Insight, the law and psychiatry: Going round in circles or playing nice?

BACKGROUND: Insight is an important facet of psychosis which can predict many clinical outcomes. Recently, the construct has come under scrutiny, particularly in medicolegal settings where lack of insight is given as a justification for involuntary treatment. OBJECTIVES: This article reviews the arguments around the use of insight in evidence in cases of involuntary treatment and admission to hospital, and capacity to make healthcare-related decisions. It aims to clarify the place of insight and how it might be used beneficially in such discussions for clinicians and legal practitioners. METHODS: This is a narrative review of the insight construct in clinical psychiatry and medicolegal settings. The article draws on case material and in particular a recent case brought before the England and Wales Court of Protection (CoP). RESULTS: The insight concept is most often used to explain non-compliance with treatment and rejection of or disbelief in a mental illness diagnosis, where it has been faulted on grounds of circular reasoning. Its invocation in legal settings has been criticised, not least by the National Institute of Health and Care Excellence (NICE) since insight is often poorly defined and is not part of the criteria for, for example, mental incapacity. Nevertheless, a deeper understanding of what psychiatrists mean by insight can help in understanding how a patient's psychotic illness might seriously impair their capacity and lead to them to require care without their consent. The case discussed in the CoP exemplifies how insight can be misunderstood and misused by parties in a dispute. DISCUSSION: Insight remains a commonly discussed aspect of psychopathology and frequently arises in medicolegal arguments. Mental health practitioners giving clinical accounts and expert testimony should be aware of the strict definition of mental capacity and criteria for involuntary treatment. If they wish to refer to the patient's insight, they should take care to define what they mean but crucially they should carefully explain how insight can shed light on aspects of capacity, as advised by NICE. However, poor insight is a core aspect of psychosis and is closely related to lack of capacity and (contra NICE) should not be treated as a distinct concept.