Theory and Society

, Volume 46, Issue 3, pp 201–228 | Cite as

“That proves you mad, because you know it not”: impaired insight and the dilemma of governing psychiatric patients as legal subjects

  • Neil GongEmail author


This article investigates “impaired insight,” a controversial psychiatric category describing a mad person unable to know his or her madness. Like “moral insanity” and other concepts before it, impaired insight offers a way to link the disparate logics of human responsibility in psychiatry and the law. I attribute its development to changes wrought by deinstitutionalization, the rise of antipsychotic medication, and patient incarceration in penal settings. In a system that aims to govern psychiatric patients through their freedom, the logic of impaired insight introduces a wrinkle: can a person make an informed choice to refuse treatment if madness itself impairs awareness of illness? Drawing on tools from the sociology of science, I trace the process by which researchers recast psychodynamic “denial” as a neurological and therefore non-volitional “impairment” in the 1990s. I then show how social movement actors mobilized the materialized form in the legal and policy fields in the 2000s, bringing insight science to bear upon the very questions of custodial management and patient rights that gave birth to it. At stake is this dilemma: how can societies that simultaneously privilege individual responsibility and somatic accounts of behavior govern those at the border of legal capacity, and with what justification?


Anosognosia Criminalization of madness Knowledge and power Liberal governance Medicalization of deviance Psychiatry and the law 



The author wishes to thank Stefan Timmermans, Hannah Landecker, Aaron Panofsky, Rogers Brubaker, Joel Braslow, Iddo Tavory, Bill Roy, Jacob Foster, Ed Walker, Jeffrey Prager, Mariana Craciun, Corey Abramson, Marcia Meldrum, Bradley Lewis, Nev Jones, Neil Gross, Daniel Navon, Zach Griffin, Winston Chou, Zachary Psick, Michael Bakal, Jeremy Levenson, Alex Barnard, Joyce Hee, the Theory and Society Editors and reviewers, and participants in UCLA’s 237, Theory, and Social Medicine groups. A special thanks to Gil Eyal, who offered the most thorough comments the author has ever seen in a peer review process. Any remaining inconsistencies or errors in this article are the author’s own. Finally, acknowledgments to the National Science Foundation, UCLA, and the Davis Foundation, whose financial support made this research possible.


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© Springer Science+Business Media Dordrecht 2017

Authors and Affiliations

  1. 1.Department of SociologyUniversity of California, Los AngelesLos AngelesUSA

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