Have you ever wondered what would happen to you if you didn’t understand that you needed treatment for your bipolar disorder (or other mental illness)? Have you heard of legal concepts like “Assisted Outpatient Treatment (AOT)” or “forced treatment” and wondered how they relate to “lack of insight?”

Turns out there’s a name for lacking insight — anosognosia. And it affects some people with severe and persistent mental illness. Listen as Gabe and Dr. Nicole explore what anosognosia means, what a diagnosis entails, and if the word is overused or weaponized contemporarily. Get ready, cause you won’t see what this episode has coming.

Gabe Howard

Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author.

He is also the host of Healthline Media’s Inside Mental Health podcast available on your favorite podcast player. To learn more about Gabe, or book him for your next event, please visit his website, gabehoward.com.

Dr. Nicole Washington
Dr. Nicole Washington

Dr. Nicole Washington is a native of Baton Rouge, Louisiana, where she attended Southern University and A&M College. After receiving her BS degree, she moved to Tulsa, Oklahoma to enroll in the Oklahoma State University College of Osteopathic Medicine. She completed a residency in psychiatry at the University of Oklahoma in Tulsa. Since completing her residency training, Washington has spent most of her career caring for and being an advocate for those who are not typically consumers of mental health services, namely underserved communities, those with severe mental health conditions, and high performing professionals. Through her private practice, podcast, speaking, and writing, she seeks to provide education to decrease the stigma associated with psychiatric conditions.

Find out more at DrNicolePsych.com.

Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.

Announcer: You’re listening to Inside Bipolar, a Healthline Media Podcast, where we tackle bipolar disorder using real-world examples and the latest research.

Gabe Howard: Welcome, everybody. My name is Gabe Howard and I live with bipolar disorder.

Dr. Nicole Washington: And I’m Dr. Nicole Washington, a board-certified psychiatrist.

Gabe Howard: Dr. Nicole, anosognosia. I’m going to pronounce it like five different ways throughout this, because as I get going, the word always comes out wrong. But I want everybody to hear it’s anosognosia. That is how you pronounce the word. That’s what it is. Dr. Nicole, just remember, when I get like when I get excited, when I get ramped up, it’s going to come. I’m going to start adding T’s, anastignosia, anistagnosia, annastignosia. I’m going to like Anna from frozen.

Dr. Nicole Washington: Oh. I’m pretty sure it’s not, but it is an important topic and it is something that I think, you know, is definitely worth us jumping in feet first with.

Gabe Howard: So, Dr. Nicole, before we get too far into this, can you define anosognosia?

Dr. Nicole Washington: You know, the easiest way to say it is just poor insight. Poor insight into illness. Not thinking you have anything that needs to be treated. You have no idea why everyone in your world is telling you you need medicine or hospital or to see a doctor and you think there’s nothing wrong. So just pour insight into the fact that there is actually something there.

Gabe Howard: I’ve always heard it as a literally like a complete lack of insight. Poor insight sort of implies to me that maybe you have a little bit it’s like a complete lack of insight. You’ve been diagnosed with X and you don’t believe you have it. I’ve heard you are missing an arm and you think you have two arms would be an example of anosognosia.

Dr. Nicole Washington: Yeah, but I think maybe it’s one of those like half glass, half empty glass, half full kind of things. Right. I tend to like to say a person has poor insight because I like to believe that it is possible to gain improvement in it. So if it’s poor, we can improve it. I think if we just say you just don’t have it, it may lead us to believe that you can never have it.

Gabe Howard: Way back when in 2003 when I was diagnosed, this word was not talked about a lot. It started coming up when the Treatment Advocacy Center, TAC decided that, hey, are you having trouble managing your mentally ill loved one? You can just tag them with this and then they have no rights anymore. And that is where people in my camp were like, Well, now wait a minute. You can’t just declare that we have no insight into our illness because we disagree with you. And we saw this happening across the country. Now, as sure as you and I are sitting here, there are absolutely, unequivocally people who have no insight to their mental illness. They are unaware and they need extreme help. But talking as a guy who lives with bipolar disorder, there are many people who believe, oh, well, Gabe has that word that doesn’t have a T in it. That’s tough from an advocacy perspective. That’s tough.

