Over the last two centuries, western mental health science has focused on nosology whereby panels of experts identify hypothetical sets of signs and symptoms, label, and compile them into taxonomies such as the Diagnostic and Statistical Manual of Mental Disorders.
While this is one of the approaches that has historically driven progress in medicine, such taxonomies have long been controversial on grounds including bias, diagnostic reliability and potential conflicts of interest amongst their promoters. Over-reliance on taxonomy may have created a situation where its benefits are now outweighed by the fragmentation and constraints it has caused in the training of mental health practitioners, the range of treatments they can provide under insurance cover, and the scope of new research.
To date, no biological marker or individual cognitive process has been associated with a unique mental diagnosis but rather such markers and processes seem implicated across many diagnostic categories. For these reasons, researchers have recently begun to investigate mechanisms through which environmental factors such as poverty, discrimination, loneliness, aversive parenting, and childhood trauma or maltreatment might act as causes of many disorders and which therefore might point towards interventions that could help many people affected by them. Research suggests that transdiagnostic processes may underlie multiple aspects of cognition including attention, memory/imagery, thinking, reasoning, and behaviour.
Examples
Transdiagnostic Processes well-supported by Evidence
While an exhaustive, confirmed list of transdiagnostic processes does not yet exist, relatively strong evidence exists for processes including:
Selective attention to external stimuli.
Selective attention to internal stimuli.
Avoidance behaviour: distracting ourselves or deliberately not entering feared situations, thereby blocking the opportunity to disconfirm negative beliefs.
Safety behaviour: habitual behaviours we execute because we believe they will help us to avoid something we fear (for example, vomiting, dieting or excessive exercise to avoid weight gain).
Experiential avoidance.
Explicit selective memory.
Recurrent memory.
Interpretation reasoning: how we reach conclusions regarding the meaning of ambiguous or open-ended situations.
Expectancy reasoning: predicting likely future events and outcomes that may follow specific actions or situations.
Emotional reasoning.
Recurrent thinking.
Positive and negative metacognitive beliefs: beliefs we have about our own thinking processes.
Possible Additional Transdiagnostic Processes
Processes supported by growing evidence include:
Implicit selective memory.
Overgeneral memory.
Avoidant encoding and retrieval.
Attributions: inferring causes for the outcomes we perceive.
Detecting covariation: detecting events that tend to co-occur regularly and consistently.
Hypothesis testing and data gathering: evaluating if currently held explanations and beliefs seem accurate or need revision.
Recurrent negative thinking: worry and rumination that dwells on intrusive thoughts in an effort to work through or resolve them.
Thought suppression: deliberately trying to block or remove specific intrusive mental images or urges from entering consciousness, which may have the paradoxical effect of sustaining the thought.
Implications
Transdiagnostic processes suggest interventions to help people suffering from mental disorders. For example, helping someone to view thoughts as mental events in a wider context of awareness, rather than as expressions of external reality, may enable someone to step back from those thoughts and to see them as ideas to be tested rather than unchangeable facts. If research can identity a relatively limited number of transdiagnostic processes, people facing a wide range of mental difficulties might be helped by practitioners trained to master a relatively limited number of techniques corresponding to those underlying processes, rather than requiring many specialists who are each expert in treating a single specific disorder.
Transdiagnostic processes also suggest mechanisms through which delusions and cognitive biases may be understood. For example, the process of detecting covariation can lead to illusory correlations between unrelated stimuli, and the process of hypothesis testing and data gathering is generally subject to confirmation bias, meaning existing beliefs are not updated in the light of conflicting new information.
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The method of levels (MOL) is a cognitive approach to psychotherapy (or an approach to cognitive behavioural therapy) based on perceptual control theory (PCT). Using MOL, the therapist aims to help the patient shift their awareness to higher levels of perception in order to resolve conflicts and allow reorganisation to take place.
Brief History
The Method of Levels is an application of perceptual control theory, with theoretical roots primarily in cybernetics and engineering. The Method of Levels was first developed by William Treval Powers for his 1973 book, Behavior: The Control of Perception. However, the editor persuaded Powers to remove the chapter discussing the Method of Levels from the book prior to publication. However, Powers shared the technique verbally, particularly within the Control Systems Group.
In the 1990s, David Goldstein of New Jersey, United States, began using the Method of Levels in clinical practice with patients. Later in the 1990s, Timothy A. Carey, an Australian psychologist, became interested in the Method of Levels. Carey obtained a doctorate in clinical psychology primarily so that he could test the Method of Levels.
Theory
PCT contributes a useful perspective on psychological disorders by providing a model of satisfactory psychological functioning as successful control. Dysfunction then is understood as disruption of successful control, and distress as the experience that results from a person’s inability to control important experiences. No attempt is made to treat the symptoms of distress as though they were in themselves the problem. The PCT perspective is that restoring the ability to control eliminates the source of distress. Internal conflict has the effect of denying control to both systems that are in conflict with each other. Conflict is usually transitory. When conflict becomes chronic, then symptoms of psychological disorder may appear.
Method
The core process is to redirect attention to the higher level control systems by recognizing “background thoughts”, bringing them into the foreground, and then being alert for more background thoughts while the new foreground thoughts are explored. When the level-climbing process reaches an end state without encountering any conflicts, the need for therapy may have ended. When, however, this “up-a-level” process bogs down, a conflict has probably surfaced, and the exploration can be turned to finding the systems responsible for generating the conflict—and away from a preoccupation with the symptoms and efforts immediately associated with the conflict.
Research
A randomised controlled trial in subjects with first-episode psychosis demonstrated that the retention in the trial at final follow-up was 97%, suggesting a successful feasibility outcome. The feedback provided by participants delivered initial evidence of the intervention for this population. The approach may also be effective in the treatment of sleep disorders and suicidality.
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Coherence therapy is a system of psychotherapy based in the theory that symptoms of mood, thought and behaviour are produced coherently according to the person’s current mental models of reality, most of which are implicit and unconscious. It was founded by Bruce Ecker and Laurel Hulley in the 1990s. It has been considered among the most well respected postmodern/constructivist therapies.
