Cognition and Psychotherapy: Second Edition

Cognition and Psychotherapy Second Edition

Arthur Freeman, EdD, ABPP, received his doctorate from Teachers College—Columbia University. He is board certified in clinical, family, and behavioral psychology by the American Board of Professional Psychology. He has published 40 books and more than 60 chapters and journal articles on various aspects of cognitive behavior therapy. He has lectured extensively in the United States and in 20 other countries in recent years. Dr. Freeman is a past president of the Association for Advancement of Behavior Therapy, and is currently Dean and Professor of Psychology at the University of Saint Francis, Fort Wayne, Indiana. His work has been translated into German, Dutch, Swedish, Japanese, Spanish, Italian, Bulgarian, Polish, Portuguese, and Chinese. Michael J. Mahoney, PhD, received his doctorate at Stanford University. He is presently professor of psychology at the University of North Texas and at Saybrook Graduate School in San Francisco, CA. Honored as a fellow by the American Association for the Advancement of Science, the American Psychological Association, and the World Academy of Art and Science, he has contributed pioneering research on human change processes and the psychology of peak performance. Currently Executive Editor of the journal Constructivism in the Human Sciences, he has most recently published Human Change Processes (1991), Constructive Psychotherapy (2003), and Scientist as Subject (2004). Paul L. DeVito, PhD, has been a professor of psychology at Saint Joseph's University in Philadelphia for more than 20 years and is Executive Director of the Early Responders Distance Learning Center (ERDLC). He is an experimental psychologist with research interests in the areas of learning and motivation, cognition, and the psychological consequences of terrorism. Dr. DeVito received his undergraduate and graduate degrees at the University of Pittsburgh. He is the author of more than 40 articles, chapters, and research presentations and has received merit awards for teaching, scholarship, and service. He is the recipient of numerous extramural grants and contracts totaling over $6 million. He has been a media spokesperson, discussing the psychological consequences of terrorism. Donna M. Martin, PsyD, earned her BA in psychology from Allentown College of St. Frances DeSales, Allentown, PA, in 1992, summa cum laude, and received the Access Award for scholarship and service. She went on to receive a master's degree in counseling psychology from Kutztown University, Kutztown, PA, in 1995 and her PsyD in clinical psychology from the Philadelphia College of Osteopathic Medicine. Dr. Martin's interests include cognitive behavioral therapy and its applications, psychological testing, and teaching psychology. She is presently an instructor in the Department of Psychology at the Philadelphia College of Osteopathic Medicine.

Cognition and Psychotherapy Second Edition

Arthur Freeman, EdD, ABPP Michael J. Mahoney, PhD

Paul Devito, PhD Donna Martin, PsyD Editors

Springer Publishing Company

Copyright © 2004 by Springer Publishing Company, Inc. All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, Inc. Springer Publishing Company, Inc. 536 Broadway New York, NY 10012-3955 Acquisitions Editor: Sheri W. Sussman Production Editor: Pamela Lankas Cover design by Joanne Honigman

04 05 06 07 08 / 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Cognition and psychotherapy / Arthur Freeman . . . [et al.], editors—2nd ed. p. cm. Includes bibliographical references and index. ISBN 0-8261-2225-6

1. Cognitive therapy. I. Freeman, Arthur M. RC489.C63C6 2004 616.89142—dc22

2003067303

Printed in the United States of America by Maple-Vail Book Manufacturing Group.

This second edition, like the first, is dedicated to Aaron T. Beck, MD.

To my colleagues and friends at Philadelphia College of Osteopathic Medicine— a truly functional family, and to Sharon, friend, wife, colleague, and inspiration. —Arthur Freeman

To Doris Graves, my first-grade teacher, who encouraged me to pursue my love of words. —Michael J. Mahoney

To my parents Albert and Bertha, my wife Rebecca, and my son Zach. —Paul DeVito

Heartfelt thanks to my husband Jeff, and children—-JeffJr., their love and support.

Amber, and Elaine—-for —Donna M. Martin

Contents

Contributors Introduction Part I

Conceptual Influences

1. Human Change Processes and Constructive Psychotherapy Michael J. Mahoney 2.

Model of Causality in Social Learning Theory Albert Bandura

3. Therapeutic Components Shared by All Psychotherapies Jerome D. Frank and Julia Frank Part II Psychodynamic Influences 4. Logos, Paradox, and the Search for Meaning Viktor E. Frankl

ix xv 1 5

25 45

79 83

5. The Role of Childhood Experience in Cognitive Disturbance John Bowlby

101

6.

Cognition in Psychoanalysis Silvano Arieti

123

7.

Cognitive Therapy and the Individual Psychology of Alfred Adler Bernard H. Shulman

143

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Contents

Part III

Cognitive Influences

161

8. Misconceptions and the Cognitive Therapies Victor Raimy

165

9.

185

Expanding the ABCs of Rational Emotive Behavior Therapy Albert Ellis

10. Cognitive Therapy, Behavior Therapy, Psychoanalysis, and Pharmacotherapy: A Cognitive Continuum Aaron T. Beck

197

11. A Psychosocial Approach for Conceptualizing Schematic Development Arthur Freeman and Donna M. Martin

221

Part IV Contemporary and International Influences

257

12. Identity, Personality, and Emotional Regulation Giampiero Arciero, Paola Gaetano, Paolo Maselli, and Nicoletta Gentili

261

13. Conviviality and Psychotherapy Astrid Palm Beskow, Jan Beskow, and Mayte Miro

273

14. The Entropy of Mind: A Complex Systems-Oriented Approach to Psychopathology and Cognitive Psychotherapy Tullio Scrimali and Liria Grimaldi

297

15. Metabolism of Information as a Model of Mental Processes and Its Application for Psychotherapy Andrzej Kokoszka

323

16. Synthesis Michael J. Mahoney

349

Index

367

Contributors

Giampiero Arciero, MD, PhD, is a psychiatrist and psychotherapist. He was a research fellow at the University of Friburg (Switzerland), and was then Director of the Personal Development Laboratory at the University of Santa Barbara, California. He is a professor of cognitive postrationalist psychotherapy at the University of Siena, Italy, an executive board member of the Society for Constructivism in the Human Sciences, and a fellow of the Italian Society of Cognitive-Behavioral Therapy (SITCC). He is the Director of the Institute of Cognitive Post-Rationalist Psychology and Psychotherapy (IPRA), in Rome. Silvano Arieti, MD, was born in Pisa, Italy in 1914. He received his medical degree in 1938. He was a professor of psychiatry at New York Medical College, and a training analyst at the William Alanson White Institute in New York. He was the editor of the American Handbook of Psychiatry, Volumes I-VI, in addition to publising widely on topics in adult psychiatry. He received the National Book award in 1975 for his work on schizophrenia. Albert Bandura, PhD, was born in Canada. He received his doctorate in clinical psychology from the University of Iowa in 1952, and in 1953, he began teaching at Stanford University, where he continues to work today. Dr. Bandura has written and published widely in the areas of social learning, modeling, and self-efficacy. He was president of the American Psychological Association in 1973. Among the many awards Dr. Bandura has received from the APA are the Distinguished Scientifi Contributions, the Distinguished Scientist Award from Division 12 of the APA; the William James Award of the American Psychological Society for outstanding achievements in psychological science; and the Distinguished Contribution Award from the International Society for Research in Aggression. ix

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Aaron T. Beck, MD, was graduated from Brown University and received his MD from Yale Medical School. He joined the Department of Psychiatry at the University of Pennsylvania in 1954 and is currently University Professor Emeritus of Psychiatry. Unhappy with the lack of efficacy of traditional psychoanalysis in treating depressed patients, Dr. Beck developed a theoretical-clinical approach that he labeled cognitive therapy. Since 1959, he has directed funded research investigations of the psychopathology of depression, suicide, anxiety disorders, panic disorders, alcoholism, drug abuse, and personality disorders and of cognitive therapy for these disorders. He has published more than 375 articles and 14 books, has served on the editorial boards of many journals, is a visiting fellow of Wolfson College, Oxford University, United Kingdom, and has lectured world-wide. Astrid Palm Beskow, MA, PhD, earned a master's degree in education and a doctorate in psychiatry. She is an authorized psychologist and psychotherapist in cognitive psychotherapy, with research interests in cognitive psychotherapy. She has several publications in cognitive therapy, including a Swedish textbook. In 1985 she founded the Center for Cognitive Psychotherapy and Education in Gothenburg, Sweden, and is now the head of this rapidly expanding center. As President and head of the scientific committee she is currently arranging the International Congress in Cognitive Psychotherapy, ICCP, to be held in Gothenburg in June 2005. Together with Jan Beskow and Mayte Miró, she is now developing the concept of conviviality. Jan Beskow, MD, is a professor trained in psychiatry and public health. His primary research interest is population studies of suicides through psychological autopsies. He has many publications in this and related fields, including a Swedish textbook about suicide prevention. He is a recipient of the Stengel Award from the International Association for Suicide Prevention, and a member of the International Academy of Suicide Research. Retired from the Department of Clinical Neuroscience/Division of Psychiatry at the University of Gothenburg, he now teaches at the Center for Cognitive Psychotherapy and Education in Gothenburg. Together with Astrid Palm Beskow and Mayte Miró he is now developing the concept of conviviality. John Bowlby, MD, started his intellectual career at the University of Cambridge, where he studied medicine upon the advice of his surgeon father. In his third year of study, Bowlby became interested in what

Contributors

xi

later became known as developmental psychology. He temporarily gave up plans for a medical career, instead doing volunteer work at a progressive school. He decided to return to his studies, received his degree, and trained in child psychiatry and psychotherapy. Bowlby was interested in finding out the actual patterns of family interaction involved in both healthy and pathological development. Probably best known for his attachment theory, Bowlby wrote and researched extensively about the detrimental effect of early maternal separation and deprivation on child development. He died in 1990. Albert Ellis, PhD, received a business degree in 1934 from City College, New York. He returned to school in 1942 and received his doctorate from Teachers College-Columbia University in 1947. He was initially trained in psychoanalysis but lost faith in the process, and by 1955 had given it up entirely. He concentrated on changing people's behavior by confronting them with their irrational beliefs and persuading them to adopt rational ones. In 1959 he organized the Institute for Rational Living, where he held workshops to teach his principles to other therapists. His model, first known as Rational therapy (RT), then Rational Emotive Therapy (RET), is now known as Rational Emotive Behavior Therapy (REBT). Dr. Ellis has published 54 books and more than 600 articles. Jerome Frank, MD, PhD, received his AB in 1930, his AM in 1932, his PhD in 1934, and his MD in 1939, all from Harvard University. He trained at the Henry Phipps Psychiatric Clinic of the Johns Hopkins Hospital from 1940 to 1943 and joined the faculty of the Johns Hopkins University School of Medicine in 1940, where he taught for 40 years and is currently Professor Emeritus of Psychiatry. He is best known for his book, Persuasion and Healing, in which he asserted that all psychotherapies have both common and unique factors and that the efficacy of each rests in the fit between therapist and patient. Julia Frank, MD, graduated magna cum laude from Harvard University with an AB in social studies. She received her medical degree from Yale University School of Medicine and continued her training in psychiatry and neurology. Dr. Frank is the Director of Psychiatry Clerkship in the Department of Psychiatry and Behavioral Science at George Washington University School of Medicine, where she is also Associate Professor of Psychiatry and Behavioral Medicine. The daughter of Jerome Frank,

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Contributors

she has numerous publications and has co-authored the third edition of Persuasion and Healing with her father. Viktor E. Frankl, PhD, earned his doctorate in medicine in 1930 and continued his training in neurology. In 1942, he and his parents were deported to the first of several concentration camps, where he spent the next 3 years. After the war, Dr. Frankl returned to Vienna, and to the practice of both neurology and psychiatry. In 1948, he received his doctorate in philosophy. In his dissertation, The Unconscious God, he examined the relationship between psychology and religion. He wrote 32 books on existential analysis and logotherapy that have been translated into 26 languages. Paola Gaetano, MD, works as a psychotherapist, teacher, and supervisor at the Institute of Cognitive Post-Rationalist Psychology and Psychotherapy in Rome, Italy. She earned her medical degree and specialization in psychiatry at "La Sapienza" University in Rome. Dr. Gaetano has completed two intensive 4-year training programs with Dr. Vittorio Guidano: one in family therapy, and the other in cognitive psychotherapy. Her research interests include psychosomatics, psychopathology, personality, and emotional regulation. She is the author of several influential papers in respected professional journals. Nicoletta Gentili, MD, is a psychiatrist and psychotherapist in the Deaf Child & Family Service of Springfield University Hospital, London. She graduated from "La Sapienza" University in Rome in 1991, and completed her family therapy training in 1992, also in Rome. Dr. Gentili is currently completing her post-graduate training in cognitive psychotherapy with Dr Giampiero Arciero at the Institute of Cognitive PostRationalist Psychology and Psychotherapy, Rome. Her main areas of therapeutic and research interest are attachment, the child, and emotional regulation. She has published three papers. Liria Grimaldi, MD, completed her medical studies at the University of Catania, School of Medicine, and earned a master's degree in psychiatry and psychotherapy. She is Professor and Chair of Psychotherapy at the Medical School of the University of Catania where she teaches and carries out her extensive research. Dr. Grimaldi has authored 90 scientific articles and monographs and several books. An international speaker, she has presented her work at regional and international congresses. She has lectured at the Department of Psychiatry of the Univer-

Contributors

xiii

sity of Chicago, and has lectured and taught workshops at the Department of Psychology of the Philadelphia College of Osteopathic Medicine. Andrzej Kokoszka MD, PhD, is a university professor, and Head of the II Department of Psychiatry at the Medical University of Warsaw, Poland. He completed his psychiatric training in Cracow, Poland. In addition to his medical school teaching, he is presently a lecturer at the Warsaw School of Social Psychology. Dr. Kokoszka is a psychiatrist, psychologist, psychotherapist, group analyst, and cognitive-behavioral therapist, as well as the author of 10 books in Polish, and approximately 50 papers in Polish and 30 papers in English. He has been active in forming the Polish Association for Cognitive and Behavior Therapy. Paolo Maselli, MD, is a psychiatrist and psychotherapist who teaches at the Institute of Cognitive Post-Rationalist Psychology and Psychotherapy (IPRA) in Rome, and is also in private practice. Dr. Maselli earned his degree in Medicine and his specialization in Psychiatry at the University of Rome. He completed a 4-year post-doctoral training course in cognitive psychotherapy with Dr. Vittorio Guidano. The author of dozens of professional articles, he is a frequent contributor to Trattato Italiano di Psichiatria (The Italian Handbook of Psychiatry). His fields of interest include psychopathology, psychotherapeutic processes, and emotional regulation. Mayte Miró, MS, PhD, is a professor of psychotherapy at La Universidad de La Laguna (Tenerife). She earned a master's degree in psychology at The Pennsylvania State University and a doctorate in psychology at La Universidad de Valencia (Spain). She has published several papers on the development and change of personal meanings and therapeutic constructivism. She is co-author (together with G. Feixas) of Aproximaciones a la Psicotherapia (An Introduction to Psychological Treatments) (1993) and is the author of Epistemologia Evolutiva y Psicologia: Implicaciones para la Psicoterapia (The Epistemological Evolution and Psychology: Implications for Psychotherapy) (1994). Her collaboration with Astrid Palm Beskow and Jan Beskow is focused on developing a conviviality approach to cognitive therapy. Victor Raimy, PhD, received his undergraduate degree from Antioch College and completed his doctoral work in clinical psychology at Ohio State University. For many years he was a professor in the Department

xiv

Contributors

of Psychology at the University of Colorado, in addition to serving at various times as Director of Clinical Training, Director of Graduate Studies, and Chair of the Department. He was well known for his contributions to training in clinical psychology. As the author of the report Training in Clinical Psychology (1950) he summarized what has come to be known as the Boulder Model of scientist-practitioner training. He died in Honolulu in 1987. Tullio Scrimali, MD, received his medical degree from the University of Catania and received specialty training in psychiatry at the University of Milan. He is a professor of psychotherapy in the Department of Psychiatry at the Medical School of the University of Catania and also directs ALETEIA, an international school of cognitive psychotherapy in Enna, Sicily. Professor Scrimali has published six books and more than 100 scientific articles on topics such as the links between brain functioning and cognition, constructivist approaches to therapy, cognitive therapy, and the rehabilitation of schizophrenic patients. He has lectured and presented workshops in the United States, Canada, Mexico, Sweden, France, Denmark, Hungary, Poland, and Germany. Most recently, he set up the first cognitive therapy training program in Warsaw, Poland. Bernard H. Shulman, MD, received his medical degree from Chicago Medical School. He is board certified in psychiatry and in administrative psychiatry and is a life fellow of the American Psychiatric Association. Dr. Shulman is with the Diamond Headache Clinic, Chicago, IL, where he has been the Director of Psychiatric Services since 1984. He is involved in patient assessment and treatment planning as well as building the psychological aspects of the Headache Inpatient Program. Dr. Shulman has published several papers on the relationship of psychological factors to chronic headache. One of the best known interpreters of the work of Alfred Adler, Dr. Shulman serves on the Board of the Adler School for Professional Psychology in Chicago.

Introduction

or almost 3 millennia, philosophy and its more pragmatic offspring, psychology and the cognitive sciences, have struggled to understand the complex principles reflected in the patterned operations of the human mind. What is knowledge? How does it relate to what we feel and do? What are the fundamental processes underlying attention, perception, intention, learning, memory, and consciousness? How are thought, feeling, and action related? What are the practical implications of our current knowledge for the everyday priorities of parenting, education, productive work, and interpersonal relationships? What are their effects on the process of psychotherapy? Such meaningful and fascinating questions lie at the heart of contemporary attempts to build a stronger working alliance among the fields of epistemology (theories of knowledge), the cognitive sciences, and psychotherapy. Too often, each of these areas, and the people associated with them, are insular or even mutually exclusive in their view. The proliferation and pervasiveness of what some have called "cognitivism" throughout all quarters of modern psychology represent a phenomenon of paradigmatic proportions. The emergence or reemergence of cognitive concepts and perspectives—whether portrayed as revolutionary (reactive) or evolutionary (developmental) in nature— marks what may well be the single most important and formative theme in late contemporary psychology. Skeptics of the cognitive movement, if it may be so called, can readily note the necessary limits and liabilities of naive forms of metaphysics and mentalism. The history of human ideas is writ large in the polarities of "in here" and "out there," from Plato, Pythagoras, and Kant to Locke, Bacon, and Watson. What appears to be different among modern cognitive proponents, however, is a willingness to transcend the polarity levels of analysis in favor of more comprehensive and complex models of human adaptation and development. Mind and body, not to mention self and environment, are no

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Introduction

longer viewed as reciprocals in the symbolic functions describing human experience. We are clearly both the subject and object of inquiry, the changer and the changed, and the only thinking, feeling, acting organism known to be capable of self-consciousness. There is, to be sure, a wide range of theories and models that attempt to order the scientific and clinical literatures bearing on the nature of the cognitive processes that lie at the heart of human neurofunctions. There is some convergence worthy of attention, and there are nontrivial differences that also warrant consideration. In this volume we have asked recognized specialists from the major ideological schools to address the role and conceptualization of cognitive processes in the process and procedures of the psychotherapeutic encounter. In the almost two decades since the publication of the first edition of this volume (Mahoney & Freeman, 1985), the "cognitive revolution" has moved from being the barbarians at the gate of the establishment to having become the establishment. Three elements have served to bring this about. First, has been the interest on the part of professionals in the role of cognition as a major factor in explaining how individuals maintain their actions and emotions. Second, has been the market pressure that has dictated empirically supported and short-term approaches as the treatments of choice. Third, has been the rediscovery of the cognitive elements in a broad range of psychotherapy models. What was, in the first edition, radical, has become in the twenty-first century far more commonplace. Rather than cognitive and behavioral theorists and therapists eschewing psychodynamic constructs, and psychodynamic theorists and therapists avoiding more cognitive elements in their work, there has been a rapprochement. This has not necessarily meant an integrative perspective but rather an acceptance that there are similar aspects of the understandings of who we are and how we change. The present volume has chosen to update several of the earlier contributions and offer more contemporary views. Sadly, at least three of the original contributors, Bowlby, Frankl, and Miehl have passed on. Their work stands as tribute to their revolutionary perspectives. Our goal is to offer these diverse views and then offer the reader the opportunity to integrate and synthesize the elements brought to the table by each contributor. Part I contains chapters that offer the conceptual influences of cognition on psychotherapy. The opening chapter by Mahoney offers a metatheoretical survey of convergent themes—approximations toward principles—noted across approaches to psychotherapy. The interest in

Introduction

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the individual's confidence and perceived capacities is then thoroughly analyzed in Albert Bandura's influential theory of self-efficacy (chapter 2). The quest for basic principles and effective ingredients in psychotherapy is pursued even further by Jerome D. Frank and Julia Frank in chapter 3. The roles of relationship, rationale, and ritual in effective counseling are emphasized by Frank, as is the elusive dimension of hope and morale. Jerome Frank's theory links the sense of self-efficacy with the performance, persistence, and resilience of coping behaviors. Bandura endorses a social learning theory interpretation of the sources of information about personal efficacy, namely, self-observation, vicari ous learning, persuasion, and physiological cues. The second part of the book focuses on the psychodynamic influences. Chapter 4, by Viktor Frankl, the founder of logotherapy, traces his early theoretical development and interactions with Freud and Adler. Frankl offers a stimulating distinction between paradoxical intention and symptom prescription, and concludes with some provocative thoughts on the roles of detachment and self-transcendence in psychological development. This theme is itself expanded in chapter 5 by John Bowlby, the author of attachment theory. There is growing evidence that certain patterns of early problems in attachment appear to leave an enduring vulnerability to emotional distress and dysfunction. As Bowlby aptly notes, however, we have been relatively neglectful of research on developmental psychopathology. Such research could refine our understanding of the developmental origins and psychological functions of a syndrome and thereby enhance our capacity not only to better understand our clients, but also to guide them through developmental struggles. Cognition is seen in a somewhat different light by the late Silvano Arieti in his discussion of "Cognition in Psychoanalysis" (chapter 6). While offering his own valuable conjectures on cognitive organization, Arieti laments the fact that "cognition is or has been, up to now, the Cinderella of psychoanalysis in psychiatry. No other field of the psyche has been so consistently neglected by clinicians and theoreticians alike" (this volume). In chapter 7 Bernard Shulman aptly notes that Alfred Adler's theory of individual psychology represented one of the earliest statements of a cognitive constructivist view. The development of a lifestyle or schema through formative social interactions remains a core assumption of several modern cognitive perspectives. Frankl and Adler both emphasize self-realization as a motivational component in the struggle to be freed of neurotic preoccupations. Part III describes several of the major contributions by cognitive theorists. In chapter 8 Victor Raimy offers a valuable contribution on

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the role of misconceptions or misunderstandings in the generation and maintenance of personal problems. He calls for a cognitive-behavioral eclecticism, noting that "finding and changing faulty beliefs that interfere with adjustment is a highly specific and concrete therapeutic activity, even though it may be accomplished in many different ways" (this volume). In chapter 9, Albert Ellis expands a foundational aspect of rational-emotive behavior therapy, namely, relationships among the "ABCs" of experience: (A) activating events, (B) beliefs, and (C) consequences. Ellis joins other contemporary experts who view these elements as complexly interactive. In chapter 10, Aaron T. Beck offers a survey of integrative convergences among proponents of cognitive therapy, behavior therapy, psychoanalysis, and pharmacotherapy. In the final contribution to the cognitive section (chapter 11), Drs. Arthur Freeman and Donna Martin offer a cognitive therapy view of schema development that borrows heavily from Adler and Erik Erikson. Using a psychosocial perspective, Freeman and Martin address the "how" of schema development with implications for psychotherapeutic practice. In Part IV, contemporary authors extend the cognitive focus in rather interesting ways. In chapter 12, Drs. Giampiero Arciero, Paola Gaetano, Paolo Maselli, and Nicoletta Gentili represent structuralist and constructivist theorists. Basing their work on that of Vittorio Guidano, the authors advance the constructivist position. Drs. Astrid Palm Beskow, Jan Be skow, and Mayte Miro, in chapter 13, discuss the relationship aspects of the human encounter, using the term conviviality as meaning "to live together." It is the feelings of happiness that emerge from the social interaction that become a prime positive developmental factor. Drs. Tullio Scrimali and Liria Grimaldi describe the efficiency of the human mind as a factor of "entropy" in chapter 14. Psychiatric problems, then, are factors of the inefficiency of the mind in processing information that is then labeled as psychopathology. In the final contribution to the section, chapter 15, Dr. Andrzej Kokoszka offers an incredibly simple though profound model. Can we view the use and processing of information as similar to the way that cells, the basic building blocks of life, metabolize necessary components to maintain life? The metabolism of information becomes a metaphor for how we use data. In the final chapter, Dr. Mahoney offers his synthesis of the contributions and describes the possible direction for the cognitive focus over the next two decades. This book is dedicated to all who have gone before to set the stage, those players who appear on stage for the present act, and those waiting in the wings, whose turn will come. REFERENCE Mahoney, M. J., & Freeman, A. (Eds.). (1985). Cognition and psychotherapy. New York: Plenum.

I

Conceptual Influences

ognition and Psychotherapy are intertwined and inseparable to the extent that today it is difficult to imagine psychotherapy without some element of cognitive intervention. Yet that notion is a relatively recent one. It was not long ago, as Michael Mahoney asserts in his chapter, "Psychotherapy and Human Change Process," that the major forms of psychotherapy, psychoanalytic and behavioral, denied the need for cognitive intervention. How, then, did this major conceptual change occur? To better understand this shift, Mahoney suggests that we first study the general dynamics of change in a systematic way. Notions or ideas exist and are stable yet are always challenged with something new and different. For instance, the classic nature/nurture controversy of human development was a direct outgrowth of Plato's rational and dualistic view being challenged by Aristotle's empirical and monistic view. Change occurs when new ideas no longer fit within the old model. Hegel called this process the dialectical method: a thesis is challenged by an antithesis, so what remains is a compromise or synthesis of the original opposing views. Piaget called this process disequilibration—when new ideas cannot be assimilated they challenge the present schema such that accommodation occurs and, subsequently, creates a new schema. Going back to psychotherapy, Mahoney posits the metatheory of Constructivism to best capture these notions in contemporary psychological science and practice. The central emphasis of constructivism is to understand the human capacity in creating order and meaning

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Conceptual Influences

in experience. Across diverse individual theories and extensive interdisciplinary research, constructivism expresses basic themes that are assertions about human nature, human experience, or human development. Thus, constructivism views humans as actively complex, socially embedded, and dynamically developmental self-organizing systems. In constructivistic psychotherapy, the client is the agent of change, yet it is the therapist who presents the challenges in a comforting way that ultimately promotes change. For large-scale conceptual change to occur in a field of science, Thomas Kuhn's notion of "Normal Science" is typically the model of choice. Normal science proceeds according to a very narrow set of rules, called a paradigm, which governs the scientific method of the era. When new discoveries occur that do not fit the present paradigm, change, known as a paradigm shift, results. However, paradigm shifts do not occur in a vacuum. They are usually led by influential and visionary theorists who are able to see what others cannot initially see. One such visionary in psychological science is Albert Bandura. In his classic chapter, "Model of Causality in Social Learning Theory," Bandura presents his notion of triadic reciprocal determinism in which the individual, the individual's behavior, and the environment all interact. The interaction is rarely one-way, hence the term reciprocal To best understand human behavior and personality it is necessary to examine all of the interactions among person, place, and behavior. Thoughts and cognitions occur and are effective in this robust interactive experience. Additional issues of key importance to Bandura's notions are observational learning, including vicarious reinforcement and punishment and, most recently, self-efficacy. Through observational learning people are capable of changing their behavior and learning about their social environment by observing the actions and consequences of other people—not such a surprising notion today but rather remarkable when presented in the Zeitgeist of radical behaviorism. Self-efficacy is the notion that one can perform well in a particular situation; such beliefs strongly influence our emotions, perceptions, and cognitions. Again, not such a surprising notion today but rather remarkable when presented in the Zeitgeist of simplistic humanistic notions such as self-esteem. Bandura also asserts a self-regulatory capacity in humans that is for the most part self-evaluative and requires both personal standards

Conceptual Influences

3

and knowledge of one's performance level. It is interesting to note that this is where Bandura sees the notion of self-regulatory challenges that lead to change in human behavior. As Bandura states as an example in his chapter, "Those who have a low sense of efficacy are easily discouraged by failure, whereas those who are assured of their capabilities intensify their efforts when their performances fall short and persist until they succeed . . . personal goals are most highly motivating when persons are self-dissatisfied with substandard performances but are highly self-assured in their efficacy to achieve their self-prescribed goals" (this volume). All of these notions lead Bandura to posit that if there is any characteristic that is distinctively human it is the capability for reflective self-consciousness. Clearly, William James would not find this disagreeable, nor would the thousands of contemporary social psychologists and personality theorists who today enthusiastically focus on the new psychology of the self. The conceptual framework of cognition and psychotherapy is further explored in Jerome Frank and Julia Frank's chapter on "Therapeutic Components Shared by All Psychotherapies." Although initially beginning their chapter by challenging the present focus on evaluating the effectiveness of psychotherapy through evidenced-based methods typically driven by managed care concerns, they assert that psychotherapy can be used and should be viewed as an opportunity for personal growth and change. Furthermore, it is this human growth potential of psychotherapy that separates it from the typical medical treatments and models that are presently in vogue today and, coincidentally, best evaluated through evidenced-based measures of assessment. What are the therapeutic components shared by all psychotherapies? A short summary is not sufficient but some of the notions that the Franks discuss are noteworthy: (a) all psychotherapies work (to some extent), (b) conscious cognitive processes are at the core of all contemporary psychotherapies, (c) psychotherapy involves an emotionally charged confiding relationship with the helper, (d) psychotherapy occurs in a healing setting that provides safety, and (e) psychotherapy involves an active ritual of participation. The Franks also note that most forms of psychotherapy can be viewed as a means, either direct or indirect, to combat demoralization, a state of mind that may include subjective incompetence, loss of self-esteem, alienation, hopelessness, or helplessness. Finally, the Franks cryptically note that

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Conceptual Influences

no school of therapy ever disbanded because it concluded that another school and method were superior!! Change in conceptual themes, including cognition and psychotherapy, is ever present and enduring. Democritus's original notion, presented over 2,500 years ago, is still valid and may be all we truly need to know to understand the dynamics of change: "The only thing that is constant is change."

1

Human Change Processes and Constructive Psychotherapy* Michael J. Mahoney

here was a time, not too long ago, when the two kinds of psychotherapists in the world were either psychoanalytic or behavioral. When I was being trained in the experimental analysis of behavior, we were drilled in the dogma that behaviorism offered the only truly scientific approach to helping people change. Look at the literature of early behavior therapy. Just look. There was a time, not too long ago, when the term cognitive-behavioral was considered an oxymoron. Look at the early writings reflecting the skirmish between behaviorism and cognitivism. Only a quarter century ago, it was inconceivable to many that there could be anything legitimately called "mind sciences." Now it is difficult to imagine an adequate approach to psychotherapy that does not appreciate basic contributions from the cognitive sciences. There was a time, not too long ago, when theoretical differences meant that dialogue was either unlikely or inflammatory. Behavior thera pists talked only to one another, psychoanalysts to their own, and so on. Were there meetings or exchanges, they tended to be competitive and vitriolic.

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*Adapted from material in Mahoney (1991, 2003a).

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Conceptual Influences

But times and psychotherapy have changed. There is now much greater appreciation for the possibility that multiple theories may each contribute their own important truths about human nature and human change processes. There is much deeper respect for differences. We have begun to learn to honor the developmental role played by diversities of many forms. Some have even proposed that an integration of psychotherapies is both possible and near at hand (Goldfried, 1995; Norcross & Goldfried, 1992). I don't know whether we can or should integrate the diverse traditions that have contributed to contemporary psychotherapy. I do believe that we should encourage lively dialogue on similarities as well as differences. Discourse is central to what we have come to call science (Mahoney, 2003b, 2003c), and science and psychotherapy merit a synergistic relationship. I also believe that we are witnessing and contributing to a new level of discourse in psychotherapy. It is a challenging and exciting time to be part of this profession. I have been particularly involved in discourse on general principles of human development (whether inside or outside psychotherapy), the processes addressed by those principles, and their practical implications for how we serve people in our professional roles. In the book Human Change Processes (1991), I reviewed research and theories on human development, evolution, emotions, the self, complexity, dynamic systems and self-organization, the experience of change, and recent developments in cognitive science and psychobiology. Translating our technical knowledge into practical implications for therapeutic practice is a formidable challenge. My attempt to address that challenge took the form of a book titled Constructive Psychotherapy (Mahoney, 2003b). My goal in this chapter is to offer a readable synopsis of the essence of those two books. To even remotely approach that goal, my style is necessarily telegraphic. Citations are minimal and clustered, and I rely on the previously mentioned books and other sources to elaborate the points being made here. My remarks are first organized around a synopsis of what we now know about human change processes. Next I present an overview of constructivism as a perspective, followed by a sketch of a constructive approach to psychotherapy. HUMAN CHANGE PROCESSES: A SYNOPSIS How and why we change turns out to be intimately related to how and why we stay the same. We do change. Indeed, we are always changing.

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We entirely replace the materials that make up our bodies every 7 years. But much of that change—technically, exchange—is focused on keeping us the same. We are fundamentally conservative creatures, changing as little as possible as long as we can. There is apparent evolutionary wisdom in such a conservative strategy. Gradual change is most common, but sudden leaps do occur. An understanding of human change processes begins with an appreciation for the fact that we humans are active participants in organizing our experiences of ourselves and our worlds. Dynamic and continuous ordering processes construct, maintain, and revise activity patterns. These active ordering processes are primarily tacit (not conscious) and unique to each individual. Self-organizing processes that are most vital to life support and individual functioning are given special protection against changing. These most vital activities might be called core ordering processes (COPs). COPs organize experiences and activities along interdependent dimensions that include emotionality and valence, reality (what is stable, what is possible), personal identity, and sense of power (control/efficacy/ agency). Resistance to change is common, especially when the change is experienced as "too much" or "too quick." It doesn't matter whether the change is desired or not. Moving too quickly or too far beyond the familiar often leads to withdrawal. Such resistance reflects basic selfprotective processes that serve to maintain the coherence of the living system. Ordering processes always operate in relation to their own contrasts, which are disordering processes. Order and disorder are facets of the same dynamic diamond. The ongoing interaction of ordering and disordering processes creates a simultaneous interplay of both familiar and novel experiences. Novelty involves contrast. For something to be experienced as new, there must be a background familiarity from which it can be distinguished. Novelty is necessary for learning and development. Familiarity and consistency are essential to life support, systemic coherence, and human well-being. The dynamics between familiarity and novelty lie at the heart of human change processes. Disorder is necessary for development. All learning and development involve transitional disruptions or perturbations in systemic functioning At all levels, development feeds on disruptions and then digests them into familiarity. It is in the context of disorder that a living system exhibits both its greatest rigidity and its greatest variability. When rigidity

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reigns, stereotyped behavior or frozen passivity is common. Variability may emerge, particularly in a safe relationship that encourages ventures into flexibility. From this flexibility in being and these expressions of variability, more fulfilling and functional activities may emerge and vie for potential selection in the expression of that person's life. When novel experiences are deficient relative to an individual's capacities and developmental needs, stagnation and what George Kelly called "hardening of the categories" are likely. When novel experiences greatly exceed the individual's capacities to balance, feelings of being overwhelmed are common. Episodic or chronic disorder and "breakdown" may result. When new experiences are well timed and suited to the individual's current developmental capacities and edges, developmental breakthroughs may emerge and effect whole-system transformations in experiencing. Although disorder may be experienced and expressed in highly patterned processes of human activity, such disorder is diverse, individually unique, and systemic. Our attempts at conceptual ization and classification of the so-called psychiatric disorders are likely to improve only as we become more willing to embrace the limits of symbol systems in capturing human uniqueness and dynamic complexities. Persons can become trapped in disorder. Many psychiatric disorders are, in fact, rigidly ordered patterns. A major contributor to the pain and tenacity of such "disorders" is their extreme constrictive quality. Change is a nonlinear process. It is neither exclusively continuous nor simply cumulative. Rather, change processes reflect many small shifts punctuated by occasional sudden leaps and frequent returns to earlier patterns of activity. Popular notions of relapse and recidivism fail to appreciate the oscillative dynamics of development. Change is often experienced in waves or multirhythmic oscillations. Popular conceptual anchors for dimensions of oscillation are often abstract polarities, such as life/death, right/wrong, good/bad, real/fake, and sacred/ profane. Descriptions of experiences of oscillation often include references to opening and closing, expansion and contraction, loosening and tightening, or approach and withdrawal. Change emerges from a shifting matrix of competing possibilities. Old, tenured patterns of activity compete with new, experimental possibilities. Like all other forms of evolution and revolution, this competition is never finished. New patterns, when they gain dominance in the competition, themselves become the old and familiar order, in contrast with which newer patterns emerge and compete. Ongoing competitions

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in development are neither won nor lost in reference to allegedly absolute criteria. Some competitors (i.e., activity impulses) are selected to assume temporary positions in the driver's seat of the body. The old patterns remain as contenders, and they may "win" occasional episodes of ascendancy in future situations. Old habits are not eliminated completely, but they can be effectively displaced by new ones. Selection processes always include human agency. What decides the ongoing competition among activity patterns is a complex dynamic system that emerges out of and expresses a human will. Selection processes must mature into retention processes if a chosen activity is to become an influential pattern in ongoing self-organization. To become an enduring contribution of difference in a life, a changed pattern of activity must be actively practiced. Successful (adaptive) change is facilitated by a rhythmic orchestration of exploratory, selective, and perpetuating activities (i.e., experiments in living, evaluative choices regarding which experiments are working, and action patterns that serve to perpetuate and elaborate valued experiences). These three processes—variation, selection, and retention—are at the heart of biological evolution as well as psychological learning and development. Self-relationships, which emerge in social and symbolic relationships, powerfully influence life quality and resilience under stress. Awareness, acceptance, and celebration are common quests in self-relating. Interpersonal relationships involving strong emotions are powerful contexts for psychological development. Safe and loving intimacy is an expression of trust, and trust lies at the core of optimal contexts for development. CONSTRUCTIVISM

A metatheory that embraces these and other insights has come to be called constructivism. The term itself reflects a central emphasis on the human quest and capacity for creating order and meaning in experience. The conceptual legacy of constructivism can be traced back to ancient teachings associated with Taoism and Buddhism in Asia and process philosophy in Mediterranean and European scholarship. Vico, Kant, and Vaihinger have been most often credited with pioneering Western expressions of constructivism, but recent historical studies suggest that others deserving such acknowledgment include Arthur Schopenhauer, Wilhelm Wundt, and William James. Across diverse individual theories and extensive interdisciplinary research, constructivism expresses five basic themes. Each theme is an

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assertion about human nature, human experience, or human development. These five themes, which repeat and anticipate other parts of this chapter, are activity, order, identity, social-symbolic processes, and dynamic dialectical development. Briefly stated, constructivism views humans as actively complex, socially embedded, and dynamically developmental self-organizing systems. These themes can be succinctly elaborated as follows.

Activity

Human beings are active participants in shaping their own experiences. We are agents of choice. Our actions and activities reflect our choices, and our choices influence who and how we are. We are unaware of most of our choices. Much of our activity is anticipatory. With important exceptions, we tend to anticipate what we remember (i.e., we expect our future to resemble our past). Attention is a powerful form of activity and frequently an important focus in therapy. Many clients are helped by learning attentional skills. To be optimally useful, insight must be paired with action. Practice is a high priority. Order We actively seek order in the face of constant challenges to our order seeking. Human activity is primarily focused on the creation and maintenance of a viable order or organization in life. We seek and create meanings. Meanings are relationships that connect particulars. Loss or lack of meaning is experienced as chaos. The network or matrix of our personal meanings make up our personal realities. Although we share much with each other, we each live in and form uniquely personal realities. Major changes in psychological experiencing involve changes in meanings and, therefore, in personal realities. Biologically, emotional processes—which are intimately related to attention—are powerful organizers of our experiencing. Emotions are evaluative appraisals and preparations for action. They are natural expressions of our biological nature—our quests for order (viable meanings) and our reactions to the lack, loss, or change of order in our lives. Challenges to our order are essential for all learning and development. Novelty or new experiences are crucial.

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We live seeking a dynamic balance, looking to achieve or regain a sense of equilibrium amidst the ever-unfolding challenges to our ordering processes. Professional counseling is often sought as an attempt to change or regain a sense of order, meaning, or balance in life. Many clients benefit from developing a healthy relationship to the power and presence of emotions. Emotional experiencing and expression are often as important as emotional control.

Identity The creation and change of order hinge on contrasts. Change is experienced relative to what remains the same. A primitive and powerful contrast in most humans is that between self and not-self. The emergence of a sense of self appears to be crucial to healthy human development. The body and its sensations are fundamental to experiencing selfhood or personal identity. The body serves as a center of operations. Center and centering are important metaphors in psychological life. Sense of self and sense of reality are intimately related. Challenges to the sense of self are often experienced as life threatening. The self is paradoxical in being simultaneously changing and unchanging (historically continuous). Relationships with self are critical to life quality. These include self-concept, body image, self-esteem, and capacities for self-reflection and self-comfort. The sense of self can become dysfunctional when it is fragmented and its capacities for balance and coherence are insufficiently developed. Difficulties also occur when an individual identifies with a problem or rigidly resists the changing aspects of life. Foreclosure on the complexity or flexibility of the self can lead to painful patterns of felt isolation, unworthiness, or insufficiency. Sense of self and relationships with self most often develop and change in the context of strong emotional relationships with others. Psychotherapy can provide a secure base for examining and changing self- and interpersonal relationships.

Social-Symbolic Processes Self-organization is fundamentally shaped by social bonds and symbolic processes (e.g., imagery, language). We live in and form relationships (past, present, and potential). Symbols and symbolic processes connect

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us and help us to organize our experiencing. Words and symbols reflect powerful processes of organization and communication. The quest for order and meaning is often expressed in narrative form, that is, in the form of an unfolding story. Narrative sharing—story telling, story creation, story revision—is a powerful form of human bonding and a common element in professional counseling. Religious and spiritual beliefs, communities, and traditions are often powerful sources of support and guidance. Therapy can encourage quests for meaning via shared communities and enduring traditions. Changes in personal experience and activity patterns are often accelerated by changes in relationships. Changes in patterns of thinking may be a valuable component of counseling. Human consciousness involves capacities to transcend time and space (e.g., to remember and anticipate). Living primarily in the present is often a challenge. Counseling can encourage the development of balanced skills in remembering, being present, and planning ahead. Dynamic Dialectical Development Equilibration (balance) reflects our attempts to deal with the contrasts (dialectics) between old and new patterns. Resistance to change expresses a healthy tendency to protect against changing too much, too quickly. Cycles or waves of opening and closing (expansion and contraction) are common experiences in development. When a challenge to our ordering capacities is overwhelming, severe contraction is a natural response. Disorganization is a natural and necessary component of reorganization in life-ordering processes. The new life order that may emerge from waves of disorganization is usually more complex and differentiated than its predecessor. There are two kinds of change: gradual and abrupt (quantum). Most human lives reflect both. Counseling can encourage patience, hope, and persistence in the face of both change and its felt absence. Particularly valuable skills involve centering (finding and regaining balance) and exploratory decentering (risking excursions into new possibilities for experiencing). BASIC PRINCIPLES OF CONSTRUCTIVE PRACTICE

Psychotherapy is a special form of human relationship that serves the immediate and long-term developmental needs of the client. Ideally

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that relationship becomes a safe and secure source of compassionate counsel and encouragement. In the context of that relationship clients should feel free to feel, to reflect, and to ask for and receive help. As therapists, our primary responsibilities are to respectfully listen and witness or honor their presentations of themselves and their experiences. With sensitive attunement to their current needs and capacities, we offer comfort, reassurance, and encouragement. At appropriate times we may challenge our clients to change—to consider different ways of viewing themselves, to risk feelings that may be uncomfortable or frightening, and to experiment with new ways of living. How do we do this? We do it, I believe, by skillfully and flexibly balancing our interactions with them to suit their unique and unfolding requirements for help. Over the years I have found valuable conceptual scaffolding in Jerome Frank's early portrayal of the "3 Rs" of psychotherapy: relationship, rationale, and rituals. My working assumptions about constructive psychotherapy are as follows. Psychotherapy involves a special form of human relationship, a rationale that makes sense of the client's experience and possible courses of constructive action, and the active practice of rituals aimed at changing experience patterns. The processes of change are principled, but they are also complex, individualized, and non-linear.

Relationship The helping relationship is a co-created human bond between the individual (s) seeking counsel and the individual (s) offering to serve. A constructive helping relationship is characterized by a nonauthoritarian collaborative style in which the persons involved work together and share a joint responsibility for the process and results of their endeavors. Compassion, caring, and empathy on the part of the therapist are critical ingredients in the quality of the helping relationship. The therapeutic relationship provides a secure base—a consistently safe and confidential interpersonal context—in which and from which the client can both explore and experiment with new ways of experiencing. The client is the primary agent of change. The person of the therapist is an important ingredient in the helping relationship and in the therapeutic enterprise. Of particular significance are his or her continuing personal development, authenticity, tolerance for ambiguity, patience,

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comfort with emotionality, and faith in the possibilities of human development. The constructive therapist focuses on the client's strengths, resources, and capacities to change in personally meaningful ways, and is a consistent and trustworthy source of affirmation, encouragement, and hope. Rationale Life is change and change is stressful. People organize their lives into patterns of activity that are meaningful and that have been functional for them. These patterns become uniquely personal realities and styles of living. Personal realities are generally tacit and anticipatory; they operate without our awareness and they assume that the future will resemble the past. When life challenges are not successfully resolved by old and familiar methods of coping, people are likely to experience disorder and disorganization in many dimensions of their lives, often accompanied by strong negative emotions and a sense of confusion. Emotions are not dangerous. They are powerful patterns of organizing our experience as preparations for action and ways of communicating with self and others. Emotions are natural expressions of individuals' attempts to protect or regain a sense of meaning, order, and control in their lives. Although it may be distressing, disorder can create variations or changes in old patterns of experiencing; this variability is necessary for the emergence of new forms of adapting. Chronic distress and dysfunction often reflect reductions in variability as a result of habitual patterns of activity (including thinking and feeling). Such patterns may have been functional (adaptive) in earlier life circumstances, but they have become costly and counterproductive. In this sense, many chronic "disorders" are excessively rigid or rutted processes that reduce possibilities for novel or enriching experience. Individuals can facilitate their own change by actively experimenting with new ways of being and by selectively practicing (strengthening) new patterns that serve them well. In addition to being the primary agent of change, the client is always the resident expert on self and his or her own experience. The primary purpose of psychotherapy is to provide compassionate encouragement and professional counsel as individuals work to reorganize themselves and their lives. Personal reorganization often involves multiple attempts to emotionally rethink (revise) one's life story while at the same time redirecting one's attention and everyday activity.

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The primary responsibilities of the therapist are to honor the phenomenology (felt experience) of the client, to offer appropriate comfort and reassurance, to respectfully assess personal realities and activities, to challenge old patterns of coping that are unsuccessful or dysfunctional, to be sensitively attuned to the client's pace of change, and to encourage responsible and self-caring experiments in new ways of perceiving, acting, thinking, and feeling. For many clients these experiments will involve more viable narratives (stories) about themselves, their characteristics, and their capacities. The primary responsibilities of clients are to remain as engaged as possible in their own development and to be both patient with their process and persistent in their participation.

Rituals Rituals (techniques, exercises, and homework assignments) are structured experiments in experiencing. Rituals are an important expression of a person's intention to change and active participation in that pursuit. As such, they are trial-and-error endeavors, often reflecting symbolic meanings regarding past events, present experiences, and future directions of development. These meanings may be more important than the actual content or form of the ritual itself. Many rituals are aimed at developing skills (e.g., attention or awareness, communication, conceptualization, emotional regulation, experiential risk taking, impulse control, perspective taking, and selfrelationship—especially self-comforting). Some of the most common rituals in psychotherapy reflect basic contrasts in the processes of living (e.g., beginning or ending, opening or closing, centering or edging, accelerating or decelerating, effort or surrender, giving or receiving, etc.). Many therapeutic techniques involve creative reconstructions of clients' life stories (narratives) in a manner that modifies the meaning(s) of their past and changes their self-characterizations, their sense of agency, and their sense of alternative possibilities and hope. Personalized rituals—experiments created for or by an individual—may be particularly helpful in the exploration of new action patterns. Careful observation, especially self-observation, of the experience and effects of a ritual can provide important information on its utility in facilitating change processes and can help to strengthen new patterns of adjustment. Rituals or exercises involving supportive groups or significant

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others can be particularly powerful in influencing developmental pace and direction. The regular practice of rituals can add a sense of order and commitment to the change process. THERAPEUTIC BALANCING AND THE CYCLES OF EXPERIENCING At the beginning of this section I described a primary task of the therapist as one of balancing. I conceptualize this balancing in terms of two basic and interrelated dimensions. Both are simplifications, but I find them helpful in organizing my own way of being therapeutic. One dimension is created by the contrasts of opening and closing. The other is created by the contrasts of comforting and challenging. Opening and Closing Imagine that there are two kinds of processes in the world: opening and closing. "To open" generally means to expand or enlarge. It also can mean to begin or to create. When it has been preceded by barriers or blockage, opening involves a process of freeing the flow or movement of restrained processes. "To close" generally means to constrict or narrow. Closing something can also refer to finishing it, as in closing a book. To close also means to stop or shut, as well as to secure or cover. It is not coincidental that these verbs serve as powerful metaphors that are related to multiple bodily actions and processes. They are both associated with a vertical dimension: we open "up" but we close "down" (Johnson, 1987; Lakoff & Johnson, 1999). It may be useful to think about life as cycles of openings and closings. This metaphor may be expressed in experiences ranging from a moment to a lifetime. Each therapy session is a dynamic exchange in which the client is opening and closing to possible experiences. This is, of course, a natural expression of dynamic self-organization and attempts to maintain or regain a sense of order in one's life. A significant part of the therapist's role, in my opinion, involves an ongoing attunement with each client's processes of multidimensional expansion and contraction. Someone in extreme contraction is cut off from some kinds of exchange with his or her worlds. Someone in extreme dilation (expansion) may risk giving and receiving at rates that exceed what that person's system can currently accommodate.

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Processes of learning and development require a delicate, dynamic balance that protects the coherence of the person's core ordering processes while at the same time allowing for encounters with manageable novelties. Change requires new experience, and therefore at least episodic openness to such experience. But the living system is fundamentally conservative; it protects itself and its life support systems first and repeatedly. This is especially true when it is exploring new territory. It is also true in the context of both pleasure and pain. Thus, even after rewarding or satisfying excursions into new experience patterns, it is common for the system to pull back, to contract, to close itself off for a while. This is readily apparent in most therapeutic sessions, where close attention to subtle cues will often reflect the client's dance toward and then away from significant themes and potential experiences. I believe each client expresses an individual tempo and style of opening and closing. It is that person's habitual manner of moving through life, and his or her style is often amplified in the personally charged moments of a therapeutic hour. Neither opening nor closing is inherently good or bad. Both are required in the dynamic maintenance of a living system. To assign a value judgment to one of them would be to overlook their necessary reciprocity in life support. It would be like saying that in breathing, inhalation is better or worse than exhalation. But the metaphorical opening and closing I am talking about is much more complex than our respiration, our digestion, or any of the other processes that are essential to our being. One cannot assign a meaningful overall score to our experiential openness or closure. This is not only because it keeps changing, but also because we may be simultaneously open and closed, and there are, of course, many degrees in between. A physical illustration of this might be shown in terms of all the organs and parts of our bodies that dilate and contract: pupils, pores, sinuses, arteries, lungs, heart, digestive tract, and so on. They have complex and variable rhythms that cannot be captured in a single summary number. Isn't it possible—indeed, likely—that our consciousness also reflects rhythmic cycles? The idea is complex, to be sure, but that is how we are: life is complex, and so is psychotherapy. Imagine that this complex coordination of expansion and contraction processes is illustrated in the contrasts between thinking and feeling. Although this separation is an artificial one that colludes in the mind-body dualism of classical rationalism, it is such a familiar one that most of us can easily relate to it. We can recognize the difference

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between being mostly in our heads and totally "out of our minds" and into our bodies. We can distinguish between intellectualizing about a problem versus "really" experiencing it in parts of our body. Shuttling back and forth along the dimensions of conceptualization and experiencing is a common developmental process Vittorio Guidano (1987, 1991) liked to describe it as the dance between experiencing and explaining. In his later work with Giampiero Arciero this dialectical process was refined to address the complexities of maintaining and restoring emotional coherence (Arciero et al., chapter 12, this volume; Arciero & Guidano, 2000). Whether we think of it as oscillations along the dimensions of thinking and feeling or along any number of other dimensions, what is important, I believe, is that we recognize that our clients are always moving to the rhythms of their own self-organizational processes. Instead of being motionless in their chairs, our clients are doing anything but sitting still. They are expanding and contracting in multiple ways at every moment. We are, too. And neither of us can be totally aware of our own cycling. It is, in fact, when our habitual rhythms are disrupted that we are most likely to glimpse them.

Comforting and Challenging In our role as professional helper, we accept special responsibilities. These include our being sensitively attuned to cycles of experiencing in our clients, in ourselves, and in the unfolding moments of our interactions. We are professional mentors trying to teach life skills. We do our best to keep our own balance while we delicately adjust our actions to our student's/client's immediate and imminent needs. I believe we do this by organizing our actions along a dimension that might be called comforting and challenging. Comforting is something with which most of us are quite familiar. We know what it feels like to want comforting, and most of us have been fortunate enough to have felt genuinely comforted by people in our lives. Seeking comfort, being comforted, and learning to comfort ourselves may help us in comforting others. We metaphorically hold someone when we listen with compassion. Challenges take place at the edges of ability and possibility. But there are two kinds of challenges: aggressive and progressive. They can have very different felt meanings, depending on their emotional tone, their

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context, and the quality of the relationship from which they issue. An aggressive challenge is issued in anger, and it may imply dominance or convey doubt about the capacities of the other. This is the kind of challenge encountered in confrontations (e.g., on the battlefield, on the playground, or in power struggles). It often takes the form of an insult or a dare, and aggressive challenges often lead to destructive actions. The other kind of challenge is an invitation to stretch, and it is in this sense that it can be called progressive. Such a challenge issues from a caring relationship and conveys a message of faith in the ability of the other. It encourages a stretching forward toward new capacities and is an essential aspect of dynamic development. Soren Kierkegaard (1938) describes this type of challenge: The loving mother teaches her child to walk alone. She is far enough from him so that she cannot actually support him, but she holds out her arms to him. She imitates his movements, and if he totters, she swiftly bends as if to seize him, so that the child might believe that he is not walking alone. . . . And yet, she does more. Her face beckons like a reward, an encouragement. Thus, the child walks alone with his eyes fixed on his mother's face, not on the difficulties in his way. He supports himself by the arms that do not hold him and constantly strives towards the refuge in his mother's embrace, little suspecting that in the very same moment that he is emphasizing his need of her, he is proving that he can do without her, because he is walking alone, [p. 85]

Just as a parent or teacher will often challenge children or students to stretch themselves and their skills, a constructive therapist does likewise with clients. In so doing, the therapist is helping clients to learn and refine capacities that will ultimately reduce their need for therapy. A client caught in the grip of a severe contraction of anxiety or depression often wants to be comforted. For some clients, the comfort and compassion afforded by the helping relationship will constitute its most valuable component. Some clients do not change during the course of therapy. This does not mean that their therapy failed. The provision of a safe harbor for the heart is no small achievement. But many clients also want to be coaxed toward again taking risks. In this progressive sense of the term, challenge is an invitation to explore or experiment, to look for or try something different. Because novelty—a different or unfamiliar experience—is essential to change, challenge lies at the heart of teaching and many forms of helping. The form, focus, and timing of challenges must be attuned to the person's current skills and systemic balance, of course. This is part of what can be so

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demanding about parenting, teaching, and psychotherapy. This is, so to speak, the challenge of challenging. An inappropriate challenge—an excessive one—can be a barrier to learning and cause the individual to feel overwhelmed. An inadequate challenge—one that does not ask the person to risk new frontiers—may not only waste time and energy, but may collude in maintaining old and dysfunctional ways of being. Bear in mind that I have created an artificial contrast for the sake of simplifying a practical point. I do not believe caring, compassion, and comfort are incompatible with progressive developmental challenge. Comfort and challenge need not be a disjunction in helping style. Both are essential to optimal therapy. The necessity of comfort and security is clear in research on both early and life span emotional development; challenge is also an integral part. Life keeps coming at you. Indeed, it is the capacity of challenges to overwhelm a person that often motivates the search for professional help. Within psychotherapy, challenges initiated by the therapist should come only when safety and caring are already in place. Such challenges should emerge out of a collaborative dance. Authoritarian demands dictated by the therapist are not recommended. The client who is challenged prematurely or excessively is often done more harm than the client who is never challenged at all. Challenge should emerge out of the dynamics of the therapeutic relationship, with mutual consent that new opportunities for experiencing are possible in the overall balance of the client's personal system. The client always retains the right to say "this is too much; this is too fast." I tend to trust the client's sense of pacing in personal development. If I err, I prefer to err in the direction of challenging too little rather than too much. When clients show signs of withdrawing, I respect that. I also encourage them to witness their process of closing down and to honor its intent, which is to protect themselves. To summarize, I believe that constructive psychotherapy involves a sensitive coordination of comfort and challenge in response to each client's cycles of opening and closing. This is essentially what many specialists in education and development have been recommending. It is literally an ongoing gesture of balance in attunement with the client's current sense of balance. It honors the essential tensions in which life is lived and development unfolds (Kuhn, 2000; Mahoney & Mahoney, 2001). After initial assessments of needs, patterns, and emotional skills, I often begin counseling with exercises that emphasize abilities to find and return to a sense of a calm center (e.g., relaxation, physical balance, breathing meditation). For some clients, this will be the greater part

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of our work together. As they become skilled in regaining a sense of balance in their lives, we may move on to more advanced exercises. These exercises tend to emphasize exploratory behaviors and experimentation with new patterns of experiencing. Such explorations and experiments inevitably lead to further losses of balance. Centering skills, therefore, remain at the heart of their coping with their own growth. The processes of development have their own dynamics, which are experienced and expressed uniquely by each living system. A principled order unfolds, however, and it often reflects an expanding center and refinements in the skills that connect the center with the edges. This is where disorder and order dance the dialectic.

PROCESSES OF CHANGE Changes in patterns of experiencing are usually nonlinear, reflecting mixtures of mostly slow, small steps, frequent returns to earlier patterns, and occasionally large, sudden leaps. Although change processes reflect orderly principles, the particulars can never be perfectly predicted for a given individual (e.g., how long it will take, the consequences and repercussions of a particular course of action, the degree of difficulty or effort required). The reorganization of life patterns often occurs in waves or oscillations of success and failure, progress and regress, expansion and contraction. Small initial changes may be amplified into large and enduring ones. Changes in any area of functioning can affect all other areas; change is systemic or holistic. To emphasize an important point, reluctance or resistance to change is common, natural, and most intense when core ordering processes are involved; such resistance is an expression of self-protection. Old patterns and new patterns of coping compete for dominance and control within the individual; change is often experienced as an internal struggle or conflict. Even when new patterns are well practiced and apparently stabilized, old patterns of activity are never completely eliminated; they are most likely to reappear in contexts of fatigue, prolonged stress, and novel challenges. Psychological development is often reflected in shifts of attention, changes in perceptions and personal meanings, changes in interpersonal relationships, improved capacities to rebound from setbacks (to "regain balance"), and changes in self-relationships. Among the more common and important changes in self-relationships that occur during

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and after psychotherapy are increased self-awareness, increased comfort with emotional experience and its expression, greater openness to experience, greater self-acceptance or improved self-esteem, increased capacities to self-comfort and to receive and give affection, a greater sense of personal agency or empowerment, and a sense of more hopeful or grateful engagement with life. CONCLUDING REMARKS Psychology and psychotherapy are exhibiting the stirrings of an integral movement. This is apparent at many levels. These stirrings reflect the influence of developments that stretch from basic neuroscience and the sciences of complexity to the interface of consciousness disciplines, spiritual wisdom, and therapeutic methods (Damasio, 1995, 1999; Freeman, 1995; Gleick, 1987; Kauffman, 1993,1995; Kelso, 1995; Mahoney & Moes, 1997; Petitot, Varela, Pachoud, & Roy, 1999; Schwartz & Begley, 2002; Segal, Williams, & Teasdale, 2002; Van Geert, 1998, 2000; Velmans, 2000; Wilber, 1999). In its diverse expressions, constructivism is part of this integral movement. Constructive contributions are emanating not only from traditionally cognitive, existential-humanistic, and phenomenological quarters, but also from the "relational revolution" that has been sweeping through psychoanalysis (Mitchell, 1997; Mitchell & Black, 1995; Moore, 2000; Schore, 1994; Spence, 1982,1987; Stern, 1983; Stolorow & Atwood, 1992; Stolorow, Atwood, & Orange, 2002; Watts, 2003). As an integral metatheory, constructivism is notjust a new horse in the race. It is a perspective on horses, races, and much more. Constructive psychotherapy expresses a "creative confluence" (Gergen, 2000). Unity and diversity are being integrated in ways that speak to traditions of holism and hope. Dialogues are taking place that suggest an evolutionary leap in our understanding of what it means to be human and to be conscious. These dialogues are invaluable in these times, with our troubles, and in our professional helping roles. The emphasis is on connection rather than separation and on development rather than disorder. I believe that the constructive confluence is among the most promising developments on our professional horizon. REFERENCES Arciero, G., & Guidano, V. F. (2000). Experience, explanation, and the quest for coherence. In R. A. Neimeyer & J. D. Raskin (Eds.), Constructions of disorder:

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Meaning-making perspectives for psychotherapy (pp. 91-118). Washington, DC: American Psychological Association. Damasio, A. (1995). Descartes' error. New York: Harcourt Brace. Damasio, A. (1999). The feeling of what happens: Body and emotion in the making of consciousness. New York: Harcourt Brace. Freeman, W. (1995). Societies of brains. Hillsdale, NJ: Lawrence Erlbaum. Gergen, K. J. (2000). The coming of creative confluence in therapeutic practice. Psychotherapy, 37, 364-369. Gleick, J. (1987). Chaos: Making a new science. New York: Viking. Goldfried, M. R. (1995). From cognitive-behavior therapy to psychotherapy integration. New York: Plenum. Johnson, M. (1987). The body in the mind: The bodily basis of meaning, imagination, and reason. Chicago: University of Chicago Press. Kauffman, S. A. (1993). The origins of order: Self-organization and selection in evolution. Oxford: Oxford University Press. Kauffman, S. A. (1995). At home in the universe. Oxford: Oxford University Press. Kelso, J. A. S. (1995). Dynamic patterns: The self-organization of brain and behavior. Cambridge, MA: MIT Press. Kierkegaard, S. (1938). Purity of heart is to will one thing (D. V. Steere, Trans.). New York: Harper & Row. Kuhn, T. S. (2000). The road since structure. Chicago: University of Chicago Press. Lakoff, G., & Johnson, M. (1999). Philosophy in the flesh: The embodied mind and its challenge to Western thought. New York: Basic Books. Mahoney, M. J. (1991). Human change processes. New York: Basic Books. Mahoney, M. J. (2000a). Behaviorism, cognitivism, and constructivism: Reflections on persons and patterns in my intellectual development. In M. R. Goldfried (Ed.), How therapists change (pp. 183-200). Washington, DC: American Psychological Association. Mahoney, M. J. (2000b). A constructive view of disorder and development. In R. A. Neimeyer & J. D. Raskin (Eds.), Constructions of disorder: Meaning-making frameworks for psychotherapy (pp. 43-62). Washington, DC: American Psychological Association. Mahoney, M. J. (2003a). Scientist as subject: The psychological imperative. Clinton Corners, NY: Eliot Werner Publications. (Original work published 1976) Mahoney, M. J. (2003b). Constructive psychotherapy: Practices, processes, and personal revolutions. New York: Guilford. Mahoney, M. J. (2003c). Minding science: An update on the inside of the outside. Cognitive Therapy and Research. Mahoney, M.J., & Mahoney, S. M. (2001). Living within essential tensions: Dialectics and future development. In K. J. Schneider, J. F. T. Bugental, & J. F. Pierson (Eds.), The handbook of humanistic psychology (pp. 659-665). Thousand Oaks, CA: Sage. Mahoney, M. J., & Moes, A. J. (1997). Complexity and psychotherapy: Promising dialogues and practical issues. In F. Masterpasqua & P. A. Perna (Eds.), The psychological meaning of chaos: Self-organization in human development and psychotherapy (pp. 177-198). Washington, DC: American Psychological Association. Mitchell, S. A. (1997). Influence and autonomy in psychoanalysis. Hillsdale, NJ: Analytic Press.

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Mitchell, S. A., & Black, M. J. (1995). Freud and beyond: A history of modern psychoanalytic thought. New York: Basic Books. NorcrossJ. C., & Goldfried, M. R. (Eds.)- (1992). Handbook of psychotherapy integration. New York: Basic Books. PetitotJ., Varela, F.J., Pachoud, B., & Roy,J.-M. (Eds.). (1999). Naturalizing phenomenology: Issues in contemporary phenomenology and cognitive science. Stanford, CA: Stanford University Press. Schore, A. N. (1994). Affect regulation and the origin of the self. Hillsdale, NJ: Lawrence Erlbaum. Schwartz, J. M., & Begley, S. (2002). The mind and the brain: Neuroplasticity and the power of mental force. New York: Harper Collins. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression. New York: Guilford. Spence, D. P. (1982). Narrative truth and historical truth: Meaning and interpretation in psychoanalysis. New York: Norton. Spence, D. P. (1987). The Freudian metaphor: Toward paradigm change in psychoanalysis. New York: Norton. Stern, D. B. (1983). Unformulated experience. Contemporary Psychoanalysis, 19, 71-99. Stolorow, R. D., & Atwood, G. E. (1992). Contexts of being: The intersubjectivefoundations of psychological life. Hillsdale, NJ: Analytic Press. Stolorow, R. D., Atwood, G. E., & Orange, D. M. (2002). Worlds of experience: Interweaving philosophical and clinical dimensions in psychoanalysis. New York: Basic Books. Thompson, E. (Ed.). (2001). Between ourselves: Second-person issues in the study of consciousness. Charlottesville, VA: Imprint Academic. Van Geert, P. (1998). A dynamic systems model of basic developmental mechanisms: Piaget, Vygotsky and beyond. Psychological Review, 105, 634-677. Van Geert, P. (2000). The dynamics of general developmental mechanisms: From Piaget to Vygotsky to dynamic systems models. Current Directions in Psychological Science, 9, 64-68. Velmans, M. (Ed.). (2000). Investigating phenomenal consciousness: New methodologies and maps. Amsterdam: John Benjamins. Wilber, K. (1999). Collected works (4 vols.). Boston: Shambhala.

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Model of Causality in Social Learning Theory* Albert Bandura

any theories have been proposed over the years to explain human behavior. The basic conceptions of human nature that these theories adopt and the causal processes they postulate require careful examination for several reasons. What theorists believe people to be determines which aspects of human functioning they explore most thoroughly and which they leave unexamined. Conceptions of human nature thus focus inquiry on selected processes and are in turn strengthened by findings of paradigms embodying the particular view. For example, theorists who exclude the capacity for self-direction from their view of human potentialities confine their research to external sources of influence and indeed find that behavior is often influenced by extrinsic outcomes. Theorists who view humans as possessing self-directing capabilities employ paradigms that shed light on how people make causal contribution to their own motivation and action through the exercise of self-influence. The view of human nature embodied in psychological theories is more than a philosophical issue. As psychological knowledge gained through study is put into practice, the conceptions on which social technologies rest have even vaster implications. They can affect which

M

"'Model of Causality in Social Learning Theory," by Albert Bandura, originally appeared in S. Sukemune (Ed.), Advances in Social Learning Theory (Tokyo: Kaneko Shobo, 1983). Copyright 1983 by Kaneko Shobo. Reprinted by permission.

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Conceptual Influences

human potentialities will be cultivated and which will be underdeveloped. In this way, conceptions of human nature can influence what people become. This chapter is devoted mainly to the model of human nature and causality embodied in social learning theory. TRIADIC RECIPROCAL DETERMINISM

One-Sided Determination Human behavior has often been explained in terms of a one-sided determinism in which either environmental forces or internal dispositions are depicted as acting unidirectionally to produce behavior. As empirical evidence accumulated on the bidirectionality of influence, theorists increasingly subscribed to some form of interactional model of causality. Behavior is now commonly viewed as a product of personal and situational influences (Bandura, 1978; Bowers, 1976; Cairns, 1979; Endler & Magnusson, 1976). It is no longer interactionism, but the type of interaction advocated, that is the central issue in dispute. Interactive processes have been conceptualized in at least three different ways, as summarized in Figure 2.1. Two of these formulations subscribe to a one-sided interactionism with respect to behavior.

FIGURE 2.1 Schematic representation of three . „ . . . , . e.\ alternative conceptions ol interaction. B signifies behavior, P the cognitive and other internal events that can affect perceptions and actions, and E the external enviornment.

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One-Sided Interactionism In the unidirectional view of interaction, persons and situations are treated as independent entities that somehow combine to produce behavior. This model of causality does not adequately represent interactive processes because personal and environmental factors do not function as independent determinants; rather, they determine each other. The partially bidirectional conception of interaction acknowledges that persons and situations affect each other, but it treats influences relating to behavior as flowing in only one direction. The personsituation interchange unidirectionally produces the behavior, but behavior itself contributes nothing to the ongoing transaction. A major deficiency of this type of view is that behavior is not produced by the union of a behaviorless person and a situation. It is mainly through their actions that people influence situations, which in turn affect their thoughts, emotional reactions, and behavior. Behavior is an interacting determinant, not a detached by-product that plays no role in transactions between persons and situations.

TRIADIC RECIPROCALITY

Social learning theory favors a conception of interaction based on triadic reciprocality (Bandura, 1977a, 1982b). In this model of reciprocal determinism, behavior, cognitive and other personal factors, and environmental influences all operate as interlocking determinants that affect each other bidirectionally. Reciprocality does not mean that the two sides of the influence are of equal strength. Nor is the patterning and strength of mutual influences fixed in reciprocal causation. The relative influence exerted by the three sources of interlocking determinants will vary for different activities, different individuals, and different circumstances. It would be exceedingly difficult to study all aspects of triadic reciprocality simultaneously. Hence, different branches of psychology study different segments of it. Clarifying the interactional links among the various subsystems advances understanding of how the superordinate system operates. Cognitive psychologists, who explore the interaction between thought and action, examine how conceptions, beliefs, selfpercepts, and intentions give shape and direction to behavior. What

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people think, believe, and feel affects how they behave. The natural and extrinsic effects of their actions, in turn, partly determine their thought patterns and affective reactions (Bandura, 1982a; Bower, 1975; Neisser, 1976). Social psychologists center much of their attention on the segment of reciprocality between the person and the environment in the triadic system. They explore how thoughts, feelings, and behavioral competencies are modified through modeling, tuition, or social persuasion (Bandura, 1977a; Rosenthal & Zimmerman, 1978; Zimbardo, Ebbesen, & Maslach, 1977). People also evoke different reactions from their social environment by their physical characteristics and their social roles and statuses. The processes by which people's perceptions of each other influence the course of their interactions has been a subject of major concern to researchers working within the field of person perception (Schneider, Hastorf, & Ellsworth, 1979; Snyder, 1981). Of all the various segments in the triadic interlocking system, the reciprocal relationship between behavior and environmental events has received the greatest attention. Indeed, some theories focus exclusively on this portion of reciprocity in the explanation of behavior (Skinner, 1974). In the transactions of everyday life, behavior alters environmental conditions and is, in turn, altered by the very conditions it creates (Cairns, 1979; Patterson, 1976; Thomas & Malone, 1979). To express fully the interactive relation between behavior and environment the analysis must include cognitive determinants that also operate bidirectionally in the triadic interlocking system. This requires tapping what people are thinking as they perform responses and experience their effects.

DETERMINISM AND FORTUITOUS DETERMINANTS OF LIFE PATHS Analysis of determinism in terms of triadic reciprocality of influence sheds light on how people are influenced by, and are influencers of, the events with which they happen to have contact. But there is a fortuitous element in the events they are likely to encounter in their daily lives. People are often brought together through a fortuitous constellation of events, when their paths would otherwise never have crossed. In a chance encounter the separate paths in which people are moving have their own chain of causal determinants, but their

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intersection occurs fortuitously rather than through deliberate plan. The profusion of separate chains of events provides innumerable opportunities for fortuitous intersections. It is such chance encounters that often play a prominent role in shaping the course of career pursuits, marital partnerships, and other important aspects of human lives (Bandura, 1982c). Some chance encounters touch people only lightly, others leave more lasting effects, and still others thrust people into new trajectories of life. Psychology cannot foretell the occurrence of fortuitous encounters, however sophisticated its knowledge of human behavior. The unforeseeability and branching power of fortuitous influences make the specific course of lives neither easily predictable nor easily socially engineerable. Fortuity of influence does not mean that behavior is undetermined. Fortuitous influences may be unforeseeable, but having occurred, they enter as evident factors in causal chains in the same way as prearranged ones do. A science of psychology does not have much to say about the occurrence of fortuitous intersections, except that personal dispositions and social structures and affiliations make some types of encounters more probable than others. However, psychology can provide the basis for predicting the nature, scope, and strength of the impact they will have on human lives. The way in which personal attributes and environmental properties act reciprocally to determine the branching power of chance encounters has been extensively analyzed elsewhere (Bandura, 1982c) and will not be reviewed here.

FREEDOM AND DETERMINISM

In philosophical discourses, freedom is often considered antithetical to determinism. When viewed from a social learning perspective, there is no incompatibility between freedom and determinism. Freedom is not conceived negatively as the absence of influences or simply the lack of external constraints. Rather, it is defined positively in terms of the exercise of self-influence. This is achieved through thought, the skills at one's command, and other tools of self-influence that choice of action requires. Self-generated influences operate deterministically on behavior, as do external sources of influence. Given the same environmental conditions, persons who have the capabilities for exercising many options and are adept at regulating their own behavior will experience greater freedom than will those whose means of personal agency

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Conceptual Influences

are limited. It is because self-influence operates deterministically on action that some measure of freedom is possible. Nor is determinism incompatible with personal responsibility. Behavior always involves choices from among the various options one can pursue in a particular situation. In the face of situational inducements to behave in a particular way, persons can, and do, choose to behave otherwise by exerting self-influence. Obviously they are not the sole source of determinants but they do contribute causality to their own actions, which shape the nature of their situations. Because persons can exercise some degree of control over how circumstances will influence their actions, they cannot be entirely absolved of the responsibility of their behavior. Partial personal causality of action involves at least partial responsibility for it.

DISTINCTIVE HUMAN CAPABILITIES In the social learning view people are neither driven by inner forces nor automatically shaped and controlled by external stimuli. As we have already seen, they function as a reciprocally contributing influence to their own motivation and behavior within a system of interacting influences. Persons are characterized within this perspective in terms of a number of basic capabilities, to which we turn next.

Symbolizing Capability The remarkable capacity to use symbols provides humans with a powerful means of creating and regulating environmental events that touch virtually every aspect of their lives. It is through symbols that people process and transform transient experiences into internal models that serve as guides for future action. Through symbols they similarly give meaning, form, and continuance to the experiences they have lived through. By drawing on their knowledge and thinking skills people can generate innovative courses of action. Rather than solve problems solely by performing options and suffering the costs of missteps, people usually test possible solutions symbolically and discard or retain them on the basis of calculated consequences before plunging into action. An advanced cognitive capability coupled with the remarkable flexibility of

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symbolization enables people to create ideas that transcend their sensory experiences. Through the medium of symbols they can communicate with others at any distance in time and space. Other distinctive human characteristics to be discussed shortly are similarly founded on symbolic capability. To say that people base many of their actions on thought does not necessarily mean that they are always objectively rational. Rationality depends on reasoning skills, which are not always well developed or used effectively. Even if people know how to reason logically they make faulty judgments when they base their inferences on inadequate information or fail to consider the full consequences of different choices. Moreover, they often misread events in ways that give rise to faulty conceptions about themselves and the world around them. When they act on their misconceptions, which appear subjectively rational given their errant basis, such persons are viewed by others as behaving in an unreasoning, if not downright foolish, manner. Thought can thus be a source of human failing and distress as well as human accomplishment. Analysis of how thought enters into the determination of behavior touches on fundamental issues concerning the mind-body relationship. In social learning theory, thoughts are construed as higher neural processes that activate visceral, motoric, and other physical processes, which can in turn affect thought processes. Ideational and neural terms are different ways of representing the same brain processes, as identity theorists have argued for years. Thoughts are causative but not immaterial. Bunge (1980) presents a detailed analysis of cognitive processes as a set of brain activities in plastic neural systems of the cerebral cortex, and interprets psychophysical relations as involving reciprocal actions between specialized subsystems of the organism. The view that cognitive events are neural occurrences does not mean that psychological laws regarding cognitive functioning must be reduced to neurophysiological ones. Quite the contrary, it is important to distinguish between cortical systems and the personal and social means by which they can be orchestrated for diverse purposes. Knowing how cortical neurons function in learning does not tell one much about how best to present and organize instructional contents, how to code them for memory representation, and how to motivate learners to attend to, process, and rehearse what they are learning. Nor does understanding of how the brain works furnish rules on how to construct learning conditions best suited to cultivate skills needed to become a successful parent, teacher, or politician.

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The events needed to produce the neural occurrences underlying complex human behavior are either external to the organism or are cognitively generated. The laws of psychology therefore concern the environmental structuring and cognitive generation of influences for given purposes. Although psychological laws cannot violate what is known about the physiological system that subserves them, they need to be pursued in their own right. Were one to embark on the road to reductionism, the journey would successively traverse biology and chemistry and would eventually end in particles of atomic nuclei with neither the intermediate locales nor the final stop supplying the psychological laws of human behavior.

Forethought Capability People are not simply reactors to their immediate environment or steered by remnants of their past. Most of their behavior, being purposive, is under forethought control. They anticipate likely consequences of prospective actions, set goals for themselves, and otherwise plan courses of action that lead to valued futures. Through such exercise of forethought, people motivate themselves and guide their actions anticipatorily. By reducing the impact of immediate influences, forethought can support foresightful behavior even when present conditions are not especially conducive to it. The capability for intentional and purposive action is rooted in symbolic activity. Future events cannot serve as determinants of behavior but their cognitive representation can have strong causal impact on present actions. Thus, for example, images of desirable futures foster the type of behavior likely to bring about their realization. By the representing of foreseeable outcomes symbolically, future consequences can be converted into current motivators and regulators of foresightful behavior. In social learning analyses of telic or purposive mechanisms through goals and outcomes projected forward in time, the future gains causal influence by being represented cognitively in the present. Because outcomes affect behavior largely through the mediation of thought, consequences alone often produce little change in behavior until people become aware of what actions are being rewarded or punished (Bandura, 1969; Brewer, 1974). The way in which behavior is influenced by its effects also depends on the judgments people form

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about the rules governing outcomes, the meaning they attribute to the outcomes, and beliefs about how their actions are likely to change future outcomes over the course of time (Bandura, 1977a; Baron, Kaufman, & Stauber, 1969; Dulany, 1968). When belief differs from actuality, which is not uncommon, behavior is weakly controlled by its consequences until repeated experience instills realistic expectations. But it is not always one's beliefs that change in the direction of social reality. Acting on erroneous expectations can alter how others behave, thus shaping the social reality in the direction of the beliefs (Snyder, 1981).

Vicarious Capability

Psychological theories have traditionally assumed that learning can occur only by performing responses and experiencing their effects. Learning through action was thus given major, if not exclusive, priority. In actuality, virtually all learning phenomena resulting from direct experience occur on a vicarious basis by observing other people's behavior and its consequences for them (Bandura, 1977a; Rosenthal, 1978; Rosenthal & Zimmerman, 1978; Sukemune, Haruki, & Kashiwagi, 1977). The capacity to learn by observation enables people to acquire rules and integrated patterns of behavior without having to form them gradually by tedious trial and error. The constraints of time, resources, and mobility impose severe limits on the types of situations and activities that can be explored directly. Through social modeling, people can draw on vast sources of information, exhibited and authored by others, for expanding their knowledge and skills. Abbreviating the acquisition process through observational learning is vital for both development and survival. Because mistakes can produce costly or even fatal consequences, the prospects for survival would be slim indeed if one could learn only from the consequences of trial and error. For this reason, one does not teach children to swim, adolescents to drive automobiles, and novice medical students to perform surgery by having them discover the appropriate behavior through the consequences of their hit-and-miss efforts. The more costly and hazardous the possible errors, the heavier is the dependence on observational learning in the functional organization of behavior. Humans come with few inborn patterns. This remarkable plasticity places heavy demands on learning functions. People must develop their

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basic capabilities over an extended period, and they must continue to master new competencies to fulfill changing demands throughout their life span. It therefore comes as no surprise that humans evolved an advanced vicarious capability. Apart from the question of survival, it is difficult to imagine a social transmission process in which the language, life-styles, and institutional practices of a culture are taught to each new member by selective reinforcement of whatever behaviors happen to occur, without the benefit of models who exemplify the cultural patterns. Most psychological theories were formulated long before the advent of enormous advances in the technology of communication. As a result, they give insufficient attention to the increasingly powerful role the symbolic environment plays in present-day human lives. Indeed, in many aspects of living, televised vicarious influence has supplanted the primacy of direct experience. Whether it be thought patterns, values, attitudes, or styles of behavior, life increasingly models the media. The video system feeding off telecommunications satellites has become the dominant vehicle for disseminating symbolic environments. Further developments in cable systems that permit two-way communication, laser transmission with its enormous information-carrying capacity, and computer delivery systems with vast stored choices will provide households with diverse symbolic environments to serve almost any purpose. These extraordinary changes in communication technologies are restructuring how we live our lives. Diversity and ready choice of symbolic environments allow greater leeway for self-directedness to affect the course of personal development. In the social learning view, observational learning is governed by four component processes, which are depicted in Figure 2.2. Attentional processes determine what is selectively observed in the profusion of modeling influences and what information is extracted from ongoing modeled events. The process of attention is not simply a matter of absorbing sensory information that happens to impinge upon the organism. Rather, it involves self-directed exploration of the environment and construction of meaningful perceptions from ongoing modeled events. Perceptions are guided by preconceptions. Observers' cognitive competencies and perceptual sets dispose them to look for some things over others. Their expectations not only channel what they look for but also partly affect what features they extract from observations and how they interpret what they see and hear. People cannot be much influenced by observation of modeled activities if they do not remember them. A second major subfunction governing observational learning concerns retention processes. Retention involves

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an active process of transforming and restructuring information about events. Observational learning relies mainly upon two representational systems—imaginal and verbal. After modeled activities have been coded into images and readily utilizable verbal symbols, these conceptions function as guides for subsequent action. Cognitive rehearsal also serves as an important memory aid. If symbolic conceptions of modeled events are not rehearsed when first observed, they are vulnerable to loss from memory (Bandura &Jeffery, 1973). In the third subfunction in modeling—the behavioral production process—symbolic conceptions are translated into appropriate actions. Behavioral production primarily involves a conception-matching process in which feedback from action is compared against the conceptual model. The behavior is then modified on the basis of the comparative information to achieve close correspondence between conception and action. Feedback is not of much aid if it occurs before an adequate conceptual representation is formed (Carroll & Bandura, 1982). Lack of an internal conception to serve as a comparative standard limits the extent to which performance feedback can be used correctively. The fourth subfunction in modeling concerns motivational processes. Social learning theory distinguishes between acquisition and performance. This distinction is emphasized because people do not perform everything they learn. Performance of observationally learned behavior is influenced by three major types of incentives—direct, vicarious, and self-produced. People are more likely to exhibit modeled behavior if it results in valued outcomes than if it has unrewarding or punishing effects. Observed consequences influence the performance of modeled behavior in much the same way as do directly experienced consequences (Bandura, 1977a; Thelen & Rennie, 1972). Seeing modeled behavior succeed for others increases the tendency to behave in similar ways, whereas seeing modeled behavior punished decreases like tendencies. The impact of observed consequences depends on observers' inferences that they would experience similar or unlike outcomes for engaging in the modeled activities. The self-evaluative reactions people generate toward their own actions also regulate which observationally learned activities will be performed (Hicks, 1971). They express what they find self-satisfying and exclude what they personally disapprove. Self-Regulatory Capability Another distinctive feature of social learning theory is the central role it assigns to self-regulatory functions. People do not behave just to suit

Conceptual Influences

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ATTENTIONAL PROCESSES

RETENTION

PROCESSES

Modeled Events Distinctiveness Affective Valence Complexity Prevalence Functional Value

Symbolic Coding Cognitive Organization Symbolic Rehearsal Enactive Rehearsal

Observer Attributes Perceptual Capabilites Arousal Level Perceptual Set Acquired Preferences

Observer Attributes Cognitive Skills Cognitive Structures

MODELED EVENTS

FIGURE 2.2 Subprocesses governing observational learning.

the preferences of others. Much of their behavior is motivated and regulated through internal standards and self-evaluative reactions to their own actions. An act therefore includes among its determinants self-produced influences. Figure 2.3 depicts the three main subfunctions in the self-regulation of behavior through internal standards and selfincentives. The first subfunction concerns the selective observation of one's own behavior on dimensions that are relevant in particular situations. Behavior produces self-reactions through a judgmental function relying on several subsidiary processes, which include comparisons of perceived conduct to internal standards and the performances of others, valuation of the activities in which one is engaged, and cognitive appraisals of the personal and situational factors affecting one's performance. Performance appraisals set the occasion for self-produced consequences. Favorable judgments give rise to positive self-reactions, whereas unfavorable appraisals activate negative self-reactions. Self-evaluative incentives operate as motivational devices rather than as automatic strengtheners of behavior (Bandura, 1977a; Locke, Shaw, Saari, & Latham, 1981). When people commit themselves to explicit standards or goals, perceived negative discrepancies between what they do and what they seek to achieve create self-dissatisfactions that serve as motivational inducements for change. Both the anticipated self-satisfactions for matching accomplishments and self-dissatisfactions with insufficient ones provide incentives for action.

Model of Causality in Social Learning Theory

PRODUCTION

PROCESSES

Internal Conception Observation of Enactments Accuracy Feedback

Observer Attributes Physical Capabilites Component Subskills

MOTIVATIONAL

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PROCESSES

External Incentives Sensory Tangible Social Controllability Vicarious Incentives Self-Incentives Tangible Self-Evaluative

MATCHING PERFORMANCES

Observer Attributes Incentive Preferences Social Comparative Biases Internal Standards

Activation of self-evaluative processes through internal comparison requires both personal standards and knowledge of the level of one's performance. Neither knowledge of performance without standards nor standards without performance knowledge provides a basis for selfevaluative reactions and thus has little motivational effect (Bandura & Cervone, 1983). Whether negative discrepancies are motivating or discouraging is partly determined by people's perceptions of their efficacy to attain the standards they set for themselves. Those who have a low sense of efficacy are easily discouraged by failure, whereas those who are assured of their capabilities intensify their efforts when their performances fall short and persist until they succeed. Research examining these cognitive processes reveals that effects of goal systems on motivation are indeed mediated through self-evaluative and self-efficacy mechanisms (Bandura & Cervone, 1983). Personal goals are most highly motivating when persons are dissatisfied with their substandard performances but are highly self-assured about their efficacy to achieve their self-prescribed goals. Social learning theory distinguishes between distal goals and proximal subgoals. End goals influence the activity paths that are chosen, but they are too far removed in time to function as effective incentives and guides for present action. Focus on the distant future makes it easy to temporize and to slacken efforts in the present. It is proximal subgoals

Conceptual Influences

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Self-Observation

Performance Dimensions Quality Rate Quantity Originality Sociability Morality Deviancy Regularity Proximity Accuracy

Judgmental Process Personal Standards Level Explicitness Proximity Generality

Referential Performances Standard Norms Social Comparison Personal Comparison Collective Comparison

Self-Reaction

Evaluative SelfReactions Positive Negative

Tangible SelfReactions Rewarding Punishing

No Self-Reaction

Valuation of Activity Regarded Highly Neutral Devalued

Performance Attribution Personal Locus External Locus

FIGURE 2.3 Subprocesses in the self-regulation of behavior through internal standards and self-incentives.

