Insightlessness, the Deflationary Turn

Jennifer Radden
Philosophy, Psychiatry, & Psychology, Volume 17, Number 1,
March 2010, pp. 81-84 (Article)
Published by The Johns Hopkins University Press
DOI: 10.1353/ppp.0.0278

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Insightlessness, the
Deflationary Turn
Jennifer Radden

Keywords: insightlessness, deflationary turn, Harry

Stack Sullivan, open placebos, space of reasons

arga Reimer argues that treatment compliance in patients who are

without any, or complete, insight into
psychotic symptoms may be neither particularly
abnormal nor entirely unreasonable. In broad
sympathy with these conclusions, I wish only to
add a couple of ancillary observations and some
historical context.
Reimers discussion can be placed alongside
other research on aspects of psychosis putting
forward what have been called deflationary accounts, accounts that depict psychotic symptoms
as differing from normal states, traits, and responses in degree rather than kind. Such accounts
have been offered about auditory hallucinations
or hearing voices (Leudar and Thomas 2000;
Romme and Escher 1989; Smith 2007), about
delusional thinking (Bentall 2003; Bentall et al.
1989; Bracken and Thomas 2005; Hamilton 2007;
Kinderman and Bentall 2007), and spiritual experiences (Jackson 1997; Jackson and Fulford 1997);
in the introduction of the notion of benign psychosis (Jackson 2007), and even in recognition
that insight is a complex, dimensional attribute
(Amador and David 1998). Harkening back to the
middle years of the twentieth century, and associated with Adolph Meyers influence in the United
States, as well as the influence of psychodynamic
2010 by The Johns Hopkins University Press

(and psychoanalytic) ideas, this deflationary turn

challenges the neo-Kraepelinian presuppositions
of our contemporary biomedical psychiatry.
Rather than sharply separating psychotic states
and symptoms from normal experience, the deflationary approach emphasizes the continuities
and similarities linking them.
Reimer proceeds in two separate steps. To the
extent that treatment compliance among patients
suffering psychotic states occurs in the absence
of any or full insight, it is shown, this seems not
dissimilar from other more ordinary cases where
treatment compliant behavior occurs either withoutor without regard fora recognition that
one is ill. (The term insightlessness is here used to
indicate the absence of full and complete insight.
This recognizes the dimensional and complex nature of insight, which has been shown to involve a
range of beliefs over ones disorder, those about its
presence, about the need for treatment, and about
the social consequences of suffering it.)
Had her discussion stopped here, Reimer would
have completed the first deflationary step. By
showing that this sort of insightless treatment
compliance also occurs in the absence of mental
disorder, she encourages us to see psychotic patients lack of insight into their disorder as at least
akin to more benign and commonplace responses.
In doing so, she would have shifted something of
the burden of proof within discussions of insight.
Those insisting insightlessness is an irresoluble
obstacle to positive treatment outcomes would

82 PPP / Vol. 17, No. 1 / March 2010

now be required to explain why this should be

so. And those denying the analogy between the
insightless compliance of the psychotic patient
and more everyday cases such as those Reimer
describes, might be called upon to show why these
cases were disanalogous.
Reimer does not leave matters there. She goes
on to establish that none of the instances of insightless treatment compliance that she discusses
can be judged to be entirely unreasonable. Treatment compliance without full insight is not only
quite normal, it may not even be particularly irrational. As she explains, the patients in each case
anticipate benefits from the treatment, even though
such benefits are not understood in terms suggestive of pathology. Unfailingly, they conform to a
general human tendency: [T]o act in accordance
with what we perceive, rightly or wrongly, to be
in our best interests.
Reimer locates the error in more traditional
thinking about lack of insight at the immodest
assumption that there is but a single way to accurately characterize the patients condition
medically. This view, which she attributes to
contemporary psychiatry, she finds mistakenand
mistaken, I agree it is. Rather than one, there seem
likely to be several accurate ways to frame things.
And although the medical framing will best fit the
interests and purposes of clinicians, other framings
may better suit the interests of their patients.
When the possibility of alternative, non-medical
perspectives is granted, and our goal is to assess
insightless compliance vis vis rationality norms,
a number of considerations gain salience. The
insightless patient, Reimer shows, may comply
with treatment for a range of reasons which can
be summed up in the general formulation that
the treatment will be beneficial. In confirmation
here, Reimer cites empirical studies indicating that
treatment compliance is better correlated with a
conviction that the treatment will be beneficial
than with insight as customarily defined.
Actual case material provides several rationales
for treatment compliance: Although without full
insight, the patient may accept treatment to make
the voices go away; to get a sound sleep and
peace of mind; or to quell racing thoughts, as one
might a tonic or elixer, or an amulet or charm.

