Chasing that Elusive Insight

I think about the word “insight” a lot, as it is a term much utilized in psychiatry. Generally, in this sphere, it means acknowledging one’s mental illness and the need for medical treatment of same. I am frequently accused of having poor insight; indeed, this is the main reason I am usually an involuntary patient. Insight certainly sounds like a desirable trait. However, like “peer support” and the “right to treatment,” “insight” means different things to different people.

The psychiatric concept of insight rests on the assumption that the psychiatrist, designated sane, knows what’s best; while the patient, designated insane, needs to pay attention, listen and learn. Such is the “therapeutic relationship.” But if we question that assumption and consider that the medical model of mental illness may be incorrect, then the question of which party actually possesses insight becomes less clear.

Faking psychiatry’s definition of insight is easy enough: You need only parrot what your psychiatrist says. By all means, agree that you have a chemical imbalance that renders you helpless without medication. Agree retrospectively that forced treatment has been for the best. The line between insight and obedience in this context is a fuzzy one. But if you manage to pass that test, you can be as crazy as you want or need to be. There is nothing in this life that I want more than to pass as a normie; to look sane from the outside while still retaining my cognitive liberty.

In contrast to psychiatry’s definition, I believe insight – real insight – involves knowing and accepting that one has a susceptibility to what is termed mental illness but might be better described as emotional difficulties. In my case, a tendency to experience extreme mood states requires understanding what I have to do to avoid them and maintain stability. Coming to this place has taken me years of very painful experience. I have come to believe that I am neurodiverse, and consequently have to live more carefully. There are things that I can simply no longer do (like work full-time) and there are things I must do (sleep well, eat well, get outside lots, exercise regularly, stay connected with people, schedule plenty of quiet time, not let myself get too tired, keep to a routine).

This journey of mine started two decades ago, when I became crippled with anxiety and depression, in large part caused by an untenable financial situation – but there were other factors, too. I met and married my knight in shining armour, but it was too late. Silently but surely, I began to disintegrate before we had even made it to our first anniversary. My very serious suicide attempt was followed by forced treatment for depression, followed by mania, followed by an unrelenting storm of extreme mood states. I operated like the ball in a pinball machine, ricocheting between highs and lows. This bipolar train wreck went on for 20 years, but I have now been stable for six months and am cautiously optimistic that I’m finally on the mend.

Prior to the COVID-19 pandemic, I was regularly shuffling into the Assertive Community Treatment (ACT) office, where I would sit and wait with all the other freaks and ghouls. Some ACT clients have mental health issues; some struggle with addictions; some have both (dual diagnosis). But all of us are lumped together because, fundamentally, we are the undesirables. We are the ones who fall under the purview of forced psychiatry because we bother other people.

The purpose of ACT is to keep you out of hospital and out of jail—noble goals, but accomplished at what price? The civil liberties of patients are routinely trampled in the interests of social control. Imagine if all the money spent on coerced neuroleptics went instead into personally empowering programs such as a universal basic income, counselling, and supportive housing.

I recently acquired the medical records from my most recent hospitalization (August through October 2019), and let me tell you, they are an eye-opener. Apparently, asking repeatedly to be released is “perseverating”; favouring one mental health worker over another is “splitting”; and being fearful of losing my 78-year-old mother is indicative of “dependent personality disorder.”

While in the hospital and despairing of ever being released, I made a lame suicidal gesture. In response, I was stripped and put into a seclusion room. This doesn’t seem to me to be an insightful response. On the psych ward, however, staff’s overriding, primary goal is the smooth operation of the unit. Patients are medicated, quite often excessively, to maintain order. We are like cattle, quiet and obedient, being herded into the chute.

Personally, I would love the medical model to be accurate. A disease like diabetes, correctable with medication, would be so easy to accept. But this scenario doesn’t fit the facts. Sure, the brain is where the problem manifests, but that’s far downstream from where it starts. Nevertheless, it is where we typically intervene, because there is not much we can do about former events, including adverse childhood experiences far in the past. I was raised in a very loving but chaotic environment. My father’s frequent rages, though physically harmless, were nonetheless terrifying for me and my sister. I have no doubt that such an environment was at least a contributor to my later mental health troubles and instability.

