Cognitive Therapy and Research

https://doi.org/10.1007/s10608-020-10098-0

REVIEW

The Theory of Modes: Applications to Schizophrenia and Other

Psychological Conditions
Aron T. Beck1 · Molly R. Finkel1 · Judith S. Beck2

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
A novel, person centered approach to the understanding and treatment of severe mental illness—Recovery Oriented Cognitive
Therapy (CT-R)—has recently been implemented in many settings in the mental health care system. The theory and therapy,
originally based on clinical observations, are grounded on the assumption that the personality is composed of a number of
“modes” which are composed of specific components such as cognition, affect, motivation and behavior. The activation of
a particular mode and its status as relatively adaptive or maladaptive depends on the “fit” between an individual’s internal
impulses and cravings and external situational factors. In addition, persistent cognitive distortions within the modes may
be responsible for poor adaptation observed in psychiatric disorders. We outline here the difference between the reflexive,
automatic activation of modes and a separate superordinate function that provides oversight for the modes. We focus on
the theory of modes as it applies to schizophrenia, as individuals given this diagnosis are “stuck” in maladaptive modes.
Additionally, we outline some core therapeutic elements of CT-R, which aim to activate the adaptive modes of personality,
deactivate the maladaptive modes, and promote movement towards recovery. Finally, we project our understanding of modes
onto other psychopathological and non-clinical populations and propose suggestions for the application of this theory in
future research and practice.

Introduction and behavior. He became animated and carried on a lively

conversation with the server. More generally, he responded
David, a 37-year-old man diagnosed with schizophrenia, was adaptively to the various demands of the situation. For
generally in a withdrawn state. He would often lie on a couch example, he had no problem making change to pay for the
in the day room of the hospital and was non-responsive to hamburger when they were ready to leave. He even joked
suggestions about engaging in individual or group activi- with the cashier for a minute before paying. As soon as they
ties. One day, a clinician asked David about the activity that left the restaurant, he quickly began to revert to his previ-
he enjoyed most in the past. After much apparently serious ous psychotic behavior. The clinician recognized that the
thinking, he said, “I always enjoyed going to McDonald’s for period of adaptation to having a snack was short lived but
a hamburger.” The clinician then suggested that they go to a did demonstrate the potential for a return to more prolonged
casual restaurant on the campus of the hospital for a snack. or permeate adaptive functioning.
On the way, the individual carried on a conversation with his On further exploration, members of David’s clinical care
voices and occasionally strolled out into the road, where the team understood why going to a restaurant induced such a
clinician escorted him back onto the sidewalk. significant and adaptive shift in David’s behavior. Through
As soon as they arrived at the hamburger restaurant, various conversations with David over the next few months,
there was a rapid transformation of David’s appearance they realized that he had an intense interest in preparing and
serving food and that the underlying meaning of this particu-
* Aron T. Beck lar interest was his desire to care for others. David ultimately
[email protected] worked his way up from preparing food for himself to help-
ing prepare food for other individuals on the unit. During
1
Department of Psychiatry, University of Pennsylvania, these periods of time, which gradually progressed in dura-
Philadelphia, PA, USA
tion, his behavior was essentially adaptive. Upon discharge
2
Beck Institute for Cognitive Behavior Therapy, Bala Cynwyd, from the hospital, several months later, he no longer showed
PA, USA

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significant signs of psychosis. Importantly, David received person is composed of a collection of mental states at any
a fulfilling position in a restaurant, in which his main duty given time. Per this theory, there is a waxing and waning
was to prepare food. of these states so that as one mental state is activated, it
This individual’s clear and drastic shift in personality, replaces the previously activated mental state and therefore
which resulted in a presentation of adaptive functioning, is the self as a whole is changed (Pitson 2005).
common. In fact, we have observed this periodic transforma- Within the field of psychology, several theories share an
tion in many of the severely mentally ill individuals whom understanding of the self as multiple and distinctive ele-
we treat in hospitals and group homes. The occurrence of ments that can be activated depending on circumstance,
these episodes raises several questions: Is there a theoretical culture, or identity. Alfred Adler’s early works The Prac-
framework that describes these episodes of personality shift- tice and Theory of Individual Psychology (Adler1924) and
ing and what are the mechanisms involved in the improve- Understanding Human Nature (Adler 1954), described the
ment we see in individuals like David? Despite the lack of notion of the self as being directly related to and affected
established responses to these questions within the field by one’s self-image, one’s environmental surroundings, and
of schizophrenia research and treatment, similar episodic social interactions. Further, some humans overcompensate
shifting between depression and mania is well documented for feelings of inferiority which then leads to a superiority
in individuals with bipolar disorder. In addition, analogous complex. Later relevant theories regarding the self include
transient shifts have been observed in Dissociative Identity E. Tory Higgins’s self-discrepancy theory (Higgins 1987),
Disorder (DID) whereby a complete change in identity is Karen Horney’s theoretical concepts of the real self and the
observed during the activation of the various “alters”. ideal self (Horney 1991) and Hazel Markus’s ideas regarding
Similar types of personality transformations have been the independent self and interdependent self, and the signifi-
noted through the ages, and have formed the substance of cance of culture in understanding these distinct identities
folklore, philosophies and religious ideologies about the (Markus 1977; Markus and Kitayama 1991).
self. For example, one parable propounded by the Cherokee Other contemporary theorists within the field of person-
Indians is as follows: ality have also contemplated the notion of multiple selves.
Such theories include David Lester’s work on multiple self
“Two Wolves”: A Cherokee Legend
theory of personality which postulates that each individual
An old Cherokee is teaching his grandson about life.
self consists of intricate psychological processes includ-
“A fight is
ing thoughts, emotions and behaviors and details a for-
going on inside me,” he said to the boy.
mal description of 10 postulates and 49 corollaries (Lester
“It is a terrible fight and it is between two wolves. One
2010, 2012, 2017), Robert Lifton’s concept of the Protean
is evil—he is
Self which takes inspiration from ancient Greek mythol-
anger, envy, sorrow, regret, greed, arrogance, self-pity,
ogy (Lifton 1993), and Rita Carter’s writings of the major,
guilt,
minor, and micro sub-selves, which stem from parental influ-
resentment, inferiority, lies, false pride, superiority,
ence, past versions of individuals childhood self, and stereo-
and ego.” He
typical societal roles that individuals model such as that of
continued, “The other is good—his is joy, peace, love,
a caregiver or teacher (Carter 2008). Mendlovic (2008) has
hope, serenity,
taken a psychoanalytic approach to theorizing about multiple
humility, kindness, benevolence, empathy, generosity,
selves as sub-structures of the ego and traces the origin of
truth,
multiples selves to individuals’ childhood interactions with
compassion, and faith. The same fight is going on
their primary caregivers. While these theories have not been
inside you—and
widely applied in the clinical realm, other theories such as
inside every other person, too.”
Jeffrey Young’s schema theory have shown more clinical
The grandson thought about it for a minute and then
relevance. Young’s theory incorporates the notion of indi-
asked his
viduals having multiple mental states labeled “modes” (for
grandfather, “Which wolf will win?”
example, the Vulnerable Child mode) that include cognitive
The old Cherokee simply replied, “The one you feed.”
schemas and coping styles in response to these schemas.
It is apparent from the passage that two different states However, these maladaptive modes are only thought to form
encompass the personality but are alternately activated. if an individual’s basic needs and demands in childhood are
Descriptions similar to the Native American legend above not met (Young et al. 2006; Rafaeli et al. 2010).
have surfaced in philosophy as well. David Hume’s Bundle Religions have also focused on the concept of the self in
Theory of human nature explicates that any object consists similar ways. For example, the term Anatta in Buddhism
of a collection or bundle of elements (Hume 1969). This pertains to the idea of a “non-self” (Philip and Smith 2004).
theory has been applied to the concept of the self in that a Here, it is understood that a permanent or stagnant self does