Judging a treatment to be valuable in such ways

yet not required according to the terms understood
by medical psychiatry, as do the patients Reimer
describes here, invites an interesting analogy
with the judgement of the treatment compliant
patient who knowingly accepts placebo treatment.
For the patient lacking insight the treatment is
(at least medically) unnecessary; the patient who
knowingly accepts a placebo treatment regards
that treatment as (at least medically) ineffectual.
Recent work on open placebos (that is, the
deliberate, non-deceptive use of medicine that
is placebo) suggests that for a percentage of
patients, the effects remain with knowledge that
the medicine is a placebo (Jopling 2008). Those
whose condition improves with open placebos,
David Jopling has pointed out, may be affected by
their expectation of improvement, by the healing
power of the doctorpatient relationship, or by the
symbolism that attaches to medicine even when it
is inert. These patients reasons for complying with
a treatment regimen they believe to be (at least
medically) ineffectual, however, will presumably
include some of the sorts of reasoning sketched by
Reimer. They may be superstitious, or risk takers.
Somewhat more reasonably, they may be swayed
by the physicians remark that such drugs have
proven effective for others, impressed by the fallibility of medical science, or taking the treatment
in the wait and see spirit of scientific openness. Finally, and entirely reasonably, they may
be possessed of a conviction, actually confirmed
by placebo studies and hardly unknown in the
non-medical culture where alternative medicines,
the power of prayer, and other ideas are widely
entertainedthat there is a placebo effect. Several
of these, and many other, reasons for believing the
treatment will be beneficial, lie well within the
space of reasons.
That said, Reimer insists that the awareness
of illness that comes with insight is not, or not
alone, such a reason. Only by attributing the appropriate motivation can I am unwell be seen
as any sort of reason for treatment compliance.
The patient must want to get well in addition to
believing himself ill. (Although Reimer emphasizes
that the effort to help the patient gain insight can
take several forms, she might in fairness have ac-

Radden / Finding Insightlessness 83

knowledged that it always, although not always

successfully, involves fostering such motivational
attitudes in the patient.)
In acknowledging that an assortment of justificatory beliefs may allow us to judge much
insightless compliance as reasonable, we need
not be committed to all possible forms of such
reason-giving, however. And Reimers formulation (the treatment will be beneficial) may be too
generous. Even if exhibiting the human tendency
to act in accordance with what he (wrongly, in
this case) perceives to be his interests, the patient
who complies with treatment out of a delusional
belief that refusing would bring the immediate
end of the world, for example, is not proceeding
very rationally. The space of acceptable reasons
and reasonable action is broad, and may be much
broader than that presupposed in a medically
framed understanding of the effects of treatment.
But actions based on bizarre and delusional beliefs
such as this patients, seem to go too far. If not
outside the space of reasons, they lie uncomfortably close to its limits.
Reimer insists that this set of observations about
insightless treatment compliance has practical, and
even ethical implications. Rather than attempting to improve insight for purposes of treatment
compliance, she proposes that in cases of psychotic
patients with poor insight, the patients awareness
of the potential benefits of treatment should be
augmented using language that avoids the implication that the patient is ill. These prescriptions
bring to mind remarks by one of the most famous
practitioners of the art of psychiatry, Harry Stack
Sullivan, writing more than fifty years ago. Sullivan was acutely aware of this matter of framing,
and its effect on the patient and the therapeutic
relationship. He also believed that the element of
psychosis that mattered to the patient was not its
medical features but its effect on interpersonal
functioning. Adhering to these two tenets, his
prescriptions for working with psychotic patients
recommends omitting all emphasis on what in
the patients behavior actually demonstrates psychosis and instead focusing on the interpersonal
difficulties the patient will likely be experiencing
(and likely ready to acknowledge). In that way, he
says, the psychiatrist can sometimes refer to what

