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J Psychother Integr. Author manuscript; available in PMC 2017 June 01. Published in final edited form as: J Psychother Integr. 2016 June ; 26(2): 116–128. doi:10.1037/int0000032.
An Integrative Theory of Psychotherapy: Research and Practice Seymour Epstein and Department of Psychology, University of Massachusetts, Amherst Martha L. Epstein Park City, UT
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Abstract
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A dual-process personality theory and supporting research are presented. The dual processes comprise an experiential system and a rational system. The experiential system is an adaptive, associative learning system that humans share with other higher-order animals. The rational system is a uniquely human, primarily verbal, reasoning system. It is assumed that when humans developed language they did not abandon their previous ways of adapting, they simply added language to their experiential system. The two systems are assumed to operate in parallel and are bi-directionally interactive. The validity of these assumptions is supported by extensive research. Of particular relevance for psychotherapy, the experiential system, which is compatible with evolutionary theory, replaces the Freudian maladaptive unconscious system that is indefensible from an evolutionary perspective, as sub-human animals would then have only a single system that is maladaptive. The aim of psychotherapy is to produce constructive changes in the experiential system. Changes in the rational system are useful only to the extent that they contribute to constructive changes in the experiential system.
Keywords experiential system; rational system; dual process; adaptive system; maladaptive system
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A basic assumption in cognitive-experiential theory (CET) is that people operate with two systems, an experiential system and a rational system (Epstein, 2014). The experiential system is primarily non-verbal and imagistic and learns automatically from experience, normally doing so outside of awareness. The rational system is a uniquely human verbal reasoning system. Both systems are adaptive, though in different ways, and each has limitations. This article describes the conceptual foundation of CET, presents supporting research, and addresses its clinical implications.
A Cognitive-Experiential Theory of Human Functioning To understand the experiential system, it is useful to divide it into process and content. Process consists of operating principles, while content consists of what has been
Correspondence concerning this article should be addressed to Seymour Epstein, 37 Bay Road, Amherst, MA 01002. [email protected]. Seymour Epstein is now retired.
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automatically learned. Particularly important content includes implicit needs and beliefs automatically learned from experience. Such implicit needs and beliefs influence almost all aspects of functioning, including the interpretation of events, automatic thoughts, feelings, conscious thinking, and behavioral tendencies. Experiential System—Process
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There are three important ways humans and other higher-order animals automatically learn from experience: classical conditioning, instrumental/operant conditioning, and observational learning (i.e., modeling; Epstein, 2014). The different learning methods comprise a single system because they all serve a common purpose. That is, regardless of how we learn, if we feel good or bad, it reinforces an implicit need and/or belief. This is fundamentally different from classic learning theory that narrowly links reinforcement to modifying observable behaviors. This key difference gives CET tremendous flexibility and integrative power by providing the content for the construction of an implicit theory of reality, which directs the interpretation of events, behavioral response tendencies, and implicit thoughts and feelings. Experiential System—Content Depending on the fulfillment or frustration of an implicit need, a person will have a related implicit belief (Epstein, 2014). For example, if the need for interpersonal relatedness is fulfilled, a person will tend to view the self as love-worthy and others as caring. Alternatively, if the need for relatedness is consistently frustrated, the person will tend to have the implicit belief that the self is unlovable and others are rejecting. Such implicit beliefs, coming from the interpretation of life events, may or may not coincide with a person’s explicit beliefs.
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Discrepancies between the two kinds of beliefs can cause maladjustment. For example, assume that John has worked hard all his life, as he believed that becoming famous and wealthy would make him happy. However, instead of being happy when he achieved his goal, he felt sad. An explicit need may have been fulfilled, but not an implicit need, such as the need to be loved.
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A common fallacy is to equate implicit cognition with unconscious processing. Implicit cognitions are not equivalent to unconscious beliefs for two reasons. First, if an unconscious belief is made conscious it continues to operate as an implicit cognition that follows the same principles as before. Second, the Freudian view of the unconscious considers the unconscious as operating by “primary process thinking” (e.g., wish-fulfillment, displacement, condensation, over determination, association), whereas the experiential system has been empirically shown to operate by associative-learning principles (Epstein, 2014).
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Research Underpinnings of Experiential Knowing Operating Principles of the Experiential System
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The first author and his associates have conducted extensive research on the operating principles and attributes of the experiential system (Epstein, 2014). Among other procedures, we adapted procedures used by Tversky and Kahneman (1982) and other cognitive and social-cognitive psychologists to study heuristic information processing by using specially constructed vignettes. Most research on heuristics has failed to distinguish between two kinds of heuristic processing. Thus, some researchers interpret all their results on heuristics as indicative of only a single system that includes deliberative processing. Alternatively, others attribute all their results on heuristics to two separate systems, only one of which includes deliberate processing. This latter approach has been criticized by noting that the results supporting a different kind of information processing from deliberative processing could just as well be attributed to cognitive shortcuts in a single processing system (Kruglansky, Thompson, & Spiegel, 1999). Ways of establishing that a different system of processing exists in addition to deliberate processing are to demonstrate that they operate by different principles and attributes and may even conflict with each other. This approach was used in our research, and our results clearly support the existence of twosystems. Irrational reactions to unfortunate arbitrary outcomes—People often react to arbitrary outcomes as if they or others are responsible for the outcomes. Thus, they reward the proverbial bearer of good tidings and punish the conveyer of bad news. Such irrational reactions are readily explained by the associative-learning principle of the experiential system.
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We investigated people’s reactions to arbitrary unfavorable outcomes by asking how they would behave in situations described in several vignettes, how most people would behave, how the protagonist in the vignettes would behave, and how a completely logical person would behave (e.g., Epstein, Lipson, Holstein, & Huh, 1992). In one vignette that investigated the effect of near versus far misses, a woman missed her flight due to a lengthy, unforeseen traffic jam. In one group, a woman missed her flight by a small margin; for another group, she missed her flight by a much wider margin. Who felt more foolish about having dawdled at home? Tversky and Kahneman (1982) found that their participants reported that the protagonist who barely missed her flight was more upset, a finding we replicated. We also found that most participants reported that a logical person would feel much less foolish than they expected the protagonist to feel. The significance of the consequences of missing the flight also influenced the protagonists’ behavior. When the outcomes were very unfavorable, the protagonists were said to feel more foolish for having dawdled than when the outcomes were less unfavorable. The full results of this study support the following hypotheses based on the CET model: •
People are aware of two different modes of thinking, one that determines mainly how people normally behave, which, according to CET, is with their experiential system and the other that determines how a logical
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person would behave, which, according to CET, is primarily by their rational system. •
The more people are emotionally engaged in a situation the more they tend to think and behave according to their experiential system.
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Most people’s ratings for themselves were between those of “a logical person” and their ratings of “most people’s” behavior, suggesting that most behavior is based on a compromise between the two systems.
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The experiential system can co-opt the rational system, indicating an important source of irrationality in humans, despite their capacity for rational thinking.
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The ratio-bias phenomenon—The ratio-bias (RB) phenomenon is of particular interest for dual-process theories, as it pits experiential against rational processing in a situation in which the two modes of processing are equally accessible and in which both require negligible cognitive effort (Kirkpatrick & Epstein, 1992). Imagine if every time you blindly draw a red jellybean from a bowl containing red and white jellybeans that you win two dollars. You can choose between two bowls that both offer a 10% probability of obtaining a red jellybean. One bowl contains 1 red and 9 white jellybeans. The other contains 10 red and 90 white jellybeans. When people are asked how much they would pay to draw from the bowl of their choice, almost all said they had no preference and would not pay a cent. Yet, when they are placed in a situation in which they can actually win a significant amount of money over trials, most people parted with small sums of money to draw from the bowl with more red jellybeans (Kirkpatrick & Epstein, 1992). The preference for the bowl with more red jellybeans, despite it having no probability advantage, is referred to as the RB phenomenon and can be attributed to the experiential system. Even more impressive are the results when a bowl with more red jellybeans offers a lower probability of obtaining one. In one study, a probability-advantaged bowl always contained 1 in 10 red jellybeans, and a frequency-advantaged bowl contained 5–9 red jellybeans out of 100 jellybeans (Denes-Raj & Epstein, 1994). Most participants preferred the slightly frequency-advantaged (e.g., 9/100 versus 1/10) bowl despite its probability disadvantage. Some participants said they knew such behavior was irrational, but that they had a “feeling” that they had a better chance of getting a red jellybean when there were more of them. Additional RB studies are summarized elsewhere (Epstein, 2014), and the conclusions from these RB studies are below:
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People operate with two independent systems, experiential and rational.
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The RB effect in low-probability conditions can be attributed to a “frequency effect.” This is consistent with the concrete operation of the experiential system and that single numbers are more concrete than percentages (based on the relationship between two numbers).
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Either system can dominate depending on the situation and the person. Although most participants make compromises between the two systems
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by making non-optimal, slightly frequency-advantaged responses, many consistently make optimal, probability-advantaged responses.
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The two systems sometimes conflict with each other. Some participants reported feeling torn between frequency-advantaged and probabilityadvantaged choices. Clinically, we know that patients may indicate that they know “intellectually” something bad will not happen, but nonetheless believe it “emotionally,” which often determines their behavior.
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The experiential system is more responsive than the rational system to real situations and to vividly imagined situations, whereas the rational system is more responsive to verbal information.
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With increasing maturation from childhood to adulthood, the rational system gains increasing dominance. The dominance of the experiential system is clearly manifested when conducting therapy with adolescents before they have developed a more realistic way of viewing the world.