Dr. Nicole Washington: It is. But don’t you think we’ve gotten from a point of poor insight means we can just do whatever we want with you because you have poor insight to poor insight doesn’t necessarily mean we can involuntarily commit you or we can force things on you? Like it’s okay. It’s okay to have poor insight, right? I mean, I think it is. I think that I have patients who have poor insight and it’s okay, like we work through it, but it doesn’t necessarily mean, oh, you have to go into the hospital. But I do agree there probably was a time in mental health when that’s exactly what it meant. We used it almost as a weapon.

Gabe Howard: I’m going to push back hard and say that time has not yet passed. Now it may have passed in perhaps larger areas. Maybe this is no longer a problem in New York City or Chicago or even Columbus, Ohio, but nationally, people are using this to make laws. Just hard stop right there. If I hear one more politician say we need assisted outpatient treatment, what is assisted outpatient treatment? It’s where you have broken no laws, done nothing wrong. But we are ordering you into care against your will because you lack the insight to know that what you’re doing is damaging to you. And I’m like, awesome. So, smokers, right? They are eligible for AOT because clearly, they lack the insight that smoking causes lung cancer and therefore, we must force them into smoking cessation treatment. That’s not true. We would never do that to a smoker. Well, but they lack insight. You’re telling them that they’re going to get lung cancer. You’re a doctor, right? Smoking leads to lung cancer. It’s a bad scene. Nobody should smoke. Come on. Just admit it. Say it.

Dr. Nicole Washington: Yeah. Nobody should smoke. There is no reason for smoking cigarettes. Got it. Got it, got it.

Gabe Howard: Right. And then. And everybody says this to you. Oh, my grandfather, he smoked two packs a day and ate a pound of bacon

Dr. Nicole Washington: And he lived to be 129 years old.

Gabe Howard: Lived to be 100. Well, they clearly lack insight. So therefore, they have the word that I cannot pronounce. Right? So, you can now force them into treatment. You can force them to stop. How come nobody wants to do that one? But forcing people with bipolar disorder to be on medication, all of a sudden, this this magical diagnosis applies.

Dr. Nicole Washington: Well, okay. So, I don’t think it’s apples and apples, right. Because smoking is a behavior, not a disorder, not a diagnosis. Smoking is a behavior. And I would argue that people who smoke, they know the risk is there. Like they’re like, yeah, I could get lung cancer. And they point to that one grandpa who lived to be 175 years old, who smoked and drank and all this stuff. Right.

Gabe Howard: Got in bar fights every night. It’s always it’s always this, like, toxic masculinity, too. It’s always a man.

Dr. Nicole Washington: Yes. Yes, yes.

Gabe Howard: Who always like, did horrible things to himself and probably the people around him. These are the people that we idolize when we want to

Dr. Nicole Washington: Yes.

Gabe Howard: Slowly kill ourselves with carcinogens.

Dr. Nicole Washington: I think those people have insight into the fact that their behavior can cause something bad to happen. So, on my end, where it’s very difficult for me when I’m dealing with someone who has bipolar disorder or some other mental illness with poor insight is they don’t think anything’s wrong. Like, they just are like, no, if I don’t take my meds, I’ll be fine. Like, I’m good. Nothing bad is going to happen. You’re like, nothing could happen? And they’re like, No, I mean, I’m great. Like, I’m good. I’m getting stuff done. I’m, you know, I started my last business during my last episode. You know, they’re like, I don’t have episodes. They put them in air quotes like, you know, I’m making up stuff and I’m like, Yeah, but you went bankrupt and you wiped out your savings and your wife left you. And so, I mean, to me, that’s where it comes in. Now, the question is, how much do we need to protect someone from themselves? Like people have the right to make bad decisions, right? Smokers have the right to smoke themselves into lung cancer. People who drink a lot have the right to drink themselves into liver disease. And we don’t mess with those people. Right? We just let them be. So, we have to figure out what’s that line?

