Patient competence, defined as the ability to reason, appreciate, understand, and express a choice is rarely discussed in patients with obsessive compulsive disorder, and coercive measures are seldom used. Nevertheless, a psychiatrist of psychologist may doubt whether OCD patients who refuse treatment understand their disease and the consequences of not being treated, which could result in tension between respecting the patient’s autonomy and beneficence. The purpose of this article is to develop a notion of competence that is grounded in clinical (...) practice and corresponds with the experiences of patients with obsessions and/or compulsions. We present a naturalistic case study giving both the patient’s and the therapist’s perspective based on in-depth interviews and a narrative analysis. The case study shows that competence is not merely an assessment by a therapist, but also a co-constructed reality shaped by the experiences and stories of patient and therapist. The patient, a medical student, initially told her story in a restitution narrative, focusing on cognitive rationality. Reconstructing the history of her disease, her story changed into a quest narrative where there was room for emotions, values and moral learning. This fitted well with the therapist’s approach, who used motivational interventions with a view to appealing to the patient’s responsibility to deal with her condition. We conclude that in practice both the patient and therapist used a quest narrative, approaching competence as the potential for practical reasoning to incorporate values and emotions. (shrink)

Thought insertion is a condition characterized by the impression that one's thoughts are not one’s own and have been inserted by others. Some have explained the condition as resulting, in part, from impaired or defective self-knowledge, or knowledge of one’s mental states. I argue that such models do not shed light on the most puzzling feature of thought insertion: the patient’s experience that an introspected thought does not feel like her own. After examining ways in which existing versions of the (...) model might address this worry, I propose a significant modification. I argue that the experience of disownership consists in a rational indifference that one feels towards one’s inserted thought. I further contend that the experience is generated by an underlying absence of an expectation of rational authority towards the inserted thought, such that the patient does not expect her thought to reflect, or be shaped by, her own rational considerations. I defend my proposal using empirical studies from cognitive and social psychology which suggest that we ordinarily have and experience an expectation of rational authority towards a certain subset of our thoughts, and direct analysis of patient reports, which strongly suggest that it is this expectation and the corresponding experience that thought insertion patients lack. (shrink)