Heinrich Hoffmann (13 June 1809 to 20 September 1894) was a German psychiatrist, who also wrote some short works including Der Struwwelpeter, an illustrated book portraying children misbehaving.
Hoffmann worked for a pauper’s clinic and had a private practice. He also taught anatomy at the Senckenberg Foundation. None of this paid very well, and when the Frankfurt lunatic asylum’s previous doctor (who was a friend of his) retired in 1851, he was eager to take the post even though he had no expertise in psychiatry. This changed quickly, as his later competent publications in the field show. Hoffmann portrays himself as a caring, humane psychiatrist, who strove to be the sunshine in the life of his miserable patients. His gregarious personality may well have been popular with many of them. His statistical compilations show that up to 40% of the people with acute cases of what would today be called schizophrenia were discharged after a few weeks or months and stayed in remission for years and perhaps permanently. Always a sceptic, Hoffmann voices doubts whether this was due to any therapy he may have given them. Much of his energy from 1851 onwards went into campaigning for a new, modern asylum building with gardens in the city’s green belt. He was successful and the new clinic was built at the site of today’s Frankfurt University’s Humanities campus (The original building was demolished in the 1920s).
Irvin D. Yalom
Irvin David Yalom (born 13 June 1931) is an American existential psychiatrist who is emeritus professor of psychiatry at Stanford University, as well as author of both fiction and nonfiction.
After graduating with a BA from George Washington University in 1952 and a Doctor of Medicine from Boston University School of Medicine in 1956 he went on to complete his internship at Mount Sinai Hospital in New York and his residency at the Phipps Clinic of Johns Hopkins Hospital in Baltimore and completed his training in 1960. After two years of Army service at Tripler General Hospital in Honolulu, Yalom began his academic career at Stanford University. He was appointed to the faculty in 1963 and promoted over the following years, being granted tenure in 1968. Soon after this period he made some of his most lasting contributions by teaching about group psychotherapy and developing his model of existential psychotherapy.
His writing on existential psychology centres on what he refers to as the four “givens” of the human condition: isolation, meaninglessness, mortality and freedom, and discusses ways in which the human person can respond to these concerns either in a functional or dysfunctional fashion.
In 1970, Yalom published The Theory and Practice of Group Psychotherapy, speaking about the research literature around group psychotherapy and the social psychology of small group behaviour. This work explores how individuals function in a group context, and how members of group therapy gain from his participation group.
In addition to his scholarly, non-fiction writing, Yalom has produced a number of novels and also experimented with writing techniques. In Every Day Gets a Little Closer Yalom invited a patient to co-write about the experience of therapy. The book has two distinct voices which are looking at the same experience in alternating sections. Yalom’s works have been used as collegiate textbooks and standard reading for psychology students. His new and unique view of the patient/client relationship has been added to curriculum in psychology programs at such schools as John Jay College of Criminal Justice in New York City.
Yalom has continued to maintain a part-time private practice and has authored a number of video documentaries on therapeutic techniques. Yalom is also featured in the 2003 documentary Flight from Death, a film that investigates the relationship of human violence to fear of death, as related to subconscious influences. The Irvin D. Yalom Institute of Psychotherapy, which he co-directs with Professor Ruthellen Josselson, works to advance Yalom’s approach to psychotherapy. This unique combination of integrating more philosophy into the psychotherapy can be considered as psychosophy.
He was married to author and historian Marilyn Yalom who died in November 2019. Their four children are: Eve, a gynaecologist, Reid, a photographer, Victor, a psychologist and entrepreneur and Ben, a theatre director.
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. 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:
Metacognitive knowledge (also called metacognitive awareness) is what individuals know about themselves and others as cognitive processors.
Metacognitive regulation is the regulation of cognition and learning experiences through a set of activities that help people control their learning.
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:
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”.
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.
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.
Planning: refers to the appropriate selection of strategies and the correct allocation of resources that affect task performance.
Monitoring: refers to one’s awareness of comprehension and task performance
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.
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.
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 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.
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.
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.
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” (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).
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.
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.
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.
Introspection: Examining one’s own thoughts and feelings.
Learning styles: Largely debunked theories that aim to account for differences in individuals’ learning.
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.
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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Enmeshment is a concept in psychology and psychotherapy introduced by Salvador Minuchin (1921-2017) to describe families where personal boundaries are diffused, sub-systems undifferentiated, and over-concern for others leads to a loss of autonomous development.
Enmeshed in parental needs, trapped in a discrepant role function, a child may lose their capacity for self-direction; their own distinctiveness, under the weight of “psychic incest”; and, if family pressures increase, may end up becoming the identified patient or family scapegoat.
Enmeshment was also used by John Bradshaw to describe a state of cross-generational bonding within a family, whereby a child (normally of the opposite sex) becomes a surrogate spouse for their mother or father.
The term is sometimes applied to engulfing co-dependent relationships, where an unhealthy symbiosis is in existence.
For the toxically enmeshed child, the adult’s carried feelings may be the only ones they know, outweighing and eclipsing their own.
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Thomas Stephen Szasz (15 April 1920 to 08 September 2012) was a Hungarian-American academic and psychiatrist.
He served for most of his career as professor of psychiatry at the State University of New York Upstate Medical University in Syracuse, New York. A distinguished lifetime fellow of the American Psychiatric Association and a life member of the American Psychoanalytic Association, he was best known as a social critic of the moral and scientific foundations of psychiatry, as what he saw as the social control aims of medicine in modern society, as well as scientism. His books The Myth of Mental Illness (1961) and The Manufacture of Madness (1970) set out some of the arguments most associated with him.
Szasz argued throughout his career that mental illness is a metaphor for human problems in living, and that mental illnesses are not “illnesses” in the sense that physical illnesses are, and that except for a few identifiable brain diseases, there are “neither biological or chemical tests nor biopsy or necropsy findings for verifying DSM diagnoses.”
Szasz maintained throughout his career that he was not anti-psychiatry but rather that he opposed coercive psychiatry. He was a staunch opponent of civil commitment and involuntary psychiatric treatment, but he believed in and practiced psychiatry and psychotherapy between consenting adults.
Szasz was born to Jewish parents Gyula and Lily Szász on 15 April 1920, in Budapest, Hungary. In 1938, Szasz moved to the United States, where he attended the University of Cincinnati for his Bachelor of Science in physics, and received his M.D. from the same university in 1944. Szasz completed his residency requirement at the Cincinnati General Hospital, then worked at the Chicago Institute for Psychoanalysis from 1951-1956, and then for the next five years was a member of its staff – taking 24 months out for duty with the US Naval Reserve.
In 1962 Szasz received a tenured position in medicine at the State University of New York. Szasz had first joined SUNY in 1956.
Szasz had two daughters. His wife, Rosine, died in 1971. Szasz’s colleague Jeff Schaler described her death as a suicide.
Szasz’s views of psychiatry were influenced by the writings of Frigyes Karinthy.
Thomas Szasz ended his own life on 08 September 2012. He had previously suffered a fall and would have had to live in chronic pain otherwise. Szasz argued for the right to suicide in his writings.
Rise of Szasz’s Arguments
Szasz first presented his attack on “mental illness” as a legal term in 1958 in the Columbia Law Review. In his article he argued that mental illness was no more a fact bearing on a suspect’s guilt than is possession by the devil.
In 1961 Szasz testified before a United States Senate Committee, arguing that using mental hospitals to incarcerate people defined as insane violated the general assumptions of the patient-doctor relationship, and turned the doctor into a warden and keeper of a prison.
Szasz’s Main Arguments
Szasz was convinced there was a metaphorical character to mental disorders, and its uses in psychiatry were frequently injurious. He set himself a task to delegitimise legitimating agencies and authorities, and what he saw as their vast powers, enforced by psychiatrists and other mental health professionals, mental health laws, mental health courts, and mental health sentences.
Szasz was a critic of the influence of modern medicine on society, which he considered to be the secularization of religion’s hold on humankind. Criticising scientism, he targeted psychiatry in particular, underscoring its campaigns against masturbation at the end of the 19th century, its use of medical imagery and language to describe misbehaviour, its reliance on involuntary mental hospitalisation to protect society, and the use of lobotomy and other interventions to treat psychosis. To sum up his description of the political influence of medicine in modern societies imbued by faith in science, he declared:
Since theocracy is the rule of God or its priests, and democracy the rule of the people or of the majority, pharmacracy is therefore the rule of medicine or of doctors.
Szasz consistently paid attention to the power of language in the establishment and maintenance of the social order, both in small interpersonal and in wider social, economic, and/or political spheres:
The struggle for definition is veritably the struggle for life itself. In the typical Western two men fight desperately for the possession of a gun that has been thrown to the ground: whoever reaches the weapon first shoots and lives; his adversary is shot and dies. In ordinary life, the struggle is not for guns but for words; whoever first defines the situation is the victor; his adversary, the victim. For example, in the family, husband and wife, mother and child do not get along; who defines whom as troublesome or mentally sick?… [the one] who first seizes the word imposes reality on the other; [the one] who defines thus dominates and lives; and [the one] who is defined is subjugated and may be killed.
His main arguments can be summarised as follows:
“Myth of Mental Illness”
“Mental illness” is an expression, a metaphor that describes an offending, disturbing, shocking, or vexing conduct, action, or pattern of behavior, such as packaged under the wide-ranging term schizophrenia, as an “illness” or “disease”. Szasz wrote: “If you talk to God, you are praying; If God talks to you, you have schizophrenia. If the dead talk to you, you are a spiritualist; If you talk to the dead, you are a schizophrenic.”: 85 He maintained that, while people behave and think in disturbing ways, and those ways may resemble a disease process (pain, deterioration, response to various interventions), this does not mean they actually have a disease. To Szasz, disease can only mean something people “have”, while behaviour is what people “do”. Diseases are “malfunctions of the human body, of the heart, the liver, the kidney, the brain” while “no behavior or misbehavior is a disease or can be a disease. That’s not what diseases are.” Szasz cited drapetomania as an example of a behaviour that many in society did not approve of, being labelled and widely cited as a disease. Likewise, women who did not bend to a man’s will were said to have hysteria. He thought that psychiatry actively obscures the difference between behaviour and disease in its quest to help or harm parties in conflicts. He maintained that, by calling people diseased, psychiatry attempts to deny them responsibility as moral agents in order to better control them.
In Szasz’s view, people who are said by themselves or others to have a mental illness can only have, at best, “problems in living”. Diagnoses of “mental illness” or “mental disorder” (the latter expression called by Szasz a “weasel term” for mental illness) are passed off as “scientific categories” but they remain merely judgments (judgements of disdain) to support certain uses of power by psychiatric authorities. In that line of thinking, schizophrenia becomes not the name of a disease entity but a judgement of extreme psychiatric and social disapprobation. Szasz called schizophrenia “the sacred symbol of psychiatry” because those so labelled have long provided and continue to provide justification for psychiatric theories, treatments, abuses, and reforms.
The figure of the psychotic or schizophrenic person to psychiatric experts and authorities, according to Szasz, is analogous with the figure of the heretic or blasphemer to theological experts and authorities. According to Szasz, to understand the metaphorical nature of the term “disease” in psychiatry, one must first understand its literal meaning in the rest of medicine. To be a true disease, the entity must first somehow be capable of being approached, measured, or tested in scientific fashion. Second, to be confirmed as a disease, a condition must demonstrate pathology at the cellular or molecular level.
