The Dodo in the jigsaw puzzle

Psychology has an uncomfortable relationship with psychoanalysis and the unconscious. During the first half of the 20th century, psychologists supported a behavioural theory of mental illness and competed with psychiatrists who supported a psychoanalytic theory. Yet throughout my career, the unconscious has stubbornly refused to remain submerged…

I have been part of the cognitive paradigm for most of my academic life. When I was an undergraduate in the late 1960s, the 'cognitive revolution' was well under way. We were taught that behaviour was caused by attitudes and beliefs, both of which were conscious and therefore measurable by questionnaires. I have spent most of my academic career as a health psychologist conducting research that is predicated on an assumption that people have insight into their own minds and behaviour is caused by cognitions. 

I did not start my career as a health psychologist, however. For the first 15 years of my career I would have described myself as a theoretical psychologist. I wrote a theoretical PhD in 1976, the title of my first book was An introduction to theoretical psychology and I published several theoretical papers including those on control theory, evolutionary theory and mind body theory (Hyland, 1985, 1987, 1988, 1993).

But theoretical research is time consuming. You sit around thinking about things, and you may not come up with anything interesting to say. By the mid 1990s I had discovered a rewarding career as a health psychologist, by chance. I was given the opportunity to develop the first quality of life scale in asthma (Hyland, 1991), and, although I did not appreciate it at the time, I became the first psychologist in the UK to specialise in respiratory disease. Psychology plays an important role in respiratory disease because patient behaviour has such an important role in outcome, including life or death. Being the first in anything gives advantages and I was soon busy working on this new and stimulating research area. I taught health psychology and became one of the first BPS chartered psychologists in health.

I let my membership of the International Society for Theoretical Psychology lapse; a society I had helped found in 1985. But as I kept half an eye on new theoretical ideas in psychology, I noticed that despite the dominance of a rational, conscious, psychological theory, the idea of the unconscious kept resurfacing in psychology, but often with different terminology…  

The unconscious and mental health

In social psychology the terms 'implicit beliefs' and 'implicit attitudes' are used rather than 'unconscious beliefs' or 'unconscious attitudes'. Implicit beliefs explain unconscious bias people have towards particular groups of people. In cognitive psychology, Daniel Kahneman and others make a distinction between System 1 thinking as fast and 'automatic', unavailable to conscious introspection, 'unconscious', and System 2 thinking which is slow and deliberative and therefore available to consciousness. Implicit beliefs and System 1 thinking are just two of several examples where the unconscious, by another name, is still alive and well in psychological theory. 

The one place that the unconscious has not intruded is in mental health. Psychology's old competitor, psychoanalytic theory and its idea of the unconscious, has no place in the modern, rational CBT theory of mental illness.

Behaviourists rejected any form of mental content as having explanatory value, and therefore rejected not only the unconscious but also conscious thought in their explanatory models. Conscious content was reintroduced into psychology first by humanistic psychologists in the 1940s and then later by cognitive psychologists in the 1960 and 1970s. The cognitive revolution coincided with the development of computers, which held a fascination for psychologists. Computers are rational. If humans are like computers, their problems could be dealt with through appeals to rationality. If depression and other mental disorders are caused by erroneous cognitions, a kind of information processing error, they can be corrected by providing the client with information that the erroneous cognitions are in fact wrong. By the mid 1970s, this theory – Aaron Beck's cognitive theory of depression – really took off. Nowadays the term CBT is used for almost any form of psychologically mediated therapy, though the underlying theory remains the same. 

All must have prizes

It is sometimes claimed that CBT is the type of therapy most supported by evidence. Indeed, there are more studies showing that CBT is effective than any other type of psychotherapy. What the data does not show – but is implied by the words 'most supported' – is that CBT is better than any other therapy. Evidence that all psychotherapies are equally effective first appeared in a 1936 paper by Rosenzweig and became known as the 'Dodo bird effect' after the subtitle of that paper, a quotation from Alice in Wonderland: 'At last the Dodo bird said everyone has won and all must have prizes.'

