I think it will be especially informative for those very few people who still think that I caricature the current state of psychotherapy.
I am certainly not alone in arguing that insight does not cure, and long time readers of this blog know that I have been consistent on the point. Yesterday's post was the most recent in a rather long series.
Now, you can read a description of therapy offered by someone who is a pillar of New York psychiatry, and you will see that however many inroads cognitive approaches have made, the old insight-oriented treatment model is still hanging on. I suspect that it is hanging on for dear life, but it is still hanging on, and not among the lesser members of the therapy world.
Here is Dr. Friedman’s description of therapy: “It is practically an article of faith among many therapists that self-understanding is a prerequisite for a happy life. Insight, the thinking goes, will free you from your psychological hang-ups and promote well-being.”
Having described the current state of therapy, Dr. Friedman begins to argue against this idea. He begins with some clinical material. He writes: “Not long ago, I saw a young man in his early 30s who was sad and anxious after being dumped by his girlfriend for the second time in three years.…”
Dr. Friedman is not dealing with a novice. This man is a veteran of therapy. Naturally, his many years of therapy has given him insight into the origin of this feeling: “He could even trace this feeling back to a separation from his mother, who had been hospitalized for several months for cancer treatment when he was 4. In short, he had gained plenty of insight in therapy into the nature and origin of his anxiety, but he felt no better.
“What therapy had given this young man was a coherent narrative of his life; it had demystified his feelings, but had done little to change them.”
There you have it. You lose the girl and the other girl and yet another girl. You spend years in therapy, you don't get the girl, but you walk away with the consolation prize: a narrative. That is very expensive storytelling.
We are not surprised that therapy has done nothing to help him hold on to a relationship, or, for all we know, to choose a woman with whom he might want to sustain one.
The patient has learned to focus on his past, not his present. If you ask why therapy wants him to do this, Dr. Friedman answers that it is an article of faith.
Let’s be clear. We are in the realm of storytelling and faith. We are not in the world of medicine or science. Surely, a physician will find a medical treatment for the sadness and anxiety, but, as Dr. Friedman notes, it is not abnormal to have these feelings after having been dumped for the n-ieme time.
As for the reality of the patient's relationships, we know nothing. No physician can reveal detailed patient information in a newspaper, but it is also true that therapy does not deal with reality. It seeks to make your life fit into a pattern, then to construct a narrative that pretends to explain it away.
If there are differences between the different situations with the different women, we do not know. Many therapists do not even care to find out.
At the least, the time the patient has spent trying to connect current events to past events has been time not spent on examining the way his relationships develop or expire.
Of course, Dr. Friedman has brought up this case to show us what insight can and cannot do for a patient. In this case, the correct conclusion seems to be that insight cannot do very much, if anything.
But, then, what does help people get better in therapy? Here, Dr. Friedman reports the prevalent view of why some people get better in therapy. I have occasionally mentioned it myself.
In his words: “Since the common ingredient in all therapies is not insight, but a nonspecific human bond with your therapist, it seems fair to say that insight is neither necessary nor sufficient to feeling better.” Of course, forging a solid human connection is neither science nor medicine.
This does not mean that insight is anodyne. It might actually make things worse.
Referring to another patient, Dr. Friedman writes: “He had been in therapy for years before I saw him and had come to the realization that he had chosen his profession to please his critical and demanding father rather than follow his passion for art. Although he was insightful about much of his behavior, he was clearly no happier for it.
“When he became depressed, though, this insight added to his pain as he berated himself for failing to stand up to his father and follow his own path.”
The point deserves emphasis. Since insight seems to involve self-criticism or to lend itself to self-deprecation, it can feed a depression.
In addition, therapy that is directed toward gaining insight inhibits action. By pretending that it is not important to take action or to change conduct, it promises that once the patient gains the proper insight he will naturally act more effectively.
If a long term therapy patient gains insight and cannot change the way he conducts his life, he will be prone to blame himself.
If ever he should try to cast aspersions on therapy or his therapist, he will quickly be accused of resisting the truth.
To be fair, Dr. Friedman still thinks that insight has a use and a purpose. He is a leading psychiatrist in a leading psychiatric facility where many of the professionals still cling doggedly to their faith in insight.
His experience, however, seems to have led him to conclude that the search for insight is, at best, a waste of time.
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