Control mastery theory or CMT is an integrative theory of how psychotherapy works, that draws on psychodynamic, relational and cognitive principles. Originally the theory was developed within a psychoanalytical framework, by psychoanalyst and researcher Joseph Weiss, MD (1924-2004). CMT is also a theory of how the mind operates, with an emphasis of the unconscious, and how psychological problems may develop based on traumatic experiences early in life. The name of the theory comes from two central premises; the assumption that people have control over their mental content, and the belief that patients who come to therapy are fundamentally motivated to master their lives.
History The one-page article, "Crying at the Happy Ending" (Weiss, 1952), has been considered to mark the point where Weiss began to formulate the ideas underlying CMT. In this short article he described the phenomenon of delay of affect, where an emotion that connects to a particular upsetting situation is warded off until the situation has passed, and it is perceived safe to release the emotion. Following this, Weiss turned to focus on how patients make progress in therapy. Through studying detailed process notes of psychotherapy sessions, he identified segments thought to mark therapeutic progress, and looked at what immediately preceded such instances. Progress within sessions was defined as the emergence of new material or behavior. He concluded that patients make progress in therapy when they feel safe in the therapeutic relationship, and that patients continually make appraisals of conditions of safety in relation to others. Some of the ideas that helped form CMT were mentioned in certain passages of Freud's later writings, but the basic concepts of the theory were developed through Weiss's study of psychotherapy notes. In 1965, Weiss was joined by Harold Sampson, PhD (1925-2015). They met daily to collaborate on researching Weiss' theories. Formal research on the theory began in 1972 when Joseph Weiss together with Harold Sampson founded the Mount Zion Psychotherapy Research Group (now known as the San Francisco Psychotherapy Research Group; SFPRG). This research was based on the assumption that while therapeutic processes will be case-specific, there are also some common and lawful principles that govern how psychotherapy works, or fails to work. In 2017 an additional group was formed called the International Control Mastery Therapy Center (CMTC) whose goal is to help disseminate the theories of CMT worldwide (see CMTCenter.Net).
Core principles
Psychopathology stems from pathogenic beliefs that have developed from traumatic experiences According to CMT, psychological problems (of non-biological origin) largely come from pathogenic beliefs that have developed as a result of traumatic experiences, typically occurring in childhood. Trauma in CMT is broadly defined as experiences that impair a person's normal growth and development, with an emphasis on interpersonal experiences. Pathogenic beliefs are intrapsychic structures of distorted ideas of the self in relation to the world. These beliefs hold the patient back because they suggest pursuing developmentally normal and healthy life goals will result in terrible consequences for one self or loved ones. Pathogenic beliefs are often unconscious, but deeply rooted, and associated with negative emotions such as anxiety or guilt. Though the pathogenic beliefs in themselves may be irrational, exaggerated or incorrect, CMT holds that they are generally based on real experiences. The traumas underlying these beliefs could either be "shock traumas" or "stress traumas". Shock traumas are sudden and dramatic single events that are perceived as frightening and overwhelming, while stress traumas are repetitive events that over time create strain.
In further explaining how pathogenic beliefs develop, CMT starts with the assumption that humans through evolution are geared towards adaptation. In agreement with attachment theory, CMT acknowledges that the young child is dependent on the family for survival and emotional security, and therefore highly motivated to adapt to the family environment and maintain emotional bonds to significant others. Further, in alignment with findings from infant research, CMT assumes that children from infancy start forming and testing hypotheses about the world. As a result of this adaptive process they infer beliefs about themselves, others and their environment. However, since children have limited life experience, and not fully developed cognitive abilities, they sometimes draw false conclusions. Difficulties with understanding and interpreting traumatic experiences could result in the formation of pathogenic beliefs. Further, a core principle in CMT is the notion that behavior is thought to be regulated by perceptions of safety versus danger. When traumatic events or interchanges occur, children will attempt to understand what caused the event and what they might do to avoid it. Therefore, another component thought to be important for the formation of pathogenic beliefs, is the unconscious need to maintain a feeling of safety. For example, a child who has been abused by a caregiver might infer that the abuse happened because of something they themselves did, and that it was deserved. This belief might make them feel safer than assuming their caregiver is unpredictable and dangerous. If such experiences persist, the child might internalize a pathogenic belief that they are bad, and deserve to be mistreated. Though most pathogenic beliefs come from attempts at adaptation, they ultimately become maladaptive, as they inflict suffering and hinder the person from pursuing important life goals. Pathogenic beliefs may also develop after traumatic experiences in adulthood, but children are generally viewed as more vulnerable because of their cognitive level, and their dependence on others.
