Treatment Adherence in the Absence of Insight A Puzzle and

a Proposed Solution
Marga Reimer
Philosophy, Psychiatry, & Psychology, Volume 17, Number 1,
March 2010, pp. 65-75 (Article)
Published by The Johns Hopkins University Press
DOI: 10.1353/ppp.0.0273

For additional information about this article

http://muse.jhu.edu/journals/ppp/summary/v017/17.1.reimer01.html

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Treatment
Adherence in the
Absence of Insight:
A Puzzle and a
Proposed Solution
Marga Reimer

Abstract: Patients with psychosis often have poor

insight into their illness. Poor insight into illness is, at
least among patients with psychosis, a good predictor
of treatment non-adherence. This is no mystery, for
as Xavier Amador asks, Who would want to take
medicine for an illness they did not believe they had?
What is curious is that some patients with psychosis
do adhere to treatment despite a lack of insight. Why
do these patients adhere to treatment, given that they
do not believe they are ill to begin with? In this paper,
I attempt to answer this question. I do so by first considering cases of non-psychotic patients who adhere to
treatment despite a lack of insight. I point out that these
sorts of cases are commonplace, and attempt to explain
why they arise. The explanation is given in terms of
anticipated treatment benefits. However, these benefits
are not conceptualized by the patient in terms of pathology. The patient does not, in other words, think of such
benefits in terms of illness, symptoms, treatment, and so
forth. I then argue that the proposed explanation can be
extended to account for why psychotic patients without
insight sometimes adhere to treatment. I conclude by
drawing out some of the practical implications of the
proposed view. I first argue, on practical as well as
ethical grounds, that improving insight for purposes of
treatment adherence is misguided. I then suggest that
such adherence might be increased simply by explaining
treatment benefits in language that does not presuppose
that the patient is, in any sense, ill, diseased, sick,
unwell, and so on.
2010 by The Johns Hopkins University Press

Keywords: psychosis, illness, symptoms, medication,

side effects, anosognosia
Poor insight is among the best predictors of nonadherence to treatment. It is common sense really. Who
would want to take medicine for an illness they did not
believe they had? (Amador 2006).
Insight clearly aids compliance but what is peculiar . . .
is that patients can have no insight into illness and yet
still accept and derive benefit from treatment (David
1990).

hat insight into psychosis aids treatment

adherence is well-known (McEvoy 1998).1
Patients with psychosis are significantly
more likely to adhere to treatment if they are
aware that they are mentally ill. That insight into
psychosis does not guarantee treatment adherence is also well-known (McEvoy 1998). Some
psychotic patients who are aware that they are
mentally ill nevertheless fail to adhere to treatment. Unpleasant side effects are a common
reason for such non-adherence. Other frequently
cited reasons for non-adherence include expense,
delayed access to services, and complicated dosing schedules (McEvoy 1998). Conversely, some

66 PPP / Vol. 17, No. 1 / March 2010

psychotic patients who deny that they are mentally

ill, nevertheless adhere to treatment. Initially, at
least, this is surprising. As Xavier Amador asks in
a recent article: Who would want to take medicine for an illness they did not believe they had?
(Amador 2006, 3).
Anthony David seems to share Amadors attitude; he describes as peculiar the fact that
patients can have no insight into illness and yet
still accept and derive benefit from treatment
(David 1990, 800). One might initially suppose
that this peculiarity is easily explained: If a patient is suffering from psychosis, he might say or
do just about anything. There is often no way to
make sense of the disordered thoughts and behaviors of the psychotic patient. Thus, that a patient
suffering from psychosis might take medicine for
an illness that he does not believe he has, should
hardly come as a surprise.
As I hope to show in what follows, this sort of
attitude is completely misguided. I begin by offering an alternative explanation of the peculiarity
noted by David, thereby providing a solution to
the puzzle posed by Amadors question. I argue
that psychotic patients without insight might
adhere to treatment simply because they believe
that, by doing so, they will reap some sort of
benefit. There is accordingly nothing peculiar
in such adherence. The anticipated benefit(s) is
not, however, conceptualized by the patient in
terms of the amelioration of symptoms, such as
hallucinations, delusions, or disordered thoughts.
For the patient (by hypothesis) does not believe
that he is ill to begin with.
I motivate the proposed view by first considering cases not involving psychosis. I argue that
non-delusional patients often adhere to treatment while denying that they have the illness for
which the treatment has been prescribed. In these
ordinary everyday cases, patients adhere to treatment simply because they believe that, by doing
so, they will reap some sort of benefit. However,
the anticipated benefit(s) is not conceptualized
in terms of illness, treatment, symptoms, or any
other notion that suggests the presence of pathology. This point is then extended to cases involving
psychosis. After then generalizing the proposed
explanation so as to account for cases of treat-