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that effectively mobilize effort and direct what one does in the here and now. Attainable subgoals leading toward aspiring ultimate goals thus create the most favorable conditions for continuing self-motivation. Such proximal self-motivators cultivate competence, expand self-percepts of efficacy, and foster intrinsic interest in activities (Bandura & Schunk, 1981). After social and moral standards of conduct are adopted, anticipatory self-condemning reactions for violating personal standards ordinarily serve as self-deterrents against reprehensible acts. But development of self-regulatory capabilities does not create an invariant control mechanism within a person. Self-evaluative regulators do not operate unless activated, and many factors affect the selective activation and disengagement of internal control. There are various means by which selfevaluative reactions can be dissociated from censurable behavior or even enlisted in its service. Figure 2.4 shows the several points in the process at which the disengagement can occur. One set of disengagement practices operates at the level of the behavior. What is culpable can be made honorable by moral justification that portrays the conduct as serving moral ends, by euphemistic language that confers a respectable status on reprehensible activities, and by

FIGURE 2.4 Mechanisms through which behavior is disengaged from self-evaluative consequences at different points hi the process.

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advantageous comparison with more deplorable behavior. Another set of dissociative practices operates by obscuring, through displacement or diffusion of responsibility, the relationship between actions and the effects they cause. Self-prohibiting reactions are weak when personal agency can be easily disowned. Additional ways of weakening self-deterring reactions operate through disregard or misrepresentation of consequences of actions. The final set of dissociative practices serve selfexonerative purposes by dehumanizing and attributing blame to those who are maltreated. Because self-regulatory functions can be selectively activated and disengaged, internal standards do not always safeguard against harmful conduct. Self-Reflective Capability If there is any characteristic that is distinctively human, it is the capability for reflective self-consciousness. This enables people to analyze their experiences and to think about their own thought processes. By reflecting on their varied experiences and on what they know, they can derive generic knowledge about themselves and the world around them. People not only gain understanding through reflection, they evaluate and alter their own thinking. In verifying thought through self-reflective means, they monitor their ideas, act on them or predict occurrences from them, judge from the results the adequacy of their thoughts, and change them accordingly. Although such metacognitive activities usually foster veridical thought (Flavell, 1978), they can produce faulty thought patterns as well through reciprocal causation. Forceful actions arising from erroneous beliefs often create social effects that confirm the misbeliefs (Snyder, 1980). Among the types of thoughts that affect action, none is more central or pervasive than people's judgments of their capabilities to deal effectively with different realities. The self-efficacy mechanism plays a central role in human agency (Bandura, 1977b, 1982a). Self-judgments of operative capabilities function as one set of proximal determinants of how people behave, their thought patterns, and the emotional reactions they experience in taxing situations. In their daily lives people continuously have to make decisions about what courses of action to pursue and how long to continue those they have undertaken. Because acting on misjudgments of personal efficacy can produce adverse consequences, accurate appraisal of one's own capabilities has considerable functional value.

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It is partly on the basis of self-percepts of efficacy that people choose what to do, how much effort to invest in activities, and how long to persevere in the face of disappointing results. People's judgments of their capabilities additionally influence their thought patterns and emotional reactions during anticipatory and actual transactions with the environment. Those who judge themselves inefficacious in coping with environmental demands dwell upon their personal deficiencies and imagine potential difficulties as more formidable than they really are (Beck, 1976; Lazarus & Launier, 1978; Meichenbaum, 1977; Sarason, 1975). Such self-doubts create stress and impair performance by diverting attention from how best to proceed with undertakings to concerns over failings and mishaps. In contrast, persons who have a strong sense of efficacy deploy their attention and effort to the demands of the situation and are spurred by obstacles to greater effort. Judgments of self-efficacy, whether accurate or faulty, are based on four principal sources of information. These include performance attainments; vicarious experiences of observing the performances of others; verbal persuasion and allied types of social influences that one possesses certain capabilities; and physiological states from which people partly judge their capableness, strength, and vulnerability. In the selfappraisal of efficacy these different sources of efficacy information must be processed and weighed through self-referent thought. Acting on one's self-percepts of efficacy brings successes or missteps requiring further self-reappraisals of operative competencies. The self-knowledge, which underlies the exercise of many facets of personal agency, is largely the product of such reflective self-appraisal. Self-reflectivity entails shifting the perspective of the same agent rather than reifying different internal agents or selves regulating each other. Thus, in their daily transactions people act on their thoughts and later analyze how well their thoughts have served them in managing events. But it is the one and the same person who is doing the thinking and later evaluating the adequacy of one's knowledge, thinking skills, and action strategies. The shift in perspective does not transform one from an agent to an object. One is just as much an agent reflecting on one's experiences as in executing the original courses of action. Seen from the social learning perspective, human nature is characterized by a vast potentiality that can be fashioned by direct and observational experience into a variety of forms within biological limits. To say that a major distinguishing mark of humans is their endowed plasticity is not to say that they have no nature or that they come structureless

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(Midgely, 1977). The plasticity that is intrinsic to the nature of humans depends upon neurophysiological mechanisms and structures that have evolved over time. These advanced neural systems for processing, retaining, and using coded information provide the capacity for those very characteristics that are distinctly human—generative symbolization, forethought, evaluative self-regulation, reflective self-consciousness, and symbolic communication. Nor does plasticity mean that behavior is entirely the product of current experience. Some innately organized patterns of behavior are present at birth; others appear after a period of maturation. One does not teach crying and sucking to infants and walking to toddlers. Nor does one have to teach somatic motivators arising from tissue deficits and aversive events or have to create somatic rewards. Infants come equipped with some attentional selectivities as well (von Cranach, Foppa, Lepenies, & Ploog, 1979). These neural programs for basic physiological functions are the product of accumulated ancestral experiences that are stored in genetic codes. Most patterns of human behavior are organized by individual experience rather than provided ready made by inborn programming. Although human thought and conduct may be fashioned largely through experience, innately determined factors enter to some degree into every form of behavior. Genetic factors affect behavioral potentialities. Both experiential and physiological factors interact, often in intricate ways, in determining behavior. The level of psychological and physiological development, of course, limits what can be acquired at any given time. But it is because of their considerable plasticity and cognizing powers that humans have an unparalled capability to become many things. REFERENCES Bandura, A. (1969). Principles of behavior modification. New York: Holt, Rinehart & Winston. Bandura, A. (1977a). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall. Bandura, A. (1977b). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191-215(b). Bandura, A. (1978). The self-system in reciprocal determinism. American Psychologist, 33, 344-358. Bandura, A. (1982a). Self-efficacy mechanism in human agency. American Psychologist, 37, 122-147. Bandura, A. (1982b). The self and mechanisms of agency. InJ. Suls (Ed.), Psychological perspectives on the self (Vol.1). Hillsdale, NJ: Lawrence Erlbaum.

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Bandura, A. (1982c). The psychology of chance encounters and life paths. American Psychologist, 37, 747-755. Bandura, A., & Cervone, D. (1983). Self-evaluative and self-efficacy mechanisms: The motivational effects of goal systems. Journal of Personality and Social Psychology, 45, 1017-1028. Bandura, A., &Jeffery, R. W. (1973). Role of symbolic coding and rehearsal processes in observational \earnmg.JournalofPersonality and Social Psychology, 26, 122-130. Bandura, A., & Schunk, D. H. (1981). Cultivating competence, self-efficacy, and intrinsic interest through proximal self-motivation. Journal of Personality and Social Psychology, 41, 586-598. Baron, A., Kaufman, A., & Stauber, K. A. (1969). Effects of instructions and reinforcement feedback on human operant behavior maintained by fixed-interval reinforcement. Journal of the Experimental Analysis of Behavior, 12, 701-712. Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press. Bower, G. H. (1975). Cognitive psychology: An introduction. In W. K. Estes (Ed.), Handbook of learning and cognition. Hillsdale, NJ: Lawrence Erlbaum. Bowers, K. S. (1976). Situationism in psychology: An analysis and a critique. Psychological Review, 80, 307-336. Brewer, W. F. (1974). There is no convincing evidence for operant or classical conditioning in adult humans. In W. B. Weimer & D. S. Palermo (Eds.), Cognition and the symbolic processes. Hillsdale, NJ: Lawrence Erlbaum. Bunge, M. (1980). The mind-body problem: A psychobiological approach. Oxford: Pergamon. Cairns, R. B. (Ed.). (1979). The analysis of social interactions: Methods, issues, and illustrations. Hillsdale, NJ: Lawrence Erlbaum. Carroll, W. R., & Bandura, A. (1982). The role of visual monitoring in observational learning of action patterns: Making the unobservable observable. Journal of Motor Behavior, 14, 153-167. Dulany, D. F. (1968). Awareness, rules, and propositional control: A confrontation with S-R behavior theory. In T. R. Dixon & D. L. Horton (Eds.), Verbal behavior and general behavior theory. Englewood Cliffs, NJ: Prentice-Hall. Endler, N. S., & Magnusson, D. (Eds.). (1976). Interactional psychology and personality. Washington, DC: Hemisphere. Flavell,J. H. (1978). Metacognitive development. In I. M. Scandura & C. I. Brainerd (Eds.), Structural process theories of complex human behavior. Alphen a. LI. Rijn, The Netherlands: Sijthoff and Nordhoff. Hicks, D. J. (1971). Girls' attitudes toward modeled behaviors and the content of imitative private play. Child Development, 42, 139-147. Lazarus, R. S., & Launier, R. (1978). Stress-related transactions between person and environment. In L. A. Pervin & M. Lewis (Eds.), Perspectives in interactional psychology. New York: Plenum. Locke, F. A., Shaw, K. N., Saari, L. M., & Latham, G. P. (1981). Goal setting and task performance: 1969-1980. Psychological Bulletin, 90, 125-152. Meichenbaum, D. H. (1977). Cognitive-behavior modification: An integrative approach. New York: Plenum.

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Midgely, M. (1977). Beast and man: The roots of human nature. Ithaca, NY: Cornell University Press. Neisser, U. (1976). Cognition and reality: Principles and implications of cognitive psychology. San Francisco: Freeman. Patterson, G. R. (1976). The aggressive child: Victim and architect of a coercive system. In F. J. Mash, L. A. Hamerlynck, & L. C. Handy (Eds.), Behavior modification families. New York: Brunner/Mazel. Rosenthal, T. L. (1978). Cognitive social learning theory. In N. S. Endler & J. M. Hunt (Eds.), Personality and the behaviordisorders (Rev. ed.). New York: Wiley, 1984. Rosenthal, T. L., & Zimmerman, B.J. (1978). Social learning and cognition. New York: Academic Press. Sarason, I. G. (1975). Anxiety and self-preoccupation. In I. G. Sarason & C. D. Spielberger (Eds.), Stress and anxiety (Vol. 2). Washington, DC: Hemisphere. Schneider, D. J., Hastorf, A. H., & Ellsworth, P. C. (1979). Person perception (2nd ed.). Reading, MA: Addison-Wesley. Skinner, B. F. (1974). About behaviorism. New York: Knopf. Snyder, M. (1980). Seek, and ye shall find: Testing hypotheses about other people. In F. T. Higgins, C. P. Herman, & M. P. Zanna (Eds.), Social cognition: The Ontario symposium on personality and social psychology (Vol. 1). Hillsdale, NJ: Lawrence Erlbaum. Snyder, M. (1981). On the self-perpetuating nature of social stereotypes. In D. L. Hamilton (Ed.), Cognitive processes in stereotyping and intergroup behavior. Hillsdale, NJ: Lawrence Erlbaum. Sukemune, S., Haruki, Y., & Kashiwagi, K. (1977). Studies on social learning in Japan. American Psychologist, 32, 924-933. Thelen, M. H., & Rennie, D. L. (1972). The effect of vicarious reinforcement on imitation: A review of the literature. In B. H. Maher (Ed.), Progress in experimental personality research (Vol. 6). New York: Academic Press. Thomas, F. A. C., & Malone, T. W. (1979). On the dynamics of two-person interactions. Psychological Review, 86, 331-360. von Cranach, M., Foppa, K., Lepenies, W., & Ploog, D. (Eds.). (1979). Human ethology: Claims and limits of a new discipline. Cambridge: Cambridge University Press. Zimbardo, P. G., Ebbesen, F. B., & Maslach, C. (1977). Influencing attitudes and changing behavior. Reading, MA: Addison-Wesley.

3 Therapeutic Components Shared by All Psychotherapies* Jerome D. Frank and Julia Frank

n the current professional environment, intense competition for scarce economic and social resources impedes recognition that all psychotherapeutic procedures share certain healing components, components that account for a considerable proportion of their effectiveness. Contemporary psychotherapists experience great pressure to show they employ "evidence-based" treatment methods. Such pressures lead to the definition of nearly all problems of adaptation in quasimedical terms that highlight observable phenomena such as symptoms or patterns of behavior. Therapies, in turn, are evaluated according to their measurable effect on symptoms. This emphasis on quantifiable change in specific conditions fosters the ascendancy of psychotherapeutic methods designed to induce such changes, relegating valuable, but less phenomenological, approaches to the margins of practice. A historical review of the evidence supporting the claim that the shared elements of psychotherapies far outweigh their differences seems timely under the circumstances. All psychotherapeutic methods are

I

'This chapter is a revised version of an invited address to the American Psychological Association and is reprinted with kind permission. The original version appeared in J. H. Harvey and M. M. Parks (Eds.), The Master Lecture Series. Vol. I: Psychotherapy Research and Behavior Change, Washington, DC: American Psychological Association, 1982; pp. 73-122. Copyright 1982 by the American Psychological Association. Revisions for this edition were provided by Julia B. Frank, MD. Reprinted by permission of the publisher and authors.

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variations of age-old procedures for relieving distress. These include confession, atonement and absolution, encouragement, consolation, positive and negative reinforcement, modeling, and the promulgation of a particular set of values (Jackson, 1999). To judge psychotherapies merely by their effect on specific symptoms both exaggerates and diminishes a uniquely human form of healing. Psychotherapy is not simply an analogue to medical treatment but a broad social enterprise for relieving suffering through arousing hope, facilitating mastery, and, ultimately, transforming the meanings people attach to their experiences.

DISTINGUISHING FEATURES OF PSYCHOTHERAPY Let us now offer a definition of psychotherapy that is sufficiently broad to include everything that goes by that term but excludes informal help from relatives, friends, and bartenders. Psychotherapy is a planned, emotionally charged, confiding interaction between a trained, socially sanctioned healer and a sufferer. During this interaction the healer seeks to relieve the sufferer's distress and disability through symbolic communications, primarily words, but also sometimes artistic or bodily activities. The healer may or may not involve the patient's relatives and others in the healing rituals. Psychotherapy also often includes helping the patient to accept and endure suffering as an inevitable aspect of life that can be used as an opportunity for personal growth. Certain features distinguish psychotherapy, thus defined, from other forms of interpersonal influence. The psychotherapist has credentials as a healer. Society at large provides these to professional healers in the form of licensure or other official recognition. The therapist has earned this recognition by having undergone special training, usually prolonged, which leads to the status symbol of an academic degree. (Therapists lacking such generally recognized credentials are legitimized by the particular school, sect, or cult they represent. Persons who seek out the many extra-professional types of therapy presumably perceive their therapists as experts within a circumscribed group.) Whatever his or her credentials, the therapist is expected to abstain from making any personal emotional demands on the patient. Patients are thus free to express their own responses unguardedly, without fear of hurting the therapist. In this respect therapy differs fundamentally from interaction with family members or friends. Finally, psychothera-

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peutic procedures, in contrast to informal help, are guided by conceptual schemes, which prescribe specific rituals. Psychotherapies reflect both a society's conceptualizations of illness and health and its values. In American psychotherapy, for example, patient and therapist are generally required to "work" at some form of mutual activity to justify their spending time together. Increased autonomy is regarded as an important feature of mental health. A traditional Hindu might find these attitudes astonishing. In the Hindu tradition simply being together may be an end in itself, and dependency on others is a valued feature of life (Neki, 1973; Pande, 1968). In America, most psychotherapies derive from one of two competing perspectives: the scientific and the existential/humanist. The scientific paradigm predominates, at least among academically trained therapists, reflecting the high prestige accorded to science in the West. Practitioners of mainstream methods ranging from psychoanalysis to behavior modification claim that their procedures are grounded on scientific evidence. The scientific world-view assumes that man is part of the animal kingdom which, like all of nature, is ruled by natural laws. From this perspective, human behavior, thinking, and feeling are determined and constrained by genetic endowment, biologically based needs, and the effects of beneficial and harmful environmental influences. Therapy consists of the application of special techniques to combat maladaptive patterns and encourage more appropriate ones. The extent to which psychotherapists view themselves as applied scientists, or at least wish to be seen as such, was brought home to me* many years ago at a conference attended by leading exponents of different psychotherapeutic schools. Each speaker introduced his or her presentation by a genuflection toward science. One showed kymographic tracings, another referred to work on rats, and a third displayed anatomical charts—all of which had only tenuous relevance to the therapies they were presenting. Humanist or existential viewpoints, a minority but influential strain within American psychiatry, reject the scientific view of man. Lay expressions of this view include the widespread interest in "spirituality," heavily promulgated in twelve-step programs, religious, and other quasireligious healing activities. According to this view, the essence of being human is the right and the capacity for self-determination, guided by purposes, values, and options. Out of our free will we can give our lives "Jerome D. Frank.

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meaning, even in the face of inevitable death. The essence of existential therapy proper is a particular kind of relationship, the "encounter," which cannot be objectively described. Existential-humanist therapists describe what they do in such terms as "relating to the patient as one existence communicating with another," or "entering the world of the patient with reverent love," or "merging with the patient." Through this total acceptance, the patient comes to value his or her own uniqueness, becomes free to exert choice, to make commitments, and to find a meaning in life (Seguin, 1965). The scientific and the existential views of suffering and healing come together in the recognition that humans are driven by nature to give meaning to their experience (Gazzaniga, 2000). Available meanings are constrained by the limitations of the brain, the qualities of language, and the principles of social interaction, all of which may be studied objectively. However, meanings themselves are not quantifiable or universal. To study them requires methods outside the domain of biological science, particularly hermeneutics (Frank & Frank, 1991). This perspective underlies a number of therapies based on the idea that people create internal narratives by which they live their lives. Therapy, in turn, ultimately shapes these narratives in ways that improve adaptation and relieve distress (Goncalves & Machado, 1999). Carrying this idea further, all psychotherapies, even those that claim derivation from science, assume that humans react to their interpretations of events, which only loosely correspond to events themselves (Rue, 1994). Methods differ, but all psychotherapies seek to shape patients' views of themselves, their relations with others, and their system of values. To this extent psychotherapies resemble both religion (Szasz, 1978) and rhetoric. To enhance their credibility, psychotherapists try to project the same personal qualities as rhetoricians. These qualities include perceived expertness, trustworthiness, and attractiveness. Psychotherapists also use many of the rhetorical devices that enhance persuasive power. Freud's evocation of Oedipus exemplifies how therapists rely on metaphors and sensory images that focus the patients' attention "on ideas central to the therapeutic message and . . . [make them] appear more . . . believable" (Glaser, 1980, p. 331). Psychotherapy is also analogous to the arts—music, for example. Like the practitioner of any art, the psychotherapist must master a certain amount of scientific and technical information, but this mastery takes one only so far. For example, a composer must know something of harmony and the physical principles of pitch and volume, but the

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application of scientific method will never be able to explain a Mozart or to determine whether the music of Cole Porter is better than that of Richard Rodgers. To be sure, one can analyze harmony, pitch, and volume in their songs and administer any number of rating scales to cohorts of listeners, but this information casts little, if any, light on their aesthetic impact. To the extent that the analogy is valid, determining scientifically whether, let us say, Gestalt therapy is preferable to Transactional Analysis should prove equally futile. LIMITATIONS OF RESEARCH Recognition that simple phenomenology cannot adequately explain crucial elements of human suffering and healing suggests that typical research methods have significant limitations when applied to this field. Decades ago, an authority on research in psychology presciently concluded that "psychology is ... a collectivity of studies of various casts, some few of which may qualify as science, while most do not. . . . Extensive and important sectors of psychological study require modes of inquiry rather more like those of the humanities than the sciences" (Koch, 1981, pp. 268-269). One of these important sectors is psychotherapy, which presents special difficulties to the researcher. These difficulties permit only modest hope that applying the scientific method will lead to insights that will improve psychotherapies. A general problem that plagues all psychological experiments is that humans respond to their interpretations of situations. A subject's interpretation of an experimental situation may differ strikingly from the one that the experimenter thinks has been created (Orne, 1969). Experimental findings in psychology may reflect the subject's efforts to comply with what he or she thinks the experimenter wants, rather than reflecting a response to the experimental conditions. In psychotherapy this problem is aggravated because the patient typically experiences strong "evaluation apprehension," which has been shown to increase a psychological subject's susceptibility to influence by the experimenter's unspoken expectations (Rosenberg, 1969). In real world psychotherapy, the patient depends on the therapist for relief, thus enhancing this susceptibility. It becomes difficult to disentangle how much of a patient's measurable response to psychotherapy is an effort to meet the therapist's expectations. Another barrier to studying the effective elements of psychotherapy is that psychotherapy is just one influence operating briefly and intermit-

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tently on the patient in the context of other life experiences. At best psychotherapeutic interviews are only infrequent, intermittent, brief personal contacts wedged in among innumerable others. What goes on between sessions may be more important in determining outcome than what occurs during sessions. Changes in a patient's outlook or behavior brought about by psychotherapy inevitably affect the attitudes of others in ways that may reinforce or counteract the changes induced by therapy. Mere acceptance of the patient for treatment, for example, may lead family members to change their view of the individual from a person who is lazy or bad to one who is sick, with corresponding favorable changes in their attitudes toward the patient. Conversely, if the patient's symptoms or deviant behaviors contribute to the equilibrium of the family, losing these symptoms or behaviors might lead other family members to sabotage treatment. Thus it may be difficult to assess the relative extent to which patients' changes during psychotherapy are attributable to the treatment itself, to factors outside it, or to the interaction between treatment and outside factors. At a more fundamental level, some important experiences in psychotherapy may be inherently inaccessible to scientific study because they occur in altered states of consciousness, in ways not accessible to the senses, at levels of reality differing from the everyday one (LeShan, 1974; H. Smith, 1977). When we return from this uncomfortable line of thought to more familiar ground, we find that psychotherapy research bristles with practical difficulties, including the dearth of suitable patients and experienced therapists, inadequate ways of classifying patients and describing therapies, and problems of measuring outcome. These obstacles create an often-irresistible temptation to choose research problems on the basis of methodological simplicity rather than on intrinsic interest. Finally, motivational problems, especially in therapists, create difficulties. Not only are therapists' personal and financial security and status wrapped up in the success of their methods, but also much of their success may depend on personal qualities. So therapists are understandably reluctant to submit themselves to investigations, which could reveal that they have attributes that militate against therapeutic success. Such a finding could be devastating not only to their pocketbooks but also to their self-esteem. All in all, it is no wonder that despite the outstanding ability of many researchers in psychotherapy, and significant improvement in methodology in recent decades, findings by and large have been insuffi-

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cient to persuade skeptics of the value of psychotherapy, or to convince practitioners of different schools to adopt the methods of others. Reviews of psychotherapy research studies characteristically bemoan their lack of impact on practice and conclude with comments on their inadequacies and the need for further research (Garfield & Bergin, 1986). Our personal impression is that most innovative psychotherapeutic procedures derive from clinical experience. The discoverer or a later disciple tries to test the procedure by designing laboratory analogies. The great nineteenth-century German psychiatrist, Emil Kraepelin, for example, described his treatment for "dread neurosis"—what we would call "generalized anxiety disorder"—in terms that could easily be translated into a combination of reciprocal inhibition and operant conditioning (Diefendorf, 1915, p. 400). The influential founder of cognitive behavioral therapy, Aaron Beck, has acknowledged that his well-elaborated system of characterizing and treating psychiatric illness derives from his own early, disappointing experience with psychoanalysis and the serendipitous recognition that he could help patients make changes by addressing their fleeting but conscious patterns of thought in a systematic way (Beck, Rush, Shaw, & Emery, 1979). Though it may not uncover fundamental psychological truths, the scientific method does improve on therapeutic inspiration in that it requires the experimenter to take negative findings seriously. As a result, the scientific study of psychotherapy has performed a useful function by rescuing common sense from the clutches of dogmatic theories. A good example of such a rescue has been overwhelming scientific evidence that conscious cognitive processes are important features of human functioning—a blatant truism, one might say, but one that both dogmatic psychoanalysts and dogmatic behaviorists have been historically reluctant to accept. Placing the scientific study of psychotherapy in perspective allows us to admit that our own conclusions about the essential nature of psychotherapy are based at least as much on reflection about our own and others' clinical experience as they are on experiments. In the ideas that follow, research findings are offered as illustrations of points rather than as proofs of their validity. GENERALIZATIONS ABOUT OUTCOMES OF PSYCHOTHERAPIES Four generalizations about the essential elements of all psychotherapies are relatively firmly established. The first is that patients who receive

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any form of psychotherapy do somewhat better than controls observed over the same period of time who have received no formal psychotherapy. Such improvement does not, of course, exclude their having benefited from informal helping contacts with others (Sloane, Staples, Cristol, Yorkston, & Whipple, 1975; N. L. Smith, Glass, & Miller, 1980). Second, follow-up studies appear to show consistently that, whatever the form of therapy, most patients who show initial improvement maintain it (B. L. Liberman, 1978b). Moreover, when two therapies yield differences in outcome at the close of treatment, with rare exceptions these differences disappear over time. The closing of the gap seems to depend more on patients who receive the less successful therapy catching up than on both groups regressing equally toward the mean (Gelder, Marks, & Wolff, 1967; B. L. Liberman, 1978b). This result suggests that the main beneficial effect of psychotherapy with many patients may be to accelerate improvement that would have occurred eventually in any case. Third, more of the determinants of therapeutic success lie in the personal qualities of and the interaction between patient and therapist than in the particular therapeutic method used. Finally, the therapeutic method does make a significant difference in outcome in certain well defined conditions. Behavioral or cognitive-behavioral therapies seem to be somewhat more effective than other therapies for phobias, panic, compulsions, eating, and sexual problems. Of particular interest from the standpoint of the hypothesis to be offered presently is that cognitive therapy, which seeks to combat negative cognitions about oneself, the future, and one's relationships with other people, seems demonstrably effective with depressed patients (Elkin, Shea, Watkins, Imber, Sotsky, Collins, et al., 1989; Rush, Beck, Kovacs, & Hollow, 1977). However, much of the efficacy of this therapy turns out to be a function of the establishment of a strong therapeutic relationship between the patient and the therapist rather than to any specific cognitive behavioral techniques (Krupnick et al., 1996). No method works consistently in the absence of this relationship. (In the case of therapy as self-help, learned through books or some other medium, the relationship exists in the patient's imagination. The patient believes that the creator of the method is a skilled, caring person who has useful insight into the patient's suffering and a valid procedure for relieving it. This belief motivates the patient to implement changes based on some plausible theory, a process that may induce changes in the person's world that reinforce or maintain the new attitudes and behaviors.)

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With increasing refinement of categorization of patients and their symptom pictures, more precise delineation of therapies, and more clearly differentiated measures of outcome, further advantages of specific therapies for specific conditions may yet be found. It does seem safe to conclude, however, that features shared by all therapies account for an appreciable amount of the improvement observed in most psychiatric patients who respond at all (Frank, 1973; Frank & Frank, 1991; Wampold, 2001).

DEMORALIZATION HYPOTHESIS If the shared features of psychotherapies account for the greatest part of their effect, treatable patients, whatever their symptoms, must share a type of distress that responds to these shared elements. We have come to believe that patients seek psychotherapy not for symptoms alone but for symptoms coupled with demoralization, a state of mind characterized by one or more of the following: subjective incompetence, loss of self-esteem, alienation, hopelessness (feeling that no one can help), or helplessness (feeling that other people could help but will not). These states of mind are often aggravated by uncertainty about the meaning and seriousness of particular symptoms, not uncommonly accompanied by a sense of loss of control, leading to a fear of going crazy. Demoralization occurs when individuals cannot live up to their own or others' expectations for mastering a situation or controlling their own responses to the world around them. Subjective distress or symptoms that a person cannot adequately explain or alleviate are particularly demoralizing. Demoralization may be summed up as a feeling of subjective incompetence, coupled with distress (deFigueiredo & Frank, 1982; Frank, 1974). The most common symptoms of demoralization presented by patients in psychotherapy are subjective or behavioral manifestations. Subjective states include anxiety, depression, and loneliness. Behavior consistent with demoralization often involves impasses or irresolvable conflict with significant persons such as spouse, boss, or children (Klerman, Weissman, Rounsaville, et al., 1984). Loss of self-esteem or anxiety and depression are the most common complaints of psychiatric outpatients and the symptoms most responsive to treatment (N. L. Smith et al., 1980). Whatever their source or nature, specific symptoms interact with demoralization in various ways. They reduce a person's coping capacity,

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predisposing the individual to demoralizing failures. Whether the symptom be schizophrenic thought disorder, reactive depression, or obsessional ritual, it may cause the patient to be defeated by problems of living that asymptomatic persons handle with ease. Furthermore, to the extent that the patient believes them to be inexplicable and unique, psychiatric symptoms contribute to demoralization by heightening feelings of alienation. Finally, symptoms wax and wane with the degree of demoralization; thus schizophrenics' thinking becomes more disorganized when the patients are anxious, and obsessions and compulsions worsen when they are depressed. Most patients present themselves with specific symptoms, and both they and their therapists assume that psychotherapy is aimed primarily at relieving these symptoms. Such patients do indeed exist, but for the great bulk, I suggest, much of the improvement resulting from any form of psychotherapy lies in its ability to restore the patient's morale, with the resulting diminution or disappearance of symptoms. One must add, of course, that alleviation of the patient's symptoms may be the best way to restore morale. Klerman (1985) has argued that providing psychotropic medication is a form of psychotherapy in that controlling symptoms gives patients hope and enhances feelings of mastery. Indirect evidence for the demoralization hypothesis comes from several sources. One source consists of studies comparing cohorts of persons who seek or have sought psychotherapy with those who have not. Studies of college students (Galassi & Galassi, 1973), alumni out of college for 25 years (Vaillant, 1972), and ordinary citizens in England and America (Kellner & Sheffield, 1973) showed that the treated had a higher incidence or greater severity of social isolation, helplessness, or sense of failure or unworthiness—all symptoms of demoralization—than the untreated. While specific symptoms, education, and access to services influence who receives professional psychotherapy, recent reviews have confirmed that stress and feelings of inadequacy and helplessness remain important personal determinants of the decision to seek help (Howard, Cornille, Lyons, Vessey, Luerger, & Saunders, 1996; Veroff, 1981). The surveys of Bruce and Barbara Dohrenwend provided strong early corroboration of the importance of demoralization as a fundamental element of psychopathology in outpatients. The Dohrenwends devised a set of scales to determine the extent of psychiatric symptoms and clinical impairment in the general population (Dohrenwend, Shrout, Egri, & Mendlsohn, 1980). To their surprise, they found that eight

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of their scales correlated as highly with each other as their internal reliabilities would permit; that is, they all appeared to measure a single dimension. These scales included features of demoralization such as anxiety, sadness, hopelessness, and low self-esteem (Dohrenwend, Oksenberg, Shrout, Dohrenwend, & Cook, 1979). About one fourth of the persons in the population they surveyed appeared to be demoralized according to this criterion. Of these, about one half were also clinically impaired (Link & Dohrenwend, 1980). They also found that four fifths of clinically impaired outpatients scored above the cut-off point on a scale that later was found to correlate about .90 with the demoralization scales (Dohrenwend & Crandall, 1970). Murphy (1986) later questioned the Dohrenwends' conclusions on methodological grounds, while still endorsing the utility of the concept of demoralization in clinical work. Surveys of reported emotional distress and presence or absence of supportive social networks provide further indirect evidence for the demoralization hypothesis. A general population survey found that persons who possess such a network are much less likely to be distressed by severe environmental stresses than those who are not so supported (Henderson, Byrne, & Duncan-Jones, 1981). In response to a similar survey, respondents who had joined a religious cult reported a sharp decline in anxiety, depression, and general emotional problems and attributed this decline primarily to emotional support from all the group members (Galanter, 1978). Apparently, emotional support from others protects individuals from demoralization. Quite different, indirect support for the demoralization hypothesis is that many patients come to psychotherapy only after other forms of relief have failed. Distressed people typically seek counsel from informal helpers, turning to professionals only if these contacts are unavailable or insufficient (Howard et al., 1996). A study of college students' use of a university's psychological services similarly found out "the decision to actually use psychotherapy was likely to come only after ineffective attempts to cope with the problem one's self or with the help of a close friend or relative" (Farber & Geller, 1977, p. 306). That demoralization may account for the emergence of specific symptoms in the course of psychoanalysis is suggested by a detailed content analysis of psychoanalytic sessions that showed that complaints of migraine headaches were reported in a context of lack of self-control, hopelessness, and helplessness, and stomach pains in a context of helplessness and anxiety (Luborsky & Auerbach, 1969). Further indirect support for the demoralization hypothesis is that many patients improve very quickly in therapy. This suggests that many

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respond to the reassuring aspects of the therapeutic situation itself rather than to a particular procedure. Before the era of managed care the mean number of therapeutic interviews in representative clinic settings was between five and six (Garfield, 1978). This finding is usually interpreted to mean that many patients who are in need of psychotherapy reject it. Undoubtedly this interpretation is true of some. Others, however, probably stop because they have obtained sufficient symptom relief and no longer feel the need to continue. Unfortunately, patients who drop out of therapy early are not usually called back for reassessment. One study that did call them back found that the average symptomatic relief was just as great in those who dropped out before their fourth session as in those who had received 6 months of therapy (Frank, Gliedman, Imber, Stone, & Nash, 1959). In a more recent study, dropouts who cited improvement as their reason for ending early had superior outcomes overall (Pekarik, 1992). A finding with the same implications is that about three fourths of psychiatric outpatients in a research study were rated as improved after four months of being on a waiting list. During this period, their only contact was an occasional telephone call from a research associate to ensure that they would wait for the assigned treatment (Sloane et al., 1975). Apparently, some patients gain relief from any contact in a therapeutic setting, probably because they perceive mere contact as therapy. SHARED THERAPEUTIC COMPONENTS Turning at last to the shared therapeutic components of all forms of psychotherapy, we find that most forms can be viewed as means of directly or indirectly combating demoralization. The list that follows, with minor variations, is similar to those components propounded by many therapists (Goldfried & Padawer, 1983; Marmor, 1976; Rosenzweig, 1936). 1. An emotionally charged, confiding relationship with a helping person, often with the participation of a group. With some possible minor exceptions, the relationship with the therapist is a necessary, and perhaps often a sufficient, condition for improvement in any kind of psychotherapy (Rogers, 1957). As Sloane and colleagues (1975) found, "Successful patients rated the personal interaction with the therapist as the single most important part of their treatment" (p. 225).

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Especially thought provoking in this connection is the classic finding by Strupp and Hadley (1979) that male college students in timelimited psychotherapy experienced as much improvement, on the average, when treated by college professors chosen for their ability to form understanding relationships as when treated by highly experienced psychotherapists. Patients let themselves become dependent on the therapist for help because of their confidence in the therapist's competence and good will. This dependence is reinforced by the patient's knowledge of the therapist's training, by the setting of treatment, and by the congruence of the therapist's approach with the patient's expectations. While the therapist's status or reputation in the patient's eyes may initially determine the therapist's ascendancy, success of therapy depends on the therapist's ability to convey to the patient that the therapist cares about the patient, is competent to help, and has no ulterior motives (Gurman, 1977)—an attitude an eminent psychotherapist summed up by the term "therapeutic Eros" (Seguin, 1965). 2. A healing setting, which has at least two therapeutic functions in itself. First, it heightens the therapist's prestige and strengthens the patient's expectation of help by symbolizing the therapist's role as a healer, whether the setting is a clinic in a prestigious hospital or a private office complete with bookshelves, impressive desk, couch, and easy chair. Often the setting also contains evidence of the therapist's training such as diplomas and pictures of his or her teachers. Second, the setting provides safety. Surrounded by its walls, patients know they can let themselves go within wide limits, dare to reveal aspects of themselves that they have concealed from others, and discuss various alternatives for future behavior without commitment and without any consequences outside the office. 3. Rationale, conceptual scheme, or myth that provides a plausible explanation for the patient's symptoms and prescribes a ritual or procedure for resolving them. 4. A ritual that requires active participation of both patient and therapist and that is believed by both to be the means of restoring the patient's health. The words myth and ritual are used advisedly to emphasize that, although typically expressed in scientific terms, therapeutic rationales and procedures cannot be disproved. Successes are taken as proof of their validity, often erroneously, whereas failures are explained away. "No form of therapy has even been initiated without a claim that it had unique therapeutic advantages. And no form of therapy

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Conceptual Influences has ever been abandoned because of its failure to live up to these claims" (M. B. Parloff quoted in Hilts, 1980). To our knowledge, no therapeutic school has ever disbanded because it concluded that another's doctrine and method was superior. An often-overlooked function of therapeutic rituals is to provide a face-saving excuse for the patient to abandon a symptom or complaint when ready to do so. To relinquish a symptom without an adequate external reason would carry the implication that it was trivial or that the patient had produced it for some ulterior motive. The more spectacular the ritual, the greater its usefulness in saving face. This circumstance necessitates caution in attributing remission of a symptom to a particular maneuver. The patient might have been ready to relinquish the symptom for other reasons, and the procedure may simply have served as the occasion for doing so.

FUNCTIONS OF MYTH AND RITUAL All therapeutic myths and rituals, irrespective of differences in specific content, have in common functions that combat demoralization by strengthening the therapeutic relationship, inspiring expectations of help, providing new learning experiences, arousing the patient emotionally, enhancing the sense of mastery or self-efficacy, and affording opportunities for rehearsal and practice. Let us consider each of these briefly in turn. Strengthening the therapeutic relationship, thereby combating the patient's sense of alienation: A shared belief system is essential to the formation and maintenance of groups, so the adherence of therapist and patient to the same therapeutic myth creates a powerful bond between them. Within this context, the therapist's continued acceptance of the patient after the patient has "confessed" combats the latter's demoralizing feelings of alienation, especially if, as is usually the case, the therapist represents a group. The ritual serves to maintain the patient-therapist bond, especially over stretches when nothing much seems to be happening. By giving patient and therapist something to do together, the ritual sustains mutual interest. The chief problem of Strupp's kindly college professors (Strupp & Hadley, 1979) was that they sometimes ran out of things to talk about, a predicament never reported by the experienced therapists. Inspiring and maintaining the patient's expectation of help: By inspiring expectations of help, myths and rituals not only keep the patient coming

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to treatment but also may be powerful morale builders and symptom relievers in themselves (H. J. Friedman, 1963; Jacobson, 1968; Uhlenhuth & Duncan, 1968). Several colleagues and I were put on the track of the importance of positive expectations in the relief of symptoms by the results of our first study of psychotherapy. In this study we compared the effects on symptoms and social behavior of six months of one of three forms of psychotherapy: group therapy, individual therapy once a week, or minimal contact treatment not more than one half hour every two weeks. We found that patients in all three therapies showed equal symptom reduction on the average, but so did those who had dropped out of treatment within the first four interviews (Frank et al., 1959). Symptom reduction, therefore, seemed in large part a response to the hope of relief engendered by being offered treatment. We decided to explore this theory by studying the effects of placebos on psychiatric symptoms, since this effect must depend solely on arousing the patient's positive expectations through administering an inert medication that symbolizes the physician's role (Frank, Nash, Stone, & Imber, 1963). The experiment called for research personnel to administer a discomfort scale, followed by a half hour series of tests aimed at discovering personality attributes related to placebo responsiveness. Then the discomfort scale was readministered, followed by an administration of the placebo. After another half hour, during which the placebo was given time to "work" and the patient received additional tests, the discomfort scale was again administered. The patients were kept on the placebo for 2 weeks, the discomfort scale being administered at the end of each week, and then the placebo was discontinued. Figure 3.1 illustrates the findings. We can see that the biggest drop in discomfort occurred before the administration of the placebo, that the reduction in discomfort was largely maintained at 1 and 2 weeks, and, for those patients whom we were able to recall after 3 years, the average discomfort was still lower than it was at the time of admission to treatment. A comparison of symptom reduction by psychotherapy and by placebo is illustrated in Figure 3.2, which portrays the findings from two groups of patients, one of which had initially received a placebo and the other 6 months of psychotherapy, who were recalled after 3 years because of some recurrence of symptoms. At this point, both groups received a placebo and their discomfort levels were checked 1 or 2 weeks later. The initial average drop in discomfort was virtually identical

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FIGURE 3.1 Changes in mean discomfort over time following administration of placebo. Placebo administered at the half hour. From Effective Ingredients of Successful Psychotherapy by J. D. Frank, R. Hoehn-Saric, S. D. Imber, B. L. Liberman, and A. R. Stone. Copyright 1978 by Brunner/Mazel. Reprinted by permission.

after 6 months of psychotherapy and after the administration of a placebo for a week. On being given a placebo 3 years later, both groups showed the same average drop, which was the same as the initial drop in discomfort with 6 months of psychotherapy. An important point is that, although the mean drop in discomfort was the same after three years as it was initially, the responses of individual patients on the two occasions were widely different. Some responded the first time and not the second, and vice versa. This finding is evidence that responsiveness to placebos depends not so much on a personal trait as on the interaction of the immediate state of the patient with factors in the environment, an observation that has been confirmed by other studies (R. Liberman, 1964).

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FIGURE 3.2 Reduction in mean discomfort following placebo and psychotherapy. Interval between 1 and 2 is one week in the placebo study, 6 months in the psychotherapy study. Interval between 2 and 3 is 3 years in both studies. Interval between 3 and 4 is one week in the placebo study, 2 weeks in the psychotherapy study. From Effective Ingredients of Successful Psychotherapy by J. D. Frank, R. Hoehn-Saric, S. D. Imber, B. L. Liberman, and A. R. Stone. Copyright 1978 by Brunner/Mazel. Reprinted by permission.

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The response after 3 years also rules out a possible interpretation of the very rapid relief of discomfort in the initial placebo group, namely, that their initial mean discomfort score was artificially heightened by their apprehension as to what was to transpire. Although this apprehension may have had some effect, it could not explain the entire drop, since it would not operate with patients who three years previously had received, and therefore were familiar with, psychotherapy. To be therapeutically effective, hope for improvement must be linked in the patient's mind to specific processes of therapy as well as outcome (Imber, Pande, Frank, Hoehn-Saric, Stone, & Wargo, 1970; Wilkins, 1979). This link could be taken for granted by purveyors of traditional therapies like psychoanalysis because most patients came to them already familiar with their procedures (Kadushin, 1969). Introducers of new or unfamiliar therapies regularly spend considerable time and effort at the start teaching the patient their particular therapeutic game and shaping the patient's expectations accordingly. These considerations led us and several colleagues to devise a controlled experiment comparing the results of four months of therapy between patients who first received a preliminary "role induction interview" designed to coordinate their expectations with what they would receive, and patients who were treated identically but did not have the preparatory interview (Hoehn-Saric, Frank, Imber, Nash, & Battle, 1964; Nash, Hoehn-Saric, Battle, Stone, Imber, & Frank, 1965). The purposes of the role induction interview were (1) to clarify the processes of treatment, (2) to assure the patient that treatment would be helpful, (3) to dispel unrealistic hopes (thereby guarding against disillusionment), and (4) to help the patient behave in a way that accorded with the therapist's image of a good patient, thereby indirectly heightening the latter's interest and optimism. As a group, patients receiving the role-induction interview showed more appropriate behavior in therapy and had a better outcome than did the controls. This finding has been replicated in another setting (Sloane, Cristol, Pepemick, & Staples, 1970). It should be emphasized that by leading the patients to behave better in therapy, the role induction interview made them more attractive to the therapists, thereby improving the patient-therapist relationship. Providing new learning experiences: These new learning experiences can enhance morale by enabling patients to discover potentially helpful alternative ways of looking at themselves and their problems and to develop alternate values. In this connection, improvement in therapy

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seems to go along with movement of the patient's values toward those of the therapist (Pande & Gart, 1968; Parloff, Goldstein, & Iflund, 1960; Rosenthal, 1955). Learning may occur in several ways, including instruction, modeling (Bandura, 1969), operant conditioning (in which the therapist's responses serve as positive or negative reinforcers), and exposure to new emotionally charged experiences, including transference reactions and emotional arousal by attempts to change contingencies governing behavior. The more numerous and more intense the experiential, as opposed to the purely cognitive, components of learning, the more likely they are to be followed by changes in the patient's attitudes or behavior. It is a truism that intellectual insight alone is essentially powerless to effect change. This brings us to the fourth ingredient common to all therapeutic conceptualizations and rituals: emotional arousal. Arousing emotions: Such arousal is essential to therapeutic change in at least three ways. It supplies the motive power to undertake the effort and to undergo the suffering usually involved in attempts to change one's attitudes and behavior, it facilitates attitude change, and it enhances sensitivity to environmental influences. If the emotional arousal is unpleasant, it leads the patient to search actively for relief. When this occurs in therapy, the patient naturally turns to the therapist. Arousal intense enough to be disorganizing further increases this dependence and in addition may facilitate the achievement of better personality integration by breaking up old patterns. Eliciting intense emotions characterizes almost all healing rituals in nonindustrialized societies. In the West, the popularity of such approaches waxes and wanes. In the recent past these approaches emerged in Mesmerism and Freudian abreaction; more recently they have flourished under various labels such as implosive therapy (Stampfl, 1976), primal therapy (Janov, 1970), reevaluation counseling (Jackins, 1965), and bioenergetics (Lowen, 1975). The core effective element of cognitive behavioral therapies is exposure, an experience that necessarily arouses strong emotion. Influenced by the Zeitgeist of the 1970s, we and our colleagues conducted a series of experiments on emotional arousal and susceptibility to attitude change (Hoehn-Saric, 1978). To produce arousal we first used small doses of ether given by drip inhalation, because of the preanesthesia excitatory stage it produces in most persons. The semantic differential (Osgood, Suci, & Tannenbaum, 1957), which permits the

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ratings of meanings of a given concept on a set of bipolar scales, was used as the measure of attitude change. In consultation with their therapists during interview therapy, patients selected a "focal" concept that the therapist would try to shift and others that the therapist would not try to change (the patients were not told which concepts the therapist would try to shift). Examples of focal concepts were "my mother's influence on me" and "my tolerance of imperfections in persons close to me." In a preliminary uncontrolled experiment, patients received three interviews under a slow-drip administration of ether a week and a half apart, and the therapist tried to shift only the focal concept during or immediately after the excitatory phase. The focal concept shifted cumulatively in the predicted direction, and the shift achieved statistical significance after the third interview, as compared to the shift in the initial session without ether. The other concepts remained unchanged throughout. We next devised a controlled experiment in which the purpose and those patients who received ether were unknown to the therapists. The experimental room smelled of ether for all patients. The results, although less striking than in the preliminary study, confirmed our premise. Since ether produces confusion, which might account for the patients' increased susceptibility to influence, we repeated the experiment using inhalation of vapor containing adrenalin, which stimulates the sympathetic nervous system without clouding consciousness with essentially the same result. In all these studies the effects on patients' attitudes were transitory; that is, the concepts soon reverted to their original positions. Perhaps this reversion is related to the repeated decline of interest in abreactive techniques after a wave of popularity. Although emotional arousal may facilitate attitude change, something else seems to be needed to maintain the change. If one may generalize from this observation, which is consistent with others, it is important to distinguish factors that produce therapeutic change from those that sustain it (Liberman, 1978a). From the perspective of the demoralization hypothesis, the therapeutic effect of intense emotional arousal may be in its demonstration to patients that they can stand, at high intensity, emotions that they feared and that therefore caused them to avoid or escape from situations that threatened to arouse them. Surviving such an experience would strengthen self-confidence directly and also encourage a patient to enter and cope successfully with these feared situations, thereby indirectly further bolstering morale. Thus the maintenance of improvement fol-

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lowing emotional flooding may depend on the ability of this procedure to enhance the patient's sense of mastery (B. L. Liberman, 1978a) or self-efficacy (Bandura, 1977), to which we now turn. Enhancing the patient's sense of mastery or self-efficacy: Self-esteem and personal security depend to a considerable degree on a sense of being able to exert some control over the reactions of others toward oneself as well as over one's own inner states. Inability to control feelings, thoughts, and impulses not only is demoralizing in itself but also impedes one's ability to control others by preempting too much attention and distorting one's perceptions and behavior. The feeling of loss of control gives rise to emotions such as anxiety that aggravate and are aggravated by the specific symptoms or problems for which the person ostensibly seeks psychotherapy. All schools of psychotherapy seek to bolster the patient's sense of mastery in at least two ways: (1) by providing the patient with a conceptual scheme that labels and explains symptoms and supplies the rationale for the treatment program, and (2) by giving the individual experiences of success. Since language is a human being's chief tool for analyzing and organizing experience, the conceptual scheme increases the patient's sense of control by making sense out of experiences that had seemed haphazard, confusing, or inexplicable, and giving names to them. This effect has been termed the principle of Rumpelstiltskin (Torrey, 1972) after the fairy tale in which the queen broke the wicked dwarfs power over her by guessing his name. To have this effect, interpretations, which are the primary means of transmitting the therapist's conceptual framework, need not necessarily be correct but may merely be plausible. One therapist demonstrated this concept by offering six "all-purpose" interpretations to four patients in intensive psychotherapy. An example of such an interpretation is 'You seem to live your life as though you were apologizing all the time." The same series of interpretations, spaced about a month apart, was given to all four patients. In 20 of these 24 instances, the patients responded with a drop in anxiety level. All patients experienced this move from the "preinterpreted" to the "postinterpreted" state at least once (Mendel, 1964). Experiences of success, a major source of enhanced self-efficacy, are implicit in all psychotherapeutic procedures. Verbally adept patients get them from achieving new insights, behaviorally oriented patients from carrying out increasingly anxiety-laden behaviors. As we have already mentioned, by demonstrating to the patient that he or she can

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withstand feared emotions at their maximal intensity, emotional flooding techniques yield powerful experiences of success. Furthermore, improvements that the patient attributes to his or her own efforts enhance self-esteem more than those that the patient attributes to factors beyond his or her control, for example, a medication or the help of someone else. Psychotherapists of all persuasions recognize this principle. Nondirective therapists disclaim any credit for the patient's acquiring new insights, and directive ones stress that the patient's gains depends on his or her ability to carry out the prescribed procedures. Providing opportunities for practice. A final morale-enhancing feature of all psychotherapies is that they provide opportunities and incentives for internalizing and reinforcing therapeutic gains through repeated testing both within and outside the therapeutic session. This principle is particularly relevant to group therapies, which often improve patients' morale to a greater degree than do individual ones. The presence of other patients and the emergence of processes specific to groups introduce additional ways of combating the alienation that accompanies demoralization and provide different opportunities for cognitive and experiential learning and for practicing what has been learned. Group therapies also provide more occasions for emotional arousal and more opportunities to achieve a sense of mastery through weathering the stresses of group interactions. Finally, as social microcosms more closely resembling real life than individual interview situations, groups facilitate transfer of therapeutic insight to daily living.

DETERMINANTS OF THERAPEUTIC SUCCESS The most powerful determinants of the success of any therapeutic encounter probably lie in properties of the patient, the therapist, and the particular patient-therapist pair, rather than in the therapeutic procedure. Despite its importance, this area presents particular problems for research, as already indicated, so research findings are scanty and, for the most part, simply confirm clinical impressions. This situation enables me to be mercifully brief. There is general agreement that the good patient is characterized by sufficient distress to be motivated for treatment and by the capacity to profit from a helping relationship. Strupp (1976) suggests that the patient must have had sufficiently rewarding experiences with his or

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her own parents so that the patient has developed "the capacity to profit from and change as a result of the forces operating in a 'good' human relationship" (p. 99). Patients with a good prognosis are characterized, in addition, by such terms as good ego strength, coping capacity, resilience, or personality assets. An illuminating approach to therapeutically favorable personal qualities is provided by Harrower (1965). On the basis of a follow-up study of 622 patients in psychoanalysis or analytically oriented therapy, she was able to devise an index of mental health potential based on score patterns on projective tests that correlated highly with improvement as judged retrospectively by the patients' therapists. Mental health potential included capacity for emotional warmth and friendliness, adequate intellectual control combined with freedom and spontaneity, inner resources, and intuitive empathy for others. In short, the psychologically healthier the patient is at the start, the better the prognosis for response to treatment. One would like to know much more about factors determining ability to profit from specific therapeutic procedures. For example, Malan (1976) presents evidence that "motivation for insight" maybe important for the success of brief psychoanalytically oriented psychotherapy. A promising lead is classification of patients in terms of locus of control— that is, whether the person sees control of his or her life as lying primarily within or outside of self (Rotter, 1966; Seeman & Evans, 1962). In one study, my colleagues and I stumbled on an interesting interaction among locus of control, therapeutic improvement, and the source to which patients were led to attribute their improved performance in therapy-linked tasks (that is, whether their improvement in therapy was attributed to their own efforts or to the effect of taking a placebo pill). The internally controlled patients did significantly better than the externally controlled in the first condition, but the results were reversed in the second (B. L. Liberman, 1978a; see Figure 3.3). Studies of the relation between locus of control and responses to a variety of therapies are accumulating (M. L. Friedman & Dies, 1975; Ollendick & Murphy, 1977). In examining the therapeutic qualities of therapists, we find that the success rate of therapists varies widely, even within the same therapeutic school. For example, in a study of encounter groups that used at least two therapists from each of several therapeutic schools, B. L. Lieberman, Yalom, and Miles (1973) found that the best and the worst outcomes were in groups conducted by therapists belonging to the same school.

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FIGURE 3.3 HSCL residual scores for mastery and placebo conditions with reference to initial mastery orientation (high residual scores reflect greater maintenance of improvement). From Effective Ingredients of Successful Psychotherapy by J. D. Frank, R. Hoehn-Saric, S. D. Imber, B. L. Liberman, and A. R. Stone. Copyright 1978 by Brunner/Mazel. Reprinted by permission.

Participants in encounter groups are sufficiently similar to those in therapy groups to justify applying this finding to them. In a retrospective analysis of 150 women treated by 16 male and 10 female therapists, Orlinsky and Howard (1980) found that two thirds of the patients of the most successful therapists were much improved and none were worse, whereas for the least successful only one third were much improved and one third were worse. As to what qualities of therapists

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account for differences in therapeutic success, however, our understanding has not progressed beyond the empathy, warmth, and genuineness found by Rogers and his school (1957) to be helpful with neurotics and the active personal participation perhaps related to success with schizophrenics (Dent, 1978; Whitehorn & Betz, 1975); the ability to generalize about these findings remains questionable (Parloff, Waskow, & Wolfe, 1978). To return to our analogy of psychotherapy with music, we find that psychotherapists, like musical performers, seem to vary in innate talent, which in most cases can be enhanced by training. Almost anyone can learn to play the piano, but no amount of training can produce a Horowitz or a Rubinstein, nor can it turn someone who is tone deaf into a violinist. Analogously, some therapists seem to obtain extraordinary results while the patients of a few do no better, or even fare worse, than if they had received no treatment at all. It would be highly desirable to weed out these "tone deaf therapists early in training, thereby preventing harm to patients and sparing the therapists from misery, but, unfortunately, adequate screening methods for this purpose do not yet exist. Our own hunch, which we mention with some trepidation, is that the most gifted therapists may have telepathic, clairvoyant, or other parapsychological abilities (Ehrenwald, 1966, 1978; Freud, 1964; Jung, 1963). They may, in addition, possess something that is similar to the ability to speed plant growth (Grad, 1967) or to produce spectacular auras on Kirlian photographs (Krippner & Rubin, 1973) and that can only be termed healing power. Any researcher who attempts to study such phenomena risks his reputation as a reliable scientist, so their pursuit can be recommended only to the most intrepid. The rewards, however, might be great. Descending to more solid ground, we see that the therapeutic relationship is, of course, a two-way street; therefore efforts to determine aspects of patients and therapists that make good or poor therapeutic matches should be promising. Again, information about this is very scanty, but thought provoking. For example, it appears that with hospitalized chronic schizophrenics, composed therapists work best with anxious patients, therapists comfortable with aggression work well with hostile patients, grandparental therapists do well with seductive patients, and therapists comfortable with depression do well with depressed schizophrenics (Gunderson, 1978). Hardly a world-shaking finding but it is a beginning.

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The study of women in therapy mentioned earlier (Orlinsky & Howard, 1980) unearthed some interesting leads. The differential success rate of therapists appeared to be due primarily to interaction of patienttherapist pairs rather than to properties of the therapist alone, except that experience appeared to operate across the board. Therapists with less than 6 years' experience, compared with those with more, had twice as many patients who were unchanged or worse and only half as many who were considerably improved. The role of experience in therapeutic success, however, remains moot (Parloff et al., 1978). Of more interest is the fact that although the sex of the therapist made no difference overall, young single women benefited more from women therapists, suggesting that men may have been somewhat threatening to them. Conversely, the only female patients who did better with the men were parents without partners. Could it be that the therapists represented to them a potential new partner? Finally, the level of conceptualization may prove highly relevant to the matching of patients with therapists (Carr, 1970). Although no conclusive findings have emerged, it seems probable that persons who conceptualize at relatively concrete levels respond best with structured therapies in a structured environment. Furthermore, studies of smokers (Best, 1975), psychiatric outpatients treated by medical students, alcoholics, college students, and delinquents all found that patients whose conceptual level was similar to that of their therapist did better than those for whom there was a mismatch (Posthuma 8c Carr, 1975).

CONCLUSIONS In concluding, let me attempt to correct a common misunderstanding of the demoralization hypothesis, namely that, since features shared by all therapies that combat demoralization account for much of their effectiveness, training is unnecessary. The point we have sought to make is that healing factors mobilized by all techniques contribute significantly to the outcome of any specific one. Through personal characteristics and past experiences, however, some patients may be more attuned to behavioral, cognitive, abreactive, hypnotic, or other procedures. Thus it remains probable that certain specific techniques are more effective for some patients, or even for some symptoms, than others. But even in the unlikely eventuality that all therapeutic techniques prove to be fully interchangeable, this substi-

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tutability would not mean that mastery of one or more is unnecessary. Such an unwarranted conclusion confuses the content of therapeutic conceptualizations and procedures with their function. Some therapeutically gifted persons, to be sure, can be effective with very little formal training, but most of us need to master at least one therapeutic rationale and ritual. Because the techniques are irrefutable and are supported by a like-minded group to which the therapist belongs (Festinger, 1957), they maintain the therapist's sense of competence, especially in the face of inevitable therapeutic failures. As one young adherent of a psychotherapeutic school remarked, "Even if the patient doesn't get better, you know you are doing the right thing." This attitude indirectly strengthens the patient's confidence in the therapist as a person who knows what he or she is doing, maximizing the chance for eventual success. If any moral can be drawn from this presentation, it is that the choice of procedures should be guided by the therapist's personal predilections. Some therapists are effective hypnotists; others are not. Some welcome emotional displays; others shy away from them. Some work best with groups, others in the privacy of the dyad. Some enjoy exploring psyches; others prefer to try to change behavior. Ideally, from this standpoint, training programs should expose trainees to a range of rationales and procedures and encourage them to select those that are most congenial to their own personalities. The greater the number of approaches that the therapist can handle, the wider the range of patients he or she will be able to help. This conclusion violates or at least challenges some basic principles of medical ethics, including the values of equity and universality. Abstract ideas of professionalism and simple biomedical models of illness dictate that care providers should be able to treat anyone suffering from a condition in their sphere of expertise. Insurance plans capitalize on these assumptions, matching providers and patients simply by the contractual terms of reimbursement, rather than by the goodness of fit between different orientations, techniques, and personalities. Though they may shake prevailing scientific and economic paradigms, careful investigations such as those we have cited remind us that psychotherapy, and indeed any healing relationship, is a deeply personal enterprise. Our conclusions about the essential nature of psychotherapy support for competing ethical values acknowledging the uniqueness of individuals. Concretely, these values imply the ability to choose one's therapist (or patient) freely, continuity of therapeutic relationships,

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and permission to be creative and flexible in providing care. A new synthesis of the competing demands of science, market forces, and humanism is needed if patients are to receive the greatest benefits of which psychotherapy is capable. SUMMARY Whatever their specific symptoms, patients coming to psychotherapy are also demoralized, and this demoralization is a cause of their distress. To the extent that patients are amenable to psychotherapy, generalized demoralization or a demoralized response to specific stresses springs from warping experiences in their past histories interacting with qualities of their genetic vulnerabilities and present environment. Demoralization encompasses three interacting, mutually reinforcing components: intrapsychic conflicts coupled with low self-esteem, distorted perception of others, and deficient coping skills. In conjunction, these components engender experiences of failure or other distressing emotions that further undermine morale. All psychotherapies aim to break the resulting vicious circle and to restore morale by providing experiences with a helping person that offer general encouragement and support, in addition to sometimes combating specific distortions of meaning and maladaptive behaviors. Psychotherapies ultimately transform the meanings people attach to their experience into conceptual schemes that lessen suffering and reduce impairment. The effectiveness of any psychotherapy with a specific patient depends on the morale-building features it shares with all other psychotherapies as well as its specific rationale and procedures. The relative contribution of these elements depends on the role of demoralization in the production or exacerbation of the patient's symptoms. Selection of technique is usually best guided less by the symptoms than by the personal characteristics and predilections of therapist and patient. The more closely these accord with each other and with the type of therapy, the better the prospects for a successful outcome. REFERENCES Bandura, A. (1969). Principles of behavior modification. New York: Holt, Rinehart & Winston.

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Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191-215. Beck, A., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. Best, J. A. (1975). Tailoring smoking withdrawal procedures to personality and motivation differences. Journal of Consulting and Clinical Psychology, 43, 1-8. Carr, B. E. (1970). Differentiation similarity of patient and therapist and the outcome of psychotherapy. Journal of Abnormal Psychology, 76, 361-369. deFigueiredo, J., & Frank, J. D. (1981). Subjective incompetence, the clinical hallmark of demoralization. Unpublished manuscript. Dent, J. K. (1978). Exploring the psychological therapies through the personalities of effective therapists [Publication No. ADM 77-527]. Washington, DC: U.S. Government Printing Office. Diefendorf, A. R. (1915). Clinical psychiatry: A textbook for students and physicians abstracted and adapted from the 7th German edition of Kraepelin's "Lehrbuch derPsychiatrie." New York: Macmillan. Dohrenwend, B. P., & Crandall, D. L. (1970). Psychiatric symptoms in community, clinic and mental hospital groups. American Journal of Psychiatry, 126, 1611-1621. Dohrenwend, B. P., Oksenberg, L., Shrout, P. E., Dohrenwend, B. S., & Cook, D. (1979). What brief psychiatric screening scales measure. In S. Sudman (Ed.), Proceedings of the 3rd biennial conference on health survey research methods [DHHS Publication No. (PHS) 81-3268, pp. 188-198]. Washington, DC: U.S. Department of Health & Human Services. Dohrenwend, B. P., Shrout, P. E., Egri, G., & Mendlsohn, F. S. (1980). Nonspecific Psychological distress and other dimensions of psychopathology: Measures for use in the General population. Archives of General Psychiatry, 37, 1229-1236. Ehrenwald, J. (1966). Psychotherapy: Myth and method. New York: Grune & Stratton. Ehrenwald, J. (1978). The ESP experience: A psychiatric validation. New York: Basic Books. Elkin, L, Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M., Collins, J. F., Glass, D. R., & Pilkonis, P. A. (1999). NIMH treatment of depression collaborative research program: general effectiveness of treatments. Archives of General Psychiatry, 46, 971-982. Farber, B. A., & Geller, J. D. (1977). Student attitudes toward psychotherapy. Journal of the American College Health Association, 25, 301-307. Festinger, L. (1957). A theory of cognitive dissonance. Evanston, IL: Row, Peterson. Frank, J. D. (1973). Persuasion and healing (2nd ed.). Baltimore: John Hopkins University Press. Frank, J. D. (1974). Psychotherapy: The restoration of morale. American Journal of Psychiatry, 131, 271-274. Frank,J. D. (1980). Aristotle as psychotherapist. In M. J. Mahoney (Ed.), Psychotherapy process: Current issues and future directions. New York: Plenum Press. Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psychotherapy (3rd ed.). Baltimore: Johns Hopkins Press. Frank, J. D., Gliedman, L. H., Imber, S. D., Stone, A. R., & Nash, E. H. (1959). Patients' expectancies and relearning as factors determining improvement in psychotherapy. American Journal of Psychiatry, 115, 961-968.

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Frank, J. D., Nash, E. H., Stone, A. R., & Imber, S. D. (1963). Immediate and longterm symptomatic course of psychiatric outpatients. American Journal of Psychiatry, 120, 429-439. Frank J., li, Hoehn-Saric, R., Imber, S. D., Liberman, B. L., & Stone, A. R. (1978). Effective Ingredients of Successful Psychotherapy. New York: Brunner/Mazel. Freud, S. (1964). Dreams and occultism. In J. Strachey (ed. & trans.), The complete psychological works of Sigmund Freud. London: Hogarth. Friedman, H. J. (1963). Patient expectancy and symptom reduction. Archives of General Psychiatry, 8, 61-67. Friedman, M. L., & Dies, R. R. (1975). Reactions of internal and external testanxious students to counseling and behavior therapies. Journal of Consulting and Clinical Psychology, 42, 921. Galanter, M. (1978). The "relief effect": Asociobiological model for neurotic distress and large-group therapy. American Journal of Psychiatry, 135, 588-591. Galassi, J. P., & Galassi, M. D. (1973). Alienation in college students: A comparison of counseling seekers and nonseekers./owma/ of Counseling Psychology, 20, 44-49. Garfield, S. L. (1978). Research on client variables in psychotherapy. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change: An empirical analysis (2nd ed.). New York: Wiley. Garfield, S. L., & Bergin, A. E. (Eds.). (1986). Handbook of psychotherapy and behavior change (3rd ed.). New York: Wiley. Gazzaniga, M. (2000). Cerebral specialization and interhemispheric communication: Does the corpus callosum enable the human condition? Brain, 123, 12931326. Gelder, M. G., Marks, I. M., & Wolff, H. H. (1967). Desensitization and psychotherapy in phobic states: A controlled inquiry. British Journal of Psychiatry, 113, 53-73. Glaser, S. R. (1980). Rhetoric and psychotherapy. In M. 3. Mahoney (Ed.), Psychotherapy process: Current issues and future directions. New York: Plenum Press. Goldfried, M. R., & Padawer, W. (1983). Current status and future directions in psychotherapy. In M. R. Goldfried (Ed.), Converging themes in the practice of psychotherapy. New York: Springer Publishing Co. Goncalves, O. F., & Machado, M. P. (1999). Cognitive narrative psychotherapy: research foundations. Journal of Clinical Psychology, 155, 1179-1191. Grad, B. (1967). The "laying on of hands": Implications for psychotherapy, gentling, and the placebo effect. Journal of the American Society for Psychical Research, 61, 286305. Gunderson, J. C. (1978). Patient-therapist matching: A research evaluation. American Journal of Psychiatry, 135, 1193-1197. Gurman, A. S. (1977). The patient's perception of the therapeutic relationship. In A. S. Gurman & A. M. Razin (Eds.), Effective psychotherapy: A handbook of research. New York: Pergamon. Harrower, M. (1965). Psychodiagnostic testing: An empirical approach. Springfield, IL: Charles C Thomas. Henderson, S., Byrne, D. G., & Duncan-Jones, P. (1981). Neurosis and the social environment. New York: Academic Press.

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Hilts, P. I. (1980). Psychotherapy: Put on couch by government. Washington Post, Section A, pp. 1, 12. Hoehn-Saric, R. (1978). Emotional arousal, attitude change, and psychotherapy. In J. D. Frank, R. Hoehn-Saric, S. D. Imber, & A. R. Stone (Eds.), Effective ingredients of successful psychotherapy. New York: Brunner/Mazel. Hoehn-Saric, R., Frank, J. D., Imber, S. D., Nash, E. H., & Battle, C. C. (1964). Systematic preparation of patients for psychotherapy: Effects of therapy behavior and outcome. Journal of Psychiatric Research, 2, 267-281. Howard, K. I., Cornille, T. A., Lyons, J. S., Vessey, J. T., Luerger, R. J., & Saunders, S. M. (1996). Patterns of mental health service utilization. Archives of General Psychiatry, 53, 696-703. Imber, S. D., Pande, S. K., Frank, I. D., Hoehn-Sanic, R., Stone, A. K., & Wargo, D. G. (1970). Time-focused role induction: Report of an instructive failure. Journal of Nervous and Mental Disease, 150, 27-30. Jackins, H. (1965). The human side of human beings. Seattle: Rational Island Publishers. Jackson, S. (1999). The care of the psyche: A history of psychological healing. New Haven, CT: Yale University Press. Jacobson, G. (1968). The briefest psychiatric encounter. Archives of General Psychiatry, 18, 718-724. Janov, A. (1970). The primal scream: Primal therapy, the cure for neurosis. New York: Putnam. Jung, C. G. (1963). Memories, dreams and reflections. New York: Vintage. Kadushin, K. (1969). Why people go to psychiatrists. New York: Atherton. Kellner, R., & Sheffield, B. F. (1973). The one-week prevalence of symptoms in neurotic patients and normals. American Journal of Psychiatry, 130, 102-105. Klerman, G. L., Weissman, M. M., Rounsaville, B. J., et al. (1984). Interpersonal psychotherapy of depression. New York: Basic Books. Klerman, G. (1985). Psychoneurosis: Integrating pharmacotherapy and psychotherapy. In J. Glafhor (Ed.), Successful psychotherapy (pp. 69—91). New York: Brunner Mazel. Koch, S. (1981). The nature and limits of psychological knowledge: Lessons of a century qua "science." American Psychologist, 36, 257-269. Krippner, S., & Rubin, D. (Eds.). (1973). Galaxies of life: The human aura in acupuncture and Kirlian photography. New York: Gordon & Breach. Krupnick, J. L., Simmens, S., Moyer, J., Elkin, I., Watkins, I., Watkins, J., & Pilkonis, P. A. (1996). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in the National Institute of Mental Health Treatment of depression collaborative research program. Journal of Consulting and Clinical Psychology, 64, 532-539. LeShan, L. (1974). The medium, the mystic, and the physicist: Toward a general theory of the paranormal. New York: Viking. Liberman, B. L. (1978). The role of mastery in psychotherapy: Maintenance of improvement and prescriptive change. In J. D. Frank, R. Hoehn-Saric, S. D. Imber, B. L. Liberman, & A. R. Stone (Eds.), Effective ingredients of successful psychotherapy. New York: Brunner/Mazel. 1

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Liberman, B. L. (1987b). The maintenance and persistence of change: Long-term follow-up investigations of psychotherapy. InJ. D. Frank, R. Hoehn-Saric, S. D. Imber, B. L. Liberman, & A. R. Stone (Eds.), Effective ingredients of successful psychotherapy. New York: Brunner/Mazel. Liberman, R. (1964). An experimental study of placebo response under three different situations of pain. Journal of Psychiatric Research, 2, 233-246. Liberman, M. A., Yalom, I. D., & Miles, M. D. (1973). Encounter groups: First facts. New York: Basic Books. Link, B., & Dohrenwend, B. P. (1980). Formulation of hypotheses about the true prevalence of demoralization in the United States. In B. P. Dohrenwend, B. S. Dohrenwend, M. S. Gould, B. Link, R. Neugebauer, & R. Wunsch-Hitzig (Eds.), Mental illness in the United States: Epidemiological estimates. New York: Praeger. Lowen, A. (1975). Bioenergetics. New York: Doward, McCann & Geoghegan. Luborsky, L., &Auerbach, A. H. (1969). The symptom-context method: Quantitative studies of symptom formation in psychotherapy. Journal of the American Psychoanalytical Association, 17, 68-99. Malan, D. H. (1976). Toward the validation of dynamic psychotherapy: A replication. New York: Plenum Press. Marmor, J. (1976). Common operational factors in diverse approaches to behavior change. In A. Burton (Ed.), What makes behavior change possible? New York: Brunner/Mazel. Mendel, W. M. (1964). The phenomenon of interpretation. American Journal of Psychoanalysis, 24, 184-189. Murphy, J. (1986). Diagnosis, screening, and "demoralization": Epidemiological implications. Psychiatric Development, 4, 101-133. Nash, E. H., Hoehn-Saric, R., Battle, C. C., Stone, A. R., Imber, S. D., & Frank, J. D. (1965). Systematic preparation of patients for short-term psychotherapy. II. Relation to characteristics of patient, therapist and the psychotherapeutic process. Journal of Nervous and Mental Disease, 140, 374-383. Neki, J. S. Guru (1973). Guru-chela relationship: The possibility of a therapeutic paradigm. American Journal of Orthopsychiatry, 32, 755-766. Ollendick, T. H., & Murphy, M. J. (1977). Differential effectiveness of muscular and cognitive relaxation as a function of locus of control. Journal of Behavioral Therapy and Experimental Psychiatry, 8, 223-228. Orlinsky, D. E., & Howard, K. I. (1980). Gender and psychotherapeutic outcome. In A. Brodsky & R. T. Har-Mustin (Eds.), Women and psychotherapy. New York: Guilford Press. Orne, M. T. (1969). Demand characteristics and the concept of quasi-controls. In R. Rosenthan & R. L Rosnow (Eds.), Artifact in behavioral research. New York: Academic Press. Osgood, C. E., Suci, G. J., & Tannenbaum, P. H. (1957). The measurement of meaning. Urbana: University of Illinois Press. Pande, S. K. (1968). The mystique of "Western" psychotherapy: An Eastern view. Journal of Nervous and Mental Disease, 146, 425-432. Pande, S. K, & Gart,J. J. (1968). A method to quantify reciprocal influence between therapist and patient in psychotherapy. InJ. Shlien, H. F. Hunt,J. D. Matarazzo, &

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C. Savage (Eds.), Research in psychotherapy. Washington, DC: American Psychological Association. Parloff, M. B., Waskow, I. E., & Wolfe, B. E. (1978). Research on therapist variables in relation to process and outcome. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change. New York: Wiley. Parloff, M. B., Goldstein, N., & Iflund, B. (1960). Communication of values and therapeutic change. Archives of General Psychiatry, 2, 300-304. Pekarik, G. (1992). Relationship of clients' reasons for dropping out of treatment to outcome and satisfaction. Journal of Clinical Psychology, 48, 91-98. Posthuma, A. B., & Carr, J. E. (1975). Differentiation matching in psychotherapy. Canadian Psychological Review, 16, 35-43. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95-103. Rosenberg, M.J. (1969). The conditions and consequences of evaluation apprehension. In R. Rosenthal & R. L. Rosnow (Eds.), Artifact in behavioral research. New York: Academic Press. Rosenthal, D. (1955). Changes in some moral values following psychotherapy. Journal of Consulting Psychology, 19, 431-436. Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry, 6, 412-415. Rotter, J. B. (1966). Generalized expectancies for internal vs. external control of reinforcement. Psychological Monographs, 80,(\, Whole No. 609). Rue, L. (1994). By the grace of guile: The role of deception in natural history. New York: Oxford University Press. Rush, A. J., Beck, A. T., Kovacs, M., & Hollon, S. (1977). Comparative effects of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients. Cognitive Therapy and Research, 1, 17-37. Seeman, M., & Evans, J. W. (1962). Alienation and learning in a hospital setting. American Sociological Review, 27, 772—782. Seguin, C. A. (1965). Love and psychotherapy. New York: Libra Publishers. Sloane, R. B., Cristol, A. H., Pepernick, M. C., & Staples, F. R. (1970). Role preparation and expectation of improvement in psychotherapy. Journal of Nervous and Mental Disease, 150, 18-26. Sloane, R. B., Staples, F. R., Cristol, A. H., Yorkston, N. J., & Whipple, K. (1975). Psychotherapy versus behavior therapy. Cambridge, MA: Harvard University Press. Smith, H. (1977). Forgotten truth: The primordial tradition. New York: Harper Colophon. Smith, N. L., Glass, G. V., & Miller, T. I. (1980). Benefits of psychotherapy. Baltimore: Johns Hopkins University Press. Stampfl, T. G. (1976). Implosive therapy. In P. Olsen (Ed.), Emotional flooding. New York: Human Sciences Press. Strupp, H. H. (1976). The nature of the therapeutic influence and its basic ingredients. In A. Burton (Ed.), What makes behavior change possible? New York: Brunner/Mazel. Strupp, H. H., & Hadley, S. W. (1979). Specific vs. nonspecific factors in psychotherapy: A controlled study of outcome. Archives of General Psychiatry, 36, 1125-1136.

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Szasz, T. S. (1978). The myth of psychotherapy: Mental healing as religion, rhetoric, and repression. New York: Anchor. Torrey, F. F. (1972). The mind game. New York: Emerson Hall. Uhlenhuth, E. H., & Duncan, D. B. (1968). Subjective change with medical student therapists: II. Some determinants of change in psychoneurotic outpatients. Archives of General Psychiatry, 18, 186-198. Vaillant, G. E. (1972). Why men seek psychotherapy, I: Results of a survey of college students. American Journal of Psychiatry, 129, 645-651. Veroff, J. (1981). The dynamics of help-seeking in men and women: A national survey study. Psychiatry, 44, 189-200. Wampold, B. (2001). The great psychotherapy debate: Models, methods and findings. Mahwah, NJ: Lawrence Erlbaum. Whitehorn,J. C., & Betz, B. (1975). Effective psychotherapy with the schizophrenic patient. New York: Jason Aronson. Wilkins, W. (1979). Expectancies in therapy research: Discriminating among heterogeneous non-specifics. Journal of Consulting and Clinical Psychology, 47, 837-845. Wolberg, L. R. (1977). The technique of psychotherapy (3rd ed.). New York: Grune & Stratton.

II

Psychodynamic Influences

riginally based on the clinical practice and theoretical work of Sigmund Freud, psychodynamic therapy has a long therapeutic tradition in psychology and psychiatry. Although Freud's original theory and approach was termed psychoanalysis, the more contemporary term is psychodynamic therapy. Early psychodynamic theories assumed that unconscious conflicts based on early experiences were the core source for most psychological problems. Typically, treatment involved a series of now classic techniques that allowed the therapist to glimpse insights into these unconscious conflicts in order to help clients uncover the source of their psychological problem. Cognition, or conscious experience, was deemed to be mostly useless in these therapeutic situations. Much has changed with contemporary psychodynamic approaches and, as is the case with most contemporary approaches to psychotherapy, cognition is now at the core of most psychodynamic therapies— even if the therapists refuse to admit it! A more modern appreciation of psychodynamic theory and therapy can be seen in the following psychodynamic chapters of this text. Viktor Frankl's theory and therapy are a direct result of his experience as an inmate in Nazi death camps. He observed that those who had hopes of being reunited with loved ones, or who participated in activities that had personal meaning (including religious beliefs), were

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better able to survive than those without such supporting mechanisms. Those without hope quickly perished. In his classic chapter "Logos, Paradox, and the Search for Meaning," Frankl traces his early theoretical development and interactions with Freud and Adler as he proposed his own form of therapy known as logotherapy. Although Freud focused on pleasure and Adler focused on inferiority, Frankl focused on meaning, especially the meaning of life or logos. In his chapter, Frankl offers an insightful distinction between paradoxical intention and symptom prescription and concludes with some radical thoughts on the roles of detachment and self-transcendence in psychological development, all based in what some would call the "cognition of meaning." A great innovator of developmental theory with an emphasis on ethology, John Bowlby reviews how early experiences can lead to later cognitive disruption in his classic chapter "The Role of Childhood Experience in Cognitive Disturbance." Building on the themes he proposed in his presentation of ethological attachment theory, a notion that revolutionized developmental theory in the 1970s, Bowlby notes that patterns of problems in attachment to primary caretakers in early life appear to leave an enduring vulnerability to emotional distress and clinical dysfunction in later life. Bowlby goes on to posit that psychology and psychiatry as a whole have been fairly neglectful of research on developmental psychopathology, especially direct observational research on children's behavior. He further asserts that such research could refine our understanding of the developmental origins and psychological functions of a syndrome, thereby enhancing our capacity not only to better understand clients but to guide them through their developmental struggles. Whereas this statement is less salient today, much of what Bowlby called for in 1985 has yet to happen in contemporary psychological research. Furthermore, it can be argued that much of the present attachment research now focuses on indirect measures such as questionnaires and psychometric scales in place of direct observation of behavior. Silvano Arieti directly faces those seemingly contradictory terms in his chapter "Cognition in Psychoanalysis." While offering his own valuable conjectures on cognitive organization, Arieti laments the fact "that cognition is or has been, up to now, the Cinderella of

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psychoanalysis in psychiatry. No other field of the psyche has been so consistently neglected by clinicians and theoreticians alike." Arieti questions why psychoanalysts especially have ignored cognition even though they perform "cognitive psychoanalysis" every day and during every session. At one level he facetiously claims (we think) that it is the result of repression due to the anxiety that the mere reference to conscious thought produces in the classically trained psychoanalyst! Yet, on a more serious level, he suggests that the negligence of cognition by psychoanalysts has been based on the false assumption that a cognitive approach would neglect infancy and the precognitive aspects of early childhood behavior. Clearly, the work of Piaget, Bowlby, and others has made this point less tenable. Arieti ends his chapter with an eloquent assertion that summarizes the conflict for the psychoanalyst: "We psychoanalysts must maintain a humble attitude, because no matter how much we explore and bring to consciousness, what we will clarify will be only one part of the psyche, the whole of which we shall never know. But we shall accept this limitation of our goals without a sense of defeat because cognition teaches us that the human being is homo symbolicus, for which a small part becomes a symbol that stands for the whole." Maybe Arieti was not being facetious about psychoanalysts repressing cognition! The final article in this section is Bernard Shulman's chapter on Adler's Individual Psychology. Alfred Adler's theory postulates a single "drive" or motivating force behind all our behavior and experience. Striving for adequacy or perfection is the desire people have to fulfill their potential, allowing them to achieve their ideal. This notion is similar to that of self-actualization, which was proposed by the humanistic school of psychology. Furthermore, Adler's individual psychology argues that personality is structured around a striving to overcome an individual's basic and pervasive feelings of inferiority. Conflict arises from incompatibilities between environmental pressures and internal striving for adequacy or perfection, rather than from internal competing urges. Note how these concepts are similar to Bandura's notion of self-regulation and self-efficacy. According to Shulman, Adler's theory of individual psychology is noteworthy because it was one of the earliest statements of a cognitive constructivist view. Clearly, the development of a lifestyle or schema

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through formative social interactions today remains a core assumption of several modern cognitive perspectives. Although we asserted at the beginning of this essay that cognition is at the core of contemporary psychodynamic therapy, a closer examination of the chapters causes one to question that assertion. Yes, cognition is no longer ignored by these approaches and it clearly plays a major role in the practice of psychodynamic therapy. What still remains to be seen, however, is how cognition is, or will be, incorporated into future expressions of global psychodynamic theory.

4 Logos, Paradox, and the Search for Meaning Viktor E. Frank!

n a paper presented to the Second World Congress of Logotherapy, Alfried A. Laengle came up with the contention that "by its main term and program, logo therapy is the first cognitive psychotherapy." In fact, when logo therapy was launched in the late 1920s, the idea behind it was to overcome so-called psychologism, which represents one among the various outgrowths of reductionism, namely, the tendency to interpret a psychological phenomenon by "reducing" it, that is, tracing it back to its alleged emotional origin, thereby totally neglecting the question of its rational validity. As early as 1925, I cautioned against this one-sided approach by pointing out (Frankl, 1925) that renouncing a priori any dispute of the patient's Weltanschauung on rational grounds results in giving away one of the most powerful weapons within our therapeutic armamentarium. Anyway, the very name coined to denote the new approach, logotherapy, was intended to signify the shifting emphasis from the affective to the cognitive aspects of human behavior. In the paper previously mentioned, however, Laengle went on also to state that "the idea of logos is only partly outlined by the classical cognitive terms of cognition," indicating that during the development of logotherapy (better to say, of the logo-theory underlying it) logos included the cognition, or perception, of meaning. This ingredient of logotherapy is that which accounts for its appeal in an age such as ours, when a feeling of meaninglessness is so pervasive and predominant. Let me clarify from the start that meaning, as well as its perception, as seen from the logo therapeutic perspective, is something completely

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down to earth rather than anything floating in the air or residing in an ivory tower. Sweepingly, I would locate the cognition of meaning (that is, the personal meaning of a concrete situation) midway between an "Aha" experience along the lines of Karl Buhler's concept and a Gestalt perception. The Gestalt implies the sudden awareness of a "figure" on a "ground," whereas, as I see it, the perception of meaning boils down to becoming aware of a possibility against the background of reality, or, more simply, becoming aware of what can be done about a given situation. In addition to the paper I had published in 1925 in the journal edited by Alfred Adler, another paper of mine (Frankl, 1924) was published, on the initiative of Sigmund Freud, in the International Journal of PsychoAnalysis (1924). But why this historical digression? The Freudian and the Adlerian views on psychotherapy were diametrically opposed to one another. But this is not unusual, for wherever you open the book of the history of psychotherapy you are confronted with two pages, a left page and a right page, and both pages show pictures—pictures of man, that is—that not only differ from one another but even contradict one another. Let us symbolize such mutual contradictions by a square on one page and a circle on the facing page (Figure 4.1). And now remember what you know from mathematics, namely, the fact that the ageold problem of squaring the circle has been proven to be unsolvable. But if I may come up with a suggestion—what about turning the left page into a perpendicular position (Figure 4.2)? All of a sudden you can imagine that the square and the circle are but the (two dimensional) projections of a (three dimensional) cylinder inasmuch as they represent its profile view and its ground plan, respectively (Figure 4.3). And

FIGURE 4.1

Mutual contradiction. Two-dimensional square and circle.

Logos, Paradox, and the Search for Meaning

FIGURE 4.2

Perpendicular position removes the contradiction.

FIGURE 4.3

Profile view and ground plan, respectively.

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then we notice that the contradictions between the pictures need no longer contradict the oneness of what they depict. Incidentally, there is another contradiction that disappears as soon as we conceive the pictures as mere projections. If we assume that the cylinder is not a solid but rather an open vessel—say, an empty cup—this openness, too, disappears in the lower dimensions; both the square and the circle are closed figures (Figure 4.4). But once we view them as mere projections, their closedness no longer contradicts the openness of the cylinder. But how shall we now apply all this to our concept, our theory, of man, to our anthropological theory as it—explicitly or implicitly— underlies our psychotherapeutic practice? Well, similarly, the contradictions between the disparate pictures of man as they are propounded by the different psychotherapeutic schools cannot be overcome and surpassed unless, we proceed into the next higher dimension; that is to say, as long as we remain in those lower dimensions into which we have projected man in the first place, there is no hope for a unified concept. Only if we open up the next higher dimension, which is the human dimension, the dimension of the specifically human phenomena—only if we follow man into this dimension is it possible to catch the oneness as well as the humanness of man. Further, entering the human dimension

FIGURE 4.4

The square and circle as projections.

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becomes mandatory if we are to tap and muster those resources that are available solely in the human dimension in order to incorporate them in our therapeutic armamentarium. Among these resources, there are two that are most relevant for psychotherapy: man's capacity for self-detachment and his capacity for self-transcendence. As to the first, it could be defined as the capacity to detach oneself from outward situations, to take a stand toward them; but man is capable of detaching himself not only from the world but also from himself. And it is this very capacity that is mobilized in the logotherapeutic technique of paradoxical intention (Frankl, 1939, 1947). From what I wrote in 19471 would like to quote the following passage in order to show on what theoretical grounds the practice of paradoxical intention had been based. (In addition, the quotation may build a bridge of mutual understanding between logotherapists and behavior therapists.) All psychoanalytically oriented psychotherapies are mainly concerned with uncovering the primary conditions of the "conditioned reflex" as which neurosis may well be understood, namely, the situation—outer or inner—in which a given neurotic symptom emerged the first time. It is this author's contention, however, that the full-fledged neurosis is caused not only by the primary conditions but also by secondary conditioning. This reinforcement, in turn, is caused by the feedback mechanism called anticipatory anxiety. Therefore, if we wish to recondition a conditioned reflex, we must unhinge the vicious cycle formed by anticipatory anxiety, and this is the very job done by our paradoxical intention technique.

