Factors underlying clinicians’ judgements of patient insight and confidence in using clinical judgement in psycho-legal settings

Correspondence: Dylan P. Galloghly, Lower West Community Mental Health, 303 Rokerby Road, Subiaco, WA 6008, Australia, Tel (08) 9489 7200; Fax: Fax (08) 9382 4171, Email: ua.vog.aw.htlaeh@ylhgollag.nalyD

Abstract

This study investigates the factors that clinicians use to make clinical judgements of insight and their confidence in using clinical judgement across three clinical and forensic assessment domains. The 12 participating clinicians rated 30 DVD vignettes of psychiatric patients with a psychotic disorder. Qualitative analyses revealed eight themes that align closely with the dimensions of insight reported in the literature. However, it is unclear how clinicians weigh each dimension. The clinicians were more confident in making a judgement on insight for treatment planning than for involuntary treatment or fitness to stand trial evaluations. They wanted more information when making a judgement in the forensic domains, recognising the greater consequences for the patients and the greater level of scrutiny of their judgements in legal settings compared to clinical settings. The data obtained suggest that both clinical and forensic assessment of insight would benefit from empirically derived structured professional judgement (SPJ) tools.

Keywords: insight, clinical judgement, involuntary treatment, confidence, psychoses, schizophrenia, psycho-legal, decision-making, treatment compliance

Introduction

Clinical judgements of insight are further hampered by the construct itself (Diesfeld & Sjöström, 2007; Marková, 2005b; McGorry & McConville, 1999); whereas most mental disorders have clear diagnostic criteria outlined in standardised manuals that can guide clinicians through assessment and diagnosis in a way that improves reliability, clinicians do not have the benefit of such standardised criteria to guide their judgements of insight. Judgements can also be influenced by clinical experience, biases and attitudes (Marková, 2005a). Given these problems, it is concerning that at present there does not appear to be any research on the factors that clinicians consider when judging insight, or on whether or not these factors align with the scientific literature (e.g. Mintz, Dobson, & Romney, 2003).

Concerns about using clinical judgement are exacerbated in legal settings. The clinicians opinions given in courtrooms and other tribunals can have significant consequences for patients and community safety. Diesfeld (2003) reviewed the research on the role of insight within the decision-making processes of mental health review bodies across several jurisdictions. She found that involuntary patients’ perceived level of insight is highly relevant to the decision-making process. Diesfeld notes that in the state of Victoria in Australia, ‘lack of insight’ has been recorded in many published decisions by the Victorian Mental Health Review Board, yet it is not mentioned in the governing legislation. Diesfeld and Sjöström (2007) describe a number of cases wherein a lack of insight was portrayed as causing non-compliance, and other cases wherein a lack of insight was depicted as being evidence of non-compliance. Furthermore, the decisions made by the Board generally depict patients as either having good insight (full, complete, sufficient) or inadequate insight (poor, little), with very few decisions depicting insight as having a middle range or lying upon a continuum. Diesfeld and Sjöström’s findings regarding the role of insight within Victorian jurisdiction have been replicated in the United Kingdom (UK; Perkins, Arthur, & Nazroo, 2000; cited in Diesfeld, 2003), Sweden (Sjöström, 1997) and New Zealand (Diesfeld, 2003).

Concerns regarding the reliability and validity of assessments based on clinical judgement are more pronounced within forensic settings. Scientific evidence admitted to courts should be testable, subject to peer review, based on procedures that have known error rates and generally be repeatable and consistent (Freckelton, 2003, 2019; Ruschena, 2003). Diesfeld and Sjöström’s (2007) research suggests that judgements of insight most likely fail to meet the required legal standards of being testable, repeatable and consistent. One must therefore question how well equipped decision-making bodies are when adjudicating cases where insight is relevant. At present, there appears to be no published research on using clinical judgement to evaluate insight in forensic settings.