General Description
The basis of coherence therapy is the principle of symptom coherence. This is the view that any response of the brain–mind–body system is an expression of coherent personal constructs (or schemas), which are nonverbal, emotional, perceptual and somatic knowings, not verbal-cognitive propositions. A therapy client’s presenting symptoms are understood as an activation and enactment of specific constructs. The principle of symptom coherence can be found in varying degrees, explicitly or implicitly, in the writings of a number of historical psychotherapy theorists, including Sigmund Freud (1923), Harry Stack Sullivan (1948), Carl Jung (1964), R.D. Laing (1967), Gregory Bateson (1972), Virginia Satir (1972), Paul Watzlawick (1974), Eugene Gendlin (1982), Vittorio Guidano & Giovanni Liotti (1983), Les Greenberg (1993), Bessel van der Kolk (1994), Robert Kegan & Lisa Lahey (2001), Sue Johnson (2004), and others.
The principle of symptom coherence maintains that an individual’s seemingly irrational, out-of-control symptoms are actually sensible, cogent, orderly expressions of the person’s existing constructions of self and world, rather than a disorder or pathology. Even a person’s psychological resistance to change is seen as a result of the coherence of the person’s mental constructions. Thus, coherence therapy, like some other postmodern therapies, approaches a person’s resistance to change as an ally in psychotherapy and not an enemy.
Coherence therapy is considered a type of psychological constructivism. It differs from some other forms of constructivism in that the principle of symptom coherence is fully explicit and rigorously operationalised, guiding and informing the entire methodology. The process of coherence therapy is experiential rather than analytic, and in this regard is similar to Gestalt therapy, Focusing or Hakomi. The aim is for the client to come into direct, emotional experience of the unconscious personal constructs (akin to complexes or ego-states) which produce an unwanted symptom and to undergo a natural process of revising or dissolving these constructs, thereby eliminating the symptom. Practitioners claim that the entire process often requires a dozen sessions or less, although it can take longer when the meanings and emotions underlying the symptom are particularly complex or intense.
Symptom Coherence
Symptom coherence is defined by Ecker and Hulley as follows:
A person produces a particular symptom because, despite the suffering it entails, the symptom is compellingly necessary to have, according to at least one unconscious, nonverbal, emotionally potent schema or construction of reality.
Each symptom-requiring construction is cogent—a sensible, meaningful, well-knit, well-defined schema that was formed adaptively in response to earlier experiences and is still carried and applied in the present.
The person ceases producing the symptom as soon as there no longer exists any construction of reality in which the symptom is necessary to have.
There are several forms of symptom coherence. Some symptoms are necessary because they serve a crucial function (such as depression that protects against feeling and expressing anger), while others have no function but are necessary in the sense of being an inevitable effect, or by-product, caused by some other adaptive, coherent but unconscious response (such as depression resulting from isolation, which itself is a strategy for feeling safe). Both functional and functionless symptoms are coherent, according to the client’s own material.
In other words, the theory states that symptoms are produced by how the individual strives, without conscious awareness, to carry out self-protecting or self-affirming purposes formed in the course of living. This model of symptom production fits into the broader category of psychological constructivism, which views the person as having profound, if unrecognized, agency in shaping experience and behaviour.
Symptom coherence does not apply to those symptoms that are not directly or indirectly caused by implicit schemas or emotional learnings—for example, hypothyroidism-induced depression, autism, and biochemical addiction.
Hierarchical Organisation of Constructs
As a tool for identifying all of a person’s relevant schemas or constructions of reality, Ecker and Hulley defined several logically hierarchical domains or orders of construction (inspired by Gregory Bateson):
The first order consists of a person’s overt responses: thoughts, feelings, and behaviours.
The second order consists of the person’s specific meaning of the concrete situation to which they are responding.
The third order consists of the person’s broad purposes and strategies for construing that specific meaning (teleology).
The fourth order consists of the person’s general meaning of the nature of self, others, and the world (ontology and primal world beliefs).
The fifth order consists of the person’s broad purposes and strategies for construing that general meaning.
Higher orders (beyond the fifth order) are rarely involved in psychotherapy.
A person’s first-order symptoms of thought, mood, or behaviour follow from a second-order construal of the situation, and that second-order construal is powerfully influenced by the person’s third- and fourth-order constructions. Hence the third and higher orders constitute what Ecker and Hulley call “the emotional truth of the symptom”, which are the meanings and purposes that are intended to be discovered, integrated, and transformed in therapy.
Brief History
Coherence therapy was developed in the late 1980s and early 1990s as Ecker and Hulley investigated why certain psychotherapy sessions seemed to produce deep transformations of emotional meaning and immediate symptom cessation, while most sessions did not. Studying many such transformative sessions for several years, they concluded that in these sessions, the therapist had desisted from doing anything to oppose or counteract the symptom, and the client had a powerful, felt experience of some previously unrecognised “emotional truth” that was making the symptom necessary to have.
Ecker and Hulley began developing experiential methods to intentionally facilitate this process. They found that a majority of their clients could begin having experiences of the underlying coherence of their symptoms from the first session. In addition to creating a methodology for swift retrieval of the emotional schemas driving symptom production, they also identified the process by which retrieved schemas then undergo profound change or dissolution: the retrieved emotional schema must be activated while concurrently the individual vividly experiences something that sharply contradicts it. Neuroscientists subsequently determined that these same steps are precisely what unlocks and deletes the neural circuit in implicit memory that stores an emotional learning—the process of reconsolidation.
Due to the swiftness of change that Ecker and Hulley began experiencing with many of their clients, they initially named this new system depth-oriented brief therapy (DOBT).
In 2005, Ecker and Hulley began calling the system coherence therapy in order for the name to more clearly reflect the central principle of the approach, and also because many therapists had come to associate the phrase “brief therapy” with depth-avoidant methods that they regard as superficial.
Evidence from Neuroscience
In a series of three articles published in the Journal of Constructivist Psychology from 2007 to 2009, Bruce Ecker and Brian Toomey presented evidence that coherence therapy may be one of the systems of psychotherapy which, according to current neuroscience, makes fullest use of the brain’s built-in capacities for change.
