Role of insight based on therapeutic alliance

Since the inception of psychotherapy, it has been recognized that the relationship between the therapist and the patient makes substantial and consistent contributions to patient success in all types of psychotherapy applied, including like cognitive-behavioural, behavioural, psychodynamic, humanistic, and systemic therapies [1]. It is a partnership where both therapist and patient agree on shared goals, work together on tasks designed to bring a positive outcome, and establish a relationship built on trust, acceptance, and empathy [2].

The therapeutic alliance has been derived to be a main curative factor influencing the efficacy of a psychotherapeutic intervention, followed by other factors including the therapy model, therapist factors, client factors, extra-therapeutic factors, pharmacological factors, or any placebos [3]. Furthermore, it is this relationship which acts in concert with treatment methods used, patient characteristics, and therapist’s qualities in determining effectiveness [1]. Specific to mood disorders, compliance is a key factor in the successful management and long-term maintenance treatment of patients with bipolar disorder, and the relationship between the patient-physician have been shown to positively influence the same [4].

In psychotherapy, insight means gaining an increased awareness or experience of one’s own mental state, which leads to a growing perception and understanding of events, both in the inner world and the outer environment, then it was before [5]. In fact, insight could actually be viewed as a core process of change within the therapeutic progress, as the subjective experience of schema change is likely to facilitate therapeutic change [6].

Therefore, this paper postulates introducing an element of insight from more non-directive approaches of psychotherapy within a cognitive behavioural model. This paper is based on the premise that building on the therapeutic alliance within a cognitive behavioural setting helps in developing the patients’ insight. Such an insight can play a significant role not just in determining their willingness towards the therapy, but also in contributing to further their therapeutic alliance with the therapist, and thereby enhancing the therapeutic outcomes.

Efficacy of using insight

Though the role of insight in the context of cognitive-behavioural therapy has been found in three out of four studies [6], however the ambiguity of the results makes it difficult to formulate generalised conclusions [7]. However, simply developing an insight does not necessarily reflect an improvement in the therapeutic outcomes. Often patients, even after understanding more and more about their life, they might not be able to introduce positive changes, or might even experience some negative ones [7]. Developing an insight can encourage patients to be more actively involved in their treatment and experience better control over the situation [8].

Considering the cultural context in India, help seeking behaviour in the field of healthcare can directly challenge the individual’s autonomy, and for patients with immature defence mechanisms for dealing with inner conflicts, such an experience can be damaging [9]. Especially for patients with mental illness, a delay in seeking professional help or an issue of non-compliance towards therapy could be stemming from cultural beliefs and values systems [10]. Therefore, the postulated role of developing the patient’s insight can be viewed favourably for the Indian context, acknowledging and recognizing the patient’s role, without undermining their autonomy.

Based on the clinical case observation of an adult patients with mood disorders, a thematic analysis demonstrates the role of developing the patient’s insight in the treatment process. The case discussion in this paper focuses on the salient features of the therapeutic progress highlighting the role of developing the patient’s insight, and its impact on the therapeutic outcomes. An informed consent has been sought from the patient prior to the compilation of this paper, and to protect her confidentiality, all identifying information (if any) has been changed.

Case description

Ms. A is a 32 year old female, married, currently pursuing the final year of her doctoral degree. She had been seeking psychiatric treatment for Bipolar I disorder¹ for more than a year, with a history of five manic episodes prior to her first session with the first author. She had previously had seven sessions with another psychologist, after which she shifted therapists due to logistic considerations. She has been regularly seeking psychotherapy sessions with the first author for the past eighteen months, and is continuing till the time of compilation of the paper.

Therapeutic methodology

The case illustrated herewith showcases long-term therapeutic progress of weekly sessions over a period of eighteen months (continuing therapy with the first author at the time of paper compilation). The progressing course of the sessions was largely based on the traditional cognitive-behavioural model, including focus on psychoeducation, goal setting, cognitive-restructuring interventions, behavioural techniques, and problem-solving strategies. However, the structure of this model was not necessarily exclusive, with a more flexibility along with additional components borrowed from a holistic approach.

While a primarily cognitive-behavioural therapeutic approach was used in the case illustrated in this paper, the first author (or the therapist)² paid extra emphasis on establishing an alliance which transcended the traditionally structured model. Such an alliance was based on the premise of garnering the active engagement of the patient within the therapy, as well as establishing his/her insight towards the therapeutic process. Keeping in mind the subjectivity of gaining an insight, special emphasis has been given to the therapeutic progress to illustrate the salience of establishing an engagement with the patient and utilizing the same towards a positive influence on the psychotherapeutic outcomes.

This paper is based on the premise that a collaborative therapeutic alliance with the patient can be used as a foundation to secure the patient’s active engagement towards the formulation as well as progression of the therapeutic process. The therapeutic goal of empowering the patients with emotional regulation skills cannot be accomplished without their active engagement and insight. Besides identifying and modifying dysfunctional thoughts and emotions, patients also need to gain an in-depth understanding of their own emotional experiences. This further helps the patients develop their intuitive understanding of their mood, so they can accept as well as know what to expect from these emotional experiences.

Timing is a major determining factor, to decide how much of the time during the session is spent on allowing the patients to ponder on their experiences and their undercurrents. To ensure the optimum utilization of this insight, the patients should be encouraged to hold on to their understanding with a sense of clarity. Instead of pushing them towards the next step of modifying their maladaptive pattern, it is more beneficial to give them the time and space to form their own links with their behavioural reactions. Allowing them to stay with their insights not only helps the patients accept their discoveries, but also encourages them to acknowledge the need for change. Furthermore, it is this stage which is crucial for helping the patient prepare themselves for the readiness to change.

On examining the patients’ insight as a variable in the therapeutic process, the following pivotal points were derived from the clinical case observations of Ms. A during her therapy sessions with the first author.