This technique lends itself to the treatment of phobic and obsessivecompulsive conditions. I am used to explaining its therapeutic effectiveness to my students by starting with the mechanism called anticipatory anxiety. A given symptom evokes on the part of the patient a phobia in the form of the fearful expectation of its recurrence; this phobia provokes the symptom actually to recur, and the recurrence of the symptom reinforces the phobia (see Figure 4.5). There are cases in which the object of the "fearful expectation" is—fear itself. Our patients spontaneously speak of a "fear of fear." Upon closer interrogation it turns out that they are afraid of the consequences of their fear: fainting, coronaries, or strokes. But as I pointed out in 1953 (Frankl, 1953) they react to their fear of fear by a "flight from fear"—what you would call an avoidance pattern of behavior. By 1960 I had arrived at the conviction that "phobias are partially due to the endeavor to avoid the situation in which anxiety arises." Since that

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FIGURE 4.5

Psychodynamic Influences

The first circle formation: phobias.

time, this contention has been confirmed by behavior therapists on many occasions. Along with the phobic pattern that we may circumscribe as a flight from fear, there is another pattern, the obsessive-compulsive one, which is characterized by what one may call a "fight against obsessions and compulsions." The respective patients are afraid that they might commit suicide or homicide or that the strange ideas haunting them might be the precursors, if not already the symptoms, of a psychosis. In other words, they are not afraid of fear itself but rather afraid of themselves. Again, a circle formation is established. The more the patient fights his obsessions and compulsions, the stronger they become. Pressure induces counterpressure, and counterpressure in turn increases pressure (see Figure 4.6). In order to unhinge all the vicious circles discussed, the first thing to do is to take the wind out of the anticipatory anxieties underlying them, and this is precisely the business to be carried out by paradoxical intention. It may be defined as a procedure in whose framework the patients are encouraged to do, or wish to happen, the very things they fear—albeit with tongue in cheek. In fact, "an integral element in paradoxical intention is the deliberate evocation of humor," as Lazarus (1971) justifiably points out. After all, the sense of humor is one of the various aspects of the specifically human capacity of self-detachment. No other animal is capable of laughing. In paradoxical intention, the pathogenic fear is replaced by a paradoxical wish. The vicious circle of anticipatory anxiety is unhinged. For illustrative case material, the reader is referred to the pertinent

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FIGURE 4.6

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The second circle formation: obsessions and compulsions.

literature. As an example, take the following letter I once received from a reader (Frankl, 1978): Two days after reading Man's Search for Meaning, a situation arose which offered the opportunity to put logotherapy to the test. During the first meeting of a seminar class on Martin Buber, I spoke up saying I felt diametrically opposed to the views so far expressed. While expressing my views I began to perspire heavily. When I became aware of my excessive sweating I felt even more anxiety about the others seeing me perspire, and this caused me to sweat even more. Almost instantly I recalled a case study of a physician who consulted you, Dr. Frankl, because of his fear of perspiring, and I thought, "Here I am in a similar situation. " Being ever skeptical of methods, and specifically of logotherapy, in this instance I determined the situation was ideal for a trial and put logotherapy to the test. I remembered your advice to the physician and resolved to deliberately show those people how much I could sweat, chanting in my thoughts as I continued to express my feelings on the subject: "More! More! More! Show these people how much you can sweat, really show them!" Within two or three seconds after applying paradoxical intention I laughed inwardly and could feel the sweat beginning to dry on my skin. I was amazed and surprised at the result, for I did not believe logotherapy would work. It did, and so quickly! Again, inwardly, I said to myself, "Damn, that Dr. Frankl really has something here! Regardless of my skeptical feelings, logotherapy actually worked in my case. [p. 131]

Hand, Lamontagne, and Marks (1974), who had treated chronic agoraphobia patients in groups, observed that they spontaneously used humor as an impressive coping device. When the whole group was frightened, somebody would break the ice with a joke, which would

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be greeted with the laughter of relief. They reinvented paradoxical intention, one may say. Paradoxical intention may be effective even in severe cases. Lamontagne (1978) for one instance, cured a case of incapacitating erythrophobia that had been present for 12 years, within four sessions. Niebauer (Kocourek, Niebauer, & Polak, 1959) successfully treated a 65-year-old woman who had suffered from a hand-washing compulsion for 60 years. And Jacobs (1972) cites the case of Mrs. K. who for 15 years had suffered from severe claustrophobia and was cured by him within a week. His treatment was a combination of paradoxical intention, relaxation, and desensitization, a fact that should demonstrate that paradoxical intention, or for that matter logotherapy, does in no way invalidate any other, or previous, psychotherapies but rather presents a means to maximize their effectiveness. In the same vein, Ascher (1980a) points out that "most therapeutic approaches have specific techniques" and "these techniques are not especially useful for, nor relevant to, alternative therapeutic systems." But there is "one notable exception in this observation," namely, paradoxical intention, which "is an exception because many professionals representing a wide variety of disparate approaches to psychotherapy have incorporated this intervention into their systems both practically and theoretically." In fact, "in the past two decades, paradoxical intention has become popular with a variety of therapists" who had been "impressed by the effectiveness of the technique." Even more important, "behavioral techniques have been developed which appear to be translations of paradoxical intention into learning terms." Yalom (1980), too, holds that paradoxical intention is an "effective" technique that "anticipated the similar technique of symptom prescription and paradox employed by the schools of Milton Erickson, Jay Haley, Don Jackson, and Paul Watzlawick." I would recommend to take heed not to confound "the similar technique of symptom prescription" with paradoxical intention. They are two different things. When I apply symptom prescription, I want the patient to increase, say, anxiety. When I use paradoxical intention, however, I want the patient to do, or wish to happen, that of which he is afraid. In other words, not fear itself but rather its object is dealt with. Let me invoke a case published by the logotherapist Byung-Hak Ko (1981), a professor at the National University of Korea. The patient had been suffering from fear of death. Treating him by paradoxical intention, the psychiatrist did in no way recommend for him to increase the thanatophobia but, to quote from the paper, the respective instruc-

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tions read: "Try to be more dizzy, have faster palpitations, and choke more. Try to die in front of the people." And the next time, in fact, the patient entered the psychiatrist's office cheerfully and reported success. Compare this type of intervention with what I would call symptom description, although it was intended by a professor at the University of Nebraska to serve as an illustration of paradoxical intention. For example, a person who had an obsession to wash his hands ten times a day will be invited to do so thirty times a day. Of course, this is symptom prescription rather than paradoxical intention. How much the treatment would have been different if paradoxical intention had been enacted should be illustrated by a case of washing compulsion that I myself published in German (Frankl, 1947). The patient felt compelled to wash her hands several hundred times a day. Thereupon a doctor on my hospital department suggested that, "for a change," the patient, instead of being afraid of bacteria, should wish to contract an infection. "I can't get enough bacteria," she was advised to tell herself. "I want to become as dirty as possible. There is nothing nicer than bacteria." And the patient really followed the advice. She asked the other patients at the hospital department to let her borrow from them as many bacteria as possible and came up with the resolution no longer to wash "the poor creatures" away but, instead, to keep them alive. But certainly no one on my staff would have dreamt of recommending that the patient no longer wash her hands several hundred times a day, but, along the lines of symptom prescription, that she do so several thousand times a day. Ascher and Turner (1979) were the first to come up with a "controlled experimental validation of the clinical effectiveness" of paradoxical intention in comparison with other behavioral strategies. But Solyom, Garza-Perez, Ledwidge, and Solyom (1972) also proved experimentally that paradoxical intention works. Inasmuch as the two human capacities, self-detachment and selftranscendence, equally derive from logotherapy's concept of man, both paradoxical intention and the business of finding meaning in life belong to one another. It is true that paradoxical intention is not "specifically related to life meaning" (Yalom, 1980). Yet I cannot subscribe to the statement made by Weisskopf-Joelson (1978) to the effect that "paradoxical intention is not closely related to the logo-therapeutic position in ways other than owing its origin to Frankl." I rather think that the effectiveness of the technique, in the final analysis, is due to some basic trust in Dasein, ultimately, to some sort of faith, which is reinstalled and

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reinstated by the technique. As far, however, as fear is concerned, faith proves to be the very antagonist. In fact, there is an old saying that reads: "Fear knocked at the door. Faith answered, and no one was there." Nor can Yalom (1980) persuade himself "that paradoxical intention is specifically related to life meaning." Yet to the extent that it "allows one to assume responsibility for one's symptoms, it may be considered within the domain of existential therapy." Regarding logotherapy, however, Lukas (1982) makes the following statement: In my twelve years of practicing logotherapy I have never doubted that paradoxical intention is a true child of logotherapy, even though it is frequently adopted, under various names, by other schools of psychotherapy. Its logotherapeutic origin, however, can easily be identified. The concept of self-distancing legitimizes paradoxical intention as a true child of logotherapy because this method constitutes ninety percent of a therapeutic dialogue with the self. This legitimacy is not invalidated by the many "illegitimate children "—practices used by other schools that do not admit the paternity for methods strikingly similar to paradoxical intention.

But let us turn to the second human capacity, that of self-transcendence. It denotes the fact that being human always points, and is directed, to something other than oneself, namely, to meanings to fulfill, or to other human beings lovingly to encounter. And only to the extent to which a human being lives out this, his self-transcendence, is he really becoming human and actualizing his self. This always reminds me of the ironic fact that the capacity of the eye visually to perceive the surrounding world is contingent on its incapacity to perceive itself, to see anything of itself. Whenever the eye sees anything of itself, its function is impaired. When does the eye see anything of itself? If I am affected by a cataract, I see something like a cloud—then my eye sees its own cataract. Or if I am affected by glaucoma, I see rainbow halos around the lights—then my eye perceives, as it were, the heightened tension that causes the glaucoma. The normally functioning eye does not see itself but rather is overlooking itself, and similarly man is human to the extent to which he overlooks and forgets himself by giving himself to a cause to serve or another person to love. By being immersed in work or in love, we are transcending ourselves and thereby actualizing ourselves. Why has the self-transcendent quality of the human reality been so completely ignored and neglected by psychology? As I see it, this has something to do with the Heisenberg law—provided that I am allowed to restate it, a bit freely, as follows: The observation of a process unavoid-

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ably and automatically influences the process. Something similar holds for the strictly scientifically (rather than phenomenologically) oriented observation of human behavior in that it cannot escape making a subject into an object. But, alas, it is the inalienable property of a subject, I would say, that it has objects of its own. (According to the phenomenological terminology [Brentano, Husserl, and Scheler], they are called intentional objects or intentional referents.)* Understandably, at the moment the subject is made into an object, its own objects disappear. And inasmuch as the intentional referents form the world in which a human being is as a "being-in-the-world," to use Heidegger's more often than not misused phrase, the world is shut out as soon as man is seen no longer as a being, so to speak, acting into the world but rather as a being reacting to stimuli (the behavioristic model) or abreacting drives and instincts (the psychodynamic model). In either way, the human being is dealt with as a worldless monad or a closed system, and now we remember what was said at the outset, namely, that the openness of a vessel projected into lower dimensions disappears. To repeat, human behavior is really human to the extent to which it means acting into the world. This in turn implies being motivated by the world. In fact, the world toward which a human being transcends itself is a world replete with meanings that constitute the reasons to act and full as well of other human beings to love. As soon as we project human beings into the dimension of a psychology conceived in strictly scientific terms, we cut them off from the world of potential reasons. Instead of reasons there are only causes. The difference? Reasons motivate me to act in the way I choose. Causes determine my behavior unwillingly and unwittingly, whether I know it or not. When I cut onions I weep. My tears have a cause. But I have no reason to weep. When a loved one dies I have a reason to weep. And what are the causes that are left to the psychologist with a blind spot for self-transcendence and consequently for meanings and for reasons? If he is a psychoanalyst, he will substitute for motives drives and instincts as that which causes human behavior. If he is a behaviorist, he will see in human behavior the mere effect of conditioning and learning processes. If there are no meanings, no reasons, no choices, determinants must be hypothesized, one way or another, to replace them. To be sure, the humanness of human behavior is done away with in the circumstances. And if psychology, or for that matter psychotherIntentionality may be viewed as the cognitive aspect of self-transcendence.

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apy, is to be rehumanized it must remain cognizant of self-transcendence rather than blotting it out. One of the aspects of self-transcendence is what is called in logotherapy the will to meaning. If man can find and fulfill a meaning in his life he becomes happy but also capable of coping with suffering. If he can see a meaning he is even prepared to give his life. On the other hand, if he cannot see a meaning he is equally inclined to take his life even in the midst, and in spite of, all the welfare and affluence surrounding him. Just consider the escalating suicide figures in welfare states such as Sweden and Austria. Deliberately to quote a behaviorist, namely, L. Bachelis (1976), director of the Behavioral Therapy Center in New York, "many undergoing therapy at the Center tell [him] they have a good job, they're successful but they want to kill themselves, because they find life meaningless." I do not intend to say that most suicides are undertaken out of a feeling of meaninglessness, but I am convinced that people would have overcome the impulse to kill themselves if they had seen meaning in their lives. Meanwhile, people have the means to live but no meaning to live for. As you see, logotherapy squarely faces the situation confronting us in a post-petroleum society and even "has special relevance during this critical transition," to quote Wirth (1980). Happiness is not only the result of fulfilling a meaning but also more generally the unintended side effect of self-transcendence. It therefore cannot be pursued but rather must ensue. The more one aims at it the more one misses aim. This is most conspicuous with sexual pleasure and it is the characteristic of the third pattern to be discussed, the sexually neurotic, that people strive directly for sexual performance or experience, male patients trying to demonstrate their potency and female patients their capacity for orgasm. In logotherapy, we are used to speaking of hyperintention in this context. Since hyperintention is often accompanied by what we call in logotherapy hyperreflection, that is, too much self-observation, both, hyperintention and hyperreflection join to form another, the third, circle formation (Figure 4.7). In order to break it up, centrifugal forces must be brought into play. Hyperreflection can be counteracted by the logotherapeutic technique called de-reflection, that is to say, the patients, instead of watching themselves, should forget themselves. But they cannot forget themselves unless they give themselves. Again and again, it turns out that the hyperintention of sexual performance and experience is due to the patient's sexual achievement orientation and tendency to attach to sexual intercourse a "demand quality." To eliminate the tendency is the very purpose of a logotherapeutic strategy which, along with the dereflection technique, I described in

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FIGURE 4.7 The third circle formation: sexual dysfunctions.

English for the first time in 1952 (Frankl, 1952) and more elaborately in The Unheard Cry for Meaning (1978). Sahakian and Sahakian (1972) were the first to point out what later on was confirmed by Ascher (1980b) and finally by Bulka (1979), who sees in dereflection "a clear anticipation of the approach of Masters and Johnson." The feeling of meaninglessness not only underlies the mass neurotic triad of today, that is, depression-addiction-aggression, but may also eventuate in what we logotherapists call a noogenic neurosis. Thus far, 10 researchers have estimated, independently of each other, that about 20% of neuroses are noogenic (cf Klinger, 1977). In such cases, logotherapy comes in as a specific procedure devised to assist the patient in finding meaning. As such, logotherapy is based on a logotheory, and the logotheory in turn is empirically based. The logotherapist never prescribes meaning but he may well describe how the process of meaning perception is enacted by the man or woman in the street, more specifically, by virtue of their "prereflective ontological self-understanding," as I am used to calling it. In other words, logotherapists neither preach meaning nor teach it but learn it from people who for themselves have discovered and fulfilled it.* And a phenomenological analysis re*To quote C. Buhler (1971), "All we can do is study the lives of people who seem to have found their answers to the questions of what ultimately a life was about."

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veals that there are three main avenues on which one arrives at meaning in love. The first is finding it by creating a work or by doing a deed. However, in addition to the meaning potential inherent and dormant in creating and doing, a second avenue to meaning in life is available in experiencing something or encountering someone; in other words, meaning can be found not only in work but also in life. WeisskopfJoelson (1980) observes in this context that the logo therapeutic "notion that experiencing can be as valuable as achieving is therapeutic because it compensates for our one-sided emphasis on the external world of achievement at the expense of the internal world of experience." Most important, however, is a third avenue to meaning in life: It finally turns out the even the helpless victim of a hopeless situation, facing a fate he cannot change, may rise above himself, may grow beyond himself, and by so doing change himself. He may turn a personal tragedy into a triumph. To quote a pertinent example from the Texarkana Gazette of April 15, 1980: Jerry Long has been paralyzed from his neck down since a driving accident, which rendered him a quadriplegic three years ago. He was 17 when the accident occurred. Today Long can use his mouth stick to type. He "attends" two courses at Texarkana Community College via a special telephone. The intercom allows Long to both hear and participate in class discussions. He also occupies his time by reading, watching television and writing.

In a letter I received from him he writes: / view my life as being abundant with meaning and purpose. The attitude that I adopted on that fateful day has become my personal credo for life: I broke my neck, it didn 't break me. I am currently enrolled in my first psychology course in college. I believe that my handicap will only enhance my ability to help others. I know that without the suffering, the growth that I have achieved would have been impossible.

For a quarter of a century I was running the neurological department of a general hospital, and I bear witness to my patients' capacity to turn their predicament into a human achievement. Who tells the story of the young men who yesterday were skiing in the Austrian Alps or riding a Yamaha and today are paralyzed from the neck down? Or of the girls who yesterday were dancing in a disco and today are confronted with the diagnosis of a brain tumor? Weisskopfjoelson (1958) once expressed the hope that logo therapy "may help counteract certain unhealthy trends in the present-day culture of the United States, where the incurable sufferer is given very

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little opportunity to be proud of his suffering and to consider it ennobling rather than degrading so that he is not only unhappy, but also ashamed of being unhappy." But also, empirical evidence is available regarding the possibility of finding meaning even in suffering. Researchers at the Yale University School of Medicine (Sledge, Boydstun, & Rabe, 1980) "have been impressed with the number (61%) of POWs of the Vietnam War who explicitly claimed that although their captivity was extraordinarily stressful—filled with torture, disease, malnutrition, and solitary confinement—they nevertheless benefited from the captivity experience seeing it as a growth experience. They believed they are wiser than before their captivity, stronger, and more mature" (p. 431). By virtue of the fact that meaning may be squeezed out even from suffering, life proves to be potentially meaningful, literally up to its last moment, up to one's last breath. Even death may be turned into something potentially meaningful. Again, empirical evidence is available. Thomas and Weiner (1974) reported that patients who were critically ill had higher Purpose in Life Test (PIL) scores than had patients with a minor ailment or nonpatients. Thus, not only life itself is potentially meaningful but also "the end of life is always a time of unparalleled potential for personal and interpersonal growth," as the surgeon, Balfour Mount, of McGill University once said, adding the words "for the patient and his family." How true. Let me cite an example: An elderly general practitioner consulted me because of his severe depression. He could not overcome the loss of his wife who had died 2 years before and whom he had loved above all else. I confronted him with the question, "What would have happened, Doctor, if you had died first, and your wife would have had to survive you?" "Oh," he said, "for her this would have been terrible; how she would have suffered!" Whereupon I replied, 'You see, Doctor, such a suffering has been spared her, and it is you who have spared her this suffering; but now you have to pay for it by surviving and mourning her." Of course, this was no therapy in the proper sense since his despair was no disease. But in that moment I did succeed in changing his attitude toward his unalterable fate inasmuch as from that time on he could at least see a meaning in his suffering. In fact, despair could be defined as suffering without meaning. And that is why in the courses that I give to my medical students, I write on the blackboard the equation: D(espair) + S(uffering) = M(eaning)

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But let me make it perfectly clear that in no way is suffering necessary to find meaning. I only insist that meaning is possible even in the presence of suffering, provided, to be sure, that we have to deal with unavoidable suffering—if it were avoidable, the meaningful thing to do would be to remove its cause, be it psychological, biological, or political. To suffer unnecessarily is certainly masochism rather than heroism. But if you really cannot change a situation that causes your suffering, what you still can choose is your attitude. And I will not forget an interview I once heard on Austria's television given by a Polish cardiologist who during World War II had organized the Warsaw ghetto upheaval. "What a heroic deed," exclaimed the reporter. "Listen," calmly replied the doctor, "to take a gun and shoot is no great thing, but if the SS leads you to a gas chamber or to a mass grave to execute you on the spot, and you can't do anything about it—except for keeping your head high and going your way with dignity, you see, this is what I would call heroism." He should know.* So life is potentially meaningful under any conditions, be they pleasurable or miserable, and precisely this cornerstone of logotherapeutic teaching (which had been based solely on the intuitions of a teenager named Viktor E. Frankl) has lately been corroborated on strictly empirical grounds, through tests and statistics applied to tens of thousands of subjects. The overall result (of research conducted by Brown, Casciani, Crumbaugh, Dansart, Durlak, Kratochwill, Lukas, Luneeford, Mason, Meier, Murphy, Planova, Popielski, Richmond, Roberts, Ruch, Sallee, Smith, Yarnell, and Young) was that meaning is in principle available to each and every person irrespective of sex, age, IQ, educational background, character structure, and environment, and, last but not least, irrespective of whether one is religious or not, and, if religious, irrespective of the denomination to which one belongs. Those suffering from obsessive-compulsive and phobic conditions to be aided by paradoxical intention are but a minority. As to the majority, however, it is not a silent one. To those who know to listen, it is rather a crying majority—crying for meaning! For too long a time the cry has remained unheard. Psychotherapy must give a hearing to the unheard cry for meaning. *An empirical study recently conducted by Austrian public opinion pollsters evidenced that those who are held in highest esteem by most of the people interviewed were neither the great artists nor the great scientists, neither the great statesmen nor the great sports figures, but those who master a hard lot with dignity.

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REFERENCES Ascher, L. M. (1980a). Paradoxical intention viewed by a behavior therapist. International Forum for Logotherapy, /(3), 13-16. Ascher, L. M. (1980b). Paradoxical intention. In A. Goldstein & F. B. Foa (Eds.), Handbook of behavioral interventions. New York: Wiley. Ascher, L. M., & Turner, R. M. (1979). Controlled comparison of progressive relaxation, stimulus control, and paradoxical intention therapies for insomnia. Journal of Consulting and Clinical Psychology, 47, 500-508. Bachelis, L. (1976, May). Depression and disillusionment. APA Monitor. Buhler, C. (1971). Basic theoretical concepts of humanistic psychology. American Psychologist, 26, 378. Bulka, R. P. (1979). The quest for ultimate meaning: Principles and applications oflogotherapy. New York: Philosophical Library. Frankl, V. E. (1924). Zur mimischen Bejahung und Verneinung (Affirmation and Denial). Internationale zeitschrift fur Psychoanalyse, 10, 437-438. Frankl, V. F. (1925). Psychotherapie und Weltanschauung (Psychotherapy and Worldview). Internationale Zeitschrift Fur Individualpsychologie, 3, 250-252. Frankl, V. F. (1939). Zur medikamentosen Unterstutzung der Psychotherapie bei Neurosen. Schweizer Archiv fur Neurologic und Psychiatric, 43, 26-31. Frankl, V. F. (1947). Die Psychotherapie in der Praxis (Psychotherapy in Practice). Vienna: Deuticke. Frankl, V. F. (1952). The pleasure principle and sexual neurosis. International Journal of Sexology, 5, 128-130. Frankl, V. F. (1953). Angst und Zwang (Anxiety and Compulsion). Acta Psychotherapeutica, 43, 26-31. Frankl, V. F. (1960). Paradoxical intention: A logotherapeutic technique. American Journal of Psychotherapy, 14, 520-535. Frankl, V. F. (1978). The unheard cry for meaning. New York: Simon & Schuster. Hand, I., Lamontagne, Y, & Marks, I. M. (1974). Group exposure (flooding) in vivo for agoraphobics. British Journal of Psychiatry, 14, 588-602. Jacobs, M. (1972). An holistic approach to behavior therapy. In A. A. Lazarus (Ed.), Clinical behavior therapy. New York: Brunner/Mazel. Klinger, F. (1977). Meaning and void. Minneapolis: University of Minnesota Press. Ko, B.-H. (1981). Applications in Korea. International Forum for Logotherapy, 4(2), 89-93. Kocourek, K,, Niebauer, F., & Polak, P. (1959). Ergebnisse der klinisehen Anwendung der Logotherapie (Outcome in a Clinical Application of Logotherapy). In V. F. Frankl, V. F. von Gebsattel, &J. H. Schultz (Eds.), Handbuch derNeurosenlehre und Psychotherapie (Handbook of Neurology and Psychotherapy). Munich: Urban & Schwarzenberg. Lamontagne, Y. (1978). Treatment of erythrophobia by paradoxical intention. Journal of Nervous and Mental Disease, 166(4), 304-406. Lazarus, A. A. (1971). Behavior therapy and beyond. New York: McGraw-Hill. Lukas, F. (1982). The "birthmarks" of paradoxical intention. International Forum for Logotherapy, 5(1), 20-24.

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Sahakian, W. S., & Sahakian, B. J. (1972). Logotherapy as a personality theory. Israel Annals of Psychiatry, 10, 230-244. Sledge, W. H., Boydstun, J. A., & Rabe, A. J. (1980). Self-concept changes related to war captivity. Archives of General Psychiatry, 37, 430-443. Solyom, L., Garza-Perez, J., Ledwidge, B. L., & Solyom, C. (1972). Paradoxical intention in the treatment of obsessive thoughts: A pilot study. Comprehensive Psychiatry, 13(3), 291-297. Thomas, J., & Weiner, F. (1974). Psychological differences among groups of critically ill hospitalized patients, noncritically ill hospitalized patients and well controls. Journal of Consulting and Clinical Psychology, 42(2), 274—279. Weisskopfjoelson, E. (1958). Logotherapy and existential analysis. Acta Psychotherapeutica, 6, 193-204. Weisskopfjoelson, E. (1978). Six representative approaches to existential therapy: A. Viktor E. Frankl. In R. S. Valle & M. King (Eds.), Existential-phenomenological alternatives for psychology. New York: Oxford University Press. Weisskopfjoelson, E. (1980). The place of logotherapy in the world today. International Forum for Logotherapy, 1(3), 3-7. Wirth, A. G. (1980). Logotherapy and education in a post-petroleum society. International Forum for Logotherapy, 2(3), 29-32. Yalom, I. D. (1980). Existential psychotherapy. New York: Basic Books.

5 The Role of Childhood Experience in Cognitive Disturbance John Bowlby

he evidence that adverse experiences with parents during childhood play a large part in causing cognitive disturbance is now substantial. For example, at least some cases in which perceptions and attributions are distorted and sonic states of amnesia, both minor and major, including cases of multiple personality, can be shown with considerable confidence to be the outcome of such experiences. Yet systematic research into these causal sequences is still scarce. Having myself recognized the importance of the area a little belatedly, all that I can do in this brief chapter is to open a door to a field calling urgently for a major research effort. Before doing so, however, it is worth considering why the field has been so neglected. Ever since 1897, when Freud changed his mind about the role of childhood seduction in the etiology of hysteria and decided, instead, that the alleged episodes were the fruits of fantasy, there has been reluctance to give weight to the real-life experiences of childhood. To do so has often been regarded as naive, or else as mere scapegoating of parents. Coupled with these prejudices has been the tendency of

T

This chapter is an expanded version of an article titled "On Knowing What You Are Not Supposed to Know and Feeling What You Are Not Supposed to Feel," which appeared in the Canadian Journal of Psychiatry, 1979, 24, 403-408. Permission to reprint is gratefully acknowledged.

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those who have nonetheless looked for relevant real-life experiences to focus on such variables as bottle- versus breast-feeding or type of toilet training, which have subsequently been shown to be of negligible or at most marginal significance. Added to that, moreover, is the undoubted difficulty of doing systematic research in the field. For example, those engaged in seeing only adult patients are usually ill placed to investigate events alleged to have occurred many years earlier. Those whose childhoods have been spent among reasonably stable families and who, like all too many psychiatrists and psychotherapists, are ignorant of the recent family and child development literature, have no norms against which to match their patients' stories. Above all, clinicians are often faced with a blanket of silence, from patient and family alike, which neither training nor their experience has qualified them to penetrate. Little wonder, therefore, if the likelihood that many cases of psychiatric disorder, both mild and grave, having had their origins in adverse events of childhood have been discounted or else completely ignored—not only by general psychiatrists but by psychotherapists as well. Even the fact that some children are physically or sexually assaulted by their own parents, often repeatedly and over long periods, is missing from discussions of causal factors in psychiatry. Today the scene is changing. First, knowledge of parent-child interactions in general, including a wide range of potentially pathogenic relationships and events, is increasing in both quality and quantity as systematic research is applied. Second, the psychological consequences for the children exposed to these relationships and events are becoming much better understood and documented. As a result, there are now many occasions when a clinician is on reasonably firm ground in drawing etiological conclusions. This is so especially when (1) his patient presents problems and symptoms that resemble the known consequences of certain types of experience, and (2) when in the course of skilled history taking, or perhaps much later during therapy, he is told of experiences of these same types. In reaching his conclusion, the reasoning a psychiatrist uses differs in no way from that of a physician who, having diagnosed a patient as suffering from mitral stenosis, proceeds unhesitatingly to attribute the condition to an attack of rheumatic fever suffered by the patient many years earlier. When considering childhood antecedents of cognitive disorders, a good place to start is with amnesia. In one of his classical papers on analytic technique, Freud (1914) made an important generalization,

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the truth of which probably every psychotherapist would endorse: Forgetting impressions, scenes, or experiences nearly always reduces itself to shutting them off. When the patient talks about these "forgotten" things he seldom fails to add, "As a matter of fact I've always known it; only I've never thought of it" (p. 148). Such observations call for explanations of at least three kinds. First, are there special features that characterize the impressions, scenes, and experiences that tend to become shut off? Second, how do we best conceive of the processes by which memories become shut off and apparently forgotten? Third, what are the causal conditions, internal and external to the personality, that activate the shutting-off process? The scenes and experiences that tend to become shut off, though often continuing to be extremely influential in affecting thought, feeling, and behavior, fall into at least three distinct categories: 1. those that parents wish their children not to know about 2. those in which parents have treated children in ways the children find too unbearable to think about 3. those in which children have done, or perhaps thought, things about which they feel unbearably guilty or ashamed. Because a great deal of attention has for long been given to the third category, here I discuss only the first two. We start with the first. Children not infrequently observe scenes that parents would prefer they did not observe; they form impressions that parents would prefer they did not form, and they have experiences that parents would like to believe they have not had. Evidence shows that many of these children, aware of how their parents feel, proceed then to conform to their parents' wishes by excluding from further processing such information as they already have, and that having done so, they cease consciously to be aware that they have ever observed such scenes, formed such impressions, or had such experiences. Here, I believe, is a source of cognitive disturbance as common as it is neglected. Yet, evidence that parents sometimes press their children to shut off from further, conscious, processing information the children already have about events that the parents wish they had never observed comes from several sources. Perhaps the most vivid concerns the efforts made by a surviving patent to obliterate his or her child's knowledge of the (other) parent's suicide. Cain and Fast (1972) report findings from their study of a series of 45 children, aged between 4 and 14, all of whom had lost a parent by

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suicide and all of whom had become psychiatrically disturbed, many of them severely so. In reviewing their data, the authors were struck by the very large roles played in the children's symptomatology by their having been exposed to pathogenic situations of two types, namely, situations in which intense guilt is likely to be engendered (not discussed here) and situations in which communications between parent and child are gravely distorted. About one quarter of the children studied had personally witnessed some aspect of the parent's death and had subsequently been subjected to pressure from the surviving parent to believe that they were mistaken in what they had seen or heard and that the death had not been due to suicide but to some illness or accident: A boy who watched his father kill himself with a shotgun . . . was told later that night by his mother that his father had died of a heart attack; a girl who discovered her father's body hanging in a closet was told he had died in a car accident; and two brothers who had found their mother with her wrists slit were told she had drowned while swimming. [Cain & Fast, 1972, p. 102]

When a child described what he had seen, the surviving parent had sought to discredit it either by ridicule or by insisting that he was confused by what he had seen on television or by some bad dream he had had. Such confusion was sometimes compounded, moreover, by the child's hearing several different stories about the death from different people or even from his surviving parent. Many of the children's psychological problems seemed directly traceable to their having been exposed to situations of these kinds. Their problems included chronic distrust of other people, inhibition of their curiosity, distrust of their own senses, and a tendency to find everything unreal. Rosen (1955) describes an adult patient, a man of 27, who developed acute symptoms after his fiancee had jilted him because she had found him too moody and unpredictable. The patient began to feel that the world about him and also his own being were fragmenting and that everything was unreal. He became depressed and suicidal and experienced a variety of peculiar bodily sensations, which included a feeling that he was choking. His thoughts, he said, felt like cotton wool. Sometime during the second year of therapy, the analyst, struck by a series of associations the patient gave and bearing in mind the life history, ventured a reconstruction, namely that the patient's mother may have made a suicide attempt during the patient's childhood that he (the

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patient) had witnessed. No sooner had this suggestion been offered than the patient became racked with convulsive sobbing. The session proved a turning point. Subsequently, the patient described how it had seemed to him that, when the analyst made his suggestion, it was not so much that he was restoring a memory as giving him (the patient) permission to talk about something he had always in some way known about. The authenticity of the memory was vouched for by the patient's father who admitted, when pressed, that the patient's mother had made several suicide attempts during the patient's childhood. The one the patient had witnessed occurred some time during his third year. His nurse had heard sounds in the bathroom and had arrived in time to prevent his mother from strangling herself. It was not clear just how much the little boy had seen. But whenever later he had mentioned the event both father and nurse had disconfirmed his memories by alleging that it was something he must have imagined or had simply been a bad dream. His father now claimed that he had felt it would have been harmful to his son to have remembered such an incident, but he also admitted that his attitude was dictated partly by his wish that the incident be kept secret from friends and neighbors. A year or so later the nurse had been discharged because the mother had found her presence too painful a reminder of the incident. During one of the sessions before the vital reconstruction was offered, the patient had recalled the discharge of his beloved nurse as an event that he had always felt had been in some way his fault. Among many associations to it were recurrent references to his having been, as a child, witness to something that had changed his life, though he did not know what. He also had the notion that his nurse had been the one witness on his behalf. Thus, although the memory had been shut away from conscious processing, it continued to influence both what he thought and how he felt. Elsewhere (Bowlby, 1971) I have drawn attention to the far from negligible incidence of suicidal attempts made by parents, and perhaps the even higher incidence of their threatening suicide, and have remarked how little attention has been given to either attempts or threats in the psychiatric and psychotherapeutic literature. Perhaps there are many more cases similar to Rosen's than have yet been realized. Among the many other situations that parents may wish a child had not observed and that they may press him to suppose he never did are those concerning their sexual activities. An example of this was told to

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me by a speech therapist who was trying to help an extremely disturbed little girl who hardly spoke at all. That she was well able to speak was, however, shown on certain dramatic occasions. She would sit a Teddy bear on a chair in a corner, then go over and, shaking her finger at him, would scold him in tones of extreme severity: 'You naughty—naughty Teddy—you didn 't see that—you didn 't see that, I tell you!" This she repeated again and again with increasing vehemence. What the scenes were that Teddy was being instructed he never saw was not difficult to guess; the little girl's mother was a teenage prostitute. Clearly the purpose of these pressures by parents is to ensure that their children develop and maintain a wholly favorable picture of them. In the examples thus far given the form of pressure exerted is crude. More frequent perhaps and just as damaging are instances in which the pressures are more subtle. During the past several decades renewed attention has been paid to incest, both to its unrecognized high incidence and to its pathogenic effects on children. The commonest forms are between father and daughter or stepfather and stepdaughter. Among the various problems and symptoms in the children and adolescents concerned that are believed to be due to these experiences, the commonest include withdrawal from all intimate relationships, sleep disturbances, and suicidal intentions (Adams-Tucker, 1982; Meiselman, 1978). Conditions likely to cause cognitive disturbance are more prominent when the children are prepubertal. When a sexual liaison develops between a father and his adolescent daughter, MacCarthy reports, the liaison is usually acknowledged by the father during the daily life by such means as secret glances, secret touching, and innuendoes. In the case of a younger child, however, a father is likely to make no such acknowledgments. Instead, he behaves during the day as though the night episodes never occurred, and this total failure to acknowledge them is commonly maintained even long after the daughter has reached adolescence. MacCarthy describes the case of a married woman, Mrs. A., whom he treated for depression and reliance on tranquilizers and alcohol, and who mentioned the ten years of sexual interference she had suffered from her adoptive father only after she had been in therapy for four months. It had begun when she was 5 or 6, soon after her adoptive mother had died, and had continued until she was 16, when she had fled. Among her many problems were frigidity and finding intercourse disgusting, and a sense of inner blackness, of "a black stain." Her prob-

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lems had become exacerbated when her own daughter was 4 years old. Whenever the daughter became affectionate to father and sat near him, Mrs. A. felt agitated, protective, and jealous; on these occasions she could never leave them alone together. During therapy she was obsequious and terrified, and intensely vigilant of the analyst's every move. In regard to the incestuous relationship, Mrs. A. described how her adoptive father would never at any time during the day allude to his nocturnal visits to her room, which had always remained darkened. On the contrary, he had lectured her incessantly on the dangers of allowing boys to go too far, and on the importance of chastity before marriage. When at the age of 16 she had fled the home, he not only insisted she tell no one, but added sarcastically, "And if you do no one will believe you." This could well have been so since her adoptive father was a headmaster and the local mayor. In commenting on this and similar cases, MacCarthy emphasizes the cognitive split between the respected and perhaps loved father of daytime and the very different father of the strange events of the night before. Warned on no account to breathe a word to anyone, including her mother, the child looks to her father for some confirmation of those events and is naturally bewildered when there is no response. Did it really happen or did I dream it? Have I two fathers? Small wonder if in later years all men are distrusted, and the professional stance of a male therapist is seen as a mere facade that hides a predatory intent. Small wonder also if the injunction on no account to tell anyone remains operative and if the expectation that in any case no one would believe you ensures silence. How often, we may wonder, do ill-informed therapists discourage a patient from telling the truth and, should she do so nonetheless, confirm her expectation that no one will believe her story? In the examples so far described, the information a parent is pressing a child to shut away is information relating to events in the outside world. In other situations the information to be shut away relates to events in the child's private world of feeling. Nowhere does this occur more commonly than in situations of separation and loss. When a parent dies, the surviving parent or other relative may not only provide the children with inadequate or misleading information but he or she may also indicate that it would not be appropriate for the child even to be distressed. This may be explicit: Miller (1979a) describes how, when a 6-year-old's mother died, his aunt told him, "Don't cry; now go to your room and play nicely." At other times the indication is only implicit. Not infrequently widows or widowers, afraid

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to express their own distress, in effect encourage their children to shut away all the feeling they are having about their loss. Palgi (1973) describes how a small boy whose mother was chiding him for not shedding tears over his father's death retorted, "How can I cry when I have never seen your tears?" There are in fact many situations in which a child is expressly told not to cry. For example, a child of 5 whose nanny is leaving is told not to cry because that would make it more difficult for nanny. A child whose parents leave him in the hospital or a residential nursery insist he not cry, otherwise they will not visit him. A child whose parents are frequently away and who leave him with one of a succession of au pair girls is not encouraged to recognize how lonely, and perhaps angry, he feels at their constant absence. When parents separate it is often made plain to a child that he is not expected to miss the departing parent or to pine for the parent's return. Not only are sorrow and crying condemned as inappropriate in such situations, but older children and adults may jeer at a distressed child for being a crybaby. Is there any wonder that in such circumstances feeling should become shut away? All these situations are plain enough but have, I believe, been seriously neglected as causes of information and feeling becoming excluded from consciousness. There are, however, other situations also, more subtle and hidden but no less common, that have the same effect. One such arises when a mother, who herself had a childhood deprived of love, seeks from her own child the love she has hitherto lacked. In doing this she is inverting the normal parent—child relationship— requiring the child to act as parent while she becomes the child. To someone unaware of what is going on it may appear that the child is being "overindulged," but a closer look shows that mother is placing a heavy burden on him. What is of special relevance here is that more often than not the child is expected to be grateful for such care as he receives and not to notice the demands being made upon him. One result of this is that, in conformity with his mother's wishes, he builds up a one-sided picture of her as wholly loving and generous, thereby shutting away from conscious processing much information also reaching him that she is often selfish, demanding, and ungrateful. Another result is that, also in conformity with his mother's wishes, he admits to consciousness only feelings of love and gratitude toward her and shuts away every feeling of anger he may have toward her for expecting him to care for her and for preventing him from making his own friends and living his own life.

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A related situation is one in which a parent, having had a traumatic childhood, is apprehensive of being reminded of past miseries and so becoming depressed. As a result, her children are required always to appear happy and to avoid any expression of sorrow, loneliness, or anger. As one patient put it to me after a good deal of therapy, "I see now that I was terribly lonely as a child but I was never allowed to know it." Most children are indulgent toward their parents, preferring to see them in a favorable light and eager to overlook many deficiencies. Yet, they do not willingly conform to seeing a parent only in the light the parent requires or to feeling toward him or her only in the way demanded. To ensure that, pressure must be exerted. Pressure can take different forms but all forms depend for their effectiveness on the child's insistent desire to be loved and protected. Miller (1979b), who has given these problems much attention, reports the words of an adult patient who was born the eldest child of an insecure professional woman: / was the jewel in my mother's crown. She often said: "Maja can be relied upon, she will cope. " And I did cope. I brought up the smaller children for her so that she could get on with her professional career. She became more and more famous, but I never saw her happy. How often I longed for her in the evenings. The little ones cried and I comforted them but I myself never cried. Who would have wanted a crying child? I could only win my mother's love if I was competent, understanding and controlled; if I never questioned her actions nor showed her how much I missed her; that would have limited herfreedom which she needed so much. That would have turned her against me.

In other families pressures are less subtle. One form, threatening to abandon a child as a means of controlling him, is an extremely powerful weapon, especially with a young child. Faced with such threats, how could a child do other than conform to his parents' wishes by excluding from further processing all that he knows they wish him to forget? Elsewhere I have given reasons for believing that threats of this sort are responsible for much acute and chronic anxiety (Bowlby, 1971) and also for a person responding to bereavement in later life with chronic depression in which the dominant belief is one of having been deliberately abandoned, as a punishment, by the dead person (Bowlby, 1980). The hypothesis that various forms of cognitive disturbance seen in children and also in later life are to be traced to influences acting initially during the preadolescent years is compatible with indications that during these years children's minds are especially sensitive to outside influence. Evidence of this, already emphasized, is the extent to

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which young children are vulnerable to threats by parents to reject or even abandon them. After a child has reached adolescence, clearly, his vulnerability to such threats diminishes. The extent to which the minds of preadolescent children are prone to the influence of parents is well illustrated by an experiment of Gill (1970). The sample comprised 10-year-old children drawn from a London primary school and their parents. Of the 40 non-immigrant families invited to participate, 25 agreed. Each family was visited in its own home and was shown a series often pictures on a screen, each for two minutes. Of the pictures used, five came from picture books or film and the rest from thematic apperception tests. Some were emotionally benign—for example, a mother watching a small girl holding a baby. Some showed scenes of an aggressive and/or frightening sort. Three depicted a sexual theme: a woman obviously pregnant lying on a bed, a couple embracing on the grass, and a woman clutching the shoulders of a man who seems to be pulling away, with the picture of a seminude woman in the background. The series of 10 pictures was presented three times in succession. On the first showing, father, mother, and child were asked to write down, independently, what they saw happening in the picture. On the second, members of the family were asked to discuss each picture for the two minutes it was shown. During the third showing, each member was asked again to write down, independently, what they now saw happening. When the children's responses to the three pictures depicting sexual themes were examined, it was found that whereas half the children (12) described the sexual themes in a fairly direct matter-of-fact way, the other half failed to do so. For example, to the picture of the obviously pregnant woman, one child's candid response ran: "She's having a rest. I can see that she's expecting a baby. She's asleep, I think." Descriptions of the same picture by other children omitted all reference to pregnancy: "Somebody is asleep in bed," and "There's a man on a bed. He is asleep." A second step was to analyze how the parents discussed the picture in the child's presence during the second showing. This was done by a psychologist blind to the children's responses. Here again, it was evident that, whereas some parents were candid about the scene depicted, others made no reference to it and/or expressed disgust. For example, to the picture of the pregnant woman, the mother of one child remarked frankly and on three occasions that the woman was

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expecting a baby and was having an afternoon rest. By contrast, the parents of another child completed their 2-minute discussion without any such reference. Instead, they concentrated on emotionally neutral details such as the woman's hairstyle, the material of her dressing gown, and the quality of the furniture. Not surprisingly, there was a high correlation between the way the children responded to the pictures and the way the parents had discussed them subsequently. On the third showing, the descriptions given by all the children improved in accuracy, but those of the twelve who had responded candidly on the films' showing improved more than did the descriptions given by the thirteen who had failed to report the pictures' content on the first occasion. There could be little doubt that during their discussion of the pictures some of the parents were, consciously or unconsciously, avoiding reference to the content of the pictures. It was a reasonable inference also that their children's failure to describe the sexual themes on the first showing was in some way influenced by the "climate" they had experienced in their homes. What the experiment could not show, of course, was whether these children had truly failed to perceive the scene depicted or whether they had perceived it but had failed to report what they saw. Since preadolescent children tend to be slow and often uncertain in their perceptions, my guess would be that at least some of the children in the experiment had truly failed to register the nature of what was happening. Others may have known intuitively that the scene was one they were not supposed to know about and so avoided seeing it. At first sight the notion that information of a certain meaning can be shut off, or selectively excluded from perception, appears paradoxical. How, it is asked, can a person selectively exclude from processing a particular stimulus unless he first perceives the stimulus that he wishes to exclude? This stumbling block disappears, however, once perception is conceived as a multistage process, as nowadays it is. Indeed, experimental work on human information processing enables us to have a much better idea of the nature of the shutting-off processes we have been discussing than was possible when Freud and others in the psychodynamic tradition were first formulating the theories of defense that have been so very influential ever since. In what follows I give a brief sketch of this new approach.* *A fuller account is given in Bowlby (1980).

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Studies of human perception (Erdelyi, 1974; Norman, 1976) have shown that before a person is aware of seeing something or hearing something, the sensory inflow coming through his eyes or ears has already passed through many stages of selection, interpretation, and appraisal, during the course of which a large proportion of the original inflow has been excluded. The reason for this extensive exclusion is that the channels responsible for the most advanced processing are of limited capacity and must therefore be protected from overload. To ensure that what is most relevant gets through and that only the less relevant is excluded, selection of inflow is under central or, we might say, ego control. Although this processing is done at extraordinary speeds and almost all of it outside awareness, much of the inflow has nonetheless been carried to a very advanced stage of processing before being excluded. The results of experiments on dichotic listening provide striking examples. In this type of experiment, two different messages are transmitted simultaneously to a person, one message being transmitted to one ear and the other to the other ear. The person is then told to attend to one of these messages only, say the one being received by the right ear. To ensure that he gives it continuous attention, he is required to "shadow" that message by repeating it word for word as he is hearing it. Keeping the two messages distinct is found to be fairly easy, and at the end of the session the subject is usually totally unaware of the content of the unattended message. Yet there are significant exceptions. For example, should his own name or some other personally significant word occur in the unattended message, he may well notice and remember it. This shows that, even though consciously unattended, this message is being subjected to continuous and fairly advanced processing during which its meaning is being monitored and its content being appraised as more or less relevant, and all this without the person's being in any way aware of what is going on. In the ordinary course of a person's life, the criteria applied to sensory inflow that determine what information is to be accepted and what is to be excluded are readily intelligible as reflecting what is at any one time in the person's best interests. Thus, when he is hungry, sensory inflow concerned with food is given priority while much else that might at other times be of interest to him is excluded. Yet, should danger threaten, priorities would quickly change so that inflow concerned with issues of danger and safety would take precedence and inflow concerned with food be temporarily excluded. This change in

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the criteria governing what inflow is to be accepted and what excluded is effected by evaluating systems central to the personality. In thus summarizing the findings from a neighboring discipline, the main points I wish to emphasize are, first, that throughout a person's life he is engaged in excluding, or shutting out, a large proportion of all the information that is reaching him; second, that he does so only after its relevance to himself has been assessed; and third, that this process of selective exclusion is usually carried out without his being in any way aware of its happening. Admittedly, so far most of these experiments have been concerned with the processing of current sensory inflow, namely, with perception, and not with the utilization of information already stored in memory, namely, with recall. Yet it seems likely that the same general principles apply. In each case, criteria are set by one or more central evaluating systems and it is these criteria that govern what information is passed through for further, and conscious, processing amid what is excluded. Thus, thanks to the work of cognitive psychologists, there is no longer any difficulty in imagining and describing in operational terms a mental apparatus capable of shutting off information of certain specified types and of doing so without the person's being aware of what is happening. Let us consider next the second category of scenes and experiences that tend to become shut off and forgotten while at the same time continuing to be more or less influential in affecting a person's thoughts, feelings, and behavior. These are the scenes and experiences in which parents have treated children in ways the children find too unbearable to think about or remember. Here again, not only is there amnesia, partial or complete, for the sequence of events, but also exclusion from consciousness of the thoughts, feelings, and impulses to action that are the natural responses to such events. This results in major disorders of personality, which in their commoner and less severe forms tend to be diagnosed as cases of narcissism or false self and in their more severe forms may be labeled as a fugue, a psychosis, or a case of multiple personality. The experiences that give rise to such disorders have probably continued or been repeated over several years of childhood, perhaps starting during the first two or three but usually continuing during the fourth, fifth, sixth, and seventh years, and no doubt often for longer still. The experiences themselves include repeated rejection by parents combined with contempt for a child's desire for love, care, and comforting, and, especially in the more severe forms, physical violence (battering) , repeated and sometimes systematic, and sexual exploitation by

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father or mother's boyfriend. Not infrequently, a child in this predicament is subjected to a combination of such experiences. We start at the less severe end of what appears to be a spectrum of related syndromes. An example of a patient labeled as "false self which, on the basis of what the patient was able to recall during therapy can be attributed to repeated rejection by mother, is described by Lind (1973). The patient was a young graduate of 23 who, though severely depressed and planning suicide, maintained that his state of mind was less an illness than "a philosophy of life." He was the eldest of a large family, and by the time he was 3, two siblings had already been born. His parents, he said, quarreled, both frequently and violently. When the family was young, father had been working long hours away from home training for a profession. Mother was always unpredictable. Often she was so distraught by her quarreling children that she would lock herself in her room for days on end. Several times she had left home, taking the daughters with her but leaving the sons behind. He had been told that he had been an unhappy baby, a poor feeder and sleeper, who had often been left alone to cry for long periods. His crying, it was said, had been just an attempt to gain control of his parents and to be spoiled. On one occasion he had had appendicitis and he remembered lying awake all night moaning, but his parents had done nothing and by next morning he was seriously ill. Later, during therapy, he recalled how disturbed he used to be at hearing his younger brothers and sisters being left to cry and how he hated his parents for it and felt like killing them. He had always felt like a lost child and had been puzzled to understand why he had been rejected. His first day at school, he said, had been the worst in his life. It had seemed a final rejection by his mother; all day he had felt desperate and had never stopped crying. After that he had gradually come to hide all desires for love and support; he had refused ever to ask for help or to have anything done for him. Now, during therapy, he was frightened he might break down and cry and want to be mothered. This would lead his therapist, he felt sure, to regard him as a nuisance and his behavior simply as attention seeking, and, were he to say anything personal to her, he fully expected her to be offended and perhaps lock herself in her room. Fortunately, he was in the hands of a therapist who understood his problem and gave full credence to the childhood experiences he described and sympathetic recognition to both his unrequited yearning

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for love and care and also the violent feelings toward his mother that her treatment of him had aroused and that initially were directed toward herself (the therapist). A patient with rather similar problems but whose experiences included also a period of 18 months in an impersonal institution, starting when she was 4 years old, is reported by Mintz (1976). Although both these patients made rewarding progress during treatment, both remained more sensitive than others to further misfortune. A number of patients, both children and adults, whose disorders appear to have originated in similar, though mainly worse, experiences and to have resulted in personality splitting of an even greater degree have been described by therapists during the past decade. An example is Geraldine, aged 11, who had been found wandering in a dazed state and who had lost all memory both of her mother's terminal illness and of events of the three subsequent years. At the end of a long period of therapy, described in great detail by McCann (in Furman, 1974), Geraldine summed up the experiences that had preceded her amnesia: With Mama, I was scared to death to step out of line. I saw with my own eyes how she attacked, in words and actions, my Dad and sister and, after all, I was just a little kid, very powerless. How could I ever be mad at Mama—she was really the only security I had. . . . I blotted out all feelings—things happened that were more than I could endure—I had to keep going. If I had really let things hit me, I wouldn 't be here. I'd be dead or in a mental hospital*

The complex psychological state of Geraldine and also the childhood experiences held to have been responsible for it bear close resemblance to the states of patients suffering from multiple personality and to the childhood experiences held responsible for them. In an article by Bliss (1980), based on clinical examinations and therapy carried out by means of hypnosis, a description is given of 14 patients, all female, diagnosed as suffering from multiple personality. The hypothesis Bliss advances is that the subordinate personalities that take possession of a patient from time to time are the cognitive creations of the principal personality when, as a child of between 4 and 7 years, she was subjected for extended periods to intensely distressing events. According to Bliss, each such personality is created initially to serve a distinct purpose or role. To judge from the examples he gives, the roles are of three main kinds. The simplest and most benign is to act as a *A long abstract of McCann's account is given in Bowlby (1980, pp. 338-344).

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companion and protector when the creating personality is feeling lonely and isolated, as for example when parents are persistently hostile and/ or absent and there is no one else to turn to. A second role is to be anesthetic to unbearably distressing events, as in the case of a child of 4 or 5 who shared a room with her mother who, dying of cancer, spent hours screaming in pain. The third role is more complex: namely, to shoulder the responsibility for thinking, feeling, and acting in ways that the patient cannot bear to accept as her own. Examples given by Bliss include feeling violent hatred of a mother who had attempted to kill the patient when a child; a hatred amounting to an intent actually to murder her; feeling and acting sexually after having been raped as a child; and feeling frightened and tearful after crying had led to punishments and threats from parents. Because findings derived from hypnotic procedures are controversial, it is important to note that a clinical research group at the University of California at Irvine, who use conventional procedures and who have studied a number of cases, have reached conclusions very similar to those of Bliss. The therapeutic procedures proposed have much in common also and are, moreover, strongly in keeping with the concepts of therapy outlined briefly at the end of this contribution. Lastly, a number of child psychiatrists and child psychotherapists (e.g., Bloch, 1978; Hopkins, 1984; Rosenfeld, 1975; Stroh, 1974) have described children whose thought and behavior make them appear either nearly or frankly psychotic, who show pronouncedly paranoid ideas, and whose condition, the evidence suggests, can be attributed to persistently abusive treatment by parents. Such children are often charming and endearing one moment and savagely hostile the next, the change occurring suddenly and for no apparent reason. Their greatest violence, moreover, is most likely to be directed against the very individual to whom they appear, indeed are, most closely attached. Not infrequently, these children are tormented by intense fear that some monster will attack them, and they spend their time trying to escape the expected attack. In at least some of these cases there is cogent evidence that what is feared is an attack by one or the other parent but, that expectation being unbearably frightening, the expected attack is attributed to an imaginary monster. As an example, let us consider the case of 6-year-old Sylvia, reported by Hopkins (1984), one of whose principal symptoms was a terror that the chairs and other items of furniture, which she called Daleks, would fly across the room to strike her. "Her terror was intense and when she

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kept cowering and ducking as though about to receive a blow from a Dalek or some other monster, I thought she was hallucinating." From the first, Sylvia also expressed the fear that her therapist would hit her as her mother did. Not only did she constantly attack her therapist but also she often threatened to kill her. Sylvia's father had died in an automobile accident 2 years earlier. During many months of twice-weekly interviews with a social worker, the mother was extremely guarded and told little of family relations. At length, however, after nearly 2 years, the veil was lifted. She admitted her own massive rejection of Sylvia from the time of her birth, amid the murderous feelings both she and father had had for her. Her treatment of Sylvia, she confessed, had been "utterly brutal." Father had had an extremely violent temper and in his not infrequent rages had broken the furniture and thrown it across the room. He had frequently beaten Sylvia and had even thrown her across the room. Thus, the identity of the Daleks was not in doubt. Behind the "fantasy" of a Dalek attack lay the serious, reality-based expectation of an attack by father or mother. As Bloch (1978) has put it, a basic premise of the therapeutic approach that she and others like her advocate for these cases is that what is so facilely dubbed as fantasy be recognized as the reflection of a grim reality, and that an early therapeutic task is to identify the real-life experiences lying close behind the deceptive camouflage. Not only are the childhood experiences of these near-psychotic children the same as those believed characteristic of adult patients with multiple personality, but the states of mind described by the respective therapists have features strikingly similar, too. It seems highly likely, therefore, that the two conditions are closely related. It should be noted, furthermore, that these findings give support to the hypothesis advanced by Niederland (1959a, 1959b; discussed by Bowlby, 1971) that the paranoid delusions of Judge Schreber, on which Freud based his theory of paranoia, were distorted versions of the extraordinary pedagogic regime to which the patient's father had subjected him from the early months of life. In this contribution, as in almost all my work, I have focused attention on psychopathology and some of the conditions that give rise to it. My reason for doing so is the belief that only with a better understanding of etiology and psychopathology will it be possible to develop therapeutic techniques and, more especially, preventive measures that will be at once effective and economical in skilled manpower.

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My therapeutic approach is far from original. The basic hypothesis can be stated simply: So long as current modes of perceiving and construing situations, and the feelings and actions that ensue therefore, are determined by emotionally significant events and experiences that have become shut away from further conscious processing, the personality will be prone to cognition, affect, and behavior maladapted to the current situation. When the yearning for love and care is shut away, it will continue to be inaccessible. When there is anger, it will continue to be directed at inappropriate targets. Similarly, anxiety will continue to be aroused by inappropriate situations and hostile behavior will be expected from inappropriate sources. The therapeutic task is therefore to help the patient discover what these events and experiences may have been so that the thoughts, feelings, and behavior that the situations aroused and that continue to be so troublesome can be linked again to the situations that aroused them. Then the true targets of his yearning and anger amid the true sources of his anxiety and fear will become plain. Not only will such discoveries show that his modes of cognition, feeling, and behavior are far more intelligible, given the circumstances in which they originated, than they had seemed before but, once the patient has grasped how and why he is responding as he is, he will be in a position to reappraise his responses and, should he wish, to undertake their radical restructuring. Since such reappraisal amid restructuring can be achieved only by the patient himself, the emphasis in this formulation of the therapist's task is on helping the patient, first, discover for himself what the relevant scenes and experiences probably were and, second, spend time pondering how they have continued to influence him. Only then will he be in a position to undertake the reorganization of his modes of construing the world, thinking about it, and acting in it, which are called for. The concepts of therapeutic process outlined here are similar to those described in much greater detail by others. Examples are publications by Peterfreund (1982) and by Guidano and Liotti (1983). Although the authors of these two books started their therapeutic work from radically different positions, namely traditional versions of psychoanalysis and of behavior therapy, respectively, the principles that now guide their work show a striking convergence. Similarly, current forms of bereavement therapy, which focus on distressing events in the comparatively recent past, are found to be based on the very same principles even when developed within equally different traditions (Melges & DeMaso, 1980; Raphael, 1977). In whatever form divergent tactics may still appear, strategic thinking is on a convergent course.

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When applying these principles, the therapist has several roles to play, some of which I have sketched in a previous publication (Bowlby, 1977). Here I pick out two only. One is our role in sanctioning the patient to think thoughts that his parents have discouraged or forbidden him to think, to experience feelings his parents have discouraged or forbidden him to experience, and to consider actions his parents have discouraged or forbidden him to contemplate. In giving such sanction we have to be keenly aware that what we are doing is in flagrant opposition to what the patient's parents have constantly insisted on and that the patient may well regard our stance as, at best, misguided and morally mistaken and, at worst, as positively evil. A sensitive awareness of the patient's dilemma is therefore essential. The second therapeutic role to which I draw attention here is that of providing a patient with a secure base from which he can explore.* For it is only when he can trust us sufficiently to respond to him and to what he has to say in a kindly and helpful way, instead of with the criticism and rejection that his earlier experiences have led him to expect, that he will be able to pluck up courage to undertake the explorations we are proposing, and that he quickly senses will be both frightening and painful. There are, of course, still many disagreements about the most useful tactics for a therapist to adopt for different patients and different situations. Productive discussion of such disagreements turns, however, on prior agreement on what we are trying to do. It is to that issue that this contribution is addressed. REFERENCES Adams-Tucker, C. (1982). Proximate effects of sexual abuse in childhood: A report on 28 children. American Journal of Psychiatry, 139, 1252-1256. Bliss, E. L. (1980). Multiple personalities: A report of 14 cases with implications for schizophrenia and hysteria. Archives of General Psychiatry, 37, 1388-1397. Bloch, D. (1978). So the witch won't eat me. Boston: Houghton Mifflin. Bowlby, J. (1975). Attachment and loss: Vol. 2. Separation: Anxiety and anger. London: Hogarth; New York: Basic Books, 1973. Bowlby, J. (1977). The making and breaking of affectional bonds. British Journal of Psychiatry, 130, 201-210, 421-431. (Reprinted in Bowlby, The making and breaking of affectional bonds. New York: Methuen, 1979.) *The concept of a secure base from which to explore is central to attachment theory (Bowlby, 1977).

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Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss: Sadness and depression. London: Hogarth; New York: Basic Books. Bowlby, J. (1982). Attachment and loss: Vol. 1. Attachment (2nd ed.). London: Hogarth; New York: Basic Books. Cain, A. C., & Fast, I. (1972). Children's disturbed reactions to parent suicide. In A. C. Cain (Ed.), Survivors of suicide. Springfield, IL: Charles C Thomas. Erdelyi, M. H. (1974). A new look at the New Look: Perceptual defense and vigilance. Psychological Review, 81, 1-25. Freud, S. (1914). Remembering, repeating and working through. Standard Edition 12, 147-156. Furman, E. (1974). A child's parent dies: Studies in childhood bereavement. New Haven and London: Yale University Press. Gill, H. S. (1970). Parental influences in a child's capacity to perceive sexual themes. Family Process, 9, 41-50. (Reprinted in R. Gosling (Ed.'), Support, innovation and autonomy. London: Tavistock, 1973.) Guidano, V. F., & Liotti, G. (1983). Cognitive processes and emotional disorders. New York: Guilford. Hopkins, J. (1984). The probable role of trauma in a case of foot and shoe fetishism: Aspects of the psychotherapy of a six-year-old girl. International Review of Psychoanalysis, 11, 79-91. Lind, E. (1973). From false-self to true-self functioning: A case in brief psychotherapy British Journal of Medical Psychology, 46, 381-389. MacCarthy, B. (in preparation). The psychoanalytic treatment of incest victims. Meiselman, K. C. (1978). Incest—A psychological study of causes and effects with treatment recommendations. San Francisco: Jossey-Bass. Melges, F. T., & DeMaso, D. R. (1980). Grief resolution therapy: Reliving, revising and revisiting. American Journal of Psychotherapy, 34, 51-61. Miller, A. (1979a). The drama of the gifted child and the psychoanalyst's narcissistic disturbance. International Journal of Psycho-analysis, 60, 47-58. Miller, A. (1979b). Depression and grandiosity as related forms of narcissistic disturbances. International Review of Psychoanalysis, 6, 61-76. Mintz, T. (1976). Contribution to panel report on effects on adults of object loss in the first five years. Reported by M. Wolfenstein. Journal of 'the American Psychoanalytic Association, 24, 662-665. Niederland, W. G. (1959a). The "miracled-up" world of Schreber's childhood. Psychoanalytic Study of the Child, 14, 383-413. New York: International Universities Press. Niederland, W. G. (1959b). Schreber: Father and son. Psychoanalytic Quarterly, 28, 151-169. Norman, O. A. (1976). Memory amid attention: Introduction to human information processing (2nd ed.). New York: Wiley. Palgi, P. (1973). The socio-cultural expressions and implications of death, mourning and bereavement arising out of the war situation in Israel. Israel Annals of Psych iou—v., 11, 301-329. Peterfreund, E. (1982). The process of psychoanalytic therapy: Modes and strategies. New York: Analytic Press.

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Raphael, B. (1977). Preventive intervention with the recently bereaved. Archives of General Psychiatry, 34, 1450-1454. Reagor, P. A. (in preparation). A reparenting model for management of therapeutic relationships with multiple personalities. Rosen, V. H. (1955). The reconstruction of a traumatic childhood event in a case of derealization. Journal of the American Psychoanalytic Association, 3, 211—221. (Reprinted in A. C. Cain (Ed.), Survivors of suicide. Springfield, IL: Charles C Thomas, 1972.) Rosenfeld, S. (1975). Some reflections arising from the treatment of a traumatized child. In Hampstead Clinic Studies in Child Psychoanalysis (pp. 47-64). New Haven, CT: Yale University Press. Stroh, G. (1974). Psychotic children. In P. Barker (Ed.), The residential psychiatric treatment of children (pp. 175-190). London: Crosby.

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6 Cognition in Psychoanalysis* Silvano Arieti

n a paper published in 1965 in Volume 8 of Science and Psychoanalysis, edited by Masserman, I wrote:

I

Cognition is or has been, up to now, the Cinderella of psychoanalysis and psychiatry. No other field of the psyche has been so consistently neglected by clinicians and theoreticians alike. Isolated studies and manifestations of interest have not so far developed into a definite trend.

Since then the attitude of the profession has changed but, until recent years, only to a modest degree. For a person like me, who wrote his first paper on cognition in the year 1949, these 32 years of waiting have been a taxing experience, but not a "waiting for Godot." Now cognition has become a growing stream of study and concern. And yet, if some colleagues who have been interested in this subject were to ask me to define cognition and then hear my answer, they would feel like Moliere's famous character, M. Jourdain, who, when his teacher explained what prose was, said, "I spoke prose all my life without even knowing it." Similarly, even those of us psychoanalysts who have not been interested in cognition have done cognitive psychoanalysis every day, during every session, because cognition is the study of ideas and their precursors, that is, the study of the development, formation, content, interconnections, and dynamic effect of ideas. It is through ideas that we communicate with our patients; it is by hearing the content of '"Cognition and Psychoanalysis," by S. Arieti, originally appeared in thefournal of the American Academy of Psychoanalysis, 1980, 8, 3-23. Copyright © 1980 byjohn Wiley & Sons, Inc. Reprinted with minor editorial emendations by permission of John Wiley & Sons, Inc.

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their ideas that we get to know them and to know what ideas do to them. It is through ideas that we bring about improvement and cure. In the present chapter, cognition will not be discussed as a medium by which we get to know and represent reality—this is the usual representation made by academic psychologists—but as a major component of our inner reality and as a dynamic force. Space limitations will compel me to make a cursory presentation and a selection of topics that may seem arbitrary. Under the influence of classic psychoanalysis, many psychoanalysts have stressed only the primitive—the bodily needs and instinctual or primitive behavior that can exist without a cognitive counterpart or with a very limited one. Simple levels of physiopsychological organization, such as states of hunger, thirst, fatigue, need for sleep and a certain degree of temperature, sexual urges, or relatively simple emotions, such as fear about one's physical survival, are undoubtedly powerful dynamic forces. They do not include, however, the motivational factors that are possible only at preconceptual levels of development. Freud stressed how we tend to suppress and repress ideas that elicit anxiety. But we psychiatrists and psychoanalysts have suppressed or repressed the whole field of ideas, that is, cognition. We have repressed it apparently because it is anxiety provoking. As a matter of fact, as we shall see later, there would be very little anxiety in the human being without ideas or precursors of ideas. But psychoanalysts have for a long time preferred to think that cognition deals with those so-called conflictfree areas and therefore does not pertain to psychoanalysis. The contention of cognitive psychoanalysis is that very few conflicts, and only elementary ones, would exist in the human being if he were not able to think, to formulate ideas, old or new, to assimilate them, make them part of himself, face and compare them, distort them, attribute them to others, or, finally, repress them. When I stated that cognition has been neglected, some could have pointed out to me that this is not really so. At least three giants—Freud himself Jean Piaget, and Hans Werner—have been very much interested in cognition. This is true, but let us see what kind of impact the contributions to cognition of these three giants have made to psychoanalysis. One of Freud's great breakthroughs was his discovery of the primary process and the description of the primary and secondary processes. Freud, however, did not maintain a great interest in the primary process as a mode of cognition, but only as a carrier of unconscious motivation stemming from an instinctual source. Inasmuch as motivational theory

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in the Freudian system came to be interpreted in the function of the libido theory, the primary process came to be studied not in a framework of cognition, but in a framework of energetics. Primary and secondary processes came to be considered primarily not as two different ways of thinking, but as two different ways of dealing with cathexes. In the primary process the cathexis was described as free. In other words, cathectic quantities of energy are easily shifted from some objects to others. Inasmuch as this shifting may easily occur from realistic and appropriate objects to unrealistic and inappropriate ones, the primary process becomes an irrational mode of functioning. These points of view leave many unexplored aspects, especially those that pertain more closely to cognition. Cognition is relegated to being a medium and is not considered as a source of conscious or unconscious motivation. Piaget's contributions are very significant, especially in child psychology. But they have not made much impact on psychoanalytic therapy, mainly because they are difficult to integrate with a psychodynamic view of the human being. Piaget's works reveal very well the process of cognitive maturation and adaptation to environmental reality and disclose the various steps by which the child increases his understanding and mastery of the world. Although they are important, they do not represent intrapsychic life in its structural and psychodynamic aspects. They neglect affect as much as classic psychoanalytic studies neglect cognition and do not deal with motivation, unconscious processes, and conflicts of forces. The cognitive functions, as described by Piaget, seem really autonomous and conflict free, as the ego psychologists have classified them. All attempts up to the present to absorb Piaget's contributions into the core of classic psychoanalysis—including the attempt made by Odier (1956)—have, in my opinion, not gone very far. The only contributions of Piaget that could be reconciled with classic psychoanalysis are those he made very early in his career when he was still under the influence of the psychoanalytic school (Piaget, 1919). For instance, his concept of the child's egocentrism is related to the psychoanalytic concept of the child's feeling of omnipotence. The contributions of Hans Werner (1948) are perhaps more pertinent to psychiatric studies because, in following a comparative developmental approach, they take into consideration pathological conditions. However, like the works of Piaget, they do not make significant use of the concepts of the unconscious and unconscious motivation. When my first writings on cognition appeared, from 1947 to 1955, such studies were looked at askance in America, whether they dealt

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with psychological structure or content (Arieti, 1947, 1948, 1953, 1955). And yet in France, Levi-Strauss (1951) was very well received for his structural approach, and in America, Chomsky (1957) introduced structuralism to linguistics. In the 1940s and the 1950s, psychology, under the influence of behaviorism, was concerned mainly with overt behavior; classic psychoanalysis focused on energetics and instinctual precognitive life, and neo-Freudian, cultural psychoanalysis was concerned with the study of conflicts without considering their cognitive origin. In France in the meantime, Lacan (1966) started his cognitive studies of inner life and stressed the importance of the signifier in conscious and unconscious life. By signifier (in French, significant] he meant "language" or the "word," whatever gives a meaning to things. Unfortunately, his works are written in such a difficult style as to discourage many readers.

OTHERNESS AND INWARDNESS Another reason that has induced many psychoanalysts to neglect cognition has been the assumption that a cognitive approach would neglect infancy and early childhood, a period of life during which there is little cognition and which in some respects can be called precognitive. It is a period during which sensations and elementary perceptions prevail. The child lives at what Piaget called a sensorimotor level, regulated mostly by the simple stimulus-response mechanism. In spite of this poverty of cognitive processes, many people rightly point out that at this level the baby and his mother are already capable of establishing a bond of love, with attachment, empathy, and mutual concern. Is not this bond of love, or the lack of it, or its vicissitudes, of fundamental importance for the subsequent life? A dialogue of love has already started in the first few hours of life. A large number of clues and signals are exchanged between the few-days-old baby and his mother. What is more meaningful than the eye-to-eye language, the body contact between mother and baby, contact established by sucking at the breast and by the embrace? What is more full of meaning than the reciprocal smile between the baby and his mother? The beauty of the embrace and the contact with the body of the mother cannot be spoiled even when we use our arid scientific language and call it an activation of sensorimotor systems in the infant (Harlow & Harlow, 1965). A cognitive approach does not deny the importance of this early stage of human life. However, the following considerations have to be made.

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The dialogue of love between mother and baby is unequal. Even though the mother may not speak to the child, she touches him, feeds him, holds him, rocks him, smiles at him, and sings to him, and she attributes an affective-cognitive meaning to these actions. For her, each gesture and action has a meaning. She embraces her child with the warmth and love of her adulthood. When we see this beautiful scene, mother and baby together, and we call it a "dialogue" of love, we attribute to it our meanings, our words, and our word about words. Happy the baby who, in the smile on the face of his mother intuitively perceives in a precognitive way a reflection of his own smile. But this precognitive intuition will not develop into a real and bilateral bond of love unless cognitive developments follow. This exchange between mother and child is a superb beginning; but no matter how superb and beautiful, in the human infant it will remain at a level not superior to that occurring in animal forms unless one of the two partners is a human adult, equipped with cognitive power, sowing cognitive seeds so that the primitive embrace does not remain primitive but becomes eventually an embrace capable of including other members of the family, the whole group of people with whom the child has significant contacts, and eventually, possibly, humankind. But how can the maternal embrace become a potentially world-wide embrace? By the gradual and subsequent acquisition of cognitive and symbolic forms. Language, concepts mediated through language, and emotions made possible by the acquisition of language will expand, deepen, transform the life of the child and give rise to a universe of ideas, mutual understandings, interpersonal ties, loves. The gradual independence from mother is accompanied by a gradual immersion in the big world. Thus whatever pain is involved in the gradual separation from mother is compensated for by the opening and joy of the world, which is gradually better understood and savored. But it must be a world from which mother is not absent. Mother is still there, symbol of the concrete precognitive attachment and representative and intermediary of the world of incoming symbols. The openness to the big world has its earliest beginning when the child is approximately 9 months old. Mother becomes increasingly absent, but to the increasing absence of mother I shall return later. Now let us give another look at these early 8 to 9 months of life. In these early months, actually as soon as he is born, the baby is more or less receptive to some exchanges with the other. The other at first is only the mother, who becomes instantly the forerunner and representative of all future others: family members,

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people, mankind. So the first other is the person who is experienced the least as an other. Even those of us who do not believe the child considers himself part of mother do agree that the first Thou is the least other. It is through this relatedness to mother that the child starts to develop the I-Thou relation described by Martin Buber (1953). This relatedness is the prototype of subsequent meaningful interpersonal relations, leading to attachment, affection, friendship, intimacy, and love. Martin Buber also describes another encounter of the individual, the I-It, the encounter with the inanimate world, be it that of a simple object or a solar system. Buber rightly stresses the superiority of the I-Thou relation over the I-It. Buber is the philosopher of what I call otherness, the relation with the other, which later was further explored by many authors, especially by George Herbert Mead and Harry Stack Sullivan. Buber's contribution is very important. Nevertheless, it has limitations. As a philosophical or psychological entity the human being cannot be defined exclusively in terms of the formulas I-Thou and I-It. Although Buber has made it clear that by reaching out to a fellow man a person reaches into himself, and that in reaching out to others one reaches oneself, this formulation is vague. The I, or self, needs a special consideration, a more profound treatment, which is not included in the concept of otherness. The I or self is a human being, too, but is not just an other. In reaching myself, I have an attitude different from the one I have in reaching others. The attitude toward oneself is based on introspection, or self-awareness, which other animal species have only to a rudimentary degree. It is only with the human being that this attitude or mental set expands to an enormous degree. Otherness requires openness to the world. Introspection and self-awareness require openness to oneself, that attitude or mental set that I call inwardness. Although in his otherness the human being is by far superior to, and extremely more complicated than, other animal species, in the beginning and first stages of otherness the human being is not completely dissimilar to other animals. Of course, he changes dramatically later when he is able to act, to embrace, to touch, to love, and to hate with words, too. Inwardness unfolds later and would not develop at all unless at least a rudimentary otherness already existed. Inwardness makes us reach for ourselves, inside, opens to us our inner life. I enter into a special dialogue with a special person, me, and I face myself, speak to myself, and read myself. I am not an object to myself. I have a special encounter, I-I, and what I can discover can be unexpectedly new; a whole universe opens up to me, my own.

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But this inner universe consists of cognitive structures with cognitive content. If it were not for cognition, I could not have an inner life, or perhaps I could have only a very limited one. Moreover, if I want to discover my unconscious, I must do so in a cognitive way. For what I have repressed from consciousness is predominantly cognitive in nature; that is, I repress ideas, attitudes, mental dispositions, and in most cases the emotions derived from them. Many cognitive forms have a double entity; they consist of what seems to be a psychological bifurcation. One branch is interpersonal, reaching the other with a word, an idea, a complicated relation. The other branch is intrapsychic and makes it possible to retain such an idea, attitude, or disposition within oneself. When I acquire a new cognitive form, let us say a new word or a new concept, not only is it my otherness that expands but also my inwardness. I have a new way to reach not only others but also myself. The new word or concept, and the emotions that accompany it, will enrich my self as well and will become from now on part of my inner life.

IMAGERY

At this point I wish to give a bird's eye view of the development of cognition from babyhood to adulthood, as far as inner life is concerned. In this brief review, I will be able to discuss the development of cognitive forms and their content only in a succinct way. I shall try to show how they are necessary for the origin of emotions and psychodynamic mechanisms. When we psychoanalysts interested in cognition stress the importance of ideas and systems of ideas, we do not minimize the importance of affective life, or of motivation, conscious or unconscious. On the contrary, we stress a fact that is very seldom acknowledged, namely, that at a human level most emotions would not exist without a cognitive substratum. The expansion of the neocortex and consequently of our cognitive functions has permitted an expansion of our affective life also. In a classic paper, published in 1937, Papez demonstrated that several parts of the rhinencephalon and archipallium are not used for olfactory functions in the human being, but for the experience of emotion. In spite of the diminished importance of olfaction, these areas have expanded, not decreased, in man and have become associated with vast neocortical areas. It is at approximately 9 months of age that the "second birth" of the child occurs. This is when the child realizes that mother becomes more

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and more frequently absent. He gradually learns to understand language and to talk, but he acquires another faculty, which at first develops much more rapidly than language: imagery. The very first stage of internalization, that is, of inner life and inwardness, occurs through images. For the sake of simplification we shall consider only visual images. Brodmann's area 19 in the occipital lobes now becomes myelinized and capable of functioning. Visual sensations and perceptions that were mediated in areas 17 and 18 have left memory traces that assume the form of representation, that is, of images. The image is now an internal quasi-reproduction of a perception that does not require the corresponding external stimulus in order to be evoked. The image is indeed the earliest and one of the most important foundations of human symbolism. By symbol we mean something that stands for something else that is not present. Whereas previous forms of cognition and learning permitted an understanding based on the immediately given or experienced, from now on cognition will rely also on what is absent and inferred. Mother is now more and more frequently absent. But the child can endure her absence. Her image is with him; it stands for her. The image is based on the memory traces of previous perceptions of her. The mother acquires a psychic reality that is not tied to her physical presence. Image formation is actually the basis for all the following higher mental processes. It enables the child not only to re-evoke what is not present, but to retain an affective disposition for the absent object. For instance, the image of the mother may evoke the feelings that the child experiences toward her. If we adopt the terminology generally used in reference to computers, we can say that now the psyche or the brain is capable of analogic codification. The image thus becomes a substitute for the external object. It is actually an inner object, although it is not well organized. It is the most primitive of the inner objects if, because of their sensorimotor character, we exclude motor engrams from the category of inner objects. When the image's affective associations are pleasant, the evoking of the image reinforces the child's longing or appetite for the corresponding external object. The image thus has a motivational influence in leading the child to search out the actual object, which in its external reality is still more gratifying than the image. The opposite is true when the image's affective associations are unpleasant: the child is motivated to exchange the unpleasant inner object for the corresponding external one, which is even more pleasant. Imagery soon constitutes the foundation of inner psychic reality. It helps the individual not only to understand the world better but also

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to create a surrogate for it. Moreover, whatever is known or experienced tends to become a part of the individual who knows and experiences. Thus, cognition can no longer be considered only a hierarchy of mechanisms but also must be seen as an enduring psychological content that retains the power to affect its possessor, now and in the future. The child who has reached the level of imagery is now capable of experiencing not only such simple emotions as tension, fear, rage, and satisfaction, as he did in the first year of life, but also anxiety, anger, wish, perhaps in a rudimentary form even love and sadness, and, finally, security. Anxiety is the emotional reaction to the expectation of danger, which is mediated through cognitive media. The danger is not immediate, nor is it always well defined. Its expectation is not the result of a simple perception or signal. At subsequent ages, the danger is represented by complicated sets of cognitive constructs. At the age level that we are discussing now, it is sustained by images. It generally refers to a danger connected with the important people in the child's life, mother and father, who may punish or withdraw tenderness and affection. Anger, at this age, is also rage sustained by images. Wish is also an emotional disposition, which is evoked by the image of a pleasant object. The image motivates the individual to replace the image with the real object satisfaction. Sadness can be felt only at a rudimentary level at this stage, if by sadness we mean an experience similar to the one the sad or depressed adult undergoes. At this level, sadness is an unpleasant feeling evoked by the image of the loss of the wished object and by the experience of displeasure caused by the absence of the wished object. As I described in the paper written in 1947, this is the stage when the child becomes capable of anticipating the future and is no longer capable only of expecting imminent events. This is also the stage when the baby becomes able to experience security, or the first forerunners of what will be security. As Sullivan (1953) was the first to point out, security is different from satisfaction. Satisfaction occurs when all the bodily needs, like food, sleep, rest, warmth, and contact with the body of mother, are satisfied. No cognition is necessary for the experience of satisfaction, but it is for the experience of security. Security does not consist only of removal of unpleasant emotions or removal of uncertainty, but also of pleasant anticipation, a feeling of well-being, a trust in people and things to come. Security is experienced by the 1-yearold child not only by his contacts with his mother, but by the feeling that, if she is absent, she will return. The inner image of his mother, which he always carries inside himself, gives him this feeling of trust.

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Many other things could be said about images, imagery, and imagination. I shall limit myself to saying that imagery not only emerges as the first or most primitive process of reproducing, or substituting for, the real, but also is the first and most primitive process of creating the unreal. The French philosopher, Gaston Bachelard, has stressed this point repeatedly in his books (1960, 1971). It is true that the image does not reproduce reality faithfully; it emerges as an innovation, a state of becoming, a force of transcendence, and it is the beginning of human creativity (Arieti, 1976). Unfortunately, we cannot explore this subject here but must pass on to the next stage of cognitive development, represented by the endocept or amorphous cognition. THE ENDOCEPT The endocept is a mental construct representative of a level intermediary between the image and the word. At this level, there is a primitive organization of memory traces, images, and motor engrams. This organization results in a construct that does not tend to reproduce reality as it appears in perceptions or images: it remains nonrepresentational. The endocept, in a certain way, transcends the image, but inasmuch as it is not representational, it is not easily recognizable. On the other hand, it is not a motor engram that leads to prompt action. Nor can it be transformed into a verbal expression; it remains at a preverbal level. Although it has an emotional component, most of the time it does not expand into a clearly felt emotion. The endocept is not, of course, a concept. It cannot be shared. We may consider it a disposition to feel, to act, and to think that occurs after simpler mental activity has been inhibited. It is an interrelation of feelings and residues of former experiences that has not yet crystallized into a concept. The awareness of this construct is vague, uncertain, and partial. Relative to the image, the endocept involves considerable cognitive expansion, but this expansion occurs at the expense of the subjective awareness, which is decreased in intensity. The endocept is at times experienced as an "atmosphere," an intention, a holistic experience that cannot be divided into parts or words—something similar to what Freud called "oceanic feeling." At other times, there is no sharp demarcation between endoceptual, subliminal experiences and some vague primitive experiences. On still other occasions, strong but not verbalizable emotions accompany endocepts. For the evidence of the existence of endocepts and for their importance in adult life, dreams, and creativity, the reader is referred else-

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where (Arieti, 1967,1976). It is more likely that it is the right hemisphere that is mediating endoceptual activity. MOVING TOWARD CONCEPTUAL THINKING At this point I should open up the extensive area of cognition, which includes the acquisition of language and the various stages of preconceptual thinking leading to the formulation of the mature concept. This is the stage in which, in addition to the analogic codification of imagery and the diffuse grouping of the endocept, the psyche or the brain becomes capable of digital codification, mediated chiefly by the left hemisphere. Entire libraries have been written on these subjects. From the acquisition of language (naming things) to a logical organization of concepts, various substages follow one another so rapidly and overlap in so many multiple ways that it is very difficult to retrace and individualize them. These intermediary stages are more pronounced and more easily recognizable in pathological conditions. Some of them appear in the most fleeting way in ontogenesis (Arieti, 1967), and some of them reappear in schizophrenia (Arieti, 1974). In other writings (1967, 1970) I have described how the acquisition of language and concepts is necessary for the experience of high-level emotions like sadness, depression, hate, love, or joy. In studying preconceptual stages of thinking, we view a vast cognitive realm that extends from the primitive cognition of the primary process to the elaborate one of the secondary process and Aristotelian logic. Unfortunately, I cannot deal here with this vast subject. I shall make only a few remarks. During these stages the child tends to explore more and more the external world, but also himself. The randomness of the cognitive experiences is more and more superseded by the gradual organization of inner constructs. These inner constructs at first consist of the forms we have already mentioned: images, endocepts, and preconceptual forms. Later they consist also of simple concepts and finally of complicated concepts with all their conscious and unconscious ramifications. THE IMAGE OF MOTHER AND THE SELF-IMAGE These constructs continuously exchange some of their components and increase in differentiation, rank, and order. A large number of them, however, retain the enduring mark of their individuality. Some of them

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have powerful effects and have an intense life of their own, even if at the stage of our knowledge we cannot give them an anatomic location or a neurophysiological interpretation. They may be considered the very inhabitants of inner reality. The two most important ones in the preschool age, and the only two to which I shall devote a few words, are the image of mother and the self-image. At this point the word image is used with a different meaning. It is no longer used exclusively to signify an attempted reproduction of a perception, but a complicated cluster of cognitive components. For instance, the image of the mother is a conglomeration of what the child feels and knows about her. In normal circumstances the mother as an inner object will consist of a group of agreeable images: as the giver, the helper, the assuager of hunger, thirst, cold, loneliness, immobility, and any other discomfort. She becomes the prototype of the good inner object. At the same time she will become, as we have already mentioned, the representative of the Thou. Any other fellow human being, in his essential human qualities, will be modeled after her. Much more difficult to study in early childhood is the self-image. At the precognitive sensorimotor level, the primordial self probably consists of a bundle of relatively simple relations among feelings, kinesthetic sensations, perceptions, motor activity, and a partial integration of these elements. At the image level, the child who is raised in normal circumstances learns to experience himself not exclusively as a cluster of feelings and of self-initiated movements but also as a body image and as an entity having many kinds of relations with other images, especially those of the parents. Inasmuch as the child cannot see his own face, his own visual image will be faceless, as, indeed, he will tend to see himself in dreams throughout his life. He wishes, however, to be in appearance, gestures, and actions like people toward whom he has a pleasant attitude or by whom he feels protected and gratified. The wish tends to be experienced as reality, and he believes that he is or is about to become like the others or as powerful as the others. As the child grows, his self-image will consist less and less of analogic images and preconceptual cognition, and more and more of concepts related to the self. CONCEPTUAL LIFE Struggling rapidly through preconceptual stages, the child finally reaches the conceptual level. As Vygotsky (1962) has illustrated, concep-

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tual thinking starts early in life, but it is in adolescence that it acquires prominence. Whereas psychiatrists and psychoanalysts study primitive and preconceptual types of thinking from the points of view of both form and content, they generally study concepts only in relation to their content. The study of conceptual forms remains almost exclusively an object of study for academic psychologists. I shall follow this tradition, and I shall discuss concepts only from the point of content. In a large part of psychiatric, psychoanalytic, and psychological literature, concepts are considered static, purely intellectual entities, separate from human emotions and unimportant in psychodynamic studies. I am among those who cannot adhere to this point of view. Concepts and organized clusters of concepts become depositories of emotions and also originators of new emotions. They have a great deal to do with the conflicts of man, his achievements and his frustrations, his states of happiness or despair, of anxiety or of security. They become the repositories of intangible feelings and values. Not only does every concept have an emotional counterpart, but concepts are necessary for high emotion. In the course of one's reaching adulthood, emotional and conceptual processes become more and more intimately interconnected. It is impossible to separate the two. They form a circular process. The emotional accompaniment of a cognitive process becomes the propelling drive not only toward action but also toward further cognitive processes. Only emotions can stimulate man to overcome the hardship of some cognitive processes and lead to complicated symbolic, interpersonal, and abstract processes. On the other hand, only cognitive processes can give origin to, and extend indefinitely, the realm of emotions (Arieti, 1967). Between known conceptual meanings there are gaps of potential meanings and consequently of potential emotions. Perhaps it is more accurate to say that clusters of meanings are islands in an uncharted ocean of potential meanings and emotions. Unstable clusters produce conflict-laden waves of anxiety, sorrow, and anger. A perennial effort is made to diminish the cognitive dissonance (Festinger, 1957) and to form new clusters, which either do not make waves or repress the wave-making clusters. A perennial effort is also made to diminish the contrast between the concepts that echo the objectivity of the universe and those that echo the inner subjectivity—the subjectivity that shifts between harmony and turmoil, craving and satisfaction. From a psychiatric and psychoanalytic point of view, the greatest importance of concepts resides in the fact that to a large extent they

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come to constitute the self-image. When this development occurs, the previous self-images are not completely obliterated. They remain throughout the life of the individual in the forms of minor components of the adult self-image or as repressed or suppressed forms. In adolescence, however, concepts accrue to constitute the major part of the self-image. Such concepts as inner worth, personal significance, mental outlook, more mature evaluations of appraisals reflected from others, attitudes toward ideals, aspirations, capacity to receive and give acceptance, affection, and love are integral parts of the self and of the selfimage, together with the emotions that accompany these concepts. Like other concepts, the concepts and emotions that constitute the self are generally not consistent with one another, in spite of a prolonged attempt made by the individual to organize them logically. The motivation of the human being varies according to the various levels of development. When higher levels emerge, motivations originated at lower levels do not cease to exist. At a very elementary sensorimotor level, the motivation consists of obtaining immediate pleasure and avoidance of immediate displeasure by gratification of bodily needs. When imagery emerges, either phylogenetically or ontogenetically, the individual becomes capable of wishing for something that is not present and is motivated toward the fulfillment of his wish. Let us remember that no wish is possible without a cognitive component, perhaps one of the most primitive, the image. The child will continue to be wish motivated as he moves on to more advanced stages of primary cognition, such as the prelogical stage. As I have already mentioned, although the motivation can always be understood as an attempt to retain pleasure and avoid unpleasure, gratification of the self or of the self-image becomes the main motivational factor at a conceptual level of development. Certainly, the individual is concerned with danger throughout his life: immediate danger, which elicits fear, and a more distant or symbolic danger, which elicits anxiety. However, whereas at earlier levels of development this danger is experienced as a threat to the physical self, at higher levels it is often experienced as a threat to an acceptable image of the self. To reduce the emotional factors that accompany complicated cognitive processes to the status of cover-up of primitive instinctual drives is a reductionistic assessment of the human psyche; it is forcing a return to a presymbolic or prehuman level. Even feelings, sensations, and bodily needs, which theoretically stand on their biological processes, become involved with systems of symbolism that give them special meaning and involve them in intricate networks of motivation.

