"From the Conscious into the Unconscious:" What Can Cognitive Theories of Psychopathology Learn from Freudian Theory?

"From the Conscious into the Unconscious:" What Can Cognitive Theories of PsychopathologyLearn from Freudian Theory?Author(s): Karin Mogg, Lusia Stopa and Brendan P. BradleySource: Psychological Inquiry, Vol. 12, No. 3 (2001), pp. 139-143Published by: Taylor & Francis, Ltd.Stable URL: http://www.jstor.org/stable/1449390 .

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COMMENTARIES

with which our world is peopled. I am also aware that the demand for something like psychoanalysis is an urgent one. As Macmillan notes in the final pages of his book, ordinary people (who may or may not include psychologists) demand that something like psychoanalysis should exist. Many undergraduates assume that the psychology they study at university will be akin to psychoanalysis and are very disap- pointed when they discover it is not. Their demands are not only for a psychology that discusses the really interesting questions like sex and why my parents never get along, like death and why boys like pressing buttons, but a psychology that can be talked about over coffee, beer, in the gym or bed, that is challeng- ingly personal. This has obviously been the function of psychoanalytic theory (or "talk" if one is feeling fastidious) for a century or so. I detect little enthusi- asm for building a competitor or successor amongst its critics. More's the pity for us all, because someone has to.

Note

John Forrester, Department of History and Philosophy of Science, University of Cambridge, Free School Lane, Cambridge, CB2 3RH, England. E-mail: jpfl [email protected]

References

Cioffi, F. (1998). Freud and the Question of Pseudoscience, Chi- cago: Open Court.

Freud, S. (1955). Sigmund, Notes upon a case of obsessional neurosis. With an addendum: Original record of the case. SE X. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 10, pp. 155-318). London: Hogarth. (Original work published 1 909)

Freud, S. (I 958a). The interpretation of dreams. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vols. 4-5, pp. 1-62 1). London: Hogarth. (Original work published 1900)

Freud, S. (1 958b). On beginning the treatment. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 12, pp. 123-144). London: Hogarth. (Original work published 1912)

Freud, S. (1 958c). Remembering, repeating and working-through. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Volume 12, pp. 147-156). London: Hogarth. (Original work published 1914)

Freud, S. (1961). Remarks on the theory and practice of dream-interpretation SE XIX. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 19, pp. 109-12 1). London: Hogarth. (Original work published 1923)

Freud, S., & Pfister, 0. (1963). Psychoanalysis and,faith: The letters of Sigmund Freud and Oskar Pfister (H. Meng & E. Freud, Eds.). London: Hogarth & The Institute of Psycho-Analysis.

Riviere, J. (1973). An intimate impression. In H. M. Ruitenbeek (Ed.), Freud as we knew him. Detroit, MI: Wayne State University Press.

"From the Conscious into the Unconscious:" What Can Cognitive Theories of Psychopathology Learn From Freudian Theory?

Karin Mogg, Lusia Stopa, and Brendan P. Bradley Department of Psychology University of Southampton

Psychoanalytic theory has been widely criticized in recent years and Macmillan's article (this issue) is a contribution to that body of work. As Macmillan points out in his critique of Freudian theory, it contains many faulty assumptions and is based on erroneous logic, in- cluding uncritical acceptance of the validity of the method of free association. Many of the criticisms in Macmillan's thesis will be familiar to the scientific community of clinical, experimental, and cognitive psychologists. These criticisms focus on free association and interpretation processes. For example, the validity and reliability of self-report data are questionable as these may be confounded by response bias and demand effects. Other problems of Freudian theory include untestable assumptions regarding the nature and organi-

zation of unconscious processes and their relation with conscious processes. A key assumption behind the therapeutic process is that bringing unconscious conflicts into consciousness is an effective method of treating a variety of psychopathologies and that this can be achieved by appropriate analysis of a person's thoughts. This assumption lacks objective, empirical evidence to substantiate it, and consequently, like much of Freudian theory, does not stand up to scientific scrutiny. For many psychologists, from both academic and clinical backgrounds, these issues are unlikely to provoke substantial new interest or controversy because the scientific limitations of Freudian theory are widely accepted.