The Dodo bird effect has been confirmed numerous times since that publication. Writers have suggested that the effect is due to factors common to all psychotherapies, namely expectancy, therapeutic bond and a meaningful ritual, and not the specific factors suggested by the different psychotherapies.

Psychotherapy is effective but the question of why it is effective is controversial. Bruce Wampold published his book The great psychotherapy debate in 2002 and a follow up some 13 years later (Wampold & Imel, 2015). The meta-analysis of many different studies concludes that psychotherapy is effective because of the context of the therapeutic encounter – and hence the contextual model – rather than because of the mechanisms suggested by Aaron Beck or proponents of other types of psychotherapy. The meta-analysis also reveals a worrying finding for those training psychotherapists. The effectiveness of psychotherapy varies substantially between psychotherapists and is independent of gender, age, type of therapy or length of training.

Not surprisingly, the contextual model and its supporting data have been criticised. However, the Dodo bird effect is surprisingly robust and has been referred to as 'psychology's dirty little secret'. It is not the only dirty little secret when it comes to treating depression. Irving Kirsch was the first to show, confirmed by others, that the effectiveness of anti-depressant drugs is at least 80 per cent due to placebo (Kirsch & Sapirstein, 1999). Together, this evidence suggests that pharmaceutical and talking therapies are effective in treating depression due to contextual factors.

Beck never lived in Birmingham

I was impressed by Wampold's and Kirsch's findings and even did research on the placebo effect, showing that placebos could be more effective if the underlying philosophy of the ritual matched the motivation of the person (Hyland & Whalley, 2008). I was naturally sympathetic towards the contextual model, yet it has struggled to break CBT's dominance.

One reason for the lack of popularity of the contextual model is that it provides a less plausible story than the CBT story. The contextual model story starts from the assumption that depression and anxiety are caused by 'demoralisation' and that the context of therapy (relationship, hope and ritual) 'remoralises' people. The theory works fine for people who live in poor circumstances. The problem is that depression and anxiety also afflict people who, on objective criteria, have perfectly satisfactory lives.

By contrast the CBT model explains why people with perfectly satisfactory lives are depressed or anxious: they have erroneous cognitions. Indeed one of the criticisms of CBT is that it is a middle class theory designed for middle class people for whom their only problem is that their cognitions are incorrect. In a 2004 article, 'Beck never lived in Birmingham', Paul Moloney and Paul Kelly, clinical psychologists working in Birmingham, make the point that some people's circumstances are poor and their negative cognitions are a fair appraisal of the situation. As a health psychologist interviewing people about their quality of life, I understood their point entirely. There are many people whose circumstances are very challenging and a world away from the privileged life of undergraduates and university lecturers.

Both the CBT model and the contextual model therefore have limitations. The CBT theory works well but only for people living in objectively good circumstances but whose cognitions are wrong; the contextual model works well but only for people living only in poor circumstances who have become demoralised.

A jigsaw

When I retired in 2018, I had time to go back to my first love, theoretical psychology. I wondered if I could develop a theory that had the advantages of both the CBT and contextual model. Theory development is rather like solving a jigsaw puzzle when you don't know what the final picture is like. It is only when the different ideas are combined that the theory becomes clear. Learned helplessness and cognitive dissonance are both good theories. In retrospect, they both seem obvious, but they were not obvious before they were developed.

The reformulated contextual model is made from several jigsaw pieces, from theoretical ideas I came across throughout my career. These ideas include implicit beliefs and System 1 thinking, control theory, evolutionary theory, mind-body theory and machine learning or artificial intelligence. The reformulated model draws on ideas from psychoanalytic theory, humanistic theory, behavioural theory and cognitive theory.