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Let us take as an example the sexual need. It is obvious that sexual life cannot be considered only from a sensuous or instinctive point of view. Sexual gratification or deprivation becomes involved with such concepts as being accepted or rejected, desirable or undesirable, loved or unloved, lovable or unlovable, capable or incapable, potent or impotent, normal or abnormal. Thus sexual gratification and deprivation become phenomena that affect the whole self-image. The self is a system of interrelated cognitive items and of the emotions to which they give origin. The value and identity of these items are defined not only by their history but by their place or distribution in the system. The historical identity, although extremely important, does not coincide with the present identity. The way I am today cannot totally be subsumed by my past. In other words, what counts is not only the sequence of historical events but their integration and cognitive transformation. Each of us to some extent is created by the acts of cognition that we initiate or at least in which we participate. We must study how each item is distributed and integrated with the others. Preexisting structures, or schemas, are brought to bear upon the present. Schemas concerning the future are also brought to bear upon the present, so that our present day may be brightened or darkened by the vision of tomorrow. Since the realm of cognitive symbolism is potentially infinite and consequently the distribution of these cognitive elements can vary in an infinite number of ways, complete or absolute knowledge of the psyche and sure predictability are impossible. What is possible, however, are presumable knowledge and the assessment of probability. In other writings I have shown the importance of cognitive life in schizophrenia. I have shown how the preschizophrenic, in a period of life that precedes the psychotic break, generally during adolescence or young adulthood, finds himself threatened on all sides, as if he were in a jungle (Arieti, 1974). It is not a jungle wherein ferocious animals are to be found, but a jungle of concepts that remain unconscious until shortly before the onset of the psychosis, or the phase that I have called the prepsychotic panic. The threat is again not to physical survival, but to the self-image. The dangers are concept-feelings, such as those of being unwanted, unloved, inadequate, unacceptable, totally dependent on others, inferior, awkward, clumsy, not belonging, peculiar, different, rejected, humiliated, guilty, unable to find one's own way among the different paths of life, disgraced, discriminated against, kept at a distance, suspected, and so forth. Some of these concepts were conscious even in earlier periods of life. What had remained unconscious was

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their full significance, their ramifications and connections, especially with similar concepts about the self that originated in early childhood. When these constellations of concepts are interconnected and become vividly conscious, they are experienced as unbearable and undergo drastic changes. At this point, the patient undergoes a conceptual transformation of cosmic magnitude. He either withdraws from the world or becomes possessed by a system of unusual beliefs that makes him see the world in a different way. In order to do so, he has to make a drastic shift: he must adopt a different type of cognition, the cognition of the primary process, of the dream. And then no longer will he be besieged by the jungle of concepts that hurt his inner self; no longer will he consider himself inadequate, worthless, and deserving of contempt. The inner danger has now been transformed into a danger that comes from others. Inwardness is projected into otherness. I cannot possibly talk about schizophrenic cognition in the space at my disposal. But I shall mention how the patient, at a certain period of his psychotic transformation, enters into the world of metaphor. A patient thinks his wife is putting poison in his food. He really believes his wife is poisoning his life, but he cannot accept that belief. If she disturbs his life, he may have something to do with the marital difficulties. Another patient has an olfactory hallucination. He smells a bad odor that emanates from his body. We can be fairly sure that he attributes to his body what he thinks of himself. He has a rotten personality, one that stinks. It is easier for him to blame his body than his character. Another patient, while he was in a teenage camp, believed that at night people were going into his closet and drawers and putting female clothes in the place of his own. He was still concerned with his identity, especially gender and sex identity. Was he really a man? Another patient believes that a mysterious, unidentified person from another planet controls his thoughts. But this man is a symbol of the patient's father, toward whom he felt so emotionally distant, as if he were on another planet, and whom the patient experienced as wanting to control his ideas and the direction he wanted to give to his life. When another patient tells us that invisible rays pierce him and cause him harm, he refers to the hidden, or hard to detect, ways in which society has treated and harmed him. The patient uses what is for us metaphorical language. From what he tells us, we can indeed learn some hidden truths, as we would learn from a poet. But is the patient a poet? He is not. The big discrepancy between him and the poet lies in the difference I described in the book

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Creativity: the magic synthesis between the cognition of the primary process of the schizophrenic and the cognition of the tertiary process of the creative person (Arieti, 1976). The patient is not at all aware of the metaphorical meaning of his delusions; he accepts them literally. The metaphors are for him metamorphoses. For him it is literally true that his wife poisons his food, that a bad odor emanates from his body, that a man controls his thoughts from a distant planet, that invisible rays go through his body. He is like a dreamer who, while he is dreaming, thinks the dream is true. The dream is true, of course, not just as an act of life, but also in its symbolic content. It is as true as the poetry which, in its metaphorical revelations, discloses to us ways and feelings deeper than those usually attached to a daily reality. It is one of our tasks to guide this pseudopoet, the patient, to return to the reality of the secondary process, but it must be a reality that is less anxiety provoking and, one hopes, not prosaic. I regret that lack of space does not permit me to discuss further either schizophrenic cognition or creative cognition. I must also omit discussing the importance of cognition in depression, as Bemporad and I have illustrated (Arieti & Bemporad, 1978). I must overlook Barnett's studies on obsessive neurosis (Barnett, 1966, 1968, 1972), and I cannot even open the extremely important and vast topic of how culture provides the individual with innumerable basic concepts that lead to growth as well as to pathological conflicts. Before concluding, however, I want to refer again to an important issue to which I alluded in passing throughout my presentation: the relation between cognition and the unconscious. It is a basic tenet of the cognitive school of psychoanalysis that the unconscious and unconscious motivation include much more than infantile strivings. They include also a great deal of inner life, built in childhood, adolescence, and adulthood with cognitive forms. Because of the enormous expansion of the neopallic areas, the human being is the first entity, at least in the history of our solar system, to be confronted with an infinite array of symbols and of emotions to which they give origin. We would not be able to bear this tremendous burden unless we had relief mechanisms. Other species have only the mechanism of nonattending or of reducing to tacit knowledge what they do not use at the moment. We, too, have the mechanism of nonattending. For instance, when I speak to you in English, I do not attend to my knowledge of Italian. As a matter of fact, I try not to let my Italian interfere with my English. But this is not equivalent to making conscious material unconscious, or transforming it into dynamically different

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forms. In other words, nonattending is not a mechanism of repression. But we do repress. As a relief mechanism, we do have the mechanism of repression, first described by Freud. Whatever disturbs one's cherished self-image tends to be modified, re-evaluated, denied, or removed from consciousness. Whatever might make the individual appear to himself unworthy, guilty, inadequate, sadistic, vindictive, inconsistent with his ideas or ideals, escapist, or not living up to his ideals tends eventually to be repressed. Indeed, some of these evaluations of the self remain conscious, but even so, what is eliminated from consciousness is much more than the individual realizes. Psychoanalytic practice reveals how many of these cognitive constructs about oneself, and how many of their ramifications, are kept either in a state of unconsciousness or in dynamically acceptable or less unacceptable cognitive transformations. Repression of the main motivation (protecting the self-image) is often achieved with the help of psychological mechanisms that detour consciousness toward other avenues of thought and behavior. Intricate cognitive configurations lead the patient to feelings, ideas, and strategic forms of behavior that make the self-image acceptable or at least less unacceptable. At times any form of self-criticism is repressed, and even benevolent criticism from others is restricted with awkward cognitive strategies. We may thus conclude that we human beings are confronted not only by the infinite external cosmos but by the infinite cognition that reflects the cosmos, the infinite cognition that we internalize, and the infinite cognition that we repress. The self remains a unity, a giant enriched and battered on all sides. We psychoanalysts must maintain a humble attitude, because no matter how much we explore and bring to consciousness, what we will clarify will be only a part of the psyche, the whole of which we shall never know. But we shall accept this limitation of our goals without a sense of defeat because cognition teaches us that the human being is Homo symbolicus, for which a small part becomes the symbol that stands for the whole. The proper symbol may be a little spark that sheds an intense light and guides us to a vast understanding and to the depths of our hearts.

REFERENCES Arieti, S. (1947). The processes of expectation and anticipation. Journal of Nervous and Mental Disease, 106, 471-481.

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Arieti, S. (1948). Special logic of schizophrenic and other types of autistic thought. Psychiatry, 11, 325-338. (Reprinted in Arieti, 1978, pp. 23-45.) Arieti, S. (1953, November). Some aspects of language in schizophrenia. Paper presented at Clark University, Worcester, MA. Arieti, S. (1955). Interpretation of schizophrenia (1st ed.). New York: Brunner/Mazel. Arieti, S. (1965). Contributions to cognition from psychoanalytic theory. InJ. Masserman (Ed.), Science and psychoanalysis (Vol. 3). New York: Grune & Stratton. Arieti, S. (1967). The intrapsychic self: Feeling, cognition and creativity in health and mental illness. New York: Basic Books. Arieti, S. (1970). The structural and psychodynamic role of cognition in the human psyche. In S. Arieti (Ed.), The world biennial of psychiatry and psychotherapy (Vol. 1). New York: Basic Books. Arieti, S. (1974). Interpretation of schizophrenia (2nd ed., completely revised and expanded). New York: Basic Books. Arieti, S. (1976). Creativity: The magic synthesis. New York: Basic Books. Arieti, S. (1978). On schizophrenia, phobias, depression, psychotherapy and the farther shores of psychiatry: Selected papers. New York: Brunner/Mazel. Arieti, S., & Bemporad, J. (1978). Severe and mild depression: The psychotherapeutic approach. New York: Basic Books. Bachelard, G. (1960). The poetics of reverie. Boston: Beacon. Bachelard, G. (1971). On poetic imagination and reverie. Indianapolis, IN: Bobbs-Merrill. BarnettJ. (1966). On cognitive disorders in the obsessional. Contemporary Psychoanalysis, 2, 122-134. Barnett,J. (1968). Cognition, thought and affect in the organization of experience. InJ. Masserman (Ed.), Science and psychoanalysis. New York: Grune & Stratton. Barnett, J. (1972). Therapeutic intervention in the dysfunctional thought processes of the obsessional. American Journal of Psychotherapy, 26, 338-351. Buber, M. (1953). / and thou. Edinburgh: Clark. Chomsky, N. (1957). Syntax structures. The Hague: Mouton. Festinger, L. (1957). A theory of cognitive dissonance. Palo Alto, CA: Stanford University Press. Harlow, H. F., & Harlow, M. K. (1965). The affective systems. In A. M. Schrier, H. F. Harlow, & X. X. Stollnitz (Eds.), Behavior in nonhuman primates. New York: Academic Press. Lacan, J. (1966). Ecrits. Paris: Editions du Seuil. Levi-Strauss, I. (1951). Language and the analysis of social laws. American Anthropologist, 53, 155-163. Odier, C. (1956). Anxiety and magic thinking. New York: International Universities Press. Papez, J. W. (1937). A proposed mechanism of emotion. Archives of Neurology and Psychiatry, 38, 725-743. Piaget, J. (1919). La psychoanalyse dans ses rapports avec la psychologic de 1'enfant. Bulletin de la Societe Alfred Binet de Paris, 20. Sullivan, H. S. (1953). Conceptions of modern psychiatry. New York: Norton. Vygotsky, L. S. (1962). Thought and language. Cambridge, MA: M.I.T. Press. Werner, H. (1948). Comparative psychology of mental development. Chicago: Follet.

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7

Cognitive Therapy and the Individual Psychology of Alfred Adler Bernard H. Shulman

n our 1979 book, Forgus and I presented Alfred Adler as a cognitive theorist with a constructionist viewpoint. Adler's theory emphasizes that the person is an active, creative agent in the construction of his own personality, not merely a passive reactor shaped by his environment (Forgus & Shulman, 1979). In its preliminary stages, Adler's theoretical constructs were more motivational in nature than cognitive. He spoke, early on, about the striving for mastery, status, and significance in human beings and about the feelings of inferiority and its compensations. The origin of this striving was in the innate propensity of living organisms to expand, to develop, and to fulfill biological destiny. This striving, a continuously adaptive process, was also represented in Adler's concept of the Law of Compensation, which said that it is the natural behavior of an organism to vary its behavior in such a way that it compensates for physical or psychic deficiencies that impair its adaptive capacities. These motivational constructs were not sufficient for a theory of human behavior, and Adler found a balancing set of propositions that allowed him to expand his set of hypotheses by introducing a number of cognitive concepts. These eventually placed him securely among the cognitive personality theorists and cognitive therapists. The key to casting the theory in cognitive terms came from the philosopher Hans Vaihinger's The Philosophy of "As If (1925). Vaihinger, a neo-Kantian,

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reasoned that each individual human being constructs for himself a set of guiding fictions that enable him to make sense of his world and that are derived from the person's own experiences in the world. Vaihinger used the word fiction, not in the sense of "falsehood" but in the sense of "made" or "manufactured." A guiding fiction could be unrealistic or could be a reasonable approximation of reality. Vaihinger also proposed that these fictions could become more refined and eventually become dogma for the person who used them. In this way, convictions and beliefs could be formed. Fergus and Shulman (1979) have schematized how such a process takes place. That the newborn human is soon capable of learning is obvious. The early learning comes from the responses the infant receives from its own built-in action programs. This information eventually leads to modification of these innate programs. Forgus and Shulman postulate the presence of the innate program for handling information—a perceptual program. New stimuli (external and internal) provide new information, allowing the original innate program to become elaborated and modified in the service of the biological goal of adaptive striving. This concept has a haunting similarity to Freud's concept of the ego splitting off from the id in order to cope with the demands of reality. The difference from Freud is the fact that Adler never saw the organism's attempt to cope with the real world as bringing one part of the mental life into conflict with another part. Instead, the modified perceptual program became the plan by which striving would take place, not a suppressor of organismic striving. From this point, Adler developed the cognitive aspect of his theory, which we can now examine. THE PRIMACY OF PERCEPTION IN ORGANIZING THE PURSUIT OF MOTIVES "A person's behavior springs from his ideas," said Adler (1964, p. 19). As one construes the world, so does one act in it. One behaves as if one's self-constructed picture of the world is the true picture. These subjective beliefs guide the striving of the organism. They provide direction and goals for the striving. They constitute one's definition of the situation. THE APPERCEPTIVE SCHEMA Subjective beliefs have a relationship to each other. They form part of a schema for apprehending and coping with the demands of the real

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world. The schema is not limited to beliefs about the world but also includes beliefs about the self and the self-world interrelationship. Furthermore, it contains instructions for coping with the world, simple at first, then more complex. These instructions again grow out of early experiences. Example of a simple instruction:

If the stove is hot, don't touch it. It will hurt my hand if I touch it. Example of a more complex instruction:

If I tell mother something is wrong, she will ask me questions. If I don't tell her, she will leave me alone. When I want her to pay attention to me, I will tell her something is wrong. Both of these examples are apperceptive schemas. The schemas are used by the child in order to find its way in the world. As these schemas are used, they are continually refined to allow more accurate prediction of the outcome of events and hence of their meaning. Early learning consists of the construction of schemas and their meanings and values.

THE GUIDING IDEAL Individual psychology holds that behavior is always a movement toward something, that behavioral movement always has a direction toward a goal. The goals are motivators; they act as a final cause for behavior; they are the end points of intentions. The goals themselves are often unconscious or at best dimly envisaged. However, this is not only a motivational construct but also a cognitive one, since the goal that induces to action is perceived as a valuable object. The goal can become valuable because it gives pleasure or because it provides security or a feeling of superiority, increased self-esteem, or mastery over a situation or task. Most important are those goals that the deepest convictions of the person say are crucial to his own worth—the striving for significance. Thus, the organismic striving of the individual becomes embodied in a cognitive construct: an ideal. This guiding ideal, in turn, becomes a motive for directed movement. In its concrete forms, the ideal is found as an expression of the meaning assigned to life. Thus one person's concrete form of the guiding ideal will be to have financial security, that of another to make a favorable impression on everyone, that of a third always to overcome challenges, that of a fourth always to avoid dangers, whereas that of a fifth may be a combination of two or more

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such concrete forms. The ideal shows the way in which the individual conceptualizes the meaning of life.

THE LIFESTYLE Apperceptive schemas grow in number and finally require integration into a master plan so that action in the world does not lose sight of the guiding idealized fiction. The overall direction of movement, no matter how many hesitations and detours occur, remains aimed at the guiding ideal. The master plan is actually a cognitive blueprint for striving in the world. This blueprint must contain certain elements: a set of constructs about the self, the world, and the relationship between the two; a construct about what the relationship should be; an image of the ideal self; and a plan of action. All of these elements are attitudes, values, and meanings that the individual has conceived in the attempt to reduce life to manageable proportions.

PERCEPTUAL SELECTIVITY The function of a blueprint is to provide direction for carrying out a task. The lifestyle gives direction for living life. It begins as a template for action in the world and becomes progressively refined. It contains what Kelly (1955) called "core constructs." It can be said to become the main modified perceptual program in the whole perceptual system in that it applies to a wider range of behavior than does any other set of perceptions. Once it begins to operate, it leads to selective perceptual processing of all other incoming information. Since core constructs provide a basis for organizing the blueprint, these become the least modifiable part of the blueprint. The fictional ideal is shored up as the organism looks for information that confirms its rule of thumb, selectively perceiving information from events so that it proves to itself what it already suspects. Eventually, the rule of thumb takes on the character of the law for living, which provides an assumed certainty about how to behave in life. Early difficulties and insecurities (inferiority feelings) accentuate the tendency to give the rule of thumb a dogmatic character. When faced with a situation for which a plan of action is wanting or insufficient, the child tends to fall back on behavior that it already knows well (this is an individual psychologist's version of the

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psychoanalyst's concept of regression). At these times, the child holds on more tightly to its comforting "law of movement," which at least gives it a plan of action. One concrete form of such behavior is seen in the increased dogmatism and intolerance for ambiguity that are found in many people in times of insecurity.

COGNITIVE FUNCTIONS INFLUENCED BY PERCEPTUAL SELECTIVITY Perhaps the great majority of cognitive functions are influenced by selective perception. Memory is a prime example of such a function. Subject to distortion in probably everyone, memory depends upon attention, registration, and retrieval, all of which operate selectively. What is watched for and what is later recalled will be influenced by the instructions in the master plan and subject to safeguarding tendencies that serve the master plan. Learning, as such, is more attractive to the individual when it fits in with the person's own goals. Expectancy is influenced by one's constructs about one's self in the world. Fantasy becomes a rehearsal, a one's self preparation for what might happen. Symbol creation allows one to have a set of markers by which one can measure one's success or failure in reaching the goals. A patient recently told me, "I am 35 years old, I am unmarried, and I don't have job. That means I am a failure." One result of the master plan is thus a private frame of reference by which one orients one's self and arranges one's coping strategies in the world-as-perceived.

CREATIVE SELF The ability of the person to give meaning to life and to construct a master plan for coping with the world led Adler to conceive the theory of a creative self. By age 3 or 4 the child has formed a prototypical life plan of action. The meanings contained in the prototypical plan are applied to subsequent experiences. In this way, the child creates its own law of movement that directs further psychic development. The person functions like an actor writing his own script and directing his own actions, forming his own personality through what Adler called selftraining.

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UNITY OF PERSONALITY The basic dynamic force in Adler's theory is the striving for perfection or completion (Ansbacher & Ansbacher, 1956), which in the social context of human life most often takes the form of striving for significance (Geltungsstreberi) or superiority. However, other Adlerian writers have argued that the social nature of human life itself plays a more important role and that the basic dynamic is toward attachment, "belonging." Significance and superiority actually refer to location and value within one's self-perceived group, the security and satisfaction of one's self-perceived group, the security and satisfaction of one's social relationships, and the competition for available, desirable social roles (Ferguson, 1989). Whichever aspect of the theory one wishes to stress, behavior, cognition and affect are all involved in this striving. A motive (conscious or unconscious) evokes goal-directed behavior, which may be direct action response without emotional arousal, emotional arousal that catalyzes an action response, or a series of cognitions that can evoke an emotion and action together. In humans, cognitive abilities are more fully developed than in any other animal; thought, therefore, can be expected to have correspondingly more influence on emotion and behavior in them.

SOCIAL INTEREST The tendency of human beings to form attachments was stressed by Adler (1931). In discussing the role of the mother, he stated that from the moment of birth a baby seeks to bond with his mother. However, as they go through various stages of development, humans will develop other bonds and will form group assimilations and societies in which they try to order their relationships and manage the tasks of living. This concept of affiliation between all peoples became an important part of Adler's later attention to what he called Gemeinschaftsgefuhl, a sense of being part of a larger grouping (such as "humankind"), which would lead to the concept of ethics in relationships and support of the common good. This German word, which means something like a feeling of being together in the same boat, has been translated in English as social interest. The main importance of this issue for this particular chapter is that the tendency to pay attention to whether behavior and thinking are prosocial or antisocial becomes almost automatic for Individual

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Psychologists. The inability to feel that one belongs to one's group is a dynamic that calls for compensation. The difficulty in feeling empathy with others, or understanding relational cues (as in autism), will lead to pathological behavior or deficit of one type or another. Therefore, the most crucial of the core constructs always deal with existence, with self-in-the-world perception.

THE ROLE OF COGNITION IN PSYCHOPATHOLOGY Much psychopathology is characterized by heightened inferiority feelings, underdeveloped social interest, and an exaggerated goal of personal superiority, which leads to striving in a self-centered way rather than in a cooperative and socially useful way. However, in its bare essence, psychopathology is the result of faulty training that leads to inappropriate fictions. Maladaptive behavior results from mistaken attitudes toward life. These mistaken attitudes have been described by Shulman (1973) as distorted perceptions about the self and life and distorted conclusions that result from these perceptions. A more extensive description of these attitudes as distorted cognitions has been provided by Ford and Urban (1964).

MISTAKEN ATTITUDES AS DISTORTED COGNITIONS 1. Private perceptions—understandings of stimuli that are personally coded and have meaning only for the individual. 2. Perceptual sensitivity—hyperreactivity to specific events, persons, places. This is seen in specific phobias. 3. As-if thinking—responding to stimuli "as if the individual was at fault for a particular behavior. This may be seen in paranoid thinking. 4. Rigidity of thought—lack of flexibility in seeing alternate meanings in an event or experience. 5. Jumping to conclusions—lack of logical or orderly reasoning. The individual reacts without logical analysis. A cardinal feature of impulse disorders and highly reactive personality disorders. 6. Overdiscrimination—looking for the "key" or "important" issue in a range of problems. Often unable to respond as they are so busy discriminating.

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7. Overambitious standards/inappropriate self-image—overreaching one's ability. Not simply optimistic, but unrealistically so. 8. Pessimism—starting with a negative set and then seeing the world through the gray-tinted lenses. 9. The use of private and idiosyncratic logic rather than common sense (Examples are seen most clearly in the psychotic patient. Sullivan's concept of prototaxic thinking fits this category.) 10. An exaggerated tendency to make certain interpretations repeatedly from information that is more logically subject to different interpretation (This is easily seen in the paranoid, who uses almost any information as evidence to confirm his suspicion.) 11. All black/all white thinking, the failure to appreciate shades of gray (An example would be conjuring up frightening images in order to feed and expand an anxious mood.) 12. The refusal to let facts interfere with one's previous assumptions or global/impulsive thinking 13. Being overly "careful," which is the opposite of global/impulsive thinking; essentially one cannot see the forest for the trees 14. Unrealistic aspirations for the self, unrealistic expectations from others 15. A tendency to exaggerate inferiority or superiority feelings (The latter is seen in the narcissistic personality.) 16. The tendency to focus on any information that confirms one's negative expectations (After Ford & Urban, 1964).

COGNITIVE MANEUVERS

The mistaken attitudes toward life invade the core constructs and are part of the personality style of the individual. In addition to these personality factors, psychopathological conditions display a wide use of cognitive maneuvers that help to sustain the pathology. The life problem of the neurotic, according to Adler (1964), is not how to fit in with the demands of self-living, but how to satisfy his desires for superiority. The pathological symptoms are a creative arrangement designed to help the person achieve this goal. This arrangement partakes of a number of cognitive maneuvers, some of which are described below.

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SAFEGUARDING AGAINST ANTICIPATED DIFFICULTIES A simple example in such a maneuver is the technique of ignoring unwelcome information. Such selective perception is recognized in common speech when we say "love is blind" to indicate that a person in love glosses over defects in the beloved. Another maneuver, often used for resisting therapeutic interpretations, is the depreciation tendency. In this maneuver, the person deflects threats to his own self-image by minimizing the threatening interpretation. A familiar example is Aesop's fox, who, after failing to reach the grapes, consoles himself that they were probably sour anyway. The creation of obstacles is a maneuver that turns easy tasks into seemingly impossible ones so that one is excused from attempting them. This maneuver is not exclusively cognitive, since behavior such as procrastination can accomplish the same goal. A cognitive example is seen in the conjuring up of disabling images, which set obstacles in the way of the task. "How can I go to the party?" asks the socially insecure young man. "Everybody there will see that I am nervous and they will laugh at me." The image of others' knowing his inner thoughts is disturbing enough that he will not risk the experience. A fourth example is the creation of a "resonance" between thought and an emotion by associating the two so that the occurrence of one brings on the other. Adler called this creation ajunktim (an inappropriate) joining together of a thought and feeling for safeguarding purposes. The clearest example is in the phobic disorders, wherein a situation that does not frighten others is invested with such anxiety that the phobic person disables himself from functioning in the feared situation (Adler, 1968). CARE AND FEEDING OF SYMPTOMS This term, coined by Mosak (personal communication, 1983), refers to the concept that symptoms will eventually tend to fade with time. Depressive reactions will eventually leave, anger will eventually subside, and anxiety will eventually diminish in the absence of new fearsome stimuli. Since the symptoms are an integral part of the creative arrangement, there must be some way of maintaining them so long as the original life problem exists. One such maneuver is arranging for experiences that will confirm the neurotic arrangement and exploiting them

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to justify one's behavior. Thus, the woman who believes that men will exploit her, unconsciously invites her male friends to do so. We say of such people that "they run after their slap in the face."

OVERSENSITIVITY TO SMALL THINGS The compulsive neurotic is disturbed if one small thing is out of place. The hypochondriac is alert to any body process he can notice and misinterprets normal physiological phenomena as symptoms of illness. The junktim is also useful in maintaining symptoms. One patient suffering from frigidity did not reach orgasm during sexual contact with her husband. She reported a persistent connection between loss of sexual arousal and a particular thought. She enjoyed the lovemaking every time and would always be aroused. In the middle of her enjoyment, she would think to herself, "I am sexually aroused. I wonder if I will be able to reach orgasm." This thought was immediately followed by the loss of the sexual arousal and disappointment. Cognitive maneuvers are thus thoughts that are used in the immediate situation and have near-term effect. Beck's description (1976) of the thoughts of the depressive that evoke the depressed mood are excellent examples of such maneuvers. O'Connell (1981) has described several cognitions that he calls "ego-constricting," that is, they lower self-esteem and lead to maladaptive behavior. He described "hidden demandments," by which a person abjures himself that he "must" or "must not" do or be something. In addition, he calls the tendency to place blame on the self or other "negative nonsense" that leads to no useful behavior, but instead to the "search for proof which maintains the cycle of self-defeating cognitions." Continual practice, says O'Connell, leads to expertise in self-constriction. By means of unconscious invidious comparisons, selfesteem is lowered and cognitive "demandments" (similar to Ellis's irrational ideas and Horney's neurotic demands) follow. These demands on the self and life lead to feelings of defeat and discouragement. Then the blaming begins. Blaming, says O'Connell, serves no useful purpose except to provide one with adversaries. This is followed by the continuing search for proof, which, when found, leads to further lowering of the self-esteem and increased discouragement or to fictitious ways of proving one's superiority in the face of the feeling of defeat.

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LIFESTYLE (CORE) CONSTRUCTS IN VARIOUS PATHOLOGIC STATES Adler described behavior in terms of movement; the action could be understood by understanding its goal and direction. However, throughout his writings on various pathological states, Adler described how the person perceived his situation in the world and the cognitive operations used. Thus, in discussing paranoia, Adler says: The patient blames others for lack of success in his exaggerated plans and his active strivingfor complete superiority results in an attitude of hostility to others. This expresses itself in ideas of reference and delusions. In these conditions, the patient sees himself as the center of the world. The ideas of the paranoiac are difficult to correct because he needs them in their very form to fortify his position. At the same time, they permit him to retain the fiction of his superiority without submitting them to the test [1968, pp. 191-192]

In this example, we can see how Adler wove motivational and cognitive concepts together in accord with his theory that cognition always had motivational power and fit in with the dominant motives of the lifestyle. Another example can be seen in his (1919) description of euphoric mania as a state in which the patient, rather than facing the actual situation, decides to devalue reality and act as if he is already what he wants to be. Fergus and Shulman (1979) have tried to convey the cognitive core of various psychopathological conditions by describing it in some of the personality disorders. The lifestyle constructs of the schizoid are described thus: I am a misfit. Life is a difficult place for me and human relationships are troublesome. Therefore, it is better for me to keep my distance and maintain a low profile, [p. 332]

The compulsive personality has the following type of constructs: I am liable to be held responsible for whatever goes wrong. Life is unpredictable. Therefore, I have to be on guard against anything that might go wrong, [p. 334]

COGNITIVE ASPECTS OF THERAPY Since the theory pays so much attention to the cognitive aspects of personality, it is not surprising that psychotherapy has a strong cognitive

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cast. The Adlerian therapist does not think of his treatment solely as cognitive therapy because he sees cognition as part of the thinkingfeeling-acting-organ language tetrad that constitutes behavior. However, in a psychotherapy that focuses on the patient's perceptions, the amount of what can be called cognitive therapy is large indeed. The main thrust of Adlerian therapy is to explain to the patient those subjective convictions that hamper his effective functioning in life and to encourage the patient to use his insights to meet the challenges of life with courage and cooperation. Clarification and explanation are used for the purpose of helping the patient to understand both that he has been mistaken and that he does not have to continue these mistakes. The therapist tries to build encouragement into this process by his manner of interpretation and clarification, which is consistently ego syntonic and holds out hope. A patient from a severely disturbed family had pulled himself out of the pathologic situation, attained an education, and had become a respected university dean. He suffered from anxiety and feelings of inferiority about his acceptability to others. An ego-syntonic remark was very helpful to him. The therapist told him that, considering how he had started in life, he had overcome many more difficulties than most people had and had every right to be proud of himself. This interpretation by the therapist is a deliberate attempt to create in the patient's mind a different image of himself, to suggest that the patient think about himself in a different way. The therapeutic intent is to correct the patient's mistaken apperception. Some of the cognitive techniques used by Adlerians have been described by Mosak (1979). One is instructing the patient to act "as if." When the patient complains, "If only I could . . . ," the therapist instructs him to act in a certain situation "as if he could and observe the results of the experience. Creating images is another technique. Mosak reports the case of a patient who was afraid of being sexually impotent. The therapist mused that he had never seen an impotent dog. The patient concurred, saying, "Dogs just do it without worrying about it." The therapist then suggested that the patient smile and say "Bow-wow" before his next attempt. The patient returned the next week to report that he had "bow-wowed" (Mosak, 1979, p. 72). The push-button technique is another method. The patient is asked to think of an unpleasant experience and to describe it. As expected, this produces some unpleasant feelings in the patient. Next, the patient is asked to recall and describe a pleasant experience. Again, as expected, this produces a more pleasant effect.

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This method is used to teach that one can produce various affects within oneself by selecting various affect-laden topics to think about. The patient can push the "happy button" or the "sad button" and it is his choice to make. Calling his technique metaphor therapy, Kopp (1995) teaches his clients to create metaphors from their own thoughts and elaborate them into conscious constructs and schemata that can be examined and discussed.

PARADOXICAL RESPONSES Mozdzierz, Macchittelli, and Lisiecki (1976) have discussed the use of paradoxical techniques in Adlerian therapy. Paradox is used to neutralize the patient's neurotic maneuvers by not responding to them in the way the patient expects. Where the patient repeatedly expresses a neurotic fear that he is going to die, for example, the therapist says, "Well, if you are absolutely convinced of it, I guess there's nothing I can do to change your mind." From the viewpoint of the cognitive therapist, a paradoxical technique is intended to create cognitive dissonance. The unexpected paradox interferes with the smooth flow of habitual cognitions and, one hopes, impels the patient to examine the implications of what he is saying. Confrontation is an active therapeutic technique that is used to facilitate movement when the patient remains dead center, or to bring movement up short where it is anti-therapeutic. Confrontation asks the patient to consider what is going on here and now in the therapy situation. Shulman (1971, 1972) has described a number of confrontations that utilized sudden questions. In confronting resistance, one may say: "I notice you become defensive every time I wonder if you've made a mistake. Why is that?" 'You just changed the subject. Were we getting too close to something?" Not only resistance, but other aspects of behavior can be noted: "A look just passed over your face. What thought was on your mind?" "Do you remember what I just said?" 'You just made a slip of the tongue. Did you catch it?"

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Specific symptoms lends themselves to specific confrontations (always in a friendly tone of voice, of course): (To the depressed patient): 'You are berating yourself again. Keep it up and you'll get yourself really depressed." "I see you're telling yourself you're a failure again. Well, I guess you're trying to show me what high standards you have." (To the anxious patient): 'You are very good at frightening yourself. You are truly creative. I'm impressed at how you can create an atmosphere of fear. That you are so worried is really a tribute to your creativity." In recent years, there has been a growth in the literature comparing Alfred Adler's Individual Psychology and cognitive therapy. A paper by Master (1991) and another by Scott, Kelly, and Tolbert (1999) also found common ground between constructions and Adler's theory. In 1997, the Journal of Cognitive Psychotherapy devoted a whole issue to an integrative dialogue between the Adlerian and the cognitive psychotherapies. There is so much common ground between them that they can find no major disagreements with each other. The language is slightly different, but always familiar (Freeman & Urschel, 1997; Jones, 1995; Jones & Lyddon, 1997). A few technical words may be puzzling, but surely the perception of human behavior and misbehavior rings out in the same tone. The textbook by Mosak and Maniacci (1999) is subtitled The Analytic-Behavioral-Cognitive Psychology of Alfred Adler. Kopp (1995) enlists the creative imagination of the client to create images of metaphors. Metaphor statements (such as "hitting my head against the wall) that have been made by the client are used by the therapist as the object of discussion and introspection. In working with the cognitive and underlying constructs of clients, Adlerian therapists have also specifically attempted to manipulate the cognitions themselves by asking clients to actively consider other possibilities, to review their memories and change the endings, to rewrite their histories, to actively use metaphors and act them out, or to create sketched or painted images. Mosak's previously mentioned "push button" and imagery techniques are examples of such active intervention into the structures of schemas: deliberate attempts to create dissonance in the automatic

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thought program of the client, so that the "unconscious" cognitions become not only pinpointed, but uncoupled from the thought process and thus nullified and disempowered.

COGNITIVE LEARNING IN FAMILY, GROUP THERAPY, AND CLASSROOM SITUATIONS Influenced by Rudolf Dreikurs, Adlerian psychologists have done considerable work with family and school situations. Their methods are described in Christensen and Schramski (1983), Dreikurs (1948, 1972), Dreikurs and Grey (1968), Dreikurs, Grunwald, and Pepper (1971), and Dinkmeyer, Pew, and Dinkmeyer (1979). In addition to the usual Adlerian method of revealing goals and misconceptions, a number of specific cognitive behavioral techniques are used, of which two are listed below:

Changing One's Own Attitude Dreikurs (1972) gives the example of an infant who cried excessively when put in the play pen. Dreikurs advised the mother that the infant was reacting to the mother's own insecurity in dealing with the infant and recommended that the mother be calm and realize that the crying would not harm the infant. In this example, the mother reported that as soon as she calmed her own behavior, the infant stopped crying when put into the play pen.

Keeping a List On another occasion, Dreikurs (personal observation by the author) noted a power contest between mother and child. The mother was constantly afraid the child would come to harm and kept telling him not to do things. The child was constantly doing whatever the mother told him not to. Dreikurs asked the mother, "How many times a day do you say 'don't' to the child?" The mother answered that she tried to stop the child about ten times a day. "I think it's more like five hundred," said Dreikurs. He then asked her to keep a list on the bulletin board in the kitchen. When the mother returned the next time, she

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reported that she had kept the list for only one day. She had reached fifty check marks and stopped, seeing that Dreikurs was right. She stopped the constant admonitions and the child stopped the disobedience. Changing the other's behavior by changing one's own first is a method applied to family, marital, group, and school situations by Adlerians working in these areas. The method includes (1) revealing the purpose of the behavior (as in the child's use of attention-getting mechanisms), (2) revealing the interaction by which one person provokes responses in others, (3) prescribing a change in attitude and behavior that will not reinforce the objectionable behavior, and (4) prescribing new behavior that will reinforce cooperative responses from others. Group-learning formats are extensively used by Adlerian counselors working with families, teachers, and in personnel situations. The group members study a book and discuss it intensively under the guidance of a trained group leader. At first glance, such a method may seem far from traditional psychotherapy, but it contains important identical ingredients: an atmosphere of openness and self-disclosure and discovery of the meaning of behavior in self and others.

CONCLUSIONS Murray andjacobson (1978), discussing early cognitive theorists, state: The most notable of these early cognitivists was Alfred Adler. Adler believed that the neurotic person had unrealistic and often anti-social goals, such as wanting to be superior to all others or to dominate others. In his therapy, Adler would attempt to change the patient's belief that he or she had to attain such goals, and he would try to encourage more socially productive ideas. In fact, Adler may be viewed as the forerunner of many modem cognitive therapists such as Albert Ellis, Julian Rotter, George Kelly, Eric Berne, and Aaron Beck. [p. 66]

Since the Adlerian theory assigns to perception the task of giving meaning to the world and to cognition the power to program movement and evoke emotions, the Adlerian therapist seeks to understand in each patient the basic cognitive map of the world and the instructions for coping with it—what the Adlerian calls "the life style." In addition, the maintenance of any systematic behavior that flies in the face of common sense requires a set of supporting cognitions. It is these faulty plans

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and supporting cognitions that the therapist seeks to ferret out and display to the patient.

REFERENCES Adler, A. (1919). Problems of neurosis. London: Kegan Paul. Adler, A. (1931). What life could mean to you. Oxford: One World. Adler, A. (1964). Social interest: A challenge to mankind. New York: Putnam. Adler, A. (1968). The practice and theory of Individual Psychology. Totowa, NJ: Littlefield Adams. Ansbacher, H. L., & Ansbacher, R. R. (1956). The Individual Psychology of Alfred Adler. New York: Basic Books. Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press. Berne, E. (1964). Games people play. New York: Grove. Christensen, O. C., & Schramski, T. C. (1983). Adlerian family counseling. Minneapolis, MN: Educational Media Corporation. Dinkmeyer, D. C., Pew, W. L., & Dinkmeyer, D. C., Jr. (1979). Adlerian counseling and psychotherapy. Belmont, CA: Wadsworth. Dowel, E. T. (1997). A cognitive reaction: Adlerian psychology, cognitive (behavior) therapy, and constructivist psychotherapy: Three approaches in search of a center. Journal of Cognitive Psychotherapy, 11, 215-220. Dreikurs, R. (1948). The challenge of parenthood. New York: Duell, Sloan, and Pearce. Dreikurs, R. (1972). Coping with children's misbehavior. New York: Hawthorn. Dreikurs, R., & Grey, L. (1968). Logical consequences. New York: Meredith. Dreikurs, R., Grunwald, B., & Pepper, F. C. (1971). Maintaining sanity in the classroom. New York: Harper & Row. Ferguson, E. D. (1989). Adler's motivational theory: An historical perspective on belonging and the fundamental human striving. Individual Psychology, 45, 354361. Ford, D. H., & Urban, H. B. (1964). Systems of psychotherapy: A comparative study. New York: Wiley. Fergus, R., & Shulman, B. H. (1979). Personality: A cognitive view. Englewood Cliffs, NJ: Prentice-Hall. Jones, J. V. Jr. (1995). Constructivism and Individual Psychology: Common ground for dialogue. Individual Psychology, 51, 231-243. Jones, J. V., & Lyddon, W. J. (1997). Adlerian and constructivist psychotherapies: A constructivist perspective. Journal of Cognitive Psychotherapy, 11, 195-210. Journal of Cognitive Psychotherapy. (1997, Fall). Kelly, G. A. (1995). The psychology of personal constructs, vol. 1. New York: Norton. Kopp, R. R. (1995). Metaphor therapy. New York: Brunner/Mazel. Master, B. M. (1991). Constructivism and the creative power of the self. Individual Psychology, 47, 447-455.

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Mosak, H. H. (1979). Adlerian psychotherapy. In R. I. Corsini (Ed.), Current psychotherapies (pp. 44-94). Itasca, IL: F. E. Peacock. Mosak, H. H., & Maniacci, M. D. (1999). A primer of Adlerian psychology: The analyticbehavioral-cognitive psychology of Alfred Adler. Philadelphia: Brunner/Mazel. Mozdzierz, G. I., Macchittelli, F. I., & Lisiecki, I. (1976). The paradox in psychotherapy: An Adlerian perspective. Journal of Individual Psychology, 32, 169-184. Murray, F. I., &Jacobson, L. T. (1978). Cognition and learning in traditional and behavioral therapy. In S. L. Garfield & A. F. Bergin (Eds.), Handbook of psychotherapy and behavior change (pp. 661-687). New York: Wiley. O'Connell, W. F. (1981). Natural high therapy. In R. I. Corsini (Ed.), Handbook of innovative psychotherapies (pp. S54-S68). New York: Wiley. Powers, R. L., & Griffith, J. (1987). Understanding life style: The psycho clarity process. Chicago: American Institute of Adlerian Studies. Scott, C. N., Kelly, F. O., & Tolbert, B. L. (1999). Realism, constructivism and the Individual Psychology of Alfred Adler. Individual Psychology, 51, 4-20. Sherman, R., & Dinkmeyer, D. (1987). Systems of family therapy: An Adlerian perspective. New York: Brunner/Mazel. Shulman, B. H. (1968). Essays in schizophrenia. Baltimore: Williams & Wilkins. Shulman, B. H. (1971). Confrontation techniques in Adlerian psychotherapy. Journal of Individual Psychology, 27, 167-175. Shulman, B. H. (1972). Confrontation techniques. Journal of Individual Psychology, 28, 177-183. Shulman, B. H. (1973). Contributions to Individual Psychology. Chicago: Alfred Adler Institute. Shulman, B. H., & Watts, R. E. (1997). Adlerian and constructivist psychotherapies: An Adlerian perspective. Journal of Cognitive Psychotherapy, 11, 181-194. Sperry, L. (1997). Adlerian psychotherapy and cognitive therapy: An Adlerian perspective. Journal of Cognitive Psychotherapy, 11, 157-164. Stern, D. H. (1985). The interpersonal world of the infant. New York: Basic Books. Vaihinger, H. (1925). The philosophy of "as if." New York: Harcourt, Brace. Watts, R. E., & Critelli, J. (1987). Roots of contemporary cognitive therapies in the Individual Psychology of Alfred Adler. Journal of Cognitive Psychotherapy, 11, 147156.

in Cognitive Influences

The historical roots of cognitive psychotherapy can be found in the behavior therapy that was popular in the 1960s and beyond. Whereas both behavioral and cognitive theories reject the medical model of psychotherapy, the behavioral approach views abnormal behavior as a set of learned responses that can be modified through conditioning and learning. Alternatively, cognitive theory seeks to change behavior by countering negative or irrational thoughts with more positive and constructive thought patterns or problem-solving techniques. Two giants in the field of cognitive psychotherapy, Aaron Beck and Albert Ellis, have contributed classic chapters to this text. Before we discuss those chapters, we first begin with Victor Raimy's chapter, "Misconceptions and the Cognitive Therapies." By misconceptions, Raimy refers to the misunderstandings that clients use in their generation and maintenance of personal problems and maladaptive behaviors. In addition to clients, Raimy asserts that therapists may also hold faulty beliefs that can interfere with the course of treatment, including the "teacher fallacy" in which therapists are likely "to believe that their clients understand all that has been explained, interpreted, reflected, and posed in confrontation." Raimy's most valuable contribution is his call for a behavioral eclecticism, noting that "cognitive therapy is not just a matter of attitude as the varied methods simply testify to the fact that there are many ways to change misconceptions. A cognitive approach can, therefore, be eclectic where methods or techniques are concerned, but its goal is 161

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certainly not eclectic. Finding and changing faulty beliefs that interfere with adjustment is a highly specific and concrete therapeutic activity, even though it may be accomplished in many different ways." One of the earliest forms of cognitive psychotherapy was developed by Albert Ellis. His rational-emotive therapy is primarily based on modifying irrational beliefs that produce volatile emotional behaviors, including anxiety and anger. Ellis's goal is to show the client that his or her emotional reaction is based upon some unrecognized belief about the event that produced the reaction. By ridding the client of these faulty beliefs Ellis attempts to increase the individual's sense of worth, which ultimately fosters personal growth. In the classic chapter, "Expanding the ABCs of Rational Emotive Behavior Therapy," Ellis further develops the foundational aspect of rational-emotive therapy by referring to the "ABCs" of experience: (A) as activating events, (B) as beliefs, and (C) as consequences. He then goes on to add (D), which stands for disputing irrational beliefs, discriminating them from rational beliefs, and ultimately debating them, and, finally (E), which stands for effective new philosophies to replace irrational beliefs. Ellis then makes the point that the ABCs and the DEs were oversimplified in their original form and he uses the remainder of the chapter to show how they can be usefully expanded. In doing so, Ellis joins other contemporary experts like Bandura, who view these elements as complexly interactive. By far, Aaron Beck is the most influential of the cognitive psychotherapists (Beck's) cognitive therapy is one of thefew forms of psychotherapy that has been scientifically tested and found to be effective in over three hundred clinical trials for many different disorders. In contrast to other forms of psychotherapy, cognitive therapy is usually more focused on the present, more time-limited, and more problem-solving oriented. Indeed, much of what the patient does is solve current problems. In addition, patients learn specific skills that they can use for the rest of their lives. These skills involve identifying distorted thinking, modifying beliefs, relating to others in different ways, and changing behaviors.

In his classic chapter, "Cognitive Therapy, Behavior Therapy, Psychoanalysis, and Pharmacotherapy: A Cognitive Continuum," Beck offers a survey of integrative convergences among proponents of each of the stated therapies. Noting that the phenomenon of depression can be viewed from each of these perspectives, Beck states that, "the

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various perspectives have varying degrees of explanatory power. By relating them to each other, we can attempt to construct an integrated model that will have greater explanatory power than the individual perspectives." We think you will agree that Beck succeeded in his stated endeavor! The last chapter in this section is "A Psychosocial Approach for Conceptualizing Schematic Development" by Arthur Freeman and Donna M. Martin. In this chapter, Freeman and Martin set a lofty goal of reformulating Erik Erikson's psychosocial model of development from the viewpoint of cognitive schema theory. According to Freeman and Martin, schemas are equivalent in meaning to beliefs, underlying assumptions, and attitudes. Schemas direct our behavior and give meaning to our world. Schemas can be personal, familial, or cultural, and are formed early in life, possibly even in utero. For each of Erickson's eight stages Freeman and Martin offer schemas that are representative of the crisis addressed in a particular stage. For instance, Erickson's third crisis involves initiative versus guilt in which the major theme of the stage is that life and activity have a purpose. Schemas typical of a negative resolution to this stage include "I feel aimless and adrift" and "there is no place to go and nothing to do," whereas schemas typical of a positive resolution to this stage include "I'm on my way!" and "I have a direction." By dealing with schemas in a direct manner, Freeman and Martin assert that better resolution of life crises can be effected, with a concomitant impact on present functioning. The final part of the chapter deals with the therapeutic use of schematic understanding. Through the use of two cases studies, Freeman and Martin show that by helping patients become aware of their schemas they can be more actively collaborative in the therapeutic endeavor. They further assert that "by confronting, disputing, or responding more adaptively to powerful, long-held schemas and to the emotional, affective, and cognitive sequelae of the schemas, we can begin to help the patient to move in more productive and coping directions." In each of the chapters in this section, the original goal of cognitive psychotherapy is robustly restated and modified in ways to conform to other competing therapeutic approaches. In all cases, the method is the same—change behavior by countering negative or irrational thoughts with more positive and constructive thought patterns or problem-solving techniques.

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8

Misconceptions and the Cognitive Therapies Victor Raimy

haos prevails," declared Colby when prefacing his review of psychotherapy in the mid-1960s (Colby, 1964). By then, even many Freudians were questioning the effectiveness of psychoanalysis. And chaos still prevails, since by now the number of psychotherapies seems roughly to equal the number of its practitioners. For a cognitive therapist, however, the apparent chaos may simply mean that different techniques change the faulty cognitions that produce psychological disorders. This violates, of course, our expectation that there should be one best way to do anything—treat a medical disorder, learn how to read, or build a home. The single best solution stereotype is valid, if at all, only for limited and highly specified activities. Particularly in the psychological realm there are usually many different ways of solving problems. If psychotherapy is the modification or elimination of faulty conceptions, there is little reason for surprise that different treatment procedures produce similar results. There is even research support for the latter contention, as Smith and Glass (1977) have shown. Such a proposition does not imply that anything one does is therapeutic. There must be limits, since persons with problems have retained them over long periods after having been "treated" informally by friends and relatives. Conversely, there is also a good likelihood that most psychological problems are solved spontaneously, without professional ministrations. This presents another challenge to theories of psychotherapy, because it makes highly improbable the necessity for formal techniques such as free association or systematic desensitization. Formal

"C

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techniques may be helpful but unnecessary. For if spontaneous recoveries occur, they must result from "experiments in nature," and nature, though prodigal, is unlikely to create formal techniques. Troubled people may, of course, think intensively about their problems, as in free association, or repeatedly picture themselves with feared objects, as in systematic desensitization, but these spontaneous mental activities are only prologues to techniques rather than techniques in themselves. Faced by spontaneous recovery plus the large number of apparently successful methods of treatment, whether we like it or not, therapists must live in a pluralistic universe of treatment methods and techniques. The same can be said for cognitive therapy. Wherever that appellation occurs in this chapter, it should be understood as a referent to the cognitive therapies. The terminological waters have, however, been somewhat muddied. Beck (1976), for example, termed his approach cognitive therapy although it represents only one such approach. Others have also muddied the waters, particularly the cognitive behaviorists. Where that group is concerned, there seems to be a continuum from the behaviorists at one end, who admit only a bit of cognition to their practice, to the cognitivists at the other end, who admit only a bit of the behavioral. This chapter is written from the cognitive end of the spectrum, but with due regard for the trend toward finding common factors in the various approaches to therapy. That trend is best exemplified by Goldfried's 1982 book on converging themes in psychotherapy. My book (Raimy, 1975) shows how many psychotherapists of different schools made major contributions to the cognitive therapies. Cognitive therapists themselves have suggested many terms for the faulty beliefs or cognitions that constitute the core targets of a cognitive therapy. I tend to prefer misconceptions but feel equally at home with irrational beliefs or faulty assumptions, or even Janet's fixed ideas. Labeling is not, of course, a major issue. The cognitive therapies have much more basic questions, one of which is how misconceptions produce psychological problems, some as severe as the psychoneuroses.

MISCONCEPTIONS AS FAULTY GUIDES Conceptions are the psychological tools we use to organize and deal with not only the world around us but also our thoughts and feelings. Faulty conceptions, however, are likely to defeat us in both the external and internal worlds because they are erroneous maps or guides. There is no need to show how faulty conceptions about the physical and

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biological worlds can lead to serious disruptions in our behavior, even to death. On the other hand, correct conceptions or adequate maps have produced awesome achievements such as the fifteenth-century voyages of discovery or the modern-day exploration of space in manned vehicles. Misconceptions, however, may produce defeat and disruption in all realms, including our social lives. Mistaking the look-alike next door for one's wife can produce more or less disconcerting moments depending upon the circumstances. At a different level, misinterpreting an employer's veiled reproof as praise can eventuate in much misery and despair. Social maladjustment is often the result of the many stumbling blocks we encounter in trying to understand our significant persons who may be just as vague, inconsistent, unreliable, and ambivalent as we are. Misconceptions about the self, however, are those most likely to produce defeat, disruption, maladjustment, and neurosis. These misconceptions become anchored in the self-concept, where as faulty guides to dealing with ourselves they often create havoc. Faulty beliefs about the self are particularly malignant because we always act upon them, since they are the only guides we have to ourselves. To illustrate, imagine someone who through life's vicissitudes develops a faulty belief about the self to the effect that, "No one could possibly like me if I reveal my true self." Such a person is likely to spend time endlessly avoiding others, avoiding spontaneous behavior, and eating his heart out in loneliness. Another set of circumstances may convince someone that continued "bad luck" means that whatever happens next is likely to be disastrous. Thereupon the individual becomes an impendiac, always fearful of the impending. Or after many frustrations and conflicts, the resulting anxiety convinces someone that a "nervous breakdown" is imminent. The person then tries to avoid all stress, fearing that it will produce insanity, when the best cure would probably be subjection to normal stresses, as success in handling them would provide the only convincing evidence of mental well-being. The doctrine that misconceptions are the villains mostly responsible for psychological problems is by no means a novelty. In the next section we shall look at a few of the major misconceptions proposed by mostly modern psychotherapists. SOME COMMON MISCONCEPTIONS Therapists often seem to fasten upon pet misconceptions as central to the problems of most of the people they treat. Freud, for example,

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fastened on his patients' unconscious misconceptions about sex and aggression, acquired in early childhood, as his primary therapeutic targets even though Freud did not write in cognitive terms. Adler (Ansbacher & Ansbacher, 1956) taught that the major error of neurotics was to believe mistakenly that personal superiority must be achieved without concern for others. Failure to contribute to the social interest was, for Adler, the result of pampering in childhood. The list of major misconceptions proposed by various therapists can be expanded almost indefinitely. These, of course, constitute a major resource for the practitioner. Sullivan (Perry & Gawel, 1953) wrote of "parataxic distortions," which he thought were acquired in early childhood and which often persisted into adulthood side by side with more accurate conceptions learned at a later time. Combs and Snygg (1959) describe the common retention of beliefs about the self that were appropriate in the past but are now inappropriate, such as the aging woman thinking of herself as still the young girl, or the troubled adolescent who still sees himself as a young child. Ellis (1962) has proposed ten main irrational ideas he commonly finds in the people he treats. Among them are "I must be loved and approved of by everyone important to me" and "I am controlled by my history and my important past experiences." Rotter (1970) discusses six generalized expectancies, each of which can be viewed as a misconception. The best known of the six is the belief that one's behavior is not under one's own control and that therefore one cannot control one's positive reinforcements. I happen to be partial to three major misconceptions or clusters of misconceptions, which will be discussed at greater length below. The three are phrenophobia, or the belief that one is verging on insanity; the Special Person misconception, or the notion that one is a superior person with special entitlements; and the incapability misconception, or the false belief that one lacks certain capabilities that most others possess. Although faulty beliefs have played a prominent role in psychotherapy, they have been competing with the emotions for the role of principal villain of the psychological disorders.

EMOTION VERSUS COGNITION The major bone of contention in the century-long struggle between emotion and cognition is the control of affect. For some years, research

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results have supported the contention that emotion depends upon the prior cognitive assessment of the situation. Arnold wrote in 1970, "There is hardly a rival in sight for cognitive theory in the field of emotion. Today, most of the newer theories of feeling and emotion assume that emotional experiences depend upon the interpretation and evaluation of the situation" (p. 123). Acceptance of this conclusion today is, however, by no means universal. Two psychologists in particular, Tomkins (1981) and Zajonc (1980), have materialized as the archrivals Arnold failed to find in 1970. A little more recently, Lazarus (1982) has tried to rebut Zajone's contentions that emotions can occur without perceptual and cognitive encoding and that emotion and cognition are controlled by different neural systems. Zajonc's article provides an excellent critique of the cognitive viewpoint, but it seems to err much as do many clients when they infer or are told that therapy should consist of a discussion of their feelings. Everything is then prefaced with, "I feel. . . . " By such word magic they assume that they transform their thoughts, judgments, and conclusions, all good cognitive fare, into feelings. Although Zajonc denies that he does the same, a close analysis of his arguments makes it difficult to accept his conclusions. He assumes, for example, that preferences are content-free and are therefore affective experiences rather than cognitions. My problem is that ordinary preferences seem to me to be cognitions even though they have traditionally been regarded as affects. Preferences may have arisen from emotion-suffused situations and when ignored or violated may produce emotional responses, but simply because a statement is prefaced by "I prefer . . . " does not mean that arousal or emotion has occurred. There is, nonetheless, little likelihood that theoretical, social, or experimental psychologists are about to resolve the old argument over the origins and control of affect, but at the moment cognitive appraisal, if only to a minimum degree, seems to be the leading contender for the control of affect. That, at least, is one currently acceptable answer to Bergin (Bergin & Strupp, 1972), who suggested that the central problem in psychotherapy is how to break the bonds between cognition and affect. If the cognition is changed, the affect alters. Despite the differing positions on the relation of affect to cognition, there is, curiously enough, considerable agreement on a proposition first espoused by Leeper in 1970 when he wrote, "Emotions are perceptual processes. I mean this in the full sense of processes that have definite cognitive content" (p. 156). Leeper was joined by Zajonc, who

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wrote in his 1980 paper, "And perhaps all perceptions contain some affect" (p. 153). And in his 1982 article, Lazarus suggests that "cognition and emotion are usually fused in nature" (p. 1019). In cognitive therapy, Leeper's statement that emotions have "definite cognitive content" has considerable practical application. Individuals, for example, frequently conclude that they must be "highly emotional as a person" after observing their emotional reactions based upon the "cognitive content" at the time of arousal. This aspect of their self-concept usually carries an implication, which is likely to be completely faulty, that they are unable to control their emotional reactions. This faulty conclusion has probably sanctioned as many sins as good intentions, perhaps more. The failure to recognize that affect has cognitive content also leads to some curious consequences. In a 1980 critique of cognitive therapy, Mahoney, who labels himself a cognitive behavior modifier or cognitive therapist, discusses at some length the tendency of some cognitive therapists to neglect feelings. After some preliminary remarks indicating that he would probably accept Leeper's proposition, he comments, "A single traumatizing experience can sometimes override thousands of nontraumatic exposures" (p. 166). This illustration seems to join the issue. Does the single traumatic experience outweigh thousands of nontraumatic exposures only because of the added affect, or does the cognitive content of the trauma inform the individual that a hitherto harmless experience is potentially harmful? My conjecture is that people are likely to reject probabilities intellectually in ensuring their safety and welfare. This is often vividly brought to a therapist's attention when an attempt is made to convince a client that the chances are only one in ten that some untoward event will occur. The frequent and intelligent rebuttal is likely to be, 'Yeah, and how do I know that I am not the one in ten?"—a reply that fuses a cognitive base with some affect. The general agreement on the fusion of cognition and affect may also account for my observation, while reading verbatim accounts of therapy conducted by affect-oriented therapists, that they are trying to bring about changes in beliefs, although their efforts are ostensibly directed toward affect. Fritz Perls, whose emphasis upon increasing sensory awareness was implemented by having his patients act out their feelings, provided a good example of the affect-oriented virtuoso clinician trying to change misconceptions. Perls presents several verbatim treatment sessions with Liz (1969, pp. 82-89). In front of the group where he is treating Liz, Perls says that her problem is "I can only be important if I am perfect," an obviously faulty belief that was one of

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Perls's favorite targets. In the thirty-minute episode he was obviously trying to convince Liz that she should abandon the misconception. There is insufficient space here, but in my 1975 book (pp. 70-72) I have detailed the 26 sorties he made to change her belief by explanation, exhortation, derision, and even by enlisting group support. This example is not an isolated one. In fact, as I read most verbatim accounts by therapists of all persuasions, I am convinced over and over that much therapy consists of attempts, using a remarkable array of techniques, to root out or to change relevant misconceptions. AFFECT PROVIDES CLUES TO MISCONCEPTIONS Although we have argued that affect is controlled by cognitions, that does not mean that affect is unimportant in psychotherapy (see also Mahoney, 1980, pp. 164-167). Leeper's statement that "emotions are perceptual processes" supports the observation that reported or actedout displays of feeling or emotion can be helpful in detecting misconceptions. Emotions tend to be associated with misconceptions because the latter are often challenged since they are misconceptions. The closer the belief to the core of the self-concept, the more affect is aroused. Not only do others challenge our faulty beliefs, but we do so ourselves, particularly when conflict occurs. To illustrate, a 40-year-old client complained that he must have a "great well of meanness" because he was so upset by the lies and distortions from public characters during a recent election campaign. I was surprised that he would make such a self-reference, and also by his additional comment that he might be repeating a previous depressive episode "and this time I could lose my mind." I can see how people might kill during a campaign but hardly become severely depressed. The apparent irrationality of the two comments embedded in a strong emotional display alerted me to the possible presence of a significant misconception. It was quickly discovered. His anger and despair were actually displaced from a recent "first real argument with my new wife," for whom he felt great ambivalence. He had to displace his emotions because he was unaware of his ambivalence and could not, initially, express anger toward a wife whom he also loved and desired. Ambivalence is very difficult to deal with even for bright people who are not psychologically sophisticated. In addition to providing clues to misconceptions, affect can also facilitate the bringing into focus of much cognitive content that might

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ordinarily go unremarked by the client. As a client becomes more emotional about an experience, reintegrative effects are likely to occur as more details are brought to mind. For example, a girl expressed great frustration and guilt because she could not bring herself to thank her mother for some recent gifts. When I asked her to describe the gift-giving scene, she became very emotional and raged, quite unlike herself, "She's always doing nice things for me. I feel like I'm nothing." When that elliptical outburst was examined, it appeared that she meant that she lost her integrity by accepting gifts from a mother for whom she had feelings of dislike. When I asked for still more details, she burst into tears and described the usual ambivalence. She then gained insight into the fact that she loved as well as hated her mother who, she claimed, made her develop many misconceptions about herself during adolescence. Thus an emotional display can be a good jumping-off point for detecting misconceptions, and the reintegrative effects can bring to the surface many of the hidden aspects of a cluster of misconceptions. There are, of course, other ways to discover misconceptions in addition to the clues provided by emotion. Since the search for misconceptions usually occurs during treatment, their detection will be discussed in that general context.

COGNITIVE METHODS OF TREATMENT

There is little doubt that misconceptions can be changed in many different ways. Adherence to a cognitive approach does not, therefore, require the practice of any specific methods, although some cognitive therapists have marked preferences for certain techniques. Beck, Rush, Shaw, and Emery (1979) for example, have minutely detailed instructions for treating depression using Beck's form of cognitive therapy. Despite the detailed instructions, there is no reason to believe that those techniques are uniquely effective. Thus psychoanalysts with a cognitive orientation can continue to practice analytically if they are explicit in trying to change faulty cognitions. The same is true for therapists of other orientations. The only essential for cognitive therapy is the attempt to discover and change those misconceptions thought to be central to the client's problems. This proposition that no specific techniques are required probably runs counter to the grain of most psychotherapists, for traditionally

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schools of therapy have prescribed certain methods of treatment thought to be uniquely effective. Such prescriptions now seem naive unless they are regarded simply as sometimes useful techniques that can be replaced by many other equally useful techniques. For example, I have counted at least ten different methods for bringing about fear or phobia reduction, all supported by studies cited in the research literature. The cognitive therapist need not invent his own techniques for discovering relevant misconceptions. The psychotherapy literature contains a broad array of methods ranging from the straightforward interview to free association. Psychodiagnostic testing may be helpful, particularly those tests that elicit much content, such as the Thematic Apperception Test, the Minnesota Multiphasic Personality Inventory (if item answers are scrutinized), and various personality questionnaires. Sometimes such preliminary diagnostic procedures strike pay dirt and permit work to begin immediately on the identified misconceptions. More often, however, finding the relevant misconceptions depends upon a more laborious search throughout the different phases of treatment. Attention to expressive behavior, such as displays of affect, is also useful. In addition to using their preferred techniques for discovering misconceptions, cognitive therapists can also follow their own inclinations in selecting techniques for treatment. So many treatment techniques are described in the literature, it becomes necessary to lump them into broad categories for survey purposes. Each of the four categories selected for that purpose has its counterpart in educational methods. Education, as well as psychotherapy cognitively interpreted, is devoted to implanting, improving, correcting, or eliminating conceptions. 1. Self-examination in its purest form is practiced by hard-core client-centered therapists who are passionately devoted to a minimum of intervention and a maximum of nondirectiveness. In its purest form, the therapist tries only to facilitate the client's own search for, discovery of, and alteration of the relevant misconceptions. No interventions such as interpretations or confrontations are sanctioned. Less Spartan therapists may combine self-examination with other techniques, such as explanation. In so doing, periods of selfexamination are followed by interpretations. Analysts and dynamic therapists often utilize such a combination. (In education, Socratic questioning is in many ways the counterpart of self-examination.)

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2. Explanation is a far more active procedure in which the therapist tries to use whatever knowledge is at hand to convince the client that some of his beliefs are faulty. Explanation is not limited to formal explanations or mini-lectures. Interpretations and confrontations are also explanatory techniques. In its pure form explanation is likely to be quite directive, although it can usually be tempered by discussions with the client. Explanation can also be combined with self-examination and is usually combined with self-demonstrations and modeling. (In education, lecturing is a clear example of explanation, while the combined lecture-discussion method is the counterpart of combining self-examination with explanation.) 3. Self-demonstration consists of the therapist's arranging or proposing special situations either in real life or in approximations of it, such as group therapy, where the client can observe himself in action and discover, or perhaps change, his important misconceptions. (In education, any assigned activity, such as homework that is more than just drill, can be considered the equivalent of selfdemonstration.) 4. Modeling as a therapeutic method was formally introduced by Bandura (1969), although it was employed much earlier informally by those therapists who were aware that their clients often identified with them. In formal modeling, misconceptions are changed or eliminated by inducing the client to imitate a model either vicariously or in reality. (When the teacher expects the class to imitate any kind of demonstrated activity, the counterpart of modeling is being employed.) All therapists can only try to modify beliefs, behavior, or affect. Although the therapist proposes, the client always disposes. What happens in the client? THE PATIENT'S TASK—COGNITIVE REVIEW Little is known of how the client disposes of the therapist's proposals. Most research and theory have been concerned with what the therapist does and not with the client. Nonetheless, certain conjectures about the client's role in the change process can be ventured, as belief modification is not confined to psychotherapy. Since opinions, or beliefs, or conceptions are ordinarily formed on the basis of evidence, adequate or inadequate, we can also assume that

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beliefs are modified by evidence, adequate or inadequate. Thus in successful modification of misconceptions clients must somehow review their evidence in some fashion, be it slipshod or systematic. The process, which is more often slipshod than systematic, we can refer to as cognitive review. We can conjecture further that the reviews that occur must usually be repeated, often many times, as one-trial learning is the exception. An emphasis upon the review process as slipshod helps to avoid the notion that cognitive review is a coldly mechanical process akin to the systematic analyses performed byjudges, scientists, and business experts. Their systematic analyses are the product of long-term training based upon concrete principles with appropriate criteria for judging the success of the analysis. Of perhaps greatest importance is the fact that they can be assured of external reviewers, whereas most of us conduct our review in secret. For most of us the rules of evidence are not even shattered; they never existed. Our wishes are taken as valid evidence. Leading questions are the rule for we are pleading before our own bars, which are hopelessly prejudiced. We practice hearsay shamelessly. Affect is accepted as fact. An observer might wonder how anything ever gets done right. What happens in typical cognitive reviews can be inferred to some extent by attending closely to what clients do in interviews. There is usually a hasty survey of what comes to mind, a tentative conclusion, which is then tested against a tentative forecast of how a changed belief might affect the status quo, usually accompanied by interruptions to think about other pressing topics. Except when crises call for immediate decisions, there is always time to prevaricate, falsify the facts out of whimsy, fantasize impossible wish fulfillments, and then to postpone some more. Cognitive review is rarely a formal kind of reckoning because people are rarely aware that they are weighing evidence against a possible faulty belief. They recognize only that they are dealing with a problem that requires some thought and that an immediate decision may entail some discomfort. Muddling through is not confined to governments. Psychotherapy may, in fact, provide one of the few times when the individual is enticed or bullied into thinking somewhat systematically about some of his beliefs, particularly those about himself. Most clients under the scrutiny of the therapist try to behave like rational, responsible persons most of the time, since most therapists also expect clients to behave in that fashion most of the time. Therapists may protest that

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they accept the client totally, but carrying on a reasonable conversation at least some of the time requires constraints on both sides. What the therapist may not demand may be read into him by the client.

INSIGHT The end point of the client's process of cognitive review, slipshod, helter-skelter, and biased as it may be, can be referred to as insight. Although insight has acquired a bad name in recent years, practitioners still work toward it. The reason for this seeming paradox is that insight probably does work, but perhaps not in the way specified by the analysts who laid so much store by it. Although there are many definitions of it, the most frequent refers to the discovering of developmental patterns that have produced current psychological difficulties. A more useful and more specific definition is needed to understand why many clients recover even when they still lack knowledge of the history of their disturbance. From a cognitive standpoint, insight can be defined as the recognition that one suffers from a specific misconception or a cluster of related misconceptions. The client has insight if he says, "I display great compassion for others because I'm afraid of what people might say if I don't, not because I'm a great humanitarian." With such a definition of insight we need not get into the useless arguments over the necessary time frame for achieving insight. It can be achieved by dredging up and sorting out one's recollections, or it can occur following an examination of events in the psychological present. A longitudinal approach is no better or worse than a cross-sectional approach in therapy. Clients can escape into the present just as well as into the past. Intellectualizing can be practiced with either past or present material. The definition of insight as recognition of a misconception also eliminates the need for concern over so-called intellectual versus emotional insight. The latter somehow implies that emotion is welded onto understanding to promote conviction. From the present standpoint, however, either the individual who displays only intellectual insight is parroting words, or the insight is unrelated to the problem at hand, or the insight may be so partial and fragmented that it fails to explicate the relevant misconception. Passive acceptance of the doctrine of emotional versus intellectual insight deprives the therapist of the opportunity to stimulate the client to explore the misconception further. Freud re-

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ferred to this as the need for working through. People respond with conviction when their problems have been worked through, but not necessarily when they emote. The "aha!" experience is not necessarily characteristic of the insights achieved in therapy since such understanding ordinarily comes about slowly and hesitantly. Mahoney's "cognitive click" is much more descriptive of the usual insight, since it is simply a recognition that things have fallen into place. There are, of course, faulty insights, so that invalid clicking is certainly not unknown in this subjective game we call psychotherapy.

THE CLUSTERING OF MISCONCEPTIONS The problems that bring people to therapy are usually so complex that the simple solutions have failed. The complexity may involve not only contradictory beliefs, such as ambivalence, but also myriad related events that have occurred over long periods of time. Because of this complexity, clustered misconceptions arranged in some loose hierarchy are usually found rather than isolated misconceptions. For illustration, I have selected three clusters of misconceptions. Although by no means universal, each when present exercises a broad influence on its possessor and levies a considerable toll. The three are phrenophobia, the Special Person misconception, and the incapability misconception. The first two have been discussed at greater length in my 1975 book. Phrenophobia This belief that one is in danger of imminent mental collapse usually develops after inexplicable, recurring anxiety attacks. The accompanying fear of insanity probably sends a large proportion of clients into psychotherapy, but even more into physicians' offices in the hope of finding medical explanations. Thorne (1961) reported that 78% of the patients seen in his psychiatric practice had fears of imminent mental breakdown. In several small studies with the help of graduate students we found that 75% of hospitalized mental patients had phrenophobia, and about 20% of college students reported having feared at one time that they might break down.

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The disabling aspect of this cluster is largely due to the layman's fuzzy knowledge about "nervous breakdown" based largely on misconceptions. The layman usually thinks of psychotics as being homicidal, suicidal, sexually assaultive, and suffering from loss of identity. The consequences are seen as banishment to an asylum for life with permanent estrangement from family and friends. Those suffering from moderate to severe phrenophobia face enormous horrors. It is little wonder that denial of illness is as common in those with mental problems as in those with medical problems. Treatment of this tenacious misconception is difficult. In direct treatment, which may be helpful to some, the therapist explains how constant apprehension, confusion, supposed loss of memory and concentration (the highly anxious concentrate on and remember their symptoms splendidly), and insomnia are products of anxiety usually resulting from severe stress. Direct reassurance can also be helpful, particularly during crises when fear is likely to become panic. Difficulties often arise in treatment because clients experience weird and subtle internal sensations from prolonged anxiety that are often impossible to describe to the therapist. Thus the client believes that the clinician's reassurance is based on partial evidence. Indirect alleviation of phrenophobia occurs when the therapist consistently treats the client like a normal person. Those who live in fear of imminent breakdown become acutely sensitive to how others react to them. Thus when the doctor treats the phrenophobic as a normal individual, the fear of impending insanity tends to be dissipated and the phrenophobia relieved. Tranquilizers can also be helpful in reducing this concern, but a surprisingly large number of mental patients see medications as only temporary crutches. I usually castigate myself if I neglect to question clients about phrenophobia near the beginning of treatment. Direct treatment and reassurance act far more quickly than do the client's covert observations of the therapist's manner. When phrenophobia is reduced or eliminated, rational consideration of other misconceptions is possible.

The Special Person Misconception One of the most puzzling aspects of neurotic behavior is the person's refusal to give in to or to compromise with reality. The neurotic who could solve many problems simply by accepting his place in line absolutely refuses to do so. This may represent a grandeur of temperament

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in the abstract but it hardly compensates for the misery endured in the concrete by the refusal to compromise. This misconception is a conviction that one has special rights and should have special dispensations. Anderson (1981) writes of their belief in their "special entitlement." The Freudian narcissism, or enhancement of self-love, is a related phenomenon. Kohut (1971), building on the Freudian notion, has a related concept of the "grandiose self," which is "the grandiose and exhibitionistic structure which is the counterpart of the idealized parent imago" (p. 26). In all of these notions the core is an exaggerated belief in one's superiority or desirability. There is no reason the belief in one's superiority could not have several etiologies, among which I would emphasize the pampering of children or the direct indoctrination of specialness. Most mental health professionals, however, have been so indoctrinated with the Adlerian notion that a "superiority complex" is only a cover for an underlying "inferiority complex" that they reject out of hand any other etiology. Even Freud's narcissism is dependent on the principle of compensation following rebuff, rejection, and pain from others. Many Special Persons can be successful, at least for a time, in obtaining constant reaffirmation of their superiority, at least within their own reference group. As long as they succeed they are symptom free. But when they fail to obtain such confirmation, the major handicaps of their misconception are borne in on them—devastated self-esteem and loss of specialness. The resulting depression and anxiety may become so severe that phrenophobia occurs, and the welter of symptoms obscures the underlying character disorder. Often the Special Person finds different ways of maintaining the appearance of being special. Doing extensive homework before encounters with others is a favorite way of displaying intellectual superiority. Resorting to the hysteric's typical pattern of practicing constant and exaggerated charm is a less intellectual solution. Charm, real or fancied, brings its own reward in the attention it evokes from others, unless and until they sicken of the charm. Treatment of this misconception is also difficult. The feeling of entitlement is so embedded that its possessor is ordinarily unable to perceive it even when it is salient to others. Direct confrontation is likely to be painful, for the Special Person sees this challenge as completely unfair and is then more likely to withdraw than to understand. I confront only when I have been able to collect a number of detailed incidents of rejection resulting from the client's inveterate practice of one-upman-

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ship. With that ammunition I have at times been able at least to gain the client's attention. I usually also play it doubly safe by inserting at some point in the confrontation a brief description of the Special Person to which is appended, "Of course, you are not responsible for acquiring that misconception You did not pamper yourself, someone else pampered you." Some clients rapidly come to realize that they are pampered children grown up, but often their growth in this respect falters when giving up the satisfactions of the Special Person becomes intolerable.

The Incapability Misconception The core of this misconception is an exaggerated belief in one's inabilities. The so-called inferiority complex is an extreme, generalized form of the incapability misconception. Although I have encountered few of the extreme forms, most clients I see have scattered patches of selfevaluated incapability that make it difficult for them to deal with problems. This misconception's development is nourished from two sources—real incapabilities and the confusion between inability and aversion, between "I cannot" and "I don't want to." How much conscious deceit occurs in the incapability misconception is a vexing question. Keats took the skeptic's role when he suggested that "The fancy cannot cheat so well as she is famed to do." On the other hand, there must be many genuine beliefs about one's deficiencies that are factually incorrect. For example, there must be thousands, if not millions, of all ages who honestly believe they cannot learn mathematics, just as there are untold others who profess in all honesty their inability to perform painful or aggressive acts. The client, for example, who says, "I can't tell my mother that she is destroying my marriage," usually honestly believes it, even though he is confusing his aversion with his capability. Phobias represent a special and extreme form of this misconception. Over the years I have become convinced that this belief is one of the most frequently encountered and troublesome of the common misconceptions. For some, it becomes a routine defense against any discomfort. There are standard phrasings such as, "I can't think about that because it's too painful," or "I can't learn how to do that, and my mother couldn't either." This misconception may protect one from much discomfort in the short run, but it tends to become an opiate used whenever discomfort intrudes. It is also intricately linked with the

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avoidance reaction, the tactic above all others that keeps the person from reassessing and confronting the reality underneath the faulty facade. Treatment of the incapability misconception tends to be easier than that of phrenophobia, probably because concern about one's capabilities is unlikely to arouse intense fear except in special circumstances. Thus fewer avoidance reactions occur. It is also easier to deal with than the Special Person, since questioning incapabilities poses less threat to self-esteem than does questioning rights to special entitlement.

A SUMMING UP The disadvantages encountered in employing a cognitive approach in psychotherapy are no different from those found with any other approach. Those unfamiliar with a cognitive approach may be dismayed by the prospect of trying to modify what they see as a dishearteningly large number of misconceptions. Fortunately, there is no need to treat all misconceptions since most are benign and have little influence on adjustment. Those held in common with one's reference group, for example, are probably benign, since they are accurate guides to the social milieu. The ones that create problems are primarily faulty beliefs about the self and the self in relation to others. As we have seen, offending misconceptions also tend to be clustered hierarchically, so that if one that subsumes many faulty beliefs is eliminated the whole structure collapses. Clients also tend to discuss symptoms and issues related to their important misconceptions that help not only in their discovery but also in narrowing down those in need of treatment. Not only clients, however, suffer from misconceptions. Therapists may also hold faulty beliefs that may interfere with the course of treatment. The well-known countertransference is the therapist's misperception of the client, a counterpart of transference, or the client's misperception of the therapist. Another therapist misconception is the "teacher fallacy." Just as teachers are prone to assume that students must understand what has been carefully explained to them, therapists are likely to believe that their clients understand all that has been explained, interpreted, reflected, and posed in confrontation. There appear to be few if any inherent disadvantages to a cognitive approach, but many advantages. One is that most therapists are familiar with a large number of misconceptions, even though they may not think

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of them as such. If a client says, "I'm sure no one could like me if he got to know me well," most therapists prick up their ears and begin to plan their strategy for changing this faulty belief. As a matter of fact, and for many reasons, non-therapists as well as therapists spend much of their lives listening for faulty beliefs, usually those of others. Another advantage of the cognitive approach is that procedures for discovering relevant misconceptions have been proposed by many therapists of different persuasions, even though the proposals may not have emerged from a cognitive orientation. Misconceptions can be elicited by any method that encourages a client's verbal or expressive behavior, such as free association, nondirective interviewing, Gestalt therapy techniques for nonverbal behavior, dream interpretation, or straightforward history taking and questioning. In cognitive therapy, identified misconceptions are usually phrased in the everyday language of the client so that the client's self-knowledge and language can be used immediately to discuss faulty beliefs. No special language need be introduced, although occasionally technical terms, such as ambivalence, can be taught if they help to sharpen understanding and permit better communication. Cognitive therapists also have a consistent orientation toward the tasks of therapy, as everything that happens there is grist for the cognitive mill. Initial unsatisfactory client attitudes toward therapy or the therapist are usually, but not always, the products of misconceptions, including those that create ambivalence. If history is taken, it may well provide clues to patterns or clusters of misconceptions from remote or recent times. Sudden changes in established patterns of normal behavior probably bear witness to the birth of important misconceptions following traumatic or other kinds of unusual life events. Content-laden diagnostic tests, such as the TAT, the items of the MMPI, or personality questionnaires, can be scrutinized for relevant misconceptions. The relationship between client and therapist provides rich opportunities for detecting misconceptions, particularly if the therapist is skilled at detecting transference reactions. When clients put on an emotional display or report strong emotional reactions that occurred between sessions, they can usually be profitably examined for clues to important misconceptions. Problems may occur, however, as many clients are skilled ventriloquists who distort the therapist's perception of "where they are coming from." Ventriloquism is only one of many resistances. Resistance per se is based on misconceptions about the whole process of change. The defense mechanisms are also based on misconceptions, since they are devices for falsifying or avoiding one's true reactions.

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Another advantage of the misconception approach is that changes in relevant misconceptions can often reorganize behavior rapidly and radically. Such changes are probably due to the elimination or modification of a misconception central to a cluster of faulty beliefs. The biblical story of Saul's transformation into Paul on the road to Damascus is a classic recognition of a radical transformation in personality brought about by insight. Finally, there are three questions commonly asked about a cognitive approach that seem to represent genuine puzzlement. The most frequently asked implies that it is probably too "intellectual" for most clients. But this stems from a misunderstanding, for affect occurs as profusely or as sparsely as in any other approach, unless the therapist tries unwisely to dampen it. In view of their usefulness as clues to misconceptions, affective reactions play an important role in treatment. The second question asks whether cognitive therapy as I outline it is not just a matter of attitude, since its methods can be so varied. The third question, related to the second, is a query about cognitive therapy's being an eclectic approach, since so many methods can be used. Inasmuch as the last two relate to the wide array of methods they can be answered together. Cognitive therapy is not just a matter of attitude, as the varied methods simply testify to the fact that there are many ways to change misconceptions. A cognitive approach can, therefore, be eclectic where methods or techniques are concerned, but its goal is certainly not eclectic. Finding and changing faulty beliefs that interfere with adjustment is a highly specific and concrete therapeutic activity, even though it may be accomplished in many different ways. REFERENCES Anderson, C. M. (1981). Self-image therapy. In R. J. Corsini (Ed.), Handbook of innovative psychotherapies. New York: Wiley. Ansbacher, H. L., & Ansbacher, R. R. (Eds.). (1956). The Individual Psychology of Alfred Adler. New York: Harper & Row. Arnold, M. (Ed.). (1970). Feelings and emotions. The Loyola Symposium. New York: Academic Press. Bandura, A. (1969). Principles of behavior modification. New York: Holt, Rinehart & Winston. Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press. Beck, A. T., Rush, A. I., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford.

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Bergin, A. E., & Strupp, H. H. (1972). Changingfrontiers in the science of psychotherapy. Chicago: Aldine-Atherton. Colby, K. M. (1964). Psychotherapeutic processes. In P. R. Farnsworth (Ed.), Annual review of psychology. Palo Alto, CA: Annual Reviews. Combs, A. W., & Snygg, D. (1959). Individual behavior: A perceptual approach to behavior (Rev. ed.). New York: Harper. Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart. Goldfried, M. R. (Ed.). (1982). Converging themes in psychotherapy: Trends inpsychodynamic, humanistic, and behavioral practice. New York: Springer. Kohut, H. (1971). The analysis of the self. New York: International Universities Press. Lazarus, R. S. (1982). Thoughts on the relation between emotion and cognition. American Psychologist, 37, 1019-1024. Leeper, R. S. (1970). The motivational and perceptual properties of emotions as indicating their fundamental character and role. In M. Arnold (Ed.), Feelings and emotions: The Loyola Symposium. New York: Academic Press. Mahoney, M.J. (Ed.). (1980). Psychotherapy process: Current issues and future directions. New York: Plenum Press. Perls, F. S. (1969). Gestalt therapy verbatim. Lafayette, CA: Real People Press. Perry, H. S., & Gawel, M. L. (Eds.). (1953). The interpersonal theory of psychiatry. New York: Norton. Raimy, V. (1975). Misunderstandings of the self: Cognitive psychotherapy and the misconception hypothesis. San Francisco: Jossey-Bass. Rotter, J. B. (1970). Some implications of social learning theory for the practice of psychotherapy. In D. J. Levis (Ed.), Learning approaches to therapeutic behavior change. Chicago: Aldine-Atherton. Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psychotherapy outcome studies. American Psychologist, 32, 752-760. Thorne, F. C. (1961). Personality: A clinical, eclectic viewpoint. Journal of Clinical Psychology, 18, 172-176. Tomkins, S. S. (1981). The quest for primary motives: Biography and autobiography of an idea. Journal of Personality and Social Psychology, 41, 306-329. Zajonc, R. B. (1980). Feeling and thinking: Preferences need no inferences. American Psychologist, 35, 151-175.

