The approach outlined in this article is almost exactly opposite of how I work with my clients who have symptom collections that are labeled schizophrenia (an intersubjective, relational model), but it's an interesting attempt to create a more integrated and practical model.

The intersubjective model is much more relational than this approach, and it seeks to join with the client in order to understand his/her experience in an experience-near manner. In doing so, we can help the client regain access to emotions that have been dissociated by the psychosis.

Full Citation:

Lecomte, T, Corbière, M,  Simard, S, and Leclerc, C. (2014, Nov 6). Merging Evidence-Based Psychosocial Interventions in Schizophrenia. Behavioral Sciences; 2014, 4(4): 437-447; doi:10.3390/bs4040437

Merging Evidence-Based Psychosocial Interventions in Schizophrenia

Tania Lecomte, Marc Corbière, Stéphanie Simard and Claude Leclerc

This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

(This article belongs to the Special Issue Management and Treatment of the Major Mental Disorders)

Abstract: Psychosocial interventions are an essential part of the treatment for people with severe mental illness such as schizophrenia. The criteria regarding what makes an intervention “evidence-based” along with a current list of evidence-based interventions are presented. Although many evidence-based interventions exist, implementation studies reveal that few, if any, are ever implemented in a given setting. Various theories and approaches have been developed to better understand and overcome implementation obstacles. Among these, merging two evidence-based interventions, or offering an evidence-based intervention within an evidence-based service, are increasingly being reported and studied in the literature. Five such merges are presented, along with their empirical support: cognitive behavior therapy (CBT) with skills training; CBT and family psychoeducation; supported employment (SE) and skills training; SE and cognitive remediation; and SE and CBT.

1. Introduction

Psychosocial interventions are an essential part of the treatment and recovery of people with severe mental illness such as schizophrenia. It is well-accepted that medication alone is not sufficient to help with the recovery and various issues a person might encounter when attempting to lead a satisfying life in the community. Some practices have gathered sufficient empirical data to be strongly recommended by national guidelines such as the PORT (Patient outcome research team) [1], or the NICE (The National Institute for Health and Care Excellence) [2] guidelines in the UK, whereas others are considered promising until more studies support its effect. In order for a psychosocial practice, namely an intervention or program (an intervention is specific treatment with a targeted therapeutic aim whereas a program typically includes various interventions), to be considered evidence-based, it must not only have accumulated sufficient empirical proof of its efficacy (often in the context of at least two randomized controlled trials) but it must answer a need (such as improve functioning, overcome a deficit or help to cope with symptoms) and be standardized in order to be easily replicable [3]. The 2009 PORT report on psychosocial practices for schizophrenia highlighted eight interventions or programs that could be considered evidence-based [1]. These were in terms of interventions: family psychoeducation, cognitive behaviour therapy, social skills training, weight management, and token economy. In terms of programs, they described: intensive community treatment, supported employment and integrated dual-disorder programs (with first episode programs almost meeting criteria). Since, Mueser et al. [3] has added cognitive remediation, which has demonstrated in various meta-analyses its efficacy in helping individuals overcome cognitive deficits in areas such as memory, attention or problem solving. Although all of the above-mentioned interventions and programs are considered evidence-based and can truly improve the lives of people with severe mental illnesses, implementation studies reveal that few, if any, are ever implemented in a given setting [4]. For some interventions, this is understandable—for instance token economy is only effective in changing problematic behaviors when used in a closed and controlled environment, like a forensic ward [5]. However, most of the other interventions and programs have demonstrated positive effects in improving symptoms, deficits, and community functioning and are under-utilized. A recent review on implementation of evidence-based psychosocial interventions and programs in psychiatry describes various strategies that have been used in order to improve implementation of one or many evidence-based practice [4]. Of the most common strategies, large demonstration projects and effectiveness trials run by researchers, broad service reforms based on new government policies and national agency-led initiatives were identified. Few of these implementation strategies have been studied over the long-term, and fewer even have considered consumer outcomes [4]. Other smaller-scale implementation strategies have also been developed, when large-scale funding was not available. For instance, supported employment programs’ implementation have been facilitated by a group of researchers and clinicians [6] offering standardized training, consultation and encouraging the use of their implementation fidelity scales (The Quality of Supported Employment Implementation Scale (QSEIS) [7] or the Individual Placement and Support (IPS) fidelity scale [8]. In the UK, US and Canada, the implementation of CBT for psychosis has been improved by offering the clinical training to mental health professionals from various backgrounds (e.g., nurses, occupational therapists), offering structured manuals, and brief training sessions [9,10] rather than limiting the treatment delivery to clinical psychologists.

Another approach to improving implementation of evidence-based psychosocial interventions or programs that is being seen more and more in the literature, particularly in the last decade, is to merge two evidence-based interventions, or to offer an evidence-based intervention within an evidence-based program. Are considered merges both: (a) the simultaneous delivery of two practices (two interventions or an intervention and a program) and, (b) modified practices: interventions changed in order become integrated with another intervention or within a program. In settings with limited means, offering such merges has the advantage of targeting more than one therapeutic goal at once (e.g., cognitive distortion and work integration). Some of the merges have been developed in order to adapt an evidenced-based intervention to a specific population group or setting (such as older consumers). However, most of the merges have been developed with the hope of improving the effectiveness of an evidenced-based program by adding an empirically recognized intervention. It is important to mention that few of the merges presented here simply “co-deliver” interventions—most are well-integrated merges or at least aim at truly integrating the interventions and programs together. The following are descriptions of such merges.