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not exist but rather the self is an illusion (Carlisle 2006; Identity Disorder (DID)) that fit the idea of modes, whereby
Fulton 2008). In Christianity, there are also dueling versions the “separate personalities” could be seen as an extreme rep-
of the self, namely the true and false selves. In this case, resentation of the activation of different modes. The alter-
the true self speaks to the moral, socio-centric qualities of nate identities/personalities each display cognition, affect,
a person while the false self pertains to the immoral and motivation and behavior that is unique and untethered from
egocentric aspects, which are connected to the concept of the host identity/personality. Despite similarities between
sin (Vaden 2016). the construct of modes and the presentation of DID, no arti-
What the Cherokee legend, Hume’s philosophy, psycho- cles pertaining to the concept of modes in DID were ever
logical theories of the self, and religious views all have in published. Further refinements of the theory of modes fol-
common are their perspectives on the different aspects or lowed in a volume on depression (Clark and Beck 1999) and
structures of the central identity of the self. We consider a more recent article regarding the Generic Cognitive Model
that these different expressions are the result of the activa- (Beck and Haigh 2014).
tion of different structures within the personality that we The current iteration of the theory of modes and the
label as modes. In this paper, we will define a theory of simultaneous development of a clinical program entitled
modes, which clarifies the apparent oscillations in personal- Recovery Oriented Cognitive Therapy (CT-R) was a result
ity in psychopathology and non-pathological behavior. We of several observations that our schizophrenia research and
will also attempt to show the mechanisms responsible for clinical team made while working with individuals living
the activation and shift of the components of personality in in psychiatric hospitals or group homes in the community.
schizophrenia and demonstrate how the theory provides a First, we noted an interesting phenomenon that was not pre-
basis for a new psychotherapy for schizophrenia and other dicted by any of the current theories of schizophrenia. As
disorders. mentioned in the above in the case of David, we observed
that individuals would make drastic, periodic shifts in their
personality from being socially withdrawn, actively psy-
The Evolution of the Theory of Modes chotic and aggressive to being energetic, communicative,
friendly and totally in touch with reality. Additionally, we
The idea of modes first occurred when I (ATB) was working determined that consistently implementing certain therapeu-
with patients diagnosed with depression. It seemed that the tic strategies, such as providing opportunities for individuals
following observation required an explanation. I noted that to engage in personalized, meaningful activities, facilitated
the individuals were very different when depressed and non- the shift from a state of maladaptation to adaptation, and
depressed. Not only was there a profound shift in behavior thus had significant positive impact on the individuals.
towards withdrawal and avoidance when individuals were Throughout this discussion, we continue to focus on how
depressed, but there was also a system of corresponding the theory of modes has been inspired by and was adapted
beliefs such as “Life is hopeless” in the depressive phase. based on recent work with individuals diagnosed with
However, these maladaptive behaviors and beliefs seemed schizophrenia, since their shift from the maladaptive psy-
to disappear when the depression was lifted. Another indi- chotic and/or negative symptom mode to an adaptive mode
vidual compared himself quite unfavorably to other profes- has yet to be holistically theorized. Additionally, the theory
sionals in his field when depressed but tended to dismiss of modes constitutes an essential aspect of the therapeutic
these ideas as silly when the depressive symptoms were alle- intervention for this population (CT-R). However, we begin
viated. The changes in the individuals between depressed by introducing the basic definitional and structural concepts
and non-depressed phases were pronounced and required within the theory of modes in order to clarify the theory
an explanation. It seemed possible that unique facets of the and its applications to psychopathology and non-clinical
personality are activated in these unique phases. functioning.
I later realized that similar dynamics occurred in cases
of anxiety in which the anxiety was largely situational. The
individual, for example, experienced anxiety in a social situ- Definition of a Mode
ation but not in a non-social situation. This seemed to war-
rant the consideration of an anxiety organization (or mode) We define a mode as a specific internal construction of per-
that was activated by anxiety-driving stimuli. These observa- sonality. We propose that the role of the personality is adap-
tions then led to a preliminary theory of modes that could be tation and thus the function of the mode is to automatically
extended to all of psychopathology (Beck 1996), including modify a person’s adaptation to a specific context. More
a depression mode, an anxiety mode, a phobic mode, an specifically, the mode attempts to create a fit between the
OCD mode, and so on. Additionally, there were valid cases internal desires, needs, and impulses of an individual and
of multiple personality disorder (now labeled Dissociative the external demands of the stimulus situation. Ordinarily,

