I will be trying to show that Insight and Capacity are terms of limited use, as they are generally used by busy and overworked care staff.
We’ll start with a made up (more than normal) client. Today her name is Dorothy.
Dorothy is a middle aged married woman. First admission to hospital. Very depressed. Thinks no one likes her and she is too terrible to live. Claims she feels guilty all the time. Family say no known reason for this. On admission admitted to hearing ‘voices’ of ‘dead spirits and demons‘ telling her she was awful and deserved to die and go to hell. Does have a religious background, attends a splinter group of Christians regarded by the local tabloid press as a ‘cult‘.
Let’s consider three degrees of insight. We will use the fairly common working definition used in the previous ranting post.
1. Full Insight
Dorothy accepts that all her experiences are due to a chemical imbalance in the brain following discussion with the multidisciplinary team. She agrees that something needs to be done about it. Happily accepts medication. Gets much better. When discharged is very glad that she is no longer ‘ill‘, is happy to have been ill as she is now ‘better‘.
Doctors and nurses write “excellent insight” in her notes. Everyone is very happy.
Unlikely. But you never know. Some people, honest, actually like the medical model because it allows them to distance themselves from their ‘ill personality‘. Doesn’t mean they blindly accept everything the mental health services tell them but having a medical mental framework can be good for some people.
2. Partial Insight
Dorothy understands that people do actually like her and she is not an awful person. But still considers her voices to be ‘dead spirits and demons‘. Is happy to take antidepressants to help lift her mood but does not imagine that mere chemicals can fight the ’spiritual forces of evil’; therefore she will not touch anti-psychotics. Wants some involvement from fellow members of her congregation. A prayer session may help.
Now there may be an urge to fight Dorothy on the subject of the voices. Convince her they are illness related and have her take the tablets. It may be felt that her religious beliefs are contributing to her problems.
If Dorothy does not develop insight she will not be able to get ‘better‘.
3. As Much Insight As A Sack Of Tayto Crisps
Dorothy considers herself to be possessed by the demons and spirits. The entire hospital does not believe, they all hate her. She deserves to die. Does not accept that anything is wrong with her so does not feel the need to be in hospital.
She may be considered a suitable case for slow rehabilitation ! How is she going to get better if she does not accept she is ill. Dorothy could be looking forward to a long and unpleasant stay on an acute ward that is going to do nothing for her peace of mind.
The above examples may look quite different and in need of various responses from nurses staff. This is not actually the case. The main problem would be the full insight example. Dorothy may not be in hospital long enough for good work to be done with her, hopefully high quality CPN followup will help.
The first thing staff have to do (especially the primary nurse) is build a good relationship with Dorothy. Without that everything else will become nigh on impossible. Remembering the golden rule of never lie to a client goes a long way here.
Do a thorough assessment and identify needs. Try to identify the needs from Dorothy’s perspective.
You may see a jargonified version of the following support plan:
Problem: Dorothy is very very ill. She is depressed and suicidal.
Stuff To Do: convince Dorothy she is ill so she accepts input and treatment from team.
Goal: For Dorothy to accept she is ill.
If Dorothy does not accept this at all you may have problems. Obviously if she considers her right to kill herself to be fine you’re going to override her freedom to do anything about it. The plan would be to allow her as much freedom as possible outside of the limits of dangerous behaviour.
Dorothy may prefer a plan more like the following;
Problem: The spirit voices tell me terrible things. They make me upset and depressed.
Strength: I feel better when I pray.
Stuff To Do: Discuss with staff methods of dealing with the voices. Or at least to stop them from shouting so much. Look at input from church.
Goal: I want to stop feeling suicidal.
Written up properly and with Dorothy’s input a version of the above is probably going to be better for Dorothy.
The hearing voices network have had great success with helping people deal with voices in their own way.
Better than considering her a hopeless case until she develops some insight.
My point, if I ever have one, I think 
Insight is not a goal in and of itself.
People are often happier with their strange and odd beliefs.
One of the many roles of the nurse is to find something that works for the client. We are there to ease suffering and improve their lives. Not force people to accept a world view that may not help them. Not to deny opportunity when they are awkward, impertinent or just plain contrary.
That’s why we work as part of a team so we can share these decisions and use the wisdom of others.
I would far prefer to think I have an Angel following me about telling me I am really nice than have a psychiatrist make me know I am mad.
The problem with us is that we work with people who are often not happy with their odd & strange beliefs won’t consider for a moment they may be ill; there will disregard any good the mental health services can do.
As stated before my reason for wittering on about insight is, rarely, I hear nurses use it as an excuse to not do potentially beneficial work with a client.
I see I have missed anything to do with capacity and it is now too late.
I have to go cook my Pot Noodle Of The Night before I starve to death.
Also my cat is engaging in very Attention Seeking Behaviour.
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*hides*