Using patient’s active engagement

An insightful approach to cognitive behaviour therapy need not necessitate the patient to maintain thought records, because as the patient and therapist together work towards exploring the thoughts, feelings and experiences of the patient within the session, the patient also plays a much more active role. As compared to maintaining thought records in between sessions, introducing an insightful component to such a cognitive behavioural model would entail the patient’s ability to focus on his/her thoughts within the session. Hereby, the patients are inevitably likely to extend such a focus outside the sessions as well. Therefore, the patient’s active engagement is not simply restricted to the weekly sessions, but is able to find an application in his/her daily life as well. Therefore, there is a higher likelihood of the patient to continue processing the insight in between sessions as well, maintaining a continuation through the process of therapy.

While orienting the patients about the approach to therapy, it is sometimes helpful to appoint the patient to monitor his/her own subjective progress, and therefore be able to serve as a facilitator for the direction for his/her psychotherapy. However, such a non-directive approach should not be restrictive for the therapist. To point to the case of Ms. A, despite of allowing her to direct the flow of the therapy, the non-directive approach did not restrict the first author from working towards Ms. A’s behavioural activation by proactively rescheduling her daily activities. Therefore, the therapist should focus on the undercurrents of the dialogues within a session, and should utilise them to discretely guide the session, while allowing the patient to feel a sense of responsibility.

Facilitating exploration of experiences

A cognitive behavioural approach emphasizes the alleviation of distress by modifying cognitive content and processing, attempting to realign the individual’s thinking with reality. However, for the patient, his or her experiences are a reality. Instead of directly challenging their realities, the therapeutic process could be abbreviated by encouraging them to focus on their experiences, rather than simply aiming at a transition. This does not mean isolating the emotions from the underlying thoughts or the manifesting behaviour. It involves allowing the emotional experiences to be at the forefront, not necessarily accepting them, but exploring their depths intuitively. Regardless of labelling their own emotions, the patients gain a clearer understanding of what they feel, and the why’s and the how’s related to their feelings.

In the case of Ms. A, three to four sessions were spent on allowing her to explore her thoughts and feelings associated with her husband and their marriage, as she discussed her struggles to marry out of religion, against the desires of the family, and the subsequent adjustments and sacrifices that were required of her. Over the next few sessions, the therapist helped Ms. A to re-examine her own thoughts, feelings, and perceptions, giving direction to understanding her relationship with her husband. In this process, Ms. A reported finding herself to be excessively dependent on her husband. With the exception of financial security, she relied on her husband to fulfil her emotional, physical, as well as social needs. As she confessed that even her happiness depended on the smallest of his actions, she began to question her own right to be happy. She felt she deserved to be able to control her own emotions, and not allow ‘another person to be her remote control’. This insight was very meaningful for her, as she reiterated this sentence many times in subsequent sessions.

Insight as a mediating factor for therapeutic change

However, an insight cannot always mediate a change in the patient’s dysfunctional thoughts or maladaptive behaviour. As reported by Ms. A by the end of around twelve sessions, the therapy was helping her not just by providing a safe space for her to express her thoughts and feelings without fearing any judgements. In addition, the process was helping her understand her own self better, and realize ‘the what’s and why’s of her behaviour’. Such an understanding helped her in seeking guidance of how to behave in the future, and she reported that even if she found herself unable to do so, she felt satisfied in understanding ‘why’ she had not succeeded in her endeavours.

During the end of a year’s therapy, there was a point when Ms. A felt overburdened by her job, her studies as well as her marital relationship, and she reported feeling as though she were on the brink of a breakdown. As she discussed this feeling with her therapist, she reported fearing the onset of another manic episode. Though her fear came true within the next few weeks, it was a month subsequent to her remission that she began to contemplate about her own ability to identify the potential trigger for her manic episode. She felt empowered as she considered consulting the psychiatrist for reviews at such times, which might help prevent a recurrence or reduce the severity of the episode. This made her feel her role in the therapeutic process to be not just acknowledged but also rewarded. She reported feeling a great sense of satisfaction as well as control over herself and her illness. For her, the therapeutic process proved its significance by helping her become capable of not just bearing the responsibility for her own actions, but also being able to exert her control over them.

While many ‘insightful moments’ might be interspersed within therapeutic sessions, it is also important to use that insight to bring about a change in the therapeutic progress. Often despite gaining an insight, the patients might not be able to correct or modify their behavioural patterns. However, with the help of the therapist, the patients’ realizations can help them in understanding and subsequently accepting their experiences. This feeling of empowerment gained through their insight goes a long way in preparing the patients for a therapeutic change, while also leading to further modifications in their thoughts, perceptions and behavioural reactions, as per the cognitivebehavioural mechanism.

A thematic analysis of incorporating insight within cognitive behavioural therapy for patients with mood disorders revealed the significant role of insight as a confounding variable to the treatment process. This paper reiterated the importance of transcending the structured models of therapy to include an insight-based engagement with the patient, to achieve greater therapeutic outcomes both in terms of coping as well as resilience building. The clinical case observation demonstrated that patients’ insight empowers them with a sense of mastery and a clearer understanding, preparing them towards a therapeutic change, while also making them capable of acknowledging their inability to do so. Building a therapeutic alliance and facilitating an exploration of the patient’s experiences leads to the development of an insight that can further mediate a therapeutic change. Besides ensuring an active role of the patient, such an awareness was also seen be potentially helpful in improving rates of relapse prevention and engagement with the therapy as well.

¹The diagnostic terminology used in this paper is in accordance with the DSM-5.

²The case discussed herewith has been in therapy with the first author; henceforth, the terms ‘first author’ and ‘therapist’ shall be used interchangeably with reference to the illustrated case.