Making sense of unusual experiences: A discursive approach to insight

Insight is a term in psychological and psychiatric practice, most frequently used
when referring to individuals who have been given diagnoses of schizophrenia
or other psychotic disorders. It is often used to define a range of different
situations in which a service user resists or disagrees with the professional
account of their difficulties and/or treatment. Dominant psychological and
psychiatric models construct a lack of insight as a symptom of illness that can
be linked to specific deficits of psychological process (e.g. denial or Theory of
Mind) or brain functioning (e.g. lesions to specific parts of the brain or blood
flow). A lack of insight is considered to be a relatively stable deficit, which takes
a period of time to resolve, particularly in service users defined as 'chronically'
unwell.
The present research aimed to examine the concept of insight from a social
constructionist perspective. This approach was used to examine the naively
realist assumptions underpinning the concept and its utility in re-labelling
disagreement between professionals and service users. The first aim was to
explore how service users who had been given a diagnosis of schizophrenia or
other psychotic disorder, constructed the term. A second aim was to explore
how service users rhetorically managed issues of stake and accountability
during discussion of disagreements with mental health professionals. The final
aim was to explore fluctuation or contradictions in service users' accounts of
insight and disagreement with mental health professionals.
Eight participants who had been given a diagnosis of schizophrenia or a related
psychotic disorder were recruited. Participants took part in semi-structured
interviews about their experiences of mental health services and their
understanding of 'insight'. The transcripts were analysed using a discursive
psychology methodology.
The results showed that the term 'insight' was relatively unknown to the
participants, although all participants discussed disagreements with mental
health professionals. Those who had heard of the term drew on a variety of
constructions of insight during the interviews. These constructions seemed to
relate to the factuality and credibility of the participants' account in different
ways (e.g. aligning the account with the dominant psychiatric view). The
participants also drew on several rhetorical strategies to manage stake and
accountability (e.g. constructing the doctor's diagnostic decision as personally
motivated). Fluctuation between positions that could be defined as 'insightful'
and 'insightless' was found throughout the accounts. These findings clearly
demonstrated the limited validity of the term insight. Furthermore, they
suggested that it clinically functions as a discursive form of control, limiting the
challenges that can be made by service users, rather than a meaningful clinical
construct. The findings also suggested that even with this threat of
undermining, service users found complex and subtle methods to discursively
challenge the psychiatric position. The applications of these findings for service
users, professionals and researchers are discussed.

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