Gabe Howard: I agree with you that smoking is a behavior. You’re not going to get any any pushback from that because it’s true. But when this happens to people with mental illness, they don’t say mental illness. There’s a behavior that people don’t like, like you listed. Well, it’s apples to oranges because one is a behavior and one is an illness. Okay. And then as the example, you gave me a list of behaviors, started a business and failed. Spend all your money, quit your job a lot. Put your, in air quotes. I have seen many a smoker do the air quote thing about lung cancer. Right. Because they just don’t believe it. We live in a post-COVID nation where a significant portion of the population believes that the COVID vaccine is putting trackers in your body. And as a government way of controlling you, we’re not in a rush to lock them up. And you just said, well, somebody could lack insight if they start a business that fails. The majority of businesses in this country will fail. So clearly, clearly having failed businesses is that word that I cannot pronounce.

Dr. Nicole Washington: And that is not what I said either, because I am talking of more extreme cases where a person starts a business that from the jump, everybody knows it’s going to fail. If you decide I want to start a business and you do it during a phase where your thoughts are clear and you are making good decisions, reasonable decisions, you could still have a business fail, right? But you probably will take more reasonable steps to get there. You won’t wipe out all your savings. You won’t have a business plan written on a legal notepad that you spent days writing that nobody can read but you. You won’t have these things right? So, people come out of these episodes and they’re like, Holy crap, what did I do? Nobody stopped me. And it’s like, Oh, hello. I tried, but you weren’t listening to me. So, I mean, there is a difference.

Gabe Howard: I agree with you. I want to take a pause right now before I say this next part and say that this is the problem with trying to argue two sides of something. I’m trying to point out, of course, all of the pitfalls to this line of thinking, and you’re trying to point out all of the pluses. And that’s the purpose of the podcast and that’s the purpose of the show. I don’t want anybody to hear that Dr. Nicole is heartless and thinks that, Oh, doctors can just look at people and decide who can’t think for themselves, because that’s not what she is saying. Right?

Dr. Nicole Washington: No, that’s not what I’m saying. And I need people to know I am perfectly okay with people making bad decisions even as a result of their mania or psychosis. Like, I’m totally okay. I will let you go out there and be. I will tell you I think it’s a bad idea, but I will not say, oh, well, you don’t have the right to be manic or hypomanic or psychotic. I won’t even push medications on you. I won’t send you to the hospital as long as you’re not dangerous. But I do still think it’s a bad idea. And it’s a result of your poor insight.

Gabe Howard: And here is where you and I flip flop completely. On a personal level, I want to stop that person. I will follow that person around screaming, Don’t do it. Save your money, buy a house, invest in the stock market. But my point is, I got to tell you, I’ve got a concern because I watch a lot of reality TV. I watch a lot of people who cannot sing. They have no ability to sing. They suck. They are terrible. And they have no insight into it. They walk out on that stage and say that they’re a triple threat. They’re going to win a Tony; they’re going to be an EGOT winner. They can’t pronounce this word either. And nobody thinks that it’s mental illness. They’re just like, oh, somebody raised him to believe that he could sing. Somebody lied to him. You know, I bet his whole life his mama was like, you are the best singer ever. And he believed her. Right. I just I’m pointing out that people with mental illness, people like me, we live in the same world as everybody else. And some of us are going to believe that we are great businessmen and start every MLM not because of bipolar disorder. We’re going to sign up for every pyramid scheme, not because of bipolar disorder, but because we’re stupid, right? Just because many, many, many, many, many, many people get caught up in these things. I believe Amway is, what, a multibillion-dollar business? But when was the last time you saw a rich Amway rep? It doesn’t work, but nobody is rushing to take away these people’s rights and slap them with a label. I know that you’re seeing these people personally, and I think those are the people that you have pictured in your head, Dr. Nicole.