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Priming the rational system in children before they have formal knowledge of ratios by asking them to give the reasons for their responses interferes with their experiential thinking. This indicates that processing in the rational system can interfere with processing in the experiential system.
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An increase in incentive produces an increase in optimal, rational responses in some participants, but an increase in experiential processing, non-optimal responses in an approximately equal number of participants. This suggests that these two systems are always operational and the interaction between them depends on both the person’s predisposition (e.g., tendencies to process rationally vs. experientially) and the situation (e.g., importance, emotional involvement, etc.).
The global-evaluation heuristic—The global-evaluation heuristic refers to the tendency for people to evaluate others as generally being either good or bad people, rather than restricting their evaluations to specific behaviors (Epstein, 2014). As the experiential system operates holistically, it follows that global evaluation is attributable to the experiential system, and therefore, will be automatic, compelling, and not easily overcome. This heuristic is particularly important because of its prevalence in causing serious problems, as in stereotyping others and in misattributing the motives and emotions of others.
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The first author and his associates investigated the global-evaluation heuristic (Epstein, 1994) by having participants respond to a vignette adapted from a study by Miller and Gunasegaram (1990). In the vignette, a rich benefactor tells three friends that if each throws a coin that comes up heads, all three will be given $100. The first two throw a heads, but Smith, the third, throws a tails. Most participants reported that Smith would feel guilty and the others would be angry at him. In an alternative version in which we reduced the stakes to a more modest sum, the ratings of guilt and anger were reduced. When asked if the other two would be willing to invite Smith on a gambling vacation in Las Vegas, where they would share wins and losses, most participants said that now they would not invite him,
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“because he’s a loser.” These responses were made both from the perspective of how the participants reported they would react and how they reported most people would react. When responding from the perspective of how a completely logical person would behave, most said a logical person would recognize that the outcome of the coin tosses was completely arbitrary, that they would not resent Smith, and that they would invite him on their gambling venture. This study indicates that people are intuitively aware of two systems of information processing that operate in a manner consistent with the operating principles and attributes of the experiential and rational systems.
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Conjunction problems—The “Linda conjunction problem” is probably the most researched vignette in the history of psychology (Epstein, 2014). It has evoked great interest because of its paradoxical results. Although the solution to the Linda problem requires the application of one of the simplest rules of probability, almost everyone, including individuals who are sophisticated about statistics, use their intuition rather than logic when responding to it. In the vignette, Linda is described as 31 years old, single, outspoken, and very bright. In college she was a philosophy major who participated in anti-nuclear demonstrations and was concerned about social justice. In our research, we asked participants to rank-order the following alternatives: Linda is a feminist, Linda is a bank teller, and Linda is a feminist and a bank teller. Most ranked Linda as being a feminist and a bank teller ahead of Linda just being a bank teller. In doing so, they made what Tversky and Kahneman (1982) labeled a “conjunction error (CE),” because, according to probability theory, the occurrence of two events cannot be more likely than the occurrence of only one of them.
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The usual explanation of the high rate of conjunction errors (CEs) elicited by the Linda problem is that people either do not know the conjunction rule or they do not think of it in the context of the Linda vignette. According to Tversky and Kahneman (1982), they make such errors because they respond by the representativeness heuristic in making judgments, according to which being both a bank teller and a feminist is more representative or likely of Linda’s personality than being just a bank teller. In several studies on conjunction problems, including several on the Linda problem (Donovan & Epstein, 1997; Epstein, Denes-Raj, & Pacini, 1995; Epstein, Donovan, & Denes-Raj, 1999), we demonstrated that the major reason for the difficulty of the Linda problem is that it provides a very unusual way of presenting a conjunction problem. Consequently, people tend not to view the Linda problem as a probability problem, even when told to do so.
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The difficulty of the Linda problem cannot, however, be fully explained by the misleading manner in which it is presented in the form a personality problem, for even with full disclosure about the nature of the problem and the request to treat it as a probability problem, most participants make CEs. However, when responding to a conceptually equivalent problem presented in a concrete, natural manner, as in a problem in judging the likelihood of winning one or two lotteries or one or two horse races, almost no one makes a CE (Epstein, Denes-Raj, & Pacini, 1995).
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Making CEs in the Linda problem is so compelling that when presented with the correct conjunction rule (i.e., “two events are less likely to occur than just one of them”) among several incorrect rules, most selected a wrong rule that was consistent with making a CE. In other words, they made the rule correspond to their incorrect response, rather than using the correct rule and then applying it appropriately to the Linda problem. This demonstrates the highly compelling nature of experiential processing and its ability to co-opt rational processing. Priming intuitive knowledge by presenting easy-to-solve, natural conjunction problems followed by unnatural ones, like the Linda problem, facilitates solving unnatural problems that people are otherwise unable to solve. Conclusions from the Linda studies are summarized below:
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The difficulty of the Linda problem can be explained by the operating rules and attributes of the experiential system, which is the mode employed by most people when responding to it. Thus, people automatically tend to process information associatively, concretely, holistically and in a narrative way, rather than abstractly, analytically, and rationally when responding to the Linda problem.
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Processing in the experiential mode is intrinsically highly compelling and can over-ride processing in the rational mode even when the latter does not require more effort or resources. Thus, many participants, despite knowing and thinking of the conjunction rule, simply find an experiential response more compelling than a rational response.
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The experiential system can contain learning that is not understood and cannot be articulated by the rational system.
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The rational system, especially when it is evoked initially, can influence the experiential system.
Interactions Between Systems and Among Needs
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Interactions between the two processing systems—An important research finding is that the experiential and rational systems are both simultaneously and sequentially interactive. Simultaneous interaction was demonstrated in the compromises between the two systems in the ratio-bias studies described earlier. Sequential interaction was demonstrated in research that shows that processing in the experiential mode can compromise subsequent processing in the rational mode (Chaiken & Maheswaren, 1994; Denes-Raj, Epstein, & Cole, 1995; Epstein, Lipson, Holstein, & Huh, 1992). There is also considerable evidence that priming the experiential system subliminally can influence subsequent responses in the rational system (Bargh, 1989). Research on conjunction problems in which presenting problems first in a natural way that taps the experiential system made participants more likely to successfully solve abstract, out-of-context problems presented subsequently suggests that experiential processing may sometimes also improve rational processing.
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Interactions among basic needs—A basic assumption in CET is that behavior often represents a compromise among basic needs. This process is considered to be particularly important, as it provides checks and balances against the excessive investment in the fulfillment of a particular need. It occurs because greatly fulfilling any need (e.g., the need for relationship) at the expense of fulfilling other needs (e.g., the need for autonomy) increases the strengths of the other needs. To test this assumption about interactions among needs we examined the combined influence of the needs for self-enhancement and selfverification. Swann and his associates previously demonstrated that the needs for enhancement and verification often operate sequentially, with the former preceding the latter (e.g., Hixon & Swann, 1993; Swann, 1990). We demonstrated that the interaction also occurs simultaneously in the form of compromises between needs. Our procedure consisted of varying the favorableness of evaluative feedback and observing whether participants had a preference for feedback that either matched or was more favorable than their selfassessments (Epstein & Morling, 1995; Morling & Epstein, 1997). In support of this hypothesis, participants preferred feedback that was only slightly more favorable than their self-assessments, consistent with a compromise between fulfilling the needs for verification and self-enhancement. Individual Differences in Experiential and Rational Information Processing
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Individual differences in the experiential system—There are excellent intelligence tests that measure the intelligence of the rational system. Such tests are fairly good predictors of academic performance and, to a somewhat lesser extent, of performance in the real world, including workplace performance, particularly in situations that require complex operations (see Gordon, 1997; Gottfredson, 1997; Hunter, 1983). However, as there was no test that measured experiential intelligence we constructed one, which we named the Constructive Thinking Inventory (CTI; Epstein, 2001).
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People respond to the CTI by reporting the degree to which they have certain adaptive and maladaptive automatic or spontaneous thoughts or feelings. An example of an item is, “I tend to dwell more on pleasant than unpleasant incidents from the past.” The CTI provides a Global Constructive Thinking scale and six main scales, all but one of which have subscales. The six main scales are Emotional Coping, Behavioral Coping, Categorical Thinking, Esoteric Thinking, Naïve Optimism, and Personal Superstitious Thinking, and are predictive of a wide variety of criteria related to success in living. A review of the extensive literature supporting the CTI’s validity is available in the CTI manual (Epstein, 2001). Experiential intelligence has been found to be directly related to a wide range of successful performance, including performance in the work-place, superior achievement by managers, superior academic performance, social competence, leadership ability, ability to cope with stress, emotional adjustment, physical wellbeing, and an absence of drug and alcohol abuse. It was found in several studies that scores on the Global CTI scale were either unrelated or negligibly related to IQ (see review in Epstein, 2001), supporting the view that the experiential and rational systems process information differently. Of particular interest, constructive thinking and intellectual intelligence exhibit a nearly opposite course of development across the life span. Constructive thinking is at its nadir in adolescence when
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intellectual intelligence is near its peak and then gradually increases throughout most of the adult years when IQ is gradually declining. Constructive thinking is less strongly related to academic achievement than intellectual intelligence. Nevertheless, it contributes significant variance beyond that of intellectual intelligence to performance in the classroom, as indicated by grades received and by class rank (Epstein, 2001). Apparently, good constructive thinkers are able to behave in ways that gain them recognition for and appreciation of their intellectual ability, whereas poor constructive thinkers are less able to do so. A finding of particular importance is that there is a general factor of experiential intelligence that is measured by the CTI. As this factor includes a wide variety of favorable nonintellective abilities and attributes, it is suggestive of a general factor of nonintellective ability comparable to the general factor of intellectual ability.
