Reflections on Insight Dilemmas, Paradoxes, and Puzzles

Marga Reimer
Philosophy, Psychiatry, & Psychology, Volume 17, Number 1,
March 2010, pp. 85-89 (Article)
Published by The Johns Hopkins University Press
DOI: 10.1353/ppp.0.0281

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http://muse.jhu.edu/journals/ppp/summary/v017/17.1.reimer.html

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Reflections on
Insight:
Dilemmas, Paradoxes,
and Puzzles
Marga Reimer

Keywords: insight, psychosis, treatment adherence,

medical model, autonomy, open placebos, rationality

The Practitioners Dilemma

he psychiatrist aware of the potential

intractability of what Jennifer Radden calls
insightlessness, faces a dilemma. Should
she encourage her patient to embrace a medical
model of his troubles, a model whose adoption is likely to motivate treatment adherence?
She might then be trying to do the impossible;
she might also alienate her patient in the process.
Should she instead encourage her insightless
patient to embrace his own non-medical model,
according to which treatment adherence makes no
medical sense whatsoever? She might then see herself as encouraging a kind of uninformed consent:
Her insightless patient might be taking powerful,
potentially harmful, medication for reasons (such
as sound sleep and peace of mind) that would
never medically justify adherence.
In my original paper, I suggested that the way
out of this dilemma might be to embrace the latter option, while characterizing the very real (and
medically based) benefits of treatment adherence in
non-medical terms. I now realize that my proposed
resolution reflects an oversimplified understanding
of what might be called the practitioners dilem-

2010 by The Johns Hopkins University Press

ma. As Michaela Amering (2010) makes clear, the

situation for those with mental illness is improving dramatically. With recovery orientation as
the guiding principle of mental health policy,
the emphasis is on health promotion, individual
strengths, and resilience. The question becomes:
Can the practitioner encourage her insightless patient to partake in this recovery movement if she
does not simultaneously encourage him to embrace
a medicalized understanding of his troubles?
Not obviously. For although a recovery
model might eschew notions like illness1 and
disease, pathology and dysfunction, and even
schizophrenia, it will inevitably involve some
medical notions. The patient who partakes in
the recovery movement described by Amering, would seem to have no choice but to accept
a model that is essentially medical. Consider the
language used by Amering in characterizing that
movement. She talks of mental health problems,
therapeutic relations, patient self-determination,
diagnosis and, of course, recovery. The concepts
underlying such language are intrinsic to the
patient-oriented movement Amering describes.
The question becomes:
How can the insightless patient rationally partake in
such a movement without embracing some version of
the medical model of mental illness?

86 PPP / Vol. 17, No. 1 / March 2010

This question suggests the importance of promoting some kind of insight, even if not insight
into psychosis. At the close of these comments,
I consider briefly what such revisionary insight
might involve.

Paradoxes of Conditional
and Relinquished Autonomy
Autonomy among patients with psychosis presupposes the sort of clear-headedness that arguably
comes only with treatment adherence. This may
provide some justification for the coercive treatments that Anthony (2006) finds so offensive.
For patients with psychosis, genuine autonomy
is conditional, requiring some degree of insight:
Recognition that their troubles are at least
amenable to medical treatment. Once the patient
recognizes this, he can choose freely to decline
such treatment (regardless of whether that choice
is ultimately respected). Call this the paradox of
conditional autonomy. The conditional nature
of autonomy is a familiar point in philosophical
discussions regarding free will. There is no genuine
freedom without the sort of knowledge required
for informed choices. What distinguishes the patient with psychosis from persons more generally
is that his autonomy is further conditioned: The
knowledge required for autonomous decision
making arguably requires some degree of treatment adherence.
However, the mentally ill patient has the right,
as do all patients, to relinquish autonomy. He
may opt for deference to, and dependency on, the
relevant experts: Mental health care professionals
(Campbell 1994). We are led once again to paradox. To respect the patients autonomy, the mental
health care professional must respect his right to
forego autonomy in favor of deference and dependency. This paradoxical situation, involving a kind
of deferred autonomy, is not unique to psychiatry
but applies to medicine across the board. Indeed, it
applies to the human service industry more generally where, as McGorry (1992) suggests, there is
an implicit assumption that the service user is to
defer to the expertise of the service provider.
This assumption is rightly challenged. Suppose
Justin and Ashley decide to go to a marriage counselor. The counselor recommends that they begin

