The Research

In 1958 Weiss began his investigations through the close review of the process notes of an analysis. Weiss noticed certain phenomena, which could not be explained by Freud’s original theories, but were compatible with Freud’s later writings. He noted, for example, that patients may acquire insight spontaneously without the therapist’s interpretation. Weiss published his first article, “Crying at the Happy Ending,” in 1952 (Psychoanalytic Review, Vol 39, p. 333). What follows is an excerpt from the Bulletin of the Psychoanalytic Research Society (1994) which offers an overview of the research on Control Mastery Theory. The article was written by Joseph Weiss, M.D., Harold Sampson, Ph.D. & Lynn O’ Connor Ph.D.

• Joseph Weiss, M.D. and Harold Sampson, Ph.D. began a research collaboration in 1964 with the purpose of studying by rigorous, quantitative research how psychoanalysis and psychotherapy work. Their research was inspired by earlier informal studies that Weiss had carried out over a number of years using process notes of psychoanalysis. Weiss’s approach to these informal studies was empirical. He investigated what events precede significant therapeutic progress; for example, patients becoming aware of previously repressed ideas, experiencing new emotions, developing new insights, or relinquishing symptoms. Weiss observed in his process notes that patients often made significant progress without any preceding interpretation by the analyst. Weiss inferred, from studying sequences leading to this progress, that patients made progress when they felt safe enough to do so. Moreover, patients work actively, often without awareness, to increase their sense of safety. One way they do so is by unconsciously testing beliefs about themselves and their interpersonal world in relation to the analyst. For example, a patient who believes that any disagreement with her analyst may hurt him (as she believed disagreements with her father in childhood had caused him harm) tested this belief over a long period of time in analysis. She did so by disagreeing with the analyst’s interpretations, at first timidly, and later forcefully. When the analyst’s reactions tended to disconfirm her belief (that is, when the analyst passed her tests), she became more relaxed, more bold, and more insightful.
• Weiss gradually developed a new psychoanalytic theory of the mind, of psychopathology and treatment. He proposed that psychological problems stem from pathogenic beliefs acquired in traumatic relational experiences in childhood, that these beliefs tell him that it is dangerous to pursue certain important goals, and that therapy is a process in which patients work to change these beliefs through experiences with the therapist as well as through knowledge acquired in therapy.
• A distinctive aspect of Weiss’s theory is the assumption that patients are highly motivated to solve their problems and that they work actively throughout treatment (by testing the therapist) to obtain experiences and knowledge that will help them to do this. Also distinctive is the assumption that the patient works in accord with unconscious plans as to which problems to tackle first, and which ones to defer until later. Patients decide unconsciously how they may work with their therapists to get help. They unconsciously coach their therapists with the aim of guiding them, so that they may provide the experiences, or display the capacities, or convey the knowledge that the patients need to disconfirm their pathogenic beliefs.
• Patients unconsciously monitor their therapists’ attitudes toward the pathogenic beliefs they are working to change. Because Weiss’s new theory was based on observations of how change takes place, and appeared to have considerable explanatory power, Weiss and Sampson decided to subject it to rigorous empirical scrutiny. They met daily over a period of years to plan how to test Weiss’s hypotheses about the therapeutic process. They figured out precisely what Weiss’s theory asserted about nature, deduced specific empirical consequences of the theory, identified situations in which alternative psychoanalytic hypotheses predict different clinical observations, selected or developed reliable measures, and finally, devised research designs with appropriate controls for sources of error (Weiss and Sampson, 1986; Sampson in Weiss, et al., 1986; Weiss, 1993). In effect, they developed over time the intellectual capital required to undertake a program of formal research. Pilot studies were initiated in 1967, and the first research paper was published several years later (Sampson, Weiss, Mlodnosky, and Hause, 1972).
• In 1972, Weiss and Sampson established the Mt. Zion (now called the San Francisco) Psychotherapy Research Group. This group began a series of interrelated studies of the therapeutic process, using verbatim transcripts of psychoanalysis and psychotherapies. Research findings of this group support the idea that patients want to overcome their problems, that they exert unconscious control over their repressions, and that they make progress in therapy when they unconsciously decide it is safe to do so. For example, one study showed that repressed mental contents frequently become conscious in treatment without prior interpretation, that they are experienced vividly yet without stress or conflict, and that they are kept in consciousness and used by patients to increase their understanding of their mental life (Gassner, Sampson, Weiss, and Brumer, 1982). Moreover, therapy events that increase patients’ sense of safety, such as the therapist passing the patient’s’ tests or giving patients interpretations that help them to understand and disconfirm their pathogenic beliefs, are typically followed by immediate patient progress (Broitman, 1985; Bush and Gassner in Weiss et al., 1986; Davilla, 1992;Fretter, 1984; Fretter, Bucci, Broitman, Silberschatz & Curtis, 1994; Kelly, 1989; Linsner, 1987; Silberschatz in Weiss et al., 1986; Silberschatz, Curtis, Sampson, and Weiss, 1991; Silberschatz, Fretter, and Curtis, 1986; Weiss, 1993a, 1994, JAPA article; Weiss, Sampson and the Mt. Zion Psychotherapy Research Group, 1986).