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there is a reasonable fit and the selection of a specific mode higher-level process which we call the superordinate process
is adaptive to the situation (for example, anxiety when there is then activated to inhibit this maladaptive response.
is a real threat; anger in response to an insult; sadness in
response to a loss; or pleasure in response to a gain). How-
ever, when the fit between the internal forces and external Structure of the Mode
situational demands is poor, there is interference of success-
ful adaptation and therefore inappropriate or maladaptive The personality functions of cognition, affect, motivation
behavior is expressed. and behavior, along with physiological responses, work syn-
Two examples from non-clinical experiences of adaptive chronously for the operation of a mode. The processes of
or “well-fitting” modes corresponding to demand character- activation, shifting of modes and deactivation is automatic.
istics are as follows. During a symphony concert, adapting Cognition, affect, motivation and behavior, provide unique
to the demands of the situations might include inhibiting and necessary functions for adaptation including providing
self-expression, intently watching the musicians and listen- context, understanding and meaning to stimulus situations
ing quietly. Conversely, while attending a baseball game, and activating or suppressing behavioral responses when
expressing one’s self through psychical exertion such as indicated.
clapping and cheering loudly is considered adaptive. Clearly,
the context of these two situations are vastly different and Cognition
thus, adaptive behavior for each situation is similarly dis-
tinct. Importantly, the activation of a mode also relies on In response to an external stimulus or event, the first func-
social and cultural expectations in addition to the fit between tion to be activated in a given mode is generally cognition
the self and the external environment. (automatic or preconscious) that then activates other person-
Important to the definition of this construct is the idea that ality functions such as affect, motivation and behavior. The
a given mode encompasses all of the personality domains mode consists of beliefs and attitudes that act as formulae
including cognitive, affective, motivational and behavioral for making rapid and automatic appraisals. The content of
components. This element of the definition sets the modal these cognitions is largely based on an appraisal of the cur-
construct apart from earlier work on depression by Beck rent situational demands, the perceived efficacy and dura-
et al. regarding negative/ maladaptive cognitive schemas bility of the self within that specific context (self-concept),
(Beck 1967, 1971; Dozois and Beck 2008), which generally past learning experiences (memories), attitudes and social
only consist of the cognitive components (both content and and cultural norms. Therefore, cognitions are often subject
process) that are systematically grouped to form the patterns to many personal biases. These cognitions, whether biased
of maladaptive cognitions. While, these cognitive schemas or not, form structures that we label schemas (Beck and
are a critical component of a mode, the mode more holisti- Haigh 2014). Depending on the particular situations that
cally includes cognition and any subsequent changes to the individuals face, different schemas may be activated that
affective, motivational and behavioral domains of person- can then induce a pattern of activated beliefs regarding one’s
ality. Throughout the historical iterations of the theory of view of the self, the outside world/others and the future (the
modes (Beck 1996, Beck 1999, Beck and Haigh 2014), this Cognitive Triad) (Beck 1967). Therefore, a mode is often
core feature of the definition has remained present and is maladaptive when persistent negative cognitive schemas are
vital to the understanding of how modes become activated. present, irrespective of the variability of external situations.
These individual components of the personality react in syn- Similarly, we note that adaptive cognitive schemas (which
chrony during the activation of a given mode. For example, were significantly less discussed in earlier work on cogni-
when in a maladaptive angry mode, an individual may have tive therapy) are vital to the activation of an adaptive mode.
the thought “They hurt me, and I should retaliate against Importantly, the intensity of particular beliefs directly cor-
them” and simultaneously experience a negative, angry responds to the degree of activation of a particular mode,
affective response. A corresponding motivational response as beliefs have direct effects on other personality domains
of taking action against the person who hurt them might within the mode.
follow, and a behavioral response of acting out retaliation
or revenge could then ensue. This example demonstrates Affect
that while a person may have other more positive attributes,
emotions and thoughts, during the activation of the angry The subjective experience that we label affect—such as
mode, only the functions of personality that are activated to sadness, happiness, pleasure, anger, and excitement—is
satisfy this mode are expressed. However, when the individ- generally stimulated after the activation of an automatic or
ual deems a particular behavior to be situationally or mor- preconscious thought. However, when affect is particularly
ally maladaptive or inappropriate in a particular situation, a salient, the preceding cognition may be overshadowed, and