ment non-adherence in the presence of insight,

I conclude by drawing attention to some of the
practical implications of the proposed view. I first
argue against trying to improve insight for purposes of treatment adherence. I then suggest that,
in cases of psychotic patients with poor insight,
treatment adherence might be increasednot by
improving insightbut simply by increasing the
patients awareness of the potential benefits of
treatment adherence. The crucial point would be
to explain these benefits without using language
that presupposes that the patient is, in any sense,
ill sick, or diseased.

Adherence Without Insight:

Non-Psychotic Cases
Consider the following three cases.

Ms. A
Ms. A complains to her doctor about a cold that
she just cant shake. Shes had it for months! Her
doctor diagnoses her with seasonal allergies and
recommends that she try some diphenhydramine
(Benadryl). Ms. A remains convinced that she
has a cold, not allergies, but decides to give the
diphenhydramine a try anyway. Perhaps it will
help with her cold symptoms (sniffles, sore throat,
headache). It does indeed help and eventually her
cold goes away. However, Ms. A continues
with the diphenhydramine because, when taken
before bedtime, it allows her to sleep through her
husbands incessant snoring.

Ms. B
Ms. B goes to a dermatologist for an Obagi
Blue Peel, as the local salon informed her that
such (chemical) peels should only be performed in
a doctors office. During the mandatory pretreatment consultation, the doctor diagnoses Ms. B
with acne, a common skin disease. He recommends that she hold off on the chemical peel and
try some Retin-A for her acne. Ms. B is convinced
that the doctor is wrong, teenagers get acnenot
grandmothers like herself. She might have a few
blemishes, but she certainly does not have a
skin disease. However, she really wants the
chemical peel (shes seen the before and after

Reimer / Insight 67

pictures on the Internet), and so she gives the

Retin-A a try. The blemishes do clear up, but she
hardly notices. What she does noticeor rather
fails to noticeare her wrinkles, especially the
ones around her eyes. They are all but gone. She
decides to forego the chemical peel, but continues
with the Retin-A. She does not want the wrinkles
coming backand they do not (neither do her
blemishes).

Mr. C
Mr. C, whos in the middle of a contentious
divorce, always seems to be irritable. In fact, as
he informs his doctor, hes been feeling really
grumpy for the past two or three years. The
doctor diagnoses Mr. C with dysthymia, chronic
low-grade depression. She does not prescribe
medication, but instead recommends that Mr. C
exercise daily and improve his diet (more fruits
and vegetables, less fast food). Mr. C does not
agree with the doctors diagnosis and jokingly
remarks, Im not depressed, I just have grumpy
old man syndrome. Still, he adheres to the doctors recommendation because he wants to be in
good physical shape when he starts dating again.
After about six weeks, Mr. Cs irritability gradually
starts to subside. Within the year, he is back to his
old self and feels great. He attributes his new
lease on life to the ego-boost of being in such
fantastic shape. He vows to eat healthy and take
regular exercise for the rest of his life.

Why Adhere?
Why do these patients adhere to treatment
when they do not believe they have the condition
for which the treatment has been prescribed? The
answer is straightforward. The patients in question
associate treatment adherence with some clearly
identifiable benefit. The benefit varies from patient
to patient. Ms. A is able to sleep through her husbands snoring, Ms. B no longer has any wrinkles
around her eyes, and Mr. C, because hes gotten
into such great shape, feels fantastic. These three
hypothetical cases illustrate a pervasive, rather
than isolated, phenomenon. It is a phenomenon
with which we are all familiar. The toddler who
reminds his mother that its time to give him some

more of that yummy purple stuff, may have no

idea that he is taking medication for a sinus infection; the college student who remains skeptical
of his doctors claim that he has something called
GAD, might nevertheless request a second refill
on his alprazolam (Xanax), and become panicky
when the doctor hesitates.
Similar considerations arguably apply to nonpsychotic patients with insight. Such patients,
when they adhere to treatment, do so because they
believe that adherence will benefit them. The difference is that the patients with insight, in contrast
to those without insight, tend to conceptualize the
benefits of treatment adherence in overtly medical
terms (illness, symptoms, treatment) that presuppose the presence of pathology.

