INTEGRATION OF JUNGIAN AND SCHEMA THERAPIES TO INCREASE PATERNAL INVOLVEMENT IN THEIR SON’S MENTAL HEALTH TREATMENT
Cognitive theory informs the majority of evidence-based approaches to treating adolescent mental health disorders. While some cognitive approaches attempt to incorporate families, they do not have a model for engaging and utilizing fathers in adolescent mental health treatment. This dissertation will provide an integrated theory that incorporates core elements from Jungian theory and schema theory, to provide a theoretical scaffold for future research and practice for engaging father’s in adolescent male’s mental health treatment.
CHAPTER 1. INTRODUCTION
Adolescence is often a difficult time for families (Arnett, 2006; DuPont-Reyes et al., 2019). More than a century ago G. Stanley Hall (1904) described adolescence as a time of “storm and stress.” As children transition from identification with and dependence upon parents, to differentiation and independence from parents, families experience stress (Darling et al., 2008). Adolescents experience rapid physical, cognitive, biological, physical, psychological, emotional and behavioral changes (Kapetanovic et al., 2019). While they are beginning to mature sexually, their peer relationships become more complex, nuanced, and central to their lives. Through this process, adolescents are developing their individual identity and sense of self, as well as their understanding of who they are in relation to their social world (Shaffer & Obradović, 2017).
Erickson (1950/1963) asserted that the developing personality moves through eight stages of psychosocial development, beginning in infancy and continuing through adulthood. Within each stage; the developing individual encounters a psychosocial crisis, the outcome of which shapes ongoing personality development. Adolescents, according to Erickson (1950/1963), enter the fifth stage of development: Identity vs. Role Confusion, which is characterized by adolescents’ efforts to develop of sense of their individual identity, while looking toward the future and the roles/identities they will assume as adults in their social, sexual and vocational occupational relationships. Erickson (1963) used the word “moratorium” (p. 262) to describe adolescence, in the sense that adolescents are suspended in an in-between space, between childhood and adulthood. At times adolescents feel and behave like rapidly developing adults; moments later they may feel and behave like children. During this chaotic time, parents frequently struggle to understand and effectively communicate with the adolescents in their lives, which can result in volatility, emotional distance and isolation, for the parents and their teenagers (Li et al., 2018).
Within the context of this challenging time for adolescents and their families, depression, anxiety problems, and behavioral/conduct problems are common among adolescents. As Sherman et al. (2019) noted, the 2016 National Survey of Children’s Health (NSCH) found that among children ages 3-17 years, 7.1% have anxiety related concerns, 7.4% have current behavioral/conduct problems, and 3.2% have depression. With each disorder the prevalence becomes higher as children transition into adolescents, and with anxiety and behavior/conduct problems, the prevalence appears to have increased significantly since previous surveys in 2007 and 2012. Significant correlations were noted between childhood/adolescent mental health disorders, children’s overall health, and parent/caregivers mental/emotional health issues (Sherman et al., 2019).
In contrast to the increased prevalence of anxiety and behavioral/conduct disorders, mental health services are underutilized among adolescents in the United States (Englar-Carlson, 2013), particularly among boys (APA, 2018; DuPont-Reyes et al., 2019; Rice et al., 2018). Rice et al. (2018) found that adolescent boys and younger adult males are underserved relative to their mental health needs, noting that for boys in the 16–24 age range, population estimates suggest that only 13.2% of that population who experience a mental health problem will access mental health services. Adolescent mental health issues dramatically increase the tension, stress and complexity families experience during typical adolescent development. Research has consistently found correlations between adolescent emotional / behavioral problems, parental stress, parental mental health issues, poor parenting practices, parent–adolescent conflict, and lower levels of perceived family support (Kuhn & Laird, 2014; Zeynel & Uzer, 2020). The family environment and parent / child relationships impact adolescent mental health problems. Parent–child relations are significant contributors to adolescent growth, personality development, and mental health. Kapetanovic et al. (2019) cite research which finds that girls are typically more emotionally connected with their parents than are boys, are more likely than boys to share information with parents, and more closely monitored by their parents than boys. They posit that these factors likely contribute to the behavioral differences between boys and girls. In their study, Kapetanovic et al. (2019) found that boys are indeed more likely to engage in risk-taking behaviors than girls, and engage in more delinquent behaviors than girls.
Adolescents who report positive feelings toward their parents tend to have good mental health, while those with negative feelings were more likely to exhibit problem behavior (Hoang Thuy et al., 2019). Many studies have examined how the relationship between mothers and children impacts child / adolescent development and mental health (Asselmann et al., 2015; Frampton et al., 2010; Reidler & Swenson, 2012; Sherman et al., 2019), but relatively little attention has been paid to the impact of fathers upon child/adolescent development and mental health (Cabrera et al., 2018; Clauss-Ehlers, 2017). Much of the research that does exist focuses on the impact of fathers’ absence/non-participation on the development of child/adolescent psychopathology, rather than the impact of the father–child relationship (Panter-Brick et al., 2014). Father involvement during childhood and adolescence can significantly influence developmental outcomes, including reduced child psychopathology (Barker et al., 2017). Parental engagement in interventions targeting child and adolescent mental health is known to improve beneficial outcomes. Pitsoane and Gasa (2018) found that emotional and behavioral difficulties experienced by adolescent boys are associated with strained father-son relationships. The clinical and empirical literature offers little research or guidance regarding programs to engage fathers in boys’ mental health treatment (Panter-Brick et al., 2014; Rice et al., 2018), which is disappointing, because adolescent boys are more inclined to seek mental health treatment when a warm, engaged, and supportive father figure is involved in their lives (Reeb & Conger, 2009).
While programs designed to engage, equip, and support fathers in their relationships with their children are emerging across the country, reviews of the literature on evidence-based approaches to promote effective parenting practices (Clauss-Ehlers, 2017; Rice et al., 2018) found that these programs, generally, do not successfully engage fathers. Among the programs that do exist, no current theoretical model has been designed specifically to successfully engage fathers in their son’s mental health treatment (Rice et al, 2018).
While multiple studies indicate that paternal participation in mental health treatment for children and adolescents is associated with positive treatment outcomes, fathers are less likely than mothers and other female caregivers to participate in psychological treatment for children and adolescents (Barker et al. 2017; Isaacs et al., 2015; Tiano & McNeil, 2005; Walters et al., 2001). Studies consistently demonstrate that men are less likely than women to seek help in general (Juvrud & Rennels, 2017; Kealy et al., 2020), including mental health treatment (Cole & Ingram, 2020). Consequently, it is not surprising that fathers, and other male caregivers, are also less likely to engage in psychological treatment for children and adolescents.
In meta-analysis of evidence-based approaches to promote effective parenting, Clauss-Ehlers (2017) found a wealth of research examining the role of mothers in effective parenting, and a dearth of research examining the role of fathers in effective parenting. Clasuss- Ehlers (2017) noted that these findings are surprising, given the important role fathers play in their children’s lives, and the fact that there are approximately 70.1 million fathers in the United States. Clasuss- Ehlers (2017) stressed that research is needed to explore the impact of parenting interventions on fathers’ sense of self-efficacy and parenting competence.
Research conducted by Livingston (2014) found that over the past 5 decades, the amount of time fathers spend with their children has increased threefold. Cultural expectations of fathers, and father’s willingness to meet these expectations, have shifted dramatically, from the primary expectation being “breadwinner,” to fathers actively engaging in childcare, emotional nurturance, and co-parenting (Humberd et al., 2015). The number of fathers electing to stay-at-home with their children has almost doubled since 1989 (Livingston, 2014). In 1965, the average father spent 2.5 hours per week engaged in caretaking activities with children. This number had increased to 7 hours per week in 2011. When asked to rate the importance of being a parent, in 2015 fathers were just as likely as mothers to indicate that being a parent was extremely important to their identity (Parker & Livingston, 2018).
Not only have cultural expectations changed for fathers, boys and men encounter a variety of complex and conflicting pressures and expectations associated with being someone who identifies a male. In August of 2018 the American Psychological Association (APA) introduced “Guidelines for Psychological Practice with Boys and Men.” The guidelines are informed by more than 40 years of research which suggests that boys and men are struggling to understand and fulfill the complex, and often conflicting, cultural expectations associated with manhood, characterized by idealized and unrealistic levels of toughness and self-reliance. Men and boys are expected to be strong, stoic, confident and capable in the face of any adversity. The guidelines reference traditional masculinity ideology, which is characterized by competitiveness, aggression, stoicism, and dominance. The traditional masculine ideology perspective asserts that masculine gender roles are culturally generated; psychologically harmful; and detrimental to the overall physical and mental health of boys and men (Pappas, 2018). The APA (2018) guidelines assert that traditional masculine ideology negatively impacts fathers’ willingness and ability to parenthood effectively, and contributes to many fathers’ unwillingness to seek services for themselves and their children.
Chapter 2 of this dissertation will discuss the theoretical underpinnings of the traditional masculine ideology perspective, as well as the evolutionary psychology perspective, which acknowledges the influence of culture upon human behavior, but also asserts that many of the attitudes and behaviors traditionally associated with masculinity (e. g. toughness, competitiveness, risk-taking, stamina, endurance, physical strength, and aggressiveness) are significantly influenced by biological and genetic factors, which have evolved over the course of human evolutionary history (Buss, 2020; French, 2019).
This dissertation will present a new theoretical approach to working with adolescent males and their fathers, which stands in the tension between the evolutionary psychology perspective and the traditional masculine ideology perspective. After demonstrating that Schema Theory and Jungian theory identify identical psychological mechanisms as the source of persistent mental health symptoms, this dissertation will integrate these two theories to create a new theoretical approach to engaging fathers in mental health treatment with their adolescent sons.
Within the field of psychology, there is a long-standing tradition of polarized perspectives regarding the nature and study of the human psyche. Psychodynamic theories assume that personality, behavior, interests and psychopathology are primarily influenced by unconscious forces (Sollod et al., 2009). Psychodynamic theories have been thought of as incompatible and antithetical to cognitive theories. Historically, cognitive approaches have assumed a blank slate/learning theory conceptualization of the human psyche (Pinker, 2016), For the past 40 years, the psychoanalytic and cognitive dichotomy has been framed as a science, although the pseudoscience / mysticism and empiricism debate continues. (Last, 2010). To some degree, this polarization can be traced to Aaron Beck (1976), the originator of Cognitive Behavioral Therapy (CBT). In his 1976 book, Cognitive Therapy and the Emotional Disorders, he characterized non-cognitive based approaches as twisting and overcomplicating psychological phenomena . For instance , Beck (1976) stated that “neuropsychiatrists” assume that “under every twisted thought is a twisted molecule,” and psychoanalysts assume that individuals’ perceptions and interpretations are “a superficial screen over a non-existent and unnecessary ‘deeper meaning,’” (p.48).
