richard a. friedman, m.d.essay

Therapy examines problems without always fixing them.

It is practically an article of faith among therapists that selfunderstanding is a prerequisite for a happy life. Insight, the thinking goes,

will free you from your hang-ups and promote wellbeing.

But recent experience makes me wonder whether insight is all it’s thought to be.

Not long ago, I saw a young man who was sad and anxious after his girlfriend left him. “I’ve been over this many times in therapy,” 

he said. He had trouble tolerating any separation from his girlfriends, whether they were gone for a weekend or he was traveling for work.

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.

Therapy had demystified his feelings, but had done little to change them.

One interesting clue about the relevance of insight comes from comparative studies of different types of psychotherapy — only some of which emphasize insight.

It has often been hard to find differences between their results.

The meaning for patients is clear. If you’re depressed, you are likely to feel better whether your therapist uses a cognitive behavioral approach, which aims to correct distorted thoughts and feelings, or an insight-oriented psychodynamic therapy.

Since the common ingredient in all therapies is not insight, but a human bond with your therapist, it seems fair to say that insight is neither necessary nor sufficient to feeling better. And sometimes it seems that insight even adds to a person’s misery.

I recall one chronically depressed patient. “Life is just a drag,” he told me, listing various social and economic ills.

Of course, he was right about the parlous state of the economy, even though he was affluent and not directly threatened by it. He was a financial analyst, but was bored with his work.

He had been in therapy for years before I saw him and had realized that he had chosen his profession to please his father.

Although he was insightful about 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.

Researchers have known for years that depressed people have a selective recall bias for unhappy events. Their negative views and perceptions can bedepressingly accurate, if biased and incomplete. A lot of good their insight does them!

It even makes you wonder whether a little self-delusion is necessary for happiness. None of this is to say that insight is without value. If you don’t want to be a captive of your psychological conflicts, insight can be a powerful tool to loosen their grip. But that’s different from happiness.

My depressed patient came to see me recently looking happy. He had quit his job and taken one in art. “I’m doing what I like,” he said.

I realized then that I am pretty good at treating clinical misery with drugs and therapy, but that bringing about happiness is a stretch. Perhaps happiness is a bit like self-esteem: you have to work for it.