How's your insight today?

A reader asked: "Would you be able to write something with as much detail as possible about insight and capacity to consent within the psychiatric and mental health system, and the MHRT?"

If the lady meant "Could I write something about insight and capacity to consent that would sway a mental health tribunal?" this could be the shortest post of all: No. Nothing I can say will sway them. Their minds are made up, locked and the keys thrown away.

"Insight" is a meaningless term with no scientific standing. The dictionary defines it as "... the capacity to gain an accurate and deep understanding of someone or something." The problem with trying to use it in a scientific or legal context is that it cannot be operationalised. That is, "insight" is a decision we make about another person which has no steps or procedures that must be followed in order to arrive at a verifiable outcome (i.e. it has no reliability). Following on, there are no tests to show whether that outcome correctly states something real about the person (i.e. no validity). In other words, it is a value judgement or sentiment, of the same class of words such as faith, honour, inspiring, likable, and so on.

Just as these terms could not be used in a scientific context, so too with "insight." It is wide open to abuse, especially in the setting of deciding on somebody's liberty. Imagine a "hearing" where the tribunal said "Well sir, if you had sufficient faith, you wouldn't be in this mess. You'd better stay here until you develop faith" (I'm sure that's been said many times through history; it's why American prisons are called 'penitentiaries', places for penitence).

The lady added: "... insight is not mentioned once in the Qld MHA 2016." I'd be surprised if it was ever mentioned as Acts are written by parliamentary draughtsmen who usually know better than to rely on an undefined word. The dictionary adds that in psychiatry, insight is "... awareness by a mentally-ill person that their mental experiences are not based in external reality." That's not how it's used in practice. Most people who hear voices know that others can't hear them but that doesn't reduce the sense that they are real. A person can say: "I know you can't hear them, I know they're caused by something going wrong in my head but they're still there and still horrible." By the definition, that's insight but... If the person then says "And no, I don't want your drugs, they make me fat and dopey and they wreck my sex life," that's considered "insightless."

This also applies to people complaining of feeling depressed. A person can say "I feel hopeless and useless, I can never do anything right and if I dropped dead now, everybody would be better off." It may in fact be an accurate reflection of that person's reality but if the person then says "No, I don't want your ECT, I'd rather see a therapist who listens while I sort it out myself," then that person would be deemed "insightless and unreasonably refusing treatment," and would be detained and get the ECT anyway.

The reason insight has never been operationalised is that doing so would expose the heart of the concept as a falsehood, that it is purely a subjective decision in a field claiming to be an objective science of mental disorder. As it is used in psychiatry, the word refers only to the imbalance of power between psychiatrist and nominated patient, which is written into mental health acts. Capacity to consent is somewhat different, as we can quickly devise steps to follow to determine whether the person has capacity, e.g. Is she conscious? Is her memory intact? Can she focus long enough on the topic? Can she make other decisions? and so on. Using these steps, it's not difficult to decide whether the person has legal capacity or not.

Psychiatrists, however, aren't satisfied with that. They don't want to know the patient has the wit to decide against their treatment, so the problem here is whether capacity measures something valid and general. Correctly applied, capacity to consent would still be true regardless of the outcome, but in practice, that never happens because of a further, hidden step, like: "Does she agree with us or disagree?" If she agrees to go along with the drug injections and ECT, then everybody's happy she has legal capacity but if she disagrees, suddenly it's a different story.

I haven't surveyed sitting members of MHRTs anywhere but I'm quite sure that they all believe insight is a valid mental quality that can be reliably assessed by psychiatrists using one of the many mysterious tools of trade they learned in psychiatry school. There is no truth in this. Joan Robinson, the late socialist economist from Cambridge, said that the value of studying economic theory lies in being able to avoid being deceived by economists. This is also true of psychiatry, which has managed to pull the wool over the eyes of the general public, the funding and supervising agencies, governments, and themselves, with the story that they actually know what they are doing. They don't. There is no test of insight. End of story.

Putting that aside, I've sat through hundreds of tribunal hearings in three states and I have zero confidence that a person going into one can be sure of a fair and unbiased hearing. Part of this is because the evidence is unsworn, and hearsay is given full weight - when it supports the hospital. Partly it is because some 97% of people appearing before tribunals in Queensland have no legal representation and are generally too confused and over-awed to state their case; partly because very often, the patients haven't seen any of the documents being used and even then, generally can't understand them; and the rest because the people who are appointed to these posts are vanishingly unlikely to disagree with the hospital. I am not aware that a critic of mainstream psychiatry has ever been appointed to a mental health tribunal. Tribunals represent the bureaucratic status quo: paternalistic; convinced that mental disorder is a biological "thing" because the experts tell them; rule-abiding; risk-averse; totally oriented toward institutions and legal form and process; eagerly deferential to authority; and resentful of challenges. But that's the nature of power hierarchies the world over.

So what's the answer? In the short term, there isn't one. This is the system we've got so we're stuck with it. However, this system is why the legislative guidelines issued by World Health and the UN Human Rights Commission last week are so important: they are the first serious challenge to the status quo regarding society's attitude toward and treatment of mental disorder. Anybody reading this should have a copy, available here. The first chapter is the important bit. Nonetheless, I would be very wary about walking into a tribunal hearing waving the Guidelines as it will not go down well, so legal advice is essential. Trouble is, the lawyers all believe the same thing anyway. We'll come back to this topic in due course.

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My submission to the Senate ADHD enquiry has just been published, nearly five months after it went in. It is No. 634, on about p32. You might also like to look at two more, the first by the Critical Psychiatry Network of Australia, which is No. 7, and one by Dr Martin Whitely, of Curtin University, in Perth, No. 64.

On the subject of ADHD (sorry), a paper from 2 years ago has just arrived which reviews the relationship between ADHD (a diagnosis in young people) and Parkinson's Disease (the second most common neurologic diagnosis in the elderly) [1]. After a great deal of flummery, the author concluded:

(a) there is an association between the two diagnoses (notice how I'm not saying ADHD is a "condition");

(b) it is unlikely to be genetic,

(c) it is therefore likely to be something in the environment,

(d) amphetamines are known to cause Parkinson's symptoms in animals and drug abusers, so

(e): " Among the possible environmental exposures, stimulant treatment of ADHD is the most salient. Further research on the possible link between clinical use of stimulants and PD is urgently needed... If an association between clinical use of stimulants and Parkinson's Disease or related disorders is confirmed, it could have serious implications for therapeutics and public health."

Well, who could have suspected that giving children long-term toxic and addictive drugs could possibly have affected their young, growing brains? Wonders will never cease. We'll have to make sure the Senate enquiry is aware of this before they issue their inevitable call for more drergs for more people for longer for less reason. Meantime, the ADHD industry probably should start saving their small change for the barrage of law suits claiming damages.

On the topic, I'm sure you will be worried to hear that Mr Sam Bankman-Fried, he of the $8billion FTX fraud, is complaining that his Adderall (drug used to treat ADHD) isn't lasting the whole day in court and he loses concentration. That's so sad to hear: maybe when he gets out (they're talking of 115 years in the slammer), maybe he'll lift his game so he doesn't end up in court again. But more to the point, when he pleads that he should be acquitted because his mental disorder made him do it, he makes life just that little bit harder for people who genuinely do have mental problems.

Reference:
Baumeister AA (2021). Is Attention-Deficit/Hyperactivity Disorder a Risk Syndrome for Parkinson’s Disease? Harvard Review of Psychiatry, DOI: 10.1097/HRP.0000000000000283