This dissertation will review recent developments in the cognitive sciences which have revealed that the etiology of human personality and behavior is much more complicated, and unconscious, than Beck originally imagined. Ironically, research in learning theory, information processing theory, anthropology, neuroscience and evolutionary psychology has determined that personality and behavior are powerfully influenced by the “molecules” and “deeper meanings,” (Buss, 2020) which Beck (1976) dismissed.
At the turn of the 20th century, without the benefit of the tools available to present-day neuroscience, Carl Jung (1966) concluded that each person is born with innate, biologically based cognitive mechanisms that predispose them to typical patterns of behavior, once the mechanism is triggered. More than a century later, research has revealed a surprising amount of common ground between contemporary cognitive theory and psychoanalytic theory, and in particular, Jungian theory.
While Beck (1976) contributed to the theoretical divide between cognitive and psychoanalytic theories, he also meaningfully expanded upon a foundational idea which now bridges the divide between cognitive and psychodynamic theories: cognitive schema. Beck et al. (1979) asserted that in any given situation, individuals filter through an enormous number of stimuli, and choose to attend to only a select few in any given moment. Beck et al. (1979) suggested that, in order to facilitate this process, individuals group stimuli into a pattern in order to characterize the situation. Building upon a theoretical foundation laid down by Piaget (1957), Beck (1979) utilized the term “schema” to label these relatively stable cognitive patterns. Piaget (1957) described schema as, “a cohesive, repeatable action sequence possessing component actions that are tightly interconnected and governed by a core meaning,” (p. 7). Piaget (1957) understood schema as a way of organizing knowledge that is used to both understand and to respond to situations. Piaget (1957) believed that babies are born with a number of innate, genetically programmed schemas, which were limited to the most basic functions: sucking, reaching, grasping, smiling, and response to touch. In recent years Piaget’s research methodology and aspects of his developmental theory have been the target of considerable criticism (Burden & Smith, 2000; Siegel, 1993), but his foundational understanding of cognitive schema is still consistently referenced in contemporary schema theory research (Aloi et al., 2020; Gibson & Francis, 2019; Zeynel & Uzer, 2020).
Through their earliest experiences with primary caregivers, children begin to form foundational beliefs about themselves and the world. Beck (1979) argued that these early childhood beliefs form into cognitive structures (schema) which form the basis for “molding data into cognitions” (p. 12). By molding, Beck (1979) means that schema functions as a filter to screen, differentiate and code stimuli so that they can be categorized and evaluated. Individuals categorize and evaluate experiences through a matrix of schemas, associated with emotional states activated in response to frequently encountered life situations. Beck (1979) explains that when an individual encounters a particular situation, a schema related to the circumstance is activated. This matrix of schema is referred to as a schema mode (Young et al., 2014).
Beck’s protegee Jeffrey Young identified early maladaptive schemas (EMS) as very stable, unconscious thought/interpretive themes that develop during childhood as the result of a conflict between a child’s early negative life experiences (particularly with parental figures) and the child’s innate temperament. EMS tends to develop when a child’s environment does not meet his or her developmental needs (Young et al., 2014). Once the schema has been activated, the individual unconsciously selects, encodes and categorizes information and perceptions in ways that align with and perpetuate the schemas. Everything that an individual is thinking, feeling and doing at a given point in time, filtered through the lens of EMS, is referred to a schema mode.
There are positive/functional and negative/dysfunctional schema modes. “A dysfunctional mode is activated when specific maladaptive schemas have erupted into distressing emotions, avoidance responses, or self-defeating behaviors that take over and control and an individual’s functioning at a given point in time” (Young et al., 2014, p. 286). Maladaptive modes are autonomous ego states which assume control of an individual’s thinking and behavior. It is somewhat similar to a dissociative state in which the ego, to some extent, relinquishes control to another aspect of the personality (Young et al., 2003).
Beck’s (1979) notion of the cognitive schema has come full circle. It seems that the human psyche, as conceptualized by schema theory (Young et al., 2014), is primarily influenced by “unconscious” forces, rather than conscious cognitions. In alignment with Jungian theory, the human psyche is not a single unitary entity, but instead a multiplicity of independent, somewhat autonomous, but interrelated ego-states. The Jungian T heory refers to these independent, autonomous ego states as complexes. Cognitive theory refers to them as schema, and when functioning collectively, schema modes.
For decades, Jung’s (1966) understanding of human psyche has taken a back seat to cognitive theory, which boasts thousands of studies which appear to lend support to cognitive theory’s blank slate/learning theory conceptualization of the human psyche (Pinker, 2016), but as Sollod et al. (2009) describes, Jung’s notion of archetypes has received validation through contemporary neuroscience and evolutionary psychology’s suggestion that humans possess inborn hardwiring (cognitive modules and inherited predispositions) to process information and experiences in pre-programmed ways. Jung (1966) posits that archetypes predispose humans to develop as individuals and communities according to patterns already laid down in the psyche at birth.
The concept of inborn hardwiring is also supported by anthropological research. Brown (1991) has identified dozens of universal traits, attitudes and behaviors which are common to all known human cultures (e. g. customs and rituals associated with birth and transitions into adolescence and adulthood; belief in supernatural/religion; dream interpretation; and common themes in legends, myths.). Elman et al. (1996) describe advances from the marriage of connectionist cognitive models and developmental neurobiology which have established that there cannot be learning without innate neurological circuitry that is predisposed to do the learning. Cognitive theorists and researchers now agree that there are innate learning or information processing networks in the human brain that prepare and predispose individuals to learn and engage in all the patterns of behaviors that are universal and common to all cultures (Pinker, 2016). Jung (1966) labeled these learning or information processing networks archetypes. Beck (1979) and Young et al. (1993) labeled them cognitive schema.
Carl Jung (1989) viewed psychological symptoms as the psyche’s way of drawing attention to unconscious or underdeveloped aspects of the personality, with the intent of making the unconscious aspects of personality conscious, and integrating them into the total personality (Singer, 1994). Symptoms are seen as purposive, rather than defective. Jung (1966) affirmed that each person is born with biologically endowed abilities, preferences, and affinities. The entire personality is understood as present in potentia at birth. From a Jungian perspective, the developmental process (individuation) is under the direction of a transpersonal aspect of the personality (The Self), which serves a structuring/ordering function. The Self utilizes universal patterns and images, common to all the world’s religions and mythologies, with the intent of forming each person into the individual he or she was born to be (Edinger, 1992). Jung referred to the universal patterns and images as archetypes.
According to Jung, archetypes are the psychological equivalent of instincts, the “innate releasing mechanisms” (Stevens, 1994, p. 51) which an animal inherits that predisposes it to a pattern of behavior once the mechanism is triggered, similar to the way that goose is triggered to migrate, or a deer is triggered to seek a mate, or a bear is triggered to hibernate (Stevens, 1994). Archetypes predispose humans to develop as individuals and communities according to patterns already laid down in the psyche (Jung, 1966). Jung asserts that there are as many archetypes as there are typical situations in life. There are archetypal figures (e.g., mother, child, father, God, wise man), archetypal events (e.g., birth, death, separation from parents, courting, marriage, etc.) and archetypal objects (e.g. water, sun, moon, fish predatory animals, snakes) (Stevens, 1994). From a Jungian perspective, each part of the genetic endowment, which enables humans to develop and thrive socially, culturally, and psychologically, is expressed archetypally through stories found in religion, myth, ritual, art, music, fairy tales, and dreams (Cambray, 2010).
When archetypes are active in the personality Jung (1966) referred to them as complexes. A complex is active when it has been triggered, or activated, by an environmental cue. When some complexes activated, it generates dysfunctions and extreme psychological discomforts.
Jung stated that complexes often generate emotions, thoughts, or behaviors which run counter to the intentions of the ego (Versey-McGrew, 2010). “Not only do we all have complexes, but complexes have us,” (Jung, 1966, p. 15).
Quite similar to the way Young et al. (2003) described the formation of early maladaptive schema, Jung (1966) argued that complexes are formed when an individual, typically during childhood, encounters a situation which is incompatible or incongruent with their innate disposition, and their developmental needs are unmet. This experience creates a psychic wound that “lays bare the vital, pattern-forming, archetypal elements of the psyche. Those experiences which threaten our deepest beliefs – in our gods and in ourselves – those are the ones which give rise to complexes” (Singer, 1994, p. 44). Both Schema Theory and Jungian theory posit that maladaptive personality and behavioral features are influenced and shaped by universal, biologically based predispositions.
This dissertation will argue that cognitive theory and Jungian theory identify the same cognitive structures as the source of persistent, treatment resistant mental health disorders. Cognitive theory labels these structures Early Maladaptive Schema. Jungian theory identifies them as complexes. Both theoretical perspectives assert that, when the schema/complex is active, it assumes control of an individual’s thinking and behavior, and functions as an autonomous ego state, which is somewhat similar to a dissociative state in which the ego, to some extent, relinquishes control to another aspect of the personality. This same pattern is identified in internal family systems theory (Schwartz and Sweezy, 2020), which notes that people have historically assumed that the human psyche is a unitary entity, “a mono-mind.” In contrast, internal family systems theory offers a paradigm for thinking of the human mind as made up of many sub-minds (or “parts), which are continually interacting with each other, in complex, often dysfunctional ways, in patterns similar to how individual family members interact with each other.
Let’s consider an example: Within many (if not most) individuals, there exists an aspect of their personality, which aspires to follow a healthier lifestyle: regular vigorous exercise, eating more vegetables and fruits, and avoiding the doughnuts, pizza and French fries. This part motivates individuals to commit to make significant life changes, such as signing a contract with a local gym, making a trip to the grocery store to load up on vegetables and fruit, tossing the chips and ice cream into the trash. And yet, within these same people, there is another part, or more likely several parts, which have a different agenda. These parts make a convincing case that vegetables, fruit, and exercise will be there tomorrow, because today has been a hard day, and calls for another episode on Netflix and another large bowl of ice cream. Most individuals will recognize similar polarities within themselves, which continually pull them in conflicting directions regarding work / life balance, or relationship patterns and behaviors, especially in times of stress.
A Jungian would say that something in the commitment to a healthier lifestyle triggered or activated a complex, associated with an archetypal theme, such as unmet needs for emotional sustenance; doubts about one’s value, strength, intelligence, or will power, or fear of deprivation/abandonment, or a resistance to boundaries, limits, and structure. A theorist operating from a schema theory perspective would say that a maladaptive schema was triggered, activating a schema mode, associated with emotional deprivation, or defectiveness/shame, or insufficient self-control/discipline. Regardless of what the experience is called, the important part to understand is that an autonomous ego-state, a self-governing or “splinter personality,” operating “outside the control of consciousness,” with an agenda which runs counter to the conscious personality, basically yanked the steering wheel out of the ego’s hand and took control.