The reformulated contextual model (Hyland, 2020) starts from the assumption that feelings of sadness and anxiety have evolved for a reason. Emotions are part of the body's communication system, designed to control behaviour, evolved because they are adaptive to human survival. Failure leads to sadness. Sadness and anxiety inhibit behaviour. They create avoidance. If you fail when trying to catch a mammoth, then attempting mammoth catching makes you sad and you are more likely to try to catch a horse.

Emotions are one of the body's many control systems and are largely automatic. When a Palaeolithic person saw a sabre-toothed tiger, they did not have to stop to think whether it was dangerous. The emotions of sadness and anxiety are the consequence of automatically formed (System 1) implicit beliefs rather than cognitions formed through System 2 thinking. Sadness is created from an implicit belief that a particular situation is unrewarding, state anxiety from the implicit belief that a particular situation is threatening. Clinical depression and trait anxiety are the consequence of a generalised and more severe form of those implicit beliefs. Depression is caused by an implicit belief that all situations are very unrewarding and trait anxiety that all situations are very threatening.

So far the reformulated contextual model is similar to the contextual model, with the small difference that demoralisation is caused by implicit beliefs. The theory works for people who constantly experience lack of reward and threat and therefore explains the association between stress and mental illness. The theory still lacks the ability to explain why people who have objectively good circumstances are depressed or anxious. In order to do that, the reformulated contextual model borrows the idea of a self-correcting control system from artificial intelligence (AI). Emotions are part of a control loop. Behaviour is controlled by anxiety and sadness. In an AI system, control loops can 'learn' so as to function better. The reformulated model proposes that implicit beliefs and their accompanying emotions increase when they fail to change behaviour. Put formally:

• If the implicit belief that a behaviour is unrewarding fails to inhibit that behaviour, then gradually over time the implicit belief of lack of reward increases so that all situations are perceived as unrewarding, leading to the emotion of depression.
• If the implicit belief that a behaviour is dangerous fails to inhibit that behaviour then over time all situations are perceived as dangerous, leading to the emotion of trait anxiety.

To put it informally, you become depressed or anxious if you keep doing things that make you sad or anxious. Although large adverse events still matter, it is behavioural persistence in the event of minor negative emotions that causes those minor emotions to potentiate and generalise and become the major pathological emotions of depression and anxiety. 

Circumstance plays a role in why people persist in behaviours that run counter to their automatically generated feelings: it is often to achieve some other goal or out of obligation to others. A person persists in an unrewarding job to make money to support a family. A child persists in attending threatening examinations in order to gain qualifications. People can feel trapped by their circumstances. But personality also predicts the tendency to suppress acting on one's feelings. Altruism and perfectionism are both associated with mental illness, as is the personality characteristic 'silencing the self' (Hyland, 2020). Positive personality attributes can get in the way of experiencing the world as rewarding, because implicit beliefs that the world is rewarding form only if the person's intrinsic and unique goals are satisfied, rather than extrinsic goals and the goals of others.

Matching context and person

According to the reformulated contextual model, therapy is effective because it changes implicit beliefs by providing the experience that the world is safe and rewarding. The experience of safety and reward is provided in many different ways, including the therapeutic bond, expectancy that health will improve, the experience of positive ritual, as well as specific techniques suggested by CBT and other psychotherapies. The reformulated contextual model makes no dividing line between specific and contextual mechanisms: they all help change implicit beliefs. 

Although all the different components of psychotherapy are consistent with the contextual model, the explanation for their effectiveness differs from other accepted explanations. The CBT explanation of mindfulness is that it reduces rumination of negative cognitions. The reformulated contextual model suggests that mindfulness is effective because it contributes to an implicit belief that world is safe. The reformulated contextual model draws on the idea from humanistic psychology that what is rewarding for one person may not be rewarding for another. For an implicit belief that the world is rewarding to form, the person has to satisfy their own unique goals. An intervention that is effective for one person may not be for another. Matching of context and person achieves the best results (Whalley & Hyland, 2009). The skilled psychotherapist adjusts each session to the unique needs of the client, rather than following a set script.