A genuine disease must also be found on the autopsy table (not merely in the living person) and meet pathological definition instead of being voted into existence by members of the American Psychiatric Association. “Mental illnesses” are really problems in living. They are often “like a” disease, argued Szasz, which makes the medical metaphor understandable, but in no way validates it as an accurate description or explanation. Psychiatry is a pseudoscience that parodies medicine by using medical-sounding words invented especially over the last one hundred years. To be clear, heart break and heart attack, or spring fever and typhoid fever belong to two completely different logical categories, and treating one as the other constitutes a category error. Psychiatrists are the successors of “soul doctors”, priests who dealt and deal with the spiritual conundrums, dilemmas, and vexations – the “problems in living” – that have troubled people forever.
Psychiatry’s main methods are assessment, medication, conversation or rhetoric and incarceration. To the extent that psychiatry presents these problems as “medical diseases”, its methods as “medical treatments”, and its clients – especially involuntary – as medically ill patients, it embodies a lie and therefore constitutes a fundamental threat to freedom and dignity. Psychiatry, supported by the state through various Mental Health Acts, has become a modern secular state religion according to Szasz. It is a vastly elaborate social control system, using both brute force and subtle indoctrination, which disguises itself under the claims of being rational, systematic and therefore scientific.
“Patient” as Malingerer
According to Szasz, many people fake their presentation of mental illness, i.e., they are malingering. They do so for gain, for example, in order to escape a burden like evading the draft, or to gain access to drugs or financial support, or for some other personally meaningful reason. By definition, the malingerer is knowingly deceitful (although malingering itself has also been called a mental illness or disorder). Szasz mentions malingering in many of his works, but it is not what he has in mind to explain many other manifestations of so-called “mental illness”. In those cases, so-called “patients” have something personally significant to communicate – their “problems in living” – but unable to express this via conventional means they resort to illness-imitation behaviour, a somatic protolanguage or “body language”, which psychiatrists and psychologists have misguidedly interpreted as the signs/symptoms of real illness. So, for example:
“analyzing the origin of the hysterical protolanguage Szasz states that it has a double origin: – the first root is in the somatic structure of human being. The human body is subject to illnesses and disabilities expressed through somatic signs (like paralysis, convulsions, etc.) and somatic sensations (like pain, tiredness, etc.); – the second root can be found into cultural factors.”
Separation of Psychiatry and the State
Szasz believed that if we accept that “mental illness” is a euphemism for behaviours that are disapproved of, then the state has no right to force psychiatric “treatment” on these individuals. Similarly, the state should not be able to interfere in mental health practices between consenting adults (for example, by legally controlling the supply of psychotropic drugs or psychiatric medication). The medicalisation of government produces a “therapeutic state”, designating someone as, for example, “insane” or as a “drug addict”.
In Ceremonial Chemistry (1973), he argued that the same persecution that targeted witches, Jews, gypsies, and homosexuals now targets “drug addicts” and “insane” people. Szasz argued that all these categories of people were taken as scapegoats of the community in ritual ceremonies. To underscore this continuation of religion through medicine, he even takes as an example obesity: instead of concentrating on junk food (ill-nutrition), physicians denounced hypernutrition. According to Szasz, despite their scientific appearance, the diets imposed were a moral substitute to the former fasts, and the social injunction not to be overweight is to be considered as a moral order, not as a scientific advice as it claims to be. As with those thought bad (insane people), and those who took the wrong drugs (drug addicts), medicine created a category for those who had the wrong weight (obesity).
Szasz argued that psychiatrics were created in the 17th century to study and control those who erred from the medical norms of social behaviour; a new specialisation, drogophobia, was created in the 20th century to study and control those who erred from the medical norms of drug consumption; and then, in the 1960s, another specialisation, bariatrics (from the Greek βάρος baros, for “weight”), was created to deal with those who erred from the medical norms concerning the weight the body should have. Thus, he underscores that in 1970, the American Society of Bariatric Physicians had 30 members, and already 450 two years later.
Presumption of Competence and Death Control
Just as legal systems work on the presumption that a person is innocent until proven guilty, individuals accused of crimes should not be presumed incompetent simply because a doctor or psychiatrist labels them as such. Mental incompetence should be assessed like any other form of incompetence, i.e. by purely legal and judicial means with the right of representation and appeal by the accused.
In an analogy to birth control, Szasz argued that individuals should be able to choose when to die without interference from medicine or the state, just as they are able to choose when to conceive without outside interference. He considered suicide to be among the most fundamental rights, but he opposed state-sanctioned euthanasia.
In his 2006 book about Virginia Woolf he stated that she put an end to her life by a conscious and deliberate act, her suicide being an expression of her freedom of choice.
Abolition of the Insanity Defence and Involuntary Hospitalisation
Szasz believed that testimony about the mental competence of a defendant should not be admissible in trials. Psychiatrists testifying about the mental state of an accused person’s mind have about as much business as a priest testifying about the religious state of a person’s soul in our courts. Insanity (defence) was a legal tactic invented to circumvent the punishments of the Church, which at the time included confiscation of the property of those who committed suicide, often leaving widows and orphans destitute. Only an insane person would do such a thing to his widow and children, it was successfully argued. This is legal mercy masquerading as medicine, according to Szasz.
No one should be deprived of liberty unless he is found guilty of a criminal offense. Depriving a person of liberty for what is said to be his own good is immoral. Just as a person suffering from terminal cancer may refuse treatment, so should a person be able to refuse psychiatric treatment.
The Right to Drugs
Drug addiction is not a “disease” to be cured through legal drugs but a social habit. Szasz also argues in favour of a free market for drugs. He criticised the war on drugs, arguing that using drugs is in fact a victimless crime. Prohibition itself constituted the crime. He argued that the war on drugs leads states to do things that would have never been considered half a century before, such as prohibiting a person from ingesting certain substances or interfering in other countries to impede the production of certain plants, e.g. coca eradication plans, or the campaigns against opium; both are traditional plants opposed by the Western world. Although Szasz was sceptical about the merits of psychotropic medications, he favoured the repeal of drug prohibition.
Szasz also drew analogies between the persecution of the drug-using minority and the persecution of Jewish and homosexual minorities.
The Nazis spoke of having a “Jewish problem”. We now speak of having a drug-abuse problem. Actually, “Jewish problem” was the name the Germans gave to their persecution of the Jews; “drug-abuse problem” is the name we give to the persecution of people who use certain drugs.
Szasz cites former US Representative James M. Hanley’s reference to drug users as “vermin”, using:
“the same metaphor for condemning persons who use or sell illegal drugs that the Nazis used to justify murdering Jews by poison gas – namely, that the persecuted persons are not human beings, but ‘vermin.'”
The “Therapeutic State” is a phrase coined by Szasz in 1963. The collaboration between psychiatry and government leads to what Szasz calls the therapeutic state, a system in which disapproved actions, thoughts, and emotions are repressed (“cured”) through pseudomedical interventions. Thus suicide, unconventional religious beliefs, racial bigotry, unhappiness, anxiety, shyness, sexual promiscuity, shoplifting, gambling, overeating, smoking, and illegal drug use are all considered symptoms or illnesses that need to be cured. When faced with demands for measures to curtail smoking in public, binge-drinking, gambling or obesity, ministers say that “we must guard against charges of nanny statism.” The “nanny state” has turned into the “therapeutic state” where nanny has given way to counsellor. Nanny just told people what to do; counsellors also tell them what to think and what to feel. The “nanny state” was punitive, austere, and authoritarian, the therapeutic state is touchy-feely, supportive – and even more authoritarian.
According to Szasz:
“the therapeutic state swallows up everything human on the seemingly rational ground that nothing falls outside the province of health and medicine, just as the theological state had swallowed up everything human on the perfectly rational ground that nothing falls outside the province of God and religion.”
Faced with the problem of “madness”, Western individualism proved to be ill-prepared to defend the rights of the individual: modern man has no more right to be a madman than medieval man had a right to be a heretic because if once people agree that they have identified the one true God, or Good, it brings about that they have to guard members and non-members of the group from the temptation to worship false gods or goods. A secularization of God and the medicalization of good resulted in the post-Enlightenment version of this view: once people agree that they have identified the one true reason, it brings about that they have to guard against the temptation to worship unreason – that is, madness.
Civil libertarians warn that the marriage of the state with psychiatry could have catastrophic consequences for civilisation. In the same vein as the separation of church and state, Szasz believes that a solid wall must exist between psychiatry and the state.
American Association for the Abolition of Involuntary Mental Hospitalisation
Believing that psychiatric hospitals are like prisons not hospitals and that psychiatrists who subject others to coercion function as judges and jailers not physicians, Szasz made efforts to abolish involuntary psychiatric hospitalisation for over two decades, and in 1970 took a part in founding the American Association for the Abolition of Involuntary Mental Hospitalisation (AAAIMH). Its founding was announced by Szasz in 1971 in the American Journal of Psychiatry and American Journal of Public Health. The association provided legal help to psychiatric patients and published a journal, The Abolitionist.
Relationship to Citizens Commission on Human Rights
In 1969, Szasz and the Church of Scientology co-founded the Citizens Commission on Human Rights (CCHR) to oppose involuntary psychiatric treatments. Szasz served on CCHR’s Board of Advisors as Founding Commissioner. In the keynote address at the 25th anniversary of CCHR, Szasz stated:
“We should all honor CCHR because it is really the organization that for the first time in human history has organized a politically, socially, internationally significant voice to combat psychiatry. This has never been done in human history before.”
In a 2009 interview aired by the Australian Broadcasting Corporation, Szasz explained his reason for collaborating with CCHR and lack of involvement with Scientology:
Well I got affiliated with an organisation long after I was established as a critic of psychiatry, called Citizens Commission for Human Rights, because they were then the only organisation and they still are the only organisation who had money and had some access to lawyers and were active in trying to free mental patients who were incarcerated in mental hospitals with whom there was nothing wrong, who had committed no crimes, who wanted to get out of the hospital. And that to me was a very worthwhile cause; it’s still a very worthwhile cause. I no more believe in their religion or their beliefs than I believe in the beliefs of any other religion. I am an atheist, I don’t believe in Christianity, in Judaism, in Islam, in Buddhism and I don’t believe in Scientology. I have nothing to do with Scientology.
Responses and Reactions
Szasz was a strong critic of institutional psychiatry and his publications were very widely read. He argued that so-called mental illnesses had no underlying physiological basis, but were unwanted and unpleasant behaviours. Mental illness, he said, was only a metaphor that described problems that people faced in their daily lives, labelled as if they were medical diseases. Szasz’s ideas had little influence on mainstream psychiatry, but were supported by some behavioural and social scientists. Sociologist Erving Goffman, who wrote Asylums: Essays on the Condition of the Social Situation of Mental Patients and Other Inmates, was sceptical about psychiatric practices. He was concerned that the stigma and social rejection associated with psychiatric treatment might harm people. Thomas Scheff, also a sociologist, had similar reservations.
