British Journal of Psychiatry (1992), 160, 850—860
The Meaning of Insight in Clinical Psychiatry I. S. MARKOVAand G. E. BERRIOS
‘¿1
Insight can be defined not only in terms of people's understanding of their illness, but also in terms of understanding how the illness affects individuals' interactions with the world. The term ‘¿insight' encompasses a complex concept which should not be considered as an isolated symptom which is present or absent. Instead, it may be more appropriate to think of insight as a continuum of thinking and feeling, affected by numerous internal and external variables. Different psychiatric disorders involve different mechanisms in the process of impairment of insight; this may influence the ways in which insight should be assessed in clinical practice.
“¿I
In the description of psychopathological phenomena,
of morbidity. It thus appears that while the patient's
terms are used whose meanings remain unclear. One such term is ‘¿insight'. The OxfordEnglish Dictionary defines insight as ‘¿ ‘¿an inner sight, a discernment, wisdom, or a glimpse of you beneath the surface―. Lexical definitions, however, may undergo marked change when terms in ordinary language are adopted in technical vocabulary. In psychiatry the term ‘¿insight' refers to a ‘¿state of
insight is included in the psychiatric examination, it is not clear what ‘¿good' or ‘¿bad' insight should mean in relation to the clinical value of other symptoms
mind' or ‘¿mental act', knowledge of which is inferred from the patient's response to illness. That a patient does, or does not, have insight, is a claim made on the basis of the speech content and behaviour of that patient. Thus conceptualised, ‘¿insight' plays a crucial role in psychoanalytic (Richfield, 1954;
assessed
and
response
to treatment.
as part of the standard
Insight
mental
This paper examines the ways in which the concept
of insight is used in clinical psychiatry, and the role lack of insight may play in the manifestation of some mental disorders. The question is raised of how insight is to be distinguished from other related concepts. Insight as a concept
and as
patients' response to illness While the term ‘¿insight' has a relatively short history,
Blum, 1979), gestalt (Conrad, 1958), and pheno
notions such as self-examination and self-knowledge
menological ( Jaspers, 1959) approaches to mental illness. Inferences about patients' insight are also important to evaluate severity of illness, suicidal risk, compliance,
or illness outcome.
can be traced back to ancient Greek philosophy and Plato (Watts, 1987, l64e—l67c).It is unclear when the concept of insight as a ‘¿symptom'was first introduced into Western psychiatry, but during the
is
state
but no guidelines exist on how to
latter part of the 19th century, work was already
qualify or quantify it. Patients are said to have no insight, good insight, or partial insight. Such statements convey little about insight itself. In contrast to the frequent allusions to insight in
being done on the effects of mental illness on self
psychiatric practice, the literature on it is scanty and
as the
confusing. Current emphasis on the objectivity and
of insight willbe dealt with elsewhere. Only two aspects
reliability of psychiatric diagnosis has devalued the
of ‘¿insight'are discussed here: its constitution as a concept, and its validity as inferential knowledge
examination,
views patients themselves have of their illness (i.e. their awareness of illness and their insight). Although patients' attitudes to symptoms are likely to bias
awareness (Dagonet, 1881). During the same period interest also developed into the psychological
functions that might be affected in phenomena such anosognosias.
The
historical
exploration
concerning patients' ‘¿understanding' of their illness.
the recollection and reporting of mental events, the information obtained by means of the conventional psychiatric interviews may be affected by the mental disorder. In fact, it seems as if it must be assumed that the mental disorder does not distort subjective information (e.g. hallucinations or anhedonia), since a great deal of the latter is used as a marker
Insight in phenomenological
psychiatry
I
Karl Jaspers was one of the first to explore these two aspects of insight. He wrote:
850
“¿Patients' self-observationis one of the most important sources of knowledge in regardto morbid psychic life;
so istheirattentivenessto theirabnormalexperienceand I
851
THE MEANING OF INSIGHT the elaboration of their observations in the form of a psychological judgement so that they can communicate to us something of their inner life.―( Jaspers, 1959,
@ pr ,1,_
p. 420) (our emphases)
Jaspers observed that in the early stage of their illness
stated, is intrinsically linked with the patients' selves,
and hence cannot be divorced from knowledge of
patients
became
perplexed,
this
being
an
under
tried to make sense of their experiences, for example
by elaborating delusional systems. Thereafter, Jaspers ,
described
how,
when
the
illness
produced
changes
in personality, a patient's attitude to the illness ,
became
less
understandable
to
others
as
he/she
could
appear indifferent or passive to the most frightening 4
delusions. Jaspers also observed that while transient insight
may occur during acute psychoses, there was no @1
lasting
or complete
insight.
