Monday, December 25, 2006

Insight and Psychotherapy

Now that Chanukah has passed, my round of parties and events has also passed. Christmas is a pretty boring day for me, so it gives me a chance to catch up on this poor, neglected blog.

There have been several good articles in the New York Times over the last few weeks. This one, entitled, "Sometimes the Why isn't Crucial," caught my attention. The author, Sally Satel, is a psychiatrist. She works in a substance abuse treatment facility and she questions the effectiveness of insight as a psychotherapeutic tool for her. She argues that explaining "why" someone drinks isn't as important as developing resources to resist urges to drink.

Developing insight is the primary vehicle of change for psychoanalysis and related therapies. Freud famously observed, "The child is the father of the man," meaning who we are today comes from our previous experiences. For these insight-based therapies, developing insight means not only explaining why someone has their problem, but also helping them get in touch with the feelings associated with it. Along with the couch, it's a stereotypical view of psychotherapy.

The public is generally unaware that arguments against insight-based therapies dates back many years. Albert Ellis has been arguing this point since the 1950's. In a more recent book titled (as only he can title it), How to Refuse to Make Yourself Miserable about Anything Yes Anything, he says (as only he can say):

Your early childhood experiences and your past conditioning did not originally make you disturbed. You did. (p.70).
Ellis argues that how we think and act in the present is what really matters. He says, speaking of his clients, "Their early thoughts and feelings did not make them anxious today. Rather, their present and continuing dogmas...were really the more direct cause of their current neurosis." (p.70; Emphasis in the the original). So, according to Ellis, we effect emotional and behavioral change by addressing current irrational beliefs, not by uncovering how the beliefs were acquired.

Ellis is not the only one. Behaviorists, such as Joseph Wolpe , also writing in the 1950's, argued that exposure to the feared stimulus was a more effective way of treating phobias than insight-based therapies. Fifty years later, and God knows how many studies, we still treat phobias with exposure-based treatments. The data is conclusive. Insight alone is at best minimally effective in treating phobias or almost any psychological dysfunction.

Satel identifies one reason why insight isn't effective. We have a tendency to distort our memories of life events in an effort to develop a coherent narrative:
What scientists call hindsight bias kicks in when we try to figure out the causal chain of events leading to the current situation. We may well come up with a tidy story but, inevitably, it will contain large swaths of revisionist history. It’s not that we bias ourselves deliberately; it happens because the mind tends to make events in the past appear comprehensible and orderly. We forget the uncertainties that might have beset us as we struggled in real time.
So, how do we develop insight based on "large swaths of revisionist history?" If we're reconstructing our past, an erroneous reconstruction would logically hinder our progress. Is insight important at all?

I think so. Insight has a limited, but important place because it helps us deal with resistance in psychotherapy. To illustrate, here are two vignettes. To guard my clients' privacy, they are composites of several past clients with a little bit of stereotyping mixed in.

First, consider a client who resists going to AA meetings. Normally, the therapist would take this as a sign the client is still denying his alcoholism. Without looking at his past, the therapist's natural tendency would be to confront the client about his denial. However, there is another issue.

The AA meetings remind the client of prayer meetings his family attended while he was a child. The religious sect that sponsored these meetings encouraged physical abuse of children, and the client is still coping with intense feelings of guilt and powerlessness stemming from this. After identifying this source of resistance do you think the client will then jump up and go to AA meetings? Of course not.

Putting the resistance into that context will do two things. It will relieve the client's guilt for not following through with clinical recommendations. Second, giving the client the right to refuse AA and still be respected will help him feel less powerless. Then, the therapist should look for other ways of working on recovery.

The second example involves cognitive therapy for a female client who is unable to trust men. She goes through cycles where she meets a man and falls deeply in love with him. Then, without reason, she becomes extremely jealous. She harasses him, checks on him, and eventually drives him away. She comes into therapy depressed and hopeless about ever having a normal relationship.

Without dealing with this in historical context, cognitive therapy would focus on changing the dysfunctional cognitions the client has about men. The therapist would probably identify the thought, "If my boyfriend were to cheat on me, it would be so awful, I couldn't survive it." Then, the therapist would challenge (a) the probability of cheating; and (b) whether or not her boyfriend's cheating would be survivable. However, each effort to challenge her beliefs is met by "Yes, but...." It is classic resistance behavior.

The "yes, but..." indicates the therapist is arousing anxiety which is itself interfering with therapy. A review of the client's history indicates she grew up in a family where the father had frequent affairs. There were chaotic arguments between the parents each time an affair was uncovered. The mother became increasingly depressed and spent most of her time in bed. After years of chaos, in which the client wound up being a parent to both her mother and her younger siblings, her parents finally divorced. Her mother remained angry and embittered for the rest of her life, insisting that all men are worthless.

So, the client's belief is closer to this: "All men are cheaters and when (not if) my boyfriend cheats on me, it will be awful! I'll turn into my mother and the rest of my life will be ruined." With this historical context, the therapist and client understand the "why" of her behavior. Without that understanding, there is no way to help the client will take the risk of changing her beliefs. The anxiety engendered by being reminded of her childhood is too great. Still, for change to happen, she needs to know that, in the present, she has the resources to deal with loss, rejection, and betrayal, without turning into her mother. Then, she can say, "It would be bad if my boyfriend cheated on me, but I can survive it. The risk is worth it, because it gives me a chance to have a happy, rewarding relationship."

In conclusion, explaining "why" has its place in therapy, but is useless by itself. Good therapy stays in the present, but uses the past as context. Even if the story is distorted, it still has value, providing meaning and motivation for change.

1 comment:

Anonymous said...

An excellent post. This 'holy war' between talk v drug v behavior therapies never made sense and is detrimental to clients - but calling yourself 'eclectic' doesn't solve anything if the therapist doesn't have a firm grip on what that really means or how to apply it to the real people with real problems sitting there in the room with them.