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A measure of individual differences in rational and experiential thinking styles —The Rational-Experiential Inventory (REI) was constructed to measure individual differences in the extent to which people process information according to the two processing modes (Epstein, 2001). The REI includes two main scales that measure the extent of processing information in rational and in experiential thinking styles. Each of the main scales has subscales of the degree to which one uses a particular processing mode and one’s self-assessed ability to use it effectively. In studies with the REI (Epstein, 2001; Epstein, Pacini, Denes-Raj, & Heier, 1996; Norris & Epstein, 2011; Pacini & Epstein, 1999b; Pacini, Muir, & Epstein, 1998), a rational thinking style was more strongly positively associated than an experiential thinking style with intellectual performance, as well as with low anxiety, low depression, low stress, low neuroticism, high self-esteem and high meaningfulness of life. An experiential thinking style was more strongly associated than a rational thinking style with measures of creativity, empathy, aesthetic judgment, intuitive ability, and establishing satisfactory interpersonal relationships. It follows that no statement can be made about the general superiority of either thinking style, as each is superior in some important ways and inferior in other important ways.
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Individual differences in basic beliefs about the self, others, and the impersonal world—The content of beliefs in the experiential system is of particular importance for clinical practice. People’s implicit beliefs about themselves, others, and the impersonal world are acquired automatically from emotionally significant experiences, mostly in childhood. Such beliefs are important determinants of feelings, behavior, adjustment, and overall quality of life. Based on this consideration, the Basic Beliefs Inventory (BBI; Catlin & Epstein, 1992) was constructed. The BBI is a self-report questionnaire that includes a global measure of the overall favorability of basic beliefs. It also includes scales for measuring the favorability of more specific beliefs: self-esteem, love-worthiness, competence, meaningfulness of life, views about relationships, and views about the world. A study with the BBI (Catlin & Epstein, 1992) tested the hypotheses that two important sources of basic beliefs are extreme life-events, as in the loss of a loved one or experiencing a transforming love relationship, and relationships with parents during early childhood. In J Psychother Integr. Author manuscript; available in PMC 2017 June 01.
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support of the hypothesis, both kinds of experiences were related to individual differences in basic beliefs. People who reported favorable relationships with their parents and those who obtained high scores on overall favorableness of extreme life-events based on both positive and negative events obtained higher scores than others on the BBI scales of self-esteem, meaningfulness of life, favorable views of others, and an optimistic view about the world. Those who reported unfavorable relationships with their parents or who reported predominantly unfavorable extreme life-events, such as the death of a beloved pet or a significant failure in an important event obtained less favorable scores than others on all basic beliefs.
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It was also found that the more recently an extreme negative event occurred, the less favorable a person’s current basic beliefs. Over time, the effect of extremely unfavorable life events became less unfavorable and sometimes even favorable. Several participants reported that they ultimately gained strength from having had to cope with adversity (Epstein, 1979).
A General Cognitive-Experiential Framework for Psychotherapy Cognitive Experiential Psychotherapy’s (CEP) major contribution to psychotherapy is that it provides an integrative framework for all forms of psychotherapy. CEP is based on the following: The automatic, experiential learning in the form of implicit needs and beliefs is of particular importance and much more so than the learning of behavioral responses.
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According to CEP, psychopathology is the result of implicit needs and beliefs that, regardless of how they were acquired, are currently maladaptive. Identifying maladaptive implicit needs and beliefs is important because it reveals the problems that have to be resolved. However, this is more easily said than done. Since a need or belief may be implicit, the client will be unaware of it and, therefore, unable to report it. Alternatively, the client may have no awareness of the maladaptive implicit need or belief, because he or she has repressed it (i.e., has an automatic avoidance reaction to it). Lastly, one may be aware of the maladaptive need or belief and be able to articulate it, but avoid discussing it because it is too upsetting to do so. A number of procedures can be used to uncover implicit maladaptive needs and beliefs. One procedure for identifying such needs and beliefs is to look for maladaptive repetitive behavior patterns in the real world or in the psychotherapy sessions. Another is to attend to automatic thoughts. Still another is to infer from negative emotions the implicit beliefs that are their likely source.
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Intellectual insight is important, as it provides a road map to what important changes in the experiential system need to be corrected, but insight alone is insufficient.
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Successful therapy requires changes in the experiential system. Therapists can use the considerable information that is available about automatic,
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associative learning to bring about these changes in the experiential system. In most cases, therapy based on CEP begins with instructions on the rudiments of the two systems, and that the source of an emotion is an underlying implicit or explicit cognition. Remediation has two components, diagnosis and treatment. The diagnostic phase requires identification of the dysphoric emotion that is experienced (e.g., fear, anger, sadness, jealousy, envy), the underlying belief or cognition, and the unmet need that is the root cause. For example, anger (the dysphoric emotion) may result from a heightened sensitivity to believing that one has been unjustly treated, which may stem from an unfulfilled need for unconditional love, likely stemming from one’s treatment as a child.
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The treatment phase consists of fulfilling the frustrated need in a constructive way. An important starting point is to establish a therapeutic relationship, so the client genuinely experiences being treated with unconditional positive regard. It is also helpful for the client to learn to identify and reframe maladaptive thinking in a constructive manner. The first author taught a college class in constructive thinking that helped students become skilled at doing this. Students were asked to keep a journal in which they recorded the most negative experience of each day for 30 days. In addition to recording the relevant situation (e.g., a bad grade, a distressing conversation with a parent, a romantic breakup) students were asked to note their accompanying emotions (e.g., anger, frustration, sadness). Most importantly, they were required to explore what implicit or explicit thought produced the emotion and to consider alternative ways of thinking about the same situation that would lead to more constructive feelings and actions. Class time was used to discuss what students had written and learned about themselves, as well as for other students to offer additional constructive ways of reframing their thinking. Anecdotally, most students reported that this was a growth experience, as they had not previously understood how thoughts influence feelings and that the way people frame a situation can affect their well-being.
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This process can also be used in a therapeutic setting, with journal-keeping and discussion. Writing or typing out entries in full is preferred because it is more deliberate (than say talking, texting, dictating, and/or using emoji shorthand) and allows one to re-experience the situation and allows more time to attend to accompanying thoughts and emotions. The main difference between the class and the therapeutic setting is the presence of other students to offer reframing options. In therapy, reframing options can be explored by discussion between the client and therapist. Of course, prompting clients to come up with constructive reframing options on their own is preferable. Yet, if clients struggle to accomplish this, the therapist can offer possibilities. As clients replace their maladaptive thoughts with more constructive ones, it is important for them to attend to the different feelings that result. As one does this repeatedly, the positive feelings that result from having more constructive thoughts should be self-reinforcing and will therefore become increasingly automatic. There may be times when clients are unable to discern any thoughts that accompany their emotions. In such cases, a therapist can work with clients to infer their implicit thoughts from their emotions. For example, sadness is likely to be the result of feeling one has
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suffered a significant, irreplaceable loss. Likewise, anger often follows an implicit thought that one has been treated badly and unfairly. It is also helpful to provide and encourage other constructive experiences (either in real life, in therapy, or in fantasy) and to encourage clients to apply their new way of thinking constructively to these experiences. The final step is to discuss with the client adaptive procedures for coping with the situation after therapy. Specifically, there should be an emphasis on the importance of establishing positive relationships and avoiding toxic ones. If the client returns too soon to the same environment that created and reinforced feelings of being unlovable, it may produce a relapse from the improvement that had taken place.
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Since CEP is integrative, there are several standard forms of psychotherapy that use treatment procedures that are relevant to CEP. The first author’s recent book (Epstein, 2014) discusses all of them from the perspective of CET. In the present article, because of space limitations, we will only discuss client-centered therapy and psychosynthesis. Client-Centered Therapy An important agreement between Rogers’ theory and CEP is that both assume that people’s beliefs are the most important sources of their behavior and feelings. The two theories also agree that discrepancies between beliefs acquired from direct experience (e.g., if a child is consistently rejected by their parents) and how that experience is labeled by significant others (e.g., the rejecting parents tell the child how much they love the child) are an important source of maladjustment.
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Both also assume that people have a basic need to maintain and enhance their conceptual systems. However, for Rogers this is the only basic need whereas for CEP there are six basic needs, two of which are super-ordinate (behaving according to the hedonic principle and controlling arousal within homeostatic limits) and four of which are subordinate (the needs for a stable, coherent conceptual system; security; relatedness; and self-esteem). In addition, client-centered therapy relies on only one procedure, reflecting clients’ statements with acceptance and positive regard. According to CEP, this procedure is insufficient, and it is preferable once a therapeutic relationship has been established to change from an initial reflective approach to an approach that is based on an equal relationship between therapist and client where the therapist feels free to make clarifications and interpretations, albeit in a warm, accepting and tentative manner. It should be noted that, according to CEP, an important reason for the effectiveness of client-centered therapy may be the experience of a warm and accepting relationship with a person who likes and respects the client apart from the particular technique that is used. Psychosynthesis and The Use of Fantasy If the aim of therapy is to produce changes in the experiential system, the use of fantasy can help to do this for several reasons. First, people react to vividly imagined situations in a similar way to how they react to real situations (Crisp, & Turner, 2009; Dadds, Bovbjerg, Redd, & Cutmore, 1997; Epstein, Pacini, & Epstein, 2001; Kosslyn, Ganis, & Thompson,
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2001; Taylor, Pham, Rivkin, & Amor, 1998). Second, the same principles of learning theory can be applied to representations in fantasy as to representations in reality. Third, one can try out things in fantasy that would be impractical or too risky (emotionally and/or physically) to do in reality. Fourth—and perhaps most important—in fantasy, one can create and implement powerful metaphors laden with symbolism that can reach deeply into the experiential system, triggering change.
