Anosognosia and Getting a "Borderline" into Therapy

borderline personality disorder, anosognosia, and therapy
R. Skip Johnson

A mental illness is a disease that causes mild to severe disturbances in thought and/or behavior, resulting in an inability to cope with life’s ordinary demands and routines. There are more than 200 classified forms of mental illness. Some of the more common disorders are Depression, Bipolar Disorder, Dementia, Schizophrenia, anxiety disorders, and personality disorders such as Borderline Personality Disorder. 

22% of the Population Suffers from a Mental Illness

The current prevalence estimate is that 22 percent (22%) of the US population are affected by one of the 200 diagnosable mental disorders during any given year. This estimate comes from two epidemiologic surveys. Mental illness was defined according to the prevailing editions of the Diagnostic and Statistical Manual of Mental Disorders.

  1. The Epidemiologic Catchment Area (ECA) study of the early 1980s 
  1. The National Comorbidity Survey (NCS) of the early 1990s.

These surveys suggest that during a 1-year period, 22 to 23 percent of the U.S. adult population—or 44 million people—have diagnosable mental disorders, according to reliable, established criteria.  In general, 19 percent of the adult U.S. population have a mental disorder alone (in 1 year); 3 percent have both mental and addictive disorders; and 6 percent have addictive disorders alone. Consequently, about 28 to 30 percent of the population have either a mental or addictive disorder (Regier et al., 1993b; Kessler et al., 1998)

Yet, even with a prevalence rate 200% greater than that of pregnancy, most people believe that mental disorders are far more rare and likely to happen to someone else. 

Anosognosia: Treatment is a Goal, Not a Given

Unfortunately, many people with a mental illness do not fully grasp that they are afflicted.  What is often viewed by family members to be immaturity, stubbornness,  or defensiveness, is really a much more complex problem - Minimization, Abnegation and in some cases, Anosognosia. 

  1. "Anosognosia" is the clinical term for having a deficit of self-awareness, a condition in which a person who suffers a certain disability is unaware of its existence.  According to Edwin Fuller Torrey, M.D, Anosognosia is the single largest reason why individuals with schizophrenia and bipolar disorder do not take their medications.
  1. "Abnegation" is a defense mechanism postulated by Sigmund Freud. When a person is faced with facts that are too uncomfortable to accept, they are rejected - despite what may be overwhelming evidence. 
  1. "Minimization" is an exaggerated or irrational thought pattern that is believed to perpetuate the effects of psychopathological states, especially depression and anxiety.

The idea of impaired awareness of illness is very difficult to comprehend. 

Xavier Amador, Ph.D., former professor in the Department of Psychiatry at Columbia University, and the Director of Psychology at the New York State Psychiatric Institute, and his colleagues found in a 1994 study that nearly 60 percent of a sample of 221 patients with Schizophrenia did not believe they were ill.  Amador, himself, who suffers from Bi-Polar Depression, didn't even see the symptoms in himself until a colleague challenged him to answer a screening questionnaire for an electroconvulsive therapy (electroshock treatment)- and he qualified for this treatment that is reserved for severe mood disorders.  Ironically, he was writing a book on Bi-Polar Depression at the time - a chapter of symptomatology.

It's not always easy to see mental disorders in ourselves, or to accept them.

In the video series below, Amador explains that "People will come up with illogical and even bizarre explanations for symptoms and life circumstances stemming from their illness, along with a compulsion to prove to others that they are not ill, despite negative consequences associated with doing so."

Many families have encountered this same reaction when they reached out to a loved one with mental illness. Instead of being seen as an ally, they were seen as an adversary.

Amador describes what it is like to work with someone who does not believe they are ill. One patient he encountered was paralyzed on his left side and he had problems writing. "When asked to draw a clock the patient thought he did fine", Amador recalls.  However, when he pointed out to the patient that the numbers were outside of the circle, the patient became upset. "The more I talked to him [about the drawing], the more flustered he got...  Then he got angry and pushed the paper away, saying, 'it's not mine-it's not my drawing.'"

In mental health, we all believe ourselves to be "ground zero" for normalcy and measure everyone else based on our standard. The only way a person knows that they are different is based on the feedback and reactions of others - and this is  complex information to process.  Imagine, for example, if someone told you that the sky was not blue - that you perceived it differently than everyone else.  What would it take for you to believe this?

