One of the complications pertaining to the role of insight in capacity assessment is that insight has no single definitive meaning. A survey of 412 rulings from the Court of Protection identified at least five different meanings associated with lack of insight:
- P does not believe/accept/agree that s/he has a (mental health) problem.
- P does not comprehend/understand his/her (mental health) problem.
- P does not recognize/understand risk(s).
- P does not recognize/understand care/support needs.
- P does not recognize the value of treatment.
Other Related Concepts
The terms anosognosia and appreciation are closely related to the concept of insight.
In the context of brain injury, lack of self-awareness of impairment or deficit is sometimes described as anosognosia. In its purest form anosognosia is a neurological syndrome characterised by the lack of awareness of abnormality (most commonly paralysis) arising from damage to the right cerebral hemisphere and affecting the left side of the body. It can also apply to sensory loss (e.g. blindness) and loss of cognitive functions (e.g. articulate language).
Some clinicians and commentators extend the term more broadly. For example, a patient with a frontal lobe injury or dementia may have significantly reduced memory but may be unaware of their impairment. Such a patient might be described as exhibiting anosognosia. This usage has spread to psychiatric thinking where the term is sometimes used to describe particularly striking cases of lack of insight in a person with psychosis or a mood or behavioural disorder. In describing such cases as anosognosia, clinicians may be emphasising the ‘fixed’ character of the absence of self-knowledge, often in conjunction with the assumption that the condition has what clinicians describe as an ‘organic’ (i.e., physiological) origin.
Appreciation is a term that is used in a variety of more and less technical senses. It is not uncommon to find the word ‘appreciation’ used in explaining the concept of ‘insight’ – and vice versa. But because both terms admit of a range of meanings, equivalence cannot be assumed.
In their preparatory work for the Mental Capacity Act, the Law Commission considered including appreciation as an element of the legal standard for capacity, but ultimately decided against its inclusion. However in US legal standards for mental capacity, appreciation often is included as a component – notably in the MacAurthur Competence Assessment Tool for Treatment Decisions (MacCAT-T). In the MacCAT-T, the appreciation standard encompasses elements of insight.
Judgments in the Court of Protection (CoP) regularly invoke appreciation in adjudicating capacity. For a survey of CoP judgments, Kane and colleagues defined appreciation as “understanding information as relevant or applicable to oneself in the particular,” and found that lack of appreciation was frequently related to incapacity in Court of Protection rulings.