Gabe Howard: The people who see you and how you treat them. But let’s look at this in a broader legislative approach. Can a doctor declare unequivocally that a person lacks insight and you take away their fundamental rights to choose? And these are real laws that are on the books in certain states and laws that are being debated all over the country. And there are people right now who are having their rights taken away. And it all comes back to anosognosia every single time. When you ask, what right did you have to do this? That’s what they say. They lack insight. They’re not aware that they’re sick and we have to save them for their own good. I am just saying, as a person living with bipolar disorder, it bothers me that people are openly discussing what rights I have based on this sweeping idea that there is a definitive way to determine that I lack insight, a definitive diagnosis that a doctor can give, remembering, of course, that there is not a definitive bipolar diagnosis, but there is a definitive way to determine that I lack insight. That’s just that’s amazing to me. Doctors cannot definitively diagnose me with anything behind all shadow of a doubt. Right. You agree with that? There’s no blood test. Skin test. You can’t swab me.

Dr. Nicole Washington: I mean, there is no blood test, but I feel very comfortable in the majority of cases. Like if we

Gabe Howard: Right.

Dr. Nicole Washington: If I’m saying someone has bipolar disorder, I feel firm that I can stand behind that because I think we have enough data. We have our DSM. We have, you know, longitudinal history of people that we I feel pretty good about that diagnosis when I make it.

Gabe Howard: I feel 100% that you do, and I agree with you 100%. Have you ever had a patient go to another doctor? And that doctor said that they didn’t?

Dr. Nicole Washington: Absolutely.

Gabe Howard: Okay. Now, how do you decide who’s right? Because you say they have bipolar and you are confident. You just said so. That other doctor is confident that they don’t. So now we’ve got to determine a winner. How we do that?

Dr. Nicole Washington: Well, I’m confident in my diagnosis, right? I’m not confident in anybody else’s. So let me just say that, like I’m confident in mine, because I don’t throw that around all willy-nilly. And just anybody who has a mood swing like, oh, you got bipolar disorder and you got bipolar disorder and you. I’m not doing that. I’m not doing the Oprah of diagnosing. No.

Gabe Howard: Look under your chair, you have a mood disorder. Whooo.

Dr. Nicole Washington: Not doing that, not doing that at all. But I mean, you’re right. So, we can disagree and we disagree all the time.

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Gabe Howard: And we’re back talking about anosognosia. Did I get it? Is that right?

Dr. Nicole Washington: Yes. Listen, I do a lot of inpatient psychiatric work a lot, and I go to court a lot because I am requesting that we be able to hold someone against their will. I do it more than I like to do it because frankly, I’d love it if everybody just signed in voluntarily and had the insight to know that in that moment that was the best thing for them. So, I completely hate doing it and I only do it when someone is, I feel a big danger either to themselves or somebody else, or they just can’t make good decisions to take care of their basic needs. Right. Like to me, those are the three criteria. But you are right, everybody’s threshold is different. There are some doctors who will say you need to go in because you don’t want to wear shoes, you know, and that doesn’t make sense to me. So, I’m going to put you in, right? Like there are doctors whose threshold is a little bit lower than others.

Gabe Howard: So, let’s talk about that for a moment, because what you just described to me is not the thing that ruffles my feathers and that I rally against, because everything that you just described there seems very temporary, right? The person is in crisis in the moment. They need to get care right now. They need to be committed. They need to stay in the hospital. They need to. It all seems very time limited. And people who are familiar with my story know that if I was not committed to a psychiatric hospital, if I did not end up in a psychiatric hospital or a place that I did not want to go and did not believe could ever happen to me, I would be most likely, there’s no guarantees in the world. But I most likely would have died by suicide because I absolutely lacked insight. I had no idea what was going on. And I was ready to take my own life. Thankfully, somebody stepped in, recognize that I didn’t know what was going on and got me care. So, you and I are on the same page with that. We can completely agree with that and we can put that aside.