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Psychosynthesis relies heavily on fantasy in therapy. What follows is an in-depth look at a single case of the use of fantasy in psychosynthesis, that of Alice Epstein—the first author’s wife—and her use of fantasy in her successful battle against terminal cancer (A. Epstein, 1989). When traditional medical treatments offered little hope, Alice was given three months to live. She decided to explore alternative approaches to fight her cancer or at least to improve the quality of her life in her remaining months. One of the approaches was psychotherapy. Alice chose a therapist who used a psychosynthesis approach and, unlike other therapists we interviewed, said she would help Alice work on becoming the person she wanted to be with whatever time was left to her. That was exactly what Alice wanted to hear.
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The psychosynthesis approach relies heavily on the use of imagery and fantasy. One of the psychosynthesis tools Alice found most helpful was the creation of subpersonalities. A subpersonality is a personified aspect of oneself. One vividly imagines this subpersonality as a person, giving it a name and personality. It can be aggressive, strong, empathic, helpful, or anything else one can think of. One of the tools of psychosynthesis is to ask each subpersonality what it really needs and wants. At some point, when the subpersonality is ready, each subpersonality is taken “up the mountain.” Going “up the mountain” is a metaphor for moving to a higher state of perception and understanding. By going “up the mountain” the subpersonality is often transformed, happier and more accepting of and cooperative with the other subpersonalities. The final aim of psychosynthesis is to create an integrated and constructive overall personality. Alice embraced identifying and exploring her subpersonalities with great interest and enthusiasm. Her first subpersonality was “Baby Alice.” Baby Alice is about 2 1/2 years old and sits in a corner and cries. She knows that her mother is always right. Her main wish is to have a perfect mother, and this subpersonality will make significant compromises to believe in her mother’s perfection. Baby Alice even lies to her father to cover up her mother’s failings. Baby Alice says she wants a perfect mother. What she really wants at the experiential level is unconditional love. Out of the five major subpersonalities, Baby Alice was the one who developed the most until she became a highly competent and mature adult who was the leader of the subpersonalities and helped them finally become a unified whole.
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Alice quickly moved on to creating other subpersonalities. Hope and hopelessness were very important to her. She envisioned a crab running aimlessly on the beach holding its front legs up in the air in a helpless manner. He belonged to a gray haired lady who spoke sweetly to him and always called him “dear.” His need is to be free, but she tells him that’s impossible because she needs him to cut the threads on a tapestry she is making. When he asks her what he can hope for, she laughs and says he can hope to be the flying horse in the tapestry.
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The crab was the first one Alice took “up the mountain.” He got excited when he reached a ledge at the top of the mountain and he jumped off. Alice expected to see his mangled remains at the bottom of the hill. Instead there was a beautiful Baltimore oriole that sang so sweetly that she knew he was happy. He perched on her shoulder, and he continued to do so on all further trips up the mountain. The next subpersonality was Amanda, who was very strong and competent. Alice kept chanting to herself when she felt depressed or helpless, “I am Amanda. I am strong. Kill the cancer. Kill the cancer. Kill the cancer. I am Amanda. I am strong.”
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“Little One” was the next subpersonality. She is very angry and aggressive. She throws her head back and laughs a lot. She is nasty, aggressive, devious and joyously happy about her evil thoughts and deeds. She hates Baby Alice and thinks she is stupid and deserving of contempt. Alice found Little One very interesting and liked her. When Little One was taken “up the mountain,” she became Bagera, a beautiful tiger who uses her power only when justified. She likes Baby Alice and lets her ride on her back. Mickey is the most complicated subpersonality. She hates and wants to kill Baby Alice. Mickey is a very jealous little girl. She wants to be admired by her playmates, but no one likes her because she takes away their things. And she is critical of everyone. In the valley below the mountain, she keeps saying that the flowers at home are more beautiful than the wild flowers. All the other subpersonalities taken “up the mountain” had highly positive transformations. In contrast, Mickey became “Chicken Little,” who considered her life to be a sham and, if she were found out “the sky would fall.” Alice indicated that Mickey was the ghost in her closet, a dark part of her that she hid while presenting an opposite picture of herself to the world.
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Alice decided to take Mickey “up the mountain” again, but while still in the meadow she became a giant chicken who came running after Alice as if she wanted to kill her. Alice realized this was the part of her that wanted her dead. She did not know what to do or say, so she said, “I forgive you.” With that, the giant chicken turned into a huge vampire bat that came straight at Alice. Alice wrestled her down and stabbed her to death. How does one explain the dire consequence of providing forgiveness in this fantasy? Forgiveness implies that someone has done something wrong and, as the chicken sees it, the chicken is not at fault. Instead, Alice is at fault because of her false personality and the things she is hiding. It is Alice who is not only at fault; it is Alice who does not even deserve to live.
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The next day in therapy when Alice told her therapist about this fantasy, her therapist got upset and told her never to kill anything again. The therapist was sympathetic to Mickey and asked Alice to try to love her. Alice responded by saying, “How can I love someone who is trying to kill me? Right now I hate her.” Sometime later, Alice told Mickey she had to go. A clear and powerful image suddenly came to mind. She saw Mickey standing at a train station carrying a small suitcase. She was all alone and Alice was walking away telling her she could not come. Mickey sobbed and
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sobbed, begging to come with Alice. It broke Alice’s heart to see her that way. Suddenly Alice realized that it was Mickey who was in fear of her life. Alice realized that Mickey contained all her passion and she could not live without her. Alice once more took Mickey and all the other sub-personalities “up the mountain.” Amanda changed into a flying horse and invited all of them to ride on her back. They had a wonderful time with Amanda catching the wind and soaring into space. Alice now loved all her subpersonalities and they were beginning to cooperate with each other.
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The main source of Alice’s maladjustment warrants discussion. She believed, implicitly and explicitly, that unless you sacrifice fulfilling your own needs for fulfilling other people’s needs, no one would like you. Consequently, Alice consistently subjugated her own needs. This left her prone to feelings of rage and to anti-social behavioral tendencies, which she needed to suppress constantly. Moreover, the conflict between wanting her own needs fulfilled but feeling she had to sacrifice her own needs in order to be liked and loved pitted parts of her personality against one another, resulting in an overall lack of integration. The use of fantasy effectively addressed all these conflicts. Alice’s self-sacrificing attitude was overcome by the transformations that occurred on her trips “up the mountain.” For example, Little One evolved into Bagera, a beautiful and powerful tiger, that asserts her own needs but only when appropriate. In addition, when the crab went “up the mountain,” it broke free of its controlling owner, leapt off the ledge, and was changed into a beautiful, joyous bird. This is likely a metaphor for Alice believing that if she “took a leap of faith” and “broke free” of subjugating her needs to those of others that she could have a rewarding life instead of having a life without freedom and love.
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Alice’s suppressed frustration and anger were addressed in two important ways. First, they were released by instilling in Mickey and Little One the ability to express hostility freely. Second, and more importantly, by showing Alice how to communicate her needs in a socially acceptable way, Bagera helped Alice become less angry and frustrated and to be more authentic, satisfied and fulfilled. Lastly, Alice’s unintegrated personality was improved by Baby Alice encouraging cooperation among the elevated forms of the subpersonalities at every opportunity. Alice’s image of Amanda as a flying horse and taking the other sub-personalities for a wonderful ride on her back was likely only possible when Alice’s fundamental unmet need was finally satisfied, allowing the sub-personalities to be at peace and work harmoniously with each other.
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Summary and Conclusions Cognitive-Experiential Therapy (CET) rests mainly on two basic assumptions: (1) in some fundamental respects, people are no different from other higher-order animals in that they share the same experiential system, and (2) humans did not give up their experiential systems when they developed language and a rational system. Thus, to understand people, it is necessary to recognize that most behavior is primarily automatically determined by their
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experiential system. The aim of therapy, therefore, should be to produce changes in the experiential system. Cognitive-Experiential Psychotherapy (CEP) draws attention to the importance of the rules that govern the operation of the experiential system (e.g., reinforcement, reward, punishment, extinction, spontaneous recovery). These are well known aspects of associative learning, such as having good or bad feelings after behaving in a certain manner serves to reinforce the behavior. That is, behavior followed by good feelings tends to be repeated, while behavior followed by bad feelings tends to be avoided. Because this normally occurs outside of awareness, it has obvious implications for psychotherapy. Namely, it indicates the importance of identifying the unmet need that is the root cause of the problem.
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To produce change, it is insufficient to simply provide intellectual knowledge; one must reach a person’s experiential system. To do so, it is necessary to communicate with it via the “language” it understands, namely the language of associative learning (e.g., of having new experiences with positive outcomes). This can be done by providing corrective experiences and by continuously practicing replacement of the maladaptive implicit thinking with more constructive implicit thinking. Specifically, one has to provide corrective experiences in everyday life, in fantasy, and in therapy sessions. Relapse can be avoided by correcting the root cause of the maladaptive, automatic thinking with repeated corrective experiences coupled with constructive ways of viewing the experiences and by discussing coping with the environment to which the client expects to return.
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This research was supported by National Institute of Mental Health (NIMH) Research grant MH 01293 and NIMH Research Scientist Award 5 K05 MH00363 to Seymour Epstein.
