Understanding insight: An exploratory study of insight in a forensic psychiatric inpatient setting

Kym Walford1, Fiona Black2, Laura J. Ferris3, Carla Meurk3, Dominic Beer4

1Forensic and Secure Services, West Moreton Health; 2West Moreton Health, 3Queensland Forensic Mental Health Service, Metro North Hospital and Health Service; Queensland Centre for Mental Health Research, West Moreton Health; 4Addiction and Mental Health Services, Metro South Health 

Impaired insight is common in individuals with major mental illness, and there are significant implications for treatment outcomes. Individuals with poor insight are at increased risk of treatment non-adherence, relapse, hospitalisation, and poorer quality of life. Despite these implications, research in the field is limited and has highlighted a lack of consensus about how to define and measure insight, as well as the mechanisms underlying insight. Recently, it has been suggested that insight can be broken into two constructs: clinical insight and cognitive insight. Clinical insight refers to the individual’s awareness of having an illness, the need for treatment, and the ability to recognise and re-label symptoms as part of an illness. Cognitive insight focuses on the metacognitive processes of evaluating and correcting beliefs; referring to an individual’s willingness to acknowledge the fallibility of their thoughts, overconfidence in beliefs, and their openness to feedback. For mentally ill offenders, who often have comorbid substance use, personality pathology, and cognitive impairment, insight is even more complex and has an added layer of clinical significance in its implications for risk of violence and associated hospitalisation and treatment.

Within the forensic psychiatric inpatient population of the state-wide hospital at The Park Centre for Mental Health in Queensland, the current study aimed to: examine and describe clinical and cognitive insight; and examine relationships between insight and other characteristics such as demographics, psychopathology, cognitive functioning, and personality pathology. Data was collected from 43 inpatients, including measures of demographics and clinical features, clinical insight, cognitive insight, psychopathology, cognitive functioning, and personality. Results suggest that insight is not a unitary construct and that poor cognitive insight is associated with lower cognitive functioning and personality pathology. Implications for practice include recommendations for improved measurement of insight and targeting treatment dependent on insight levels, particularly within forensic settings. Conclusions are drawn with the ultimate aim being to minimise risk of relapse and violent reoffending and upholding the principles of least restrictive practice.


Ms Kym Walford is a Psychologist who trained at UNSW, CDU, and JCU in Australia. Kym has worked in corrections, forensic mental health, research and service evaluation, and private practice. She is currently working in the statewide High Security Inpatient Service of The Park Centre for Mental Health, Queensland. Kym’s clinical and research interests focus on the interface between mental illness and offending behaviour, complex patient populations, and interventions for challenging behaviour and personality disorders.

Dr Fiona Black is a Clinical Psychologist who trained at UQ and QUT in Australia. Fiona has worked in corrections, child and youth mental health, brain injury, forensic mental health, and private practice. She is currently working as the Director of Psychology at West Moreton Health, and as Interim Chair of the Psychology Board of Australia (Queensland). Fiona’s clinical and research interests focus on reflective practice of health practitioners, complex and co-morbid psychopathology, and psychological assessment and intervention with forensic psychiatric inpatients.

Dr Laura Ferris is a registered Psychologist and researcher with contributions in the fields of social psychology, child and adolescent psychiatry, and mental health. Laura is a Principal Researcher with the Queensland Centre for Mental Health Research, and a Project Manager in Partners in Prevention: Understanding and Enhancing First Responses to Suicide Crisis Situations with Queensland Forensic Mental Health Service, Queensland Health. She has a background in law and justice policy, and her current research considers first responses to suicide crisis; insight in specific forensic populations; social identity in mass gatherings; and the social psychology of pain and suffering.

Dr Carla Meurk is Principal Researcher within the Queensland Centre for Mental Health Research Forensic Mental Health Group, project manager for Partners in Prevention: Understanding and Enhancing First Responses to Suicide Crisis Situations at the Queensland Forensic Mental Health Service, and honorary senior fellow at The University of Queensland. Carla’s expertise is in mixed methods translational research to improve the use of evidence in forensic mental health services and policy. She is involved with the National Mental Health Service Planning Framework Forensic Mental Health Services Modelling, and active in research governance and strategy within Queensland.

Mr Dominic Beer is a registered Psychologist who completed his training at Griffith University and QUT in Brisbane Australia. He has worked in forensic mental health, child and youth mental health and adult community mental health. He is currently working as a psychologist in the Inala – Psychosis Academic Clinical Unit in Metro South Hospital and Health Service. Dominic’s clinical and research interests are working with and understanding complex patient populations, particularly individuals with psychosis, with the aim of empowering them in their recovery.

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