2. Cognitive Behavior Therapy (CBT) and Social Skills Training

Granholm and colleagues [11,12] have merged two evidence-based psychosocial interventions to cater to the specific needs of aging individuals with psychosis who might be struggling not only with symptoms but also with social and cognitive deficits. CBT for psychosis has been studied in over 40 randomized controlled trials and various meta-analyses since the first promising studies of the 1990s [13]. Overall, most studies have found that CBT for psychosis is effective in reducing symptoms and improving other indexes of well-being, often with stronger results compared to other interventions overtime than at post-treatment [14,15,16]. However, as in most psychotherapy studies, the most rigorous studies often reveal smaller effect sizes than the non-controlled studies [17]. CBT for psychosis aims at modifying dysfunctional beliefs by helping the person understand the link between perceptions, beliefs and emotional and behavioural reactions. CBT also helps the person question the evidence supporting his beliefs (whether they are psychotic or not). Furthermore, CBT brings the person to self-observe himself, his thoughts and behaviors, and explores various coping strategies the person might use when dealing with distressful thoughts or voices. Finally, CBT for psychosis takes into account cognitive biases a person might have and aims at modifying those biases, by seeking alternatives instead of jumping to conclusions, for instance.
CBT for psychosis has been adapted for various clienteles, used with individuals at high risk of developing psychosis, individuals with early psychosis as well as older individuals with a long history of schizophrenia. This latter group was of particular interest for Granholm and colleagues [12] who wished to offer CBT for psychosis in a format that would be appealing and adapted to clients who were often isolated, and who might have difficulties grasping some CBT concepts, given their cognitive deficits. They therefore decided to include social skills training to the CBT treatment and offer the merged treatment in a group format.
Social skills training has been around since the 1980s in the USA and was considered especially useful for helping people reintegrate society after a long period of institutionalization. The goal behind skills training is to offer skills that are deemed essential to interact with others, manage one’s medication and symptoms, as well as problem solve in different contexts. Skills training is based on Bandura’s self-efficacy theory [18] and uses repetition and positive reinforcement to help people acquire and remember new skills. To date, over 23 randomized controlled trials have shown that skills training can help acquire skills, decrease negative symptoms, and has a moderate impact on independent living skills [19,20]. Skills training can be offered individually but works best in groups, with the use of multiple role-plays preparing for real-life interactions.

Merging CBT and Skills Training

Granholm and colleagues [11,12] developed a group CBT/skills training approach that focuses on CBT for psychosis techniques, such as checking for facts, but presents these in a skills training manner (i.e., a lot of repetition, wallet cards with key words/concepts, use of a big flag in the group to “flag” the beliefs without apparent facts or proof). The group included modules that were repeated over time, enabling the participants to go over the content more than once and allowing new participants to enter the group at any given moment. Although the results did not show an improvement in positive symptoms, it did show improvements in functioning and negative symptoms [11,12]. Of importance, the participants were able to remember the concepts and CBT techniques regardless of the severity of their cognitive deficits.

3. CBT and Family Psychoeducation

Leclerc and Lecomte [21] have recently published promising preliminary data on 40 family members who received a merged group CBT/psychoeducation family intervention. Family intervention, in particular family psychoeducation, is recognized as one of the evidence-based interventions with the most empirical support, especially regarding decreasing rehospitalization rates [3]. More than 50 randomized controlled trials have been published to date supporting the effects of family psychoeducation on increased medication adherence, and decreased stress and symptoms in those receiving psychiatric care [15,22]. As for their family members, these same studies report decreased perceived burden and psychological distress. Most family interventions last an average of six to nine months and offer: information on symptoms and mental illness, recommendations for dealing with crises, emotional support, and coping skills to deal with symptoms and mental illness [23]. Family interventions can be offered to each individual family or multiple families together, with or without the family member receiving psychiatric care. Many family intervention manuals were developed in the 1990s and do not address recent concepts such as recovery and tend to focus mostly on medication, chronicity, and symptoms. During a recent trial on CBT for early psychosis, many family members asked to learn more about CBT for psychosis and how they could use the tools in their lives. We therefore developed the family psychoeducation/CBT module entitled WITH (Wellness-Inform-Talk-Help) [21]. The module can be offered in parallel to the CBT for psychosis groups, i.e., during 24, hourly multiple family sessions, or can be offered in a more intensive format: eight two-hour multiple family sessions (covering 16 activities in the module). Each multiple family group typically consists of an average of 10 parents and two co-therapists. The content of the group is psychoeducational in that it addresses concepts such as recovery, expressed emotions, parental role, personal limits, and expectations, but it is also considered CBT given that the participants learn about CBT principles and techniques and apply them to their own lives during the group and at home (homework). The parents therefore learn to not only use the skills learned with their family member with a mental illness, but also use them with themselves when they are experiencing distress for instance.

Merging CBT and Family Psychoeducation

The intensive (eight two-hour sessions) format was recently studied in a non-controlled study [21] whereby the 40 parents who participated showed significant clinical improvements in psychological distress, namely in psychoticism, depression and interpersonal sensitivity compared to their baseline scores. Qualitative data obtained revealed that parents appreciated the group, found it helpful, and they had integrated recovery as well as CBT notions and skills in order to improve their relationship with their family member receiving psychiatric services. The group format was especially appreciated, as well as the information covered in the module. Although more studies are warranted in order to compare the WITH multiple family intervention to other family interventions, social workers offering the group anecdotally mentioned that their previous multiple family psychoeducational intervention had a retention rate of only 20% of participants from the first to the last session whereas WITH had a retention rate of 80%. The merged intervention has the advantage of covering essential elements of family psychoeducation for psychosis, including updated information on recovery, and also offers concrete CBT tools that can be useful for the person with a mental illness as well for their family members.

4. Supported Employment and Other Evidence-Based Interventions

Supported employment is another evidence-based program that has attracted a few merges over the past decade. Supported employment programs help people with severe mental illness obtain real-world competitive employment, with regular wages, based on their clients’ preferences [6]. Employment specialists working in supported employment programs aim at quickly finding regular paid work for their clients, and offer them unlimited support according to their needs at work. Supported employment programs are recognized as being evidence-based with more than 15 trials in various countries having demonstrated that SE programs are more efficacious in helping people with severe mental illness obtain regular jobs than other vocational or rehabilitation programs [6]. Nonetheless, there is room for improvement given that on average, in North America, between 40%–60% of the clients in SE programs obtain regular jobs and most jobs are only kept for three to five months. Many reasons have been suggested to explain why some individuals might struggle in finding work or in maintaining their jobs. Some have suggested lack of appropriate work-related social skills, others that cognitive deficits impede on work performance, and others still that people with mental health problems might hold irrational beliefs about themselves and the workplace.