• The consistent finding of immediate patient progress following a therapy event that increases a patient’s sense of safety supports the idea that patients unconsciously and continuously monitor the therapist’s behavior and attitudes and are immediately influenced by indications that support or challenge their pathogenic beliefs. Patients unconsciously are in touch with their environment and guided by their appraisals of their reality.
• We have also accumulated a great deal of evidence to support Weiss’s concept that patients work in treatment in accord with unconscious plans as to how to use their therapy to change their pathogenic beliefs and solve their problems. For example, studies of the patient’s testing of the therapist demonstrate that patients carry out trial actions to test their pathogenic beliefs in relation to the therapist (Silberschatz in Weiss et al., 1986; Silberschatz & Curtis, 1993; Kelly, 1989). They become less anxious, bolder, more insightful, and more productive in treatment following “passed tests,” i.e., tests to which the therapist responds in a way that tends to disconfirm the belief being tested. These studies lend support to the idea that patients work in accord with unconscious plans to change their pathogenic beliefs.
• The unconscious plan concept is also supported by studies of the effects of interpretations (Fretter, 1984; Broitman, 1985; Caston, 1986; Bush & Gassner in Weiss et al., 1986). Patients respond with progress to interpretations that are compatible with their unconscious plans. They do not show progress following interpretations that are incompatible with their plans. These findings demonstrate that the unconscious plan concept predicts whether or not an interpretation will prove helpful to a patient. This finding cannot be predicted or explained except by the plan concept. Studies investigating changes in the patient’s level of insight in psychotherapy further support the plan concept. The level of “pro-plan” insight–that is, insight that helps the patient go where he or she wants to go–was determined in each session of five psychotherapies that the patient knew in advance would be limited to 16-sessions. In each case it was found that the patient had a relatively high level of insight in the intake interview and the first therapy session, then appeared to lose insight during the middle of the therapy, and regained it towards the end of the therapy. In each of the five cases a graph of the changes in the level of insight was best fit by a parabolic curve. These findings may be explained by the assumption that the patients each had an unconscious plan for the therapy. They unconsciously controlled their behavior in accordance with the time allotted to them, and their level of insight statements was a reflection of this unconscious assessment and planning (Weiss, 1993; O’Connor, Edelstein, Berry and Weiss, 1994). They showed high insight during the first sessions in order to provide their therapists with the information they needed to help them. Their insight dropped when they began testing their therapists, and rose only towards the end of treatment, when they were no longer actively testing their therapists because their therapy was coming to an end.
• In a study investigating the changes in the level of insight in the first 100 hours of an open-ended psychoanalytic case, a different pattern emerged. In this case, the initial level of insight dropped more slowly than in the time-limited therapies and it rose and dropped again in several places throughout the first 100 hours of treatment. A graph of the changing level of insight was best fit by a fifth order polynomial curve. This suggests that the patient devises a different unconscious plan in an open ended treatment. In this instance, we assume that the patient, having unlimited time, allowed himself more time to carry out his initial testing. We assume that when time is not limited, a patient’s plan for use of his therapy is not driven by time considerations, and thus differs from that found in the brief therapies.
• Another line of research supporting Weiss’s theory of psychopathology has developed through empirical studies of guilt and shame in larger populations. According to Weiss, pathogenic beliefs are inhibiting and constricting, particularly because they connect the pursuit of certain developmental goals with feelings of guilt, shame, fear and anxiety. For example, as the result of traumatic experiences in childhood, people may develop the belief that if they pursue certain adaptive goals, they will harm their parents or siblings. These beliefs may continue into adulthood when efforts to pursue these goals, or even consideration of such efforts, evoke feelings of guilt. Thus, Weiss’s theory emphasizes interpersonal guilt –that is guilt that arises out of altruism and a concern about harming others– and its importance in the development and maintenance of psychopathology. In therapy, a patient’s unconscious plan often involves changing those pathogenic beliefs that give rise to irrational interpersonal guilt.