Clearly, anyone can lack insight. My father, now in a nursing home and requiring a wheelchair for mobility, is unaware that he can no longer walk. I believe, too, that when I am in an extreme mood state I do lose insight. There’s no question that when I’m what is termed “manic,” I have no idea I’m making an ass of myself, spreading chaos with my boorish behaviour and reckless, regrettable actions. Later, during the depression that inevitably follows, I look back and am ashamed. My behaviour, or at least what I remember of it, has been reprehensible. Through a series of appalling decisions, I trashed my marriage, my career, my finances, and several friendships. As in the case of the proverbial frog remaining in a pot of increasingly hot water until it boils, things got gradually worse and worse until I had obliterated my life as I used to know it. Now I am paying the price, and bipolar regrets will haunt me for the rest of my life.

I used to rage against the psychiatric machine, but that was futile. I’ve learned a lot in the course of my countless hospitalizations over the last 20 years. I believe that involuntary treatment will always exist, and that calling for its abolition is a non-starter. There is the usual divide between voluntary and involuntary care – but there is also a third category, its size both unknown and unknowable. I am referring to all the many patients who come into the hospital voluntarily, but whose ostensible voluntary status is removed as soon as they fail to follow direction. I’ve found myself in all three categories and am certainly not the first to point out that, as long as involuntary psychiatric treatment exists, there can be no truly voluntary care. And forced psychiatry is here to stay.

I often wonder how life would have unfolded had I never been forced into treatment. What if I had been treated respectfully? What if, after my first suicide attempt, I had had a real conversation with a knowledgeable and empathic psychiatrist about the best way forward? What if I had been told that medication could help prevent my extreme mood states and had it offered to me, rather than having it crammed down my throat?

What if …

And yet, as impossible to ignore as a pebble in one’s shoe, some fundamental truths are apparent. It is true that I am susceptible to extreme mood states. And the other big truth is that psychiatric drugs can help. After being weaned off most of the preposterous cocktail of drugs I was forced to take during my last hospitalization, I am now taking only clozapine and lamotrogine. (I also take metformin to counteract the weight gain from clozapine and previously prescribed antipsychotics). I am doing pretty well. As antipsychotics go, I think clozapine is the best I’ve been on, but that is damning it with faint praise.

As I have a long history of noncompliance, my drugs are witnessed at the pharmacy to ensure that I take them. Unfortunately, the drugstore closes at 6 p.m. (weekdays) or 5 p.m. (weekends) these days, so that pretty much kills my evenings. For three or four hours after taking the antipsychotic, I am sedated to the point of incapacity. If I try to walk during this time, the best I can manage is the “Thorazine shuffle” seen so often on the psych ward, arms hanging limp. I prefer to sleep during this period if I can; but I often can’t, due to night terrors. After the drug has worn off, I feel much better and enjoy the quiet of my apartment, puttering around and loving the socks off my cat, Sunny. Sunny is better medicine than anything I can find in a pill bottle but, as wonderful as she is, she is not able to smooth out my mood states on her own.

Today, for the first time, I have a psychiatrist for whom I have a very high regard. Although I am currently an involuntary outpatient, within that framework he treats me both kindly and respectfully. I trust him. I am not a believer in the medical model of psychiatric disorders, yet I believe that medication has its place. I also accept that I’ll be taking it for the foreseeable future. I have no doubt that the drugs negatively affect my brain chemistry; however, without them, my thoughts and behaviour eventually negatively affect my whole life. I don’t know if I developed wonky brain chemistry on my own or if it resulted from psychiatric treatment, but it doesn’t matter. It is clear to me that the drugs are helping at this time. And this isn’t me demonstrating insight; this is me finally conceding defeat.