Merging Social Skills Training and Supported Employment Programs

The first merge proposed was to offer social skills training that was work specific to people registered in a supported employment program. Charles Wallace [24] developed the Workplace Fundamentals, aiming at helping participants recognize the advantages of work in their lives, their potential stressors at work, how to problem solve various work-related situations, and how to avoid drugs and alcohol to maintain their jobs. The module is offered over the course of 24 sessions, typically twice a week, in groups of six to eight participants. As with most social skills training, the goal is to develop spontaneous behaviors and therefore involves multiple role-plays and repetitive behaviors. Two studies were conducted to verify its efficacy in improving job tenure. The first, including 34 participants, showed improved job tenure and better work satisfaction for those having received the skills training + SE program compared to SE program alone [24], whereas the second study did not show any differences between the two conditions on work outcomes (but reported that the sample was not typical of most studies with higher education and longer tenure, with rates close to one year for their first job) [25]. The participants receiving both conditions did show greater knowledge regarding their work setting, stressors and showed better problem solving abilities than those receiving only the SE program.

5. Cognitive Remediation and Supported Employment

Another explanation for poor work tenure in people receiving SE programs pertains to cognitive deficits. Cognitive deficits are well documented in people with severe mental illness, namely regarding deficits in memory, attention, speed of processing and various executive functioning tasks, and can make performing at work difficult. Various cognitive remediation programs and strategies have been developed over the years with more than 40 randomized controlled trials supporting its efficacy in improving cognitive skills and overall functioning [26]. Cognitive remediation can take many forms: paper-pencil tasks, computer tasks, group training, or training in real-world tasks (using errorless learning, for instance [27]). Although some cognitive remediation can include modifying the environment to compensate for the person’s most important cognitive deficit, most cognitive remediation programs aim at improving cognitive deficits to the point that they no longer interfere with work performance.

Merging Cognitive Remediation and Supported Employment Programs

McGurk and colleagues developed a cognitive remediation program called Thinking Skills for Work specifically for people registered in supported employment programs [28]. The program involves individual computerized training (using CogPack) for an average of 24 hours over the course of 12 weeks, along with cognitively-informed job support consultation with the employment specialist. The computerized program aims at improving attention, concentration, psychomotor speed, learning and memory as well as executive functions. The consultation aims at targeting jobs or at modifying the work environment as needed according to the person’s performance and progress during the cognitive remediation training. Results at the two to three year post- cognitive remediation follow-ups revealed that those who had received the cognitive remediation program had improved on the cognitive tasks and had superior job retention rates than the control condition (registered in supported employment programs only) [29]. These results were however not found for those who presented with comorbid substance use disorders—their work outcomes were poor regardless of the extra treatment added [30].

6. CBT and Supported Employment

A potential obstacle to job maintenance in people registered in supported employment is dysfunctional beliefs regarding the workplace and one’s own abilities. Individuals with severe mental illness who have been away from the job market for some time can hold beliefs and act in ways that are deleterious for their work integration, and could be influenced by lack of confidence, jumping to conclusions bias, and poor coping skills, to name a few. As mentioned previously, CBT has proven efficacious in modifying beliefs and cognitive biases and helps in developing better coping strategies when dealing with stressful situations. CBT has also been modified by Davis and colleagues [31] to target work beliefs and behaviours in a transitional vocational program for veterans with severe mental illness. This program, entitled IVIP, has demonstrated improvements in work performance and job maintenance in those receiving the group IVIP compared to those participating in the vocational program alone [32]. These results were also replicated in a larger trial [33].

Merging CBT and Supported Employment Programs

Lecomte, Corbière, Titone and Lysaker [34] developed a brief CBT group intervention, inspired by the IVIP, but specifically tailored for people in supported employment programs called CBT-SE. The CBT-SE intervention is offered during 8 sessions over the course of one month, in order to ensure that the group does not impede on the rapid job search principle of supported employment programs. The content covered many essential aspects linked to the workplace, such as recognizing and managing one’s stressors at work, determining and modifying dysfunctional thoughts (e.g., not jumping to conclusions, finding alternatives, seeking facts), overcoming obstacles (e.g., problem solving), improving one’s self-esteem as a worker recognizing strengths and qualities), dealing with criticism, using positive assertiveness, finding coping strategies (for symptoms and stress) to use at work, negotiating work accommodations and overcoming stigma. Although the results from the trial of 160 participants are not yet available, preliminary data have been published on 24 participants [35] and suggest that the CBT-SE intervention is feasible, and acceptable, with good attendance and positive feedback regarding the group’s usefulness. In terms of work outcomes, 50% of all participants in both conditions found competitive work but those in the CBT-SE condition were more likely to work more hours per week and for more consecutive weeks than those in the supported employment program alone. These preliminary results are promising, although results from the full trial are needed before concluding that CBT-SE is efficacious in improving job tenure.

7. Conclusions

Evidence-based psychosocial practices for individuals with severe mental illness can greatly improve people’s lives but are unfortunately scarcely implemented. When large-scale governmental or agency supported implementation initiatives are not available, clinical or community settings who are tempted to offer one evidence-based program or intervention could also opt for a merged intervention. Merged interventions have the advantage of targeting two sets of skills at once, and could therefore generalize in other aspects of the person’s life. For instance, individuals having received cognitive remediation within a supported employment program [28] could see improvements in other areas of their lives, outside of work, from their improved memory and attention skills. Similarly, the cognitive behavioural strategies used in the CBT-SE skills [34] are similar to those used in more general CBT for psychosis treatments and could be used to help the person assess situations differently at work as well as outside of work, with friends or family for instance.