• In 1989, O’Connor, Berry and Weiss initiated a series of pilot studies which led to the development of a questionnaire, The Interpersonal Guilt Questionnaire (IGQ) designed to operationalize and measure interpersonal guilt. This instrument includes subscales of Survivor Guilt, Separation Guilt, Omnipotent Responsibility Guilt, and Self-Hate. Survivor guilt is characterized by the belief that a person experiences good things at the expense of others, and that by attempting to further their own cause, they may harm others. Separation guilt is characterized by the belief that one is harming one’s parents or other loved ones by separating from them, or by being different from them. Omnipotent responsibility guilt is characterized by an exaggerated sense of responsibility for the well being of others. Self hate is an extreme form of guilt that occurs in compliance with harsh and/or neglectful parents and is characterized by people punishing themselves with negative thoughts and feelings. Initial pilot studies using the IGQ have shown significant correlations between these types of interpersonal guilt and various problems such as depression, a pessimistic explanatory style, negative automatic thoughts, and child abuse and trauma. In several populations studied thus far, survivor guilt and self-hate guilt appear to be particularly associated with depression. And in each sample we have found an especially high correlation between survivor guilt and shame (O’Connor, 1994; O’Connor, Berry, Weiss, Bush and Sampson, in preparation). Furthermore, these pilot studies have demonstrated that a clinical group, a group of drug addicted clients, were higher than a non-clinical population in interpersonal guilt (Meehan, O’Connor, Berry, Weiss, Morrison, Acampora, in preparation). Thus the significance of interpersonal guilt to psychopathology, suggested by Weiss’ theory is supported by these studies.
• As seen from the body of work described in this brief history, Weiss’s theory, from its inception, has maintained a grounding in empirical data. Both in studies of the psychotherapy process and more recently, in studies of emotion and psychopathology, the basic assumptions of this theory–that psychopathology stems from pathogenic beliefs derived from childhood trauma; that people are striving for health; and that people think and plan unconsciously–have been shown to be testable, and supported by empirical research.
• Most of the psychotherapy research has been carried out on completed therapies which were recorded and transcribed, and where neither the therapist nor the patient was familiar with the theory. The goal has been to investigate how psychotherapy works regardless of the therapist´s orientation or approach.[15] The main tool for studying and evaluating these psychotherapies has been the case formulation. CMT researchers have attempted to operationalize the clinical process of understanding a case, in order to assess and increase agreement between different clinical judges adhering to CMT.
• The first attempt to assess whether it was possible for trained judges to formulate reliable case formulations based on CMT were done by Caston (1986).[16] In several studies applying this procedure on brief therapies, the interjudge reliabilities were found to be high, typically between .7 and .9.[15] Curtis and Silberschatz later modified and revised the procedure, and termed it the Plan Formulation Method (1991).
• The Plan Formulation Method, or PFM, is a comprehensive case formulation method that was developed primarily for clinical research on CMT.[17] Plan formulations developed for psychotherapy research are based on reviews of transcripts from early therapy sessions. A plan formulation starts with a description of the patient, including his or her current life circumstances and presenting complaints. Beyond that a Control Mastery plan formulation consists of the following elements:
  • Traumas: Experiences that may have led to the development of pathogenic beliefs.
  • Goals: The patient’s conscious and unconscious goals for therapy.
  • Obstructions: Pathogenic beliefs that are inhibiting the patient from attaining or pursuing his or her goals.
  • Tests: Ways in which the patient is likely to work in therapy to check the validity of pathogenic beliefs.
  • Insights: Information that may be helpful to the patient in order to disprove pathogenic beliefs and overcome obstructions.
• Research on the PFM has consistently demonstrated that trained independent judges can achieve a high degree of agreement in formulating case formulations based on CMT concepts, including traumas, goals, obstructions, tests and insights. A large body of research support that patients bring out new material when they feel safe in the therapeutic relationship, and that patients make progress when therapist´s passes tests or make plan-compatible interpretations, that help contradict pathogenic beliefs. When analyzing recorded therapies, trained judges reliably agree on when in a session a patient is testing the therapist, and whether or not the therapist’s response fails or passes the test.