9 Expanding the ABCs of Rational Emotive Behavior Therapy Albert Ellis

he ABCs of Rational Emotive Behavior Therapy (REBT) go back to its very beginnings in 1955, and I continually used them with my early clients (Ellis, 1962). When the Albert Ellis Institute in New York founded its psychological clinic in 1968, cognitive homework forms were printed for its clients, and they added D and E to the original ABCs (Ellis, 1968), as explained in chapter 3 of Humanistic Psychotherapy: The Rational-Emotive Approach (Ellis, 1973). A stands for Activating events, Activating experiences or Adversities that people disturb themselves about. RB stands for Rational Beliefs or Realistic Beliefs about the Activating events that tend to lead to C, healthy Consequences. IB stands for Irrational Beliefs about the Activating events and tends to lead to UC, Unhealthy Consequences (especially emotional disturbances and dysfunctional behaviors). D stands for Disputing Irrational Beliefs— Detecting them, Discriminating them from rational beliefs, and Debating them (Phadke, 1982). E stands for Effective New Philosophies to replace people's Irrational Beliefs and also for Effective healthy emotions and Effective functional behaviors to replace their disturbed emotions and dysfunctional behaviors. The ABCs and the DEs have served REBT very well over the last four decades and have been copied in hundreds of books and articles and used with many thousands of clients. In their original form, however, they are oversimplified and omit salient information about human dis-

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turbances and its treatment. Several REBT writers have tried to expand them, with some degree of success (Dryden, 1999, 2001; Walen, DiGiuseppe, & Dryden, 1992). In this chapter I shall try to give my own version of how I think they can be usefully expanded. DEFINITIONS OF THE ABCs OF REBT Let me start with some definitions involved in the REBT outlook on human personality and behavior and particularly its view of emotional disturbance. REBT holds that humans are purposeful, or goal-seeking creatures (Adler, 1929; Ellis, 1973) and that they bring to A (Activating events or Adversities) general and specific goals (G). Almost always, their basic Goals are (1) to stay alive and (2) to be reasonably happy and free from pain while alive. Their main subgoals as they strive for happiness include: to be happy (a) when alone, by themselves, (b) when associating with other people, (c) when engaging in intimate relationships with others, (d) when earning a living, and (e) when engaging in recreational activities (e.g., sports, study, art, music, drama). Rational Beliefs (RBs) in REBT mean those cognitions, ideas, and philosophies that aid and abet people's fulfilling their basic or most important Goals. Irrational Beliefs (IBs) are those cognitions, ideas, and philosophies that sabotage and block people's fulfilling their basic or most important Goals. Nonevaluative observations, descriptions, and cold cognitions are people's observations of what is going on (WIGO) in the world and in their own thoughts, feelings, and actions. Evaluative assessments, inferences, expectations, and conclusions are people's evaluations of what is going on (WIGO) in the world. These may be either (1) flexible and preferential evaluations—involved with people's desires, wishes, and preferences, or (2) rigid and demanding evaluations—involved with people's absolutistic demands, commands, musts, and necessities. ACTIVATING EVENTS OR ACTIVATORS (A) OF COGNITIVE, EMOTIONAL AND BEHAVIORAL CONSEQUENCES (C) The REBT theory of personality and of personality disturbances begins with people's attempts to fulfill their Goals (Gs) in some kind of environ-

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ment and encountering a set of Activating events or Adversities (A's) that tend to help them achieve or block these Goals. The A's they encounter are present or current events or their own thoughts, feelings, or behaviors, but they may be imbedded in conscious or unconscious memories or thoughts about past experiences. People are prone to seek out and respond to these A's because of (a) their biological or genetic predispositions, (b) their constitutional history, (c) their prior interpersonal and social learning, and (d) their innately predisposed and acquired habit patterns (Ellis, 1976, 1979, 2001a, 2001b, 2002). A's (Activating events) virtually never exist in a pure or monolithic state but almost always interact with and partly include B's and C's. People bring themselves (their goals, thoughts, desires, and physiological propensities) to A's. To some degree, therefore, they are these Activating events and the A's (their environments) are them. They can only think, emote, and behave in a material milieu—as Heidegger (1962) notes, only have their being-in-the-world, and they almost always exist in and relate to a social context—live with and relate to other humans. They are never, therefore, pure individuals, but are world-centered and social creatures.

BELIEFS (B's) ABOUT ACTIVATING EVENTS (A's) According to REBT theory, people have almost innumerable Beliefs (B's)—or cognitions, thoughts, or ideas—about their Activating events (A's), and these B's importantly and directly tend to exert strong influences on their cognitive, emotional, and behavioral consequences (C's). Although A's often seem directly to "cause" or contribute to C's, this is rarely true, because B's normally serve as important mediators between A's and C's and therefore more directly cause or create C's (Beck, 1976; Ellis, 1957, 1962, 1968; Goldfried & Davison, 1994; Mahoney, 1974; Raimy, 1975; Walen et al., 1992). People largely bring their beliefs to A, and they prejudicially view or experience A's in the light of these biased Beliefs (expectations, evaluations) and also in the light of their emotional Consequences (C's) (desires, preferences, wishes, motivations, tastes, disturbances). Therefore, humans virtually never experience A without B and C, but they also rarely experience B and C without A. People's B's take many different forms because they have many kinds of cognitions. In REBT, however, we are mainly interested in their

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Rational Beliefs (RBs), which we hypothesize lead to their self-helping behaviors, and in their Irrational Beliefs (IBs), which we theorize lead to their self-defeating (and society-defeating) behaviors. We can list some of their main (but not only) kinds of B's as follows: 1. Nonevaluative observations, descriptions, and perceptions (cold cognitions). Examples: a. "I see people are laughing." 2. Positive preferential evaluations, inferences, attributions, and automatic thoughts (warm cognitions). Examples: Because I prefer people to like me and they are laughing— a. "I see they are laughing with me." b. "I see they think I am funny." c. "I see that they like me." d. "I like their laughing with me." e. "Their liking me has real advantages, which I love." 3. Negative preferential evaluations, inferences, attributions, and automatic thoughts (warm cognitions). Examples: Because I prefer people not to dislike me and they are laughing— a. "I see they are laughing at me." b. "I see they think I am stupid." c. "I see that they don't like me." d. "I dislike their laughing at me." e. "Their disliking me has real disadvantages, which I abhor." 4. Positive absolutistic evaluations, inferences, and attributions (hot cognitions; Irrational Beliefs). Examples: Because people are laughing with me and presumably like me and I must act competently and must win their approval— a. "I am a great, noble person!" (overgeneralization) b. "My life will be completely wonderful!" (overgeneralization) c. "The world is a totally marvelous place!" (overgeneralization) d. "I am certain that they will always laugh with me and that I will therefore always be a great person!" (certainty) e. "I deserve to have only fine and wonderful things happen to me!" (deservingness and deification) f. "I deserve to go to heaven and be beautiful forever!" (deservingness and extreme deification) 5. Negative absolutistic evaluation, inferences, and attributions (hot cognitions; Irrational Beliefs). Examples: Because people are laughing at me and presumably dislike me and because I must act competently and must win their approval— a. "I am an incompetent, rotten person!" (overgeneralization)

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b. "My life will be completely miserable!" (overgeneralizatiori) c. "The world is a totally crummy place!" (overgeneralizatiori) d. "I am certain that they will always laugh at me and that I will therefore always be a rotten person!" (certainty) e. "I deserve to have only bad and grim things to happen to me!" (deservingness and damnation) f. "I deserve to roast in hell for eternity! (deservingness and damnation) 6. Common cognitive derivatives of negative absolutistic evaluations (additional hot cognitions and Irrational Beliefs). Disturbed ideas: Because I must act competently and must win people's approval, and because their laughing at me shows that I have acted incompetently and/or have lost their approval— a. "This is awful, horrible, and terriblel" (awfulizing, catastrophizing) b. "I can't bear it, can't stand it!" (I-can 't-stand-it-itis, discomfort anxiety, low frustration tolerance) c. "I am a thoroughly incompetent, inferior, and worthless person!" (self-downing, feelings of inadequacy) d. "I can't change and become competent and lovable!" (hopelessness) e. "I deserve misery and punishment and will continue to bring it on myself!" (damnation) 7. Other common cognitive derivatives of negative absolutistic evaluations (additional Irrational Beliefs). Logical errors and unrealistic inferences: Because I absolutely must act competently and must win people's approval, and because their laughing at me shows that I have acted incompetently and/or have lost their approval— a. "I will always act incompetently and have significant people disapprove of me." (overgeneralizatiori) b. "I'm a total failure and completely unlovable." (overgeneralization, all-or-none thinking) c. "They know that I am no good and will always be incompetent. (non sequitur, jumping to conclusions, mind reading) d. "They will keep laughing at me and will always despise me." (non sequitur, jumping to conclusions, fortune telling) e. "They only despise me and see nothing good in me." (focusing on the negative, overgeneralizatiori) f. When they laugh with me and see me favorably that is because they are in a good mood and do not see that I am fooling them." (disqualifying the positive, non sequitur) g. "Their laughing at me and disliking me will make me lose my job and lose all my friends." (catastrophizing, magnification)

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People can learn absolutistic evaluations, inferences, and conclusions (hot cognitions and Irrational Beliefs) from their parents, teachers, and others—for example, "I must have good luck, but now that I have broken this mirror fate will bring me bad luck and that will be terrible!" But they probably learn these Irrational Beliefs easily and rigidly retain them because they are born with a strong tendency to think irrationally. More important, people often learn family and cultural rational standards—for example, "It is preferable for me to treat others considerately"—and then overgeneralize, exaggerate, and turn these into irrational Beliefs—for example, "Because it is preferable for me to treat others considerately"—and then overgeneralize, exaggerate, and turn these into Irrational Beliefs—for example, "Because it is preferable for me to treat others considerately I have to do so at all times, or else I am a totally unlovable, worthless person." Even if all humans were reared utterly rationally or self-helpingly and other-helpingly, REBT hypothesizes that virtually all of them would often take their learned standards and their rational preferences and irrationally escalate them into absolutistic demands on themselves, on others, and on the universe in which they live (Ellis, 1958, 1962,1973,1976, 2001a, 2001b, 2002; Ellis & Blau, 1998; Ellis & Whiteley, 1979).

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CONSEQUENCES (C's) OF ACTIVATING EVENTS (A's) AND BELIEFS (B's) ABOUT A's C's (cognitive, effective, and behavioral Consequences) follow from the interaction of A's and B's. We can say, mathematically, that A x B = C, but this formula may actually be too simple and we may require a more complex one adequately to express the relationship. C is almost always significantly affected or influenced but not exactly caused by A, because humans naturally to some degree react to stimuli in their environments. Moreover, when A is powerful (e.g., starvation conditions, war, or an earthquake) it tends profoundly to affect C. When C consists of emotional disturbance (e.g., severe feelings of anxiety, depression, hostility, self-deprecation, and self-pity), Beliefs (B) about C may lead to more Adversity (A). Emotional disturbances, however, may at times stem from powerful A's—for example, from environmental disasters such as floods or wars. And they may follow from factors in the organism—hormonal or disease factors, for instance—that are somewhat independent of or may actually cause Beliefs (B's). When strong or unusual A's significantly contribute to or cause C's or when physiological factors create C's, they are usually accompanied by contributory B's as well. Thus, if people are caught in an earthquake or if they experience powerful hormonal changes and they therefore become depressed, their A's and their physiological processes may influence them to create Irrational Beliefs (IB's), such as "This earthquake shouldn't have occurred! Isn't it awfull I can't stand it." These IB's, in turn, add to or help create their feelings of depression at C. C's (thoughts, feelings, and behavioral Consequences) that result from A's and B's are virtually never pure or monolithic but also partially include and inevitably interact with A and B. Thus, if A is an obnoxious event (e.g., a job refusal) and B is first a Rational Belief (RB) (e.g., "I hope I don't get rejected for this job") and second an Irrational Belief (IB) (e.g., "I must have this job! I'm no good if I don't get it"), C tends to be, first, healthy feelings of frustration and disappointment and, second, unhealthy feelings of severe anxiety, inadequacy, and depression. So A x B = C. But people also bring feelings (as well as hopes, goals, and purposes) to A. They would not apply for a job unless they desired

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or favorably evaluated it. Their A therefore, partially includes their C. The two, from the beginning, are related rather than completely disparate. At the same time, people's Beliefs (B's) also partly or intrinsically relate to and include their A's and their C's. Thus, if they tell themselves at B, "I want to get a good job," they partly created the Activating event at A (going for a job interview) and they partly create their emotional and behavioral Consequence at C (feeling disappointed or depressed when they encounter a job rejection). Without their evaluating a job as good they would not try for it or have any particular feeling about being rejected. A, B, and C, then, are all closely related and none of them tends to exist without the other two. Another way of stating this is to say—as some psychologists have clearly stated—that environments only exist for humans (who are quite different from certain other animals), and humans only exist in certain kinds of environments (e.g., where temperatures are not too hot or too cold) and are part of their environment. Similarly, individuals usually exist in a society (rarely as hermits), and societies are only composed of humans (and are quite different when composed, say, of ants or birds). As the systems theory devotees point out, individual family members exist in a family system and change as this system changes. But REBT also points out that a family system is composed of individuals and may considerably change as one or more of the individual family members change. In all these instances interaction is a key, probably an essential, concept for understanding and effectively helping people to change. Similarly with cognition, emotion, and behavior. Thinking, as I pointed out in 1956 (Ellis, 1958), importantly includes feeling and behaving. We largely think because we desire (a feeling) to survive (a behavior) and to be happy (a feeling). Emoting significantly includes thinking and behaving. We desire because we evaluate something as good or beneficial and, as we desire it, we move toward rather than away from it (act on it). Behaving usually involves thinking and emoting. We perform and act because we think it is advisable for us to do it and because we concomitantly feel like doing it. Occasionally, as certain people claim, there maybe 100% pure thoughts, emotions, or behaviors, which have no admixture of the other two processes. If so, they seem to be exceptionally rare. Even when they occasionally appear to occur—as when a person is tapped below the knee and gives a kneejerk response without any apparent concomitant thought or feeling—the original response (the knee jerk) seems to be immediately followed by a thought

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("Look at that! My knee jerked!") and a feeling ("Isn't that nice that my nerves function well!"). So pure cognitions, emotions, and behaviors may exist, but rarely during normal waking (or conscious) states, and even when they do they are quickly followed by related cognitiveaffective-behavioral states (Schwartz, 1993). I emphasized in my first professional paper on REBT (Ellis, 1958) that thinking, feeling, and behavior are integrated and interactional. But it wasn't until a little later that I began to practice REBT by showing my clients that they preferably should work hard to change their Irrational Beliefs (IB's) strongly and emotionally as well as actively and behaviorally. They also preferably should change their disturbed feelings quite thinkingly and actively, and they preferably should change their dysfunctional behaviors very thinkfully and emotionally. Integratively and interactionally! REBT practice, therefore, includes many "cognitive," "emotional," and "behavioral" techniques, but is particularly integrative and interactional, as described in some of my early writings (Ellis, 1962, 1963), and even more clearly emphasized in my recent writings (Ellis, 200la, 2001b, 2002). Humans uniquely are involved in cognitive processes and these often instigate, change, and combine with their emotive and behavioral reactions. When they feel and behave, they almost always have some thoughts about their feelings and actions, and these thoughts lead them to have other feelings and behaviors. Thus, when they feel sad about, say, the loss of a loved one, they usually see or observe that they are sad, evaluate this feeling in some way (e.g., "Isn't it good that I am sad—this proves how much I really loved this person" or "Isn't it bad that I am sad—this shows that I am letting myself be too deeply affected"). When people feel emotionally disturbed at C—that is, seriously anxious, depressed, self-downing, or hostile—they quite frequently view their symptoms absolutistically and awfulizingly, and irrationally conclude, "I should not, must not be depressed. It's awful to feel this way! I can't stand it. What a fool I am for giving in to this feeling!" They then develop a secondary symptom—depression about their depression or anxiety about their anxiety—that may be more severe and more incapacitating than their primary symptom and that may actually prevent them from understanding and working against their primary disturbance. REBT assumes, on theoretical grounds, that they often use their cognitive processes in this self-defeating manner because this is the way they naturally, easily tend to think, and it routinely looks for secondary

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symptoms and treats them prior to or along with dealing with primary symptoms. The observable fact that people tend to spy on themselves and condemn themselves when they have primary symptoms, and thereby frequently develop crippling secondary symptoms, tends to support the REBT hypothesis that cognition is enormously important in the development of neurotic feelings and behavior, and that efficient psychotherapy had better usually include considerable rational emotive behavior techniques. When people develop secondary symptoms—for example, feel very anxious about their anxiety, as agoraphobics tend to do—their secondary feelings strongly influence their cognitions and their behaviors. Thus, they feel so strongly that they tend to conclude, "It really is awful that I am panicked about open spaces!" and they tend to behave more self-defeatingly than ever (e.g., they withdraw all the more from open spaces). This again tends to demonstrate that A (Activating events), B (Beliefs), and C cognitive, emotive, and behavioral consequences) are interactive—that thoughts significantly affect feelings and behaviors, that emotions significantly affect thoughts and behaviors, and that behaviors significantly affect thoughts and feelings. In REBT, we are mainly concerned with people's emotional disturbances—both their primary and secondary disturbances. But the ABC theory also is a personality theory that shows how people partly create their own normal or healthy (positive and negative) feelings and how they can change them if they wish to and work at doing so. I hope that the formulations in this chapter will add to the ABC theory and make it more complex and more useful. REFERENCES Adler, A. (1929). The science of living. New York: Greenberg. Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press. Dryden, W. (1999). Rational emotive behavior therapy: A training manual. New York: Springer Publishing Co. Dryden, W. (2001). Reason to change: A rational emotive behavior therapy (REBT) workbook. Hove, UK: Brunner/Routledge. Ellis, A. (1957). How to live with a neurotic: At home and at work. Hollywood, CA: Wilshire Books. Ellis, A. (1958). Rational psychotherapy. Journal of General Psychology, 59, 35-49. Reprinted: New York: Albert Ellis Institute. Ellis, A. (1962). Reason and emotion in psychotherapy. Secaucus, NJ: Citadel.

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Ellis, A. (1963). Toward a more precise definition of "emotional" and "intellectual" insight. Psychological Reports, 13, 125-126. Ellis, A. (1968). Personality data form. New York: Institute for Rational Emotive Therapy. Ellis, A. (1973). Humanistic psychotherapy: The rational-emotive approach. New York: McGraw-Hill. Ellis, A. (1976). The biological basis of human irrationality. Journal of Individual Psychology, 32, 145-168. Reprinted: New York: Albert Ellis Institute. Ellis, A. (1979). Rational-emotive therapy: Research data that support the clinical and personality hypotheses of RET and other modes of cognitive-behavior therapy. In A. Ellis & J. M. Whiteley (Eds.), Theoretical and empirical foundations of rational-emotive therapy (pp. 101-173). Monterey, CA: Brooks/Cole. Ellis, A. (2001a). Feeling better, getting better, staying better. Atascadero, CA: Impact. Ellis, A. (2001b). Overcoming destructive beliefs, feeling and behaviors. Amherst, NY: Prometheus Books. Ellis, A. (2002). Overcoming resistance: A rational emotive behavior therapy integrated approach. New York: Springer. Ellis, A., & Blau, S. (Eds.). (1998). The Albert Ellis reader. New York: Kensington. Ellis, A., & Whiteley, J. M. (1979). Theoretical and empirical foundations of rationalemotive therapy. Monterey, CA: Brooks/Cole. Goldfried, M. R., & Davison, G. (1994). Clinical behavior therapy (3rd ed.). New York: Wiley. Heidegger, M. (1962). Being and time. New York: Harper & Row. Mahoney, M.J. (1974). Cognition and behavior modification. Cambridge, MA: Ballinger. Phadke, K. M. (1982). Some innovations in RET theory and practice. Rational Living, 17(2), 25-30. Raimy, V. (1975). Misunderstandings of the self. San Francisco: Jossey-Bass. Schwartz, R. (1993). The idea of balance and integrative psychotherapy. Journal of Psychotherapy Integrated, 3, 159-181. Walen, S., DiGiuseppe, R., & Dryden, W. (1992). A practitioner's guide to rationalemotive therapy. New York: Oxford University Press.

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10 Cognitive Therapy, Behavior Therapy, Psychoanalysis, and Pharmacotherapy: A Cognitive Continuum* Aaron T. Beck

PHILOSOPHICAL SYSTEMS AND PSYCHOPATHOLOGY To a large degree our scientific interpretations are based on a particular, often tacit, philosophical system. The philosophical system that we use as investigators may differ widely from what we use as clinicians. Thus, the laboratory investigator who studies depression may work within the trappings of a materialistic (or monistic) model while he is in the laboratory. When he takes off his lab coat and replaces it with his sports jacket as he prepares to treat a patient in psychodynamic therapy, he switches to a new philosophical system—either dualism or mentalism. Moreover, the philosophy that guides our scientific or clinical endeavors may be completely different from that which shapes the view of the practical realities of everyday life. Thus, when our investigator arrives home to confront a troubled wife, he may advise her to stop worrying or she will get an ulcer (interactionist system). In sum, we may jump from materialism in the laboratory, mentalism in psychotherapy, and interactionism outside our professional activities. 'This chapter is an extended version of the Paul Hoch Award Address, American Psychopathological Association, March 3, 1983.

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In order to find the common ground among the psychotherapies and pharmacotherapy we need to have some understanding of the philosophical background that shapes the quite diverse approaches to an individual case. Psychopharmacology has drawn on a materialistic (or monistic) system; behavior therapy, also, predominantly uses a materialistic system; psychoanalysis depends primarily on a mentalist system; and cognitive therapy has been primarily interactionist. Despite the obvious philosophical, theoretical, and technical differences among cognitive therapy, psychoanalysis, behavior therapy, and pharmacotherapy, there are enough subtle but important similarities to justify attempts to construct a maximodel to encompass those systems of therapy. As a springboard for clarifying these similarities, let us take a typical case of a patient who showed a marked change during and after a particular intervention in cognitive therapy. I will condense the description of the patient and interview to a few salient points in order to save space. The patient was a 40-year-old married attorney who had been depressed for at least 6 months. He finally sought psychiatric evaluation after continuous prodding by his wife. Among the most salient features were insomnia, loss of gratification from any of the kinds of experiences that had brought gratification in the past (anhedonia), loss of appetite, loss of weight, early morning awakening, loss of libido, general slowing down, and difficulties in concentration. He was highly self-critical and pessimistic and did not think that any kind of psychiatric treatment would be helpful because his depression was "realistic"—that is, was derived from his basic inadequacy and ineffectiveness on the job, his failure in all spheres of his life. On interview, the patient appeared to be very depressed and slowed down in all of his observable behaviors. He scored near the top on the Depression Inventory (50). The patient's pervasive view of himself was that he was totally inadequate and incapable of dealing with even minimal demands or expectations. He believed firmly that he was incapable of performing any of his work at the office, that this would always be the case, and if indeed he did attempt to do something he would be incapable of completing it or of doing an adequate job. His sense of hopelessness, inadequacy, and selfcriticism also spread to his role as a husband and parent (he had two teenage sons). Because of his sense of inadequacy and failure, he had been spending progressively less time at the office and had accumulated a pile of work that he had not attended to. He expected that he would be fired by the senior partners at any time and thus he and his family would be destitute. He saw suicide as a way of relieving his family of the emotional burden he believed he had imposed on them and also as a way to provide them with some financial support from his life insurance policy.

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The only indication of precipitating factors had been the death of a senior partner of the firm a few months prior to the onset of the depression. The patient had been very attached to, and probably dependent on, him and "took his death very hard." The patient was so suicidal that it was obvious that a quick intervention was indicated. This consisted essentially of starting cognitive-behavioral procedures immediately in the first interview. I discovered that the patient's belief that he would be fired in a day or two had a realistic basis. He was unprepared to try a case coming up for trial the next day and he had felt incapable of doing the necessary paperwork to request a continuation (that is, postponement) of the trial. He had tried many times to draft a letter or to make the appropriate phone call to the clerk of the court but felt incapable of mobilizing the degree of concentration for either action. He also had avoided telling his senior partners of the problem because of his sense of shame. The therapeutic approach consists essentially of modified graded task assignments (Beck, Rush, Shaw, & Emery, 1979). Because he felt incapable of writing the letter, I asked him to give me some idea what he would say in the letter. As he warmed up to the project, he became unusually fluent and in a few minutes was able to produce orally an appropriate request. I took notes during this period of time and then handed him the written letter. He was surprised at this "success" and then we went on to dictate several other more complicated letters that he had been unable to attend to previously. After leaving the office he felt considerably better, more "alive" and more energetic. He started to walk through the campus and noted a number of buildings that had been erected since he graduated from the University of Pennsylvania. On an impulse he decided to go to the student cafeteria to see what the students were up to. As he went through the cafeteria line, he began to feel hungry and he had his first complete meal in several months. He later reported that he had enjoyed the meal and also enjoyed seeing various old familiar sights on the campus. These were the first experiences of pleasure that he recalled having had since his depression started. How can we understand this particular case? From the standpoint of the materialistic system (centralist type), we could say that the patient had some kind of biochemical disturbance that was responsible for his symptoms. The basic problem, according to current theories, might be variously ascribed to a disturbance in functioning, a decreased sensitivity of specific receptors, a deficiency in steroid metabolism, some imbalance in the regulation of growth or thyrotropic hormones, or any combination of these or some other endocrine or normal neurochemical disturbance. According to the materialistic system, the treatment would consist of an administration of a drug to correct the deficiency or imbalance.

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The psychodynamic approach would work within a mentalistic system and assume that the symptoms evolved from certain unconscious forces such as "loss of a love object" or recollected hostility. Behavior therapy would use a materialistic model (peripluralist type) and look for a deficit in reinforcements of positive behaviors. By environmental modification, the individual would be given positive reinforcements, particularly in constructive behaviors, and nonreinforcements for self-defeating behaviors. The usual cognitive model is interactionist (M. Mahoney, personal communication, 1982), although I personally favor the model I shall present in this chapter. Thus, the cognitivist assumes that the individual's primary problem has to do with his construction of reality. The remedy lies in modifying the cognitive set. This psychological modification then produces biochemical changes that in turn can influence cognitions further. There are a number of reasons none of the aforementioned philosophical systems can totally "explain" a phenomenon such as depression. For instance, the philosophical system dictates what type of instruments one uses for making observations, what kinds of observations are actually made, and how these observations are interpreted. If the investigator is interested in the phenomenon as a psychological entity, then all of the data and conceptualizations would be shaped to conform to the psychological mold. If he perceives of it as a biochemical entity, then the observations and inferences will deal with tangibles (neurons, synapses, neurotransmitters, etc.). This philosophical position may be illustrated by aligning the cognitive approach to the preceding case with the neurochemical. The philosophical system that I endorse rests on the following postulates: 1. Nonmaterial, nonspatial phenomena or processes are just as real as material, spatial phenomena. Nonspatial means that the particular process cannot be located in space. Nonmaterial means that the phenomena or process does not consist of stuff that we can touch, see, or taste. Further, these phenomena are private and dependent on the introspective report of the individual who is experiencing the phenomena and thus cannot be directly validated by another individual. 2. A phenomenon such as depression may be viewed alternately from a biochemical perspective, a psychological perspective, a behav-

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ioral perspective, or other perspectives. The biochemical and behavioral perspectives are similar insofar as they deal with public, spatial stimuli. The cognitive and psychoanalytic perspectives deal primarily with private, nonmaterial, nonspatial data. Neither perspective is more correct or more real than the other perspectives. 3. The various perspectives have varying degrees of explanatory power. By relating them to each other, we can attempt to construct an integrated model that will have greater explanatory power than the individual perspectives have. It is important to recognize that the thoughts and beliefs of the patient do not constitute the cognitive process any more than do the neurochemical changes that are taking place simultaneously. Thoughts do not cause the neurochemical changes and the neurochemical changes do not cause the thoughts. Neurochemical changes and cognitions are the same process examined from different perspectives. However, correspondences between one perspective and the other tend to validate the formulations of each perspective and provide a more complete explanation of the phenomenon. We can now apply this unitary system to understanding how the cognitive-behavioral intervention improved the patient's anhedonia, sadness, and loss of appetite. We can conceptualize this as follows: The psychological intervention by the therapist was processed by the patient's information-processing apparatus. This processing involved changes in the brain, reflected in a biochemical modification and simultaneous modification in the cognitive set. If we took a "psychological biopsy" after the cognitive-neurochemical modification, we would obtain cognitions such as "He really believes he can help me," and "I didn't believe I could write this letter—but I did." If we took a neurochemical biopsy at that point in time, we would find an intricate pattern of neurons firing and chemical changes at the synapses. If we conceptualize depression as an abnormal or dysfunctional phenomenon, the cognitive processes and neurochemical processes are abnormal. This abnormality maybe corrected in a variety of ways. The cognitive approach, expressed in terms of the verbal and nonverbal behavior of the therapist, produces cognitive-neurochemical changes. Similarly, the pharmacological approach, specifically the administration of an antidepressant drug, leads to cognitive-neurochemical changes. As we will see later, biochemical interventions have the same type of cognitive impact as does cognitive therapy. How do we explain the

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biological changes in this case after a psychological intervention? We can take anhedonia as an example. The lawyer patient had a rigid idea: "Nothing matters. Life has gone stale. . . . How can I enjoy anything when I'm a failure?" The cognitive-behavioral intervention reversed the cognitive set to "I can experience pleasure," and the patient did experience pleasure. A successful pharmacological intervention would produce the same cognitive changes (Simons, 1982). Couched in biological terms, the improvement in cognitive processing is expressed in a reversal of a biochemical chain reaction, leading further to a reversal of those biochemical processes involved in the experience of dysphoria.

THE UNIVERSAL DEFICIT We can approach this case from the vantage point of the treatments listed in the title of this chapter. Each of these systems qualifies as a system of therapy, by which we mean a coherent theoretical framework, a body of clinical data to support it, and a therapeutic approach intrinsically related to the theory. As we shall see, each theory revolves around the concept of loss and deficit and each approach includes a replacement therapy to fill in the gaps. The psychoanalytic formulation of the case would rest largely on the loss of the "loved object" (death of the firm's partner) and a consequent negative affect. This negative affect, presumably anger, is not overtly expressed but is .turned against the self and is transformed into depressive affect. Similarly, behavior therapy would postulate that the loss of reinforcements from the senior partners and other members of the firm led to a reduction in the individual's spontaneous behaviors (Lewinsohn, 1975); Rehm's self-control model (1977) would indicate that the patient's termination of self-reinforcement for achievement led to negative affect. Seligman's learned helplessness model (1975) would explain the patient's depressive behavior as the basis of loss of control over reinforcement (the partner) and attribution of responsibility to himself. According to these models, the positive reinforcement of constructive behavior by the therapist increased the patient's positive behavior (Lewinsohn) and the self-reinforcement (Rehm) and the concept of control over reinforcement (Seligman). The cognitive model postulates a similar deficit in this patient. As a by-product of the serious loss, the individual begins to overinterpret his experiences as losses; the usual positive constructions of reality

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have been deleted and, thus, negative constructions become dominant. Because the negative constructions are presumably tied to negative affect, not only does the individual make negative appraisals of himself and his present, past, and future experiences, but he also experiences unpleasant affect, loss of constructive motivation, and suicidal impulses. According to the cognitive model, the positive deficits were counteracted by providing for more positive constructions of experience. The psychopharmacological approach would also rest on an analogous hypothesized deficit. It would propose, for example, that the patient suffered from some disturbance in the availability or utilization of certain chemical transmitters at synaptic junctions in the brain. The derived remedy (not employed in this case) would be the administration of a monoamineoxidase inhibitor or tricyclic compound to counteract this defect. Other hypothesized deficiencies might involve defects in regulation of the entire neuroendocrine system or insufficient output of brain cells bearing noradrenergic receptors to meet increased demands resulting from stress (Stone, 1983).

THE KEYS TO THE BLACK BOX As was indicated previously, clinicians of the major schools of thought have focused on the concept of loss or deficit in depression. In general, an external loss is postulated (loss of reinforcements or of control over them or loss of loved object). If the loss leads to depression, there are certain processes that need to be stipulated to bridge the gap between the external deprivation and the depressive behaviors. Each of the theories either directly describes or alludes to some type of structure that mediates between the external situation (loss) and the ultimate depressive reaction. This intervening structure has been described in elaborate detail (psychoanalysis), in simplified terms (cognitive model), or simply alluded to as the "black box" (behavioral model). The concept of the black box was applied originally to the unspecified "location" in the conditioning model in which stimuli connect up with the conditioned response. According to behavioral theories, it is here that the positive inputs (reinforcements) make their connections and produce the positive outputs (constructive behaviors). If the positive inputs (reinforcements) are inadequate for a sufficient period of time, then the outputs (behaviors) become extinguished and, according to the theory, the individual shows the typical slowing down of depression.

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The treatment prescribed by Lewinsohn attempts to increase the number of reinforcements through exposing the patient to potentially pleasant activities and thus increasing the positive outputs. In the case described above, the patient's constructive activities were positively reinforced by the therapist and this led to more activity. Rehm's approach is to activate the patient to engage in activities for which he will reinforce himself, and this will tend to increase positive behavior. The psychoanalytic and cognitive models presuppose several levels of organization, the lowest of which corresponds to the black box. Thus, the psychoanalytic version of the black box is represented by the complex formulation of the Unconscious, as the repository of the Id, or as the site of Primary Process thinking. Through the process of interpretation, the patient is able to lift the lid off the box and use his mature Ego to counteract these disruptive forces. The attempt is to "make the unconscious conscious" or to fulfill the dictum "where the Id was, there the Ego shall be." From a different standpoint, the Primary Process thinking (lower level) is subjected to contact with reality in the form of the Secondary Process (higher level) and is brought into a more logical and less disruptive framework. One psychoanalytic explanation of the lawyer's rapid symptomatic response is that he found a longlost father figure in the therapist, with whom he could identify. Another interpretation is that the therapist's nurturance neutralized the patient's overwhelming sense of emptiness and satisfied his dependence and/ or needs. The theoretical framework of cognitive therapy is somewhat similar to that of psychoanalysis (Beck et al., 1979). The constructs of "mature thinking" (higher level) and "immature or primitive thinking" (lower level) correspond to Secondary Process and Primary Process. The mechanism of successful treatment may or may not involve introspection. The thrust in this case was (a) to negate the hopelessness through behavioral experiments and thus undermine the negative bias, and (b) to promote, through the doctor-patient relationship and the assignment of success and pleasure experiences, a build-up of positive behavioral and affective experiences. According to the underlying rationale, as the patient's negative constructions diminish, the negative feelings diminish; as the positive constructions increase, the positive feelings increase. In summary, in addition to having a common thematic content relevant to depression, the three systems of psychotherapy have a similar structural basis. The black box of the behavioral model corresponds to

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the Primary Process of psychoanalysis and the primitive thinking of the cognitive model. The neurochemical correlates of this construct constitute an area for future research.

The Common Pathway: Cognitive Processing Another commonality among the systems of psychotherapy is the mechanism by which the specific therapy produces therapeutic results. There is considerable evidence accumulating that each of the effective therapies has an impact on cognitive processes. When measures of these cognitive processes show a shift from negative to positive, they are accompanied by a general improvement in depression and anxiety. Since only a few studies have been reported to date, I will have to cite disparate reports to illustrate my point. Psychoanalytic therapy has not been studied to an extent using the kinds of measures that have been applied in other studies. However, a study by Carrington (1979), which used insight therapy based on psychodynamic principles, demonstrated that the depressed patients who improved on insight therapy showed changes in the cognitive items on the Depression Inventory. A study by Hammen, Jacobs, Mayol, and Cochran (1981), using social skills training for the treatment of socially anxious individuals, showed significant positive changes on the Dysfunctional Attitude Scale, an instrument developed by Weissman and Beck (1978) to define the dysfunctional attitudes in depression. If you randomly select two groups of depressed patients and one receives cognitive therapy and the other receives antidepressant medication, what changes take place? Cognitive therapy presumably affects cognition; antidepressant medication allegedly affects physiological processes. Is there a common denominator? The most appropriate study to illustrate the cognitive impact of successful treatment was Simons' analysis (1982) of an outcome study conducted by Murphy and his associates at Washington University. She analyzed the data on the depressed outpatients who received cognitive therapy alone and those who received antidepressant medication alone. In looking at the change scores in the instruments specifically designed to measure, respectively, automatic thoughts, dysfunctional attitudes, and negative expectancies, she found that the clinically improved patients showed a corresponding improvement in these measures of .cogni-

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tive phenomena. More significantly perhaps, the patients who did not improve did not show a change on the cognitive measures. What is most salient for our present discussion is that pharmacotherapy had essentially the same impact on the cognitive content as did cognitive therapy. These findings are in line with those reported by Eaves and Rush (1984) in a study of depressed outpatients and inpatients. It should also be noted that Eaves and Rush found the endogenous depressions showed as much cognitive distortion as did nonendogenous depressions, a result supporting the thesis that cognitive processes are an intrinsic component of depressions, even those assumed by some writers to be biological in origin.

ANHEDONIA: FUSION OF THE PERSPECTIVES A promising area for examining the overlap of the systems of psychotherapy with psychopharmacology is anhedonia, specifically as related to depression. Investigators have linked the presence of high concentrations of norepinephrine and dopamine to hypothetical pleasure centers in the brain. More recently, evidence that stimulation of specific brain areas containing high concentrations of the endorphins acts as a powerful positive reinforcer of behavior has suggested the importance of these substances as mediators of pleasure. By inference it could be hypothesized that depletion of the catecholamines or endorphins could lead to anhedonia. In fact, drugs designed to counteract the reduced availability or utilization of catecholamines in depression have been shown to be effective in this disorder. In view of the progress in expanding the biochemical perspective, it would seem valuable to broaden the psychological perspective. Moreover, comparison of these perspectives can serve as a guide to further research. Ultimately, the fusion of the perspectives on anhedonia should provide a more comprehensive model than is currently available. A good deal of publicity has been attached to the biochemistry of anhedonia (Belson, 1983). Some writers appear to regard this condition as a primary biological phenomenon presumably due to some aberration of the neuroendocrine system. The reductionist models of this disorder seem to rest on the assumption that biochemical processes of the brain proceed in splendid oblivion of environmental demands. It is more in keeping with contemporary concepts to analyze the phenome-

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non in terms of its functions and its relationships to normal processes. Furthermore, it would seem that anhedonia may well have—or has had—evolutionary value in order to have survived a multitude of selective pressures. Thus, a broad view of anhedonia should include not only concepts regarding internal regulatory mechanisms but also notions regarding adaptation to changing environmental stressors. It should be noted that the reductionist explanation may also dictate notions regarding the appropriate therapy for this condition. Thus, part of the skepticism about the impact of cognitive therapy on primary affective disorders has been based on the notion that these are biochemical in origin. However, it has been found that even the endogenous depressives, characterized largely by loss of responsiveness to pleasurable stimuli, respond well to this type of psychological intervention (Rush, Beck, Kovacs, & Hollon, 1977). Further, the item on the Beck Depression Inventory relevant to anhedonia shows an early responsiveness to cognitive therapy. Anhedonia may be analyzed in terms of an elevation of the threshold for positive experience. This relative imperviousness accounts, in part, for the selective focus on the negative. This type of response may be precipitated by an absolute subtraction from the domain (for example, being abandoned by a loved one) or by a hypothetical, relative loss (specifically, a disappointment, such as not performing as well as expected or not getting as much affection or approval as expected). Following a significant meaningful loss, the depression-prone individual is likely to make an overgeneralized absolute judgment (for example, "I can never get what I want") even though the loss is only partial or relative, representing the discrepancy between anticipated gain and actual gain. Such a conceptualization indicates the formation of a negative cognitive set, sometimes a prelude to depression. Positive experiences are blacked out, interpreted negatively, forgotten, or devalued on recall. Negative experiences are selectively abstracted or exaggerated. If the cognitive blockade becomes fixed, it sets in motion a sequence of other cognitive, motivational, and affective symptoms of depression. It should be noted that in many situations we function with bias toward the positive: We tend to be optimistic and have a somewhat elevated hedonic tone ("the illusory glow"). The dominance of positive processing appears to be a function, in part, of the reduction in negative processing. As the positive apparatus becomes less active (shows increased thresholds), the negative organization becomes relatively more prominent.

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The Cognitive Blockade Let us analyze the psychological mechanisms by which anhedonia and dysphoria may be produced in depression. Anhedonia, which is present in 92% of cases of severe depression, may be described along a dimension ranging from "I feel bored most of the time" to "I am dissatisfied with everything" (Beck, 1967), and dysphoria, present in 88% of cases of severe depression, from "I feel sad" to "I am so sad I can't stand it" (Beck, 1967). The experimental and clinical studies cited below have suggested that there is a cognitive blockade that interferes with the reception and/ or integration of positive data in depression. The term cognitive is used because the interference may occur at various points along the cognitive continuum: perception, recognition, interpretation, integration, learning, immediate recall, long-term memory. This refractoriness to the integration of positive aspects of experience increases with the severity of depression. The blockade against utilization of positive experiences may account for the loss of pleasure response associated with depression. If the positive experiences do not "get through," are diverted from active storage, or are minimized on recall, they are prevented from having any impact on the hedonic system. Sadness is a consequence of the relative predominance of negativity as a result of the blockage of the positive inputs. Thus, the elimination of positive factors from the conception of past, present, and future leaves the patient with an exclusively negative view, which leads to sadness. The evidence suggesting a cognitive blockade in depression may be pieced together for a variety of experimental paradigms. Alloy and Abramson (1979) have reported that normal subjects have an "illusion of control" in contrast to realistic self-appraisals by nonclinical depressives. If generalized to normal experiences, their experiments suggest that we are generally inclined to be optimistic and thus maintain a somewhat pleasurable hedonic tone. If our bias toward the positive (e.g., the illusion of control) is negated, however, our hedonic tone is likely to drop to or below the baseline, as in the case of Alloy and Abramson's depressives. Thus, in the mildly depressed state we have dropped our positive illusions and process negative information as readily as positive. Further, increasing depression is associated with increased refractoriness to positive inputs and a relative negative bias. Analogue studies using induced mood procedures to produce sadness or "minidepressions" indicate that normals or "elated" subjects have a

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positive bias that is eliminated in the sad subjects (Bower, 1981; Clark & Teasdale, 1982; Goodwin & Williams, 1982; Rholes, Riskind, & Lane, 1982). Stiles (1978) reported that depressed subjects recall experiences less positively with the passage of time. Although initial appraisals of enjoyment, performance, and success following an experience task were realistic, these assessments declined at subsequent testing up to two weeks following the task. A different type of experiment (by Muller, 1982) supports the notion that normals have a positive bias that is vitiated in depressives. Using tachistoscopically presented scenes, he found that normals had a greater sensitivity to positive than to negative words. This positive bias (or, more precisely, anti-negative bias) was eliminated in the depressed student volunteers who showed the same latency for positive exposures as for negative exposures. An interesting study by Gilson (1983) presented evidence suggestive of the cognitive blockade. Using a binocularscope, he showed unpleasant and neutral or pleasant slides to "depressed" students and normals. The depressed subjects showed a significant main effect for the depressive slides (i.e., the "perception" of only depressed slides and "nonperception" of positive or neutral slides when presented simultaneously). The normals, in contrast, showed a main effect for the slides with the positive or neutral scenes. A subsequent unpublished study by Gilson showed the same results with hospitalized depressed patients. A variety of state-dependent studies indicate that clinically depressed patients have impaired recall of favorable feedback (e.g., DeMonbreun & Craighead, 1977), pleasant events (Clark & Teasdale, 1982; Lloyd & Lishman, 1975), self-referent positive adjectives (Bradley & Mathews, 1983), or pleasant schemes in stories (Breslow, Kocsis, & Belkin, 1980). Further support for the notion that depressives selectively block out positive aspects of experiences is found in a study by Butler and Mathews (1983). They reported that depressive and anxious patients attached much higher probabilities to mishaps occurring to them than did normals. Of interest to the present review, they found a trend for depressives to attach lower probabilities for positive events than did either anxious patients or normals. This finding is in line with Giles and Shaw's report (1982) that depressives underestimate probabilities of success on an experimental task.

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The tendency of normals to block out negative self-references and of depressives to block out positive self-references is borne out in tests of social desirability response style. The normals tend to eschew items reflecting unfavorably on them, whereas depressives generally will not endorse favorable items. This tendency of depressives to give a fairly accurate statement of socially undesirable characteristics, such as symptoms, accounts for the validity of certain types of self-report instruments, such as the Depression Inventory. Some of the aforementioned studies are reminiscent of an earlier trend in psychology subsumed under the rubric, the "New Look in Perception." The newer concepts of raising and lowering thresholds for recognition are suggestive of earlier notions of "perceptual defense" and "perceptual vigilance." Erdelyi (1974) has reformulated these two phenomena as a special instance of selectivity in cognitive processing. His concepts are close to those presented here. Selectivity consists of multiple processes operating through varied mechanisms brought into play at multiple loci of the information-processing sequence. Anticipating the studies reported here, he states: "Thus, selectivity is pervasive throughout the cognitive continuum, from input to output, and no single site is likely to provide exhaustive explanations of any substantial selective phenomenon" (p. 1). Thus, the slide studies cited above fit into the notion that a complex of sites and functions is involved in the selectivity observed in the cognitive processing of favorable and unfavorable information by the depressed individual. The influence of the negative cognitive set may be detected at multiple points along the pathway from perception to long-term memory. Thus, the depressives show a bias against the positive at the level of recognition (Muller, 1982), recent memory (Clark & Teasdale, 1982; DeMonbreun & Craighead, 1977), more remote memory (Lloyd & Lishman, 1975; Stiles, 1978), and expectancies (Butler & Mathews, 1983; Giles & Shaw, 1982).

Mechanisms of Cognitive Blockade in Anhedonia The addition of a positive factor to the personal domain represents a gain and ordinarily produces gladness; the subtraction of a positive (e.g., the departure of a valued person or the nonfulfillment of a positive expectancy) leads to sadness. If the subtraction is significant, the individual adjusts to the loss by reducing his expectations of pleasure or gain. Consequently, his overall goal-oriented striving, which is derived

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from his expectations, is reduced. Another adjustment also occurs. The threshold for subjective satisfaction is raised ("loss of reinforcer effectiveness"—Costello, 1972). The previously cited experimental evidence suggests that this hedonic adjustment is derived from an increased threshold for the integration of positive inputs. In addition, there seems to be relative loss of the ability to assign positive meaning to events ordinarily regarded as positive. These cognitive changes may be regarded as expressions of the change from a positive to a negative cognitive set. A serious question raised by this formulation is: Why does a loss lead to an increased threshold for positives? The increased threshold may, conceivably, be understood as a response to hemeostatic or cybernetic regulation. The organism is "wired" to achieve a balance between action and passivity. The function of activity is related to goals relevant to longterm survival and reproduction. If the organism were not deterred by disappointment, it might continue in unending attempts to gain satisfaction and thus would be eventually exhausted (as in manic states). The shift to negative expectations and the raising of a minimal level of satisfaction following disappointment damp down spontaneous motivations and activity and thus serve as a check against the runaway quest for gratification. The individual experiences dysphoria not only following a deprivation but also in anticipation of a future deprivation. The individual consequently anticipates further dysphoria if he attempts to undertake a project and thus retreats further into an anhedonic passivity. In a broader sense, we may view the intricate process of increasing and decreasing thresholds for positive experiences as playing a role in overall adaptation (and reproduction). The system of "rewards" regulated by enhanced sensitivity to positive stimuli enhances behavior directed toward these goals. The reduction of rewards reduces such behavior. Thus, in depression the increased thresholds for perceiving satisfying activities plus the negative expectancies lead to reduction in appetite for activities relevant to long-term survival (eating) and reproduction (sex). In cognitive therapy of depression we attempt to exceed the thresholds along the cognitive continuum by providing a series of selected positive experiences ("the mastery and pleasure principle"). In "running the cognitive blockade," we seek to increase positive expectancies, which in turn increase motivation, leading to more success experiences and consequent positive feedback. By swamping the thresholds with a series

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of immediate, concrete, unmistakable success experiences, we "force" the threshold and inject a positive view of the immediate and near future. We also instruct the patient to write down experiences relevant to pleasure and mastery and to repeat them during the therapy sessions. These successful experiences stimulate increased positive expectancies, and the threshold for perceiving positives consequently drops; the writing down and forced recall increases the integration of positive experiences, and the patient experiences a gradual return of gratification. Anhedonia is an interesting phenomenon to discuss from the perspectives of the various psychotherapies and psychopharmacology. The psychoanalytic perspective would focus on the antithesis between the pleasure principle and the reality principle. It could be suggested, for instance, that as a result of a series of disconfirmations of expectations, the pleasure principle is suspended temporarily: In order to bring cognitive processes more in line with the reality, the expectations are switched to a more realistic but negatively tinged data-processing apparatus. In essence, excesses resulting from regulation by the pleasure principle are counteracted by the imposition of the reality principle that directs attention to scarcity rather than abundance, to failure and deprivation rather than success and fulfillment. The displacement of the pleasure principle by the reality principle inactivates the pleasure response mechanism. The adjustment to reality, however, may overshoot the mark and lead to a negative cognitive set. The cognitive model, as indicated above, spells out the consequences of the switch from the positive to the negative cognitive set. The behavioral model can account for anhedonia in terms of the removal of external reinforcements (Lewinsohn, 1975). As the self-reinforcing has become switched off, the individual no longer receives satisfaction for activities that were previously reinforcing. It is of interest that the sequence of positive cognitive set —> realistic set —» negative set may culminate in depression. The road back to normal functioning appears to be based on a reversal of this sequence. Thus, cognitive therapy and psychoanalysis use techniques calculated to inject a more realistic perspective into the patient's thinking. The realistic perspective that is a link in the chain leading to depression is a crucial link in the chain back to normality. The overlapping psychological theories of anhedonia may point the way for further brain research. It may be possible through some of the recent advanced techniques to pinpoint particular areas in the brain

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or neurochemical systems involved with the experience of pleasure. It would be interesting to demonstrate what effects manipulating the cognitive set would have on the activity of such systems.

COGNITIVE COMPONENTS OF SPECIFIC TREATMENTS

Behavior Therapy We are now ready to analyze the various therapies within the framework of the model I have just presented. The traditional formulation of behavior therapy bypasses the role of cognitive processes in the therapeutic process. Writings by Wolpe (1982) suggest that in some cases of phobia, specifically those in which the patient has been exposed to erroneous information about the phobic situation, cognitive restructuring is valuable. However, Wolpe tends to equate cognitive with "conscious" ideas. The more comprehensive view presented in this chapter treats the cognitive organization as composed of several levels. Only the higher levels (mature level) are characterized by free decision making, objectivity, rationality, and the like. According to the scheme I have presented (Beck et al., 1979) the lower levels of cognitive organization (primitive level) are characterized by features attributed to conditioned emotional responses—the cognitive reaction occurs as if by reflex, is automatic and maladaptive, and occurs despite the patient's considering it irrational and consciously opposing it. Hence, Wolpe's initial notion regarding cognitive processes is correct as far as it goes, in that the higher-level cognition is bypassed in the reflex arc, but he overlooks the concept of low-level cognition, a significant component of the conditioned emotional response (Beck, 1976). The agoraphobic demonstrates graphically how a patient can recognize at the higher "rational" cognitive level that a situation is safe, but the lower primitive level generates a sequence of automatic thoughts relevant to losing control or dying. The patient's experience and interpretation of physiological feedback such as rapid heartbeat or faintness further reinforce the primitive cognitive content such as fear of dying, losing control, and being abandoned, and swamps attempts at the mature level to view the situation realistically. The therapeutic mechanism of behavior therapy may be readily analyzed within a cognitive framework. Let us turn to the treatment of the

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agoraphobic. Exposure therapy—in vivo flooding, for example— switches on the primitive level: The individual experiences a sense of danger and intensification of symptoms of anxiety. The symptoms themselves trigger further cognitions about danger (Last & Blanchard, 1982). At that point the individual believes with close to 75-100% certainty that he is having or is about to have a heart attack, stroke, loss of control, loss of sanity, or whatever. Within a therapeutic structure, that is, with a therapist present, he is enabled to assimilate the experience. Given a sufficient period of time during the exposure therapy, he receives cumulative feedback that indicates that he is not dying, losing control, having a heart attack, or going crazy, and that the fear of disaster is unwarranted. Even without coaching, he can recognize increasingly that his fright is a false alarm. Incidentally, it is crucial that the patient experience anxiety in order to ensure that the primitive cognitive levels have been activated (since these levels are directly connected to the affects). The repeated, direct, immediate recognition that the danger signals do not lead to catastrophe eventually provides sufficient disconfirming evidence to enable the patient to switch off the alarm reaction. Subsequent practice sessions further reinforce the new learning experience. They enhance the responsivity of the primitive level to more realistic inputs from "above" (that is, from the mature cognitive level), which then turn off the alarm reaction. In the course of time, the agoraphobic is able to switch off the alarm reaction at an early stage because he has learned that the physiological reactions are not signs of danger and that he can ignore his fearful cognitions. There is obviously much more to the cognitive component of behavior therapy than the foregoing, but this brief analysis demonstrates how its action can be brought within a cognitive framework. Behavior therapy has shown that it is possible to "cure" a neurosis without the person's having insight into the origin of the disorder. Although behavior therapy explicitly shortcuts the high-level cognition insofar as it focuses exclusively on direct exposure to threatening situations, it actually provides the patient with a powerful framework to correct—cognitively—his unrealistic fears. The patient is aware of the unreasonableness of the primitive belief system as indicated by statements such as "I know that nothing will happen to me (in the crowded store), but I am still afraid of suffocating," and thus exposure therapy is able to produce cognitive restructuring. It is important to emphasize the overlap between cognitive therapy and behavior therapy despite differences in terminology. The concept of primitive level (in the cognitive model) has much in common with

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the notion of conditioned reflex. The conditioning model postulates that the inappropriate response is due to the previous pairing of an innocuous stimulus with a realistically dangerous one. The cognitive model posits that the innocuous stimulus is construed as dangerous because of an idiosyncratic (low-level) cognitive set. Both the conditioning and cognitive models require low-level cognitive mediation because of the rapid stereotyped, inappropriate response. In both models, the response to the innocuous stimulus involves immediate motivational and affective components. In the cognitive model the automatic cognitive structuring determines the affect (anxiety) and the behavioral response (avoidance). In behavior therapy, the affect (anxiety) and behavioral response (avoidance) are chained to the specific stimulus situation. Psychoanalysis The theory of cognitive therapy differs from psychoanalysis in several ways but shares many similar concepts. Psychoanalysis postulates that the content of the unconscious is diametrically opposite to that of the content of consciousness—in fact, that a variety of defenses such as reaction formation, displacement, rationalization, and sublimation are used to disguise any unconscious material that might leak through the wall of repression. In cognitive therapy, in contrast, the distorted content is exposed (for example, by eliciting automatic thoughts) and the bulk of the work from there on is spent on fortifying this reality testing through behavioral experiments, checking observations, looking for evidence, and so forth. Thus, the dominant emphasis is on the technical procedures sometimes referred to in the psychoanalytic literature as "ego support" or "ego analysis." In sum, psychoanalysis attempts to expose the unconscious processes (primary process) and assumes that the ego, relieved of the burden of trying to seal off the taboo material, will then spontaneously provide realistic corrections. Cognitive therapy explicitly attempts to induce the patient to draw continually on his rationality (logic, empiricism, etc.) to correct the irrationality. Psychopharmacology The system of psychopharmacology has been primarily empirically derived and is not theoretical in any systematic sense. Many of the somatic

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treatments such as insulin coma therapy and electroconvulsive therapy were discovered serendipitously. When a drug was found to work, it was then refined to be more effective, with fewer side effects, and an attempt was made to map out mechanisms of actions. Some of the current neurochemical theories of depression have been based in part on the known neurochemical effects of antidepressant drugs. There has been a concerted attempt to apply findings regarding the nervous system as a basis for developing new and effective drugs. Progress has been limited by several factors: (a) the integrated knowledge of the central nervous system (CNS) is still limited although rapidly growing, (b) a broad schema that emphasizes a systems approach to CNS function is lacking, and (c) there has been little attempt to utilize psychological findings or schemas as a guide for searching for or integrating biochemical findings. As a result of the tendency toward reductionist thinking prevalent in much scientific work, neurochemical abnormalities have often been labeled as the cause or the explanation for depression. An example of an attempt to link psychological and pharmacological data has been the development of the Dexamethasone Suppression Test and attempts to correlate neuroendocrine deviations with specific subtypes of depression. Thus far, neuropsychopharmacotherapy has adopted a deficiency model for understanding depression. Certain deficiencies have been found (for example, in pre- or post-synaptic neurotransmitter function) or in neuroendocrine response (as in the Dexamethasone Suppression Test). As the abnormal findings have not been woven into an adequate explanatory model, a comprehensive psychobiological model would integrate the psychological and neurochemical perspectives. It would enable the researcher to look at the psychological levels and correlate them with neurochemical findings and drug actions on the basis of these levels. It would also correlate neurochemical findings with the major spheres: cognitive, affective, motivational and behavioral. This maximodel might, for example, prompt the investigator looking for the equivalent of an ego deficit to search for an abnormality in the neocortex. Or he might consider a dysfunction of the paleocortex contributing to the cognitive distortions. We found that the initial change with drug therapy was in cognitions, not the affect of depression (Rush, Beck, Kovacs, Weissenburger, & Hollon, 1982). What are the cognitions being affected by drugs? Are they low level (primary process) or high level (secondary process) or both? A better model for understanding psychopharmacology may be found.

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There is increasing evidence of a rapprochement between biological and psychological approaches. The theme of the 1983 meeting of the Society of Biological Psychiatry was the biology of information processing. Gevins (1983) proposed a new model of neurocognitive functioning. A promising line of research attempting to bridge the gap between psychosocial and psychopharmacological approaches has been the work by Kraemer and McKinney (1979), who found that the combination of a psychosocial stressor (maternal deprivation) and a drug (AMPT) that depletes brain catecholamines had a synergistic effect in producing depression in monkeys. This is an example of how loss or deprivation at an abstract symbolic level may be brought into apposition with loss or deficiency at the concrete biochemical level. Studies such as this, by investigators well versed in the psychological perspectives as well as the biochemical perspectives, may advance the day when the understanding and treatment of the psychiatric disorders can be encompassed within a sophisticated comprehensive model.

SUMMARY

Psychological observations are just as real as biological observations. The biological and psychological systems are different perspectives of the same phenomenon and use, respectively, a public, spatial, concrete focus and a private, nonspatial, nonmaterial focus. Despite differences in the level of abstraction, there should be correspondences between the two, and a unified theory should provide clues as to where to look for these correspondences. Commonalities across the systems of psychotherapy and pharmacotherapy and their underlying theories may be delineated. When we examine specific disorders such as depression, we find that each theory focuses on a relative deficit of the positive components of experience. This common concept is represented by terms such as loss of reinforcement (behavior therapy), loss of object (psychoanalysis), and deprivation or defeat (cognitive therapy). It is speculated that the concept of psychological deficit may have some relationship to deficits in neuroendocrine function. Although different terms are used, there are other similarities in theory and therapy. Structurally, the locus of the problem in a disorder such as depression can be ascribed to the primary process or uncon-

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scious—to the "black box" of behaviorism, or to the primitive cognitive organization. The key to therapy consists of correcting the negative balance through insight, through reestablishing positive reinforcements, through changing the negative cognitive set, or through increasing the availability of catecholamines and/or serotonin. A common denominator of the various systems is the ascription of cognitive mechanisms to the process of therapeutic change. Research has indicated that improvement in the clinical condition is associated with changes in cognitive structuring of experience irrespective of the type of therapy. It is suggested that changes in the cognitive processes play an essential therapeutic role with each type of treatment. REFERENCES Alloy, L. B., & Abramson, L. Y. (1979). Judgment of contingency in depressed and nondepressed students. Journal of Experimental Psychology: General, 108, 441-445. Beck, A. T. (1967). Depression: Clinical, experimental and theoretical aspects. New York: Hoebep. (Republished in 1972 as Depression: Causes and treatment. Philadelphia: University of Pennsylvania Press.) Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford. Belson, A. A. (1983). New focus on chemistry of joylessness. The New York Times, Match IS, 1983, Science Times section, p. 1. Bower, G. H. (1981). Mood and memory. American Psychologist, 36, 129-148. Bradley, B., & Mathews, A. (1983). Negative self-schemata in clinical depression. British Journal of Clinical Psychology, 22, 173-181. Breslow, R., Kocsis, L, & Belkin, B. (1980). Memory deficits in depression: Evidence utilizing the Wechsler Memory Scale. Perceptual and Motor Skill, 51, 541-542. Butler, G., & Mathews, A. (1983). Cognitive processes in anxiety. Advances in Behavior Research and Therapy, 5, 51-62. Carrington, C. (1979). A comparison of cognitive and analytically oriented brief treatment approaches to depression in black women. Dissertation Abstracts, University of Maryland, Baltimore. Clark, D. M., & Teasdale, J. D. (1982). Diurnal variation in clinical depression and accessibility of memories of positive and negative experience. Journal of Abnormal Psychology, 91, 87-95. Costello, C. C. (1972). Depression: Loss of reinforcers or loss of reinforcer effectiveness? Behavior Therapy, 3, 240-247. DeMonbreun, B. G., & Craighead, W. E. (1977). Distortion of perception and recall of positive and neutral feedback in depression. Cognitive Therapy and Research, 1, 311-329.

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Eaves, C., & Rush, A. I. (1984). Cognitive patterns in symptomatic and remitted unipolar major depression. Journal of Abnormal Psychology, 93, 31-40. Erdelyi, M. H. (1974). A new look at the new look: Perceptual defense and vigilance. Psychological Review, 81, 1-25. Gevins, A. (1983, April). Shadows of thoughts: Towards a dynamic network model of neurocognitivefunctioning. Paper presented at the meeting of the Society of Biological Psychiatry, New York. Giles, D. E., & Shaw, B. F. (1982). A test of the cognitive triad in Beck's cognitive theory of depression. Unpublished manuscript. Goodwin, A. M., & Williams, J. M. C. (1982). Mood-induction research—Its implications for clinical depression. Behavior Research and Therapy, 20, 373-382. Hammen, C. L., Jacobs, M., Mayol, A., & Cochran, S. D. (1981). Dysfunctional cognitions and the effectiveness of skills and cognitive-behavioral assertion training. Journal of Consulting and Clinical Psychology, 48, 685-695. Kraemer, G. W., & McKinney, W. T. (1979). Interactions of pharmacological agents which alter biogenic amine metabolism and depression. Journal of Affective Disorders, 1, 33-54. Last, C. G., & Blanchard, E. B. (1982). Classification of phobics versus fearful nonphobics: Procedural and theoretical issues. Behavioral Assessment, 4, 195-210. Lewinsohn, P. M. (1975). The behavioral study and treatment of depression. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification, Vol. 1. New York: Academic Press. Lloyd, C. C., & Lishman, W. A. (1975). Effect of depression on the speed of recall of pleasant and unpleasant experiences. Psychological Medicine, 5, 173-180. Muller, R. L. (1982). The recognition times to depressive and neutral stimuli by the depressed and non-depressed. Unpublished master's thesis, Farleigh Dickinson University, Teaneck, NJ. Rehm, L. P. (1977). A self-control model of depression. Behavior Therapy, 8, 787-804. Rholes, W. S., Riskind, I. H., & Lane, I. W. (1982). Emotional states and memory biases: The effects of cognitive priming on mood. Journal of Personality and Social Psychology. Rush, A. J., Beck, A. T., Kovacs, M., & Hollon, S. D. (1977). Comparative efficacy of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients. Cognitive Therapy and Research, 1, 17—37. Rush, A. J., Beck, A. T., Kovacs, M., Weissenburger, I., & Hollon, S. D. (1982). Differential effects of cognitive therapy and pharmacotherapy on hopelessness and self-concept. American Journal of Psychiatry, 139, 862-866. Seligman, M. E. P. (1975). Helplessness. San Francisco: W. H. Freeman. Simons, A. (1982). The process of change during the course of cognitive therapy or pharmacotherapy of depression: Changes in mood and cognitions. Dissertation, Washington University, St. Louis, MO. Stiles, J. C. (1978). Cognitive devaluation of past experiences in depression. Dissertation, University of Texas. Stone, E. A. (1983). Problems with current catecholamine hypotheses of antidepressant agents. Behavioral and Brain Sciences, 6(4), 535-577.

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Weissman, A., & Beck, A. T. (1978). Development and validation of the Dysfunctional Attitude Scale. Paper presented at the meeting of the Association for Advancement of Behavior Therapy, Chicago. Wolpe, I. (1982). The practice of behavior therapy (3rd ed.). New York: Pergamon.

11

A Psychosocial Approach for Conceptualizing Schematic Development Arthur Freeman and Donna M. Martin

"You ask, How did this tradition get started? I'll tell you . . . I don't know. But it's a tradition and because of our tradition each of us knows who he is and what God expects of him." —Tevye in Fiddler on the Roof

Tiether we call them traditions, rules, or schemas, virtually every human action, reaction, and interaction, is guided by the templates imposed by the personal, cultural, familial, religious, gender, and age-related schemas that we have each developed over the years (Beck, Freeman, & Associates, 1990; Beck, Freeman, Davis, & Associates, 2004; Beck, Rush, Shaw, & Emery, 1979; Freeman, Pretzer, Fleming, & Simon, 1990; Freeman, Pretzer, Fleming, & Simon, 2004). The term schemas, as used in this chapter, is equivalent in meaning to beliefs, underlying assumptions, and attitudes. Our schemas direct and influence our behavior and help to give meaning to our world. At the same time our schemas are established and reinforced in our interactions with significant others and the environment. The extent and manner of our response and perceptions are functions of the breadth, valence, activity, and compelling or noncompelling nature of our schemas (Freeman, 1988; Freeman & Leaf, 1989). Schemas are involved in memory (what is selected for recall or what is "suppressed"), cognition (the abstraction and interpretation of information), affect (the genera-

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tion or avoidance of feelings), motivation (wishes and desires), and action and control (self-monitoring, inhibition, or direction of action). The careers and avocational pursuits that we choose are similarly governed by our schemas. For example, the famous open ocean racer, Sir Francis Chichester, was known for his single-handed transoceanic crossings. He was quoted as saying, "Somehow, I never seemed to enjoy so much doing things with other people. I know I don't do a thing nearly so well when with someone. It makes me think I was cut out for solo jobs, and any attempt to diverge from that lot only makes me half a person" (Page, 1980, p. 19). In the preceding quote, Chichester describes schemas typical of the schizoid personality disorder (Beck et al., 1990; Freeman, 1988; Freeman & Leaf, 1989). As his life was governed by these schemas, he sought a career that allowed him the maximum comfort, that is, the expression of the schemas. He sailed alone for months at a time. Colin Powell, the U.S. Secretary of State and former Chairman of the Joint Chiefs of Staff, says he fell instantly in love with the military when he joined the ROTC program his first semester in college. Although never a strong academic student, he excelled in the army. Powell served two tours of duty in Vietnam and went on to retire as a general from a successful military career "The discipline, the structure, the camaraderie, the sense of belonging were what I craved," he wrote, comparing it to the other pillar of his life, the Episcopal church. This need for structure and order can be seen as a driving force that directed his behavior and decisions, in this case successfully. His life, too, was governed by a schema, and he likewise sought a career that allowed him the maximum expression of it. And Secretary of State Powell continues to be so governed in his second career in the highly structured bureaucracy of the federal government (ABCNEWS.com, 2000). Therapists are often at the disadvantage voiced by Tevye. We can understand many of the rules that drive behavior. We see that individuals choose to abide by some rules, challenge others, and ignore some. But where the rules come from is often a mystery. In the present chapter, the formation and function of schemas will be discussed, along with the therapeutic impact and techniques for change. Our goal in this chapter is to develop a reformulation of Erikson's psychosocial model (1950) from the viewpoint of schema theory, emphasizing those schemas that are most specific and central to each of the eight stages in Erikson's model. Reciprocally, our understanding of schema theory will be enriched by examining it through the psychosocial lens of Erikson's stages of crisis.

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NATURE OF SCHEMAS Understanding schemas, belief systems, or underlying attitudes, is, then, the essential ingredient in understanding the behavior of the individual, families, groups, or cultures. Further they are essential in understanding an individual in his or her role as a member of a family, group, or culture. The schemas are the wellspring of assumptions (about the way that things are), standards (relative to what should be), demands (about what must be), perceptions (the way experiences are interpreted), attributions (about the causality of events and behaviors), and expectations (about how things likely will be). These then serve to generate the idiosyncratic thoughts, feelings, and behavior of the individual. These schemas and the resultant behaviors begin to be established from the moment of birth, possibly even in utero. Some of these schemas are strongly and vigorously held, while others are more transient and easily surrendered, disputed, or modified by the individual. Schemas that are strongly held often appear immutable to both therapist and patient and become the ways in which the patient is defined by self and others. For example, a particular pattern of schemas about the need for perfection in thought and deed would likely result in the individual's perceiving the world in dichotomous terms. It is either perfect or it is completely flawed. This would result in the individual experiencing a constant demand on self and others for perfect performance with consequent feelings of failure if performance is only 98 percent. Schemas are not isolated but are interlocking and appear in various constellations. For example, although most of us would subscribe to the basic personal religious cultural schema "Thou shalt not steal," we would probably not give back money to the telephone company that was returned in a pay telephone after we completed a call. Our rationale for this would probably be based on other parallel "rules" such as "getting even is okay/important," which may serve to generate the idea that since the phone company has taken our money for so many years, we can rightfully take theirs. If, however, we apply the rule "Getting even is okay/important" more broadly, it would allow us to take money from someone else (be he stranger or friend) as a way of getting even if our money had been taken by someone entirely different. Although we may deem it acceptable to "get even" with a large corporation, we would probably not deem it appropriate to get even with an individual. The two ideas are quite different.

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The schemas that govern behavior are idiosyncratic and hard to judge objectively. We might observe an individual respond to a particular stimulus with equanimity. At another time, that individual may respond with anger to what appears, to the observer, to be the identical stimulus. The meanings of the circumstance and situation are interpreted differently at different times and in differing contexts. Schemas may also be active or inactive. The more active schemas may be called the rules that govern day-to-day behavior (Freeman & Dattilio, 2000). Inactive schemas are dormant until they are stimulated into activity by either internal or external stressors. For example, a dormant schema may be triggered by a stressor or a life situation that taps into a particular problem area or personal vulnerability (Layden, Newman, Freeman, & Byers-Morse, 1993). It will then return to its dormant state when the stressor subsides. The activity-inactivity dimension can easily explain the psychoanalytic phenomenon of the "transference cure" or "flight into health" defined by Campbell (1996, p. 282) as "a relinquishing of symptoms that occurs not because the patient has resolved his neurosis, but rather as a defense against further probing by the analyst into painful, unconscious material. In many instances, the flight into health depends upon the patient's passive-dependent relationship to the analyst, whom he endows with magical power and omnipotence." Rather than ascribing the patient's changes to an avoidance of therapy, we can conceptualize the behavior in the following way. The patient encounters a stressful situation that activates dormant schemas. Although the patient's active schemas may be functional and adaptive, the inactive schemas that have been activated under stress and that now govern behavior are less functional. It is at this point that the patient is most likely to seek therapy to return to his or her previous (and more adaptive) manner of responding. After several therapy sessions, the patient, having had a chance to discuss various problems with the therapist, obtain guidance and structure, establish a therapeutic relationship, experience the caring and regard of the therapist, and develop problem-solving strategies, can reduce the internal or external stressors. The reduced stress allows the schemas to return to their previous dormant state, and what the therapist and patient then see is the previous, more adaptive behavior. Of course, we would expect that when and if the patient is stressed in the future, dormant and dysfunctional schemas will emerge once again. Conceptually, an important focus of therapy must be on stress reduction or techniques to allow the client to keep dormant schemas inactive

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(Freeman & Simon, 1989), modify schemas when possible (Beck et al., 1990; Freeman et al., 1990), and identify any of a number of "vulnerability factors" that increase the likelihood of dormant schemas being activated (Freeman & Simon, 1989; Freeman & DeWolf, 1992). These vulnerability factors decrease the active threshold of response to stressors and make individuals more likely to interpret stimuli as stressful and to respond to stimuli that they were previously able to ignore. The vulnerability factors have a summation effect, so that in combination they become part of a feedback loop. The lower the threshold, the more sensitive and vulnerable the individual becomes. The more sensitive and vulnerable the individual becomes, the lower the threshold. These vulnerability factors include acute health problems (such as influenza); chronic illness (such as respiratory problems); chronic pain and deterioration of health (such as occur in aging); hunger, anger, fatigue, or loneliness; any major life loss (such as the death of a spouse); any major life change (such as the birth of a child); substance abuse; poor problemsolving ability; poor impulse control; sequelae of any traumatic event (such as post-traumatic stress disorder); psychological vulnerability (such as to depression); and cognitive rigidity (such as that resulting from neurological insult). The situational nature of schemas has been examined by Schank and Abelson (1977), who found that many of our governing schemas appear to shift, depending on our construction of a particular situation. Accordingly, a single schema may be responsible for generating a broad range of dysfunctional thoughts, feelings, and behaviors. For example, the schema "To be loved (approved of, accepted, cherished), I must be perfect" might generate a number of cognitions and behaviors in both work and interpersonal areas. On the other hand, the schema might be specific to either work or interpersonal issues. When more vulnerable, for example, the individual may be far more responsive to the schema, place greater weight on the consequent cognitions, and find the schema far more believable than might be expected at other higher-threshold times. Inasmuch as schemas are the basis for our construction and understanding of the world, they are also the source of our everyday internal dialogue. When the schemas serve to generate negative and self-deprecating thoughts about self, world, or the future, they are a major ingredient for depression. If the schemas generate fear or concerns about personal safety, the result is anxiety. The self-deprecating life view may have been learned by an individual or be part of a broader cultural

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sense of inferiority, such as "We're no good." Significant others not only help to form schemas but also help to maintain them, regardless of whether the effect is negative or positive. McGoldrick (1982) stresses that families view the world through their own cultural filters, so particular belief systems may be familial or more broadly cultural. The homeostatic model often posited by family systems theorists describes the phenomenon of the entire system working toward maintaining a balance. If an individual within a family system attempts to change that system or alter his or her strength of belief in the system, the system may be mobilized into action to close ranks against the heretic or to work toward keeping the individual within the system. Family schemas based on cultural beliefs might be basic rules regarding sexual behavior; food; education; reaction to other racial, ethnic, or religious groups; or particular religious beliefs. Family-based schemas may be rooted in a particular culture or be present in many apparently diverse cultures. For example, many of us learned to eat everything on our plate because of the parental injunction "Children are starving in " The rule "Eat everything on your plate" may persist long after the parent is gone. We can be at a fine restaurant and be satiated, yet we may have the thought that we must finish everything on our plate. Rules about eating can be easily traced to parents and their direct instructions or modeling. The essential therapeutic question is not where the behavior comes from but what maintains the schemas as active over many years. Young (1990) proposes the notion of early maladaptive schemas (EMS). He identifies them as having several defining characteristics. According to Young, these schemas are 1. unconditional as opposed to more conditional underlying assumptions that "hold out the possibility of success" (p. 9) 2. self-perpetuating and, therefore, more resistant to change 3. by definition, dysfunctional in some significant and recurring manner 4. activated by events relevant to the schemas 5. tied to high levels of affect 6. the result of early life experiences within the family constellation and with peers Young goes on to identify 15 early maladaptive schemas divided into four categories. We would suggest that schemas in and of themselves

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are not necessarily good or bad, adaptive or maladaptive. It is instead individuals' interpretation or expression of their schemas rather than the schemas themselves that determines whether they behave adaptively or not. If we look at Young's first EMS, which he labels dependence (belief that one is unable to function on one's own), we can question whether dependence, in and of itself, is maladaptive. It might be the motive for seeking a supportive and nurturant partner or choosing a bureaucratic job wherein all eventualities are prescribed. The shift from adaptive to maladaptive can be seen when individuals who had been quite functional when guided by particular schemas experience a life change. The schemas may very quickly become maladaptive. The following example illustrates this point. Alan was a 67-year-old male. He had recently retired as chief executive officer of a large international firm. He had worked himself up in the company from the lowest level as a high school student to the chief position over a period of fifty years. In his retirement, he was physically healthy, had a great deal of money, good marital and family relationships, and a circle of friends. When he came for therapy he was, however, moderately-to-severely depressed (Beck Depression Inventory score of 35). The operative schemas that drove him to success, that is, "I am what I do or produce," "One is judged by others by one's productivity," and "If one isn't working, one is lazy/worthless," were now contributing to his depression. The schemas were the same, but the effect on his life was far different.

Young states that by compensating for particular early maladaptive schemas, an individual can overcome them and replace them with healthier schemas. The question is whether to label the schemas maladaptive or to label only those schemas for which there is no compensation as maladaptive. We would argue that the manner in which the schemas are addressed is what makes them maladaptive. DEVELOPMENT OF SCHEMAS Schemas are in a constant state of change and evolution. From children's earliest years, previously formed schemas are altered and new schemas are developed to meet the increasingly complex demands of the world. Infants' perceptions of reality are governed by their limited interaction with their world. Thus, they may initially perceive the world as crib and the few caretakers that care for them. As infants develop additional skills of mobility and interaction, they perceive their world

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as significantly broader, both in size and complexity. During the exploratory period, children develop mobility and begin to examine their world more extensively. They can then see that their world is indeed huge. With increased interaction with the world, children begin to incorporate familial and cultural schemas. One way of conceptualizing the change process is to utilize the Piagetian concept of adaptation, with its two interrelated processes of assimilation and accommodation (Piaget, 1936; Rosen, 1989). Assimilation can be defined as the way in which individuals utilize their environment in terms of how they conceive of the world. Environmental data and experience are only taken in by an individual as they can be utilized in terms of the individual's own subjective experiences. The individual's self-schemas then become self-selective, as the individual may ignore environmental stimuli that he or she was not able to integrate or synthesize. The process of accommodation involves the ability to modify a schema based on the subjective judgment that the schema no longer serves to organize and explain experiences adequately. The assimilative and accommodative processes are interactive and stand in opposition to one another. Therefore, we have an active and evolutionary process whereby all perceptions and cognitive structures are applied to new functions (assimilation), while new cognitive structures are developed to serve old functions in new situations (accommodation). Some individuals persist in utilizing old structures without fitting them to the new circumstances in which they are involved by using them in toto without measuring for fit or appropriateness. These individuals may further fail to accommodate or build new structures. Schemas are often difficult to alter because they are composed of five factors in differing proportions. The first factor is a strong affective component. A particular belief or belief system may engender a great deal of emotion and is emotionally bound to the individual's past experience. The second factor involves the amount of time that the schemas have been held. Schemas that have been part of the individual's personal history for many years will be more powerful than those acquired more recently. The third factor involves the individuals from whom the schemas were acquired. The more important and credible the source, the more powerful the schema. The fourth factor, the cognitive element of the schema, accounts for the manner in which schemas pervade the individual's thoughts and images. Schemas can be described in great detail and can also be deduced from behavior. The fifth factor is the

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behavioral component, which involves the way the belief system governs the individual's responses to a particular stimulus or set of stimuli. In seeking to alter particular schemas that have endured for a long period of time, are strongly believed, and were learned from a significant and credible source, it would be necessary to help the patient examine the belief from as many of these five different perspectives as possible. A purely cognitive strategy would have limited impact on the behavioral and affective elements. A predominantly affective strategy is similarly limited, and, of course, a predominantly behavioral approach can be limited by its diminished regard for cognitive-affective elements. The goal of psychotherapy, according to Adler (1927), is to help the patient to recognize the mistakes in his or her life-style (schemas), as the therapist has understood them, and thereby to increase the patient's ability to cooperate in the change process. This is a process of cognitive reorganization and of belated maturation. Patients often describe themselves as displaying particular characteristics as far back as they can remember. Objective observation may support their views that they have behaved in a certain way as far back as early childhood. For some individuals, a particular set of core schemas are well established in early to middle childhood. What then differentiates the child who develops a schema that is held with moderate strength and is amenable to change later on from the child who develops a core belief that is powerful and apparently immutable? I would posit the explanation to be one or more of the following factors: 1. In addition to the core belief, the child maintains an associated belief that he or she cannot change. 2. The belief system is powerfully reinforced by parents or significant others. 3. Although the dysfunctional belief system is not especially reinforced, any attempt to believe the contrary may not be reinforced or may even be punished; for example, it may be implied to a child that "you may be able to change, but we are not sure we would love you if you did change." 4. The child is not explicitly told he or she lacks worth, but any attempt to assert worth is ignored. 5. The parents or significant others may offer direct instruction contrary to developing a positive image; for example, they may say, "It's not nice to brag" or "It's not nice to toot your own horn because people will think less of you."

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The structure of schemas that comprise what we see as self may, at times, hinder performance or life satisfaction. Despite the negative impact, the rules are not easily shaken, much less given up. When the rules are challenged, an individual often experiences great anxiety. Although the schematic structure may be quite limiting, it provides a structure and protection against the world, against the unknown. By sticking to the rules, the individual can minimize anxiety. When stepping outside the rules, the individual becomes vulnerable, with anxiety accompanying the feelings of vulnerability.

UNDERSTANDING SCHEMAS An understanding of the patient's individual, familial, and cultural schemas is essential for both therapist and patient. It will explain past behavior, make sense of present behavior, and help to predict future behavior. The difficulty often experienced by therapists is how to classify the schemas, how to conceptualize the patient's problems, and how to develop therapeutic interventions to modify the schemas. Toward that end, we have found that Erik Erikson's (1950) psychosocial model serves as a way of organizing and understanding schemas, thereby assisting the therapist in structuring specific therapeutic interventions. Erikson's focus on the psychosocial context emphasizes that an individual does not grow and emerge from within a vacuum but rather within a social context of home, school, church, and peers. Each of these agencies has a marked effect on people, both individually and in combination with the others. The particular effect for an individual is based upon the individual's ability to assimilate and integrate the socialization demands of each of these areas. Erikson's model is a "crisis" model because it states that throughout life an individual encounters a number of life crises. By the nature and degree of resolution or non-resolution of these crises, the individual grows and develops in a particular direction. As each individual develops, he or she acquires an idiosyncratic life view with attendant behaviors, cognitions, and affects that are uniquely specific to that particular life view. Erikson sees these crises as amenable to change throughout life, as opposed to the much more rigid formulation of fixation at various stages of psychosexual development proposed by Freud (1949). All of Erikson's eight crises are concurrent at all points in life, rather than

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emerging in a sequential fashion. His model presents a much more optimistic view for crisis resolution than does Freud's psychosexual stage theory because the opportunity to resolve the various crises is more readily available throughout the life cycle. Often, age ranges are noted in conjunction with the various stages. These are not meant to indicate that the crises begin and end within rigid age constraints but rather that at particular ages certain crises are more compelling and important than at other ages. An individual may have been unable, for many reasons, to successfully cope with a particular crisis and to resolve it in an adaptive manner at a certain age. Based on the concurrence model, the individual will have many opportunities to confront that crisis and to resolve it in an adaptive manner. The schemas are not resolved in an all-or-nothing fashion but rather on a continuum. Individually and in combination, Erikson's eight crises subsume virtually every possible schema. By understanding the particular types of behaviors that emerge from the resolution or non-resolution of a crisis, the therapist can then begin to more effectively tailor interventions to help individuals and families resolve or cope with crises that were ineffectively resolved earlier in life. The first major therapeutic task is discerning and making manifest specific schemas, which will allow the therapist to work with the client to examine the schemas, the advantages and disadvantages of maintaining them, and ways of disputing or modifying them.

CHANGING SCHEMAS

The therapist has five options of how to help the patient to alter the identified schemas. These options are on a continuum from the most to the least complex. The first option is schematic restructuring or reconstruction. Having decided that a schematic structure is unsound, useless, or simply unwanted, the therapist and the patient may decide to tear down the old structure and build a new, more useful, and adaptive structure in its place. The reconstruction of unwanted schemas has been a goal of therapy for many years, particularly the psychoanalytic therapies. Whether this restructuring is reasonable or possible is very questionable. As in urban renewal, the old structure might be knocked down if it exists in isolation. If, however, a structure exists in the midst of other structures, the demolition must be done carefully, slowly, and in a stepwise fashion. An example of schematic restructuring is to have

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a person with a paranoid personality disorder become a fully trusting individual. A second possibility is schematic construction. This involves building a structure where one never existed before. There is no need to remove older structures but the therapist might be hard pressed to find the "construction" materials necessary for the structure. The third option is schematic modification. This approach involves maintaining the schematic structure but making smaller changes in the schemas than in the previous approach. The number of changes may be large or small. I would liken this strategy to remodeling an old house. One remodeling job might require a new roof, new plumbing, new wiring, foundation supports, pointing the brick walls, painting the exterior, and interior design. Another remodeling job might only require some minor changes. An example of this approach would be to have an individual with a paranoid personality disorder trust some people in some situations. The fourth possibility is schematic reinterpretation. This approach involves helping patients to understand and reinterpret their schemas in more functional ways. Through schematic reinterpretation, the therapist can find ways for the patient to deal with his or her schemas/rules in a more adaptive and functional manner. Rules are not necessarily good or bad; it depends on how they are interpreted. For example, if a woman had a great need to be loved or admired, she might choose to teach preschool children, who kiss and hug the teacher. If one wanted to be looked up to and respected, earning a title such as professor, doctor, or colonel can meet the need for status. Many vocational choices are made because the career or occupation offers an opportunity to meet the individual's schematic press. A final treatment focus is what we call schematic camouflage. This approach involves behavioral changes that are more cosmetic than those in the other options. For example, a schizoid individual can be helped, through social skills training and behavioral rehearsal, to learn and to then try a certain behavior with a co-worker. Although the patient did not necessarily understand fully the meaning and subtleties of the behaviors, he was willing to do them, thereby making himself much more acceptable in the office. Given that the schemas become how one responds to stimuli, they are the factors that are used in making diagnostic statements. If the clinician is told of the diagnosis of a client (assuming that it is an accurate diagnosis), the clinician can expect certain schemas to be

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prepotent. Conversely, the verbal and behavioral expressions of the schema are diagnostic.

VIEWING SCHEMAS THROUGH ERIKSON'S PSYCHOSOCIAL MODEL In reviewing Erikson's theory (1950), we can see that a number of cognitive, affective, and behavioral themes emerge from the unlimited combinations and permutations of the sequelae of how the individual resolves the various crises. While working within Erikson's psychosocial framework and addressing the crisis-oriented themes specific to each of his stages, we hope to provide a deeper and more differentiated understanding of each stage by introducing and discussing the cognitions specific to them. Similarly, Erikson's theory provides a framework for imparting a developmental order to what might otherwise appear to be a random array of diverse schemas. One of the most effective ways of seeing the powerful impact of schemas is by examining the specific schemas of personality-disordered clients in relation to Erikson's psychosocial stage theory. It is in the personality-disordered behavior that the schemas observed normally in all people are exaggerated and seen in caricature. Clinical examples will be used to illustrate the generic schemas that result from various levels of each crisis resolution. By identifying schemas and their stage source, the therapist can develop a more adaptive resolution of the particular crises.

Crisis One: Trust Versus Mistrust Human infants are born unable to care or fend for themselves. They are dependent on others to provide that care for a longer time, relative to life span, than are other animals. Because of this inability to be mobile and feed themselves easily, human infants must learn to trust the environment, specifically the major caregiver, to provide this basic care. If basic needs are met, the infant will develop a sense of trust and hope, learning, in effect, 'Yes, this world can be trusted, my needs are met, and I am or perceive myself to be comfortable and protected." If, on the other hand, the environment provides little comfort and care, the infant learns that discomfort is a way of life, thereby establishing ideas that "the environment cannot be trusted, my needs will not be

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met (or will be met in an intermittent fashion), I am not comfortable, and I will not be protected." The establishment of hope for the future is the major theme underlying schemas related to the trustworthiness of the world. Individuals who manifest suspiciousness of others or difficulty maintaining close work or interpersonal relationships because of a constant fear of being hurt can be seen to manifest this lack of trust and the concomitant lack of hope that the current state of affairs will ever change. This is a style often seen most dramatically in borderline personality disorders and paranoid personality disorder. To some degree, the lack of hope generated by low levels of trust is also part of the avoidant personality disorder. Schemas that reflect the negative or positive resolution of the crisis and a lack or presence of trust can be inferred from the behavior and automatic thoughts of any patient. These include: Negative Resolution

Positive Resolution

"People can't be trusted."

"People can be trusted."

"I'll always get hurt."

"I may get hurt."

"The world is a killer."

"The world can be a killer."

"Nothing I do will soothe me."

"I do/can self soothe."

Automatic thoughts occur spontaneously and will point to schemas of trust or mistrust. These will be found in every area of the cognitive triad (Beck et al., 1979) and can involve trust or mistrust of self, of one's body, of the world, and of the future. Given that the resolution of schemas is not an all-or-nothing matter, varying degrees of resolution will yield differing amounts of trust. The schemas are utilized adaptively or nonadaptively. Some individuals may withdraw because of their lack of trust and may seclude themselves to prevent being hurt or damaged. They may even affiliate with others who are equally mistrustful but will not easily trust the others. For example, political or religious groups that have as a tenet of their creed that they must be isolated to preserve themselves would be perceived by others (outsiders) to have a siege mentality. Other individuals may stay involved with the world but may directly and overtly manifest this lack of trust in adaptive ways. A person who chooses a career as an enforcement officer of any set of rules, be they financial (Internal Revenue Service) or legal (police), may be driven by the notion that

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people can only be trusted "so far" and that it would be a life's work to "get" the untrustworthy offenders. Further along the resolution continuum are individuals who have a greater sense of trust. They are more willing to take risks and chance loss inasmuch as they believe that it would not be so terrible. Typical schemas for these individuals include: "If by chance I lose, I can always regroup and try again." "If I fall, I trust that there will be people there to support me." This world-view allows these individuals to take more risks in life. The applications of the schemas to different areas, such as career, business, or interpersonal realms, will differ because of other schemas that are active. For example, an individual might be adventuresome in work activities but decidedly mistrustful in interpersonal areas. The greater the trust, the more optimistic or hopeful the individual.