Application to Cases
Involving Psychosis
Now lets turn to cases involving psychosis.
Some psychotic patients might take medication,
not because they believe they have the illness for
which the medication has been prescribed, but
simply because they want to be rid of their distressing thoughts and experiences. Perhaps they want
something to calm their nerves, something to
reduce the strain that they are currently experiencing (David 1990, 800). Even if a patient is
convinced that the voices are real, he might
nevertheless believe that, with treatment adherence, those voices will eventually go away, or at
least subside. Similar considerations might apply
to a patient unable to focus on anything other
than her colleagues plot to get her fired. Perhaps
if she adheres to the prescribed treatment, she will
regain her ability to concentrate on other matters.
Previous experience with treatment adherence
might well support, and thereby strengthen, such
beliefs.
In these sorts of cases, what we have are patients taking medicine prescribed for illnesses they
do not believe they have. It would be misleading
to say (echoing Amador) that we have patients
taking medicine for illnesses they do not believe
they have. Whereas a physician might say of her
psychiatric patient that he is taking medicine for
his mental illness, the patient himself might em-

68 PPP / Vol. 17, No. 1 / March 2010

phatically deny this. Suppose, for instance, that

a physician prescribes clozapine (Clozaril) for a
schizophrenic patient, who takes the medication as
prescribed. It does not follow that the patient sees
himself as taking clozapine for schizophrenia, or
even for mental illness more generally. Perhaps
he takes it only because it makes the voices go
away, voices that are (to the patient) very real, and
so not indicative of any sort of pathology.
The point generalizes beyond the medical
realm. An item might be sold as a doorstop and
yet be purchased by someone who intends to use
it as a paperweight. Suppose that the purchaser
does in fact use the doorstop in question as a
paperweight. In such a case, we would not say
that the purchaser was using the doorstop as a
doorstop; we would say that she was using it as a
paperweight, despite the fact that it was sold as a
doorstop. There need not be anything peculiar
about purchasing, and making use of, a doorstop
even when one has no need of doorstops per se. For
the purchased doorstop might be used as something other than a doorstop; it might (for example)
be used as a paperweight. Using the doorstop as
a paperweight is a perfectly reasonable (even if
aesthetically questionable) thing to doprovided,
of course, that it serves the intended purpose of
weighting down papers.
In the same way, taking medication prescribed
to treat psychosis for the purpose of (for example)
sound sleep and peace of mind, might be quite
reasonable. It might be reasonable if the medication does in fact induce sound sleep and peace of
mind in a patient who would otherwise be up all
night on account of his racing thoughts.2 Thus,
there need not be anything peculiar about taking
medication prescribed for an illness that one does
not believe one has.
For some psychotic patients without insight,
taking neuroleptics might be analogous to wearing
a cross, a charm, or an amuletor even a good set
of noise-reducing headphones. For others, taking
neuroleptics might be analogous to taking vitamins
or some sort of tonic or elixir. Still others
might view themselves as taking the prescribed
medication for an off-label use. This might, for
instance, be true of a bipolar patient who views
himself as taking quetiapine (Seroquel), not for any

sort of mental illness, but only so that he can

concentrate during the day and sleep through the
night. Even if his doctor says that the medication is
for bipolar disorder, this would not prevent the
patient without insight from taking it solely for his
difficulties with concentration and sleep. Such rationalizations of treatment adherence are perfectly
in keeping with the idea that one is not suffering
from any sort of serious mental illness.
Viewed thusly, there is nothing especially peculiar (pace David) about patients without insight
adhering to treatment. The phenomenon is not
restricted to patients with psychosis. As we have
seen, it easily generalizes to non-psychotic patients.
Like the patient taking clozapine to quiet the
voices, Ms. A takes diphenhydramine so that she
can sleep through her husbands snoring. Neither
the delusional patient nor the sleep-deprived wife
believe that they are, in any sense, ill. In this
respect, they both lack insight. Nevertheless, they
willinglyand rationallytake the prescribed
medication. What such cases show is that there
need not be anything peculiar about treatment
adherence in the absence of insight. Indeed, in
cases of the sort described, such adherence makes
perfect sense.

