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Pathology Is in the Eye of the Beholder

Insight, denial, and the grand illusionist inside our skulls.

Mental health providers sometimes face patients who don’t believe they need help. There is a bullet item, “insight,” devoted to this in the standard “Mental Status Examination,” the psychiatric equivalent of a physical exam. “Insight” refers to how well a patient understands their mental condition. At one extreme are involuntary patients who don’t believe they have a problem and are brought in for treatment by family, friends, or the legal system.

Even among patients who actively seek help, levels of insight vary: Some are very insightful about their perceptions, emotions, and behavior. Others have depression or anxiety but are not fully aware of their emotions. Some may express negative emotions as physical complaints, such as headaches, stomach pains, or heart palpitations. Some struggle internally but are so good at coping that most people around them don’t realize it. Others have poor coping skills that cause repeated disruptions and drama in their relationships, workplace, or business, yet they firmly believe other people or circumstances are the source of their problems.

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To know thyself is the beginning of wisdom.
Source: Alfa Photo/Shutterstock

Many clinicians view poor insight as a reflection of mental illness. I think the opposite can sometimes be true: Sometimes poor insight reflects normal mental functioning. How can a lack of self-understanding be a sign of normal mentality, let alone of mental health? Given that the mind is produced by the brain, how can it be healthy for the brain not to recognize that something is amiss with what it’s doing?

To explore this, let’s first consider the function of the human brain. We all know that it’s bigger than those of other animals, especially relative to body size, but what does that make it especially good at? This is a fascinating question that’s impossible to definitively answer—so it’s fertile ground for philosophers and scientists. Theories abound. Proposed explanations for why our species has a large brain include: to hunt large game1; to hunt small game2; not to hunt (to forage)3; to fight (compete) with each other4; to avoid fighting (get along)5; to woo mates6; to adapt to changes in climate7; to cope with common habitat challenges8; and to create and share intersubjective realities (organizing myths) that enable large-scale cooperation9.

While I'm not disputing these theories, from my vantage as a psychiatrist I would point to another major function of the human brain: to hide from itself. I don’t know if that makes our brain unique among animals, but one thing the human brain certainly does extremely well is pretend it’s not there. Our brain constantly deceives itself into believing that something else is perceiving the world and controlling our reactions. So, the thing we all believe to be in control (our “self,” “mind,” “consciousness,” "psyche," etc.) is not 3.5 pounds of electrochemical flesh inside our skulls—it’s intangible. Here’s the big reveal: It’s intangible because it’s not really there: “Abracadabra!”

Among the first, if not the very first, modern Western thinker to recognize the human brain is a master of illusion was Sigmund Freud. Freud formulated the idea of “subconscious” and “unconscious” parts of the mind that the “conscious” part is unaware of. According to Freud and subsequent psychoanalytic thinkers, the keys to keeping these parts of the mind closed off from conscious view are psychological “defense mechanisms” that prevent us from detecting the authentic motivations underlying our feelings, thoughts, and actions.

In the psychoanalytic framework, some defense mechanisms are always pathological, but most mature as individuals mature—they go through a developmental progression as we go from infancy to adulthood. It's considered normal for an adult to use mature defense mechanisms; pathological for an adult to routinely use immature ones. So, if your 3-year-old daughter with crumbs all over her face points at the dog when you ask her who ate all the cookies, you chuckle—but you don’t find similar behavior endearing in an adult co-worker.

In general, immature defenses tend to be more easily detected by an observer because they are ham-handed, like the clumsy moves of a novice illusionist. But whether they are “mature” or “immature,” “healthy,” or “pathological,” all defense mechanisms serve the same purpose: They disguise from the conscious mind what the unconscious mind is doing. Put another way, psychological defense mechanisms are elements of the brain’s grand illusion show; they are Freud’s formulation of the basic toolkit our brain uses to hide from itself.

This psychoanalytic framework of mature vs. immature or pathological defenses is probably one source for the modern mental health provider’s tendency to view poor insight as pathological. But these days most clinicians are only dimly aware of Freud’s work, and there is another, more immediate source: A patient’s poor insight presents a practical challenge for the clinician. After all, it’s the clinician’s job to help a patient overcome their mental health problem, and it’s hard to do that if they don’t believe there is a problem. It’s also hard to do that if the patient misattributes the problem’s source (e.g., “It’s not me, it’s them”; “I don’t need you, I need a ‘real’ doctor to fix my...,” “Everything would be fine if it weren’t for X, Y, Z,” etc.).

 Muskocabas/Shutterstock
Who is behind the curtain?
Source: Muskocabas/Shutterstock

The fact that poor insight is inconvenient doesn’t make it a sign of mental illness. When a patient doesn’t recognize they have an emotional or behavioral problem it could be abnormal, or it could indicate that at least one part of their mind is operating normally. It’s the part that, like the Wizard of Oz, is frantically yelling: “Pay no attention to that (brain) behind the curtain!”10

That’s a normal human reflex. That it is normal is another feature that makes poor insight a particular challenge for the mental health provider. One aspect of our art is having the skill to convince a patient that, despite what the “great and powerful wizard” hiding inside their skull is telling them, the source of their problem is located there, and we have the perspective, expertise, and tools to help it get better.

(#2 of 3 in a series)

References

1. Grover S Krantz, “Brain Size and Hunting Ability in Earliest Man,” Current Anthropology 9(5), 450-451. (1968).

2. Miki Ben-Dor, Ran Barkai, “Prey Size Decline as a Unifying Ecological Selecting Agent in Pleistocene Human Evolution,” Quaternary 4(1), 7 (2021)

3. Alex R DeCasien, Scott A Williams, James P Higham, “Primate brain size is predicted by diet but not sociality.” Nat Ecol Evol 1, 0112 (2017)

4. Drew H Bailey, David C Geary, “Hominid brain evolution: Testing climatic, ecological, and social competition models,.” Human Nature, 20(1), 67–79 (2009)

5. Miguel dos Santos, Stuart A. West, “The coevolution of cooperation and cognition in humans,” Proc. R. Soc. B. (2018) 2852018072320180723

6. Geoffrey Miller, The Mating Mind: How Sexual Choice Shaped the Evolution of Human Nature (New York City: Random House, 2001)

7. Jessica Ash, Gordon G Gallup, Jr, “Paleoclimatic Variation and Brain Expansion during Human Evolution,” Hum Nat 18, 109–124 (2007)

8. Mauricio González-Forero, Andy Gardner, “Inference of ecological and social drivers of human brain-size evolution,” Nature 557, 554–557 (2018)

9. Yuval Noah Harari, Sapiens: A Brief History of Humankind (New York City, HarperCollins, 2015)

10. https://www.youtube.com/watch?v=_nc2GSjmsYQ

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