Crisis Two: Autonomy Versus Shame and Doubt A second crisis is the establishment of a sense of willfulness. Willfulness is the perceived freedom to make attempts to affect one's environment and meet one's own needs. Children in the second year of life become increasingly mobile. No longer relegated to passively hoping that the environment will provide for their needs, they can crawl, walk, climb, and reach. As neurological integration proceeds, they develop receptive and expressive language that allows them to ask for what they want in many ways. For example, sweetly ("Daddy, can I please have that? I love you"), assertively ("I want that"), irritatingly ("Pleeeeeassse"), or threateningly ("If I don't get that, I'll be sad and won't be your friend"). Ideally, at this point, children learn to meet many of their own needs. However, children who have learned earlier in life that the environment is untrustworthy and dangerous are less likely to take risks, resulting in decreased practice in taking care of themselves. They are, by virtue of the decreased practice, less likely to develop autonomy and therefore are doubtful of their ability to respond in broad or more specific areas of life skills. Conversely, the individual who has resolved this crisis in a positive direction and has developed a sense of personal freedom will be more assertive in a broad range of life situations. Schemas that relate

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to this crisis concern the issue of choice. The schemas resulting from the resolution of this crisis include: Negative Resolution

Positive Resolution

"I have no choices." "I have no options." "I'm stuck." "I'm unassertive and cannot get (or have) what I want." "I can't find a life direction or directions."

"I have choices." "My options are limited." "I have many options." "I can ask for what I want." "I have several possible ways to get going."

The beliefs related to the negative resolution of this crisis revolve around the issues of believing that one's horizons are limited, a general inability to make decisions for oneself, and a more general sense of helplessness. A manifestation of the more negative resolution of these schemas may be seen in the individuals who are dependent on others to make decisions because they do not have faith that their choices will be reasonable or correct. For example, the bureaucrat who cannot make any personal choices and is known as someone who sticks to the rules can be very successful within the bureaucratic system. The positive resolution of this crisis results in greater risk taking, a greater sense of personal autonomy, increased practice in a variety of life-skill areas, and a greater sense of personal efficacy. Individuals who have resolved this crisis in a positive way see their horizons as less limited and are more likely to "try their wings and try to fly" because they believe that even if they do not fly (or do not fly very high), they will be able to recover and to try their flight behavior again.

Crisis Three: Initiative Versus Guilt The major theme of this stage is that life and activity have a purpose. Having learned that one can exert control, to a greater or lesser degree, over the environment, the child can now move toward developing personal volition or will, with the goal of developing a sense of life purpose. Thus, the individual becomes more goal oriented or directed. The cumulative nature of the positive resolutions of the first three crises

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can be seen in the individual who has first developed a sense of trust, which sets the stage for a greater sense of autonomy, which leads to a greater sense of purpose and the expectation that they can be successful. These three stages are to Erikson (1950) the basic foundational stages upon which all other stages will stand. Having tried various activities and having developed skills in a broad range of activities, the individual is now able to actively seek various activities, rather than waiting for the environment to provide the desired activity. The positive resolution of this crisis would result in the individual's acquisition of a sense of resourcefulness. The negative resolution would result in the individual's harboring cognitions regarding whether he or she has the right to make choices. Typical schemas related to the resolution of this crisis include: Negative Resolution

Positive Resolution

"Life has no purpose." "I feel aimless and adrift." "There is no place to go and nothing to do." "I can't get started. I'm paralyzed." "I can only work with external pressure."

"Life has a purpose." "I have a direction." "Life has untold possibilities." "I'm on my way!" "I can get started by myself."

The children's story of the little locomotive who puffed to the top of the hill saying, "I think I can, I think I can" exemplifies the positive resolution of the crisis. Individuals who have resolved this crisis relatively well will be more likely to do things for themselves without urging or pushing from others. Those who have a relatively negative resolution will be less likely to be successful on their own.

Crisis Four: Industry Versus Inferiority This crisis will, ideally, eventuate in the development of a work ethos. The two extremes of this crisis are either the development of a sense of competence or the development of a sense of inferiority in work or productive areas. In any society, an individual must gain the skills neces-

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sary to successfully function in that society. In primitive tribal societies, the most basic skills involve helping to skin and dress animals, tending to the garden, and sharpening tools. The older or more competent individuals have learned to hunt and are responsible for providing food and caring for the tribe as a whole and for their personal families. In an agricultural society, the basic skills may involve feeding chickens and tending a house garden, and the more advanced skills involve running the entire farm. It is interesting to note that in both types of societies, competence is not necessarily age related. When an individual becomes too old to effectively function in the caretaker role, he or she may once again be relegated to basic (less competent) behaviors. In our complex technological society, the development of competence includes the acquisition of basic skills in reading, learning, and technology. The development of competence begins at birth. Progressively developing skills, we become competent at walking and talking. The development of the particular skills required for productivity in a society occurs most frequently for individuals in all societies between the ages of 5 and 12. The search and striving for competence never stops. As a case in point, the reader going through the present work does so with the goal of increased knowledge of or competence in psychology. In our society, whether a child establishes a sense of competence will likely be linked to the child's experience in school. The foundational blocks of competence are the development of trust, autonomy, and purpose. A negative resolution of the crisis will establish a lack of confidence in the child. This may be manifested by a sense of inferiority about his or her skills and may produce an inability to maintain a job or any focused work. Verbal representations of the resolution of this crisis include: Negative Resolution

Positive Resolution

"I can't do anything."

"There are many things that I can do." "I am competent." "I have some talent." "I may possibly fail." "There are areas in which I am better." "I have many talents."

"I am incompetent." "I am inept." "I will probably fail." "I am stupid. "I am untalented."

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The positive resolution of the crisis gives the individual a sense of confidence to deal not only with the specifics of school but more generally with work and life activities. The positive resolution yields ideas about "anything being possible" or the thought that "if one puts his or her shoulder to the wheel, then almost anything can be accomplished."

Crisis Five: Identity Versus Identity Diffusion Throughout life, the question that is asked of self and others is "Who or what am I?" This query is not meant simply as an existential question but as a way of placing oneself within the various categories of personhood: Am I a girl or a boy? Am I in the robin or bluebird reading group? Am I cool? While generally seen to be the focus of the adolescent, the search for identity is lifelong. The goal of this crisis is the acquisition of a sense of identity (self) and an overcoming of identity diffusion. If an individual has not developed a sense of competence, purpose, will, or trust, that individual will begin to define himself or herself as incompetent, unable to cope, and incapable of effective action. This negative sense of identity becomes one of the most frequent presenting problems in therapy. Called low selfesteem, negative self-image, poor ego identity, or poor sense of self, it is the prime factor in the cognitive triad (Beck et al., 1979). When an individual is attempting to establish a sense of identity, he or she may experiment socially, sexually, and intellectually in an attempt to find out what fits best. Through the use of modeling experiences and peer pressures, the teenager is in a position of being able to make major changes in his or her identity. The pattern of identity set out in adolescence may serve well for many years, only to be questioned at later points. For example, a woman at age 18 may willingly assume the identity of wife and mother. This role image may be very satisfying for many years. However, at 35 or 40 years of age, this same woman may feel that she has no "self or identity except as she is seen by her husband and children. At that point, she may attempt to alter her identity or, at the extreme, establish a new identity. She might do this by returning to school, becoming competent in new areas, finding new friends, or asking that her family see her in new ways. Or, she may bemoan her fate, thinking that all is lost, that she can never be different, and that she is not a competent woman who can alter what she does and become a "new" self. This may involve changing or giving up who

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she was and experimenting with new ways of responding. Schematic representations of the resolution of this crisis include: Negative Resolution

Positive Resolution

"There is no me." "I don't know who I am or where I am going or what I will do when I get there." "I only exist in the eyes of others." "They think, therefore, I am."

"I know who I am." "I have a life direction."

"I have value." "I believe that I am important."

This identity crisis can, of necessity, only be partially resolved as an intrapersonal issue. Developing or changing the sense of self within the social context often becomes an essential therapeutic issue. Who we are in our own view is often tempered by the view of others. At either extreme, there is difficulty. To totally ignore the view of others is typical of the schizoid personality disorder. To always bow to the view of others is more typical of the dependent or avoidant personality disorders. The constant question of who we are in a variety of life interactions often pervades our lives. The positive resolution of the crisis helps answer the question for the time being. As we age, encounter new life circumstances, and experience various life stressors, our sense of identity will constantly be in flux, though based on the foundation of whom we have decided we are and the value we give to our view of self. Crisis Six: Intimacy Versus Isolation The interpersonal nature of schematic development is highlighted in the crisis involving the acquisition of a sense of interpersonal intimacy. The basic theme of this stage is love. In this stage, the individual has an opportunity to more fully resolve the identity crisis. During the adult years, people focus on the acquisition of an interpersonal identity and the acquisition of a significant other. This focus begins during middle childhood, when we recognize that we are attracted to others, both within and across gender distinctions. Children will identify with a same-gender individual whom they perceive as attractive, powerful, or popular. They also recognize that others of the opposite gender are attractive and popular.

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During adolescence, dating helps to confirm or refute ideas developed in the childhood years. For some individuals, the apparent inability to establish intimacy becomes the major focus of their life and work. These individuals will lead lives of "quiet desperation," seeking and then avoiding intimate contact. Despite the many sexual liberation movements, a significant number of women still maintain the dysfunctional belief "I am nothing without a man" (Russianoff, 1983), just as many men believe that they must have a woman or they lack value or worth as a male. The positive resolution of crisis six is the establishment of an intimate relationship, and the non-resolution of this crisis is the experience of isolation. Verbalizations associated with the resolution of this life crisis and the attendant schemas include: Negative Resolution

Positive Resolution

"I can't get close to anyone."

"I can connect with others."

"In relationships I always get hurt."

"I can take risks in relationships."

"I'm nothing without a man/ woman."

"I have value by myself."

"I am unlovable."

"I am lovable."

"Nobody would want me?"

"There are those who would want me." "I may be alone."

"I'll always be alone."

The individual who has developed a sense of intimacy can develop and maintain relationships with members of the same and the opposite sex. Intimacy can take the form of being part of an institution such as a religious order, fraternity, or club. It is not limited to heterosexual relationships but is a basic issue in all relationships. Any behavior that keeps the individual from being isolated contributes to an intimate focus in life. For the individual who has developed a sense of closeness and intimacy, breakups in relationships become troublesome, upsetting, and irritating but not catastrophic. Building on a foundation of trust, autonomy, initiative, and identity, the individual will, after a period of time in which he or she mourns a lost or broken relationship, move toward establishing new or different relationships.

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Crisis Seven: Generativity Versus Self-Absorption The major theme of this crisis is the development of a sense of caring for others. It involves "reaching ahead" to have an influence on the next generation. The negative resolution leaves the individual isolated and self-absorbed. The essence of this crisis is exemplified in Charles Dickens' classic story A Christmas Carol (1843/1939). He describes the misanthropic (and isolated) Ebenezer Scrooge, who upon being wished a happy Christmas by Bob Cratchit, responds, "Bah, humbug." When asked to contribute to orphans and widows, Scrooge asks about the existence and maintenance of prisons and workhouses. After the visit by the three specters of Christmases past, present, and future, Scrooge resolves his life crises in a new and very different manner. He sees the light, and not wanting to die a lonely and scorned individual, becomes one of the best men the town had ever known and as good a friend as one could be. By reaching out to Tiny Tim and behaving as a second father to him, Scrooge moves away from the stagnation and self-absorption of his present life to a more giving and generative life-style. The concern for the next generation involves helping one's own children resolve their life crises. We also see it in the workplace when we help new workers acquire the skills necessary to effectively do their job by sharing what we have learned over the course of our work life. We see children acting in caring and generative ways when siblings reach out to help one another. We can see 3-year-olds reach out and help 2-year-olds. The individual who has made a negative resolution of this crisis remains isolated, alone, and unloved. Thoughts that result from the resolution of this crisis include: Negative Resolution

Positive Resolution

"I don't care about anyone else."

"I care about others."

"I'm only looking out for number one."

"No man is an island."

"No one cares about me so why should I care about them?"

"Love thy neighbor as thyself."

"Screw the world!"

"The world is not as kind as it could be."

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Crisis Eight: Integrity Versus Despair The goal of this eighth crisis is the acquisition of a sense of integrity while overcoming a sense of despair about what one has done or not done. The basic theme of this stage is the attainment of wisdom. All of us have at some time expressed the wish "to do it over again." The sense of integrity is exemplified by the individual who can look back over past activities and can say, "It's been good" or even more moderately, "It's been okay." The individual who has developed a sense of despair looks back over his or her life with a wish to do it over again, which may be impossible. This style of thinking has been labeled as "Woulda, Coulda, Shoulda" thinking (Freeman & DeWolf, 1989). It involves an individual's constantly reviewing past activities and thinking or saying what he or she could have done, might have done, or should have done. This rumination does not necessarily change or enhance future behavior but leads to nonproductive and preservative inaction. We can, however, use our experience and acquired wisdom to act differently in the future. Verbalizations representing the possible resolutions of this crisis and the resulting schemas include: Negative Resolution

Positive Resolution

"I should be able to do it over again."

"I have to live with what I have done."

"Life has been too short."

"Life has been full."

"I haven't done all I wanted to do."

"I have done much in life."

"Life has been unkind to me."

"Life has been hard in many ways."

"Misery is endless and a product of the mistakes I have made throughout my life."

"It is time to let go of upset."

Individuals, who have established a sense of integrity in their life, either generally or specifically, accept behaviors within the context in which they occurred. The belief that they did their best and that they are satisfied with the result of their efforts leads to self-satisfaction and an enhanced sense of identity.

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APPLICATIONS TO PSYCHOTHERAPEUTIC TREATMENT By listening to and understanding the nature of the patient's words and thoughts, the therapist can begin to identify the patient's schemas by general thematic areas of concern. The patient's verbalizations are the signposts that point to the schemas. Specifically, the particular crisis that the schemas may represent becomes clear, allowing the therapist to begin to develop affective, cognitive, or behavioral interventions to help the patient to test out not only automatic thoughts but also underlying schemas. To promote long-term therapeutic gain, it is important for the therapist and the patient to focus on the schemas, rather than merely having the patient challenge or dispute his or her automatic thoughts. The testing of the automatic thoughts is the first step in the therapeutic process. The initial therapeutic goal is to focus the therapy in the most fruitful areas for change and adaptation; this is in the area of dealing with the automatic thoughts. The patient can be helped to verbalize his or her thoughts not simply because the verbalization in and of itself is cathartic and curative but more because by identifying the automatic thoughts, the patient can gain the skills to confront his or her problems and to challenge the thoughts. Listening to the patient's automatic thoughts, the therapist must ask how the dysfunctional schemas are presently being maintained and how they have been maintained over the years. If a particular belief is only partially believed by an individual, it is much easier for the individual to give up the belief because he or she is giving up a small piece of a belief system as opposed to challenging what he or she sees and regards as self. The effect that a schema has on an individual's life depends on (1) how strongly the schema is held and believed, (2) how essential the individual sees that schema to be to his or her existence, (3) the lack of disputation that the individual engages in when a particular schema is activated, (4) previous learning vis-a-vis the importance and essential nature of a particular schema more generally, and (5) how early a particular schema was internalized. We all hold certain schemas more strongly than others. If a particular schema has been strongly reinforced, it will be powerfully held. The patient who manifests chronic "neurotic" behaviors and character disorders often sees his or her symptoms as "me." This patient will readily say, "This is who I am and this is the way I have been all my life." The belief in a particular schema may, in fact, be altered by life context.

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For example, if an individual is in a threatening situation, his or her schemas relative to self-protection or the danger inherent in being within that context will be more active or believed more strongly. By asking patients to challenge or directly dispute their dysfunctional beliefs, the therapist is asking them to directly challenge their very being. When the challenge to self is perceived, the individual usually responds with anxiety. The patient is then placed in conflict as to whether he or she would prefer to maintain particular symptoms or to experience anxiety. Particular schemas become powerful underlying core schemas and are pervasive in the individual's cognitions and behavior. The core schemas are those that are continuously reinforced by others and utilized by the individual and that have self-reinforcing and maintenance mechanisms. For example, individuals who are perfectionistic generally maintain the belief that if they are not perfect, they are not lovable or acceptable. This schema is difficult to challenge because it is usually reinforced by the family and the society. Given that one can always find others to validate one's own perfectionism, the schema endures. The schema also has a built-in survival mechanism, the thought by the individual that "those people who don't see the need for perfection are limited and flawed." For these patients, the disputation or labeling of a particular cognition is an intellectual challenge. They often report that they are unable to feel the challenge to their schema "in their gut." These patients request help but see challenging their symptoms as uncomfortable and dysfunctional and have great difficulty in changing the behavior. They take the position that they cannot or, more correctly, choose not to or are afraid to change that which they see as "them." As they see themselves defined by the problem, they hesitate to give up the problem because they believe that they would be left with nothing but an empty shell. We can then see that a challenge to the self should be the result of a careful, guided discovery based on collaboration, as opposed to a direct, confrontational, and disputational stance. The earlier a schema is learned and internalized, the stronger it will be. The experiences of our childhood provide the learning situations that are the basis of schematic development. Alfred Adler (1927) once commented to a patient that the patient was cowardly and had been much braver as a child. When the patient asked him what he meant, Adler explained that when the patient was a child first learning to walk, he likely crawled to a chair or other suitable object and slowly pulled

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himself up. After becoming comfortable with that part of the task, he then allowed himself to let go and, inevitably, fell. The child, however, Adler pointed out, continued to practice letting go and falling until he achieved balance and did not fall as often. The child began to take steps, once again finding himself falling until he had mastered walking. It is through the risk of failure that the individual achieves mobility. The adult patient, Adler pointed out, was frightened of taking risks and failing (falling). It is not then merely the failure that causes the individual to back away but also the fear of that failure and the particular idiosyncratic meaning that failure will have. In virtually every endeavor, there is an element of risk. We may be more or less likely to undertake an action based on our appraisal of the risk involved and our ability to effectively cope with that risk. The individual who has maintained a particular life pattern and life-style would then be less willing to be a risk taker, despite the difficulty that the maintenance of a neurotic behavior may cause. By structuring affective experiences (that is, abreaction) as part of therapy and behavioral experiences that can be used for testing out personal/familial beliefs, by helping the patient to question, challenge, and modify beliefs, the therapist can help the patient gain symptomatic relief and better life adaptation. The opportunities to test and modify schemas occur constantly throughout life. For example, a woman approached by a man at a party encounters the first crisis of an incipient relationship, that is, trust versus mistrust. Based on the way he is dressed, how he carries himself, and what and how he verbalizes, she will make preliminary judgments such as 'Yes, this is an interesting person, and I would like to get to know him a bit better." This amounts to demonstrating a sense of trust. The following cases illustrate the use of schematic understanding via a psychosocial framework and the focused cognitive therapy interventions that are suggested by the conceptualization.

CLINICAL EXAMPLE: THE CASE OF JENNIFER The focus of the first case discussion is related to the treatment of marital and sexual dysfunction wherein the therapist saw only one member of the couple. Her husband had told the patient, Jennifer, that he refused to come to therapy. Jennifer was a White, Jewish, 33-year-old, married female referred by her family physician. She described herself as depressed, so depressed, in fact, that for the past year she reported that she has been "paralyzed." She

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described her depression as affecting her work life, her marital and sex life, and her social life. Although not presently as depressed as she had been several months earlier, she did not feel that she was as functional as she has been at the peak of her productivity. She described her marital difficulty, at first, as being in part due to conflict with her career needs and her husband's life-style. She was reluctant to make any changes in either career or marital status, as she was fearful of losing her husband and then feeling that she was unlovable and would never be able to be with anyone. The sexual difficulty involved painful intercourse. As a result of the discomfort, she had avoided sexual intercourse for the past 3 years. Her husband was aware of her coming for therapy, but made it clear that he considered the problem (s) to be hers, and that while he would be supportive of her efforts, he had no interest in participating in the therapy. This was true throughout the therapy. She lived with her husband in a northern suburb of a large city, and worked in a far southwestern suburb of that city. This amounted to a 2-hour commute through the city, in either direction daily. Her husband worked in the area in which they lived and had a 15-minute commute in either direction daily. To ease the commuting problem Jennifer maintained a small apartment near her work. They had lived apart for 2 years with Jennifer seeing her husband on weekends to avoid the 140-mile round trip commute. She was employed as the equal opportunity officer and assistant to the president of a large corporation She was concerned that her work had been unsatisfactory and she was in danger of being fired, although she had no evidence that the president was thinking of firing her. She had been married for 7 years but there had been no sex in the marriage (or outside the marriage) for the last 3 years. Jennifer was the second youngest of four children, having brothers aged 36 and 35, and a sister 28. Her mother was a teacher and her father a retired chemist. Both were physically active, her mother still working as a teacher. She described her childhood as relatively unhappy with episodes of depression from about age 12 on. She was the butt of insults and teasing from her second older brother who would constantly call her "elephantiasis," a reference to her being overweight and later having acne. Jennifer described herself as unpopular as a child with very poor social skills. She was seen as "brainy" and uninvolved in the social activities of her childhood and adolescent peers. She had no dates throughout her adolescence and first starting dating in college. She met her husband when she was 24 years old; they dated for 2 years and married. She reported having few friends, except friends at work with whom she did not socialize. Jennifer always did well in school. She was graduated from high school with high honors and was graduated from a small, prestigious private college where she received high honors and was a member of Phi Beta Kappa, graduating summa cum laude. She continued her graduate work at Yale University getting her M.A. degree and her Ph.D. in history. For the past 3 years she was responsible for the implementation of equal opportunity and affirmative action programs at the company.

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The findings of a recent general medical evaluation were that she was in good health, 15 to 20 pounds overweight, with no other medical findings. A gynecological examination found no physical reason for the painful intercourse. Jennifer had been in therapy with a social worker once or twice a week for 4 years while a graduate student in New Haven. She described the therapy as "helpful" but was unable to verbalize what she learned. She felt that the therapist was supportive and offered a critical listening ear. For the past 2 years, she and her husband were in sex therapy to deal with the lack of sexual activity but the result was that they terminated therapy but did not initiate sex. She described the therapist's approach as focusing on their communication difficulties. They were encouraged to put time aside each day to talk, even if by phone. There was little to no discussion of the sexual problem directly. According to Jennifer, this was due to two factors. The first was the therapist's orientation, which was that if she and her husband could be encouraged to relate better "standing up," they would be able to relate better lying down. The second factor was her husband's oft-stated reaction that sex was not something one spoke of in public with strangers. At intake, Jennifer appeared well groomed and neat. She was cooperative throughout the interview. Her mood was depressed, and she appeared sad and cried several times throughout the first session. She was, however, able to smile and laugh appropriately. Her speech and thought were clear and appropriate. There were no hallucinations or delusions, but some minimal depersonalization. She was oriented in all spheres.

Major Problem Areas/Cognitive Distortions Major areas of difficulty were (1) depression, (2) marital difficulty, (3) sexual problems, and (4) vocational difficulty. Her intake diagnosis was: Axis I—Major Depression, Recurrent, Dysthymic Disorder, Axis II—R/O Obsessive-Compulsive Disorder, Axis III—None, Axis IV—Marital Difficulty (severe), job difficulty (moderate), Axis V—Excellent functioning at work, poor functioning in marriage. On intake, Jennifer's BDI score was 42, placing her in the severely depressed range. She endorsed ten of the 21 items at the highest level. An assessment of her suicidal ideation indicated a score of 6, endorsing a weak wish to die, and her reasons for living and dying about equal. Her general attitude toward the suicidal ideation was ambivalent; her reason for contemplating a suicide attempt was to escape and solve her problems through a surcease of the depression and difficulty she was presently experiencing. The major deterrent to her attempting suicide was her husband and the thought that "it was going to get better."

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Jennifer was seen for a total of 28 sessions from the initial interview to the termination interview, over a period of eight months. She was seen twice weekly for the first 2 weeks of therapy and then approximately once weekly thereafter. Formulation of the Problem The patient presented several discrete problems: (1) an overriding sense of hopelessness with a consequent suicidal ideation, (2) marital difficulty (e.g., relating to her husband and maintaining the marital relationship), (3) sexual difficulty involving abstinence from intercourse because of pain and discomfort, (4) career difficulty—a sense of dissatisfaction with her present position in terms of whether or not she can effectively work and do the kind of job that she feels she needs to do, and (5) lack of a social support network. Conceptually the patient was a perfectionist who used an all-or-nothing approach to problem solving. A major goal of treatment was to have her alter this dichotomous thinking to allow herself to be successful. Part of treatment would also necessitate an exploration of the marital/ sexual difficulties. The direct treatment for the sexual problems will be the main focus of this case report. Because of the suicidal ideation, a rather immediate set of interventions focused on Jennifer's sense of hopelessness to relieve the suicidality and make it less likely to pose a danger to the patient. At termination and in 2!/2 years follow-up: (1) the patient had changed her job so that she now worked for higher pay and equal prestige, 4 miles from her home; (2) there was no longer an issue of hopelessness and suicidality; (3) she had become more conscious of her health and physical appearance, had lost weight, and had maintained the weight loss; and (4) she described her marital relationship as excellent, maintaining an active and gratifying sexual relationship with her husband. Through direct addressing of her cognitive distortions and the often-irrational underlying belief systems, the patient was helped to think more clearly, to behave more functionally, and to cope more rationally. CASE #2: ELLEN

In the following case, the problems of the personality disorder were interwoven with the patient's depression.

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Ellen came to therapy because of her recurring, severe depression. She had been employed as an elementary school teacher for the past 9 years. She taught first grade, and reported that her depression was exacerbated whenever she had to do school-related work, for example, grading papers, completing report cards, or preparing her class for school-wide testing. At those times she would become, "totally nonfunctional," would cry constantly, withdrew from any social activities, had nightmares, lost interest in previously pleasurable activities, and worked constantly without relief of her depression. At intake, her BDI score was 31, indicating a high level of depression. She endorsed the hopelessness item, self-hate, and self-blame at the highest level. Her scores on the Beck Anxiety Inventory Scale (BAIS) were 29 for severity and 18 for frequency of symptoms. On the Sociotropy-Autonomy Scale (SAS) she scored significantly above the mean on the need to be close to others, and lower than average on those items that assess individualistic achievement and freedom from control. On the WAIS-Clark she scored 39/ 40, indicating superior intelligence. She described a work pattern that involved teaching very slowly so that every child in her class mastered the material. She did this despite evaluations from her principal that suggested she speed up her pace. Her concern was that if every child did not master the material she would be held accountable by the parents, the principal, and ultimately the child. She did not, in her words, want to be "what kept them out of law school or medical school." She also reported life-long irritability, feelings of anger that she had trouble expressing, lack of social confidence, and compulsive checking. Her social life was minimal. She did not date very much, and had had few relationships that lasted over 3 months. Her most recent relationship ended when her boyfriend refused to do as she had asked. She had asked him to sit with her for hours when she was grading papers and to constantly encourage her with remarks such as 'You can do it," "Just a few more," "It's easy." Ellen saw his refusal as unwarranted and cruel. "It wasn't too much to ask. After all, he just had to help. Why won't people help me?" Despite such difficulties, she is far happier when she is dating. She feels lonely and empty, and has considered, on several occasions, having a pet. On each of these occasions she has had trouble deciding what kind of pet, and on two occasions had gotten a cat, but had to get rid of the animal because she was concerned that she was not caring properly for it. She held a bachelor's degree in liberal arts, and a masters degree in education. During herjunior year at the university, her father left her mother for another woman. It was at this time that her father told her that he had spoiled all of the children, and was no longer supporting her. This sent her into a severe depressive episode. He also said, "I've wasted my life with all of you." One of the consequences of the divorce was that Ellen immediately gave up her goal of going to law school. She stated that she did not think that she could have coped with law school without her father's support. She was the youngest of three children. Her older sister was a social worker. Both siblings were married and had families. Her father was a psychiatrist, as was her older brother. Her father had a history of psychiatric hospitalizations, and had been diagnosed with bipolar disorder. Ellen had

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never had any psychiatric hospitalization, although she had been in therapy for many years, dating back to college. She had been in psychoanalytic psychotherapy for 7 years, on a once or twice a week basis. This was combined with pharmacotherapy prescribed by her father, using both tricyclic antidepressants and benzodiazapenes. A trial of lithium carbonate was abandoned after Ellen had a toxic reaction. The letter from her previous therapist read, in part, "It is my considered professional judgment that Ellen is untreatable. She is resistant to treatment, combined with an inability to use insight, thereby making the treatment unsuccessful." He ended his report with "I wish you luck with this impossible patient." (Since this is the case study of Ellen, we will resist interpreting or commenting on the therapist's letter.) Ellen had never, in her 9 years of teaching, been on a vacation. She spent her summers preparing for the next year's academic work. There were tests to prepare, her classroom to decorate, and all of the catching up to do. Things that were left undone for the year such as balancing her checkbook, cleaning her apartment, and so on, were the things that she finally completed during the summer. It was decided to address her overall dysfunction from two different perspectives: the first the intrapsychic, and the second, behavioral skill building. In establishing a treatment problem list, Ellen placed work as the top priority. Her goal in therapy was to successfully teach her class, grade papers easily, have successful parent conferences, and please her principal. Dating was fifth on her priority list.

Conceptualization The two major themes in Ellen's life seemed to be how much she needed people to help her and how important work was for her. The dependent nature of her life experience seemed clear as she described her reaction to the loss of those she needed to help her (father, boyfriend, principal). A significant event occurred in the second session that served as a critical incident. She came into the therapy session crying. She spent the first 5 minutes trying to compose herself so that she could relate the traumatic experience she had just had. She related the following: "I was just on my way to the session. I come a certain way, you know, I come down 34th Street, and make a right up Walnut, and then park in the lot across from your office. You know what I mean? But when I came up to Walnut, there was a large construction crane blocking the street. They had the street closed so I couldn't make a right. There was a policeman directing traffic in the middle of the street. I pulled alongside of him and wanted to ask him if he could let me make the right turn. When I stopped and opened my window to ask him my question, he told me to move on. When I tried to ask him again, he yelled at me. He said, 'Lady, get this car out of here before I give you a ticket for blocking traffic.' I tried to ask him again to tell me how to get to your office, but he just blew his whistle at me and began screaming.

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I closed my window and drove away. It took me hours to get here. I had to keep making all sorts of turns." (In point of fact, she was 4 minutes late due to crowding in the parking lot. The detours involved going one extra block south, two west, and two north.) When I asked her about the incident, and what made it so upsetting, several points emerged: (1) She had always been taught that policemen were our friends, and that when in need, the police would help. (2) He could have allowed her to make the turn and go her "familiar way" as she would have been careful not to interfere with the construction crane. (3) She was concerned that she would be late and either the therapist would not wait for her or would think that she did not care about therapy. (4) She was breaking the plan that she had formulated for getting to the therapist's office (leaving school at a certain time, taking a certain route, parking in a certain place, being in the waiting room by a certain time to complete the requested BDI and BAI forms prior to the session). Overall, the theme of expected help not being forthcoming was very powerful. It presaged a pattern of expectation regarding the role of the therapist and her expectations/demands of what the therapy would do for her. The obsessive-compulsive problems came from her need to be perfect and have her students be perfect. The two issues, dependency and compulsive behavior, were connected in that the way she learned to win love, esteem, and recognition was directly tied to how well she performed. This early schematic connection was active and compelling for Ellen, and was the way she tried to structure her world to obtain love, to achieve safety, and to feel good about herself.

The Therapy One of the first problems tackled was what Ellen described as a mountain of work on her dining table. These were all tests that needed to be graded and then the grades entered in her record book. When she was asked to estimate the time it would take to complete the task, Ellen said, "days." The intervention chosen was to try to help Ellen to identify alternate ways of completing the work. After all, if she could identify new work possibilities, her pervasive all-or-nothing idea would be altered. Ellen was asked to describe the test to be graded. The task called for the children to count the number of objects in a series of boxes drawn on a page and to write down the number in a space next to the objects. Even though each test was identical to every other, Ellen's approach to grading them was to re-count every box on every paper rather than using an answer key. When she was asked why an answer key could not be used she responded that this might cause an error in her grading. "What if on one paper, the copier misprinted, and because of that the child correctly counted the number of objects but would be downgraded by my use of an answer key? That will affect his grade for the marking period, and might ultimately affect his grade for the semester. If he does poorly, succeeding teachers might think he's dumb, and not give

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him challenging work that could result in his not being able to get into some professional school like law or medicine." Ellen saw no possibility other than counting the objects and checking the answers on every paper. For homework, she was asked to bring a number of papers into the next session. Given Ellen's dependence, the therapist decided that rather than working to change the dependent style at this point, the style could be used in the service of the therapy. The in-session experiment was to have her grade five randomly selected papers using an answer key. If there were no discrepancies she was to assume that there were no misprints. If, however, there was even one discrepancy she was to grade papers using her "old" way. Time after time she discovered that there were no differences. This reduced her anxiety significantly. She could also take out an additional two papers for the "new" techniques on a random basis, but not more often than every three sets of papers. Given Ellen's dependent and obsessive styles, she could easily accept the therapist's new rules for paper grading. This same technique could then be applied to other tasks in her life. Overall, this experiment was quite successful. Ellen's homework was to grade papers the "new" way. By demonstrating the tiny difference, the minimal danger to herself, Ellen was able to remove the paper problem as a major issue.

SUMMARY

The first part of this chapter outlined the basic importance of understanding schemas. The personal, familial, and cultural schemas were discussed with a goal of conceptualizing problems within a schematic framework. The evolutionary nature of the schemas, with a specific emphasis on the powerful and proactive schemas one sees clinically, was examined. The second part of the chapter focused on the developmental model for the understanding of schematic development using Erikson's psychosocial crisis model. The particular themes inherent in each of the stages were presented to help the therapist explicate and fully detail the patient's schemas so that more appropriate and direct therapeutic interventions and strategies can be mounted. Inasmuch as all of the crises described by Erikson exist concurrently, crisis resolution can be done at any point. The resulting schemas can then be modified for improved mood or changed behavior. By dealing with schemas in this direct manner, therapists and patients can better resolve life crises, with a concomitant impact on present functioning. The final part of the chapter dealt with the therapeutic use of schematic understanding. It is by helping patients become aware of their schemas that they can be more actively collaborative in the therapeutic endeavor.

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The therapeutic steps are (1) explication of the schemas based on the patient's verbalizations, (2) exploration of the schemas to ascertain the value and power they have for the individual, (3) assessment of the thoughts and ideas that maintain particular schemas, (4) identification of and focusing on the attendant feelings and behaviors that derive from the schemas, (5) structuring specific interventions based on the patient's idiosyncratic personal, familial, and cultural schemas, and (6) structuring relapse prevention strategies to assist the patient in generalizing the therapeutic gain to other situations and occurrences. By confronting, disputing, or responding more adaptively to powerful, long-held schemas and to the emotional, affective, and cognitive sequelae of the schemas, we can begin to help the patient to move in more productive and coping directions.

REFERENCES ABCNEWS.com (2000). General Colin Powell: Symbol of integrity walks moderate path. Politics, December 20. http://abcnews.go.com/sections/politics/Daily News/profile_powell.html Adler, A. (1927). What life should mean to you. New York: Capricorn. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders—-fourth edition (text revision). Washington, DC: Author. Beck, A. T., Freeman, A., & Associates. (1990). Cognitive therapy of personality disorders. New York: Guilford. Beck, A. T., Freeman, A., Davis, D. D., & Associates. (2004). Cognitive therapy of personality disorders (2nd ed.). New York: Guilford. Beck, A. T., Rush, A.J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford. Campbell, R. J. (1996). Psychiatric dictionary (7th ed.). New York: Oxford University Press. Dickens, C. (1843/1939). A Christmas Carol. New York: Washington Square Press. Erikson, E. (1950). Childhood and society. New York: Norton. Freeman, A. (1988). Cognitive therapy of personality disorders. In C. Ferris, I. M. Blackburn, & H. Ferris (Eds.), Cognitive psychotherapy: Theory and practice (pp. 223-252). Berlin: Springer-Verlag. Freeman, A., & Dattilio, F. M. (2000). Introduction. In F. M. Dattilio & A. Freeman (Eds.), Cognitive-behavioral strategies in crises intervention (2nd ed., pp. 1-23). New York: Guilford. Freeman, A., & DeWolf, R. (1989). Woulda/coulda/shoulda: Overcoming regrets, mistakes, and missed opportunities. New York: Morrow. Freeman, A., & DeWolf, R. (1992). The ten dumbest mistakes that smart people make. New York: HarperCollins.

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Freeman, A., & Leaf, R. (1989). Cognitive therapy applied to personality disorders. In A. Freeman, K. M. Simon, L. E. Beutler, & H. Arkowitz (Eds.), Comprehensive handbook of cognitive therapy: A psychosocial approach (pp. 403-433). New York: Plenum. Freeman, A., Pretzer, J., Fleming, B., & Simon, K. M. (2004). Clinical applications of cognitive therapy (2nd ed.). New York: Plenum. Freeman, A., & Simon, K. M. (1989). Cognitive therapy of anxiety. In A. Freeman, K. M. Simon, L. E. Beutler, & H. Arkowitz (Eds.), Comprehensive handbook of cognitive therapy: A psychosocial approach (pp. 347-365). New York: Plenum. Freud, S. (1949). A general introduction to psychoanalysis. New York: Garden City Publishing. Layden, M. A., Newman, C. F., Freeman, A., & Byers Morse, S. (1993). Cognitive therapy of borderline personality disorder. New York: Allyn & Bacon. McGoldrick, M. (Ed.). (1982). Ethnicity and family therapy. New York: Guilford. Page, F. (1980). Alone against the Atlantic: The story of the single-handed transatlantic race 1960-1980. London: The Observer. Piaget, J. (1936). The origins of intelligence in the child (H. Cook, Trans.). New York: Norton, 1963. Rosen, H. (1989). Piagetian theory and cognitive therapy. In A. Freeman, K. M. Simon, L. E. Beutler, & H. Arkowitz (Eds.), Comprehensive handbook of cognitive therapy: A psychosocial approach (pp. 189-212). New York: Plenum. Russianoff, P. (1983). Why am I nothing without a man? New York: Bantam. Schank, R. C., & Abelson, R. P. (1977). Scripts, plans, goals, and understanding. Hillsdale, NJ: Lawrence Erlbaum. Young, J. F. (1990). Cognitive therapy for personality disorders: A schema-focused approach. Sarasota, FL: Professional Resource Exchange.

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IV Contemporary and International Influences

The final section of our text is organized around the conceptual themes of contemporary and international influences on cognition and psychotherapy. In each of the four chapters in this section you will note that the authors focus on more global issues and topics, each attempting to build models to better help us understand human psychology and subsequent applications to psychotherapeutic treatment. One major organizing theme across the chapters is the metatheory of Constructivism with its central emphasis on understanding the human capacity in creating order and meaning in experience. "Identity, Personality, and Emotional Regulation," by Arciero, Gaetano, Maselli, and Gentili, is based on the pioneering work of Vittorio Guidano, who proposed the theory of Personal Meaning Organization (PMO). Demonstrating its constructivistic roots, the PMO model is based in an amalgam of theories, ranging from evolutionary epistemology to self-organizing systems theory, with Bowlby's attachment theory as a major cornerstone. Guidano's PMO describes the construction of a coherent sense of self through interacting with others; yet it is based on recurrent organizational categories that give meaning to life. Guidano initially described four of these categories based on observations of psychopathology but later modified them to describe the following general 257

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personality styles: the eating disorder organization, the obsessive organization, the phobic organization, and the depressive organization. As the authors state, "different ways of constructing identities coincide with different dysfunctions and, therefore, different treatments. Although it is crucial to treatment that the uniqueness of each individual be respectfully and carefully addressed, the rigorous methodological exploration that transforms psychotherapy into a scientific adventure continues to deepen our understanding of, and extend our reach into, the complexity of human experience." The notion of conviviality is used by Beskow, Beskow, and Miro as the centerpiece of their chapter, "Conviviality and Psychotherapy." According to the authors, "Conviviality refers to the myriad actions by which another emerges as a legitimate other in being together with me, from which feelings of joy and happiness naturally emerge. Joy and happiness are the feelings with the strongest impact on our will to change." They further assert that conviviality underlies the development of consciousness from both evolutionary and psychotherapeutic perspectives and that it increases the possibilities of coping with the complexities and problems of our world. Using a series of case studies, the authors effectively demonstrate the relationship of conviviality with psychotherapy and then conclude with the metaphor of the four-leaf clover as a method for the development of self-consciousness. That is, the stalk of the clover is conviviality and each individual leaf respectively represents developmental theory, theory of emotion, theory of language, and systems theory. They conclude by positing that "the four-leaf clover is thus a metaphor of one's life based on science. It facilitates the accommodation of scientific findings and makes them meaningful and functional in a personal context. Accepting them, working with them and developing them is one way to increase the level of consciousness. But the basic assumption that promotes the self-development is the respect for the legitimacy of oneself and the others, which creates the positive feelings of conviviality." In "The Entropy of the Mind: A Complex Systems-Oriented Approach to Psychopathology and Cognitive Psychotherapy," authors Scrimali and Grimaldi initially present a historical review of the development of cognitive psychotherapy that ultimately leads them to the presentation of their own model. In this model, the authors use the term entropy as a measure of the efficiency of a system in transmitting

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information. Hence, entropy of the mind refers to measuring how efficiently the human mind transmits and processes information—a key notion used throughout much of contemporary psychological science. The authors state: "According to this approach, the disorder and the clinical picture, observed at the clinical level, are the final result of a complex chain of events starting from conception. Such events act in a chain-like fashion. The factors related to it may be classified in terms of information theory, which is the reference point in the development of Cognitivism. The negative functioning of a subject showing a psychiatric disorder may be thought of as a series of information dysfunctions." To that end, the authors believe that most dysfunctions are primarily rooted in parenting and the formation of the attachment bond but other factors, including biological vulnerability, clinical decompression, and stimulus events, are also involved. Treatment of the dysfunction within this approach includes a multimodal intervention that includes behavioral techniques (e.g., gradual exposure methods), cognitive techniques (e.g., cognitive restructuring), emotional techniques (e.g., biofeedback instruction), and social/relational techniques (e.g., family cognitive therapy). Ultimately, the combined treatment modalities attempt to restructure the way an individual processes information in a more functional manner. Another mechanism referred to frequently in contemporary psychological science, especially neuroscience, is metabolism. Andrzej Kokoszka uses this notion in combination with information processing in his chapter, "Metabolism of Information as a Model of Mental Processes and its Application in Psychotherapy." By using the biological cell, Kokoszka presents a model of human experiences based on the metabolism of energy and information. According to Kokoszka, his model "significantly differs from technical models of information processing and describes psychological processes in terms of synthesis, catabolism, and energy production and utilization . . . these mental conditions were considered in terms of the pathology of functional structures constituting the system of values underlying the systems of decision making. . . the model is applied in illustrating mental structures and processes as well as interpersonal relationships that can be useful in psychotherapeutic practice."

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Kokoszka further argues that "a model of mental organization has to underlie every psychotherapeutic intervention, even when the therapist is not conscious of its existence or when he or she denies its application. The concept of information metabolism has an integrative power as a metarationale for the comprehensive understanding of cognitive, psychodynamic, and biological approaches." As originally stated at the beginning of this essay, constructivism, with its central emphasis on understanding the human capacity in creating order and meaning in experience, is the driving force behind each of the contemporary international chapters of this section. Furthermore, the willingness of the authors to mix old notions with new ones and to combine the best features from a series of seemingly paradoxically opposing viewpoints allows for a refreshing and creatively robust new generation of theory that will guide both the science and practice of psychotherapy and cognition for the coming decades.

12 Identity, Personality, and Emotional Regulation Giampiero Arciero, Paola Gaetano, Paolo Maselli, and Nicoletta Gentili

uidano's theory of Personal Meaning Organization (PMO) has firmly established itself as a hermeneutic instrument within constructivist psychotherapeutic approaches, as well as a general theory of personality. Recent innovations address this theory's potential risk of losing sight of subjects' personal uniqueness as they assert well-defined categories of personal style. One such innovation is the concept of a Narrative Identity that mediates between the continuous aspects of identity and the variable, unique nature of individual experience. Two modalities of constructing narrative identity, based on particular ways of developing and regulating emotions, have been specified: Inward and Outward. Similar to the four PMO categories (see p. 262) these two modalities appear to be determined by the attachment style developed by the child with the primary caregiver, and from an early life-stage determination of one's mode of emotional regulation. The theory of narrative identity adds new insights into the construction of personality, identity, and emotional regulation, building on Guidano's pioneering work. The most widely accepted personality theories focus on the necessity of integrating biological determinants with psychological and environmental ones. According to Airport's (1937) definition, personality is a "dynamic organization within the individual of those psychophysical systems that determine his or her unique adjustment to the environment." Despite such statements, accepted theories of personality offer

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an essentially structural perspective. In fact, personality is widely considered the result of interaction between a biologically determined temperament (or "emotional core") and character (acquired as the consequence of interchanges with the environment). In this view, temperament involves procedural memory, pre-semantic knowledge, and affective valence, while character corresponds to the processes of symbolization and abstraction based on conceptual learning (propositional knowledge). Essentially, temperament represents individual biases that govern the acquisition of emotion-based, automatic behavior traits and habits that remain relatively stable throughout one's life span (Cloninger, Svrakic, & Przybeck, 1993). Some theorists disagree about the persistence of such habits, maintaining that situations are the ultimate determining factors of behavior. (This is known as the "situationists" versus "personologists" debate.) A model that takes into account both dynamic and processing aspects of personality is Vittorio Guidano's systems- and process-oriented approach, called post-rationalist, developed from within the cognitive school of thought (Guidano 1991). This model, initially conceived with Giovanni Liotti (Guidano & Liotti, 1983), is firmly rooted in theories and disciplines largely accepted across a wide range of scientific fields. Evolutionary epistemology, complexity, and self-organizing systems theories, cognitive psychology, and emotional and cognitive development theories from within the constructivist perspective offer support to the post-rationalist model (Mahoney, 1991, 1995; Neimeyer 8c Mahoney, 1995). One of the most important cornerstones on which this model is developed is attachment theory (Ainsworth, Blehar, Waters, & Wall, 1978; Bowlby, 1969, 1988; Bretherton, 1991). Guidano, recognizing the value of the attachment relationship, developed the concept of Personal Meaning Organization to describe the gradual construction of a coherent sense of self through interaction with others. The PMO model pays specific attention to recurrent categories of organization that give meaning to the experience of living. Guidano described four categories of personal meaning organization, initially based on observation of relationships between cognitive styles and attachment patterns in psychopathological conditions, originally using the terms "Eating Disorder Organization (ED)," "Obsessive Organization," "Phobic Organization," and "Depressive Organization" (Guidano, 1987, 1995). The direct links to specific psychopathological conditions were subsequently removed, however, from the model. In-

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stead, it became focused exclusively on the ways in which an individual on the one hand discriminates and gives meaning to immediate experience, and on the other hand reorders and integrates past and present experiences into a sense of continuity. This dichotomous dynamic can develop in various ways, defining phenomenological patterns ranging from normalcy to neurosis and psychosis. The model considers individual ways of thinking, performing, and feeling as expressions of an internal coherence that organizes the self. This coherence reflects the way in which personal identity maintains stability in relation to the continuous happening of the outside world. Hence, this conceptualization is aligned more closely with the field of personality theory than with studies of psychopathology. It is not a coincidence that in the latest evolution of the model, the term "Personality Style" replaces "Personal Meaning Organization" (Arciero, 2002). For further explication of the four personality styles, see Guidano (1987, 1991, 1995), Arciero and Guidano (2000), and Arciero (2002). However, to aid in the understanding of the topic discussed in this chapter, we offer a brief explanation of each personality style. The Eating Disorder Organization identifies individuals who develop a vague and undefined sense of self, and who tend to select internal states and opinions based on an external point of reference. On this basis it is possible to identify (idiosyncratically for each individual) a strong attention to expectations perceived in others, a need for consent and approval, a sensitivity to judgement and vulnerability to criticism, a fear of exposure to unpredictable judgements, an aspiration to perfection in performance, and a latent sense of inadequacy. This type is thus characterized by the tendency to maintain an acceptable and distinct sense of self through a disposition that oscillates between compliance and opposition. Likewise, emotional states oscillate between a sense of emptiness/annulment and shame (often enacted as a perception of intrusiveness by others). The Obsessive Organization is characterized by a dichotomous sense of self, triggered by emotional arousal perceived as ambiguous or inconsistent with the individual's system of rules of reference. In this type, recognition of internal states is limited, and sense of self is based primarily upon conscious control of behavior and thinking (both of which are expected to match abstract principles). These individuals tend to show a great trust in logic and rationality, to reach for certainties (and if these are threatened, employ strategies based on systematic doubt), and present themes of responsibility, anticipatory control, equity, order, certainty, duty, and coherence.

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The Phobic Organization identifies a vulnerable sense of self, which interprets emotional states as impediments to action. The need to control one's own sense of weakness is typical, as is the tendency to perceive affective bonds as both indispensable sources of protection and as constrictive ties. Themes of freedom, invincibility, and facing challenges of perceived danger are commonly entangled with those of health, friendship, and affective stability. The Depressive Organization highlights the link between a sense of personal ineptitude on the affective level and a constant experience of solitude within one's primary attachment. This relationship is expressed in various forms, characterized by the common tendency to perceive a continuous and latent sense of loss in life events. A compulsive selfsufficiency is also characteristic of this type, as these individuals try to maintain personal balance while denying the importance of the support of others. A well-defined sense of self prevails, along with the perception of a limited level of belonging to the human community and a difficulty being acknowledged and understood by others. Due to its general characteristics and its relation to the various fields of psychopathology, the concept of Personal Meaning Organization has become extremely valuable in the comprehension of human experience as well as in clinical activity. It is supported by the results of a recent empirical study utilizing a self-evaluation questionnaire. The questionnaire items were elaborated through theoretical descriptions of the four organizations, referring to the general ways of feeling, performing, and thinking that characterize them (Picardi & Mannino, 2001; Picardi et al., in press). Guidano's model lends a clear understanding of how different domains of experience are interlinked and how, beginning with the primary attachment relationship (subsequently modulated by meaningful relationships developed over one's life span), it is possible to construct a steady and permanent sense of self that progressively organizes experiential data and directs individual choices. Such a concept of self partly coincides with Erikson's notion of Psychosocial Identity. Thus, it is referred to as the "sense of self-sameness and continuity in time" and "embeddedness in the environment" (Erikson 1959,1968). These terms emphasize the importance of embodied being and the function of reflective consciousness. It is important to note that the concept of Personal Meaning Organization, while allowing an understanding of personality based on categories, inevitably neglects the uniqueness of the subject. Also, while the four organizations recognize the polarity of

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identity that remains steady over time (sameness), the PMO model can lose sight of the basic changeability that ultimately makes our lives unique.

SELF-IDENTITY AND THE EMOTIONAL DOMAIN How does one reconcile the necessary dimension of permanence and continuity with the inevitable changeability of life that gives us choices and makes us "players in the game"? The relationship between these polarities is mediated by narrative explanation, which interprets events by constructing a meaningful story from them. The connection of events in a plot corresponds to the organization of the meaning of those events into a life story, which in turn takes place within the overall unity of one's life. Based on Ricoeur's ideas (Ricoeur, 1983, 1992), we define Narrative Identity as the composition and recomposition of a plot (emplotment) through which a sense of personal continuity (sameness) is integrated with the variability and discontinuity of experience (ipseity). This process is able to generate, in concert with the dynamic configuration of the life-story, a continuously composed (and recomposed) sense of self. Therefore, incidental events may represent discrepancies within the story, contradicting expectations created by previous experiences and resulting in fractures in one's sense of personal continuity. At the other end of the spectrum, discrepancies can be negotiated, or integrated, into the meaning of the plot, allowing the story to progress and the identity to maintain stability. In this way, the individual is the author of his or her own story. In Ricoeur's (1991) words, "the story manufactures the individual's identity, which can be called his narrative identity, creating the identity of the known story" (p. 436). We see, therefore, that Narrative Identity is a process that dynamically unifies, by means of a plot, the recurrent aspects of self with the situational self (Bruner, 1990; Bruner & Kalmar, 1998). In the narrative process, continuity is maintained as unpredictable and discrepant events are simultaneously integrated, allowing the story to progress. Narrative Identity creates a consistent dialectic between the factors that allow one to identify and reidentify oneself as the same person over time (sameness) and the variability, instability, and discontinuity of his or her experience of living (ipseity). The dialectic between sameness and ipseity influences the structuring of the emotional domain: sameness in the reconfiguration of recurrent emotional traits, ipseity in moments

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of unpredictable emotional arousal. The consideration of such a dialectic, and the regulation of emotions it necessitates (in order to allow the articulation of a coherent narration), leads us to distinguish two basic modalities of identity construction: the "Inward" and "Outward" modes (Arciero, 2002; Arciero & Mazzola, 2000; Guidano, 1999). These modes generally relate to the organization of aspects of the self linked to continuity (Inward) or to variability (Outward). The fundamental variable that appears to direct the construction and development of personal identity is the predictability, from the child's viewpoint, of parental response to requests for proximity. In this initial relationship, reciprocity built on predictability allows the child to make a defined, marked, and early differentiation of his or her inner world. In fact, emotional flow is more clearly differentiated when the parent responds clearly and with a limited variability of response to the child's requests for proximity, regardless of the quality of the emotional exchange (Arciero, 2002; Arciero & Mazzola, 2000; Guidano, 1999). In this case, the child does not feel the need to continuously check the parent's emotional attitude in order to discriminate between rejection and acceptance. From the first year of age, he or she can develop a sound ability to differentiate internal emotional flow. Therefore, the child begins to focalize primary emotions starting with visceral activation, and personal identity is polarized onto internal stability (Inward). The Inward polarity, which is associated with Phobic- and Depressive-prone personality styles, allows a clear demarcation of one's own experience from the experiences of others. Consequently, visceral emotions become important constituents of the Inward's identity. On the other hand, reciprocity built on inconsistency, ambiguity, or extreme variability in parental response will make it more difficult for the child to discriminate between emotional states, leading to a less defined demarcation of his or her inner world. The child is compelled to continuously focus attention onto the caregiver, seeking "news" of the possibility for acceptance from one moment to the next. Being constantly centered on the external world constructs a limited ability to discriminate among internal emotional states. This also induces the development of a barely differentiated emotional arousal from the basic emotions, which progressively promotes "cognitive" and "self-conscious" emotions (typical of Obsessive- and Eating Disorder-prone personality styles). Therefore, an undifferentiated arousal prevails, which can only be interpreted with the aid of specific circumstances and external context. The external world, seen as intersubjective and as a system of

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collectively shared rules, acquires ontological value for the individual. He or she will build inner stability by continuously referring to the outside world, attempting to synchronize his or her own feelings with it. This style of emotional behavior, which is associated with the Outward polarity, appears to agree in general with some classic formulations in theories of emotions. According to these formulations, a generic sense of arousal becomes a true emotion through subjective evaluation (Mandler, 1984; Ortony & Turner, 1990; Schachter & Singer, 1962). Inward identities, on the other hand, appear to be more in line with the "theory of discrete emotions" (Ekman, 1992; Izard, 1977; Izard & Ackerman, 1993; Lewis & Michalson, 1983; Plutchik, 1980; Tomkins, 1962). According to this theory, a specific arousal must be present with characteristic valence and tonality, linked to universally present stimuli. These two modalities of identity construction shape the emotional domain in different ways. Identities associated with the Inward polarity develop a more profound centrality of basic emotions inscribed in the life texture, while identities associated with the Outward polarity are affected by a variable lack of differentiation of emotional states.

SELF-IDENTITY AND EMOTIONAL REGULATION It is clear that the Inward and Outward modes imply different types of access and different potentials for regulating the emotional sphere. According to Michael Lewis (2000), it is important to specify three distinctive forms of emotional domain to clearly comprehend the different dynamics of regulation.

Emotional States Emotional states are recurring somatic and/or neurophysiological configurations that may appear without being fully consciously perceived. There are two different ideas concerning such emotional states, both recognized by the scientific community (but yet to be specified uncontentiously). First, there is the "specific theory," which postulates that there is a full correlation between an emotion and its matching internal physiological state. Therefore, some basic emotions are universally differentiated and biologically rooted (Ekmann, 1992; Izard, 1977, 1992; Tomkins, 1962). These specific emotions (basic emotions), according

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to the theory outlined in this chapter, are particularly delineated in Inward-polarized identities. The second theory postulates nonspecific emotional arousal, to which a precise tone (i.e., anger, sadness, fear) is attributed cognitively. From our theoretical viewpoint, this happens when the variability of the parental response inhibits the discrimination of internal states (Outward-polarized identities). In this case, the specificity of an emotion can be constructed only through cognitive and appraisal mediation (Mandler, 1984; Schachter & Singer, 1962).

Emotional Experiences Emotional experiences result from the interpretation of an event or emotional state. In this domain, there is again a clear differentiation between Inward- and Outward-directed identities. The Inward's emotional experiences are a result of focusing on internal states, based on different grades of conscience and articulation. Even in the presence of an emotional state: An emotional experience cannot take form without focalization. Due to the undifferentiated nature of emotional flow in the Outward identity, it is not necessary for emotional experience to correspond with an internal state. An emotional experience can emerge in the absence of autonomic activation. In short, emotional experience depends upon cognition. Emotional Expressions Emotional expressions are facial, postural, vocal, and motor changes. These cannot be specifically related to the two modalities. From the above, it is possible to distinguish two aspects of emotional regulation: one concerning characteristics of arousal (emotional intensity, persistence, modulation, onset and rise time, range and variability of and recovery from responses), the other concerning characteristics of appraisal (evaluation of quality, value and salience of stimulus in relation to self and one's own objectives; Thompson, 1994). The prevalence of one over the other depends on which polarity an individual's sense of stability is centered around. Individuals with Inward orientation tend to be set on arousal. In fact, their sense of personal stability is focused on recurrent aspects of identity (basic emotions), which are not modifiable. Therefore, in order to maintain continuity of self, it is

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important for these individuals to keep the intensity of internal activation within a manageable range. Individuals with Outward orientation tend instead to be set on appraisal. Because their sense of personal stability is anchored in an external, referential context, the regulation of emotional states depends upon the individual's modification and interpretation of current situations. It becomes clear that the regulation of any emotion, if it is experienced as visceral, is different from the regulation of the same emotion when it is, instead, "mentally perceived." In the first instance, emotional activation is amplified (variably, depending on the intensity of the visceral emotion) by affects, memories, thoughts, and images semantically linked to the triggering event (semantic priming; Kitayama & Howard, 1994). On the one hand, this limits the range of compatible aspects of the occurring situation and on the other, it facilitates the conscious articulation of emotional experience, allowing a reduction in its intensity (feeling articulation). In the case of "mentally perceived" emotions, one's emotional state is affected by determinations or interpretative codes of a cognitive nature, so the "creation" and management of these emotions derives from the intellectual sphere (conceptual priming). Therefore, regulation can occur by changing interpretative parameters, allowing a qualitative modification of the emotional experience as well as a more accurate conceptual articulation (Arciero, 2002). Such a differentiation carries great importance for the comprehension and praxis of therapeutic processes. Indeed, it is difficult to ignore the emerging concept that different ways of constructing identities coincide with different dysfunctions and, therefore, different treatments. While it is crucial to treatment that the uniqueness of each individual be respectfully and carefully addressed, the rigorous methodological exploration that transforms psychotherapy into a scientific adventure continues to deepen our understanding of, and extend our reach into, the complexity of human experience.

REFERENCES Ainsworth, M., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of attachment: Assessed in the strange situation and at home. Hillsdale, NJ: Lawrence Erlbaum. Allport, G. W. (1937). Personality: A psychological interpretation. New York: Holt. Arciero, G. G. (2002). Studi e dialoghi sutt'identitd personak. Riflessioni suU'esperienza umana (Study of the personal dialogue—reflections on the human experience). Torino: Boringhieri.

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Arciero, G. G., & Guidano, V. F. (2000). Experience, explanation and the quest for coherence. In R. A. Neymeyer &J. D. Raskin (Eds.), Constructions of disorder: Meaning-making perspectives for psychotherapy. Washington, DC: American Psychological Association. Arciero, G. G., & Mazzola, V. (2000). Le organizzazioni di personalita: 1'approccio post-razionalista (The organization of personality: A post-rationalist and approach). In B. Nardi (Ed.), Vittorio Guidano e I'origine del cognitivismo sistemico processuale (Victor Guidano and the origin of the cognitive processing system). Ancona, Italy: Accademia dei Cognitivi della Marca. Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. New York: Basic Books. Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation. New York: Basic Books. Bowlby, J. (1979). The making and breaking of affectional bonds. London: Tavistock. Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss. New York: Basic Books. Bowlby, J. (1984). Caring for the young: Influences on development. In R. S. Cohen & S. H. Weissman (Eds.), Parenthood: A psychodynamic perspective. New York: Guilford. Bowlby, J. (1988). A Secure base. London: Routledge. Bretherton, I. (1991). Roots and growing points of attachment theory. In C. M. Parkes, J. Stevenson-Hinde, & P. Marris (Eds.), Attachment across the life cycle. London: Roudedge. Bruner, J. (1990). Acts of meaning. Cambridge, MA: Harvard University Press. Bruner, J., & Kalmar, D. A. (1998). Narrative and metanarrative in the construction of self. In M. Ferrari & R. J. Sternberg (Eds.), Self awareness. Its nature and development. New York: Guilford. Cloninger, R. C., Svrakic, D. M., & Przybeck, T. R. (1993). A psychobiological model of temperament and character. Archives of General Psychiatry, 50, 975. Ekman, P. (1992). Are there basic emotions? Psychological Review, 99, 550-553. Erikson, E. (1959). The problem of ego identity. Psychological Issues, 1, 379. Erikson E. (1968). Identity. In Youth and crisis. New York: Norton. Guidano, V. F. (1987). Complexity of the self. New York: Guilford. Guidano, V. F. (1991). The self in process. New York: Guilford. Guidano, V. F. (1995). A constructivistic oudine of human knowing processes. In M. J. Mahoney (Ed.), Cognitive and constructivepsychotherapies: Theory, research and practice (pp. 89-102). New York: Springer Publishing Co. Guidano, V. F. (1999). Lessons of 1999 training course on Post-Rationalist Cognitive Psychotherapy. Unpublished. Guidano, V. F., & Liotti, G. (1983). Cognitive processes and emotional disorders. New York: Guilford. Izard, C. (1977). Human emotions. New York: Plenum. Izard, C. (1992). Basic emotions, relations among emotions, and emotion-cognition relations. Psychological Review, 99, 561-565. Izard, C., & Ackerman, B. (1993). Motivational, organizational and regulatory functions of discrete emotions. In M. Lewis &J. M. Haviland-Jones (Eds.), Handbook of emotions. New York: Guilford. Kitayama, S., & Howard, S. (1994). Affective regulation of perception and comprehension: Amplification and semantic priming. In P. M. Niedenthal & S. Kitayama (Eds.), The heart's eye. New York: Academic Press.

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Lewis, M. (2000). The emergence of human emotions. In M. Lewis &J. M. HavilandJones (Eds.), Handbook of emotions (2nd ed.). New York: Guilford. Lewis, M. D., & Douglas, L. (1998). A dynamic systems approach to cognitionemotion interactions in development. In M. F. Mascolo & S. Griffin (Eds.), What develops in emotional development? New York: Plenum. Mahoney, M. J. (1991). Human change processes: The scientific foundation of psychotherapy. New York: Basic Books. Mahoney, M.J. (Ed.). (1995). Cognitive and constructive psychotherapies: Theory, research, and practice. New York: Springer. Mandler, G. (1984). Mind and body. New York: Norton. Neimeyer, R., & Mahoney, M.J. (Eds.). (1995). Constructivism in psychotherapy. Washington, DC: American Psychological Association. Ortony, A., & Turner, T. J. (1990). What's basic about basic emotions? Psychological Review, 3, 315-331. Picardi, A., & Mannino, G. (2001). Le "organizzazioni di significato personale": verso una validazione empirica (The organization of the significant person: Empirical validity). Rivista di Psichiatria, 36, 224-233. Picardi, A., Mannino, G., Arciero, G., Gaetano, P., Pilleri, M. F., Arduini, L., et al. (in press). Costruzione e validazione del QSP, uno strumento per la valutazione dello stile di personality secondo la teoria delle "organizzazioni di significato personale." Rivista di Psichiatria. Plutchik, R. (1980). A general psychoevolutionary theory of emotion. In R. E. Plutchik & H. Kellerman (Eds.), Emotion: Theory, research, and experience: Vol. I. New York: Academic Press. Ricoeur, P. (1983). Time and narrative. Chicago: University of Chicago Press. Ricoeur, P. (1991). Life: Astory in search of a narrator. In P. Ricoeur, M.J. Valdes, & P. Rico (Eds.), A Ricoeur reader: Reflection and imagination. Toronto: University of Toronto Press. Ricoeur, P. (1992). Oneself as another. Chicago: University of Chicago Press. Schachter, S., & Singer, J. (1962). Cognitive, social and physiological determinants of emotional states. Psychological Review, 69, 379-399. Thompson, R. A. (1994). Emotion regulation: A theme in search of definition. In N. A. Fox (Ed.), The development of emotion regulation: Biological and behavioral considerations. Monographs of the Society for Research in Child Development, 59. Tomkins, S. S. (1962). Affect, imagery, consciousness. Vol. I: The positive affects. New York: Springer Publishing Co.

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13 Conviviality and Psychotherapy Astrid Palm Beskow, Jan Beskow, and Mayte Miro

To show me respect is to speak a language that I can live in. —Hip-hop musician in a Swedish newspaper interview, July 2001

n developing a working relationship to their clients, cognitive psychotherapists have typically and traditionally expressed the relationship as two researchers working together in what has been called collaborative empiricism. Kelly (1955) printed out the directions, but it is up to others to elaborate it further. Conviviality refers to the myriad actions by which another emerges as a legitimate other in being together with me, from which feelings of joy and happiness naturally emerge. Joy and happiness are the feelings with the strongest impact on our will to change. We believe that cooperation, which is based on equality, a mutual acceptance of another person's legitimacy, and the mutual trust that it engenders, offers a great scope for each individual to use his or her talents. This, in turn, leads to greater multiplicity, creativity, and opportunities for development. Conviviality is a condition underlying the development of consciousness, both from an evolutionary and a psychotherapeutic perspective. Consciousness is used in order to understand being and reality. It is created with the support of language and thinking and can be described as the capacity to synthesize information from

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our different information systems such as the sensory-motor, affective, and cognitive systems into a unified meaning system. If the information from these different systems is conflicting or absent the result may be psychological symptoms. We will illustrate this with a brief review of the case of Sophie and then return for a more in-depth analysis.

THE CASE OF SOPHIE Sophie, aged 25, was, for many years, more or less barricaded in her room on the ward of the psychiatric department. She was involuntarily admitted, under the influence of heavy psychiatric medication, hopelessly depressed and suicidal, as well as unreachable for psychotherapeutic efforts. Every attempt to show kindness toward her resulted in outbursts of aggression and violence toward the therapists and staff. It seemed to us that the only way we could reach Sophie was to show respect for and acceptance of the legitimacy of her behavior, even if we disapproved of it. That meant that we needed to understand and take into account information from the three systems with which she tried to communicate: a violated body; feelings of fear, helplessness, and anger; and a description of her positive intention and meaning. In this way we tried to grasp the dominant schema behind her verbal and behavioral expressions. This resulted in the condensed internal sentence: "Good words mean bad emotions and a tormented body." This meaning structure had been created in previous situations in which cruelties against her were legitimized with the words "This is really good for you!" Sophie certainly had positive feelings too, but they were repeatedly blocked by the negative ones. This schema kept her feeling constant threat and anxiety. It made her believe that she was defenseless and pushed against the wall with no possibilities for escape. The concept of conviviality is closely interwoven with the concept of respect for the legitimacy of oneself and of the other. This implies the view that all beings are endowed with autonomous intentions and the will to grow and develop according to their special psychogenetic conditions and program. This can best be done within an atmosphere of acceptance of the other as a unique individual, with this attitude as a basis to create a place for linguistic exchange between the self and the other. As both you and I are self-organizing systems this process of respect for mutual legitimacy will continue in a creative and increasingly differentiating loop that contributes to feelings of joy and happiness.

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To conceptualize and start the therapy from this point meant that the therapist needed to create a theoretical and practical structure, a joint language, in which Sophie could consciously and willingly experience the fact that good words sometimes did not mean bad emotions or a violated and tormented body. An opposite organization would be one characterized by a dominance-submission pattern based on feelings of aggressiveness and fear. It is maintained with and by various actions and measures that are forced on an individual and is therefore characterized by competition and a manipulation of relations. Those at the top receive selected instead of comprehensive information. This type of organization has a tendency to become rigidly fixed. The consensus sphere, as well as closeness and joy, are also limited. To recognize the value of legitimization improves the understanding of our own being and reality as well as that of the other. Conviviality is thus of fundamental importance for the development of a human consciousness that increases the possibility of coping with the complexity and problems of our era and environment. This involves a physical/ interpersonal contact, an emotional contact, a free exchange of thoughts, and, above all, a "spiritual" presence, that is, a connection beyond the here-and-now. The energy-charged here-and-now process of conviviality demands care and attention in order to be kept alive. It colors language itself, which is characterized by trust and communicative openness, with little need for defenses and secretiveness. Dialogues conducted in loving closeness engender a harmonic, creative, and productive atmosphere. Contributions to the creation and maintenance of such an atmosphere in relation to patients are among the psychotherapist's most important tasks.

THE "OTHERNESS" OF THE OTHER In order to be able to create a convivial conversation with the client, it is necessary for the therapist to understand how and why the "other" differs in our explication of respect for the legitimacy of the other. The novelty of this view can be grasped by its contrast with the traditional view. For centuries, the most common view in psychotherapy has been to consider the other as another "I." This is a most important psychological principle, since it underlies our sense of belonging to a family, a group, a nation, and, indeed, to humankind. In this view we can understand

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that the other is a human being like me, but by no means can we understand that he or she is also another, that is an other different from me and legitimate in this difference. The "otherness" of this individual has not been taken into account in the traditional way of explaining the relationship with the other. We can find many expressions for dealing with the other, such as alter ego, identification mechanism, projective identification, and so on. The core of these expressions is analogical reasoning. In order to illustrate the limitations of this view, let us consider how Descartes concluded that the basis for human understanding lies in analogical reasoning. Alone in his room, Descartes wondered how he could be sure that the bodies that he observed from his window were people and not automatic machines. The question itself is evidence of a consciousness of not being like others and of feeling separated and alone. To explore his doubt he reasoned that if the other could use language as he did, act intentionally as he did, and had a rational capacity as he had, then the other was just like him: a rational substance like him, except that it was put in another body (Lain Entralgo, 1998). To understand the other from this perspective, all you have to do is mentally put yourself in the place of the other, since the body is just a mechanical device. When this procedure is not enough to understand the other, then one must add something, like the concept of identification. After all, it requires a lot of imagination to enter inside the body of another. When even this is not enough to understand the other, we can add the idea of compassion to explain the feelings that the situation of another provokes in ourselves. Identification then is putting oneself in the shoes of the other person. Most psychotherapists can easily recognize in this description the traditional concept of empathy. However, this only explains the similarities between oneself and the other, but does not address the differences. From this traditional concept of empathy and this analogical reasoning, the other is only a mirrored image of myself. The ultimate consequence of this thinking is that living in relationships becomes a labyrinth of mirrors, that is, as if living together was only a matter of continuously making inferences (Miro, 2000). A Self-Organizing System To understand the otherness of another person one needs to recognize the other as a self-organizing system, both from physiological and psy-

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chological perspectives. A self-organizing system is closed so that by its own activity it creates a boundary against the exterior and circular relationships among its components and component-producing processes. The circular connections among the components and processes of the system imply circular causality, which is different from linear cause-effect relationships (Foerster, 1960, 1981; Maturana & Varela, 1984). The importance of the circular causality of a self-organizing system is that the effect of stimuli in the system at any specific moment is dependent on the structure of the system at that moment. The primary aim in every moment is to guarantee long-term equilibrium and stability (Damasio, 1994, 1999). A self-organizing system is self-referential. In order to change or to maintain itself in a situation of external pressure or internal conflict a self-organizing system only needs to make reference to itself and to its history. Thus, from the point of view of an external observer, using a self-organizing system model is one way of understanding the otherness of the another person.

The Emergence of the Other From a methodological perspective, to understand self-organizing systems, one needs to keep in mind that a system exists simultaneously in two different domains or perspectives. The first is the internal, which refers to the above-mentioned components and component-producing processes that form the circular organization. The second is the external perspective in which the systems exist as units to an external observer. This could also be the way in which one perceives oneself. The psychotherapist has to conceptualize the client's problems and circumstances in order to structure the treatment possibilities. It is therefore necessary to understand the client's position as an external observer and to accept the self-organizing properties of his or her internal perspective. In other words, thoughts, feelings, and body sensations are internal, and to understand them fully, knowing the history of the system is essential. This can be identified by the way in which the system has organized its internal components in different memory systems. This organization is what the client depends upon, essentially the "the remembered present" (Edelman & Tononi, 2000). The internal perspective refers to what Edelman calls the first level of consciousness, that is, the neurophysiological perspective. As soon as language emerges,

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the observer and the external perspective emerge—the second level of consciousness. As Maturana and Varela (1984) stated, "Everything said is said by an observer to another observer who could also be oneself."

The Emergence of the Observer Is the Emergence of the Other Thus, within a self-organizing system, a person is both an internal and an external observer, an "I" and a "me." With the emergence of language and the external observer the individual can observe himself or herself, and in that way, he or she is also an "other." This implies that the notion of respect for the legitimacy of the other applies to both the other person and also to the self as "another."

The Sense of the Other When we consider the development of human beings from a psychobiological point of view, it thus becomes clear that self-organization is not a monadic, but a dyadic organizing process. From the beginning, the child self-organizes in attachment relationships by maintaining proximity to the caregiver or attachment figure. This means that through movements and sounds, the child indicates its intent to share with another person what arouses its interest with that other person. The relationship between the child and the primary caregiver can develop in various ways, which can be recognized as different attachment patterns. These attachment patterns aim at protecting the child from danger and are organized through emotional attunement (Bowlby, 1988; Stern, 1985; Trevarthen, 1984). Within different patterns the child develops strategies to maintain the proximity to the attachment figure (Ainsworth, Blehar, Waters, & Wall, 1978). It is thus in the attachment relationship that the child's own protective mechanisms are developed. Small children, who have learned the predictive and communicative value of interpersonal signals, are skilled at using both cognitive and emotional sources of information. Sensitive caregivers help their children to understand both the communicative meaning of their behavior and that the effects of those behaviors on others are often predictable. The mother's way of meeting the child's anxiety becomes a model by which the child can learn to comfort him- or herself. In turn, over time, the child becomes better able to govern feelings and behavior, an

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important form of self-regulation (Greenberg & Paivio, 1997). Normally, the mother's reactions are not questioned by the child; thus the sense of the mother as "other" will be as a legitimate other, creating feelings of joy and happiness, of conviviality, in both of them. This atmosphere of conviviality strongly promotes the development of the child and of the mother in her specific role as this child's mother. In contrast, when the child is continually under heavy strain, developmental paths can lead to different types of psychopathology (Crittenden, 1995). In the child for whom various mental traumas dominate experience, the sense of reality and of the "other" is developed based on these experiences. For example, when the mother uses misleading emotional signals, the child has greater difficulty engaging in emotional regulation. The mother's unpredictability results in the child's being unable to trust in cognitive strategies in order to reach out to her and attain emotional regulation with her help. Some children do not admit the mother into the emotional regulation process. Still others force the mother to give them uninterrupted attention so as to induce her to play a particular role in their development of the emotional regulation process.

Language Although the sense of the other emerges in the attachment relationship at the first level of consciousness, its articulation depends on the acquisition of language. When we take into account the intersubjective reality in which the child lives, the emergence of words seems a natural step for the task of communicating intentions and internal states. In this sense the child learns how to do things with words. An action to speak is an intention to say something to someone. Therefore the model for speech is dialogue. Given that one speaks to another person with the intention of communicating something, it is understood that the other will recognize that person as a communicator. In other words there can only be a first person "I" when there is a second person "you." To be meaningful, words must reflect the intention of the speaker to make the internal state of the system visible to another. For this reason the sense of an "I" and a "you" are co-constructed at the same time (Ricoeur, 1991). As a complete system, language stands outside time and space, as its existence is virtual. It exists only as an abstraction in the mind of its users. It is only in those realms in which dialogue takes place that

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language actually exists. Thus, language is a mediator among three realms created simultaneously: Every time we speak we say something about something (ontological level), to someone (social or relational level), from some point of view (psychological level). For humans living in language, the natural way to order experience is to construct stories about what has happened to us, what we have experienced, and so on.

Building Narratives Narrative thinking is concerned with those aspects of a situation that are unique, unusual and personal, and idiosyncratic. The function of narrative thinking is to explain the unusual, those experiences that go against the expected. To explain this we order what we have experienced in sequence with a beginning, a middle, and an end. The function of a story thus is to make sense of something unusual (Bruner, 1986,1990). If the natural way of human beings to bring order to experiences is to construct narratives, then it follows that these narratives are also the way we develop a sense of who we are. By constructing a personal life story, our own narrative, we integrate those significant events, often governed by chance, which are part of the environment and make them parts of our destiny (Ricoeur, 1991). In narrating one's own life story, consciousness emerges. The belief and the will to construct a different future also come, through acceptance of the past and the present. This opens the door to the world of choice, responsibility, freedom, and the acceptance of and respect for the legitimacy of the other. The consequent atmosphere of conviviality thus is the basis for development both in children and adults, including patients in psychotherapy.

INDIVIDUAL PSYCHOTHERAPY Training in the ability to regulate one's feelings in an assertive and appropriate manner, given the surroundings, begins at a tender age. As noted above, it comes via the early attachment between child and caregiver. If the child does not experience reliable responses in the emotional interplay with the mother, in the canonical song, then there is a great risk that deficiencies or disturbances in the ability for emotional regulation will appear later in life, or that this ability will collapse completely. These persons can develop deviant and unhealthy patterns

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for emotional regulation (Alford & Beck, 1997; Clark & Beck, 1999; Freeman & Reinecke, 1993). These patterns may be observable as fueling critical emotions in especially frustrating situations. Such disorders can, among other things, be precipitated by oversensitivity to what may be regarded as acceptable (chiefly with regard to expressing feelings) within one's own family or culture. In these cases the client has often developed metaconsciousness about the family and is thus able to give an account of the rules he or she is reacting against. Many individuals have great difficulties in accepting their negative feelings for attachment figures. To finally be able to disclose their thoughts and feelings, they would require a convivial atmosphere.

THE CASE OF CLARA: NEGATIVE FEELINGS FOR ATTACHMENT FIGURES SEPARATED FROM THE NARRATIVE Clara, a 40-year-old teacher, found herself in a crisis. She was anxiety ridden and confused when it came to interpreting and managing her life. Old friends and colleagues often disappointed her by not behaving as she expected good friends to behave. They did not do what they had promised and failed to respect agreements. This had gone on for a long time, but it was only lately that the Clara had become aware of the situation. In therapy multiple events that concerned the client's relations were reconstructed. During this process, when Clara could see herself as a legitimate "other" she realized that she had cast herself in a submissive role through her uncritical admiration of others. This insight reinforced her self-image, which provided her with increased security and a feeling of belonging. The therapist asked whether she recognized this pattern from earlier relationships. Clara was easily able to see that the critical emotions that bothered her now were similar to ones she had felt earlier. Through recognizing these fundamental emotions, which went back to her relationship to her father and brother, Clara was also able to understand how, in order to compensate for the feelings of inferiority arising from her subordinate position, she herself had constructed more and more exaggerated ideas about others. It was only when this consciousness and metaconsciousness were developed and established that Clara reached a point where she was free to choose between retaining the patterns of dominance/subordination in her old and new relations or invest in changing them. In this instance cognitive elements dominated emotional and behavioral ones. These were unnecessary obstacles constructed earlier in life. The goal of therapy was to strengthen Clara's ability to manage her situation without being further burdened by them. This pattern of

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dominance/subordination, which she understood, may be regarded as a sort of redistribution of meaningfulness: At the same time as Clara exaggerated others, in effect, inflating the other like a balloon, her selfimage shrank to a corresponding degree. Her ego caved in and appeared as less and less significant. It is often the case that people who experience themselves as diminished feel as if it is the other who is doing something humiliating to them and thus should bear the guilt for their insignificance. In order to effect change it was necessary to assist Clara in legitimizing both herself and the others as separate self-organizing systems. This had to be done through her own thoughts and linguistic processing. Apart from strengthening Clara's self-image, it provided her with increased security and a more distinct narrative and personal story. It also led to an understanding that many of her friends' actions were not conditioned by interaction with her, but emanated from their selforganizing system, that is, their current needs. Clara further understood that such systems constantly construct borders between themselves and their surroundings. This knowledge strengthened her ability to construct a border between her own inner and outer worlds, between herself and others. She also realized that autonomy in self-organizing systems enables each and every one of us to enlarge, reduce, or equate ourselves in comparison to others. THE CASE OF SOPHIE: DEEP VIOLATIONS OF PERSONAL LEGITIMACY Let us now return to the case of Sophie. In connection with severe stress, such as incest, neglect, or other forms of abuse, similar deficiencies or disturbances may have serious consequences for the child in that they lead to blocks between the individual's cognitive and emotional subsystems or sometimes to long-term breakdowns in links between these subsystems. This in turn can result in a total breakdown in the client's self-organizing system. Sophie was extremely overweight because of an eating disorder and medication with psychopharmacological drugs. She was bedridden and was not even able to cope with her activities of daily living (e.g., personal hygiene, visits to the toilet, etc.). Her language was incoherent and obscure. Her behavior was outwardly aggressive but also self-destructive. For example, when possible, she cut herself all over her body, often in the neck. Her background showed that she had been subjected to serious physical and mental assaults and violations by family members. She was diagnosed with a personality disorder, a deep depression, and extreme anxiety. At times her internal imbalance turned into psychotic confusion, which was treated

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with increasing amounts of anti-psychotic medication. The staff had begun to regard her as a hopeless case. She was a burden on the staff and on the clinic's budget. As the situation was critical, one of the authors (APB) was asked to function as supervisor of the treatment team.

Treatment Planning and Course Together with the team, the supervisor attempted to analyze Sophie's situation and reactions. It was clear that her self-regulative capacity and radical reality had totally fallen into pieces. The assessment was that the stresses in childhood and adolescence, reinforced by unpleasant experiences during psychiatric care, had resulted in a breakdown in her self-organizing system. The first task was to try to reconstruct this system. Without even minimal selfregulation ability any other intervention would have been doomed to failure. The meeting resulted in a focus on an intervention in line with a few simple psychotherapeutic principles. Chief among these was legitimizing Sophie as a person. This entailed, among other things, that those members of staff who felt that they could relate to the patient in a positive way—and in no other way—would make an attempt to establish some form of structured dialogue. This took place with the help of a notebook. Sophie was asked to write down anything that she perceived as positive in her surroundings every day. In return the staff offered to daily note something positive they had experienced in their contact with her. Sophie agreed to this. Her consent was a very important step. It was, however, difficult for her to take, as she was so ambivalent regarding positive statements about herself so that the least praise could lead to an anxiety attack. Other treatment would remain unaltered (anti-psychotic medication) though reduced if possible. The treatment commenced. The patient wrote short messages such as, "Dinner was nice today." The staff could, for example, respond to her with, "I liked it that you smiled at me today." This went on for a time and Sophie became accustomed to this form of written communication. After a while she became disappointed and angry if the staff forgot to leave their comments. Gradually, however, she began to feel better and better. After six months she managed to make an excursion with a staff member to visit the supervisor at her place of work. In time she was able to look after ADLs and cope with her everyday surroundings so well that with continual support from the psychiatric outpatient services, she moved to her own apartment. Later on she was also able to develop a relation with a man and marry. Since then the patient has had a few relapses in the form of depressive conditions or anxiety attacks. It has, however, been possible to treat these via telephone consultations.

The Life-Story and Radical Reality of the Patient It is evident from an analysis of Sophie's life-story that her radical reality was concentrated upon her personal life. Her capacity for metacognition

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(e.g., to understand the rules according to which she functioned) was nonexistent. Her I-me relation (her understanding of her self) was weak and confused. The self was hurt and destructive. In her me-you relation the borders were dissolved. She could not comprehend the meaning of what other people said and did to her. Her way of projecting and creating her future was primarily rooted in, and reflected, the way in which others had treated her. Her brutal attitude to her own self mirrored the outrages against her that had characterized her earlier relationships. Her lack of linguistic clarity reflected the splitting that mirrored her relationship to significant others. These close attachment figures had, among other things, conveyed to her that these assaults to which she had been subjected were all right and that they were, somehow, good for her. In her confusion she was unable to distinguish between what was good and what was not. She also did not know what she could expect of others. Sophie's perception of reality was dominated by experiences of existing in an unreliable and unpredictable world. In this world she saw herself as an object, unconditionally offered to others, who could exploit her as they wished. An acceptance of this reality meant that she denied herself as a person. To not accept this reality resulted, on the other hand, in unendurable anxiety. The ultimate way of resolving this dilemma was to refrain from doing anything at all, to flee into a fully developed depressive behavior, which thwarted all progressive changes. This was a total breakdown of the self-regulating process. The example also shows the total hopelessness in curing mental illness from a consistently objectifying approach. It ignores the critical point that the person herself must be the center of her life, that is, that she herself in her personal life is the radical reality. Gradual Reconstruction of the Patient's Radical Reality In the case of Sophie, we can see the consequences for a child who could neither integrate the cognitive nor the emotional information in the early relationships, which led to the breakdown of the system. What we see in Sophie is the implied breakdown of the sense of the "other" and the sense of reality. The patient's acceptance of the simple tasks and the staffs wholehearted participation started a series of psychological processes within this woman. Sophie contributed to changing her reality and the functioning of her self-organizing system in a healthier manner. Some of the most important processes may be described in the following way:

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1. We realized that we could not understand her specific form of otherness. Nevertheless we accepted her as she was. This made her reorganize her ability to distinguish between good and bad. 2. The ability to distinguish between good and bad gave her the experience of existing in a more and more predictable reality. 3. Sophie began to express her feelings by linking emotional experiences to words and putting them down on paper. 4. The written messages to and from the staff helped her develop the feeling of "the other," and laid the foundation for an I-you relationship, which was regulated by reciprocity in the actions "I write to you/you write to me." 5. When her experience showed that others behaved in a predictable and reliable manner, she was gradually able to tolerate the fact that responses were sometimes delayed and perhaps even failed to appear. 6. Her experiences of predictability and reliability in the I-you relations meant that she finally began to experience the feeling of internal continuity, which was a prerequisite for her being able to continue experiencing that something was good without becoming full of anxiety in connection with it. 7. The appearance of this internal security, this feeling of continuity, also made it possible for her to experience the feeling of "similarity," being one among others. This in turn led her to begin regarding herself as a "legitimized other." 8. The experience of being a "legitimized other" finally made it possible for her to establish a loving I—you relationship with a man. 9. This inner development increased her freedom and provided her with greater opportunities to choose among different alternatives. 10. This finally resulted in a completely different life story of the future than the one she had so far experienced.

THE CASE OF JANE: DELUSIONAL NARRATIVE During a trip to Greece, Jane, a 20-year-old woman, experienced, in one day, a number of completely normal but unusually intense stimuli. She experienced heat and abundant sunshine, in addition to many stimuli that were incomprehensible to her, linguistic as well as social. For example, there were foreign words and strange customs. Back in her hotel room Jane felt

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confused and was at the same time filled with a diffuse and threatening feeling of there being another person in the room. She felt a powerful throbbing and a heaviness in her body, particularly in the rib cage and stomach. She felt completely helpless, but remained in her room. Jane subsequendy explained the whole thing, for herself and others, by saying that someone had entered her room during the night and had installed a machine inside her that was now causing her physical symptoms. When she came home she was later admitted to a psychiatric treatment home.