Now, consider the example of a young father who has a 2-year-old son, his first child. The father is confused and embarrassed by the fact that he consistently finds himself feeling irritated and angry when his 2-year-old exuberantly seeks his attention and affection. When his son attempts to hug or kiss him, the young father feels a powerful need to push his son away and create physical distance between them. Understood from a Jungian or schema perspective, the father’s anger and irritation suggest that, when the young father was a child, he experienced criticism or rejection in response to his need for emotional and physical closeness with his father. He was wounded by his father. Now, some 30 years later, the young father’s level of injury is triggered by his son reaching out to him, in the same way that he had reached out to his father. If the young father’s schema/complex remains unconscious, he will likely wound his son, in the same way he was wounded by his father. This pattern of fathers wounding sons will continue to be repeated, generation after generation (Bowen, 1978; Zeynel & Uzer, 2020; Zonnevijlle & Hildebrand, 2018). A new approach to working with fathers and sons is needed, an approach designed to help fathers become conscious of their wounds and understand how they occurred. This thesis will argue that conscious and understanding fathers will be better able to heal their own wounds and be less likely to injure their sons, and that sons will be better equipped and more inclined towards mental health treatment.
A ligning early maladaptive schema and complexes with archetypal stories, characters, and themes which saturate ancient and contemporary cultures, (e. g. fairy tales, myths, legends, religious stories, rituals, and music) this dissertation will provide a theoretical framework for future research and clinical practice to integrate the structured assessment and therapeutic process of schema therapy with the archetypal focus of Jungian therapy. This integration will help provide non-threatening pathway for fathers to enter into their sons’ mental health treatment, as well as destigmatize mental health concerns by providing therapists, adolescent male clients, and their fathers a means to conceptualize mental health symptoms, and masculinity itself, through the lens of familiar archetypal themes as they occur in religion, mythology, fairy tales and contemporary media (i.e. movies, books, television shows, comic book characters, and historical figures).
The application of this new integrated theory described in this dissertation will primarily utilize fairy tales found in The Complete Fairy Tales of the Brothers Grimm (Zipes, 1988). Ancient myths, fables, religious or creation stories from any culture could be used in this approach, as well as more contemporary stories, movies, novels, etc., but for consistency, continuity, and clarity, this dissertation will focus primarily on fairy tales as told by the Brothers Grimm. Bettelheim (2010) asserts that fairy tales are powerful, and essential, for children, because of the archetypal themes found in fairy tales (e. g. the quest/journey, good vs. evil, help arriving from unexpected characters, rule- breaking, flawed parents, the tendency to disobey, frightening/repulsive things which turn out to be blessing, deceptive predators) depict the real, problematic nature of life, in a way that children understand intuitively. Beetleheim (2010) argues that, in spite of parents’ efforts to shield their children from experiencing the harsh, often frightening aspects of human existence, children know that bad things can, and do happen. They know that life is frightening and unpredictable. They know that adults, including parents, are sometimes careless , cruel, selfish, and dangerous. Bettleheim (2010) also notes that fairy tales take very seriously the things that frighten and worry children, things which parents often want to dismiss or gloss over: (e. g. the difficulty of resisting temptation; the need to be loved, and the consequences if one is not loved; fear of abandonment; fear of death; the insecurities and incompetence of caregivers). Fairytales are full of characters who face their fears, make tragic mistakes, experience failure and loss, but are able to overcome, and ultimately prevail. The themes and characters in fairy tales are archetypal because they are universal and foundational for all humans. In the Grimm Brothers’ (1988) fairy tales, parent child relationships are complex. In some tales, parents abandon their children (e. g. # 15 Hansel and Gretel; #93 The Raven). Parents have favorites among their children, and often see their children as flawed and defective (e. g., # 64 The Golden Goose; #90 The Young Giant). Parent’s sometimes make poor decisions, and put their wants and needs above those of their children (#31 The Maiden Without Hands; #92 The King of the Golden Mountain).
Bettleheim (2010) criticisms of parenting level and educational level philosophies assume that it is best to keep a child’s attention away from what worries and irritates them the most, or to divert a child’s attention from something: formless anonymous anxiety and fears, chaotic, angry, and often violent thoughts. Bettelheim (2010) description below accurately describes today’s helicopter parents (Segrin et al., 2020), who plan, micro-manage, and supervise every moment of their children’s lives.
“There is widespread refusal to let children know that the source of much that goes wrong in life is due to our very own natures – the propensity of all [people] for acting aggressively, a-socially, selfishly, out of anger and anxiety. Instead, we want our children to believe that, inherently, all [people] are good. But children know that they are not always good; and often, even when they are, they would prefer not to be. This contradicts what they are told by their parents, and therefore makes the child a monster in his own eyes.” (Bettelheim, 2020, p. 7).
Fairy tales depict the archetypal struggles all humans face, and consequently children and adults experience fairy tales as powerfully resonate, do not tire of them. This is evidenced by the repeating retellings of Cinderella, Beauty, the Beast, Snow White, and Rapunzel in movies over the past 30 years. The themes and characters of fairy tales (forgotten or disguised princes and princesses; lost or abandoned children; missing, dead, selfish, or neglectful parents; unrecognized treasures; tricksters; helpful animals; magicians; witches; simpletons/fools; and monsters) populate the most popular movies, video games, and binge- watched series.
As Freud (2010) described, children’s feelings toward their parents are complex and often conflictual. All humans, adults and children alike, feel things they “should not feel,” want things they “should not want,” are selfish, fear abandonment, fear failure, and frightened by metaphorical witches, trolls, dragons, monsters, and giants. All children fear these things, as all children fear strangers, spiders, snakes, and heights (Ehrensaft, 2009). In her book So the Witch Won’t Eat Me, Dorothy Bloch (1994) notes the universality of children’s fear of infanticide, present in familiar stories such as Pinocchio, Hansel and Gretel and Little Red Cap. Writing from a psychoanalytic perspective, Ehrensaft (2008) notes that these stories echo the theme of the myth of Oedipus:
“Oedipus’ troubles do not start when he kills his father and marries his mother. They begin much earlier with his parents’ willingness to put him out to die in order to save Laius from the prophecy that he will be murdered by his son. Therein lies the first so-to-speak pre-Oedipal childhood fear: that one’s parents will kill you. The child in the family with good-enough parents will not be exempt from this fear: Becoming aware very early in life of their vulnerability and their dependence on the good will of their parents for their very lives, even a temporary absence of a parent’s succor can result in a disintegrating fear that the child is being killed by the parents who are supposed to feed her, hold her, and protect her from harm.” (p. 102)
Of course, parents do not literally “eat their children,” but parents do, quite frequently,
metaphorically feed off their children, using their children as a means to end, be it pride, privilege, status or resources, and Bettleheim (2010) asserts, children know this to be true. Fairy tales are “children’s stories” full of things and “cannot be true,” such as talking animals, invisibility cloaks, ghosts, and shapeshifters , so these stories have a disarming impact upon adults, because it is “just a fairy tale. This dissertation will provide a framework and guide for utilizing fairy tales as a non-threatening point of entry for fathers and sons to share space, experience and respond to a story, which, on a surface has nothing to do with them, but at an archetypal level, is everyone’s story.
The intended outcome of this dissertation is to provide a new theoretical framework for future research and clinical practice utilizing schema therapy within the archetypal context of Jungian theory. While the media that children and adolescents consume (movies, television series, comics, and video games) are saturated with archetypal themes (e. g. Hero Characters in Fortnight; movie and video game themes and characters spun off of Marvel and DC comic series, which are derived from much older mythological stories and characters), the research examining the efficacy of Jungian therapy when applied to adolescents is quite limited. A limitation of this to this applied theoretical dissertation is that Jungian theory is not typically applied to adolescents or to families in clinical practice. It is typically utilized with adults in individual therapy, or in play therapy settings with young children. Additionally, there is limited evidence-based support for Jungian therapy, particularly when compared to the wealth of research on cognitive based therapeutic approaches.
Given these limitations, the overarching theme of Jungian therapy will provide an accessible , culturally versatile framework to destigmatize adolescent mental health issues and improve the engagement of fathers with their son’s treatment.
Active Imagination: The conscious process of focusing on dream images, strong familiar emotional patterns, or fantasy figures to facilitate psychological insights and personal transformation (Singer, 1994).
Analytical Psychology: The term Jung gave to identify his personality theory and hypno
therapeutic approach (Jung, 1966).
Anima: An archetype, consisting of the female component of the psyche. Positive aspects are inspiration, warmth, nurturance, intuitive understanding. The negative aspects are moodiness, dependence and irrationality (Stevens, 1990).
Animus: An archetype consisting of the male component of the psyche. On the positive side it includes the ability to reason and use logic to solve problems, and on the negative side it leads to argumentativeness, uninformed, often willfully inornate opinionated-ness, and social insensitivity (Stevens, 1990).
Archetypes: Jung’s term for universal themes or symbols that are a residue of ancestral emotional life. They lead to the predispositions to behave and to experience reality in certain ways. Jung conceived of archetypes as hardwired into human brain structure (Stevens, 1990).
Collective Unconscious: According to Jung, that part of the psyche that is presumed to contain representations of the collective experiences or humanity. It is the depository of instinct and archetypes that go beyond one’s own personal experience (Singer, 1994).
Complex: Singer (1994) asserts that clients’ most troubling and persistent symptoms primarily show up in the form of complexes. “What Jung called complexes are certain constellations of psychic elements (ideas, opinions, convictions, etc.) that are grouped around emotionally sensitive areas” (Singer, 1994, p.43). These emotionally sensitive areas are sites where some psychic wound has occurred.
Conscious Ego: The conscious part of the psyche. It consists of all those internal and external events that are within our awareness at any given moment, including all sense impressions and self-awareness (Sollod et al., 2009)
Enantiodromia: The play of opposites within every personality. Jung discerned a multiplicity of conflicting themes, discordant opposites, and antagonistic forces that individuals face in their pursuit of wholeness (Edinger, 1992).
Evolutionary Psychology: a theoretical approach that explains behaviors and psychological traits as a consequence of natural selection. “Evolutionary psychology provides a sound scientific framework for understanding human nature—one that is consilient with known causal processes of all life forms, particularly natural and sexual selection,” (Buss, 2020, p. 1).
Extroversion: The tendency to be externally oriented, confident, outgoing, and accommodating (Myers & Myers, 1980).
Fairy Tale: A traditional story, typically intended for children, that contains magical creatures, setting or influences. Fairy tales have been passed down through an oral tradition prior to being written down. “Through the centuries (if not millennia) during which, in their retelling, fairy tales became ever more refined, they came to convey at the same time overt and covert meanings – came to speak simultaneously to all levels of the human personality, communicating in a manner which reaches the uneducated mind of a the child as well as the sophisticated adult” (Bettelheim, 2010, p. 6).
Individuation: The full development of all aspects of the personality into a unique harmonious whole. In this process the individual becomes conscious of and incorporates the underdeveloped aspects of his or his personality (Singer, 1994).
Introversion: The tendency to be internally oriented, reserved, reflective and socially inhibited. Introverts get their energy from solitary activities, self-reflection, or authentic, deep interpersonal relationships (Myers & Myers, 1980).