Ecker and Toomey argued that the mechanism of change in coherence therapy correlates with the recently discovered neural process of “memory reconsolidation”, a process that can “unwire” and delete longstanding emotional conditioning held in implicit memory. The assertions that coherence therapy achieves implicit memory deletion align with the growing body of evidence supporting memory reconsolidation. Ecker and colleagues claim that:
(a) their procedural steps match those identified by neuroscientists for reconsolidation;
(b) their procedural steps result in effortless cessation of symptoms; and
(c) the emotional experience of the retrieved, symptom-generating emotional schemas can no longer be evoked by cues that formerly evoked it strongly.
The process of removing the neural basis of the symptom in coherence therapy (and in similar postmodern therapies) is different from the counteractive strategy of some behavioural therapies. In such behavioural therapies, new preferred behavioural patterns are typically practiced to compete against and hopefully override the unwanted ones; this counteractive process, like the “extinction” of conditioned responses in animals, is known to be inherently unstable and prone to relapse, because the neural circuit of the unwanted pattern continues to exist even when the unwanted pattern is in abeyance. Through reconsolidation, the unwanted neural circuits are “unwired” and cannot relapse.
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The role is broadly similar to the role of the approved social worker but is distinguished in no longer being the exclusive preserve of social workers. It can be undertaken by other professionals including registered mental health or learning disability nurses, occupational therapists and chartered psychologists after completing appropriate post-qualifying masters level training at level 7 NQF and being approved by a local authority for a period of up to five years, subject to re-warranting. An AMHP is approved to carry out functions under the Mental Health Act 1983, and as such, they carry with them a warrant card, like police officers. The role of the AMHP is to coordinate the assessment of individuals who are being considered for detention under the Mental Health Act 1983. The reason why some specialist mental health professionals are eligible to undertake this role is broadly to avoid excessive medicalisation of the assessment and treatment for individuals living with a mental disorder, as defined by section 1 of the Mental Health Act 1983. It is the role of the AMHP to decide, founded on the medical recommendations of doctors (or a doctor for the purpose of section 4 of the Act), whether a person should be detained under the Mental Health Act 1983.
Professional Role
Approved mental health professionals (AMHPs) are trained to implement elements of the Mental Health Act 1983, as amended by the Mental Health Act 2007, in conjunction with medical practitioners. They have received specific training at least at Level 7 on the National Qualifications Framework, such as a MSc Mental Health (AHMP) or PGDip in Mental Health Studies relating to the application the Mental Health Acts, usually lasting one or two years and perform the role in assessing and deciding whether there are grounds to detain mentally disordered people who meet the statutory criteria. The AMHP is also an important healthcare professional when making decisions under guardianship or community treatment orders.
Assessment and detention under the Act is colloquially known as being ‘sectioned’, or ‘sectioning’, in reference to the application of sections of the Mental Health Act relevant to this process. The role to apply for the ‘section’ remains with the AMHP, not the medical doctor, as many professionals and lay individuals think, thus a doctor may feel a section is needed, although it is actually the AMHP who is the individual who will decide if this is required after detailed assessment and consultations with the medical doctors.
Mental Health Act Assessments
AMHPs are responsible for organising, co-ordinating and contributing to Mental Health Act assessments. It is the AMHP’s duty, when two medical recommendations have been made, to decide whether or not to make an application to a named hospital for the detention of the person who has been assessed. To be detained under the Mental Health Act individuals need to have a mental disorder, the nature or degree of which warrants detention in hospital on the grounds of their health and/or the risk they present to themselves and/or the risk they present to others. The AMHP’s role includes arranging for the assessment of the person concerned by two medical practitioners who must be independent of each other and at least one of whom should be a specialist in mental health, called being ‘section 12 approved’ under section 12 of the Mental Health Act 1983. Preferably one of the medical assessors should have previous acquaintance with the person being assessed. Efforts should be made to seek less restrictive alternatives to detention if it is safe and appropriate to do so, such as using an individual’s own support networks, in line with the principle of care in the least restrictive environment. AMHP’s are expected to take account of factors such as gender, culture, ethnicity, age, sexuality and disability in their assessments. Efforts should be also made to overcome any communication barriers, such as deafness or the assessors and the assessed not sharing a language, and an interpreter may be required. It is not good practice for one of the assessors to act as interpreter.
The Nearest Relative
An important factor in assessments is the role of the Nearest Relative. Which person qualifies as the Nearest Relative is determined according to a hierarchy outlined in the Mental Health Act. If the individual is to be detained under Section 2 (assessment) of the Act, the AMHP is expected to make reasonable efforts to contact the Nearest Relative and invite their views. It is also the AMHP’s role to inform them of their right to discharge the person concerned in some circumstances. If the individual is to be detained under Section 3 (treatment) of the Act, the AMHP must ask the Nearest Relative if they object to the individual being detained and if they do then the detention cannot go ahead. There are occasions when the Nearest Relative need not be contacted or might need to be displaced by a court. A Nearest Relative can delegate their role to another appropriate person.
Detention in Hospital
The assessors are encouraged by the Code of Practice to discuss the assessment together once the two medical examinations and the AMHP’s interview have taken place. For Section 2 and Section 3, assessments by medical practitioners need to take place with no more than five clear days between each other. AMHPs then have up to fourteen days from the time of the second medical assessment to make the decision whether or not to make an application for detention. If proceeding with the application, AMHPs are then responsible for organising the detained individual’s safe conveyance to hospital. The best method of conveyance is that which ensures the individual’s dignity, comfort and safety. This might be by ambulance or by the police or by some other method. The AMHP will attend at the named hospital and will give the paperwork to nursing staff who check it and receive the application on behalf of the hospital managers. Some errors in the paperwork can be rectified later and the application remains valid. Some other errors invalidate the application and the detention is then no longer lawful.
Community Treatment Orders
The revised Mental Health Act makes provision for community treatment orders (CTOs). CTOs can be arranged for patients detained under Section 3 (treatment) of the Act, allowing them to return to a place of residence in the community, depending on particular specified conditions, such as to the taking of medication or participating in therapies. If conditions are breached, patients can be formally recalled to hospital for a period of up to 72 hours, during which a decision should be made as to whether their CTO should be revoked. If the CTO is revoked, patients return to being at the beginning of a Section 3 and are automatically referred for a mental health review tribunal. AMHPs work with the responsible clinician and others in the process of assessment and decision making in setting up CTOs and in making decisions on revocation.