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the individual may not be aware of the cognition. Affect social compass guiding us into appropriate behaviors (Freud
plays an important role, not only in adding richness to an 1923). In the cognitive psychology and cognitive therapy
individual’s life, but also being involved in the process of literatures, metacognition, or the ability to have awareness
motivation and memory. Additionally, the intensity of the and cognition regarding one’s own thought processes, is one
affective reactions signifies the significance of an event for example of this higher-level cognitive processing at work
both the person experiencing the affect and observers. (Metcalfe and Shimamura 1994; Moritz and Woodward
2007; Dunlosky and MetcalfeS 2008). In terms of cogni-
Motivation tion, the superordinate function acts as oversight, leading
individuals to reflect on the appropriateness of automatic
Along with the cognitive processing and affective responses cognitions. Similarly, this conscious cognitive process also
that coincide in a given mode, motivation is also activated. includes problem solving, decision making, deliberation and
Similar to automatic thoughts and affect, motivation often reasoning.
occurs automatically and spontaneously. These automatic There are unique circumstances where this superordinate
motivations have their roots in the primary schemas and process does not function adaptively. For example, when an
include protection (fight/flight reaction), reproduction, appe- individual is intoxicated or engaging in substance use, he/she
tite, and the need for social connection and love. Impor- may make maladaptive decisions that defy logic or reason.
tantly, motivations, whether adaptive or maladaptive to a This may be due to the inability to access one’s cognitive
particular situation, determine the subsequent behavioral resources and take part in reflective adaptive thoughts pro-
responses. cesses as well as a loosening of inhibition. Motivation is also
relevant within the superordinate function. In other words,
Behavior superordinate processing is responsible for the restraint or
disinhibition of an action when an individual consciously
The expression or inhibition of behavior is typically the last considers the appropriateness of that action in a particular
component of personality to be activated in a given mode. situation.
Thus far, we have stated that adaptive cognitive processing Because the modes are initiated and operate automati-
and relevant cognitions lead to adaptive affect, and adaptive cally, the superordinate component to modes is crucial to
motivation. From this understanding one could imply that function adaptively. In psychopathology, such as in cases of
the behavioral response indicated by the adaptive motivation suicidal individuals or those with substance use disorders,
would also be adaptive (a “good” fit between the internal there is often a lack of adaptive reflective oversight by the
needs and external circumstances). While this is generally superordinate function to inhibit these behaviors. These neg-
the case, there are some unique circumstances whereby the ative or maladaptive modes need to be moderated in order
intended adaptive behavior is not expressed and instead the for the individual to survive. Therefore, strengthening these
behavior is maladaptive despite prior adaptive motivation. higher-level processes is imperative to block the operation
For example, if the intended, adaptive behavioral response of a maladaptive mode or at least curtail its implementation
induces a fear of negative consequences such as in the cases by blocking the impulse and instead, initiating an adaptive
of social anxiety or test anxiety, this adaptive behavior will response. Additionally, the reflective, higher level processing
be suppressed. A non-clinical example would be if an adap- is typically available to an individual in an adaptive mode.
tive motivation to be assertive is activated, yet this motiva- Thus, a therapeutic target also becomes activating these
tion may trigger an interfering belief such as “If I am asser- adaptive modes more readily and frequently. In summary,
tive, the other person may be angry at me and that will be the superordinate function acts as reality testing, perspec-
terrible”. In this case, the adaptive behavioral response may tive-taking, objectivity, and logical and analytic thinking.
be suppressed. These clinical and non-clinical examples
show the critical, chain-like movement between personal-
ity functions of cognition, affect, motivation and behavior. Theory of Modes and Psychopathology

Superordinate/Reflective Processing Modal Conceptualization of Schizophrenia

We conceptualize that above the automatic processes of a The current understanding of the role of modes stemmed
mode, which includes the thread of cognition, affect, motiva- from working with individuals diagnosed with schizophre-
tion, and behavior, lies an overlapping conscious and delib- nia. It is well established in the literature that symptoms
erate function that we have named superordinate processing. of schizophrenia are grouped into clusters labeled posi-
This function can be compared to the Superego element of tive and negative symptoms (Andreasen and Olsen 1982;
the Freudian psychic apparatus in that it acts as a moral and Cutting 2003). We have relabeled the positive symptoms

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as psychotic symptoms to avoid confusion with our thera- maladaptive/ negative symptom mode and thus the therapeu-
peutic emphasis on the positive aspects of personality. The tic target becomes activating an alternative adaptive mode.
psychotic symptoms include delusions, hallucinations, The term adaptive mode is used to indicate that the pre-
disorganized speech and delusion-based behaviors such as dominance of the personality, including cognition, affect,
unwarranted aggression (Andreasen 1984). The negative motivation, and behavior, appears to be adaptively respond-
symptoms include anhedonia, asociality, anergia, amotiva- ing to both internal needs and external factors. Addition-
tion /avolition, and alogia along with the behavioral mani- ally, in the adaptive mode, individuals seem to have greater
festations of withdrawal and expressions such as flat affect access to reflective cognitive processing, effective decision-
(Andreasen 1982; Kirkpatrick et al. 2006). The questions making and problem-solving skills (superordinate organiza-
arise: how does one account for the emergence of these tion). In the beginning of treatment, the adaptive mode may
symptoms and how can professionals in the mental health be rather weak and thus the activation is usually short-lived.
field target these symptoms effectively using psychosocial In this case, individuals’ powerful negative beliefs often lead
methods. One can begin to make sense of the development them to revert to the psychotic and/or withdrawn modes.
of schizophrenia as well as the psychotherapeutic interven- Due to the positive outcomes observed when individuals are
tions by considering the symptoms domains as representing in the adaptive mode, the therapeutic goal is to incorporate
various modes: the psychotic mode, the negative symptoms/ interventions that will aid in increasing the frequency, dura-
withdrawn mode, and the adaptive mode, which represents a tion, and durability of the adaptive mode until this becomes
distinct shift away from the two symptomatic modes. the individual’s primary mode.
The psychotic/positive symptom mode is one example of
a mode which falls under the broader categorization of mala- Application of the Theory of Mode to the Treatment
daptive. The expression of these symptoms often reflects the of Schizophrenia
usual fears and worries of non-psychotic individuals but are
expressed in a symptomatic, maladaptive framework. For The critical observations of individuals with schizophrenia
example, psychotic symptoms such as paranoia reflect the shifting between maladaptive and adaptive modes aided in
individual’s sense of vulnerability to danger and the percep- conceptualizing and developing Recovery Oriented Cog-
tion of other people as hostile, controlling, and/or intrusive. nitive Therapy (CT-R). With these observations in mind,
Thus, the delusion of being poisoned by one’s family may the developers of CT-R and their clinical team attempted
reflect a deeper belief of being diminished or ostracized by to understand what factors accounted for this transition and
them. The delusion of being followed, having one’s mind indirectly, contributed to the theory as indicated. Generally,
read, or being observed by cameras, reflects the self-con- we have come to understand that individuals have strong yet
scious belief of being evaluated, judged, or controlled. The latent needs to be effective, accepted, respected, competent,
grandiose delusions for the most part, are an extreme over- and connected to others. Importantly, we found that when
compensation for the belief in one’s own inferiority, weak- individuals shift into an adaptive mode, these critical needs
ness or immorality. We have found that bizarre delusions and meanings in their lives can be met. Therefore, we con-
sometimes represent the fulfillment of a wish or drive. For ceptualized that one overarching therapeutic target would
example, the delusion of pregnancy in males often has the be a consistent activation of the adaptive mode and a cor-
underlying meaning of the desire to have someone to take responding deactivation of the maladaptive (psychotic and
care of, having a close friend or relationship, or being “nor- withdrawn) modes. Of course, the broader therapeutic target
mal” like other people. In this mode, individuals often can- would be to facilitate a pathway towards recovery. In order to
not express their underlying fears, challenges, and concerns activate and maintain an individual’s adaptive mode, clini-
via adaptive communication, affective expression, or behav- cians and other members of a clinical team can use a number
ior, and thus we label this psychotic mode maladaptive. of successful therapeutic interventions that are included in
The function of the negative symptom mode is far more Recovery Oriented Cognitive Therapy (CT-R) treatment.
easily comprehensible. In this maladaptive mode, the indi- The therapeutic style of the CT-R clinician is quite differ-
viduals often endorse the following beliefs: “I don’t have ent from the typical therapeutic approach to schizophrenia
the energy to do anything” (amotivation), “I can’t connect within the medical model. CT-R shies away from a focus
with other people” (asociality), and “I don’t enjoy any- on symptom reduction and observable behavioral strategies
thing” (anhedonia) (Beck et al. 2009, 2018; Campellone such as reinforcement, and cognitive remediation. CT-R
et al. 2016). These negatively biased beliefs are dysfunc- must also be distinguished from traditional cognitive ther-
tional attempts to protect the person from future experi- apy. Cognitive Therapy is generally more narrowly focused,
ences that they anticipate will lead to failure, social rejec- problem-centered and symptom-oriented in that it deals with
tion, powerlessness, and so on. These negative beliefs aid in highly specific maladaptive automatic thoughts/ attitudes
the strength, durability, and frequency of activation of the such as, “Since I failed this test, I am worthless”. Once these

