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Insight: The Lost Cause in Psychotherapy

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Is self-knowledge a good thing, or is it just fuel for self-absorption and depressive rumination? We look through four psychotherapies to learn what makes the difference between meaningful insight and navel gazing.

Published On: 8/24/2020

Duration: 19 minutes, 38 seconds


Dr. Aiken: Welcome to The Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of The Carlat Psychiatry Report.

Kellie Newsome: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

Leo Rengall was a firebrand of a man. He had led the American Psychoanalytic Association in the 1960’s, and in 2002 he came back to their annual meeting to defend psychoanalytic theory from the forces of cultural relativism that threatened to dilute it. His crosshairs were focused on intersubjectivity – a branch of psychoanalysis which held that the analyst does not have a unique grasp on objective truth, but that the insights that arise out of psychoanalysis are more of a helpful fiction that’s created between the analyst and the patient. Fiction, relativisim, pluralism, postmodernism… Dr. Rengall had no patience with these ideas. In his mind psychoanalysis was even more pure than the scientific method, a knife that when correctly applied would reveal the true inner workings of the human mind.

“In the ongoing debate over ‘one theory or many’,” he began, “I favor one: Total, unified, and cumulative.” He went on to call for a return to the Frued’s theories of the mind that he laid out in the early 1900’s; to bring back the id, ego, and the superego

I asked Dr. Rangell how all this truth finding would help patients, expecting him to tell me that people can live more free and function better when they know the truth about their problems. He did not. “It’s not the job of psychoanalysis to help people,” he told me, “it may and it may not…. But what we can do is deliver the truth – with a capital T.” Well, I thought, at least he was being honest.

Dr. Rengall’s Sermon on the Mount ultimately failed to move the field. Insight – the introspective quest for truth about the self – usually doesn’t rank at the top of the list of agents of change in psychotherapy. Warmth, empathy, behavioral change, and the therapeutic alliance usually rest there. But in this month’s Carlat Report we present new data on insight as a force of change in psychotherapy.

Insight is traditionally associated with psychoanalysis and psychodynamic therapy – often called the “insight oriented therapies”,  but it plays a part in nearly every psychotherapy. And with apologies to Dr. Rengall for diluting the concept, we’re going to look at how those therapies view insight. Through that journey, we’ll see that these therapies are more alike than not in how they use insight.

First stop, psychoanalysis

Here the idea of insight is deep and broad: It means awareness of unconscious drives and conflicts, of resistance and transference. As Freud put it, “Understanding and cure almost coincide.” But from its early days psychoanalysts struggled with the everyday reality they faced in practice: Insight by itself did not lead to cures. At least two other ingredients were necessary: The patient had to arrive at the insight on their own. It wasn’t enough to just lay it out for them. And second, the insight they arrived at had to be more than just an intellectual understanding. It needed an emotional component to instigate change; they had to feel it.

Cognitive Therapy is Born
Fast forward to 1954. Philadelphia, PA. A young psychoanalyst named Aaron Beck has run into a problem. Dr. Beck had recently joined the faculty at the University of Pennsylvania and was testing out Freud’s theories on depression. Those theories were not holding up to empirical tests, and this was not going to bode well for Beck’s role at U. Penn which like many other mid-century psychiatric departments was yoked to psychoanalytic theory.  Freud believed that depression was caused by repressed anger. Well, repressed stuff is supposed to come out in dreams, so Beck studied the dreams of depressed patients, hoping to find themes of repressed anger. He did not. The dreams of depressed people were much like their conscious lives – overburdened with loss and rejection with little trace of anger and hostility.

Meanwhile, Beck’s day job as a fledgling psychoanalyst raised further doubts. While treating a woman with anxiety, he suggested that her anxiety was caused by unconscious attempts to repress her own sexual impulses. The patient did not seem convinced, and Beck paused to ask what was going through her mind when he made that interpretation. “Actually,” she said, “I was more worried that I was boring you, it’s a thought I often have when I’m with other people.”