What is the relevance of these arguments for contemporary theories of psychopathology? Macmillan

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raises important questions about the validity of con- cepts such as unconscious processes in Freudian theory. Our commentary concentrates upon whether contemporary theories of psychopathology are exempt from the criticisms leveled here at the assumptions behind Freudian theory. Over the last century, the domi- nant influence of psychoanalytic ideas in the study and treatment of emotional disorders has been usurped by a cognitive revolution. In current clinical practice in the United Kingdom, United States, and elsewhere, the psychological treatment of choice for a range of anxiety, depressive. and personality disorders is cognitive behavior therapy (CBT). The success of CBT is im- pressive, and its clinical effectiveness has been demon- strated in a substantial number of controlled treatment trials (Butler, Fennell, Robson, & Gelder, 1991; Roth & Fonagy, 1996; Simons, Murphy, Levine, & Wetzel, 1986). Cognitive therapy has widespread scientific backing, but what about the theory underpinning the therapy?

Aaron Beck is widely regarded as the founder of CBT, and it is of interest to note that he was originally trained in psychoanalysis. Perhaps then it is not sur- prising to note parallels between some of the assumptions behind psychoanalytic theory and those of Beck's cognitive schema theories. For example, a primary source of data in CBT is self-report of "automatic thoughts" and images. In common with the criticisms made about the self-report data generated by free association, little is known about the reliability and validity of reports of automatic thoughts or of confounds from response bias or demand effects. Moreover, a key assumption of schema theory is that there are cognitive constructs-dysfunctional assumptions and core beliefs-which are often unavailable to consciousness but nevertheless have an important role in causing and maintaining emotional disorders. In some variants of cognitive therapy, one aim of treatment is to help pa- tients identify these underlying cognitive constructs to change or modify them. However, there is a dearth of evidence to support either the validity of these con- cepts or the effectiveness of the change methods that are currently used.

A generic model of cognitive therapy comprises three different levels of cognitions: At the surface level are negative automatic thoughts; at an intermediate level, dysfunctional assumptions; and at a deeper more fundamental level, there are core beliefs or schemas (Greenberger & Padesky, 1995). The question we ad- dress in this commentary is how well this tri-partite conceptualization of cognition stands up to scientific scrutiny. In particular, is the theory that underpins cognitive therapy open to the same or similar criticisms as those outlined by Macmillan in response to Freud's work?

Surface level cognitions such as negative automatic thoughts may be regarded as easier to investigate as

they appear accessible to awareness. There is a range of evidence that seems to support the existence of negative automatic thoughts, although this evidence is largely correlational (Williams, 1984), and some of it may be compromised by the use of poor measures. There is also some evidence to support the cognitive specificity hypothesis that different emotional disorders are associated with different types of negative automatic thoughts (Woody, Taylor, McLean, & Koch, 1998), although further research is needed in this area. The problems with relying on self-report of automatic thoughts and images to support cognitive theory were previously outlined. However, improved methodolo- gies for reporting negative automatic thoughts and the use of experimental tasks, which are sensitive to the presence of these thoughts indirectly, provide converg- ing support for the concept of negative automatic thoughts and their role in maintaining emotional disorders (Gelder, 1997). Their status as a causal factor in the development of psychopathology has not been con- clusively established to date (Teasdale, 1997).

What happens when we start to look at the other two levels of cognition: dysfunctional assumptions and schemas? Dysfunctional assumptions are identified in therapy through inferring a particular rule as a result of observing patterns of thoughts and behavior or through the use of self-report questionnaires such as the Dys- functional Attitudes Scale (Weissman, 1979). In cognitive therapy, the therapist and client work collaboratively and conduct experiments to test out assumptions that they have identified. However, despite the application of a quasi-scientific method to therapy, this does not establish the validity of the concept. There is some preliminary evidence to suggest that cognitive therapy may work by producing change in underlying cognitive structures, such as dysfunctional attitudes (Hollon, DeRubeis, & Evans, 1996). There is also evidence to suggest that dysfunctional assumptions may have a role in causing cognitive vulnerability to psychopathology (Miranda, Gross, Persons, & Hahn, 1998; Segal, Gemar & Williams, 1999). How- ever, these studies are far from conclusive, and many of them use a single self-report measure of dysfunctional assumptions to investigate the putative influence of the underlying cognitive structure on the development of psychopathological states.

