Insight into “Insight”
Examining the inadequacies in the common understanding of a clinical concept
“Insight” is a widely misunderstood concept by psychiatrists and critics alike. Perhaps it would be more accurate to say that it is superficially understood. The usual understanding that people have of “insight” is so shallow that it doesn’t survive much scrutiny. The legitimacy of the notion of “insight” is also hotly contested by many activists and psychiatric survivors, who consider a judgment of “lack of insight” to be little more than an oppressive concept used to justify coercive treatment. The denial of “insight” as a clinical phenomenon is, however, in my opinion, also unsustainable.
The problem arises from the fact that the usual definitions of insight describe it with reference to concepts such as “mental illness,” “pathology,” “causes,” and “need for treatment” (usually pharmacological), yet these concepts are not factual in any straightforward sense, which makes them vulnerable to all sorts of disagreements.
Femi Oyebode in Sims’ Symptoms in the Mind: Textbook of Descriptive Psychopathology (Seventh Edition, 2023) describes insight as:
“Insight, in psychiatry, refers to the capacity of the patient to recognize that their mental symptoms are indicative of mental illness and that these symptoms require treatment.” (page 169)
Landi et al. (2016) describe insight in Harvard Review of Psychiatry as: “[Insight] encompasses at least three fundamental characteristics: the awareness of suffering from an illness, an understanding of the cause and source of this suffering, and an acknowledgment of the need for treatment.”
What about more critical writers? How do they understand the concept?
Rob Wipond writes in Your Consent is Not Required (2023):
“The most common reason given for treating people against their will is that they “lack insight”—they’re incapable of understanding their mental illness and their need for treatment. Such people allegedly cannot be reasoned with and cannot sensibly make choices.” (p 41)
“Certainly, some people who are obviously struggling nevertheless assert that they don’t have a “clinical mental illness”—but that’s much more understandable in light of the questionable science of diagnosing and the potentially dire legal consequences of getting so labeled. Meanwhile, characterizing such people as merely “lacking insight” encourages thoughtlessness—like when we brand those who vote for a certain political party as “too stupid to realize how stupid they are,” while not seriously considering that this notional Zen koan could as well apply to us. In fact, surveys regularly show that the most common reasons patients give for refusing psychotropics are consummately understandable: they feel that the drugs don’t help them enough and the adverse effects are too severe.” (p 42)
Rachel Aviv writes in Strangers to Ourselves (2022):
“In a seminal 1934 paper in The British Journal of Medical Psychology, the psychiatrist Aubrey Lewis defined insight as the “correct attitude to a morbid change in oneself.” … But the concept largely ignores how the “correct attitude” depends on culture, race, ethnicity, and faith.” (p 22)
“In the starkest terms, insight measures the degree to which a patient agrees with his or her doctor’s interpretation.” (p 22)
“[With] Biomedical explanations of illness, which began to dominate in the eighties and nineties… The “correct attitude” came to rest on a new body of knowledge: patients were insightful if they understood that their disorders arose from diseases of the brain.” (p 23)
Slade and Sweeney (2020) write in World Psychiatry:
“The psychiatric concept of insight involves recognition that one has a mental illness, that unusual mental events are pathological, and that treatment is needed.”
“… being labelled as lacking insight can prevent credible self-representation and frustrate people's exploration and understanding of their own stories. Whatever a practitioner's motivations, and whatever the external unintelligibility of a person's experiences, claims to epistemic authority silence those who have “stories to tell.” This makes the concept of insight a core site of epistemic struggle.”
They go on to say that people have “the right to construct personal meaning and explanatory frameworks, alone and collectively.” In contrast to the clinical construct of insight, they define “narrative insight” as “developing a meaningful and useful narrative about one's experiences within cultural contexts…”
In this context, I want to outline what I think we often get wrong about insight and how it might be better understood.
We have to distinguish between the phenomenon of “(lack of) insight” itself and the manner in which insight is used to justify things such as commitment or forced treatment. We also have to appreciate that “lack of insight” points towards a genuine phenomenon that doesn’t go away or disappear if we don’t talk about it, a phenomenon that we can very well describe without explicit reference to pathology or diagnosis.
The meaning of insight also varies in different clinical contexts. Insight in a psychotherapy context, for instance, or insight in the case of addiction, or insight into one’s personality characteristics and their interpersonal consequences, all require unique considerations. Here I’m restricting myself to a narrow notion of insight, as it is usually considered in a routine mental status examination and in the management of mania and psychosis.