Dr. Nicole Washington: Okay.

Gabe Howard: The anosognosia label that I pronounce wrong, how do you pronounce that word?

Dr. Nicole Washington: Anosognosia.

Gabe Howard: The anosognosia label is different. It seems to be broader and last longer, and that’s the reason that it came out when TAC, the Treatment Advocacy Center, brought it up and pushed it to the forefront. First off, this entire term comes from brain disorders, like actual head trauma.

Dr. Nicole Washington: Like strokes and things like that. Yeah.

Gabe Howard: Yeah, just that’s where this term comes from. And then it started to be applied to mental illness. So that rubbed me the wrong way too. The research, the discovery, the previous medical practices of this terminology and this diagnosis and this long-term idea was developed in other areas. And then sort of. Sort of.

Dr. Nicole Washington: We do that all the time. I mean, we do that all the time. And I’m constantly jumping up and down saying, let’s treat mental illness like a brain disease and not a behavioral disorder. Because I hate that we call it behavioral health. Let’s treat it like it is a brain disease. And if that’s the case, then it’s okay to take something from the neurology world, the world of brain trauma and strokes, and apply it to mental illness, because we are saying it is a brain disorder. So I don’t I don’t know why that is problematic.

Gabe Howard: It’s problematic for me because when anything is new, that’s when you need to watch it the closest, right? That’s when you need to be most on guard for. Okay, we’re used to it in this area, but let’s see how it behaves. Like I’m going to use a dog, right? We, we have a dog. Our dog is fine at home. Our dog is great. And then we decided to take our dog out in public. You have a higher level of care now. You can’t just take your dog and drop it off in the mall with no, you know, no muzzle or no leash or no anything, because somebody would say, well, why did you do it? And you’re like, Well, my dog never did that at home. Well, right. And then somebody says, Well, I don’t understand. People bring their dogs all the time, like, right? But we’ve now decided that we’re going to put dogs in this area or this particular dog in an area where they’ve never been before. I know the analogy is messy, but you understand what I’m saying, right? The very first time you bring your animal to a place your animal has never been, it is expected that you will have a higher level of care and anticipate the unexpected over here. And it’s Nokia. They were just like, Hey, this is a good thing. Let’s apply it to people with mental illness. And suddenly it was everywhere and I’m like, Hey, did we do any studies on people with mental illness? I kind of I mean, we did their brains over there when they had strokes. But you’re tagging somebody with this for life. And I understand that individual doctors often aren’t. But the way that this is discussed as an advocacy point and as a legal point and as a law-making point, once you have it, it does not go away. There’s no temporary in front of that word.

Dr. Nicole Washington: I don’t think that’s true because people’s insight can change. And even, even the assisted outpatient laws. Most of the states that I work in, the ones I’m familiar with, there’s always the ability for a person to improve and not need it anymore, right? Like there’s always that ability. But I think it came from and the reason everybody jumped on it when it was like, oh, we can use this word, I think because especially when it comes to mental illness, especially when it comes to like bipolar disorder and schizophrenia, the illnesses that we think of as being kind of in the more severe basket, we have felt very hopeless, I think, on the other side of it. Right? So we felt hopeless. And we’re all thinking of those worst-case scenario stories where I wanted to get somebody in assisted outpatient treatment because the writing was on the wall. Right? Everybody in this person’s life knew that they were going to at some point do something dangerous to themselves, somebody else. They were going to get killed by the police. They were going to get killed by somebody because they were knocking on their door thinking that aliens were in their house. They were going to. Like something was going to happen to them. Right? Bad. And we could never do anything because why? It’s like, well, but they I mean, they aren’t, they said they weren’t suicidal.