In fact,
he stated
that
where insight persisted, the patient was more likely ,@
to
be
suffering
from
a
personality
disorder
than
.@
,
@
related to what Jaspers called ‘¿insight'. Conrad named the early stage of the schizophrenic illness the ‘¿trema';during this stage patients found it difficult to express their feelings and experiences; some would talk about fear, tension, anxiety and anticipation, while others would describe feelings of guilt and helplessness. Conrad believed that the
common theme was a feeling of oppression, an awareness that something was not right, and a sense
psychoses
of restriction of one's freedom. During the next stage
such
as
mania
and
alcoholic
hallucinosis
where the patients were able to look back on their @
self-existence itself. Conrad (1958) in turn carried out long-term observations on schizophrenic patients and described the development and progression of the psychotic state. Although he did not use the term, his conceptualisation of the awareness of change in the self and the environment due to mental illness is
psychotic state, Jaspers made a distinction between
a psychosis. In patients who recovered from the ,
knowledge to themselves, than their “¿comprehending appropriation― of it. This latter function, Jaspers
his
standable reaction to the new experiences they were undergoing. As the illness progressed, the patients @
it was easier to assess patients' objective knowledge, that is their ability to understand and apply medical
experiences with ‘¿complete'insight, and a psychosis such as schizophrenia where they did not show full insight. He described the latter patients as unable to talk freely about the contents of their experiences, becoming overtly affected when pressed to do so, and occasionally maintaining some features of their illnesses. In chronic psychotic states, he described patients who, from their verbal contents, often appeared
to
have
full
insight,
yet
in
fact
these
of the illness, the ‘¿apophany',patients attributed meaning to feelings and experiences; for example, when in the state of ‘¿anastrophe',patients believed themselves to be the centre of the world. Conrad described further stages during which destructive
processes
were
followed
by
partial
resolution as residual schizophrenic effects persisted,
and postulated that schizophrenia was an illness affecting
the higher mental functions which dif
ferentiate humans from animals. Thus, it affected
verbal
contents would turn out to be learnt phrases and
the whole self-concept and, in particular, the ability
meaningless
of the individual to effect the normal transition from looking at oneself from within to looking at oneself
to the patients
themselves.
Jaspers' concept of insight, partly based on clinical observation, was that it was the patients' ability
from the outside, by the eyes of the world.
to judge what was happening to them during the development of psychosis, and the reasons why it was @
happening.
So,
he
made
a
distinction
between
awareness of illness, that is experiences of feeling ill or changed, ,
estimate
could
and insight proper, where a correct be
made
of
the
type
and
severity
of
the illness. These judgements, however, depended on the intelligence and education of the individual; indeed, because judgements of this nature are
@
inherently a part of the personality make-up, in the case of patients with intelligence below a certain level (e.g. idiocy), it would be more appropriate to think of loss of personality rather than loss of awareness as the feature in their lack of knowledge of themselves. Jaspers was aware of the difficulty involved in theorising about patients' ‘¿insight', and of the extent
@
*
to
which
the
outsider
can
hope
to
understand
patients' attitudes to their illness. In other words,
Insight in psychodynamic
theory
Two aspects of insight remain controversial in this area; one relates to the concept itself, the other to its role in analytical
psychotherapy.
They are
interlinked. The aim of psychoanalytic therapy is to uncover repressed impulses/emotions and bring to conscious ness the unconscious mechanisms thought to underlie
the patient's psychopathology. Thus it would appear that one of its tasks is to promote insight. Freud used the term ‘¿insight', or in German ‘¿Einsicht/Einblick', predominantly to denote knowledge of or awareness of being ill (A. Freud, 1981). According to A. Freud, there were only two instances where Freud used the term ‘¿insight' in the deeper sense of revelation, as in the much quoted line from the 1931 preface to
852
MARK0vA & BERRIOS
the 3rd English edition of The Interpretation Dreams:
of
“¿The pathological factor is not his [the patient's]
“¿Insightsuch as this comes to one's lot
ignorance in itself, but the root of his ignorance in his
but once in a lifetime―(S. Freud, 1900, p. 32). Nevertheless, in psychoanalytic literature it is this search for the deepest awareness of self that is taken
to encompass the concept of insight. Within this broad concept there subsequently arose numerous modalities of insight, for example insight through clarification
and insight through
interpretation (Bibring, 1954), neutral, emotional and dynamic insight (Reid & Finesinger, 1952), descriptive and ostensive insight (Richfield, 1954), and others such as intellectual, experiential, uncon scious/conscious insight and verbal insight. Insight itself has been variously defined, for example as a process making use of the ego-function of self-observation in both experiential and reflective
forms (Kris, 1956), as a first awareness of oneself or of the world as it affects oneself (Myerson, 1960), as an ability to see and move freely through the inner world that contains both changing and stable representations of the self and of other environ mental objects (Shengold, 1981), as a bridging of different levels of the mind (Scharfman, 1981), and so on. Strachey (1934) criticised the use of the term ‘¿insight'when there was such a lack of clarity
and consistency in its meaning. This criticism has been echoed since (e.g. Zilboorg, 1952; Neubauer, 1979; Wallerstein, 1983; Linden, 1984). Richfield (1954) pointed out that it was difficult to define and classify the concept of insight because of ambiguity in the concept of knowledge. He proposed
that
insight
should
not
be classified
Since then there have been disparate views on the relationship between insight and cure. Blum (1979) maintained that the goal of analysis was the attainment of insight, achieved mainly through interpretation: “¿Insight is a sine qua non of the and, “¿analytic ‘¿cure' is primarily effected through insight and not through empathy, acceptance, tolerance etc.―(Blum, 1979, pp. 47, 66). Loewenstein (1956)
had likewise
pointed
crucial to the therapeutic
out that
insight
was
effect of psychoanalysis.