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Transactional analysis is a psychoanalytic theory and method of therapy wherein social interactions (or “transactions”) are analysed to determine the ego state of the communicator (whether parent-like, childlike, or adult-like) as a basis for understanding behaviour. In transactional analysis, the communicator is taught to alter the ego state as a way to solve emotional problems. The method deviates from Freudian psychoanalysis, which focuses on increasing awareness of the contents of subconsciously held ideas. Eric Berne developed the concept and paradigm of transactional analysis in the late 1950s (refer to reachback and afterburn).
Brief History
Eric Berne presented Transactional Analysis to the world as a phenomenological approach, supplementing Freud’s philosophical construct with observable data. His theory built on the science of Wilder Penfield and René Spitz along with the neo-psychoanalytic thought of people such as Paul Federn, Edoardo Weiss, and Erik Erikson. By moving to an interpersonal motivational theory, he placed it both in opposition to the psychoanalytic traditions of his day and within what would become the psychoanalytic traditions of the future. From Berne, transactional analysts have inherited a determination to create an accessible and user-friendly system, an understanding of script or life-plan, ego states, transactions, and a theory of groups.
Berne’s theory was based on the ideas of Freud but with distinct differences. Freudian psychotherapists focused on client personalities. Berne believed that insight could be better discovered by analysing a client’s social transactions. Berne mapped interpersonal relationships to three ego-states of the individuals involved: the Parent, Adult, and Child state. He then investigated communications between individuals based on the current state of each. He called these interpersonal interactions transactions and used the label games to refer to certain patterns of transactions which popped up repeatedly in everyday life in every human interaction.
The origins of transactional analysis can be traced to the first five of Berne’s six articles on intuition, which he began writing in 1949. Even at this early juncture and while still working to become a psychoanalyst, his writings challenged Freudian concepts of the unconscious.
In 1956, after 15 years of psychoanalytic training, Berne was refused admission to the San Francisco Psychoanalytic Institute as a fully-fledged psychoanalyst. He interpreted the request for several more years of training as a rejection and decided to walk away from psychoanalysis. Before the end of the year, he had written two seminal papers, both published in 1957.
In the first article, Intuition V: The Ego Image, Berne referenced P. Federn, E. Kahn, and H. Silberer, and indicated how he arrived at the concept of ego states, including his idea of separating “adult” from “child”.
The second paper, Ego States in Psychotherapy, was based on material presented earlier that year at the Psychiatric Clinic, Mt. Zion Hospital, San Francisco, and at the Langley Porter Neuropsychiatric Clinic, UCSF School of Medicine. In that second article, he developed the tripartite scheme used today (Parent, Adult, and Child), introduced the three-circle method of diagramming it, showed how to sketch contaminations, labelled the theory, “structural analysis”, and termed it “a new psychotherapeutic approach”.
A few months later, he wrote a third article, titled “Transactional Analysis: A New and Effective Method of Group Therapy”, which was presented by invitation at the 1957 Western Regional Meeting of the American Group Psychotherapy Association of Los Angeles. With the publication of this paper in the 1958 issue of the American Journal of Psychotherapy, Berne’s new method of diagnosis and treatment, transactional analysis, became a permanent part of the psychotherapeutic literature. In addition to restating his concepts of ego states and structural analysis, the 1958 paper added the important new features of transactional analysis proper (i.e. the analysis of transactions), games, and scripts.
His seminar group from the 1950s developed the term transactional analysis (TA) to describe therapies based on his work. By 1964, this expanded into the International Transactional Analysis Association. While still largely ignored by the psychoanalytic community, many therapists have put his ideas in practice.
In the early 1960s, he published both technical and popular accounts of his conclusions. His first full-length book on TA was published in 1961, titled Transactional Analysis in Psychotherapy. Structures and Dynamics of Organisations and Groups (1963) examined the same analysis in a broader context than one-on-one interaction.
Overview
TA (Transactional Analysis) is not only post-Freudian, but, according to its founder’s wishes, consciously extra-Freudian. That is to say that, while it has its roots in psychoanalysis, since Berne was a psychoanalytically-trained psychiatrist, it was designed as a dissenting branch of psychoanalysis in that it put its emphasis on transactional rather than “psycho-” analysis.
With its focus on transactions, TA shifted the attention from internal psychological dynamics to the dynamics contained in people’s interactions. Rather than believing that increasing awareness of the contents of unconsciously held ideas was the therapeutic path, TA concentrated on the content of people’s interactions with each other. Changing these interactions was TA’s path to solving emotional problems.
TA also differs from Freudian analysis in explaining that an individual’s final emotional state is the result of inner dialogue between different parts of the psyche, as opposed to the Freudian hypothesis that imagery is the overriding determinant of inner emotional state. (For example, depression may be due to ongoing critical verbal messages from the inner Parent to the inner Child.) Berne believed that it is relatively easy to identify these inner dialogues and that the ability to do so is parentally suppressed in early childhood.
In addition, Berne believed in making a commitment to “curing” his clients, rather than just understanding them. To that end he introduced one of the most important aspects of TA: the contract—an agreement entered into by both client and therapist to pursue specific changes that the client desires.
Revising Freud’s concept of the human psyche as composed of the id, ego, and super-ego, Berne postulated in addition three “ego states” – the Parent, Adult, and Child states—which were largely shaped through childhood experiences. These three are all part of Freud’s ego; none represent the id or the superego.
Unhealthy childhood experiences can lead to being pathologically fixated in the Child and Parent ego states, bringing discomfort to an individual and/or others in a variety of forms, including many types of mental illness.
Berne considered how individuals interact with one another, and how the ego states affect each set of transactions. Unproductive or counterproductive transactions were considered to be signs of ego state problems. Analysing these transactions according to the person’s individual developmental history would enable the person to “get better”. Berne thought that virtually everyone has something problematic about their ego states and that negative behaviour would not be addressed by “treating” only the problematic individual.
Berne identified a typology of common counterproductive social interactions, identifying these as “games”.
Berne presented his theories in two popular books on transactional analysis: Games People Play (1964) and What Do You Say After You Say Hello? (1975).