In the summer of 2001, Szasz took a part in a Russell Tribunal on Human rights in Psychiatry held in Berlin between 30 June and 02 July 2001. The tribunal brought in the two following verdicts: the majority verdict claimed that there was “serious abuse of human rights in psychiatry” and that psychiatry was “guilty of the combination of force and unaccountability”; the minority verdict, signed by the Israeli Law Professor Alon Harel and Brazilian novelist Paulo Coelho, called for “public critical examination of the role of psychiatry”.
Szasz was honoured with over fifty awards including:
American Humanist Association named him Humanist of the Year (1973).
Award for Greatest Public Service Benefiting the Disadvantaged, an award given out annually by Jefferson Awards (1974).
Martin Buber Award (1974).
He was honoured with an honorary doctorate in behavioural science at Universidad Francisco Marroquín (1979).
Humanist Laureate Award (1995).
Great Lake Association of Clinical Medicine Patients’ Rights Advocate Award (1995).
American Psychological Association Rollo May Award (1998).
Robert Evan Kendell presents (in Schaler, 2005) a critique of Szasz’s conception of disease and the contention that mental illness is “mythical” as presented in The Myth of Mental Illness. Kendell’s arguments include the following:
Szasz’s conception of disease exclusively in terms of “lesion”, i.e. morphological abnormality, is arbitrary and his conclusions based on this idea represent special pleading.
There are non-psychiatric conditions that remain defined solely in terms of syndrome, e.g. migraine, torticollis, essential tremor, blepharospasm, torsion dystonia.
Szasz’s scepticism regarding syndromally defined diseases – only in relation to psychiatry – is entirely arbitrary.
Many diseases that are outside the purview of psychiatry are defined purely in terms of the constellation of the symptoms, signs and natural history they present yet Szasz has not expressed any doubt regarding their existence.
Is syndrome-based diagnosis only problematic for psychiatry but without issue for the remaining branches of medicine?
If syndrome-based diagnosis is unsound on account of its absence of objectivity then it must be generally unsound and not only for psychiatry.
Szasz’s ostensibly exclusive criterion of disease as morphological abnormality – i.e. a lesion made evident “by post-mortem examination of organs and tissues” – is unsound because it inadvertently includes many conditions that are not considered to be diseases by virtue of the fact that they do not produce suffering or disability, e.g. functionally inconsequential chromosomal translocations and deletions, fused second and third toes, dextrocardia.
Szasz’s conception of disease does not distinguish between necessary versus sufficient conditions in relation to diagnostic criteria.
In branches of medicine other than psychiatry, morphological abnormality per se is not considered sufficient cause to make a diagnosis of disease; functional abnormality is the necessary condition.
Szasz’s criticism of syndrome-based diagnoses is divorced from a consideration of the history of medicine.
In medicine (in general) diseases are defined in terms of a multitude of criteria, these include: (a) morbid anatomy, e.g. mitral stenosis, cholecystitis; (b) histologically, e.g. most cancers, Alzheimer’s disease; (c) infective organism, e.g. Tuberculosis, Measles; (d) physiologically, e.g. myasthenia gravis; (e) biochemically, e.g. aminoaciduria; (e) chromosomally, e.g. trisomy 21, Turner’s syndrome; (f) molecularly, e.g. thalassemia; (g) genetically, e.g. Huntington’s disease, cystic fibrosis; and (h) syndrome, e.g. migraine, torticollis, essential tremor, blepharospasm, torsion dystonia and most (so-called) mental disorders.
The more objective definitions of disease – specified as (a) through (g) – became possible through the accumulation of scientific knowledge and the development of relevant technology.
Initially the underlying pathology of some diseases was unknown and they were diagnosed only in terms of syndrome – no lesion could be demonstrated “by post-mortem examination of organs and tissues” (as Szasz requires) until later in history, e.g. malaria was diagnosed solely on the basis of syndrome until the advent of microbiology.
A strict application of Szasz’s criterion necessitates the conclusion that diseases such as malaria were “mythical” until medical microbiology arrived, at which point they became “real”.
In this regard Szasz’s criterion of disease is unsound by virtue of its contradictory results.
Szasz’s contention that mental illness is not associated with any morphological abnormality is uninformed by genetics, biochemistry, and current research results on the aetiology of mental illness.
Genes are essentially instructions for the synthesis of proteins.
Hence, any condition that is even partly hereditary necessarily manifests structural abnormality at the molecular level.
Regardless of whether the actual morphological abnormality can be identified, if a condition has a hereditary component then it has a biological basis.
Twin and adoption studies have strongly demonstrated that heredity is a major factor in the aetiology of schizophrenia; thus there must be some biological difference between schizophrenics and non-schizophrenics.
These results in addition to twin and adoption studies provide evidence of an underlying molecular – hence structural – abnormality to depression.
Szasz contends that, “Strictly speaking, disease or illness can affect only the body; hence, there can be no mental illness” and this idea is foundational to Szasz’s position.
In actuality, there are no physical or mental illnesses per se; there are only diseases of organisms, of persons.
The bifurcation of organisms into minds and bodies is the product of the Cartesian dualism that became dominant in the late 18th century and it was at this time that the notion of insanity as something qualitatively different from other illnesses became entrenched.
In actuality, brain and body comprise one integrated and indivisible system and no illness “respects” the abstraction of mind vs. body upon which Szasz’s argument rests.
There are no illnesses that are purely mental or purely physical.
Somatic pain is itself a mental phenomenon as is the subjective distress produced by the acute phase response at the onset of illness or immediately after trauma.
Similarly, conditions such as schizophrenia and major depressive disorder produce somatic symptoms.
Any illness lies somewhere within a continuum between the poles of mind and body; the extrema are purely theoretical abstractions and are unoccupied by any real affliction.
The mind/body division persists purely for pragmatic reasons and forms no real part of modern biomedical science.
Shorter replied to Szasz’s essay “The myth of mental illness: 50 years later”, which was published in the journal The Psychiatrist (and delivered as a plenary address at the International Congress of the Royal College of Psychiatrists in Edinburgh on 24 June 2010) – in recognition of the 50th anniversary of The Myth of Mental Illness – with the following principal criticisms:
Szasz’s critique is implicitly premised on a conception of mind drawn from the psychiatry of the early-mid 20th century – namely psychoanalytic psychiatry – and Szasz has not updated his critique in light of later developments in psychiatry.
The referent of Szasz’s critique – Freud’s mind – is to be found only in the historical record and some isolated islands of psychoanalytic practice.
To this extent, Szasz’s critique does not address contemporary biologically-oriented psychiatry and is irrelevant.
Certainly the phrase mental illness occurs in the contemporary psychiatric lexicon, but that is merely a legacy of the earlier psychoanalytic influence upon psychiatry; the term does not reflect a real belief that psychiatric disease – Shorter’s preferred term – originates in the mind, an abstraction as Szasz rightly explains.
Szasz concedes that some so-called mental illnesses may have a neurological basis – but adds that were such a biological basis discovered for these so-called mental illnesses, they would have to be reclassified from mental illnesses to brain diseases, which would vindicate his position.
Shorter explains that the problem with Szasz’s argument here is that it is the contention of biological psychiatry that so-called mental illnesses are actually brain diseases.
Modern psychiatry has de facto dispensed with the idea of mental illness, i.e. the notion that psychiatric disease is mainly or entirely psychogenic is not a part of biological psychiatry.
There exists at least prima facie evidence that psychiatric illness has a biological basis and Szasz either ignores this evidence or attempts to insulate his argument from such evidence by effectively claiming that “no true mental illness has a biological basis.”
Shorter cites hypothalamic-pituitary-adrenal axis (HPA) dysregulation, a positive dexamethasone suppression test result, and shortened rapid eye movement sleep latency in those with melancholic depression as examples of this evidence.
Inner Relationship Focusing (IRF) is a psychotherapeutic system and process developed by Ann Weiser Cornell and Barbara McGavin, as a refinement and expansion of the Focusing process discovered and developed by Eugene Gendlin in the late 1960s.
IRF is a process for emotional healing, and for accessing positive energy and insights for forward movement in one’s life.
Cornell, while a graduate student in Linguistics at the University of Chicago, met Gendlin in 1972 and learned his technique. In 1980 she began collaborating with him in teaching his Focusing workshops. Using her capacity for linguistics, Cornell helped develop the concept of Focusing guiding, and in the early 1980s she offered the first seminars on Focusing guiding. Her continuation of this process led to her development, with Barbara McGavin, of Inner Relationship Focusing.
IRF took shape when Ann Weiser Cornell moved from Chicago to California in 1983 and began teaching Focusing to people who knew nothing about it. She discovered that many people who were not automatically adept at it needed new techniques and new language to draw out their ability to learn the process. Eventually her discoveries of what worked best for the majority of people, combined with the input, inspiration, and insights of her British collaborator Barbara McGavin, evolved into IRF in the 1990s. Cornell incorporated her new techniques and insights into her first books, The Focusing Student’s Manual (1993) and The Focusing Guide’s Manual (1994) – both later revised with Barbara McGavin and published in 2002 as The Focusing Student’s and Companion’s Manual – and in all of her subsequent books, which have become classic textbooks on Focusing.
IRF is a refined and expanded form of Eugene Gendlin’s original six-step process of Focusing, which he had detailed in his 1978 book of the same title. IRF emphasizes being in gentle, allowing relationship with all parts of one’s being, including parts that are in conflict, parts often denied or pushed away as unacceptable or demeaning, parts that are overwhelming, and parts that are so buried or subtle they need to be drawn out with patience and gentleness. In allowing all aspects of the personality to be held in acceptance and awareness, new insights and shifts can emerge and healing can occur. IRF therefore emphasizes the relationship of the Self with the various inner aspects, however painful, and it relies specifically on a quality of Presence, or the ability of the Self to be present with these aspects in a quality of friendliness, gentle curiosity, and nonjudgement. A major feature of IRF is gently finding out how a specific aspect or felt experience feels from its point of view. Another feature is giving awareness to parts of oneself that are opposing – either afraid of or objecting to – a difficult or troublesome part. IRF radically allows and accepts all parts or inner experiences. It also avoids the extremes of denial/”exile” and merging/identification/overwhelm, through using the quality of Presence to gently experience and navigate one’s inner world in a calm, detached, but gently curious and inviting way.
Differences from Gendlin’s Original Focusing
Eugene Gendlin’s original Focusing process, described in his 1978 book, is a process that he generalises as having six steps:
Clearing a space;
Allowing a “felt sense” to form;
Finding a handle;
IRF, developed in the late 1980s through the late 1990s, is a more fluid process, and eschews or modifies certain aspects of Gendlin’s. For instance, rather than clearing a space, IRF uses a mental scan of the body for what feels open and alive, and what needs acknowledging – without moving any issue “out” – in order to more fully accept or find what may be wanting attention.
Rather than “asking”, the Focuser uses the quality of Presence to allow what wants to be expressed – hidden feelings, thoughts, and incipient information – to come forth. The guide, if used, gives gentle suggestions rather than asking questions in order not to intrude on the process or deflect attention away from the inner experience. This stage, which includes the stage called “resonating” in Gendlin’s format, is an important and lengthy one in IRF, and includes settling down with “it” (the felt experience or the partial self), keeping it company, and sensing its point of view, including what it wants and what it does not want.