Experiences like this lead Beck to shift away from psychoanalytic insights about unconscious conflicts and toward cognitive insights about automatic thoughts like, “I’m boring.” By changing those automatic thoughts, patients could change how they feel and live, and thus cognitive therapy was born. But it soon ran into the same hurdle that psychoanalysis did. Whether it was an analytic interpretation or a challenge to automatic thoughts, patients didn’t change much unless their new beliefs came with some emotional weight.

As Albert Ellis, a cofounder of the cognitive approach put it, “It appears that simply comprehending the notion that one’s beliefs are dysfunctional or irrational is insufficient in fostering change. Thus, the primary appeal to logic and reason during the process of disputing irrational beliefs, while compelling, may be rather limiting in the long run.”  Ellis drew the same line between emotional and intellectual insight as the psychoanalysts had. “Emotional-insight” he wrote in 1963, is a “radically different, essentially more forceful, effective, and committed kind of behavior.”

Insight in Behavior Therapy
In the 1970’s, cognitive therapy and behavior therapy merged, effectively putting the B in CBT. But the two are not always happy cabin mates, and in some ways cognitive therapy’s approach to insight bears more resemblance to psychoanalysis than behavior therapy.

Unlike analysts and cognitive therapists, the behavior therapist has no interest in whether a patient’s beliefs and insights are true or false. They view beliefs as behaviors – thinking is a behavior, as is feeling.  That’s right, feeling is a behavior.  It sounds strange to our ears because we’re used to thinking of behavior as an act of free will, while feelings are reactions. But free will has no concept in behavior therapy. The behaviorist is interested in what happens, and the reinforces that make it more or less likely to happen again.

Here’s how that looks in therapy.  Both cognitive and behavioral therapists start with a situation, like “My friend called me up and invited me for dinner.” The cognitive therapist then wants to know about the automatic thought that was triggered by the situation, such as “I’m not likeable.”  The thought then causes a behavior: “I stayed at home.”

The behavior therapist skips right over the thought and goes to the action. The invitation triggered a behavior: “I stayed at home.” The behavior then has a consequence, which goes in column three: “I felt less anxious.” A Ha says the behavior therapist – when you stay at home you feel better – you feel less anxious – we have discovered what reinforces your avoidance! You’re doing it for a good reason.

So how does the behaviorist help them change?  They help the patient get in touch with the positive reward of going out to dinner, or the long-term negative result of staying at home. To do this, they connect the actions with emotions through questions like, how does it affect your life to stay at home and turn down invitations?” They might try to connect going to dinner with more heartfelt, emotive values that the patient has, say if they value building friendships: “how is staying at home consistent with your values, dreams, and plans?” Just like therapists before them, they are trying to make these ideas emotionally relevant.

The Dangers of Insight
“Where ignorance is bliss, ’tis folly to be wise” wrote the poet Thomas Gray in 1742. Some have questioned whether too much insight is a good thing. It’s uncomfortable to learn of one’s own fears, doubts, conflicts, painful memories, or paranoid beliefs.

One place where insight can go wrong is rumination. Rumination is a repetitive style of thought that keeps wrestling with a problem without ever arriving at a conclusion. We see it a lot in depression, and the things that trigger rumination are the same themes that contribute to insight:  Thoughts about the self, about the meaning of things, and existential questions like “Why does this keep happening to me.”

Rumination focused CBT is a new form of cognitive behavioral therapy developed by Edward Watkins; we interviewed him in June of 2018. There’s some evidence that addressing rumination through RF CBT can bring patients to fuller remission than regular CBT.

RF CBT looks on rumination as a behavior, and it’s a slightly addictive one that’s – even when it’s painful – is reinforced. One reinforcer is insight. Patients who ruminate often report that rumination gives them greater insight into the self so that they can solve problems and learn from past mistakes. Research shows the opposite: these same patients have poorer problem solving abilities than non-ruminators.

