Wanderer Above the Sea of Fog by David Casper, 1818

Earlier this year I stumbled across a thoughtful article appearing in The New York Times written by a professor of psychiatry at Weill Cornell Medical College in Manhattan.  Dr. Richard Friedman's piece entitled "When Self-Knowledge Is Only the Beginning" got me thinking: What makes therapy work? 

In the article Dr. Friedman discusses the case of a young man in his 30s who came to him feeling sad and anxious due to a breakup with his girlfriend.  Through therapy this man had traced his feelings of anxiety and sadness back to an earlier trauma of being separated from his mother at the age of 4.  All of this sounds probable enough, however, what use is such self-awareness if it fails to alleviate this man's psychological distress?  I'm reminded of what my own clients sometimes say after arriving at their own meaningful insights during therapy: "Well, that's great, but what do I do about it?

I practice a form of psychotherapy derived from Freudian psychoanalysis and work on helping my clients become self-aware and insightful about their internal lives.  Such an approach to therapy is in keeping with the Socratic mantra that "The unexamined life is not worth living."  However, as much as I would like to believe this, my clinical experience has also taught me that insight only gets you so far. It is what you do with that insight that really determines whether you are able to live a healthier and happier existence.

Freud believed that the key to curing neuroses lay within the unconscious.  Through careful examination of his patients' unconscious processes, Freud believed he could relieve their suffering. From personal experience, however, I can tell you that such palliative effects rarely follow directly from insight, no matter how profound. We all need encouragement, if not guidance, in translating our own personal insights into concrete behavioral changes.  This is where therapy becomes more of an art form than a hard science.

Researchers such as the late Lester Luborsky, Ph.D. (2002) have shown that when different types of therapies are compared to one another, there really isn't much difference in outcome. These researchers have focused instead on the common factor of the strength of the therapeutic alliance.  This is in keeping with what I have seen in my own practice. It is the relationship between patient and therapist and the insight derived there from that ultimately brings about true change.


Tyger Latham, Psy.D. is a licensed clinical psychologist practicing in Washington, DC.  He counsels individuals and couples and has a particular interest in sexual trauma, gender development, and LGBT concerns.  His blog, Therapy Matters, explores the art and science of psychotherapy.

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