What is the Abraham Low Self-Helps Systems?


Abraham Low Self-Help Systems (ALSHS) is a non-profit organisation formed from the merger of Recovery International and the Abraham Low Institute.

ALSHS facilitates the estimated 600 worldwide Recovery International meetings and all projects formerly run by the Abraham Low Institute including the Power to Change programme. The organisation is named after Abraham Low, founder of the mental health self-help organisation now known as Recovery International.

Brief History

Recovery, Inc., often referred to simply as Recovery, was officially formed 07 November 1937, by neuropsychiatrist Abraham Low in Chicago, Illinois. Low created the organisation to facilitate peer support self-help groups for former mental patients and later allowed for participation of those who had not been hospitalised, but with a desire to improve their mental health. During the organisation’s annual meeting in June 2007 it was announced that Recovery, Inc. would thereafter be known as Recovery International. As of 2008 there were over 600 weekly Recovery International meetings held throughout North America, Ireland, the United Kingdom, Israel and India.

The Abraham Low Institute was founded in 1989 to develop programmes, in addition to Recovery, based on Low’s self-help principles. The Institute awarded grants to further scholarly research on Low’s work, provided research resources for people interested in Low’s methods, and developed the Power to Change programme and The Relatives Project.

On 01 January 2008 Recovery International merged with The Abraham Low Institute and provisionally renamed the new organisation Recovery International / The Abraham Low Institute (RI/TALI). Celinda Jungheim, a community volunteer from Los Angeles, was elected as president of the Board of Directors. Abraham Low Self-Help Systems was incorporated on 01 January 2009, completing the merger of Recovery International and The Abraham Low Institute. Abraham Low Self-Help Systems is now the provider of Recovery International community, phone and online meetings and The Power to Change programme, which was a programme of The Abraham Low Institute.

The Relatives Project

The Relatives Project, found in 1993, provides support for family and friends of people who have mental and emotional problems. The Relatives Project teaches coping skills and stress management through meetings similar to those held in Recovery International groups, but using literature written by Abraham Low specifically for the families of his patients. Relatives are taught to maintain empathy and unconditional positive regard for their ill relative, while reframing their domestic environment to provide an empowering atmosphere for all members. The Relatives Project groups are open to adults and teenagers, and allow professionals to observe but only to participate if it is in support of a family member’s mental health. Mental health becomes a shared goal for a family, and all family members share in responsibility to achieve it.

Power to Change

Power to Change is a cognitive-behavioural peer-to-peer programme based on Low’s self-help principles. Power to Change primarily teaches at-risk students and ex-prisoners principles of Low’s Self-Help system in peer-to-peer groups. Power to Change groups generally consist of 8-12 members, meeting weekly, who learn the principles of the Low Self-Help System by describing their personal experience of disturbing events and commenting on each other’s experiences using a highly structured format.

Specifically, Power to Change consists of five components:

  • A peer-to-peer process intended to provide a safe environment for members to disclose their experiences to a supportive group,
  • A meeting structure intended to keep discussion on topic,
  • A four-part format to help members frame their experiences as useful examples, and
  • Group feedback utilising a set of tools (principles of Abraham Low’s therapeutic technique).

The four-part example consists of an objective description an event; a report of the feelings, sensations, thoughts, and impulses experienced in the members mind and body; how the member used the Power to Change tools to manage the experience; and a self-endorsement to remind the member of the progress made and to reward their effort. The Power to Change groups use much of the language suggested in the Recovery International programme, such as identifying “temper” and avoiding judgment of right and wrong.

The W.K. Kellogg Foundation has provided grants for Power to Change since 2003. The most recent grant was awarded in November 2008, and will provide funding until November 2010.

Chicago Public Schools

In 2007 Urban Networks Associates (UNA) conducted an evaluation of Power to Change as it was implemented in seventeen secondary and middle schools in the Chicago Public School system. In each school 12-24 group sessions were held and facilitated by either staff from the Abraham Low Institute or by a local facilitator trained by the Abraham Low Institute. Participating students showed significant improvement in prosocial behaviour as measured by pre-testing and post-testing of emotional intelligence, specifically increasing self-restraint and decreasing violent behaviours. Although statistically significant, the effect sizes of changes were low or medium.

UNA’s SEM evaluation of the Power to Change logic model, the required steps and conditions for the program to be effective, found it fit the data collected well. To improve the effectiveness of the program UNA recommended improving communication with and training of local facilitators, encouraging students to develop plans to apply programme tools outside of the group, updating the literature used to make it more age appropriate for the young students, adding activities to encourage confidentiality of what was said in group meetings and developing more interactive activities to teach programme concepts. UNA also suggested asking for a commitment from participating schools to guarantee facilities were always available and that students would not be prohibited from attending group sessions.

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Who was Abraham Low?


Abraham Low (1891 to 1954) was an American neuropsychiatrist noted for his work in establishing self-help programmes for people with mental illness, and for his criticism of Freudian psychoanalysis.

Refer to Abraham Low Self-Help Systems (ALSHS).

Early Years

Low was born 28 February 1891, in Baranów Sandomierski, Poland.

Low attended grade school, high school and medical school in France from 1910 to 1918. He continued his medical education in Austria, serving in the Medical Corps of the Austrian Army. He graduated with a medical degree in 1919, after his military service, from the University of Vienna Medical School. After serving an internship in Vienna, Austria from 1919 to 1920, he immigrated to the United States, obtaining his US citizenship in 1927.


From 1921 to 1925 he practiced medicine in both New York, New York and Chicago, Illinois. In 1925 he was appointed as an instructor of neurology at the University of Illinois College of Medicine and became an associate professor of psychiatry. In 1931 Low was appointed assistant director and in 1940 became acting director of the university’s Neuropsychiatric Institute.

From 1931 to 1941 he supervised the Illinois State Hospitals. During this time he conducted demanding seminars with the staff and interviewed the most severe mental patients in the wards. In 1936, Low’s Studies in Infant Speech and Thought was published by the University of Illinois Press. Some sixty papers are by Low dealing variously with such topics as: Histopathology of brain and spinal cord, studies on speech disturbances (aphasias) in brain lesions, clinical testing of psychiatric and neurological conditions, studies in shock treatment, laboratory investigations of mental diseases; and several articles on group psychotherapy had been published in medical periodicals.

Death and Legacy

Low died in 1954 at the Mayo Clinic in Rochester, Minnesota. His contributions to the psychiatric and mental health communities are often not well known, but his work has and continues to assist numerous individuals in the area of mental health. The psychologist and founder of REBT, Albert Ellis, credits Low as a founder of cognitive behavioural therapy.

Recovery International

In 1937, Low founded Recovery, Inc. where he served as its medical director from 1937 to 1954. During this time he presented lectures to relatives of former patients on his work with these patients and the before and after scenarios. In 1941, Recovery Inc. became an independent organization. Low’s three volumes of The Technique of Self-help in Psychiatric Aftercare (including “Lectures to Relatives of Former Patients”) were published by Recovery, Inc. in 1943. Recovery’s main text, Mental Health Through Will-Training, was originally published in 1950. During the organisation’s annual meeting in June 2007, it was announced that Recovery, Inc. would thereafter be known as Recovery International.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Abraham_Low >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is Recovery International?


Recovery International (formerly Recovery, Inc., often referred to simply as Recovery or RI) is a mental health self-help organisation founded in 1937 by neuropsychiatrist Abraham Low in Chicago, Illinois.

Recovery’s programme is based on self-control, self-confidence, and increasing one’s determination to act. Recovery deals with a range of people, all of whom have difficulty coping with everyday problems, whether or not they have a history of psychiatric hospitalisation. It is non-profit, secular, and although it uses methods devised by Low, most groups are currently led by experienced non-professionals.

Brief History

In 1937, Abraham Low, a neuropsychiatrist, was on the faculty at the University of Illinois at Chicago, and participants in Recovery were limited to those who had been hospitalised in the Psychiatric Institute at the University. At that time, Recovery Inc. was an entity of the Neuropsychiatric Institute at the University of Illinois Research and Education Hospital. The original thirty-seven founding members had recovered their mental health after receiving insulin shock treatments at the Institute.

Low began the groups as part of an attempt to improve the patient’s care following discharge from his hospital. In the early years of the organisation he encouraged members to advocate for improvements in social policies regarding state mental health regulations. Following backlash from the medical community to these efforts, Low disbanded the group in 1941. His patients, however, asked to be trained to teach Recovery’s methods to others and in 1942 Low began to teach members to lead groups in their homes.

The organization separated from the Psychiatric Institute in 1942, operating out of private offices in Chicago. New membership at this time was drawn largely from patients in Low’s private psychiatry practice. During the first years following its separation Low remained in close contact with all Recovery groups and received regular reports from group leaders. As the membership and number of meetings grew, it made this level of cooperation with the groups untenable. In 1952, Low allowed expansion of Recovery outside of Illinois, giving control of local groups to former patients who had become group leaders. Following Low’s death in 1954, Recovery transitioned completely from a professionally run treatment adjunct, to a peer-run self-help group.

Effective 01 January 2007 Recovery, Inc. formally changed its name to Recovery International. On 02 January 2008 Recovery International merged with The Abraham Low Institute and provisionally renamed the new organisation Recovery International / The Abraham Low Institute (RI/TALI). On 01 January 2009, Abraham Low Self-Help Systems was incorporated to umbrella several new programmes, and the group continues operations as Recovery International and Abraham Low Self-Help Systems in various states and internationally.

Fundamental Concepts


The causes and classification of mental illnesses are considered irrelevant in the Recovery method. Recovery members are simply viewed as people who have developed disturbing symptom-reactions leading to ill-controlled behaviour. Symptoms are threatening sensations; including feelings, impulses, and obsessive thoughts. The phrase, “symptomatic idiom” describes the mental association of danger with symptoms.

The symptomatic idiom implies that there is an impending catastrophe of physical collapse, mental collapse, or permanent handicap. In the first instance, for example, a person may consider heart palpitations as signalling that sudden death is imminent, or that a painful headache is caused by a brain tumour; phobias, compulsions, and ruminations would eventually cause a mental collapse. The fear of permanent handicap insists that there is no cure or relief for one’s mental illness and that recovery is impossible.


Temper is a combination of a feeling and a judgement about oneself or others. The feeling is related to one of the two types of temper, fear or anger. The judgment is that one has been wronged by another, or that one has done something wrong. “Fearful temper” arises from thoughts that one has made a mistake (has done something wrong) which in turn causes feelings such as fear, shame and inadequacy. “Angry temper” results from the belief that one has been wronged which in turn creates feelings of indignation and impatience. There is a two-way relationship between temper and symptoms. Symptoms induce emotions such as fear and anger, which in turn induce temper, which increases the intensity of the symptoms.

“Temperamental lingo” describes language related to judgments of right and wrong, and the use of defeatist language when discussing symptoms. When discussing symptoms, temperamental lingo includes the use of adjectives such as “intolerable,” “uncontrollable,” “unbearable,” and similar language that places an emphasis on the dangerous and fatalistic implications of feelings, impulses, or thoughts.