In CMT, children are understood to be intensely loyal to their parents, and also driven by prosocial concern for the well-being of their family members. For these reasons, pathogenic beliefs resulting from traumatic experiences with significant others is thought to have a moral component. They are not only beliefs about how things actually operate in the world, but also about how things morally should be. The interpersonal manifestations of pathogenic beliefs, where the patient repeats negative experiences from childhood, are called compliances and pathogenic identifications. A compliance would be when a person thinks that the way he or she was mistreated as a child, is the correct way he or she should be treated. A pathogenic identification would be when a person repeats the traumatizing behaviors of a parent, and believes it is morally correct to treat others in this way.
Patients are motivated and have a plan for the therapy CMT posits that patients who come to therapy are motivated to master their trauma, and overcome their pathogenic beliefs. In addition, it is thought that the patient has an unconscious plan for how they will get better, which involves how they will test pathogenic beliefs with the therapist. The most important task of the therapist is to create conditions of safety to allow the patient to carry on with their plan, and react to the patient in ways that will help disconfirm their pathogenic beliefs. Interventions that are successful in achieving this are called pro-plan, while interventions that the patient perceive as confirming a pathogenic belief are considered anti-plan and a hindrance to therapeutic progress. Weiss described that there are three primary ways pathogenic beliefs may become disconfirmed or less powerful; 1) by use of the therapeutic relationship in itself, 2) by gaining insight through interpretations that help disconfirm such beliefs, or 3) when the patient tests a pathogenic belief directly with the therapist, and the therapist reacts in a way that help disconfirm the belief (passes the test).
Treatment by attitudes Interpersonal relationships are seen as inherently transformative in CMT, and the therapeutic relationship is seen as a context where the patient is motivated and change is likely to occur under the right conditions. It is held that the therapeutic relationship in itself may help patients overcome pathogenic beliefs, through what is called treatment by attitude. Therapists are assumed to consciously and unconsciously convey attitudes about the patient through their actions, words, silences, mannerisms, and affective responses or the lack of them. Similarly, the patient is assumed to be especially attentive, both consciously and unconsciously, toward therapist attitudes that relate to their own goals and pathogenic beliefs. It is believed that the therapeutic relationship may be transformative when the patient feels safe in the relationship, and perceives the therapist's attitudes toward them as disconfirming a pathogenic belief. Treatment by attitude may be planned according to the therapist's understanding of the patient's history and psychology, or happen spontaneously and outside the conscious awareness of either participant. The concept of treatment by attitudes can be likened to the concept of the corrective emotional experience described by Alexander and French in 1946, but there are some differences. In CMT, the therapeutic work is viewed more as a collaborative effort. CMT underlines that patients play an active role in seeking out experiences that will lead to progress, and coach the therapists in how to help them.
Patients coach the therapist The concept of coaching is unique to CMT, and refers to patient behaviors and communications designed to attune the therapist to the patient's conscious and unconscious goals, and how best to address the patient's issues. Through coaching the therapist, the patient informs and guides the therapist in how to most efficiently support them in carrying out their plan for treatment. Coaching behaviors are thought to be most prevalent at the beginning of therapy, as well as before, during and after presenting important tests to the therapist. Also, coaching may be used to alter the therapeutic relationship, for example when patients want to change their strategy for disconfirming pathogenic beliefs.
Patients test the therapist