A number of studies have demonstrated a significant association between insight and mental capacity/competency in patients with psychoses (e.g. Capdevielle et al., 2009; Owen et al., 2009). The MacArthur Treatment Competence Study is perhaps the most comprehensive exploration of the relationship between mental illness and legal decision-making processes (Appelbaum & Grisso, 1995; Grisso & Appelbaum, 1995; Grisso, Appelbaum, Mulvey, & Fletcher, 1995). The study suggests that four legal standards must be met for a person to be deemed competent, one of which – namely the ‘ability to appreciate the situation and its likely consequences’ – has similar foundations to having insight (Appelbaum & Grisso, 1995, p. 110). Grisso et al. (1995) state that the reasons behind an expert’s opinion, and the inferences that are being made by that expert, must be understood before it can be concluded that someone lacks insight or is incompetent. However, opinions drawn from unstructured clinical judgement are unlikely to meet this standard due to the lack of standardisation.

Rationale for the present study

Given that clinical judgement is commonly used in psychiatric assessment, the aim of this study is to evaluate firstly the factors that clinicians use when making a clinical judgement of insight and secondly whether or not these factors are consistent with those highlighted in the scientific literature. Study 1 poses two questions:

What factors do clinicians use when making a clinical judgement to assess insight in patients with psychoses?

Judgements of insight in forensic contexts are more likely to be scrutinised – and to carry more serious implications for patients’ lives – than in clinical contexts. Therefore, the issue of whether or not clinicians are less confident to make a clinical judgement of insight in forensic contexts than in clinical contexts is also explored, along with the factors that influence their confidence. Study 2 poses two questions:

Does mental health clinicians’ confidence in making a clinical judgement to assess insight vary across clinical and forensic contexts?

Study 1

Method

Design

Both studies use a vignette rating design. Previous research incorporating vignettes has generally only used written case studies. The superior method of DVD vignettes is used in the present study, allowing participants to observe actual patients as they describe their illness and respond to structured clinical questioning. This method is routinely used in studies of clinical judgement and inter-rater reliability across a number of psychiatric domains (e.g. Hjortsø et al., 1989; Kitamura & Kitamura, 2000).

Sample

There are two samples used in this study: (a) a sample of video-recorded interviews of patients with psychoses and (b) a sample of clinicians who evaluated the patients.

Sample of video-recorded interviews of patients with psychoses

We randomly selected 30 vignettes from a database of 350 video-recorded diagnostic interviews of patients in the Western Australian Family Study of Schizophrenia (WAFSS) (Hallmayer et al., 2003). Patients in that study met both ICD-10 (World Health, 2004) and DSM-IV (American Psychiatric Association, 2000) criteria for a diagnosis of schizophrenia or schizophrenia spectrum disorder based on the Diagnostic Interview for Psychoses (DIP-DM) (Castle et al., 2006). We used a representative group of both inpatients and outpatients at varying stages of treatment. Patient demographics are outlined in Table 1 .

Table 1.

Patient demographics, diagnoses, DIP-DM insight and symptom summaries.

Note: M = mean or population percentage.

The vignettes were edited to produce 30 DVD vignettes with running times of between 6 and 11 minutes (M = 9.08, SD = 0.84). The vignettes comprise four subsections of the DIP-DM interview relevant to the assessment of insight: (1) initial description of the psychotic illness/onset, (2) mood and negative symptoms, (3) description of phenomena and positive symptoms and (4) insight and medication.

Patient summary sheets were also developed that provided the clinicians with the relevant background data of each patient, including basic demographics and treatment history.

Sample of clinicians who evaluated the patients

The clinician sample comprises seven psychiatrists and five clinical psychologists recruited from mental health facilities in the Perth metropolitan area. All participants had significant experience working with patients with psychoses, ranging from 4 to 30 years (M = 14.1, SD = 10.5).

Data collection

In a written questionnaire, the 12 clinicians were asked to list the factors they took into account when judging insight for each vignette.

