 50%. This doesn’t mean treatment isn’t worthwhile; it means people have to be prepared to try multiple medications and therapies to find the combination of approaches that works for them.
Sometimes people refuse treatment because they are not sure it can help or they believe that the therapist doesn’t truly care about helping them and is just a “rent a friend” (treating them because they are being paid to do so). This can stem from attachment issues or an all-or-nothing perspective (“splitting”) where the client swings back and forth between idolizing and demonizing the therapist and others. For example, people with borderline personality disorder know they are in distress – they are not denying this – but they are at cross purposes with treatment.
Lack of access
People who are interested in getting help for mental illness may not know how to find effective treatment. They may live in areas with few or no mental health professionals or they may not be able to afford the care they need. Lack of transportation and child care are other barriers to treatment. The growth of telemedicine and the expansion of mental health insurance coverage have helped many who wouldn’t otherwise have access, but there’s great need for further mental health care reform.
What Leads People to Mental Health Treatment?
Many people don’t actively seek out treatment. Instead, what often happens is the person develops physical complaints; for example, a person with depression may have trouble sleeping or they may have lost or gained 20 pounds and they’re worried they could have cancer or some serious physical health problem. So they see a primary physician who may eventually refer them to mental health treatment.
Another common path to treatment is through the legal system. In the case of schizophrenia, for example, the person may start wandering or get confused, or their sleep cycle may be disrupted, so they’re out in the middle of the night. As a result, they get picked up by the police and are given a mental health evaluation.
Sometimes families are the impetus for treatment. In the case of bipolar disorder, for example, manic symptoms may be so disruptive that the family becomes alarmed. The person may be recklessly spending money, acting on impulses, or coming in at all hours of the night, and the family encourages the person to see a mental health professional.
How to Overcome Resistance to Mental Health Treatment
Even if mental illness prevents someone from recognizing the problem, friends and family members don’t have to accept that their loved one will always suffer. Here are some ways to break through resistance:
Find the Right Therapist.
Different approaches are effective for different people and conditions, but some are particularly helpful for those who resist change. Look for a therapist who understands attachment theory and uses approaches like cognitive behavioral therapy, which helps people challenge their thoughts and behaviors and replace negative beliefs with more realistic ones.
Motivational interviewing is another powerful tool for helping people discover their internal motivation to change. With many illnesses where people often resist treatment, such as bipolar disorder, borderline personality disorder and addiction, the most effective approach may be to discuss belief systems and expectations of treatment and to educate them about their illness and the various treatments available.
When a client is resisting treatment or doubting that the issue lies with them, there will likely be no agreement around their delusion. Rather than trying to explain to them that they are delusional, the client is better served by figuring out what we can agree on. For example, we can focus on issues that are bothering them, such as sleep or relationship conflicts, and work on addressing those first.
Even when they recognize it’s not willful denial, arrogance or stubbornness, people who love someone with mental illness can feel frustrated by refusals of help. Since people tend to be motivated by natural consequences, respectfully set limits on what behaviors and situations you aren’t willing to accept and stick to them. If they seem open, encourage the person to talk with a mental health professional.
Be an Ally.
Where there’s trust, there’s influence. A mentally ill loved one will be more receptive to treatment suggestions if they have a close relationship with the person that is encouraging them to get help. Express your love and concern for the person. Spend time with them and listen empathetically without disagreeing so you can understand their perspective. If your loved one acknowledges certain issues but not others, work with the issues they see rather than trying to convince them of all the others you see.
If your loved one decides to start treatment, support them by helping them get to appointments and encouraging them to stick with their medication and therapy program. Remember to also support yourself by talking with a mental health professional or joining a support group with people who share similar struggles.
It can be heartbreaking to watch someone’s life fall apart. But your loved one may not be able to see what you see when they’re struggling with a mental health disorder. Arguing, judging, blaming and confronting only make the person defensive or withdraw from the relationship. They need help, but that help might have to happen on their terms. Approach with love, patience, compassion and a message of hope and be ready to take action when the opportunity to help arises.
By Meghan Vivo