On the other hand there have been others, notably 4
Alexander et al(1946), Coons (1957), and Wallerstein (1983),
who
have
questioned
such a weighting
of
insight in the determination of change. Empirical studies have mostly compared outcomes
of insight-orientated psychotherapy versus non insight-orientated psychotherapy (e.g. Anker & Walsh, 1961; Paul, 1966, 1967; Hartlage, 1970). The problem with such studies lies again in the lack of definition of insight, of measures to ensure that mentioned (Roback, 1971, 1974). In addition, the assumption equates
has been made that
‘¿insight' - when
‘¿interpretation'
interpretations
have
been
given, insight is assumed to have been attained. Similar difficulties have beset other studies e@mining,
for example, psychological-mindedness and benefit from insight-orientated group therapy (Abramowitz
of knowledge, Richfield distinguished between insight gained by description and insight gained by acquaintance. When patients attained descriptive insight, they became aware of the ‘¿truths' about themselves by acknowledging the words of the analyst. When, however, they attained ostensive insight, they became ‘¿personally acquainted' with the ‘¿truths',for example through transference, when the particular emotions were brought directly into their awareness. A second area of controversy relates to the role of insight within psychoanalytic therapy. Fisher & Greenberg (1977) pointed out how Freud's own concept of insight in relation to therapy and cure changed. While initially Freud maintained the existence of a direct relationship between the attainment of insight and behavioural change/cure, he later acknowledged the equal importance of time, working through, and inner resistances:
I
insight was achieved, and of evidence that the therapists actually carried out the specific techniques
knowledge
Using Russell's classification
‘¿1
psychoanalytic process and is a condition, catalyst, and consequence of the psychoanalytic process,―
according to content, but according to the form of involved.
V
inner resistances. . . . Informing the patient of what he does not know because he has repressed it is only one of the necessarypreliminariesto the treatment . . .“ (Freud, 1910,pp. 225—226)
& Abramowitz,
1974), or assessment of suitability
for insight-orientated Alstrom,
I
psychotherapy
(Persson &
1983).
An interesting measure of insight was constructed by Tolor
& Reznikoff
(1960).
They
developed
subjects was equivalent
to self-understanding.
•¿1
a
test consisting of 27 hypothetical situations, depicting the use of common defence mechanisms, and applied this to college students and psychiatric patients, where they found it correlated with intelligence. However, whether this was a valid measure of insight is debatable, as they assumed that the ability to appreciate motivation in other
‘¿a
4
This
test was used in a study by Roback & Abramowitz (1979), who found that the schizophrenic patients scoring higher on it were rated by hospital staff as better adjusted behaviourally though more distressed subjectively.
p
THE MEANING
Insight in clinical psychiatry: theoretical and empirical studies
by the length of stay in hospital of 300 psychotic patients. However, no measure of insight was used,
In his much quoted paper “¿The psychopathology of insight―, Aubrey Lewis (1934) did not overtly ‘¿r@ commit himself to any particular theoretical point
of view. He recognised different meanings and usages, which he felt were a source of confusion. In @
contrast to Jaspers, Lewis analysed the different usages of ‘¿insight'but provided few empirical observations. He offered his own ‘¿temporary'
@ -
definition
@.
—¿â€œ¿a correct
attitude
to
a
853
OF INSIGHT
morbid
and patients were simply divided into those showing full insight, partial insight, and no insight; how these distinctions
were made was not clarified.
Lin et al (1979) studied insight in 100 chronic schizophrenic
patients.
They concluded
that the
presence of insight and perceived benefits from medication increased compliance. However, the term ‘¿insight' was loosely defmed, and said to be present if patients answered in the affirmative as to whether
they thought they had to be in hospital, or had to
change
in oneself― (Lewis, 1934, p. 333) —¿ and defined each see a doctor/psychiatrist. Thus insight was assumed term in turn. Terms such as ‘¿attitude',‘¿morbid to be an all-or-none concept. In addition, the reasons
change', ‘¿correct attitude', ‘¿health' and ‘¿normality' behind the patients' responses were not explored,
@ . benefited morefromhisefforts thantheconcept of insight. In keeping with the linguistic philosophy of @-
his
period
(Urmson,
1958),
he
tried
to
‘¿dissolve'
the
problem by breaking insight into isolated concepts, ‘¿3 but without qualifying
it as a whole. A similar
approach has been followed by David (1990). Lewis made no attempt to compare the types of insight -
,
displayed
by
disorders,
patients
although
within
he
categories
made
the
of
important
mental
point
that the presence of insight could not be used to differentiate between psychosis and neurosis, as in both there could be good insight or lack of insight.
@
Lewis also distinguished between patients' immedi
ate perceptions and their perceptions based on secondary data (between the expressions ‘¿there is a change' and ‘¿there must be a change', respectively)
and to relate this to different levels of awareness. .
