- The concept of insight is widely used in psychiatry and related care professions. For example, clinicians commonly describe some patients as having insight and other patients as having impaired insight – or even as lacking insight altogether. The terms ‘insight’ and ‘lack of insight’ have a complex history and are used in a variety of senses. One form of lack of insight is found in the patient who presents with clear evidence of a serious mental disorder (e.g., schizophrenia, anorexia, mania … ) but insists that they are not unwell and are not in need of treatment. As such, insight is sometimes described as lack of self-awareness as regards illness or impairment. In a different context, an elderly person with dementia might be described by a social worker as lacking insight on the grounds that, while the person acknowledges her declining abilities, she remains unaware of the risks associated with her situation.
- However commonly the term is used, however, it is important to remember that, when it comes to the application of the MCA 2005, whether or not a person is thought to have insight is relevant to but not determinative of the question of whether they have capacity to make the decision in question:
- The MCA 2005 makes no mention of insight, and insight is not itself a legal requirement for mental capacity in England and Wales.
- Although case law has sometimes treated belief of diagnostic and treatment information as a prerequisite for capacity, belief is not included in the MCA 2005 definition of mental capacity.
- In the context of capacity assessments, therefore, the concept of insight should be handled with care. When assessors suspect that impaired insight affects a person’s decision-making capacity, NICE Guidelines emphasise the importance of recording (a) what is meant by insight or lack-of insight, and (b) how impaired insight affects the person’s mental capacity. You should therefore avoid any direct inference from lack-of-insight to lack-of-capacity, and should probe for positive evidence of the abilities to understand, retain, use and weigh relevant information – even in cases where insight is thought to be absent or impaired.
- Where impaired insight is considered to be a factor in a person’s capacity, you should document in detail what the person lacks insight about, how the impaired insight is manifested, and how it impacts upon the person’s ability to understand, retain, use or weigh relevant information in reaching a decision.
- As we discuss in more detail here, we suggest that a person who does not, after probing, have insight into their condition or care needs can be understood for purposes of the MCA 2005 as a person who cannot appreciate, and hence use and weigh that information. It is, though, often a very useful exercise to translate out of the idiom of insight – in other words, to see if it is possible to describe the person’s condition and abilities in other terminology. In doing so, it may be useful to make use of the categories found in insight scales. For example, in a clinical context, the Schedule for the Assessment of Insight (SAI) analyses impaired insight into three discrete dimensions: a general awareness or acceptance of illness; awareness of the need for treatment; and the ability to relabel psychiatric phenomena (e.g., hearing voices) as pathological. These different aspects of insight should be considered separately, and both their relation to the associated impairment (e.g. schizophrenia or bipolar or dementia) and their impact upon the ability to make decisions should be assessed.
- Where decision-making capacity is found to be absent due to impaired insight, you should consider what practicable steps might be taken to support insight, for example by mitigating any physical or psychological factors that might be interfering with the person’s insight. Insight is often held and sustained collectively, in the context of relationships with trusted friends, family members or supporters, and can sometimes be undermined by dysfunctional relationships. Steps to support the person’s relationships can therefore serve to support insight and thereby to support capacity. It should also be noted that impairment in insight is not fixed; it can fluctuate and will often improve as the person’s underlying mental disorder improves.