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specific maladaptive misinterpretations about the self, the memories, or communication come about. In therapy, we
outside world and the future are identified, logic and reason- call the elements that activate energy and passion in indi-
ing are used to correct these cognitions. viduals the “sweet spot”. Of course, the sweet spot varies
By contrast, the central focus in CT-R is on activating from one individual to another—which allows for ultra-
the adaptive mode rather than directly deactivating the individualized treatment plans.
maladaptive modes. CT-R employs a holistic and humanis- When individuals are in the adaptive mode, it is impor-
tic approach to ferret out the individual’s values, interests, tant to help them notice the positive meaning of a learning
capacities, skills, provide collaborative experiences that experience. With each successive positive experience, the
cater to these attributes and provide new learning, and help clinician and individuals collaboratively draw conclusions
individuals draw positive conclusions that will support their that indicate that the individuals are safe, effective, in con-
pathway towards recovery. These fundamental aspects of trol, confident, and accepted. To return to the case of David
CT-R show resemblance to the basic tenets of positive psy- at the hamburger restaurant, a few very significant meanings
chology (Seligman and Csikszentmihalyi 2000) and more aided in the switch to the adaptive mode. For him, the suc-
specifically, some of the beliefs held by the field of positive cessful experience of ordering his food and interacting with
clinical psychology (Wood and Tarrier 2010). In addition the cashier at the restaurant meant that he was an effective
to understanding activities that may activate an individual’s and sociable person.
adaptive mode, it is also crucial to understand why this acti-
vation occurred. More specifically, the underlying meanings Aspirations
of skills, hobbies, or activities hold great therapeutic value
and often pertain to themes of connection, control, confi- Whereas the interventions listed above help to activate the
dence, empowerment, and safety. When clinicians and indi- adaptive mode, placing significant focus on an individual’s
viduals work collaboratively together to draw conclusions aspirations is important in order to ground the adaptive
regarding the meanings of events that activate the adaptive mode and maintain its activation throughout the course of
mode, future activities and aspiration setting can be focused treatment. This focus on aspirations in the treatment of the
around these meanings. severely mentally ill is akin to “valued goals” in Acceptance
Individuals might have different opportunities for activity and Commitment Therapy (ACT) (Bach and Hayes 2002).
while in treatment versus in the community. It is important However, a vital difference in the treatment of CT-R is the
to recognize the unique challenges that individuals face in focus on cognition. In CT-R, once the individual is in the
the community such as social isolation, lack of support and adaptive mode, it is then possible to identify their aspirations
disengagement. However, the hope is for individuals to find and reinforce positive beliefs about their ability to achieve
a similar meanings and purpose in the community. Thus, for these aspirations. Sometimes, the aspiration is not appar-
example, an individual who helped to organize plays put on ent but a therapist and individual search for meaningful and
by the individuals in an inpatient unit of a hospital eventu- gratifying activities that will bring purpose and meaning to
ally received a job in the community as a stagehand. The the individual’s life and thus shift or keep them in the adap-
former and the present activity both led to the individual’s tive mode. For the aspiration to resonate with the individual
feeling worthwhile and productive. Below we discuss some throughout the course of therapy, the following is required:
of the core therapeutic strategies of Recovery Oriented Cog- a) it must be authentic, individualized and meaningful, b)
nitive Therapy (CT-R) that are aimed to shift individuals reflecting on the aspiration must be accompanied by positive
from the maladaptive modes to the adaptive mode and sup- affect, and c) the path towards the aspiration must incorpo-
port a pathway towards recovery. rate successive steps. Important strategies to determine the
aspiration and build positive affect and confidence around
Activating the Adaptive Mode/ the “Sweet Spot” the idea of aspiration attainment include the use of imagery
and guided discovery regarding the meaning of the aspi-
We attempt to activate individuals’ adaptive modes by ration. The treatment then continues to provide activities
facilitating their participation in enjoyable and meaningful and experiences for the individual that either moves them
activities. The selection of an individualized and meaningful toward their aspiration or, when the aspiration is not yet
activity is based on a collaborative discussion about the indi- attainable or unrealistic, provide the same purpose or mean-
viduals’ interests, past enjoyments, skills, and values. Addi- ing as achieving the aspiration.
tionally, energizing experiences such as going for a walk
or listening to music can activate an individual’s adaptive Setbacks & Resilience Building
mode. Clinicians must be truly interested and engaged in the
activity that the individual agrees upon and be cognizant of Individuals should also be prepared to cope with the differ-
any content during the discussions in which positive affect, ent challenges, frustrations and disappointments that they