Without referring to Jaspers, Lewis described insight
as concerning both awareness of self-change and the judgement of such change, and stated that it was 4-
with
the
“¿disordered mind,
contemplates
@ ,@
the
patient
,@
In a retrospective study using the case notes of 38 schizophrenic out-patients, Heinrichs et al (1985) examined early insight in schizophrenic decompensation. During the early stage ofthe illness, 63% of their sample had insight, and this correlated significantly
with successful
resolution
ofthe
psychotic
episode on an out-patient basis. Again, however, there are problems in the methods employed in this study. Early insight was defined as the “¿patient's
ability, during the early phase of a decompensation, to recognize that he or she is beginning to suffer a
relapse of his or her psychotic illness―(Heinrichs et al, 1985, p. 134). The presence of this early insight was subsequently determined by the authors' judgements of the progress notes on the patients. Although some of these judgements were then vali
dated by discussions with the responsible clinicians, they remain subjective and dependent on the accuracy of the case notes. And once more, insight
was considered only in terms of being present or
(Lewis, 1934, p. 343). Thus it would be impossible for patients to look at and judge their experiences as they would be judged by others. Since insight was judged by non-affected individuals, in those terms, patients could never attain complete insight. Because
absent.
it was with their disordered
measured by the Brief Psychiatric Rating Scale) or
mind that patients
looked
at themselves, it was necessary, when discussing insight, to look not only at the change in the patients' condition, but to study the whole psychopathology of the disorder. Rather than linking the concept of insight with the patient's personality, as Jaspers did, Lewis thus made an intrinsic connection between the
@
@
[that]
his state or individual symptoms―
so that further assumptions were made about the patients' recognition of their problems.
Heinrichs et al (1985) briefly discussed possible determinants of the presence or absence of early insight. There was no correlation between early insight and severity of the psychotic episode (as socio-economic
variables.
The authors
speculated
that perhaps it was the qualitative differences in symptoms that determined the presence or absence of insight; for example, patients with grandiose
symptoms were less likely to have insight. Limitations in the methods used however precluded the explora tion of these important issues. patient's insight and the disease process itself. Eskey (1958, p. 426) defined insight as “¿verba Other empirical studies (e.g. Small et al, 1964; lized awareness on the part of the patient that Appelbaum et a!, 1981; McEvoy et al, 1981) exam impairment of intellectual functioning existed―. ining the relationship between insight in schizophrenic Eskey found no significant relationship between patients and compliance with medication/hospital the presence of insight and prognosis as measured admission have also been based on vague definitions
854
MARKOVA
of insight, on its being either present or absent, and have not included a measuring instrument.
McEvoy et a! (l989b) constructed a questionnaire on insight and attitude to treatment to examine the relationship between insight and acute psycho
pathology in schizophrenia. They state: ‘¿ ‘¿patients
with
insight
judge
some
of
their
perceptual
experiences, cognitive processes, emotions, or behaviors
to be pathological in a manner that is congruent with the judgement of involved mental health professionals, and that these patients believe that they need mental health treatment, at times including hospitalization and pharmacotherapy.―(McEvoy et al, l989b, p. 43). Their questionnaire,
validated against taped open
interviews, was based on questions relating to patients' attitudes towards admission, medication, and the need for follow-up. In this sense it reflects well the authors'
definition of insight. In other ways it is, however, a limited definition, focusing less on awareness of
& BERRIOS
for such a relationship on the results of the previous studies mentioned (i.e. Lin et a!, 1979; Heinrichs et al, 1985; McEvoy et a!, 1989a,b), but, as shown
above, these studies used different definitions of insight, often within narrow limits and reflecting the authors' own conceptions. It would thus seem difficult to extrapolate results from such studies and assume they are all dealing with the same concept.
The importance of David's paper lies in his emphasis on the need to standardise the measurement of insight. Whether insight itself is adequately defined
may not be as important
as reliably
measuring perhaps only aspects of the concept. This could be a starting point, while further exploration of insight as a concept could be carried out. Non-recognition in neurological
of illness states
self-change than on correlations between attitudes
Subjects suffering from neurological disease may,
of patients and attitudes of staff; that is, it defines
on occasions, show apparent impairments of insight, ranging from denial of illness to complex states of
insight as social acquiescence. Using the questionnaire,
McEvoy et al (l989a) found that involuntary patients with schizophrenia showed less insight than voluntary patients. However, the degree of insight was not consistently related to the severity of the acute psychopathology, nor did changes in insight during admission vary consistently with changes in acute
fluctuating conviction of reality. Although from a purely descriptive point of view these may seem to reflect pathological changes in insight, their phenomenological analysis shows that they are often
‘¿insight' (as used in this paper) should be diagnosed at all in the presence of brain disease. A total
insight and psychosis, and while emphasising that insight is not an ‘¿all-or-none'phenomenon, he does not define insight as a whole. Instead, he suggests it could be thought of as comprising three overlapping dimensions, namely: (a) recognition that one has a mental illness, (b) the ability to relabel unusual mental events as pathological, and (c) compliance with treatment. In a sense, (a) and (b) relate closely to Jaspers' analysis; thus, like Jaspers, David distinguishes between awareness of illness and the
exclusion may, however, be unduly restrictive, as
is an active process in the mind that is involved in
making a judgement of the illness affecting it. Whereas Jaspers looked upon these distinctions as stages in the process of illness and recovery, which the individual could/would adopt depending on
his/her
personality,
distinct
entities.
David separates them into
From a practical
viewpoint
this
would seem advantageous, but, as a theoretical basis, he provides little empirical evidence for this. David's third ‘¿dimension', relating to compliance with treatment, is also valid. He bases his argument
I
due to difficulties in communication or impairment of memory. It is then questionable whether lack of
psychopathology (McEvoy et al, 1989b). David (1990) has also examined the concept of
judgement of its significance. In other words, when referring to the patient's ability to relabel unusual mental events as pathological, David implies there
1
the study of some localised brain lesions may be
informative regarding the neurobiological basis of insight. It is beyond the scope of this paper to deal with this issue at length; however, a brief account is offered of the problems involved.