The problems are compounded when we come to the question of schemas or core beliefs. Schemas are hypo- thetical constructs that have an important role in the development and maintenance of emotional disorders according to generic cognitive theories (e.g., Beck, 1979; Beck, Emery, & Greenberg, 1985; Young, 1999). Schemas are conceptualized as templates that both guide the interpretation of incoming information and shape cognitive, affective, psychophysiological, and behavioral responses. Schemas are presumed to be active during periods when the individual experiences symp-

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toms, for example, of depression or anxiety. At other times schemas can be latent, reflecting a chronic, underlying vulnerability to emotional disorders, even though the person is symptom-free. However, we need to ask whether the use of the concept of latent schemas in cognitive therapy is open to the same criticism as Freud's use of the term unconscious and whether the methods of accessing schemas-diaries, the interpretation of themes and patterns in therapy, exploration of images, self-report questionnaires such as the Young Schema Questionnaire (Young & Brown, 1994)-are any more valid than the method of free association championed by Freud as the royal road to the unconscious.

Beck described a schema as an "attitude or assumption" (Beck, 1979, p. 3) and argued that the term schema designated "stable cognitive patterns" (p. 12). He also proposed the idea that schemas are latent and can be activated by a specific event, usually an event that in some way mirrors the original event(s) that led to the original formation of the schema in early child- hood. We have already entered a conceptual mine- field-is a schema synonymous with a belief or an assumption, or is it a pattern that incorporates a range of information, and, if so, what? As noted earlier, the problems multiply when we get to the issue of latency. If schemas are latent, how are they stored and repre- sented? Do they influence information processing while they are latent, or do they only affect information processing once active? Most important of all, does the concept of latency render schema theory unfalsifiable?

The concept of schema has been further elaborated by Jeff Young, who has developed an entire therapy for personality disorders based on the central importance of schemas. Young defines schemas as "extremely stable and enduring themes that develop during child- hood, are elaborated throughout an individual's lifetime, and are dysfunctional to a significant degree. These schemas serve as templates for the processing of later experience" (Young, 1999, p. 9). This definition, although clinically useful, is problematic because it is so all-encompassing. Young's conceptualization incorporates belief, affect, memory, and self-concept. Again we need to question the validity of the concept, subject the schema concept to scientific scrutiny and empirical test, examine the methods for measuring the schema concept, and empirically validate the therapy. Although it is certainly the case that we are urgently in need of the therapies that tackle the more complex and intractable problems manifest in personality disorders, we also need to stand back and evaluate whether we are falling into any of the traps outlined in Macmillan's critique of Freud's theory. In the following section, we consider the contribution of experimental research ap- proaches to the evaluation and development of cognitive theories of emotional disorders.

How well do contemporary theories of psychopathology stand up to experimental scrutiny?

Experimental tests of hypotheses from schema models of anxiety and depression have questioned the validity of some of the key assumptions concerning information-processing biases for emotional information. Schema models predict that both anxiety and depression are characterized by similar patterns of cognitive bias, which favor emotion-congruent information and which operate throughout all aspects of information processing. For example, anxious individuals should selectively attend to and remember anxiety-relevant information (e.g., threatening events), whereas de- pressed individuals should selectively attend to and remember depression-relevant information (e.g., events related to loss and failure). According to schema theory, these cognitive biases play an important role in causing and maintaining emotional disorders, and consequently, an important aim in therapy is to identify and neutralize these biases.

