Effective communication and “fair fighting”

I wrote in my last post that I’d share my “fair fighting rules” for couples in a later post. I’m feeling on a roll with the topic of effective communication, so here goes. Arguments inevitably arise in all long-term committed relationships. They can be constructive or destructive. As a therapist, I coached individuals and couples in communicating effectively and avoiding destructive disputes. The successful use of these guidelines depends on good faith between the persons involved, meaning that neither partner tries to dominate the discussion, and both want there to be a positive outcome, based on honest communication. In honest, good faith disputes between equal partners, there doesn’t have to be a winner and a loser. (In game theory an I win/you lose interaction is known as a “zero sum game.”)  It’s possible to “win all the battles, but lose the war.” If you follow some basic rules, a disagreement is more likely to lead to a win/win outcome.

(1) Be mindful. Stay in the here-and-now and be aware of your emotions. (2) No attacks, threats or generalized judgments. Easy to say, but if you’re both mindful and acting in good faith, you can avoid these traps. (3) Be an active listener, with one person talking at a time. Don’t interrupt. Each of you gets to express yourself, each of you wants to be understood. (4) One topic at a time. Don’t drag in other issues or stuff from the past. (5) Try to express yourself in I-statements. You-statements, especially generalizations, tend to lead to defensiveness and denials. If you say, “I think/feel/want _____,” the other person can’t contradict you, can’t say “No you don’t.” I-statements invite understanding and empathy. (6) Avoid generalizations, often characterized by “always” and “never,” or  “should.” If you’re critical of something about your partner, try to frame it constructively. (7) Be assertive. Clearly state what you want/don’t want, or what you mean. Don’t expect your partner to read your mind. (8) Don’t miss opportunities to validate, or to acknowledge your understanding of, your partners feelings or point of view. What’s your common ground? Try to understand your partner’s position and express any empathy you may feel. (9) Avoid questions-that-aren’t-really-questions. They’re usually characterized by “why”s, such as “Why don’t you ever listen to me?” This is actually a statement (“You never listen to me.”) phrased as if it were a question. There is no answer to this emotionally-loaded pseudo-question that would satisfy the asker, because it’s not really a question. (10) If appropriate, turn the tables. Ask, “What do you think we need to do?”

I had the professional privilege of working in a Dialectical Behavior Therapy (DBT) program for two years. DBT programs are designed to treat people diagnosed with Borderline Personality Disorder. The program I worked in was run by Dr. Shari Manning, who studied with Dr. Marsha Linehan, creator of DBT. I spoke briefly with Dr. Linehan at a professional conference years ago and mentioned that I’d worked in a DBT program under Shari’s supervision, to which she replied, “You’re a lucky man.” And indeed I was. My participation in the DBT program at Columbia Area Mental Health Center was a great opportunity for professional development. Working in a DBT program requires adherence to a model and methodology as precise and rigorous as psychoanalysis. You have to follow fixed protocols and work within a peer consultation team that supports and guides your work with this very challenging population.

I’ll get into DBT in more detail over time, but suffice it to say for now, DBT programs teach specific skills to people who frequently have difficulty with relationships. For two years I co-led DBT skills training groups, and worked individually with clients in the program, coaching them in the use of the skills. One of the skills modules is interpersonal effectiveness. For now I won’t go into the acronym DEAR MAN that DBT uses as a mnemonic device, but will briefly describe the process that it outlines. First, you strive to be mindful and stay in the here-and-now. If necessary, you describe the situation or set the context. You express your feelings and/or opinions, then assert yourself, asking for what you want or saying “no” to something you don’t want. Next you try to say something positive, if only to express your appreciation that you were listened to.

An interpersonally effective communication might go something like this: “We’ve been friends for a while now and you’ve helped me when I needed it. I value your friendship and I hope we stay friends. But I can’t hang out with you when you’re drinking anymore. You know I’m going to meetings and trying to stay clean and sober. It’s not that you get obnoxious when you’re drinking, like some people. You can be lots of fun when you’re high, but I just can’t risk getting triggered and relapsing. You don’t drink during the day, so we can meet for lunch. Or if you want to try quitting again, maybe we can go to meetings together, and hang out over coffee afterward. You’re really a special person and I want you in my life, but my sobriety has got to come first.”