An important principle in IRF is not denying or exiling any thoughts, feelings, or partial selves – not even the inner critic – but rather empathising with all parts and aspects and sensing what they want to communicate and why. Cornell calls this “the radical acceptance of everything”. Another central principle is the aspect of Presence, or “Self-in-Presence”: gentle listening, with equanimity, to everything that comes up in the Focusing process. In addition, specific language and language/thought patterns are encouraged, which Cornell calls “Presence language”, in order to facilitate this process. And as indicated by its name, IRF gives high priority to the relationship of the Focuser to his inwardly felt experience or aspects of his inner life. The role of the guide, if one is used, is to support this relationship.
Since the early 1990s Cornell has taught IRF throughout the US at venues including Esalen, the National Institute for the Clinical Application of Behavioural Medicine, and the American Psychological Association, and also around the world. IRF is now used and taught all over the world, including in Afghanistan and Pakistan.
Psychologist and self-help author Helene Brenner calls IRF “one of the most powerful techniques I know for emotional healing”. CC Leigh, whose Inseeing Process of self-healing and spiritual growth is largely based on IRF, calls IRF a “highly refined technology for getting in touch with the inner dynamics that typically lie beneath the threshold of awareness, and befriending them from a state of Presence so they can open up and organically evolve”. IRF has been recommended in several 21st-century psychology textbooks, stress-reduction manuals, and other self-improvement texts, and it is the commonest adaptation of the Focusing form used today.
Emotionally focused therapy and emotion-focused therapy (EFT) are a family of related approaches to psychotherapy with individuals, couples, or families.
EFT approaches include elements of experiential therapy (such as person-centred therapy and Gestalt therapy), systemic therapy, and attachment theory. EFT is usually a short-term treatment (8-20 sessions). EFT approaches are based on the premise that human emotions are connected to human needs, and therefore emotions have an innately adaptive potential that, if activated and worked through, can help people change problematic emotional states and interpersonal relationships. Emotion-focused therapy for individuals was originally known as process-experiential therapy, and it is still sometimes called by that name.
EFT should not be confused with emotion-focused coping, a category of coping proposed by some psychologists, although clinicians have used EFT to help improve clients’ emotion-focused coping.
EFT began in the mid-1980s as an approach to helping couples. EFT was originally formulated and tested by Sue Johnson and Les Greenberg in 1985, and the first manual for emotionally focused couples therapy was published in 1988.
To develop the approach, Johnson and Greenberg began reviewing videos of sessions of couples therapy to identify, through observation and task analysis, the elements that lead to positive change. They were influenced in their observations by the humanistic experiential psychotherapies of Carl Rogers and Fritz Perls, both of whom valued (in different ways) present-moment emotional experience for its power to create meaning and guide behaviour. Johnson and Greenberg saw the need to combine experiential therapy with the systems theoretical view that meaning-making and behaviour cannot be considered outside of the whole situation in which they occur. In this “experiential–systemic” approach to couples therapy, as in other approaches to systemic therapy, the problem is viewed as belonging not to one partner, but rather to the cyclical reinforcing patterns of interactions between partners. Emotion is viewed not only as a within-individual phenomena, but also as part of the whole system that organises the interactions between partners.
In 1986, Greenberg chose “to refocus his efforts on developing and studying an experiential approach to individual therapy”. Greenberg and colleagues shifted their attention away from couples therapy toward individual psychotherapy. They attended to emotional experiencing and its role in individual self-organisation. Building on the experiential theories of Rogers and Perls and others such as Eugene Gendlin, as well as on their own extensive work on information processing and the adaptive role of emotion in human functioning, Greenberg, Rice & Elliott (1993) created a treatment manual with numerous clearly outlined principles for what they called a process-experiential approach to psychological change. Elliott et al. (2004) and Goldman & Greenberg (2015) have further expanded the process-experiential approach, providing detailed manuals of specific principles and methods of therapeutic intervention. Goldman & Greenberg (2015) presented case formulation maps for this approach.
Johnson continued to develop EFT for couples, integrating attachment theory with systemic and humanistic approaches, and explicitly expanding attachment theory’s understanding of love relationships. Johnson’s model retained the original three stages and nine steps and two sets of interventions that aim to reshape the attachment bond: one set of interventions to track and restructure patterns of interaction and one to access and reprocess emotion (Refer to Stages and Steps below). Johnson’s goal is the creation of positive cycles of interpersonal interaction wherein individuals are able to ask for and offer comfort and support to safe others, facilitating interpersonal emotion regulation.
Greenberg & Goldman (2008) developed a variation of EFT for couples that contains some elements from Greenberg and Johnson’s original formulation but adds several steps and stages. Greenberg and Goldman posit three motivational dimensions that impact emotion regulation in intimate relationships:
Identity or Power; and
Attraction or Liking.
Similar Terminology, Different Meanings
The terms emotion-focused therapy and emotionally focused therapy have different meanings for different therapists.
In Les Greenberg’s approach the term emotion-focused is sometimes used to refer to psychotherapy approaches in general that emphasize emotion. Greenberg “decided that on the basis of the development in emotion theory that treatments such as the process experiential approach, as well as some other approaches that emphasized emotion as the target of change, were sufficiently similar to each other and different from existing approaches to merit being grouped under the general title of emotion-focused approaches.” He and colleague Rhonda Goldman noted their choice to “use the more American phrasing of emotion-focused to refer to therapeutic approaches that focused on emotion, rather than the original, possibly more English term (reflecting both Greenberg’s and Johnson’s backgrounds) emotionally focused.” Greenberg uses the term emotion-focused to suggest assimilative integration of an emotional focus into any approach to psychotherapy. He considers the focus on emotions to be a common factor among various systems of psychotherapy: “The term emotion-focused therapy will, I believe, be used in the future, in its integrative sense, to characterize all therapies that are emotion-focused, be they psychodynamic, cognitive-behavioural, systemic, or humanistic.” Greenberg co-authored a chapter on the importance of research by clinicians and integration of psychotherapy approaches that stated:
In addition to these empirical findings, leaders of major orientations have voiced serious criticisms of their preferred theoretical approaches, while encouraging an open-minded attitude toward other orientations…. Furthermore, clinicians of different orientations recognised that their approaches did not provide them with the clinical repertoire sufficient to address the diversity of clients and their presenting problems.
Sue Johnson’s use of the term emotionally focused therapy refers to a specific model of relationship therapy that explicitly integrates systems and experiential approaches and places prominence upon attachment theory as a theory of emotion regulation. Johnson views attachment needs as a primary motivational system for mammalian survival; her approach to EFT focuses on attachment theory as a theory of adult love wherein attachment, care-giving, and sex are intertwined. Attachment theory is seen to subsume the search for personal autonomy, dependability of the other and a sense of personal and interpersonal attractiveness, love-ability and desire. Johnson’s approach to EFT aims to reshape attachment strategies towards optimal inter-dependency and emotion regulation, for resilience and physical, emotional, and relational health.
All EFT approaches have retained emphasis on the importance of Rogerian empathic attunement and communicated understanding. They all focus upon the value of engaging clients in emotional experiencing moment-to-moment in session. Thus, an experiential focus is prominent in all EFT approaches. All EFT theorists have expressed the view that individuals engage with others on the basis of their emotions, and construct a sense of self from the drama of repeated emotionally laden interactions.
The information-processing theory of emotion and emotional appraisal (in accordance with emotion theorists such as Magda B. Arnold, Paul Ekman, Nico Frijda, and James Gross) and the humanistic, experiential emphasis on moment-to-moment emotional expression (developing the earlier psychotherapy approaches of Carl Rogers, Fritz Perls, and Eugene Gendlin) have been strong components of all EFT approaches since their inception. EFT approaches value emotion as the target and agent of change, honouring the intersection of emotion, cognition, and behaviour. EFT approaches posit that emotion is the first, often subconscious response to experience. All EFT approaches also use the framework of primary and secondary (reactive) emotion responses.
Maladaptive Emotion Responses and Negative Patterns of Interaction
Greenberg and some other EFT theorists have categorized emotion responses into four types (refer to Emotion Response Types below) to help therapists decide how to respond to a client at a particular time: primary adaptive, primary maladaptive, secondary reactive, and instrumental. Greenberg has posited six principles of emotion processing:
Awareness of emotion or naming what one feels;
Regulation of emotion;
Reflection on experience;
Transformation of emotion by emotion; and
Corrective experience of emotion through new lived experiences in therapy and in the world.
While primary adaptive emotion responses are seen as a reliable guide for behaviour in the present situation, primary maladaptive emotion responses are seen as an unreliable guide for behaviour in the present situation (alongside other possible emotional difficulties such as lack of emotional awareness, emotion dysregulation, and problems in meaning-making).
Johnson rarely distinguishes between adaptive and maladaptive primary emotion responses, and rarely distinguishes emotion responses as dysfunctional or functional. Instead, primary emotional responses are usually construed as normal survival reactions in the face of what John Bowlby called “separation distress”. EFT for couples, like other systemic therapies that emphasize interpersonal relationships, presumes that the patterns of interpersonal interaction are the problematic or dysfunctional element. The patterns of interaction are amenable to change after accessing the underlying primary emotion responses that are subconsciously driving the ineffective, negative reinforcing cycles of interaction. Validating reactive emotion responses and reprocessing newly accessed primary emotion responses is part of the change process.
Goldman & Greenberg 2015 proposed a 14-step case formulation process that regards emotion-related problems as stemming from at least four different possible causes:
Lack of awareness or avoidance of emotion;
Dysregulation of emotion;
Maladaptive emotion response; or
A problem with making meaning of experiences.
The theory features four types of emotion response (refer to Emotion Response Types below), categorizes needs under “attachment” and “identity”, specifies four types of emotional processing difficulties, delineates different types of empathy, has at least a dozen different task markers (refer to Therapeutic tasks below), relies on two interactive tracks of emotion and narrative processes as sources of information about a client, and presumes a dialectical-constructivist model of psychological development and an emotion schematic system.
The emotion schematic system is seen as the central catalyst of self-organisation, often at the base of dysfunction and ultimately the road to cure. For simplicity, we use the term emotion schematic process to refer to the complex synthesis process in which a number of co-activated emotion schemes co-apply, to produce a unified sense of self in relation to the world.
Techniques used in “coaching clients to work through their feelings” may include the Gestalt therapy empty chair technique, frequently used for resolving “unfinished business”, and the two-chair technique, frequently used for self-critical splits.
Emotion Response Types
Emotion-focused theorists have posited that each person’s emotions are organised into idiosyncratic emotion schemes that are highly variable both between people and within the same person over time, but for practical purposes emotional responses can be classified into four broad types:
Secondary reactive; and
Primary adaptive emotion responses are initial emotional responses to a given stimulus that have a clear beneficial value in the present situation – for example, sadness at loss, anger at violation, and fear at threat. Sadness is an adaptive response when it motivates people to reconnect with someone or something important that is missing. Anger is an adaptive response when it motivates people to take assertive action to end the violation. Fear is an adaptive response when it motivates people to avoid or escape an overwhelming threat. In addition to emotions that indicate action tendencies (such as the three just mentioned), primary adaptive emotion responses include the feeling of being certain and in control or uncertain and out of control, and/or a general felt sense of emotional pain – these feelings and emotional pain do not provide immediate action tendencies but do provide adaptive information that can be symbolised and worked through in therapy. Primary adaptive emotion responses “are attended to and expressed in therapy in order to access the adaptive information and action tendency to guide problem solving.”