What is insight?
In contexts where the notion of “mental disorder” is itself disputed (or cannot be taken for granted), for insight to do any meaningful work, it has to refer to descriptive phenomena that underlie the notion of mental disorder. Insight is about awareness, but awareness of what exactly? Insight in instances of psychosis is awareness that one is experiencing (or has experienced in the past) something extraordinary, unusual, anomalous, alarming, concerning, or peculiar; an awareness that the changes one is experiencing have affected and impaired one’s day-to-day functioning and interpersonal relationships. Insight is about the awareness that a rupture in shared reality has occurred and that what one is experiencing is profoundly at odds with, or misaligned with, how the world is to everyone else.
Insight in instances of psychosis is awareness that one is experiencing (or has experienced in the past) something extraordinary, unusual, anomalous, alarming, concerning, or peculiar; an awareness that the changes one is experiencing have affected and impaired one’s day-to-day functioning and interpersonal relationships. Insight is about the awareness that a rupture in shared reality has occurred and that what one is experiencing is profoundly at odds with, or misaligned with, how the world is to everyone else.
Among available descriptions in the literature, I think Marková and Berrios (1992) get it right when they say:
“Insight is a form of self-knowledge which includes not only information on problems and personality traits as applied to the self, but also an understanding of their effect on the way in which self interacts with the world.”
Femi Oyebode writes in Sims’ Symptoms in the Mind:
“Self-awareness obviously takes in much more than an awareness of illness, but it is plain that the psychiatric notion of insight is a subset of the general concept of self-awareness or self-knowledge. Insight, as a notion, is much wider than just knowing whether one is ill, and if so, having a sensible view regarding treatment. It involves our capacities for introspection, empathy and communication; not only is it glimpsing ourselves as we really are but also ourselves as others see us, and therefore others as they really are because they go through the same repertoire of mental mechanisms that we do.” (p 170)
Lewis referred to a “correct attitude” and Oyebode refers to a “sensible view.” I think that is basically right. Insight is about self-awareness of the changes in perception and behavior one has experienced, followed by a “sensible” view of the nature of these experiences. What counts as “sensible” or “correct” obviously depends on, as Aviv puts it, “culture, race, ethnicity, and faith.” This doesn’t delegitimize the notion of insight; it only makes it sensitive to these considerations.
Insight is not fundamentally about agreement with the doctor’s interpretation
“The assessment of insight is substantially a judgment of discrepancy between the perspective of a clinician and that of a patient… using a framework derived from the assessor’s perspective.” (McGorry and McConville, 1999)
Insight can be about disagreement with a clinician only to the extent that we use clinician judgment as a proxy for the accurate characterization of the psychological problem. Clinician judgment is fallible and can be questioned using the very standards that the clinician is expected to follow, including expectations that sociocultural differences have been taken into account. The appropriate reference then is not the clinician judgment per se, but rather the state of affairs as judged by the standards upheld by the clinical community. (In cases of forced treatment, it is common for jurisdictions to require a concurring opinion of an independent clinician.)
Insight can be about disagreement with a clinician only to the extent that we use clinician judgment as a proxy for the accurate characterization of the psychological problem.
In frank cases of mania and psychosis, a person’s lack of awareness of aberrant behavior is obvious not just to clinicians, but even to family members, friends, and non-clinicians such as lawyers and judges. I remember a forced medication court hearing in which a patient disagreed with physician testimony and wanted the judge to hear his side of the story; the judge asked the patient about their involvement with the CIA. When the patient answered, the judge, and everyone else present at the hearing, could see for themselves that the person was delusional and lacked awareness of that fact. If lack of insight is a form of disagreement, it is not simply a disagreement with one doctor’s interpretation but rather a disagreement with the judgment of an entire community of people, a community that typically includes their own family and friends. In any particular clinical encounter, the clinician is serving as a representative of this community.
Insight is not about causal explanation or about currently fashionable explanatory ideas about the nature of mental illness
Many definitions of insight make reference to “explanation about the cause or source” of signs and symptoms (reviewed by McGorry and McConville, 1999). I don’t see how insight can be about the causes of mental illness when psychiatrists themselves fully acknowledge that we lack adequate scientific accounts of the etiology of mental illness. Is insight then an acceptance of popular buzzwords like “brain disorder” and “chemical imbalance”?