The speaker  here is attempting to preserve the relationship, but setting clear boundaries. She’s specifying the conditions under which they’ll meet in the future, without attacking or judging or blaming. In some interpersonal exchanges, a willingness to compromise is called for, but not in this case. Whether or not the relationship survives, the communication will have been effective. Effective communication is a learnable skill set.

Metacommunication and boundary setting

In a previous post I wrote about metacommunication as a concept in communications theory. It’s the idea that every verbal communication in a relationship works on two levels: the message content, and as a means of defining (or re-defining) the relationship. It’s as if every statement within a relationship were preceeded by, “We have the kind of relationship in which I can say to you _____.” This kind of metacommunication starts early in our development. When a rebellious three-year-old says to a parent, “I don’t have to if I don’t want to!” he’s testing the limits, attempting to re-define the relationship as one in which he has the power. When the parent replies, “Oh yes you do!” she’s re-affirming her definition that she, as a parent, has the power in the relationship.

Metacommunication has another meaning in the realm of interpersonal communication. Two people in a relationship metacommunicate when they talk about the way they talk, communicate about their communication. It’s a good way to address boundary issues when they arise, whether with a friend or spouse, or in therapy. “How are we doing?” is an open-ended way to initiate metacommunication in a long-term romantic relationship.  The invitation to metacommunicate by one of the partners in the relationship has led to the early, easy resolution of many a misunderstanding or relationship conflict. When two people metacommunicate in good faith, they usually come out of the discussion with a shared definition, or re-definition, of the nature of the relationship and its boundaries.

Here are some examples of metacommunications: “I don’t feel comfortable when you talk that way.” “Hey, can we come up with a ‘time out’ signal for when we’re both too angry to talk?” “You seem to be easily annoyed lately.” “I wish you’d stick to the issue and not bring up old stuff.” Metacommunications can also be positive: “I really like the way we handled that.” “We’re getting better at avoiding silly arguments.”

The clearer the boundaries in a relationship, the less likely that conflicts and power struggles will come about. Boundaries can involve issues of personal space, preferences regarding communication habits and styles, performance expectations, kinds of preferred touching, standards for personal disclosure, sexual boundaries, and many other issues – especially in intimate, committed relationships. People who can metacommunicate in good faith spare themselves and their partners unnecessary conflicts.

Obviously, some people are better than others at setting and maintaining boundaries. Assertive people can more easily set boundaries and confront people who cross them. People pleasers and shy or passive people might find it hard to deal with people who cross their boundaries. Assertiveness is, to some degree, a learnable skill.

Metacommunication only works to improve communication in a relationship if both parties are honest with one another and sincerely want a positive outcome. The words “always” and “never” are seldom helpful, and the use of I-statements can facilitate the process. Almost anything that can be expressed in a you-statement can be re-framed as an I-statement. Open-ended I-statements  (“I wish we went out more often.”) are easier to take in than absolute you-statements (“You never want to go out anymore.”) I-statements can be used to express anything in a metacommunication: I wish, I think, I feel, I expect, I love/hate, I want/need, I don’t like it when _____.

When people in long-term relationships don’t metacommunicate in good faith, the parties can get stuck in dysfunctional patterns, and problems can stack up. There can be frequent misunderstandings and hurt feelings. Important thoughts go unexpressed, important feelings are repressed, and intimacy suffers. In troubled marriages, learning to metacommunicate in good faith can break up logjams of misunderstandings and hurt or angry feelings. It’s a skill I taught to many couples in therapy, along with “rules for fair fighting.” I’ll cover those in a later post.

