Mental Nurse

I noted from an ancient posting of Mental Nurse the suggestion of a posting something on “Insight”. I have not seen one yet within these pages and wasn’t sure in what direction Mental muight have been thinking of going but I thought I’d begin one anyhow (as I’ve had two recent dealings of suitable dispute to comment on).

Before you read on, I would note I tend to write in an academic style, not a ‘blog’ writing style. Sorry about that!

This opener looks at my own recent dealings into the “insight” of two distinctly different people.To clarify, my understanding of ‘insight’ isn’t “How well do they understand what I tell them about themselves and how to be better”; it’s more “How well do they know themselves and the effect they have on themselves.”

I recently came across the Mental Health timeline which turned into an interesting read.Amongst many interesting things there, there is reference to writings by John Locke, English philosopher (1632 – 1704) “An Essay on Understanding”, on the mind and the origins of ‘ideas’.

Essentially he proposed ‘ideas’ come from ’sensation’ and ‘reflection’; ie what we sense and how we interpret that sense. He also furthered that we take simple ‘reflections’ and can put them next one another or add them together to make more complex ideas or even reduce them down to more simple ideas.

Eg

Side by side: Sun is out = it is warm. Dog is panting = he is hot. Side by side – sun makes dog hot.

Adding: Sun is out = it is warm. When I get warm I need less clothes – wearing shorts is a good idea

Reducing: sun is out; dog is panting and I’m wearing shorts. It’s probably hot then.

(I have no idea if that is a good analogy of what he was trying to say – but it’s how I understood it!)

Bearing in mind his writings were nearly 300 years ago, he laid down here the basis of social learning theory.

A suitable extract from the essay, in the vein of “insight”:

There is scarce any one that does not observe something that seems odd to him, and is in itself really extravagant, in the opinions, reasonings, and actions of other men. The least flaw of this kind, if at all different from his own, every one is quick-sighted enough to espy in another, and will by the authority of reason forwardly condemn; though he be guilty of much greater unreasonableness in his own tenets and conduct, which he never perceives, and will very hardly, if at all, be convinced of.

Anyhow, back to my recent dealings;

1. A young guy with long illicit drug use history and anti-social traits and a 6 year history of revolving door syndrome; in-patient detention and community restriction under the MHA.

His story is not dissimilar to many others; broken home, violent father and step fathers. Introduced to cannabis by one step father. He remembers his childhood for what it was worth and pretty much understands how he got heavily into illicit drugs and consequentially acquisitive crime. One bad dose or 3 of amphetamine IV and he flipped out. He admits it, he was ill. The man up his nose stealing his oxygen can confirm it. He got treated and the psychoses more or less passed. He had a relapse after winning a substantial amount of money – wonder where that went? After that, he quit IV amphetamines. He continues to have psychotropic depot, despite his clearly evident akithisia side effect. He still imbibes in the weed and occasionally self medicates with benzodiazepines (Valium) to combat the muscular tension of akithisia.

Regardless of the medical recommendation, he continues to use illicit substances tho (tells me he) abstains from amphetamines. Sometimes he self medicates, other times he needs relaxation. He knows IV amphetamines run the highest risk of mental relapse and does not discount the paranoia potential of cannabis. He’s actually taught me a huge amount (more) about illicit drugs; the psychology, physiology and the lifestyle.

Regarding “insight”; the doc records him as a) lacking insight and b) having poor judgment.

This is based on the notion that

a) He says he’s not mentally ill

b) He refuses/fails to cease taking illicit substances.

The point in this matter on both those issues is:

a) He isn’t actively mentally ill, but he knows he has been and runs a risk of becoming so again – even with just stress. He knows the man up his nose who was stealing his oxygen was crazy talk. How that isn’t insight, I don’t know.

b) He chooses to self medicate for genuine reason. Either need to relax (avoid the stress that may bring on the mental illness) or to qualm the akithisia (that prevents him sleeping without Valium and wakes him every morning after it wears off). He might be limited in his knowledge of how to deal with himself in other ways. I would say his judgment is only limited by his knowledge and ability to remedy his issues. So is mine.

He understands the chances he takes in relapsing. He understands his ‘personality’ issues and how they originate from past experiences and his responses. He’s not altogether sure on how to do things differently. Of course, all he has to do is change his coping mechanisms of the last 15 years and he’ll be fine….