By the 1970s, because of TA’s non-technical and non-threatening jargon and model of the human psyche, many of its terms and concepts were adopted by eclectic therapists as part of their individual approaches to psychotherapy. It also served well as a therapy model for groups of patients, or marital/family counselees, where interpersonal (rather than intrapersonal) disturbances were the focus of treatment.
TA’s popularity in the US waned in the 1970s. The more dedicated TA purists banded together in 1964 with Berne to form a research and professional accrediting body, the International Transactional Analysis Association, or ITAA.
Fifty Years Later
Within the framework of transactional analysis, more recent transactional analysts have developed different and overlapping theories of transactional analysis: cognitive, behavioural, relational, redecision, integrative, constructivist, narrative, body-work, positive psychological, personality adaptational, self-reparenting, psychodynamic and neuroconstructivist.
Some transactional analysts highlight the many things they have in common with cognitive behavioural therapy: the use of contracts with clear goals, the attention to cognitive distortions (called “adult decontamination” or “child deconfusion”), the focus on the client’s conscious attitudes and behaviours and the use of “strokes”.
Cognitive-based transactional analysts use ego state identification to identify communication distortions and teach different functional options in the dynamics of communication. Some make additional contracts for more profound work involving life plans or scripts or with unconscious processes, including those which manifest in the client-therapist relationship as transference and countertransference, and define themselves as psychodynamic or relational transactional analysts. Some highlight the study and promotion of subjective well-being and optimal human functioning rather than pathology and so identify with positive psychology. Some are increasingly influenced by current research in attachment, mother-infant interaction and by the implications of interpersonal neurobiology and non-linear dynamic systems.
Outline
Transactional analysis integrates the theories of psychology and psychotherapy because it has elements of psychoanalytic, humanist and cognitive ideas.
According to the International Transactional Analysis Association, TA “is a theory of personality and a systematic psychotherapy for personal growth and personal change.”
As a theory of personality, TA describes how people are structured psychologically. It uses what is perhaps its best known model, the ego-state (Parent-Adult-Child) model, to do this. The same model helps explain how people function and express their personality in their behaviour.
As Berne set up his psychology, there are four life positions that a person can hold, and holding a particular psychological position has profound implications for how an individual operationalizes his or her life. The positions are stated as:
I’m OK and you are OK. This is the healthiest position about life and it means that I feel good about myself and that I feel good about others and their competence.
I’m OK and you are not OK. In this position I feel good about myself but I see others as damaged or less than me and this is usually not healthy.
I’m not OK and you are OK. In this position the person sees him/herself as the weak partner in relationships as the others in life are definitely better than the self. The person who holds this position will unconsciously accept abuse as OK.
I’m not OK and you are not OK. This is the worst position to be in as it means that I believe that I am in a terrible state and the rest of the world is as bad. Consequently, there is no hope for any ultimate supports.
It is a theory of communication that can be extended to the analysis of systems and organisations.
It offers a theory for child development by explaining how our adult patterns of life originated in childhood. This explanation is based on the idea of a “Life (or Childhood) Script”: the assumption that we continue to re-play childhood strategies, even when this results in pain or defeat. Thus it claims to offer a theory of psychopathology.
In practical application, it can be used in the diagnosis and treatment of many types of psychological disorders and provides a method of therapy for individuals, couples, families and groups.
Outside the therapeutic field, it has been used in education to help teachers remain in clear communication at an appropriate level, in counselling and consultancy, in management and communications training and by other bodies.
Philosophy
People are OK; thus each person has validity, importance, equality of respect.
Positive reinforcement increases feelings of being OK.
All people have a basic lovable core and a desire for positive growth.
Everyone (with only few exceptions, such as the severely brain-damaged) has the capacity to think.
All of the many facets of an individual have a positive value for them in some way.
People decide their story and destiny, therefore these decisions can be changed.
All emotional difficulties are curable.
Freedom from historical maladaptations embedded in the childhood script is required in order to become free of inappropriate, inauthentic and displaced emotions which are not a fair and honest reflection of here-and-now life (such as echoes of childhood suffering, pity-me and other mind games, compulsive behaviour and repetitive dysfunctional life patterns). The aim of change under TA is to move toward autonomy (freedom from childhood script), spontaneity, intimacy, problem solving as opposed to avoidance or passivity, cure as an ideal rather than merely making progress and learning new choices.
Ego-State or Parent–Adult–Child (PAC) Models
Many of the core TA models and concepts can be categorised into
Structural analysis – analysis of the individual psyche.
Transactional analysis proper – analysis of interpersonal transactions based on structural analysis of the individuals involved in the transaction.
Game analysis – repeating sequences of transactions that lead to a result subconsciously agreed to by the parties involved in the game.
Script analysis – a life plan that may involve long-term involvement in particular games in order to reach the life pay-off of the individual.
At any given time, a person experiences and manifests his or her personality through a mixture of behaviours, thoughts, and feelings. Typically, according to TA, there are three ego-states that people consistently use:
Parent (“exteropsyche”): a state in which people behave, feel, and think in response to an unconscious mimicking of how their parents (or other parental figures) acted, or how they interpreted their parent’s actions. For example, a person may shout at someone out of frustration because they learned from an influential figure in childhood the lesson that this seemed to be a way of relating that worked.
Adult (“neopsyche”): a state of the ego which is most like an artificially intelligent system processing information and making predictions about major emotions that could affect its operation. Learning to strengthen the Adult is a goal of TA. While people are in the Adult ego state, they are directed towards an objective appraisal of reality.
Child (“archaeopsyche”): a state in which people behave, feel, and think similarly to how they did in childhood. For example, a person who receives a poor evaluation at work may respond by looking at the floor and crying or pouting, as when scolded as a child. Conversely, a person who receives a good evaluation may respond with a broad smile and a joyful gesture of thanks. The Child is the source of emotions, creation, recreation, spontaneity, and intimacy.
Berne differentiated his Parent, Adult, and Child ego states from actual adults, parents, and children, by using capital letters when describing them. These ego states may or may not represent the relationships that they act out. For example, in the workplace, an adult supervisor may take on the Parent role, and scold an adult employee as though he were a Child. Or a child, using the Parent ego-state, could scold her actual parent as though the parent were a Child.
