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A voice in the night whispered:” there is no voice in the night that whispers”
Development of a Mind Identification Questionnaire as a Predictor of Psychotherapy
Outcome
Specific aims
Psychotherapy is historically a relatively new discipline within healthcare. As paramedical
treatment, it presents an intervention to help people with mental health problems. The last 60
years’ research has shown that between 70% and 80% of out-patients relate their improved
mental health status to psychotherapeutic treatment (Hubble et al., 1999). In the last two
decades, public resource control over psychotherapy as treatment and, to a larger degree,
particular schools of psychotherapy, was motivated by results based on scientific
investigations. The most important motivation for public financing of psychotherapy has
switched from a general view that ”psychotherapeutic treatment is of value” (a view that
formed the basis for political decisionmaking) to a consensual endorsement of specific
therapies such as Cognitive therapy and CBT. Since research has shown that these therapies
are effective in treating patients suffering from different psychiatric diagnoses. This stands in
contrast to the fact that the majority of international meta-analyses of psychotherapy research
demonstrated that ”all therapies are effective. However, the Swedish council on technology
assessment in health care (SBU) exclusively recommends CBT and cognitive therapy for
depression and anxiety disorders (those two core diagnoses together make up more than 70%
of out-patient treatment activities in psychiatry). Research concerning psychotherapy has been
limited in its investigation of which patient characteristics contribute to a successful outcome
in psychotherapy.
Mind identification
Mind, as understood in this research is not just equivalent to thoughts; “Mind” includes
emotions as well as all unconscious mental, emotional and behavioural reactive patterns.
An emotion arises in the place where mind and body meet; it encompasses the body’s reaction
to the mind or the body’s mirroring of the mind..
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The definition of mind is a psychological and psychotherapeutic one that unavoidably covers
aspects of philosophy, neuropsychology, evolutional psychology and daily life psychology.
Nevertheless psychotherapy has to deal with the above mentioned aspects of the mind. In this
definition, the mind is distinct from thinking, reacting, and feeling (and can be described as
being comprised of a) an observing and a watching part. To demonstrate this duality the
reader of this draft is asked to close his/ her eyes and think the following: “I wonder what my
next thought is”. Try to stay alert like a guard that watches people coming and leaving a
room….
The quality of mind that was “mindful” about the thoughts, the part of the mind that asks it
self “I wonder what my next thought is” and is able to watch its thoughts can be defined as the
observing mind. (Watching the thinker).
If you read the instruction and spontaneously thought: “What a ridiculous idea! What does
that mean?” “I can not (watch) catch my thoughts etc.”, that part is the thinking mind
(identification with the thinker). The moment that you start watching the thinker the higher
level of consciousness becomes activated. This is the essence of all psychotherapy regardless
of the method, theoretical background, interventions and treatment philosophy. Reexperiencing, cognitive mastering, and behaviour regulation indeed are components to help
the patient move from the thinking to the observing mind regardless of the particular school
of psychological theory followed. Furthermore, therapeutic alliance itself functions as a tool
to open the door of the “observation room”. In every form of psychotherapy, the implicit and
final goal of treatment is to help the patient recognize “You are not your mind”.. In modern
psychotherapy (ACT, DBT, Mindfulness etc.) with influences from the contemplative
traditions, this statement “you are not your mind” is more pronounced than in psychodynamic
therapy, cognitive therapy and CBT, where the pathway to the observational part of the mind
is via emotions, thoughts and behaviour patterns.
Neuroscience and neuropsychology have showed that there are no different centres for
thoughts and emotions. At the same time that we are thinking a thought, emotions are present.
Thinking and Observing mind
We derive the sense of self from the content and activity with the “thinking mind” while the
observing mind includes the thinker activities. The thinking mind is a part of the observing
mind (the silent watcher)
The thinking mind excels in categorizing, analyzing and constructing information. When the
sense of the self, the ego, is involved in such processes the thinking mind is very limited
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(handicapped?). It is like a policeman who wants to catch a thief, while the thief is the
policeman himself…
The mind identification questionnaire
According to the hypothesis, the degree of availability and access to the observing quality of
the mind (reflection is possible only as a function of the observing mind) might predict the
outcome of psychotherapy since all change in psychotherapy and outside psychotherapy is a
process that begins within (primer reality within, seconded reality without). Capacity for
change could be measured by how in touch the person is with his observing mind. One could
say that if a patient was in touch with the observing mind, he may not be in need of
psychotherapy; the fact is that we all have access to the silent watcher but the observing mind
is concealed depending on the degree that the thinker dominates the mind as a whole.