Dr. Nicole Washington: They said they weren’t homicidal. They look like they’re eating and they’re grooming as well. And they’re I mean, they look fine. They have a place to live. But everybody around them is jumping up and down screaming. Do you not see that this is not going to end well for this person? And then we all know the story of, you know, the 10th time the family is called to try to get help or try to get him admitted or try to and then that person ends up dead and some very tragic way and everybody’s like, see if we could have just gotten them help sooner. Like we could have gotten them more stable. So I think all that came out of like fear and just, you know, grasping at, oh, this is something we can do to help people. Have we overcorrected? Absolutely. Has it become a little bit too paternalistic? Absolutely, I think in some cases. But I think it came from a place of like fear of what do we do?

Gabe Howard: I know that in American history, legislation based on fear has always turned out well. It’s, that’s just. Oh, wait. No, it hasn’t. I want to be clear on that point. It’s not because I disagree with you. I agree with you 100%. Gabe Howard the person. Yeah, I’m a I’m a certified peer supporter. I get the phone calls; I get the emails. I talk with people who have my exact same diagnosis, who honestly believe that a dragon is following them around. And I want to be able to help them. I want to do something. And this, this may well be it. And depending on where you live in America, there wasn’t an overcorrection, there are reasonable laws. People are able to get assigned a case manager, an attorney, representation. They’re getting full wraparound services to go with their Dr. Nicole. In other places, people are literally getting swept up, given this label and they’re said, Hey, if you don’t want the label, hire an attorney. I, and as far as the legislature, it just the politicians and even many mental health advocates are concerned. Well, if they don’t like the label, they can hire an attorney.

Dr. Nicole Washington: Yeah. Sure they can. Sure they can.

Gabe Howard: Listen, you’ve already established that they’re sick. They may not be sick to the level that that you believe they are, but we know that they’re not at zero. Right. They got this label, this diagnosis. They got it somehow. Something is not right. I may think you overcorrected, but what I don’t think is that there’s nothing wrong and that you’re just being malicious. Right. I know there’s more to the story and you’re like, yes, well, all that’s going on, the homeless guy can just hire an attorney.

Dr. Nicole Washington: Yes. Well, that’s dumb.

Gabe Howard: I know that it’s dumb.

Dr. Nicole Washington: That’s dumb.

Gabe Howard: And sincerely, it reminds me of every single article that I read about somebody who is wrongfully convicted. And for some reason, all of the politicians and the legislators and the talking heads, they’re all like, Well, they had a fair trial. Oh, well, then what was? What was I thinking? You wrongfully convicted this person? They spent five, ten, 20, 30, 40 years in prison, but they had a fair trial, so it’s fine. No, it’s not fine. I, because I don’t want to beat a dead horse. And, you know, Dr. Nicole, I want to say this here is the best and worst part of working with you.

Dr. Nicole Washington: Oh. Okay.

Gabe Howard: You and I work together because we have a lot of things in common. We agree, I believe, with all my heart that you are a strong, competent, fair and capable psychiatrist. There is zero doubt in my mind. And obviously, if I thought that you were like an evil, malicious hate-monger abusing people with mental illness, I never would have wanted to work with you. Right? But here’s the downside to that. You’re like, well, I do this, this, this and this. And I’m like, Yeah, I know you do. But they’re not all you

Dr. Nicole Washington: I know.

Gabe Howard: One, they’re not all you. And two, even the you’s out there get defeated by the people who are not you. Because somebody’s just like, Oh, we’ll just shop around for the diagnosis we want. We’ll just shop around for the doctor who will take away my child’s rights, my wife’s rights, my husband’s rights, my, my, my coworkers rights, whatever. We’ll just find that person that’s willing to slap them with that label. We have done such a great job of bringing anosognosia to the forefront of. Did I pronounce it wrong?