Within each of these ego states are subdivisions. Thus Parental figures are often either:
more nurturing (permission-giving, security-giving) or
more criticising (comparing to family traditions and ideals in generally negative ways);
Childhood behaviours are either
more natural (free) or
more adapted to others.
These subdivisions categorise individuals’ patterns of behaviour, feelings, and ways of thinking, which can be functional (beneficial or positive) or dysfunctional/counterproductive (negative).
Berne states that there are four types of diagnosis of ego states. They are: “behavioural” diagnosis, “social” diagnosis, “historical” diagnosis, and “phenomenological” diagnosis. A complete diagnosis would include all four types. It has subsequently been demonstrated that there is a fifth type of diagnosis, namely “contextual”, because the same behaviour will be diagnosed differently according to the context of the behaviour.
Ego states do not correspond directly to Sigmund Freud’s ego, superego, and id, although there are obvious parallels: Superego/Parent; Ego/Adult; Id/Child. Ego states are consistent for each person, and (argue TA practitioners) are more observable than the components of Freud’s model. In other words, the ego state from which someone is communicating is evident in their behaviour, manner and expression.
Emotional Blackmail
Emotional blackmail is a term coined by psychotherapist Dr. Susan Forward, about controlling people in relationships and the theory that fear, obligation, and guilt (FOG) are the transactional dynamics at play between the controller and the person being controlled. Understanding these dynamics are useful to anyone trying to extricate from the controlling behaviour of another person, and deal with their own compulsions to do things that are uncomfortable, undesirable, burdensome, or self-sacrificing for others.
Forward and Frazier identify four blackmail types each with their own mental manipulation style:
Type
Example
Punisher’s Threat
Eat the food I cooked for you or I will hurt you.
Self-Punisher’s Threat
Eat the food I cooked for you or I will hurt myself.
Sufferer’s THreat
Eat the food I cooked for you. I was saving it for myself. I wonder what will happen now.
Tantaliser’s Threat
Eat the food I cooked for you and you may get a really yummy desert.
There are different levels of demands – demands that are of little consequence, demands that involve important issues or personal integrity, demands that affect major life decisions, and/or demands that are dangerous or illegal.
Effectiveness
A 1995 research article by the staff of Consumer Reports, with Martin Seligman as consultant, assessed that psychotherapy conducted by a group of Transactional Analysts is more effective than that of groups of psychiatrists, psychologists, social workers, marriage counsellors, and physicians; and that psychotherapy lasting more than six months is 40% more effective than that lasting less than six months.
A 2010 review found 50 studies on transactional analysis that concluded it had a positive effect, and 10 where no positive effect was found. No studies that concluded a negative effect were found.
Criticism
The three major limitations of Berne’s work are:
Berne’s emphasis on structural explanation (rather than on those derived from an energy theory).
His failure to develop a script reversal technique which would satisfy his own criteria of conciseness and theoretical consistency.
An apparent dependence upon content analysis.
In Popular Culture
When Will Hunting from the movie Good Will Hunting is being choked by Sean Maguire, you can see the spine of the book I’m OK, You’re OK in the bookcase that Will is being pinned against.
Thomas Harris’s successful popular work from the late 1960s, I’m OK, You’re OK, is largely based on transactional analysis. A fundamental divergence, however, between Harris and Berne is that Berne postulates that everyone starts life in the “I’m OK” position, whereas Harris believes that life starts out “I’m not OK, you’re OK”.
New Age author James Redfield has acknowledged Harris and Berne as important influences in his best-seller The Celestine Prophecy (1993). The protagonists in the novel survive by striving (and succeeding) in escaping from “control dramas” that resemble the games of TA.
Singer/songwriter Warren Zevon mentions transactional analysis in his 1980 song “Gorilla, You’re a Desperado” from the album Bad Luck Streak in Dancing School.
Singer-songwriter Joe South’s 1968 song, “Games People Play”, was based directly on transactional-analytic concepts and Berne’s book of the same name.
TA makes an appearance in Antonio Campos’ 2016 biographical drama Christine, a film covering the events that led TV journalist Christine Chubbuck to die by suicide on TV. She is brought to a transactional analysis therapy session by a colleague, where they introduce her to the “Yes, But…” technique.
Singer John Denver references transactional analysis in his autobiography. His wife at the time, Annie Denver, was getting into the movement. John says he tried it but found it wanting.
Eric Berne’s Games People Play was featured prominently on an episode of Mad Men. The book was seen in Season 4, Episode 11, titled “Chinese Wall”. The approximate time period for this episode is September 1965. By late September 1965, Games People Play had been on the New York Times non-fiction bestseller list for nine weeks already.
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Reachback is a psychological term coined by Eric Berne. Reachback, in Berne’s lexicon, is the period of time during which an impending event begins to influence an individual’s behaviour, including their level of stress.
Berne’s Formulation
Berne, the founder of transactional analysis, coined the term in his book What Do You Say After You Say Hello?. He considered that reachback “is most dramatically seen in people with phobias whose whole functioning may be disturbed for days ahead at the prospect of getting into a feared situation, such as a medical examination or a journey.”
For instance, a person expecting to take a trip on Monday starts getting irritable and worried on Friday. He may start trying to clear his overflowing inbox, cut short his evening relaxation, start preparing and packing for the trip, worry about what clothes to take, and so on. However, “for people who have unusual difficulties with anticipatory stress, the reach-back of an event such as a major vacation trip or a wedding may be several weeks.”
Berne differentiates reachback from forward planning, which is done to mitigate negative effects such as reachback.
The flip side of reachback is afterburn, which is defined as the effect a past atypical event continues to have on a person’s schedule, activities and mental state even after it is materially over. Berne considered that “each person has a sort of standard ‘reachback time’ and ‘afterburn time’ for various kinds of situations […] domestic quarrels, examination or hearings, work deadlines, travel, visits from or to relatives, etc.”
Prevention
Following William Osler’s prescription for equable living day-by-day, Berne explained that “living day by day means living a well-planned and organized life, and sleeping well between each day, so that the day ends without reachback, since tomorrow is well planned, and begins without afterburn, since yesterday was well-organized”.
Defence Usage
Reachback is also used in the US Department of Defence as the process of obtaining products, services, applications, forces, equipment, or material from organisations that are not forward deployed.