Results

Data analysis

Inductive content analysis was used to identify the themes that emerged from the qualitative data. The initial thematic analysis of the qualitative data was conducted without reference to the theories of insight found in the scientific literature. The data were coded into themes according to the principles outlined by Strauss (1987, p. 30) and were then consolidated through ongoing reviews between the researchers. The validity of the findings was strengthened by validating the themes in follow-up interviews with the participants (Berg, 1998; Creswell, 1998).

Factors that the clinicians reported taking into account when judging insight

Recognition of being psychiatrically unwell

All the clinicians mentioned the importance of patients’ recognition and acknowledgement of being psychiatrically unwell. This is the dominant theme in the data. Illustrative quotes include: ‘does not believe he is suffering from an illness at the present time’ and ‘acknowledges that he has become unwell’.

Capacity to relabel psychotic symptoms as abnormal

The clinicians reported that patients’ ability to view their psychotic symptoms as abnormal is intrinsic to insight. This includes the ability to differentiate between psychotic and non-psychotic states. For example, one clinician noted that a patient was ‘insightless in respect to her abnormal experiences’, while another stated ‘at the very least, patients need to recognise that other people see it as abnormal’.

Attribution of symptoms to mental illness

This theme concerns patients’ capacity to acknowledge and understand the pathological causality of their symptoms. Examples of this theme include ‘little connection made between diagnosis and symptoms experienced’ and ‘thought broadcasting and other symptoms understood as symptoms of illness’. The reported factors associated with acceptance of having a mental illness include cultural factors, stigma, preservation of self-esteem, malingering and patients giving learnt, mechanistic or parroting responses without authentic understanding.

Compliance with treatment

This theme encompasses both behavioural compliance and verbal acknowledgement of needing treatment. Reported examples include: ‘agrees that this time she needs to be in hospital’ and ‘numerous admissions to hospital due to non-compliance’. The clinicians reported a consensus that the association between compliance and insight is ambiguous, and requires contextual investigation. For example, patients can be compliant for many reasons (e.g. family pressure, involuntary treatment) without having insight, and they can be non-compliant for various reasons (e.g. medication side effects, cultural issues) while having insight.

Ability to recognise function of treatment

The clinicians detailed a greater interest in patients’ subjective understanding of treatment as opposed to treatment compliance. Factors include patients’ understanding of the benefits of taking medication in reducing symptoms (e.g. ‘patient accepts that she needs to be on medication, otherwise she starts to hear voices’) and secondary gain issues such as taking anti-psychotic medication for stress as opposed to treating psychotic symptoms.

Higher level of awareness of illness and functioning

This theme comprises patients’ ability to demonstrate a higher (than basic) level of awareness of their illness and associated functioning, and their ability to articulate this understanding. Reported indicators of such understanding include an understanding of the secondary symptoms of their illness, the triggers of psychoses, the impact of substance abuse, the impact of illness on functioning and a capacity for abstract reasoning and reflection. For example, one clinician noted: ‘patient made the connection between cognitive, behavioural, emotional experiences to being unwell and the diagnosis’.

Present-state positive symptomatology

A common theme across patients pertains to their level of present-state positive symptomatology (e.g. ‘a sense of being persecuted, hearing whispers are current and real for this man’). Further exploration of this theme revealed that the clinicians were generally not of the opinion that high levels of symptomatology simply equate to low insight, as insight can be displayed if patients are able to demonstrate some observational capacity as opposed to being submerged in psychotic phenomena.

Patient interaction with the assessment process

This theme encompasses factors such as engagement, openness and defensiveness. Demonstrative example responses include ‘patient gives evasive answers at times’ and ‘patient is open, lists symptoms, history and not defensive’. The clinicians asserted that, in general, positive interaction with the assessment indicates good insight. Reported influencing factors include rapport, interviewing skills of the assessor, patients’ fear of the repercussions of being open, possible secondary gain reasons for being open about their illness and cultural factors.