Libido: In Jungian theory, the libido is a general life energy, of which sexual urges are only one aspect. This life force or energy manifests itself in our diverse feelings, thoughts and behaviors. Libidinal energy can be shaped, channeled, suppressed, repressed, or blocked (Singer, 1994).
Mandala: According to Jung’s theory, a circular figure represents the synthesis of the union’s opposites within the psyche. . It can be understood as a symbolic representation of the totality’s individual personality/psyche or Self (Edinger, 1992).
Psyche: The personality of all aspects’ sum up, including conscious and unconscious components (Singer, 1994).
Self: The “center of being” which the ego “circumambulates; at the same time it is the superordinate, unifying aspect of the personality, the source of the drive toward wholeness and fulfillment of potential (Stevens, 1991).
The Shadow: The archetype which represents the undesirable, rejected and repressed aspects of an individual’s personality. The shadow is often thought of like the dark, evil, and repulsive side of human nature (Singer, 1994).
Teleological: Goal- directed. In Jung’s theory, the development of the psyche is directed toward consciousness and expression of an individual’s total personality. The Self- drives / orchestrates this teleological process (Stevens, 1991).
Traditional Masculine Ideology: A set of “descriptive, prescriptive, and proscriptive” (APA, 2018, p. 2) cognitions about boys and men which some argue are culturally generated, shaped and transmitted. These cognitions take the form of standards and expectation which are described as influential in men and boys across diverse segments of the population (e. g. eschewal of the appearance of weakness, anti-femininity, adventure, achievement, competitiveness, risk- taking, aggressiveness, and violence) (Pappas, 2018).
Transcendent Function: The driving force behind individuation, the innate tendency to pursue inner harmony (Singer, 1994).
The anticipated outcome of this dissertation is to provide a more comprehensive and practical integrated theoretical framework to inform future research and clinical practice targeting adolescent males and their fathers. In addition to challenges that adolescent mental health issues present to families, fathers additionally struggle to find ways to maintain close, productive relationships with their sons. The archetypal themes which are present in fairy tales, as well as ancient and contemporary rituals, myths, traditions, visual art, music and stories can hopefully provide a theoretical framework on which researchers, clinicians, and teachers can develop more effective ways to engage fathers in their son’s mental health treatment.
Organization of the Remainder of the Paper
Following the introduction, Chapter 2 of this dissertation will review the recent literature on adolescent mental health issues impacting adolescent males; the obstacles which prevent fathers from engaging in their son’s mental health treatment; the tension between the traditional masculine ideology and evolutionary psychology perspectives; cognitive theory, with particular emphasis upon schema therapy; and Jungian therapy.
Chapter 3 will analyze the theoretical perspectives and the strengths and weaknesses of the current literature will be examined. Gaps in the current literature and areas for future research will be identified, synthesizing them into a new theoretical integration that will hopefully inspire future research. Chapter 3 will also examine ethical and cultural considerations related to the adolescent population, and their fathers. Chapter 4 will assess the strengths and weaknesses of applying this new integrated theory to the problem of engaging fathers in their adolescent son’s mental health treatment. Chapter 5 will discuss the strengths and limitations of the new application of the theory and provide suggestions for future research.
The purpose of this chapter is to review the existing literature related to factors impacting the mental health of boys and men, parental impact upon adolescent development and adolescent mental health, specifically the value of engaging fathers in adolescent males’ mental health treatment (Barker et al., 2017). Recent theoretical and research literature related to Jungian theory and Schema theory will be reviewed as well as theoretical literature related to traditional masculine ideology, evolutionary psychology, and the impact of parental engagement upon adolescent development.
In August of 2018, the American Psychological Association (APA) introduced “Guidelines for Psychological Practice with Men and Boys.” The guidelines argue that many boys and men do not acknowledge the need for, seek, or receive the mental services they need
in an effort to conform to cultural expectations to embody idealized and unrealistic levels of toughness, self-reliance, strength, stoicism, confidence, and competence (APA, 2018).
Boys and men are disproportionately impacted by a wide range of social and psychological problems including learning difficulties, behavior problems and incarceration rates (APA, 2018). In her discussion of APA (2018) guidelines, Pappas (2019) controversially asserted that the research on which the guidelines are based has demonstrated that masculinity is characterized by competitiveness, aggression, stoicism, and dominance. Pappas (2019) described traditional conceptualizations of masculinity as “psychologically harmful,” (p. 34) because they encourage boys to suppress their emotions, the impact of which is evident in both internalizing and externalizing symptoms, and in the fact that men experience higher rates of alexithymia (the inability to recognize and describe emotional states) than women (Levant et al., 2018)
To support her assertions, Pappas (2019) cited studies which report that 90 percent of homicides in the United States are committed by men, and men make up 77 percent of homicide victims. Pappas (2019) also noted studies which indicate that men are substantially more likely than women to be the victim of violent crime; are 3.5 times more likely than women to die by suicide; a man’s life expectancy is 4.9 years shorter than a woman’s; boys are far more likely to be diagnosed with attention-deficit hyperactivity disorder than girls; and boys face harsher punishments in school.
Some have interpreted Pappas (2019) comments, and the guidelines themselves, as an attack on men and masculinity, arguing that some of the attitudes, expectations, and behaviors associated with traditional conceptions of masculinity essential for boys and men to function effectively (French, 2019). Wright et al., (2019) have expressed concern regarding the APA’s (2018) reliance upon the construct of traditional masculine ideologies, which, they claim, lacks evidence-based support (Peterson, 2019), and ignores biological and genetic factors which impact men and boys (Gorelik, 2019). Wright et al (2019) noted that the APA (2018) conceptualized traditional masculine ideologies in a way which blames men for their psychological symptoms, an attitude which psychologists typically try to avoid with other groups, and assumes that, with every male client, gender is the leading cause of the client’s difficulties.
The pressure to live up to idealized and unrealistic standards of any sort can be psychologically harmful, and sometimes physically harmful, for both men and women (Sherlock and Wagstaff, 2019; Reidy et al., 2016). This is true of the characteristics the 2018 APA guidelines associate with traditional masculine ideology (e. g. toughness, self-reliance, competitiveness, strength, stoicism, competence, and confidence) as well as characteristics which do not fall under the umbrella of traditional masculine ideology (e. g. compassion, intelligence, patience, creativity, nurturance, empathy, and emotional expressiveness). It is important to note that women and girls also face circumstances throughout their lives which call on them to utilize toughness, self-reliance, competitiveness, strength, stoicism, competence, and confidence. These traits, in and of themselves, are not harmful, or masculine.
The 2018 “APA Guidelines for Psychological Practice with Boys and Men” define traditional masculine ideologies as a set of culturally generated, shaped and transmitted “descriptive, prescriptive, and proscriptive” cognitions about boys and men (APA, 2018, p. 2.). These cognitions take the form of culturally specific standards and expectation which are described as influential in men and boys across diverse segments of the population (e. g. eschewal of the appearance of weakness, anti-femininity, adventure, achievement, competitiveness, risk taking, aggressiveness, and violence.) The guidelines suggest that traditional masculine ideology influences fathers’ attitudes toward fatherhood, mental health issues, as well as their attitudes toward asking for help in general. The guidelines also argue that attitudes and behaviors associated with traditional masculine ideology impact the mental and physical health of boys and men. A significant amount of research data supports this latter claim.
Reidy et al., (2016) found that boys who did not align with traditional masculine gender roles, and were concerned about their nonconformity, tended to engage in more risky behavior and report poorer psychiatric health. In contrast, gender role discrepant boys who were not distressed by their nonconformity were less likely than their peers to engage in risky health behaviors. Thus, Reidy et al., (2016) concluded that not conforming to masculine gender roles appears to be protective against adverse health outcomes when boys do not feel pressure or stress about the need to conform. Adherence to traditional masculine gender roles also appears to have a negative impact upon the overall physical health of boys and men, and upon their willingness to seek health care (Ramaeker & Petrie, 2019). A 2019 editorial in The Lancet noted statistics from a 2019 World Health Organization (WHO) report which indicated men continue to have shorter life expectancy than women. Globally, boys born in 2018 have a predicted life expectancy of 68.6 years, whereas girls have a live expectancy of 73.1 years. The editorial noted that this gap in life expectancy between genders is larger in high-income countries than in low-income countries, suggesting that, while biology certainly plays a role in life expectancy, “the biggest drivers of life expectancy are linked to social determinants of health,” (p. 1779).
The Harvard School of Public Health updated a report originally published in 2010 which indicated that men are nearly 10 times more likely to get inguinal hernias than women, and five times more likely to have aortic aneurysms. American men are about four times more likely to be hit by gout; they are more than three times more likely than women to develop kidney stones, to become alcoholics, or to have bladder cancer. And they are about twice as likely to suffer from emphysema or a duodenal ulcer. Although women see doctors more often than men, men cost our society much more for medical care beyond age 65. (Harvard Health Publishing, 2019).
Men who are boys are clearly influenced by harmful and unrealistic cultural pressures that impact their emotional and physical health, but some psychologists are troubled by the fact that the APA (2018) guidelines call into question the notion of masculinity itself. The guidelines explicitly describe masculinity as a culturally generated construct. Guideline 1 states: “Psychologists strive to recognize that masculinities are constructed based on social, cultural, and contextual norms” (p. 4). The commentary associated with Guideline 1 states that “When trying to understand the complex role of masculinity in the lives of diverse boys and men, it is critical to acknowledge that gender is a non-binary construct that is distinct from, although interrelated to, sexual orientation.” (p. 4). The guidelines lean heavily on a feminist perspective epitomized by sociologist Raewyn Connell (2014), who rejects the existence of universal, archetypal, and characterological, masculine traits which are common to all men across all cultures. Connell (2014) asserts that each cultural context constructs and values its own specific hegemonic (culturally dominant) masculinity. Connell (2014) was influenced by philosopher Judith Butler (1990), who challenged the binary understanding of sex, gender, and sexuality. Connell (2014) asserted that gender is not an essential or inherent identity that is the product of biological sex. Instead, gender is an “act” is flows out of and is reinforced by social norms which create the illusion of binary sex.
While acknowledging that some of the APA guidelines provide much needed guidance to psychologists working with men and boys, some psychologists (Peterson, 2019; Wright et al., 2019, Gorelik, 2019) have expressed concern with the guideline’s reliance upon research which they believe is biased toward the feminist conceptualization of gender espoused by Connell (1994) and Butler (1990). They also raise concerns regarding an over- reliance on the notion of traditional masculine ideology, which, they assert, lacks a broad scientific consensus or support. For example, in a 2019 interview with one of the authors of the 2018 guidelines, Ryon McDermott, Pappas (2019) summarizes research by McDermott, et. al. (2019) as finding that, when the researchers “strip away stereotypes and expectations there isn’t much difference in the basic behaviors of men and women,” (Final section of article, paragraph 5). Wright et al. (2019) criticize the research upon which the 2018 guidelines are based, and the guidelines themselves, for conflating the traits, behaviors, and attitudes, traditionally associated with masculinity (e. g. protectiveness, ambition, competitiveness, hierarchy, self-reliance, stoicism, toughness) with the worst of male behavior (e. g. misogyny, predatory behavior, physical, emotional, and sexual abuse; destruction of national resources). They assert that guidelines neglect to consider individual responsibility and attribute men’s violent, destructive, and abusive behaviors exclusively to the effects of masculine ideology, rather than the content of one’s character, or the symptoms of one’s mental illness.