Reconstruction of the Narrative To begin by talking to this patient about her attacks, as one might do with patients with panic/anxiety disorder, the therapist would most likely increase her anxiety and therefore make a continued conversation impossible. Instead, the workers at the treatment home determined that this patient was in need of long-term therapy at an inpatient treatment facility in which she could gradually get to know the staff. During her stay at the treatment home her anxiety increased on several occasions and gave rise to new and frightening symptoms. The phenomena about which the patient tried to gain some clarity, with the help of her narratives, were not fantasy in the normal meaning of the word, but they appeared as exceedingly real to her. In psychiatric language they would be called delusions. It was therefore important for the staff to be certain that Jane's feelings were being fully legitimized and were well anchored inside her. It was only then that she would be able to muster sufficient courage to make the effort necessary to master the situation. The next step was to teach various anxiety regulation techniques, followed by sessions about the patient's feelings and thoughts in the immediate present. These were then connected with her physical experiences and functions. To be able to regulate her anxiety was a prerequisite for continued progress. With time, a less frightening and more normal patient story evolved, which gradually became more meaningful and comprehensible both for the patient and her partner in dialogue. This narrative then developed into, and reflected, a new experience and new feelings of reality, which could also contain an understanding of the former one. Legitimization and Communication Jane's experiences of being invaded were not free fantasies, but were a legitimate part of her reality. This is important to understand in the

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legitimization of the patient. Equally important is that the therapist realize that the language the patient selects is in all respects a reasonable way for him or her to deal with the situation. It is this attempt to construct a story that makes it possible to create security, prediction, and hope for further life. The communication between therapist and patient must be characterized by the greatest possible sensitivity on the therapist's part, likewise by mutual trust, in order for the story that the patient puts together over time to be more comprehensible, both for the therapist and for the patient. As a rule this takes a long time, but may show itself to be a good investment. If the therapist is able to introduce an emotionally acceptable and scientifically based explanation of the disorder in a step-by-step manner into the patient's world of ideas, this often leads to the patient's gradually reformulating his or her story in a more comprehensible way. This, in turn, is a step in the direction toward a healthier behavior and the reacquisition of the motivation for developing new functional connections and contexts. Traditional Treatment Within traditional psychiatric care, delusions have, for the most part, been perceived as just as impossible to comprehend as the other symptoms springing from the physiological imbalance in the brain. For this reason patients have often been left with their own powerful anxiety and great loneliness. They have been denied the trusting dialogue, which is an essential condition if some form of development is to be possible. This has exacerbated their anxiety and other symptoms, which in turn have been the basic justification for increased medication. For these patients, medical treatment with neuroleptics has undoubtedly meant an important step forward, if at a high price. These medications work directly on the activation of the brain and reduce, in the desired manner, the patient's anxiety and other symptoms. However, at the same time they reduce the possibilities to understand and overcome problems on a cognitive plane. Self-regulation is more or less disconnected and is at a serious disadvantage. In the long run, medication also entails risks for brain damage. It further undermines the patient's own capacity for understanding and dealing with symptoms. Conversation in Conviviality Within the framework of a conversation that is characterized by trust and loving closeness, and in which the patient and his or her situation

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are completely legitimized, the patient's ability to understand and formulate a personal life-story can be radically improved. This helps the patient to understand and manage the severe mental handicap with which he or she must live. Such an intervention, which includes family or friends, should occur as soon as possible (i.e., immediately and preferably at the first onset of illness). On an acute home visit, the therapist's work often begins with helping the patient to handle acute symptoms with techniques that suit the individual. This is easier if there is an earlier established and trustful atmosphere. During such a conversation it is usually possible for the patient and family to render a more detailed description of, and to interpret, their experiences in the immediate present. This is the introduction to a narrative that must now be formulated completely differently than if the patient is rushed to a hospital without anyone having the opportunity to have a conversation with him or her. This conversation often exposes the fact that certain stress factors, which have also earlier affected the patient's state of mind, have existed for a shorter or longer period prior to the current outbreak of symptoms. A further step in the treatment may be, in intimate dialogue, to help the patient relate physical sensations to normal physical feelings, and in this venue information the central nervous system can be introduced. This may help the patient to normalize his or her acute experiences and seek to summarize them in a comprehensible story/description. Such a procedure may prevent the emergence of a pathological language and a pathological narrative. Intervening at early onset may not change the picture of the disorder itself, but as a rule it explains how an outbreak of symptoms develops and what their potential consequences might be. An example would be inpatient care and/or unnecessary suffering for the patient and relatives. MENTAL HEALTH To meet today's challenges, public health has expanded from prevention of specific disorders to health promotion to health policies. The goal is to secure reasonable possibilities for individuals to promote their own health. As technology has made the world seem smaller, we are somehow more interconnected. It is therefore time for the global community to wake up and understand these global threats (WHO, 2002). Western Civilization, defined by individualism, humanism, and rationalism, has for centuries been bound to a naive belief in continuous progress. The Second World War definitely questioned the possibility

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of such progress. Today many people experience feelings of confusion, anxiety, depression, and powerlessness. These feelings are further nourished by a deluge of daily stimuli, more rapid changes in living circumstances than previously experienced, clashing values in an overpopulated globe, and the extensive availability of information via the Internet. For many people these factors contribute to a sense of fragmentation. Many people's stressful lives leave them with little time for reflection. In Sweden, among other countries, this has led to a disproportionate number of long-term sick leaves, challenging the whole economy of the country. As a consequence, medical science in Western countries focuses on stress disorders more than ever before. The human body and mind are perceived as one single system of continuous interactivity between different regulation systems working to achieve a delicate balance. Because the individual is a closed system only the person/self can experience and deal with his or her own health problems. To recommend remedies based on observations from the outside may be useful, but insufficient. The experiences of a person, of the mental and bodily processes, is becoming more important in solving health problems. This means that the personal life as the radical reality of our time requires both an outside and an inside perspective. Every person can now assume a more meaningful role in designing a treatment program. To cure disorders or to detect them early is not enough. Health promotion requires that individual, social, and environmental factors be attended to on a daily basis. This puts forth the question of whether some of the principles of cognitive psychotherapy are useful. The perception in cognitive psychotherapy of the patient as a researcher, exploring his or her own mind and body, and as the only person who can promote his or her own mental health may be a useful point of departure. This means looking at oneself as both an active "I" and a "me" for observation, evaluation, and change, with a self-respect that acknowledges one's aspiration, including faults and imperfections. The individual can best develop self-regulating powers and foster the ability to differentiate and adapt. THE FOUR-LEAF CLOVER—A METHOD FOR THE DEVELOPMENT OF CONSCIOUSNESS From this perspective we have developed a special model for group treatment of people in the risk zone for stress disorders. A more exhaustive description has been published in Swedish (Beskow et al., 2000).

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Conviviality

The basis of the treatment method is conviviality—the stalk of the four-leaf clover. When confronted with its basis—the legitimacy of the other—the participants in the groups are often shocked. They may feel respect for the authority as part of a dominance/submission hierarchy. But legitimacy inherent in the human state—embracing everyone—is quite another concept. It is about honoring and respecting one's right to be and to express oneself both as similar and different from others. It is the insight that everyone has to decide for him- or herself, because he or she is the best person to do it. It has to do with the borders between self and others. To show another person respect is easy to talk about but difficult to practice. It becomes workable when one breaks it down to details concerning feelings, thoughts, and actions. Skills have to be exercised so that such everyday problems as turn-taking and dominance in interpretations demonstrate the difficulties. The same is true of respect for self. The patient might say, "Of course I respect myself." But thoughts, feelings, and actions inevitably demonstrate short-comings. Respecting self is the basis of taking care of self and self s development. This is the first responsibility and necessity. It means to respect oneself even in less successful moments, even in unrighteousness, since we are all humans and therefore imperfect. When the group participants have been helped to understood and accept the legitimacy of others, and when they have understood and accepted respect for the legitimacy of others, there is a basis for group work. It rapidly generates a harmonic, creative atmosphere, characterized by inquiry, communicative openness, and trust. Conviviality is thus an essential condition for the development of consciousness that takes place with the help of the four-leaf clover.

Scientific Base The self-regulating system has a capacity to develop through being affected by and incorporating external information. The method uses images as a governing factor in mental development and thus builds on the fact that our thinking during childhood is developed via images and concepts. Goal-directed images are frequently used, for instance in religion and sports (e.g., winning a gold medal). The images used here are examples from scientific knowledge, taken from four fields of

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science: developmental theory, theory of emotion, theory of language, and systems theory. Each cloverleaf is composed of two images, each pointing toward the rich knowledge available within that specific field. They are meant to be a core from which the participants can construct their own images and narratives and thus actively promote the development of their consciousness. First Leaf: Developmental Theory The Child's Smile. The infant child smiles and stretches its arms toward the mother. The child is satisfied and prepared to use its emotional capacity for the encounter with her. When the mother attentively answers the child's smile and adds words, formulated in a language that is adapted to the child's level of development, the child's whole body shudders with feelings of joy. The cooing of the mother is met with even greater smiles, with contented, gurgling sounds—the beginnings of a language of its own. This scenario underlines the value of the dialogue that arises when nothing is permitted to disturb loving closeness between human beings; it is the archetype of conviviality. It also points out that living in close relations is a prerequisite for development. The First Step. Having learned to crawl and stand up on unsteady legs, the small child approaches a major decision. There is a force driving him or her to dare to take the first step. The parents can provide security and encouragement, but in the moment of truth the little boy or girl is alone. The child has to mobilize the necessary courage to do this on its own. This image also refers to the existential loneliness of modern humanity and our fate of constantly being forced to make new choices in new situations. The image reminds us of the fact that feelings of loneliness belong to human destiny and can never be completely eliminated. However, they can be reduced through interaction with others. Second Leaf: Theory of Emotion Don't Kill the Messenger. For days a messenger hastens toward the court of a prince in ancient Greece to tell of the negative outcome of a battle. On his arrival he has to report that their army has lost. The consequence is unexpected—he is executed for his painful and catastrophic message. This image reminds us of the fact that we often treat our emotions in

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an irrational and impatient way. Every emotion is loaded with a message and with energy. They both deserve to be met with respect and attention. The Swell and Rhythm of the Waves. Small waves lap against the beach. Wave upon wave rushes forward in a lazy rhythm. When the wind rises they grow larger and stronger. When the storm roars the waves rage and their upper layers are whipped to foam. The idyllic atmosphere is changed to one of fearfulness. The image of the rhythm of the sea turns our thoughts to the powerful need of the rhythm of the child, to cradling and lulling, to rocking and humming, to the canonical song. It leads further to the need in all of us to sing and dance to the rhythm of words and conversation. It also leads to the art of recognizing and reinforcing the bodily rhythms, which often are so deeply hurt in our time. In spite of that, we feel them and long for them. Third Leaf: Theory of Language Looking for Words. Replete with equal parts of desire and anguish, with the pencil in her hand, a woman leans over the empty paper in her concentrated search for the right words. This image invites us to a dialogue about the most remarkable invention of the human species, namely language—thought, spoken, written down—that is an essential condition for communication with other people but also with ourselves and thus for the development of consciousness. Story, Narrative. A campfire lights up the night. An old man tells about his life to shadowlike, listening figures, with wide-eyed hunger for knowledge, human company, and the need for sharing. The air is charged with ideas and feelings. Perhaps the story awakens wonder, longing, joy. Maybe love. Maybe doubt, anger, jealousy, sorrow. The image draws us into dialogues about the structure and meaning of the narratives of individuals, groups, societies, and cultures, and these stories are used to increase our self-understanding and to develop a consciousness of ourselves and others. Fourth Leaf: Systems Theory The Path in the Forest. A narrow path winds through a deep forest at night. The moon has disappeared behind clouds. A traveler who does not want to get lost has a small lantern to help him. This image poses vital questions: How shall I find the red thread, the path through my life? What is the goal, the meaning?

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Internet. A teenager in the middle of the night cooperates intensely with hundreds of fellow players and opponents engaged in virtual and real worlds. He gathers points in a sophisticated computer game that goes on around the clock on the Internet. This is an image of our time, of a global, chaotic, but also to a great degree, self-organizing, network. It is a picture that links further to dialogues about how our new world is constructed. The lack of overview and control, the understanding of linear and circular cause-and-effect systems, the polar points of causality versus interactive models of internal and external equilibrium and for differentiation and complexity, all offer an interplay for the individual leading to growth and development. The Four-Leaf Clover—An Image of Personal Development These images are condensed pictures of development within some important scientific research fields. At the same time they are basal images—metaphors—to which the person can accommodate in a more and more differentiated and detailed way. Taken together the images constitute a life-story of psychological development. They start with the existentially important polarity between being together and being alone. The next two images deals with the understanding of emotions and rhythms. Then it is time for cognitions and language: the sensitive searching for the right word—the word loaded with meaning—and the understanding of life as a story, the process into which the words should fit. The last two images bring in the perspectives of time and space: the individual life as a continuous path through darkness and at the same time part of an interactive network together with others. The four-leaf clover is thus a metaphor of one's life based on science. It facilitates the accommodation of scientific findings and make them meaningful and functional in a personal context. Accepting them, working with them, developing them is one way to increase the level of consciousness. But the basic assumption that promotes self-development is the respect for the legitimacy of oneself and others to create positive feelings of conviviality. REFERENCES Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Lawrence Erlbaum. Alford, B. A., & Beck, A. T. (1997). The integrative power of cognitive therapy. New York: Guilford.

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Beskow, J., Palm Beskow, A., & Miro, M. T. (Eds.)- (2000). Fyrklovern—en arbetsbok for medvetenhetsutveckling. Goteborg, Sweden: Center for Cognitive Psychotherapy and Education. Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York: Basic Books. Bruner, J. (1990). Actual minds, possible worlds. Cambridge, MA: Harvard University Press. Bruner, J. (1990). Acts of meaning. Cambridge, MA: Harvard University Press. Clark, D., & Beck, A. T. (1999). Scientific foundations of cognitive theory and therapy of depression. Chichester, UK: Wiley. Crittenden, P. (1995). Attachment and psychopathology. In S. Goldberg, R. Muir, & J. Kerr (Eds.), Attachment theory: Social, developmental and clinical perspectives (pp. 367-406). Hillsdale, NJ: Analytic Press. Damasio, A. (1996). Descartes' error: Emotion, reason and the human brain (2nd ed.). London: Papermac. Damasio, A. (1999). The feeling of what happens: Body, emotion and the making of consciousness. New York: Guilford. Edelman, G., & Tononi, G. (2000). A universe of consciousness. How matter becomes imagination. Cambridge, MA: MIT Press. Foerster, H. (1960). Self-organizing systems. In M. C. Yorits & S. Cameron (Eds.), On self-organizing systems and their environments (pp. 31-50). London: Pergamon. Foerster, H. (1981). On cybernetics of cybernetics and social theory. In G. Roth & H. Schwegler (Eds.), Self-organizing systems (pp. 102-105). Frankfurt: Campus Verlag. Freeman, A., & Reinecke, M. A. (1993). Cognitive therapy of suicidal behavior: A manual for treatment. New York: Springer Publishing Co. Greenberg, L., & Paivio, S. (1997). Working with emotions in psychotherapy. London: Guilford. Kelly, G. (1995). The psychology of personal constructs. Vol.1: A theory of personality. Vol.11: Clinical diagnosis and psychotherapy. New York: Norton. Lain Entralgo, P. (1998). Hacia la recta final, revision de una vida intelectual. Madrid: Galaxia Gutenberg. Maturana, H. R., & Varela, F. J. (1984). The tree of knowledge: The biological roots of human understanding. Boston, MA: Shambhala. Miro, M. T. (2000). El problema del otro en el post-racionalismo. Revista dePsicoterapia, 11, 115-127. Palm Beskow, A., Beskow, J., & Miro, M. T. (2000). Kognitivpsykoterapi och medvetenhetsutveckling. Om att leva i konvivialitet. Goteborg, Sweden: Center for Cognitive Psychotherapy and Education. Ricoeur, P. (1984-1988). Time and narrative. London: University of Chicago Press. RicoeurP. (1991). From text to action: Essays in hermeneutics II. Evanston, IL: Northwest University Press. Stern, D. N. (1985). The interpersonal world of the infant. New Haven, CT: Yale University Press.

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Trevarthen, C. (1984). Emotions in infancy: Regulators of contact and relationships with persons. In K. R. Sherer & P. Elkman (Eds.), Approaches to emotion. Hillsdale, NJ: Lawrence Erlbaum. World Health Organization. (2000). The world health report: Reducing risks, promoting healthy life. Geneva: Author.

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14 The Entropy of Mind: A Complex Systems-Oriented Approach to Psychopathology and Cognitive Psychotherapy Tullio Scrimali and Liria Grimaldi

ognitive psychotherapy (CPT) is a relatively recent scientific clinical movement. At least three different cognitivist approaches can be currently identified, each characterized by different epistemological, theoretical, and clinical perspectives. These three approaches are standard cognitive psychotherapy, constructivist psychotherapies, and complex systems therapies. Standard cognitive psychotherapy (Clark, 1995) is developed from a scientific background that includes human information processing, sensorial theories of mind, and a rationalistic epistemology. Constructivist psychotherapies (Goncalves, 1989; Greenberg & Tobach, 1990; Guidano, 1987, 1992; Lyddon, 1987; and Mahoney, 1988, 1991) stem from a background of cybernetics, motor theories of mind, constructivist epistemology, and human ethology. Bowlby's attachment theory (Bowlby, 1960, 1977, 1980) has also been a contributing force in the constructivist approach. The scientific background of complex systems therapies (Neimeyer & Mahoney, 1995; Scrimali, 2000; Scrimali & Grimaldi, 2002) includes "far-from-equilibrium" (complex) systems theories.

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These approaches developed more or less chronologically. The first developmental stage in cognitive psychotherapy, beginning in the sixties, was influenced by information theory and cybernetics, thanks to the contributions of Bruner and Postman (1947), Von Neuman (1958), Shannon and Weaver (1949), and Wiener (1947). Cognitive psychology had a major influence as well, represented by the work of Piaget (1950), Miller, Galanter, and Prihram (1960), Neisser (1967), and many others. The clinical voices of this early movement included Ellis (1962), Beck (1963, 1964), Bandura (1969), Meichenbaum (1977), and Lazarus (1971). One of the most crucial aspects of standard cognitive therapy is the central role of cognition. In this perspective, emotion is considered a by-product of cognition, illustrated by Beck's (Alford & Beck, 1998) paraphrase of Epictetus: "As you think so you will feel!" At present, the standard approach to cognitive therapy is not aligned with a well developed psychopathological or pathogenic theory (Leahy, 2001). Carlo Ferris, an Italian author working in Sweden, contributed significantly to the field of cognitive therapy during the eighties and nineties (Ferris, 1989; Ferris, Arrindel, & Eiseman, 1994). He developed a cognitive approach to the therapy and rehabilitation of schizophrenic patients that must be considered seminal. Ferris devoted major emphasis to ethological aspects concerning both psychopathology and therapy (Ferris et al., 1994). He also underlined the crucial role of the therapeutic relationship in cognitive therapy. Starting in the second half of the seventies, a proposal was developed by Vittorio Guidano (who prematurely passed away in Buenos Aires on August 31, 1999) and Giovanni Liotti (Guidano, 1987,1992; Guidano & Liotti, 1983). In 1983, the two authors published Cognitive Processes and Emotional Disorders, a work that greatly influenced the development of international clinical cognitivism. Their model was based on the following fundamental aspects: an evolutionary viewpoint regarding the relationship between cognition and reality a motor (active) paradigm of mind a central role assigned for self-knowledge process, and a double articulation in the knowledge processes, divided into tacit and explicit knowledge. From this foundation, a new view of psychopathology and psychotherapy, defined as "systems-processes oriented" and "post-rationalistic," was

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progressively elaborated in the following ten years by Guidano (1987, 1992). His work is an important building block of contemporary cognitive psychotherapy. Guidano's articulated constructivist proposal led to a psychotherapeutic approach no longer aimed at correcting the patient's "mistakes" in reality processing (as per the approach of classic cognitivism). Rather, the focus turned toward reordering the perceptual experience of the patient in order to restructure the coherence patterns of self. In this model, the role of emotions is crucial. No longer considered a cognitive by-product, they are framed as an active and powerful form of knowledge, utilizing parallel and analogue computational processes. The function of the therapeutic relationship thus becomes the provision of a specific emotional situation in which the reordering of perceptual experience and changes in coherence patterns of self are possible. Guidano's observations on the intersubjective dynamics of the idea of self are an important aspect of this model. Upon examination of human beings' marked social aptitude, and the role of language in structuring and maintaining relationships, Guidano stresses the importance of social learning processes, as well as relationships with other human fellows (caregiving figures in particular) in the organization of self. The structuring of self and the development of self-consciousness are dependent upon these social dynamics. Guidano describes the life cycle as an orthogenetic development process, moving through different stages of balance and continuously increasing in integration and organization of self. The primary function of therapy lies in the reordering of perceptual experience. This has triggered strong resistance by some cognitivist authors, who criticize the progressive detachment of Guidano's approach from traditional clinical practice. This is largely due to his emphasis on awareness of general existential problems, rather than technique-dependent, behavioral change approaches. Our clinical research in cognitive psychotherapy began in the second half of the seventies, allowing us to promote the establishment of a Chair of Cognitive Psychotherapy at the University of Catania Medical School in 1980. In the late eighties, at our Laboratory of Cognitive Psychophysiology, we developed a motor and constructivist approach strongly influenced by the systems-process view, later formalized in the monograph On the Tracks of Mind (Scrimali & Grimaldi, 1991). Our research later focused on the processes of mind, experimentally studied via methodologies of psychophysiology, neurophysiology, and cognitive psychotherapy of schizophrenia. Obviously, we included other pathologies such as anxiety, mood, eating, and personality disorders (Scrimali &

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Grimaldi, 1991,1996a, 1996b). Moreover, at our Department of Psychiatry Clinic at the University of Catania, a remarkable new energy was devoted to experimental studies of parenting and attachment processes in adults. From this foundation of diverse research, we progressively developed a complex biopsychosocial model for the pathogenesis and psychopathology which we called "Entropy of Mind." This model was, in turn, used as the foundation for a psychotherapeutic and rehabilitative approach we call "Negative Entropy." Our developments in this cognitivist orientation inspired our theories of complex systems to develop in a more organic way during the nineties. In 1992 we established the scientific journal Complexity & Change. The important development in the second half of the twentieth century of complex systems theories will allow us to get back to research on the brain in innovative ways. Additionally, these developments should serve to activate interest in reinterpreting systemic aspects of relationships in the light of recent observations in human ethology. The applicability of classic laws and methods of physics and mechanics is diminishing as we continue to discover elements animated by a disordered motion, such as the gas in molecules. The use of probability and statistics in developing interpretive and predictive models to explain chaotic (complex) systems behavior offers us far more insight. The establishment during the sixties of disciplines for studying complex systems promised a possibility for realizing man's hope to fully understand and control nature (and to understand human reality as well), using a reductionist and disjunctive approach. The field of physics was moving toward the clear and documented perception of what the great mathematician, Henry Poicar, had anticipated at the beginning of the previous century. Any physical system, he proposed, even if relatively simple and subject to the deterministic rules of Newton's mechanics, may suddenly start exhibiting chaotic and complicated behaviors, eluding what reductionistic scientists prefer to find: clear expectations and control. In fact, apparently similar systems may start evolving in very different directions and lead to very different outcomes. Since the complex systems approach addresses the highest possible number of levels of integration, it underlines the need for a global understanding of systems, their organization, and the relationships of circular (rather than linear) causality among them. Ilya Prigogine, one of the protagonists of the complexity revolution, after elaborating a new discipline in the field of physics involving the thermodynamics of far-from-equilibrium (complex) systems, reached

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an epistemologic synthesis representing one of the most emblematic challenges of our times (Prigogine & Stenger, 1984). One fundamental aspect of complexity theories is the criticism of determinism, along with the proposal of a "logic of possibility" in which uncertainty is the base variable. While the laws of physics, in their classic formulation, describe an idealized, symmetrical, stable, and foreseeable world, Prigogine describes a world characterized as unstable, uncertain, and capable of rapid evolution. An adequate understanding of these chaotic systems may be reached only in terms of possibilities, rather than deterministic certainty. From probability, the fundamental dimension of irreversibility develops, starting from Clausius's second principle of thermodynamics, according to which universal entropy constantly grows until it reaches its highest level. This continuous increase in entropy delineates an arrow in time, an irreversible directionality of dynamic processes, from past to future. The nonlinear physics of far-from-equilibrium systems is therefore the physics of unstable processes, of bifurcations, of the possibility of behavior, of multiple choices and, ultimately, of self-organization. Another fundamental aspect of Prigogine's elaboration is the substantial differentiation between open and closed systems. The former exchange energy and matter with the outside world. Thanks to this constant flow, open systems are capable of keeping their level of entropy relatively constant over time, since the continuous degradation of their structures is compensated for by reconstruction and reorganization activities. Biological systems are open systems, operating under far-fromequilibrium conditions. We, as human beings, are made of atoms and molecules, but we are also open and highly organized complex systems, continuously exchanging matter, energy, and information with the external world. Our life events are subject both to the laws of particle physics (and therefore to the second principle of thermodynamics), and the laws of far-from-equilibrium systems. Based on the second principle of thermodynamics, our body and brain are constantly subject to increasing entropy, ultimately leading to the disorganization of the molecules and atoms of which we are constructed. Since we are also open, self-organized systems, however, we continuously engage active organizational processes against the entropy increase, subtracting matter from the environment to get energy. In this light, we see the life cycle dramatically unraveling between two antithetical positions. Our body constantly degrades according to the second principle of thermodynamics, but simultaneously reshapes itself

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based on the far-from-equilibrium processes of physics. The match is uneven, however, since reorganization processes lose ground every day. Entropy gradually increases until the body finally fails us. The molecules we are made of cannot indefinitely maintain a well-organized pattern. The brain knows this melancholic parable, but the mind is not subject to the second principle of thermodynamics. The mind is composed of information and does develop indefinitely, organizing and articulating itself, evolving, and becoming more powerful until its physical support ends. In death, the energy flux to the brain is interrupted. It once again becomes a closed system, subject to the second principle of thermodynamics. The Krebs cycle stops, sodium-potassium pumps block themselves, ions arrange themselves freely according to concentration gradients, and organization fails. The construct of the mind can partially outlive the brain, however. As such, the mind can locate itself in other physical supports, for example, the books we write. Our thoughts and ideas may be transferred, by means of action and language, to the minds of our children, their children, and so on. From prehistory to the present, the mind of homo sapiens has continued to develop, passing information from one generation to the next. Societies developed by humankind can be viewed as nonlinear dynamic systems as well. Such systems evolve out of interaction between the behavior of individuals and restrictions imposed by their environment. The individual's behavior is, in turn, determined by individual projects and wishes interacting with the social system. Does each individual human being tend to self-organize his or her complexity based on physical and cultural bonds, according to rules that may be deductively written? In substance, is it possible to foresee the future when we know the past? Or, rather, is the overall essence of life determined by dynamic processes evolving in a constantly far-from-equilibrium situation, characterized by indeterminacy and unpredictability? Recent developments in physics would suggest the latter. An important aspect of contemporary scientific understanding is the interaction between information theory and the second principle of thermodynamics. In cybernetics, entropy is categorized as the rate of contingency (indeterminacy) among the causal factors. According to a fundamental axiom of cybernetics, the sum of three rates— indeterminacy (entropy), determination, and organization—is always equal to one. When a system's level of indeterminacy increases, a proportional decrease in rates of determination and organization will be re-

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corded. As an open system, the central nervous system tends to maintain very high energy and information levels; this facilitates the development of higher and higher levels of organization. The evolutionary indeterminacy of open systems allows humans to construct their own developmental scenery in a flexible and teleonomic pattern. During this evolutionary unfolding, unforeseen events can occur in which transactions between humans and their environment are altered. According to this approach, as we will discuss later, psychiatric disorders fall into this category. The theory of complex biological systems, applied to the study of the brain, implies new modalities of categorization relevant to the domains of brain biochemistry, molecular biology, genetics, biology, anthropology, psychology, and ethology. Within both the central and peripheral divisions of the nervous system, chemical substances play a very important role, favoring or inhibiting the transmission of information from one neuron to the other. The discovery of the neuronal synapse has demonstrated that nerve cells communicate through a specific and highly organized structure. The transfer (or blockage) of information from one neuron to the other is mediated by chemical and physical events. The discharge of chemical mediators capable of interacting with special post-synaptic receptors causes the bio-electric (physical) phenomena of depolarization or hyperpolarization. If the availability of various chemical mediators (adrenalin, noradrenaline, serotonin, dopamine, gaba, etc.) changes, the functioning of information transmission mechanisms is altered at the synaptic level. Therefore, when we administer substances capable of interacting with neuromediators, dynamic pharmacological actions on the nervous system may be caused; in some cases, such actions may be utilized for therapeutic purposes. For instance, it is evident that some of the symptoms of depression may be created by a decreased availability of catecholamines, particularly serotonin. In the case of schizophrenia, an alteration in the functioning of nervous centers and paths mediated by dopamine has been suggested. Since the sixties, the introduction in therapy of substances that interact with synaptic biochemical mechanisms has evolved into a reductionist approach to psychiatry. The reasoning involved may be summarized as follows: Symptoms of schizophrenia improve when we administer neuroleptics that act at the level of the dopaminergic synapse. From a pathogenic viewpoint, schizophrenia is therefore related to a gap in the dopaminergic synapses. By the same logic, some reductionist psychi-

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atrists claim that depression is primarily a biochemical disorder, treatable by the administration of a serotonin-activating drug. As the biochemical mechanisms of information transmission are open systems, however, they are closely related to the overall flow of information through the nervous system. Therefore, information input may modify the synaptic set as well as chemical intervention, and this change in the synaptic set may modulate the subject's emotional state. For example, if I attend a psychotherapy session as a result of which my mood is elevated, my serotoninergic synapses have been activated. If I take an antidepressant, I may feel equally relieved since the serotoninergic synapses have been chemically activated. In our view, change in emotional patterns does not take on a real therapeutic valence if it is not associated with a change in cognitive patterns as well, indicating development in the individual's knowledge system. Sedating anxiety symptoms by using benzodiazepines, raising the mood by administering antidepressants, or reducing hallucinations with neuroleptics has therapeutic meaning only if the provision of medication is part of the restructuring of the patient's knowledge system through modification of cognitive patterns (followed by changes in emotional patterns). Recently developed disciplines like ecology and ethology share several assumptions and problems with evolutionary logic, one of the most important being a historical approach. Psychological and biological realities, as well as relational and social ones, are the result of millions of years of history. It seems impossible to understand developmental processes without referring to the historical processes of biological and epistemological philogenesis and ontogenesis. In the organization and architecture of the human brain, signs of an articulated series of developmental processes are clearly observable. One can trace the transition from the reptilian brain to the mammalian brain to the primate brain. Hemispheric specialization, along with related language competence, is considered the most important developmental jump during the hominization process (MacLean, 1973). It is therefore possible to state that modern human beings are the synthesis of a powerful confluence between biological and cultural development. When the first hominid was able to communicate a subjective experience to one of his fellows, the doors of a new reality sprung open: the world of culture. Since then, both biological and cultural evolution have become closely linked dynamic processes. For hundreds of thousands of years, increasing cultural capabilities and the growth of the encephalic mass (and the concurrent increasing

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complexity of brain structure) have been a hallmark of human evolution. This process resulted in our enormous power over our environment. Neanderthals likely had no need of fearing rivalry with other mammalians living in their territory. Unfortunately, the achievement of dominance over other living species triggered competition and intraspecies aggressiveness. Cultural evolution, and the progressive development of more and more articulated and complex social organizations, led humankind to dramatically modify its own biological evolution. These observations are full of consequences at the clinical level of family and psychosocial intervention. The three issues upon which our model is built are the modular brain and coalitional mind; understanding, development, and advancement of a new science of the mind; and, finally, the entropy of mind. These concepts combine to form a complex systemsoriented approach to the etiology of psychopathology, ultimately leading to a multidimensional and multicontextual approach to therapy and rehabilitation. MODULAR BRAIN AND COALITIONAL MIND AS A PROLEGOMENA FOR A NEW SCIENCE OF THE MIND The theory on which the complex systems model is centered begins with the conceptualization of the brain as a combination of several modular systems of information processing, and the mind as a coalition of many (various) processes articulating themselves at different levels (Fodor, 1983). Fodor proposes that man is endowed with "multifarious minds," each related to specific functions and characterized by individual dynamics. Additionally, Robert Ornstein has contributed the concept of "mind in place" (Ornstein, 1992). According to this theory, the most suitable coalition of specialized modules to carry out the requested computational task is activated and influenced by environmental demands. When environmental contingencies change, and the "active mind" is no longer suitable to carry out the requested task, a more appropriate module is activated in its place. In order for the global dynamics of the mind to function in a generative and flexible way, it is crucial that the various modules are active and functioning properly. This conceptualization of mental functioning refers to the following components of knowledge processes: tacit knowledge (emotion) explicit knowledge (cognition)

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Tacit Knowledge Basic activity: To keep the individual in immediate touch with the environment, focusing attention on events with immediate valence (here and now). Goal: Short term adjustment and survival. Information-processing modalities: This modality is analogic. It is a high capacity channel, capable of processing, in parallel, large quantities of information in very short periods of time. This makes information available for necessary rapid adjustments to environmental changes. Memory systems: Short-term (procedural) memory, and long-term (episodic and emotional) memory. Awareness and relations with consciousness: The activities of tacit knowledge develop outside of awareness and cannot be communicated if they are not subject to a digitalization process. Reference nervous structures: Right temporal lobe, limbic system, rhinencephalon, hypothalamus. Ontogenetic chronology: This system of information processing develops very early. Its organization may be seen in the first stages of newborn development. Phylogenetic chronology: This is an archaic system, well developed in all mammalians.

Explicit Knowledge Basic activities: To create a conceptual order out of the chaotic disorder of the flow of information; to create a strategically articulated theory of Self and the world; and to formulate flexible heuristic models aimed at problem solving. Goal: To facilitate long-term adjustment through the construction of a body of knowledge that may be transferred to others (fellows and offspring) via spoken and written language.

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Information-processing modalities: Serial, performed in limited capacity channels. Processing times are longer than those necessary for analog and parallel codification. Memory systems: Short-term and declarative. Typology of long-term memory: Semantic. External brain supports (writing, etc.) may be used. Moreover, nonbiological information-processing systems, interfaced with the brain through specific input and output units, like computers, maybe recruited. A brain connection via the mediation of electronic supports, like the World Wide Web, is also possible. Awareness and relations with consciousness: The activities of explicit knowledge develop within awareness. Explicit knowledge continuously carries out a decoding activity, in digital and semantic terms, of the contents of other forms of knowledge. This makes data available to consciousness. Reference nervous structures: Left frontal lobe. Ontogenetic chronology: This is a later-developed system. It begins maturing with the acquisition of language and has a long evolutionary process, characterized by the passage from concrete to abstract thought. Phylogenetic chronology: This is a very recent system. This knowledge typology belongs exclusively to homo sapiens and is related to the onset of hemispheric specialization.

Procedural Knowledge and Executive Functions Basic activity: To perform a series of behavioral sequences targeted at carrying out complex interaction with the environment. Goal: To act within the environment to acquire energy, matter, and information, in order to keep the system alive, as well as to avoid threats to survival and welfare. To optimize the individual's interaction with reality in an evolutionary and flexible fashion. Information-processing modalities: Both digital and semantic computational systems and parallel information-processing systems occur. Memory systems: Short-term (procedural) and long-term (procedural) . Awareness and relations with consciousness: The activities of the procedural system may or may not be controlled by awareness. Typically, when a new executive competence is learned, it is strictly controlled

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Contemporary and International Influences by aware activities. Progressively, newly developed aptitudes are performed out of awareness. In this way, a large part of the digital elaboration process is devoted to learning new executive activities. Reference nervous structures: Frontal lobes and motor areas. Ontogenetic chronology: This is a "mixed" system (archaic systems combined with more recently activated systems). Phylogenetic chronology: In general, this level of coalitional activity is not evident in other mammals and primates. The latter may acquire remarkable abilities of manipulation of objects, but these abilities remain far below the executive competencies of humans.

Social or Machiavellian Intelligence Basic activity: To perform and optimize transactions with others. Language is of fundamental importance. Goal: To maintain positive relations with others, increasing personal power and the possibility of survival and welfare. To become part of a relationship aimed at procreation of progeny and stable parenting. Information-processing modalities: Both analogic and digital. Several information acquisition and transmission channels act contemporaneously, for example, verbal and nonverbal communication sequences. Memory systems: Short-term (declarative and procedural) and longterm (declarative and procedural). Awareness and relations with consciousness: Some activities associated with social or Machiavellian intelligence fall under the domain of awareness. Typically, verbal communication is strictly controlled by consciousness, but this does not always apply to nonverbal components of communication (during both transmission and reception) . Reference nervous structures: Dorsolateral structures of the prefrontal cortex linked in a complex network, including parts of the upper temporal cortex and lower parietal cortex. Also limbic structures, amygdala, caudatum and thalamus. Ontogenetic chronology: Late (following the development of language). Phylogenetic chronology: Late, with marked peculiarities in homo sapiens.

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The knowledge processes described above are unified by the self, which constructs a personal identity and produces an explanatory "narrative" (Guidano, 1992). Human knowledge is a complex system in which activities are carried out in coalitional terms, simultaneously involving much of the brain. Each knowledge activity implies the acquisition, selection, and processing of information, the utilization of memory, and the construction of plans and strategies to interact with the environment and with others. Knowledge activities are supported by specific modular nervous structures, and develop according to biochemical, computational, and neuronal mechanisms. The most archaic structures (archipallium and paleopallium) operate in constant cooperation with more evolved knowledge structures (neopallium and the prefrontal lobe system). The proper functioning of the mind is the result of an ontogenetic process that overlaps a phylogenetic evolutionary process, which the cerebral architecture reflects. This ontogenetic process of knowledge helps to explain the relational, behavioral, cognitive, and emotional patterns of individual human beings.

THE ENTROPY OF MIND: A COMPLEX SYSTEMS-ORIENTED APPROACH TO ETIOLOGY AND PSYCHOPATHOLOGY Following this complex model, the genesis of psychiatric disorders can be examined in terms of the following dynamics: Biological vulnerability Development history (the role of parenting is crucial) Stimulus events capable of deranging the subject to the extent of decompensation Clinic decompensation Course According to this approach, the disorder, observed at the clinical level, is the final result of a complex chain of events. The factors involved may be classified in terms of information theory, which is the reference point in the development of cognitivism. The negative functioning of a subject displaying a psychiatric disorder may be thought of as a series of information dysfunctions, summarized as follows. Parenting is obviously an important factor, as outlined by attachment theory. Psychiatric disorders are connected to the presence of dysfunc-

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tional schemas established in childhood; in other words, they begin with negative parenting experiences (Bowlby, 1960). Various dysfunctional parenting styles have been found to correspond to specific psychiatric disorders (Bowlby, 1969). The anxious attachment, characterized by excessive emotion on the part of the mother, and associated with a controlling attitude that limits the child's normal exploratory behavior, is associated with phobic type disorders (De Ruiter, 1994). In this case, the child progressively develops a prevalent emotional modulation of anxiety, based on a perception of reality as threatening and the self as vulnerable. The resulting dysfunctional coping mechanisms are avoidance, escape, and attempted control of the environment, in order to avoid unexpected occurrences. A difficulty dealing with restrictions and constrictions (material, metaphoric, or relational) is also established. Parenting described as "affectionless" is associated with obsessivecompulsive disorders (Parker, Tuplin, & Brown, 1979). In this case, the child is subject to excessively strict formal and material bonds, with a continuous and anxious focus on the importance of rules. The emotional nucleus for this is the idea (or feeling) that there is a given order to reality. In the child's view, this order is so complex and arcane that only parents are able to understand it or impose it. The child is thus compelled to search constantly for "clues" for understanding each situation in an attempt to avoid reproach or punishment. To relieve anxiety, the child begins to develop rituals, though they generally do not provide the comfort the child seeks. The development of depressive disorders is associated with a developmental history that includes an avoiding attachment (Ainsworth, Blehar, Waters, & Wall, 1978). This occurs when the child is not positively cared for or offered emotional support. The self organizes around perceptions and feelings of unlovability, and the impossibility of getting help from others; therefore a perceived need to rely solely on oneself is expressed. These coping mechanisms, which structure themselves as basic strategies of living, were identified by Guidano as the "challenge to loneliness" and "forced self-esteem." The former entails the wish to rely completely on oneself, refusing any help from others. The latter pushes the individual to maintain extremely high standards of functioning in order to maintain an acceptable self-image or self-esteem. An attachment pattern characterized by difficulty in recognizing one's own emotional patterns is associated with eating disorders. In this case, the child builds an image of self in which the schemas related to personal value and lovability are vague and defined by the external

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world. These children tend to be very vulnerable in interpersonal situations, as they are open to a felt negation of their lovability. From an emotional point of view, a continuous feeling of emotional activation, which is progressively decoded as "hunger," is perceived. Guidano defined the dynamics of systemic coherence of self in patients with these disorders as "vague and fluctuating." The dysfunctional parenting modality associated with schizophrenia can be referred to as excessive control. Hostility, criticism, and emotional hyperinvolvement characterize the child's experience of parental relations. The family of origin's communication and respect for roles is disturbed. In this perspective, we begin to see that the functioning patterns of knowledge processes vary for each individual. Idiosyncratic aspects of emotional, cognitive, procedural, and social processes serve to create different perceptual frameworks. There is not a large gap between normal and disturbed conditions, but rather a continuum characterized by higher or lower levels of adjustment and compensation. A human being displaying a high level of emotional stability, explicative and heuristic competence, procedural efficiency, and adequate social capabilities will be able to flexibly adjust to the environment. He or she will be able to effectively cope with the challenges and changes of living. On the other hand, a subject whose functioning is characterized by strict epistemic bonds that reduce the dynamics of the knowledge processes to a few monotonous, repetitive, and idiosyncratic patterns will be continuously compelled to search for problematic solutions and a precarious adjustment to an environment that may be easily compromised by stressful events. Therefore, subjects with a psychiatric disorder will not positively integrate themselves into a social niche characterized by high emotionality or hostility, but may instead adjust well to a niche permeated by a less intense emotional climate. In this way, the life cycle of each human being moves between stages of balance and non-balance, ultimately characterized by an increase in entropy. When a subject is in a phase of decompensation and turbulence, he or she may overcome such a condition either through a progressive emotional "sliding" or through a regressive readjustment under less evolved conditions that may be more rigid and archaic. The impetus for these adjustments (on both tactical and contingent levels) is a search for balance. If, during the decompensation phase, the individual is able recover a sense of balance by utilizing dysfunctional mechanisms of self (e.g., a pharmacological treatment or estrangement from troubling

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situations by means of hospitalization), this apparent success is, in reality, a limited victory. Inevitably, another set of problems will cause the next phase of decompensation. Ideally, an evolution of the patterns of self up to the different levels of knowledge processes will occur. This necessarily involves special attention to the emotional mechanisms which, being phylogenetically and ontogenetically more ancient, tend to be particularly persistent. This may allow the individual to foresee a more flexible adjustment in the future. A subject who is flexible (with limited dysfunctional bonds in the patterns of self) is able to evolve throughout the course of life. He or she will, from time to time, develop newer and more refined coping and problem-solving strategies. On the contrary, an individual whose knowledge process functioning is plagued with idiosyncratic bonds will not be able to deal with the life cycle in a creative and generative way. He or she will specialize in few, repetitive, and very expensive negative attitudes, which will create a problematic adjustment. This individual will function inside an ecological niche that, although protected, remains exposed to new circumstances and, therefore, decompensation. Vittorio Guidano was the first author to suggest such a finished formulation of psychopathology within the constructivist/cognitivist field. He described four specific organizations of personal meaning: phobic, obsessive-compulsive, depressive, and psychogenic eating disorders (Guidano, 1987). As may be evident, Guidano's observations neglect the important area of psychosis, particularly schizophrenia. We believe that the study of schizophrenia (obviously including a focus on developing an efficient therapeutic and rehabilitative approach) can offer a great deal to an articulated complex model in psychopathology. The biological dimension, which plays a very important role in schizophrenia, must be considered. In our opinion, dysfunctions afflicting the emotional sphere, information processing, and cognitive, procedural, and Machiavellian intelligence processes in schizophrenia are not exclusive to this disorder (since they can be found in other pathologies). According to this formulation, the pathognomic aspects of schizophrenia should be brought back to a triad, as suggested by Beck (1979) with reference to depression as clear, including compression of personal identity, alteration in the meaning of unity and continuity of self, and a disruption in the personal narrative. According to Bleuler (1911), individual signs and symptoms are not the peculiarity of schizophrenia, but rather the fact that in this disorder the unity of mind is affected due to a gap in unification processes.

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In the first part of this chapter, we underlined the notion that the brain works in modular terms and, consequently, that the mind develops according to coalitional processes. The most important of these are personal identity, self, and personal narrative. In a schizophrenic individual, self-unifying processes are altered and the identity begins to dissolve, resulting in a fragmentation and disorganization of the personal narrative. The ability to process, in unique and organic terms, life events and their narration is disorganized by the intrusion of new rules and new scenarios that suddenly transfer the individual to a situation that feels completely alien. The thread of personal history breaks. After this dramatic psychotic experience, the patient slides into a dimension where the fundamental reference points (the results of the unifying processes of the mind) are lost. The adoption of a constructivist view of motor theories of mind facilitates a new approach to the psychopathology of schizophrenia, in particular what are referred to as delusions and hallucinations. Chadwick, Birchwood, and Trower (1996) suggested, at a strictly clinical level, a reading of the schizophrenic psychopathology from a rationalist cognitivist viewpoint, applying Ellis's ABC model: Activating event, .Belief, and Consequences. According to this model, a delusion would be the final result of a series of malfunctions in information processing. Intense negative emotions, associated with the delusional condition, are classically considered a by-product of this alteration of cognition. Finally, the idea that there must be an objective order to external reality, and that it must be decodable through specific and coherent information-processing patterns, is corroborated. Thus, the construction of "meaning" does not result from the activities of the mind, but is instead related to the external world. According to constructivist theories, meaning results from the processes of the mind, particularly the narrative developed by the individual in his or her current life cycle transition. Therefore, meaning construction is a historical process relevant to the specific and subjective becoming of each individual. Within a rationalistic logic, the schizophrenic patient is not capable of understanding the "real" meaning of reality, due to malfunctions of the mind. In our view, delusion is generated at the level of the interface between experiencing and explaining. The schizophrenic patient understands the experience of tacit and analogic data in relation to reality. His or her problem lies in the rigid tendency of the explicative processes. A typical example is that of poisoning. For example, a patient states, "My parents put poison in my food!" In reality

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these parents, who have highly expressed emotions, "poisoned" the patient with their hostility and emotional hyperinvolvement. In addition, they were dropping heavy doses of neuroleptics into the patient's food. Such patients understand an experience datum that is present in reality, but their explicative competencies do not allow them to process it in a realistic and adaptive way. This theory regarding the specific gap between explicit knowledge and the normal functioning (or hyperfunctioning) of tacit processes is supported by a series of neurophysiological and psychophysiological data. Callaway and Naghdi (1986) formulated a neurophysiological theory of schizophrenia that starts with a description of two modalities of information processing, relevant to two cerebral processors, defined as "System 1." This system operates in a serial modality with limited capacity. "System 2," on the other hand, is capable of automatically and simultaneously processing more than one series of information. We have used Callaway and Naghdi's model within our description of the different knowledge processes by associating System 1 with explicit knowledge and System 2 with tacit knowledge. Experimental data collected at our psychophysiology laboratory corroborate this association. Among them, study of evoked potentials bound to the event, and the analysis of hemispheric functional coherence, were especially compelling. The first method involves documenting an alteration in the wave known as P300, which is the evoked electroencephalographic display of sensorial processes with limited capacity. Within the second method, a gap in the sensorial processors of the left frontal lobe is evidenced when the patient is engaged in mathematical calculations. Recent research (by means of computerized electroencephalographic test techniques) illustrates the increase in entropy of the schizophrenic patient's central nervous system during stages of clinical decompensation. As for hallucinations, little consideration of the psychopathological mechanisms is evident in the cognitivist field. In our view, this may be due to the difficulty of the classic rationalistic cognitivist approach in confronting a phenomenology that questions the human information-processing paradigm when facing a process of cognitive elaboration and in the absence of information. A series of observations on the structural and functional organization of the central nervous system (within the motor theories of mind) allows us to build a frame of reference for the development of a cognitivist (but constructivist and non-rationalist) model for hallucinations. In the

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use of a motor approach to an understanding of the central nervous system and the functioning of the mind, it is necessary to stress that each input entering the nervous system through any of the sensory modalities is continuously modulated by control centers located in the central nervous system. The resulting hypothesis is that hallucinations result from the activation and utilization of sensory material stored in memory systems. This information pattern, present in some modules of the brain, eludes the self s coalitional control and therefore is experienced as originating in external reality.

NEGATIVE ENTROPY: A MULTIDIMENSIONAL AND MULTICONTEXTUAL APPROACH TO THERAPY AND REHABILITATION Psychotherapy has continued to develop throughout the twentieth century, representing a significant scientific and cultural body of knowledge. There are not, however, univocal viewpoints on what should be the prime characteristics of a therapeutic process aimed not only at treating symptoms, but also at finding definitive cures for psychiatric disorders. Psychoanalysis has founded its method substantially on increasing awareness in the patient (making conscious what was unconscious). The behavioral approach proposes to modify the individual's manifest behavior, utilizing methodologies borrowed from theories of learning. Systemically inspired family therapies focus attention on communication, roles, and relationships. Finally, the classic cognitivist approach proposes to correct the patient's errors in information processing. Because the coalitional mind processes (emotion, knowledge, behavior, and relational patterns) are connected by interaction relationships, it is obvious that a behavioral intervention may modify the emotional patterns and the belief system. Likewise, cognitive restoration will allow the patient to display more adaptive behavioral patterns. On the other hand, effective management of emotional dynamics causes clear changes at cognitive and behavioral levels. Interventions on the patient's relational situation (for example, improvement of the family emotional climate) also have an effect on emotional, cognitive, and behavioral patterns. In reality, all of the major psycho therapies developed during the twentieth century are capable of activating a process of change. This

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varies according to the circumstances, in the coalitional mind system of knowledge, acting at different levels and with different modalities. We propose a multicontextual and multidimensional therapeutic process resulting from a complex approach, aimed at carrying out (in a direct, planned, and structured manner) specific operations on the different levels of knowledge. This will affect changes at emotional, cognitive, behavioral, and relational levels. The progressive abandonment of behavioral techniques by Guidano and other exponents of the constructivist trend was possible due to their focus on patients mainly affected with a general existence disorder or with mild/limited pathologies. There are no controlled studies showing the large scale efficacy, efficiency, and repeatability of constructivist therapeutic protocols that were fundamentally based, at the level of basic methodology, on the reordering of current experience as described by Guidano (1992). Our 20 years of clinical experience took place in a number of settings, such as our cognitive psychotherapy ambulatory, a ward for crisis management, our day hospital, a therapeutic community, home rehabilitative intervention, social service intervention on the network, and psychoeducational interventions in schools and with younger populations. We have successfully treated more than 500 patients affected with most of the psychiatric disorders, and we have published several controlled studies. We have examined in particular anxiety, mood, eating, and schizophrenic disorders, as well as the three clusters of personality disorders. Based on this background of experience, we developed a complex constructivist approach to therapy and rehabilitation that can be described as strategically oriented and tactically articulated. The use of behavioral and cognitive techniques initially seems to achieve conditions of symptom resolution. After these conditions have been reached, the therapist can attempt to promote a revolutionary transition, which implies an evolutionary process in the organization of the patient's knowledge system (Mahoney, 1980). Within our complex and constructivist therapeutic and rehabilitative approach, we have developed a general frame that articulates into protocols specifically constructed for different pathologies. An important part of our model is the therapeutic relationship (Safran & Segal, 1990). This crucial aspect of the therapeutic process is conceptualized in the light of attachment theory, considering the therapist as a "secure base" and the psychotherapeutic relationship as a caregiving relationship between adults. Within this relationship, the patient should be able to experience a feeling of safety, allowing the process of exploration of self and reality to begin (West & Sheldon-Keller, 1994).

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In line with the previously illustrated model, it is relatively easy to modify behavioral patterns, but more difficult to promote cognitive restoration. Reaching an evolution and, therefore, a rewriting of the inner operative models, proves even more problematic. Based on this principle, the levels on which the phases of therapeutic intervention must be focused may be summarized as follows: I. The Relational Level: Operations to Perform: Establishing the therapeutic relation Activating the motivational system of attachment between adults Establishing a "secure base" relationship Analyzing the patient's life environment and promoting a change in emotional climate II. The Behavioral Level: Operations to Perform: Opposing the dysfunctional coping mechanisms, which are the most obvious aspect of clinical symptoms, specifically: - escape and avoiding (phobic) - rituals and controls (obsessive) - activity interruption (depressed) - binge and starve (bulimia and anorexia) - disorganized behavior (schizophrenia) III. The Cognitive Level: Operations to Perform: Promoting a restructuring of peripheral convictions in the hierarchic organization of the convictions system through an informative approach Progressively focusing the discussion on the most central convictions in the knowledge system Detecting dysfunctional cognitive activities such as automatic thoughts, systematic biases in information processing, delusions, and hallucinations Promoting a restructuring of the personal narrative, not only here and now, but the whole historical event, with particular reference to developmental history IV. The Emotional Level: Operations to Perform: Monitoring emotional patterns through the use of psychophysiological instruments; understanding their dynamics and learning new emotional coping strategies and modalities

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We should point out that although there are specific techniques for each indication, as often as possible a multimodal intervention should be used. This involves both cognitive and behavioral approaches to coping with emotional dynamics and relational techniques. Some of the techniques that are currently part of our therapeutic instruments include: Behavioral techniques: coping and problem-solving training gradual exposure techniques for phobias techniques of answering avoidance in obsessions assignment and gradual execution of homework for depression control of impulses to binge in bulimic subjects control of food avoidance in anorexic individuals Cognitive techniques: cognitive restructuring developmental history reconstruction sentimental history reconstruction neurocognitive rehabilitation (for schizophrenic patients) Emotional techniques: biofeedback Social and relational level techniques: social skills training videomonitoring and video-feedback family cognitive therapy In order to outline the whole picture, we will now describe the general structure of the complex and constructivist therapeutic protocol we have developed. The preliminary step, which allows the activation of the therapeutic process, is the establishment of the therapeutic alliance and the construction of the care-giving relationship by the therapist. The first goal is then to take care of the patient, specifically to make him or her feel part of a supportive and caring relationship. The next

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step is to begin exploring ways to help the patient overcome suffering and solve difficulties. This very early stage of the therapeutic process is particularly difficult for patients who have no awareness of their illness and do not ask for a therapeutic intervention. In particular, we refer to schizophrenic patients in an acute decompensation situation or to patients with manic decompensation. In such cases, it is vital to build an agreement at the emotional level based on taking care of patients rather than treating them. Once this preliminary therapeutic alliance is built, it needs to be consolidated. This occurs more easily if symptomatologic successes are achieved that offer relief to the patient and help him or her understand that change, although gradual, is possible. This offers a perfect opportunity to apply specific behavioral techniques. Simultaneously, it is possible to start the practice of biofeedback, building the patient's ability to begin confronting the self and disturbed emotional patterns. This can only occur in a setting that allows the gradual and progressive control of this self-confrontation. At this point, it becomes necessary to begin working at the cognitive level. Also of importance here is the process of training the patient (through homework) to be self-observant. This will facilitate the identification and understanding of dysfunctional information-processing mechanisms, progressively allowing their correction. Once the symptomatologic solution is underway, the promotion of a revolution in the knowledge system is required. This coincides with the analysis and rewriting of the most central schemas in the knowledge system, with particular reference to the inner operative models. This stage of therapeutic work is pursued through the reconstruction of the patient's development history. The individual must be allowed to relive or re-experience emotions and prototypical scenes of childhood. This cannot be limited to a detached chronicle reconstruction, but requires an immersion in the history, images, and emotions of early experiences. In conclusion, relational dynamics and aspects of social competence must not be neglected. This is especially true in working with schizophrenic patients. Whenever possible, relatives must be involved in therapeutic work aimed at improving the family climate by means of training in communication, role playing, and problem solving. A crucial aspect of this complex and constructivist therapeutic work is the development and maintenance of the therapeutic relationship; this is dependent upon the therapist's ability to be a secure base. The centrality of this aspect has renewed interest in therapists' personal training. Several

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years ago, we introduced a facet in our training that required specific work in self-observation and promotion of the students' personal knowledge system evolution. We need to acquire not only technical, methodological knowledge, but the ability to be secure in ourselves, enabling us to become a secure base for our patients. REFERENCES Ainsworth, M. D. S., Blehar, M., Waters, F., & Wall, S. (1978). Patterns of attachment assessed in the strange situation and at home. Hillsdale, NJ: Lawrence Erlbaum. Alford, B. A., & Beck, A. T. (1998). The integrative power of cognitive therapy. New York: Guilford Press. Beck, A. T. (1963). Therapy and depression: Idiosyncratic content and cognitive distortions. Archives of General Psychiatry, 9, 324-333. Beck, A. T. (1964). Therapy and depression: Thinking and therapy. Archives of General Psychiatry, 10, 561-571. Beck, A. T. (1979). Cognitive therapy of depression. New York: Guilford. Beck, A. T., Rush, A. J., Shaw, B. F., & Emory, G. (1979). Cognitive therapy of depression. New York: Guilford Press. Bleuler, E. (1911). Dementia praecox or the group of schizophrenia (Translated 1950). New York: International Universities Press. Bowlby,J. (1960). Separation anxiety. International Journal of Psycho-Analysis, 41,1-25. Bowlby, J. (1969). Attachment and loss (Vol. 1): Attachment. New York: Basic Books. Bowlby, J. (1973). Attachment and loss (Vol. 2): Separation, anxiety, and anger. New York: Basic Books. Bowlby, J. (1977). The making and breaking of affectional bonds. British Journal of Psychiatry, 130, 201-210. Bowlby, J. (1980). Attachment and loss (Vol. 3): Loss, sadness and depression. London: Hogarth Press. Bruner, J., & Postman, L. (1947). Emotional selectivity in perception and reaction. Journal of Personality, 16, 69-77. Callaway, E., & Naghdi, G. (1986). A human information model for schizophrenia. Archives of General Psychiatry, 22, 193-208. Chadwick, P., Birchwood, M., & Trower, P. (1996) Cognitive therapy for delusions, voices and paranoia. Chichester, UK: Wiley. Clark, D. A. (1995). Perceived limitations of standard cognitive therapy: A consideration of effort to revised Becks' theory and therapy. Journal of Cognitive Psychotherapy: An International Quarterly, 9, 153-172. DeRuiter, C. (1994). Anxious attachment in agoraphobia and obsessive-compulsive disorder: A literature review and treatment implications. In C. Perris, W. A. Arrindell, & M. Eisemann (Eds.), Parenting and psychopathology. Chichester, UK: Wiley. Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart. Fodor, J. (1983). The modularity of mind. Cambridge, MA: MIT Press.

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Goncalves, O. F. (1989). Advances in cognitive psychotherapies: The constructivist— developmental approach. Lisbon: Apport. Greenberg, G., & Tobach, E. (Eds.). (1990). Theories of evolution of knowledge. Hillsdale, NJ: Lawrence Erlbaum. Guidano, V. F. (1987). Complexity of the self. New York: Guilford, Guidano, V. F. (1992). The self in progress. New York: Guilford. Guidano, V. F., & Liotti, G. (1983). Cognitive processes and emotional disorders. New York: Guilford. Lazarus, A. A. (1971). Behavior therapy and beyond. New York: McGraw-Hill. Leahy, R. (2001). Why the standard approach to cognitive psychotherapy parnering is never considered. Message sent to the Lis of the Academy of Cognitive Therapy, 2201-2001. Lyddon, W. J. (1987). Emerging views of health: A challenge to rationalist doctrines of medical thoughts. Journal of Mind and Behavior, 8, 365-394. MacLean, P. D. (1973). A triune concept of the brain and behavior. Mahoney, M. J. (1980). Psychotherapy and the structure of personal revolution. In M. J. Mahoney (Ed.), Psychotherapy process. New York: Plenum. Mahoney, M.J. (1988). Constructive metatheory: Basic features and historical foundations. International Journal of Personal Construct Psychology, 1, 1-35. Mahoney, M.J. (1991). Human change processes. New York: Basic Books. Meichenbaum, D. (1977). Cognitive behavior modification. New York: Plenum. Miller, G. A., Galanter, E., & Pribram, K. (1960). Plans and structures of behaviour. New York: Holt, Rhinehart & Winston. Neimeyer, R. A., & Mahoney, M.J. (1995). Constructivism in psychotherapy. Washington, DC: American Psychiatric Press. Ornstein, R. (1992). The evolution of consciousness. New York: Simon & Schuster. Parker, G., Tuplin, H., & Brown, L. B. (1979). Parental bonding instrument. British Journal of Medical Psychology, 52, 1-10. Ferris, C. (1989). Cognitive therapy with schizophrenic patients. New York: Guilford Press. Perris, C., Arrindell, W. A., & Eisemann, M. (Eds.). (1994). Parenting and psychopathology. Chichester, UK: Wiley. Piaget, J. (1950). The psychology of intelligence. New York: Harcourt, Brace. Prigogine, I., & Stenger, I. (1984). Order out of chaos: Man's new dialogue with nature. New York: Bantam. Safran, J. Z., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. New York: Basic Books. Scrimali, T. (2000). Constructivist and complex approach in cognitive psychotherapy. Psychotherapia, 2(113), 5-21. Scrimali, T., & Grimaldi, L. (1991). Sulk tracce della mente (On the tracks of mind). Milan: Franco Angeli. Scrimali, T., & Grimaldi, L. (1996a). Negative entropy. Complessita & Cambiament, 5(1), 14-49. Scrimali, T., & Grimaldi, L. (1996b). Schizophrenia and cluster A personality disorder. Journal of Cognitive Psychotherapy, 10, 291-304. Scrimali, T., & Grimaldi, L. (2002). Complex systems cognitive therapy. A new perspective in psychiatry and psychotherapy. In T. Scrimali & L. Grimaldi (Eds.),

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Cognitive psychotherapy toward a new millennium. New York: Kluwer Academic/ Plenum Publishers. Shannon, C. E., & Weaver, W. (1949). The mathematical theory of communication. Chicago: University of Illinois Press. Von Neuman, J. (1958). The computer and the brain. New Haven, CT: Yale University Press. West, M., & Sheldon-Keller, A. E. (1994). Patterns of relating. New York: Guilford Press. Wiener, P. P. (1947). Cybernetics. New York: Wiley.

15 Metabolism of Information as a Model of Mental Processes and Its Application for Psychotherapy Andrzej Kokoszka

his chapter presents a concise model of human experiences based on the main structures and functions of the metabolism of energy and the information metabolism in the biological cell. It significantly differs from technical models of information processing and describes psychological processes in terms of synthesis, catabolism, and energy production and utilization. This model was created by Antoni Kepinski (1970) and is described in a series of his monographs on the main mental disorders (e.g., 1972a, 1973,1974,1977a, 1977b, 1978). These mental conditions were considered in terms of the pathology of functional structures (cognitive structures) constituting the system of values underlying the systems of decision making. The concept of information metabolism was developed by Kokoszka, and applied in the construction of models of consciousness states (1987-1988, 1993a), relaxation (1992-1993,1994), human experiences (1997b), and psychotherapy (1996). The model is applied in illustrating of mental structures and processes as well as interpersonal relationships that can be useful in psychotherapeutic practice. It will be argued that a model of mental organization

T

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has to underlie every psychotherapeutic intervention, even when the therapist is not conscious of its existence or when he or she denies its application. The concept of information metabolism has an integrative power as a metarationale for the comprehensive understanding of cognitive, psychodynamic, and biological approaches. Finally, the concept of the corrective axiological experience (Kokoszka, 1996; Kokoszka & Curylo, 1999) is introduced as a third main psychotherapeutic factor, besides insight (intellectual understanding) and the corrective emotional experience. The corrective axiological experience is explained in terms of conscious, volitional, executive aspects of functional structures responsible for action. I discuss the specific Polish roots of the model, despite the good advice of one of my foreign colleagues, who, in making comments on drafts of my early papers in English said, "Do not mention the specificity of the situation in Poland, because this may suggest that your findings are rather specific, whereas the international community is interested in general rules." However, in the presentation of Kepinski's ideas, the social and political context of their development has to be considered in order to explain why he did not make references to other scientists who developed similar concepts in other parts of the world. He created his theory working in nearly total isolation from Western scientists from the end of the Second World War until he died in 1972. This was the case for most Polish scientists until 1980, when international contacts became possible, though very limited. Political restrictions for the international exchange of knowledge finally ended in 1989. Polish psychiatrists, similar to other Polish professionals, were trained by Polish teachers who did their best, despite having very limited access to Western journals and other publications. Kepinski's views, therefore, lack a discussion of his theories in the context of similar views developed contemporaneously by others. While such a discussion might be historically interesting, it is beyond the scope of this chapter. The scientific status of psychotherapeutic knowledge is a good example of methodological limitations of scientific knowledge, and especially of knowledge applied in therapeutic practice. Perhaps recounting my personal experiences is the easiest way to illustrate the issue. As a teenager I was interested in studying about "mental life," so I decided to study medicine. I made this choice because theories of psychopathology as described in medical texts seemed to be less ambiguous than psychological theories. Unfortunately, I could not learn enough about human mental activity during my medical studies (30 hours of medical psychology and 120 hours of psychiatry) so I attended university classes and completed studies in psychology.

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Disappointed with the lack of unequivocal criteria for the selection of the best psychological approach, I began to study philosophy, which I stopped when I learned that it is not possible to create any system of scientific knowledge free of some arbitrarily accepted presumptions; from Kuhn (1962) about the social determinants of change of paradigms in science; from Amsterdamski (1975,1983a, 1983b) that contemporary philosophical reflection on scientific knowledge claims that it is not an isolated system, but that it is dependent upon common sense knowledge and related to the currently adopted ideal of science, which in turn depends upon numerous psychological, cultural, ideological and ethical factors; and eventually from Bochenski (1985) that each philosophy is involved in some outlook-on-life statements, and currently has two functions: (1) as an adjunct of science and (2) as a destructive force against some false myths and prejudices. Scientific knowledge cannot avoid some arbitrariness; therefore, we can only consider sets of possible descriptions of reality. In therapeutic practice we are expected to provide the most effective available methods of treatment, but not to search for ultimate and true knowledge. Eventually, as therapists, being conscious of the limitations of psychotherapeutic theories, we are faced with the following solutions to the choice of a method of psychotherapy: To leave the choice of the best psychotherapeutic approach completely up to the patient To decide upon the best approach for the patient according to our knowledge To consider the problem in a dialogue with the patient It seems that all of these solutions have their own areas of application because there are, of course, a variety of patients. Some of them are competent enough to make a real choice on their own. Others are significantly handicapped (e.g., mentally retarded) and are not able to consider their problem. However, for the majority of patients, making the choice of a method of treatment in a dialogue with the therapist is the best solution. MODELS FOR APPLICATION IN GENERAL PSYCHOTHERAPY The philosophy of sciences states that it would be impossible to make any system of knowledge free from some arbitrarily accepted presumptions.

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Eventually, each system of psychotherapy has some presumptions dealing with ideas about the mechanisms of symptom formation. Moreover, a more or less precisely formulated working model of mental processes organization is also presumed. Some existential approaches directly take an anthropological theory of the human being as the main frame of reference. The so-called humanistic approaches acknowledge the assistance of the patient in his or her efforts aimed at personal development, but are not free from these discussed presumptions. The result of a meta-analysis by Smith, Glass, and Miller (1980) indicated that a variety of psychotherapeutic approaches ultimately do not differ significantly in their effectiveness. The outcomes of more recent studies resulted in findings of some differences in the effectiveness among particular psychotherapies for specific pathological conditions; however, in general, the differences are relatively small. There is substantial documentation that psychotherapies produce beneficial results in the majority of cases. However, the probability for a fully effective treatment, (meaning the full recovery from, or cure of, the mental disorder that underlies the presenting symptoms), is rather low. There is evidence from case descriptions that cure is sometimes possible, but there is a lack of unequivocal data that specific psychotherapeutic procedures are fully effective in all precisely defined cases. It is difficult to imagine that psychotherapy could be offered as so effective that if symptoms did not disappear, there would be "money back guarantee." Although data suggests that it may be possible in some special cases, like that of simple phobia without any comorbidities and without personality disorders, in most cases, the real problem is to choose an optimal treatment, bearing in mind the possibility of symptom relief, the endurance of improvement, and the length and cost of therapy. Taking into consideration the current state of knowledge about psychotherapy, it seems reasonable to attempt an elaboration of rules of multidimensional diagnosis aimed at the estimation of (1) possible changes in short-term therapy, (2) possible changes of mental organization in long-term therapy, (3) features of personality that may be minimally changed, (4) features of personality that are permanent, and (5) which specific therapeutic method should be applied in the treatment of which mental disorder. These rules should also include an application of auxiliary diagnostic and therapeutic methods. In order to create a comprehensive diagnostic system, a commonly accepted model of mental functioning is necessary. There are a wide

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variety of different psychotherapeutic models applied in practice. Under each psychotherapeutic intervention lies a model of mental process organization and the mechanisms of symptom formation. However, those models are rarely a topic of scientific research and verification. Practitioners tend to accept them if they find them helpful in the conceptualization that then leads to effective psychotherapy. Unfortunately, therapists often develop their theories in the hermetic languages of their approaches and in increasing isolation from other schools of psychotherapy. It is noteworthy that a movement toward the integration of different psychotherapeutic approaches, focused on unspecific therapeutic factors common for all therapies, has been observed during the last decade, but it has had limited impact on psychotherapeutic practice. There is a strong need for a relatively neutral metatheory that would, at least, enhance effective communication and collaboration among the representatives of different approaches. The model should clarify areas of efficacy for the most indicated applications of existing schools, rather than focus on so-called unspecific therapeutic factors. Clinical experience with a particular approach suggests that in addition to the common elements of all psychotherapies, which have received support in the empirical literature, there are some therapeutic factors specific to one particular modality of psychotherapy. However, they are more difficult topics for research than the so-called common, basic therapeutic factors shared by all psychotherapies (described by Frank and Frank, chapter 3 this volume), for example, it is difficult to find control groups for long-term psychodynamic psychotherapies. The reduction of all psychotherapies to the application of unspecific psychotherapeutic factors raises objections by the representatives of specific approaches whose knowledge and methods are devalued by proponents of this way of integration. It seems more pragmatic to begin a process of integration from the formulation of a very wide and comprehensive model that would take into consideration the idea that most of the applied psychotherapeutic approaches have a merit justification, at least in some range of treated conditions. Such a model could be gradually empirically tested and modified. Therefore, the optimal model should be formulated in a way that makes scientific verification possible. Unfortunately, there is no single model adequate to this enterprise. Extant models include different modifications of the psychoanalytic model formulated by Freud (the division of mental apparatus into id, ego, superego on one hand and into conscious, preconscious, and

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unconscious parts on the other hand); behavioral models that formulate symptoms and therapy programs in terms of processes of learning (mainly conditioning); and cognitive models stressing the development of schemas as underlying symptom formation. It should be stressed that models applied in neurophysiology, artificial intelligence studies, and experimental psychology are not helpful in psychotherapeutic practice. They do not take into consideration those mental phenomena that are a subject of psychotherapy. These models are focused on different levels of mental process organization. The optimal model should be comprehensive and detailed enough for use in psychotherapeutic practice. Therefore it should be complex and multileveled. It should be applicable, on the general level, as a metamodel for the integration of a variety of psychotherapies, have clear links with a more specific model applied in defined psychotherapeutic processes and interventions, have the possibility of taking into consideration the achievements of neuroscience that are meaningful for psychotherapy, and be compatible with mathematical and computing data significant to psychotherapy. Toward this end, this chapter aims at the concise presentation of the information metabolism concept, considered here as a model that may serve as an example of a general model of organization of mental processes that may be helpful in psychotherapy, as well as in the development of its theory, diagnosis, and practice. THE INFORMATION METABOLISM MODEL Kepinski (1970) applied the model in a series of nine books that focused on the major psychopathological conditions. He preliminarily edited all but one during two years of incurable disease. They were published after his death in 1972, attaining a status of instant popularity in Poland, even though the political isolation of Poland kept Kepinski's ideas from being published in English at a time when they were being formulated. In his books he presented phenomenological descriptions of experiences of schizophrenia (1972c), depression (1974), neuroses (1972a), personality disorders (1977b), sexual disorders (1973), and anxiety states, as well as providing an explanation of their mechanism in an eclectic way, but mainly in terms of his metabolism of information concept. He emphasized the importance of psychotherapy in any psychiatric treatment and considered the patient-therapist relationship as a central phenomenon of the psychotherapy encounter (1978).

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Kepinski briefly outline the concept of information metabolism in one journal article (1970) and applied it in his nine monographs. Unfortunately, he did not present a comprehensive version of this theory. The concept of information metabolism was later discussed in English by Struzik (1987a, 1987b) and analyzed in detail by Kokoszka (1993b, 1993c, 1996, 1997a). They were reformulated, developed, and applied in the elaboration of a model of states of consciousness (Kokoszka, 1987-1988,1993a), in the rationale of a general theory of relaxation (Kokoszka, 1992-1993, 1994), as a model of human experiences in health and in pathological conditions (Kokoszka, 1997a, 1999a), and as a description of psychotherapy (Kokoszka, 1996; Kokoszka & Popiel, 2000). Kepinski (1970) argued that technical models characterize human beings in a dualistic manner, thus implying that mental processes govern somatic processes in a mechanical way and explain very little about the psychological aspects of life such as experiences and creativity. He considered biological models to be closer to psychological reality than technical ones. It should be stressed that the functioning of the brain differs significantly from that of computer mechanisms. The brain mechanisms are mainly biochemical (interactions of neurotransmitters and receptors), whereas present-day computers are completely electrical and less flexible than the brain. The biochemical structure of the neuron is in a process of continuous transformation, and may be modified as needed. The possibility that computers will react in different ways to the same commands is much less than that of the brain. The computer works according to external algorithms, whereas the brain can work following programs created to a significant degree by itself. The term "energetic-informational metabolism" was used by Kepinski (1970,1974) to denote life. More specifically, he identified two processes without which life would not be possible. In the initial phases of phylogenetic development, energy metabolism dominated, but it always coexisted with information metabolism (e.g., the processing of information concerning sources of nourishment). As development progressed, information metabolism gained greater importance, and in the most extreme of situations, all available energy may have been utilized for information processing. A theory of information metabolism states that human experience and behavior cannot be explained by a technical model of information processing. The process in humans is influenced, to a significant degree, by the subjective meanings of information, which were shaped during

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the life history of the individual person. They constitute a unique set of experiences contained in the functional structures of the individual's and the society's system of values. This specificity of personal functional structures may be compared to the specificity of an individual's proteins, and the main elements in the structure of human experiences may be considered analogous to the structures and functions of the biological cell. This idea receives some support from biology and the philosophy of biology. According to current knowledge, "The cell is, as a matter of fact, the complete microcosmos, in which life takes place; it is the smallest unit, which can undergo all life processes independently. . . . The cell's existence is a key witness of the unit on the living world" (Solomon, Berg, Martin, & Villee, 1996). Metabolism, reproduction, and changeability are considered the three main features of life (Kuppers, 1986). Paradoxically, there is no unequivocal and commonly accepted definition of the notion of information, which has complex relations with other phenomena and processes. Given the variety of theories, Kupper's (1986) concept of biological information is compatible with the metabolism of information theory. According to him, biological information is related to everything that has a "sense" and a "meaning" from the point of view of maintaining the order of the functioning of living systems. However, in human psychology, the psychological, cultural, and transcendental sense and meaning, as well as the physical objects, should be taken into consideration. In other words, human information considered in the metabolism of information theory denotes everything that has a sense and a meaning from the point of view of the order of three worlds as distinguished by Popper (1977): World 1—physical objects and states, including inorganic matter, biology, and artifacts (material substrates of human activity, e.g., tools, machines) World 2—states of consciousness, including subjective knowledge and experiences World 3—knowledge in the objective sense, including cultural heritage coded on material substrates and theoretical systems Following Kupper's idea of biological information, three aspects of information, as described by Seiffert (1968) should be taken into consideration: syntactic (relationship among signs), semantic (relationship between signs and what they refer to), and pragmatic (relationship among

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signs, what they refer to, and appropriate actions of the sender and of the recipient). "Pragmatic information is a trial of the presentation of the process of comprehension of sense as a natural process; it is a step toward a vision of the unity of nature which also encompasses a human being" (von Weizsacker, 1986, p. 15). The information metabolism model is based on the structural organization of the cell, and it attempts to describe information processing as an analogy of energy metabolism. At the basis of the theory lies a need for the input of information, which varies with time, a point acknowledged by other theories of information processing. Kepinski's view was based on a generalization of Carnot's principle, which states that the organism is an open system and its negentropy rises or falls as a result of processes described by the laws of self and species preservation (Struzik, 1982). Information metabolism occurs within a defined space and time. It has a control center, that is, ego or "I," and functional structures enabling the reception, processing, and assimilation of information, as well as the normal regulation of the organism's own activities. Information metabolism is determined by the phylogenetic and ontogenetic past of an organism, but it is also involved in pursuing goals that extend into the future. It creates individually varying pictures (i.e., functional structures) of the outside world, which, although objectively uniform, are perceived as unique and different by each individual. The term "functional structure" is used by Kepinski for the schematic representation of perception and activity. This concept is close to cognitive schemas, as described by Freeman and Oster (1999) and Freeman and Martin (this volume). However, the term "functional structures" will be used here, with a further division of those structures into cognitive, emotional, and executive/motor/volitional parts. Decision making is recognized as one of the basic features of life; it has different degrees of freedom in different organisms. A hierarchy of values governs the mechanisms, which select and filter the information reaching any particular decision-making level. The main structures of information metabolism are identified in a biological cell. Eventually the "metabolism of information" (i.e., processing of information) has its own boundary analogous to the cell membrane, a control center analogous to the cellular nucleus, a system for information distribution and processing analogous to the endoplasmic reticulum and the lysosome, and a source of energy analogous to the mitochondria (Kepinski, 1970). The actual structure and functions of the cell are much more complex (for a comprehensive description see Scott, 1995). Moreover, along

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with phylogenesis, the central nervous system is responsible for the development of information metabolism. Within all organisms the same basic structures and function of information metabolism may be distinguished. METABOLISM OF INFORMATION IN PSYCHOTHERAPY The usefulness of the concept of the metabolism of information in psychotherapy was clearly justified by Kepinski: The notion of psychotherapy implies that a therapeutic factor is a psychological influence, as an analogy to pharmacotherapy where the influence of pharmacological agents is such a factor, and to hydrotherapy, in which the influence is reached by the use of water. . . . This effect can be described as a change in experiencing and behavior under the influence of another person, which can be: words, mimics, gestures and finally just the presence of another person . . . mental influence does not mean any influence by the mysterious and unknown "mental energy. " In an analogy to the physical effects, different kinds of energy are present here, but not the amount of energy, nor its quality is important, but its significance. Minimal amounts of energy are enough to cause serious changes. A whisper can have a more important meaning than a machine's thunder, a delicate touch—more impact than a powerful blow, etc. Considering an energetic exchange as an important feature of every human being, it can be said that physical influence can be seen as the energetic metabolism, while the psychological influence can be seen as the metabolism of information. [1972a, p. 258]

These processes take place not only during psychotherapy, but also in everyday life. Kepinski argued that our sense of personal identity is based on the constancy of continuously developing functional structures. During the life span of the organism, its atoms are changing, and this contributes to the permanence of the functional structures, which guarantees the continuum of self-consciousness. These structures are changing as they are in contact with the world and with other people. But this change has to occur as an analogy to energetic metabolism, according to the rule of total assimilation, i.e. that everything that comes from outside has to be converted according to the proper plan of the structure, for example, theforeign protein is converted into the proper one in the process of assimilation. The patient is changing under the influence of the doctor, but he changes himself, the doctor does not change the patient. The exchange is an active process. The living organism chooses what is necessary from the environment, nothing can be changed without his active participation, because it would be a transplant or some kind of artificial limb, something so strange, that the organism would try to reject it, as is the case in transplantation. [Kepinski, 1972a, pp. 246-247]

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STRUCTURES AND FUNCTIONS OF INFORMATION METABOLISM We can, then, formulate the primary thesis of this concept in a schematic way. The main function is the organism's preservation and the species' preservation. The most important global functions are maintenance of order of the individual's structures, autonomic psychical activity, the sense of reality, and the feedback between an individual and its environment. Within the main structures is the central point—"I"—or control center (nucleus). This structure corresponds to the universal experience of being the subject of one's own psychical activity. It controls one's activity in a manner similar to that of the nucleus, which governs the biological cell activity. The individual's system of values represents the more stable functional structures. The structures include: 1. Biological, inherited factors, personal, subjectively shaped during one's own life ("emotional" in Kepinski's terms), and sociocultural levels reflecting knowledge of social values. 2. Boundaries of mental activities (the "membrane" of the whole individual) represent self-identity and as a means for enabling the discrimination of one's own limits and the differentiation of one's self from other people and from the external world. 3. Functional structures maintain order in space and time and are responsible for reception, transformation, and assimilation of incoming information. Creation of these structures may be compared to the centers of synthesis of biochemical compounds in a biological cell. The amount, complexity, and plasticity of functional structures increase along with ontogenetic and personal development. At least three layers in these structures may be distinguished: the biological (inherited), the developmental shaped during one's own life (ontogenesis), and the current, reflecting currently metabolized information. The functional structures differ in their stability; the most stable and important are considered as a part of the value system included in the nucleus. 4. Energy centers (equivalent to the mitochondria) necessary for preservation of metabolism of information, i.e., proper stimuli reception, selection and integration; as well as decision making. 5. Elimination centers, where useless and unimportant information is removed. It is noteworthy that within the matrix system of

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values activity centers may be active at the same time, which may serve to illustrate internal conflicts between id (biological layer of values system) and superego (sociocultural layer) or ego (subjective, developmental layer). It is also possible to illustrate the hierarchy of controlling processes when the social layer of the value system is currently dominating, and heterarchy (decentralization) when the structures from subjective or biological layers are currently dominating.

THE LOWER LEVELS OF THE MODEL There is a paradoxical difference between the attitude toward the understanding of neurophysiological processes and psychological processes. There seems to be a common acceptance that the former are very complex and difficult to learn, while on the other hand there seems to be a common expectation of a very simple theory of mental processes.

A CONCEPTION OF PERMANENT EVOLUTION AND DISSOLUTION Personality may be understood as the synergy of autonomous layered functional structures where evolutionarily younger structures absorb the structures of previous levels, which are appropriately repressed and controlled. However, in some conditions younger structures may dominate. In addition, heterarchical processes (see Mahoney, chapter 1 this volume) also take place. A similar idea was formulated by Foulkes (1964), who considered the mental functioning of an individual in a social group as occurring simultaneously on several levels: • Current—of realistic social communication • Transferential—mature object relations, shaped in relationship to significant persons in the life of the individual • Projective—of bodily image and mental image shaped in a stage of primitive, narcissistic "inner" object relations • Primordial—related to the collective unconscious In everyday life, interpersonal functioning occurs mainly on the current level; however, influences of dysfunctional patterns of experiencing

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and behavior from lower levels may influence or even distort it. The levels differentiated above are controversial, and their critical consideration is beyond the scope of this presentation. They were presented only to illustrate the thesis that mental processes occur simultaneously on all levels of mental organization, and that there is a tendency for control of the processes on lower levels by the processes from higher levels. However, some processes from lower levels may have a significant impact on the actual functioning of the individual. According to the presented model, personality is shaped by innate biological and psychophysiological structures and processes (formed during phylogenesis), functional structures shaped by an individual's life experience (during ontogenesis), information coming from the environment, and autonomous psychical activity recognized as well. Currently incoming information is assimilated to accommodate functional structures (Piaget, 1952) that can be properly or improperly shaped within the range of the information being accepted. When the structure is properly shaped and when it is prepared for the reception of the information given (i.e., has intermediate structures), assimilation and accommodation occur simultaneously. This change of one structure yields new information for the other ones, which undergo analogous processes. When it is not prepared (i.e., does not have enough intermediate structures developed), the process of seeking additional information that allows reception of the information is activated as an orientation reflex. Finally, depending on the results of the search, the information may be rejected or accepted properly or improperly. When the structure is improperly shaped and the new information is not too contradictory to the structure, it can be incorporated, usually with some changes. If the new information is too contradictory to the schema, the level of anxiety accompanying the orientation reflex (Pavlov, 1951) is so high (strong anxiety) that disorganization of information metabolism occurs along with a regression to the level that enables rejection of the threatening information. This occurs because the information becomes too incompatible with the functional schemas on that plane. It also seems possible that regression to more harmonious functioning may enable a correction (modification) of improper structures, and then the new information may become assimilated to the newly accommodated schemas that represent microdevelopment. However, it may lead to a situation in which threatening information makes functioning at the more developed level impossible, and causes a more general impairment of the mental functioning of the individual.

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The processes described previously occur in parallel; they are mutually dependent systems of the schemata. Therefore, it is possible to believe that within the variety of parallel active systems of functional schemas the interrelated microevolution and microdissolution processes take place. The current centers of activity may represent the activity of different levels of functional schemas, according to the stage of the individual's life history and when it was shaped. Moreover, the currently active center may have contradictory or conflicting tendencies. Nevertheless, with some simplification, it seems justified to consider that the interaction of those activity centers influences the resultant general level of the currently dominant processes of mental organization according to their developmental roots. The theoretical model helps to illustrate some clinical observations. It fits with statements on the optimal differences between the patient's schemas and the content of the therapist's interventions. If there is too great a difference, the interpretation will be rejected (Andersen, 1990). The disruptive effect of incompatible information with the current functional schemas corresponds with observations that too many changes are not possible within the same period of time. The series of new insights may increase anxiety to a level that causes disorganization. Moreover, the "maintenance of order" in the mental organization of the patient is a necessary condition for psychotherapeutic processes. IMPACT OF INTERNAL REPRESENTATION ON INFORMATION METABOLISM The model that can be applied to the realization of definite goals does not have to include aspects that are not related directly to them. Psychological functioning depends to a significant degree on the mental representation (s) of the external world and on the representation of oneself. These representations are stored and processed in the brain. The activity of these mental structures depends on brain activity, but they have some autonomy that enables self-regulation. A variety of existing psychotherapeutic approaches distinguish and conceptualize some structures in terms of their own theories. Utilizing an information metabolism model, we can illustrate the psychodynamic concepts showing conflicting tendencies in the control center and consider these tendencies in terms of id, ego, and superego activity. The metabolism of information is influenced by a variety of more specific functional structures that may be illustrated by considering self

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and object, that is, the mental representations of oneself and of other significant persons, shaped during life by one's unique experiences. An integrated psychodynamic-evolutionary model of mental states presented below illustrates these features. According to the above model, it is possible to illustrate some personality features manifested in the structure of self and object that may not be separated from each other. Within those structures a possibility for the synthesis of the opposite aspects of the self (marked as black and white areas) and the object may be shown as a range of gray space. For example, an immature personality may be though of, in psychodynamic terms, as not having developed boundaries between the self and the object and as having a tendency toward idealization and devaluation (black and white thinking). Current inflow of information is a condition of life and development in the same way as is energy. The optimal range stimulation changes according to the current phase of biological rhythms (sleep-waking and rest-activity). The microevolution and microdissolution of functional structures are permanent processes taking part in different spheres that are more or less mutually dependent. Any disturbance of metabolism of information as well as any disturbance of psychophysiological functioning causes the movement of activity centers (and the central point) to the lower, more strongly organized, automatic level, and enables correction in functional structures and eventually their microdevelopment.

THE CONCEPT OF CORRECTIVE AXIOLOGICAL EXPERIENCE The concept of functional structures is wide enough to incorporate the idea of a corrective axiological experience (CAE), as formulated in studies on specific psychotherapeutic factors of therapy described in the writings of Kepinski (Kokoszka, 1991,1996). Axiological experience was defined as "an experience that allows the attainment of a feeling of personal meaning to the realization of defined values and improves coping with pathological symptoms" (Kokoszka, 1996, p. 27). A psychological value is "understood as a justification for a given way of behaving, thinking or feeling. Its behavioral and observable aspects may be defined as a motive, or a psychological experience of values may be understood as an internal experience of a motive" (Kokoszka,

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1990—1991, p. 76). Values may be experienced according to different modes of mental processes organization; among them some main levels may be distinguished, such as instinctive, reflexively conditioned, prelogical, logical, and hypothetical supralogical (transcendental). The corrective axiological experience is a specific conscious experience of values and should be differentiated from the corrective emotional experience that allows for the repair of the negative consequences of earlier traumatic experience (Alexander, 1946). The concept of corrective axiological experience has three roots: 1. Philosophical description of the axiological experience by J6zef Tischner 2. Antoni Kepinski's notes on the meaning of the experience of values in psychotherapy 3. Concept of demoralization described by Jerome Frank—the corrective axiological experience is understood as a specific factor in the process of the restoration of morale. In the search for a more specific explanation of this phenomenon, Kepinski suggested the importance of the value experience in the restoration of morale (Kokoszka, 1991, 1996). Kepinski (1972ab, 1972b, 1978) further described a specific psychotherapeutic encounter with the patient that supported the patient in dealing with his illness. He referred to the concept of "heroic tendencies," and his approach to psychotherapy may be considered in terms of the restoration, or of the awakening, of those tendencies. Kepinski pointed out that heroic tendencies exist in everyone and that the capacity for decision making is the crucial attribute of life. The same phenomenon seems to be taken into consideration by Frank (1974). According to Frank, people who come to psychotherapy suffer not only from symptoms, but also from a demoralization that results from a persistent failure to cope with internally or externally induced stresses that the person and those close to him expect him to handle. The state is characterized by feelings of impotence, isolation, despair, worsening of self-esteem, and the feeling of being rejected by persons from the environment as a result of not being able to act according to their expectations. While Frank (1973, 1974, 1996) considered therapy in terms of nonspecific factors that were common to a wide variety of therapeutic approaches, he does not find specific mechanisms for the restoration of morale.