We could approach the observing mind and reacting mind (thinking mind) by questions that
are assumed to assess those opposite aspects of mind. Whilst the observing quality of mind
could be measured by questions relating to the degree of “mindfulness” and being in presence,
the degree of mind identification could be measured by questions concerning reactions pattern
mentally and behaviourally in inter –and intrapersonal level
(I took out the first occurrence and discussion of “degree” because describing degree in the
second sentence made the paragraph much clearer.).
Survey of the field
Psychotherapy usually is an interpersonal, relational intervention used by trained
psychotherapists to aid clients in solving some of their problems in life. This treatment usually
includes increasing the individual’s sense of well-being and reducing subjective experience of
discomfort. Psychotherapists employ a range of techniques based on experiential relationship
building, dialogue, communication and behavior change that are designed to improve mental
health of a client or patient, or to improve group relationships (like in a family). Most forms
of psychotherapy use only verbal conversation; some also use various other forms of
communication such as the written words, art, drama, narratives, or therapeutic touch. (It
would be good to name just a few examples of these) Psychotherapy, then takes place within a
structured encounter between a trained therapist and client(s).
The factors that are assumed to be of importance for the success of psychotherapy
independent of the type of psychotherapy are the following:
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General psychotherapy factors
Re-experience of feelings
All psychotherapeutic systems use some form of re- experience of feelings and emotions. In
different times and in different cultures, releasing ones feelings has functioned as a
therapeutic tool. To ”load” a situation, by means of incenses, drugs or music is an example of
one method of releasing emotions. Such an emotionally loaded atmosphere could facilitate
regression and confession for an individual. This type of feeling purifying process can be
considered as prototype to a more structured psychotherapy.
In psychoanalytic/ psychodynamic therapy such emotional release is called catharsis.
According to the theoretical background, psychological material can be released or accessed
through free association. Freud, however, found that catharsis was not sufficient for lasting
change and the relief that it gave was temporary. Wilhelm Reich then continued to give the
process of catharsis an important role in his work. He developed the theory of character
formation as a protection against painful memories in childhood. His theory about the
connection between character and muscle excitements (?) became the origin to that
therapeutic method called vegetotherapi. Fritz Perls was also inspired by Reich’s ideas and
developed gestalt therapy. Behavioural therapy used also psychotherapeutic interventions
such as abreaction that corresponded with this idea; during relaxation patient is introduced to
focus on anxiety arousing thoughts, memories etc. The idea was to teach the patient to cope
with increasing anxiety. This process is called deconditioning. In cognitive and CBT therapy
releasing and accessing emotions is important in order to identify what cognitions are
associated with which situation. Different studies confirm that emotional release is one of the
effective components in asuccessful psychotherapy (Karasu, 1986).
Cognitive mastery
Cognitive mastery can be defined as the manner in which one obtains and integrates new
views, thoughts and behaviour patterns. It also forms a person’s self awareness through
interpretation (of events, stimuli?), practical experiences, and information. Unlikeemotional
release, cognitive mastery is a rationalized component in psychotherapy, which facilitates and
organizes the change possibility.
The original “spiritual reflective talk”(unclear what you mean by this. Source?) is similar to
psychotherapy in a sense that both emphasize the release of emotions. However,
psychotherapy, in general, exposes the patient's complex of problems with rationalized
explanations (and attempts to explain these problems rationally). Examples of such
explanatory models are psychoanalysis featuring the unconscious and behavioural therapy
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featuring the learning process. (Frank, 1971). The early psychotherapy was characterized by
directive assertions, while modern therapies, regardless of theoretical emphasis, encourage the
patient to understand the problem on his or her own and strives for the patient’s
independence. Common for all psychotherapeutic schools is the emphasis on understanding,
i.e. mobilizing the patient’s potential for change via cognitive procedures. Examples of This
type of approach are new explanations (redefining?), clarification, and confrontation with
irrational beliefs.
” Cognitive mastery” (remember; a term in quotations should be footnoted) can be defined in
various ways: From a CBT perspective, “insight” oriented therapy is directly compatible with
cognitive learning. From another perspective, original behavioural therapy featuring classic
conditioning applied social learning and information processing theory for the last two
decades. Other schools of psychotherapy based on constructivism (cognitive therapy,
systemic therapy, and narrative therapy) focus on stereotypical thoughts and dysfunctional
values. Other therapies for example Frankl’s logo therapy and existential therapy transform
that and emphasize cognitive mastery through focusing on life and its 2nd (explain) meaning from
a cognitive angle. Finally, direct experience focused therapy, such as gestalt therapy, also
includes cognitive mastery (Karasu, 1986).
