Problems of Clinical Insight When Listening to the Voices of Psychiatric Patients

1. Problems of Clinical Insight When Listening to the Voices of Psychiatric Patients Laura Guidry-Grimes, M.A. Doctoral Candidate, Philosophy  Georgetown University

2. Introduction:The Issue

3. The Issue • Preemptive paternalism • Stance clinicians might be inclined to take toward patients who they think are not reliable reporters of their own experiences, needs, values, and interests • Designation of poor insight  mutual distrust • Need to examine assumptions behind paternalistic interferences • Moral concerns of presumptive distrust of patients’ testimonial evidence

4. Outline • Conceptual territory of insight • Debates, ambiguities, lack of clarity • Ethical concerns of “poor insight” label • Greenlights increased distrust of reports, paternalism? • To consider: • Over-idealizing self-awareness • Neglecting/diminishing patient perspectives • Well-being interests of patients

5. Conceptual territory fraught with Ambiguities

6. “As the central feature of key psychotic symptoms such as delusion and hallucination, loss of insight has proven peculiarly difficult to define, so much so that determined attempts have been made to eliminate the traditional psychotic/non-psychotic distinction from psychiatry.” Bill Fulford (2004)

7. All-or-Nothing, Unidimensional? • Aubrey Lewis (1934) • “correct attitude to a morbid change in oneself” • WHO (1973) • Some awareness of emotional illness • …current clinical practice? • Nonspecific, unidimensional “Amongst the unclarities which are of utmost clinical importance and which cause utmost confusion is the term ‘insight.’” Gregory Zilboorg (1952)

8. Multidimensional, Continuous? • Anthony David(1990) • Treatment compliance • Awareness of illness • Relabeling unusual mental events as pathogical • Xavier Amador, et al. (1991) • Knowledge of mental deficit • Proper attribution of deficit to mental disorder

9. Lasting Ambiguities ? ? ? ? ? ? ? ? ? From Amador & Kronengold, “Understanding and Assessing Insight”, p. 13

10. Ethical Concerns:The “Poor Insight” Label

11. Over-IDealizations • Threshold for… • grasp of biomedical discourse? • understanding features of phenomena? • demarcating delusions, hallucinations? • transparency of beliefs, values? • Problem of demanding, exclusionary standards

12. Neglecting/Diminishing Pt’s Perspective • Acquiescence with • treating physician • community, culture • Problems of • contrary cultural, religious views • sociocultural biases in insight assessments • slant against anything but biomedical modeling

13. Dubious Subjective Value • Insight linked to depression, suicidality, hopelessness • Engulfment • Poor insight as coping mechanism? • Not a worthwhile therapeutic goal?

14. Does the patient himself benefit from conceptualizing his difficulties in these same terms [as the physician]? Unless he already understands and accepts the validity of the concepts underlying those terms—as well as their potential applicability to his own case, the answer is surely ‘no.’ Marga Reimer (2010)

15. Laura Guidry-Grimes lkg8@georgetown.edu Presentation available at www.lauragg.com Thank You!