However, experimental research findings indicate that clinical anxiety and depression are associated with fundamentally different patterns of cognitive bias: Gen- eralized anxiety seems to be primarily characterized by a bias in selective attention (but not memory) for threat, whereas depression is primarily associated with a bias in memory (but not selective attention) for negative information (e.g., Bradley & Mathews, 1983; Bradley, Mogg, & Williams, 1995; Bradley, Mogg, Millar, & White, 1995; MacLeod, Mathews & Tata, 1986; Mogg, Mathews, & Weinman, 1987). These findings contra- dict a key assumption of schema models that in each of these emotional disorders a dysfunctional schema acts as a filter on all aspects of information processing. In- stead, the research evidence suggests that the notion of a schema may be too simplistic to account for the specific ways in which information processing is biased in each emotional disorder.

Despite the aforementioned critical comments, it is not our intention to give the impression that cognitive schema models have no utility. Indeed, a striking difference between cognitive-behavioral therapy, which is based on schema models, and psychoanalytic therapy is that there is substantial evidence testi- fying to the effectiveness of the former. Thus, clinicians such as Beck and Young have made a significant contribution to the development of helpful treatment techniques and have stimulated experimental research into underlying cognitive processes in emotional and personality disorders. Indeed, it is noteworthy that schema models have been remark- ably successful in generating effective treatments, despite their providing an inaccurate and incomplete theoretical account of emotion-related processing biases, as noted previously. Consequently, this poses an important challenge: If more precise and accurate cognitive models of emotional disorders can be developed, this should, ideally, lead to the development of even more effective treatments.

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Experimental research into fundamental cognitive processes in emotional disorders has led to the proposal of several recent cognitive models of anxiety (e.g., Clark, 1999; Eysenck, 1997; Mogg & Bradley, 1998; Ohman, 1996; Williams, Watts, MacLeod, & Mathews, 1997). Although cognitive models of anxiety commonly pro- pose that information-processing biases play a causal role in anxiety, there has been relatively little research that di- rectly addresses the issue of whether biases are a cause or consequence of emotional states. Moreover, each of the aforementioned models has different assumptions about the role of cognitive processes in causing and maintaining anxiety disorders. For example, Williams et al. suggest that an attentional bias for threatening infornation plays a critical role in underlying vulnerability to, and maintenance of, clinical anxiety states. In contrast, Mogg and Bradley suggest that a key index of cognitive vulnerability to anxiety is a tendency to overestimate the threat value of stimulus information, rather than the attentional bias per se. It remains for further research to establish whether biases in stimulus evaluation processes or attentional processes play a primary role in detennining vulnerability to clinical anxiety. Moreover, such issues have important clinical implications (e.g., in indicating whether anti-anxiety treatments should primarily target cognitive biases in evaluative/appraisal processes or in attentional processes).

At present there seems to be an uneasy tension, because contemporary psychological treatments for emotional and personality disorders appear to be based on incomplete and imperfect cognitive models. Conse- quently, it is essential that we critically evaluate, and ex- pose to intense scientific scrutiny, contemporary theoretical models of emotional and personality disorders, which have revolutionized clinical treatment. Be- cause cognitive-behavior therapy has been found to be effective, this may have encouraged a tendency to ac- cept uncritically many of the assumptions of the underlying theory. However, a demonstration of treatment effectiveness does not in itself provide evidence in support of the validity of the core assumptions of the underlying cognitive models, particularly as cognitive-behavior therapy is a complex, multi-compo- nent package of interventions. Perhaps in 100 or so years, scientific journals will publish critical re- views-similar to current critiques of Freudian psychoanalytic theory-but the focus of their criticisms will instead be the cognitive models of psychopathology that dominate current clinical practice.

Notes

Karin Mogg holds a Wellcome Senior Research Fellowship in Basic Biomedical Science.

Karin Mogg, Department of Psychology, Univer- sity of Southampton, Highfield, Southampton S017 1BJ, England. E-mail: kmogg(soton.ac.uk

References

Beck, A. T. (1979). Cognitive Therapy of Depression. Guilford. Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety Disor-

ders and Phobias: A Cognitive Perspective. New York: Basic Books.