Empirical Support
Fortunately, there is more than common sense
to support the idea that psychotic patients without
insight might adhere to treatment simply because
they perceive such adherence as somehow benefiting them. There are experimental data, gathered
over several decades, that suggest as much. Some
of the more revealing data are discussed in McEvoys (1998) The Relationship Between Insight
in Psychosis and Compliance with Medication.
Indeed, the data suggest that perceived (or anticipated) treatment benefit may be an even better
predictor of treatment adherence than insight.
Consider, for instance, the study by Irwin et al.
(1985), involving 33 patients with schizophrenia.
As McEvoy reports:
Neither acknowledgment of illness, factual understanding about the medications, nor prior experience
of extrapyramidal side-effects predicted consent vs.
refusal. Rather, patients perceived benefits from prior
antipsychotic treatment most powerfully predicted

Reimer / Insight 69

willingness to consent [to treatment]. (Emphasis added;

1998, 295)

A study by Buchanan (1992) is also illuminating. Buchanan, purporting to measure insight,

asked sixty-one soon to be discharged schizophrenic patients the following six questions:
1. Do you think that you have been unwell during this
admission?
2. Do you think that you will become ill again?
3. Did treatment help?
4. Will you take treatment after you discharge?
5. Will you ever get back to your old self?
6. Why were you at the hospital?

Note, first of all, that all but questions 3 and

4 are directly relevant to insight as traditionally
conceived: Awareness of illness.3 Yet, it was affirmative responses to questions 3 and 4 (not to
questions 1 and 2) that were significantly positively associated with treatment adherence over
the follow-up period. What this suggests is that
perceived treatment benefitrather than awareness of illnessis, at least in some cases, what
drives treatment adherence.
Finally, consider Soskis (1978) study, which
compared twenty-five schizophrenic inpatients
receiving neuroleptics, with fifteen non-psychiatric
inpatients receiving medication for a variety of serious non-psychiatric illnesses. As McEvoy (1998,
293) reports: Both groups were more likely to
say they would take medications the more they
reported that the medications helped them. In
other words, patientswhether or not they were
mentally illperceived themselves as more likely
to adhere to treatment if they actually perceived
the benefits of doing so.
All in all, the studies in question suggest that,
at least among psychotic patients, perceived
treatment benefit is not only a good predictor of
treatment adherence, but an even better predictor
of such adherence than insight.4
Although the studies discussed above were conducted in the 1970s, 1980s, and early 1990s, more
recent studies confirm much the same hypothesis.
Some such studies, discussed by Dieter Naber
and colleagues (2005), suggest that subjective
well-being has a direct bearing on treatment adherence, particularly among psychiatric patients
prescribed neuroleptics. Not surprisingly, these

patients tend to adhere to treatment when such

adherence is perceived (by the patients) as improving their sense of well-being, where well-being
is conceptualized in terms of (inter alia) emotional
regulation, self-control, mental functioning, social
integration, and physical functioning.
This is of course consistent with the proposed
view, according to which the driving force behind
treatment adherence is the belief, often supported
by past experience, that adherence will yield
tangible benefits to the patient. This is a belief
that can, and apparently often does, exist in the
absence of insight.

Seeking Medical Advice

Thus far, my central aim has been to argue
that there need not be anything peculiar about
psychotic patients without insight adhering to
treatment. In motivating this view, I have appealed
to cases of non-psychotic patients without insight
adhering to treatment. I do not, however, mean
to suggest that the two sorts of cases are exactly
parallel. There is at least one striking difference
between them. The non-psychotic patients tend to
seek out medical advice. They might seek medical advice for an apparent cold or for problem
skin; or maybe its just time for an annual physical. These patients are aware of the fact that they
might have a condition for which medical treatment is appropriate. The same cannot be said
of patients with psychosis, who typically do not
seek medical advice for the particular difficulties
caused by their illness. Instead, these patients are
often brought to a doctor or a hospital by friends,
family, or even the police. We might attempt to
capture this epistemic difference by saying that
the patients without psychosis, in contrast to
those with psychosis, have a kind of partial, or
perhaps potential, insight. Whereas the former
do not believe that they have the condition for
which the treatment has been prescribed, they
do not assume that they have no condition(s) for
which medical treatment might be appropriate.
However striking this difference may be, it does
not affect the point for which I have been arguing:
That patients, whether or not they are delusional,
might rationally adhere to treatment prescribed for
conditions they do not believe they have.