Three types of disorders of ‘¿insight'may be recognised in neurological disease. Firstly, those states in which a symptom, a disease, or part of the body, is denied, for example anosognosia; in clinical practice, this symptom is complex and may include, in addition to the verbal denial of disability, denial of ownership of a side of the body and more bizarre claims which, on occasions, may be interpreted as delusions or hallucinations (Weinstein & Kahn, 1955). Conceptual issues also arise here
in regard to the meaning of ‘¿denial', namely, to what extent the ‘¿lost' information is beyond the patients' consciousness (i.e. is an unretrieved memory), and hence the term ‘¿denial' cannot be said to apply. This word, however, is often used in a psychodynamic sense (e.g. by Weinstein) to refer
to states where information has been ‘¿suppressed' or ‘¿repressed'. I
THE MEANING OF INSIGHT
855
4disease includes states where the subject believes
Insight and related concepts
A second disorder of insight in neurological
in the reality of a symptom; these states may also
,
be
accompanied
by
denial
of
illness.
In
Anton's
syndrome, for example, blind subjects who have ‘¿@ visual
@
hallucinations
may
believe
them
to
be
real and claim that their vision has been restored
@
(Swartz
@ @
also include subjects who offer (on examination or spontaneously) information about the self or the world which is false, but in whose truth they
& Brust,
1984).
The
confabulation
states
seem to believe; these states may be accompanied ,,
by
explicit
or
(Weinstein
implicit
denials
of
et al, 1956; Berlyne, 1985).
Once
loss
@
1981;
@
whether or not ‘¿insight' is impaired in confabulatory
@
Berrios,
memory
1972; Whitlock,
again,
the
issue
of
states revolves around the fact that affected subjects .(
believe
that
what
they
are
saying
has
actually
happened. Symptoms such as prosopagnosia (the 4 L
@
.@
@
during the task. The third group of disorders includes experi .
@ @
mental
‘¿4 A
@
@
@
meanings of the phrase “¿not having a correct attitude to a morbid change in oneself ‘¿ ‘¿ should be first
explored. Firstly, one can simply have no knowledge! be unaware of any such change taking place. Secondly, one can have incorrect knowledge, owing to misinformation
about, or misperception of, the
morbid change. Finally, one may adopt an incorrect attitude towards a morbid change in oneself while
consciously or unconsciously ‘¿knowing' that such an attitude is false; in other words, one can engage in self-deception. Moreover, to be unaware, to have incorrect knowledge, or to deceive oneself are not
in which
it is possible
to
striking
example
is
provided
by
Gloor
et
a!
ness' or ‘¿incorrectknowledge' do not present conceptual problems because both can be accounted
for in purely informational
terms. By providing
patients with correct and more specific information,
their knowledge should increase and, as a result, they should change their attitude, providing their cognitive capacities allow that. In contrast, the notion of self-deception raises major conceptual difficulties.
(1982), who showed that simultaneous stimulation @-
@
situations
control the extent of conviction of the reality of provoked experiences such as hallucinations.
@
as “¿a correct attitude to a morbid change in oneself― (Lewis, 1934, p. 333) will suffice, although the several
all-or-none states of mind. Just as one can have different levels and qualities of insight, one can engage in different degrees of self-deception, or be are aware of their disability and hence the question only partly lacking in knowledge or have partly of insight does not arise. Of all symptoms in this incorrect attitudes towards a morbid change in group, ‘¿blindsight' isperhaps themostinteresting oneself. and difficult to catalogue (Weiskrantz, 1986). It In ordinary situations, notions such as ‘¿unaware refers to states of blindness in which the subject is able to perform visual tasks at levels far higher than chance. ‘¿Blindsight' relates to insight inasmuch as subjects deny that they are ‘¿seeing'anything
@ @ @
impairment of recognition of faces) (Whiteley & Warrington, 1977; Damasio et a!, 1982) can be included in this group, although most individuals
Here the relationship between insight and concepts
that, broadly speaking, have something to do with the knowledge, or lack of knowledge, of the self are examined. For this purpose a definition of insight
of
neocortex
and
limbic
structures
could
confer
Insight and self-knowledge on the hallucination a sort of “¿experiential immediacy― (qualities of reality), suggesting Hamlyn (1977) makes a distinction between the that limbic structures may modulate the manner concepts of self-knowledge and the knowledge about in which the self relates to incoming sensory the self. He argues that much literature in philosophy input. and psychology has been concerned with the It is not yet clear which neurological syndromes knowledge about the self, that is with the individual's are likely to throw light on the problem of awareness of his/her personality traits, with how lack of insight. Before an impairment of insight he/she appears to others, with his/her self-esteem is suspected, communication difficulties must and self-evaluation. According to Hamlyn, this is not be ruled out, and access to memory ascertained. a proper knowledge but only reflects beliefs about On the other hand, localised brain disease, the self. Self-knowledge proper, Hamlyn argues, is leading to specific hallucinatory or delusional one's knowledge about things as they affect oneself. @‘¿ states (e.g. misidentification syndromes, redupli For example, if a person knows he has a disfigure cative paramnesia), might be included, as in these ment or a propensity to avoid certain situations, then cases it can be postulated that specific neurological he knows these features about himself. However, mechanisms, perhaps concerned with insight, are only if this person recognises the ways in which his compromised.
