Insight and Change in Psychotherapy

In a recent comment on CBT and psychoanalytic therapy, a commenter, Dr. Jason Ramsay offered a familiar criticism levied against psychoanalysis:

I loosed the boundaries of CBT and found myself working from a psychodynamic perspective more and more, because that is what they wanted. What I found was that lots of insight was generated. Some could, some could not. But in the end, insight was rarely enough to help them change years and years of maladaptive behaviour. In the end, I think that what many of my patients in the study wanted was a combination of insight and technique oriented treatment, just for much much longer than the 12 weeks we were able to offer.

There is much to reflect on here, especially in the wake of a paper I recently presented on social adaptation and the goal(s) of psychoanalysis. Psychoanalytic clinicians are consistently critiqued by others in the profession that knowledge and truth are not sufficient to facilitate change. Some go so far to even discourage exploration and view it as a defense against making “real behavioral change.” While I am not absolutely against providing certain patients with skills (particularly in extreme situations such as psychosis) I always wonder a bit about this argument. I should note that I have yet to be trained to provide psychoanalysis just psychotherapy (although the dividing line is questionable as my old Lacanian teacher once told me). One is led to believe that unless certain folks are given skills they will never be able to make lasting changes. Let me try and break this idea down further.

One often hears in psychoanalytic circles that “real insight” necessarily produces change and that an interpretation must be wrong (in some sense) if it is not mutative. However, is that necessarily the case? A major goal of psychoanalysis is helping the patient put his or her unconscious conflict on the table to analyze the antagonism. Now that the patient has fully understood the source of her symptoms and the conflict that drives the problem: what is the clinician to do? Most psychoanalytic clinicians observe neutrality vis-à-vis the patient’s conflicts in an attempt to not unduly influence or control the patient’s behavior. The patient is faced with a serious existential choice to decide between options. I am of the opinion that at this point the clinician has done her job and has nothing else to do other than help the patient confront the anxieties and conflicts that prevent him from making a decision and sticking with it. An old supervisor of mine used to say that she put her pants on the same way every morning and that she will do the same tomorrow regardless of what her patient’s choose, which is a clear example of the neutral mindset.

Let us also examine why we do not tell the patient or cleverly guide (or suggest) the patient to a certain option. Psychoanalysis was founded upon a break from hypnosis, which Freud criticized as a treatment whose mechanism of change was suggestion. Isn’t CBT something very similar? You aren’t really depressed. It’s just that your thinking is negativistic! Stop thinking that way because depression is bad.

Another problem with suggestion is that human nature is fickle and petty. I have long given up believing that I could tell my patients what to do or who to date or which job offer to accept. Everyone else in their life does the exact same thing. Friends and family are always dying to tell the patient how to live her life. The clinician is trying to do something differently than represent common-sense wisdom. Also, it is my experience that people are more inclined to persist in their symptoms if you try and tell them to give them up.  Some people would rather suffer than cede that power to the clinician.

Third, most patients find seeking therapy narcisstically wounding as they have to admit that they are unable to figure out how to realize their desires. If the clinician attempted to direct the patient to a certain option not only would this be an abuse of the transference (leading to the infamous and unstable transference cure) but one would be making the patient unduly dependent upon the clinician for guidance. Tonight a graduate school friend told me he tells his patients that treatment is working whenever they stop asking him what he thinks and whenever they stop asking him what they should do. After all, the clinicians’ task (and this is very Lacanian) is ultimately to vanish as the patient hosts a conversation with herself to discern what she wants from life, making the clinician redundant.

Fourth, a major danger with the clinician making suggestions is that the clinician might unwittingly enforce his own prejudices and biases onto the patient. Moreover, in the United States, the happiness ideology is very strong as clinicians (and worthless life coaches) promise patients happiness, self-realization and an end to suffering. Lacan would empathically disagree with this bullshit moralism. In Seminar VII Lacan says: “However we regulate the situation of those who have recourse to us in our society, it is only too obvious that their aspiration to happiness will always imply a place where miracles happen. To make oneself the guarantor of the possibility that a subject will in some way be able to find happiness even in analysis is a form of fraud. There’s absolutely no reason why we should make ourselves the guarantors of the bourgeois dream.” (p. 303). I would never have signed up for this job if my sole goal were to help someone figure out how to live and die in accordance with the Big Other’s wishes. This is why neutrality is fucking key. If clinicians actively encouraged bourgoisie values such as the importance of the nuclear family, gainful employment, a comfortable retirement and some (but not too much) community activism then we would undoubtedly miss out on loads of conflicts and problems that often remain un-analyzed if these normative values are upheld as sacrosanct.

Finally, as Freud would remind us, analysis is basically interminable. It is not as if conflicts are ever fully reconciled or dreams realized. A major accomplishment is being able to tolerate anxieties and insecurities that are unavoidable aspects of life. Moreover, this fantasy of a symptom-free existence is an illusion that is absolutely hollow. All of our behaviors are negotiations of conflicts. What makes one behavior or choice symptomatic and another one adaptive is relatively arbitrary. The DSM (the psychiatric handbook of mental disorders) emphasizes a distress and functional model of mental health. In other words, if a certain behavior interferes with one’s lifestyle and causes one distress then it can be considered pathological (in other words, adaptation is good). This is exactly why it is so naïve to act as if treatment is ever completed or successful. Treatment just ends and the patient gets to decide when in most cases. The most honest way to end treatment is to just realize one’s ambivalence and attempt to continue the struggle. There is no peace, as conflicts are eternal.