Free will is fundamental to Recovery’s method. The subconscious, as it is known in psychoanalysis, as well as viewpoints emphasizing unconscious motivations, drives, and instincts are considered to be self-defeating. Recovery considers adults as capable of behaving based on deliberate plans, settled decisions, reasoned conclusions and firm determinations. Will gives adults the ability to accept or reject thoughts and impulses. Recovery members achieve mental health by training their Wills to reject self-defeating thoughts and impulses, countering them with self-endorsing thoughts and wellness-promoting actions.

External and Internal Environment

Recovery distinguishes between the External Environment, the realities of a situation, and the Internal Environment, one’s own subjective feelings, thoughts, impulses, and sensations. Two components of the Internal Environment, thoughts and impulses, can be directly controlled by Will. Control of thoughts and impulses allows indirect control over sensations and feelings. For instance, thoughts of insecurity and anxiousness can be replaced with thoughts of security. Similarly, a feeling of fear can be disposed by removing the associated belief of danger (symptomatic idiom). While the Internal Environment can be changed with cognitive reframing, changing one’s External Environment may or may not be possible.


Recovery focuses on treating former mental patients, sometimes referred to as post-psychotic persons, as well as psychoneurotic persons. The latter group is most often referred to as “nervous” or “nervous patients”. Recovery members may refer to themselves as “nervous patients” regardless of whether they are being treated by a physician or other professional. Sociologist Edward Sagarin described this as a compromise between the term neurotic and the more colloquial phrase “nervous breakdown”.

Common Techniques

Recovery encourages members to cognitively reframe their experiences using several techniques. Spotting, reframing defeatist language, self-endorsement and creating Examples are the most commonly cited in scholarly reviews of Recovery.


Spotting is an introspective relabelling of thoughts and symptoms. When a thought arises related to angry temper, fearful temper, or associating danger with a symptom it must be spotted and reframed. Members practice spotting and reacting appropriately to the distressing thought or symptom.

Reframing Language

Recovery developed its own language for labelling psychiatric symptoms and responding to them. This language is centred around two concepts, “authority” and “sabotage.” It is suggested that members rely on the authority of a physician’s diagnosis with respect to their symptoms. For instance, if a member self-diagnoses a headache as being caused by a brain tumour, but a physician has diagnosed it otherwise, then the member is said to be sabotaging the physician’s authority. This is similarly true for the member’s prognosis, if a member despairs that their condition is hopeless, but a physician has found the prognosis to be good, this is also sabotage of the physician’s authority. Using the physician’s perspective to reframe defeatist thoughts is intended to help members recognise that they have not lost control, and their situation can be coped with.


Members practice self-endorsement of every effort made to use a Recovery method, no matter how small and regardless of the outcome. In this way, similar subsequent efforts will require less work and are more likely to be successful. Similarly members are taught to change their behaviour in “part acts” (small steps), to simply “move their muscles” to complete tasks, however small, to eventually complete larger overwhelming tasks.

Creating Examples

The Example format was created by Low as a means to allow Recovery to function as a stand-alone lay self-help group that would not require professional supervision. Members create Examples by following a four-part outline, each part requiring a description.

  • Details of an event that caused distress.
  • The symptoms and discomfort that the event aroused.
  • How Recovery principles were utilised to cope with the event.
  • How the member would have behaved in response to the event before joining Recovery.

Examples are a formalised way to practice the Recovery programme. A successful outcome is not required to create an Example, as all attempts at practicing Recovery methods are endorsed.


1937 to 1952

During the first fifteen years of Recovery, Low required members to attend classes and meetings for at least six months at a cost of ten dollars per month, not including the membership dues of two dollars per year. Members would meet at least three days a week and on Wednesdays take part in panel discussions as panellists or audience members held at a private home. Panel discussions would consist of three to four panellists with considerable experience in Recovery discussing a topic from Low’s literature, focusing on spotting and conquering symptoms. Dr. Low would address the audience at the end of each panel discussion summing up the discussion and correcting any misinformation given about Recovery. Every Thursday Low would conduct a group psychotherapy class for Recovery members.

No meetings were held between Saturday and Wednesday. Commonly, novice members would have a “setback,” a relapse of psychiatric symptoms, during this time. As setbacks were considered unavoidable, the novice members were assigned to a more experienced member to call or visit should they need assistance. If the assistance provided by the experienced member was not helpful, they could contact a chairperson in their area (a member who functioned like the physician’s deputy), and if that was still not satisfactory they could contact the physician, Dr. Low.

1952 to Present

At the meetings, members share examples from their lives that caused nervous symptoms, the thoughts that occurred just beforehand, how they spotted them and reacted to them. Other members offer alternative ways of looking at the situation and suggest how to better handle similar symptoms in the future. Meetings range in size from 6 to 30 members and follow a rigid schedule to ensure adherence to Recovery methods. Each meeting has a leader in a permanent position; leadership duties do not rotate from meeting to meeting. Each meeting is split into five parts. Members introduce themselves by first name only, as is practiced in Alcoholics Anonymous.

Impact of Pandemic (2020-2021)

Due to COVID-19, more than 300 community meetings were closed, and many new telephone and online meetings were added. This gives people access to more meetings at various times during the week, regardless of geography.

Reading of Recovery Literature

The beginning of a meeting is generally reserved for reading from Recovery literature. Members take turns reading sections of a chapter or article. Group leaders will often call on new members during this period, or members who are hesitant to volunteer. After finishing a paragraph a group leader will often ask a member if they experienced any symptoms while reading the literature and will endorse them for the efforts to continue reading despite feelings of discomfort or fear of making mistakes.

Presentation of Examples

Only members who have read Mental Health Through Will Training are allowed to participate in this portion of the meeting. Those participating form a “panel” although they are usually seated face-to-face around a table. The group leader reminds the members that examples should be constructed around day-to-day events as Recovery is a non-professional organisation and cannot help people with major problems. This statement is qualified, however, with Low’s opinion that the majority of a nervous patient’s problems are related to “trivial” incidents. Rather than being a limitation of Recovery’s programme, this is intended to be a novel treatment approach. A day-today trivial event may generalise to other problems experienced by the member. Discussion of trivialities is less threatening than complex problems, making a discussion of coping mechanisms possible.

A survey of groups in Chicago in 1971 and 1977 found that most examples presented were stories of successful application of the Recovery method, less than 10% represented “problem examples” where the application was not successful.

Group participation

After an Example has been given, the meeting is opened for “group spotting”. During this period other members of the panel are allowed to comment on the Example based on Recovery principles. This group leader usually makes the first comments, and if there are no volunteers to continue, he or she may call on panel members to provide commentary. Comments not based on Recovery’s concepts or not related to the example are stopped by the group leader. Comments are either classed as positive, praise for application of a Recovery method, or negative, related to an instance where a method was not applied. An Example rarely passes without mention of additional Recovery techniques that could be applied to it. This serves as a constant reminder that Recovery’s method can never be practiced perfectly; members can always learn from experience and benefit from group practice.

For example, a person may experience “lowered feelings” (depression) because they are aiming for a perfect performance. Trying to be perfect or trying to appear perfect leads one to feel down if one makes even the slightest mistake. All improvements, no matter how small, are acknowledged and members are encouraged to endorse themselves for their efforts – not for their successes. Longstanding members are encouraged to share their success with the Recovery methods to help newcomers. Low saw the sharing of successes by veteran members as an essential component of meetings, as it demonstrates that distressing sensations can be endured, impulses can be controlled, and obsessions can be checked.

Question and Answer

Following the panel presentation, about fifteen minutes are set aside for a question and answer period. Any member may ask a question of the panel during this time, newcomers are especially encouraged to participate. Discussion, however, must be limited to the Examples given and related Recovery concepts. Discussion questioning Recovery’s method is not allowed. Discussion of psychological theories outside of Recovery is similarly discouraged. In a case where a member brings up a disagreement between his physician and a Recovery concept, he or she is told that the panel is not qualified to provide an answer not related to the Examples presented. Members are expected to follow the advice of their professional; Recovery is not intended as a substitute for psychiatric services, but a self-directed programme that can be used as an adjunct to professional treatment, or alone when professional treatment is not available.

Mutual Aid Meeting

The formal meeting ends with the question and answer period, and an informal “mutual-aid” gathering usually follows. During this time refreshments are usually served. Members may speak freely with one another and discuss problems or ask for advice, although there is an attempt to keep the discussion within the bounds of Recovery concepts. By convention, discussion of problems are limited to five minutes in an attempt to discourage self-pity and complaining.

Organisational Structure

From 1952 to 2008, Recovery was run from its office in Chicago by a twelve-member Board of Directors, a number of committees, organisation officers, and a full-time paid administrative staff. The Board of Directors was elected at Recovery’s annual meeting and served for a period of three years. Authority from the Board of Directors was passed to Area Leaders then to Assistant Area Leaders, District Leaders, and lastly to Group Leaders. Leaders are trained to run Recovery meetings, but are not considered experts or authorities. Policies and practices of Recovery were made by the Board of Directors.

Family Participation

In the early years of Recovery, an event was held on Saturday afternoons at Recovery’s office in Chicago for Recovery members as well as their relatives and friends. Later, family and friends of members were allowed to attend meetings, although not to participate. In 1943 Low published a book, Lectures to Relatives of Former Patients to help assist them with the recovery effort; this information was later reprinted in Peace Versus Power in the Family: Domestic Discord and Emotional Distress in 1967.


In 1945, Abraham Low found the average member improved considerably after the first or second week in the programme as it existed at that time. However, members were required to lose their major symptoms within two months of membership and class attendance. If they did not, this was taken as an indication that the member was still sabotaging the physician’s efforts.

A 1984 study found that following participation in Recovery, former mental patients reported no more anxiety about their mental health than the general public. Members rated their life satisfaction levels as high, or higher, than the general public. Members who had participated two years or more reported the highest levels of satisfaction with their health. Members who participated for less than two years tended to still be taking medication and living below the poverty level with smaller social networks.

A 1988 study found that participation in Recovery decreased members’ symptoms of mental illness and the amount of psychiatric treatment needed. About half of the members had been hospitalised before joining. Following participation, less than 8% had been hospitalised. Members’ scores of neurotic distress decreased, and scores of psychological well-being for longstanding members were no different from members of a control group in the same community. Long-term members were being treated with less psychiatric medication and psychotherapy than newer members.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Recovery_International >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is the Paranoia Network?


The Paranoia Network, founded in November 2003, is a self-help user-run organisation in Sheffield, England, for people who have paranoid or delusional beliefs.


In contrast to mainstream psychiatry, that tends to see such beliefs as signs of psychopathology, the Paranoia Network promotes a philosophy of living with unusual and compelling beliefs, without necessarily pathologising them as signs of mental illness. It was partly inspired by the Hearing Voices Network’s approach to auditory hallucinations.

What would otherwise seem to be a relatively minor disagreement over theory is complicated by the fact that people diagnosed as delusional can often be detained under mental health law and treated without their consent. Therefore, many of the criticisms of the diagnosis or definition have important ethical and political implications, which often leads to heated public debate.

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What was the New Freedom Commission on Mental Health?


The New Freedom Commission on Mental Health was established by US President George W. Bush through Executive Order 13263 on 29 April 2002 to conduct a comprehensive study of the US mental health service delivery system and make recommendations based on its findings. The commission has been touted as part of his commitment to eliminate inequality for Americans with disabilities.

