Insight

 by Gina Duncan, M.D.

As defined within the context of psychiatry, insight is the ability to recognize that one has a mental illness or is experiencing symptoms of mental illness.¹

Working with someone who appears to lack insight into having a mental illness—a person who denies or refuses to acknowledge the condition—is often among the most difficult issues facing mental health care providers and loved ones. When speaking in the community, one of the most frequent questions I receive is how to help a loved one realize he or she could benefit from treatment. The challenge may seem daunting, but it remains incumbent on us as providers to cultivate insight by reaching out to people who are suffering and disengaged from care.

A pertinent question, however, is insight into what?

A deficit-oriented approach would focus on a person's recognition and acceptance of a diagnostic label such as schizophrenia; acceptance of the fact that he or she has an illness; and acceptance of the limitations this illness might impose, i.e., accepting there will be things he or she cannot have, do, or achieve as a result. A recovery-oriented approach seeks to foster insight into the possibilities as well as the challenges associated with mental illness.

Not having reliable research data or a crystal ball to predict the long-term outcome of a person's illness (there is tremendous heterogeneity of outcomes for these disorders), it is best to stay away from definitive pronouncements about what a person will or won't be able to have or do in the future. When trying to help someone accept the reality of having a mental illness, suggestions for how to approach the situation and person are included below.

Start with the individual's understanding of the situation. This does not mean the practitioner should ignore or downplay the illness, but recognize that trying to force someone to identify with a diagnostic label he or she rejects is likely to be unproductive and lead to an impasse. This is especially true in the case of diagnostic labels that have been stigmatized by society for centuries, some that are associated with discrimination and suggest to people they have lost their minds or are dangerous. A very common and understandable response to being told one has an illness called "schizophrenia," for example, is for the person to protest that he or she is not a serial killer or doesn't have a "split personality."

Rather than fighting such a lose–lose battle, find out what is meaningful for the person and connect with the goals he or she wants to achieve. What dictates a meaningful life is subjective and unique to each individual, whether the person has a mental illness or not. If we are to help promote significant growth in another person, we must be cognizant of and sensitive to this. What are the individual's unique life goals? What would he or she want life to look like if all current challenges could be magically erased?

Without judgment, positively affirm any goals the person has that would be constructive to pursue. Your own opinion of how realistic the goal is (for example, getting a Ph.D. if the person has yet to complete high school) is not nearly as important as the fact that this individual has a goal he or she is willing to work toward. This offers the two of you a basis for discussing what would help the person progress toward the goal (e.g., a first step might be getting a GED).

Avoid diagnostic labels or terms. Instead, describe elements of the individual's life (over which he or she has some control) that conflict with his or her expressed life goals. Then elicit the person's observations and sense of whether these things are perceived as personally problematic. For example, "You said your goal is to have a job so you can leave the group home and support yourself independently, but as I see it, staying in bed all day and drinking are actively working against that goal. What do you think?"

Find the person's "buy-in." What aspects or byproducts of the illness can you both agree are problematic? Even if the person rejects the diagnosis, he or she may still be able to agree that a painful byproduct of the current situation has been fractured family relationships or job loss. Once these issues are identified as problematic, the two of you can begin to explore ways to improve them.

Inspire hopefulness by highlighting past successes and available strengths and resources. Rather than focusing on limitations, help the person develop insight into what it will take to achieve a specific goal, using past successes as examples. Specifically noting how treatment can aid in this process could also be helpful. If the goal is to have a job, you might point out that when the person took medication in the past, he or she was able to get adequate sleep and had the energy to work and concentrate.

Engage in a discussion about what needs to happen for the person to reach his or her goals. For some people, this might take a long time and the process may stall after you state your concerns. However, do not let this deter you from returning to the discussion on future occasions. You never know when a turning point might present itself. For the person who is ready to engage in this discussion, focus on hopeful and realistic steps. In the above example of an individual with no high school diploma interested in pursuing a doctorate, this means finding resources to connect the person with a GED course.

Be mindful that what concerns you in terms of a person's experience of symptoms may not be significantly concerning to him or her, and accept that what is meaningful to you may not be meaningful to someone else. For example, if the individual's voices have a special spiritual meaning, he or she may not agree the voices are hallucinations that should be treated with medication. Similarly, someone who feels artistic creativity is dampened by medication may choose not to take it. For that person, the ability to creatively express him or herself may be more important than not hearing voices, holding a job, or experiencing other side effects.

As providers, we all too often focus on the complete eradication of symptoms, to the point of excluding other elements of well-being. But it is critical to remember recovery can occur in the illness, not just from the illness—something both the person and the practitioner should know.

Do we seek to foster insight into limitations or possibilities? Regardless of a person's level of impairment, we can strive to offer insight into the possibilities of a meaningful life.

Gina Duncan is Assistant Professor in the Department of Psychiatry and Health Behavior at Georgia Health Sciences University.

Reference
Charmaine C. Williams and April Collins. 2002. Factors Associated with Insight Among Outpatients with Serious Mental Illness. Psychiatric Services, 53, 96–98. Retrieved 2012 from http://ps.psychiatryonline.org/article.aspx?articleid=86973.

Posted at Recovery to Practice Newsletter. Reposted at http:/www.darkestcloset.blogspot.com