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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
Reflections on
Insight:
Dilemmas, Paradoxes,
and Puzzles
Marga Reimer
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
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-
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?
Note
1. Amering talks of mental health problems, rather
than mental illness, in her discussion of the recovery
orientation guiding mental health policy.
References
Amering, M. 2010. Finding partnership: The benefit of
sharing and the capacity for complexity. Philosophy,
Psychiatry, & Psychology 17, no. 1:7780.
Anthony, W. A. 2006. Personal accounts: What my
MS has taught me about severe mental illnesses.
Psychiatric Services 57:10802.
Campbell, A. V. 1994. Dependency: the foundational
value in medical ethics. In Medicine and moral
reasoning, ed. K. W. M. Fulford, G. R. Gillet, and
J. M. Soskice, 18492. Cambridge: Cambridge
University Press.
David, A 1990. Insight and psychosis. British Journal
of Psychiatry 156:798808.