The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness

17 Being Self-Aware: Insight

C H A P T E R 1 7 Being Self-Aware Insight Psychic illness looks different to the medical observor from what it looks like to the patient who is reflecting on himself. —KARL JASPERS, 1913 1. Thus far I have surveyed the traditional subject matters of psychiatry: psychosis , depression, mania, personality, nosology. One phenomenon has been touched on that underlies all those discussions; it is, to my mind, the central phenomenon of psychiatry: insight. The term here refers to the perspective that an individual maintains toward her own psychological state. If one knew, from a God’s-eye perspective, so to speak, that certain individuals suffered from certain psychopathologies (depression, mania, psychosis), then those persons would have insight if they were aware of experiencing those mental states. For physical conditions, nonpsychiatric medical illnesses, this is usually not a problem . I have a pain here; the patient is aware of the pathological physical state of a part of the body. With rare but important exceptions in certain neurological diseases, most nonpsychiatric conditions are not, by nature, associated with impairment of insight. Psychiatric conditions, however, often entail impaired insight. Is this something special about psychiatric illnesses? Does this argue decisively against the psychiatric belief that mental illnesses are disease states like physical illnesses? In other words, is impaired insight merely disagreement between doctor and patient? And when the doctor is a psychiatrist, with his poor diagnostic methods and lack of laboratory tests, who is to say who is right? The problem of insight is a central conundrum for psychiatry. At one level, it simply raises the question, How can we know that someone else’s mental states are pathological? How can we know that a person is mentally ill? How can we know anything about anyone else? Indeed, at its extreme, the question is, How can we know anything about any mental states, our own or those of others? A popular belief about psychiatrists is that they actually possess this power. They can know the mental states of others; they almost seem to read the minds of others. The ubiquity of this view is amazing. A minority hold the opposite view. Psychiatrists are quacks, understand nothing, and are nothing but pretenders to science. One wonders how many of those who attack psychiatrists actually fear shrinks because they secretly are believers in psychiatric omniscience . But to say this would be to act the part of a psychiatrist. Psychiatrists do not tend to vehemently argue with those who believe in their powers; instead they dispute with those who attack the field wholesale. But when honestly speaking among themselves, psychiatrists focus on how little they know about other human beings, how unpredictable patients are, how difficult it is to diagnose, how haphazard success at healing is. In more philosophical moments , they may applaud human unpredictability; after all, that is freedom. If psychiatrists could know everything about anyone, what would stop such knowledge from leading to a police state? Did not Hitler’s men exercise such rudimentary knowledge (“the big lie”)? But practically speaking, for psychiatrists , some knowledge must be possible if patients are to be helped. We must be able to understand our patients’ minds, sometimes better than they do, in order to help them. But can we really do this? How do we get inside someone else’s head? At a very basic level, we don’t. Everything in psychiatry is inference. Sometimes those inferences are correct. And we are correct with certain matters frequently enough to become rather confident in those inferences. But this is a probabilistic matter. In any one instance, we cannot be sure we have divined someone else’s mental state correctly. 2. But can we really know anything about another person’s mental states? Some hold that we cannot even know what is in our own heads, much less those of others. And some argue that we know everything in our own heads but nothing in those of others. I have alluded to these philosophical arguments in the first part of this book. Here I want to emphasize the clinical syndromes in which insight into oneself is impaired and try to conceptualize what these syndromes mean. Insight 227 There is a set of psychological syndromes characterized by a relative lack of awareness of oneself or of one’s surroundings. Knowledge about these syndromes is advancing only gradually, but it is touching upon important...