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are likely to encounter as they move through treatment and biases can range from mild to extreme and thus directly
eventually assume a more adaptive life in the community. predict the intensity, charge and durability of a maladap-
These challenges have the potential to induce a setback in tive mode. Because of the powerful effect of egocentrically
the individual’s treatment. In terms of the theory of modes, biased information processing, individuals display subjectiv-
we define setback and resilience as follows: ity toward their present situation. They fail to discern that
A setback is represented by an exacerbation of the indi- they are engaged in jumping to unreasonable conclusions,
viduals’ symptoms and a partial regression from the adaptive making snap judgments about themselves, others, and their
mode to the maladaptive mode. However, major elements of future, and selectively focusing on significant negative
the adaptive mode may still be still energized. events to the exclusion of neutral and/or positive events.
Resilience is represented as either a continual activation They also may be incapable of gaining perspective, that is,
of the adaptive mode despite a challenge or a return to the seeing present challenges as catastrophic or representative
adaptive mode following a setback or relapse. of their character in a holistic way rather than as setbacks
Often the setback and activation of the maladaptive within the broader context of their lives.
modes occur when there is a shift in care, when individuals Conversely, when people are engaged in adaptive think-
are confronted with a series of problematic tasks, or when ing, they are aware of the irrational or dysfunctional ele-
they have been involved in one or more unpleasant social ments of a particular maladaptive mode. This kind of aware-
experiences. These stressors impinge on a congruent nega- ness is often called cognitive insight (Beck et al. 2004; Riggs
tive belief and set in motion the reactivation of a maladaptive et al. 2010). When individuals can see or imagine a reality
mode. Increasing constructive thinking through role-play or outside of the content of this biased mode, they may gain
in-vivo activities after a setback can be helpful in re-initiat- perspective by distancing themselves from the content of the
ing the adaptive mode. Another strategy for building up the mode and be able to take in information in a broader context.
adaptive mode after a setback is identifying previous suc- Therefore, one of the most vital elements in the treatment
cess experiences that can be used in the current treatment as of all disorders is the attempt to shift from a biased, subjec-
examples of the individual’s strength, control, and resilience. tive, egocentric maladaptive mode to an unbiased, broad and
Finally, it is important for clinicians to explain the normality perspective-taking adaptive mode.
of setbacks and challenges along the pathway to recovery. In Standard cognitive behavior therapy has achieved great
fact, we believe that certain cognitive and behavioral skills popularity in academic and clinical realms, as well as excel-
can be enhanced only by experiencing challenges and suc- lent results for its conceptual validity and efficacy for a num-
cessfully overcoming them. With proper application, these ber of clinical populations(Hofmann and Smits 2008; Beck
CT-R interventions serve to enhance the individual’s adap- and Alford 2009; Bisson et al. 2013; Cuijpers et al. 2014;
tive qualities including competence, self-confidence, and Öst et al. 2015 (for general reviews see Butler et al. 2006
control, and simultaneously reduce negative aspects such and Hofmann et al. 2012)). Traditional techniques include
as insecurity, low self-esteem, and dysfunctional attitudes. the use of reasoning and logic to modify the negative misin-
terpretations of individuals’ experiences. These techniques
Application of Theory of Modes to Other Conditions have been well outlined in the volume Cognitive Therapy:
Basics and Beyond by Judith Beck (Beck 2011). Despite the
Following the successful work using the theory of modes as efficacy of these interventions for many individuals, they are
a framework with individuals diagnosed with schizophrenia, often insufficient for individuals who are chronically afflicted
another interest was in determining whether the principles of with mental health disorders. We believe that CT-R, with
the theory of modes applied to non-psychotic populations. its person-centered, holistic approach, would be particularly
Indeed, we found that there is a wide variety of disorders effective with these individuals, who tend to be poorly inte-
for which the concept of modes is applicable. The various grated and have a variety of challenges other than their out-
non-psychotic disorders tend to be partially characterized ward symptomatology (including lack of confidence, beliefs
by the presence of specific biases in cognitive processing about being ineffective, difficulties in relationships and/or
which permeates the entire mode. For example, in anxiety, interpersonal interactions, and a general lack of enjoyment
the bias is often related to vulnerability. In depression, it is in life (See Beck et al. (in press), which describes CT-R for
self-devaluation. The cognitions that create the dominant individuals diagnosed with serious or complex mental health
biased beliefs are largely drawn from internal information conditions and Beck (in press) for a blending of traditional
such as memories of past failures and expectations of future and recoveryCarlisle -oriented techniques for higher func-
failure. The biases created by focusing on such information tioning clients). CT-R directly addresses these challenges by
extends to attention, information processing and interpreta- emphasizing the positive aspects of personality (the adap-
tion (or rather misinterpretation). Depending on the degree tive mode) and increasing pleasurable, efficacious and social
of activation, the attentional, processing and interpretative experiences to build up the individual’s morale and sense