 

My psychology grad school reunion

I’ve already written about humanistic psychology as the “third force” in twentieth century psychology, after Freudian psychodynamic theory and behaviorism. I recently attended a reunion of my psychology graduate program at the University of West Georgia (West Georgia College when I attended), and I’d like to share with you some of the reasons I’m so thankful for my preparation as a psychotherapist in this particular program.

Dr. Chris Aanstoos, a faculty member for over two decades, wrote that the graduates of the program have gone on to be “not only psychologists and professors, but also city commissioners, college presidents, U.S. congressmen, computer wizards and millionaires, as well as poets, magicians, mystics, theologians and farmers. Essentially they have gone on to become themselves.” To which list I’ll add corporate consultants, business entrepreneurs, and all sorts of holistic healers.

Part of the lyric of the Crosby, Stills, and Nash song Teach Your Children is “. . . and so become yourself/ because the past is just a goodbye.” Their are forces in our society that conspire to make us conform, to be “normal.” Becoming your authentic self and living up to your unique potentials was what the West Georgia psychology department was all about. The program wasn’t organized so much to train you for a specific profession as to help you discover and realize your potentials, and to find your vocation – your calling. Since the inception of the humanistic program in 1967, it’s always been a program freed from the conventional stereotypes of the day, and in it I learned that no scientific or therapeutic model has all the answers for everybody. I learned about holistic health long before it caught on.

The WG psychology program is characterized by cultural diversity (i.e. both Eastern and Western psychologies) and innovation, and was ahead of its time in many respects. Carl Rogers’ client-centered therapy is being re-discovered in the corporate world as person-centered management. Yoga and meditation were validated as ancient transformative psychotechnologies – ways of re-wiring the brain – long before they went mainstream. There was an emphasis on wellness, and the holistic unity of body and mind.

While I received an excellent preparation for a career as a psychotherapist dealing with (for the most part) chronically mentally ill persons, psychopathology wasn’t the primary focus. We also studied creativity, and barriers to achieving one’s highest potentials. We questioned the notion of “adjustment therapy,” asking, “adjustment to what?” (See my prior post, “Who is normal?”) Behavioral psychology was the dominant force in psychology at that time, and the medical model was the unquestioned basis for determining diagnosis and treatment.

No faculty member ever told me what model I should follow or recommended which therapeutic techniques I should use. Although behavioral psychology wasn’t popular in the program, over the years I became a practitioner of cognitive and cognitive behavioral therapies, along with Rogerian,  gestalt, and other therapeutic modalities. My faculty advisor never advised me; he dialogued with me about goals, choices, opportunities. My love of learning caught fire as never before, because I was encouraged to think for myself and choose my own path.

The man who made the WGC psychology department into a humanistic program was Dr. Mike Aarons, and at the reunion I finally heard the full story that I’d heard pieces of over the years. As a child in public school, he was labeled “unteachable/retarded,” and wasn’t expected to be able to complete high school. But he earned a high school diploma and went on to college. Working as a cab driver, he found a book someone had left on the back seat of his taxi. It was Viktor Frankl’s Man’s Search for Meaning, and it changed his life. (See my post, “Freedom of attitude.”) It introduced him to existentialist  psychology, and he found a French mentor in existentialism who encouraged him to apply to the psychology PhD program at the Sorbonne University, in Paris. Mike had no bankroll and spoke no French, but that didn’t stop him. Long story short, he returned from Paris a few years later with a French wife and a PhD from the Sorbonne. His dissertation was on the topic of creativity. He went on to post-graduate studies with Abraham Maslow, at Brandeis University.

Dr. Jim Thomas, a behaviorist in the WG psychology department, had read Carl Rogers and Abraham Maslow, and had a vision of  establishing a humanistic program in the department. He won over some of the other faculty members, then wrote Maslow, asking if he could recommend someone to start a humanistic psychology program. To everyone’s surprise, Maslow answered, recommending Mike Aarons without  reservation.  Mike was hired and set about recruiting a faculty on the cutting edge of the humanistic psychology revolution. The rest is history.