The President directed the Commission to identify policies that could be implemented by Federal, State and local governments to maximise the utility of existing resources, improve coordination of treatments and services, and promote successful community integration for adults with a serious mental illness and children with a serious emotional disturbance. The commission, using the Texas Medication Algorithm Project (TMAP) as a blueprint, subsequently recommended screening of American adults for possible mental illnesses, and children for emotional disturbances, thereby identifying those with suspected disabilities who could then be provided with support services and state-of-the-art treatment, often in the form of newer psychoactive drugs that entered the market in recent years.

A broad-based coalition of mental health consumers, families, providers, and advocates has supported the Commission process and recommendations, using the Commission’s findings as a launching point for recommending widespread reform of the nation’s mental health system.

A coalition of opponents questioned the motives of the commission, based on the results from a similar 1995 Texas mandate while Bush was Governor. During the Texas Medication Algorithm Project mandate, psychotropic medication was wrongfully prescribed to the general public. Specifically, TMAP and drug manufacturers marketed ‘atypical antipsychotic drugs’, such as Seroquel, Zyprexa, and others, for a wide variety of non-psychotic behaviour issues. These drugs were later found to cause increased rates of sudden death in patients.

In addition to atypical antipsychotic drugs, earlier versions of psychotropic medications, including Prozac, were found to sharply increase rates of suicide, especially during the first month of drug use. Also during TMAP, psychotropic medication was wrongfully prescribed to people not suffering from mental illness, including troublesome children and difficult elderly people in nursing homes. In 2009, Eli Lilly was found guilty of wrongfully marketing Zyprexa for non-psychotic people.

Opponents also assert the New Freedom initiative campaign is a thinly veiled proxy for the pharmaceutical industry to foster psychotropic medication on mentally healthy individuals in its pursuit of profits. Opponents also contend that the initiative’s wider objectives are to foster chemical behaviour control of American citizens, contrary to civil liberties and to basic human rights.


Interim Report

The commission issued an interim report on 01 November 2002. Findings in the report included estimated prevalence of severe mental illness among adults and severe emotional disturbance in children, the existence of effective treatments, and barriers to care.

Final Report

On 22 July 2003, the President’s commission returned a report containing nineteen formal recommendations, organised under six proposed national goals for mental health. The commission emphasised recovery from mental illness, calls for consumer and family-centred care, and recommendations that states develop a more comprehensive approach to mental health.

The commission reported that “despite their prevalence, mental disorders often go undiagnosed,” so it recommended comprehensive mental health screening for “consumers of all ages,” including preschool children, because “each year, young children are expelled from preschools and childcare facilities for severely disruptive behaviors and emotional disorders.”

In contradiction, the Congressional Research Service, stated the commission did not specifically recommend a nationwide screening programme for mental illness, while it did discuss the need to identify mental illness in certain settings (juvenile detention facilities, foster care). The commission also recommended deeper study of the safety and effectiveness of medication use, especially among children.


Noting the country’s services for people with mental illness and disabilities were “fragmented,” the commission’s final report offered 19 recommendations within six larger goals to improve service coordination, move toward a recovery model, and help all individuals with mental illness and disability recover:

  • Americans Understand that Mental Health Is Essential to Overall Health.
    • Advance and implement a national campaign to reduce the stigma of seeking care and a national strategy for suicide prevention.
    • Address mental health with the same urgency as physical health.
  • Mental Health Care Is Consumer and Family Driven.
    • Develop an individualised plan of care for every adult with a serious mental illness and child with a serious emotional disturbance.
    • Involve consumers and families fully in orienting the mental health system toward recovery.
    • Align relevant Federal programmes to improve access and accountability for mental health services.
    • Create a Comprehensive State Mental Health Plan.
    • Protect and enhance the rights of people with mental illnesses.
  • Disparities in Mental Health Services Are Eliminated.
    • Improve access to quality care that is culturally competent.
    • Improve access to quality care in rural and geographically remote areas.
  • Early Mental Health Screening, Assessment, and Referral to Services Are Common Practice.
    • Promote the mental health of young children.
    • Improve and expand school mental health programmes.
    • Screen for co-occurring mental and substance use disorders and link with integrated treatment strategies.
    • Screen for mental disorders in primary health care, across the life span, and connect to treatment and supports.
  • Excellent Mental Health Care Is Delivered and Research Is Accelerated.
    • Accelerate research to promote recovery and resilience, and ultimately to cure and prevent mental illnesses.
    • Advance evidence-based practices using dissemination and demonstration projects and create a public–private partnership to guide their implementation.
    • Improve and expand the workforce providing evidence-based mental health services and supports.
    • Develop the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care.
  • Technology Is Used to Access Mental Health Care and Information.
    • Use health technology and telehealth to improve access and coordination of mental health care, especially for Americans in remote areas or in underserved populations.
    • Develop and implement integrated electronic health record and personal health information systems.


Opponents of the plan see little in the way of potential benefits from the plan, except increased profits for pharmaceutical companies, and have concerns about the potential for unnecessarily causing neurological damage and contributing to increased substance abuse and drug dependence. Critics are also concerned by what they see as the pharmaceutical industry’s use of front organisations and the compromise of scientific integrity under colour of authority, look askance at the irony of the commission’s ‘freedom’ descriptor, contending the commission is yet another example of the excesses of drug industry marketing, and that the effects of its recommendations will simply foster drug use rather than the prevention of mental illness and use of alternative treatment modalities.

Screening Recommendations

Mad in America author Robert Whitaker criticized the commission’s screening recommendations as “fishing for customers.” A coalition of over 100 advocacy organisations, united under the banner of Mindfreedom.org in representing the psychiatric survivors movement, has been galvanised by their strong opposition to the New Freedom Commission. Using celebrity to advance their opposition, the MindFreedom coalition has again enlisted the support of long-time member and Gesundheit Institute founder Patch Adams, a medical doctor made famous by the movie that bears his name. Since 1992, Adams has supported MindFreedom campaigns, and in August, 2004, he kicked off the campaign against the New Freedom Commission by volunteering to screen President Bush himself. “He needs a lot of help. I’ll see him for free,” said Adams.

Others, including Congressman Ron Paul (R-TX14), were more concerned by the commission’s suggestion to use schools as a site for screening. Paul’s concern led to the introduction of H.R. 181 Parental Consent Act of 2005 in the US House of Representatives on 04 January 2005. The bill, which died in committee, would have forbidden federal funds from being used for any mental health screening of students without the express, written, voluntary, informed consent of parents. Paul introduced similar bills in May 2007 (H.R. 2387), April 2009 (H.R. 2218), and August 2011 (H.R. 2769); those, likewise, died in committee.

TMAP Origin Criticism

Critics also contend that the strategy behind the commission was developed by the pharmaceutical industry, advancing the theory that the primary purpose of the commission was to recommend implementation of TMAP based algorithms on a nationwide basis. TMAP, which advises the use of newer, more expensive medications, has itself been the subject of controversy in Texas, Pennsylvania and other states where efforts have been made to implement its use.

TMAP, which was created in 1995 while President Bush was governor of Texas, began as an alliance of individuals from the University of Texas, the pharmaceutical industry, and the mental health and corrections systems of Texas. Through the guise of TMAP, critics contend, the drug industry has methodically influenced the decision making of elected and appointed public officials to gain access to citizens in prisons and State psychiatric hospitals. The person primarily responsible for bringing these issues to the public’s attention is Allen Jones, a former investigator in the Commonwealth of Pennsylvania Office of Inspector General (OIG), Bureau of Special Investigations.

Jones wrote a lengthy report in which he stated that, behind the recommendations of the New Freedom Commission, was the “political/pharmaceutical alliance.” It was this alliance, according to Jones, which developed the Texas project, specifically to promote the use of newer, more expensive antipsychotics and antidepressants. He further claimed this alliance was “poised to consolidate the TMAP effort into a comprehensive national policy to treat mental illness with expensive, patented medications of questionable benefit and deadly side effects, and to force private insurers to pick up more of the tab.”

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What is Metacognition?


Metacognition is an awareness of one’s thought processes and an understanding of the patterns behind them. The term comes from the root word meta, meaning “beyond”, or “on top of”. Metacognition can take many forms, such as reflecting on one’s ways of thinking and knowing when and how to use particular strategies for problem-solving. There are generally two components of metacognition:

  • Knowledge about cognition; and
  • Regulation of cognition.

Metamemory, defined as knowing about memory and mnemonic strategies, is an especially important form of metacognition. Academic research on metacognitive processing across cultures is in the early stages, but there are indications that further work may provide better outcomes in cross-cultural learning between teachers and students.

Writings on metacognition date back at least as far as two works by the Greek philosopher Aristotle (384-322 BC): On the Soul and the Parva Naturalia.


This higher-level cognition was given the label metacognition by American developmental psychologist John H. Flavell (1976).

The term metacognition literally means ‘above cognition’, and is used to indicate cognition about cognition, or more informally, thinking about thinking. Flavell defined metacognition as knowledge about cognition and control of cognition. For example, a person is engaging in metacognition if they notice that they are having more trouble learning A than B, or if it strikes them that they should double-check C before accepting it as fact. J.H. Flavell (1976, p. 232). Andreas Demetriou’s theory (one of the neo-Piagetian theories of cognitive development) used the term hyper-cognition to refer to self-monitoring, self-representation, and self-regulation processes, which are regarded as integral components of the human mind. Moreover, with his colleagues, he showed that these processes participate in general intelligence, together with processing efficiency and reasoning, which have traditionally been considered to compose fluid intelligence.

Metacognition also involves thinking about one’s own thinking process such as study skills, memory capabilities, and the ability to monitor learning. This concept needs to be explicitly taught along with content instruction.

Metacognitive knowledge is about one’s own cognitive processes and the understanding of how to regulate those processes to maximize learning.

Some types of metacognitive knowledge would include:

Content Knowledge (Declarative Knowledge)Content knowledge (declarative knowledge) which is understanding one’s own capabilities, such as a student evaluating their own knowledge of a subject in a class. It is notable that not all metacognition is accurate. Studies have shown that students often mistake lack of effort with understanding in evaluating themselves and their overall knowledge of a concept.[10] Also, greater confidence in having performed well is associated with less accurate metacognitive judgment of the performance.
Task Knowledge (Procedural Knowledge)Task knowledge (procedural knowledge), which is how one perceives the difficulty of a task which is the content, length, and the type of assignment. The study mentioned in Content knowledge also deals with a person’s ability to evaluate the difficulty of a task related to their overall performance on the task. Again, the accuracy of this knowledge was skewed as students who thought their way was better/easier also seemed to perform worse on evaluations, while students who were rigorously and continually evaluated reported to not be as confident but still did better on initial evaluations.
Strategic Knowledge (Conditional Knowledge)Strategic knowledge (conditional knowledge) which is one’s own capability for using strategies to learn information. Young children are not particularly good at this; it is not until students are in upper elementary school that they begin to develop an understanding of effective strategies.

