“Patient lacks insight.” “Patient has good insight.” “Judgment: fair, Insight: poor.” These types of comments are typically seen in reports from mental status exams conducted by psychiatrists and psychologists and will be familiar to most mental health professionals. They comment on insight as something that can be regarded as “present” or “absent,” and make it clear that having more of it is “good” and less of it is “poor.” But what does insight mean? For most mental health professionals, insight refers to the extent to which the client or patient accepts their diagnosis and acknowledges the need for treatment. It certainly seems straightforward that the effects of having more insight would be “good”—right?
While this is still the conventional wisdom among most professionals, research that I, my colleagues, and others have been conducting over the past decade indicates that the effects of insight are more complicated. Specifically, in a study we published in 2007, we found that “good” insight is associated with poorer outcomes for people diagnosed with schizophrenia-spectrum disorders when it coincides with the endorsem*nt of self-stigma.
Self-stigma concerns the extent to which members of a stigmatized group believe that negative stereotypes endorsed by general community members about their group are true. For people diagnosed with severe mental illnesses, elevated self-stigma corresponds with beliefs that people with mental illness are dangerous, incompetent, and incapable of functioning in society.
Our research found that, when “good” insight into having a mental illness coincides with elevated self-stigma, it is associated with increased hopelessness, lower self-esteem, diminished participation in community life, and even increased symptoms. In many respects, people who lacked insight were actually doing better than people with “high” insight who also endorsed elevated self-stigma. Note that other, more recent, studies have largely replicated these findings.
On the other hand, of course, insight can also have very good effects, and we found that it was associated with a range of positive outcomes when people did not endorse self-stigma. This has led us to believe that the effects of insight are strongly shaped by the meanings that are associated with the “mentally ill” label. If it is associated with images of a life lived in institutions, with no possibility of achieving one’s goals, its effects can be toxic. But if it is seen as associated with something that is challenging but not debilitating, and even possibly positive, it will have a completely different impact on people. In fact, for these individuals, high insight can be associated with positive outcomes and a minimal impact of mental illness on one’s life.
Why should this finding be important? By and large, the mental health system focuses its energies on urging people with mental illnesses to accept the need for treatment, regardless of what this acceptance means to the person. But, time and again, we find that people reject treatment after it’s been initially offered, in part because they associate it with the acceptance of a “hopeless destiny.”
While some advance the idea that forcing people with mental illnesses into treatment is the solution to this problem (as seen by the current popularity of involuntary outpatient commitment programs in the U.S.), I believe that we should instead be working to make our system something that people would feel good about receiving services from. That is, we should make sure that the system promotes affirming messages and explicitly counteracts the images of hopelessness featured in popular media and promoted by others in the community. Until we manage to consistently do that, many people who need mental health services will continue to avoid them, and the effects of good “insight” will, unfortunately, continue to be a mixed blessing.
Happy New Year and welcome to the “Written Off” Blog. In this blog I will be discussing issues that relate to the impact of stigma on people diagnosed with severe mental illnesses (a topic that is discussed further in my book of the same name). I will write about ways to overcome the impact of stigma and, at times, will discuss current events and recently published research findings that relate to this issue. I hope you find it informative, and thanks for reading.
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