The New York Times had a very interesting article this week by Dr. Sally Satel, staff psychiatrist at the Oasis Drug Treatment Clinic and a resident scholar at the American Enterprise Institute. In the article, Dr. Satel discusses the role of insight in helping an individual overcome an addiction or other life problem and suggests that the need for insight may be over-rated and in some cases actually a detriment to further movement.

I certainly recall a similar range of experiences from my own days as a therapist. While I worked with many clients who struggled to turn their lives around and made excellent use of psychotherapy, there were certainly exceptions to that rule.

On more than one occasion I remember clients lighting up with some apparently life-changing insight into the roots of their behavior or emotional state only to come back the next week in the same place, stating that they didn't really think about the session again once they left my office. I distinctly remember confronting one client, much as Dr. Satel did, on how the quest for insight seemed to result in his stagnation in therapy rather than his moving forward. I asked him why he was in therapy. His reply?

"It's a great conversation for $5 a week."

That was his insurance co-pay.

The act, in and of itself, of seeking self-understanding with the support of a concerned individual, whether a professional or a friend, often makes one feel better. The client who enjoyed his $5 a week conversation is certainly not unique. This is an often unacknowledged downfall of the model of using insurance for psychotherapy. While many highly motivated individuals benefit from therapy that they could not have access to without insurance support, there are certainly individuals who abuse the system.

Many of my clients were very aware of their mental health insurance benefits and were clear they wanted all the sessions they were "entitled to" and not a single session more. Who wouldn't want to talk to a concerned and devoted listener week after week on someone else's dime? Just that process alone can tap off enough stress to make the rest of the week go slightly better until the next "great conversation." Therapists are humans and they like to help. Some have nice-sized egos, too, like people everywhere. It can be an unhealthy "win-win" when a therapist feels week after week like progress is being made, in part because the client knows just where to stroke, and both client and therapist get their superficial needs met.

But what about those clients who earnestly do want to understand themselves and the roots of their problems better in the hope of creating a better life in the future? It’s tricky territory. As Dr. Satel points out, the whole quest is something of a fool's errand as we cannot go back and see what our lives would have been if one thing had been different. This is precisely why "It's a Wonderful Life" has such timeless appeal. We love the fantasy of it but in reality we don't get the chance to view all the different scenarios that might have played out in our lives. We don't get to look down the road to see the actual consequences of any of our actions much as we would like to.