Metacognition is a general term encompassing the study of memory-monitoring and self-regulation, meta-reasoning, consciousness/awareness and autonoetic consciousness/self-awareness. In practice these capacities are used to regulate one’s own cognition, to maximise one’s potential to think, learn and to the evaluation of proper ethical/moral rules. It can also lead to a reduction in response time for a given situation as a result of heightened awareness, and potentially reduce the time to complete problems or tasks.

In the domain of experimental psychology, an influential distinction in metacognition (proposed by T.O. Nelson & L. Narens) is between Monitoring – making judgements about the strength of one’s memories – and Control – using those judgments to guide behaviour (in particular, to guide study choices). Dunlosky, Serra, and Baker (2007) covered this distinction in a review of metamemory research that focused on how findings from this domain can be applied to other areas of applied research.

In the domain of cognitive neuroscience, metacognitive monitoring and control has been viewed as a function of the prefrontal cortex, which receives (monitors) sensory signals from other cortical regions and implements control using feedback loops (see chapters by Schwartz & Bacon and Shimamura, in Dunlosky & Bjork, 2008).

Metacognition is studied in the domain of artificial intelligence and modelling. Therefore, it is the domain of interest of emergent systemics.


Metacognition is classified into three components:

  1. Metacognitive knowledge (also called metacognitive awareness) is what individuals know about themselves and others as cognitive processors.
  2. Metacognitive regulation is the regulation of cognition and learning experiences through a set of activities that help people control their learning.
  3. Metacognitive experiences are those experiences that have something to do with the current, on-going cognitive endeavour.

Metacognition refers to a level of thinking that involves active control over the process of thinking that is used in learning situations. Planning the way to approach a learning task, monitoring comprehension, and evaluating the progress towards the completion of a task: these are skills that are metacognitive in their nature.

Metacognition includes at least three different types of metacognitive awareness when considering metacognitive knowledge:

  1. Declarative knowledge: refers to knowledge about oneself as a learner and about what factors can influence one’s performance. Declarative knowledge can also be referred to as “world knowledge”.
  2. Procedural knowledge: refers to knowledge about doing things. This type of knowledge is displayed as heuristics and strategies. A high degree of procedural knowledge can allow individuals to perform tasks more automatically. This is achieved through a large variety of strategies that can be accessed more efficiently.
  3. Conditional knowledge: refers to knowing when and why to use declarative and procedural knowledge. It allows students to allocate their resources when using strategies. This in turn allows the strategies to become more effective.

Similar to metacognitive knowledge, metacognitive regulation or “regulation of cognition” contains three skills that are essential.

  1. Planning: refers to the appropriate selection of strategies and the correct allocation of resources that affect task performance.
  2. Monitoring: refers to one’s awareness of comprehension and task performance
  3. Evaluating: refers to appraising the final product of a task and the efficiency at which the task was performed. This can include re-evaluating strategies that were used.

Similarly, maintaining motivation to see a task to completion is also a metacognitive skill. The ability to become aware of distracting stimuli – both internal and external – and sustain effort over time also involves metacognitive or executive functions. The theory that metacognition has a critical role to play in successful learning means it is important that it be demonstrated by both students and teachers.

Students who underwent metacognitive training including pretesting, self evaluation, and creating study plans performed better on exams. They are self-regulated learners who utilise the “right tool for the job” and modify learning strategies and skills based on their awareness of effectiveness. Individuals with a high level of metacognitive knowledge and skill identify blocks to learning as early as possible and change “tools” or strategies to ensure goal attainment. Swanson (1990) found that metacognitive knowledge can compensate for IQ and lack of prior knowledge when comparing fifth and sixth grade students’ problem solving. Students with a high-metacognition were reported to have used fewer strategies, but solved problems more effectively than low-metacognition students, regardless of IQ or prior knowledge. In one study examining students who send text messages during college lectures, it was suggested that students with higher metacognitive abilities were less likely than other students to have their learning affected by using a mobile phone in class.

The fundamental cause of the trouble is that in the modern world the stupid are cocksure while the intelligent are full of doubt. Bertrand Russell.

Metacognologists are aware of their own strengths and weaknesses, the nature of the task at hand, and available “tools” or skills. A broader repertoire of “tools” also assists in goal attainment. When “tools” are general, generic, and context independent, they are more likely to be useful in different types of learning situations.

Another distinction in metacognition is executive management and strategic knowledge. Executive management processes involve planning, monitoring, evaluating and revising one’s own thinking processes and products. Strategic knowledge involves knowing what (factual or declarative knowledge), knowing when and why (conditional or contextual knowledge) and knowing how (procedural or methodological knowledge). Both executive management and strategic knowledge metacognition are needed to self-regulate one’s own thinking and learning.

Finally, there is no distinction between domain-general and domain-specific metacognitive skills. This means that metacognitive skills are domain-general in nature and there are no specific skills for certain subject areas. The metacognitive skills that are used to review an essay are the same as those that are used to verify an answer to a math question.

Social Metacognition

Although metacognition has thus far been discussed in relation to the self, recent research in the field has suggested that this view is overly restrictive. Instead, it is argued that metacognition research should also include beliefs about others’ mental processes, the influence of culture on those beliefs, and on beliefs about ourselves. This “expansionist view” proposes that it is impossible to fully understand metacognition without considering the situational norms and cultural expectations that influence those same conceptions. This combination of social psychology and metacognition is referred to as social metacognition.

Social metacognition can include ideas and perceptions that relate to social cognition. Additionally, social metacognition can include judging the cognition of others, such as judging the perceptions and emotional states of others. This is in part because the process of judging others is similar to judging the self. However, individuals have less information about the people they are judging; therefore, judging others tends to be more inaccurate. Having similar cognitions can buffer against this inaccuracy and can be helpful for teams or organisations, as well as interpersonal relationships.

Social Metacognition and the Self Concept

An example of the interaction between social metacognition and self-concept can be found in examining implicit theories about the self. Implicit theories can cover a wide range of constructs about how the self operates, but two are especially relevant here; entity theory and incrementalist theory. Entity theory proposes that an individual’s self-attributes and abilities are fixed and stable, while incrementalist theory proposes that these same constructs can be changed through effort and experience. Entity theorists are susceptible to learned helplessness because they may feel that circumstances are outside their control (i.e. there is nothing that could have been done to make things better), thus they may give up easily. Incremental theorists react differently when faced with failure: they desire to master challenges, and therefore adopt a mastery-oriented pattern. They immediately began to consider various ways that they could approach the task differently, and they increase their efforts. Cultural beliefs can act on this as well. For example, a person who has accepted a cultural belief that memory loss is an unavoidable consequence of old age may avoid cognitively demanding tasks as they age, thus accelerating cognitive decline. Similarly, a woman who is aware of the stereotype that purports that women are not good at mathematics may perform worse on tests of mathematical ability or avoid mathematics altogether. These examples demonstrate that the metacognitive beliefs people hold about the self – which may be socially or culturally transmitted – can have important effects on persistence, performance, and motivation.

Attitudes as a Function of Social Metacognition

The way that individuals think about attitude greatly affects the way that they behave. Metacognitions about attitudes influence how individuals act, and especially how they interact with others.

Some metacognitive characteristics of attitudes include importance, certainty, and perceived knowledge, and they influence behaviour in different ways. Attitude importance is the strongest predictor of behaviour and can predict information seeking behaviours in individuals. Attitude importance is also more likely to influence behaviour than certainty of the attitude. When considering a social behaviour like voting a person may hold high importance but low certainty. This means that they will likely vote, even if they are unsure whom to vote for. Meanwhile, a person who is very certain of who they want to vote for, may not actually vote if it is of low importance to them. This also applies to interpersonal relationships. A person might hold a lot of favourable knowledge about their family, but they may not maintain close relations with their family if it is of low importance.

Metacognitive characteristics of attitudes may be key to understanding how attitudes change. Research shows that the frequency of positive or negative thoughts is the biggest factor in attitude change. A person may believe that climate change is occurring but have negative thoughts toward it such as “If I accept the responsibilities of climate change, I must change my lifestyle”. These individuals would not likely change their behaviour compared to someone that thinks positively about the same issue such as “By using less electricity, I will be helping the planet”.

Another way to increase the likelihood of behaviour change is by influencing the source of the attitude. An individual’s personal thoughts and ideas have a much greater impact on the attitude compared to ideas of others. Therefore, when people view lifestyle changes as coming from themselves, the effects are more powerful than if the changes were coming from a friend or family member. These thoughts can be re-framed in a way that emphasizes personal importance, such as “I want to stop smoking because it is important to me” rather than “quitting smoking is important to my family”. More research needs to be conducted on culture differences and importance of group ideology, which may alter these results.

Social Metacognition and Stereotypes

People have secondary cognitions about the appropriateness, justifiability, and social judgability of their own stereotypic beliefs. People know that it is typically unacceptable to make stereotypical judgments and make conscious efforts not to do so. Subtle social cues can influence these conscious efforts. For example, when given a false sense of confidence about their ability to judge others, people will return to relying on social stereotypes. Cultural backgrounds influence social metacognitive assumptions, including stereotypes. For example, cultures without the stereotype that memory declines with old age display no age differences in memory performance.

When it comes to making judgements about other people, implicit theories about the stability versus malleability of human characteristics predict differences in social stereotyping as well. Holding an entity theory of traits increases the tendency for people to see similarity among group members and utilise stereotyped judgments. For example, compared to those holding incremental beliefs, people who hold entity beliefs of traits use more stereotypical trait judgements of ethnic and occupational groups as well as form more extreme trait judgments of new groups. When an individual’s assumptions about a group combine with their implicit theories, more stereotypical judgements may be formed. Stereotypes that one believes others hold about them are called metastereotypes.

Animal Metacognition

In Nonhuman Primates


Beran, Smith, and Perdue (2013) found that chimpanzees showed metacognitive monitoring in the information-seeking task. In their studies, three language-trained chimpanzees were asked to use the keyboard to name the food item in order to get the food. The food in the container was either visible to them or they had to move toward the container to see its contents. Studies shown that chimpanzees were more often to check what was in the container first if the food in the container was hidden. But when the food was visible to them, the chimpanzees were more likely to directly approach the keyboard and reported the identity of the food without looking again in the container. Their results suggested that chimpanzees know what they have seen and show effective information-seeking behaviour when information is incomplete.

Rhesus Macaques (Macaca Mulatta)

Morgan et al. (2014) investigated whether rhesus macaques can make both retrospective and prospective metacognitive judgements on the same memory task. Risk choices were introduced to assess the monkey’s confidence about their memories. Two male rhesus monkeys (Macaca mulatta) were trained in a computerised token economy task first in which they can accumulate tokens to exchange food rewards. Monkeys were presented with multiple images of common objects simultaneously and then a moving border appearing on the screen indicating the target. Immediately following the presentation, the target images and some distractors were shown in the test. During the training phase, monkeys received immediate feedback after they made responses. They can earn two tokens if they make correct choices but lost two tokens if they were wrong.

In Experiment 1, the confidence rating was introduced after they completed their responses in order to test the retrospective metamemory judgements. After each response, a high-risk and a low-risk choice were provided to the monkeys. They could earn one token regardless of their accuracy if they choose the low-risk option. When they chose high-risk, they were rewarded with three tokens if their memory response was correct on that trial but lost three tokens if they made incorrect responses. Morgan and colleagues (2014) found a significant positive correlation between memory accuracy and risk choice in two rhesus monkeys. That is, they were more likely to select the high-risk option if they answered correctly in the working memory task but select the low-risk option if they were failed in the memory task.

