Patient “insight” is a much-discussed topic in psychotherapy. Most clinicians believe that developing insight is a crucial aspect of recovery from a mental illness. Many clinicians believe that insight is a necessary prerequisite for change. There are some types of treatment, such as psychoanalysis and psychodynamic psychotherapy, which are based entirely on the development of insight. These types of treatment are predicated on the assumption that increased insight naturally leads to positive behavior change and recovery from mental illness.
These assumptions originated with Sigmund Freud, who believed that mental illness was the result of unconscious psychic conflict. He believed by bringing this conflict into the patient’s conscious awareness, it would no longer have power over the patient and the neurotic or psychotic symptoms would disappear.
The notion that exploration into one’s innermost psyche leads to healing is alluring and romantic. It makes for great novels, memoirs, and movies. The problem is, it rarely works this way in real life. While most people suffering from mental illnesses do indeed experience tremendous inner psychological conflict, there is no evidence that this inner conflict is the cause of any mental illness or that gaining insight into the conflict will promote recovery. Insight, as discussed in psychoanalytic theory or pop psychology, refers to something along the lines of “why I am the way I am” or “why I developed this mental illness.”
There are several reasons why this type of insight alone rarely leads to recovery:
1.) Contrary to popular belief, we do not know what causes most mental illnesses. We may know what factors may trigger, perpetuate, or exacerbate the illness. For example, a loss of some sort often triggers or exacerbates depression, and dieting often triggers or exacerbates an eating disorder. We may know what types of treatment are effective for certain illnesses. For example, we know that DBT is effective in treating borderline personality disorder. But any notion about causality is, at this point in time, largely speculative. So if we don’t really know what causes mental illness, insight into the supposed cause will not promote recovery.
2.) The “insights” encouraged by the therapist are often based upon antiquated theories of mental illnesses which have no empirical support (e.g., that depression is “anger turned inward”). These theories may feel good, or make intuitive sense, or seem to validate the patient’s suffering, but that doesn’t make them accurate or useful in terms of recovery.
3.) We learn and mature emotionally through experience. Thoughts and feelings follow from behavior, not the other way around. Simply knowing why you think the way you think, or why you feel the way you feel, does not change your thoughts or feelings. What does help change your thoughts and feelings is by acting opposite to them. So, for example, if you are feeling depressed and lethargic, sitting around the house all day by yourself trying to figure out why you’re depressed doesn’t make you less depressed. However, dragging yourself off the couch to go for a brisk walk outside, and then inviting some friends over to watch a funny movie, may very well lift your spirits, at least a little bit.
4.) Our neural pathways are rewired not through developing insight, but through consistent, repetitive practice of new behaviors. You will not become a good athlete by watching sports or reading about sports. Rather, you develop and hone your athletic skills by consistent practice and physical conditioning. This is why the behavioral therapies such as CBT, DBT, ACT, and FBT are so much more effective than insight-oriented therapies such as psychodynamic therapy.
5.) Some mental illnesses, such as schizophrenia, bipolar disorder, and anorexia nervosa, involve a symptom called anosognosia, which is a brain-based lack of insight. Because of abnormalities in brain function, individuals with anosognosia are unable to recognize that they are ill even when loved ones are extremely worried. For instance, a person with anorexia nervosa may feel great and perceive her body as normal and healthy, even when she is markedly underweight and clearly suffering from the physical and psychological effects of malnourishment. And an individual with bipolar mania may perceive himself as “on top of the world” and vehemently resist intervention as loved ones stand by and watch him make one self-destructive decision after another. Individuals with anosognosia should not be expected to seek treatment on their own, or to “want to recover,” because they will not have the insight to do so until they are well on their way to recovery.
