Insight

The presence and absence of awareness of illness is a palpable reality in clinical settings, and a significant variable in the population of patients. Clinical approaches to patients are of necessity different, depending on the nature and degree of the patient’s insight into their own illness. Where insight is present, there is a common basis for the clinical encounter from the outset. Where insight is lacking this common ground is diminished. Coercion and treatment non-compliance become more likely.

From a legal perspective, the concept of insight is fraught. Anecdotal evidence suggests that insight is sometimes used as a proxy for decision-making capacity (DMC), and a lack-of-insight is sometimes taken as sufficient evidence of lack of DMC. But at least in England and Wales, insight is not included in the legal definition of capacity. Some have argued that the concept of insight has no place in legal proceedings. The aim of WS4 is to investigate the clinical concept of insight, the variety of forms that insight (and absence-of-insight) can take in different patient populations, and to develop guidance for the use of evidence regarding impaired insight in legal proceedings that impact upon a patient’s autonomy and human rights.

WS4 is identifying the structure of insight and lack-of-insight as a feature of a person’s experience. Using a large corpus of rich interview data unanalysed for this purpose, and deploying a methodology of “second person phenomenology” developed in earlier work, we are studying the presence and absence of experience-of-illness in four groups of persons with mental disorder.

We are interviewing legal and clinical professionals, observing at ward rounds, and undertaking a systematic study of case law to develop an analysis of the use of the concept of insight in clinical and legal discourse.

We are undertaking a “translational” exercise, mapping clinical uses of the concept of insight onto three legal concepts: legal capacity, DMC and appreciation. Finally, drawing on the preceding phases, and engaging our service user-research collaborators, we are developing guidelines for increasing service user involvement in articulating areas of shared understanding and areas of divergence between the clinician’s and the service user’s perspective, and identifying strategies for support of decision-making capacity where insight is impaired.

In addition to academic outputs, WS4 is producing guidelines for frontline professionals who are involved in gathering, reporting and adjudicating evidence concerning impaired insight – particularly in contexts which may affect the rights of patients. We are currently piloting training curricula for clinicians, social workers and legal professionals who deal with the concept and phenomena of impaired insight.