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Writer's pictureDr J

I’m fine! You’re the one with the problem!

How many of us struggle with people in our lives who have no insight? Maybe we, ourselves, are that person. Lack of insight is the human condition. Most of us don’t like being judged, labelled, criticized…diagnosed. Early in training, a perfectly well-meaning therapist will lose a patient because they were too honest, too soon. Later with experience, one learns to make oblique comparisons, hoping the patient will make conclusions about themselves that the skillful therapist has led them toward. It may take a long time, maybe even never, for the patient to gain insight.


When a person suffers from a severe mental illness, one of the best predictors of prognosis is the level of insight. For example, three people are certain that someone or some organization, usually the government, is spying on them via cell phone camera. They notice coincidences around them that reinforce this idea. Person one, Pink, says to herself, “let ‘em look, who cares”. Pink does not let this belief affect her cell phone use. She jokes about it, sometimes. Person two, Magenta, says to themselves, “Oh, gosh, I don’t want people invading my privacy!” They decide to cover their cell phone camera and disable the camera function in all their apps, but they keep using their phone. They feel comforted and stop seeing the coincidences. A few months later, Magenta gets really stressed out and sees the coincidences return. They decide to get medication for ‘anxiety’ and they stop noticing odd things so much. Person three, Purple, after covering the camera and disabling his apps, still notices the coincidences. He concludes that he is being spied on in other ways. He stops using his cell phone. Ultimately, Purple writes a letter to his congressperson demanding that the government end their surveillance. Then, the government steps in to have Purple involuntarily hospitalized, which only reinforces his idea that there is a conspiracy against him.

Purple obviously represents the severely mentally ill. Imagine being his wife, child, sibling, or friend. Several times along the way, someone who cares likely tried to counter his delusional ideas. There are people who yell and throw plates and punch holes in walls. People who lose jobs and relationships because they feel too hopeless to get out of bed. People too fearful of panic attacks to leave the house. I wish I could say that psychiatric treatment always works. Even when one finds a good medication regimen, and has years of stability, medication can stop working. One may experience some crisis that brings back clinically severe symptoms despite compliance with treatment.

So, what can we do when someone we care for is ill, but not so ill that they can’t be forced into treatment? I have encountered many who have chosen to seek treatment themselves to cope with someone else’s behavior. A therapist can help one to communicate more effectively. Sometimes, this leads their loved one into treatment, also, but more often does not. Sadly, everyone has a breaking point. Jobs are lost, relationships end, and the person who is most in need of treatment is left alone to deteriorate.

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