disfigurement or avoiding habit affect his perception
MARKOVA& BERRIOS
856
of the world around him and his interaction with other people, can he be said to have self-knowledge. While the concept of self-knowledge
may encom
pass any aspect of knowledge of the self in Hamlyn's sense, the concept of insight can be restricted to illness. Thus, insight is a subcategory of self knowledge. One would not claim that a patient has insight into his/her personal characteristics (personality, attributes etc.) unless he/she has knowledge of the relationship between such charac teristics
and his/her
illness.
The
knowledge
of facts
about one's illness is therefore only a prerequisite for insight, and is not insight proper. In order to have insight, patients should not only be able to comprehend the illness and understand facts about it, but they should also know how the illness and
him/herself deliberately with false infonnation about the subject in question. In order to do so, he/she must have both the knowledge of the self and lack that knowledge at the same time. This can happen only if that person is somehow split into two individuals, the deceiver and the victim. The deceiver
must have easy access to knowledge that is not available to the victim (Haight, 1980). This is obviously
paradoxical.
Martin
(1985),
however,
points out that there are two senses of paradox, namely the literary and the logical. In the literary sense, the apparent contradiction between the statements can disappear following a deeper exam ination of them in their broader context. Such analysis can show that under the circumstances both statements are plausible and, therefore, what is called
facts affect them as a person. However, it is too much
self-deception will appear to be a metaphor for other
to expect of an ordinary person that he/she would
phenomena. On the other hand, when formal logic
be able to spell out such knowledge. Surely this would require a great deal of training and practice in focusing on oneself, and it is questionable whether such complete insight is desirable or attainable. What one faces in clinical practice is much less
is applied to contradictory statements on their own,
outside the context in which they apply, the law of non-contradiction
is violated and such statements
sophistication on the part of the patient. In the case of mental illness there is an extra problem; if one
imply absurdities (Martin, 1985). By applying the interpersonal model (i.e. the model of deceiving others) to the conceptualisation of self-deception, one naturally comes up against such paradox in the
believes that the illness affects the self, can a patient
logical sense. It is in this area that a great deal of
with a mental illness truly have insight into his/her
work on self-deception has focused (Martin, 1985).
problem? Furthermore, the patient may not wish to have proper insight into his/her problem because it
the individual's defence mechanism (A. Freud, 1941).
is too threatening for the integrity of the self. This
According
brings us to the question of self-deception.
unwanted beliefs by not allowing them to become
of self-deception
are
available, ranging from those based on interpersonal models to those based on intrapersonal approaches (Martin, 1985). What these conceptions have in common is that self-deception is a failure of self
knowledge. However, they differ considerably with respect to what kind of failure it is, why the person engages in self-deception, and, indeed, how to conceptualise this. Since we have defined insight as a subcategory of self-knowledge, we can pursue this direction
further
self-deception
as
to his theory, the ego struggles against
conscious. It is thus assumed that the person unconsciously knows about, but defends him/herself
Insight and self-deception A number of conceptions
Sigmund Freud conceptualised
by claiming
that
just
as
self-deception is a failure of self-knowledge, it is also a failure of insight. Thus, it is unclear, for example, what is meant by the oft-made claim that patients do not ‘¿want to know the truth' about their illness, or that they are denying their problems. There are no motivational theories, apart from Freud's (see below), as to what is meant by saying that the patient engages in self-deception. One concept of self-deception
is derived from the
model of deceiving others. The self-deceiver provides
against, undesirable biological instincts such as forbidden sex or aggression and violence. Following Sartre's (1957) ideas, Fingarette (1969) argues that self-deception is not an unconscious belief, but that it is a conscious effort to avoid engagement with reality. It is not that one has clearly formulated knowledge of what one is suppressing one simply does not have this knowledge because one refuses to spell out clearly to oneself ‘¿the facts' about oneself. This model emphasises that people are agents who, under normal circumstances, are in close contact
with
reality,
act
upon
it, and
pursue
self
knowledge. This concept does not accept division between the unconscious and the conscious mind. Instead, Fingarette refers to Sartre's metaphor of getting to sleep. Before one gets to sleep, one is in a state of vagueness, not speffing out one's engagement with the world. According to Fingarette, the main motive for self-deception is the threat of losing one's identity. By choosing a volition-action rather than a cognition-perception approach to self-deception,
857
THE MEANING OF INSIGHT Fingarette abandons a passive model for conscious @rness and substitutes it with an active skill model.
Thus he claims that terms such as ‘¿know', ‘¿be aware of', and ‘¿be conscious of' “¿are readily linked by the metaphor of seeing, - the essentially passive registration
What then is the meaning ofinsight as used in clinical
@
the world presents to our eyes―(Fingarette, 1969, p. 35). Instead, Fingarette continues, vision and consciousness should be conceptualised in active
terms, such as looking, turning eyes towards, and
the apparent knowledge the patients may have about
attending to something. This means that emphasis is shifted from passive visual imagery to active spelling out of one's engagement with reality.
their self and about their condition,
.
reflection
to
the
‘¿mind' of
unconsciousness.