Not only has the UWG psychology department continued to offer an exceptional education in psychology, it has continued to grow. While a Master of Arts (MA) degree remains the only masters degree available for now, the department now offers a Bachelor of Science (BS) degree program. What used to be a Doctor of Psychology (PsyD) degree program is now a PhD program.

The department has drawn students from all over the country – as well as many international students – to the Georgia town of Carrollton. The question I heard most often at the reunion was “What brought you to the program?” I heard story after story about so-called coincidences, “accidental” meetings, and things (usually books) found – like Mike Aarons finding the copy of Man’s Search for Meaning – that pointed people in the direction of the program. What I also heard a lot over the weekend was expressions of gratitude by alumni for having had the good fortune to study in this unique psychology department.

Who is an addict?

Who is an addict? It depends on who you ask.  To some people it’s an ugly word with negative connotations relative to, say, substance abuser. To others it’s a term with an important meaning, and recovering addict is a badge of honor, one day at a time. Addict is just a word for something real; it’s not a specific thing like a tiger or the Pope. It has no absolute meaning, but is associated with the medical model, in that it classifies addiction as a disease – specifically a chronic, progressive, relapsing disease.  Some add “fatal” to the list of adjectives, believing that if you can’t maintain recovery, your addiction will eventually kill you. To admit you’re an addict is to admit that you’ve lost control.

I’ve attended open Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings, and believe that regular attendance of 12 Step meetings is the only path to recovery for some addicts. I’ve recommended checking out 12 Step programs to many substance abusers during my career, but I disagree with anyone who claims there’s only one way – whether 12 Step programs, or Rational Recovery, or the Bible – to stay clean and sober.

My prescription for long-term recovery from substance abuse is “whatever works for you.” If believing you have a treatable life-long disease works to keep you in recovery, or believing you have an addictive personality, or believing that you have to “get right with God” to stay clean and sober, go with it. Your path to recovery is yours, but might not be what others need. It takes most people with substance abuse problems many relapses to learn what does and doesn’t work for them, as was the case with my recovery from nicotine addiction.

Not everyone has to “hit rock bottom” before getting it right. I’ve known a few people with many years in recovery who didn’t relapse once after resolving to quit. I’ve also known people in long-term recovery who initially needed to attend 12 Step meetings, but said that at some point they internalized the principals of the program and no longer had to attend meetings. Nobody has the authority to tell you that you’ll have to go to meetings for the rest of your life, in order to stay in recovery. But if you do, that’s not  a sign of weakness. It’s just part of your personal recovery plan.

Substance abuse occurs along a spectrum, and people’s definitions of abuse may differ; but being addicted generally means not being able to control your drug use once you start using mind altering chemicals. Within the recovery community it’s generally believed that if you’re addicted to whatever “drug of choice,” you also have to abstain from all other chemical highs in order to keep from relapsing on your favorite drug. I’ve known a number of chronic substance abusers who believed that substituting alcohol and/or marijuana would help them to keep from relapsing on “hard drugs” like meth or heroin or crack. (Alcohol is a hard drug, but it’s legal.) I’ve never seen it work and have concluded that you can’t solve a chemical dependency problem with chemicals.

The concept of addiction has broadened, and now a lot of people believe that sex and gambling and other non-drug-related behaviors can be addictive. The “old school” definition of addiction was characterized by three clinical phenomena: tolerance, withdrawal and physiological cravings. Tolerance means that you have to increase your dose over time to get the high you used to get from a lower dose. Withdrawal means that when you abruptly stop using an addictive drug, your body goes through distinct physiological changes – ranging from unpleasant or painful to potentially fatal – for a period of time. Physiological cravings are like hunger. Your body is telling you it needs something, and a strung-out heroin addict craves a fix the same way a starving man craves food.