The psychologists who raise issues with the APA guidelines are not refuting the notion that boys and men are negatively influenced by the dominant cultural pressures and narratives in our society. The research is clear on this issue. Ramaeker & Petrie (2019) summarized research which found that men socialized to have the strongest adherence to traditional beliefs about masculinity are more likely to endorse the use of violence and the demonstration of dominance; are more likely to engage in risk-taking and sexual activity with multiple partners; substance use; and unhealthy cardiac behaviors; are less likely to seek preventive health care; less likely to eat vegetables; more likely to consider and engage in heavy drinking, tobacco use and abstain from vegetables, and more likely to have negative attitudes about seeking mental health services than those less rigid gender role beliefs. The results of Adams et al., (1996) study support the notion that the pressure to align with traditional masculine gender roles leads homosexual men to repress, deny, and possibly mask their attraction to men by developing and expressing homophobic attitudes. Adams et al. (1996) exposed homophobic and non-homophobic men to sexually explicit erotic video material, which included male homosexual, lesbian, and heterosexual scenes. Changes in their penile circumference were monitored. Both homophobic and non-homophobic men exhibited increases in penile circumference in response to the heterosexual and lesbian videos. Only the homophobic men exhibited an increase in penile erection in response to male homosexual stimuli. Adams et al, (1996) concluded that homophobia is associated with homosexual arousal which the homophobic individual denies, represses, or which exists in the individual’s unconscious.
Cultural attitudes about men and boys also influence mental health providers. Men are under- diagnosed with depression and anxiety disorders because symptoms associated with these disorders do not align with traditional gender role stereotypes about men’s emotional experience and expression (e. g. sadness, hopelessness, helplessness, worthlessness, guilt, indecisiveness, suicidal ideation, anxiety, worry, easily fatigued, and difficulty concentrating) (APA, 2018; Rice et al. (2018). When boys and men do seek mental health treatment, they often experience bias (Rabinowitz & Cochran, 2002; Rochlen & Rabinowitz, 2014). Consequently, men and boys are reluctant to report these emotions, and clinicians often do not explore these emotions with boys and men, out of fear of contributing to the stigma associated with these symptoms for many men and boys (Ramaeker & Petrie, 2019). This results in men and boys being less likely to be diagnosed with internalizing disorders, in spite of the fact that men and boys are significantly more likely to die of suicide than their female peers (Ramaeker & Petrie, 2019).
As the research described above suggests, boys and men are certainly influenced by cultural expectations traditionally associated with masculinity and manhood, and yet, the guidelines are interpreted by many as denigrating and demonizing all traits traditionally associated with masculinity, and calling into question the value and validity of masculinity itself.
In a 2019 interview with New York Times columnist Thomas B. Edsall, Harvard psychologist Steven Pinker criticized the 2018 APA “Guidelines for the Treatment of Men and Boys” from an evolutionary psychology perspective, stating that the APA guidelines ignore biological and genetic factors which impact men and boys, as well as recent advances in cognitive neuroscience, which demonstrate that behavioral, emotional and psychological patterns are influenced by biological, as well as environmental factors.
Butler (1990); Connell (2014); and the APA’s (2018) position that the construct of masculinity is culturally generated is in contrast to the evolutionary psychology perspective (Buss, 1999), which acknowledges the reality and influence of cultural pressure for both men and women to conform to gender role expectations but also affirms the reality of biological and genetic influences on human behavior, which evolved over the course of human evolutionary history, and to some extent, influenced and shaped the cultural expectations.
The oldest fossils and artifacts suggest that homo-sapiens first appeared approximately 300,000 years ago (Gibbons, 2017). The oldest reliably classified hominid fossils date as early as 4.4 million years ago (Gibbons, 2010). Evolutionary psychology asserts that the human brain evolved over millions of years to solve ancestral problems, such as feeding, hunting, mating, and most importantly surviving (Ozkan, 2017; Buss, 1999). Wyckoff (2019) describes an evolutionary framework for understanding intra-sexual mate competition asserts that ancestral men and women experienced differing sexual selection pressures which resulted in sex-differentiated mate preferences, and behaviors that are biologically based, and still active in the human brain. Ozkan (2017) argues that, for ancestral males, the ability to acquire more food, better shelter, and more effective weapons, provided rank and status, which in turn resulted in more promising mating opportunities. Aggression and a desire to demonstrate dominance proved beneficial for ancestral males. Physical aggression, and the ability to use violence effectively, played an essential role in sexual competition among ancestral male humans. This is not to say being a total “brute” was the key to reproductive success. Buss (1999) lists the following additional characteristics which led to reproductive success for ancestral males; dependability, industriousness, stability, health, and a willingness to invest in children.
Evolutionary psychology asserts that the psychological traits that provided survival and procreational benefits in the past are biologically based, and still present and impactful in humans today, including psychological and behavioral differences in males and females (Buss 2020; Buss 2012; Ozkan, 2017; Campbell, 2012). This does not mean that evolutionary psychology has a deterministic viewpoint. Men and boys, as well as women and girls, are certainly influenced and shaped by cultural and familial expectations. Evolutionary psychology asserts that concurrent with cultural influences, human beings are also powerfully influenced by biological factors older and deeper and much older than contemporary culture.
As Buss (2012) describes, much of the resistance to utilizing evolutionary theory to understand human behavior is due to the assumption that evolutionary theory suggests genetic determinism. In reality, evolutionary theory is an interactionist framework. Evolutionary psychology asserts that human behavior requires two ingredients: 1) evolved adaptations and 2) environmental input that “triggers the development and activation of these adaptations,” (Buss, 2012, p. 18). When evolved behaviors have been activated by environmental input triggers, knowledge of these mechanisms allows for the possibility of change:
“Knowledge about our evolved psychological adaptations along with the social inputs that they were designed to be responsive to, far from dooming us to an unchangeable fate, can have the liberating effect of changing behavior in areas in which change is desired. This does not mean that changing behavior is simple or easy. More knowledge about our evolved psychology, however gives us more power to change” (Buss, 2012, p. 18).
The notion that there might be a biological basis for the difference in men’s and women’s tendency by behaving aggressively or violently is in contrast to the traditional feminist view that any difference between males and females are the product of culture, and can be eradicated through education and social reform (Davis, 2020). In support of the evolutionary psychology perspective, Blair (2007) describes physical differences between men and women which likely influence psychological characteristics: males have proportionately more bone mass, more muscle mass, and a lower percentage of body fat than women, and these differences are, to a significant degree, the consequence of the gonadal steroid hormones influence on skeletal muscle and bone metabolism. Along with the typically visible differences of height, musculature, facial hair, facial features, external reproductive organs, Blair (2007) describes that males have a Y chromosome but only one X chromosome, whereas females have two X chromosomes but no Y chromosome. There are genes on the Y chromosome that have no counterpart on X chromosomes, and, conversely, genes located on the X chromosome can, in some cases, be expressed at higher levels in females than in males. Blair (2007) notes that these differences have a direct influence on both the reproductive and non-reproductive tissues.
Campbell (2012) described brain imaging studies that have identified sex differences in functional connectivity in emotional and facial processing, language processing, and working memory. Campbell (2012) also noted that sex based structural differences exist in the volume of multiple brain structures, the number of nerve cells, the distribution of the various neurotransmitters, and the patterns of synaptic connections.
The research which informs the 2018 APA guidelines rejects the premise that there are inherent biologically based psychological differences in men and women, and ignores the possible psychological influence of the differences in body composition between the majority of men and women. Evolutionary psychologist Anne C. Campbell (2012) provides criticism of feminists’ opposition to the biological approach to studying human behavior. Campbell (2012) defines feminists as those who reject biological explanations of sex differences and identify men and patriarchal institutions as the major oppressors of women. Campbell (2012) notes that feminists accuse biologists of claiming that psychological sex differences are genetic and hence unresponsive to their environment, and thus eternally fixed features of human sexual relations. Campbell (2012) indicates that some feminists go so far as to question the origins of sex differences by rejecting the validity of sex as a binary category, claiming that the categories “man” and “woman” are socially constructed, not biologically based, and consequently untenable.
Campbell (2012) notes that this view of biology as fixed and unresponsive to environmental influences represents some feminists’ failure to understand that genes are highly responsive to the external and internal environment. While behavioral genetics has demonstrated that individual differences in physical characteristics, as well as temperament, are strongly impacted by genetic differences, genetics interact with experience, often in ways which are epigenetic (i.e. effects in which environmental factors change the expression of genes, turning them on or off.) For example, in some, but not all individuals, stress triggers depression.
When individuals who have a specific allele of the serotonin transporter gene encounter stress, their reuptake of serotonin is impacted, leading to low serotonin availability and consequent depression (Caspi et al., 2003). As another example, most men tend to perform better than women on measures of three-dimensional rotation. Campbell (2012) described a study by Hausmann et al. (2009), in which the gender stereotype (men are better at 3D tasks) was triggered by asking some participants in the experimental group to rate the likelihood that males or females would perform better at a 3D task, then they were then asked to perform the 3 D tasks. The men in the stereotype activated group did indeed perform better than women, and better than men in the control condition. Testosterone levels were also 60% higher in the experimental group than in the control group, suggesting that the sex hormone testosterone mediated the effect of the gender stereotype challenge on 3D tasks of cognitive performance.
Buss (2020) describes how evolutionary psychology has refuted the assumptions of behaviorism, which claimed that humans were born with only a small number of exclusively domain-general learning mechanisms and that adult behaviors are solely the products of their “developmental history of paired associations (e.g., a bell with food) and reinforcement contingencies (e.g., pellets after regimented forms of pecking a disk)” (p. 2). He argues that evolutionary processes are essential in explaining and predicting human thoughts and behaviors. In contrast to behaviorism’s assumption of an extremely small number of domain- specific learning mechanisms, evolutionary psychology asserts that the human mind contains a large number of “specialized psychological mechanisms, each tailored to solving fundamentally different adaptive problems,” (p. 2). Buss (2020) asserts that understanding how the adaptive functions of these psychological mechanisms contributed to reproductive fitness is indispensable in understanding contemporary human behavior. He argues that evolutionary psychology provides a unified theory of human nature which makes the “false” dichotomies of innate versus learned; nature versus nurture; and biological versus cultural obsolete.
