Insight and capacity

The phenomenon of unawareness of illness/lack of insight is closely linked with that of mental capacity when it comes to assessment for involuntary care. This is implied by the “impaired judgement” phrase in MHA2001, since a patient whose judgement is not impaired will usually appreciate the need for care and consent to voluntary admission and treatment when recommended. The focus on capacity is substantially inflated in (the current draft of) MHB2024, wherein substantial requirements are applied in relation to assessments of capacity to consent to treatment, with an extreme level of external legal oversight that would likely prevent timely care for such patients (Kelly, Reference Kelly2024). Capacity to consent is always related to a concrete situation such as inpatient admission or medical treatment. It can be defined in different ways, but is classically recognised to incorporate the abilities to 1) communicate choices, 2) understand and retain relevant information, 3) appreciate the situation and its consequences and 4) use and weigh up the information rationally to assess the risks and benefits of treatment options (Appelbaum & Grisso, Reference Appelbaum and Grisso1988). Lack of insight and lack of capacity intersect in the third and fourth of these criteria, since the patient with psychotic illness undergoing involuntary care may be well able to understand and retain information, but unable to appreciate their situation or to use and weigh information given to them by a clinician about their diagnosis and symptoms, its effects of their behaviour and need for specific treatments. In acute situations patients with psychosis may also fail to fulfil the first and second capacity criteria, since the cognitive dysfunction associated with extreme distress or formal thought disorder can impair the ability to understand and retain information and even to communicate choices, but this is usually short term. Lack of insight has been demonstrated empirically to be a better clinical discriminator of incapacity than other clinical variables, including symptoms and cognitive dysfunction, for patients with psychotic disorders in an acute psychiatric setting (Owen et al., Reference Owen, David, Richardson, Szmukler, Hayward and Hotopf2009). Furthermore improvement in insight after inpatient treatment is associated with regaining capacity for decision making in patients with psychotic illnesses, especially bipolar disorder (Owen et al., Reference Owen, Ster, David, Szmukler, Hayward, Richardson and Hotopf2011).

Given the centrality of incapacity to justify involuntary care for mental illness, and the understandable criticism that having a whole piece of controversial legislation which can only be applied to people who suffer a psychosocial disability is discriminatory and at odds with the United Nations Convention on the Rights of Persons with Disabilities, some advocates have called for combining involuntary care legislation and incapacity legislation into one “fusion” legislation (Szmukler, Reference Szmukler2020). Indeed such legislation is undergoing phased implementation in Northern Ireland (Lynch et al., Reference Lynch, Taggart and Campbell2017).

Although the presence of impaired insight is a pivotal factor in establishing lack of capacity, it represents only one element in determining that a mental disorder under MHA2001 is met. Also central to a recommendation of proceeding with or continuing involuntary care is that it is likely “to benefit or alleviate the condition of that person to a material extent” (criterion 3(1)(b)(ii) of MHA2001). For many patients with episodic psychotic illness such as bipolar disorder, awareness of illness correlates with symptomatic improvement and patients realise on recovery that their psychotic beliefs and experiences were illness driven and not based in reality. Other patients with severe and enduring psychotic illnesses such as schizophrenia may recover from an episodic exacerbation and be discharged from an approved centre, without having experienced improvement in their level of insight. Empirical research demonstrates that insight levels in schizophrenia improve with treatment, but also display “trait” like features with poor insight persisting in many patients and correlating with poor premorbid functioning and less affective symptoms (Wiffen et al., 2010). It can be difficult for carers to understand why the decision is being made by a clinician to revoke involuntary care after symptomatic improvement when they perceive that their loved one is at high risk of discontinuation of treatment and relapse, due to persistent impaired insight and consequent likely non-adherence with treatment. However the patient is most likely no longer detainable because, despite ongoing impaired judgement, the criterion of further treatability in an inpatient setting is not met. Although persistent lack of insight is a risk factor for repeated relapse and “revolving door” admissions, clinicians generally seek to boost adherence to community care planning through alternative therapeutic strategies which seek to sidestep rather than confront impaired insight, such as providing wraparound services where medication adherence is only one component of a therapeutic recovery plan. Indeed persuasion, kindness and increased therapeutic alliance, all elements of compassionate care, may help to improve adherence with treatment and thus a better outcome for many severely ill patients, without substantially changing their insight into the nature of their psychotic symptoms or capacity for autonomous decision making.

When absent insight persists after hospital discharge to such an extent that (i) capacity is continuously impaired, (ii) adherence with care planning is impossible due to nonengagement despite optimising therapeutic supports, and (iii) the patient is still able to cognitively absorb the link between non-adherence with treatment and an undesirable return to inpatient care, then there is arguably a role for community treatment orders to ensure community care is provided on a sustained basis. Such orders are available in multiple jurisdictions, but not in Ireland which is a source of debate (McDonald et al., Reference McDonald, O’Reilly, Kelly and Burns2017). However in their absence prolonged periods of approved leave under MHA2001 can help some patients with absent insight to achieve clinical stability (Bainbridge et al., Reference Bainbridge, Byrne, Hallahan and McDonald2014).