by reading Gottman and Silvers (2000) The Seven

Principles for Making Marriage Work. Although
Justin might not be particularly interested in the
credentials of Gottman and Silver, Ashley might.
Her requests for information on this matter should
not be ignored or met with an arrogant Whats it
to you? attitude; nor should they be met with a
patronizing Trust me attitude. However, Justin
should not be viewed as in any way falling short
if he chooses to trust the judgment of the licensed
marriage counselor. That he does not ask the sorts
of questions that Ashley wants answered does
not mean that he has no concern with the quality
of the counseling they are receiving. Perhaps the
counselor came highly recommended by several
of the couples close friends.
Similarly, the psychiatric patient who, in contrast to his more proactive peers, implicitly
trusts the judgment of his psychiatrist, should
not be judged as in any way falling short. I
therefore hesitate to agree wholeheartedly with
McGorrys (1992) suggestion that the concepts
of treatment compliance and case management
reflect a failing on the part of the mental health
care profession. Such concepts do indeed suggest
that the psychiatric patients role in the treatment
and management of his illness is not an active
one. Such a suggestion is certainly wrong insofar
as it is intended to cover psychiatric patients generally. Nevertheless, dependency concepts such
as treatment compliance and case management
(along with the attitudes behind them) can, and
arguably should, coexist alongside the attitudes
underpinning such proactive concepts as patient
self-determination and empowerment. After all,
some patients might choose to comply with
(rather than question) the recommendations of
their psychiatrist; they might choose to have
their case managed by those trained in such
management. The choices of such patients should
be treated with as much respect as the choices of
their more proactive peers.

Puzzling Placebos: Open

Placebos That Are Effectively
Closed
Is the anticipation of a placebo effect, construed
as genuine improvement in a medical condition,

Reimer / Reflections on Insight 87

a reason to adhere to treatment with a placebo?

In the case of closed placebos, the answer is
clearly yes. The patient is told (or is at least led
to believe) that the medication he is being offered
is, or at least might be, medically efficacious. In
the case of open placebos, the answer is less clear.
As Radden notes, some subjects might believe that,
because others with similar ailments have benefitted, they too might benefit. This belief might help
account for any placebo effect observed with
open placebos, and suggests that open placebos
are (for some patients) not really open: The patient
believes, deep down, that the allegedly ineffectual medication might really work. For such
patients, anticipation of a placebo effect is indeed
a reason, and a good one, to adhere to treatment
with the placebo in question.
In the case of the insightless patient with
psychosis, anticipation of a genuine placebo
effect does not, and indeed cannot, occur. Such
patients do not believe that they have a medical
condition amenable to improvement. They might
nevertheless choose to adhere because they believe
that adherence will be accompanied by tangible
non-medical benefits. They might continue to
adhere because the anticipated benefits do indeed
come with adherence. As with the non-psychiatric
patient, however, the psychiatric patient might
adhere to a particular treatment for reasons other
than the belief that they have an illness for which
the treatment in question is known to work.
That is what makes Raddens analogy such an
apt one.
However, despite the aptness of the analogy,
there is a striking difference between the two
cases. The non-psychiatric patient who takes an
open placebo might feel better, not as ill, as
previously. He might therefore continue treatment.
Unfortunately, the situation is often very different
when the open placebo is a neuroleptic, taken
by a psychiatric patient without insight. These
patients often feel worse, rather than better, with
treatment adherence. Although their relationships
with friends and family might improve, their overall sense of well-being might not. Much of this has
to do with the side effects associated with neuroleptics, which can mimic the symptoms of illness
(Naber 1995). Consequently, the patients belief

that there was never anything medically wrong

with him to begin with, is sometimes confirmed
and treatment is discontinued.

Irrational Reasons
Radden notes that my rationality analysis of
treatment adherence seems too generous. The
patient who adheres to treatment on the grounds
that otherwise the world will come to an end, is not
(in any intuitive sense) acting rationally. The subject who acts rationally tends to act only on beliefs
that are probably true or at least not outrageously
false. Culturally ingrained beliefs, such as theistic
ones, are arguably an exception. Beliefs that are
probably true tend to be supported by evidence,
inter-subjective evidence, in particular. Thus, the
fact that the patient has seen numerous signs
supporting his delusion, doesnt make acting in
accordance with that delusion rational.
This same patient might, however, be rational in Donald Davidsons (1985) sense. For
Davidson, rationality is a matter of internal consistency within ones system of propositional
attitudes (beliefs, desires, intentions). There is
therefore a sense in which the deluded patient is
acting rationally: He wants to avoid the worlds
coming to an end and believes that the only way
to avoid this catastrophe is to take his meds.
He acts accordingly: He takes his meds. This is
not merely semantics; Davidsonian rationality
is perhaps all that we can reasonably expect from
some insightless patients who nevertheless adhere
to treatment.
What is the psychiatrist to do in such cases,
in cases where the patient adheres to treatment
for patently delusional reasons? She might not
have to do anything, as such cases might prove
self-eliminating. If the patient adheres to treatment, the delusions motivating adherence might
well subside. He might no longer believe that the
world will come to an end if he doesnt adhere. Of
course, he will then need an alternative reason to
adhere. Why should I take these pills now that I
know that the world will not come to an end if I
dont? Perhaps an analogy with God and sobriety
would be helpful here. The alcoholic reasons, I
am giving up drinking because God wants me
to. What does he do when he comes to the real-