This article aimed at presenting some merges of evidence-based programs but is in no way exhaustive. Other merges exist, such as social skills training with token economy for substance misuse [36] cognitive remediation with social skills training (e.g., Integrated Psychological Therapy - IPT [37]) or social cognitive training with CBT and skills training (i.e., Social Cognition and Interaction Training—SCIT [38]). These programs are however described as distinct and unique programs, not as merges of evidence-based interventions. Although evidence-based interventions are empirically supported, their impact on various outcomes can likely be improved by adding elements from other evidence-based interventions, or by offering them within an evidence-based program, as was demonstrated here. Although some of the proposed merged interventions have only been studied in small or uncontrolled studies so far, the strong empirical support for the non-merged evidence-based interventions from which they are derived and the preliminary data available so far is quite encouraging. Future studies on merged evidence-based interventions are warranted, particularly in terms of trials assessing the effectiveness of offering such interventions simultaneously rather than separately and at different times. Furthermore, studies should also consider measuring the level of integration of the practices in order to determine if closely-knit merges are more effective than less integrated practices. Finally, studies should also investigate if these merges increase or not generalization of the skills to other life domains.

 

Author Contributions
The authors contributed equally to this work.

Conflicts of Interest
The authors declare no conflict of interest.

References at the Behavioral Sciences site

 

From the open access journal, Frontiers in Psychology: Psychology for Clinical Settings, this is an interesting review article suggesting grounded cognition as the foundation for the mind-body relationship in psychotherapy.

I get that the mainstream is still far behind the leading edge on understanding the mind, but for me, when someone talks about the "mind-body relationship," it's clear that they don't get that the body (including, of course, the brain) IS the mind, or at least part of it (mind is also the relational context to other people, environment, and temporal space).

Anyway, this is an article definitely worth a quick read.


Full Citation: 
Leitan, ND, and Murray, G. (2014, May 20). The mind–body relationship in psychotherapy: grounded cognition as an explanatory framework. Frontiers in Psychology: Psychology for Clinical Settings; 5:472. doi: 10.3389/fpsyg.2014.00472

The mind–body relationship in psychotherapy: Grounded cognition as an explanatory framework

Nuwan D. Leitan and Greg Murray
Department of Psychological Sciences and Statistics, Faculty of Health, Arts and Design, Swinburne University of Technology, Hawthorn, VIC, Australia

Abstract

As a discipline, psychology is defined by its location in the ambiguous space between mind and body, but theories underpinning the application of psychology in psychotherapy are largely silent on this fundamental metaphysical issue. This is a remarkable state of affairs, given that psychotherapy is typically a real-time meeting between two embodied agents, with the goal of facilitating behavior change in one party. The overarching aim of this paper is to problematize the mind–body relationship in psychotherapy in the service of encouraging advances in theory and practice. The paper briefly explores various psychotherapeutic approaches to help explicate relationships between mind and body from these perspectives. Themes arising from this analysis include a tendency toward dualism (separation of mind and body from the conceptualization of human functioning), exclusivism (elimination of either mind or body from the conceptualization of human functioning), or mind–body monism (conceptualization of mind and body as a single, holistic system). We conclude that the literature, as a whole, does not demonstrate consensus, regarding the relationship between mind and body in psychotherapy. We then introduce a contemporary, holistic, psychological conceptualization of the relationship between mind and body, and argue for its potential utility as an organizing framework for psychotherapeutic theory and practice. The holistic approach we explore, “grounded cognition,” arises from a long philosophical tradition, is influential in current cognitive science, and presents a coherent empirically testable framework integrating subjective and objective perspectives. Finally, we demonstrate how this “grounded cognition” perspective might lead to advances in the theory and practice of psychotherapy.

Introduction

As a discipline, psychological science is “mounted above the philosophical gap between mind and body” (Tschacher and Haken, 2007, p. 1). The inherent challenges of this position are clearly seen in psychology’s primary application, psychotherapy (the use of psychological science to improve mental health and wellbeing). The theoretical foundation of psychopathology (the study of the nature and treatment of mental disorders) has been described as akin to that of biology’s before Darwin (Frances and Egger, 1999), and arguably, the elephant in the room is the lack of consensus, both implicit, and explicit, about the relationship between mind and body (Kendler, 2008). Whether expressed as human versus natural sciences, hermeneutic versus positivist methods, or understanding versus explanation, Cartesian or substance dualism (mind and body are two types of substance) is yet to be resolved in psychopathology and psychotherapy. The field is consequently characterized by polarized schools of thought, identifying it as an immature science in Kuhnian terms (Kuhn, 1962).

In the absence of a consensus position on the mind–body relationship, psychotherapists juggle tangible and intangible features of their clients without integrative models (Murray, 2011). It is noteworthy that international guidelines for psychology training programs rarely require a competency around this ontological issue, suggesting that the discipline may have relegated it to the “too hard” basket. Contemporary research across multiple disciplines, however, suggests that the case should be re-opened.

Recent research in philosophy (Clark, 1997; Lakoff and Johnson, 1999), cognitive science (Brooks, 1991; Chemero, 2009) and psychology itself (Barsalou, 1999; Glenberg and Robertson, 1999) advocates a fundamental reappraisal of the relationship between mind and body. The “embodied cognition” research program has many strands, but all commence with a rejection of the dualistic separation of body and mind (Shapiro, 2011). Here, we propose grounded cognition as an embodied, psychological framework which provides a holistic conceptualization of body and mind. It is our position that articulating the relationship between body and mind from a psychological perspective will provide a consensus position and an organizing framework for the mind–body relationship for psychotherapy research and practice. We contend that this will encourage practitioners to reflect on their assumptions about cognitions and how they conceptualize body and mind in treatment, leading to a better understanding of the tensions between psychotherapy theory and practice and the identification of gaps in existing therapies and consequently an expansion of the range of therapies offered to the patient.

The paper is structured in four sections. First, we briefly consider a range of approaches to psychotherapy through the lens of their apparent assumptions about mind–body. Themes arising from this analysis include a tendency toward an uncritical dualism (separation of mind and body from the conceptualization of human functioning), exclusivism (elimination of either mind or body from the conceptualization of human functioning), or mind–body monism (conceptualization of mind and body as a single, holistic system) and we conclude that the psychotherapy literature, as a whole, does not demonstrate consensus, regarding the relationship between mind and body. We propose that an organizing framework for the mind–body relationship, underpinned by a holistic conceptualization of the relationship, would benefit psychotherapy research and practice. Second, philosophical accounts which portray a holistic mind–body relationship from phenomenological and objective perspectives are outlined. Third, we propose that these perspectives are integrated, psychologically, by “grounded cognition,” constituting a comprehensively articulated, empirically informed, organizing framework for conceptualization of the mind–body relationship in psychotherapy. In the final section we consider how the application of psychological science in psychotherapy might advance through a thoroughgoing consideration of “grounded cognition.”