Then Morgan et al. (2014) examine monkeys’ prospective metacognitive monitoring skills in Experiment 2. This study employed the same design except that two monkeys were asked to make low-risk or high-risk confidence judgement before they make actual responses to measure their judgements about future events. Similarly, the monkeys were more often to choose high-risk confidence judgment before answering correctly in working memory task and tended to choose the low-risk option before providing an incorrect response. These two studies indicated that rhesus monkeys can accurately monitor their performance and provided evidence of metacognitive abilities in monkeys.

In Rats

In addition to nonhuman primates, other animals are also shown metacognition. Foote and Crystal (2007) provided the first evidence that rats have the knowledge of what they know in a perceptual discrimination task. Rats were required to classify brief noises as short or long. Some noises with intermediate durations were difficult to discriminate as short or long. Rats were provided with an option to decline to take the test on some trials but were forced to make responses on other trials. If they chose to take the test and respond correctly, they would receive a high reward but no reward if their classification of noises was incorrect. But if the rats decline to take the test, they would be guaranteed a smaller reward. The results showed that rats were more likely to decline to take the test when the difficulty of noise discrimination increased, suggesting rats knew they do not have the correct answers and declined to take the test to receive the reward. Another finding is that the performance was better when they had chosen to take the test compared with if the rats were forced to make responses, proving that some uncertain trials were declined to improve the accuracy.

These responses pattern might be attributed to actively monitor their own mental states. Alternatively, external cues such as environmental cue associations could be used to explain their behaviours in the discrimination task. Rats might have learned the association between intermediate stimuli and the decline option over time. Longer response latencies or some features inherent to stimuli can serve as discriminative cues to decline tests. Therefore, Templer, Lee, and Preston (2017) utilised an olfactory-based delayed match to sample (DMTS) memory task to assess whether rats were capable of metacognitive responding adaptively. Rats were exposed to sample odour first and chose to either decline or take the four-choice memory test after a delay. The correct choices of odour were associated with high reward and incorrect choices have no reward. The decline options were accompanied by a small reward.

In experiment 2, some “no-sample” trials were added in the memory test in which no odour was provided before the test. They hypothesized that rats would decline more often when there was no sample odour presented compared with odour presented if rats could internally assess the memory strength. Alternatively, if the decline option was motivated by external environmental cues, the rats would be less likely to decline the test because no available external cues were presented. The results showed that rats were more likely to decline the test in no-sample trials relative to normal sample trials, supporting the notion that rats can track their internal memory strength.

To rule out other potential possibilities, they also manipulated memory strength by providing the sampled odour twice and varying the retention interval between the learning and the test. Templer and colleagues (2017) found rats were less likely to decline the test if they had been exposed to the sample twice, suggesting that their memory strength for these samples was increased. Longer delayed sample test was more often declined than short delayed test because their memory was better after the short delay. Overall, their series of studies demonstrated that rats could distinguish between remembering and forgetting and rule out the possibilities that decline use was modulated by the external cues such as environmental cue associations.

In Pigeons

Research on metacognition of pigeons has shown limited success. Inman and Shettleworth (1999) employed the delayed match to sample (DMTS) procedure to test pigeons’ metacognition. Pigeons were presented with one of three sample shapes (a triangle, a square, or a star) and then they were required to peck the matched sample when three stimuli simultaneously appeared on the screen at the end of the retention interval. A safe key was also presented in some trials next to three sample stimuli which allow them to decline that trial. Pigeons received a high reward for pecking correct stimuli, a middle-level reward for pecking the safe key, and nothing if they pecked the wrong stimuli. Inman and Shettleworth’s (1999) first experiment found that pigeons’ accuracies were lower and they were more likely to choose the safe key as the retention interval between presentation of stimuli and test increased. However, in Experiment 2, when pigeons were presented with the option to escape or take the test before the test phase, there was no relationship between choosing the safe key and longer retention interval. Adams and Santi (2011) also employed the DMTS procedure in a perceptual discrimination task during which pigeons were trained to discriminate between durations of illumination. Pigeons did not choose the escape option more often as the retention interval increased during initial testing. After extended training, they learned to escape the difficult trials. However, these patterns might be attributed to the possibility that pigeons learned the association between escape responses and longer retention delay.

In addition to DMTS paradigm, Castro and Wasserman (2013) proved that pigeons can exhibit adaptive and efficient information-seeking behaviour in the same-different discrimination task. Two arrays of items were presented simultaneously in which the two sets of items were either identical or different from one another. Pigeons were required to distinguish between the two arrays of items in which the level of difficulty was varied. Pigeons were provided with an “Information” button and a “Go” button on some trials that they could increase the number of items in the arrays to make the discrimination easier or they can prompt to make responses by pecking the Go button. Castro and Wasserman found that the more difficult the task, the more often pigeons chose the information button to solve the discrimination task. This behavioural pattern indicated that pigeons could evaluate the difficulty of the task internally and actively search for information when is necessary.

In Dogs

Dogs have shown a certain level of metacognition that they are sensitive to information they have acquired or not. Belger & Bräuer (2018) examined whether dogs could seek additional information when facing uncertain situations. The experimenter put the reward behind one of the two fences in which dogs can see or cannot see where the reward was hidden. After that, dogs were encouraged to find the reward by walking around one fence. The dogs checked more frequently before selecting the fence when they did not see the baiting process compared with when they saw where the reward was hidden. However, contrary to apes, dogs did not show more checking behaviours when the delay between baiting the reward and selecting the fence was longer. Their findings suggested that dogs have some aspect of information-searching behaviours but less flexibly compared to apes.

In Dolphins

Smith et al. (1995) evaluated whether dolphins have the ability of metacognitive monitoring in an auditory threshold paradigm. A bottlenosed dolphin was trained to discriminate between high-frequency tones and low-frequency tones. An escape option was available on some trials associated with a small reward. Their studies showed that dolphins could appropriately use the uncertain response when the trials were difficult to discriminate.


There is consensus that nonhuman primates, especially great apes and rhesus monkeys, exhibit metacognitive control and monitoring behaviours. But less convergent evidence was found in other animals such as rats and pigeons. Some researchers criticised these methods and posited that these performances might be accounted for by low-level conditioning mechanisms. Animals learned the association between reward and external stimuli through simple reinforcement models. However, many studies have demonstrated that the reinforcement model alone cannot explain animals’ behavioural patterns. Animals have shown adaptive metacognitive behaviour even with the absence of concrete reward.


Metacognitive-like processes are especially ubiquitous when it comes to the discussion of self-regulated learning. Self-regulation requires metacognition by looking at one’s awareness of their learning and planning further learning methodology. Attentive metacognition is a salient feature of good self-regulated learners, but does not guarantee automatic application. Reinforcing collective discussion of metacognition is a salient feature of self-critical and self-regulating social groups. The activities of strategy selection and application include those concerned with an ongoing attempt to plan, check, monitor, select, revise, evaluate, etc.

Metacognition is ‘stable’ in that learners’ initial decisions derive from the pertinent facts about their cognition through years of learning experience. Simultaneously, it is also ‘situated’ in the sense that it depends on learners’ familiarity with the task, motivation, emotion, and so forth. Individuals need to regulate their thoughts about the strategy they are using and adjust it based on the situation to which the strategy is being applied. At a professional level, this has led to emphasis on the development of reflective practice, particularly in the education and health-care professions.

Recently, the notion has been applied to the study of second language learners in the field of TESOL and applied linguistics in general (e.g. Wenden, 1987; Zhang, 2001, 2010). This new development has been much related to Flavell (1979), where the notion of metacognition is elaborated within a tripartite theoretical framework. Learner metacognition is defined and investigated by examining their person knowledge, task knowledge and strategy knowledge.

Wenden (1991) has proposed and used this framework and Zhang (2001) has adopted this approach and investigated second language learners’ metacognition or metacognitive knowledge. In addition to exploring the relationships between learner metacognition and performance, researchers are also interested in the effects of metacognitively-oriented strategic instruction on reading comprehension (e.g. Garner, 1994, in first language contexts, and Chamot, 2005; Zhang, 2010). The efforts are aimed at developing learner autonomy, interdependence and self-regulation.

Metacognition helps people to perform many cognitive tasks more effectively. Strategies for promoting metacognition include self-questioning (e.g. “What do I already know about this topic? How have I solved problems like this before?”), thinking aloud while performing a task, and making graphic representations (e.g. concept maps, flow charts, semantic webs) of one’s thoughts and knowledge. Carr, 2002, argues that the physical act of writing plays a large part in the development of metacognitive skills.

Strategy Evaluation matrices (SEM) can help to improve the knowledge of cognition component of metacognition. The SEM works by identifying the declarative (Column 1), procedural (Column 2) and conditional (Column 3 and 4) knowledge about specific strategies. The SEM can help individuals identify the strength and weaknesses about certain strategies as well as introduce them to new strategies that they can add to their repertoire.

A regulation checklist (RC) is a useful strategy for improving the regulation of cognition aspect of one’s metacognition. RCs help individuals to implement a sequence of thoughts that allow them to go over their own metacognition. King (1991) found that fifth-grade students who used a regulation checklist outperformed control students when looking at a variety of questions including written problem solving, asking strategic questions, and elaborating information.

Examples of strategies that can be taught to students are word analysis skills, active reading strategies, listening skills, organisational skills and creating mnemonic devices.

Walker and Walker have developed a model of metacognition in school learning termed Steering Cognition, which describes the capacity of the mind to exert conscious control over its reasoning and processing strategies in relation to the external learning task. Studies have shown that pupils with an ability to exert metacognitive regulation over their attentional and reasoning strategies used when engaged in maths, and then shift those strategies when engaged in science or then English literature learning, associate with higher academic outcomes at secondary school.

Metastrategic Knowledge

“Metastrategic knowledge” (MSK) is a sub-component of metacognition that is defined as general knowledge about higher order thinking strategies. MSK had been defined as “general knowledge about the cognitive procedures that are being manipulated”. The knowledge involved in MSK consists of “making generalizations and drawing rules regarding a thinking strategy” and of “naming” the thinking strategy.

The important conscious act of a metastrategic strategy is the “conscious” awareness that one is performing a form of higher order thinking. MSK is an awareness of the type of thinking strategies being used in specific instances and it consists of the following abilities:

  • Making generalisations and drawing rules regarding a thinking strategy;
  • Naming the thinking strategy,
  • Explaining when, why and how such a thinking strategy should be used;
  • When it should not be used;
  • What are the disadvantages of not using appropriate strategies; and
  • What task characteristics call for the use of the strategy.

MSK deals with the broader picture of the conceptual problem. It creates rules to describe and understand the physical world around the people who utilise these processes called higher-order thinking. This is the capability of the individual to take apart complex problems in order to understand the components in problem. These are the building blocks to understanding the “big picture” (of the main problem) through reflection and problem solving.