Behaviour regulation
Learning is a non-specific (universal?) element of all psychotherapeutic treatments. Behaviour
regulation as an important part of therapy gives the patient the opportunity to identify
problems by practical application and by learning through repetition and practice. In
behaviour modification therapy one important pathway is through behaviour. Behaviour
modification theory was based on the Pavlov- Skinner stimulus- response experiments. The
theory developed into the reward- punishment model. On the basis of these theories, Bandura
(2001) developed the social-cognitive model in the 70’s. Behaviour regulation is not limited
to behavioural therapy or CBT, however. Behaviour regulation is an implicate part of
dynamic therapy (Karasu.1986). According to Karasu (1986) confrontation of repressed
memories is a form of behaviour confrontation/ regulation. Other interventions such as”
feedback”, indirect modelling”, and” therapeutic agreeing” (as in Rogerian non directive
therapy) are further examples of behaviour regulation.
Therapeutic alliance
Research in psychotherapy has repeatedly shown that the quality of therapeutic relationships
is a major predictor of successful therapy (Safran & Muran, 2000) (flera referenser här!). All
psychotherapeutic approaches, regardless of epistemological basis, paradigm, human
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perspective on psychological development or underlying theory of change mechanisms,
emphasize the importance of the therapeutic alliance.
Furthermore, evidence from a huge body of randomized studies confirms that the
effectiveness of all types of psychotherapy depends on a good working alliance between
patient and therapist .The difficulty, however, remains in identifying the therapeutic alliance
as a specific factor since all psychotherapy research is, somehow, based on the assumption of
causality namely that psychological diseases can be improved or even be remedied by
psychological methods (Armelius & Armelius, 1985). In studies that compare different
psychotherapeutic schools’ effectiveness, the focus seems to be on the comparison of : 1- the
extent to which these schools highlight the patient's schema and its hierarchy, 2 - the level of
the attention that the therapies pay to the patient's history, and issues surrounding how he or
she organizes his or her structures, defenses and cognitive organisation 3- emphases on
psychotherapeutic interventions (Ryle, 1984). In earlier comparative studies, Mofidi (1995)
presented differences between various psychotherapeutic schools concerning
psychotherapeutic interventions and the therapeutic alliance: “While in the psychodynamic
therapy, therapeutic technique and therapeutic alliance are not separated, in psychotherapy
such as CBT and other cognitive therapies the alliance and technique are two different
components.”
Hubbel et al (1999) in a meta –analytic review of psychotherapy research selected the major
components of therapy that provide a bridge between the various schools. The common
factors in psychotherapy are categorized by Hubble and his colleague (1999) as follows:
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Client/extra-therapeutic factors account for 40% of outcome variance.
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Relationship factors contain 30% of successful outcome.
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Placebo, hope and expectancy contribute to psychotherapeutic outcome at 15%.
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Model/ technique factors account for 15% of improvement in psychotherapy.
Patient specific factors
Independent of the therapy's length and direction, the patient's participation is one of the
central factors for predicting therapy's outcome. The patient's participation also includes the
relationship with the therapist in terms of alliance. These two factors together constitute the
most important predictive variables for prediction of the treatment's outcome according to
Tallman and Bohart (1999).
Furthermore, the authors stated that a defined agreement about the responsibilities of both the
patient and the therapist is associated with positive results in therapy (Tallman and Bohart,
1999). A summary of current therapy research with focus on the patient showed that
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successful treatment is positively associated with the degree of collaboration from the
patient's side (in contrast to resistance). Is the patient's motivation therefore of significant
importance to the treatment outcome? However, there are different opinions relating to this
topic. Certain research suggests that the patient's motivation is not important as a predictive
factor, but other studies found that motivation explains about 50% of the therapy outcome.
The conclusion could be that motivation is a significant but inconsistent factor (Tallman&
Bohart, 1999).
Review of psychotherapy predictors
” Suitability for psychotherapy” began with Freud's selective criteria for psychoanalysis
(Towfik, 1996). Freud's criteria were not specific; but some consideration was given to
intelligence level, neurotic structure and the general level of development of the patient.
In the 1920’s, the question about the time aspect (duration of? Session length?) in the
psychotherapeutic treatment was actualized. Ferenczi and Ranks were concerned with time
restriction and the therapist's activity in the analysis (Towfik, 1996). The continuation of
Ferenczi’s line of thought resulted in an assessment system in the 40’s created by Alexander
and Franch (Towfik 1996). The criteria in this assessment implicitly targeted the patient's ego
strength, his or her ability to take an active interest (play and active role?) in therapy and the
degree of motivation for change.
In a review of literature concerning prediction of therapy with focus on patients, four authors
are frequently referenced (quoted): Davanloo 1984, Malan 1976, Mann 1973 and Sifneos
1972 and 1979.
Habib Davanloo’s work with suitability assessment for short term therapy is from the 70’s
In an early assessment system, Davanloo (receptivity?) observed the patient's motivation, and
interaction with the therapist as indicators for suitability for short-term therapy (Moras &
Strupp, 1982). Later, Davanloo developed the assessment system to include a more distinct
criteria system stating: 1- The patient should have had at least one meaningful relationship in
the past. 2- He should be able to tolerate anxiety and feelings of guilt. 3- He should be able to
reflect on himself. 4- He should be motivated to focus on problems that come up in therapy.