Like behavioural theory, the reformulated contextual model emphasises the importance of behaviour and the experience gained from behavioural choice. If a person is unhappy living at the top of tower block then the answer is not to change cognitions and learn to enjoy the view, but rather to find some way of leaving the tower block. However, cognitions remain important. Decisions about behavioural choices involves a rational, conscious, System 2 process. Leaving the tower block requires problem solving and may be far from easy. A solution that is helpful for one person may not be for another. Sometimes what a person needs is not psychotherapy but a good holiday. Rational, conscious cognitions remain important because they help people make life changing decisions that lead to experiences that influence implicit beliefs.

What the Dodo bird in the jigsaw tells us

Theories are never proved true, they are merely corroborated by evidence. The reformulated contextual model is consistent with all existing data, but new and more demanding tests are needed. However, one thing makes me confident that the theory has more than a grain of truth to it. When I tell non-psychologists that 'you become depressed or anxious if you keep doing things that make you sad or anxious', they often say, 'but that's obvious, isn't it?' I take that as a compliment.

Finding the Dodo bird in the jigsaw has taught me that we, as psychologists, need to leave behind an old prejudice against the unconscious. The reality is that the body, and not just the brain, is a complex system that uses multiples types of signalling. Some of these signals are available to consciousness; some are not, and whether the non-conscious signals are called automatic, implicit or unconscious is simply a matter of terminology. Conscious signals, in the form of cognitions, are certainly relevant to behaviour, but they are not the only form of signal that is relevant. More importantly, whether a signal is conscious or not, the system acts as a whole, so an understanding of both conscious and unconscious signals is needed to understand how the system functions.

The reformulated contextual model does more than provide a new view of existing psychotherapy. It also provides a theoretical rationale for prevention. Prevention is always more important than cure. If you want to avoid depression and anxiety, make sure you keep away from sabre-toothed tigers and listen to what you really want to do, not what others want or expect you to do. This advice may seem obvious. The most important freedom people have is the freedom to choose, and choice involves cognitions. But successful choice requires an understanding of the psychological consequences of different kinds of choice, and that can involve the unconscious.

- Michael Hyland is Honorary Professor at the University of Plymouth. [email protected]

References

Beck, A.T. (1967). Depression: Clinical, experimental, and theoretical aspects. University of Pennsylvania Press.

Hyland, M.E. (1985). Do person variables exist in different ways? American Psychologist, 40(9), 1003-1010. 

Hyland, M.E. (1987). Control theory interpretation of psychological mechanisms of depression: comparison and integration of several theories. Psychological Bulletin, 102(1), 109-121.

Hyland, M.E. (1988). Motivational control theory: An integrative framework. Journal of Personality and Social Psychology, 55(4), 642-651. 

Hyland, M.E. (1991). The living with asthma questionnaire. Respiratory medicine, 85, 13-16.

Hyland, M.E. (1993). A functional theory of psychogenic illness. Theory & Psychology, 3(1), 79-113.

Hyland, M.E. (2020). A reformulated contextual model of psychotherapy for treating anxiety and depression. Clinical Psychology Review, 101890.

Hyland, M.E. & Whalley, B. (2008). Motivational concordance: An important mechanism in self-help therapeutic rituals involving inert (placebo) substances. Journal of psychosomatic research, 65(5), 405-413.

Kirsch, I. & Sapirstein, G. (1999). Listening to Prozac but hearing placebo: A meta-analysis of antidepressant medications. In I. Kirsch (Ed.), How expectancies shape experience (p. 303-320). American Psychological Association.

Moloney, P. & Kelly, P. (2004). Beck never lived in Birmingham: Why CBT may be a less useful treatment for psychological distress than is often supposed. Clinical Psychology, 34, 4-10.

Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry, 6(3), 412-415.

Whalley, B. & Hyland, M.E. (2009). One size does not fit all: Motivational predictors of contextual benefits of therapy. Psychology and Psychotherapy: Theory, Research and Practice, 82(3), 291-303.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work. Routledge.