Both social and cognitive dimensions of sporting expertise can be adequately explained from a metacognitive perspective according to recent research. The potential of metacognitive inferences and domain-general skills including psychological skills training are integral to the genesis of expert performance. Moreover, the contribution of both mental imagery (e.g. mental practice) and attentional strategies (e.g. routines) to our understanding of expertise and metacognition is noteworthy. The potential of metacognition to illuminate our understanding of action was first highlighted by Aidan Moran who discussed the role of meta-attention in 1996. A recent research initiative, a research seminar series called META funded by the BPS, is exploring the role of the related constructs of meta-motivation, meta-emotion, and thinking and action (metacognition).

Mental Illness

Sparks of Interest

In the context of mental health, metacognition can be loosely defined as the process that “reinforces one’s subjective sense of being a self and allows for becoming aware that some of one’s thoughts and feelings are symptoms of an illness”. The interest in metacognition emerged from a concern for an individual’s ability to understand their own mental status compared to others as well as the ability to cope with the source of their distress. These insights into an individual’s mental health status can have a profound effect on overall prognosis and recovery. Metacognition brings many unique insights into the normal daily functioning of a human being. It also demonstrates that a lack of these insights compromises ‘normal’ functioning. This leads to less healthy functioning. In the autism spectrum, it is speculated that there is a profound deficit in Theory of Mind. In people who identify as alcoholics, there is a belief that the need to control cognition is an independent predictor of alcohol use over anxiety. Alcohol may be used as a coping strategy for controlling unwanted thoughts and emotions formed by negative perceptions. This is sometimes referred to as self medication.


Adrian Wells’ and Gerald Matthews’ theory proposes that when faced with an undesired choice, an individual can operate in two distinct modes: “object” and “metacognitive”. Object mode interprets perceived stimuli as truth, where metacognitive mode understands thoughts as cues that have to be weighted and evaluated. They are not as easily trusted. There are targeted interventions unique of each patient, that gives rise to the belief that assistance in increasing metacognition in people diagnosed with schizophrenia is possible through tailored psychotherapy. With a customised therapy in place clients then have the potential to develop greater ability to engage in complex self-reflection. This can ultimately be pivotal in the patient’s recovery process. In the obsessive-compulsive spectrum, cognitive formulations have greater attention to intrusive thoughts related to the disorder. “Cognitive self-consciousness” are the tendencies to focus attention on thought. Patients with OCD exemplify varying degrees of these “intrusive thoughts”. Patients also with generalised anxiety disorder (GAD) also show negative thought process in their cognition.

Cognitive-attentional syndrome (CAS) characterises a metacognitive model of emotion disorder (CAS is consistent with the attention strategy of excessively focusing on the source of a threat). This ultimately develops through the client’s own beliefs. Metacognitive therapy attempts to correct this change in the CAS. One of the techniques in this model is called attention training (ATT). It was designed to diminish the worry and anxiety by a sense of control and cognitive awareness. ATT also trains clients to detect threats and test how controllable reality appears to be.

Following the work of Asher Koriat, who regards confidence as central aspect of metacognition, metacognitive training for psychosis aims at decreasing overconfidence in patients with schizophrenia and raising awareness of cognitive biases. According to a meta-analysis, this type of intervention improves delusions and hallucinations.

Works of Art as Metacognitive Artefacts

The concept of metacognition has also been applied to reader-response criticism. Narrative works of art, including novels, movies and musical compositions, can be characterised as metacognitive artefacts which are designed by the artist to anticipate and regulate the beliefs and cognitive processes of the recipient, for instance, how and in which order events and their causes and identities are revealed to the reader of a detective story. As Menakhem Perry has pointed out, mere order has profound effects on the aesthetical meaning of a text. Narrative works of art contain a representation of their own ideal reception process. They are something of a tool with which the creators of the work wish to attain certain aesthetical and even moral effects.

Mind Wandering

There is an intimate, dynamic interplay between mind wandering and metacognition. Metacognition serves to correct the wandering mind, suppressing spontaneous thoughts and bringing attention back to more “worthwhile” tasks.

Organisational Metacognition

The concept of metacognition has also been applied to collective teams and organisations in general, termed organisational metacognition.

  • Educational psychology: Branch of psychology concerned with the scientific study of human learning.
  • Educational technology: Use of technology in education to improve learning and teaching.
  • Epistemology: Branch of philosophy concerning knowledge.
  • Goal orientation.
  • Introspection: Examining one’s own thoughts and feelings.
  • Learning styles: Largely debunked theories that aim to account for differences in individuals’ learning.
  • Meta-emotion.
  • Metaknowledge.
  • Metaphilosophy: Philosophy of philosophy.
  • Münchhausen trilemma: A thought experiment used to demonstrate the impossibility of proving any truth.
  • Metatheory: Theory whose subject matter is itself a theory.
  • Mentalisation.
  • Mindstream: Buddhist concept of continuity of mind.
  • Mirror test: Animal self-awareness test to determine self-recognition in a mirror.
  • Phenomenology (philosophy): Philosophical method and schools of philosophy.
  • Phenomenology (psychology): Psychological study of subjective experience.
  • Psychological effects of Internet use.
  • Second-order cybernetics: Recursive application of cybernetics to itself and the reflexive practice of cybernetics according to this critique.

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What is the Hearing Voices Network?


Hearing Voices Networks, closely related to the Hearing Voices Movement, are peer-focused national organisations for people who hear voices (commonly referred in western culture as auditory hallucinations) and supporting family members, activists and mental health practitioners. Members may or may not have a psychiatric diagnosis.

Networks promote an alternative approach, where voices are not necessarily seen as signs of mental illness. Networks regard hearing voices as a meaningful and understandable, although unusual, human variation. In themselves voices are not seen as the problem. Rather it is the relationship the person has with their voices that is regarded as the main issue.


Twenty-nine national Hearing Voices Networks have been established worldwide. There are also regional networks in Australia (Western Australia, Victoria, Tasmania and southwest Australia), Quebec, UK (Greater London, southwest England) and the United States. The National and Regional Networks are affiliated to the international umbrella organisation known as INTERVOICE (The International Network for Training Education and Research into Hearing Voices) and often referred to as the Hearing Voices Movement. Within these international networks, the combined experience of voice-hearers and professionals have overseen the development of ways of working with people who hear voices that draw on the value of peer support and which help people to live peacefully and positively with their experiences.


The principal roles of Hearing Voices Networks are as follows:

  • To support and develop local Hearing Voices Support Groups.
  • Raise awareness of the hearing voices approach.
  • To campaign for human rights and social justice for people who hear voices.
  • To provide information, advice and support to people who hear voices, their family, friends.
  • To provide training and education for mental health services and practitioners.

Description and Philosophy

The first hearing voices network was founded in the Netherlands in 1987 by the Dutch psychiatrist Marius Romme, the science journalist, Sandra Escher and voice hearer, Patsy Hage. This was followed by the founding of the UK network in 1988 based in Manchester, England. Subsequently Networks have been established in 29 countries over the world, including Australia (2005), Austria, Belgium, Bosnia, Canada, Denmark (2005), England (1988), Finland (1996), France (2011), Hungary (2013), Germany (1998), Greece, Ireland (2005), Italy, Japan, Kenya, Palestine, Malaysia, New Zealand (2007), Netherlands (1987), Norway, Northern Ireland, Scotland, Sweden, Switzerland, Tanzania, Uganda, USA (2010) and Wales (2001). The first 15 years of the development of the global networks is outlined by Adam James in his book Raising Our Voices (2001).

These networks provide support to voice hearers specifically through the establishment of local hearing voices support groups, where people who hear voices are afforded the opportunity in a non-medical setting to share their experiences, coping mechanisms and explanatory frameworks. These groups are run in different ways and some are exclusive to individuals who hear voices, whilst others are supported by mental health workers.

National networks have developed considerably over the years and host websites, publish newsletters, guides to the voice hearing experience and workbooks where individuals can record and explore their own experiences with voice hearing.

Dutch psychiatrist Marius Romme, the co-author of Accepting Voices, has provided an intellectual basis for these group. He advocates a view that the hearing of voices is not necessarily an indication of mental illness, and that patients should be encouraged to explore their voices and negotiate with them.

Hearing Voices Groups

The development of peer support groups for voice-hearers, known as “hearing voices groups” (HVGs), are an essential part of the work of Hearing Voices Networks throughout the world. For instance there are over 180 groups in England, 60 in Australia and growing numbers of groups in the USA. The groups are based in a range of settings including community centres, libraries, pubs, churches, child and adolescent mental health services, prisons and inpatient units.

Hearing Voices Groups are based on an ethos of self-help, mutual respect and empathy. They provide a safe space for people to share their experiences and support one another. They are peer support groups, involving social support and belonging, not therapy or treatment. Hearing Voices Groups are intended to help people to understand and come to terms with their voices and begin to recover their lives.

Members are encouraged to talk about their experiences, to learn what the voices mean for them and how to gain control over their experiences. In voices groups, people are enabled to choose the way they want to manage their experiences. Voices groups assist people to access information and resources so they can make their own choices. Furthermore, voices groups allow people to explore the relationship between their life history and their experience of hearing voices, should they want to do so.

Studies have found that after attending hearing voices groups, members’ hospital bed use decreased. There was also a trend for less formal admissions. People used far more coping strategies and were able to talk to far more people about their voices after attending groups. Learning coping strategies was something people valued about groups and one of the common topics was to explore and experiment with different coping strategies. After attending groups, self-esteem increased. User empowerment also increased. Feeling more empowered is one of the aims of groups particularly valued by voice hearers and may be associated, not only with the voices themselves, but also with other aspects of recovery and getting better. People’s relationships with the voices were mostly improved. They heard the voices less frequently. The voices were perceived as less powerful (omnipotent) relative to them. People felt much better able to cope with their voices, and there were trends towards people feeling less controlled by their voices and feeling less alone. Perhaps most importantly, evaluations show that people improved in relation to what they had identified as their own goals for the group.

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What is Introjection?


In psychology, introjection is the unconscious adoption of the thoughts or personality traits of others.

It occurs as a normal part of development, such as a child taking on parental values and attitudes. It can also be a defence mechanism in situations that arouse anxiety.

The tendency is also known as identification or internalisation. It has been associated with both normal and pathological development.


Introjection is a concept rooted in the psychoanalytic theories of unconscious motivations. Unconscious motivation refers to processes in the mind which occur automatically and bypass conscious examination and considerations.

Introjection is the learning process or in some cases a defence mechanism where a person unconsciously absorbs experiences and makes them part their psyche.

Introjection in Learning

In psychoanalysis, introjection (German: Introjektion) refers to an unconscious process wherein one takes components of another person’s identity, such as feelings, experiences and cognitive functioning, and transfers them inside themselves, making such experiences part of their new psychic structure. These components are obliterated from consciousness (splitting), perceived in someone else (projection), and then experienced and performed (i.e. introjected) by that other person. Cognate concepts are identification, incorporation and internalisation.

Introjection as a Defence Mechanism

It is considered a self-stabilising defence mechanism used when there is a lack of full psychological contact between a child and the adults providing that child’s psychological needs. Here, it provides the illusion of maintaining relationship but at the expense of a loss of self. To use a simple example, a person who picks up traits from their friends is introjecting.

Projection has been described as an early phase of introjection.