5- He should show good ability to collaborate in a therapy selection interview. 6- He should
have problems of an oedipal nature (Safran & Segal, 1996).
Malans suitability evaluation is based on two criteria: 1- a psychiatric anamnesis with starting
point from psychodynamic developmental psychology as a tool to interpret the patient; an
interpretation of the patient 's core conflict according to psychodynamic theory about
neurosis. The patient's reaction on this initial interpretation was of crucial importance in the
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assessment. If the patient accepts the interpretation, it is an indicator of suitability for short
term therapy. 2- The patient's motivation to change, and his ability to describe and distance
himself from the core problem (Safran&Segal, 1996).
The interest for the time aspect in psychotherapy involved Mann (1973) in developing a
working model for psychodynamic short term therapy. Unlike other psychodynamic short
term therapies, his short term therapy is limited to twelve sessions (Mann, 1973). Another
difference is that Mann’s selection criteria are not as strict as the other psychodynamic
oriented assessments. Mann excluded psychotic patients, patients, with very sever depression
since they can not actively participate in the treatment, and persons with insufficient ability to
tolerate object relationships (Mann, 1973). After the assessment deliberation, if a patient
seems to be appropriate for the psychotherapy, the therapist presents one focus- or in Mann’s
terminology - a central theme for the treatment and asks the patient if he agrees focusing the
therapy on this (Mann 1973).
Sifneos psychodynamic short term model is referred as Short - term Anxiety - Provoking. The
method requires patients with - psychodynamic terms - high” motivation” and ”ego strength”
(Sjöstedet, 1999). Sifneos’ criteria can be summarized as the following:” 1-a limited main
problem (Sjöstedet, 1999) 2 - at least one meaningful relationship in the past 3-ability to
interact freely with the therapist and ability to describe feelings in an adequately 4– having
psychological capacity (explain) 5- problem-solving ability.
Common for these assessment models of the patient’s suitability for psychodynamic shortterm therapy is that they pay attention to factors such as a clear-cut problem, motivation,
interaction with therapist and quality in interpersonal relationships (Höland, Sörbye, Sörile,
Fossum,& Engelstad, 1992)
The literature searched by these authors showed that suitability assessment is related to
psychodynamic therapy. There is however no evaluation model for other therapeutic schools
such as Cognitive therapy or CBT. One reason for that might be that Cognitive therapy or
CBT are short term therapies per se whereas psychodynamic therapy, having initially no time
limit on therapy duration, has to set criteria for time limited therapy specially.
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References
Hubble, M, Duncan, B & Miller, S (1999). The Heart and Soul of Change. What works in
therapy. APA: Washington.
Karasu TB. The "specificity vs. nonspecificity" dilemma: towards identifying therapeutic
change agents. Am J Psychiatry 143:687-695, 1986
Frank, JD. Psychotherapists need theories Int J Psychiatry.1970-1971;9;146-9
Bandura, A. “Social cognitive theory: An agentive perspective,” Annual Review of
Psychology (52:1), 2001, pp. 1-26.
Armelius, B-Å & Armelius,K (1985) Psykoterapiforskning- en introduktion. Raben &
Sjöberg, Stockholm.
Ryle, A. How can we compare different psychotherapies? Why are they effective?. Br J Med
Psychol. 1984 Sep; 57 (Pt 3):261-4.
Saferan, J.D., & Muran,J.C. Negotiating the therapeutic alliance: A relational treatment
Guide. New York: Guilford Press. 2000.
Mofidi, N. Psychodynamic Psychotherapy vs. Cognitive psychotherapy. Examens uppsats
1995. H. Davanloo: "Short-Term Dynamic Psychotherapy", in: Kaplan H., and Sadock B.
(eds), "Comprehensive Textbook of Psychiatry", 4th edn., Chapter 29.11, Baltimore, MD,
Williams & Wilkins, 1984
Malan, D. (1976):The frontier of brief psychotherapy. New York: Plenum Medical Book
Company.
Mann, J., 1973. Time-limited psychotherapy Harvard University Press, Cambridge, MA.
Sifneos, P.E.Short-term psychotherapy and emotional crisis, Harvard University Press,
Cambridge, MA (1972).
Moras K, Strupp HH (1982) Pretherapy interpersonal relations, patients' alliance and outcome
in brief therapy. Arch Gen Psychiatry. 39:405-409.
Interpersonal Process In Cognitive Therapy. Safran, Jeremy D. & Segal, Zindel: Jason
Aronson; Published : 1996
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