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.
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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.
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.
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.
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).
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.
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).
‘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).
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).
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.
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.
‘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).
Beauboeuf-Lafontant, T. 2007. You Have to Show Strength: An Exploration of Gender, Race, and Depression. Gender and Society 21 (1): 28–51.
Blum, L. M., and N. F. Stracuzzi. 2004. Gender in the Prozac Nation: Popular Discourse and Productive Femininity. Gender and Society 18 (3): 269–286.
Bondi, L., and E. Burman. 2001. Women and Mental Health a Feminist Review. Feminist Review 68 (1): 6–33.
Boyle, M. 2011. Making the World Go Away, and How Psychology and Psychiatry Benefit. In De-medicalizing Misery: Psychiatry, Psychology and the Human Condition, ed. M. Rapley, J. Moncrieff, and J. Dillon, 27–44. New York, NY: Palgrave Macmillan.
Burstow, B. 2015. Psychiatry and the Business of Madness: An Ethical and Epistemological Accounting. New York: Palgrave Macmillan.
Cairns, R., C. Maddock, A. Buchanan, A. S. David, P. Hayward, G. Richardson, G. Szmukler, and M. Hotopf. 2005. Prevalence and Predictors of Mental Incapacity in Psychiatric In-Patients. The British Journal of Psychiatry 187 (4): 379–385.
Cappleman, R., I. Smith, and F. Lobban. 2015. Managing Bipolar Moods Without Medication: A Qualitative Investigation. Journal of Affective Disorders 174: 241–249.
Chesler, P. 2005. Women and Madness. New York: Palgrave Macmillan.
Coles, S., S. Keenan, and B. Diamond. 2013. Madness Contested: Power and Practice. Herefordshire: Pccs Books.
Collins, P. Hill. 2000. Black Feminist Thought: Knowledge, Consciousness, and the Politics of Empowerment. New York: Routledge.
Daley, A., L. Costa, and L. Ross. 2012. (W)Righting Women: Constructions of Gender, Sexuality and Race in the Psychiatric Chart. Culture, Health and Sexuality 14 (8): 955–969.
Diesfeld, K., and S. Sjöström. 2007. Interpretive Flexibility: Why Doesn’t Insight Incite Controversy in Mental Health Law? Behavioral Sciences and the Law 25 (1): 85–101.
Fernando, S. 2010. Mental Health, Race and Culture. London: Palgrave Macmillan.
Galasiński, D. 2010. A Linguist’s Insight into Insight. Social Theory and Health 8 (1): 66–82.
Galasiński, D., and K. Opaliński. 2012. Psychiatrists’ Accounts of Insight. Qualitative Health Research 22 (11): 1460–1467.
Galasiński, D., and J. Ziólkowska. 2013. Managing Information Misrepresentation in the Patient’s Notes. Qualitative Inquiry 19 (8): 589–599.
Georgaca, E. 2013. Social Constructionist Contributions to Critiques of Psychiatric Diagnosis and Classification. Feminism and Psychology 23 (1): 56–62.
Gibson, M. 1997. Clitoral Corruption: Body Metaphors and American Doctors’ Constructions of Female Homosexuality 1870–1900. In Science and Homosexualities, ed. V. Rosario, 118–121. New York: Routledge.
Gilman, S. L. 1985. Difference and Pathology: Stereotypes of Sexuality, Race, and Madness. New York: Cornell University Press.
Hamilton, B., and C. Roper. 2006. Troubling ‘Insight’: Power and Possibilities in Mental Health Care. Journal of Psychiatric and Mental Health Nursing 13 (4): 416–422.
hooks, b. 2004. We Real Cool: Black Men and Masculinity. New York: Routledge.
Høyer, G. 2000. On the Justification for Civil Commitment. Acta Psychiatrica Scandinavica 101 (399): 65–71.
Jacob, K. S. 2010. The Assessment of Insight Across Cultures. Indian Journal of Psychiatry 52 (4): 373.
Jimenez, M. A. 1997. Gender and Psychiatry: Psychiatric Conceptions of Mental Disorders in Women, 1960–1994. Affilia 12 (2): 154–175.
Jiwani, Y. 2011. Discourses of Denial: Mediations of Race, Gender, and Violence. British Columbia: UBC Press.
Johnstone, L. 2000. Users and Abusers of Psychiatry: A Critical Look at Psychiatric Practice. Philadephia, PA: Routledge.