I think there needs to be a 3^rd aspect that covers c) ability to choose to act more wisely – his ability is impaired or compromised, not his understanding, and this is for discernible reason. It’s the nature of his issues that are the problem. He’s well aware of them. If it wasn’t his problem, or he had a better way to cope, he wouldn’t be taking drugs or stealing stuff (or under MHA detention).

Locke again…

in all cases where any idea is called true or false, it is from some judgment that the mind makes, or is supposed to make, that is true or false

or….
We only know what we know.

2. A man of late 30’s, ex service man (originally I assessed PTSD as he served in the Gulf – but it seemed unlikely as he was not directly in any conflict. I’m re-evaluating that now based on his stories of only being allowed to sleep 3 hours a night on a good night for 6 months or so).

Diagnosed schizophrenia. Has been maintained in the community. Recent involvement with the police caused him to be re-admitted.

He is recorded as ‘no insight’ but judgment is ‘ok’.

Before I relate the detail, Locke again….

“there is a degree of madness in almost everyone. This is because emotions force us to persist in falsely or unreasonably associating some ideas. Madness is the inability to let reason sort out ideas by relating them correctly to our experiences.”

Locke thinks madness is an inability to reason ideas. Although he says ‘emotions’ force us to be irrational in our thinking when we go mad, I would disagree, and in further comments, he disagrees with himself.

“For our ideas, being nothing but bare appearances, or perceptions in our minds, cannot properly and simply in themselves be said to be true or false, no more than a single name of anything can be said to be true or false.”

Where here he says; we only believe what we believe is true.

Distorted perceptions and hallucinations may be of ‘false origin’ but just because we don’t experience them, doesn’t mean they’re not real to the person. We remember that from training don’t we?

Beliefs (reflections) originate in rationale thinking of experiences (sensations). But in ‘mental illness’ it depends on the false origins of the experiences and subsequent reflections of the person that often lead to false beliefs, or ‘delusions’.

Sherlock Holmes puts it better, if you apply this edict to how people can turn ‘crazy thoughts’ or hallucinatory experiences into fixed deulsional beliefs…

“when you have eliminated the impossible, whatever remains, however improbable, must be the truth”

So back to guy #2. He is schizophrenic. He does hear voices. He does see faces in the floor. He did think his dog wanted him to open a bank account so they could sell puppies and the dog’s live in luxury. He thinks lots of things happen (like clocks stopping, or inconsequential coincidences) as a miracle. He also believes in coincidence though too. I know this, because he tells me, just like he tells the doctor.

The doc told him “You have schizophrenia”

“No I don’t. I’m clairvoyant”

“Insight – nil”.

I talked to him about his experiences. He told me the spirits offered him guidance (?command hallucinations), but he never acts on it without applying his own moral judgment to the issue. He always has the final say. The only time he became angry at the spirit guides was because they didn’t advise him on a particular issue.

He tells me he gets stressed and angry with his dad who yells at him when working on the farm. Or because his dad doesn’t care to hear about his goings on. I’m going to take “A Beautiful Mind” in for him when I can find a copy. He’s never seen it he told me.

My issue with this “insight” is the ’semantics’. He knows exactly what experiences he is having. And they are happening. He doesn’t act on them always, only when he chooses to. Much as Mr Sane would act on his conscious thought or decision-making considerations. He doesn’t act irrationally on the guidance – I asked him if the spirits told him to kill a child, would he. He looked at me as if I were mad – “No! Of course not.”

The fact he doesn’t want to call it shizophrenia shouldn’t matter a fig.

As for the dog and the bank account; I haven’t got to that one with him yet. But I’ll bet there’s a truthful experience and reflection somewhere at the heart of his false belief.

I’ve posted this because, for those who may have read my earlier PTSD posting, I have often (and recently again) come across those ‘deluded’ or ‘psychotic’ patients who, by discussion and discovery, have made more sense to me within their psychotic state than those who seek to treat them.

Psychological therapies with delusions can work. The ‘trick’, I believe, is to accept their world as it is, understand their beliefs from within their world and seek to help them rationalise the context of their experiences. I think that’s psychotherapy. Anyone who doesn’t take the time to get into the world of the person they are treating will never truly know them. That would be known as lacking insight.

Applying unconvincing drug therapies to a supposed disease of unknown origin in which the clinician has no understanding or insight and, even when it stops, improvement is believed only to be because of the medication they’re on – and so they shall stay on it forever – in my reasoning, constitutes poor judgment.

To close, I’ll let the clairvoyant have the last say:

I asked him why he seemed to accept the spirits for who they were and not be distressed by them.

He simply said “Ah, well if I didn’t do that… then I’d probably go mad”.