Date of Award

2009

Document Type

Thesis - ECU Access Only

Publisher

Edith Cowan University

Degree Name

Doctor of Psychology (Clinical / Forensic)

School

School of Psychology

Faculty

Faculty of Computing, Health and Science

First Supervisor

Dr Greg Dear

Second Supervisor

Professor Assen Jablensky

Abstract

Recent reviews suggest insight is generally measured as either a scaled or categorical variable. While some instruments have been developed to specifically assess insight, these tools are principally research-based measures that are rarely used in general clinical practice. Moreover, assessments of insight for both clinical and forensic purposes tend to be carried out by way of clinical judgement. This study investigated inter-rater reliability of clinical judgements of insight using both scaled and categorical methods, the clinical factors associated with such judgements, and clinician confidence and influencing factors when applying insight ratings to three assessment scenarios pertaining to treatment planning, involuntary treatment and a fitness to stand trial evaluation.

A clinician sample of seven psychiatrists and five clinical psychologists rated thirty DVD vignettes of psychiatric patients with a diagnosis of a psychotic disorder. Quantitative analyses found that judgements of insight on an ordinal scale were significantly more reliable (ICC = 0.62) than judgements made using a binary (categorical) rating (k = 0.37). Multiple regression analyses suggested that present-state positive symptomatology and inpatient treatment status were associated with lower insight ratings. Qualitative analyses revealed eight primary themes upon which ratings were based. Although most of these themes can be primarily matched to dimensions of insight reported in the literature, a number of inconsistencies were revealed that are generally not taken into consideration by instruments developed to measure insight, while treatment compliance was reported as having limited worth in the assessment of insight.

Clinicians were generally confident in rating insight for treatment planning, but were less confident to make a rating for involuntary treatment decisions and fitness to stand trial evaluations. Reported reasons for varying levels of confidence included whether a case was clear-cut as opposed to ambiguous, the availability of longitudinal, collateral and contextual information, clinician experience, and perceived consequences and legislative ramifications of judgements. The findings of the current study add to the broad body of research on the clinical applications of insight and suggest that clinical judgement can be an appropriate methodology for assessing insight in clinical settings but not in forensic settings. The findings of this study support the view that insight assessments for legal decision-making should use an empirically validated scaled measure that captures the contextual and nuanced elements of insight, and that allows for judgements to be compared to criteria depending on the legal question in dispute.

LCSH Subject Headings

Edith Cowan University. Faculty of Computing, Health and Science -- Dissertations

Psychoses

Clinical psychology -- Decision making

Mental illness -- Diagnosis

Mental status examination

Insight

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