Insight and outcome

Insight in psychotic illness is not a binary construct, but is rather best conceptualised as incorporating different dimensions, including acknowledging the presence of a mental health condition, ability to relabel unusual experiences such as delusions and hallucinations as manifestations of illness, and acknowledging the need for treatment (David, Reference David1990). When measured using validated quantitative scales, higher levels of insight are generally associated with better outcomes including reduced psychotic symptom severity, less use of coercion and better psychosocial functioning (David et al., Reference David2020). Insight is only weakly associated with cognitive ability, in that intact neurocognitive function is likely a precondition for insight, but much more strongly linked to meta-cognitive ability, ie. the ability to think of one’s own and other’s thinking (Gan et al., Reference Gan, Fu and Zhu2022). A meta-analysis of randomised controlled trials has demonstrated that metacognitive training, a form of group therapy which focuses upon correcting cognitive errors and problem solving biases, can improve insight in psychosis (Lopez-Morinigo et al., Reference Lopez-Morinigo, Ajnakina, Martínez, Escobedo-Aedo, Ruiz-Ruano, Sánchez-Alonso, Mata-Iturralde, Muñoz-Lorenzo, Ochoa, Baca-García and David2020).

Impaired insight also negatively impacts the patient experience of the involuntary care process. In a longitudinal observational study conducted with patients admitted involuntarily to Irish psychiatric units, which incorporated multiple clinical assessments including severity of symptoms and the experience of restrictive practices, awareness of illness was the strongest predictor of higher satisfaction with the clinical services (Bainbridge et al., Reference Bainbridge, Hallahan, Mc Guinness, Gunning, Newell, Higgins, Murphy and McDonald2018). Furthermore improvement in awareness of illness over time, between admission and follow-up three months post revocation of involuntary admission, was the best predictor of improved satisfaction with clinical services (Bainbridge et al., Reference Bainbridge, Hallahan, Mc Guinness, Gunning, Newell, Higgins, Murphy and McDonald2018). A subsequent mixed methods study stratifying patients by their levels of insight after revocation of involuntary care found that those with higher levels of awareness of illness were more likely to consider their involuntary admission, the nature of care received, and receiving a diagnosis, as beneficial (Smyth et al., Reference Smyth, McFarland, McGuiness, Summerville, Bainbridge, Hallahan, Higgins, Casey, Murphy and McDonald2022).

Insight and autonomy

The ethical principles of autonomy, beneficence, non-maleficence, and justice (Beauchamp & Childress, Reference Beauchamp and Childress2009) are central to clinical practice and in most cases can be fully adhered to. Underpinning autonomy is the concept of informed consent and shared decision making, where the clinician outlines the risks and benefits of evidence based interventions and helps the patient to make a decision based on their own free will, and having weighed up the likely beneficial and adverse consequences of receiving or not receiving a treatment. Whilst this standard can reasonably be achieved in practice with sufficient time resources, it often breaks down when a patient lacks insight due to a psychotic illness. The reason involuntary care exists at all is because the application of these principles comes directly into conflict, in which case which principle should take precedence – autonomy or beneficence? In practice it depends on how beneficial the treatment and how undermined the autonomy, and clinicians balance these on a daily basis when making decisions about involuntary care. At a more fundamental level however, a reasonable question is to what extent a patient with absent insight can be considered to be engaging in autonomous decision making about psychiatric admission and medical treatment if they are unable to appreciate information about their mental illness and its treatment? Arguably the phrase of being admitted “against their will” becomes meaningless in such a situation, since their will may be unclear or must be inferred from past beliefs or from what a reasonable person might wish in terms of safety and alleviation of distress. In this regard a distinction between “will” and “preferences”, usually bundled inseparably in guidelines and legislation, can be helpful to consider, as outlined by Szmuckler (Reference Szmukler2019). Preference is taken to mean a greater liking for one alternative over another, however will is a manifestation of a person’s deeply held and stable personal beliefs, values and commitments. Will and preference can diverge in relation to involuntary care. A treating clinical team may often form an opinion that a particular therapeutic action, such as continued inpatient admission or the administration of antipsychotic medication, is actually in keeping with that person’s will in the sense that it will help them achieve a sustained and previously expressed goal, but is not in keeping with a currently stated preference.

A clinical case scenario can demonstrate this point. Consider John who was involuntarily admitted to a psychiatric inpatient unit with a severe episode of psychotic mania at age 19, and recovered after treatment with olanzapine, lithium and psychosocial support. He was established on lithium prophylaxis and experienced a lengthy period of clinical stability, although expressed ambivalence about taking this medication in the longer term since he stated that it made him feel emotionally dulled. Since his teenage years he had expressed a desire to be a doctor. He gained entry to medical school and completed the first three years of the course uneventfully. At the age of 23, John stopped taking lithium and had a period of time medication free. After three months off lithium and in the run up to a stressful exam period, John began missing sleep and experiencing symptoms of manic relapse with racing thoughts, grandiosity and overspending. He decided to drop out of his course, telling relatives that his musical talent was underappreciated and he will achieve fame and wealth as a musician rather than continue his medical studies. John’s parents intervened to gain psychiatric support and he was admitted involuntarily, where he received close nursing supervision, antipsychotic medication and reinstitution of lithium, a care plan to which he vociferously objected at the time. After 4 weeks of inpatient treatment John had recovered from the manic episode, continued willingly on lithium prophylaxis and successfully passed his third year medical exams at the repeat autumn sitting. John had no insight into his illness at the time of his involuntary admission and was unable to weigh up the risks and benefits of treatment. In this scenario it is inaccurate to describe the involuntary care and medical treatment as being “against his will.” Rather the intervention can be conceptualised as against his stated preference at the time, but consistent with his manifest will as expressed in a sustained pattern of decisions and behaviours over time. When absent insight undermines autonomous decision making in this way, a more accurate description of involuntary care is “without informed consent”.