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J Psychother Integr. Author manuscript; available in PMC 2017 June 01. Published in final edited form as: J Psychother Integr. 2016 June ; 26(2): 116–128. doi:10.1037/int0000032.
An Integrative Theory of Psychotherapy: Research and Practice Seymour Epstein and Department of Psychology, University of Massachusetts, Amherst Martha L. Epstein Park City, UT
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Abstract
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A dual-process personality theory and supporting research are presented. The dual processes comprise an experiential system and a rational system. The experiential system is an adaptive, associative learning system that humans share with other higher-order animals. The rational system is a uniquely human, primarily verbal, reasoning system. It is assumed that when humans developed language they did not abandon their previous ways of adapting, they simply added language to their experiential system. The two systems are assumed to operate in parallel and are bi-directionally interactive. The validity of these assumptions is supported by extensive research. Of particular relevance for psychotherapy, the experiential system, which is compatible with evolutionary theory, replaces the Freudian maladaptive unconscious system that is indefensible from an evolutionary perspective, as sub-human animals would then have only a single system that is maladaptive. The aim of psychotherapy is to produce constructive changes in the experiential system. Changes in the rational system are useful only to the extent that they contribute to constructive changes in the experiential system.
Keywords experiential system; rational system; dual process; adaptive system; maladaptive system
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A basic assumption in cognitive-experiential theory (CET) is that people operate with two systems, an experiential system and a rational system (Epstein, 2014). The experiential system is primarily non-verbal and imagistic and learns automatically from experience, normally doing so outside of awareness. The rational system is a uniquely human verbal reasoning system. Both systems are adaptive, though in different ways, and each has limitations. This article describes the conceptual foundation of CET, presents supporting research, and addresses its clinical implications.
A Cognitive-Experiential Theory of Human Functioning To understand the experiential system, it is useful to divide it into process and content. Process consists of operating principles, while content consists of what has been
Correspondence concerning this article should be addressed to Seymour Epstein, 37 Bay Road, Amherst, MA 01002. [email protected]. Seymour Epstein is now retired.
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automatically learned. Particularly important content includes implicit needs and beliefs automatically learned from experience. Such implicit needs and beliefs influence almost all aspects of functioning, including the interpretation of events, automatic thoughts, feelings, conscious thinking, and behavioral tendencies. Experiential System—Process
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There are three important ways humans and other higher-order animals automatically learn from experience: classical conditioning, instrumental/operant conditioning, and observational learning (i.e., modeling; Epstein, 2014). The different learning methods comprise a single system because they all serve a common purpose. That is, regardless of how we learn, if we feel good or bad, it reinforces an implicit need and/or belief. This is fundamentally different from classic learning theory that narrowly links reinforcement to modifying observable behaviors. This key difference gives CET tremendous flexibility and integrative power by providing the content for the construction of an implicit theory of reality, which directs the interpretation of events, behavioral response tendencies, and implicit thoughts and feelings. Experiential System—Content Depending on the fulfillment or frustration of an implicit need, a person will have a related implicit belief (Epstein, 2014). For example, if the need for interpersonal relatedness is fulfilled, a person will tend to view the self as love-worthy and others as caring. Alternatively, if the need for relatedness is consistently frustrated, the person will tend to have the implicit belief that the self is unlovable and others are rejecting. Such implicit beliefs, coming from the interpretation of life events, may or may not coincide with a person’s explicit beliefs.
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Discrepancies between the two kinds of beliefs can cause maladjustment. For example, assume that John has worked hard all his life, as he believed that becoming famous and wealthy would make him happy. However, instead of being happy when he achieved his goal, he felt sad. An explicit need may have been fulfilled, but not an implicit need, such as the need to be loved.
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A common fallacy is to equate implicit cognition with unconscious processing. Implicit cognitions are not equivalent to unconscious beliefs for two reasons. First, if an unconscious belief is made conscious it continues to operate as an implicit cognition that follows the same principles as before. Second, the Freudian view of the unconscious considers the unconscious as operating by “primary process thinking” (e.g., wish-fulfillment, displacement, condensation, over determination, association), whereas the experiential system has been empirically shown to operate by associative-learning principles (Epstein, 2014).
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Research Underpinnings of Experiential Knowing Operating Principles of the Experiential System
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The first author and his associates have conducted extensive research on the operating principles and attributes of the experiential system (Epstein, 2014). Among other procedures, we adapted procedures used by Tversky and Kahneman (1982) and other cognitive and social-cognitive psychologists to study heuristic information processing by using specially constructed vignettes. Most research on heuristics has failed to distinguish between two kinds of heuristic processing. Thus, some researchers interpret all their results on heuristics as indicative of only a single system that includes deliberative processing. Alternatively, others attribute all their results on heuristics to two separate systems, only one of which includes deliberate processing. This latter approach has been criticized by noting that the results supporting a different kind of information processing from deliberative processing could just as well be attributed to cognitive shortcuts in a single processing system (Kruglansky, Thompson, & Spiegel, 1999). Ways of establishing that a different system of processing exists in addition to deliberate processing are to demonstrate that they operate by different principles and attributes and may even conflict with each other. This approach was used in our research, and our results clearly support the existence of twosystems. Irrational reactions to unfortunate arbitrary outcomes—People often react to arbitrary outcomes as if they or others are responsible for the outcomes. Thus, they reward the proverbial bearer of good tidings and punish the conveyer of bad news. Such irrational reactions are readily explained by the associative-learning principle of the experiential system.
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We investigated people’s reactions to arbitrary unfavorable outcomes by asking how they would behave in situations described in several vignettes, how most people would behave, how the protagonist in the vignettes would behave, and how a completely logical person would behave (e.g., Epstein, Lipson, Holstein, & Huh, 1992). In one vignette that investigated the effect of near versus far misses, a woman missed her flight due to a lengthy, unforeseen traffic jam. In one group, a woman missed her flight by a small margin; for another group, she missed her flight by a much wider margin. Who felt more foolish about having dawdled at home? Tversky and Kahneman (1982) found that their participants reported that the protagonist who barely missed her flight was more upset, a finding we replicated. We also found that most participants reported that a logical person would feel much less foolish than they expected the protagonist to feel. The significance of the consequences of missing the flight also influenced the protagonists’ behavior. When the outcomes were very unfavorable, the protagonists were said to feel more foolish for having dawdled than when the outcomes were less unfavorable. The full results of this study support the following hypotheses based on the CET model: •
People are aware of two different modes of thinking, one that determines mainly how people normally behave, which, according to CET, is with their experiential system and the other that determines how a logical
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person would behave, which, according to CET, is primarily by their rational system. •
The more people are emotionally engaged in a situation the more they tend to think and behave according to their experiential system.
•
Most people’s ratings for themselves were between those of “a logical person” and their ratings of “most people’s” behavior, suggesting that most behavior is based on a compromise between the two systems.
•
The experiential system can co-opt the rational system, indicating an important source of irrationality in humans, despite their capacity for rational thinking.
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The ratio-bias phenomenon—The ratio-bias (RB) phenomenon is of particular interest for dual-process theories, as it pits experiential against rational processing in a situation in which the two modes of processing are equally accessible and in which both require negligible cognitive effort (Kirkpatrick & Epstein, 1992). Imagine if every time you blindly draw a red jellybean from a bowl containing red and white jellybeans that you win two dollars. You can choose between two bowls that both offer a 10% probability of obtaining a red jellybean. One bowl contains 1 red and 9 white jellybeans. The other contains 10 red and 90 white jellybeans. When people are asked how much they would pay to draw from the bowl of their choice, almost all said they had no preference and would not pay a cent. Yet, when they are placed in a situation in which they can actually win a significant amount of money over trials, most people parted with small sums of money to draw from the bowl with more red jellybeans (Kirkpatrick & Epstein, 1992). The preference for the bowl with more red jellybeans, despite it having no probability advantage, is referred to as the RB phenomenon and can be attributed to the experiential system. Even more impressive are the results when a bowl with more red jellybeans offers a lower probability of obtaining one. In one study, a probability-advantaged bowl always contained 1 in 10 red jellybeans, and a frequency-advantaged bowl contained 5–9 red jellybeans out of 100 jellybeans (Denes-Raj & Epstein, 1994). Most participants preferred the slightly frequency-advantaged (e.g., 9/100 versus 1/10) bowl despite its probability disadvantage. Some participants said they knew such behavior was irrational, but that they had a “feeling” that they had a better chance of getting a red jellybean when there were more of them. Additional RB studies are summarized elsewhere (Epstein, 2014), and the conclusions from these RB studies are below:
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•
People operate with two independent systems, experiential and rational.
•
The RB effect in low-probability conditions can be attributed to a “frequency effect.” This is consistent with the concrete operation of the experiential system and that single numbers are more concrete than percentages (based on the relationship between two numbers).
•
Either system can dominate depending on the situation and the person. Although most participants make compromises between the two systems
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by making non-optimal, slightly frequency-advantaged responses, many consistently make optimal, probability-advantaged responses.
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•
The two systems sometimes conflict with each other. Some participants reported feeling torn between frequency-advantaged and probabilityadvantaged choices. Clinically, we know that patients may indicate that they know “intellectually” something bad will not happen, but nonetheless believe it “emotionally,” which often determines their behavior.
•
The experiential system is more responsive than the rational system to real situations and to vividly imagined situations, whereas the rational system is more responsive to verbal information.
•
With increasing maturation from childhood to adulthood, the rational system gains increasing dominance. The dominance of the experiential system is clearly manifested when conducting therapy with adolescents before they have developed a more realistic way of viewing the world.
