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. In the context of capacity assessments, these concepts should be handled with care. Where impaired insight is considered to be a factor in a person’s capacity, assessors 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.
The terms ‘insight’ and ‘lack of insight’ have a complex history, lack an agreed definition, 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. In psychiatric medicine, impaired insight is correlated with higher rates of readmission, treatment non-compliance, and coercion.
Insight is relevant to but not determinative of capacity. The MCA 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 definition of mental capacity. 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. Assessors should 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. If a person’s impaired insight renders them unable to understand information relevant to a decision, or unable to use or weigh that information, then the consequence of impaired insight is that they are unable to make that decision.
Where lack-of-insight appears to undermine a person’s decision-making abilities, the best way to ensure that an assessment of capacity is MCA-compliant is to translate out of the idiom of insight – i.e., 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, 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. It should be noted that the SAI dimensions are designed to apply primarily in clinical settings, and so may need to be adapted for use in other contexts.
Where decision-making capacity is found to be absent due to impaired insight, consideration should be given to any practicable steps that 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.