It’s common for people who are actively psychotic and/or manic to lack insight into their disturbed state. The term for this is anosognosia. The reasons for this lack of insight have everything to do with our brains being the organ through which we perceive the world. If someone’s brain is making her hear voices, see visions, or experience delusions, such as the belief that she’s being videotaped by the CIA or has been imbued with magical power, it is entirely real to that person. It’s as though she’s been tuned into a station that the rest of us can’t get. In the past this lack of insight into the illness was mostly viewed as a form of denial, of avoiding the truth. Increasingly, it’s now understood that anosognosia is part of the disordered state, a brain that is not working right.
Beyond that, for some people who have a euphoric mania, there’s the issue of why they would want to let anyone take away their wonderful, giddy, super-productive, and top-of-the-world feeling. If somebody truly believes he is Jesus Christ out to spread the word, the thought of taking medication to change that doesn’t make sense to him.
When confronted, the person who is manic or delusional may view the other person as the one having the problem. This response can run the gamut from the person becoming demeaning and condescending to open hostility and, in worst-case-scenarios, violence. This standoff is one of the most challenging to negotiate for all involved, the person with bipolar disorder, her family, her friends, and her treators. The best approach is not to directly confront the person but to listen, be empathic, and if possible, find an acceptable middle ground that will allow everyone to win. For example: “Perhaps the medication might help you get a bit of sleep?”