The types of insights described above are relatively useless. However, there is another type of insight which results from successful treatment and is one of many markers of a psychologically healthy individual. Insight, as I conceptualize it, is best described by both the dictionary definition and the wikipedia definition. Thus, in order to successfully manage or overcome a mental illness, one must be able to discern the true nature of their mental illness and must understand cause and effect insofar as it applies to their symptoms. The following insights are extremely important to recovery:
1.) Insight into the fact that one has a mental illness. This element of insight includes acceptance of the fact that the illness is, to some extent, out of the person’s control, and cannot simply be wished away or overcome by willpower.
2.) Insight into the symptoms of one’s mental illness and how they manifest. This insight includes the ability to recognize signs and symptoms in oneself and the skills to eliminate, manage, or cope with the symptoms when they occur.
3.) Insight into the effects of following, or not following, the treatment plan and clinician’s recommendations. This insight involves understanding not only what the clinician is doing or recommending, but why she is doing or recommending it. That is, understanding the mechanism of change.
4.) Understanding how various choices one makes impact the course of one’s illness. For example, a person with a mood disorder needs to learn that by getting 8-9 hours of sleep nightly, exercising regularly, taking medication daily, and monitoring mood changes on a daily basis are essential to stabilizing moods. She will also need to learn that getting drunk on her 21st birthday, traveling across time zones for vacation without making up missed sleep, missing her medication for two days because she forgot to get refills on time, or burning the candle at both ends during final exams, will likely trigger a return of symptoms, even though “normal people” do these things all the time without a second thought. “But that sucks!” They exclaim. “That’s not fair!” They are correct on both counts.
I believe that a patient must develop all four of these insights during treatment. It is the clinician’s responsibility to assist the patient in developing these insights. It is also the clinician’s responsibility to ensure that the patient’s family members develop these insights during treatment, as it is often a parent or a spouse who will first notice the signs of relapse and encourage a return to treatment. This is especially true in disorders characterized by anosognosia.
9 Replies to “Insights on Insight”
Brilliant! I’ll be sharing this all over the place.
Brilliant. Thank you so much
It is indeed brilliant. Thank you.
This is brilliant, and something I will refer back to many times over the next couple of years, I’m sure. I’m training to be a therapist and the way that some people who subscribe to the older theories of mental health problems insist that all mental illnesses have a psychological root cause drives me up the wall. I am boring everyone with discussions of biology instead!
I had extensive therapy during my eating disorder, and for years I had a very good idea of what I thought had caused it. None of that helped me change a thing, my insights were of no practical use at all. Worse, most of my thoughts were influenced by the irrational thinking caused by my eating disorder, so very few of them had any merit anyway. Now I believe that my eating disorder had a biological basis, and although I still think therapy has a place (in learning ways to cope with anxiety, coming to terms with life after recovery when you have been unwell for several years and may be a long way behind your peers, and so on), I am annoyed that there was no genuinely helpful treatment when I was much younger, and that I was instead stuck with therapists who subscribed to such outdated views.
How can you be sure if you have anonagosia (I surely got that wrong), or if people are just concerned about nothing because you’re a little thinner than normal, or whatever? I just think people over react.
There is no definitive way to know if you have anosognosia. Most mental health professionals are not even aware of this phenomenon and don’t know how to manage its dire consequences.
I would say, however, that if you have an eating disorder, or have ever suffered from an eating disorder in the past, and your loved ones are expressing concern, there is a very good chance that something’s wrong and you need help.
Also, if you have a history of anorexia nervosa or bulimia nervosa, it is never OK to be “a little thinner than normal, or whatever” because losing weight or maintaining a low weight, even if it is unintentional, very often triggers relapse.
Thank you so much for this wonderful post. It makes so much sense to me. As an older person (38) with anorexia I think I have far more insight into my illness (certainly than I did 20 years ago when it first started) -and I’m talking about the useful insight – the one which allows me to actually see that I have a problem. But I can’t say I find endlessly talking about ‘why’ I might have this problem is all that useful. I’d rather just work with what I’ve got and get on with getting better. And I’m going to bookmark this page and work on keeping all 4 of those useful insights at the forefront of my thinking.
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