Discussion

Eight primary themes that the clinicians considered when judging insight were identified. These themes generally align well with the literature and with the factors included within structured research measures of insight (Amador & David, 1998; Chakraborty & Basu, 2010; David, 1990; Marková & Berrios, 1992; Mintz et al., 2003). While this indicates that the clinicians defined insight in accordance with research findings and expert opinion, it is unclear how they synthesised their observations into an overall opinion about the adequacy of their patients’ insight. Unlike structured measures of insight, clinical judgement varies from clinician to clinician in terms of the weight they give to different factors and where they draw the line between adequate and inadequate. In a previous study these judgements were found to be unreliable (Galloghly et al., 2013), so it is unlikely that all the clinicians are weighing and combining the factors in a similar way, or in a similar way to how factors are integrated to calculate overall insight scores on reliable standardised measures.

Study 2

Method

Design

The participants were the same 12 clinicians who participated in Study 1. The same 30 video-recorded vignettes and patient summary sheets were also used.

Instruments

The clinicians were given a questionnaire that outlines three assessment scenarios related to treatment planning, involuntary treatment and fitness to stand trial. These assessment domains were chosen to replicate typical contexts where insight is often a relevant issue. They allow for gradation of legal scrutiny and consequence, as there is typically greater scrutiny in court than in involuntary treatment contexts, and little to no legal scrutiny within clinical contexts. For each domain, the clinicians were asked if they would be confident about giving a judgement on patient insight based on the available data. The scenarios are as follows:

Scenario 1 – treatment planning: The patient has been referred by a family member who is concerned about the patient’s mental well-being.

Scenario 2 – involuntary treatment: The patient is an involuntary patient whom you have been requested to assess in order to provide an opinion for the Mental Health Review Board.

Scenario 3 – fitness to stand trial: The patient has been charged with assaulting a public officer and has been referred for an evaluation for the court regarding fitness to stand trial.

For the three scenarios, the clinicians were requested to state whether or not they were sufficiently confident (yes/no) to give a judgement about the patient’s level of insight for treatment planning, as part of an evaluation of the need for further involuntary treatment or as part of an evaluation of fitness within a written court report, respectively.

Follow-up qualitative clinician interview

The clinicians were interviewed following the completion of the ratings. They were questioned on their reasons for feeling confident or unconfident in making a judgement across the scenarios, and on their overall opinions on decision-making across the three domains.

Results

Data analysis

Clinician confidence in making a judgement of insight within the three applicable assessment scenarios was measured as a proportion of the 30 cases. The qualitative data were analysed using the principles outlined in Study 1.

Confidence ratings

The confidence ratings for each decision-making scenario are presented in Figure 1 . Clinicians 1 to 7 were psychiatrists and Clinicians 8 to 12 were clinical psychologists. The scenario data and the qualitative data from the follow-up clinician interviews are presented below.

Cases in which clinicians were confident in making a judgement of insight across assessment scenarios.

Scenario 1: treatment planning

The clinicians were more confident than not to make a judgement of insight for the treatment planning scenarios, and overall were confident in 78.1% of the cases. Clinicians 1, 2 and 6 were confident to give a judgement in all 30 cases. The psychiatrists were confident to make a judgement of insight for this scenario in 84.8% of the cases, and the clinical psychologists were confident in 68.7% of the cases.

Scenario 2:involuntary treatment

The combined sample was confident in 53.3% of the cases within the context of a decision related to involuntary treatment. The psychiatrists were confident in 68.1% of the cases, with Clinicians 1, 2 and 6 confident in over 90% of the cases, whereas the clinical psychologists were confident in only 38.7% of the cases.

Scenario 3:fitness to stand trial

With the exception of Clinicians 1 and 2, the sample was generally not confident to make a judgement of insight for a written court report. Overall, the combined sample was confident in 31.1% of the cases. Although Clinicians 1 and 2 were confident in 90% of the cases, the psychiatrists as a group were confident in only 42.4% of the cases and the clinical psychologists were confident in just 15.3% of the cases.

