Insight in psychosis: Standards, science, ethics and value judgment

Background: The clinical assessment of insight solely employs biomedical perspectives and criteria to the complete exclusion of context and culture and to the disregard of values and value judgments. Aim: The aim of this discussion article is to examine recent research from India on insight and explanatory models in psychosis and re-examine the framework of assessment, diagnosis and management of insight and explanatory models. Methods: Recent research from India on insight in psychosis and explanatory models is reviewed. Results: Recent research, which has used longitudinal data and adjusted for pretreatment variables, suggests that insight and explanatory models of illness at baseline do not predict course, outcome and treatment response in schizophrenia, which seem to be dependent on the severity and quality of the psychosis. It supports the view that people with psychosis simultaneously hold multiple and contradictory explanatory models of illness, which change over time and with the trajectory of the illness. It suggests that insight, like all explanatory models, is a narrative of the person’s reality and a coping strategy to handle with the varied impact of the illness. Conclusion: This article argues that the assessment of insight necessarily involves value entailments, commitments and consequences. It supports a need for a broad-based approach to assess awareness, attribution and action related to mental illness and to acknowledge the role of values and value judgment in the evaluation of insight in psychosis.