Wednesday, April 06, 2011

Unawareness Versus Denial

Because of the neurological research coming out over the last decade or two, psychiatry is increasingly making a distinction between denial and unawareness. Some of the research is being done up at Dartmouth MS by folks I admire and used to work with, so I keep up with this more than other areas.

Everything has been in the "denial" category since Freud, or before: the idea that mentally ill people really do know, at some level, what reality is, but hide it from themselves. Therapy was a way of developing insight, and having the courage to accept the unpleasant.

Unawareness, in contrast, is the idea that certain brain dysfunctions make the owners of those brains unable to see their illness, no more than a blind person can see, or even more exactly, than a color-blind person can distinguish colors. Like an amputee who feels a phantom limb, or like Oliver Sacks, losing the sense of ownership of a limb after injury, they cannot perceive their illness, regardless of the evidence submitted. Dr. Flashman gave the example of the patients who believed he had implanted chips in their brain, shown their chipless MRI's. The responses were varied - my sort of chip doesn't show up...that's not my doctored the photo... but none were able to muster even a 0.1% acceptance of the no-chip idea. Not evn in theory. Not even as a "what if" scenario.

We are moving more and more lack of insight from the "denial" pile into the "unawareness" pile, for psychotic disorders certainly, but even for mood disorders when they are untreated. How far will this go? Will it turn out that no depressed people ever respond to any offered advice or insight, but only to the intervention of attention, of exercise, of medication, of practicing agency? Lincoln's comment that people are about as happy as they make up their minds to be might turn out to be completely untrue, and useful only for the reminding the folks outside the depression that nothing, absolutely nothing they advise is going to have the slightest effect.

I am increasingly convinced of this for many illnesses, and it makes me feel shame at the conversations I have had over the years with patients, attributing (usually, but not always, unconsciously) their lack of insight to some stubbornness or cowardice on their part - a refusal to engage reality rather than a biological inability to perceive it. It's not just a waste of time. It's thirty-plus years of unnecessary cruelty.

If you absorb this, you will see that it makes things both better and worse. If the patient is not going to be convinced, whether you explain for two seconds or two hours, why bother to give any explanation at all? Or if you listening to her for two hours will make no more difference than listening for two seconds, why listen at all? Isn't it just a waste of time and ultimately cruel, pretending to a patient that her opinion makes the slightest difference when if fact it doesn't? So let's just ignore everything she says until we get a guardian then, and hold her down and give her medicine and be done with it. Why any charade?

I don't think it takes much imagination to see that as a chilling scenario, and an enormously bad precedent to set.

But is badgering a deaf person because they can't hear any better? Because even if the mental health practitioner is speaking in the kindest tones, is really rooting for the patient to "get it," and has the best intentions, if we really think that underneath it all they are denying reality, that some trick or intervention on our part will help them turn the corner and begin to see, then badgering is what we are actually doing.

It gets worse. It may apply to a high percentage of all beliefs, not only to mental illness.

Update: Roper's comment reminds me that I have at least a half-dozen professionals reading here, so I should provide some links. Xavier Amador looks like he'd be pop psych, but he is not. His books cover a fair bit of the brain research.

Laura Flashman

Thomas McAllister


terri said...

One question...

I am curious....what do you do with a concept like that in the midst of your religious beliefs?

How do you incorporate it without restructuring everything?

OK....that's two questions.

kitten said...

This may explain the near impossibility of getting people with certain mental illnesses to take their medication. Why do you need medicined if _you_ know you're not sick?

Relatedly, when ever I've been depressed (not often thank God) I never knew it until _after_ I was starting to feel better. Even though my personality is such that I always want to know what makes me tick I still _couldn't_ tell until looking back afterwards. I wasn't in denial because the problem wasn't even on my radar.

lelia said...

It is scary.
I know that when I am depressed, I can't even think good thoughts or remember good thoughts. Aggravating, that is.
I think listening to a patient is still good, because you are then telling them that they are worthwhile people.
Not being listened to is so invalidating. When I told my husband that his brother had pulled out the rug from under my feet, he said, No, he didn't, thinking of the intent, while I was thinking of the result. I was enraged for days that my husband would so belittle me. We got it taken care of, but I now know what people mean when they say they were invalidated. It hurts.

Assistant Village Idiot said...

Terri, the initial, easier, answer is that it ultimately isn't different from other brain conditions: Alzheimer's, developmental delays, autism, brain injury. There is a continuum of insight in attribution. One of the things that used to enrage me (and still does, though I don't encounter it so much now) is that brand of fundamentalism which declares "we have the mind of Christ," and so do not have to be subject to feelings of depression, or OCD, or what have you. I always wanted to challenge such people to go into a Christian nursing home and yell at the grannies there that they shouldn't be forgetting things, berating them and making them feel guilty for their errors. It's the same thing, ultimately, but a lot of Christians don't want to face up to that. They want their natural ebullience to be counted as evidence of spiritual superiority, I suppose.

Yeah, it's one of those theories that works great, until it doesn't.

