It is also often assumed that insight returns once a psychotic episode ends. In reality, insight may remain impaired even between episodes, affecting a person’s ability to recognize their condition and engage in ongoing treatment.

In my experience living with Bipolar I disorder with psychotic features, this distinction was critical. For many years, I experienced repeated episodes of psychosis. Outside of hospital settings, I did not believe I was ill and did not engage in sustained treatment. Even after episodes resolved, I did not have true insight into my condition or the need for ongoing care.

The consequences were not abstract. Untreated bipolar disorder affected every area of my life. It strained and, at times, destroyed relationships. It led to repeated encounters with law enforcement during periods of psychosis, including being tased during a crisis. It resulted in multiple criminal charges that remain part of my record.

Despite these outcomes, insight did not reliably emerge.

This is an important point. There is a common assumption that significant consequences will lead to awareness or behavioral change. In the presence of anosognosia, that assumption does not hold. The ability to recognize illness and make informed decisions about treatment depends on neurological access that is not consistently available.

Because of this, expectations around responsibility, treatment adherence, and decision-making become more complex than they are often treated in both clinical and legal systems. Behaviors that appear intentional or noncompliant may instead reflect an impaired capacity to understand one’s own condition.

This has real implications. Individuals may cycle through repeated crises, lose stability, and encounter systems that respond to medical vulnerability as if it were a behavioral or criminal issue. Without recognition of anosognosia, opportunities for effective intervention are often missed.

I now have insight into my condition, and I recognize that this is not something to take for granted. With that awareness, I choose to remain engaged in treatment, including long-acting medication, to help protect stability over time.

It is also important to acknowledge that not everyone regains this level of insight, even with treatment. For some individuals, anosognosia remains persistent. This further underscores that insight is not simply a matter of choice or character. It is biologically driven.

Anosognosia challenges a foundational assumption across systems—that individuals are consistently aware of their condition and able to act accordingly. When that assumption is incorrect, the consequences extend beyond the individual to the systems designed to respond to them.

If we want more effective outcomes, both clinical and legal frameworks must account for the reality that insight cannot be assumed, even between episodes. Recognizing anosognosia as a medical condition, rather than a personal failing, is a necessary step toward more accurate, humane, and effective responses not criminal ones.