My own sense is that rumination is problem solving gone awry. It’s like when you’re trying to close a broken window in an antique house and you can’t get it closed but you keep pushing from different angles – all the while you think you’re getting closer but you’re really just breaking the window more. When patients ruminate, it gives them the illusion that they’re solving a problem, which feels good, but in reality they never take action or arrive at a decision… they remain with the same level of depressive avoidance as before.

Therapy is supposed to be a place where you mull over problems, but this kind of set up can just fuel more rumination with these patients. So RF CBT comes with a warning to avoid “co-ruminating” with the patient – less the therapy turn into a two-party exercise in rumination. Here’s how you’ll know a patient is ruminating with you. They bring you a problem like “my cousin moved in with me and I can’t stand him.” You offer a reasonable solution like, “have you tried sitting down with your cousin to clarify your expectations,” and the patient replies, “Yes but…” and goes on to tear that good idea down.  After a few volleys like this you’re likely to feel as defeated and depressed as the patient.

And that’s exactly what happens when you’re not there. The patient thinks of problems all day, conjures up solutions, and then defeats them with the old “Yes but.” The ruminative stream just goes in circles.

One reason that patients ruminate to is avoid negative feelings. In ruminating, they are being overly abstract and rational, instead of sitting with the nitty gritty details of their life – because that is too painful. Better to think about life than to actually live it. So they use techniques like mindfulness, compassion, and concrete thinking – which is where you get the patient to slow down and get into all the sensory details of their story instead of the abstract meanings – to help shift people out of the ruminative real and into a more grounded, heart-felt space.

And here’s where the podcast comes full circle. From psychoanalysis to CBT, all therapists seem to agree that insight is helpful when it’s grounded in emotions.  And it’s that lack of grounding that creates rumination – and fuels depressive. Like we talked about on 60 second psych episode August 15th: “Depressed and Indecisive” – people with depression are indecisive because they have trouble attaching emotional weight to any decision.

In the late 1980’s psychologists Kuiken and Mathews conducted an EEG experiment that pulls this all together. They asked people to think about a problem in their life – one group was asked to pay attention to their feelings while the others were asked to do so in a more intellectual way – searching for an explanation to make sense of the problem. While they mulled over the problem, EEGs attached to the head revealed an interesting pattern. The emotional thinkers had more activation in the right hemisphere, which is associated with feelings and creativity, while the rational thinkers were more active in their logical left hemisphere. And the emotional thinking seemed to work better, at least by EEG. Theta bursts, which are EEG patterns that tend to happen when people arrive at new insights, were 3 times as common in the emotional thinkers as the rational ones.

Emotions guide us and ground us. Without them, insights fall flat, leave no theta burst, and don’t lead to any change.

And now for the word of the day…. Insight.  WAIT – we just covered insight.

No this is the secondary meaning – when we use “insight” in psychopathology we’re talking about whether a patient is aware that they have an illness. The original idea of insanity was that the person lost all awareness, but in the early 1800’s psychiatrists started to recognize that some patients were actually aware that their thinking was off. In 1820 Georget wrote that “a small number of patients were able to asses their mental state, who will say….

The first empiric study of insight was conducted in 1870 at the French asylum Vaucluse, and it found that only 10% of psychiatric admissions had awareness of their condition.

Patients who lack insight are thought to have a more severe form of the disorder, but you have to be careful about raising insight. In 2001 psychiatrists in Edinburgh randomized 114 patients with schizophrenia to two groups – one watched a 15 minute educational video about their illness and received some pamphlets on schizophrenia prior to discharge, and the other group got no such education. When the followed up a few months later, the ones who got this impersonal education had more suicidal thoughts. That’s not to say that education has no role in schizophrenia, but it has to be done with a human touch. When integretaed into a therapeutic program that teaches skills to live with schizophrenia, psychoeducation reduces suicidality.

Kellie: Join us next week…. For an interview with Nassir Ghaemi on Existential Despair in Bipolar Depression

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