On a deeper level, it is indeed disquieting about all personal insights, or decisions and choices we make. Could we have done other, or are we brain-limited in what we can understand?

Can only the elect choose Christ, and all others forever unable to find the humility to confess the need? The more things move from the "denial" pile to the "unawareness" pile, the stronger the Calvinist case, I guess. Though I haven't yet put any energy into following the trails on that.

GM Roper said...

AVI, you do make me think. I seldom use denial as a "cause" but your explanation makes perfect sense. Damn, you're good!

Uncle Bill said...

I think this issue is a lot broader than what you discuss here.

My mother used to say things that were clearly, obviously, demonstrably untrue. And yet, when I would challenge her on them, she would insist steadfastly that they were correct. For a long time, I thought she was just making things up, and was then too embarrassed to admit they were untrue - it was easier just to persist in the lie.

Much later, I came to the conclusion that she actually believed the things she was saying - that somehow, she had developed the ability to mentally convince herself of whatever she wanted to believe.

Now, these were all things that were somehow in her favor. For example, after leaving a doctor's office in which he had told her she needed to cut out all desserts, she told me with a straight face that he had said she could have all the angel food cake that she wanted. I said, "Mom, I was sitting right there, I heard what he said, and that was not it." But, she continued to insist that she was right, and went straight to the store to buy an angel food cake.

Was she mentally ill, in some way? I don't think so. I'm just a layman, but I don't think she had any other symptoms. I believe this was just something that she had developed, or allowed to develop, as a way of refusing to face reality.

Since then, I have encountered a few other people with the same problem. Of course, they don't see it as a problem, but it sure is a problem for other folks who have to deal with them.

Any advice on how to deal with someone like this?

Assistant Village Idiot said...

Uncle Bill, I will be saying more on this. It is a continuum, as I said. We all have things we deny in the classic sense - things we could know, should know, that we refuse to acknowledge. But, the mental health examples I am thinking of are so extreme that you cannot get a thread through to the other side. Between this are many varieties, and I have not thought about it for a long time. Much that we think people should be able to see, perhaps they can't, and we should stop losing our tempers at them.

No answers yet, just some things for us all to think about. It's going to tie in with tribalism, certainly, but the whole angle of mood affecting insight is quite powerful as well. I don't know where we will end.

Assistant Village Idiot said...

Cousin Dave sent a comment that came in my email, but hasn't shown here. I don't know why. Reprinted here in full:

"AVI, I have to admit I found this to be troubling. As you know, the mainstream though in current libertarianism is that one is entitled to liberty by virtue of simply being a citizen, and meeting a few other very basic requirements (being of majority age, etc.) Even those who commit crimes are denied only some of their liberty, and for only a limited time (usually).

We take this view because we hold it as an essential truth that nearly all people have the capacity to improve themselves enough so as to not be a net drag on society, for most of their lives. We limit the duration of prison terms because we assume that most who commit crimes have the ability to rehabilitate; not all do so, but some do. And, we cringe at the idea of government having the authority to decide, in general, who "deserves" liberty and who does not; we have plenty of historical evidence to conclude that giving government (or any other institution) that authority is a bad idea.

However... if the theories you mention turn out to be true, then we have to accept that there is some percentage of the population whose presence in society will always be harmful, and that they do not have the ability to improve themselves. As long as we hold that self-awareness is a necessary condition for self-improvement (and I haven't seen anything that seriously challenges that notion), then it follows that some people cannot improve or rehabilitate, no matter how much help we give them. And so, unless they are high-functioning to begin with, their presence will always be a net loss.

What to do, then? There's always the Darwinist option of simply disposing of them, but somehow I don't see too many people getting behind that idea. The only other options available are: (1) give them liberty anyway and live with the resulting losses, or (2) try to place and retain them in situations where the harm they cause is minimized. The latter of course means permanently depriving such people of at least some of their liberty. That sounds bad, but note that we already do this with our most severely mentally impaired, as well as those who commit the most serious crimes. But in general, we've been experimenting with option 1 for about half a century now. I think most people would agree that the results have been less than satisfactory.

So we may turn back to some form of option 2. It could mean the implementation of a more Heinlein-like libertarianism: liberty is something that must be earned, by providing a service to society and/or passing some sort of test. This is also an idea that will make a lot of current libertarians uncomfortable, as it should. But if the theories expressed in your post turn out to be true, what else is there to do?"

Posted by Cousin Dave to Assistant Village Idiot at 11:11 AM

Assistant Village Idiot said...

Cousin Dave, I think you will see hybrid solutions clustering around 2). People who have poor abilities to see themselves, and thus choose in one sphere may have unimpaired abilities in another. There are theories of guardianship, in fact, that are used by public guardians which are pretty sophisticated.

If you take a good founding father's perspective on this - (Their rhetoric, at least. In practice we would find them quite controlling of others. They came from a controlling age and culture) - the limitations on government are enacted, not because the individuals are going to do all that well with freedom, (they won't) but because government will ultimately be worse.

More to come on this.