Dr. Nicole Washington: Anosognosia. There’s no T.

Gabe Howard: Anosognosia.

Dr. Nicole Washington: No T.

Gabe Howard: We have done such a great job of bringing anosognosia to the forefront, of getting people to understand what it is, how their loved ones lack insight, and how we can use it to intervene. Right? And as we’ve pointed out, it may be an overcorrection, but as we’ve definitely pointed out, there’s pitfalls. There’s holes, there’s issues, there’s problems. And people like me, people who live with bipolar disorder, are like, wait a minute, I saw you get this term from nowhere to national prominence in record time. But there does not seem to be the desire to fix the loopholes, to fix the cracks, to fix the problems. There’s not that same urgency. Everybody can explain to me how to get somebody AOT’ed, how to get somebody pink-slipped, how to get somebody committed. Everybody that I talk to that is dealing with mental illness or love somebody with mental illness can explain it to me. And then I ask one follow-up question. How do you know when that person no longer needs this level of involvement? And suddenly the knowledge drops off. I ask people, How does somebody like me that has been labeled with zero insight, doesn’t understand my disease, I’ve been court mandated to do these things, how do I get my freedom back?

Gabe Howard: And everybody just kind of shrugs and says, oh, we don’t know. Is anybody looking? Yeah, not really. And in fact, whenever people with mental illness complain about it, we’re just like, God, it’s like they don’t want help. It’s like they don’t want to get better. It’s always our fault. We’re always the bad people for pointing out that there doesn’t seem to be an exit strategy. What’s our exit strategy?

Dr. Nicole Washington: I think you’re right. So we will we will use someone’s poor insight to make those things happen. But then we will turn around and get frustrated with people when they do things that are against their best interests because of their poor insight. Right. So I do think that that is something I mean, me personally, I’m constantly like, you know, as a psychiatrist, I’m often the leader of the treatment team. So when I hear those conversations happening, I’m like, But hold on, guys. Like we’ve established this person has poor insight, so why are we getting upset with them for doing something that we expect them to do? Because we know they have poor insight. Right. Will they ever regain insight? I don’t know. Do they? Sometimes. Yeah, sure. Sometimes they can. Sometimes with treatment, sometimes with therapy, sometimes with, you know, child reality testing, you know, challenging them on delusional things and challenging them on their behaviors and using, you know, therapy to kind of help them see. Can we do that? Yes. Do we often have resources to help people get to that point? Absolutely not.

Dr. Nicole Washington: We often do not fund the services to try to get that person more insight because we haven’t deemed it as something that’s important enough to put money at. Regardless of where you live, we all see mental health budgets taking a hit every year. Every year. Right? And what kind of programs get cut? The ones like that. Right. Like a program that would help someone who, you know, has a severe illness and who’s on AOT to give them more intense services. That we think is where we’re saving money. But really, it’s preventing that person from really ever getting to a point where they could be better, right? Where they could. So one of I think is a funding issue. Like we just don’t have the resources available in most places to be able to put that kind of work in because it takes work. Can it happen? Absolutely. Does it happen often? No. No.

Gabe Howard: I want people to think about this, the reason that we’re doing all of these interventions is because people with mental illness deserve better lives. They deserve the opportunity to live their own lives under their own steam, get treatment for their disorder and move forward. This is very, very personal to me because I can only imagine if somebody decided when I was first diagnosed that I lacked insight and that I would never have insight ever again. And I was given this label and people believe this label. Would I be sitting here now? I mean, could I get a job at Healthline Media, one of the biggest Internet sites in the world? If literally my diagnosis was completely lacks insight and has no idea he’s sick? Right. Because that’s a that’s scary. That that’s terrifying.