Complex and Competing Cultural Expectations for Boys and Men
While attempting to behave in accordance with traditional masculine gender norms appears to have a negative impact upon the overall mental and physical health of boys and men (Bogen et al., 2020; Kealy et al., 2020; Juvrud & Rennels, 2017; Cole & Ingram, 2020), there are times when stoicism, strength, competitiveness and aggressiveness are essential (French, 2019; Peterson, 2018). There are even times when utilizing physical violence is essential to protect oneself and others (Bogen et al., 2020). Boys and men face contradictory messages and expectations regarding what qualifies as appropriate male behavior. Bogen et al. (2020) examined the journalistic and social media reactions to the January 11, 2019 Gillette Super Bowl ad which depicted men intervening to stop other men who were engaged in bullying, sexual harassment and other aggressive threatening behavior. The ad encouraged men to “be better” by stepping into the role of protector and defender of women and children. Bogen et al. (2020) noted that the ad generated conflicting reactions. Some called for a boycott of Gillette products, complaining that the ad “makes white men in particular look bad. (Tiffany, 2019). Others praised advertisement as a bold, and much needed step toward challenging behavior traditionally associated with negative aspects of masculinity (violence and aggression) (Bogen et al., 2020)
The Pew Research Center’s (2015) “Parenting in America” report identified multiple cultural changes which have occurred over the past 50 years which have impacted individuals and families, including the growing complexity and diversity within families, the rise in single parent families; the increased number of blended families; and the increased percentage of mothers entering the workforce (28% in 1934 and 70% in 2014). These, and other cultural changes, have impacted the roles and expectations for boys and men. In addition to the characteristics traditionally associated masculine gender roles, men and boys are also expected to be kind, compassionate, empathetic, and emotionally intuitive, receptive, expressive, and vulnerable (Bly, 1990; Jones & McCammon, 2019). Much of the popular literature which purports to inform men about what women look for in a potential mate contains a daunting list of desired characteristics: emotionally and verbally expressive, a willingness to be vulnerable, intelligent, romantic, well dressed, a good sense of humor, facially attractive, muscular, generous, a good listener, prioritizing emotional intimacy over sex; a willingness to cook and clean, and good earning potential (Jones and McCammon, 2019; Adair et al., 2020).
Helm et al. (2020) conducted a study of gender differences in mate selection which built upon nine previous assessment periods beginning in 1939. The participants (55 males, 125 females) completed an online survey which asked them to rank 18 mate characteristics. Some of the 18 mate characteristics were consistently ranked in the top five across all 10 assessment periods. For both males and females this top 5 list includes both Dependable Character; Emotional Stability/Maturity; and Mutual Attraction/Love. Across all ten assessment periods, males ranked both Good Looks and Good Health higher than females, and females ranked Good Financial Prospect and Ambitious/Industrious higher than males. The fact that the top preferences for both males and females remained consistent over the 70+ year history of the assessment periods suggests that contemporary cultural standards are not the only influencer of mate selection preferences
Ozkan (2017) asserts that ancestral females preferred mates who displayed cues indicating the ability and willingness to provide resources and parental investment (e. g. physical prowess, aggression, a desire to demonstrate dominance, as well as dependability, industriousness, stability, health, and a willingness to invest in children). The predominant messaging boys and men receive in contemporary culture assure them that women prefer men and boys who exhibit characteristics on the kind, nurturing, committed, empathetic end of the spectrum. In reality, when men completely devote themselves to understanding, anticipating, and conforming to the expectations of women, to the exclusion of more traditionally masculine traits (e. g. adventurous, risk- taking, independent, ambitious, competitive) they frequently find that women, over the course of a relationship, communicate that something essential is missing (Bly, 1991; Peterson, 2018). Further complicating matters, multiple studies have found that women and girls frequently find the “psychologically harmful,” (Pappas, 2018) traditional masculinity ideology traits, characterized by in men by competitiveness, aggression, stoicism, and dominance, quite attractive (Barelds et al., 2020; Carter et al, 2014), particularly younger women (Qureshi et al., 2016). Boys and men are caught in the tension between their biology, which is hardwired for the conditions of humans’ evolutionary past, and the rapidly changing cultural, elusive, and contradictory expectations for boys and men.
In his controversial 1991 book, Iron John; A Book About Men, Robert Bly asserts that, in response to generations of oppressive, violent, and corrupt behavior by men in positions of power and authority, a cultural reaction against masculinity began in the 1920s and 1930s, typified by the early 20th Century comics “Maggie and Jiggs” and “Blondie and Dagwood” in which males are depicted as “weak and foolish” (p. 24). He notes that this depiction of weak men began to emerge in cartoons and other media.
The father in contemporary TV ads never knows what cold medicine to take. In situation comedies, The Cosby Show notwithstanding, men are devious, bumbling, or easy to outwit. It is the women who outwit them, and teach them a lesson or hold the whole town together by themselves. (p. 24).
In an analysis of depictions of fathers in situation comedies from the 1950s to 2018, Scharrer et al. (2020) found that, as men deviate from the hyper-masculine stereotype, they are increasingly depicted as more foolish, dumb, irresponsible, silly, childish, buffoonish, irrational, ineffective and worthy of ridicule. They also found that fathers in situation comedies are increasingly depicted as relatively uninvolved in parenting interactions, and when they are involved, they are depicted as doing so in a foolish and incompetent manner.
Bly et al. (1991) and Scherrer et al. (2020) analysis suggests that as men increasingly attempt to deviate from traditional masculine ideologies (e. g. avoidance of the appearance of weakness, seeking adventure, risk, and achievement, approaching activities with a sense of competitiveness; and a tendency toward aggressiveness and occasional violence) they are increasingly depicted as incompetent and bumbling in the entertainment media. While Bly’s (1991) examples are a bit dated, contemporary examples of the bumbling father in situation comedies abound: Homer Simpson (“The Simpsons”), Phil Dunhy (“Modern Family”); Peter Griffin (“Family Guy”); Hank Thunderman (“The Thundermans”) & Lawrence Fletcher (“Phineas and Ferb”); Johnny Rose (Schitt’s Creek). In reality, it is difficult to find situation comedies which do not utilize the bumbling, incompetent father trope.
In the day-to-day lives of boys and men, patience, compassion, vulnerability, understanding, and flexibility are desperately needed, and yet boys and men often struggle to find positive models for maleness and masculinity that harness the efficacious aspects of traditional masculinity without identifying and embodying the destructive, darker side of masculine (Reichert, 2019; Bly, 1990; Peterson, 2018). Utilizing concepts from Jungian theory, the Christian Bible, mythology, evolutionary biology and evolutionary psychology, Peterson (2018) encourages men to embrace a positive, but traditional masculinity characterized by taking responsibility, creating order, aspiring to grow and get better each day, but also by compassion, self-awareness and self-care. Peterson’s (2018) perspective has been greeted by mixed reviews. Young men flock to his presentations and carry his books like it is a sacred text. Young men are desperately seeking someone to help them be better men. From generation to generation of fathers has believed and struggled to align themselves with traditional masculine models, which have not provided the full tool kit needed to meet their son’s developmental or psychological needs (Reichert, 2020).
Baumrind’s (1971) research identified two aspects of parental behavior which have been found to predict positive adaptive characteristics in children and adolescents: parental warmth (also referred to as parental responsiveness) and parental control (also referred to as parental demandingness). Warm and responsive parents make a consistent effort to be engaged in their adolescents’ lives and to understand, accept and take seriously their adolescent’s expressed feelings and needs. Warm and responsive parents also make a point of explaining their own actions, especially when they enforce boundaries and limits with the adolescent. Parental control or demandingness involves having mature expectations for children. Parents who exhibit high levels of parental control set and enforce rules, consistently monitor their children and confront and provide meaningful consequences when their children do not meet parental expectations.
Treating responsiveness and demandingness as two distinct dimensions, Baumrind (1971) described four categories of parenting style: Authoritative (described above), authoritarian, permissive (also referred to as indulgent), and neglecting (also referred to as uninvolved or dismissive). Authoritarian parents have high expectations for their children and make multiple demands, but are not responsive to their teens expressed feelings and needs. Permissive parents are very responsive to their children, but make few demands upon their children. Neglecting or dismissive parents are neither engaged nor do they make demands upon their children.
Baumrind’s (1971) research found that authoritative parents put forth tremendous effort into parenting their adolescents. Adolescents raised by authoritative parents, were exceptionally competent (i.e. mature, prosocial, high internal locus of control, low internalizing and externalizing problem behavior, low substance abuse.) (Baumrind, 1971). In the large-scale study (approximately 4,000 14- to 18-year-olds) Baumrind’s parenting style framework was associated with four aspects of adolescent adjustment: psychosocial development, school achievement, internalized distress, and problem behavior. The adolescents of authoritative parents scored best on all of the majority of these indicators. Adolescents with neglectful parents scored the lowest (Lamborn et al., 1991). In a one year follow up the adolescents’ adjustment status was reassessed, and parenting style was found to predict changes in the adolescents. Adolescents with authoritative parents exhibited increases in self-reliance. The adolescents whose parents had authoritarian and permissive parenting styles showed little change. Adolescents with neglectful parents showed continued declines over the 1-year period and exhibited dramatic drops in school performance, and increases in externalizing behaviors and alcohol and drug use (Steinberg et al. , 1994).
Multiple studies (Cuccì, 2019; Fletcher et al., 1999; Wittig & Rodriguez, 2019) have found that authoritative parenting, characterized by parental warmth/ responsiveness and parental control/demandingness is the most efficacious approach to parenting children and adolescents. And yet, socialized masculine gender roles in western societies tend to run counter to the attitudes and behaviors associated with an authoritative parenting approach. Traditional masculine gender roles are typically characterized by a reluctance to admit vulnerability, a fear of expressing emotions, especially to other men, conceptualizing success primarily through the lens of competition, and prioritizing work over family relationships (Ramaeker and Petrie, 2019). These attitudes have been shown to have significant negative consequences for men, their families and coworkers.
Bowlby (1969) identified the quality of child-parent attachment as a determining influence on children’s emotional and social development. According to attachment theory, children whose parents provide responsive and sensitive care during infancy and early childhood develop secure attachment relationships with parents, which results in children constructing positive cognitive models of themselves and others. Children consequently develop the view that they are worthy of the love and support of others, and that others will be responsive, available, and trustworthy. In contrast, children who experience unresponsive and insensitive parenting are likely to construct negative cognitive models of themselves, and others, form insecure attachment relationships (Bowlby 1980). Studies have tended to show that mothers are the primary attachment figures throughout childhood and adolescence (Borelli et al., 2020; Kammrath et al., 2020. Keresteš et al. (2019) found that the quality of adolescent’s current attachment to parents is related to both anxiety and depression. They also found no differences in the strength of associations between maternal versus paternal attachment and either depression or anxiety. Adolescents who reported poorer quality of current attachment to mother and father also reported higher levels of anxiety and depression.
Barker et al. (2017) summarized existing research and reported that parental sensitivity and engagement are consistently associated with reduced child psychopathology and that secure father – child attachment, independently predicts decreased adverse child outcomes. They reviewed a wide body of research that clearly demonstrates the impact that fathers have on their children’s social, emotional and psychological development.