@
@
and
accounts of self-deception differ from that of Freud. Thus Haight does not specify in what ways her ‘¿buried' knowledge differs from Freud's
what
Fingarette makes it clear that the ‘¿spelling out' is not ,
just making something explicit verbally, but involves all activities requiring some skill such as driving a
car, playing a violin, etc. In addition, “¿we are also q
@
It would appear to be more than simply as generally
assessed in the psychiatric interview. Insight is a form of self-knowledgewhich 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 the self interacts with the world. Richfield's
psychodynamic
analysis (1954) pointed
become conscious of our consciousness of something― (Fingarette,
need for the patient to gain this knowledge through
to
spell
out
that
we
have
spelled
it
out
i.e.
to
1969, p. 49).
theory is restricted. She points out that the self deceiver can avoid engagements with the world in a number of ways and not just through not spelling out engagement. What he/she does, though, is
direct experience. In a similar vein, though from a descriptive perspective, Jaspers also referred to insight as a “¿comprehendingappropriation― of illness. This is an important point, as a level of insight would depend on patients' individual assimilation of
consistently to avoid some course of action (Haight, 1980, p. 100). According to Haight each person has both knowledge that is easily accessible to consciousness and knowledge that is ‘¿buried'.People
information, as presented to them both through their internal world (i.e. their personality, their particular disorder, etc.) and through their external world (i.e. through books, television, therapists, etc.). One can
have a variety of strategies to avoid recollecting
thus conceive insight in terms of the cognitive and emotional representations of such information in the
Haight (1980) argues, however, that Fingarette's
@ @
psychiatry?
out the insufficiency in the patient merely coming to understand his/her condition, and emphasised the
able
4
Conclusion
buried knowledge.
Thus they may spell out in a few
‘¿safe' ways while avoiding others that are less ‘¿safe'. patient. These representations 3
@
They
may redefme
the situation
for themselves;
they
may shift from one mode of disavowed engagement to another ‘¿@-
enable
(Haight,
people
to
be
1980, p. 106). These strategies engaged
yet
act
in
such
a
way
that they can pursue their intended course of action. -
Haight
does
not
strictly
reject
but
widens
Fmgarette's
theory of self-deception. As she puts it, Fingarette's ‘¿
@ @
theory
of
self-deception
seems
to
entail
hers,
though
variables, which is why it is unlikely that the assessment of patients' insight will ever be complete. Nevertheless, there is scope for further exploration of patients' self-awareness and factors affecting awareness. One cannot talk of insight as an isolated phenomenon; to say a person has or has not got insight is meaningless. There are at least three
ception of self-deception
is concerned with similar
insight exist for the different psychiatric disorders;
issues to Haight (1980). Hamlyn points out that although a self-deceiver may be engaged, he/she may
separate explanations have been developed for the different disorders characterised by ‘¿poor'insight. For example, impaired insight in the psychotic disorders has been assumed by definition, since being
Firstly,
it is apparent
that different
models of
psychotic means being out of touch with real events and experiences. It is then incompatible for such that these strategies are of the same kind as those people to have knowledge of, or be aware of, described by Freud as “¿mechanisms of defence―. the true changes taking place within them and the him/herself
from its true nature. Hamlyn points out
For him, a self-deceiver
@
would necessarily be of internal and external
perspectives from which insight may be qualified.
of rationality and irrationality through which he/she redefines the issue in question in order to protect @
by a number
hers does not entail his (Haight, 1980, p. 104). Hamlyn's (1971) criticism of Fingarette's con
employ variouskindsof strategiesthat may be blends
@
influenced
must make him/herself
unconscious or unaware of what he/she really knows (Hamlyn, 1971, p. 57). Indeed, it is not clear in what respect both Hamlyn's
(1971) and Haight's
(1980)
environment. This is reiterated by Lewis (1934) when he states that it is with disordered minds that patients perceive themselves. On the other hand, in the neurotic disorders, the concept of disordered insight
858
MARKOVA
& BERRIOS
has been explained primarily on the basis of conflicts between unconscious needs and external reality. In other words, impaired insight is a result of
from mental illness that determines the criterion of correctness ofinsight. This leads to further questions,
repression,
the understanding or awareness of affected persons, of events which they cannot experience for them selves? One may also ask whether the term ‘¿insight'
a defence
against
awareness
of thoughts!
wishes that might be intolerable to the patient's ego. In localised neurological disorders, insight has been assumed to have become impaired as a direct result of the specific organic lesions themselves, and lastly, in dementia, the general cognitive collapse has been thought to encompass insight within it. It would appear important, therefore, to qualify definitions of insight in terms of underlying putative mechanisms.