•
Priming the rational system in children before they have formal knowledge of ratios by asking them to give the reasons for their responses interferes with their experiential thinking. This indicates that processing in the rational system can interfere with processing in the experiential system.
•
An increase in incentive produces an increase in optimal, rational responses in some participants, but an increase in experiential processing, non-optimal responses in an approximately equal number of participants. This suggests that these two systems are always operational and the interaction between them depends on both the person’s predisposition (e.g., tendencies to process rationally vs. experientially) and the situation (e.g., importance, emotional involvement, etc.).
The global-evaluation heuristic—The global-evaluation heuristic refers to the tendency for people to evaluate others as generally being either good or bad people, rather than restricting their evaluations to specific behaviors (Epstein, 2014). As the experiential system operates holistically, it follows that global evaluation is attributable to the experiential system, and therefore, will be automatic, compelling, and not easily overcome. This heuristic is particularly important because of its prevalence in causing serious problems, as in stereotyping others and in misattributing the motives and emotions of others.
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The first author and his associates investigated the global-evaluation heuristic (Epstein, 1994) by having participants respond to a vignette adapted from a study by Miller and Gunasegaram (1990). In the vignette, a rich benefactor tells three friends that if each throws a coin that comes up heads, all three will be given $100. The first two throw a heads, but Smith, the third, throws a tails. Most participants reported that Smith would feel guilty and the others would be angry at him. In an alternative version in which we reduced the stakes to a more modest sum, the ratings of guilt and anger were reduced. When asked if the other two would be willing to invite Smith on a gambling vacation in Las Vegas, where they would share wins and losses, most participants said that now they would not invite him,
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“because he’s a loser.” These responses were made both from the perspective of how the participants reported they would react and how they reported most people would react. When responding from the perspective of how a completely logical person would behave, most said a logical person would recognize that the outcome of the coin tosses was completely arbitrary, that they would not resent Smith, and that they would invite him on their gambling venture. This study indicates that people are intuitively aware of two systems of information processing that operate in a manner consistent with the operating principles and attributes of the experiential and rational systems.
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Conjunction problems—The “Linda conjunction problem” is probably the most researched vignette in the history of psychology (Epstein, 2014). It has evoked great interest because of its paradoxical results. Although the solution to the Linda problem requires the application of one of the simplest rules of probability, almost everyone, including individuals who are sophisticated about statistics, use their intuition rather than logic when responding to it. In the vignette, Linda is described as 31 years old, single, outspoken, and very bright. In college she was a philosophy major who participated in anti-nuclear demonstrations and was concerned about social justice. In our research, we asked participants to rank-order the following alternatives: Linda is a feminist, Linda is a bank teller, and Linda is a feminist and a bank teller. Most ranked Linda as being a feminist and a bank teller ahead of Linda just being a bank teller. In doing so, they made what Tversky and Kahneman (1982) labeled a “conjunction error (CE),” because, according to probability theory, the occurrence of two events cannot be more likely than the occurrence of only one of them.
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The usual explanation of the high rate of conjunction errors (CEs) elicited by the Linda problem is that people either do not know the conjunction rule or they do not think of it in the context of the Linda vignette. According to Tversky and Kahneman (1982), they make such errors because they respond by the representativeness heuristic in making judgments, according to which being both a bank teller and a feminist is more representative or likely of Linda’s personality than being just a bank teller. In several studies on conjunction problems, including several on the Linda problem (Donovan & Epstein, 1997; Epstein, Denes-Raj, & Pacini, 1995; Epstein, Donovan, & Denes-Raj, 1999), we demonstrated that the major reason for the difficulty of the Linda problem is that it provides a very unusual way of presenting a conjunction problem. Consequently, people tend not to view the Linda problem as a probability problem, even when told to do so.
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The difficulty of the Linda problem cannot, however, be fully explained by the misleading manner in which it is presented in the form a personality problem, for even with full disclosure about the nature of the problem and the request to treat it as a probability problem, most participants make CEs. However, when responding to a conceptually equivalent problem presented in a concrete, natural manner, as in a problem in judging the likelihood of winning one or two lotteries or one or two horse races, almost no one makes a CE (Epstein, Denes-Raj, & Pacini, 1995).
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Making CEs in the Linda problem is so compelling that when presented with the correct conjunction rule (i.e., “two events are less likely to occur than just one of them”) among several incorrect rules, most selected a wrong rule that was consistent with making a CE. In other words, they made the rule correspond to their incorrect response, rather than using the correct rule and then applying it appropriately to the Linda problem. This demonstrates the highly compelling nature of experiential processing and its ability to co-opt rational processing. Priming intuitive knowledge by presenting easy-to-solve, natural conjunction problems followed by unnatural ones, like the Linda problem, facilitates solving unnatural problems that people are otherwise unable to solve. Conclusions from the Linda studies are summarized below:
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The difficulty of the Linda problem can be explained by the operating rules and attributes of the experiential system, which is the mode employed by most people when responding to it. Thus, people automatically tend to process information associatively, concretely, holistically and in a narrative way, rather than abstractly, analytically, and rationally when responding to the Linda problem.
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Processing in the experiential mode is intrinsically highly compelling and can over-ride processing in the rational mode even when the latter does not require more effort or resources. Thus, many participants, despite knowing and thinking of the conjunction rule, simply find an experiential response more compelling than a rational response.
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The experiential system can contain learning that is not understood and cannot be articulated by the rational system.
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The rational system, especially when it is evoked initially, can influence the experiential system.
Interactions Between Systems and Among Needs
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Interactions between the two processing systems—An important research finding is that the experiential and rational systems are both simultaneously and sequentially interactive. Simultaneous interaction was demonstrated in the compromises between the two systems in the ratio-bias studies described earlier. Sequential interaction was demonstrated in research that shows that processing in the experiential mode can compromise subsequent processing in the rational mode (Chaiken & Maheswaren, 1994; Denes-Raj, Epstein, & Cole, 1995; Epstein, Lipson, Holstein, & Huh, 1992). There is also considerable evidence that priming the experiential system subliminally can influence subsequent responses in the rational system (Bargh, 1989). Research on conjunction problems in which presenting problems first in a natural way that taps the experiential system made participants more likely to successfully solve abstract, out-of-context problems presented subsequently suggests that experiential processing may sometimes also improve rational processing.
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Interactions among basic needs—A basic assumption in CET is that behavior often represents a compromise among basic needs. This process is considered to be particularly important, as it provides checks and balances against the excessive investment in the fulfillment of a particular need. It occurs because greatly fulfilling any need (e.g., the need for relationship) at the expense of fulfilling other needs (e.g., the need for autonomy) increases the strengths of the other needs. To test this assumption about interactions among needs we examined the combined influence of the needs for self-enhancement and selfverification. Swann and his associates previously demonstrated that the needs for enhancement and verification often operate sequentially, with the former preceding the latter (e.g., Hixon & Swann, 1993; Swann, 1990). We demonstrated that the interaction also occurs simultaneously in the form of compromises between needs. Our procedure consisted of varying the favorableness of evaluative feedback and observing whether participants had a preference for feedback that either matched or was more favorable than their selfassessments (Epstein & Morling, 1995; Morling & Epstein, 1997). In support of this hypothesis, participants preferred feedback that was only slightly more favorable than their self-assessments, consistent with a compromise between fulfilling the needs for verification and self-enhancement. Individual Differences in Experiential and Rational Information Processing
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Individual differences in the experiential system—There are excellent intelligence tests that measure the intelligence of the rational system. Such tests are fairly good predictors of academic performance and, to a somewhat lesser extent, of performance in the real world, including workplace performance, particularly in situations that require complex operations (see Gordon, 1997; Gottfredson, 1997; Hunter, 1983). However, as there was no test that measured experiential intelligence we constructed one, which we named the Constructive Thinking Inventory (CTI; Epstein, 2001).
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People respond to the CTI by reporting the degree to which they have certain adaptive and maladaptive automatic or spontaneous thoughts or feelings. An example of an item is, “I tend to dwell more on pleasant than unpleasant incidents from the past.” The CTI provides a Global Constructive Thinking scale and six main scales, all but one of which have subscales. The six main scales are Emotional Coping, Behavioral Coping, Categorical Thinking, Esoteric Thinking, Naïve Optimism, and Personal Superstitious Thinking, and are predictive of a wide variety of criteria related to success in living. A review of the extensive literature supporting the CTI’s validity is available in the CTI manual (Epstein, 2001). Experiential intelligence has been found to be directly related to a wide range of successful performance, including performance in the work-place, superior achievement by managers, superior academic performance, social competence, leadership ability, ability to cope with stress, emotional adjustment, physical wellbeing, and an absence of drug and alcohol abuse. It was found in several studies that scores on the Global CTI scale were either unrelated or negligibly related to IQ (see review in Epstein, 2001), supporting the view that the experiential and rational systems process information differently. Of particular interest, constructive thinking and intellectual intelligence exhibit a nearly opposite course of development across the life span. Constructive thinking is at its nadir in adolescence when
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intellectual intelligence is near its peak and then gradually increases throughout most of the adult years when IQ is gradually declining. Constructive thinking is less strongly related to academic achievement than intellectual intelligence. Nevertheless, it contributes significant variance beyond that of intellectual intelligence to performance in the classroom, as indicated by grades received and by class rank (Epstein, 2001). Apparently, good constructive thinkers are able to behave in ways that gain them recognition for and appreciation of their intellectual ability, whereas poor constructive thinkers are less able to do so. A finding of particular importance is that there is a general factor of experiential intelligence that is measured by the CTI. As this factor includes a wide variety of favorable nonintellective abilities and attributes, it is suggestive of a general factor of nonintellective ability comparable to the general factor of intellectual ability.
