Rethinking “insight” and “engagement” in early psychosis

Medical perspective on insight

Professor Lisa Dixon (Columbia University Irving Medical Center, USA) showed how the medical definition of “insight” has changed over time. The distinctions may seem subtle from one to another, but when viewed with a longer lens they reflect an important shift in perspective.

“Insight” is used as a judgment of discrepancy between the clinician’s perspective and that of the patient

In the 1960s, Jaspers defined “insight” as ‘objectively correct estimate of the severity of the illness and objectively correct judgment of its particular type’¹, with the underlying assumption of an absolute truth.  Ten years later, Carpenter described “poor insight” as ‘a manifestation of the illness, rather than a coping strategy’, recognising it as a symptom of schizophrenia¹. In 1990, David proposed awareness, attribution and action as three distinct dimensions to the concept of insight². By the late 1990s McGorry suggested that the term is used as ‘a judgment of discrepancy between the clinician’s perspective and that of the patient, within a framework derived from the assessor’s perspective’³.

Challenges around insight

McGorry also challenged assumptions behind the many measurement scales used for insight and highlighted five key areas to consider³:

• insight is complex and multi-dimensional
• cultural factors need to be considered
• component dimensions are continuous
• may be modality specific
• account for previous exposure to information regarding the nature of the illness

Insight is not a static concept and can fluctuate across time and within episodes

Insight is not a static concept and can fluctuate across time and within episodes. Awareness of past illness is more common than current illness.

Is “insight” always helpful?

Theories of the cause of “impaired insight” involve neuropsychological and psychological models, the latter including denial as a defense mechanism. Clinicians tend to consider it helpful for a patient to have insight, as that may improve adherence to treatment and reduce the likelihood of them acting on delusional beliefs³. But there can be negative consequences³ including adding ‘insight to injury’, depression, and assuming the sick role.

Lived experience of mental illness

From his lived experience, Micah Pearson (Executive Director of National Alliance on Mental Illness of Southern New Mexico, USA) explained some of the many reasons why a patient may not want to take medication, despite having insight into their condition. His concerns about adverse events differed from his clinician’s risk-benefit analysis but his questioning was labelled as ‘combative’.

There are many reasons why a patient may not want to take medication, despite having insight into their condition

A diagnosis, such as schizophrenia, can be highly stigmatizing, suggested Dr Nev Jones (University of Pittsburgh, USA), and clinicians often under-recognize the socially-enforced pressures to reject such a label. She described the tendency to over-generalize, assuming all patients with psychosis lack insight. As well as the tendency to attribute any decisions considered ‘poor’ by the clinician to lack of insight and therefore overridden.

The medical model of insight reinforces the hierarchy between the ‘expert’ clinician knowledge and the patient knowledge, eroding the perceived value of the patient’s experiences. There is often failure to explore the relationships between the content of hallucinations and delusions and the patient’s life events and social/cultural context. It can also result in dismissing the patient’s reports of antipsychotic adverse events, especially where the biological etiology is less clear.

Focus on engagement

Moving from prejudices about insight to asking questions, listening more and focusing on engaging patients, as human beings and individuals

The plea from the panel was to move from using phrases such as ‘they have no insight and won’t take meds’ to asking questions, listening more, and focusing on engaging patients as human beings and individuals. They all agreed that managing early psychosis is complex, uncertain, and more of a marathon than a sprint. Ronda Speight (Mental Health Association of Westchester, New York, USA) and Dr Angela Coombs (Alameda County Behavioral Health Care Services, USA) concluded that it can be transformative if clinicians enable patients to take control over their lives, where possible, even with the struggles and challenges that may bring.