Primary maladaptive emotion responses are also initial emotional responses to a given stimulus; however, they are based on emotion schemes that are no longer useful (and that may or may not have been useful in the person’s past) and that were often formed through previous traumatic experiences. Examples include sadness at the joy of others, anger at the genuine caring or concern of others, fear at harmless situations, and chronic feelings of insecurity/fear or worthlessness/shame. For example, a person may respond with anger at the genuine caring or concern of others because as a child he or she was offered caring or concern that was usually followed by a violation; as a result, he or she learned to respond to caring or concern with anger even when there is no violation. The person’s angry response is understandable, and needs to be met with empathy and compassion even though his or her angry response is not helpful. Primary maladaptive emotion responses are accessed in therapy with the aim of transforming the emotion scheme through new experiences.
Secondary reactive emotion responses are complex chain reactions where a person reacts to his or her primary adaptive or maladaptive emotional response and then replaces it with another, secondary emotional response. In other words, they are emotional responses to prior emotional responses (“Secondary” means that a different emotion response occurred first). They can include secondary reactions of hopelessness, helplessness, rage, or despair that occur in response to primary emotion responses that are experienced (secondarily) as painful, uncontrollable, or violating. They may be escalations of a primary emotion response, as when people are angry about being angry, afraid of their fear, or sad about their sadness. They may be defences against a primary emotion response, such as feeling anger to avoid sadness or fear to avoid anger; this can include gender role-stereotypical responses such as expressing anger when feeling primarily afraid (stereotypical of men’s gender role), or expressing sadness when primarily angry (stereotypical of women’s gender role). “These are all complex, self-reflexive processes of reacting to one’s emotions and transforming one emotion into another. Crying, for example, is not always true grieving that leads to relief, but rather can be the crying of secondary helplessness or frustration that results in feeling worse.” Secondary reactive emotion responses are accessed and explored in therapy in order to increase awareness of them and to arrive at more primary and adaptive emotion responses.
Instrumental emotion responses are experienced and expressed by a person because the person has learned that the response has an effect on others, “such as getting them to pay attention to us, to go along with something we want them to do for us, to approve of us, or perhaps most often just not to disapprove of us.” Instrumental emotion responses can be consciously intended or unconsciously learned (i.e. through operant conditioning). Examples include crocodile tears (instrumental sadness), bullying (instrumental anger), crying wolf (instrumental fear), and feigned embarrassment (instrumental shame). When a client responds in therapy with instrumental emotion responses, it may feel manipulative or superficial to the therapist. Instrumental emotion responses are explored in therapy in order to increase awareness of their interpersonal function and/or the associated primary and secondary gain.
The Therapeutic Process with different Emotion Responses
Emotion-focused theorists have proposed that each type of emotion response calls for a different intervention process by the therapist. Primary adaptive emotion responses need be more fully allowed and accessed for their adaptive information. Primary maladaptive emotion responses need to be accessed and explored to help the client identify core unmet needs (e.g. for validation, safety, or connection), and then regulated and transformed with new experiences and new adaptive emotions. Secondary reactive emotion responses need empathic exploration in order to discover the sequence of emotions that preceded them. Instrumental emotion responses need to be explored interpersonally in the therapeutic relationship to increase awareness of them and address how they are functioning in the client’s situation.
It is important to note that primary emotion responses are not called “primary” because they are somehow more real than the other responses; all of the responses feel real to a person, but therapists can classify them into these four types in order to help clarify the functions of the response in the client’s situation and how to intervene appropriately.
A therapeutic task is an immediate problem that a client needs to resolve in a psychotherapy session. In the 1970s and 1980s, researchers such as Laura North Rice (a former colleague of Carl Rogers) applied task analysis to transcripts of psychotherapy sessions in an attempt to describe in more detail the process of clients’ cognitive and emotional change, so that therapists might more reliably provide optimal conditions for change. This kind of psychotherapy process research eventually led to a standardized (and evolving) set of therapeutic tasks in emotion-focused therapy for individuals.
The following table summarizes the standard set of these therapeutic tasks as of 2012. The tasks are classified into five broad groups:
The task marker is an observable sign that a client may be ready to work on the associated task. The intervention process is a sequence of actions carried out by therapist and client in working on the task. The end state is the desired resolution of the immediate problem.
In addition to the task markers listed below, other markers and intervention processes for working with emotion and narrative have been specified: same old stories, empty stories, unstoried emotions, and broken stories.
Unfinished business (lingering bad feeling regarding significant other)
Let go of resentments, unmet needs regarding other; affirm self; understand or hold other accountable
Stuck, dysregulated anguish
Emotional/bodily relief, self-empowerment
Experienced therapists can create new tasks; EFT therapist Robert Elliott, in a 2010 interview, noted that “the highest level of mastery of the therapy – EFT included – is to be able to create new structures, new tasks. You haven’t really mastered EFT or some other therapy until you actually can begin to create new tasks.”
The interventions and the structure of emotion-focused therapy have been adapted for the specific needs of psychological trauma survivors. A manual of emotion-focused therapy for individuals with complex trauma (EFTT) has been published. For example, modifications of the traditional Gestalt empty chair technique have been developed.
Other Versions of EFT for Individuals
Brubacher (2017) proposed an emotionally focused approach to individual therapy that focuses on attachment, while integrating the experiential focus of empathic attunement for engaging and reprocessing emotional experience and tracking and restructuring the systemic aspects and patterns of emotion regulation. The therapist follows the attachment model by addressing deactivating and hyperactivating strategies. Individual therapy is seen as a process of developing secure connections between therapist and client, between client and past and present relationships, and within the client. Attachment principles guide therapy in the following ways: forming the collaborative therapeutic relationship, shaping the overall goal for therapy to be that of “effective dependency” (following John Bowlby) upon one or two safe others, depathologising emotion by normalizing separation distress responses, and shaping change processes. The change processes are: identifying and strengthening patterns of emotion regulation, and creating corrective emotional experiences to transform negative patterns into secure bonds.
Gayner (2019) integrated EFT principles and methods with mindfulness-based cognitive therapy and mindfulness-based stress reduction.
A systemic perspective is important in all approaches to EFT for couples. Tracking conflictual patterns of interaction, often referred to as a “dance” in Johnson’s popular literature, has been a hallmark of the first stage of Johnson and Greenberg’s approach since its inception in 1985. In Goldman and Greenberg’s newer approach, therapists help clients “also work toward self-change and the resolution of pain stemming from unmet childhood needs that affect the couple interaction, in addition to working on interactional change.” Goldman and Greenberg justify their added emphasis on self-change by noting that not all problems in a relationship can be solved only by tracking and changing patterns of interaction:
In addition, in our observations of psychotherapeutic work with couples, we have found that problems or difficulties that can be traced to core identity concerns such as needs for validation or a sense of worth are often best healed through therapeutic methods directed toward the self rather than to the interactions. For example, if a person’s core emotion is one of shame and they feel “rotten at the core” or “simply fundamentally flawed,” soothing or reassuring from one’s partner, while helpful, will not ultimately solve the problem, lead to structural emotional change, or alter the view of oneself.
In Greenberg and Goldman’s approach to EFT for couples, although they “fully endorse” the importance of attachment, attachment is not considered to be the only interpersonal motivation of couples; instead, attachment is considered to be one of three aspects of relational functioning, along with issues of identity/power and attraction/liking. In Johnson’s approach, attachment theory is considered to be the defining theory of adult love, subsuming other motivations, and it guides the therapist in processing and reprocessing emotion.
In Greenberg and Goldman’s approach, the emphasis is on working with core issues related to identity (working models of self and other) and promoting both self-soothing and other-soothing for a better relationship, in addition to interactional change. In Johnson’s approach, the primary goal is to reshape attachment bonds and create “effective dependency” (including secure attachment).
Stages and Steps
EFT for couples features a nine-step model of restructuring the attachment bond between partners. In this approach, the aim is to reshape the attachment bond and create more effective co-regulation and “effective dependency”, increasing individuals’ self-regulation and resilience. In good-outcome cases, the couple is helped to respond and thereby meet each other’s unmet needs and injuries from childhood. The newly shaped secure attachment bond may become the best antidote to a traumatic experience from within and outside of the relationship.
Adding to the original three-stage, nine-step EFT framework developed by Johnson and Greenberg, Greenberg and Goldman’s emotion-focused therapy for couples has five stages and 14 steps. It is structured to work on identity issues and self-regulation prior to changing negative interactions. It is considered necessary, in this approach, to help partners experience and reveal their own underlying vulnerable feelings first, so they are better equipped to do the intense work of attuning to the other partner and to be open to restructuring interactions and the attachment bond.
Johnson (2008) summarizes the nine treatment steps in Johnson’s model of EFT for couples: “The therapist leads the couple through these steps in a spiral fashion, as one step incorporates and leads into the other. In mildly distressed couples, partners usually work quickly through the steps at a parallel rate. In more distressed couples, the more passive or withdrawn partner is usually invited to go through the steps slightly ahead of the other.”
Stage 1. Stabilisation (Assessment and De-Escalation Phase)
Step 1: Identify the relational conflict issues between the partners.
Step 2: Identify the negative interaction cycle where these issues are expressed.
Step 3: Access attachment emotions underlying the position each partner takes in this cycle.
Step 4: Reframe the problem in terms of the cycle, unacknowledged emotions, and attachment needs.
During this stage, the therapist creates a comfortable and stable environment for the couple to have an open discussion about any hesitations the couples may have about the therapy, including the trustworthiness of the therapist. The therapist also gets a sense of the couple’s positive and negative interactions from past and present and is able to summarize and present the negative patterns for them. Partners soon no longer view themselves as victims of their negative interaction cycle; they are now allies against it.
Stage 2. Restructuring the Bond (Changing Interactional positions Phase)
Step 5: Access disowned or implicit needs (e.g., need for reassurance), emotions (e.g., shame), and models of self.
Step 6: Promote each partner’s acceptance of the other’s experience.
Step 7: Facilitate each partner’s expression of needs and wants to restructure the interaction based on new understandings and create bonding events.
This stage involves restructuring and widening the emotional experiences of the couple. This is done through couples recognising their attachment needs and then changing their interactions based on those needs. At first, their new way of interacting may be strange and hard to accept, but as they become more aware and in control of their interactions they are able to stop old patterns of behaviour from re-emerging.
Stage 3. Integration and Consolidation
Step 8: Facilitate the formulation of new stories and new solutions to old problems.
Step 9: Consolidate new cycles of behaviour.
This stage focuses on the reflection of new emotional experiences and self-concepts. It integrates the couple’s new ways of dealing with problems within themselves and in the relationship.
Styles of Attachment
Johnson & Sims (2000) described four attachment styles that affect the therapy process:
Secure attachment: People who are secure and trusting perceive themselves as lovable, able to trust others and themselves within a relationship. They give clear emotional signals, and are engaged, resourceful and flexible in unclear relationships. Secure partners express feelings, articulate needs, and allow their own vulnerability to show.
Avoidant attachment: People who have a diminished ability to articulate feelings, tend not to acknowledge their need for attachment, and struggle to name their needs in a relationship. They tend to adopt a safe position and solve problems dispassionately without understanding the effect that their safe distance has on their partners.
