I worked under an attending p-doc for a while who theorized that while some severely mentally ill patients truly want to get “better,” many don’t, and for what he called “very good reasons.”
Paraphrasing here (because I don’t have this on tape or CD, and I have acquired other knowledge since then), he said that pts who were raised by parents who made their lives a sort of “hopeless hell” become conditioned (socialized, habituated and normalized) to a (usually unconscious) belief that it is impossible to escape from their current mental prisons because it had been impossible to escape from the “prison” of their family of origin.
He then demonstrated how – in an attempt to build a twisted sense of personal power (or “competence” or “efficacy”) – some pts actually convince themselves that there is no hope for them, and that they are never going to get better, even though they display less and less physiological anxiety and/or depression over time, and require ever lower doses of medication to stabilize them.
Moreover, it was evident to us that some of the pts at that residential tx facility would defend their helpless hopelessness to the death in the face of arguments to the contrary.
This made a lot of sense to me personally, as it fit my own experience from 1994-2003, as well as much that Martin Seligman had famous written about “learned helplessness” (see https://en.wikipedia.org/wiki/Learned_helplessness) and what we could see for ourselves when we witness lab rats being subjected to shocks to their feet on the floor of a “Skinner box” while they continued to self-administer the cocaine or morphine that is tearing them to pieces rather than climb up out of the box to explore another behavioral option.
(These are often the same pts, by the way, who will rationalize not taking their meds and expecting to get “better.”)
Comments? Critiques? Harsh invective?