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A measure of individual differences in rational and experiential thinking styles —The Rational-Experiential Inventory (REI) was constructed to measure individual differences in the extent to which people process information according to the two processing modes (Epstein, 2001). The REI includes two main scales that measure the extent of processing information in rational and in experiential thinking styles. Each of the main scales has subscales of the degree to which one uses a particular processing mode and one’s self-assessed ability to use it effectively. In studies with the REI (Epstein, 2001; Epstein, Pacini, Denes-Raj, & Heier, 1996; Norris & Epstein, 2011; Pacini & Epstein, 1999b; Pacini, Muir, & Epstein, 1998), a rational thinking style was more strongly positively associated than an experiential thinking style with intellectual performance, as well as with low anxiety, low depression, low stress, low neuroticism, high self-esteem and high meaningfulness of life. An experiential thinking style was more strongly associated than a rational thinking style with measures of creativity, empathy, aesthetic judgment, intuitive ability, and establishing satisfactory interpersonal relationships. It follows that no statement can be made about the general superiority of either thinking style, as each is superior in some important ways and inferior in other important ways.
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Individual differences in basic beliefs about the self, others, and the impersonal world—The content of beliefs in the experiential system is of particular importance for clinical practice. People’s implicit beliefs about themselves, others, and the impersonal world are acquired automatically from emotionally significant experiences, mostly in childhood. Such beliefs are important determinants of feelings, behavior, adjustment, and overall quality of life. Based on this consideration, the Basic Beliefs Inventory (BBI; Catlin & Epstein, 1992) was constructed. The BBI is a self-report questionnaire that includes a global measure of the overall favorability of basic beliefs. It also includes scales for measuring the favorability of more specific beliefs: self-esteem, love-worthiness, competence, meaningfulness of life, views about relationships, and views about the world. A study with the BBI (Catlin & Epstein, 1992) tested the hypotheses that two important sources of basic beliefs are extreme life-events, as in the loss of a loved one or experiencing a transforming love relationship, and relationships with parents during early childhood. In J Psychother Integr. Author manuscript; available in PMC 2017 June 01.
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support of the hypothesis, both kinds of experiences were related to individual differences in basic beliefs. People who reported favorable relationships with their parents and those who obtained high scores on overall favorableness of extreme life-events based on both positive and negative events obtained higher scores than others on the BBI scales of self-esteem, meaningfulness of life, favorable views of others, and an optimistic view about the world. Those who reported unfavorable relationships with their parents or who reported predominantly unfavorable extreme life-events, such as the death of a beloved pet or a significant failure in an important event obtained less favorable scores than others on all basic beliefs.
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It was also found that the more recently an extreme negative event occurred, the less favorable a person’s current basic beliefs. Over time, the effect of extremely unfavorable life events became less unfavorable and sometimes even favorable. Several participants reported that they ultimately gained strength from having had to cope with adversity (Epstein, 1979).
A General Cognitive-Experiential Framework for Psychotherapy Cognitive Experiential Psychotherapy’s (CEP) major contribution to psychotherapy is that it provides an integrative framework for all forms of psychotherapy. CEP is based on the following: The automatic, experiential learning in the form of implicit needs and beliefs is of particular importance and much more so than the learning of behavioral responses.
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According to CEP, psychopathology is the result of implicit needs and beliefs that, regardless of how they were acquired, are currently maladaptive. Identifying maladaptive implicit needs and beliefs is important because it reveals the problems that have to be resolved. However, this is more easily said than done. Since a need or belief may be implicit, the client will be unaware of it and, therefore, unable to report it. Alternatively, the client may have no awareness of the maladaptive implicit need or belief, because he or she has repressed it (i.e., has an automatic avoidance reaction to it). Lastly, one may be aware of the maladaptive need or belief and be able to articulate it, but avoid discussing it because it is too upsetting to do so. A number of procedures can be used to uncover implicit maladaptive needs and beliefs. One procedure for identifying such needs and beliefs is to look for maladaptive repetitive behavior patterns in the real world or in the psychotherapy sessions. Another is to attend to automatic thoughts. Still another is to infer from negative emotions the implicit beliefs that are their likely source.
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Intellectual insight is important, as it provides a road map to what important changes in the experiential system need to be corrected, but insight alone is insufficient.
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Successful therapy requires changes in the experiential system. Therapists can use the considerable information that is available about automatic,
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associative learning to bring about these changes in the experiential system. In most cases, therapy based on CEP begins with instructions on the rudiments of the two systems, and that the source of an emotion is an underlying implicit or explicit cognition. Remediation has two components, diagnosis and treatment. The diagnostic phase requires identification of the dysphoric emotion that is experienced (e.g., fear, anger, sadness, jealousy, envy), the underlying belief or cognition, and the unmet need that is the root cause. For example, anger (the dysphoric emotion) may result from a heightened sensitivity to believing that one has been unjustly treated, which may stem from an unfulfilled need for unconditional love, likely stemming from one’s treatment as a child.
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The treatment phase consists of fulfilling the frustrated need in a constructive way. An important starting point is to establish a therapeutic relationship, so the client genuinely experiences being treated with unconditional positive regard. It is also helpful for the client to learn to identify and reframe maladaptive thinking in a constructive manner. The first author taught a college class in constructive thinking that helped students become skilled at doing this. Students were asked to keep a journal in which they recorded the most negative experience of each day for 30 days. In addition to recording the relevant situation (e.g., a bad grade, a distressing conversation with a parent, a romantic breakup) students were asked to note their accompanying emotions (e.g., anger, frustration, sadness). Most importantly, they were required to explore what implicit or explicit thought produced the emotion and to consider alternative ways of thinking about the same situation that would lead to more constructive feelings and actions. Class time was used to discuss what students had written and learned about themselves, as well as for other students to offer additional constructive ways of reframing their thinking. Anecdotally, most students reported that this was a growth experience, as they had not previously understood how thoughts influence feelings and that the way people frame a situation can affect their well-being.
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This process can also be used in a therapeutic setting, with journal-keeping and discussion. Writing or typing out entries in full is preferred because it is more deliberate (than say talking, texting, dictating, and/or using emoji shorthand) and allows one to re-experience the situation and allows more time to attend to accompanying thoughts and emotions. The main difference between the class and the therapeutic setting is the presence of other students to offer reframing options. In therapy, reframing options can be explored by discussion between the client and therapist. Of course, prompting clients to come up with constructive reframing options on their own is preferable. Yet, if clients struggle to accomplish this, the therapist can offer possibilities. As clients replace their maladaptive thoughts with more constructive ones, it is important for them to attend to the different feelings that result. As one does this repeatedly, the positive feelings that result from having more constructive thoughts should be self-reinforcing and will therefore become increasingly automatic. There may be times when clients are unable to discern any thoughts that accompany their emotions. In such cases, a therapist can work with clients to infer their implicit thoughts from their emotions. For example, sadness is likely to be the result of feeling one has
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suffered a significant, irreplaceable loss. Likewise, anger often follows an implicit thought that one has been treated badly and unfairly. It is also helpful to provide and encourage other constructive experiences (either in real life, in therapy, or in fantasy) and to encourage clients to apply their new way of thinking constructively to these experiences. The final step is to discuss with the client adaptive procedures for coping with the situation after therapy. Specifically, there should be an emphasis on the importance of establishing positive relationships and avoiding toxic ones. If the client returns too soon to the same environment that created and reinforced feelings of being unlovable, it may produce a relapse from the improvement that had taken place.
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Since CEP is integrative, there are several standard forms of psychotherapy that use treatment procedures that are relevant to CEP. The first author’s recent book (Epstein, 2014) discusses all of them from the perspective of CET. In the present article, because of space limitations, we will only discuss client-centered therapy and psychosynthesis. Client-Centered Therapy An important agreement between Rogers’ theory and CEP is that both assume that people’s beliefs are the most important sources of their behavior and feelings. The two theories also agree that discrepancies between beliefs acquired from direct experience (e.g., if a child is consistently rejected by their parents) and how that experience is labeled by significant others (e.g., the rejecting parents tell the child how much they love the child) are an important source of maladjustment.
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Both also assume that people have a basic need to maintain and enhance their conceptual systems. However, for Rogers this is the only basic need whereas for CEP there are six basic needs, two of which are super-ordinate (behaving according to the hedonic principle and controlling arousal within homeostatic limits) and four of which are subordinate (the needs for a stable, coherent conceptual system; security; relatedness; and self-esteem). In addition, client-centered therapy relies on only one procedure, reflecting clients’ statements with acceptance and positive regard. According to CEP, this procedure is insufficient, and it is preferable once a therapeutic relationship has been established to change from an initial reflective approach to an approach that is based on an equal relationship between therapist and client where the therapist feels free to make clarifications and interpretations, albeit in a warm, accepting and tentative manner. It should be noted that, according to CEP, an important reason for the effectiveness of client-centered therapy may be the experience of a warm and accepting relationship with a person who likes and respects the client apart from the particular technique that is used. Psychosynthesis and The Use of Fantasy If the aim of therapy is to produce changes in the experiential system, the use of fantasy can help to do this for several reasons. First, people react to vividly imagined situations in a similar way to how they react to real situations (Crisp, & Turner, 2009; Dadds, Bovbjerg, Redd, & Cutmore, 1997; Epstein, Pacini, & Epstein, 2001; Kosslyn, Ganis, & Thompson,
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2001; Taylor, Pham, Rivkin, & Amor, 1998). Second, the same principles of learning theory can be applied to representations in fantasy as to representations in reality. Third, one can try out things in fantasy that would be impractical or too risky (emotionally and/or physically) to do in reality. Fourth—and perhaps most important—in fantasy, one can create and implement powerful metaphors laden with symbolism that can reach deeply into the experiential system, triggering change.