Anxious attachment: People who are psychologically reactive and who exhibit anxious attachment. They tend to demand reassurance in an aggressive way, demand their partner’s attachment and tend to use blame strategies (including emotional blackmail) in order to engage their partner.
Fearful-avoidant attachment: People who have been traumatised and have experienced little to no recovery from it vacillate between attachment and hostility. This is sometimes referred to as disorganised attachment.
The emotionally focused family therapy (EFFT) of Johnson and her colleagues aims to promote secure bonds among distressed family members. It is a therapy approach consistent with the attachment-oriented experiential-systemic emotionally focused model in three stages:
De-escalating negative cycles of interaction that amplify conflict and insecure connections between parents and children;
Restructuring interactions to shape positive cycles of parental accessibility and responsiveness to offer the child or adolescent a safe haven and a secure base;
Consolidation of the new responsive cycles and secure bonds.
Its primary focus is on strengthening parental responsiveness and care-giving, to meet children and adolescents’ attachment needs. It aims to “build stronger families through (1) recruiting and strengthening parental emotional responsiveness to children, (2) accessing and clarifying children’s attachment needs, and (3) facilitating and shaping care-giving interactions from parent to child”. Some clinicians have integrated EFFT with play therapy.
One group of clinicians, inspired in part by Greenberg’s approach to EFT, developed a treatment protocol specifically for families of individuals struggling with an eating disorder. The treatment is based on the principles and techniques of four different approaches: emotion-focused therapy, behavioural family therapy, motivational enhancement therapy, and the New Maudsley family skills-based approach. It aims to help parents “support their child in the processing of emotions, increasing their emotional self-efficacy, deepening the parent–child relationships and thereby making ED [eating disorder] symptoms unnecessary to cope with painful emotional experiences”. The treatment has three main domains of intervention, four core principles, and five steps derived from Greenberg’s emotion-focused approach and influenced by John Gottman:
Attending to the child’s emotional experience;
Naming the emotions;
Validating the emotional experience;
Meeting the emotional need; and
Helping the child to move through the emotional experience, problem solving if necessary.
Johnson, Greenberg, and many of their colleagues have spent their long careers as academic researchers publishing the results of empirical studies of various forms of EFT.
The American Psychological Association considers emotion-focused therapy for individuals to be an empirically supported treatment for depression. Studies have suggested that it is effective in the treatment of depression, interpersonal problems, trauma, and avoidant personality disorder.
Practitioners of EFT have claimed that studies have consistently shown clinically significant improvement post therapy. Studies, again mostly by EFT practitioners, have suggested that emotionally focused therapy for couples is an effective way to restructure distressed couple relationships into safe and secure bonds with long-lasting results. Johnson et al. (1999) conducted a meta-analysis of the four most rigorous outcome studies before 2000 and concluded that the original nine-step, three-stage emotionally focused therapy approach to couples therapy had a larger effect size than any other couple intervention had achieved to date, but this meta-analysis was later harshly criticized by psychologist James C. Coyne, who called it “a poor quality meta-analysis of what should have been left as pilot studies conducted by promoters of a therapy in their own lab”. A study with an fMRI component conducted in collaboration with American neuroscientist Jim Coan suggested that emotionally focused couples therapy reduces the brain’s response to threat in the presence of a romantic partner; this study was also criticised by Coyne.
Some of the strengths of EFT approaches can be summarized as follows:
EFT aims to be collaborative and respectful of clients, combining experiential person-centred therapy techniques with systemic therapy interventions.
Change strategies and interventions are specified through intensive analysis of psychotherapy process.
EFT has been validated by 30 years of empirical research. There is also research on the change processes and predictors of success.
EFT has been applied to different kinds of problems and populations, although more research on different populations and cultural adaptations is needed.
EFT for couples is based on conceptualisations of marital distress and adult love that are supported by empirical research on the nature of adult interpersonal attachment.
Psychotherapist Campbell Purton, in his 2014 book The Trouble with Psychotherapy, criticised a variety of approaches to psychotherapy, including behaviour therapy, person-centred therapy, psychodynamic therapy, cognitive behavioural therapy, emotion-focused therapy, and existential therapy; he argued that these psychotherapies have accumulated excessive and/or flawed theoretical baggage that deviates too much from an everyday common-sense understanding of personal troubles. With regard to emotion-focused therapy, Purton argued that “the effectiveness of each of the ‘therapeutic tasks’ can be understood without the theory” and that what clients say “is not well explained in terms of the interaction of emotion schemes; it is better explained in terms of the person’s situation, their response to it, and their having learned the particular language in which they articulate their response.”
In 2014, psychologist James C. Coyne criticised some EFT research for lack of rigor (for example, being underpowered and having high risk of bias), but he also noted that such problems are common in the field of psychotherapy research.
In a 2015 article in Behavioural and Brain Sciences on “memory reconsolidation, emotional arousal and the process of change in psychotherapy”, Richard D. Lane and colleagues summarized a common claim in the literature on emotion-focused therapy that “emotional arousal is a key ingredient in therapeutic change” and that “emotional arousal is critical to psychotherapeutic success”. In a response accompanying the article, Bruce Ecker and colleagues (creators of coherence therapy) disagreed with this claim and argued that the key ingredient in therapeutic change involving memory reconsolidation is not emotional arousal but instead a perceived mismatch between an expected pattern and an experienced pattern; they wrote:
The brain clearly does not require emotional arousal per se for inducing deconsolidation. That is a fundamental point. If the target learning happens to be emotional, then its reactivation (the first of the two required elements) of course entails an experience of that emotion, but the emotion itself does not inherently play a role in the mismatch that then deconsolidates the target learning, or in the new learning that then rewrites and erases the target learning (discussed at greater length in Ecker 2015). […] The same considerations imply that “changing emotion with emotion” (stated three times by Lane et al.) inaccurately characterizes how learned responses change through reconsolidation. Mismatch consists most fundamentally of a direct, unmistakable perception that the world functions differently from one’s learned model. “Changing model with mismatch” is the core phenomenology.
Other responses to Lane et al. (2015) argued that their emotion-focused approach “would be strengthened by the inclusion of predictions regarding additional factors that might influence treatment response, predictions for improving outcomes for non-responsive patients, and a discussion of how the proposed model might explain individual differences in vulnerability for mental health problems”, and that their model needed further development to account for the diversity of states called “psychopathology” and the relevant maintaining and worsening processes.
In psychodynamic psychotherapy, working through is seen as the process of repeating, elaborating, and amplifying interpretations. It is believed that such working through is critical towards the success of therapy.
Interpretations are made when the client comes up with some material, be it written, a piece of art, music, or verbal, and are intended to bring the material offered into connection with the unconscious mind. Because of the resistance to accepting the unconscious, interpretations, whether correct or partially incorrect, consciously accepted or rejected, will inevitably require amplifying and extending to other aspects of the client’s life.
In a process Sandor Rado compared to the labour of mourning, the unconscious content must be demonstrated repeatedly in all its various forms and linkages – the process of working through.
Because of the power of resistance, the client’s rational thought and conscious awareness may not be sufficient on their own to overcome the maladjustment, entailing further interpretation and further working through.
Before formulating the concept of working through, in his case study of the Rat Man, Freud wrote of his interpretations:
“It is never the aim of discussions like these to create convictions. They are only intended to bring the repressed complexes into consciousness…and to facilitate the emergence of fresh material from the unconscious. A sense of conviction is only attained after the patient has himself worked over the reclaimed material”.
The necessity of working through the transference is stressed in almost all forms of psychodynamic therapy, from object relations theory, through the openings offered for working through by transference disruption in self psychology, to the repetitive exploration of the transference in group therapy.
Transference neurosis is a term that Sigmund Freud introduced in 1914 to describe a new form of the analysand’s infantile neurosis that develops during the psychoanalytic process.
Based on Dora’s case history, Freud suggested that during therapy the creation of new symptoms stops, but new versions of the patient’s fantasies and impulses are generated. He called these newer versions “transferences” and characterised them as the substitution of the analyst for a person from the patient’s past. According to Freud’s description: “a whole series of psychological experiences are revived not as belonging to the past, but as applying to the person of the analyst at the present moment”. When transference neurosis develops, the relationship with the therapist becomes the most important one for the patient, who directs strong infantile feelings and conflicts towards the therapist, e.g. the patient may react as if the analyst is his/her father.
Transference neurosis can be distinguished from other kinds of transference because:
It is very vivid and it rekindles the infantile neurosis.
It is generated by the feelings of frustration that the analysand inevitably experiences during sessions, since the analyst does not fulfil the analysand’s longings.
In transference neurosis the symptoms are not stable, but they are transformed.
Regression and repetition play a key role in the creation of transference neurosis.
Transference neurosis reveals the particular meanings that the analysand has given to current infantile relationships and events, which generate internal conflicts between wishes and particular defences formed to strive against them. These meanings are united and create several transference patterns.
Once transference neurosis has developed, it leads to a form of resistance, called “transference resistance”. At this point, the analysis of the transference becomes difficult since new obstacles arise in therapy, e.g. the analysand may insist on fulfilling the infantile wishes that emerged in transference, or may refuse to acknowledge that the current experience is, in fact, a reproduction of a past experience. However, the successful resolution of transference neurosis through interpretation will lead to the lifting of repression and will enable the Ego to solve the infantile conflicts in new ways. Furthermore, it will allow the analysand to recognize that the current relationship with the analyst is based on repetition of childhood experiences, leading to the detachment of the patient from the analyst.
The replacement of the infantile neurosis by transference neurosis and its resolution through interpretation remains the main focus of the classical psychoanalytic therapy. In other types of therapy, either the transference neurosis does not develop at all, or it does not play a central role in the therapy process. Although it is more likely for transference neurosis to develop in psychoanalysis, where the sessions are more frequent, it may also appear during psychotherapy.
Intensive short-term dynamic psychotherapy (ISTDP) is a form of short-term psychotherapy developed through empirical, video-recorded research by Habib Davanloo.
The therapy’s primary goal is to help the patient overcome internal resistance to experiencing true feelings about the present and past which have been warded off because they are either too frightening or too painful. The technique is intensive in that it aims to help the patient experience these warded-off feelings to the maximum degree possible; it is short-term in that it tries to achieve this experience as quickly as possible; it is dynamic because it involves working with unconscious forces and transference feelings.
Patients come to therapy because of either symptoms or interpersonal difficulties. Symptoms include traditional psychological problems like anxiety and depression, but they also include physical symptoms without medically identifiable cause, such as headache, shortness of breath, diarrhoea, or sudden weakness. The ISTDP model attributes these to the occurrence of distressing situations where painful or forbidden emotions are triggered outside of awareness. Within psychiatry, these phenomena are classified as “Somatoform Disorders” in DSM-IV-TR.
The therapy itself was developed during the 1960s to 1990s by Habib Davanloo, a psychiatrist and psychoanalyst from Montreal. He video recorded patient sessions and watched the recordings in minute detail to determine as precisely as possible what sorts of interventions were most effective in overcoming resistance, which he believed was acting to keep painful or frightening feelings out of awareness and prevent interpersonal closeness.