Mind–Body Assumptions Underlying Current Psychotherapies

There is no agreed taxonomy of psychological therapies (e.g., Kahl et al., 2012; Tschacher et al., 2014), but to achieve an adequate coverage of existing approaches for the present purposes, we categorise psychotherapies into five fuzzy-bordered groups: psychoanalysis, behavioral therapies, cognitive therapies, mindfulness-based therapies, and body psychotherapies. Each of these has many branches and extensive literatures – thus, in this brief review we aim only to explore different ideas regarding the relationship between mind and body from within each approach, and across approaches, rather than attempting to assign particular conceptualizations of the mind–body relationship to particular approaches.

Psychoanalysis

Although psychoanalytic theory and practice have fallen out of favor in contemporary psychological science, aspects of Freud’s thinking can still be discerned in current psychotherapy (Dowd, 2004). An important aspect of psychoanalytic theory is the “cognitive unconscious,” or the “unconscious mind.” In opposition to the popular enlightenment view at the time, Freud argued that behavior is driven by unconscious motivations and drives, rather than rational choice (Luborsky et al., 2008; Wolitzky, 2011). As discussed by Luborsky et al. (2008), central therapeutic strategies of psychoanalysis include free association (expressing any thoughts which come to mind during therapy), therapeutic listening and responding (examining the content and emotion of thought), and interpretation (drawing inferences about unconscious underpinnings of conscious experience).

However, the body also figures strongly in psychoanalytic theory. For Freud, structures of the mind (e.g., id, ego, superego) arise out of tensions between the organism’s bodily drives and societal structures (Muller and Tillman, 2007). This is reflected in the psychoanalytic conception of psychosomatic illness, which was the idea that emotions and unconscious desires caused bodily symptoms; for example Gregor Groddeck, a psychoanalyst who developed Freud’s ideas about psychosomatic illness proposed that a tumorous abdominal growth could result from a warded-off unconscious wish to be pregnant. Furthermore it has been suggested that the “ego,” in psychoanalysis, commences as an embodied entity, and emphasizes the continuity between animals and humans, suggesting a monist, or holistic mind–body conceptualization (Muller and Tillman, 2007).

Behavior Therapy

Traditional behavior therapy arose in an American setting in the early 1950s and saw a shift from the psychoanalytical ideas of studying the mind to the pragmatic, evidence-based study of behavior (Dowd, 2004). This shift was triggered by J. B. Watson’s criticism of subjectivity and mentalism as the subject matter of psychology and his advocacy of the objective study of behavior. This was followed by the advent of “modern learning theory,” which referred to the principles of classical and operant conditioning. These early ideas underlying traditional behavior therapy were exclusivist, rejecting the notion of mind and cognition, on the grounds that they are unobservable entities and therefore unfit for scientific study (Wilson, 2008; Zinbarg and Griffith, 2008).

However, later theories stemming from behaviorism developed a more complex account of the mind–body relationship. For example, Bandura (1977) spoke of a reciprocal determination between behavior and the environment, stating that “it is largely through their actions that people produce the environmental conditions that affect their behavior in a reciprocal fashion” (p. 345). Bandura also seemed to encourage conceptualization of the mind as a part of the same system as behavior and environment, for example, “…experiences generated by behavior also partly determine what individuals think, expect, and can do, which in turn affects their subsequent behavior” (p. 345).

This holistic conceptualization of the mind–body relationship is also apparent in popular behavior therapies for children with autism spectrum disorder, such as music therapy, Floortime, rhythm therapy, and reciprocal imitation training which are broadly underpinned by behavioral and functional developmental approaches (Greenspan and Wieder, 1999; Ingersoll and Schreibman, 2006; Overy, 2008; Vismara and Rogers, 2010; Srinivasan and Bhat, 2013). For example, reciprocal imitation training teaches children the spontaneous social use of imitation, which as targeted at attention, language and communication cognitions (Ingersoll and Schreibman, 2006) and Floortime utilizes child-led playful interactions, experiential problem-solving interactions and motor, sensory and spatial play, which is targeted at language and other cognitive skills (Greenspan and Weider, 1997).

Cognitive Therapy

With the advent of the cognitive revolution, pure behavioral therapies begun to fade out in favor of cognitive therapies, which followed the prominent model of human functioning at the time; computational theory (Hayes et al., 1999). Computational theory conceptualized the body as an “input-output device,” or the “hardware,” and the mind as the “central processor,” the “software,” or the “controller” (Shapiro, 2007). Due to their concurrent rise, articulation of the relationship between mind and body in cognitive therapy has been influenced by this computational perspective (Dowd, 2004).

Cognitive therapies are defined by their elevation of the cognitive system in the adjustment of information processing and initiation of positive change (Beck and Weishaar, 2008). This perspective is fundamental to a family of theories underpinning cognitive therapy, including those of Ellis (1962) and Beck (1967). Beck’s (1967) cognitive theory remains one of the most influential to this day, in particular his major contribution to cognitive therapy, the cognitive model (Triad) of depression. This model suggests that depression is underpinned by automatic, negative thoughts about the self, others and the world. Beck contends that these negative cognitions also activate negative motivational, behavioral, emotional, and physical symptoms (Beck and Weishaar, 2008). Thus, for Beck and his contemporaries, it is implied that the mind should be the primary target of psychotherapy.

One of Ellis’ major contributions to cognitive therapy was the A-B-C method used in his rational emotive behavior therapy (REBT). The A-B-C method challenged the assumption that when a consequence (C) follows and activating event (A), A causes C. Ellis posited a cognitive construct, beliefs (B), which he argued was the greatest determinate of (C). Thus, the idea was that (C) could be modified by (B), even if (A) remains stable (Dowd, 2004; Ellis, 2008). Ellis’ REBT explicitly considered the importance of content of the “mind” (i.e., thinking, feeling, wanting etc.), and of operations of the “body” (i.e., behavior). However, the relationship between mind and body was conceptualized in terms of cognitive modification to change behavior or behavior change to modify thought (Ellis, 2008). Thus, despite acknowledgment of both mind and body, REBT, akin to Beck’s cognitive therapy, implies a dualist conception of their relationship.