70 PPP / Vol. 17, No. 1 / March 2010

Insight Without Treatment

Adherence
Before discussing some of the practical implications of the proposed view, let me offer one
further consideration on its behalf. The view can
be generalized to explain treatment non-adherence
in the presence of insight. Lets start by focusing
on psychotic patients. Why do psychotic patients
with insight sometimes fail to adhere to treatment?
Perhaps the answer is often a matter of anticipated
drawbacks versus benefits: The patients believe
that the drawbacks of adherence outweigh the
benefits of adherence. Even if a patient knows that
he is psychotic, and knows (from past experience)
that the prescribed medication will ameliorate
some of his more distressing symptoms, he might
nevertheless fail to take the prescribed medication. As noted above, a common reason for nonadherence is unpleasant side effects. Indeed, there
are many such effects (see http://www.nmha.org),
including,
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.

Loss of energy and drive.

Feeling unmotivated or numb.
Daytime sedation or drowsiness.
Sleeping too much.
Muscles being tense or stiff.
Muscles trembling or shaking.
Feeling restless or jittery.
Need to move around and pace; cannot sit still.
Insomnia.
Blurry vision.
Dry mouth.
Drooling.
Memory and concentration difficulties.
Constipation.
Weight gain.
Sexual dysfunction.
Menstrual/breast problems.

It is no wonder that psychotic patients with

insight sometimes fail to adhere to treatment. The
net effect of treatment adherence might seem to
the patient more harmful than beneficial. Indeed,
side effects of the sort just enumerated sound
remarkably like symptoms of illnesswhether
mental (as in loss of energy and drive) or physical
(as in muscles trembling or shaking).
It is likely that similar considerations apply to
cases of non-psychotic patients with insight. A

patient might concur with the doctors diagnosis

that she is suffering from allergies, but not adhere to the prescribed treatment (antihistamines)
because the side effects (drowsiness, dry mouth)
are worse than the symptoms (sniffles) of the diagnosed condition. Another patient who is aware
that he has hypertension might conveniently forget
to take his medication on account of the sexual
dysfunction it causes.
The bottom line is simple: Patients tend to
adhere to treatment when, and only when, they
believe that doing so is likely to benefit them in
some way. More precisely, the patient who takes
his medication as prescribed tends to do so when,
and only when, he believes that the net effect of
doing so will amount to a benefit.5 This is true
regardless of whether the patient has insight; it is
true regardless of whether the patient is psychotic.
Such adherence is likely a consequence of a general principle of human behavior: We tend to act
in accordance with what we perceive, rightly or
wrongly, to be in our best interests. If the proposed
view is correct, this is a principle that does not
discriminate between the mentally healthy and
the mentally ill.
In concluding this section, lets return to
Amadors question: Who would want to take
medicine for an illness they did not believe they
had? The foregoing considerations suggest the
following response: Perhaps no one (who is
rational) would willingly take medicine for an
illness they did not believe they had. No rational
person who did not believe that he was (for example) diabetic would take insulin for his alleged
diabetes; no rational person who did not believe
that he was schizophrenic would take clozapine
for his alleged schizophrenia. Nevertheless, there
are undoubtedly many patients, psychotic as well
as non-psychotic, who would willinglyand
rationallytake medicine prescribed for an illness
they did not believe they had.

Practical Implications
As noted by Amador (2006), poor insight
into psychosis is among the best predictors of
treatment non-adherence. One might therefore
suppose that adherence could be increased simply