ISTDP is taught by Habib Davanloo at McGill University, as well as in other University and post-graduate settings around the world. The ISTDP Institute offers on-line ISTDP training materials, including introductory videos and skill-building exercises.
Origins and Theoretical Foundation
In 1895, Josef Breuer and Sigmund Freud published their Studies on Hysteria, which looked at a series of case studies where patients presented with dramatic neurological symptoms, such as “Anna O” who suffered headaches, partial paralysis, loss of sensation, and visual disturbances. These symptoms did not conform to known patterns of neurological disease, and neurologists were thus unable to account for symptoms in purely anatomical or physiological terms. Breuer’s breakthrough was the discovery that symptomatic relief could be brought about by encouraging patients to speak freely about emotionally difficult aspects of their lives. Experiencing these emotions which had been previously outside of awareness seemed to be the curative factor. This cure became known as catharsis, and the experiencing of the previously forbidden or painful emotion was abreaction.
Freud tried various techniques to deal with the fact that patients generally seemed resistant to experiencing painful feelings. He moved from hypnosis to free association, interpretation of resistance, and dream interpretation. With each step, therapy became longer. Freud himself was quite open about the possibility that there were many patients for whom analysis could bring little or no relief, and he discusses the factors in his 1937 paper “Analysis Terminable and Interminable.”
From the 1930s through the 1950s, a number of analysts were researching methods of shortening the course of therapy without sacrificing therapeutic effectiveness. These included Sándor Ferenczi, Franz Alexander, Peter Sifneos, David Malan, and Habib Davanloo. One of the first discoveries was that the patients who appeared to benefit most from therapy were those who could rapidly engage, could describe a specific therapeutic focus, and could quickly move to experience their previously warded-off feelings. These also happened to represent those patients who were the healthiest to begin with and therefore had the least need for the therapy being offered. Clinical research revealed that these “rapid responders” were able to recover quickly with therapy because they were the least traumatised and therefore had the smallest burden of repressed emotion, and so were least resistant to experiencing the emotions related to trauma. However, these patients represented only a small minority of those arriving at psychiatric clinics; the vast majority remained unreachable with the newly developing techniques.
A number of psychiatrists began directing their psychotherapeutic research into methods of overcoming resistance. Dr. David Malan popularised a model of resistance, known as the Triangle of Conflict, which had first been proposed by Henry Ezriel. At the bottom of the triangle are the patient’s true, impulse-laden feelings, outside of conscious awareness. When those emotions rise to a certain degree and threaten to break into conscious awareness, they trigger anxiety. The patient manages this anxiety by deploying defences, which lessen anxiety by pushing emotions back into the unconscious.
The emotions at the bottom of Malan’s Triangle of Conflict originate in the patient’s past, and Malan’s second triangle, the Triangle of Persons, originally proposed by Menninger, explains that old emotions generated from the past are triggered in current relationships and also get triggered in the relationship with the therapist. The question of how maladaptive patterns of interpersonal behaviour could arise from early childhood experiences in the family of origin was postulated within psychoanalytic theory. Independent empirical support came from Bowlby’s newly arising field of Attachment Theory.
Bowlby and Attachment Trauma
John Bowlby, a British psychiatrist and psychoanalyst, was very interested in the impact on a child of adverse experiences in relation to its primary attachment figures (usually the mother, but often the father and others) in early life. He concluded, in opposition to received psychoanalytic dogma of the day, that childhood experience was far more important than unconscious fantasy. He also elucidated the nature of attachment, a system of behaviours exhibited by human and other mammalian infants which are innate and have the goal of physical proximity to the mother. For instance, a child taken out of its mother’s arms cries loudly in protest, and it is only quieted by being restored to its mother’s arms. Bowlby observed that the innate attachment system would be activated by loss of proximity to the mother, and that long-lasting trauma to the child could result from attachment interruption. Long term consequences included increased propensity to psychiatric disorders, poor relationship function, and decreased life satisfaction.
Bowlby conducted numerous studies and noted strong correlations between adverse early-life circumstances – primarily the lack of a consistent and nurturing relationship with the mother – as the source of numerous difficulties, including persistent depression, anxiety, or delinquency in adulthood. Childhood traumatisation to the attachment bond, usually through separation from or loss of the primary mother or mother-substitute, led to adult difficulties. Since Bowlby, the effects of trauma over development have consistently been shown to have a significant detrimental impact on adult psychological functioning.
Davanloo’s Discovery of the Unconscious Consequences of Attachment Trauma
In the 1960s, while Bowlby was observing children directly, Davanloo was beginning his work with symptomatic and character-disturbed adults. As he began his video-recording work and became progressively successful against higher levels of resistance, he noted that particular themes reappeared with striking consistency in patient after patient.
First, the therapist’s efforts to get to know the patient’s true feelings often aroused a simultaneous mixed feeling in the patient, composed of deep appreciation for the therapist’s relentless efforts to get to know the patient deeply, combined with equally deep irritation at the therapist for challenging the patient to abandon long-held resistances which could thwart the therapeutic effort.
Davanloo noted, in concert with Malan’s Triangle of Conflict, that patients would unconsciously resist the therapist’s efforts to get to the root of their difficulties. He also observed, from his videotaped sessions, that patients would simultaneously send off signals of their unconscious anxiety. Davanloo carefully monitored these signals of anxiety and saw that they represented the rise of complex mixed feelings with the therapist. The mix represented that part of the patient seeking relief from painful symptoms but also an active desire to avoid painful, repressed feelings.
As Davanloo became more skilled at unlocking the patient’s true unconscious feelings, he noted an often very predictable sequence of feelings. The sequence was by no means invariable, but it occurred frequently enough to allow the therapist to hypothesise its existence in a majority of cases.
First, after a high rise of mixed feeling with the therapist, manifested as signals of intense anxiety (tension in skeletal muscle, often manifested as wringing of the hands, accompanied with deep, sighing respirations), there would often be a breakthrough of rage, accompanied by an immediate drop in anxiety. This rage, Davanloo discovered, is intensely felt. It often has a violent impulse associated with it, sometimes even a murderous impulse. Once patients feel this rage, they are able to describe vividly detailed fantasies of what the rage would do if it were to take on a life of its own.
The rage is a product of thwarted efforts to attach from the past. Those thwarted efforts to love and be loved yield pain, in the form of what Bowlby described as protest. The pain yields a reactive rage at the loved person who thwarted attachment efforts.
Complete experiencing of the rageful impulse is typically accompanied by a tremendous relief at finally getting something out which has yearned for release. However, the relief is typically short lived.
Next, Davanloo almost invariably noted that patients then experience a tremendous wave of guilt about the rage. The guilt is a product of the fact that the old rageful feelings were with a person who was also loved. It is this guilt, Davanloo discovered, which is the key ingredient in symptom formation and character difficulties. Symptoms and interpersonal difficulties (usually unconscious efforts to ward off intimacy and closeness) are the product of guilt, which turns the rage back on the self. For instance, the rage of a two-year-old toward a mother who dies may be experienced in the present as suicidal feelings (self-directed murderous rage).
Beneath the guilty feelings from the past, Davanloo almost invariably noted painful feelings about thwarted efforts at emotional closeness to parents and others in childhood. Finally, at the deepest layer of feelings are the still powerful yearnings for closeness, attachment, and love.
The goal of the ISTDP therapist is, as rapidly as possible, to help the patient overcome resistance, and then experience all the waves of mixed, genuine feeling, previously unconscious, triggered by the intense therapeutic process. Those feelings are traced back to their origins in the past, and then both therapist and patient come to understand how the patient came to be the “consciously confused, unconsciously driven” person in the present. Old pockets of emotion are drained, the patient has a clearer self-narrative, and self-destructive symptoms and defences are renounced. The understanding gained is not just cognitive, but goes to the fundamental, emotional core. The influence of Freud’s early trauma theory is evident.
Specific Therapeutic Interventions
Davanloo discovered the layers of the dynamic unconscious through a process of developing specific interventions which allow the therapist to reach those layers. Those interventions, applied in a specific fashion at specific times in the therapeutic process, are all calculated to overcome the patient’s resistance as quickly and completely as possible, to allow the earliest and fullest experience of true feelings about the present and past as quickly as possible. Those interventions are known as pressure, challenge, and head-on collision.
I. Pressure: Therapeutic Encouragement and Reaching through to the Patient
Pressure is the principal ingredient of ISTDP, and it takes many forms. Initially, pressure takes the form of encouraging the patient to describe symptoms and interpersonal difficulties as specifically as possible, so both patient and therapist get the clearest picture possible of the precise difficulties. It starts from the moment the patient walks into the room, in the form of the question, “Are there some difficulties you are experiencing which you would like us to have a look at?”
The primary form of pressure is pressure toward feeling. Again, this is exerted mainly in the form of questions, such as, “How did you feel toward your boss for humiliating you in front of your staff? We see that you got anxious and depressed, but how did you feel?”
Pressure can be toward the patient’s will: “Can we look to your feelings? Do you want us to look to your feelings?”
Pressure is also exerted toward the therapeutic task: “Our goal here, if you want, is to get to the root, the engine, driving your difficulties. So, can we look at a specific time when you experienced anxiety? This will give us a clear picture of the problem which we can use to get to the engine.”
In its essence, pressure is encouragement from the therapist to the patient. It is encouragement to renounce defences, tolerate anxiety, and walk, with the therapist, into those places which have previously been off-limits. It is a way of saying, “There’s nothing in there we cannot face together, and we do so in your service, to relieve you of painful difficulties.”
Patients with low resistance are often quite responsive to pressure alone. However, as explained above, those are the patients who are healthiest to begin with. For patients with higher levels of resistance, usually the product of a more traumatised early phase of life, pressure quickly leads to the patient erecting barriers with the therapist. Those barriers are the patient’s habitual defences against avoided feelings. The combination of intentional (conscious) and unintentional (unconscious) defences is called the resistance. The therapist is constantly monitoring for both the rise in anxiety and the appearance of resistance. When resistance does make its appearance, new interventions, in addition to pressure, are called for.
II. Challenge: Pointing Out and Interrupting Defences in Concert with the Patient
Challenge is a two-stage process. The first stage is clarification, which is the therapist’s effort to confirm that resistance is operating, and also to acquaint the patient with the specific defence being deployed. Patients are often quite unaware of their own defences. Clarification takes the form of a question, meant to clarify the defence to both patient and therapist: “Do you notice that when you speak of being angry with your boss that you smile and giggle? Is a smile something you sometimes do to cover up a deeper feeling?”
When a defence is properly clarified, both patient and therapist can work together against it, because it represents an obstacle to the therapeutic task of getting to the patient’s true feelings. A defence which has not been clarified is still invisible to the patient. It is also important to note that in childhood, defences can be a useful tool in emotionally overwhelming or traumatic situations. According to Los Angeles-based psychiatrist Katherine Watkins, M.D.:
“defenses such as dissociation and repression can shield us from intense feelings that we are developmentally unprepared to experience and process. However as we grow up, this shielding cuts us off from our full range of feelings, even when we are now emotionally able to handle the feelings.”