How knowledgeable one is about contemporary ideas and how well-versed one is in the current vocabulary tells us about an individual’s ability to acquire and accept such ideas, but that has little to do with “insight.”
To the extent that the determination of “insight” has come to rest on currently fashionable ideas about the nature of mental illness, it is an unfortunate and mistaken development. How knowledgeable one is about contemporary ideas and how well-versed one is in the current vocabulary tells us about an individual’s ability to acquire and accept such ideas, but that has little to do with “insight.” Someone who tells me that their condition is a “brain disorder” or a “chemical imbalance” is not necessarily more insightful than someone who tells me that their condition is a “spiritual crisis” or a “trauma response.” It is also not clear to me that patients ought to endorse “naturalistic” explanations of mental illness in order to demonstrate insight. Insight, if it is to do meaningful work and if it is to not be at the mercy of whatever is currently fashionable, cannot be about one’s knowledge of the causes and etiology of mental illness.
That said, patients sometimes have delusional ideas about the etiology of their condition. Delusional explanations of etiology convey a lack of insight, but that is because these are instances of delusion and not because knowledge of etiology is a component of insight.
There is one sense in which insight does involve a recognition of the nature of the condition, but this is a general, folk psychological recognition that one has become unwell or ill, or that one has gone mad. It is the sort of recognition conveyed by colloquial phrases such as, “I lost my mind.” It is a recognition by the person that they believed in the literal truth of something that was in fact not literally true, and that the mechanisms by which they came to believe in the literal truth of something false, unlikely, or preposterous are mysterious and obscure, something distinct from mundane mechanisms such as an honest mistake at inference or acquiring false beliefs from others via learning or imitation. Such a recognition is not dependent on recognition of what has caused one to become ill or mad.
Insight is not fundamentally about the diagnostic label
Insight cannot fundamentally be about a DSM/ICD label because clinicians themselves can and do disagree about these labels. If a person thinks they have psychotic depression but I think they are experiencing a schizophrenia spectrum condition, the diagnostic disagreement per se is irrelevant for insight, as long as we can agree on what the relevant symptoms or behavioral changes are. If a person thinks they are just depressed, but I think they are delusional, this disagreement is not primarily about DSM/ICD labels or the validity of the operationalized criteria. The disagreement is about the basic features of psychopathology.
Involuntary treatment is not fundamentally about lack of insight but about decision-making capacity
Insight is often involved in cases of involuntary treatment, but it is important to realize that people who receive involuntary treatment are a small subset of people with impaired insight. These are typically cases where the functioning is so impaired or the behavior is so disturbed that they cannot function in a setting outside of a psychiatric hospital and where treatment has a reasonable chance of restoring the ability to live in a less restrictive environment.
Involuntary treatment depends fundamentally on impaired decision-making capacity. The criteria for decision-making capacity are independent of the concept of insight, but they overlap with it. Four criteria are commonly used when determining decision-making capacity for medical decisions: the ability to receive, process, and understand the relevant information; to appreciate the situation and its consequences; to rationally process the information; and to express a choice. These criteria are not specific to psychiatry and apply across medicine. A psychotic patient who lacks self-awareness (“insight”) is impaired with regards to understanding, appreciation, and reasoning components of medical decision-making. In the real world, impaired insight is commonly cited as a reason for impaired decision-making capacity, but if we wanted to, we could easily state the relevant impairments in decision-making capacity without direct reference to the term “insight.”
In the real world, impaired insight is commonly cited as a reason for impaired decision-making capacity, but if we wanted to, we could easily state the relevant impairments in decision-making capacity without direct reference to the term “insight.”
Impaired decision-making capacity doesn’t automatically mean that the person receives forced treatment. In fact, we ought to respect the person’s wishes as much as possible, taking into account advance directives and our best understanding of what the patient would’ve wanted if they had decision-making capacity. Currently, for involuntary psychiatric care, physicians and the courts use a “best interest” standard. That is, would this treatment be in the best interest of the patient, as determined by the physicians? But there are other standards, such as those supported by the UN and WHO, that refer to the best interpretation of the person’s will and preferences. My main point is that it is up to us collectively to determine how we can provide care in the most therapeutic and helpful way to a person who lacks decision-making capacity or insight. Profound impairments in decision-making are a reality, and it serves no one to pretend that they don’t exist.
