When Someone Doesn’t Know They’re Sick: Understanding Anosognosia From a Therapist’s Perspective

As a therapist, there are few things more difficult to watch than someone you care about struggling with a serious mental health condition while not recognizing that they are struggling.

You may see changes in their behavior. You may notice that they aren’t sleeping, they’re becoming increasingly suspicious, they’re withdrawing from people they once trusted, or they’re experiencing beliefs or perceptions that don’t seem grounded in reality.

You may be deeply concerned.

And they may look at you and genuinely believe that nothing is wrong.

This is where anosognosia can become particularly confusing and painful for families and loved ones.

So, what exactly is anosognosia?

Anosognosia is a neurological condition in which a person has difficulty recognizing or understanding that they have an illness or that certain symptoms are related to an illness.

It’s important to understand that anosognosia is not simply denial.

Denial can involve knowing, at some level, that something is happening but refusing to acknowledge or accept it.

Anosognosia is different.

When anosognosia is present, the person’s brain may not have the ability to accurately recognize their own illness or symptoms. From their perspective, their experience may genuinely make sense.

And that’s an incredibly important distinction.

If someone genuinely doesn’t recognize that they are experiencing symptoms of a mental health condition, repeatedly telling them, “You’re sick,” “You’re delusional,” or “You need help,” may not create the insight we’re hoping for.

It can actually make the situation more adversarial.

“But they seem so aware of everything else.”

This is something I hear often from families.

A person may be able to have a completely coherent conversation about work, finances, relationships, or everyday life while simultaneously having very limited awareness of their mental health symptoms.

That can be incredibly confusing.

It can leave loved ones thinking:

“They know what they’re doing. They have to know something is wrong.”

But insight isn’t necessarily an all-or-nothing ability.

Someone can have insight into certain areas of their life while having very limited awareness of their illness.

This is one of the reasons anosognosia can be so difficult for families to understand.

Arguing usually isn’t the answer.

I know how tempting it can be.

When someone is experiencing a belief that seems completely disconnected from reality, our instinct may be to prove that they’re wrong.

We pull out evidence.

We explain.

We show them texts, dates, facts, medical records, photographs, or other information.

We say, “See? This proves it.”

And when that doesn’t work, we may try explaining it again only louder, longer, or with more evidence.

Unfortunately, when someone lacks insight into their symptoms, more information doesn’t necessarily create more insight.

From their perspective, the information you’re presenting may simply be interpreted through the belief or perception they’re already experiencing.

This doesn’t mean you have to agree with something that isn’t true.

It means there may be a more effective way to communicate.

Validation doesn’t mean agreeing.

This is an important distinction.

If someone is experiencing a belief that you know isn’t accurate, you don’t have to validate the belief itself.

You can validate the emotion behind it.

For example:

Instead of:

“That’s ridiculous. That’s not happening.”

You might say:

“I can see that this is really frightening for you.”

Or:

“I understand why you’re feeling overwhelmed right now.”

You’re acknowledging their emotional experience without confirming something you don’t believe to be true.

This approach can help preserve connection, and connection can be incredibly important when someone is struggling.

This can be exhausting for families.

I also want to talk about the people on the other side of this.

Because when someone you love is experiencing anosognosia, you may feel like you’re constantly walking a tightrope.

You may be trying to support them while also protecting yourself and other family members.

You may find yourself constantly questioning:

“Am I helping?”

“Am I making things worse?”

“Should I say something?”

“Should I let this go?”

“What if they stop taking their medication?”

“What if they become unsafe?”

And eventually, you may become exhausted.

You can love someone deeply and still need boundaries.

You can understand that anosognosia may be contributing to someone’s behavior while also recognizing that certain behaviors are not okay.

Understanding the reason behind someone’s behavior does not mean you have to tolerate abuse, threats, intimidation, or unsafe behavior.

Compassion and boundaries can exist at the same time.

You don’t have to convince someone in order to support them.

Sometimes the goal isn’t to get someone to admit, *“I have a mental illness.”

Sometimes the first step is much smaller.

Maybe it’s getting them to agree to talk with a doctor.

Maybe it’s addressing a specific concern sleep, anxiety, stress, medication side effects, or feeling overwhelmed without immediately making the conversation about a diagnosis.

This is one reason approaches such as LEAP (Listen, Empathize, Agree, Partner) can be helpful when communicating with someone experiencing limited insight.

The goal isn’t to manipulate someone into treatment.

It’s to preserve connection and find areas where you can work together.

And sometimes, safety has to come first.

This is perhaps the most important part.

Understanding anosognosia should never mean ignoring safety concerns.

If someone is experiencing severe symptoms, threatening behavior, suicidal thoughts, homicidal thoughts, extreme agitation, inability to care for themselves, or other behavior that creates an immediate safety concern, professional or emergency intervention may be necessary.

You don’t have to wait for someone to agree that they’re unwell before taking a safety concern seriously.

And as difficult as this can be, loved ones cannot single-handedly treat someone else’s mental illness.

You can support.

You can listen.

You can encourage treatment.

You can learn about the illness.

You can establish boundaries.

You can seek support for yourself.

But you cannot force insight into someone else’s brain.

If you’re the loved one, please remember this.

If you’ve found yourself thinking, “I don’t understand how they can’t see what’s happening,” you’re not alone.

If you’ve found yourself feeling angry, scared, confused, heartbroken, or completely exhausted, that doesn’t make you a bad person.

And if you’re struggling to understand why someone you love doesn’t recognize that they need help, learning about anosognosia may provide a different framework for understanding what you’re seeing.

It doesn’t make everything easier.

It doesn’t excuse harmful behavior.

And it doesn’t mean you have to abandon your own boundaries or safety.

But sometimes understanding that a lack of insight can be part of the illness itself can change the question from:

“Why won’t they just admit it?”

to:

“How can I communicate in a way that keeps the door open while also protecting myself and the people I love?”

And sometimes, that shift is a really important place to begin.

If you or someone you love is experiencing symptoms of a serious mental health condition, consider reaching out to a qualified mental health professional or healthcare provider for individualized guidance. In an immediate emergency or safety crisis, call 911 or go to the nearest emergency department. In the U.S., you can also call or text 988 for the Suicide & Crisis Lifeline.

Feel free to reach out for support if needed