The Research

• A measure called the Interpersonal Guilt Questionnaire (IGQ) has been developed to assess patients’ types and levels of guilt, and how they relate to each other. An empirical study using this questionnaire demonstrated a connection between guilt and traumatic childhood experiences, and also between guilt and psychopathology.

References

• Broitman, J. (1985). Insight, the mind’s eye. An exploration of three patients’ processes of becoming insightful. Doctoral Dissertation, Wright Institute. Dissertation Abstracts International, 46(8). University Microfilms No. 85-20425.
• Bush, M., & Gassner, S. (1986). The immediate effect of the analyst’s termination interventions on the patient’s resistance to termination. In The psychoanalytic process: Theory, clinical observation & empirical research. New York: Guilford Press, 299-320.
• Caston, J. (1986). The reliability of the diagnosis of the patient’s unconscious plan. In The psychoanalytic process: Theory, clinical observation & empirical research. New York: Guilford Press, 241-255.
• Davilla, L. (Shields) (1992). The immediate effects of therapist’s interpretations on patient’s plan progressiveness. Unpublished Doctoral Dissertation, California School of Professional Psychology.
• Fretter, P. (1984). The immediate effects of transference interpretations on patients’ progress in brief, psychodynamic psychotherapy. Doctoral Dissertation, University of San Francisco. Dissertation Abstracts International, 46(6). University Microfilms No. 85-12112.
• Fretter P., Bucci, W., Broitman, J., Silberschatz, G., & Curtis, J. (1994). How the patient’s plan relates to the concept of transference. Psychotherapy Research, 4(1), 58-72.
• Gassner, S., Sampson, H., Weiss, J., and Brumer, S. (1982). The emergence of warded-off contents. Psychoanalysis and Contemporary Thought, 5(1), 55-75.
• Kelly, T. (1989). Do therapist’s interventions matter? Doctoral Dissertation, New York University.
• Linsner, J. P. (1987). Therapeutically effective and ineffective insight: The immediate effects of therapist behavior on a patient’s insight during short-term dynamic therapy. Doctoral Dissertation, The City University of New York.
• O’Connor, L. E., Edelstein, S., Berry, J., & Weiss, J. (1994). The pattern of insight in brief psychotherapy: a series of pilot studies. Psychotherapy, Winter.
• O’Connor, L.E. (1994). Empirical Studies of Shame and Guilt: development of a new measure, the Interpersonal Guilt Questionnaire. Process Notes, 1(1), 12-15.
• O’Connor, L. E., Berry, J. W, Weiss, J., Bush, M., and Sampson, H. (in preparation). The Interpersonal Guilt Questionnaire: development of a new measure.
• Meehan, B., O’Connor, L. E., Berry, J. W., Weiss, J., Morrison, A., Acampora, A. (in preparation). Shame, guilt and depression in addicts in recovery.
• Sampson, H., Weiss, J., Mlodnosky, L., and Hause, E. (1972). Defense analysis and the emergence of warded-off mental contents: An empirical study. Archives of General Psychiatry, 26, 524-532. Silberschatz, G. (1986). Testing Pathogenic Beliefs. In The psychoanalytic process: Theory, clinical observation & empirical research. New York: Guilford Press, 256-265.
• Silberschatz, G. & Curtis, J. (1993). Measuring the therapist’s impact on the patient’s therapeutic progress. Journal of Consulting and Clinical Psychology, 61(3), 401-411.
• Silberschatz, G., Curtis, J., Sampson, H., and Weiss, J. (1991). Mount Zion Hospital and Medical Center: Research on the process of change in psychotherapy. In L. Beutler & M. Crago (Eds.), Psychotherapy Research: An International Review of Programmatic Studies. Washington, D.C.: American Psychological Association, 56-64.
• Silberschatz, G., Fretter, P., and Curtis, J. (1986). How do interpretations influence the process of psychotherapy? Journal of Consulting and Clinical Psychology, 54(5), 646-652.
• Weiss, J. Empirical studies of the psychoanalytic process. (1993). Journal of the American Psychoanalytic Association, October.
• Weiss, J. (1993). How Psychotherapy Works: Process and Technique. New York: Guilford Press.
• Weiss, J., Sampson, H., and The Mount Zion Psychotherapy Research Group. (1986). The Psychoanalytic Process: Theory, Clinical Observations, and Empirical Research. New York: Guilford Press. Brief Biographical Sketches

1. https://en.wikipedia.org/wiki/Control_Mastery_Theory

2- http://www.goodtherapy.org/learn-about-therapy/types/control-mastery-theory

3- http://www.behavior.net/forums/evolutionary/1998/25-user=&email=&depth=8&detail=description&lastread=5-3.htm

4- San Francisco Psychotherapy Research Group, Clinic and Training Center

5- Emotions, Personality and Altruism Research Group (EPARG)