Establishing sustained will over time in relation to an intervention can be challenging for clinicians, but at a minimum should be assessed when the patient in question is at their baseline in relation to their psychotic illness rather than in the midst of an exacerbation. Assessment of sustained will should be repeated over time to confirm that it is consistent, and conducted after adequate psychoeducation to ensure that the patient and any carers are appraised of the likely risks and benefits of the intervention. There is wide heterogeneity in illness course after the onset of psychosis. Some patients experience relapses and achieve recovery even though persistently refusing antipsychotic medication for prophylaxis, and rationally justify this refusal because negative previous experiences with medication outweigh potential treatment benefits (Lincoln et al., Reference Lincoln, Jung, Wiesjahn, Wendt, Bock and Schlier2016). Other patients continue to experience repeated involuntary admissions with psychotic relapses that are directly triggered by non-adherence and stabilise with the reintroduction of antipsychotic medication, and nevertheless persistently refuse prophylactic treatment after each involuntary admission has been revoked. This persistent refusal is often despite full recovery from the episode of psychosis, overwhelming evidence for the benefit of medication and exhortation by clinicians and carers, but can still be interpreted as in keeping with the patient’s sustained will. In such cases (and where active psychotic symptoms or residual negative symptoms of schizophrenia cannot be invoked to explain “unawareness of illness” after recovery from an episode, for example with bipolar disorder), the “lack of insight” can be conceptualised as more akin to the psychological denial characteristic of patients with alcohol dependence or personality disorders referred to in the introduction. Involuntary care to prevent relapse has no place in the management of such patients, since the key issue here is that the patient has capacity to make decisions about continued treatment, however unwise this may appear to carers and clinicians. This clinical situation demonstrates how lack of insight demands precision in its definition and overlaps but is not synonymous with lack of capacity (Gurbai et al., Reference Gurbai, Fitton and Martin2020; National Institute for Health & Care Excellence, 2018; Allen, Reference Allen2009). Rather the illness must be allowed to take its course, the patient experience the consequences of their decisions, exacerbations treated with episodic involuntary care should they occur, and clinicians and carers continue to provide psychoeducation and support in the hope that the patient may find sustained recovery in future.

A further area where more durable will is prioritised over short term preference is in the case of advance healthcare directives. Thus a patient with a recurrent psychotic illness may make an advance healthcare directive to crystalise their will in relation to how they would like a future episode of illness to be treated when insight and decision making capacity are impaired. Such is the case with a “Ulysses clause” (so named after Homer’s Odysseus, who required his crew to put wax in their own ears and bind him to the mast of his ship while they sailed past the isle of the Sirens, so that he could listen to the bewitching song but not run his ship aground), which could explicitly provide for clinicians to respect the autonomy of patients in following a treatment plan in accordance with their previously expressed will. Advance healthcare directives are provided for in the Assisted Decision-Making (Capacity) Act (ADMCA) (2015) in Ireland and apply to adults who have capacity to make such directives. However patients are presumed to have capacity and there is no requirement for a formal assessment of capacity or insight into illness and its treatment by a clinician before an advance healthcare directive is made. Thus it is possible for a patient with persistent unawareness of illness, who is unable to weigh up the risks and benefits of a particular intervention (for example the administration of antipsychotic medication in the context of a severe psychotic relapse) to make an advance healthcare directive in order to prevent such a treatment being implemented during involuntary admission, even if their clinicians may consider such treatment critical for recovery. The currently active MHA2001 in Ireland can override advance healthcare directives made in accordance with ADMCA 2015 in such a situation when the risk criterion is present, but this does not apply in the proposed new MHB2024 (Kelly, Reference Kelly2025). It may be possible for mental health service providers to seek a high court ruling to invalidate an advance healthcare directive if evidence could be ascertained that the patient lacked capacity to make such a directive at the time, in order to proceed with treatment. Such a scenario where absent insight outside of the period of involuntary care directly impacts upon treatment during the period is likely to pose difficult legal and clinical challenges if MHB2024 is implemented in its current form. It is unclear how stable over time the sustained will of patients with persistent psychotic illness might be in relation to treatment interventions and whether such expressed will might vary with recurrent illness exacerbation or the social consequences of untreated illness. Research incorporating longitudinal design to identify sources of variation in patient attitudes towards interventions, especially those that might be subject to advance healthcare directives, is warranted to clarify this.