There are about six million severely mentally ill people in the United States. About half of these severely mentally ill do not know they are ill. (1) (Severe mental illness includes schizophrenia, bipolar disorder and a few other diagnoses). There is a medical term for this condition: anosognosia, an impaired awareness of one’s own disturbed mental condition, despite evidence to the contrary. An ill person may claim that everything is fine, when it is not. This impaired awareness of mental illness is caused by damage to specific parts of the brain. Neurocognitive deficits, or symptoms of a brain dysfunction, are part of the mental illness. People with anosognosia do not recognize that hallucinations, mania, delusions, paranoia or other symptoms of mental illness are, in fact, mental illness. For this reason, many refuse medication if it is prescribed. Others may take medication for awhile, but then throw it away. Remaining unmedicated has many dangers, such as the illness might get worse, they may need hospitalization, they may unable to hold a job or their safety may be at risk.

Individuals with impaired awareness will not voluntarily utilize psychiatric services, no matter how attractive those services are, because they do not believe that they have an illness. (2) Without treatment, many of them end up homeless or in jail. This is a large root cause of the stigma against the mentally ill. The image of the crazy homeless person is a stereotype which produces stigmatization against all mentally ill, homeless or not. Or perhaps in small cases the untreated mentally ill individual creates the sort of violence that makes headlines. That too fuels stigmatization against the mentally ill. The public often believes that since the troubled person refused to seek treatment, they “deserve what they got”, another evidence of stigmatization.

Sometimes the individual with anosognosia is aware of their illness, and sometimes not aware. This is because the illness might fluctuate in severity. The individual might be more aware when in remission, but loses the awareness when relapse occurs.

The symptoms of someone in psychosis may be observed by others, but if the person has anosognosia, their feelings and beliefs are so real for them that when others try to persuade them that their feelings and beliefs are not real, they think that others are just insulting them. This may put a wedge between the person’s doctor, friends, family and them because the person may feel victimized, and often becomes even less cooperative. It is difficult to convince them to seek help.

Can the severely mentally ill be treated against their will in the United States? Many state laws require an individual to be an imminent danger to self or others before he or she can involuntarily be committed, but there are other jurisdictions with a broader definition. The process of involuntary commitment involves a judge or presiding panel, who go by their best judgment based on the evidence.

There are various types of involuntary treatment, including both inpatient and outpatient, and laws vary from state to state. Yet it takes a lot to get the homeless mentally ill person who has impaired awareness of illness from the streets into a psychiatric hospital. The complex problem of how to treat the mentally ill with anosognosia involves moral and ethical issues, legal issues, civil rights issues and funding issues. Some argue that “the only answer is to treat them involuntarily”, and say that “there is a budding trend toward this solution in state laws.” (3) But because of past deinstitutionalization of the mentally ill, most of the psychiatric hospital beds have been lost, and funding for outpatient treatment facilities is inadequate. It will take many factions working together to facilitate humane and effective involuntary treatment programs while, hopefully, maintaining civil rights.

Most severely mentally ill who were medicated involuntarily agreed, in retrospect, that the medication was in their best interest. Forced medication often results in a more rapid return of freedom to be discharged from involuntary hospitalization. (4) But involuntary commitment is not the only answer. “Some mentally ill persons are able to overcome the feeling of ‘I Am Not Sick’. The odds favor those whose family and care takers understand the complexities of these no fault mental illnesses. The successes are sometimes fragile and are most common when families and professionals are able to offer, with patience and persistence, opportunities for medical care, psychological counseling and supervision.” (5)

References

(1) Treatment Advocacy Center. Briefing Paper. “What Percentage of Individuals with Severe Mental Illness are Untreated and Why”.

(2) Ibid.

(3) Lowry, Rich. (July 31, 2003). Townhall.com. “Mistreating the Mentally Ill“.

(4) Treatment Advocacy Center. Briefing Paper. “The Effects of Involuntary Medication on Individuals with Schizophrenia and Manic-Depressive Illiness”.

(5) Families of People with Untreated Mental Illness. (September 23, 2005). Lack of Insight Mental Illness. “We are Their Only Voice”.