Mindfulness-Based Psychotherapies

Recently, there has been an influx of so-called “third wave” psychotherapies which have their roots in learning theory and are held together by their subordination of content-oriented cognitive interventions (Kahl et al., 2012). One of the key features of some of these psychotherapies (e.g., Acceptance and Commitment Therapy, Mindfulness-Based Cognitive Therapy etc.) is their focus on “mindfulness.” One of the features of mindfulness as applied in psychological therapies is to develop an awareness of the present experience by self-regulating attention to momentary sensations, thoughts, and feelings (Keng et al., 2011). Thus, in contrast to standard cognitive and behavioral therapies, one of the aims of mindfulness-based psychotherapies is to increase awareness of the body.

Awareness is contrasted with “thinking” during mindfulness exercises such as breathing meditation (Michalak et al., 2012). Awareness is not about cognition but more about feeling; and the body is seen as the reference point for awareness. Thus changes in cognitions (e.g., restricting rumination) following mindfulness practices are bought about by becoming more aware of the body, without referring to cognitive dominion (i.e., conscious thought) to bring about this awareness (Burg and Michalak, 2011). It is difficult to articulate the relationship between mind and body implied by mindfulness-based psychotherapies due to two reasons. First, awareness is not conceptualized as a cognitive feature, but may still be a feature of the “mind.” Second, the body is not conceptualized as a physical agent of change like behavior is assumed to influence cognition in cognitive behavior therapy (CBT); rather it is awareness of the body which is the agent of change in mindfulness-based therapies. These questions illustrate some of the issues which arise when dualistic thinking is reflected upon carefully.

Body Psychotherapy

Body psychotherapy (BP) refers to a variety of schools (e.g., dance/movement therapy, analytical body psychotherapy, concentrative movement therapy etc.) which share the aim of enhancing self-awareness, modifying behavior, and facilitating insight-oriented psychological problem solving via a mode of action concerning perceptive/self-awareness, affective-cathartic, interactive, and/or movement oriented therapy (Röhricht, 2009). Although, there have been randomized controlled trials (RCTs) conducted for some schools of body psychotherapies, they are not empirically supported to the same extent that cognitive and behavioral therapies have been (Röhricht, 2009). In practice, BP primarily works on releasing and re-shaping somatic memories in order to release associated psychological constraints (Totton, 2003). The theoretical foundation for BP has been explained as the way “core beliefs are embodied, and that until we begin to experience the pain held in them directly through our bodies they will continue to run our lives” (Staunton, 2002, p. 4).

The practice of BP implies a very close relationship between body and mind, to the point that they are seemingly undifferentiated during therapy. BP has been described as being fundamentally underpinned by an explicit theory of mind–body functioning which assumes a functional unity between body and mind in which there is no separation or hierarchical relationship between the two (www.eabp.org).

Summary

This brief review exposes a lack of consensus, both implicit and explicit, regarding the mind–body relationship across psychotherapeutic approaches. Themes arising from this analysis include a tendency toward dualism (separation of mind and body from the conceptualization of human functioning), exclusivism (elimination of either mind or body from the conceptualization of human functioning), or mind–body monism (conceptualization of mind and body as a single, holistic system). It is our position that psychotherapeutic research and practice would benefit from an organizing framework for the mind–body relationship, which could be applied across all psychotherapies. Recent research in philosophy (Clark, 1997; Lakoff and Johnson, 1999), cognitive science (Brooks, 1991; Chemero, 2009) and psychology itself (Barsalou, 1999; Glenberg and Robertson, 1999) suggests that this framework should be underpinned by a holistic conceptualization of the mind–body relationship.

Embodied cognition offers a psychological framework underpinned by a holistic conceptualisation of the mind–body relationship. Some of the abovementioned psychotherapies which have implied a holistic mind–body perspective have already started to draw on embodied cognition and related ideas. For example, Totton (2009) has recently highlighted the utility of drawing on embodiment from a social perspective to enhance the practice of body psychotherapy, while Michalak et al. (2012) has described how embodied cognition could describe some of the processes involved in mindfulness. Before describing the psychological framework of embodied cognition, it is important to briefly examine its philosophical underpinnings which form the foundation for its conceptualisation of a holistic mind–body relationship, from both phenomenological and objective perspectives.

Holistic Mind–Body Philosophies

Merleau-Ponty’s Lived-Body

Edmund Husserl developed the philosophical approach of phenomenology as a reaction to his concern that the assumptions of naturalistic, Western science about the nature of the mind, body, and world had caused it to miss fundamental questions about human nature (Marcum, 2004). He argued that primary consideration should be given to the subject’s experience in the world, before studying the mind, body, and world objectively (Marcum, 2004; Gallagher and Zahavi, 2007). Husserl’s argument was progressed by Merleau-Ponty, who proposed that this would both uncover the subjective element of knowledge, which was being overlooked by naturalistic sciences, and provide a stronger framework for its enquiries (Gallagher and Zahavi, 2007). Thus, phenomenology does not provide a mechanistic account of mind in the vein of naturalism, or psychological and biological accounts because it focuses on giving a proper description of humans’ experience in life, rather than attempting to forge an objective account of mind (Gallagher and Zahavi, 2007; Marshall, 2008).

Merleau-Ponty’s phenomenology argues for the prioritization of the subjective, lived-body in cognition and more specifically that cognitions cannot be understood without reference to the body which engages with the world (Merleau-Ponty, 1962, 1965; Marshall, 2008). Merleau-Ponty provides a comprehensive theory of the “lived-body,” or the “subject-body,” contrasting it to the “thing-body,” or the “object-body” (Merleau-Ponty, 1962, 1965; Marshall, 2008). The subject-body can be considered the body experienced from a first-person perspective which acts on the world, whereas the object-body can be considered the body as an object of the world experienced from a third-person perspective. Merleau-Ponty emphasizes the subject-body in cognition, implying that humans fundamentally are, and thus should be studied as embodied beings who form cognitions via interaction in the world with their bodies, rather than cognition as an activity of the “mind” which utilizes the object-body (Merleau-Ponty, 1962, 1965; Borrett et al., 2000; Matthews, 2004).