Chronic marijuana use can lead to psychological dependence, but cannabis doesn’t meet the old school definition of addictive. Similarly, sex and gambling aren’t characterized by tolerance, withdrawal and physiological cravings. However, in many respects compulsive sexual activity and compulsive gambling resemble addiction, because they involve loss of control over certain activities, and some of the same neurotransmitters are involved. Like drugs, sex and gambling can predictably stimulate the brain’s “pleasure centers.” Psychological learning theory provides a good framework for understanding such compulsive activities, and I’ll elaborate in a future post.

Denial has killed millions of addicts. If drug abuse or compulsive behavior is hurting you or others, or you’re losing control of some important aspect of your life, find someone reliable and get real with them. Explore options and work on developing your personal recovery plan. Even if your plan doesn’t include active participation in a 12 Step program, it may borrow from the 12 Steps or Rational Recovery or other models. And you can’t stay in recovery without help from supportive people who understand you and don’t judge you. You need someone to share your thoughts and feelings with in recovery. We come to know ourselves better by letting others know us better, warts and all.

Who is normal?

Nobody is normal.

I think normality is one of the most misunderstood concepts in our culture, in that so many people still nervously ask the question, “Am I normal?” It seems that “normal” has come to be equated with “desirable,” is in ten-fingers-and-ten-toes-on-the-baby normal. But it ain’t necessarily so. I, for one, am unapologetically not normal, and have no wish to be seen as normal, conventional or average. I don’t dress funny or anything outwardly apparent, and my  abnormalities are benign: I don’t follow sports. I don’t own a cell phone.  I create strange art. (Check out jeffkoob.com)

“Normal” is a relatively modern social concept, and is based on a statistical idea. It isn’t found in nature, and like “Justice,” only resides in the human brain. On the street, normal correlates to  average, and abnormal has come to have negative connotations. In statistics there are three “measures of central tendency” (mean, mode and median) that produce what we call averages. But there is no values correlation between average (normal) and good, or desirable. Cigarette smoking used to be a normal adult habit when I was growing up. Obesity is normal in our society, as is divorce. Five hours or more of screen time daily seems to be the new normal. Standards of normality change over time.

There’s no such thing as a normal dog or a normal day or a normal rock, let alone a normal human being. While the average American family may have (let’s say) 1.8 children, you won’t find a single family that actually has 1.8 children. Normality is an abstraction, not a reality.

We increasingly live in a world of manufactured situations and pastimes, with a high standard of standardness.  Fashion choices may seem to set us apart, but following fashion just makes us part of the fashion parade. The mass media promote conformity and superficiality as virtues. It’s easy to see why a person who sees herself as a misfit might  long to “just be normal.” But I agree with Frank Zappa, who said that while many people think normality is grand, “normality is not grand, it is merely okay.”

If you’re conflicted or alienated, you may have an unrealistic vision of normality as a desirable destination. But balance, harmony and serenity are better destinations than normality. You are unique, and you need not be normal to live well and happily. People  who strive to be normal may not recognize or cultivate creative potentials within themselves. Original art doesn’t come from normal thinking, and “thinking outside the box” means not thinking conventionally. Extraordinary people are, by definition, not normal.

In my last post I mentioned the “Unconventional Modes of Experience” course in my humanistic psychology graduate program. It didn’t take the same approach as traditional “Abnormal Psychology” courses, as it didn’t have the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) as a textbook. Instead, the focus was on the phenomenology of madness. I won’t attempt to explain phenomenology in this post, other than to say that its focus is on subjective experience, not objective diagnosis. Crazy behaviors are often the result of unconventional experiences, such as auditory hallucinations. Scientists dismiss such phenomena as mere symptoms. Phenomenologists, like shamans, explore them for meaning.

I later took DSM-based courses and professional development classes to develop my diagnostic skills, but I’ve always appreciated my exposure to phenomenology as an alternate lens to the medical model. A belief underlying my therapeutic practice was that the better I understood each client’s unique experience of being-in-the-world, the better equipped I’d be to help him therapeutically.