Bradley, B. P., & Mathews, A. (1983). Negative self-schemata in clinical depression. British Journal of Clinical Psychology, 22, 173-181.

Bradley, B. P., Mogg, K., Millar, N., & White, J. (1995). Selective processing of negative information: Effects of clinical anxiety, concurrent depression, and awareness. Journal of Abnormal Psychology, 104, 532-536.

Bradley, B. P., Mogg, K., & Williams, R. (1995). Implicit and ex- plicit memory for emotion-congruent information in depression and anxiety. Behaviour Research and Therapy, 33, 755-770.

Butler, G., Fennell, M., Robson, P., & Gelder, M. (1991). Compari- son of behaviour therapy and cognitive behaviour therapy in the treatment of generalised anxiety disorder. Journal of Consulting and Clinical Psychology, 59, 167-175.

Clark, D. M. (1999). Anxiety disorders: why they persist and how to treat them. Behaviour Research & Therapy, 3 7, 5-27.

Eysenck, M. W. (1997). Anxiety and cognition: a unified theory. Mahwah, NJ: Lawrence Erlbaum Associates, Inc.

Gelder, M. (1997). The scientific foundations of cognitive behaviour therapy. In D. M. Clark & C. G. Fairbum (Eds.), Science and Practice of Cognitive Behaviour Therapy. Oxford, England: Oxford University Press.

Greenberger, D., & Padesky, C. (1995). Mind over Mood: Change how you.feel by changing the way you think. New York: Guilford.

Hollon, S. D., DeRubeis, R. J., & Evans, M. D. (1996). Cognitive Therapy in the treatment and prevention of depression. In. P. M. Salkovskis (Ed.), Frontiers of Cognitive Therapy. New York: Guilford.

MacLeod, C., Mathews, A., & Tata, P. (1986). Attentional bias in emotional disorders. Journal of Abnormal Psychology, 95, 15-20.

Miranda, J, Gross, J. J., Persons, J. B., & Hahn, J. (1998). Mood mat- ters: Mood induction activates dysfunctional attitudes in women vulnerable to depression. Cognitive Therapy and Research, 22, 363-376.

Mogg, K., & Bradley, B. P. (1998). A cognitive-motivational analysis of anxiety. Behaviour Research & Therapy, 36, 809-848.

Mogg, K., Mathews, A., & Weinman, J. (1987). Memory bias in clinical anxiety. Journal of Abnormal Psychology, 96, 94-98.

Ohman, A. (1996). Preferential preattentive processing of threat in anxiety: preparedness and attentional biases. In R. M. Rapee (Ed.), Current controversies in the anxiety disorders. New York: Guilford.

Roth, A., & Fonagy, P. (1996). What works for whom: A critical re- view ofpsychotherapy research. New York: Guilford.

Segal, Z. V., Gemar, M., & Williams, S. (1999). Differential cognitive response to a mood challenge following successful cognitive therapy or pharmacotherapy for unipolar depression. Jour- nal of Abnormal Psychology, 108, 3-10.

Simons, A. D., Murphy, G. E., Levine, J. L., & Wetzel, R. D. (1986). Cognitive therapy and pharmacotherapy for depression. Ar- chives of General Psychiatry, 43, 43-50.

Teasdale, J. D. (1997). The relationship between cognition and emotion: the mind-in-place in mood disorders. In D. M. Clark & C. G. Fairbum (Eds.), Science andpractice ofcognitive behaviour therapy. Oxford, England: Oxford University Press.

Weissman, A. (1979). The Dysfunctional Attitudes Scale: A validation study. Dissertation Abstracts International, 40, 1389-1390B.

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Williams, J. M. G. (1984). The psychological treatment of depression: A guide to the theory andpractice of cognitive-behaviour therapy. London: Croom Helm.

Williams, J. M. G., Watts, F. N., MacLeod, C., & Mathews, A. (1997). Cognitive psychology and emotional disorders. (2nd ed.). Chichester, England: Wiley.