In an overview of the past 100 years of social science research, Pinker (2016) asserts that the notion of the blank slate has become a bedrock doctrine of the social and political sciences, especially cognitive psychology and learning theory. Pinker (2016) notes that psychology has sought to explain the entirety of human thinking, feeling and behaving through learning theory. Davis (2020) makes the identical point in describing the philosophical divide between the feminist perspective and the evolutionary psychology perspective as representative of a discrepancy between research fields guided by the standard social science model (e. g. sociology, humanities, gender studies, and cultural anthropology), and those disciplines with more positivist leanings, including biology, psychology, behavioral genetics, and behavioral ecology.
Davis (2020) echoes Buss (2020) and Pinker (2016) in arguing that the standard social science model has social constructionist leanings, in which humans are understood as “blank slates,” shaped and conditioned by culture and socialization. The notion of biologically based innate, inborn characteristics, tendencies, or abilities is still controversial in the social sciences (Buss, 2020), and researchers who produce evidence for these sorts of predispositions are often lumped in with determinist, reductionists, and “proponents of eugenics and Social Darwinism.” (Pinker, 2016, p. 109). Both The Schema Theory and Jungian theory posit that adaptive and maladaptive personality and behavioral features are influenced and shaped by universal, biologically based predispositions.
Both Jungian theory and cognitive theory began as dramatic deviations from the dominant perspectives of their time. Jung broke from Sigmund Freud and his “sexual theory,” and George Miller broke with the behaviorist academic establishment and began to study higher mental processes (Hunt, 2007; Pinker, 2013; Rachlin; 2018). While the origins of cognitive theory cannot be pinned exclusively to one individual, as Jungian theory can, Hunt (2007) and Pinker (2013) associate the beginning of cognitive theory with Harvard professor George Miller’s decision to break with his behaviorists’ tradition and begin to study “the mind.”
“To behaviorists, the mind, invisible, nonmaterial, and conjectural, was an obsolete metaphysical concept that no experimental psychologist concerned about his career and reputation would talk about, much less devote himself to.” (Hunt, 2007, p. 591)
In George Miller’s obituary for the American Psychologist, Steven Pinker (2013) wrote:
“At the time, psychology was “the science of behavior,” and mental entities such as thoughts, plans, and goals were condemned as occult forces and banned from the study. Miller realized that the new ideas he was invoking—information, recoding, hierarchical structures—together with computer simulations of thinking . . .could make mental stuff scientifically respectable. “I now believe that mind is something more than a four-letter, Anglo-Saxon word—human minds exist and it is our job as psychologists to study them” (American Psychologist, Vol. 17, p. 761).
Despite his behaviorist training, Miller’s research findings let him begin conducting experimental studies in speech and communication, fringy ideas for a behaviorist. After attending a seminar with psycho-linguist Noam Chomsky, Miller began to think about memory and higher mental processes. In the fall of 1960, Miller and a social psychologist colleague, Jerome Bruner, began the process of establishing the Harvard Center for Cognitive studies (Hunt, 2007; Pinker, 2013).
Sternberg and Sternberg (2012) described cognitive theory as the study of how people perceive, remember, learn, and utilize information. Cognitive theory is at heart a learning theory. Beck (1976) asserted that the human brain is conceptualized as a sophisticated computer, a biological information processing system. Psychological/cognitive development is understood as a product of experiencing, responding to and learning from the environment, and mental health symptoms are conceptualized as the product of distortions and misinterpretations of reality based on errant premises or assumptions. These incorrect conceptions, according to Beck (1976), originated in defective learning during the person’s cognitive development. Once these distortions are understood and corrected, the cognitive theory asserts that information will then be processed effectively, more accurate interpretations will replace the old, and then symptoms disappear (Don et al., 2019; Gillihan, 2018).
In the preface to the 1979 book Cognitive Therapy for Depression, Aaron Beck the originator of cognitive behavioral therapy (CBT) recalls that he was psychoanalytically trained. He attributes “the first stirrings” which led to the formulation of cognitive therapy to his attempt in 1956 to validate the psychoanalytic formulation of depression, which he believed to be accurate. He hoped to “pinpoint the precise psychological configuration characteristic of depression in order to develop a brief form of psychotherapy specifically directed toward alleviating the focal psychopathology,” (Beck et al., 1979, preface). His initial findings appeared to support the psychoanalytic conceptualization of depression as “retroflected hostility, expressed as ‘a need to suffer’” (preface). Surprisingly, the results of Beck’s (1979) later experiments did not align with the traditional formulations. He found that depressed individuals do not have a need to suffer. Instead, he found that depressed patients go to great lengths to avoid situations and behaviors which they believed would result in suffering. These results caused Beck to question his personal belief system.
In analyzing the dreams of depressed patients Beck (1979) found persistent themes: “The dreamer appeared as a loser; thwarted in any attempt to achieve some important goal, losing something of value, or appearing diseased, defective, or ugly” (Beck, 1979, preface). Beck noticed that the patients’ dreams aligned with their descriptions of themselves and their life experiences which were characterized by a negative conceptualization of themselves and their life experiences. These constructions, and the dreams, were, according to Beck (1979), distortions of reality. Further research utilizing newly developed instruments indicated that depressed patients systematically distorted their experiences in a negative way, and had a negative view themselves, the outside world and the future. In response, Beck began to develop techniques to correct patients’ thought distortions through the “application of logic and rules of evidence and to adjust [their] information processing to reality” (preface).
Beck et al. (1979) stated the cognitive therapy assumes that individuals’ cognitions are
a synthesis of internal and external stimuli and that these cognitions represent the individual’s structured understanding of self, the world, the past and the future. Cognitive therapy assumes that alterations to the content of individuals’ cognitive structures will impact their emotional state and behavior. Individuals can become aware of their cognitive distortions and correcting these distortions can result in clinical improvement. He traces the philosophical origins of cognitive therapy to the stoic philosophers, particularly Epictetus who wrote, “men are disturbed not by things but by the views which they take of them.” He also asserts that Buddhism and Taoism posit a similar notion that emotions are the product of ideas and thoughts.
While theorists have expanded upon the core theoretical constructs of (CBT) to develop other approaches, Bec2k’s (1976) foundational theoretical principles still undergird current CBT treatment. In a 2019 study of early interventions in CBT for depression, Don et al. (2019) write:
“The essence of the cognitive part of CBT is to alter maladaptive thoughts that may render patients depressed or keep patients vulnerable to developing depression. These thoughts often comprise ideas about oneself (e.g., “I am worthless”), the other (“other people find me unattractive”), and the future (“I will never get a satisfactory life”). If these thoughts can be changed into more adaptive ones (e.g., “I am a valuable person for my friends and family, but I am somewhat sloppy in my household”), the cognitive theory postulates that depression is likely to decrease” (p. 49).
Donald Meichenbaum’s (1977) cognitive behavior modification (CBM), expanded somewhat upon Beck’s ideas by developing an approach which focuses on changing the clients’ self-verbalizations. A foundational premise of CBM is that, before clients can change their behavior, they must first become aware of the scripted nature of how they think, feel, and behave, and how their thoughts, feelings and behavior impacts others. He posits that change occurs through three phases: 1) self-observation, 2) Starting a new internal dialogue, 3) Learning new skills.
Theorists have expanded upon the core theoretical constructs of (CBT) to develop other approaches, often referred to as third wave therapies: Dialectical Behavior Therapy (DBT) (Linehan, 1993), Acceptance and Commitment Therapy (ACT) (Hayes et al., 2012). DBT was originally developed as a treatment for borderline personality, and has been expanded in an attempt to treat a wide variety of mental health symptoms , including depression, bulimia, binge-eating, bipolar disorder, post-traumatic-stress disorder, and substance abuse. DBT is a cognitive approach which emphasizes psychosocial aspects of treatment, attempting to help clients identify and challenge inaccurate thoughts, beliefs and assumptions. In conjunction with individual therapy, DBT works with clients in psychoeducational skills groups, in which clients’ development and practice mindfulness, communication, distress tolerance, and emotional regulation skills (Harvey et al., 2019).
Acceptance and Commitment Therapy’s (ACT) (Hayes et al., 2012) utilizes mindfulness techniques to help clients think and respond differently to their internal psychological experiences. Experiential avoidance is a foundational idea within the ACT model. Experiential avoidance is the attempt to change, diminish, or extinguish unwanted feelings, thoughts, and physiological sensations (Hayes et al., 2012). Within the ACT model, psychological pain is understood as caused by the individual’s attempts to change or avoid unwanted thoughts and emotions, rather than by the thoughts and emotions themselves. The emphasis of ACT is not upon changing the content of clients’ internal experiences. Instead of that, the goal is to help clients develop psychological flexibility to be present with and make values-based choices in response to emotional experiences. ACT teaches and attempts to foster six core processes in clients: 1) Acceptance, which involves willingness to experience psychological processes (e. g., anxiety, depression, negative cognitions; 2) Cognitive defusion, which is understood as the ability to distance oneself from psychological processes, rather than fusing with them; 3) Presence involves being mindfully aware of and attuned to external and psychological events in the moment; 4) the self-as context involves helping clients develop the perspective of observer of thoughts and emotions, rather than identifying with thoughts and emotions (e. g. “I am having a thought; I am not the thought. I am experiencing an emotion; but am not the emotion”; 5) Values involves the identification of personally held values and 6) commitment involves choosing actions which reflect and are in service of the identified values (Zarling et al., 2015).
While studies have consistently shown that therapy, regardless of theoretical approach, is more effective than no mental health treatment at all (Joyce, et at., 2006; Laska et al. 2014) many clients do not respond to therapy. This is true even with therapeutic approaches which have relatively strong evidence-based support, such as CBT, and “Third Wave” cognitive approaches such as Acceptance and Commitment Therapy and Dialectical Behavior Therapy (Arch et al., 2012). CBT has a long history of evidence-based support, and yet there are questions about its efficacy. Janse et al. (2020) summarize research which indicates that randomized controlled trials comparing CBT to placebo and treatment as usual resulted in only small to moderate effect sizes. A meta-analysis Fernandez et al. (2015) found that more than ¼ of clients who begin CBT treatment drop out of treatment. The efficiency and efficacy CBT reported in randomized controlled trials are inconsistently achieved in routine care (Lutz et al. (2016). Waller and Turner (2016) posited that one possible reason for the differences which exist between outcomes in research vs routine settings is that therapists may not be strictly following evidence-based treatment protocols.
Among the 60% of individuals for whom therapy is effective, for 30% of those, the effects are short- lived (Johnson and Friborg, 2015; Young et, al., 2014). In a meta-analysis examining the effects of cognitive- behavioral therapy (CBT) as a treatment for unipolar depression from 1977 – 2014, Johnsen and Friborg (2015) found that the effects of CBT have declined linearly and steadily since its introduction. While the foundational ideas of cognitive theory have led to the development of powerful therapeutic tools, it is clear that something is missing.