Challenge to the defences represents an exhortation to the patient to abandon the defence: “Again you smile when I ask you about feelings in relation to being humiliated by your husband. If you don’t smile, how were you truly feeling?” This particular intervention is a very powerful one in the therapist’s arsenal. As with all powerful interventions, if it is misapplied, the consequences can be severe: rapid misalliance with the therapist, worsening of symptoms, and treatment dropout. This is because the patient perceives a premature challenge, applied when a defence has not been clarified, as a criticism or a personal attack.
A common misunderstanding of ISTDP is that the therapist’s role is to badger the patient through the use of Challenge. However, the proper use of challenge is as an aid or enhancement to the therapeutic alliance by removing an obstacle to the rise in complex feelings with the therapist. If challenge originates as a product of frustration in the therapist or as a misunderstanding of the unconscious, then stalemate is virtually assured.
The main purpose of challenge is to remove any obstacles in the way of the mutually agreed upon task of getting to the engine of the patient’s present difficulties: warded-off, complex feelings in relation to traumatising experiences with important attachment figures in the past.
The majority of patients are able to experience their true mixed feelings with a combination of Pressure and properly clarified Challenge. However, a sizable minority of patients erect a massive wall of resistance with the therapist. This wall is erected automatically and is an over-learned, habitual response, used to avoid emotional intimacy, both with the therapist and with other important figures in the patient’s personal orbit. When the therapist observes that the patient’s resistance has fully crystallised, it is time to deploy the ultimate intervention.
III. Head-On Collision: Pointing Out the Reality of the Defences and Encouragement to Overcome Them
The Head-on Collision is an intervention aimed not at any single defence but rather aimed at the entire defensive structure being deployed by the patient. It is an urgent appeal to the patient to exert maximal effort to overcome the resistance, and it takes the form of a summary statement to the patient which explains the consequences of continuing to resist:
Let’s take a look at what’s happening here. You have come on your own free will, because you are experiencing a problem which causes you pain. We have set out to get to the root of your difficulties, but every time we attempt to move toward it, you put up this massive wall. The wall keeps me out, and it keeps you from knowing your own true feelings. If you keep me out, you keep me useless. Is that what you want? Because, as you see, you are certainly capable of keeping me useless to you. My first question is, why would you want me to be useless? You see, the consequences of this would be that I would be unable to help you. I’d like to, but the nature of this work is that I can’t help everyone. Sometimes I fail. However, can you afford to fail? How much longer do you want to carry this burden?
This complex intervention is simultaneously aimed at the patient’s will, is a reminder of the task, and is a wake-up call to the therapeutic alliance to exert maximal effort against the resistance. It is a reminder, in stark terms, that the therapeutic task is in jeopardy and may well fail. Finally, it is a reminder to the patient of the consequences of failure, as well as an implied reminder that success is also possible.
The interventions of Pressure, Challenge, and Head-on Collision, all aimed at helping the patient experience true feelings in relation to the present and past, allowed Davanloo to expand the scope of patients who can be helped by short-term psychodynamic psychotherapy. A model which initially worked only with highly motivated patients able to describe a clearly problematic area can now be applied to patients whose difficulties are diffuse and whose motivation is also initially quite diffuse. The results are deep, lasting changes in areas of both symptomatic and interpersonal disturbances.
It is also worth stressing that ISTDP, unlike traditional psychodynamic therapies, assiduously avoids interpretation until such time as the unconscious is open. The use of trial interpretations is explicitly avoided. The phase of interpretation only commences once it is clear to both therapist and patient that there has been a passage of previously unconscious emotion. Quite often, it is then the patient who takes the lead in interpreting:
“The incredible rage I felt toward you when you refused to let me off the hook regarding my feelings is exactly the same rage that I felt toward my father when I was five years old and found out he had been killed in the war and wasn’t coming home. I buried the rage that day because I felt so guilty about it. That’s the day I became depressed.”
Davanloo’s initial research was published in the form of a qualitative case series of approximately 200 patients. He maintains a large video library of treated cases which he uses for teaching conferences, though this has not yet been made available for other psychotherapy researchers to independently verify and quantify Davanloo’s claims. Recent studies however, support the efficacy of the ISTDP technique, as described below. He claims efficacy with psychological symptoms, medically unexplained symptoms (so-called functional or somatoform disorders), and characterological disturbances (referred to as Personality Disorders in DSM).
Empirical research into the efficacy of ISTDP, and other brief psychodynamic psychotherapies is active. There are now over 60 published outcome studies in ISTDP including 40 randomised controlled trials for depression, anxiety, personality, somatic symptom and substance use disorders. There are also over 20 studies showing the cost effectiveness of the method through reducing doctor visits, medication costs, hospital costs and disability costs. Summary of cost effectiveness studies to 2018
ISTDP has been investigated for:
Depression and Treatment Resistant Depression.
Functional Neurological Disorders.
Somatic Symptom Disorders: at least 20 studies as of October 2019.
Summary of ISTDP Somatic Condition Studies:
Cost effectiveness studies: at least 22 studies as of October 2019.
As an Adjunct to Care in Severe Mental Disorders.
Substance Use Disorders.
A Cochrane systematic review examined the efficacy of short-term psychodynamic psychotherapies for common mental disorders such as depression, anxiety and personality disorders. Without distinguishing between different forms of STDP from Davanloo’s ISTDP, modest to large short-term gains were reported for a broad range of people experiencing common mental disorders. Further research is required to determine the effectiveness and long term benefits of psychodynamic psychotherapies for common mental disorders. Neuroscientist and Nobel Prize winner, Eric Kandel refers to Davanloo’s technique and its effectiveness in providing relief from emotional disturbances.
Relationship to Cognitive Therapy
Cognitive therapy (CT), developed by Aaron T. Beck, focuses on illogical thoughts as the main driver of emotional difficulties. These beliefs, such as, “Everything I attempt inevitably fails,” are postulated to cause emotional states like depression or hopelessness. The therapist collaborates with the patient to determine which faulty cognitions are currently accepted by the patient as true. Together, the patient and therapist discover these cognitions and collaboratively explore the evidence for and against them. Relief of symptoms comes from replacing unfounded cognitions with more reality-based thoughts. CBT has been shown effective in numerous trials, particularly for depression and anxiety disorders.
While ISTDP accepts the presence of faulty cognitions, the causality is thought to be reversed. The ISTDP therapist would posit that unconscious emotions lead to unconscious anxiety, which is managed by unconscious defences. These defences can certainly include hopeless, helpless, or self-deprecating cognitions. Rather than examining evidence for and against a thought like, “I am unable to know my own true feelings,” an ISTDP therapist might say, “If you adopt that position, which is essentially a position of helplessness, we will not get to the engine driving your difficulties. If you renounce this helpless position, how are you truly feeling right now?”
Both the CT and ISTDP therapist call the thought into question, with the goal of ultimately liberating the patient. The difference is that the ISTDP therapist sees the faulty cognition as preventing access to the true, buried feelings, while the CT therapist sees the faulty cognition as the cause of the painful emotions leading to the painful psychological state. It may well be the case that causality flows in both directions, dependent on the individual, the emotions, and the cognitions involved. As of this writing, though both CT and ISTDP show good evidence of clinical efficacy, the theoretical question of whether feelings drive thoughts or thoughts drive feelings remains unresolved; it could well be the case that thought and feeling are inextricably bound, and that we have not yet developed adequate psychological or neuroscientific concepts and tools to frame these sorts of questions properly.
Transference (German: Übertragung) is a phenomenon within psychotherapy in which the feelings a person had about their parents, as one example, are unconsciously redirected or transferred to the present situation.
It usually concerns feelings from a primary relationship during childhood. At times, this transference can be considered inappropriate. Transference was first described by Sigmund Freud, the founder of psychoanalysis, who considered it an important part of psychoanalytic treatment.
It is common for people to transfer feelings about their parents to their partners or children (that is, cross-generational entanglements). Another example of transference would be a person mistrusting somebody who resembles an ex-spouse in manners, voice, or external appearance, or being overly compliant to someone who resembles a childhood friend.
In The Psychology of the Transference, Carl Jung states that within the transference dyad both participants typically experience a variety of opposites, that in love and in psychological growth, the key to success is the ability to endure the tension of the opposites without abandoning the process, and that this tension allows one to grow and to transform.
Only in a personally or socially harmful context can transference be described as a pathological issue. A modern, social-cognitive perspective on transference explains how it can occur in everyday life. When people meet a new person who reminds them of someone else, they unconsciously infer that the new person has traits similar to the person previously known. This perspective has generated a wealth of research that illuminated how people tend to repeat relationship patterns from the past in the present.
High-profile serial killers often transfer unresolved rage toward previous love or hate-objects onto “surrogates”, or individuals resembling or otherwise calling to mind the original object of that hate. It is believed in the instance of Ted Bundy, he repeatedly killed brunette women who reminded him of a previous girlfriend with whom he had become infatuated, but who had ended the relationship, leaving Bundy rejected and pathologically rageful (Bundy, however, denied this as a motivating factor in his crimes). This notwithstanding, Bundy’s behaviour could be considered pathological insofar as he may have had narcissistic or antisocial personality disorder. If so, normal transference mechanisms cannot be held causative of his homicidal behaviour.
Sigmund Freud held that transference plays a large role in male homosexuality. In The Ego and the Id, he claimed that eroticism between males can be an outcome of a “[psychically] non-economic” hostility, which is unconsciously subverted into love and sexual attraction.
Transference and Counter-Transference during Psychotherapy
In a therapy context, transference refers to redirection of a patient’s feelings for a significant person to the therapist. Transference is often manifested as an erotic attraction towards a therapist, but can be seen in many other forms such as rage, hatred, mistrust, parentification, extreme dependence, or even placing the therapist in a god-like or guru status. When Freud initially encountered transference in his therapy with patients, he thought he was encountering patient resistance, as he recognised the phenomenon when a patient refused to participate in a session of free association. But what he learned was that the analysis of the transference was actually the work that needed to be done: “the transference, which, whether affectionate or hostile, seemed in every case to constitute the greatest threat to the treatment, becomes its best tool”. The focus in psychodynamic psychotherapy is, in large part, the therapist and patient recognising the transference relationship and exploring the relationship’s meaning. Since the transference between patient and therapist happens on an unconscious level, psychodynamic therapists who are largely concerned with a patient’s unconscious material use the transference to reveal unresolved conflicts patients have with childhood figures.
Countertransference is defined as redirection of a therapist’s feelings toward a patient, or more generally, as a therapist’s emotional entanglement with a patient. A therapist’s attunement to their own countertransference is nearly as critical as understanding the transference. Not only does this help therapists regulate their emotions in the therapeutic relationship, but it also gives therapists valuable insight into what patients are attempting to elicit in them. For example, a therapist who is sexually attracted to a patient must understand the countertransference aspect (if any) of the attraction, and look at how the patient might be eliciting this attraction. Once any countertransference aspect has been identified, the therapist can ask the patient what his or her feelings are toward the therapist, and can explore how those feelings relate to unconscious motivations, desires, or fears.
Another contrasting perspective on transference and countertransference is offered in classical Adlerian psychotherapy. Rather than using the patient’s transference strategically in therapy, the positive or negative transference is diplomatically pointed out and explained as an obstacle to cooperation and improvement. For the therapist, any signs of countertransference would suggest that his or her own personal training analysis needs to be continued to overcome these tendencies. Andrea Celenza noted in 2010 that “the use of the analyst’s countertransference remains a point of controversy”.