Understanding the misunderstood part of mental health recovery

Table of Contents

Introduction

If someone you know has been diagnosed with a mental health condition such as schizophrenia, a schizophrenia-spectrum disorder, bipolar disorder, or certain neurocognitive conditions (Strauss & Cohen, 2017), you might have noticed that despite the reduction of the major symptoms, the person is not yet back to their usual level of functioning.

This diminished functioning shows up in almost every corner of their daily life, and each one gets misread a little differently.

• At home, it might seem like, “Why is he or she still sleeping so late into the morning?”, "Why hasn't he showered in three days, does he not care how he looks anymore?" or "She just sits on the couch doing nothing all day, how is she still tired after sleeping so much?"
• At work or school, it's, "Why does he keep missing the deadline when he knows exactly what to do?" or "She just stares at the screen for an hour, is she even trying?"
• In relationships, it's, "Why doesn't he want to go out with his friends anymore, did we do something wrong?" And many such similar situations (Van Gool et al., 2025; Sarkar, 2015).

It is not because they’ve stopped caring, instead most of it is because something underneath is struggling. This lack of what is considered one's normal or usual level of functioning is attributed to “negative symptoms”. These are not just behavioural symptoms, but are strongly linked with structures and chemical imbalances in the person's brain.

What's happening in the brain of a recovering person?

The negative symptoms related to diminished motivation are what often get mistaken as "laziness" or "not putting enough effort" when you think of your loved one recovering from a mental health condition. This apparent "laziness" is not the person's fault, but more of a motivation deficit emerging from the "motivation & reward anticipation motor" of the brain.

• Imagine a car that isn't starting the way it used to. It may still have a working engine, and there's fuel in the tank. But the engine isn't firing up the car like it used to.
• We have a similar "engine" in the brain that controls how motivated we feel, called the “reward pathway”. The fuel that keeps it running is the famous “dopamine”. This fuel acts as a chemical messenger that turns a thought like "I could call my friend" or "I could start/finish this task" into the actual urge to get up and do it.
• But during a severe episode, this system gets overwhelmed, parts of the reward pathway shrinks in volume (Van Gool et al., 2025). The Pre-frontal Cortex (PFC), that regulates motivation and how social you are, is deficit in dopamine. Their normal functions and fuel levels do not immediately return to their usual level (Fischer et al., 2009).

This is why, even when the person genuinely wants to do something, the "ignition" just doesn't catch the way it used to. Not because the want isn't real, but because the system that turns wants into action is still recovering its power.

Then comes the emotional and speech expression-related symptoms. This is what you notice as the flat tone in their voice, the short responses, or the unusual blank face. Families often read this as the person being cold, distant, or uninterested in the conversation. But this isn't about whether they like you or not; this is also related to other brain systems still recovering.

• Normally, to speak or express emotions, our brain is coordinating between several functions in the background. It needs to juggle between attention, memory, language, and emotional expressions, all at once. In people recovering from a severe episode, the already overworked prefrontal cortex (PFC) has reduced capacity for this kind of coordination, formally called “higher-order cognitive functions”(Strauss & Cohen, 2017).
• More so, to even do such juggling, the brain cells need to communicate with each other so quickly. And like our text messages, our brain cells use a chemical called “glutamate”. Glutamate activity is also shown to be disrupted in a person with mental conditions like schizophrenia and bipolar mood disorder(Strauss & Cohen, 2017). When this communication becomes less efficient, due to a condition, the outward result may be reduced speech, limited emotional expression, or slower responses (Correll & Schooler, 2020; Fischer et al., 2009)

What can you do to help your loved one?

This snapshot of what happens in the brain could help you understand that recovery is rarely a switch that flips overnight. Pushing harder, criticizing them, or pointing out how things "used to be" doesn't speed this up. It only adds shame on top of an already-struggling system. Just like a broken bone needs time to heal, brain and mind going through a mental health difficulty also requires time to heal, even after the crisis is over. The goal isn't to excuse every behaviour, but to understand what causes these symptoms, so that support is offered where it matters most.

There is hope for recovery, even though it may take time. Specific treatment modalities along with medications do exist. What helps the most is patience, empathy, realistic expectations, and continued treatment, but also knowing when to step back (Mairs et al., 2012). Check with a mental health professional to better understand how to help them.

It is also crucial to note that long-term persistence of negative symptoms may be an effect of medications or underlying depression. Reach out to a professional to address such issues.

Finally, we also understand that as a family member or friend, you may feel sad, frustrated, or even tired. While you take care of your loved one, it is crucial to take care of yourself too. You can always consider reaching out for help through your support systems or through mental health professionals.

Written by Muthu Mithra, Intern (MAHE - Manipal Academy of Higher Education, Admissions)

Approved by Dr. Girishchandra B G, Medical Director and Senior Consultant – Adult Psychiatrist