Dewey’s Principle of Continuity

In contrast to Merleau-Ponty’s phenomenological approach, an alternative holistic account of the mind–body relationship starts from an objective position. American pragmatism offers an objective, philosophical account of a holistic mind and body in the form of naturalism (Johnson, 2006). As Horst (2002) explicates, there have been various definitions and strands of naturalism. The account we refer to in this section aligns with the Darwinian paradigm and, more specifically with physicalism, emergence, and supervenience (Harbecke, 2013; Montero, 2013; McLaughlin and Bennett, 2014).

This form of naturalism is committed to an account in which all things in the world, including body and mind are natural or naturally emergent (Horst, 2002; Aikin, 2006). In turn, it posits that all explanation should be causal and reducible to natural explanations and is consequently committed to the study of the person as an object and the natural evolution of all human functions (Aikin, 2006; Johnson, 2006). One account of naturalism, from this emergent, supervenient perspective is Dewey’s “principle of continuity” (Dewey, 1981, 1991).

The principle of continuity posits that there is no break in experience between the processes of perceiving, feeling, moving, and thinking; instead they are levels of organic functioning from which higher function emerges. It describes three levels of organization: the “physical” level of inanimate material processes; the “psycho-physical” level of living things which have needs, interests, and satisfactions; and the “mental” level of organisms which can perform higher level cognitions. The principle explains the progression from the physical level to the level of the mind without introducing new ontological entities, structures, or forces. Dewey argues that new organization is the reason that organisms with minds can do things which psycho-physical entities cannot do, and why psycho-physical entities can do things which physical entities cannot do. Thus, according to Dewey, what we refer to as “mind” is a complex new organization of what we refer to as “body,” but they are in essence the same entity. According to the principle of continuity, what is termed “mind” and “body” are simply ways to identify aspects of the organism–environment interaction which have arisen from an organic process (Dewey, 1981, 1991; Johnson, 2006, 2007).

Phenomenology and Naturalism as Complementary Approaches

Phenomenology is committed to describing subjective experience, which is where meaning putatively arises for humans, while naturalism as characterized here provides an objective explanation of how meaning arises ontogenetically, organically and biologically, independent of the personal experience of the individual (Gallagher and Zahavi, 2007; Marshall, 2008). As Aikin (2006, p. 326) puts it “Lovers may love, and pains may pain, but the naturalistic perspective can attend only to the lovers, not their love; to the pains, but not their feelings of pain.” Similarly, the phenomenological perspective can attend only to the love, not the lovers and to the feelings of pain rather than the pains. Thus, phenomenologists can provide to naturalists, psychologists and neuroscientists a more precise model of the phenomenon which they attempt to explain than they would if they were to start only with an “objective” scientific theory of cognition (Gallagher and Zahavi, 2007). Thus, phenomenology and naturalism are contrasting, but complementary approaches (Aikin, 2006; Zahavi, 2010).

Accordingly, the different directions from which Merleau-Ponty’s phenomenology and Dewey’s principle of continuity approach the question of the relationship between mind and body are complementary, providing ultimately a more comprehensive, pluralistic understanding of the holistic mind–body relationship. Merleau-Ponty’s phenomenological account can inform Dewey’s objective account of how a person experiences the holistic mind–body described in his theory.

Thus, a philosophical integration of these perspectives may be possible (Zahavi, 2010), but our aim here is to provide a framework for psychotherapeutic research and practice. Therefore, it is necessary to provide a psychological account which integrates subjective and objective perspectives of a holistic mind–body relationship. We propose that grounded cognition provides such a framework.

Grounded Cognition as a Psychological Framework Reflecting a Holistic Mind–Body Relationship

Embodied cognition is a research program consisting of a number of accounts and topics, held together by the underlying assumption that the body functions as a constituent of the mind rather than a perceiver and actor serving the mind, thus being directly, and subjectively involved in cognition (Borrett et al., 2000; Shapiro, 2007). Different accounts of embodied cognition provide various models of this underlying assumption, so it is useful to focus on one to explore the holistic conceptualization of body and mind and how it aligns with the principles of Merleau-Ponty’s phenomenology and Dewey’s principle of continuity.

“Grounded cognition” reflects the underlying embodied cognition assumption by proposing that cognition is derived from, and dependent on, bodily interactions with the world which are represented in the brain (Barsalou, 2008). Grounded cognition has been comprehensively articulated and critiqued in the literature (Barsalou, 1999, 2008), has a strong empirical foundation (e.g., Schubert, 2005; Chandler and Schwarz, 2009; Jostmann et al., 2009; Natanzon and Ferguson, 2012 etc.) and most importantly, clearly explicates the holistic relationship of body and mind, aligning with both Merleau-Ponty’s phenomenology and Dewey’s principle of continuity as considered next.

Grounded cognition is underpinned by two major assumptions, namely that cognition is dependent on the body’s interaction with the world and that these interactions are represented in the brain (Barsalou, 2008). Grounded cognition’s first assumption is illustrated neatly by Shapiro (2011) in considering the concept of a morel mushroom for Sally, a mycologist, Charles, a provencal chef, and Lucy, a young child. Sally conceptualizes a morel as an epigenous ascocarp, Charles conceptualizes a morel as a delicacy to be sautéed with butter, and Lucy conceptualizes a morel as the yucky thing she has to eat before being allowed dessert. Thus, each according to their bodily experiences with morels forms different conceptualizations of it. However, these concepts are not determinate: for example, if Lucy grows up to become a mycologist, her concept of a morel would be more similar to Sally’s. Furthermore, it is important to note that there is nothing stopping Sally, Charles, and Lucy from having the same concept for a morel, it is simply their differing bodily interactions with the morel which has determined their conceptualizations. Finally, it can be assumed that they have the same visual conceptualization of a morel; they all know one when they see it. However, if Lucy were to have been born blind, she would never be able to obtain the same concept of a morel as Sally and Charles. Thus, grounded cognition aligns with Merleau-Ponty’s phenomenology by emphasizing the importance of subjective body-in-the-world experience for cognition (Johnson, 2006).