My main point is that it is up to us collectively to determine how we can provide care in the most therapeutic and helpful way to a person who lacks decision-making capacity or lacks insight. Profound impairments in decision-making are a reality, and it serves no one to pretend that they don’t exist.
Patients do not lack insight because they question the science of diagnosis or because they reject a diagnosis due to fear of legal consequences
In clinical practice, it is rare for patients to bring up philosophical or scientific arguments against psychiatry as a basis of disagreement with their clinicians or for clinicians to judge patients as lacking insight because of philosophical or scientific disagreements. Actively psychotic patients who lack insight don’t usually dispute the general notion of mental illnesses or the existence of madness; they just don’t think that the notions apply to them at that moment in time. Someone who actively believes that the CIA is following them or that satellites are targeting their bodies lacks awareness that what they are experiencing is not aligned with reality; they don’t say, “I believe that I am being persecuted by the CIA but this is actually a metaphor about how we live in a police state, and it is a response to the trauma I’ve experienced.” They literally believe the CIA is after them. They may recognize that it “sounds delusional,” but they don’t in fact believe that it is delusional. It is only after delusions have begun to recede and have loosened their grip on the mind that some sort of meaning-making can happen, and any metaphorical value or links to life circumstances can be explored. If a patient is able to tell me that they are experiencing something anomalous, that their beliefs and experiences are no longer aligned with those of others, including people with whom they share a cultural background, and that their beliefs are not supported by available evidence, then even if they reject the notion of “mental illness” for philosophical reasons, in my view they possess insight into these elements. But such cases are rare in clinical practice.
Actively psychotic patients who lack insight don’t usually dispute the general notion of mental illnesses or the existence of madness; they just don’t think that the notions apply to them at that moment in time.
I’ve encountered delusional patients who have denied that they have severe and uncontrolled diabetes mellitus or that have HIV infection, despite objective tests demonstrating their presence. It isn’t true at all that the primary reason psychotic patients reject diagnosis is because they have scientific concerns about reliability or construct validity.
Insight is not about respecting or disrespecting patient narratives
“our notions of clinical insight need not devalue patients’ beliefs and explanations as these are often consistent with local and culturally accepted explanations.” Femi Oyebode, Sims’ Symptoms in the Mind.
Impaired insight does not mean that patients narratives should not be respected. We should respect patient narratives about their experiences as much as possible. The phase of the condition, however, does matter here. Take a delusional patient I once saw who believed that the family who raised him abducted him at birth from his biological family. What does it mean to “honor” or “respect” this delusional narrative? We should approach a delusional belief gently and without confrontation, but we should recognize it for what it is. However, the same patient, once he received treatment, developed a new narrative: “I said those things because my family had treated me like a stepson, but I recognize that they are my real family.” It means a very different thing to respect this narrative in which he interprets his now-resolved delusions in a metaphorical manner.
Delusions are not the result of a patient exercising their autonomy to develop their own narratives. To think so is to profoundly misunderstand the nature of delusions. But beyond that, it is often a healthy thing for patients to understand their symptoms in ways that are meaningful to them, and we should respect that.
Delusions are not the result of a patient exercising their autonomy to develop their own narratives. It is foolish to think that they are. To think so is to profoundly misunderstand the nature of delusions. But beyond that, it is often a healthy thing for patients to understand their symptoms in ways that are meaningful to them, and we should respect that. That is so regardless of whether they have complete insight into their psychosis or not.
How insight is commonly understood: insight is the ability to recognize that one’s mental symptoms are indicative of mental illness and require treatment.
How insight is misunderstood or misapplied: insight is the degree to which a patient agrees with their doctor’s interpretation; insight requires acceptance of biomedical explanations of mental illness; patients who reject a diagnosis for scientific reasons or reject the notion of mental illness for philosophical reasons are judged by clinicians to lack insight.
How insight is better understood: insight is the awareness of a morbid change in oneself, the awareness of the impact this change has on one’s functioning and interpersonal relationships, and a sensible attitude towards the care this entails.
Post-publication note: Chris Schuck brought to my attention this 2023 article by Sarah Kamens et al., “Enhancing insight into clinical insight: An investigation of conceptual variations.” It is very relevant to the discussion above and even has a similar play on the word insight in the title. Somehow I missed this very useful reference earlier.
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