Jody and Jim went together to their first couples therapy session. Jody was especially relieved to be getting help, as the atmosphere in their home for too many years had been poisoned by Jim’s frequent anger outbursts. Jody felt bad for their children as well as for herself. When something, almost anything, did not go as Jim had hoped, he would speak angrily, blaming his wife and shouting harshly at the children.
Jim himself also felt relieved to have a therapist they could talk with. In his perspective, their problem was that Jody was just too difficult to live with.
How does a therapist figure out who is accurately describing what has been happening?
In response to one of the therapist’s first questions—“How often do each of you get angry at home?”—Jim replied, “Jody gets mad all the time, but I don’t at all. I’m very calm at home.”
This all-or-nothing, it’s-all-her-fault perspective caused the therapist to raise her eyebrows.
As to Jody, she felt stunned. Jim’s description was totally the opposite of what she had been experiencing. Yes, she admitted, she did sometimes take the bait and allow Jim’s anger to goad her into heated replies that she later regretted. Generally, though, she was the family peacemaker, calm and good-humored.
What was going on? Was one of them lying? In denial? Or was it anosognosia?
The therapist gathered further data by watching the couple’s interactions during the therapy hour. Several times, Jody said something that Jim disagreed with. Jim then typically responded with quick annoyance. Jody, by contrast, rarely said her thoughts, seeming to walk on tiptoes lest she upset her highly flammable husband.
Individual therapy would not have clarified who had an anger tendency. Both spouses, in fact, had been going to therapy, each to their own therapist. Each therapist assumed that their client was painting an accurate picture of the homefront difficulties. Watching spouses interact, by contrast, a couple’s therapist gets a ringside seat to observe both partners’ tendencies.
What is anosognosia?
Anosognosia is a brain functioning disorder that results in insufficient self-awareness, that is, difficulties seeing a physical, cognitive, or emotional impairment. Elderly individuals experiencing memory loss and other aspects of dementia may interpret their diminished functioning as a sign that someone is playing tricks on them, hiding their car keys, etc. Similarly, individuals with ADHD may not be able to recognize that their quickness to anger is abnormal and problematic.
The self-awareness of people with anosognosia generally worsens in situations in which they are experiencing elevated emotions. Individuals with ADD/ADHD and also with bipolar disorder, for instance, tend to express too much anger. Yet such individuals are unlikely to believe that they have an anger problem.
How was anosognosia discovered?
This deficit of self-awareness was first named by a neurologist, Joseph Babinski, in 1914. Many decades later, a clinical psychologist named Xavier Amador identified anosognosia as a factor in certain psychological syndromes,
Amador’s realization arose from dealing with a brother who suffered from schizophrenia. Amador’s brother, who was often fun and caring, would frequently cease taking his medications. Without his medication, however, the brother would become at risk of hurting himself and also other family members. The brother, it turned out, lacked the ability to see himself accurately. This lack of self-awareness left him believing that he had no problem—so why take medication?.
Amador gradually realized that his brother was not being mean or even irresponsible. Rather, he lacked the ability to perceive himself correctly, particularly the part of himself that was dysfunctional. Instead of insight, his brother had out-of-sightness when it came to looking at himself.
In what psychological syndromes does anosognosia tend to appear?
ADD and ADHD, schizophrenia, bipolar illness, and substance abuse seem to be the psychiatric disorders that are especially likely to present with anosognosia.
Unfortunately, however, anosognosia has only relatively recently been receiving significant attention in the psychological and psychiatric literature. For this reason, many therapists do not recognize it.
Note that anosognosia may be subtle and may occur just occasionally—or it may be potent and frequent. Generally, however, the dysfunction tends to become more evident, as do many brain disorders, in situations of stress or emotional intensity.
How can understanding the phenomenon of anosognosia be helpful?
Therapists such as myself who treat couples generally teach collaborative dialogue, conflict resolution, and other essential partnering skills. I describe these skills in my book and workbook called The Power of Two. Anosognosia, I recently learned, can block the growth process. I was greatly relieved to learn of this phenomenon because it suddenly helped me to understand why some clients just did not seem to “get it.” Because they could not see that their critical and quick-to-anger habits were problematic, they had no will to learn new ways of interacting.
As marriage partners, as well as their therapists, come to understand that a brain dysfunction lies at the root of the anger in the household, they generally begin to see their partner in a different light. The problem becomes the brain deficiency rather than the person of their spouse. Affection and concern can again sprout forth.
In sum, next time you are interacting with someone who does not seem to understand what others are so frustrated with in their behaviors and cannot seem to see the problem themselves, ask yourself, “Is it lying, denial, or anosognosia?”
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