Abstract

In lieu of an abstract, here is a brief excerpt of the content:Insightlessness, the Deflationary TurnJennifer Radden (bio)Keywordsinsightlessness, deflationary turn, Harry Stack Sullivan, open placebos, space of reasonsMarga 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.Reimer's 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 Meyer's influence in the United States, as well as the influence of psychodynamic (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 without—or without regard for—a 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 one's 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 [End Page 81] 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 patient's condition—medically. This view, which she attributes to contemporary psychiatry, she finds mistaken—and 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 à vis rationality norms, a number of considerations gain salience. The insightless patient, Reimer shows, may...