Questions also arise concerning interactions between these mechanisms, as it is unlikely that they are mutually exclusive. However, at this stage one can
only speculate as to their role. Secondly, the term ‘¿insight' is frequently isolated
by referring to it as a symptom. Indeed, ‘¿lack of insight' is described as the most frequent symptom of acute schizophrenia in the Report of the International
Pilot Study of Schizophrenia
(World
Health Organization, 1973). Yet insight cannot, for example, be compared to hallucinations or sleep disturbance. Insight is not an isolated symptom, but must be thought of as a process or continuum of thinking and feeling, which cannot be separated from
the person's make-up/personality ( Jaspers, 1959), or from the psychopathology of the disorder itself (Lewis, 1934). If to these considerations
factors such
as patients' levels of education, cultural beliefs, inteffigence, ability to express themselves, emotional capacity etc. are added, the resulting final common
pathway becomes difficult to outline. Furthermore, as Jaspers (1959) and Conrad (1958) described, it may be a dynamic process, owing to changes both in the self and in the environment. From a practical point of view, it would seem difficult, when referring to patients' insight as part of the mental state examination,
to conceptualise
this
function
in
relation to each of these factors. Thus it may be more useful to describe specifically the particular issue concerned, rather than blanketing everything under the term ‘¿insight'. Thirdly, it would seem appropriate to grade the level of ‘¿insight',although this is strewn with difficulties. Most importantly, it is dependent on a common understanding
of insight, which is far from
the case. It is also important to be aware of what it is that one is measuring. In other words, although referring to patients'
insight, what is being assessed
is the psychiatrists' or therapists' judgement thereof. This, in turn, introduces more variables that interact with each other, such as the clinician's experience, ability to empathise, personality factors, etc. As Lewis (1934) says, it is the attitude of persons free
such as how can non-affected persons possibly judge
in itself carries a value judgement. Such issues would
seem to belong more in the realm of philosophical debate; nevertheless, it is important to take into account the difficulties involved and the assumptions made in dealing with the assessment of insight. The question of degree of insight therefore remains
1
obscure until some of these issues are addressed. In
the meantime, it is important to specify the sense in which a patient shows more or less insight. Many questions remain to be answered, not only concerning the nature of insight in respect of different people and different disorders, but also concerning
the factors influencing
it. Why should
some people have a ‘¿clearer' understanding about what is happening to them? How important are factors such as inteffigence, previous experience of illness, severity of disorder,
etc. , in relation to the
degree of insight? Unfortunately, such questions cannot at present be answered. They are dependent not only on a clear understanding of the term ‘¿insight', but also on empirical work which in turn depends on a standardised assessment ofinsight,
a I
with
some awareness of the inevitable limitations this will have. Likewise, what is the part played by conscious and unconscious mechanisms? What is the role of self-deception in the impairment of insight? It seems that there are two basic conceptualisations of self deception. One argues that in order to deceive
oneself, one must have the true knowledge in the unconscious mind (Freud, Hamlyn, Haight). The other conception argues that there is no boundary between consciousness and unconsciousness, and that self-deception is a sort of sleepy state of mind
‘¿a
in which the individual actively fails to make the
truth about him/herself explicit (Sartre, Fingarette). From the point of view of clinical psychiatry, is it important which model one holds? Does it have
implications for trying to obtain information from patients? If one believed that the patient knew and yet did not know at the same time, perhaps different lines of communication would be appropriate than if one believed that the patient really did not wish to make his/her implicit beliefs explicit. The problem in trying to apply such concepts of self-deception to
clinical psychiatry is the one raised by Lewis, when he questioned whether it was appropriate to ask if a patient with mental illness could have insight, in view of the fact that he/she would be looking at his/her illness with distorted eyes. Thus, in psychiatry,
-I
‘¿4
I V
859
THE MEANING OF INSIGHT it may be appropriate to ask at what stage of the V
r
process
of
of
the
illness
can
ABRAM0wITZ, S. I. & Aas@MowiTz, C. V. (1974) Psychological
mindedness and benefit from insight-oriented group Thefirstpossibility isthatastheillness progresses,Archives of General Psychiatry, 30, 610—615.
information
perception that
the
of the outside
patient
accepts
and
world
and
remain
@
intact,
but
it
is
the
primary
and
direct
relationship with the outside world that has been affected. So what the clinician may call self-deception may simply be the genuine inability to perceive the world in the way others do, because the biological
@ .,
system
containing
algorithms
processing of information
dedicated
to
the
concerning the self has
been disabled by the disease. The second possibility is, taking Fingarette's and
@ , @
Hamlyn's point of view, that as the illness develops, the patient does not spell out his/her engagement
with the world, that is avoids involving and @4
committing
him/herself
to a certain
kind
of action.
Instead, he/she remains in a dream-like or sleep
@
like state, failing to acknowledge that there is a certain kind of commitment he/she should make. b
So
in
this
situation,
it
is
the
speffing
out
that
@
is missing.
@
The third possibility is that the person spells out his/her engagement with the world but does so differently from other people. Thus he/she would interpret the same situation
differently,
always
fmding excuses and reasons for his/her interpretation. In this case the incoming information may be the same as for other people, but its processing and
@ ,
interpretation would be different for motivational
or emotional reasons. Whatever the nature of insight, from a clinical
@ ,@
management
point
of view one can still ask - does it
matter? Does it make any difference to patients' -
prognoses
whether
they
only
parrot
predict successful implementation ,-
@ @ @
@
description
of their illness or whether they have a deep understanding of it? The presence of insight can
@
@
the
schizophrenia
(Linn
et
a!,
1979;
of treatment Heinrichs
ALEXANDER, F., FRENCH, T.,
et
in a!,
therapy.
BACON, C. L., et a! (1946)
analytic Therapy: Principles and Applications.
interprets.
Thus, his/her thought processes may or may not -
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