Answer: Insight is always a part of cognitive therapy — an important part, but not an end in itself.
We help patients gain insight into why they have unhelpful or upsetting reactions. Their emotions and behavior make sense once they understand how they perceived a given situation. And the characteristic themes in their perceptions (represented by their automatic thoughts) make sense once they understand their underlying beliefs. This insight alone, however, is not sufficient for most patients to recover from their psychiatric disorder or improve their psychological functioning. They need to solve problems and change their thinking and behavior to bring about enduring change in their mood and functioning.
From the first session, we help patients learn how to identify and evaluate their distorted or dysfunctional thinking, a process which results in improvements in how they feel and what they do. Many patients also benefit from learning to adopt a different relationship with their thoughts (as described in Acceptance and Commitment Therapy and Mindfulness); instead of evaluating their cognitions, they note them non-judgmentally and focus their attention elsewhere.
In the next part of treatment, we add an emphasis on helping patients gain insight at a deeper level as they identify and modify their dysfunctional beliefs — their basic understanding about themselves (e.g., I’m helpless/vulnerable/incapable/defective/unlovable/worthless), their worlds (e.g., the world is dangerous/unfriendly), and other people (e.g., others will hurt me/dismiss me/judge me; others are superior/strong/bad/untrustworthy) — and their “rules” or assumptions about how they themselves should behave to get along in life (e.g., if I depend on others I’ll be okay, but if I rely on myself, I’ll fail. If I go along with what others say, I’ll be okay but if I express my own opinions or desires, they’ll judge me negatively.)
Some patients, particularly those who have personality disorders, benefit from gaining insight into how their past experiences are influencing their current experience. With many of these patients, it’s useful to help them gain insight into when (usually specific experiences in childhood, adolescence, or early adulthood) and how these beliefs developed and how they became strengthened over time. Guided discovery, imagery, and psychodrama techniques often help them develop new understandings about themselves, their relationships, and other people. We then always help them bring their new understanding back to the present. Even if their ideas were largely accurate at the time, to what degree are they still accurate (and helpful) now? What has the patient learned that will help him or her have a better week?
Insight is an important part of cognitive therapy — but rarely sufficient to bring about lasting change.