Woody, S. R, Taylor, S., Maclean, P. D., & Koch, W. J. (1998). Cognitive specificity in panic and depression: Implications

for co-morbidity. Cognitive Therapy and Research, 22, 427-443.

Young, J. E. (1999). Cognitive therapyfiorpersonality disorder: A schema-focused approach. Sarasota, FL: Professional Resource Press.

Young, J. E., & Brown, G. (1994). Young Schema Questionnaire. In J. E. Young (Ed.), Cognitive therapy forpersonality disorder: A schema-focused approach (2nd ed.). Sarasota, FL: Professional Resource Press.

Macmillan and Freud's Conception of Causality

Nathan Hale, Jr. Professor Emeritus of History

University of California, Riverside San Francisco Psychoanalytic Institute

Macmillan's (this issue) long and conscientious wrestle with psychoanalysis has provided important historical material, but also, I believe, some serious misunderstandings. Although his account of the influence of Meynert and Charcot is stimulating, relevant problems remain in his discussion of suggestion, free association, and causality. For example, he does not tell us that Freud was very aware of the role of suggestion, indeed of command in Charcot's work at the Salpetriere, that Freud wel- comed Bernheim for placing, unlike Charcot, hyp- nosis and hysteria on a psychological basis, and for asserting the therapeutic use of the latter (Freud, 1893, pp. 39-40). Thus his assumption that Freud slavishly adopted Charcot's traumatic neurosis as his compelling model seems to me exaggerated. More important, I believe he clearly misunderstands Freud's conception of causality (i.e., that it was mul- tiple and complex, and not some simple relation such as A causes B). In that same lecture, Freud wrote that in hysteria, unlike the traumatic neuroses, the cause was a "series of affective impressions-a whole story of suffering." It was precisely these affective impressions that Freud believed were decisive and that he later assumed the technique of free association could reveal. It is a complex and subjective reality that he is seeking to discover, hardly a simple "cause" in Macmillan's sense. And this complex reality makes irrelevant Macmillan's insistence that a true model of reality, if I may paraphrase his demand, is required, if an interpretation is to be judged correct or incorrect. Moreover, his argument that Freud insisted on a starting point for associations seems also exaggerated. Freud did present free association in that way early on, but a less directed use of free association seemed to characterize his later practice (Newton & Lohser, 1996).

Macmillan dismisses my argument that Freud's conceptions of transference and counter transference were his method of resolving the problem of suggestion. It would be naive to assume that Freud anticipated and solved all the problems of observer bias and "demand characteristics" as we have come to understand them. But in the context of his time, when direct suggestion and command were the chief methods of psy- chotherapy, Freud's conceptions were a conscientious attempt to deal with the problem and to explain the psychological basis of suggestion. Freud assumed that suggestion was an irreducible fact of human life but that his patient's resistance to interpretation, in addi- tion to the vigilance of the therapist in avoiding suggestion, were guarantees that it would be difficult to foist an erroneous concept on a patient. Finally, there is much clinical evidence to show that apart from emotional reactions to earlier experiences, veridical memo- ries surface in free association that are not suggested by the therapist.

Perhaps most analysts today would argue that the analytic process is a dyadic one, that there is a mutual interaction between therapist and patient and that one is not dealing with simple linear causes, but with a complex subjective reality, the patient's perception of the patterns of his behavior, clarified by the mutual un- derstanding of therapist and patient.

The work of Orme (1962) that Macmillan cites in his discussion of observer bias seems to me to be irrelevant to the clinical situation. It deals with college student par- ticipants' unconscious perception of the aims of a given psychological experiment, thus skewing their perfor- mance in the experiment to fulfill those expectations.

Macmillan exaggerates aspects of the disagreement among analysts. On theory such disagreements are indeed rife, as they are in many fields. But the work of Weiss and Sampson (1986) and Luborsky and

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"From the Conscious into the Unconscious:" What Can Cognitive Theories of Psychopathology Learn from Freudian Theory?