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Cognitive Therapy and Research

of security. As an indirect benefit of treatment, individual’s Therapy (CT-R), randomized controlled trials are needed
maladaptive modes (which include maladaptive thinking, to compare standard Cognitive Therapy, treatment as usual,
affective reactions, motivation, and behavioral expressions) and CT-R (for uncomplicated diagnoses and treatment resist-
deactivate, and the impact of the disorder on their lives ant diagnoses).
decreases. Of course, we acknowledge that further research Other interesting avenues of future research should
is required to substantiate these clinical findings. explore neurophysiological changes in the brain that cor-
respond with the activation of adaptive and maladaptive
modes. For example, a headset can be used to record an
Discussion & Future Directions individual’s EEG when they are in a maladaptive mode and
again when the individual’s adaptive mode is activated.
This updated formulation of the theory of modes and the EEGs and neuroimaging could also be used to assess the
conceptualization of psychopathology based on this theory individual’s progress as a result of the interventions. It may
was inspired by clinical observations of individuals diag- also be relevant to research the mechanism of constriction
nosed with schizophrenia, who could temporarily shift in visual fields that may be associated with “tunnel vision”
within seconds from a remote, withdrawn state, replete with biases in maladaptive modes.
voices and delusions, into an apparently adaptive state, hav- The theory of modes and its application to research and
ing full command of their faculties. We have also observed treatment have important implications as we look toward the
this paradox in non-clinical behavior where, for example, an future of cognitive theory and therapy. These include: (1)
individual can move within seconds from being gentle and refining treatment for inpatient and outpatient populations
kind, into a rage, striking out at the person whom they love. with treatment-resistant conditions using Recovery Oriented
Our work with individuals diagnosed with a serious men- Cognitive Therapy (CT-R), (2) a continuing emphasis on
tal health condition involved expanding our thesis of how enhancing the positive and adaptive features of individuals,
beliefs, affect, and motivation lead to behavior. We found and (3) reconceptualizing cognitive treatments based on an
that underlying the inappropriate or dysfunctional behav- overarching, trans-diagnostic theory of modes, rather than
ior, which we describe as maladaptive, was a sequence. The ultra-specific, manualized approaches to treat different forms
sequence begins with the activation of maladaptive cogni- of psychopathology.
tions (for example, cognitive distortions such as overgeneral-
ization, selective abstraction, tunnel vision, etc.). Often, the
strength and durability of these maladaptive beliefs overrode Author Contribution Credit for original conceptualization of the manu-
script given to A.T.B with significant contributions in idea formulation,
the individual’s capacity to take an adaptive, reality-based writing, editing and design of manuscript given to M.R.F. Literature
view, which would include accurate self-observation and review conducted by M.R.F. The first draft of the manuscript was writ-
perspective taking. These durable maladaptive cognitions ten by A.T.B and M.R.F. Supervision, critical commentary and signifi-
then quickly affect individuals’ affective expressions, access cant revisions provided by J.S.B. All authors edited and commented
on previous versions of the manuscript. All authors read and approved
to motivation and behavioral responses, thus encompassing the final manuscript.
a holistic adaptive mode. With specific Recovery Oriented
Cognitive Therapy (CT-R-) interventions, we find it possible Compliance with Ethical Standards
to modify maladaptive beliefs or entire maladaptive modes
indirectly by accessing more positive, adaptive modes. More Conflict of Interest Aron T. Beck, Molly R. Finkel and Judith S. Beck
importantly, frequent activation of adaptive modes seems to declare that they have no conflict of interest.
promote a significant reduction of individuals’ symptoms
Ethical Approval No procedures were used in this study, no humans
and progressive movement toward their aspirations and a or animals participated in this study. The writing of this manuscript
state of recovery. was in accordance with the national and international ethical standards.
There are many possible directions for future research
related to the theory of modes. First, it would be valuable to Informed Consent No informed consent had to be obtained from any
subjects.
develop instruments that measure different components of
the theory of modes, for example, the intensity or speed of Animal Rights No animal studies were carried out by the authors for
activation of a given mode. Another measure could exam- this paper.
ine specific cognitions and attitudes that may signal a shift
from one mode to another. Outcome studies are also needed
to more deeply understand the components of the theory References
of modes and the significance of specific mediators and
moderators in greater depth. Because the theory of modes Adler, A. (1924). The practice and theory of individual psychology.
is heavily incorporated into Recovery Oriented Cognitive Brace: Harcourt.