Follow-up clinician interviews

The interviews with the clinicians revealed that the majority generally felt confident to give an opinion on insight based on the vignettes and additional data when it was within a treatment context, but were less confident when the assessment scenario had a legal context. The predominant theme that emerged is that the clinicians wanted more information in order to feel confident about giving an opinion on insight when it was related to involuntary treatment or fitness to stand trial.

In relation to the involuntary treatment scenario, a number of the clinicians believed that the assessment of insight in this context necessitates the investigation of all available information, as opposed to being a standalone evaluation of mental status. One psychiatrist stated: ‘for me, it’s not a decision I take lightly. It’s one where you do need to have a lot of information, like collateral sources’. Furthermore, many of the clinicians stated that having longitudinal data would also increase their confidence in making such judgements. Reported desirable information included compliance history, treatment history and stability of insight over time.

Although a number of the clinicians felt that they needed more information at this level of decision-making, several were clearly confident to make decisions relating to involuntary treatment based on the available information.

These clinicians indicated that they were generally confident to make such decisions based on the primary themes that had emerged in Study 1 (e.g. Attribution of symptoms to mental illness). These clinicians revealed that their experience in making such judgements also gave them confidence. One such psychiatrist noted: ‘It’s a matter of experience. I feel confident in my role’. In discussing this matter, another psychiatrist stated that as a forensic psychiatrist, he tries to be as objective as possible without concerning himself with the consequences of his decision: ‘I don’t care so much about the consequences. It’s not something I should take into account. I try to be impartial, objective and look at the situation as a scientist’. Additionally, the clinicians who were confident to give an opinion on insight for involuntary treatment reasons reported that the Mental Health Review Board generally accepts opinions on insight based on the experience of the clinician: ‘assumptions are made based on the clinical experience of the clinician. People can get away with things on the Board without getting drilled down’.

In the fitness to stand trial scenario there was a more pronounced desire for obtaining more information than the video provided. The clinicians gave responses such as ‘I will require much more information to comment on, or give a forensic opinion’ and ‘the crossbar is much higher’. They reported that additional collateral and longitudinal information would be helpful. These issues were articulated by one psychiatrist, who stated:

As I went through the vignettes, I kept asking myself did I have enough evidence to withstand cross-examination around insight? For a lot of the cases, I felt given a feisty lawyer, I might not have enough evidence. I would need some of that longitudinal linkage to function.

Several clinicians reported that information pertaining to offending history would aid in assessing insight: patients’ forensic history is ‘a good indicator of behavioural pattern and insight and judgement over time – for example, repeat offending behaviour generally indicates poor judgement’.

Discussion

Clinician confidence to make a clinical judgement of insight was found to vary across the clinical and forensic contexts. The clinicians were confident about giving judgements in most cases within a treatment (clinical) context, but apart from two of the psychiatrists they were confident in far fewer cases in the forensic contexts. In essence, the clinicians communicated that they were confident in using unreliable judgements (e.g. Galloghly et al., 2013) in clinical settings where they are unlikely to be scrutinised and where the judgements are less likely to impact on patients’ welfare. However, in the forensic contexts – and particularly in court proceedings that are likely to involve cross-examination (e.g. a hearing to determine fitness) – they wanted more information to base their judgements on than what they were willing to work with in the clinical context.

General discussion

Taken together, these two studies show that clinicians make judgements about patients’ degree of insight into their illness by considering similar factors that the research has found to be critical. Moreover, the eight factors that the clinicians in the present study cited as informing their judgements of insight are generally consistent with the insight dimensions reported in the scientific literature (Amador & Kronengold, 2004; David, 2004; Marková, 2005b; Mintz et al., 2003). The meta-analysis conducted by Mintz et al. (2003) is the most recent comprehensive review of the factors or dimensions correlated with insight. It outlines five primary insight dimensions: (1) awareness of the mental disorder, (2) awareness of the social consequences of the mental disorder, (3) awareness of the need for treatment, (4) awareness of the symptoms and (5) attribution of the symptoms to the mental disorder. As displayed in Table 2 , these five dimensions can be fundamentally aligned to six of the factors that emerged from the present study. The additional factors found in this study are Positive symptomatology and Patient interaction in the assessment process.