Gabe Howard: And I do think that when we talk about lacking insight with people and we talk about diagnosis and people and we talk about a lot of these things, we’re never talking about people making it to the end. We’re never talking about getting well. And I believe this is a really just it’s a form of stigma. It’s this idea that if you are super mentally ill, you will never get better. And that’s why we don’t have to talk about you getting to the Promised Land, because nobody believes you’re going to. They believe that this is the best that they can do. And from a guy who in 2003 and before believed that there were demons following him around and believed that his mother would be happy if he died, I could have easily, easily been given this diagnosis. And where would I be? Would I still be here? Would I be living with my parents? Would I have achieved this greatness? I don’t. And by greatness, I don’t mean a podcast. I mean, you know, being married and having friends and family and getting the life that I wanted to.

Dr. Nicole Washington: Having a great quality of life.

Gabe Howard: I have an excellent quality of life, and most importantly, I have the life that I want and that I built.

Dr. Nicole Washington: Yes.

Gabe Howard: And I worry about this. The next thing that I want to say, just for everybody thinking, okay, but you know, maybe Gabe’s trying to use fear to make us think that we’re overreacting about this lack of insight thing. I just want to remind everybody that Britney Spears, a multimillionaire who’s famous, took years to litigate her case with all of those millions, with all of that media attention and with all of that money, it took her years to get a day in court. No matter what you think of Britney Spears, whether she needs care, whether she’s crazy on Instagram, whatever. That’s not the point. The point is, is that this woman said, I want a day in court. And it took her years to get one. If a famous multi-millionaire singer superstar needs multiple years to get in front of a judge. The rest of us have no hope. That’s just a hard stop. And that has to be fixed. And that terrifies people living with mental illness. This is a complex situation. And there’s no podcast in the world that’s going to be able to resolve it. But people are too cavalier with this notion of anosognosia, which does not have a T in it. But. Say it again.

Dr. Nicole Washington: [Laughter]

Gabe Howard: Lisa’s laughing her ass off. I hate her so much right now.

Dr. Nicole Washington: Anosognosia.

Gabe Howard: Anosognosia.

Gabe Howard: Okay. My point is not that it’s not real, not that it doesn’t exist. It not that some people don’t have it. It’s just that we are too cavalier with this concept of anosognosia and we need to be careful. We need to put in those safeguards and we need to stop throwing it around like it just happens to every single person who needs to be committed to a psychiatric hospital or is under the care of a Dr. Nicole or is just walking around doing things that we don’t like. It’s an extreme diagnosis and it needs to be taken very, very seriously and handled with much more care than it currently is.

Dr. Nicole Washington: And I think it’s important to remember it’s not a diagnosis. It is a symptom of an illness, just like any other symptom. It’s not a diagnosis in and of itself. So it should not be used as a weapon.

Gabe Howard: Dr. Nicole, I love hashing this out with you. I hope our listeners understand more about what lack of insight is, what challenges people with mental illness are facing, and what challenges doctors and loved ones are facing. The reality is, is there’s no good way to wrap up this podcast. There’s no happy ending. There’s just a whole bunch of information that we’ve thrown at you, and we hope that you can use it to have better conversations with your doctors, your friends, your families, your loved ones, and you can Google the word. And I want everybody to know there’s no T in it. There just isn’t. There just isn’t. My name is Gabe Howard and I am the author of “Mental Illness Is an Asshole and Other Observations,” which you can grab on Amazon or you can get a signed copy with free swag by heading over to gabehoward.com.

Dr. Nicole Washington: And I’m Dr. Nicole Washington. You can find me on all social media platforms @DrNicolePsych to see all the things that I have my hand in at any given moment.

Gabe Howard: Dr. Nicole and I love to travel. We love to travel nationally. And we could be available for your next event. You can get more information on our respective websites or give us an email at show@psychcentral.com. Wherever you download this episode, please subscribe or follow. It is absolutely free and do us a favor. Share the show. Tell a friend, a colleague, a member of a support group. Sharing the show is how we grow. We will see everybody next time on Inside Bipolar.

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