Patients with Poor Insight present a conflict in care for Psychiatrists

Part of my practice is in first episode psychosis and it is a wonderful area in which to work. It may come as a surprise, but I find this patient population dynamic, and the work itself quite optimistic. We see people experience complete personality changes, do unspeakable things in the throws of a psychotic episode and with medication and time, we see them recover. It is truly remarkable. Some gain insight, realize what has happened with shock and embarrassment then commit fully to their recovery. Some deny the symptoms ever happened, and deny their impact on themselves and their loved ones. This second groups of patients are more difficult to treat and their stability more fragile.

The presence and absence of insight is what separates these two types of patients and it is no surprise that these patients require very different approaches. The patients with insight seek out care, want a psychiatrist in their lives and respect the psychiatrist as an expert. In these cases, a therapeutic relationship is more easily formed and taking on and knowing my role to the patient's wellness comes naturally, automatically. The care for these patients is relatively less complicated and far less burdensome as patients share the responsibility of staying well. It is up to them after all whether or not they will follow through with my recommendations. A patient's ability to do this, as simple and obvious as it may seem, represents a psychological aptitude that not everyone has and happens to be a main determinant of a patient's prognosis.

Patients who do not have this insight, quite predictably, do not want my care. They did not seek it out, they did not ask for it. Often these patients are brought in unwillingly by concerned family members, or have been referred to me after a difficult psychiatric admission to hospital. From the outset, we are at odds with the goals of care. Though the patient and I both want the patient to be psychiatrically stable, the patient does not believe medication will help and very commonly does not believe he is unwell to begin with. I do not think this tension occurs as frequently in any other field of medicine than in psychiatry. And these cases challenge some of the fundamentals of what we are taught about what is good psychiatry and what is good care.

At the heart of good care is patient autonomy. I was taught to never judge the choices of a patient so long as they are mentally capable to make medical decisions. I was taught that when a patient makes a choice I would not make for myself, that this is not the wrong choice. It is likely the right choice for the patient based on any number of variables I could not possibly be fully aware of. At the heart of my philosophy of care is that it is the patient's life to live, not mine, and so let them live it on their own terms (so long as they do not harm others). I also know that natural consequences, what life doles out, can be the greatest teacher, and so it is not my place to prevent these lessons from being learned. I also know I can not convince my patients out of something they have already decided. This, I have learned from experience.

Treating patients who have no insight (meaning that despite terrible consequences of their illness and having a high risk for relapse back into psychosis, these patients still believe they do not have the illness and do not need treatment) fundamentally challenges what I feel my duty is to my patients' care and well-being. Some of these patients will never gain insight, it is a well-known symptom of psychotic illnesses known as anosognosia. But some might, and often these patients need to relapse to figure it out. I therefore believe these patients deserve a chance off medications if they want to know for themselves, the course of their illness. Over the years, I have decided that I will supervise patients coming off their medications even if against medical advice, even when almost 100% of my patients have relapsed, even when I know that after a first episode, any subsequent episode results in worse outcomes and a worse recovery. This is why a first episode of psychosis warrants special care and attention.

How do I know who will gain insight and who will not? I don't. But it is my philosophy of care to always err on the side that gaining insight is possible. I need to believe that my patients have what all humans need for basic autonomous survival and fulfillment: the ability to learn. This patient population is very young (most are under the age of 25) and physically/mentally at their prime prior to their psychosis. If I presume they can not learn from the consequences of their actions, the consequences of their illness, it is to say that they can not take responsibility for their own mental health. The implications of this presumption contradicts what I know to be good psychiatric care. Because then we treat patients against their will, and it is no longer for them, but for their families and for society. And though I find these to be very worthy causes, it no longer feels like I am abiding by the core principles of my job or staying true to why I chose psychiatry in the first place. It is no longer patient-centred. The sanctity of the patient-psychiatrist relationship is gone...and I do not know then, what there is left.