88 PPP / Vol. 17, No. 1 / March 2010

ization that there probably is no God? Perhaps

he resumes his drinking, or perhaps he simply
changes conception of God. God is a circle of
my family and friends, and I am at the center of
that circle. Similarly, the psychiatric patient might
change his conception of the really bad things
likely to accompany non-adherence. Not the end
of the world perhaps, but quite likely the end of
the patients world: Abandonment by family and
friends, loss of employment, eviction, hospitalization, and possibly even prison.
If the patient continues to adhere for patently
delusional reasons, there seems little point in trying to convince him that his reasons are not of the
right sort. It might be impossible to do so. On
the other hand, the patients delusional motivation
might lead to anxiety (What if I forget to take my
meds?) or grandiosity (The world depends on me).
Yet if the patient needs a reason to adhere (as he
will if he possesses Davidsonian rationality), then
having an irrational reason is perhaps better
than having no reason at all. It might well make
the difference between a good or fair outcome and
a very bad one.

Self-Defeating Insight
I would like to close with a few remarks regarding the views (noted by Radden) of Harry Stack
Sullivan. According to Sullivan, it is irrational
for a psychiatric patient ever to admit that he is
psychotic. To admit that you are psychotic is to
acknowledge, in effect, that you are incapable of
distinguishing between appearance and reality.
If you are incapable of doing that, you might as
well stop thinking altogether. For it is arguably
better to think no thoughts at all than to think
delusional thoughts. Admission of psychosis is
thus as stultifying as it is demoralizing. That the
consequences of insight into psychosis are not
always good for the patient is more than the conclusion of armchair reflections; recent empirical
studies (Hasson-Ohayon et al. 2006) indicate that
insight into psychosis tends to be accompanied by
reduced quality of life.
This final paradox of self-defeating insight
brings us back to the practitioners dilemma with
which I began, for it leads to the question: Is insight of any sort ever rational in cases of psychosis?

Perhaps not insight into psychosis, yet why not

admit, in the spirit of the deflationary account
(Radden 2010), that you have interpersonal difficulties that most others do not? As Radden notes,
patients might readily admit to such difficulties,
difficulties that are not conceptualized in potentially stigmatizing medical terms, such as disease,
illness, pathology, psychosis, or schizophrenia. Perhaps the patient might acknowledge
that his interpersonal difficulties stem, at least in
part, from unusual thoughts and experiences that
are disturbing or frighteningrather than
delusional or hallucinatory. Although the
latter concepts might be of use to the psychiatrist
in diagnosing her patient, they might be worse
than useless to the diagnosed patient.
Such patient-friendly insight would be of
great practical value provided the acknowledged
difficulties were seen by the patient as admitting of some sort of resolution, resolution (ideally)
in accordance with the conceptual scheme that
characterizes the recovery movement detailed
by Amering. The key question is whether the
patient who denies that he is psychotic can
accept that his admitted troubles call for a
recovery program, an essential component
of which is treatment adherence, however conceptualized. With appropriate guidance from
well-intentioned and well-informed mental health
care professionals, perhaps he can. The patient
might then emerge with a version of what Radden
characterizes as full and complete insight. For
there would be a recognition that one has problems, that these problems affect interpersonal
relations, and that their continuation is likely
without treatment adherence. We would have,
in essence, a patient-friendly version of Davids
(1990) medicalized model of insight, according
to which insight involves recognition that one
has a mental illness, the ability to relabel delusions and hallucinations as pathological, and
compliance with prescribed treatment. Suppose,
as seems reasonable, that patient-friendly insight
is as conducive to treatment adherence as is its
more overtly medicalized counterpart. In that
case, why not try to promote such insight in those
patients who understandably reject the idea that
they are psychotic?

Reimer / Reflections on Insight 89

Note
1. Amering talks of mental health problems, rather
than mental illness, in her discussion of the recovery
orientation guiding mental health policy.

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