Insight

Workstream 4

The principal focus of this workstream is the concept of insight.  The term “insight” occurs frequently in clinical discourse.  A patient who is aware that they are suffering from a mental disorder and is able to articulate their condition in the language of symptoms will often be described by their clinical care team as “having insight.”  A patient who is unwell but unaware of their own illness may be described as “lacking insight” or “having impaired insight.” WS4 is also investigating ideals of objectivity in legal proceedings under the Mental Capacity Act and related legislation.

Background

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.

Approach

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. 

Outcomes

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. 

Publications

Martin, W. et al. (2021)

SIDMA as a Criterion for Psychiatric Compulsion: An Analysis of Compulsory Treatment Orders in Scotland.

Gurbai S. (2020)

Beyond the Pragmatic Definition? The Right to Non-Discrimination of Persons with Disabilities in the Context of Coercive Interventions.

Gurbai, S, Fitton, E and Martin, W. (2020)

Insight Under Scrutiny in the Court of Protection: A Case Law Survey. 

Burch, M; Furman, K. (2019)

Objectivity in science and law: A shared rescue strategy

Recent activity

Insight and capacity – in conversation with Professor Wayne Martin

Alex Ruck Keene and Professor Wayne Martin dig into the concept of ‘insight’ and tease out how it might relate to mental capacity. https://player.vimeo.com/video/446763385 Mental Capacity Law and...

Conversation

Workstream members

Wayne Martin

Wayne Martin

Principal investigator

Professor of Philosophy and Director of the Autonomy Project at the University of Essex.  Wayne has interests in phenomenology, philosophy of psychiatry, and human rights. He directs workstream 4 and contributes broadly across the MHJ network.

Sabine Michalowski

Sabine Michalowski

Core member

Professor of Law at the University of Essex and Member of the Essex Human Rights Centre.  Sabine has interests in medical law and human rights and provides research support on legal and human rights issues arising in workstream 4.

Matt Burch

Matt Burch

Core member

Lecturer in Philosophy at the Unviersity of Essex. Matt works on issues at the intersection of phenomenology, action theory and research in the cognitive and social sciences.  Matt has played a leading role in workstream 4’s research on ideals onf objectivity in contexts where law and care practices interact.

Sándor Gurbai

Sándor Gurbai

Consultant

Staff Human Rights Lawyer at Validity (formerly MDAC).  Sándor has contributed human rights analysis on workstream 4, with particular attention to international human rights standards in the provision of mental health care.

Sherrilyn Roush

Sherrilyn Roush

Consultant

Professor of Philosophy at the University of California, Los Angeles. Sherri has interests in philosophy of science, epistemology and philosophy of medicine. She provides research support on workstream 4 and contributes widely across the research network.

Thomas Hartvigsson

Thomas Hartvigsson

Postdoctoral Researcher

Thomas recently earned his PhD in practical philosophy from the University of Gothenburg, Sweden. He wrote his dissertation on decision-making competence and the relationship between the right to make decisions and moral responsibility. Thomas is providing research support to workstream 4 in the final year of the project.