Reimer / Insight 71

by improving insight. Unfortunately, insight is

difficult, and sometimes impossible, to improve.
Amador (2006) offers a plausible, empirically supported, explanation for this. Lack of insight, when
severe and persistent, is rooted in neurological
abnormalities. Such abnormalities tend to resist
treatment, pharmacological as well as psychotherapeutic. Indeed, Amador suggests that, among
schizophrenics, lack of insight may be a form of
anosognosia: The inability to recognize (in oneself)
neurological deficits, such as blindness or paralysis, that are obvious to outside observers. Amador
accordingly recommends that the schizophrenics
characteristic lack of insight be reconceptualized
as anosognosia for schizophrenia, and that it
be regarded as a potentially intractable symptom
of the disease (Amador 2006).
However, even if it were possible to improve
insight into psychosis, doing so for purposes of
treatment adherence might raise concerns, ethical
as well as practical.6 Lets begin with the latter.
Why do patients with insight tend to adhere to
treatment in the first place? No doubt some believe
that, being ill, they might benefit from treatment
adherence. This belief might then be reinforced if
adherence is accompanied by tangible benefits. It
is therefore natural to suppose that, by improving
insight, treatment adherence might be increased.
However, it might be simpler, from a strategic
point of view, to bypass insight into psychosis
and proceed directly to awareness of treatment
benefits. A therapist might, for example, tell her
schizophrenic patient that the prescribed medication will make the voices go away, or at least
subside. If the goal is treatment adherence, she
need not add: Besides, the voices arent real, they
are all in your head; they are a symptom of your
mental illness.7
One might argue that improving insight would
only enhance any antecedent awareness of treatment benefits, and would therefore be a good thing
insofar as it would provide further motivation for
adherence. Although this way of thinking might
sound perfectly reasonable, it is not obvious that it
reflects the reality of what drives human behavior.
Having good reasons to do something does not
necessarily translate into being motivated to do
that thing. Consider a young woman who has been

a chronic smoker since her early teens. Why should

she stop smoking? The answer is clear: Smoking is
bad for ones health; it can lead to serious illnesses
such as lung cancer and emphysema. Despite having known this for years, the woman continues her
two-pack-a-day habit, until she meets a man who
refuses to date a woman who smokes. She then
quits smoking because she wants to date this man.
Who would deny that, although it was commendable that the woman quit smoking, her motivation
to do so could have been better? Consider now the
psychotic patient who, through intensive therapy,
has acquired insight into his illness. Suppose that
he now knows that, unless treated, his illness is
bound to lead to hallucinations, delusions, disordered thoughts, and ultimately hospitalization or
even prison. He then has the best of reasons to
adhere to treatmentbut that is no guarantee that
he will adhere. Perhaps, when he eventually does
adhere to treatment, he does so largely because
hes become infatuated with his caseworker, who
says that it would mean so much to her if he
took his medication as prescribed.
Still, there is surely something to the idea that
insight at least tends to increase a patients motivation to adhere to treatment (McEvoy 1998). In
some patients, this is undoubtedly true. My point
is simply that insight does not always motivate a
patient to adhere to treatment, and is arguably
unnecessary when sufficient motivation for adherence is already present.
There are, moreover, ethical considerations
that tell against improving insight for purposes
of treatment adherence. There are at least three
such considerations, two of which are concerned
primarily with the patient, one of which is concerned with both the patient and the institution
(contemporary medical psychiatry) ultimately
responsible for his diagnosis. Lets begin with the
former (two) considerations.
First, insight into psychosis might conceivably
lead to further psychological problems, including
major depression (Crumlish et al. 2005). Given the
stigma associated with mental illness, becoming
aware of the fact that one is mentally ill might
be about as uplifting as becoming aware of the
fact that one is overweight, or of merely average
intelligence. Moreover, the practical value of being

72 PPP / Vol. 17, No. 1 / March 2010

told (for example) that one is overweight or not

especially intelligent, is dubious. A family doctor
might achieve the desired result simply by telling
her patient that a healthy diet and regular exercise
might improve, not only life expectancy, but also
quality of life. There is no need to add: In medical terms, you are obese. A guidance counselor
might achieve the desired result simply by telling
her average (if mechanically inclined) charge,
that a good mechanic makes more money than an
unemployed mechanical engineer. There is no need
to add: Besides, your IQ score puts you squarely
within the average range and to be an engineer,
you have to be really smart. Similarly, perhaps
the psychiatrist should avoid emphasizing to her
patient that he is mentally ill and therefore in
need of psychiatric treatment, including treatment with antipsychotics. She might instead
emphasize that the patients difficulties (as articulated by the patient himself) might subside if
he tries something that works well for many of
those with similar difficulties. (See Beck-Sander
[1998] for a similar point.) This is not to say that
the therapist should be dishonest; it is not to say
that she should actively conceal from her patient
her belief that he is mentally ill. It is only to say
that, in psychotic patients with poor insight, increasing treatment adherence might be achieved
without emphasizing the point, potentially upsetting to the patient, that the medication is being
prescribed to treat the symptoms of a serious
mental illness.
Second, patients should of course adhere to
treatment for the right reasons, and it is doubtful
that awareness of illness is, in and of itself, such a
reason. Indeed, there is arguably only one right
reason to adhere to treatment: Potential benefit
to the patient. To see this point, consider two
schizophrenic patients, Ms. D and Mr. E, both
prescribed ziprasidone (Geodon) for their mental
illness. Suppose that a mutual acquaintance learns,
while engaged in casual conversation with Ms. D
and Mr. E, that both are taking Geodon. She then
asks them: Why are you guys taking that stuff?
Are you mentally ill? Imagine their responses are
as follows.
Ms. D: Yeah, I have schizophrenia and its really important that I take something for it because schizophrenia is