Table 2.

Insight factors found in the literature with corresponding factors found in the study.

Although the factor of Positive symptomatology is not a distinct feature amongst insight measures, positive symptoms have been demonstrated to correlate with poor insight in a number of studies (Amador et al., 1994; Baier et al., 2000; Mintz et al., 2003; Schwartz, 1998). Amador et al. (1994) found a significant relationship between insight and the severity of some symptoms, including delusions and thought disorder, while Mintz et al. (2003) found a negative correlation between insight and global, positive and negative symptomatology. Notwithstanding the small sample size in the current research, the findings support an association between present-state positive symptomatology and insight, with greater symptomatology being associated with lesser insight.

Patient interaction in the assessment process is an important part of psychiatric interviewing and assessment. Generic assessment methodologies such as the mental status examination (MSE) allow for the recording of nuanced patient behaviour and interaction that may inform opinion on issues such as insight. However, the majority of research-orientated instruments developed to measure insight are generally based on structured questioning or patient self-report. Such methodologies appear to fail to account for the complexities and nuances of insight that may be revealed through clinician–patient interaction, such as patient openness and guardedness, as well as issues relating to patients providing ‘mechanistic’ or ‘parroting’ responses. Marková (2005a) draws attention to this issue in noting that the dynamic interview process is a key component of the assessment of insight using clinical judgement, and that it is affected by factors such as the interview environment, rapport and trust.

A notable finding from Study 1 relates to how the clinicians viewed patients’ insight into their treatment. Two distinct factors emerged – Compliance with treatment and Ability to recognise the function of treatment – that can be compared respectively to David’s (1990) Schedule for Assessing the Three Components of Insight (SAI), which focuses on acceptance of treatment and compliance, and the dimension in the Scale to Assess Unawareness in Mental Disorder (SUMD) that assesses patient awareness of the achieved effects of medication (Amador et al., 1993). The findings of the present study suggest that these two themes might be two distinct dimensions, with Compliance with treatment acting only as a possible basis for insight, whereas Ability to recognise the function of treatment operates as a more nuanced and rigorous indicator of insight.

It is unclear from the present findings how clinicians might weigh various factors when using clinical judgement to make treatment decisions or form opinions to be expressed as expert evidence in legal proceedings. This is particularly concerning given the poor reliability associated with clinical judgement (Body, Cook, Burrows, Carley, & Lewis, 2014; Carlton, Than, Cullen, Khattab, & Greaves, 2015; Galloghly et al., 2013; Nadler et al., 2016). Ambiguity associated with the construct of insight has regularly been highlighted in the literature (e.g. Diesfeld & Sjöström, 2007; Marková, 2005b; McGorry & McConville, 1999). Most mental disorders have clear diagnostic criteria outlined in standardised manuals, which can guide clinicians through assessment and diagnosis when using clinical judgement. In relation to insight, clinicians do not have the benefit of standardised diagnostic criteria to guide their clinical judgements, which can be influenced by their own clinical experience and level of knowledge, as well as their personal biases and attitudes (Marková, 2005a).

The variance associated with the factors that might be used to inform insight is of particular concern in psycho-legal domains. In a review of 25 decisions from the Mental Health Review Board in Victoria, Australia, Diesfeld and Sjöström (2007, p. 85) note that the application of insight is problematic in three main ways: (1) there is little clarification of its meaning, (2) the relationship between insight and compliance is often unclear and (3) there are frequent allusions to an undefined scale of insight that offers the appearance of objectivity. The present research supports these findings that the evaluation of insight within psycho-legal settings is problematic, and that clinical judgements of insight will most likely fail to meet the requirements for the admission of scientific evidence in courts (Freckelton, 2019; Ruschena, 2003). The present study indicates that clinicians have some insight into the unreliability of their judgement and consequently are less confident to exercise it within forensic contexts, where they will be more carefully scrutinised and where their judgements will impact more significantly on the lives of their patients. This suggests that clinicians appreciate the limitations of their judgement, although the sample in the present study indicate in their qualitative data that they would have been more confident if they had been able to draw upon more information than was afforded in the vignettes. However, it is likely that drawing on more information would increase confidence without increasing reliability; therefore, researchers need to examine this issue.