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Afterburn is a psychological term coined by Eric Berne, who defined it as “the period of time before a past event is assimilated”.
Berne’s Formulation
Eric Berne, the founding father of transactional analysis, used the term “afterburn” to indicate the effect an atypical past event continues to exert on a person’s daily schedule, activities and mental state even after it is over: to “those occasions when it disturbs normal patterns for an appreciable period, rather than being assimilated into them or excluded from them by repression and other psychological mechanisms”.
For Berne, afterburn is the flip side of reachback, which is the effect that the event, thanks to the stress of anticipation, has on the person’s life before it. He considered that “in most cases one or the other can be tolerated without serious consequences. It can be dangerous for almost anyone, however, if the after-burn of the last event overlaps with the reach-back from the next … this is a good definition of overwork”.
Remedies
Berne considered that “dreaming is probably the normal mechanism for adjusting after-burn and reach-back”, but that sex and holidays were also useful remedies. “Most normal after-burns and reach-backs run their courses in about six days, so that a two-week vacation allows the superficial after-burns to burn out, after which there are a few days of carefree living. …For the assimilation of more chronic after-burns and deeper, repressed reach-backs, however, a vacation of at least six weeks is probably necessary.”
Other Views
In terms of exam stress management, “afterburn is the time needed after the exam to… set it to rest”, a period of “afterburn time… [with] a host of unexpressed feelings and incomplete tasks”.
“Referring to soldiers recently returned from Iraq, Sara Corbett described this type of delayed reaction as ‘psychological afterburn’… [quoting soldiers who spoke of it to the effect of:] ‘My body’s here, but my mind is there.'”
With respect to therapy, some consider that “you are not ending well when you find that you are thinking about the person’s problems after sessions. This is called afterburn”. Others however see opportunity in such occasions: “You’re sorting out your countertransference, you’re owning your projections, you’re separating out you from the family”—in short, one is usefully employing “those lagging emotions that afterburn following a session”.
Goffman
Erving Goffman has a related but rather different usage of the term “to refer to a sotto voce comment, one meant not to be a ratified part of an encounter, an afterburn … a remonstrance conveyed collusively by virtue of the fact that its targets are in the process of leaving the field”.
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“Fake it till you make it” (or “Fake it until you make it”) is an aphorism that suggests that by imitating confidence, competence, and an optimistic mindset, a person can realise those qualities in their real life and achieve the results they seek.
The phrase is first attested some time before 1973. The earliest reference to a similar phrase occurs in the Simon & Garfunkel song “Fakin’ It”, released in 1968 as a single and also on their Bookends album. Simon sings, “And I know I’m fakin’ it, I’m not really makin’ it.”
Similar advice has been offered by a number of writers over time:
Action seems to follow feeling, but really action and feeling go together; and by regulating the action, which is under the more direct control of the will, we can indirectly regulate the feeling, which is not. Thus the sovereign voluntary path to cheerfulness, if our spontaneous cheerfulness be lost, is to sit up cheerfully, to look round cheerfully, and to act and speak as if cheerfulness were already there. If such conduct does not make you soon feel cheerful, nothing else on that occasion can. So to feel brave, act as if we were brave, use all our will to that end, and a courage-fit will very likely replace the fit of fear. ( William James, “The Gospel of Relaxation”, On Vital Reserves, 1922).
In the law of attraction movement, “act as if you already have it”, or simply “act as if”, is a central concept:
How do you get yourself to a point of believing? Start make-believing. Be like a child, and make-believe. Act as if you have it already. As you make-believe, you will begin to believe you have received. ( Rhonda Byrne, The Secret, 2006).
In Psychology
In the 1920s, Alfred Adler developed a therapeutic technique that he called “acting as if”, asserting that “if you want a quality, act as if you already have it”. This strategy gave his clients an opportunity to practice alternatives to dysfunctional behaviours. Adler’s method is still used today and is often described as role play.
“Faking it till you make it” is a psychological tool discussed in neuroscientific research. A 1988 experiment by Fritz Strack claimed to show that mood can be improved by holding a pen between the user’s teeth to force a smile, but a posterior experiment failed to replicate it, due to which Strack was awarded the Ig Nobel Prize for psychology in 2019. A later 2022 study about strategies to counter emotional distress found forced smiling not more effective than forced neutral expressions and other strategies of emotional regulation.
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Emotion work is understood as the art of trying to change in degree or quality an emotion or feeling.
Emotion work may be defined as the management of one’s own feelings, or work done in an effort to maintain a relationship; there is dispute as to whether emotion work is only work done regulating one’s own emotion, or extends to performing the emotional work for others.
Hochschild
Arlie Russell Hochschild, who introduced the term in 1979, distinguished emotion work – unpaid emotional work that a person undertakes in private life – from emotional labour: emotional work done in a paid work setting. Emotion work has use value and occurs in situations in which people choose to regulate their emotions for their own non-compensated benefit (e.g. in their interactions with family and friends). By contrast, emotional labour has exchange value because it is traded and performed for a wage.
In a later development, Hochschild distinguished between two broad types of emotion work, and among three techniques of emotion work. The two broad types involve evocation and suppression of emotion, while the three techniques of emotion work that Hochschild describes are cognitive, bodily and expressive.
However, the concept (if not the term) has been traced back as far as Aristotle: as Aristotle saw, the problem is not with emotionality, but with the appropriateness of emotion and its expression.
Examples
Examples of emotion work include showing affection, apologizing after an argument, bringing up problems that need to be addressed in an intimate relationship or any kind of interpersonal relationship, and making sure the household runs smoothly.
Emotion work also involves the orientation of self/others to accord with accepted norms of emotional expression: emotion work is often performed by family members and friends, who put pressure on individuals to conform to emotional norms. Arguably, then, an individual’s ultimate obeisance and/or resistance to aspects of emotion regimes are made visible in their emotion work.
Cultural norms often imply that emotion work is reserved for females. There is certainly evidence to the effect that the emotional management that women and men do is asymmetric; and that in general, women come into a marriage groomed for the role of emotional manager.
Criticism
The social theorist Victor Jeleniewski Seidler argues that women’s emotion work is merely another demonstration of false consciousness under patriarchy, and that emotion work, as a concept, has been adopted, adapted or criticised to such an extent that it is in danger of becoming a “catch-all-cliché”.