a serious mental illness. Thats what my doctor says,

and she thinks Geodon is best for me. But I hate it, it
makes me feel awful. I wish I didnt have to take it.
Mr. E: Im not actually mentally ill, Im just taking
Geodon for my nerves. It makes me feel like Im in
control of my life: Of my emotions, thoughts, actions,
and interactions with other people. My doctor says I
should keep taking it because it improves my quality
of life.

What these intuitive considerations suggest is

simply that patients should adhere to treatment
for the right reasons, and although benefit to the
patient is clearly such a reason, awareness of illness
is not. If so, it is arguably wrong to improve insight
solely for purposes of treatment adherence (as Ms.
Ds doctor may have done). In contrast, improving insight for purposes of increasing awareness
treatment benefits, might seem unobjectionable. A
therapist might, for instance, inform her patient
that, because his difficulties are caused by a mental
illness, those difficulties might subside if he takes
a medication designed to treat that particular illness. That is very different from simply telling the
patient that, because he has a mental illness, it is
important that he take medication prescribed to
treat that illness. However, even improving insight
for purposes of increasing awareness of treatment
benefits, is potentially problematic. It is problematic in cases where the patient already conceptualizes his difficulties in a manner compatible with
such awarenessbut incompatible with the idea
that he is mentally ill.
This brings us to a third ethical consideration
against improving insight for purposes of treatment adherence. Endeavoring to improve insight
for such purposes might be viewed by some as
reflecting an arrogant attitudean attitude that
(some might say) pervades contemporary medical
psychiatry. This attitude, as expressed in the DSM
and ICD, amounts to the misguided view there
is only one (appropriate) way to understand the
psychotic patients difficulties. These difficulties
are to be understood in terms of the concepts of
mainstream medical psychiatry: Psychosis, delusions, disordered thoughts, paranoia, hallucinations, mental illness, and so on. Such arrogance,
if indeed that is what it is, is certainly reprehensible
and should not be tolerated.

Reimer / Insight 73

However, suppose that the concepts in question

are of genuine use to the therapist in her attempts
to understand, and thereby help to solve, her patients difficulties. The question then becomes:
Does the patient himself benefit from conceptualizing his difficulties in these same terms? Unless
he already understands and accepts the validity of
the concepts underlying those termsas well as
their potential applicability to his own case, the
answer is surely no. Besides, some psychiatric
patients, especially those lacking insight, might
find other conceptual schemes more to their liking.
As Perkins and Moodley point out,
There are many different frameworks within which
people understand their difficulties. . . . Some adopt
religious explanations of their world, while others use
models couched in physical processes, or social/interpersonal explanatory frameworks. (1993, 233)

If the patient already accepts some such framework, why should the therapist encourage him
to reject it and replace it with her own? Because
her framework is right and the patients is
wrong? Because discussions regarding diagnosis
and treatment should be conducted within the
conceptual scheme endorsed by therapist rather
than the patient? But such questions raise the issue of arrogance.
It might initially be thought that, by adopting
some such alternative framework, the patient
is less likely to adhere to treatment. However,
as suggested above and reinforced below, this is
not obviously true. What is important is that the
therapist, in explaining treatment benefits, avoid
employing a framework that is flatly inconsistent
with that adopted by the patient.
Thus, even if it were possible to improve insight
into psychosis, it is far from obvious that doing
so for purposes of treatment adherence would be
a good (practical, ethically sound) idea.
This still leaves us with a pressing practical
problem: How to increase treatment adherence
among psychotic patients with poor insight. Much
has already been written on this topic, and the
consensus (if there is one) is that simplification of
dosing and supervision of adherence are crucial
(Amador 2006). The present paper suggests an
approach to increasing treatment adherence that
is compatible with this consensus. Mental health