The second major assumption of grounded cognition is that the body’s relationship with the world is represented in the brain (Barsalou, 2008). Theories within grounded cognition differ on how these bodily interactions are represented in the brain, with some theories positing “image schemas” of bodily interactions in the world which are proposed to underpin abstract conceptual knowledge (Lakoff and Johnson, 1999). However, most grounded cognition theories propose “simulations,” which are neural reconstructions of experience using representations contained in modal systems of the brain (Glenberg, 1997; e.g., the sensorimotor system; Barsalou, 1999; Gallese and Lakoff, 2005). Thus grounded cognition is also consistent with Dewey’s principle of continuity in that from an objective, neuroscientific perspective, cognitions are emergent from, and inextricably intertwined with the body.

In sum, grounded cognition implies that cognition is emergent from and inextricably tied to the subjective, lived, experience of the body-in-the-world. Thus, “mind” and “body” only function as labels attached to properties of human functioning which we perceive as originating either mentally or physically. Conceiving of the relationship between body and mind from this holistic, psychological perspective can be expected to have a number of important implications for psychotherapy theory and practice.

Implications for Psychotherapy Theory and Practice

First, a holistic conceptualization of the mind–body relationship leads to a better understanding of the tensions between psychotherapy theory and practice. When the mind–body relationship is conceptualized from a dualist or exclusivist perspective, a tension is created between the phenomenological needs of the patient who is present mind and body and the emphasis on either mind or body according to the theoretical assumptions of the psychotherapy practiced by the therapist. One example of this is the de-emphasis of the body during the practice of psychotherapies whose underlying theory disembodies the mind. During such therapies (e.g., cognitive therapy), touch is purposefully excluded from therapeutic practice since the mind is conceptualized as the agent of change, even though therapeutic practice could possibly be enhanced by touch (Feltham, 2008).

Second, a psychologically articulated, holistic framework for the mind–body relationship encourages theoretical reflection about this relationship by challenging dualist and exclusivist assumptions inherent in some psychotherapies. In turn, this helps to clarify some of the points of difference between the psychotherapies described above. Numerous psychotherapies discussed in “Mind–Body Assumptions Underlying Current Psychotherapies,” have similar theoretical background and similar therapeutic practices. An example of this is traditional behavioral therapy and body psychotherapy. Both emphasize the body and conceptualize it as the agent of change and as a consequence, both prioritize the body in therapy. One of the primary differences between the two can be ascertained by reflecting on the mind–body relationship. Traditional behavior therapy is very much exclusivist, dismissing the mind and cognition and emphasizing the body and behavior, both methodologically and theoretically. Contrastingly, body psychotherapy recognizes cognitions whilst treating them via the body, thus implying a holistic conceptualization of mind and body.

Third, a holistic conceptualization of the mind–body relationship has the potential to further de-stigmatize mental illness (Thomas, 2013; Ungar and Knaak, 2013a,b). Ungar and Knaak (2013a) suggest that dismissive and blaming attitudes toward mental health issues can be attributed to the absence of an organic explanation for most mental health issues. Thomas (2013) suggests that promoting mental illness to non-psychiatric health professionals as an interaction between cognitive, behavioral, emotional, biological, and environmental factors would reduce dualistic thinking around mental health issues and help with de-stigmatization in these settings. The psychologically articulated, holistic conceptualization of the mind–body relationship presented here elaborates on Thomas’ idea by conceptualizing cognitive, behavioral, emotional, biological, and environmental factors as part of the same functional system, implying that “organic” causes are inseparable from “mental” causes. Thus, we propose that the holistic conceptualization of the mind–body relationship presented here will further help with de-stigmatization of mental illness in non-psychiatric settings.

Fourth, the clearly articulated, explicit position of a holistic mind–body portrayed by grounded cognition encourages a more reflective approach to the issue in practice. Theories underlying most current psychotherapies do not explicitly state their position regarding the relationship between mind and body. Consequently, practitioners unreflectively adopt the assumptions inherent in the psychotherapies they utilize. The clear articulation of a holistic mind–body from both phenomenological and objective perspectives may assist practitioners to reflect on this relationship. For example, from a grounded cognition perspective “mind” and “body” are only labels attached to properties of human functioning which we perceive as originating either mentally or physically. The issue for psychotherapy practice is that in using these labels with patients, they automatically divide psychopathologies into arbitrary categories and thus portray dualist or exclusivist agendas. This then restricts the patient’s conceptualization of what the psychopathology is and how to manage it. A grounded cognition perspective would encourage a broader language around psychopathologies as disorders of the “system,” whether the symptoms are perceived as mental or physical. This will encourage the patient to focus on the holistic nature of their symptoms during treatment, as opposed to the idea that some treatments are behavioral/bodily and others are mind/cognitive. This is but one example of changes which may come of reflecting on the mind–body relationship in practice.

Finally, a new perspective on the mind–body relationship will guide the identification of gaps in existing therapies and consequently promote an expansion of the range of therapies offered to the patient. For example, grounded cognition implies that one way to change cognitions is through the subjective, lived, bodily experience of the individual. Encouraging practitioners to reflect on a holistic mind–body approach may result in a wider range of therapies they can offer their patients stemming from this idea. Further development of these ideas may also result in the creation of new and innovative therapeutic methods to augment those already in existence.

Conclusion

Psychological science sits awkwardly between mind and body, and its application in psychotherapy inherits this awkwardness in a lack of clarity about how therapists should conceptualize their patients. By reviewing how mind and body are traditionally understood in major psychotherapies, we have attempted to underscore some of the tensions in this area. By introducing and outlining grounded cognition as a holistic psychological approach consistent with both radically subjectivist (Merleau-Ponty) and objectivist (Dewey) philosophical approaches, we hope to have proposed a new way forward for theorists and practitioners of psychotherapy. This new way forward throws light on the relationship between existing psychotherapies, the relationship between theory and practice, and highlights opportunities for new approaches to psychotherapy.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

References are available at the Frontiers site.