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This idea received some support in patients' reports during a stage of their mental disorder when they did not experience a decrease of symptoms, but when they regained the possibility to achieve their own life goals (Kokoszka, 1997b; Kokoszka & Curylo, 1999). From the point of view of information metabolism, the experience of values may be reconsidered as one of three main aspects of functional structures. Following the observations of Mazurkiewicz (1950,1980), every memory trace has cognitive, emotional, and motor aspects; that is, it has some content (cognitive) that has some meaning (emotional) and potential for a specific action (executive or motor). The three distinct aspects seem to be the main psychotherapeutic factors and focus of psychotherapeutic actions: The cognitive aspect is content that can be intellectually understood (insight in the psychodynamic approaches, and recognition of automatic thoughts and underlying cognitive schemas, and core beliefs in cognitive therapy). The emotional aspect is the corrective emotional experience. This is the experience that allows for recovery after traumatic events. It is caused by behavior of the therapist or another person that is different from that expected by the patient, who has been influenced by earlier trauma (Alexander, 1946) and is a central issue of the psychodynamic therapies. The executive aspect is the ability to act and is the focus of behavioral therapy. In an indirect way, on the conscious level, it is a topic of interest in existential and humanistic therapies that pay attention to volitional actions, including decisionmaking processes. In practice, all of the previously differentiated aspects of functional structures are combined and interrelated with each other, and it is rather improbable or unlikely that only one of them will change. They are recognized in terms of subjective experiences and observable behavior. To make these distinctions more clear, the developmental dimension of the model should be taken into consideration, according to which those aspects of functional structures are considered on all developmental levels—regressive, current, and new. Therefore, the experience of values should be considered even on the biological level, where it represents schemas responsible for the execution of actions aimed at fulfilling a biological need. However, the notion of corrective axiological experience should be limited to the conscious experiences that increase the ability to attain one's goals. The concept of corrective axiological experience gives a perspective for reinterpretation of the so-called unspecific psychotherapeutic fac-

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tors in terms of a more specific one. Philosophical analysis and psychotherapeutic practice suggest that restoration of the possibility of goal attainment is facilitated by a psychotherapeutic relationship. We might state that the encounter with another person is the source of all value experiences. From this point of view, it seems possible that experiences of values resulting in the restoration of the individual's sense of life take place in relationship with another person. However, it is necessary that such a person be personally engaged in helping and optimistic about the possibility of the disturbed person's regaining the ability for the attainment of personal goals. This could explain the greater effectiveness of psychotherapy led by trainees (who are often more enthusiastic about the effectiveness of a chosen psychotherapeutic approach) rather than by experienced psychotherapists.

METABOLISM OF INFORMATION IN PSYCHOTHERAPY The model presented previously may be applied in psychotherapeutic diagnosis and may include an estimation of the main requirements for a therapeutic alliance. This would include on the part of the patient an adequate sense of reality and feedback with the environment, some degree of autonomic mental activity, and preserved boundaries between the individual and the external world and between the internal, mental representation of self and other people (objects). The therapist's requirements of insight or supportive psychotherapy would include an energy supply, that is, biological (somatic, temperamental factors); psychological (current real, energy-consuming problems); psychosocial support; elimination abilities, that is, defense mechanisms (including oblivion and misperceptions); and maintenance of internal order and its quality. More specific issues for psychotherapy would require a control center. This would include the most stable schemas governing mental functioning (including biologically shaped schemas that are rather impossible to change and that are the most durable parts of the system of values shaped early in the life of the individual), those that cannot be easily changed, and those that may be modified in a long-term perspective. It must also include functional structures (underlying decision-making system of values) recognized as most responsible for the development and maintenance of symptoms. It includes a detailed diagnosis of schemas: cognitive, emotional, and executive. Different schools inter-

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pret the same conditions with emphasis on different emotional, cognitive, or executive aspects. In practice, in order to understand the patient (or another person) and himself or herself according to information metabolism, the therapist (or an individual) should ask a series of questions regarding the following (Kokoszka, 1996): 1. 2.

3. 4.

5.

6.

7.

Maintenance of order—Does the patient preserve internal balance? How strong is it? Autonomic mental activity—What are the current abilities of control over internal impulses? To what degree can the patient apply problem-solving strategies? Sense of reality and feedback relations with the environment—What is the level of the patient's social functioning? Control center—To what extent can the individual control him- or herself? Does the patient's control center actually find itself within the scope of his or her consciousness and within the ability to think logically? In contact with others is there any type of interference on the part of the individual's capacity for self-control? Boundaries—What are the boundaries of the self? To what degree can the individual differentiate between the product of his or her own mental life (e.g., fantasies and beliefs) and the realities of the external environment? What are the boundaries of the self in relation to the other? To what extent is the individual able to function in an autonomic way, and to what degree is his or her internal representation of self separated from the internal representation of the object (important person)? Does the person identify with the other too much? Is he or she isolating self from others? System of values—What is the real and ideal hierarchy of values for the individual? How is the metabolism of information determined by the individual's specific meaning attached to specified stimuli resultant of (1) biological make-up, (2) emotional complexes, and (3) personal social experiences shaping the sociocultural level of the system of values? Moreover, it is essential to ask, "What is the relationship between the individual's hierarchy of values and that of the therapist?" Functional structures—What are the individual's patterns of behavior? How does the individual experience himself or herself and others? How does this affect his or her own patterns of behavior?

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8. Psychical energy—What is the energy potential (ego strength) of the individual? What types of problems is the individual capable of confronting, and what types of problems are currently difficult? What is the "ego strength" at this time? 9. Elimination system—What is the ability of the individual to cope with problems? What is the person's ability to "metabolize" his or her own problems? What is the potential for "metabolizing" problems that are similar to those of others? The issues presented here should be understood conceptually according to the individual's life history, which shapes that person's functional structures, his or her current situation, and plans for the future. Information metabolism takes place within each person on many levels and in several modalities, including verbal and nonverbal communication as well as conscious and unconscious interactions. PERSPECTIVES FOR APPLICATION AND FURTHER DEVELOPMENT The concept of information metabolism belongs to the cognitive approaches (Kokoszka & Popiel, 2000), and may become a part of cognitive therapy, which, as its basis of psychopathology "draws on concepts from social and cognitive psychology as well as from information-processing and psychoanalytic theory" (Rush &: Beck, 2000, p. 2167). Information metabolism may be considered compatible with current cognitive therapy because both have similar theoretical foundations, even though they present opposite methodological approaches. Cognitive therapy originated as a result of investigations of the characteristic cognitive distortions in specific psychiatric disorders, whereas information metabolism is originally a concept of the general organization of mental processes. However, there is no contradiction between the main thesis of the information model and the theoretical assumptions of the cognitive model, as recently formulated by Clark and Beck (1999). Cognitive therapy was originally formulated as a short-term therapy aimed at the realization of well-designed goals, but recently it became more involved in longer therapeutic processes. The concept of information metabolism, as presented above, may be applied not only to the development of a diagnostic system of optimal qualification to different kinds of psychotherapy, but may also be helpful in the formulation of long-term therapeutic programs within the cognitive approach.

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Information metabolism has the potential for creation of new diagnostic psychotherapeutic tools, completely different from the current widely used questionnaires, rating scales, and self-rating scales. It is the theoretical framework for the design of a battery of experimental computer tests that could be useful in the estimation of such personality features as (1) internal order, by measuring the decrease in performance caused by stressful stimuli; (2) autonomic mental activity, by measuring the application of problem-solving strategy; (3) elimination system, by measuring the possibility of eliminating unnecessary information in changing instructions for a task performance; and (4) assimilation system, by measuring the possibility of applying new information in changing instructions for a task performance. TOWARD A MULTIAXIAL PSYCHOTHERAPEUTIC DIAGNOSIS This idea, equipped with a supporting diagnosis computing system, may serve as the basis for a multiaxial psychotherapeutic diagnosis, providing data on the probability of a variety of outcomes, including such variables as (1) psychotherapeutic approach, (2) length of treatment, (3) concurrent application of other methods of treatment, and (4) modality of psychotherapy (individual/group). Until this more ambitious goal is reached, the model may serve as an integrated model of the main psychotherapeutic approaches according to (1) levels of functional structures, which are the main area of interest. These include the biological (pharmacological treatment), past developmental (psychoanalysis, psychodynamic approach), current (cognitive-behavioral), and hypothetical (further developmental— humanistic psychology and transpersonal psychotherapy). Aspects of functional structures include the emotional (psychodynamic approach, psychoanalysis), the cognitive (cognitive therapy), and the motor/axiological (behavioral therapy, existential therapy, transpersonal and humanistic therapy. LIMITATIONS OF THE METABOLISM OF INFORMATION MODEL The present model, despite the fact that it more closely resembles human nature than does technical knowledge, is also reductionistic.

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Following the earlier mentioned differentiation of three worlds by Popper, the subjective psychological world and the social world are included in the model as a meaning of information included in functional structures. It does not include a spiritual, noetic, or transpersonal aspect of human beings. It considers them only as phenomena characterized for a hypothetically higher developmental level of mental organization. However, every scientific system of knowledge has to have some limitations, and in practice, therapists have to work on the basis of currently available knowledge, following the Hippocratic view that the goal "in general terms is to do away with suffering of the sick, or lessen the violence of their diseases. . . . " In practice, the therapist must also respect the limitations of his or her therapeutic approach. The recognition of and respect for those limitations, the search for new information, and the openness to the possibility of making discoveries during psychotherapy are other important therapeutic factors not included in the model. It should be noticed that the possible dialogic nature of human beings is also beyond the model. The philosophical descriptions of axiological experience, data on psychology of development, and psychotherapeutic practice suggest that personal contact with another person is an irreplaceable factor in personal change. CONCLUSIONS As practitioners, therapists are inevitably faced with the problem of the limitations of the theories underlying their approaches. Therefore, they should not only improve those theories, but they also should take into consideration that some, maybe even a majority, of aspects of mental functioning remain unknown. The patient-therapist relationship also has an inevitable ethical dimension. Discussion of this topic is beyond the scope of this chapter. However, a comprehensive model of a variety of possible methods of psychotherapy, describing specific features of different approaches and methods, would be helpful in making the most appropriate choices of the kind of psychotherapy applied for a particular patient. The technology may be helpful in the analysis of a variety of data dealing with psychotherapy. The biological model of information metabolism seems to be closer to reality than are the technical models of information processing. The information model emphasizes the process of the continuous transformation of mental structures, relating it to the possibility of different reactions to the same stimuli,

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depending on a wider context; flexibility of reactions (due to biochemical mechanisms of interactions); and last, but not least, the possibility of the autonomous creation of programs of action by the individual. Features of information metabolism imply some optimism toward the possibility of change existing within each individual, the creative potential of each individual, the independence of the individual from external reality, and change due to natural events outside the psychotherapeutic space. The main psychotherapeutic approaches differ in their emphasis on cognitive, emotional, or executive schemas. With some simplification, psychoanalysis concentrates on emotional schemas, cognitive psychotherapy on cognitive schemas, and behavioral and existential psychotherapy on executive schemas. It may seem paradoxical that behavioral and existential therapies are considered as focused on the same schemas. However, they work in different ways: behavioral therapy by practicing exercises, and existential therapy by expanding the range of freedom of decision making. The notion of the corrective axiological experience has some explanatory power and may serve as a theoretical justification of the psychotherapeutic activities aimed at the regaining of patients' abilities for the attainment of their life goals. All the issues discussed above give perspectives for the creation of multidimensional diagnostic and therapeutic rationale.

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Clark, D. A., & Beck, A. T. (1999). Scientific foundations of cognitive theory and therapy of depression. New York: Wiley. Foulkes, S. H. Therapeutic group analysis. London: Allen & Unwin. FrankJ. D. (1973). Persuasion andhealing. Baltimore: Johns Hopkins University Press. Frank, J. D. (1974). Psychotherapy: The restoration of morale. American Journal of Psychiatry, 131, 271-274. Frank, J. D. (1996). What is psychotherapy? In S. Bloch (Ed.), An introduction to the psychotherapies (3rd ed., pp. 1-20). Oxford: Oxford University Press. Freeman, A., & Oster, C. (1999) Cognitive behavior therapy. In M. Hersen & A. S. Bellack (Eds.), Handbook of comparative interventions for adult disorders (2nd ed., pp. 108-138). New York: Wiley. Kepinski, A. (1970). Biologiczny model w mysleniu psychiatrycznym (The biological model in psychiatric thinking). Psychiatria Polska, 4, 373-378. Kepinski, A. (1972a). Psychopatologia nerwic (Psychopathology of neuroses). Warszawa: Panstwowy Zaklad Wydawnictw Lekarskich. Kepinski, A. (1972b). Rytm zycia (Rhythm of life). Krakow: Wydawnictwo Literackie. Kepinski, A. (1972c). Schizofrenia (Schizophrenia). Warszawa: Panstwowy Zaklad Wydawnictw Lekarskich. Kepinski, A. (1973). Z psychopatologii zycia seksualnego (Psychopathology of sexual life). Warszawa: Panstwowy Zaklad Wydawnictw Lekarskich. Kepinski, A. (1974). Melancholia (Melancholy). Warszawa: Panstwowy Zaklad Wydawnictw Lekarskich. Kepinski, A. (1977a). Lek (Anxiety). Warszawa: Panstwowy Zaklad Wydawnictw Lekarskich. Kepinski, A. (1977b). Psychopatie (Psychopathy). Warszawa: Panstwowy Zaklad Wydawnictw Lekarskich. Kepinski A. (1978). Poznanie chorego (Learning of the patient). Panstwowy Zaklad Wydawnictw Lekarskich. Kokoszka, A. (1987-1988). An integrated model of the main states of consciousness. Imagination, Cognition and Personality, 7, 285-294. Kokoszka, A. (1990-1991). The evolutionary leveled model of the main states of consciousness. Imagination, Cognition and Personality, 10, 329-343. Kokoszka, A. (1991). On the psychology of values experiencing: A supplement to an evolutionary leveled model of the main states of consciousness. Imagination, Cognition and Personality, 11, 75-84. Kokoszka, A. (1992). Relaxation as an altered state of consciousness. International Journal of Psychosomatics, 39, 4-9. Kokoszka, A. (1992-1993). An evolutionary-psychodynamic model of the main states of consciousness. Imagination, Cognition and Personality, 12, 387-394. Kokoszka, A. (1993a). A rationale for psychology of consciousness. InJ. Brzezinski, S. Di Nuovo, T. Marek, & T. Maruszewski (Eds.), Creativity and consciousness: Philosophical and psychological dimensions (pp. 313-322). Poznan Studies in the Philosophy of the Sciences and the Humanities. Amsterdam: Rodopi. Kokoszka, A. (1993b). Information metabolism as a model of consciousness. International Journal of Neuroscience, 68, 165-177.

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Kokoszka, A. (1993c). Tajniki swiadomosci (Secrets of consciousness). Krakow: Instytut Ekologii i Zdrowia. Kokoszka, A. (1994). A rationale for a multileveled model of relaxation. International Journal of Psychosomatics, 41, 4-10. Kokoszka, A. (1996). Rozumiec, aby leczyc i 'podnosic na duchu': Psychoterapia wedlug Antoniego Kepinskiego (To understand in order to cure and support: Psychotherapy according to Antoni Kepinski). Krakow: Collegium Medicum Uniwersytetujagiellonskiego. Kokoszka, A. (1997a). Korektywne doswiadczenie aksjologiczne w psychoterapii (The corrective axiological experience in psychotherapy). Psychoterapia, 101, 4550. Kokoszka, A, (1997b). Integrujacy model stanow psychicznych: Podejscie neojacksonowskopsychodynamiczne (An integrating model of mental states: A neo-Jacksonian-psychodynamic approach). Krakow: Collegium Medicum, Uniwersytetu Jagiellonskiego. Kokoszka, A. (1999a). Metabolism of information as a model of human experiences. International Journal of Neuroscience, 97, 169-178. Kokoszka, A. (1999b). Jak pomagal i leczyl profesor Antoni Kepinski (Treatment and counseling by Antoni Kepinski). Krakow: Medycyna Praktyczna. Kokoszka, A., Bielecki, A., & Holas, P. Mental organization according to the metabolism of information model and its mathematical description. Manuscript submitted for publication. Kokoszka, A., & Curylo, A. (1999). Concept of the corrective axiological experience in psychotherapy and its preliminary clinical illustration. Existenzanalyse, 1, 24-27. Kokoszka, A., & Popiel, A. (2000). Information metabolism according to Antoni Kepinski, as a model for cognitive therapy. Enna, Italy: Complessita et Cambiamento. Kuhn, T. S. (1962). The structure of scientific revolutions. Chicago: University of Chicago Press. Kuppers, B. O. (1986). Der Ursprung biologischer Information: Zur Naturphilosophie der Lebensentstehung. Munchen: Piper, R Gmbh & Co. K.G. Mazurkiewicz, J. (1950). Wstep do psychofizjologii normalnej (An introduction to normal psychophysiology). Warszawa: PZWL. Mazurkiewicz, J. (1980). Zarys psychiartii psychofizjologicznej (An outline of psychophysiological psychiatry). Warszawa: PZWL. Pavlov, I. P. (1951). Wyhlady o czynnosci mozgu (Lectures on brain activity). Warszawa: PZWL. PiagetJ. (1952). The origins of intelligence in children. New York: International Universities Press. Popper, K. (1997). Materialism transcends itself. In K. Popper &J. C. Eccles (Eds.), The self and its brain. New York: Springer. Rush, J. A., & Beck, A. T. (2000). Cognitive therapy. In H. I. Kaplan, B. J. Sadock, & V. A. Sadock (Eds.), Kaplan & Sadock's comprehensive textbook of psychiatry (7th ed., pp. 2167-2178). New York: Lippincott. Scott, A. (1995). Stairway to the mind. New York: Springer. Seiffert, H. (1968). Information uber die Information (3rd ed.). Munchen: Smith, M. L., Glass, G. V., & Miller, T. I. (1980). The benefits of psychotherapy. Baltimore: Johns Hopkins University Press.

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Solomon, Berg, Martin, & Villee, (1996). Biology (3rd ed.). Struzik, T. (1982). Kepinski's information metabolism, Garnet's principle and information theory. International Journal of Neuroscience, 36, 107. von Weizsacker, C. F. (1986). Das vorwort. In B. O. Kuppers (Ed.), Der Ursprung biologischer Information: Zur Naturphilosophie der Lebensentstehung. Munchen: Piper, R Gmbh & Co. K.G.

16 Synthesis Michael J. Mahoney

ie began this text with the assertion that cognition and psychotherapy are intertwined and inseparable to the extent that it is difficult to imagine one without the other. Noting that this is a relatively recent appreciation, we pondered why and how this accepted "reality" was achieved? First, it was hard fought and hard won. The adherents of various schools of therapy would decry the models of other schools. Classical behaviorists, cognitivists, and psychoanalysts would claim little in common in understanding why people behave as they do. They have found little mutual ground in questioning what keeps people acting, feeling, and behaving in idiosyncratic and possibly dysfunctional ways. Yet, as we organized this text into the conceptual, psychodynamic, cognitive, and contemporary influences, many common themes emerged. If we view them historically, we can trace several threads that are the warp and weft of the tapestry of psychotherapy. Written histories are always and necessarily interpretive. Thus, those interested in tracing the development of cognitive psychotherapies are wise to consult the multiple historiographies that have been rendered (Arnkoff & Glass, 1992; Mahoney & Arnkoff, 1978; Vallis, Howes, & Miller, 1991). Allowing for some interpretive license, it seems clear that their heritage can be readily traced to classical philosophers. Some of the parallels between ancient and contemporary practices are, indeed, noteworthy.

w

The Pythagoreans, the Platonists, the Aristotelians, the Stoics, and the Epicureans were not just adherents of "philosophical systems" but members of organized "schools, " also called "sects," that imposed on them a specific method of training and a way of life. . . . The Pythagoreans, a community bound by strict discipline and obedience to

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the "master," followed severe dietary restrictions, exercises in self-control. . . exercises in memory recall, and memorizing for recitation. . . . The Platonists searched togetherfor truth, which was expected to emerge in conversations between teacher and disciples. The Aristotelian school was a kind of research institute of encyclopedic scope. The element of psychic training was stressed among the Stoics and the Epicureans. The Stoics learned the control of emotions and practiced written and verbal exercises in concentration and meditation. [Ellenberger, 1970, pp. 41-42]

The Stoics and the Epicureans were very successful at spreading the word, and their influence on early clinical methods was enormous. A central teaching of Galen, for instance, was the mastery of one's passions. After first curbing one's most extreme emotional impulses, the "second step was to find a mentor, a wise and older counselor who would point out your defects and dispense advice; Galen stresses the paramount importance of, and difficulty in finding, such a man" (Ellenberger, 1970, p. 43). Contemporary addenda would be "or woman" and "indeed." In the centuries that followed, developments in philosophy and religion continued to be reflected in prevailing expressions of clinical practice. Descartes's revival of rationalism and formalization of dualism contributed to the intellectual enlightenment that was to pit mind against body and reason against feeling. Because of its emphasis on experiments and experience, the empiricism championed by Bacon, Hobbes, and Locke offered a partial antidote to the doctrine of rational supremacy. Later, the constructivism of Vico and the idealism of Kant lent encouragement to more active and participatory conceptions of mind. For the most part, however, these were developments that were circumscribed in their practical effects. The first widely applied philosophy of relatively recent times was the "mind cure movement" that swept through parts of Europe and North America in the late eighteenth and early nineteenth centuries. Sometimes called the "psychology of healthy mindedness," this movement emphasized the importance of positive thinking and integrated practical exercises with the tenets of Christianity. It became (and remains) very popular, a fact acknowledged by William James (1902). Although the merits of positive thinking have been heralded most visibly by Dale Carnegie, Norman Vincent Peale, and Martin E. P. Seligman in the twentieth century, they were neither the first nor the only proponents of that approach. A casual stroll through the self-improvement section of any contemporary bookstore testifies to the fact that the mind cure movement is neither past nor moribund.

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Although there is continuing warrant for the association of positive and healthy-minded thinking with cognitive psychotherapies (Kendall, 1992), current views of the latter tend to classify them as secular applications of the cognitive sciences. The cognitive sciences, in turn, are said to have made their appearance sometime between 1955 and 1965, and the cognitive revolution in psychology was not acknowledged until the 1970s. In this respect, it is noteworthy that the major cognitive psychotherapies emerged either before or simultaneous with cognitive psychology. For example, although George Kelly denied being a cognitivist, his The Psychology of Personal Constructs (1955) was to become an inspiration to many cognitive therapists. Likewise, Albert Ellis's (1962, 1992) rational-emotive therapy preceded the major developments in cognitive psychology, and Aaron T. Beck's (1963, 1991) cognitive therapy was already apparent in his early work on depression. Thus, clinical applications of a cognitive perspective generally predated the formal theory and research associated with cognitive psychology. In 1980, there were several basic types of cognitive psychotherapy: Kelly's personal construct approach, Ellis's rational emotive therapy, Beck's cognitive therapy, Meichenbaum's cognitive behavior modification, Lazarus's multimodal therapy, the problem-solving approaches, and a more loosely grouped set of "coping skills" therapies. Another possibility for inclusion was Viktor Frankl's (1959) logotherapy, which focuses on the centrality of meaning in personal adaptation but is often classified as an existential or humanistic approach. By 1990, there were more than 20 different varieties of cognitive psychotherapy, and there had been significant changes in at least some of the original forms (Haaga & Davison, 1991). In many respects, the conceptual developments within the cognitive psychotherapies have raced ahead of much of the research in the area. These conceptual developments, in turn, appear to have emerged from the practical experiences of service providers, a phenomenon that has often been repeated in the history of psychotherapy (Freedheim, 1992; Lazarus & Davison, 1971). By way of preview, I suggest that the major conceptual developments in the cognitive psychotherapies over the past three decades have been (a) the differentiation of rationalist and constructivist approaches to cognition; (b) the recognition of social, biological, and embodiment issues; (c) the reappraisal of unconscious processes; (d) an increasing focus on self- and social systems; (e) the reappraisal of emotional and experiential processes; and (f) the contribution of the cognitive psychotherapies to the psychotherapy integration movement.

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RATIONALIST AND CONSTRUCTIVIST DIFFERENCES There has been significant evolution within the cognitive revolution that swept through psychology in the 1970s. Depending on whose account and terminology one uses, there have been at least three—and some say four—major conceptual strides in cognitive science since 1955 (Baars, 1986; Gardner, 1985; Mahoney, 1991; Varela, 1986). The first such stride involved the information-processing movement, sometimes also called the cybernetics movement because of its introduction of teleological (goal-directed) feedback loops to the infrastructure of early computers. As Jerome Bruner (1990) noted in his reflections on this first phase of the cognitive revolution, it quickly became sidetracked by computer technology and the simulation of artificial intelligence. Although there were prescient counterexamples (e.g., Miller, Galanter, & Pribram, 1960), early cognitive psychology became preoccupied with information (storage, retrieval, and processing) rather than with the processes of meaning making that are more central to contemporary cognitive science. The information-processing era began in the mid-1950s and peaked sometime around 1970. Overlapping with the information-processing era was the connectionist movement, a development that emerged in the 1970s and 1980s with the construction of super computers. (Although there are parallels with E. L. Thorndike's turn-of-the century "connectionism," the new connectionism is considerably more sophisticated and mediational in its models.) The three defining features of modern connectionism, its attempts to simulate neuronal networks in operation (Sejnowskj, Koch, & Churchjand, 1988), and its concession that some aspects of biological information processing may be subsymbolic and are therefore difficult (if not impossible) to program in explicit algorithms (Smolensky, 1988). The following are the three defining features of modern connectionism: (1) Distributed parallel processing (as compared with condensed linear processing) afforded substantial increases in computational powers relative to early computers, (2) the shift from modeling the nervous system after computers to modeling computer programs after nervous systems has spawned the hybrid field known as computational neuroscience, (3) finally, the suggestion of subsymbolic processes reflected an acknowledgment of a perplexing fuzziness in learning and knowing. Critics of connectionism have noted that it remains mired in a fundamentally computational model of knowing, and that it tends to perpetuate reification ("inner copy") models of mental representation (Fodor & Pylyshyn, 1988; Mahoney, 1991; Schneider, 1987).

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The third phase in the cognitive revolution began to emerge at about the same time as modern connectionism and is commonly known as constructivism or constructive metatheory. It reflects a substantial legacy in the history of ideas and psychobiology (Bruner, 1990; Hayek, 1952; Mahoney, 1988a). Fundamental to constructivism is an emphasis on the active—indeed, proactive (and hence anticipatory)—nature of all knowing. In contrast to the relatively passive models of mind and brain proposed by information-processing perspectives, constructivism proposes intrinsic self-organizing activity as fundamental to all knowledge processes. Thus, the mind/brain is no longer viewed as a repository (memory bank) of representations so much as an organic system of self-referencing activities. To the cybernetic notion of feedback (environmentally based information) is added the notion of "feedforward" (organismically generated form). In the tradition of Sir Charles Sherrington's (1906) idea of The Integrative Action of the Nervous System, Weimer (1977) and others have compared the motoric aspects of constructivism with the predominantly sensorial emphases of its cybernetic counterparts. Among other things, constructive perspectives emphasize the operation of tacit (unconscious) ordering processes, the complexity of human experience, and the merits of a developmental, processfocused approach to knowing. A proposed fourth contender for a distinct era or approach to cognitive science is hermeneutics. The term comes from the Greek herrneneutikos (meaning "interpretation"), and the field was pioneered by Biblical scholars specializing in the translation and analysis of sacred texts. Following a complex series of twentieth-century developments in linguistics, semiotics, and both literary and philosophical criticism, hermeneutics has become a secularized expression of the realization that all interactions between texts and readers are constrained and construed by unique individual, sociocultural, and historical influences (Madison, 1988; Messer, Sass, & Woolfolk, 1988; Palmer, 1969; Wachterhauser, 1986). Just as the constructivists have projected the mind of the knower onto the forms of the known (and the dynamics of the knowing process itself), the hermeneuts have come to contend that the reader is in the text (and vice versa). The parallels between constructivism and hermeneutics are considerable, which may be why some observers are reluctant to separate them as distinct approaches to knowing. Constructive approaches to psychotherapy are increasingly common (e.g., Feixas & Villegas, 1990; Goncalves, 1989; Guidano, 1987, 1991; Guidano & Liotti, 1983; Kelly, 1955; Mahoney, 1988b, 1991,1995; Matur-

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ana & Varela, 1987; Miro, 1989; Neimeyer, 1993; Neimeyer & Mahoney, 1995; Reda, 1986), although they have only recently been so labeled. Their differentiation from traditional cognitive psychotherapies has, in fact, created the first major conceptual debate in the field. The debate centers on whether a meaningful contrast can be drawn between rationalist and constructivist cognitive therapies (Mahoney & Lyddon, 1988). Rationalist thought is said to be characterized by three related assumptions (a) that irrationality is the primary source of neurotic psychopathology, (b) that explicit beliefs and logical reasoning can easily overpower and guide emotions and behavioral actions, and (c) that the core process in effective psychotherapy is the substitution of rational for irrational thinking patterns. The rational-emotive therapy of Albert Ellis (1962) and his followers is said to be exemplary of this perspective although Ellis (1988, 1993) denies that his system is rationalistic. Constructive metatheory, on the other hand, (a) adopts a more proactive (vs. reactive and representational) view of cognition and the organism, (b) emphasizes tacit (unconscious) core ordering processes, and (c) promotes a complex systems model in which thought, feeling, and behavior are interdependent expressions of a life span developmental unfolding of interactions between self and (primarily social) systems. Needless to say, the constructive approach is more complex and abstract than is the rationalist. Its expression has been truly international in scope, however, and it appears to be rapidly expanding. This apparent growth in popularity may also be partially attributed to the fact that some of those writers portrayed as archetypal rationalists—most notably Albert Ellis—have vigorously denied any rationalist leanings and laid strong claim to constructivist views. As illustrated by some of the chapters in this volume, the meanings of constructive and the features that differentiate and cohere the cognitive psychotherapies from the psychodynamic therapies remain sources of controversy for some of their representatives. More important than its ability to reliably differentiate camps of adherents, however, is the potential contribution that the rationalist-constructivist contrast may offer to emerging theory and research relating the cognitive sciences and clinical services (Mahoney, 1991). SOCIAL, BIOLOGICAL, AND EMBODIMENT ISSUES A second major conceptual development within the cognitive psychotherapies has been the increasing importance attributed to biological

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and social factors in the etiology, maintenance, and treatment of psychological disorders. This is not to imply that these influences were totally denied in earlier versions, but only to note the relative balance of power. Whereas Beck's early cognitive therapy for depression clearly acknowledged the role of genetic factors in some forms of that disorder, for example, more recent presentations of cognitive therapy have given decidedly more attention to ethological influences. Beck has also pioneered research into the factors contributing to individual differences in coping styles. Under conditions of stress or during the experience of distress, autonomous individuals appear to be isolative and self-reliant, whereas "sociotropic" individuals more often seek out friends and social support systems (Beck, Emery, & Greenberg, 1985). Likewise, Ellis's rational emotive behavior therapy now posits an inherited tendency toward irrational beliefs that may biologically predispose individuals toward developing common patterns of dysfunction (Ellis, 1976). The significance of these factors and the dynamic boundary between biological and social influences are perhaps most apparent in some of the constructivist approaches. Maturana and Varela (1987), for example, are both biologists, yet their current work in constructivist theory is focused on love and identity, respectively (Maturana, 1989; Varela, Thompson, & Rosch, 1991), and their work has been influential in family and systems therapies. Still other constructivists (Guidano, Liotti, Mahoney, and Reda) have embraced the significance of John Bowlby's (1988) attachment theory for understanding developmental psychopathology and the essence of effective therapy. Psychobiological inquiries into early and later emotional attachments have documented the powerful role of endogenous opiates (e.g., endorphins) in the "making and breaking of affectional bonds" (Schore, 1994). Finally, constructivists studying emotionality (see later discussion) have emphasized the significance of social realities in this domain (e.g., Safran & Segal, 1990). Almost without exception, cognitive psychotherapists now acknowledge the importance of the therapeutic relationship in effective therapy and the fact that clients' private worlds are most formatively developed and revised, for better and for worse, in the context of strong affective relationships. A related development in the cognitive therapies has been the recent attention given to issues of "embodiment" (i.e., the bodily basis for and means of experiencing; Guidano, 1987; Mahoney, 2003). This attention has been particularly apparent among the constructivists, who draw on the literatures of epistemology, ethology, hermeneutics, and phenome-

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nology to document the pervasive role of (primarily tacit) bodily experiences in psychological disorders and personality development. Although they include issues of body image and physical health, the emerging works in this area emphasize a fundamental, dynamic, and lifelong connection between mediate(d) and immediate experience. Mind-body dualism is therein challenged, and the bodily origin of "higher mental" activities is elaborated (Johnson, 1987; Varela et al., 1991). These developments overlap significantly with the trend among cognitive psychotherapists to grant greater respect to emotionality and to encourage experiential exercises (see later discussion).

UNCONSCIOUS PROCESSES One of the more surprising theoretical developments in cognitive psychotherapy has been the relatively recent acknowledgment of the important and extensive role played by unconscious processes in human experience. The surprising aspect of this development derives from the fact that many cognitive therapists have been critical of psychoanalytic theory and, until recently, virtually all discussions of unconscious processes were psychodynamic in tone. Several pioneering cognitive therapists had, of course, been originally trained in the psychoanalytic tradition (e.g., Beck, Ellis, & Goldfried). For the most part, however, they had rejected that tradition, and, along with their more behaviorally weaned peers, they had strongly challenged the merits of psychoanalytic theory and therapy. By 1990, however, the distance between some forms of cognitive psychotherapy and psychodynamic therapy had narrowed substantially. Although not entirely responsible for this apparent rapprochement, the sometimes-reluctant acknowledgment of unconscious processes by cognitive adherents has played an important role in reducing that distance. It is important to note that not all cognitive psychotherapists are comfortable with the above-mentioned rapprochement and, more important from a theoretical perspective, that cognitive renditions of the unconscious have been distinctly different from those rendered by Sigmund Freud, In some cognitive approaches, there is only limited and somewhat begrudging acknowledgment of the operation of processes outside of conscious awareness. "Automatic thoughts" are an example of such processes; they have become so habitual, it is alleged, that they are functionally automatic and occur without the individual's awareness.

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By working backward from their emotional and behavioral effects, however, such thoughts can usually be made explicit and amenable to modification. An intermediate level of acknowledgment of unconscious activity is illustrated in approaches that emphasize cognitive schemas, which are abstract organizational processes. Finally, the greatest importance attributed to unconscious processes by cognitive adherents is generally associated with some of the constructivists, who view fundamentally tacit processes as central to all epistemic (knowing) activity. The terminology and degrees of acknowledgment may vary, but the fact remains that cognitive adherents no longer consider it viable to maintain that all (or even most) important cognition is conscious and communicable. Indeed, some constructivists have elevated tacit processes to the level of a cardinal tenet. These unconscious processes of "self-organization" and "core ordering" are distinguished from psychoanalytic concepts, and distinctions are drawn between Freud's id-toego notion of psychotherapy process and what some contemporary cognitivists consider a dynamic and lifelong dance between tacit and explicit experience (Guidano, 1991; Mahoney, 1991). Nevertheless, the admission of unconscious processes onto center stage in cognitive theory and research reflects a major conceptual development (Bowers & Meichenbaum, 1984). Nor is it entirely coincidental, perhaps, that many of the modern advocates of psychotherapy integration have hailed from cognitive and psychodynamic origins.

SELF- AND SYSTEMS DYNAMICS

The cognitive revolutions helped bring experimental psychology back inside the organism, and what researchers found there was much more than they had been seeking. It has been said that the single most important (re) discovery of twentieth-century psychology may well be that of the self, and cognitive therapists have joined the rest of the field in expanding their models and methods to include this elusive core dimension of human experience. In 1990 (Vol. 14, No. 2), Cognitive Therapy and Research devoted a special issue to "Selfhood Processes and Emotional Disorders," and in 1992 (Vol. 6, No. 1) the Journal of Cognitive Psychotherapy published a special issue on personality disorders. Other illustrations of cognitivists' interest in self-system issues are not difficult to find (e.g., Hammen, 1988; Hartman & Blankstein, 1986; Hermans, Kempen, & van Loon, 1992; Segal, 1988). What is most noteworthy

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about the cognitive (re)discovery of the self, however, is its practical effect of having moved the focus back to factors outside the organism and, more accurately, dynamically between the organism and its milieu, particularly to social support systems, family and developmental history, cultural contexts, and, ultimately the therapeutic relationship. Whereas early cognitive therapies were relatively more introspective, individualistic, ahistorical, and inattentive to the emotional relationship between counselor and client, the opposite of each of these is more characteristic of contemporary cognitive psychotherapies. An apt illustration of this development is offered in Guidano's (1987, 1991) discussions of the epistemological issues involved in life span identity development. Guidano addressed the centrality of self-system .issues to all forms of psychotherapy (cognitive and otherwise). At the same time, his writings discussed the complex dynamics of the experience of self in major categories of psychological disorders (anxiety, depression, eating, and obsessive-compulsive). Also noteworthy is Gergen's (1991) constructivist portrayal of the "saturated" postmodern self and the exacerbation of identity crises by technological achievements. With an increasing focus on self-schemas and "possible selves" (Markus & Nurius, 1986), it is apparent that contemporary cognitive psychotherapies no longer focus only on specific maladaptive beliefs or even molar processes of dysfunctional cognition. (Dis) continuities of organization and phenomenological identity cannot be denied or avoided by the practitioner who views psychotherapy as applied exercises in ontology (theories of reality and existence) and epistemology (theories of knowing and, inherently, the knower). The "complexities of the self," as Guidano calls them, are now central concerns of the cognitive therapist. One of the fascinating conceptual results of this interest in the self is the current reappraisal of resistance in psychotherapy. Acknowledging that resistance to change is a professional reality, some cognitive therapists have moved beyond self-handicapping interpretations of this fact to more self-protective ones (Liotti, 1987; Mahoney, 1991). That is, they have begun to view core ordering processes as inherently protective of the individual's sense of personal coherence, resulting in varying degrees and expressions of reluctance or resistance to changing patterns with which they identify. Such conjectures also suggest a balance of continuity-maintaining (or familiarity-maintaining) processes with their change-producing alternatives. Among other things, these formulations depathologize resistance and acknowledge the complexity and difficulty of core personality change. Scrimali and Grimaldi (chapter 14, this

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volume) describe the process of "entropy" and information processing as the key issues in both therapy and in understanding psychopathology.

EMOTIONALITY AND EXPERIENTIAL EMPHASES Although not proposed as a defining feature of constructivist metatheory, the roles allotted to emotional processes in rationalist and constructivist perspectives appear to be very different. Traditionally, rationalist-cognitive therapists have viewed emotions as sources (or expressions) of problems that could be "corrected" or otherwise manipulated through the mediation of conscious reason. Constructivists, on the other hand, have challenged the validity of the distinction between cognition and emotion. They have argued, moreover, that even in an artificially conceived contest between these two dimensions, the emotional side would prove more powerful than the rational. Finally, the constructivists contend that affective processes are neither the culprits nor the causes of psychological dysfunction. They are, rather, dynamic expressions of the same (dis) organization processes that characterize the development of self-systems (Greenberg & Safran, 1987; Guidano, 1987, 1991; Mahoney, 1991, 1995). With their reappraisal of the role of emotions in adaptation and development, cognitive psychotherapists have moved significantly in the direction of the experiential aspects of psychotherapy. Rather than simply reason their way from feeling bad to feeling good, an increasing number of clients in cognitive treatment are being encouraged to actively experience, explore, and express a much broader range and more complex mixture of affect. In the process, they are also more likely to be offered exercises and techniques that have been traditionally associated with experiential therapies. In this respect, it is interesting to note that cognitivists and behaviorists alike—and certainly the popular hybrids termed cognitive-behavioral—have found themselves on the common ground of phenomenology (immediate, lived experience). The powerful role of strong and personally meaningful emotions is now widely acknowledged by these practitioners. Although they may offer different interpretations and explanations, cognitive and behavioral therapists have reached an agreement that in vivo activity is an important element in effective psychotherapy. Under appropriate guidance, pacing, and processing, such activity has become fundamental to their respective efforts to serve as mental health professionals. Notewor-

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thy here is the fact that the cognitivists and behaviorists who have found themselves in agreement on this point are also discovering that the terrain of affectively lived experience has long been a haunt of their psychodynamic counterparts. The "corrective emotional experiences" afforded by well-coordinated psychoanalysis turn out to be strikingly similar to those reported to be important in behavioral, cognitive, and humanistic approaches (Stolorow & Atwood, 1992) and echoed by Kokoszka who uses the notion of metabolism from the field of cognitive neuroscience for his model of human experience and describes the importance of the corrective experience.

PSYCHOTHERAPY INTEGRATION The sixth and final theoretical development in the cognitive and constructive psychotherapies can be summarized by saying that they have assumed a major role in the contemporary movement known as psychotherapy integration. Indeed, several writers have argued that cognitive perspectives are the most promising sources of language, theory, and research methods for exploring the possibility of rapprochement among traditionally rival systems of psychotherapy (Alford & Norcross, 1991; Beck, 1991; Goldfried, 1982, 1991; Horowitz, 1991). It is beyond the scope of this chapter to discuss the origins and developmental trajectory of the relatively recent resurgence in the popularity of eclecticism and the growing interest in the possible convergence or integration of diverse forms of psychotherapy. These phenomena are current events and show every sign of being formative elements in its second century of development (Norcross & Goldfried, 1992). The Society for the Exploration of Psychotherapy Integration was founded in 1983, and the Journal of Psychotherapy Integration began publication in 1991. Both are now truly international in scope. More pertinent to the present discussion is the fact that these expressions of the integration movement have been clearly influenced by representatives of cognitive and constructive psychotherapy. Whether their contributions have been or will be more important than those of participants from other theoretical traditions is a matter of conjecture and interpretation, of course, and it is not likely to be simply resolved by future historiographies of psychotherapy. What is important to note is that cognitive and constructive psychotherapists have entered productive dialogues with their behavioral, humanistic, and psychodynamic colleagues. This represents a

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major step beyond the sibling rivalries that characterized psychotherapy at midcentury. Of equal significance to the contribution of cognitive and constructive therapists to psychotherapy integration is the undeniable impact that the integration movement has had on these psychotherapies. As this chapter has outlined, the contacts of cognitive psychotherapists with the concepts and practices of other approaches have been extensive and appear, if anything, to still be increasing. Although less generous interpretations are clearly possible, it seems that this diversification and dialectical activity reflect positively on both the cognitive and constructive psychotherapies and the perspectives with which they have developed such dialogues.

CONCLUDING REMARKS Although they reflect the legacy of traditions ranging from classical philosophy to Christian Science, the cognitive and constructive psychotherapies are fundamentally a recent phenomenon. In the short span of less than four decades, they have emerged, multiplied, differentiated, and developed. We have suggested that the major theoretical developments in the cognitive psychotherapies have clustered around six basic themes; whether these developments are positive or progressive cannot be determined without first presuming to know what such developments "should" be or, in historical retroflection, what they "should have been." It is, however, very clear that the cognitive and constructive psychotherapies represent one of the most active clusters of theoretical development, research activity, and clinical innovations in the last decade of the twentieth century. Their involvement in and encouragement of open exchanges with other disciplines and traditions are also a commendable feature of these approaches. Finally, these psychotherapies have encouraged a commitment to self-examination and self-awareness that admirably reflects the centrality of exploration and inquiry in the continuing coalition of psychological science and clinical service. So we ask, once again, and borrowing from the old down East joke, how did we get "here" from "there" all the while knowing that, in retrospect, we did! It was a requisite journey or progression that illustrates the systematic and general dynamics of change seen in all natural endeavors.

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Goldfried, M. R. (1991). Research issues in psychotherapy integration. Journal of Psychotherapy Integration, 1, 5-25. Goncalves, O. F. (Ed.). (1989). Advances in the cognitive therapy: The constructivistdevelopmental approach. Lisbon: APPORT. Greenberg, L. S., & Safran, J. D. (1987). Emotion in psychotherapy. New York: Guilford. Guidano, V. F. (1987). Complexity of the self. New York: Guilford. Guidano, V. F. (1991). The self in process: Toward a postrationalist cognitive therapy. New York: Guilford. Guidano, V. F., & Liotti, G. (1983). Cognitive processes and emotional disorders. New York: Guilford. Haaga, D. A., & Davison, G. C. (1991). Disappearing differences do not always reflect healthy integration: An analysis of cognitive therapy and rational-emotive therapy. Journal of Psychotherapy, 1, 287-303. Hammen, C. (1988). Self cognitions, stressful events, and the prediction of depression in children of depressed mothers. Journal of Abnormal Child Psychology, 16, 347-360. Hartman, L. M., & Blankstein, K. R. (Eds.). (1986). Perceptions of self in emotional disorder and psychotherapy. New York: Wiley. Hayek, F. A. (1952). The sensory order. Chicago: University of Chicago Press. Hermans, H. J. M., Kempen, H. J. G., & van Loon, R. J. P. (1992). The dialogical self: Beyond individualism and rationalism. American Psychologist, 47, 23-33. Horowitz, M. J. (1991). States, schemas, and control: General theories for psychotherapy integration. Journal of Psychotherapy Integration, 1, 85-102. James, W. (1902). The varieties of religious experience. New York: New American Library. Johnson, M. (1987). The body in the mind: The bodily basis of meaning, imagination, and reason. Chicago: University of Chicago Press. Kelly, G. A. (1955). The psychology of personal constructs. New York: Norton. Kendall, P. C. (1992). Healthy thinking. Behavior Therapy, 23, 1-11. Lazarus, A. A., & Davison, G. C. (1971). Clinical innovation in research and practice. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (pp. 196-213). New York: Wiley. Liotti, G. (1987). The resistance to change of cognitive structures: A counterproposal to psychoanalytic metapsychology. Journal of Cognitive Psychotherapy, 1, 87-104. Madison, C. B. (1988). The hermeneutics of postmodernity. Bloomington: Indiana University Press. Mahoney, M. J. (1988a). Constructive metatheory: I. Basic features and historical foundations. International Journal of Personal Construct Psychology, I, 1-35. Mahoney, M. J. (1988b). Constructive metatheory: II. Implications for psychotherapy. International Journal of Personal Construct Psychology, 1, 299-315. Mahoney, M. J. (1991). Human change processes: The scientific foundations of psychotherapy. New York: Basic Books. Mahoney, M. J. (1995). Constructive psychotherapy. New York: Guilford Press. Mahoney, M. J. (2003). The bodily self: A guide to integrating the head and body in psychotherapy. New York: Guilford Press. Mahoney, M. J., & Arnkoff, D. B. (1978). Cognitive and self-control therapies. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (2nd ed., pp. 689-722). New York: Wiley.

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Mahoney, M. J., & Lyddon, W. J. (1988). Recent developments in cognitive approaches to counseling and psychotherapy. The Counseling Psychologist, 16, 190— 234. Markus, H., & Nurius, P. (1986). Possible selves. American Psychologist, 41, 954-996. Maturana, H. R. (1989, May). Emotion and the origin of the human. Paper presented at the International Conference at the Frontiers of Family Therapy, Brussels, Belgium. Maturana, H. R., & Varela, F. J. (1987). The tree of knowledge. The biological roots of human understanding. Boston: Shambhala. Messer, S. B., Sass, L. A., &Wooffolk, R. L. (Eds.). (1988). Hermeneutics and Psychological theory: Interpretive Perspectives on Personality, Psychotherapy and Psychopathology. New Brunswick, NJ: Rutgers University Press. Meyer, D. (1965). The Positive thinkers. Garden City, NY: Doubleday. Miller, G. A., Galanter E., & Pribram K. H. (1960). Plans and the structure of behavior. New York: Holt, Rinehart & Winston. Miro, M. (1989). Knowledge and society: An evolutionary outline. In O. F. Goncalves (Ed.), Advances in the cognitive therapies: The constructive-developmental approach (pp. 111-128). Lisbon, Portugal: APPORT. Neimeyer, R. A. (1993). An appraisal of constructivist psychotherapies. Journal of Consulting and Clinical Psychology, 61, 221-234. Neimeyer, R. A., & Mahoney, M. J. (Eds.). (1995). Constructivism in psychotherapy. Washington, DC: American Psychological Association. Norcross,J. C.,&Goldfried, M. R. (Eds.). (1992). Handbook of psychotherapy integration. New York: Basic Books. Palmer, R. E. (1969). Hermeneutics: Interpretation theory in Schleirmacher, Dilthey, Heidegger, and Gadamer. Evanston, IL: Northwestern University Press. Reda, M. A. (1986). Sistemi cognitivi complessi e psicoterapia (Complex cognitive systems and psychotherapy). Rome: Nuova Italia Scientifica. Rumelhart, D. E., & McClelland,J. L. (1986). Parallel distributed processing: Explorations in the microstructure of cognition (2 vols.). Cambridge, MA: MIT Press. Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. New York: Basic Books. Schneider, W. (1987). Connectionism: Is it a paradigm shift for psychology? Behavior Research Methods, Instruments, and Computers, 19, 73-83. Schore, A. N. (1994). Affect regulation and the origin of the self. Hillsdale, NJ: Erlbaum. Segal, Z. V. (1988). Appraisal of the self-schema construct in cognitive models of depression. Psychological Bulletin, 103, 147-162. Sejnowski, T.J., Koch, C., & Churchland, P. S. (1988). Computational neuroscience. Science, 241, 1299-1306. Sherrington, C. S. (1906). The integrative action of the nervous system. New Haven, CT: Yale University Press. Smolensky, P. (1988). On the proper treatment of connectionism. Behavioural and Brain Sciences, 11, 1-74. Stolorow, R. D., & Atwood, G. E. (1992). Contexts of being: The intersubjectivefoundations of psychological life. Hillsdale, NJ: The Analytic Press.

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Vallis, T. M., Howes, J. L., & Miller, P. C. (Eds.). (1991). The challenge of cognitive therapy. New York: Plenum Press. Varela, F. J. (1986). The science and technology of cognition: Emergent directions. Florence, Italy: Hopeful Monster. Varela, F. J., Thompson, E., & Rosch, E. (1991). The embodied mind: Cognitive science and human experience. Cambridge, MA: MIT Press. Wachterhauser, B. R. (Ed.). (1986). Hermeneutics and modern philosophy. Albany: State University of New York Press. Weimer, W. B. (1977). A conceptual framework for cognitive psychology: Motor theories of mind. In R. Shaw &J. Bransford (Eds.), Perceiving, acting, and knowing (pp. 267-311). Hillsdale, NJ: Erlbaum.

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Index

Adversity, 191 Abandonment, 109, 207 Affect, cognitive viewpoint: ABCs of Rational Emotive Behavior clues to misconceptions, 171-172 Therapy (REBT): implications of, 169-170 activating events/activators (A), Affectionless parenting, 310 186-194, 313 Affective disorders, 207 beliefs (Bs), 187-192, 194, 313 Affective reactions, 28 consequences (C), cognitive, emoAggression, 18-19, 69, 180, 282 tional, and behavioral, 186-187, Agoraphobia, 89, 194, 214 191-194, 313 "Aha" experience, 84, 177 defined, 186 Alienation, 3, 53-54, 57 Goals (Gs), 186-187 All black/all white thinking, 150 Absolutistic evaluations, 188-190 All-or-none thinking, 189-190, 249 Abstract thought, 307 Ambiguity, 13-14, 147 Abuse, impact of, see specific types of Ambivalence, 171, 182 abuse Amnesia, 102-104, 113, 115 Acceptance, 274, 280 AMPT, 217 Accommodation, 228 Activating events/activators (A), REBT: Amygdala, 308 Analogical reasoning, 276 beliefs about, 187-192, 194 Analytic-Behavioral-Cognitive Psychology of consequences of, 191-194 Alfred Adler, The, 156 defined, 185-187, 313 Anger, 118, 131, 202, 250 Active ordering processes, 7 Anhedonia: Active schemas, 224-225 characteristics of, 198, 206-207 Acute anxiety, 109 cognitive blockade, 208-213 Adaptation, 211, 228, 246, 289 Annulment, 263 Adjustment, 211 Anthropological theory, 86 Adler, Alfred, 168, 245 Antidepressants, 201, 216, 304 Adolescents: Antipsychotic medication, 283 cognitive disorders, 106, 110 Anxiety, 19, 53, 55, 65, 118, 124, 131, identity vs. identity diffusion crisis, 156, 178-179, 189, 191, 193, 214239-240 215, 245, 253, 282-284, 286-287, intimacy vs. isolation crisis, 241 299, 328, 335 self-image, 136 Anxious attachment, 310 self-organizing system, 293 367

368

Index

Appetite, loss of, 211 Apprehension, 178 Arciero, Giampiero, 18 Arieti, Silvano, 80-81 Aristotle, 1 As if technique, 149, 154 Aspiration, unrealistic, 150 Assertiveness, 235 Assimilation, 228 Attachment patterns, 127, 259, 278282, 310-312 Attachment theory, 297, 309 Attention/attentional skills, 10, 15, 17, 21, 147 Attitude: change in,157-158 cognitive misconceptions and, 182 cognitive therapy and, 183 mistaken, 149-150 Attributions, 188 Authenticity, 13 Automatic thoughts, 156-157, 188, 213, 215, 234, 244, 356 Autonomy, 235-238, 241, 282, 336 Aversion, 180 Avoidance, 181, 215, 224 Avoidant personality disorder, 240 Awareness skills, 15, 306-397 Awfulizing, 189 Bachelard, Gaston, 132 Bachelis, L., 94 Bandura, Alfred, 162 Beck, Aaron, 162-163 Beck Anxiety Inventory Scale (BAIS), 250 Beck Depression Inventory (BDI), 207, 248 Behavioral model, anhedonia, 212 Behavioral therapy, 52, 93, 118, 198, 201, 213-215, 217, 328, 339 Being-in-the-world, 93 Beliefs (Bs), REBT: about activating events, 187-192, 194, 313 defined, 186-187

Belief system: influences on, 226 primitive, 214 schema development, 228-229, 244 significance of, 12, 27, 32-33, 168 Benzodiazepines, 304 Bereavement, 109, 118 Bias, cognitive blockade, 208-210 Biochemical perspective, 200-201, 217, 303-304, 329 Bioenergetics, 63 Biofeedback, 259, 319 Biological evolution, 9 Biological information, 330 Biopsy, psychological, 201 Black box concept, 203-206, 218 Blame, 152-153 Body image, 11 Bowlby, John, 80 Brain functions, see specific areas of the brain information metabolism, 329. hemispheric specialization, 304, 307 Buber, Martin, 89, 128 Buddhism, 9 Capabilities, in social learning theory: forethought, 32-33 self-reflective, 40-42 self-regulatory, 35-40 symbolizing, 30-32 vicarious, 33-35 Carnegie, Dale, 350 Garnet's principle, 331 Catabolism, 259 Catastrophizing, 189, 214 Catecholamines, 206, 303 Caudatum, 308 Causal determinants, 28-29 Causality, 26, 30 Centralist individual, 199 Central nervous system (CNS), 216, 303, 314 Cerebral cortex, 31 Certainty, 188-189, 263 Change process, 1, 21-22

Index Chaos, 10, 165, 301 Character disorder, 179 Child abuse, 116-117 Childhood experience, see Children childhood seduction, 101 cognitive disorders and, 104-119 pampered children, 179-180 parental suicide, 103-105 systemic research, 102 Children: attachment patterns, 278-280 autonomy vs. shame and doubt crisis, 235-236 initiative vs. guilt crisis, 236-237 schema development, 310-311 self-organizing system, 291 Chronic anxiety, 109 Circle formation, 94-95 Circular reasoning, 190 Closed systems, 301 Coalitional mind system, 305-309, 315-316 Cognitive-behavioral intervention, 201 Cognitive-behavioral therapy, 51-52 Cognitive blockade, anhedonia: characteristics of, 207-210 mechanisms of, 210-213 Cognitive disorders, childhood experience and: abandonment threats, 109-110 amnesia, 102-105, 113, 115 crying behavior, 108 family pressure, 109 implications of, 101-103 incest, 106-107 multiple personality, 113, 115-117 parental death, 107-108 physical abuse, 116-117 preadolescent children, 109-115 sexual activity, 105-106 suicidal parents, 104-105 therapeutic process, 118-119 Cognitive dissonance, 155 Cognitive distortion, 206, 248-249 Cognitive learning, 157

369

Cognitive Processes and Emotional Disorders (Guidano/Liotti), 298 Cognitive processing, 205-206 Cognitive psychoanalysis, 124 Cognitive psychotherapy (CPT): approaches to, 297-298 characteristics of, generally, 183 conceptual developments, 354-356 constructivism, 352-354 defined, 166 for depression, 217 disadvantages of, 181-183 emotionality, 359-360 experietial emphases, 359-360 historical perspective, 297, 349-351 integration, 360-361 interactionist, 198 misconceptions in, see Misconceptions patient's role in, 174-176 rationalism, 352-354 self- and systems dynamics, 357-359 standard, 297-298 types of, generally, 172-174 unconscious processes, 356-357 Cognitive restoration, 315 Cognitive restructuring, 259 Cognitive review, 174-176 Cognitive schema theory, 163 Cognitive therapy, see Cognitive psychotherapy (CPT) Cognitive Therapy and Research, 357 Cognitivism, development of, 259 Coherence, 263 Communication: self-organizing system, 277, 286-288 skills development, 15 Competence, 237-238 Complexity & Change, 300 Complex systems theory: development of, 297-305, 309, 354 explicit knowledge, 305-307, 314 procedural knowledge, 307-308 social/machiavellian intelligence, 308

370

Index

Complex systems theory (continued) tacit knowledge, 305-306 therapeutic approaches, 315-320 Compulsions/compulsive behavior, 52, 54, 250 Conception-matching process, 35 Conceptions, 27 Conceptualization, 15, 18 Conceptual life, 134-140 Conceptual thinking, 133 Concrete thought, 307 Conditioned emotional responses, 213 Conditioning/conditioned response, 203, 328 Conditioning models, behavior therapy, 214-215 Conflict, 53, 171 Confrontation, 19, 155-156, 173, 179-180 Confusion, 178, 283 Connectionist movement, 352-353 Conscious motives, 148 Consciousness, see Unconscious first level of, 277 second level of, 278 Consequences (Cs), REBT: of activating events, 191-194 defined, 186-187, 313 Constructive Psychotherapy (Freeman), 6 Constructivism, see Constructivist therapies characteristics of, generally, 1-2, 257 rationalism compared with, 352-354 Constructivist therapies: behavioral level, 317-318 benefits of, 297, 315-317 cognitive level, 317-381 emotional level, 317-318 relational level, 317-318 Contemporary psychotherapy, components of, 3, 6 Contraction process, 16-18 Control, 15, 65, 168-169, 263 Convivality: case illustration, 274-275 defined, 258, 273, 290

development of, 279 four-leaf clover metaphor, 290 treatment interventions and, 287-288 Coping, generally: capacity, 53-54 mechanisms, 89, 310 skills, 72 Core constructs, 146, 153 Core ordering, 357 Corrective axiological experience (CAE), 337-340, 359-360 Countertransference, 181 Creation of obstacles, 151 Creative confluence, 23 Crises, in Erikson's psychosocial model, 230-231, 233-243, 253 Criticism, 263, 311 Crying behavior, 108, 157, 250 Cultural evolution, 304-305 Cybernetics, 297-298, 302, 352 Damnation, 189 Dasein, 91-92 Death: fear of, 213 parental, 107-108 Decision-making process, 259, 331, 345 Decompensation, 311-312, 319 Defeat, 167 Defense mechanisms, 182, 215 Deification, 188 Delusion, 117 Delusional narrative, 285-288 Demandments, 152 Demoralization hypothesis, 53-56, 70, 338 Dependent personality disorder, 240 Depersonalization, 248 Depolarization, 303 Depreciation tendency, 151 Depression: anhedonia, 206-213 behavior therapy, 213-215 biochemical perspective, 303-304 black box concept, 203-206, 218

Index case illustrations, 198-201, 282-283 characteristics of, generally, 19, 5355, 69, 104, 106, 133, 156, 162163, 179, 191, 193, 328 cognitive therapy, 355 psychoanalysis, 215 psychopharmacology, 215-217 psychosocial approach, case illustrations, 246-253 reductionist perspective, 206-207 universal deficit, 202-203 Depression-addiction-aggression, 95 Depression Inventory, 198-199, 205, 210 Depressive disorders, development of, 310 Depressive Organization, Personality Style, 258, 262, 264, 266, 312 Depressive reactions, 151 Dereflection, 94-95 Descartes, 276 Descriptions, 188 Deservingness, 188 Despair, 97, 243, 338 Determination, 302 Determinism, 2 Devaluation, 337 Developmental psychopathology, 80 Developmental theory, 291 Dexamethasone Suppression Test, 216 Diagnostic systems, 326-327, 340, 343 Disabling images, 151 Discomfort: anxiety, 189 incapability misconception, 180-181 Disengagement, 39 Disequilibration, 1 Displacement, 215 Disputing irrational beliefs (Ds), REBT, 185 Disruption, 167 Dissociation, 40 Distal goals, 37 Distress, subjective, 53 Dohrenwend, Bruce and Barbara, 54 Dopamine, 303

371

Dormant schemas, 224-225 Doubt, 235-236, 263 Dread neurosis, 51 Dream interpretation, 182 Dreikurs, Rudolf, 157 Dualism, 1, 17 Duty, 263 Dysfunctional Attitude Scale, 205 Dysfunctional belief system, 229 Dysphoria, 211 Dysthymic Disorder, 248 Early maladaptive schemas (EMS), 226-227 Eating Disorder (ED) organization, Personality Style, 258, 262-26, 3123, 266 Eating disorders, 52, 299 Effective New Philosophies (Es), REBT, 185 Ego, generally: analysis, 215 characteristics of, 204, 327, 331, 357 deficit, 216 support, 215 syn tonic, 154 Ego-constricting cognitions, 152 Electroconvulsive therapy, 216 Ellis, Albert, 162, 168, 354 Emotion: cognitive viewpoint, 168-171 theory of, 291-292 Emotional arousal, 63-65 Emotional distress, 55 Emotional disturbance, REBT, 191-193 Emotional experiences, 268 Emotional expressions, 268-269 Emotionality, 14 Emotional processes, 10 Emotional reasoning, 190 Emotional regulation, 15, 267-269, 281 Emotional states, 267-268 Empiricism, 1 Empowerment, 22

372

Index

Emptiness, 263 Endocept, 132-133 Endogenous depressions, 206 Endorphins, 206 Energetic-informational metabolism, 329 Enlightenment, 350 Entitlement, 179 Entropy of mind: defined, 259 implications of, 300-302, 309-315 negative, 315-320 Environmental disasters, 191 Environmental influences, 31-32, 72 Environmental stresses, 55 Epicureans, 350 Equilibration, 12 Equity, 263 Erikson, Erik, 163, 230 Erikson's psychosocial model: autonomy vs. shame and doubt, 235-236 generativity vs. self-absorption, 242 integrity vs. despair, 243 identity vs. identity diffusion, 239-240 industry vs. inferiority, 237-239 initiative vs. guilt, 236-237 intimacy vs. isolation, 240-241 overview of, 233 trust vs. mistrust, 233-235 Errors, logical, 189 Evidence-based approaches, 3, 45 Evolutionary epistemology, 262 Expansion process, 16-18 Expectancy/expectancies, 147, 212 Expectations, negative, 150, 211 Experiencing cycles: comforting and challenging, 18-21 opening and closing, 16-18 Experiential risk taking, 15 Explanation, in cognitive therapy, 173-174 Explicit knowledge, 305-307, 314, 357

False self, 114 Family systems: interaction in, 192 schema development, 226 Family therapy, 155, 157-158, 259, 355 Fantasy, 101, 147 Father, perceptions of, 106-107 Faulty assumptions, 166 Faulty beliefs, 170-171 Faulty conceptions, 166-167 Fear, 131, 167, 213-214 Feedback: behavior therapy, 213-214 cognitive blockade research, 209, 211 significance of, 352 in social modeling, 35 Fictional ideal, 146 Fixed ideas, 166 Flight into health, 224 Forethought capability, 32-33 Fortuitous determinants, 28-29 Fortune telling, 189 Four-leaf clover metaphor: convivality, 290 developmental theory, 290-291 implications of, 258, 289, 293 scientific base, 290-291 systems theory, 291-293 theory of emotion, 290-292 theory of language, 291-292 Frank!, Viktor E., 79-80, 89, 98 Free association, 165, 182 Freedom, 29-30, 264, 280, 345 Freeman, Arthur, 163 Freud, Sigmund, 79-80, 84, 101-102, 124, 132, 167-168, 177, 230, 327, 356-357 Freudian abreaction, 63 Freudian theory, 165, 179; see also Psychoanalysis; Psychoanalytic theory Frontal lobe, 306-308 Frustration, 189 Fugue, 113

Failure, fear of, 246 Faith, 14

Geltungsstreben, 148 Gemeinschaftsgefiihl, 148

Index General existence disorder, 316 Generativity, 242 Genetic influences, 42 Gestalt, 84

Gestalt therapy techniques, 182 Global/impulsive thinking, 150 Goals: Adlerian theory, 145, 229 motivational, 37 REBT (Gs), 186-187 Gradual exposure, 259 Grandiose self, 179 Group therapy, 157-158 Guidano, Vittorio, 257-258, 261, 298299, 312, 358 Guiding ideal, 145-146 Guilt, 236-237 Habits, 262 Hallucinations, 304, 314-315 Happiness, 94, 258, 273-274, 279 Hate/hatred, 116, 133 Healing setting, importance of, 3, 57 Health promotion, 289 Hegel, 1 Heidegger, 93, 187 Heisenberg law, 92-93 Helplessness, 3, 53-55, 96 Hemispheric specialization, 304, 307 Hermeneutikos, 353

Heroic tendencies, 338 Hidden demandments, 152 History taking, 182 Homework assignments, 15, 179, 253, 319 Hope, 234 Hopelessness, 3, 53, 55, 96, 189, 198, 249, 284 Hopelessness, 55 Hostility/hostile behavior, 117-118, 153, 191, 193, 311, 314 Hot cognitions, 188-190 Human change process: constructive psychotherapy and, 9-12 synopsis of, 6-9

373

Human Change Processes (Freeman), 6

Human perception, 112-113 Human phenomenon, 86-87 Humanistic Psychotherapy: The RationalEmotive Approach (Ellis), 185

Humor, 89 Hyperintention, 94-95 Hyperinvolvement, emotional, 311, 314 Hyperpolarization, 303 Hyperreflection, 94-95 Hypothalamus, 306 Hysteria, 101, 179 Id, 204, 327, 357 Idealization, 337 Identity vs. identity diffusion crisis, 239-241 Idiosyncratic meaning, 246 I-I relation, 128-129 I-It relation, 128 Illusory glow, 207 Imagery, 129-132 I-me relation, 284-285 Immaturity, 204, 337 Implosive therapy, 63 Impotence, 154, 338 Impulse control, 15 Inadequacy, 54, 189, 198, 263 Incapability misconception, 180-181 Incest, 106-107 Incompetence, subjective, 53 Indeterminancy, 302-303 Individual psychotherapy, 280-281 Industry, 237-239 Infants: schema development, 227-228 self-organizing system, 291 trust vs. mistrust crises, 233-235 Inferences, 188-189 Inferiority, 146, 150, 237-239 Information metabolism model: characteristics of, 259-260, 324, 328-332 corrective axiological experience (CAE), 337-340, 359-360

374

Index

Information metabolism model (continued) development of, 323-324, 328-329 future directions for, 342-343 implications of, 259-260 internal representation, impact on, 336-337 limitations of, 343-344 lower levels of, 334 permanent evolution and dissolution, 334-336 in psychotherapy, 332, 340-342 scientific knowledge, 325 structures and functions of, 333-334 Information processing, 201, 210, 306308, 312-313, 319, 352 Information theory, 298 Initiative, 236-237, 241 Insecurity, 147, 157 Insight: cognitive therapy, 176-177, 205, 218 significance of, 10, 65-66 Insomnia, 178, 198 Instructions, Adlerian theory, 145 Insulin coma therapy, 216 Integrative Action of the Nervous System, The, 353 Integrity, 243 Intellectualizing, 176 Intentions, 27 Interactionism, 26 International Journal of PsychoAnalysis, 84 Interpersonal functioning, 334-335 Interpersonal relationships, in constructivism, 9, 11 Interpretation, implications of, 150 Interviewing, nondirective, 182 Intimacy, 240-241 Invincibility, 264 Inwardness, 126-129 Inward polarity, self-identity process, 266-268 Irrational beliefs: implications of, generally, 162, 166 REBT (IBs), 185, 188-190, 193

Irrationality, 171 Irritability, 250 Isolation, 240-241, 338; see also Alienation; Withdrawal I-Thou relation, 128 I-you relationship, 285 James, William, 9, 350 Journal of Cognitive Psychotherapy, 156, 357 Journal of Psychotherapy Integration, 360 Joy, 133, 258, 273-275, 279 Judgments, 32-33, 36, 38, 40, 207, 246, 263 Jumping to conclusions, 149, 189 Junktim, 151-152 Kepinski, Antoni, 323-324, 328-332 Kierkegaard, Soren, 19 Knee jerk response, 192-193 Knowledge system, 319 Labeling, 190, 245 Laengle, Alfried A., 83 Language: acquisition, 127, 133 cognitive misconceptions and, 182 relationship development and, 299 self-organizing system, 279-280, 292 theory of, 292 Law of movement, 147 Laws of psychology, 31-32 Learning process, 17, 31 Libido, loss of, 198 Life crises, 163, 175 Life quality, 9, 11 Life-story, 283-284; see also Narratives Lifestyle, 146, 153, 158 Limbic system, 306, 308 Liotti, Giovanni, 262, 298 Logic, idiosyncratic, 150 Logos, 80 Logotheory, 95 Logotherapist, role of, 95 Logotherapy, 83-84, 89, 91-97 Loneliness, 53, 287

Index Long-term therapy, 326 Loss, depression and, 202-204, 207 Loss of control, 65 Love, 126-127, 133, 240 Machiavellian intelligence, 308, 312 Magnification, 189 Mahoney, Michael, 1 Major Depression, 248 Maladaptation, 118 Managed care, 56 Man's Search for Meaning, 89 Marital therapy, 158 Martin, Donna, 163 Mastery, sense of, 54, 58, 65, 211 Materialistic system, 197-199 Maternal deprivation, 217 Mature thinking, 204 Mead, George Herbert, 128 Meaning (s): childhood experience and, 110-111 cognition of, 84 in constructivism, 10, 313-314 of information, 329-330 in logotherapy, 93-98 Meditation, 20 Memory: cognitive blockade, 208-210 explicit knowledge, 307, 314 loss of, seeAnhedonia procedural knowledge, 307 representation, 31 significance of, 147 social/machiavellian intelligence, 308 tacit knowledge, 306 Mentalist system, 198, 200 Mentoring, 18 Mesmerism, 63 Meta-analysis, 326 Metabolism, see Information metabolism Metacognition, 283-284 Metaphors, 156-157; see also Four-leaf clover metaphor Metaphor therapy, 155

375

Metatheory, 327, 354 Migraine headaches, 55 Mind-body dualism, 17 Mind-body relationship, 31, 289 Mind cure movement, 350 Mind in place, 305 Mind reading, 189 Minidepression, 209 Minimization, 190 Minnesota Multiphasic Personality Inventory (MMPI), 173 Misconceptions: affect and, 171-172 clustering of, 177-181, 183 cognitive review, 174-176 cognitive treatment methods, 172-174 common, 167-168 emotion vs. cognition, 168-171 as faulty guides, 166-167 insight, 176-177 significance of, 31, 165-166, 181-182 Mistrust, 233-235 Modeling, 28, 174, 239 Modular brain, 305-309 Monistic system, 198 Monisticism, 1 Monoamine oxidase inhibitors, 203 Mood, 299 Mother: image of, 133-134 perceptions of, 107-108, 133-134 relationship with child, see Motherchild relationship Mother-child relationship: maternal deprivation, 217 power struggle, 157-158 significance of, 126-130 Motivational processes, 35, 37 Motor theories, 297, 313-315, 353 Multiaxial psychotherapeutic diagnosis, 343 Multimodal interventions, 259 Multiple personality, 101, 113, 115-117 Myths, functions of, 57-66

Index

376

Narcissism, 179 Narration/narratives, 280-282, 292, 313 Narrative Identity, 265 Narrative sharing, 12, 15 Nature/nurture controversy, 1 Negative affect, 202 Negative entropy, 315-320 Negative evaluations, 188-189 Neocortex, 216 Nervous breakdown, 167, 177-178 Neurochemical system, 200-201, 213, 216 Neurocognitive functioning, 217 Neuroendocrine system, 203, 216 Neuroleptics, 304 Neuromediators, 303 Neuronal networks, 352 Neuronal synapse, 303 Neuropsychopharmacology, 216 Neuroses, 167, 214, 263, 328 Neurotic behavior, 94, 150, 168, 178-

179, 244 Neurotransmitters, functions of, 216 New science of the mind, 305-309 Non sequitur, 189-190 Nondirective therapists, 66 Nonlinear physics, 301 Nonmaterial phenomena, 200-201 Nonspatial phenomena, 200-201 Nonverbal behavior, 182 Nonverbal communication, 342 Noogenic neurosis, 95 Noradrenergic receptors, 203 Observation, nonevaluative, 188 Observational learning, 2, 92-93 Observer, self-organizing system, 278 Obsessional ritual, 54 Obsessions, 54 Obsessive-compulsive behavior, 252 Obsessive-Compulsive Disorder, 248 Obsessive Organization, Personality Style, 258, 262-263, 266, 312 Oceanic feeling, 132 On the Tracks of Mind, 299

Ontogenesis, 133 Open systems, 301-303 Operant conditioning, 51, 63 Optimism, 208 Ordering processes, 7, 263 Organization, significance of, 302; see also Self-organizing system Ornstein, Robert, 305 Orthogenetic development process, 299 Otherness: emergence of other, 277-278 implications of, 126-129, 275-276 language and, 279-280 narratives, 280 self-organizing system, 276-277 sense of other, 278-279 Outward polarity, self-identity process,

267-268 Overambition, 150 Overdiscrimination, 149 Overgeneralization, 188-190, 207 Overindulgence, 108 Oversensitivity, 152 Paleocortex, dysfunction of, 216 Panic, 52 Paradoxical intention, 87-88, 90-92, 98 Paradoxical techniques, 155-157 Parallel processing, 352 Paranoia, 116, 150 Paranoid delusions, 117 Paranoid personality disorder, 232 Parataxic distortions, 168 Parent-child interaction, 102-103, 126, 266, 310 Parietal cortex, 308 Patience, 14 Patient history, 182 Peale, Norman Vincent, 350 Peer pressure, 239 Perceptions, 144, 188 Perceptual defense, 210 Perceptual selectivity, 146-147 Perceptual sensitivity, 149

Index Perceptual vigilance, 210 Perfection, 263 Peripheral nervous system, 303 Perls, Fritz, 170-171 Perris, Carlo, 298 Person perception, 28 Personal causality, 30 Personal development, 293 Personality development, 13, 335 Personality disorders: characteristics of, 113, 240, 282, 299, 328 psychosocial approach, case illustration, 249-253 Personality Style: defined, 263 Depressive Organization, 258, 262, 264, 266, 312 Eating Disorder (ED) organization, 258, 262-263, 266, 312 Obsessive Organization, 258, 262263, 266, 312 Phobic Organization, 258, 262, 264, 266, 312 Personality theories, 261-263 Personalizing, 190 Personal legitimacy, 282-287 Personal Meaning Organization (PMO): components of, 262-264 development of, 257, 261-262 significance of, 264-265 Personal realities, 14 Personal responsibility, 30 Perspective taking, 15 Pessimism, 150, 198 Pharmacologic intervention, 201-202 Pharmacotherapy, 198, 206 Phenomenology, 45 Philosphical system, 197, 200-201 Phobias, 52, 180, 213 Phobic disorders, 151, 310 Phobic Organization, Personality Style, 258, 262, 264, 266, 312 Phonyism, 190 Phrenophobia, 177-179, 181

377

Physics, complex systems theory and, 298-302 Piaget,Jean, 1, 124-126 Plasticity, in social learning theory, 31 Plato, 1 Pleasure principle, 211-212 Positive evaluations, 188 Post-rationalist approach, 262, 298 Pragmatic information, 330-331 Preadolescent children, 109-111 Preferential evaluations, 188 Prefrontal cortex, 308 Prigogine, Ilya, 300-301 Primary Process: psychoanalysis, 204-205, 217-218 psychopharmacology, 216 Primary symptoms, 193-194 Primitive thinking, 204, 214-215 Principle of Rumpelstiltskin, 65 Private perceptions, 149 Procedural knowledge, 307-308 Production processes, 36-37 Progressive challenges, 18-19 Proximal subgoals, 37, 39 Psychiatric disorders, 102, 303, 309311, 316 Psychoanalysis: characteristics of, generally, 118, 201, 204-205, 215, 327-328, 356-357 conflict, 81 demoralization hypothesis, 55 for depression, 198, 217 relational revolution, 23 Psychodiagnostic testing, 173 Psychodynamic therapy, 79, 93, 200 Psychologism, 83 Psychopathology: characteristics of, generally, 263, 279 developmental, 355 role of cognition, 149 Psychopharmacology, 198, 202-203, 215-217 Psychophysical relations, 31 Psychophysical systems, 261 Psychosexual development, 230

378

Index

Psychosis, 113, 117, 263 Psychosocial Identity, 264 Psychotherapeutic knowledge, 324 Psychotherapy: Adlerian, 153-155, 229 demoralization hypothesis, 53-56 distinguishing features of, 46-49 efficacy of, 52 general models of, 325-328 historical perspective, 45-46 outcome generalizations, 51-53 research limitations, 49-51 shared therapeutic components, see Shared therapeutic components success factors, 66-71 value of, 51 Psychotics, 116, 178 Psychotropics, 54 P300 wave, 314 Public health policy, 288-289 Punishment, 2 Purpose, 236, 238 Purpose in Life (PIL) Test, 97 Push-button technique, 154-155 Radical behaviorism, 2 Radical reality: gradual reconstruction of, 284-285 life-story and, 283-284 Rage, 131 Raimy, Victor, 161 Rape, childhood, 116 Rational beliefs (RBs), REBT, 185-186, 188, 191 Rationale, implications of, 14-15, 57 Rational Emotive Behavior Therapy (REBT): ABCs of, see ABCs of Rational Emotive Behavior Therapy historical perspective, 185 overview of, 185-186 Rational-emotive therapy, 162, 354 Rationalism, 1, 17, 352-354 Rationality, 31, 215 Rationalization, 215 Reaction formation, 215

Reactive depression, 54 Reasoning skills, 31; see also specific types of reasoning Reassurance, 178 Reciprocal determinism, 2 Reciprocal inhibition, 51 Reciprocal interaction, 26-28 Reductionism, 83, 206-207, 343-344 Reevaluation counseling, 63 Registration, memory process, 147 Regression, 146-147, 335, 339 Reinforcement, 2, 168, 200, 204, 214, 217 Rejection, 179, 338 Religious beliefs, 12 Repression, 124 Resistance: to cognitive misconceptions, 182 in confrontation, 155 in psychotherapy, 358 Respect, 280 Responsibility, 263, 280 Retention, 9 Retrieval, memory process, 147 Rhinencephalon, 306 Rituals: constructivist, 15-16 functions of, generally, 3, 57-66 Sadness, 55, 131, 133, 208 Satisfaction, 131 Schema(s): characteristics of, generally, 163, 221-222 changing, 231-233, 319 development of, see Schema development, psychosocial approach dysfunctional, 309-310 nature of, 223-227 understanding of, 230-231 Schema development, psychosocial approach: case studies, 246-254 Erikson's psychosocial model, see Erikson's psychosocial model overview of, 227-230

Index psychotherapeutic applications, 244246, 253-254 Schematic camouflage, 232 Schematic construction, 232 Schematic modification, 232 Schematic reinterpretation, 232 Schematic restructuring/reconstruction, 231, 319 Schizoid personality disorder, 222, 232 Schizophrenia, 70, 133, 299, 303, 312315, 319, 328 Schizophrenic thought disorder, 54 School situations, 157-158 Schopenhauer, Arthur, 9 Scientific knowledge, 325 Secondary Process: psychoanalysis, 204 psychopharmacology, 216 Secondary symptoms, 193-194 Security, 131 Sedatives, 304 Selection, 9 Selective perception, 146-147, 151 Selectivity, cognitive blockade, 210 Self-absorption, 242 Self-acceptance, 22 Self-actualization, 92 Self-appraisal, 208 Self-awareness, 128, 361 Self-characterization, 15 Self-comfort, 15 Self-concept, 11, 167, 170 Self-condemning reactions, 39 Self-confidence, 64-65 Self-consciousness, 332 Self-control, 55, 202, 204 Self-criticism, 198 Self-defeating behavior, 193-194, 200 Self-defeating cognitions, 152 Self-demonstration, 174 Self-deprecation, 191, 225-226 Self-destructive behavior, 282 Self-detachment, 87-88, 91 Self-dissatisfaction, 36 Self-doubt, 41 Self-downing, 189, 193

379

Self-efficacy, 20, 58, 65 Self-esteem: enhancement of, 66 loss of, 53 low, 55, 72, 239, 338 significance of, 2-3, 11, 22 Self-evaluation questionnaire, 264 Self-evaluative incentives, 36 Self-evaluative regulators, 39 Self-examination, 173-174, 361 Self-exoneration, 40 Self-help, 52 Self-identity: emotional domain and, 265-267 emotional regulation and, 267-269 Self-image, 133-134 Self-incentives, 38 Self-influence, 25, 30 Self-knowledge, 182 Self-love, 179 Self-motivation, 39 Self-observation, 15, 38 Self-organizing system/theory, 2, 7, 9, 11-12, 257, 262, 276-280, 357 Self-percepts, 27 Self-pity, 191 Self-precepts, 41 Self-prohibiting reactions, 40 Self-reaction, 36, 38 Self-references, 210 Self-reflective capability, 40-42 Self-regulation, 38, 279, 283-284, 336 Self-regulatory capability, 35-40 Self-reinforcement, 202, 212, 245 Self-relationship, 15, 21-22 Self-respect, 289 Self-satisfaction, 36, 243 Self-schemas, 228 Self-training, 147 Self-transcendence, 87, 91-94 Self-unifying processes, 313 Self-world relationship, 145 Seligman, Martin E. P., 350 Semantic information, 330 Sense of failure, 54 Sense of self, 11,263-264

380

Index

Sensorimotor levels, 1147 Sensory inflow, 112-113 Serotonin, 303-304 Setbacks, rebound from, 21 Sexual disorders/dysfunctions, 52, 95, 247-248, 328 Sexual performance, 94-95 Shame, 235-236, 263 Shared therapeutic components: myth and ritual, 58-66 overview of, 56-58 Short-term therapy, 326 Sleep disturbance, 106, 250; see also Insomnia Social individuals, characteristics of, 187 Social intelligence, 308 Social interest, 148-149 Social isolation, 54 Social learning: determinism, 26-30 human capabilities, 30-42 process, 299 theory, 2, 31 Social maladjustment, 167 Social modeling, 33-35 Social networks, significance of, 55 Social persuasion, 28 Society of Biological Psychiatry, 217 Sociotropic individuals, 355 Sociotropy-Autonomy Scale (SAS), 250 Socratic questioning, 173, 182 Special person misconception, 178-180 Spirituality, 12 Spontaneous behavior, 202 Spontaneous recovery, 166 Stoics, 350 Stress, generally: avoidance of, 167 resilience under, 9 response to, 178, 203 sources of, 41 Sublimation, 215 Substance abuse, 106-107 Suffering, 97-98

Suicidal behavior, 104 Suicidal ideation, 248-249 Suicidal intentions, 106 Suicidal parents, 103-105 Sullivan, Harry Stack, 128 Superego, 327 Superiority complex, 179 Supportive social networks, 55 Symbol creation, 147 Symbolization, 31 Symbolizing capability, 30-32 Symptoms, 151-152 Syntactic information, 330 Synthesis, 259 Systematic desensitization, 165 Systems-processes oriented, 298 Systems therapy, 355 Tacit knowledge, 305-306, 357 Taoism, 9 Teacher fallacy, 181 Temperament, 178, 262 Tension, 131 Thalamus, 308 Thematic Apperception Test (TAT), 173 Theory of discrete emotions, 267 Therapeutic alliance, 319 Therapeutic relationship: in cognitive therapy, 182-183 collaborative empiricism, 273 importance of, 3, 13-14, 56, 69-71, 328 schema development and, 224 strengthening of, 58 success factors in, 71-72 transference, 63 Therapeutic setting, 3; see also Healing setting Therapist role: Adlerian, 154, 158-159 childhood experience, understanding of, 114-115, 119 cognitive misconceptions, 173, 181-182 information metabolism, 340-342

Index positive reinforcement, 202 reassurance, 178 in self-organizing system, 277,

286-288 Thermodynamics, 301-302 Thought patterns, implications of,

27-28 Thought processes, 31 Time-limited psychotherapy, 57 Tranquilizers, 178 Transference, 63 Transference cure, 224 Trauma, response to, 182 Traumatic childhood, 109 Triadic reciprocal determinism: one-sided determination, 26 one-sided interactionism, 27 Triadic responsibility, 27-28 Tricyclic antidepressants, 203 Trust development, 131-132, 233-235, 238, 241 Tuition, 28 Turbulence, 311 Uncertainty, 301 Unconscious misconceptions, 168 Unconscious motives, 148

381

Unheard Cry for Meaning, The (Freeman), 95 Unidirectional interaction, 26-27 Unity of personality, 148 Unworthiness, 54 Value system, 333-334, 337-338 Variation, 9 Ventriloquism, 182 Vicarious capability, 33-35 Visual perception, 130 Vulnerability, 72, 110, 224-225, 259, 263, 309 Warm cognitions, 188 Well-being, 131, 167 Weltanschauung, 83 What is going on (WIGO), 186 Widow/widowhood, 107-108 Willfulness, 235 Wisdom, 243 Withdrawal, 106, 194 Work ethos, 237 World-centered individuals, 187 Wundt, Wilhelm, 9 Zeitgeist, 2, 63

Springer Publishing Company Cognitive Therapy and Dreams Rachael I. Rosner, PhD, Wiliam J. Lyddon, PhD, and Arthur Freeman, EdD, Editors "This is an excellent volume on the reawakening interest in dreaming among cognitive and constructive psychotherapists. I recommend it most highly." —Michael J. Mahoney, PhD University of North Texas Expanded from a special issue of the Journal of Cognitive Psychotherapy, this volume contains some of the most interesting and promising work on dreams coming from therapists and researchers working at the crossroads of cognitive therapy and other systems. The chapters provide a meta-theory of dreams that is unique to the cognitive perspective. As such, they begin the process of generating a comprehensive cognitive model of dream work that includes cognitive, affective, physical, and behavioral features. Contents: Part I: Historical Contexts • Cognitive Therapy and Dreams: An Introduction, R.I. Rosner, W.J. Lyddon, A. Freeman • Aaron T. Beck's Dream Theory in Context, R.I. Rosner • Cognitive Patterns in Dreams and Daydreams, A. T. Beck • A Comparison of Cognitive, Psychodynamic, and Eclectic Therapists' Attitudes and Practices in Working with Dreams in Psychotherapy, RE. Crook Part II: Objectivist Approaches • Dreams as an Unappreciated Therapeutic Avenue for Cognitive-Behavioral Therapy, H.E. Doweiko • Dreams and Dream Image: Using Dreams in Cognitive Therapy, A. Freeman and B. White • Imagery Rehearsal Therapy for Posttraumatic Nightmares: A Mind's Eye View, B. Krakow Part III: Constructivist Approaches • The "Royal Road" Becomes a Shrewd Shortcut: The Use of Dreams in Focused Treatment, D. Barrett • From Reactive to Proactive Dreaming: A Cognitive Narrative Dream Manual, O.F. Goncalves andJ.G. Barbosa • Focusing-Oriented Dream Work, M. Leijssen • The Hill Cognitive-Experiential Model of Dream Interpretation, C.E. Hill and A.B. Rochlen Part IV: Future Directions • To Dream, Perchance to Sleep: Awakening Potential for Dreamwork for Cognitive Therapy, R.I. Rosner and WJ. Lyddon 2003 224pp 0-8261-4745-3 hard

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