More broadly, the concept of emotion work has itself been criticised as a wide over-simplification of mental processes such as repression and denial which continually occur in everyday life.
Literary Analogues
Rousseau in The New Heloise suggests that the attempt to master instrumentally one’s affective life always results in a weakening and eventually the fragmentation of one’s identity, even if the emotion work is performed at the demand of ethical principles.
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Cognitive imitation is a form of social learning, and a subtype of imitation. Cognitive imitation is contrasted with motor and vocal or oral imitation. As with all forms of imitation, cognitive imitation involves learning and copying specific rules or responses done by another. The principal difference between motor and cognitive imitation is the type of rule (and stimulus) that is learned and copied by the observer. So, whereas in the typical imitation learning experiment subjects must copy novel actions on objects or novel sequences of specific actions (novel motor imitation), in a novel cognitive imitation paradigm subjects have to copy novel rules, independently of specific actions or movement patterns.
A toddler imitates his father.
The following example illustrates the difference between cognitive and motor-spatial imitation: Imagine someone overlooking someone’s shoulder and stealing their automated teller machine (ATM) password. As with all forms of imitation, the individual learns and successfully reproduces the observed sequence. The observer in our example, like most of us, presumably knows how to operate an ATM (namely, that you have to push X number of buttons on the ATM screen in a specific sequence), so the specific motor responses of touching the screen isn’t what the thief is learning. Instead, the thief could learn two types of abstract rules. On the one hand, the thief can learn a spatial rule: touch item in the top right, followed by item on the top left, then the item in the middle of the screen, and finally the one on lower right. This would be an example of motor-spatial imitation because the thief’s response is guided by an abstract motor-spatial rule. On the other, the thief could ignore the spatial patterning of the observed responses and instead focus on the particular items that were touched, generating an abstract numerical rule, independently of where they are in space: 3-1-5-9. This would constitute an example of cognitive imitation because the individuals is copying an abstract serial rule without copying specific motor-responses. In this example, the thief’s responses match those he observed only because the numbers are in the same location. If the numbers were in a different location—that is, if the numbers on the ATM’s keypad were scrambled with every attempt to enter a password—the thief would, nonetheless, reproduce the target password because they learned a cognitive (i.e. an abstract, item-specific serial rule), rather than a spatial rule (i.e. an observable motor-spatial pattern).
In Rhesus Monkeys
The term “cognitive imitation” was first introduced by Subiaul and his colleagues (Subiaul, Cantlon, et al., 2004), defining it as “a type of observational learning in which a naïve student copies an expert’s use of a rule”. To isolate cognitive from motor imitation, Subiaul and colleagues trained two rhesus macaques to respond, in a prescribed order, to different sets of photographs that were displayed simultaneously on a touch-sensitive monitor. Because the position of the photographs varied randomly from trial to trial, sequences could not be learned by motor imitation. Both monkeys learned new sequences more rapidly after observing an expert execute those sequences than when they had to learn new sequences entirely by trial and error. A mircro-analysis of each monkeys’ performance showed that each monkey learned the order of two of the four photographs faster than baseline levels. A second experiment ruled out social facilitation as an explanation for this result. A third experiment, however, demonstrated that monkeys did not learn when the computer highlighted each picture in the correct sequence in the absence of a monkey (“ghost control”).
Dissociating Cognitive and Motor-Spatial Imitation
Subiaul and colleagues, using two computerised tasks that measure the learning of two abstract rules: cognitive—item-based—rules (e.g. apple-boy-cat;) and motor-spatial-based rules (e.g. up-down-right) have shown that there are important dissociations between the imitation of these two types of rules. Specifically, results have shown that while 3-year-olds successfully imitate item-specific rules (i.e. cognitive imitation), these same 3-year-olds fail to imitate motor-spatial rules (i.e. motor-spatial imitation). This dissociation isn’t because there’s something inherently harder about learning spatial versus cognitive rules. Follow-up studies have shown that 3-year-olds easily learn new spatial rules by trial and error, correctly recalling such rules after a 30s delay, (Exp. 2). This result excludes the possibility that 3-year-olds’ motor-spatial imitation problems are due to difficulty learning (i.e. encoding and recalling) novel spatial rules in general. In another study, 3-year-olds observed a model correctly touch the first item (e.g. Top Right) in the sequence, but then skip the middle item (e.g. Top Left picture) and, instead, touch the last item in the sequence (e.g. Bottom Left picture), resulting in an error, marked as unintentional by the model who said, “Whoops! That’s not right!”. This is a goal emulation learning condition, as the child had to copy the model’s intended goal (Top-Right, Bottom-Left, Top-Left), rather than the observed (incorrect) response (Top-Right, Top-Left), similar to Meltzoff’s “re-enactment” paradigm. When given an opportunity to respond, 3-year-olds generated the intended (i.e. correct) sequence (Exp. 3.) 3-year-old’s success in the goal emulation condition excludes the possibility that 3-year-olds’ motor-spatial imitation problem is due to difficulty vicariously learning (i.e. because of a lack of interest, failure to attend, problems inferring goals, etc.) a novel spatial rule from a model. Children’s success in the goal emulation condition shows that social learning may be achieved by social reasoning (inferring goals) and causal inferences (error detection), independently of any domain-specific imitation learning mechanism.
To further explore this dissociation between cognitive- and motor-spatial imitation Subiaul and colleagues conducted a large-scale cross-sectional, within-subject study with pre-schoolers (2–6 years) using the same two tasks: cognitive (item-specific) and motor-spatial (spatial-specific). Results showed that children’s cognitive imitation performance did not predict their motor-spatial imitation learning, and vice versa. Importantly, while age predicted improved cognitive and motor-spatial imitation performance, children’s ability to individually learn each type of rule via trial and error did not predict their ability to imitate those same rules.
Subiaul and colleagues have argued that these results are consistent with the hypothesis that imitation learning is domain-specific, not domain-general. A critical caveat may be that the imitation of NOVEL rules and responses is domain-specific while the imitation of FAMILIAR responses is likely to be mediated by domain-general, non-specialised mechanisms, as Heyes and others have argued.
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