The Problem With ‘Insight’

  Oh I wanna walk with Christ my savior                                                                                 For he’s the one that’ll guide me on                                                                                               All through my life I’ve been a sinner                                                                                 Now I’m right with God so I’m travelling home.”       Bill Monroe, River of Death

In the early 1970s the psychologist David Rosenhan carried out an experiment to determine the validity of contemporary psychiatric diagnoses and practices. He and seven associates  gained “secret admission to 12 different hospitals” (Rosenhan, 1973) complaining of the single (and fabricated) symptom that they had been hearing a voice which seemed to pronounce the words ‘empty’, ‘hollow’ and ‘thud’.

However being discharged proved much harder; despite the fact that after admission they were instructed to say that the voice had disappeared, length of hospital stay ranged from 7 to 52 days. His ‘patients’ soon found that the only way to be released was to agree with the psychiatrists’ judgement: to admit that they were in fact ill, and agree to co-operate with them in order to get “better”.

Some things have changed in psychiatry. Certainly in the UK the huge shortage of psychiatric beds makes it very unlikely that anyone would get anywhere near a hospital with such a seemingly harmless auditory hallucination. However the idea that having “insight” into your condition, or, in other words “agreeing with your doctor about what is up with you, and what should be done about it” is still seen as key.

On the ward I work on we use the term all the time; “X lacks insight”, “X has limited insight”. These are used not just in the notes which are written up on patients but are sentences that carry serious weight in decisions about their treatment. If someone is seen as “possessing insight”, it suddenly becomes much more likely that they’ll be taken off their Mental Health Act section or discharged back into the community. More likely that they’ll be deemed to have the capacity to make decisions about their treatment and care. I don’t think it’s too strong to say that insight is one of the most important evaluative concepts we have in psychiatry.

However, so far I have only been able to come up with two justifications for the central role ‘insight’ is given in assessing and treating psychiatric patients (major spoiler: I think they’re both completely bogus.)

The first of these is that ‘insight’ is a mark of general wellness. A patient who agrees that they are mentally ill is correctly appraising the situation and themselves; they are demonstrating that they are not delusional. Someone who thinks that the explanation for the voices they are hearing is that Jim Morrison is trying to communicate with them from beyond the grave has, in most peoples’ opinion, a worse grasp on how the world works than someone who thinks that they are auditory hallucinations. The first one definitely seems more ill than the second. I mean they’re so ill they don’t even realise they’re ill, right?

On the surface of things, this thought is innocuous enough, but it’s rotten all the way through. We shouldn’t be evaluating the end-point of a chain of reasoning of someone we suspect to be suffering from mental health problems, but how the chain fits together as a whole. Delusions are not the same as false beliefs. Don’t get me wrong, these things are very very hard to tease out in practice, but as a general rule of thumb if someone is able to successfully communicate the reasons why they think something is the case, respond to criticisms and move from premises to conclusions and the like, then we probably just disagree with them, and should definitely not take that disagreement as a sign of mental illness. At the other end of the scale, people who’ve spent a long time engaging with psychological therapies, or even just thinking and analysing their own problems might have a very good idea about what it is that’s causing them, but still be suffering a great deal.

On top of this mental health diagnoses and classifications are something that the mental health profession is constantly changing and debating. The most recent diagnostic and statistical manual released last year differs in substantial ways from previous DSM, printed 20 years ago. So why is this option closed off to the people for whom these disputes are the most vital, those having to live under the current system of diagnoses. Why can a medical student safely voice the opinion that often sadness and depression are confused by psychiatrists, but not someone confined to a psychiatric hospital and medicated for depression, but who holds the belief that they are merely sad?

The second defence is that ‘insight’ is a good predictor of whether or not someone will continue complying with treatment if they’re not in hospital or under a section of the mental health act. The easy response is that whether or not their need treatment at all is exactly what is in question here, but even if we assume that they do it’s not at all clear why ‘insight’ and compliance necessarily go together. There are a number of reasons why a patient might agree they are mentally ill, but not comply with treatment: they might forget to, lose their medication or appointment card, experience pressure from other people not to comply with it, believe that it is ineffective or has bad side effects (and *all* psych meds have bad side effects) or even just want to get drunk or high, something incompatible with most psychiatric medication. There are equally many factors why someone might not hold the belief that they are mentally ill, but still comply with treatment: they might “feel better” on medication, accept treatment to keep other people happy or to stay out of hospital, comply with it out of habit, or even comply due to false beliefs about it’s effects (how many people take anti-depressants as ‘happy pills’?)

I’m willing to believe that they might go together, but I haven’t come across any studies which show this, though I found one that suggests that evidence for the link is inconclusive (Trauer and Sacks, 2000.)  Given the above paragraph, though, it seems presumptuous to just assume they do.

It should be clear where I’m going with this; giving the concept of ‘insight’ such a huge role to play is totally unfounded. But I don’t think that’s the end of the story. Compare this for size:

“If we claim we have no sin, we are only fooling ourselves and not living in the truth. But if we confess our sins to him, he is faithful and just to forgive us our sins and to cleanse us from all wickedness.” (1 John 1)

The similarities in structure between the two seem pretty clear; you have to offer yourself up as broken, accept that as such you can’t ever possibly hope to fix yourself, and then trust yourself up entirely to some higher power (either God or a psychiatrist). This is the only possible way of being made “better” again. But the first part is key, for how can you ‘give yourself over’ to someone in the way demanded by both these doctrines, unless you first recognize that you’re totally unfit for coping by yourself? Does it matter whether that means admitting that you’re “totally depraved”, or that you’re “mentally ill”? The importance of ‘insight’, seen through these lenses, becomes less about actually making patients better and more about a crude exertion of power over them.

On top of the obvious similarities, it doesn’t seem totally implausible that the psychiatric profession’s ideas about “insight” are derived from Christian ones of admitting sin and asking for forgiveness. ‘Insight’ (as well as Anosognosia, the lack of it) is a concept grown in the western psychiatric tradition, a tradition that is heavily steeped in Judeo-Christian culture. (I know this is a cop out, but I don’t really have the time or resources to do the proper legwork for this one right now.)

The problem is that without the idea of a supernatural being who, if you only trust in him completely does actually have the ability to save you (as well as the flipside of damning you) this kind of model doesn’t really have a whole lot of point to it. I’ve watched people recover and go back out ‘there’ to get on with their lives without ever believing they were unwell. Equally I’ve watched patients who, though they can tell you more about the specifics of their diagnosis than most psychiatrists, require the intervention of psychiatric services for years, even decades.

I don’t think we should scrap the idea of insight altogether, but I do think it needs some serious pruning. Otherwise we risk making agreeing with ‘us’ a condition of being able to be discharged from our care, and this is bad for so many reasons. Obviously it’s awful for the patients; they have the right to their beliefs however wrong we might think they are, especially given that the subject of those beliefs are them, and features of their identity.

But also it deprives mental health-care professionals of the ability to modify and improve, it deprives us of insight into the views of arguably the most knowledgeable people in mental health-care, something which can only increase the danger of us all just going to sleep at our posts. (Mill, 1859.)


One response to “The Problem With ‘Insight’

  1. Very interesting. Maybe this is an instance of institutional idolatry: asking, even requiring, people to adopt attitudes which are only appropriate towards God (complete submission).

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s