Historic Precursors

Freud and Klein

In Freudian terms, introjection is the aspect of the ego’s system of relational mechanisms which handles checks and balances from a perspective external to what one normally considers ‘oneself’, infolding these inputs into the internal world of the self-definitions, where they can be weighed and balanced against one’s various senses of externality. For example:

  • “When a child envelops representational images of his absent parents into himself, simultaneously fusing them with his own personality.”
  • “Individuals with weak ego boundaries are more prone to use introjection as a defense mechanism.”

According to D.W. Winnicott, “projection and introjection mechanisms… let the other person be the manager sometimes, and to hand over omnipotence.”

According to Freud, the ego and the superego are constructed by introjecting external behavioural patterns into the subject’s own person. Specifically, he maintained that the critical agency or the super ego could be accounted for in terms of introjection and that the superego derives from the parents or other figures of authority. The derived behavioural patterns are not necessarily reproductions as they actually are but incorporated or introjected versions of them.

Torok and Ferenczi

However, the aforementioned description of introjection has been challenged by Maria Torok as she favours using the term as it is employed by Sándor Ferenczi in his essay “The Meaning of Introjection” (1912). In this context, introjection is an extension of autoerotic interests that broadens the ego by a lifting of repression so that it includes external objects in its make-up. Torok defends this meaning in her 1968 essay “The Illness of Mourning and the Fantasy of the Exquisite Corpse”, where she argues that Sigmund Freud and Melanie Klein confuse introjection with incorporation and that Ferenczi’s definition remains crucial to analysis. She emphasized that in failed mourning “the impotence of the process of introjection (gradual, slow, laborious, mediated, effective)” means that “incorporation is the only choice: fantasmatic, unmediated, instantaneous, magical, sometimes hallucinatory…’crypt’ effects (of incorporation)”.

Fritz and Peris

In Gestalt therapy, the concept of “introjection” is not identical with the psychoanalytical concept. Central to Fritz and Laura Perls’ modifications was the concept of “dental or oral aggression”, when the infant develops teeth and is able to chew. They set “introjection” against “assimilation”. In Ego, Hunger and Aggression, Fritz and Laura Perls suggested that when the infant develops teeth, he or she has the capacity to chew, to break apart food, and assimilate it, in contrast to swallowing before; and by analogy to experience, to taste, accept, reject or assimilate. Laura Perls explains: “I think Freud said that development takes place through introjection, but if it remains introjection and goes no further, then it becomes a block; it becomes identification. Introjection is to a great extent unawares.”

Thus Fritz and Laura Perls made “assimilation”, as opposed to “introjection”, a focal theme in Gestalt therapy and in their work, and the prime means by which growth occurs in therapy. In contrast to the psychoanalytic stance, in which the “patient” introjects the (presumably more healthy) interpretations of the analyst, in Gestalt therapy the client must “taste” with awareness their experience, and either accept or reject it, but not introject or “swallow whole”. Hence, the emphasis is on avoiding interpretation, and instead encouraging discovery. This is the key point in the divergence of Gestalt therapy from traditional psychoanalysis: growth occurs through gradual assimilation of experience in a natural way, rather than by accepting the interpretations of the analyst.

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What is Expressive Suppression?


Expressive suppression is the intentional reduction of facial expression of an emotion, and it is a component of emotion regulation.

Expressive suppression is a concept:

“based on individuals’ emotion knowledge, which includes knowledge about the causes of emotion, about their bodily sensations and expressive behavior, and about the possible means of modifying them”.

In other words, expressive suppression signifies the act of masking facial giveaways (refer to facial expression) in order to hide an underlying emotional state (refer to affect). In fact, simply suppressing the facial expressions that accompany certain emotions can affect “the individual’s experience of emotion”. According to a 1974 study conducted by Kopel and Arkowitz, repressing the facial expressions associated with pain actually decreased the experience of pain in participants. However, “there is little evidence that the suppression of spontaneous emotional expression leads to decrease in emotional experience and physiological arousal apart from the manipulation of the pain expressions”.

According to Gross and Levenson’s 1993 study in which subjects watched a disgusting film while suppressing or not suppressing their expressions, suppression produced increased blinking. However, suppression also produced a decreased heart rate in participants and self-reports did not reflect that suppression had an effect on disgust experience. While it is unclear from Gross and Levenson’s study whether suppression successfully diminishes the experience of emotions, it can be concluded that expressive suppression does not completely inhibit all facial movements and expressions (e.g. blinking of the eyes). Niedenthal argues that expressive suppression works to decrease the experience of positive emotions whereas it does not successfully decrease the experience of negative emotions. If the suppression of facial expressions does not diminish negative emotions that one experiences, why is it such a common practice?

It may be that expressive suppression serves more of a social purpose than it serves a purpose for the individual. In a study done by Kleck and colleagues in 1976, participants were told to suppress facial expressions of pain during the reception of electric shocks. Specifically, “in one study the subjects were induced to exaggerate or minimize their facial expressions in order to fool a supposed audience”.  This idea of covering up an internal experience in front of observers could be the true reason that expressive suppression is utilised in social situations. “In everyday life, suppression may serve to conform individuals’ outward appearance to emotional norms in a given situation, and to facilitate social interaction”.  In this way, hiding negative emotions may cause for more successful social relationships by preventing conflict, stifling the spread of negative emotions, and protecting an individual from negative judgments made by others.


Expressive suppression is a response-focused emotion regulation strategy. This strategy involves an individual voluntarily suppressing their outward emotional expressions. Expressive suppression has a direct relationship to our emotional experiences and is significant in communication studies. Individuals who suppress their emotions are seeking to control their actions and are seeking to maintain a positive social image. Expressive suppression involves reducing facial expression and controlling positive and negative feelings of emotion. This type of emotion regulation strategy can have negative emotional and psychological effects on individuals. Emotional suppression reduces expressive behaviour significantly. As many researchers have concluded, though emotional suppression decreases outward expressive emotions, it does not decrease our negative feelings and emotional arousal.

Different forms of emotion regulation affect our response trajectory of emotions. We target situations for regulation by the process of selecting the situations we are exposed to or by modifying the situation we are in. Emotion suppression relates to the behavioural component of emotion. Expressive suppression has physiological influences such as decreasing heart rate, increasing blood pressure, and increasing sympathetic activation.

Expressive suppression requires self-control. We use self-control when handling our emotion-based expressions in public. It is believed that the use of expressive suppression has a negative connection with a human’s well-being. Expressive suppression has been found to occur late, after the peripheral physiological response or emotion process is triggered. Künh et al. (2011) compare this strategy to vetoing actions. This type of emotion regulation strategy is considered a method which strongly resists various urges and voluntarily inhibits actions. Kühn et al. (2011) also posited the notion that expression suppression may be internally controlled and that emotional responses are targeted by suppression efforts.

One of the characteristics of expressive suppression, a response-based strategy, is that it occurs after an activated response. Larsen et al. (2013) claim expressive suppression to be one of the less effective emotion regulation strategies. These researchers label expressive suppression as an inhibition to the behavioural display of emotion.

Externalisers vs. Internalisers

Regarding emotion regulation, specifically expressive suppression, there are two groups that can be characterised by their different response patterns. These two groups are labelled externalisers and internalisers. Internalisers generally “show more skin conductance deflections and greater heart rate acceleration than do externalizers” when attempting to suppress facial expressions during a potentially emotional event.  This signifies that internalisers are able to successfully employ expressive suppression while experiencing physiological arousal. However, when asked to describe their feelings, internalisers do not usually speak about themselves or specific feelings, which could be a sign of alexithymia. Alexithymia is defined as the inability to verbally explain an emotional experience or a feeling. Peter Sifneos first used this word in the realm of psychiatry in 1972 and it literally means “having no words for emotions”. Those who are able to consistently suppress their facial expressions (e.g. internalisers) may be experiencing symptoms of alexithymia. On the other hand, externalisers employ less expressive suppression in response to emotional experiences or other external stimuli and do not usually struggle with alexithymia.

Gender Differences

Men and women do not equally utilise expressive suppression. Typically, men show less facial expression and employ more expressive suppression than do women. This behaviour difference rooted in gender difference can be traced back to social norms that are taught to children at a young age. Young boys are implicitly taught that “big boys don’t cry,” which is a lesson that encourages the suppression of emotional behaviour in masculine individuals. This suppression is a result of “the punishment and consequent conditioned inhibition of all expression of a given emotion”.  If a masculine individual expresses an emotion that is undesirable and society responds by punishing that behaviour, that masculine individual will learn to suppress the socially unacceptable behaviour. On the other hand, feminine individuals do not experience the same societal pressure to the same extent to suppress their emotional expressions. Because feminine individuals are not as pressured to keep their emotions concealed, most do not feel the need to suppress them. However, there are exceptions.

Vs. Display Rules

Complete expressive suppression means that no facial expressions are visible to exemplify a given emotion. However, display rules are examples of a controlled form of expression management and “involve the learned manipulation of facial expression to agree with cultural conventions and interpersonal expectations in the pursuit of tactical and/or strategic social ends”  The utilisation of display rules differs from expressive suppression because when display rules are enacted, the action to manage expression is voluntary, controlled, and incorporates certain types of expressive behaviour. Conversely, expressive suppression is involuntary and is the result of social pressures that shape subconscious behaviours. It is not a controlled action nor does expressive suppression involve the manipulation of voluntary expressions, it is only manifested in the absence of expression. There are three ways in which facial expression displays may be influenced: modulation, qualification, and falsification. Modulation refers to the act of showing a different amount of expression than one feels. Qualification requires the addition of an extra (unfelt) emotional expression to the expression of a felt emotion. Lastly, falsification has three separate components. Falsification incorporates:

  • Expressing an unfelt emotion (simulation);
  • Expressing no emotion when an emotion is felt (neutralisation); or
  • Concealing a felt emotion by expressing an unfelt emotion (masking).

A Response-Focused Strategy

Expressive suppression is an emotion management strategy that works to decrease positive emotional experiences, however, it has not been proven to reduce the experience of negative emotions. This strategy is a response-focused form of emotion regulation, which “refers to things we do once an emotion is underway and response tendencies have already been generated”. Response-focused strategies are generally not as successful as antecedent-focused regulation strategies, which refers to “things we do, either consciously or automatically, before emotion-response tendencies have become fully activated”. Srivastava and colleagues performed a study in 2009 in which the effectiveness of students’ use of expressive suppression was analysed in the transition period between high school and college. This study concluded that “suppression is an antecedent of poor social functioning” in the domains of social support, closeness, and social satisfaction.

