insight and advent

It is difficult to treat patients who don’t believe they are ill. The inpatient psychiatric unit is full of them, firmly convinced that they are sane and that the walls of our hospital unjustly imprison them. The looks I receive in the hall make it clear that I am no longer a benevolent healer. I have become a warden. This issue is addressed every morning in my daily progress notes under the heading insight. Few of my charges would qualify as insightful. More often the adjectives I employ are “impaired, poor, limited” or on optimistic days “improving”. Insight in the psychiatric sense implies more than just the knowledge that you are diseased. It requires a global understanding of what your mental illness entails and what you must do to be well.

Insight is an odd thing. It can’t exist in a vacuum. A psychiatrist recently explained the attempt to bring patients to a place of insight as “gently telling people that they have mental halitosis”. We need others to lead us into a place of recognition in our lives. We require relationships in order to understand that our ways of relating are broken. The child who grows up in a home with bipolar parents thinks that normal functioning is mania and insomnia. It requires an outside force to reveal that normal might be something far different from our every day experience.

My own forms of spiritual halitosis are not so far separated from those of my patients. Wrist slashing takes on more civilized forms, but like them I wander about, angrily trying to escape from a trap of my own making. Now it is the advent season, time to celebrate the dawning of a light that shines in dark places. By this light I begin to see both my illness and my cure. My limited insight appears to be improving.