Granted, it's often a hard concept to wrap our hands around, but guiding a loved one with a mental illness into treatment is a goal, not a given.

What Can I Do for a Loved One with Borderline Personality Disorder Traits?

Most families are not prepared to cope with a loved one who has a mental illness. It can be physically and emotionally trying, and it can make us feel vulnerable to the opinions and judgments of others.  If you think you or someone you know may have a mental or emotional problem, it is important to remember there is hope and help. With proper care and treatment many individuals learn to cope or recover from Borderline Personality Disorder.

What can we do for a loved one with Borderline Personality Disorder traits?

If we want to help a loved one to get into therapy and, more importantly, to embrace the therapy, we need to "plug in" and understand both the perceptual filters that our loved one has, and their motivations.  This generally requires a great deal of listening.

Studies show that there are three areas that are most productive for family members to focus on.

  1. Building trust. Not blaming or not finding fault, but rather respecting our loved one's point of view, listening without telling them that they are wrong - especially regarding their point of view that they are not ill if that is their thinking. Amador says that family members and clinicians should listen carefully to the loved one's fears.  "Empathy with the patient's frustrations and even the patient's delusional beliefs are also important", remarked Amador, who said that the phrase "I understand how you feel" can make a world of difference.
  1. Reinforcing the developing awareness.  Reinforce the struggles that the loved one perceives as concerning. One of the most difficult things for family members to do is to limit discussions only to the problems that the loved one with the mental illness perceives as problems - not to try to convince them of others. Work with what you have. It is important to develop a partnership with the loved one around those things that can be agreed upon. 
  1. Our belief that the loved one will benefit from treatment.  Our loved one may be happy with where they are and moving them from this position is as much art as it is science - and it may take time.

What Not To Do

Professionals do not recommend that you tell a loved one that you suspect that they have Borderline Personality Disorder. We may think that our loved one will be grateful to have the disorder targeted and will rush into therapy to conquer their demons, but this usually doesn't happen.  Instead, this is difficult advice to receive and more likely to sound critical and shaming (e.g., you are defective) and incite defensiveness, and break down the relationship trust.  It's not like a broken leg where the affliction is tangible, the cure is tangible, and the stigma nonexistent.  While we are grateful to learn about the disorder and the pathways to recovery - for us the information is validating and represents a potential solution to our family problems- to the afflicted, it is shaming (you are defective),  stigmatizing (mental illness in general, Borderline Personality Disorder specifically), and puts all the responsibility for the family problems on the loved one's shoulders.

Very often when we say we want to help a loved one with Borderline Personality Disorder, we mean that we want the loved one to stop being a burden to the family, and to better attend to our own needs and expectations.

  1. Not good for us.  If a loved one enters therapy or alters their behavior mostly to please us or out of fear that we will abandon them, are we helping them or are we being selfish and emotionally manipulating?  If so, this is not the best starting point for healing and recovery - and even if successful in getting someone in - will likely see pushback in the form of passive aggressiveness and resentments.
  1. Not good for them.  Loved ones often see these efforts to help as threatening or condescending - even bullying.

Note: While parents of children under 18 can enroll them into therapy, Intensive Outpatient Treatment, or Residential Treatment, and should, the principals above apply. Perceptions of collaboration will be more successful than perceptions of avoidance or punishment.

Video on Understanding How To Get A Loved One Into Therapy

For more information on how to help a loved one get into therapy, please view the video series below. The author uses the example of Schizophrenia, but these principles apply to Borderline Personality Disorder as well.

Amador is a clinical psychologist who treats adults, children, and adolescents in individual, couples and family therapy. Previously, he was a professor in the Department of Psychiatry at Columbia University, College of Physicians & Surgeons; Director of Research at NAMI; and the Director of Psychology at the New York State Psychiatric Institute. Amador has written about getting people with serious mental illness to accept treatment in a book he coauthored with Anna-Lisa Johanson titled, "I am Not Sick, I Don't Need Help: A Practical Guide for Families and Therapists", (2000 by Vida Press.)

Last modified: 
January 04, 2021