———. 2006. The Limits of Biomedical Models of Distress. In Critical Psychiatry: The Limits of Madness, ed. D. Double, 81–98. New York: Palgrave Macmillan.
Keating, F., and D. Robertson. 2004. Fear, Black People, and Mental Illness: A Vicious Circle? Health and Social Care in the Community 12 (5): 439–447.
Kilty, J. M. 2012. ‘It’s Like They Don’t Want You to Get Better’: Psy Control of Women in the Carceral Context. Feminism & Psychology 22 (2): 162–182.
King, D. K. 1988. Multiple Jeopardy, Multiple Consciousness: The Context of a Black Feminist Ideology. Signs: Journal of Women in Culture and Society 14 (1): 42–72.
LeFrançois, B. A., R. Menzies, and G. Reaume. 2013. Mad Matters: A Critical Reader in Canadian Mad Studies. Toronto: Canadian Scholars’ Press.
Lupton, D. 1992. Discourse Analysis: A New Methodology for Understanding the Ideologies of Health and Illness. Australian Journal of Public Health 16 (2): 145–150.
Metzl, J. 2009. The Protest Psychosis: How Schizophrenia Became a Black Disease. Boston: Beacon Press.
Mosher, L. R. 2017. The Biopsychiatric Model of ‘Mental Illness’: A Critical Bibliography. Accessed March 8, 2017. http://www.mackinac.org/4525.
Munn, M., and C. Bruckert. 2010. Beyond Conceptual Ambiguity: Exemplifying the ‘Resistance Pyramid’ Through the Reflections of (Ex)Prisoners Agency. Qualitative Sociology Review 6 (2): 137–149.
Norvoll, R., and R. Pedersen. 2016. Exploring the Views of People with Mental Health Problems’ on the Concept of Coercion: Towards a Broader Socio-Ethical Perspective. Social Science and Medicine 156: 204–211.
Pilling, M. D. 2014. Queer and Trans Madness: Biomedical and Social Perspectives on Mental Distress. PhD diss., York University.
Rimke, H. 2016. Introduction-Mental and Emotional Distress as a Social Justice Issue: Beyond Psychocentrism. Studies in Social Justice 10 (1): 4–17.
Ryan, K. M. 2011. The Relationships Between Rape Myths and Sexual Scripts: The Social Construction of Rape. Sex Roles 65 (11–12): 774–782.
Saravanan, B., K.S. Jacob, S. Johnson, M. Prince, D. Bhugra, and A. S. David. 2007. Assessing Insight in Schizophrenia: East Meets West. The British Journal of Psychiatry 190 (3): 243–247.
Showalter, E. 1985. The Female Malady. New York: Penguin.
Smith, D. E. 1999. Writing the Social: Critique, Theory, and Investigations. Toronto: University of Toronto Press.
———. 2005. Institutional Ethnography: A Sociology for People. Toronto: Rowman Altamira.
Somerville, S. B. 2000. Queering the Color Line: Race and the Invention of Homosexuality in American Culture. Durham: Duke University Press.
Terry, J. 1999. An American Obsession: Science, Medicine, and Homosexuality in Modern Society. Chicago: University of Chicago Press.
Trzepacz, P. T., and R. W. Baker. 1993. The Psychiatric Mental Status Examination. Oxford: Oxford University Press.
Tupper, K. W. 2008. Drugs, Discourses and Education: A Critical Discourse Analysis of a High School Drug Education Text. Discourse: Studies in the Cultural Politics of Education 29 (2): 223–238.
Ussher, J. M. 1997. Framing the Sexual ‘Other’: The Regulation of Lesbian and Gay Sexuality. In Body Talk: The Material and Discursive Regulation of Sexuality, Madness and Reproduction, ed. J. Ussher, 131–158. New York: Routledge.
———. 2011. The Madness of Women: Myth and Experience. New York: Routledge.
Vaughan, M. 2007. Introduction. In Psychiatry and Empire, ed. S. Mahone and M. Vaughan, 1–16. New York: Palgrave Macmillan.
Waldram, J. Burgess. 2004. Revenge of the Windigo: The Construction of the Mind and Mental Health of North American Aboriginal Peoples. Toronto: University of Toronto Press.
Weber, L. 1998. A Conceptual Framework for Understanding Race, Class, Gender, and Sexuality. Psychology of Women Quarterly 22 (1): 13–32.
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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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