Is insight enough?
Is insight enough?
Issue 32 – October 2012Author: Aisling Mannion (firstname.lastname@example.org)
- The aim of most therapies is to increase insight
- Insight focuses on the individual, ignoring important external factors. The concept of outsight (looking outwards to the wider world) is a useful alternative
- Insight as a concept may vary across cultures. We need to bear in mind cultural attributions of mental illness when defining insight
- Psychotherapy and psychiatric practice are cultural practices, which contain Western assumptions and values
Implications for practice
- Patients and professionals can help in building up an understanding of the patient’s difficulties, taking into account personal, social and material circumstances
- Therapists need to consider whether insight alone is enough for their patients, or whether patients need to be encouraged to actively change their behaviour within the limits of the resources they have available
Insight and PsychotherapyA range of definitions of insight have been used. The aim of many forms of psychological therapy is to increase insight and so to help the client make sense of their difficulties. Many psychodynamic therapists would argue that by increasing insight and self-awareness, the patient is in a better position to be able to make choices about how they respond to situations. However, others, such as David Smail, a clinical psychologist, argue that insight is not enough. In his book, How to Survive Without Psychotherapy1, Smail argues that merely understanding why something has happened does not in itself lead to any change. Regarding psychodynamic therapy, Smail argues that the theory sees the patient as having the necessarily skills and will power to be able to change events in their life once they have increased their awareness or insight. However, he points out that this approach is solely focused on the individual and excludes other external factors which will influence the client’s presenting problem and/or may limit what the client is able to do about their difficulties. For instance, factors such as adequate finances and safe accommodation have been found to be important in maintaining good mental health. A client who lacks these resources may struggle to implement changes in their life, even if they understand the benefit of those changes. Smail argues that insight is not enough in itself; instead what needs to happen is the client needs to be encouraged to do things to bring about change, bearing in mind the resources that are available to them. Research into the effectiveness of insight-oriented therapies has shown mixed results. Some studies have found that in comparison to behaviour therapy, in which patients are encouraged to actively change their behaviours, insight-oriented therapies are not as effective2. Others have found that when therapists and clients are separately asked about what aspects of therapy are most important to them, insight is deemed as the most important factor by the therapists, whereas the patients rated finding a solution to their problems as most important3. On the contrary, others have found that insight leads to symptom reduction4 and insight-oriented therapy has been shown to be more effective than behaviour therapy for married couples5. It perhaps depends on the resources available to act on any insights.
Mental Health, Culture and Psychiatric PracticeAs described above, insight-oriented therapies aim to increase the individual’s awareness of themselves. This is based on Western views of the importance of individualism, in which people are viewed as self-contained units with sole responsibility for their actions. Other cultures, however, such as Chinese culture, take a more collectivist stance, in which the needs of the larger group, such as the family, are seen as more important than individual needs. For individuals from such cultures, a client-centred approach aimed at increasing self-awareness is unlikely to be viewed as helpful. A large body of research has shown that individuals from different cultures attribute the causes of mental illness to a variety of factors, including curses and spirit possession. David (1990)6, in his work on psychosis, defined insight as consisting of three dimensions: 1) treatment compliance; 2) awareness of illness; and 3) ability to re-label psychotic experiences correctly. If we take such a Western perspective to defining insight, then individuals who don’t accept that they are psychiatrically unwell due to cultural beliefs about other causes, are likely to be deemed as lacking insight. Some individuals will chose not to take medication, as culturally ills are dealt with in other ways, such as through spiritual healers; under David’s definition of insight (e.g. treatment adherence) such people will be deemed as lacking insight due to their cultural beliefs. Level of insight then is used to describe the degree to which an individual agrees or disagrees with the more powerful psychiatric system in which they find themselves. In other words, patients who don’t fit with a Western model of mental illness are deemed as having poor insight and therefore are seen as being mentally unwell. We should therefore view psychiatric practice as a western cultural practice, which contains the values and assumptions of Western culture7, including an emphasis on biological treatments for psychological distress. However, even within Western culture there is disagreement about some of the key tenets of psychiatric practice, including concepts of diagnosis, which furthermore makes defining insight problematic.
Final ThoughtsAlthough Smail argues that insight is not enough, he does point out the importance of supporting people to make sense of their distress. Many patients seek therapy as they do not understand why their life is as it is, and helping them to understand the connection between past and present events can be very important. Smail highlights the importance of social and environmental factors on an individual’s current difficulties, a notion he refers to as ‘outsight’. Smail particularly notes that the process of increasing such awareness can help to demystify incorrect beliefs the individual holds about how they are to blame. In summary, insight as a concept has still not been clearly defined, although there is a general consensus that it is related to increased self-awareness. Forming a shared understanding of a person’s difficulties will be beneficial for many patients. However, for others, understanding alone is unlikely to result in any changes. It is probable that, particularly for these individuals, actively making changes in their behaviour, based on a clear rationale that comes out of increased understanding, is likely to be an important ingredient in effective help for their difficulties. Therapists need to question the benefits, or otherwise, of the therapies they are offering, so that patients are able to make realistic and achievable improvements, which ultimately is the aim of all such approaches.
- Smail. D. (1996). How to Survive Without Psychotherapy. London: Constable
- Liberman, R.P. & Eckman, T. (1981). Behavior therapy vs insight-oriented therapy for repeat suicide attempters. Archives of General Psychiatry, 38, 1126-1130
- Llewelyn, S.P. (1988). Psychological therapy as viewed by clients and therapists. British Journal of Clinical Psychology, 27, 223-237
- Kivlighan, D.M., Multon, K.D. & Patton, M.J. (2000). Insight and symptom reduction in time-limited psychoanalytic counselling. Journal of Counselling Psychology, 47, 50-58
- Snyder, D.K., Wills, R.M. & Grady-Fletcher, A. (1991). Long-term effectiveness of behavioural versus insight-oriented marital therapy: A 4-year follow-up study. Journal of Consulting and Clinical Psychology, 59, 138-141
- David, A.S. (1990). Insight and psychosis. British Journal of Psychiatry, 156, 798-808
- Kleinman, A. (1991). Rethinking Psychiatry: From Cultural Category to Personal Experience. New York: The Free Press
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