by Joye C. Anestis, M.S.
When writing about catharsis as a common factor of therapy, I had a pretty easy time finding the appropriate research and coming to some conclusions. Trying to write about insight, however, is another story. It is incredibly difficult to find good research on the role insight in psychotherapy. A lot of individuals have written theoretical articles about insight - defining it, discussing it, etc. - but very few have systematically examined it as a factor which cuts across therapies.
One of the difficulties in studying insight is the difficulty defining it and measuring it in a reliable manner. Some clinical psychologists view insight as the achievement of understanding into the sources of one's problems and difficulties. Others view it as the gaining understanding into the presence and symptoms of one's mental illness. And once a construct definition can be agreed upon, the question then becomes: how do we measure it? Is it more appropriate to get client ratings of insight, or are therapists the best assessors of client insight? These basic questions have yet to be answered, really crippling the literature on insight.
Another complication inherent in a discussion of insight and the study of insight is the fact that different theoretical approaches view insight very differently. For example, psychodynamic approaches to psychotherapy believe that insight is the endgame of therapy. Through the use of psychodynamic techniques, the client will gain insight into the origins of their symptoms and, thus, be cured of them. In essence, insight causes improvement (symptom alleviation). In contrast, cognitive conceptualizations imply that insight comes as a result of symptom alleviation. Insight is not viewed as a goal or an active treatment component, but as a byproduct of improvement (insight is actually rarely discussed in the cognitive therapies). Furthermore, some therapies emphasize insight into past events, and others focus on insight into current events. These varying conceptualizations further muddy the research picture. Actually, I question the inclusion of insight as a common factor present in all forms of therapy, if it is viewed differently in each type of therapy. Do you have any thoughts on this?
In spite of these methodological problems, what do we know about the role of insight in different forms of psychotherapy? I was only able to find a handful of studies which examined the hypothesis that insight causes symptom reduction. Kivlighan, Multon, & Patton (2000) found a significant linear increase in insight and corresponding decrease in target distress in time-limited psychoanalytic counseling. It should be noted that the sample consisted of 12 subjects who sought counseling for "relationship difficulties". In a review of the role of insight in bipolar disorder, McEvoy & Wilkinson (2000) note that insight improves with treatment (in this case, medication treatment). Eisen et al. (2001) found that insight improved as symptoms reduced in sample with obsessive-compulsive disorder.
The remainder of the studies examine insight as a mechanism for treatment compliance. For example, Rathod, Kingdon, Smith, & Turkingdon (2005) randomized patients with schizophrenia (n = 422) to a brief, insight-oriented cognitive behavioral therapy. Results indicated a significant increase in total insight and, specifically, insight into treatment compliance (i.e., antipsychotic medication) in the individuals who received the intervention. Thus, in this sample, insight led to better outcomes by improving treatment compliance.
Even though insight is considered to be a common factor of therapy, and thus should be an area of treatment focus for proponents of the dodo bird hypothesis (the hypothesis that all therapies are equally effective), insight has received very sparse treatment and research consideration. We don't know enough about the definition and function of insight to come to any firm conclusions. To my knowledge, insight has not been examined as a factor in the majority of therapeutic styles, making the argument for insight as a common factor tenuous. Additionally, most of the research I came across did not use the front-line treatment for a specific disorder. I think it would be interesting to have some investigations into the role of insight in empirically supported treatments (e.g., is insight an important process, or even a process at all, in cognitive therapy for depression?). The bottom line: at this point, it is unclear if insight should really be considered a common factor of therapy. A significant amount of research is required before we can consider insight to be a curative factor in the therapeutic process.
Do you know of some studies that I missed? If so, please send them along. What do you think about insight as a common factor across therapies? How about the definitional issues that arise in studying this construct?
Also, if you have a request for a common factor, send me an e-mail (firstname.lastname@example.org) & I'll be happy to oblige!