13
 Cognitive Therapy and Research

Adler, A. (1954). Understanding human nature (WB Wolfe, Trans.). Fulton, P. R. (2008). Anatta: Self, non-self, and the therapist. In S. F.
New York: Fawcett Premier. (Original work published 1927). Hick & T. Bien (Eds.), Mindfulness and the therapeutic relation-
Andreasen, N. C. (1982). Negative symptoms in schizophrenia: Defi- ship (pp. 55–71). New York: Guilford Press.
nition and reliability. Archives of General Psychiatry, 39(7), Freud, S. (1923). The ego and the id. SE, 19, 1–66.
784–788. Higgins, E. T. (1987). Self-discrepancy: A theory relating self and
Andreasen, N. C. (1984). Scale for the assessment of positive symp- affect. Psychological Review, 94(3), 319–340. https ​ : //doi.
toms. Iowa City: University of Iowa Department of Psychiatry. org/10.1037/0033-295X.94.3.319.
Andreasen, N. C., & Olsen, S. A. (1982). Negative v positive schizo- Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy
phrenia: Definition and validation. Archives of General Psychia- for adult anxiety disorders: A meta-analysis of randomized pla-
try, 39(7), 789–794. https:​ //doi.org/10.1001/archps​ yc.1982.04290​ cebo-controlled trials. The Journal of Clinical Psychiatry, 69(4),
07002​5006. 621.
Beck, A. T. (1967). Depression: Causes and treatment. University of Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A.
Pennsylvania Press. (2012). The efficacy of cognitive behavioral therapy: A review of
Beck, A. T. (1971). Cognition, affect, and psychopathology. Archives meta-analyses. Cognitive Therapy and Research, 36(5), 427–440.
of General Psychiatry, 24(6), 495–500. Horney, K. (1991). Neurosis and human growth: The struggle toward
Beck, A.T. (1996). Beyond belief: A theory of modes, personality, and self-realization. WW Norton & Company.
psychopathology. In Salkovskis, P.M. (Ed) Frontiers of Cognitive Hume, D. (1969). A treatise of human nature. London: Penguin. (Origi-
Therapy. Guilford Press nal work published 1739–1740)
Beck, A. T., & Alford, B. A. (2009). Depression: Causes and treatment Kirkpatrick, B., Fenton, W. S., Carpenter, W. T., & Marder, S. R.
(2nd ed.). University of Pennsylvania Press. (2006). The NIMH-MATRICS consensus statement on negative
Beck, A. T., Baruch, E., Balter, J. M., Steer, R. A., & Warman, D. M. symptoms. Schizophrenia Bulletin, 32(2), 214–219.
(2004). A new instrument for measuring insight: the Beck Cogni- Lester, D. (2010). A multiple self theory of personality. Hauppauge,
tive Insight Scale. Schizophrenia Research, 68(2–3), 319–329. NY: Nova Science.
Beck, A.T., Grant, P.M., Inverso, E., Brinen, A., & Perivoliotis, (in Lester, D. (2012). A multiple self theory of the mind. Comprehensive
press). Recovery oriented cognitive therapy for serious mental Psychology, 1, 02–09.
health conditions. New York, NY: The Guilford Press. Lester, D. (Ed.). (2017). On multiple selves. Routledge.
Beck, A. T., & Haigh, E. A. (2014). Advances in cognitive theory and Lifton, R. J. (1993). The Protean self. New York: Basic Books.
therapy: The generic cognitive model. Annual Review of Clinical Markus, H. (1977). Self-schemata and processing information about
Psychology, 10, 1–24. the self. Journal of Personality and Social Psychology, 35(2), 63.
Beck, A. T., Himelstein, R., Bredemeier, K., Silverstein, S. M., & Markus, H. R., & Kitayama, S. (1991). Culture and the self: Implications
Grant, P. (2018). What accounts for poor functioning in people for cognition, emotion, and motivation. Psychological Review,
with schizophrenia: a re-evaluation of the contributions of neu- 98(2), 224–253. https​://doi.org/10.1037/0033-295X.98.2.224.
rocognitive v. attitudinal and motivational factors. Psychological Mendlovic, S. (2008). L’ordine sociale dei sè multipli [The social order
Medicine., 48, 1–10. https​://doi.org/10.1017/S0033​29171​80004​ of the multiple self-s]. Rome: Alpes Italia.
42. Metcalfe, J., & Shimamura, A. P. (Eds.). (1994). Metacognition: Know-
Beck, A. T., Rector, N. A., Stolar, N., & Grant, P. M. (2009). Schizo- ing about knowing. MIT press.
phrenia: cognitive theory, research, and therapy. New York, NY: Moritz, S., & Woodward, T. S. (2007). Metacognitive training in
Guilford Press. schizophrenia: from basic research to knowledge translation and
Beck, J. S. (2011). Cognitive behavior therapy (2nd ed.). New York, intervention. Current Opinion in Psychiatry, 20(6), 619–625.
NY: The Guilford Press. Öst, L. G., Havnen, A., Hansen, B., & Kvale, G. (2015). Cognitive
Beck, J.S. (in press). Cognitive Behavior Therapy (3rd ed.). New York, behavioral treatments of obsessive-compulsive disorder. A sys-
NY: The Guilford Press. tematic review and meta-analysis of studies published 1993–2014.
Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R., & Lewis, C. Clinical Psychology Review, 40, 156–169.
(2013). Psychological therapies for chronic post-traumatic stress Philip, N., & Smith, H. (2004). Buddhism: A concise introduction.
disorder (PTSD) in adults. The Cochrane Library, 12, CD003388. Harper San Francisco.
Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). Pitson, T. (2005). Hume’s philosophy of the self. Routledge.
The empirical status of cognitive-behavioral therapy: a review of Rafaeli, E., Bernstein, D. P., & Young, J. (2010). Schema therapy:
meta-analyses. Clinical Psychology Review, 26(1), 17–31. Distinctive features. Routledge.
Campellone, T. R., Sanchez, A. H., & Kring, A. M. (2016). Defeatist Riggs, S. E., Grant, P. M., Perivoliotis, D., & Beck, A. T. (2010).
performance beliefs, negative symptoms, and functional outcome Assessment of cognitive insight: A qualitative review. Schizo-
in schizophrenia: A meta-analytic review. Schizophrenia Bulletin, phrenia Bulletin, 38(2), 338–350.
42(6), 1343–1352. https​://doi.org/10.1093/schbu​l/sbw02​6. Seligman, M. E. P., & Csikszentmihalyi, M. (2000). Positive psychol-
Carlisle, C. (2006). Becoming and Un-becoming: The theory and prac- ogy: An introduction. The American Psychologist, 55, 5–14.
tice of Anatta. Contemporary Buddhism, 7(1), 75–89. https​://doi. Vaden, M. B. (2016). The false self and true self: A christian
org/10.1080/14639​94060​08780​34. perspective.
Carter, R. (2008). Multiplicity. New York: Little Brown. Wood, A. M., & Tarrier, N. (2010). Positive clinical psychology: A new
Clark, D. A., & Beck, A. T. (1999). Scientific foundations of cognitive vision and strategy for integrated research and practice. Clinical
theory and therapy of depression. John Wiley & Sons. Psychology Review, 30(7), 819–829.
Cuijpers, P., Sijbrandij, M., Koole, S., Huibers, M., Berking, M., & Young, J. E., Klosko, J. S., & Weishaar, M. E. (2006). Schema therapy:
Andersson, G. (2014). Psychological treatment of generalized A practitioner’s guide. Guilford Press.
anxiety disorder: A meta-analysis. Clinical Psychology Review,
34, 130–140. Publisher’s Note Springer Nature remains neutral with regard to
Cutting, J. (2003). Descriptive psychopathology. Schizophrenia, 42, jurisdictional claims in published maps and institutional affiliations.
15–24.
Dozois, D. J., & Beck, A. T. (2008). Cognitive schemas, beliefs and
assumptions. In Risk factors in depression (pp. 119–143). Elsevier.
Dunlosky, J., & Metcalfe, J. (2008). Metacognition. Sage Publications.

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