I know that gay people didn’t choose to be gay any more than I chose to be straight. Being gay isn’t statistically normal, but it’s a normal variation from the heterosexual norm in every known culture on earth. I worked in therapy with a number of gay people who expressed their longing to be normal, to meet the standards of normality they were raised with in their families and communities. Some knew they’d be shunned if they were labeled abnormal. But what is considered normal is always culture-bound. Arranged marriage is normal in some cultures. That doesn’t mean it’s good or bad, just that it’s what most people do.

As long as you live your life productively and responsibly, and don’t exploit or abuse others, being normal is optional. Being abnormal isn’t necessarily a bad thing, if it’s an authentic expression of who you are. There’s no objective and timeless standard for what’s normal, anyway; so you should feel free to be your unique self. Other people’s judgments may be their problem, and may not have to be yours.

 

Who is mentally ill?

Sometimes as the group leader in my psychoeducational groups, I’d start my standard rap on psychopathology by writing two words on the board: sad and depressed. Then I’d ask, “Do these two words mean the same thing?” After listening to responses from group members, I’d proceed in this manner: Yes and no. On the street they’re synonymous, but to a psycho-diagnostician they can be very different things. Sadness is a universal human experience. Sometimes we can identify the reason or reasons for our sadness, other times not. When a person says, “I’m depressed because my friend is moving away,” they’re likely describing “normal” sadness that will probably diminish over time.

Sadness is a mood, and moods come and go. If a sad mood becomes persistent and affects your functioning, depression may be a better description for the experience. This persistent mood may also be due to an identifiable cause, such as a romantic breakup, or it may be unrelated to life circumstances. The former is referred to by some  clinicians as “functional” (caused by some external circumstance), the latter as “endogenous” (caused by internal, biologic factors). This isn’t an absolute distinction in all cases, but it has its utility.

There’s a deeper level of depression that isn’t a universal experience. Even at the lowest points of my life, I’ve never been as sad as the clinically depressed people I’ve known personally and professionally. People living with this kind of depression may experience hopelessness, despair, and suicidal ruminations. I’ve never been there, and I have great compassion for those who have.

One way of classifying psychopathology is assigning people to distinct diagnostic categories. You either do or don’t meet the diagnostic criteria for depression, or schizophrenia, or bipolar disorder, or antisocial personality disorder. If you don’t have the disorder, you may have traits associated with it. Another way of classifying pathological traits is to view them along continuua: straight lines with opposite poles. Everybody can be placed somewhere on a continuum between happy to be alive and suicidal, gentle and violent, honest and dishonest, paranoid and trusting, and other traits and tendencies.

If I’m extremely unconventional but functional, some people may refer to me as “crazy,”  but to others I’m merely eccentric. If I’m unconventional to the point I can’t function in society and may endanger myself or others, I could be mentally ill. In my graduate program in humanistic psychology, we didn’t even have a course titled “Abnormal Psychology”; that was considered too pejorative. Our course was titled “Unconventional Modes of Experience,” lest we apply unnecessary or judgmental labels to people.

Psychopathology is characterized by impairment or disability. I have obsessive-compulsive traits, but I don’t think of them as pathological, because I’ve been able to recognize, control and channel them. I’ve had doctors and lawyers tell me that they never could have made it through medical school or law school if not for obsessive-compulsive traits. You too may have traits of a mental disorder, but not meet the diagnostic criteria, because you’re not impaired by them. For instance, you might have some symptoms of depression, but not be pathologically depressed. Or you might have paranoid traits,  but not be diagnosable as having a paranoid disorder. The hyper- vigilance characteristic of a truly paranoid person might even be desirable, if you’re a spy.

Even if you have a diagnosed mental illness or engage in crazy behavior, you can’t be involuntarily committed to a treatment facility without a Probate Court hearing. (I only refer to behaviors as “crazy,” not people.) In most states you must be interviewed before the hearing by two Designated Examiners (DEs), one of them an MD, and have court-appointed legal counsel to represent you at the hearing. In order for you to be involuntarily committed, both DEs must agree – and convince the court – that you are of danger to yourself or others, due to a diagnosable mental illness. I’ve had the privilege and responsibility of being a DE for most of my career, and in my experience the system works most of the time to prevent people from being “railroaded” onto locked wards against their will.