workers should, by all means, do what they can

to simplify dosing and supervise treatment adherence. In addition, they might consider using (as
perhaps some already have) a neutral conceptual
scheme when discussing the potential benefits of
treatment adherence with patients lacking insight.
In conversations with such patients, mental health
workers should not presuppose the so-called
medical model of contemporary psychiatry. The
models associated conceptual scheme is bound to
be counterproductive in discussions with those
who reject, from the start, the idea that they are
mentally ill and therefore in need of psychiatric treatment. By recognizing this fact, the
therapist will be well-equipped to respond to the
familiar argument: I am not mentally ill, so theres
no reason for me to take any medication. For
she has a readyand rationalresponse: What
matters is not whether or not you are mentally ill;
what matters is whether or not you will benefit, in
some way, from taking medication. She might go
on to articulate the potential benefits of treatment
adherence by talking in neutral terms of the ability
of the prescribed medication to quiet the voices,
calm the mind, induce sound sleep, improve social
relations, and so on. Improved quality of life
(rather than treatment of mental illness) might
then be the core rationale for treatment adherence.
Were the relevant discussions to take place, not in
a mental health clinic, but in a more neutrally
labeled setting, the patients (or clients) sense
that the prescribing physician believes that there
is something seriously wrong with his mind,
might be further abated.
In this way, the mental health worker might be
able to avoid the sort of tension that is bound to
arise in cases where there is overt disagreement as
to whether or not the patient is mentally ill and
therefore in need of psychiatric help, including treatment with antipsychotics. As noted
above, talking in neutral terms when describing
potential treatment benefits does not require that
the therapist actively conceal from her patient her
belief that he is mentally ill. That would arguably
be wrong, as would actively concealing any potentially serious (let alone unpleasant) side effects of
the prescribed medication. My point is simply that
the therapist should consider explaining treatment

74 PPP / Vol. 17, No. 1 / March 2010

benefits in a way that might encourage, rather

than discourage, treatment adherence in patients
with poor insight.
Of course, taking such an approach is no guarantee of treatment adherence. The patient might be
skeptical of the medications alleged benefits and
so hesitate, or simply refuse, to consider adherence. Perhaps he is one of those people who not
only denies that he is mentally ill but also denies
that there is anything about his current situation
that is in need of changing. Or, he might give the
medication a try but fail to see any significant
improvement in his situation. The side effects
might be judged intolerable; the expense and/or
inconvenience might be judged as outweighing
any recognizable benefits. Nevertheless, characterizing treatment benefits without the language of
mainstream psychiatry might reduce significantly
cases of non-adherence motivated largely (if not
entirely) by lack of insight into psychosis.

Notes
1. But see Beck-Sander (1998) for some concerns
regarding this claim, as well as other claims having to
do with the theoretical value of the concept of insight
into psychosis.
2. A qualification is in order. Because neuroleptics
are associated with potentially serious side effects,
adherence is arguably rational only if the seriousness
of these side effects is outweighed by the increased
quality of life that would result from clearer thinking
and better sleep.
3. On Davids (1990) multidimensional model of
insight, insight includes both treatment adherence
and the ability to re-label pathological thoughts/experiences as such.
4. In fact, some of the evidence that seems to support
the hypothesis that insight predicts adherence might
be the result of conflating insight (awareness of illness)
with perceived benefit from/need for treatment. That
this is so is suggested by McEvoys summary of the data
discussed in his 1998 paper, where he writes (p. 299),
we have demonstrated the link that those patients
who deny illness or need for treatment are significantly
more likely to be among the group who noncomply
(emphasis added). The present paper suggests that there
is a theoretically and practically important distinction to
be drawn between awareness of illness and awareness
of benefit from (or need for) medication. For a similar
point, see Beck-Sander 1998.
5. Talk in terms of tendencies is important here.
A patient might recognize that treatment adherence is

in his best interest, but be unable to adhere for reasons

beyond his control (e.g., inability to pay for medication
or get to the pharmacy, cognitive difficulties including
memory problems).
6. This is not to deny that there might be sound
reasons for improving insight, such as (for example)
increasing patient autonomy so as to enable the patient
to engage in fully informed decisions regarding his
treatment program. My point is simply that increasing
treatment adherence is not such a reason. Moreover,
patient autonomy is not without its critics (see Campbell 1994).
7. If, on the other hand, the goal is (for example)
patient autonomy rather than treatment adherence,
informing the patient that the voices are a symptom
of mental illness would arguably be appropriate. However if, as Amador (2006) suggests, poor insight is often
intractable, such information might fall on deaf ears,
and so be ill-advised.

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