Psychological Consequences

Suppressing the expression of emotion is one of the most frequent emotion-regulation strategies utilized by human beings. Clinical traditions state that a person’s psychological health is based upon how affective impulses are regulated; the consequences of affective regulation have become, therefore, a main focus of psychological researchers. The psychological consequences directly related to expressive suppression are frequently disputed. Some early 20th-century researchers state that suppressing a physical emotional response while emotionally aroused will increase the emotional experience due to concentration on suppressing that emotion. These researchers argue that common sense tells us emotions become more severe the longer they are bottled up. Other researchers dispute this theory, saying that emotional expression is so significant to the overall emotional response that when suppression occurs, all other responses (e.g. physiological) are weakened. These researchers solidify this argument with the tradition that people are taught to count to ten when emotionally aroused in order to calm themselves down. If suppressing emotions were to increase the emotional experience, this counting exercise would only intensify a person’s reactions. However, it has been deemed to do the opposite. Unfortunately, few studies have been carried out to test these hypotheses. The idea that people have conflicting views on what is better – to bottle up emotions by counting to ten before acting/speaking or to release emotions as bottling them up is bad for your mental health – is of constant interest to researchers in the field of emotion. These differing views on such a commonplace human behaviour suggest that expressive suppression is one of the more complicated emotion-regulation techniques.

As a solution to these opposing ideas, it has been suggested (and mentioned in the Externalisers vs. Internalisers section above) that people have a tendency to be either emotionally expressive (externalisers) or inexpressive (internalisers). The habitual use of one expressive technique over the other leads to different psychological and physiological consequences over time. Expressive behaviour is directly related to emotional suppression as it is assumed that internalisers consciously choose not to express themselves. However, this assumption has gone primarily untested with the exception of a 1979 study by Notarius and Levenson, whose research found that internalisers are more physiologically reactive to emotional stimuli than externalisers. One explanation for these findings was that when a behavioural emotional response is suppressed it must be released in other ways, in this case physiological reactions. These findings lend themselves to the suggestion by Cannon (1927) and Jones (1935) that emotional suppression intensifies other reactions.

It has also been suggested that illness and disease is increased by continued emotional suppression, especially the suppression of intensely aggressive emotions such as anger and hostility which can lead to hypertension and coronary heart-disease. As well as physical illness, expressive suppression is said to be the cause of mental illnesses such as depression. Many psychotherapists will try to relieve their patients’ illness/strain by teaching them expressive techniques in a controlled environment or within the particular relationship in which their suppressed emotions are causing problems. A counter-argument to this idea suggests that expressive suppression is an important part of emotional regulation that needs to be learned due to its beneficial use in adulthood. Adults must learn to successfully suppress certain emotional responses (e.g. those to anger which could have destructive social consequences). However, then the question is whether or not to suppress all anger-related responses, or to release those less volatile in order to reduce the risk of contracting physical and mental illnesses. The Clinical Theory implies that there is an optimum level between total suppression and total expression which, during adulthood, a person must find in order to protect their physical and psychological being.

While expressive suppression may be socially acceptable in certain situations, it cannot be considered a healthy practice at all times. Concealing and suppressing expressions can cause stress-related physiological reactions. Stress occurs because “the social disapproval and punishment of overt emotional expression that causes suppression is itself intimidating and stressful”.  There are several occupations which require the suppression of positive or negative emotions, such as estate agents masking their happiness when an offer is placed on a house to maintain their professionalism, or elementary-school teachers suppressing their anger so as to not upset their young students when teaching them right from wrong. Only in recent studies have researchers begun looking into the effects that continual suppression of emotion in the workplace has on people. Continual suppression causes strain on those utilising it, especially on those who may be natural externalisers. Strain elicited by such suppression can cause an elevated heart-rate, increased anxiety, low commitment and other effects which can be detrimental to an employee. The common conception is that expressive suppression in the workplace is beneficial for the organization and dangerous for the employee over long periods of time.[citation needed] However, in a 2005 study, Cote found that factors contributing to the social dynamics of emotions determine when emotion regulation increases, decreases, or does not affect strain at all. The suppression of unpleasant emotions such as anger contribute to increasing high levels of strain

Link with Depression

Expressive suppression, as an emotion regulation strategy, serves different purposes such as supporting goal pursuits and satisfying hedonic needs. Though expressive suppression is considered a weak influence on the experience of emotion, it has other functions. Expressive suppression is a goal-oriented strategy which is guided by people’s beliefs and potentially by abstract theories about emotion regulation. In a 2012 study by Larsen and colleagues, the researchers looked at the positive association between expressive suppression and depressive symptoms among adults and adolescents which are influenced by parental support and peer victimisation. They found a reciprocal relationship between parental support and depressive symptoms. The same was not true for the relationship between peer victimisation and depressive symptoms. Depressive symptoms followed decreased perception of parental support one year later. They found that initial suppression occurred after increases in depressive symptoms one year later, yet depression did not occur after suppression.

However, in a continuation of their original study, Larsen and colleagues found that this relationship between suppression and depression was reversed. Depressive symptoms occurred after the use of suppression, and suppression did not occur after future depressive symptoms. The authors of this study support that expressive suppression has physiological, social, and cognitive costs. Some evidence says that “depressed people judge their negative emotions as less socially acceptable” than non-depressed people. ”Appraising one’s emotions as unacceptable mediates the relationship between negative emotion intensity and use of suppression”.

Negative Social Consequences

As an appropriate level of expressive suppression is important for physiological and psychological health, it is equally as important for the maintenance of social situations. However, excessive use of expressive suppression can negatively affect social interactions. While expressive suppression may seem like an easier way of coping with emotions in society or of becoming more likable in a social environment, it actually alters behaviour in a way that is visible and undesirable to others. Because expressive suppression is an action that occurs in social interactions, it is reasonable that this emotion regulation strategy would have social implications. Specifically, suppression involves three social costs. The act of suppressing facial expressions prohibits others in the social world from gaining information about a suppressor’s emotional state. This can prevent a suppressor from receiving social emotional benefits such as sympathy or sharing in collective positive and negative emotions that “facilitate social bonding”.  Secondly, expressive suppression is not always fully successful. If a suppressor accidentally shows signs of concealed feelings, others may perceive that the suppressor is covering up true emotions and may assume that the suppressor is insincere and uninterested in forming legitimate social relationships. Lastly, expressive suppression is hard work and therefore requires more cognitive processing than freely communicating emotions. If a suppressor is unable to devote full attention to social interactions because he/she is using cognitive power to suppress, the suppressor will not be able to remain engaged nor put in the work to maintain relationships.

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What is Olmstead v .L.C. (1999)?


Olmstead v. L.C., 527 U.S. 581 (1999), is a United States Supreme Court case regarding discrimination against people with mental disabilities.

The Supreme Court held that under the Americans with Disabilities Act, individuals with mental disabilities have the right to live in the community rather than in institutions if, in the words of the opinion of the Court, “the State’s treatment professionals have determined that community placement is appropriate, the transfer from institutional care to a less restrictive setting is not opposed by the affected individual, and the placement can be reasonably accommodated, taking into account the resources available to the State and the needs of others with mental disabilities.”

The case was brought by the Atlanta Legal Aid Society, Inc.


Tommy Olmstead, Commissioner, Georgia Department of Human Resources, et al. v. L. C., by Zimring, guardian ad litem and next friend, et al. (Olmstead v. L.C.) was a case filed in 1995 and decided in 1999 before the United States Supreme Court. The plaintiffs, L.C. (Lois Curtis) and E.W. (Elaine Wilson, deceased 04 December 2005), two women were diagnosed with schizophrenia, intellectual disability and personality disorder. They had both been treated in institutional settings and in community based treatments in the state of Georgia.

  • Guardian ad litem: A legal guardian is a person who has been appointed by a court or otherwise has the legal authority to care for the personal and property interests of another person, called a ward.
  • Next Friend: In common law, a next friend is a person who represents another person who is underage, or, because of disability or otherwise, is unable to maintain a suit on his or her own behalf and who does not have a legal guardian. Also known as litigation friends.

Following clinical assessments by state employees, both plaintiffs were determined to be better suited for treatment in a community-based setting rather than in the institution. The plaintiffs remained confined in the institution, each for several years after the initial treatment was concluded. Both sued the state of Georgia to prevent them from being inappropriately treated and housed in the institutional setting.

Opinion of the Court

The case rose to the level of the United States Supreme Court, which decided the case in 1999, and plays a major role in determining that mental illness is a form of disability and therefore covered under the Americans with Disabilities Act (ADA). Title II of the ADA applies to ‘public entities’ and include ‘state and local governments’ and ‘any department, agency or special purpose district’ and protects any ‘qualified person with a disability’ from exclusion from participation in or denied the benefits of services, programs, or activities of a public entity.

The Supreme Court decided mental illness is a form of disability and that “unjustified isolation” of a person with a disability is a form of discrimination under Title II of the ADA. The Supreme Court held that community placement is only required and appropriate (i.e. institutionalisation is unjustified), when:

  • The State’s treatment professionals have determined that community placement is appropriate;
  • The transfer from institutional care to a less restrictive setting is not opposed by the affected individual; and
  • The placement can be reasonably accommodated, taking into account the resources available to the State and the needs of others with mental disabilities.

Unjustified isolation is discrimination based on disability. Olmstead v. L.C., 527 U.S. 581, 587 (1999).

The Supreme Court explained that this holding “reflects two evident judgments.”

  • First, “institutional placement of persons who can handle and benefit from community settings perpetuates unwarranted assumptions that persons so isolated are incapable or unworthy of participating in community life.”
  • Second, historically “confinement in an institution severely diminishes the everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment.” Id. at 600-601.

However, a majority of Justices in Olmstead also recognized an ongoing role for publicly and privately operated institutions:

“We emphasize that nothing in the ADA or its implementing regulations condones termination of institutional settings for persons unable to handle or benefit from community settings…Nor is there any federal requirement that community-based treatment be imposed on patients who do not desire it.” Id. at 601-602.

A plurality of Justices noted: “[N]o placement outside the institution may ever be appropriate . . . ‘Some individuals, whether mentally retarded or mentally ill, are not prepared at particular times – perhaps in the short run, perhaps in the long run – for the risks and exposure of the less protective environment of community settings ’ for these persons, ‘institutional settings are needed and must remain available’” (quoting Amicus Curiae Brief for the American Psychiatric Association, et al). “As already observed [by the majority], the ADA is not reasonably read to impel States to phase out institutions, placing patients in need of close care at risk… ‘Each disabled person is entitled to treatment in the most integrated setting possible for that person—recognizing on a case-by-case basis, that setting may be an institution’[quoting VOR’s Amici Curiae brief].” Id. at 605.

Justice Kennedy noted in his concurring opinion, “It would be unreasonable, it would be a tragic event, then, were the Americans with Disabilities Act of 1990 (ADA) to be interpreted so that states had some incentive, for fear of litigation to drive those in need of medical care and treatment out of appropriate care and into settings with too little assistance and supervision.” Id. at 610.

The Supreme Court did not reach the question of whether there is a constitutional right to community services in the most integrated setting.

About ten years after the Olmstead decision, the State of Georgia and the United States Department of Justice entered a settlement agreement to cease all admissions of individuals with developmental disabilities to state-operated, federally licensed institutions (“State Hospitals”) and, by 01 July 2015, “transition all individuals with developmental disabilities in the State Hospitals from the Hospitals to community settings,” according to a Department of Justice Fact Sheet about the settlement. The settlement also calls for serving 9,000 individuals with mental illness in community settings. Recently, the federal court’s Independent Reviewer for the settlement found significant health and safety risks, including many deaths, plaguing former State Hospital residents due to their transition from a licensed facility home to community-settings per the settlement. The Court has approved a moratorium on such transfers until the safety of those impacted can be assured.

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