Mentally ill people are often shunned, and even blamed for their symptoms. With good treatment most mentally ill people can function in society, although some are too disabled to hold a steady job. All people with mental and emotional illnesses deserve good treatment, regardless of income. But unfortunately, state mental health systems all over the country are terribly under-funded, and many folks don’t get the treatment they need to remain functional. A significant portion of homeless people have mental illnesses. Hospital ERs, jails, and prisons have become major mental health service providers. I’ll describe how we got to this sorry state of affairs in a later post.

Is insight necessary?

A major influence of psychoanalytic theory on contemporary psychotherapy is the notion that insights can be breakthrough experiences, opening the door to liberation from undesirable behaviors.  Freud posited that repressed memories and emotions could block our progress, and that insight into the blockage in psychoanalysis could “resolve ” it. He also identified resistance as a phenomenon in treatment. The patient might want to change his dysfunctional behavior, but unconsciously resists the change, not knowing what’s on the other side of the door.

Epiphanies can happen in or outside of the therapy session, but is insight necessary for a client in treatment to choose to change her behavior in a positive way? I’ve witnessed “Aha!” moments in therapy sessions that led to chosen changes in behavior in short order. In therapy, as in standup comedy, timing is crucial. You may, as a therapist, know something about your client that he isn’t ready to face or accept yet. If you’re a strategic therapist, you try to help build a framework that will facilitate eventual insight. A poem about psychotherapy put it this way: “I do not open that rusty door/I show you how you’ve locked it, nothing more.” When epiphanies have occurred in session, it’s almost like the cliché of seeing the lightbulb light up.

Such an epiphany in therapy can be a watershed in treatment. As Carl Rogers put it, once you accept yourself as you are, you can begin to change. Susan’s sudden realization that she harbors a lot of justified anger toward her father might allow her either to forgive him, or to place the blame where it belongs without feeling guilty for doing so. Tom’s breakthrough understanding, that accepting he’s gay isn’t the end of the world, opens up a new world of possibilities. So insight has its place in therapy, but is it necessary?

Not necessarily. I’ve had alcoholic clients who declared that they couldn’t stop drinking until they understood why they turned out to be alcoholics in the first place – why they couldn’t control their drinking once they got started, unlike their friends who could. Because I often used sly humor in therapy, I’d earnestly ask clients with this rationalization, “Were you breast-fed or bottle-fed?” Regardless of their response, I’d frame it as the answer to their question. “Now that we’ve established why you can’t control your drinking, let’s discuss what you’re going to do about it.” The what is often more important to focus on than the why.

Sometimes people who aren’t in treatment choose to change their behavior in positive ways, then have insights into their past problem behaviors. Avoidance reinforces avoidance, because it relieves you of anxiety for the moment. People in therapy can be given behavioral prescriptions (as in cognitive behavioral therapy) to do things they typically avoid. It’s called exposure, and it can not only extinguish the fears underlying the avoidance, but result in insight into the origins of those fears. There is value in studying the ways that positive change occurs spontaneously in people’s lives, and adapting the findings for use in psychotherapy. Ericksonian therapists work in this manner.

In conclusion, insight isn’t necessary for a person to change dysfunctional behavior patterns, in or outside of therapy, although it can be helpful sometimes. Waiting for insight to kick in can be a means of avoidance. We’re more likely to learn from the consequences of our changed behavior than by insights we don’t act on. Insight can be a motivating factor in changing your behavior, but not necessarily. I think there’s something to Freud’s notion of resistance. Some  clients in therapy are deeply ambivalent about changing their behavior, and insight might not serve to resolve that ambivalence. I used to say to clients, “Insight and a dollar will get you a cup of coffee.” Now it’s more like two bucks, minimum.