are in essence the patients psychotic difficulties

with others, without actually communicating the
idea to the patient that these difficulties constitute
a particular very severe mental disorder (Stack
Sullivan 1959, 91; my emphasis).
To insist the patient acknowledge his disorder
will not be a good idea, Sullivan implies. A reason
this might be so, noted by Reimer, is that it will
prove ineffective. The patients lack of insight
may itself be symptomatic, as some thinka kind
of delusional inability to grasp the nature of the
disorder akin to the anosognosia that sometimes
afflicts the victims of neurological damage. But
Sullivan hints at another idea as well. The psychiatrist, he says in this same passage, cannot expect
a patient who is deeply disturbed to give up his
shadowy vestiges of security by agreeing with the
psychiatrist that he is psychotic.
It would be unreasonable for the patient to
accept this about himself, Sullivan implies. Acknowledging that ones difficulties constitute a
particular very severe mental disorder would
be tantamount to the kind of madness that is
found not in assessments of pathology, but of irrationality. Following Sullivan, perhaps it is not
only within the bounds of reason to comply with
treatment even in the absence of insight; it may
also be somehow contrary to reason to acknowledge oneself to be (presently) psychotic. As Reimer
saw, something must be added to I am (presently)
psychotic for it to count as any kind of practical
reason. But even suitably supplemented (I am
[presently] psychotic and want to get better), I
believe Sullivan would still resist: For the patient,
he seems to imply, this has too much of the quality of a self-referential paradox to be a reasonable
assertion of any kind.

Acknowledgments
I am grateful to Nassir Ghaemi and David
Jopling for helpful comments on this discussion.

References
Amador, X. F., and A. David. 1998. Insight and psychosis. Oxford: Oxford University Press.
Bentall, R. B. 2003. Madness explained. London:
Penguin.

84 PPP / Vol. 17, No. 1 / March 2010

Bentall, R. B., G. S. Claridge, and P. Slate. 1989. The

multidimensional nature of schizotypal traits. British
Journal of Clinical Psychology 28:36375.
Bracken, P., and P. Thomas. 2005. Postpsychiatry: Mental health in a postmodern world. Oxford: Oxford
University Press.
Hamilton, A. 2007. Against the belief model of delusion.
In Reconceiving schizophrenia, ed. M. C. Chung, K.
W. M. Fulford, and G. Graham, 21734. Oxford:
Oxford University Press.
Jackson, M. C. 1997. Benign schizotypy? The case of
spiritual experience. In Schizotypy: Implications for
illness and health, ed. G. Claridge, 227-50. Oxford:
Oxford University Press.
. 2007. The clinicians illusion and benign
psychosis. Reconceiving schizophrenia, ed. M. C.
Chung, K. W. M. Fulford, and G. Graham, 23554.
Oxford: Oxford University Press.
Jackson, M. C., and K. W. M. Fulford. 1997. Spiritual
experience and psychopathology. Philosophy, Psychiatry & Psychology 4, no.1:879.

Jopling, D. 2008. Talking cures and placebo effects.

Oxford: Oxford University Press.
Kinderman, P., and R. B. Bentall. 2007. The function
of delusional beliefs. In Reconceiving schizophrenia,
ed. M. C. Chung, K. W. M. Fulford, and G. Graham,
27594. Oxford: Oxford University Press.
Leudar, I., and P. Thomas. 2000. Voices of reason,
voices of insanity: Studies of verbal hallucinations.
London: Routledge.
Reimer, M. 2010. Treatment adherence in the absence
of insight: A puzzle and a proposed solution. Philosophy, Psychiatry, & Psychology 17, no. 1:6575.
Romme, M., and S. Escher. 1989. Hearing voices.
Schizophrenia Bulletin 15:20916.
Smith, D. 2007. Muses, madmen, and prophets: Rethinking the history, science, and meaning of auditory hallucination. New York: Penguin.
Stack Sullivan, H. 1959. The psychiatric interview. In
The collected works of Harry Stack Sullivan, ed. H.
S. Perry, and M. B. Cohen, 1243. New York: W.W.
Norton & Company, Inc.