Abstract
In this chapter, we draw on a critical analysis of 120 inpatient charts from a large psychiatric institution in Toronto, Ontario to examine the concept of ‘insight’ as it is operationalized by psychiatrists in chart documentation. We argue that psychiatrists use insight as a discursive means to delegitimize patient perspectives that diverge from the medical model of mental illness, particularly those that are more likely to be held by marginalized people. Patients who expressed the logics and lived realities of white, middle class, male heteronormativity were often accorded more respect and were more likely to be perceived as insightful. The construct of ‘insight’ plays a fundamental role in the justification of coercive measures such as involuntary hospitalization or detention and compulsory treatment. Thus, the attribution of ‘insight’ and its associated discursive logic has serious implications for patient agency and bodily autonomy.
Keywords
- Large Psychiatric Institutions
- medicationsMedication
- Diesfeld
- diagnosisDiagnosis
- Kundalini Energy
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Notes
- 1.
Our review of the psychiatric inpatient charts did not allow for the identification of clinicians’ social identities. Having this type of information may contribute to a more robust analysis of power dynamics during patient-clinician interactions. Similarly, our analysis may be limited in that the chart excerpts centred in our analysis are those of various psychiatrists, rather than a single psychiatrist. This means that our analysis is limited in terms of the specific ways that gender, sexuality, race, and class are implicated in psychiatric assessments of insight, generally. However, while it is important to attend to power dynamics within the specificities of a patient-clinician dyad, we also understand power dynamics as shaped by the ways in which patients are positioned in relation to normative whiteness that undergirds the psychiatric institution. Thus, we might consider that all psychiatrists (and other mental health professionals), regardless of gender, sexuality, race, and class represent and operationalize the norms and values of the psychiatric institution.
- 2.
This includes trans and cisgender women and men. The institution’s method of taxonomizing gender does not explicitly allow for those who identify as non-binary.
- 3.
While we structured the chart selection and review in relation to these inpatient programs and associated diagnoses, we recognize that individuals often receive multiple and/or inaccurate diagnoses that are not fully aligned with the programs to which they are admitted. As such, there are more than the four identified diagnoses shaping inpatients’ experiences related to psychiatric documentation of ‘insight’, and therefore, our analysis is not organized around particular diagnoses.
- 4.
The MSE is used to assess a patient’s current functioning and mental state. It is considered objective and analogous to a physical examination (Trzepacz and Baker 1993). Components of the MSE beyond insight and judgment include appearance, attitude, behaviour, level of consciousness, orientation, speech and language, mood, affect, thought process/form, thought content, suicidality and homicidality, and intellectual functioning (http://psychclerk.bsd.uchicago.edu/mse.pdf).
- 5.
We are politically aligned with psychiatric survivor/mad movement critiques of medicalizing labels such as ‘patient’ (Burstow 2015). We employ it here to indicate how the people whose charts we analyzed were interpellated by the psychiatric institution.
- 6.
The ‘arm of failure to appreciate consequences’ presumably refers to the Guidelines for Conducting Assessments of Capacity in Ontario under the Substitute Decisions Act, 1992, which states that in order to be considered mentally capable one must be able to ‘understand information relevant to decision-making, and to appreciate the consequences of a decision or non-decision’ (for more information see https://www.attorneygeneral.jus.gov.on.ca/english/family/pgt/incapacity/capacity_assessment.php#assessor).
- 7.
‘Section 33.1 (3) of the MHA [Mental Health Act] stipulates that a physician may issue a CTO if the criteria spelt out in Section 33.1 (4) are satisfied … these are that within the last three years, a patient either has been an inpatient on two occasions or has for at least 30 days or has been on a CTO; the physician has examined the patient in the last three days; the person is suffering from a mental disorder such that in the absence of the care spelt out in the Community Treatment Plan (CTP) they would be committable involuntarily. Additionally, they must be seen as able to comply with the accompanying treatment plan; and the necessary services in the community must be available’ (Burstow 2015, 124–125).
- 8.
It is possible that findings of incapacity to consent to treatment may often be reserved for patients who are deemed psychotic (Cairns et al. 2005). This brings up larger questions about bias in diagnosis and who is more likely to be perceived as psychotic that are beyond the scope of this chapter. For a discussion of the gendered, raced, classed, and sexualized character of diagnosis see Fernando (2010), Metzl (2009), Somerville (2000), and Terry (1999).
- 9.
In our sample of 120 charts, we noted that ECT was commonly used in cases where several trials of medication were perceived to have failed, as was the case for A-006. However, the respect for A-006’s ambivalence about ECT and the promotion of his agency in making a decision about it was remarkable.
- 10.
In making this assertion, we recognize that various bodies are read as more or less likely to be ‘insightful’ even before expressing refusal or misgivings about psychiatric diagnoses and treatments . In other words, the perception of patients’ embodiment (for example as white, heterosexual, middle class , masculine, cisgender) works in tandem with the worldviews they express.
- 11.
‘In Ontario … there are two different tribunals with jurisdiction over the “mentally disordered.” One, the Consent and Capacity Board (CCB), is civil and falls under the general health and mental health legislation. The other, the Ontario Review Board (ORB), falls under the criminal code and applies to people found not criminally responsible or unfit to stand trial. In both cases: (a) appeals can be made to the courts; (b) panel members are drawn from a working group appointed by the provincial cabinet; (c) panels are chaired by members of the legal profession; (d) hearings occur at the hospital where the detainee resides (ORB hearings are also commonly heal in court rooms)’ (Burstow 2015, 127–128).
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Pilling, M.D., Daley, A., Gibson, M.F., Ross, L.E., Zaheer, J. (2018). Assessing ‘Insight’, Determining Agency and Autonomy: Implicating Social Identities. In: Kilty, J., Dej, E. (eds) Containing Madness. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-319-89749-3_9
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