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Psychosynthesis relies heavily on fantasy in therapy. What follows is an in-depth look at a single case of the use of fantasy in psychosynthesis, that of Alice Epstein—the first author’s wife—and her use of fantasy in her successful battle against terminal cancer (A. Epstein, 1989). When traditional medical treatments offered little hope, Alice was given three months to live. She decided to explore alternative approaches to fight her cancer or at least to improve the quality of her life in her remaining months. One of the approaches was psychotherapy. Alice chose a therapist who used a psychosynthesis approach and, unlike other therapists we interviewed, said she would help Alice work on becoming the person she wanted to be with whatever time was left to her. That was exactly what Alice wanted to hear.
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The psychosynthesis approach relies heavily on the use of imagery and fantasy. One of the psychosynthesis tools Alice found most helpful was the creation of subpersonalities. A subpersonality is a personified aspect of oneself. One vividly imagines this subpersonality as a person, giving it a name and personality. It can be aggressive, strong, empathic, helpful, or anything else one can think of. One of the tools of psychosynthesis is to ask each subpersonality what it really needs and wants. At some point, when the subpersonality is ready, each subpersonality is taken “up the mountain.” Going “up the mountain” is a metaphor for moving to a higher state of perception and understanding. By going “up the mountain” the subpersonality is often transformed, happier and more accepting of and cooperative with the other subpersonalities. The final aim of psychosynthesis is to create an integrated and constructive overall personality. Alice embraced identifying and exploring her subpersonalities with great interest and enthusiasm. Her first subpersonality was “Baby Alice.” Baby Alice is about 2 1/2 years old and sits in a corner and cries. She knows that her mother is always right. Her main wish is to have a perfect mother, and this subpersonality will make significant compromises to believe in her mother’s perfection. Baby Alice even lies to her father to cover up her mother’s failings. Baby Alice says she wants a perfect mother. What she really wants at the experiential level is unconditional love. Out of the five major subpersonalities, Baby Alice was the one who developed the most until she became a highly competent and mature adult who was the leader of the subpersonalities and helped them finally become a unified whole.
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Alice quickly moved on to creating other subpersonalities. Hope and hopelessness were very important to her. She envisioned a crab running aimlessly on the beach holding its front legs up in the air in a helpless manner. He belonged to a gray haired lady who spoke sweetly to him and always called him “dear.” His need is to be free, but she tells him that’s impossible because she needs him to cut the threads on a tapestry she is making. When he asks her what he can hope for, she laughs and says he can hope to be the flying horse in the tapestry.
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The crab was the first one Alice took “up the mountain.” He got excited when he reached a ledge at the top of the mountain and he jumped off. Alice expected to see his mangled remains at the bottom of the hill. Instead there was a beautiful Baltimore oriole that sang so sweetly that she knew he was happy. He perched on her shoulder, and he continued to do so on all further trips up the mountain. The next subpersonality was Amanda, who was very strong and competent. Alice kept chanting to herself when she felt depressed or helpless, “I am Amanda. I am strong. Kill the cancer. Kill the cancer. Kill the cancer. I am Amanda. I am strong.”
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“Little One” was the next subpersonality. She is very angry and aggressive. She throws her head back and laughs a lot. She is nasty, aggressive, devious and joyously happy about her evil thoughts and deeds. She hates Baby Alice and thinks she is stupid and deserving of contempt. Alice found Little One very interesting and liked her. When Little One was taken “up the mountain,” she became Bagera, a beautiful tiger who uses her power only when justified. She likes Baby Alice and lets her ride on her back. Mickey is the most complicated subpersonality. She hates and wants to kill Baby Alice. Mickey is a very jealous little girl. She wants to be admired by her playmates, but no one likes her because she takes away their things. And she is critical of everyone. In the valley below the mountain, she keeps saying that the flowers at home are more beautiful than the wild flowers. All the other subpersonalities taken “up the mountain” had highly positive transformations. In contrast, Mickey became “Chicken Little,” who considered her life to be a sham and, if she were found out “the sky would fall.” Alice indicated that Mickey was the ghost in her closet, a dark part of her that she hid while presenting an opposite picture of herself to the world.
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Alice decided to take Mickey “up the mountain” again, but while still in the meadow she became a giant chicken who came running after Alice as if she wanted to kill her. Alice realized this was the part of her that wanted her dead. She did not know what to do or say, so she said, “I forgive you.” With that, the giant chicken turned into a huge vampire bat that came straight at Alice. Alice wrestled her down and stabbed her to death. How does one explain the dire consequence of providing forgiveness in this fantasy? Forgiveness implies that someone has done something wrong and, as the chicken sees it, the chicken is not at fault. Instead, Alice is at fault because of her false personality and the things she is hiding. It is Alice who is not only at fault; it is Alice who does not even deserve to live.
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The next day in therapy when Alice told her therapist about this fantasy, her therapist got upset and told her never to kill anything again. The therapist was sympathetic to Mickey and asked Alice to try to love her. Alice responded by saying, “How can I love someone who is trying to kill me? Right now I hate her.” Sometime later, Alice told Mickey she had to go. A clear and powerful image suddenly came to mind. She saw Mickey standing at a train station carrying a small suitcase. She was all alone and Alice was walking away telling her she could not come. Mickey sobbed and
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sobbed, begging to come with Alice. It broke Alice’s heart to see her that way. Suddenly Alice realized that it was Mickey who was in fear of her life. Alice realized that Mickey contained all her passion and she could not live without her. Alice once more took Mickey and all the other sub-personalities “up the mountain.” Amanda changed into a flying horse and invited all of them to ride on her back. They had a wonderful time with Amanda catching the wind and soaring into space. Alice now loved all her subpersonalities and they were beginning to cooperate with each other.
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The main source of Alice’s maladjustment warrants discussion. She believed, implicitly and explicitly, that unless you sacrifice fulfilling your own needs for fulfilling other people’s needs, no one would like you. Consequently, Alice consistently subjugated her own needs. This left her prone to feelings of rage and to anti-social behavioral tendencies, which she needed to suppress constantly. Moreover, the conflict between wanting her own needs fulfilled but feeling she had to sacrifice her own needs in order to be liked and loved pitted parts of her personality against one another, resulting in an overall lack of integration. The use of fantasy effectively addressed all these conflicts. Alice’s self-sacrificing attitude was overcome by the transformations that occurred on her trips “up the mountain.” For example, Little One evolved into Bagera, a beautiful and powerful tiger, that asserts her own needs but only when appropriate. In addition, when the crab went “up the mountain,” it broke free of its controlling owner, leapt off the ledge, and was changed into a beautiful, joyous bird. This is likely a metaphor for Alice believing that if she “took a leap of faith” and “broke free” of subjugating her needs to those of others that she could have a rewarding life instead of having a life without freedom and love.
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Alice’s suppressed frustration and anger were addressed in two important ways. First, they were released by instilling in Mickey and Little One the ability to express hostility freely. Second, and more importantly, by showing Alice how to communicate her needs in a socially acceptable way, Bagera helped Alice become less angry and frustrated and to be more authentic, satisfied and fulfilled. Lastly, Alice’s unintegrated personality was improved by Baby Alice encouraging cooperation among the elevated forms of the subpersonalities at every opportunity. Alice’s image of Amanda as a flying horse and taking the other sub-personalities for a wonderful ride on her back was likely only possible when Alice’s fundamental unmet need was finally satisfied, allowing the sub-personalities to be at peace and work harmoniously with each other.
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Summary and Conclusions Cognitive-Experiential Therapy (CET) rests mainly on two basic assumptions: (1) in some fundamental respects, people are no different from other higher-order animals in that they share the same experiential system, and (2) humans did not give up their experiential systems when they developed language and a rational system. Thus, to understand people, it is necessary to recognize that most behavior is primarily automatically determined by their
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experiential system. The aim of therapy, therefore, should be to produce changes in the experiential system. Cognitive-Experiential Psychotherapy (CEP) draws attention to the importance of the rules that govern the operation of the experiential system (e.g., reinforcement, reward, punishment, extinction, spontaneous recovery). These are well known aspects of associative learning, such as having good or bad feelings after behaving in a certain manner serves to reinforce the behavior. That is, behavior followed by good feelings tends to be repeated, while behavior followed by bad feelings tends to be avoided. Because this normally occurs outside of awareness, it has obvious implications for psychotherapy. Namely, it indicates the importance of identifying the unmet need that is the root cause of the problem.
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To produce change, it is insufficient to simply provide intellectual knowledge; one must reach a person’s experiential system. To do so, it is necessary to communicate with it via the “language” it understands, namely the language of associative learning (e.g., of having new experiences with positive outcomes). This can be done by providing corrective experiences and by continuously practicing replacement of the maladaptive implicit thinking with more constructive implicit thinking. Specifically, one has to provide corrective experiences in everyday life, in fantasy, and in therapy sessions. Relapse can be avoided by correcting the root cause of the maladaptive, automatic thinking with repeated corrective experiences coupled with constructive ways of viewing the experiences and by discussing coping with the environment to which the client expects to return.
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This research was supported by National Institute of Mental Health (NIMH) Research grant MH 01293 and NIMH Research Scientist Award 5 K05 MH00363 to Seymour Epstein.
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