Using standardised measures of insight – rather than unstructured clinical judgement – would overcome these problems, because clinicians would know that their judgements were as reliable as they can be, and they would have a scientific basis for justifying their opinions in legal proceedings. Greater uniformity of such procedures and standards may also go some way towards improving the consistency of civil commitment decision-making. However, standardised self-report measures do not capture the important clinical and diagnostic information that can emerge from direct examination and interview of the patient, as discussed above. Structured professional judgement (SPJ) tools would combine the benefits of each approach while minimising their limitations (Abidin et al., 2013; Hart, Douglas, & Guy, 2017). SPJ tools involve the clinician rating the patient on a specific set of empirically derived factors according to standardised criteria. Factors can be weighted – if there is an empirical basis for doing so – prior to being summed, in order to give an overall insight score that can then be categorised according to empirically derived cut-off points (e.g. adequate level of insight for a specific purpose such as involuntary status). Hart et al. (2017) present a detailed overview of the application of SPJ methods in forensic mental health.

The findings of the present study evidence varying degrees of clinician confidence in making judgements on insight, dependent upon the assessment context. Most of the clinicians demonstrated a reduction in confidence in making a judgement as the perceived legal consequences for the patient increased. The clinicians generally confirmed that they felt the need to consult secondary sources of information in order to feel more confident in their judgements. Incorporating contextual, longitudinal and collateral information is congruent with promoted psycho-legal assessment methodology (Melton, Petrila, Poythress, & Slobogin, 1997; Zapf, Roesch, Weiner, & Hess, 2006). However, a proportion of the clinicians in the present study were clearly confident to make a judgement on insight without using secondary sources of data. This group generally attributed their confidence to their level of experience, which includes a familiarity with both the patient group and the psycho-legal assessment context. The notion of mental health professionals justifying their diagnoses and evaluations based on their years of experience is consistent with previous research (Dawes, 1989). The main issue that arises from high confidence levels however is the possibility of inaccurate judgements due to overconfidence (Dawes, 1986, 1989; Garb, 1989, 2006; Oskamp, 1965), as researchers have generally failed to demonstrate a consistent association between confidence and accuracy of judgements (Dawes, 1989; Garb, 1989). A comprehensive review of clinical and statistical judgements is therefore recommended, wherein mental health professionals using clinical judgement should be sceptical of the accuracy of their judgements, and avoid overconfidence and habituation to the assessment setting (Ægistdóttir et al., 2006).

Limitations

The small clinician sample size used in this study restricts the generalisation of the findings. The clinician sample may also be criticised for disproportion of forensic experience. Furthermore, the use of DVD vignettes evidently placed a number of restrictions on the assessment process – namely, vignettes cannot replicate the full assessment of insight inclusive of direct interviewing. The assessment process was also impeded by the lack of collateral and longitudinal information provided. Although the patient summary sheets attempted to provide a synopsis of such information, they did not supply the relevant background information associated with both clinical and forensic assessment (Groth-Marnat, 2003; Melton et al., 1997)

Future research

Future research needs to examine the forensic validity of standardised measures of insight within various legal contexts (involuntary treatment, fitness to stand trial, civil capacities, parenting capacity, etc.). Attention should be given to developing SPJ tools that integrate the benefits of standardisation, reliability, empirical basis and clinical impressions and judgement. SPJ tools have become the instruments of choice in other areas of forensic and clinical practice, such as risk assessment (Hart et al., 2017). Researchers should also investigate the reasons why clinicians continue to use clinical judgement in preference to structured standardised measures, despite their apparent awareness that unstructured clinical judgement is unreliable, and despite the empirical evidence of its unreliability.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.