While the clinical concept of ‘insight’ is typically used as a diagnostic criterion of schizophrenia (Endicott, et al., 1982) and in mental health nursing, as a key indicator of treatment compliance (Pinkihana, Happell, Taylor and Keks, 2002; Coombs, Deane, Lambert and Griffiths, 2003; Hamilton and Roper, 2006), for several of the student nurse participants, it seemed more to raise the ‘normative uncertainty’ evaluation dilemma.
“I remember that when I was working out on community placement there was this African lady patient who believed that the voices she was hearing was connected to her religious beliefs. She thought that was perfectly acceptable for her to believe, but in this culture, it is not acceptable to believe that. Rather, these voices and beliefs are
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connected to an illness such as psychosis. And she had to have depo injections for what was diagnosed as schizophrenia. She did not want to have those injections, as I think that from her perspective-psychiatric medicine was unacceptable. Rather, she believed that what she was experiencing had a spiritual basis. That seemed to be her cultural worldview if you like.
From my perspective, I felt very torn about that and I felt very uncomfortable about getting involved with that. She was eventually taken back into hospital, and it was very upsetting to hear that. She talked to herself a lot and she would come in to have the depo injection, but she thought she was losing her soul when she was having the injection. She thought that what she was experiencing in terms of her distress was connected to this soul loss. She felt the mental health team were not listening to her about her concerns, and were taking her spiritual beliefs away from her. They were denying the reality of her spiritual beliefs and putting it down to a lack of insight. I don’t think it was in her belief system to have Westernised medicine, and I felt that was enforced on her whether she liked it or not. I did not feel there was any attempt to understand this lady’s cultural beliefs. I am not saying that she was not ill, as obviously, when you look at it from the vantage point of this society and psychiatry, those beliefs and the symptoms of speaking to yourself and hearing voices are indicative of a psychosis. So in that situation, I think it is very difficult to interpret whether it is down to cultural beliefs or a psychosis. And in the culture of mental health services, the fact that she believed she was suffering from ‘soul loss’, means that this lady does not have insight into her illness. But I think everything was just passed on as part of her illness”.
(Male 2nd Year Student, Interview)
“I am actually working with a lady client of Lebanese origin on an older adult assessment ward. She has had acute psychosis, delusions, and she is still responding to auditory and visual hallucinations. She does not believe she is poorly. Rather, she thinks about her condition in a godly sense. And what she has told me and from some of the evidence I have read, that it is acceptable within her culture to hear voices and experiences and these types of hallucinations. It is seen as a gift that is given to them. It is currently a struggle, as she is on a Section 3. She is very upset, as she does not want to be having these depo injections anymore. It is difficult, as she has been assessed that she has no insight into her illness. It seems like the sensible thing to do is to treat her, because we have got a lady who from previous history is known that if she does come off these injections, she is going to be acutely psychotic. The doctor is saying that she has got no insight, but she does, because it is her beliefs. There are patients out there who of course do not have insight, and once they are well, they will look back and think I was really poorly. There are some patients who will never accept they are ill, because that is not their background and that is not their beliefs. So it is our beliefs and our judgements that we do put upon some of our patients.
This lady does talk to me about where she is from and her community, and she was telling me about a relative of hers. I believe it was her nephew and he had visual and auditory hallucinations. And in her community in Lebanon, it was seen like a gift from the spirit world. It was given to them by the spirit world to approach other people and to talk about things they would not normally be able to talk about. They were like messages to other people in the community. It is a hard one, as it is about our beliefs
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and what we feel is right for the individual, which depending on their history and background, may not be the right thing to do. I think that it is a futile attempt really to get her to agree with it. It is something that she believes in so strongly”.
(Female 3rd Year Student, Interview)
These narratives bring to mind cultural critiques of the clinical concept of ‘insight’ (Lazare, 1989; Littlewood, 1990; Perkins and Moodley, 1993; Johnson and Orrell, 1995; 1996; Beck-Sander, 1998; David, 1998; McGorry and McConville, 1999; Saravanan, et al., 2004; 2005; 2007a; Hamilton and Roper, 2006; Lipsedge, 2007; Fernando, 2010; Jacob, 2010). In particular, how its assessment can alternatively be viewed as a judgement about the discrepancy of the service user’s explanatory models (Kleinman, Eisenberg and Good, 1978) with that of the biomedical model. Thus, the assessment of insight can be a form of control and a way of dismissing the (‘emic’) perspective of the service user who resists the biomedical interpretation of their illness and help-seeking strategies (Kilshaw, Ndegwa and Curran, 2002). Research evidence also suggests that in some cases, service users will try to protect themselves from the stigma of mental illness by denying its existence (Kennard, 1979; Lally, 1989; McGorry, 1992; Johnson and Orrell, 1995; Hsu, 1999; Hudelson, 2005; 2006; Perron and Hudelson, 2006). As Kilshaw, Ndegwa and Curran (2002) argue, a person may deny that they are ill not as a consequence of the illness, but as a conscious effort at self-protection. Similarly, Johnson and Orrell (1996, p. 1084) note that a lack of insight could be “a way of coping where the patient finds the implications of a diagnosis of mental illness or the prospect of treatment very unacceptable”. These issues particularly are salient for marginalised cultural groups who have justified concerns about psychiatric medicine and the sorts of interventions it offers (Fernando, 1988; 1998; 2002; 2009; 2010; Bhugra and Bahl, 1999; Bhui, 2002; Ndegwa and Olajide, 2003; Sewell, 2009). Resisting interpretations and diagnostic labels may even be seen as important statements (Kilshaw, Ndegwa and Curran, 2002). Saravanan et al. (2004; 2005) have responded to such criticisms of the clinical concept of insight, by recommending that cultural perspectives be taken into account in assessment. In particular, they encourage practitioners to bring the evaluation of insight in line with the DSM-IV’s (American Psychiatric Association, 1994) guidelines on the cultural assessment of delusions.