Young et al. (2014) summarize studies that demonstrate the 40% – 50% of individuals do not complete or respond to CBT treatment for depression; 50% of individuals treated for depression with medication do not experience full remission, even after two courses of medication; 20% of incidents of diagnosed depression persist after two years; and 25 – 35% of outpatient patients experience chronic depression. Young et al. (2014) note that many individuals are not helped, or continue to experience impaired functioning and/or emotional distress after receiving CBT treatment. Young et al. (2014) note that individuals who experience chronic, treatment resistant depression typically experience the onset of symptoms during mid-adolescence. Young et al. (2014) A lso note that childhood / adolescent trauma and adverse family experiences such as abuse, neglect and over-protection, are more prevalent individuals who experience chronic depression.
In an examination of meta-analyses of cognitive- behavioral therapy Wampold et al. (2017) identified four problems which they claim mitigate the findings of meta-analyses which found that CBT is superior to other treatments: 1) concerns with effect size, power, and statistical significance, 2) focusing on disorder-specific symptom measures to the exclusion of other important aspects of psychological functioning, (3) classifying treatments provided in primary studies into classes of treatments, and (4) the inclusion of problematic studies/trials and the exclusion of studies/trials that fail to find differences among treatments. Given these findings, they concluded the apparent superiority of CBT treatments were typically small or non-significant; were limited to very specific symptoms targeted in the study; or the consequence of flawed primary studies. Wamplold et al. (2017) concluded that the meta-analytic support for the superiority of CBT in the three meta-analyse s they examined are weak or nonexistent. Sanders and Hunsley (2018) raised similar concerns regarding meta-analyses in general and provided recommendations for meta-analytic reviews.
Critique of “3rd Wave Treatments
In a systematic review of research examining the efficacy of Dialectical behavioral therapy, (DBT), Harvey et al. (2019) found that the vast majority of research on DBT has focused on DBT’s effectiveness in reducing life-threatening behavior (self-harming and suicidal behaviors). They found a very limited number of studies that examined long- term treatment goals. They also found that existing studies do not demonstrate consistent benefits when compared to existing psychological treatments targeting improving emotional regulation skills, which is the purported mechanism of change of in DBT treatment.
In a 2017 meta-analysis of randomized clinical trials, Cristea et al. (2017) found that the outcomes of psychotherapies (particularly dialectical behavior therapy and psychodynamic approaches) significantly decreased life-threatening symptoms associated with BPD (self-harm behavior and suicide) compared with control interventions. They found that the differences were considerably less in well-designed and implemented randomized controlled trials, when the control group also received a manualized treatment; or when the involvement of the study team in treatment was considered.
A-tjak et al. (2015) conducted a meta-analysis which included 39 RCTs which examined Acceptance and Commitment Therapy’s (ACT) efficacy with mental and physical health difficulties. They found that ACT outperformed control conditions on both initial outcome and follow up measures. They found that ACT was as effective, but not more effective, than CBT. In a meta-regression analysis they found that studies with more rigorous methodology were associated with smaller effect sizes.
Hacker et al. (2016) conducted a meta-analysis of studies that examined the efficacy of ACT in treating depression and anxiety. They found that ACT demonstrated at least moderate symptom reductions in the group and pre-post effects for both anxiety and depression. Their data analysis found insufficient evidence to confidently affirm that ACT is efficacious for anxiety when compared to active control conditions or as primary treatment for anxiety. They also found insufficient evidence to affirm moderate efficacy of ACT, when compared to active control conditions, in treating depression. Yıldız (2020) conducted a meta-analysis of 30 randomized controlled trials that examined ACT’s efficacy across a broad range of health-related behaviors (substance abuse and addiction, weight management, eating, and physical activity). While noting several limitations to the studies reviewed, Yildiz (2020) concluded that ACT is a transdiagnostic approach which promotes health‐related behaviors across many disorders and populations.
Schemas can be both adaptive or maladaptive. Cognitive schema are cognitive templates that individuals use for screening, coding, and interpreting the information and experiences that they encounter (Beck, 1975; Young et al., 2014). Schemas are enduring and pervasive over an individual’s lifetime (Riso et al., 2006; Young et al., 2003). While the majority of schemas are adaptive, Early Maladaptive Schema (EMS) are (highly) dysfunctional. Young et al. (2003) defined EMS as “broad, pervasive themes or patterns, comprised of memories, emotions, cognitions, and bodily sensations, regarding one- self and one’s relationships with others, developed during childhood or adolescence, elaborated throughout one’s lifetime, and dysfunctional to a significant degree” (p. 7).
Schema theory postulates that individuals who suffer from chronic, difficult to treat mental health symptoms have developed EMS (Young et al., 2003) as the product of the interaction between their innate temperament and negative early life experiences. Over time, and repeated experiences, children develop maladaptive views (schemas) of themselves, relationships and the world. Early Maladaptive schemas are described as “(1) a priori truths about oneself and/or the environment; (2) self-perpetuating and resistant to change; (3) dysfunctional; (4) often triggered by some environmental change . (5) tied to high levels of affect when activated,” (Young et al., 2014, p.286).
Beck (1979) asserted that in any given situation, individuals filter through an enormous number of stimuli in order to attend to select stimuli, combine them into a pattern in order to characterize the situation. Individuals tend to conceptualize and respond to similar situations in consistent ways. “Relatively stable cognitive patterns form the basis for the regularity of interpretations of a particular set of situations. The term ‘schema” designates the stable cognitive patterns” (p. 12). Beck (1979) explained that when individuals encounter a particular situation, a schema related to the circumstance is activated. Beck posited that schema are the basis for “molding data into cognitions” (p. 12). By molding, Beck (1979) means that schema functions as a filter to screen, differentiate and code stimuli so that it can be categorized and evaluated. Individuals categorize and evaluate experiences “through a matrix of schemas” (Beck, 1979). These matrixes are called Schema Modes (Young et al., 2003). According to schema theory, a schema mode may be inactive, and out of awareness, for extended periods of time and then activated by a situation which triggers the schema mode.
Young et al. (2014) identified 18 cognitive schema which they divided into broad categories they labeled schema domains. Individuals with schema in Domain 1, Disconnection and Rejection, are impaired in their ability to establish and maintain secure, rewarding attachments. These individuals believe that their needs for love, belonging and nurturance will not be met. The maladaptive schema in this domain are Abandonment/Instability, Mistrust/Abuse, Emotional Deprivation, Defectiveness/Shame, and Social Isolation/Alienation.
Domain II is Impaired Autonomy and Performance. Individuals with Schema in this domain have developed beliefs about themselves and the expectations of others that interfere with their ability to separate appropriately from parent figures and function autonomously. The four schemas in this domain are Dependence/Incompetence, Vulnerability to Harm or Illness, Enmeshment/Underdeveloped Self, Failure (Young et al., 2003)
Domain III Impaired limits. Individuals with schema in this domain have not developed adequate interpersonal limits regarding self-discipline or reciprocity, meaning they find it difficult to cooperate , respecting the rights of others, and meeting their long-term goals. Often, they present as irresponsible, spoiled, narcissistic, or selfish. The schema in this domain is Entitlement/Grandiosity, Insufficient Self-Control/Self-Discipline (Young et al., 2003)
Domain IV is Other Directedness. Individuals with schema in this domain have difficulty placing an emphasis on meeting their own needs and tend to excessively emphasize meeting the needs of others, with the goal of gaining approval, maintaining an emotional connection, or avoiding retaliation. The schema in this domain are Subjugation of Needs/Emotions, Self-Sacrifice, Approval Seeking/Recognition-Seeking (Young et al., 2003)
Domain V is Over-vigilance and Inhibition. Individuals with schema in this domain tend to suppress their feelings and impulses in order to meet rigid, internalized rules about their own performance. They sacrifice their happiness, self-expression, close relationships and personal health. The schema in this domain is Negativity/Pessimism, Emotional Inhibition, Unrelenting Standards/Hyper-criticalness, and Punitiveness (Young et al., 2003)
Once schema have been activated, the individual selects, encodes and categorizes information and perceptions in ways that align with and perpetuates the schema(s). Everything that an individual is thinking, feeling and doing at a given point in time is referred to a schema mode. There are positive and negative schema modes. A dysfunctional mode is thought to be activated when specific maladaptive schemas have erupted into avoidance responses, distressing emotions, and/or self-defeating behaviors that take over and control an individual’s thoughts , emotions, and functioning (Young et al., 2003). Maladaptive modes are autonomous ego states which essentially assume control of an individual’s thinking and behavior. It is somewhat similar to a dissociative state in which the ego, to some extent, relinquishes control to another aspect of the personality, (Young et al. , 2003).
Young et al. (2003) identified 10 schema modes which they grouped into four general categories: Child Modes, Dysfunctional Coping Modes, Dysfunctional Parent Modes, and the Healthy Adult Mode. A primary goal of schema therapy is to help clients become conscious of their Healthy Adult modes so that they can learn to nurture, parent or neutralize dysfunctional modes. Schema therapy involves (1) Increasing the individual’s awareness of modes (adaptive and maladaptive) and labeling the modes with the patient; (2) Exploring the origins of modes in childhood or adolescence; (3) Linking current problems and symptoms to maladaptive modes; (4) Uncovering advantages and disadvantages of each mode; (5) Using imagery to access the vulnerable child mode; (6) Conducting dialogs between modes; (7) Generalizing results from mode work to real life (Young et al., 2003).
Critique of Schema Theory
Glaser et al. (2002) conducted a construct validity study of the Early Maladaptive Schema Questionnaire-Short Form (EMSQ-SF). The EMSQ-SF (Young, 1994) is a 75-item instrument that was used to assess the extent to which an individual manifests a particular early maladaptive schema. The study examined the degree to which the EMSQ subscale predicted the Beck Depression Inventory (BDI), as well as the GSI and Anxiety subscales of the Symptoms Checklist-90-Revised – SCL-90-R (Derogatis, 1983). They also examined the ability of EMSQ-SF subscales to predict other measures of general symptomatology (the depression subscale of the Positive and Negative Affect Schedule (PANAS) (Watson, Clark, & Tellegen, 1988) and the Anxiety and Major Depression subscales of the Milton Clinical Multiaxial Inventory-II (MCMI-II). The MCMI-II (Milton, 1987). The findings largely supported the psychometric soundness of the scores from the EMSQ-SF in a clinical sample. They identified several statistically significant relationships between the 15 subscales of the EMSQ-SF and each measure of general symptomatology. They reported that all of the EMSQ-SF subscales, with the exception of Entitlement/Self-Centeredness, were significantly correlated with most of the general symptomatology scales. They concluded that high endorsements of EMS signal the presence of stress, anxiety, depression, and negative affect.
Multiple studies have examined the 18 Early Maladaptive Schema as they are measured by the YSQ (Lee et al., 1999; Schmidt et al., 1995). While there is some variance across the studies, all 18 Early Maladaptive Schemas have been supported.
TheYoung Schema Questionnaire (YSQ; Young & Brown, 1994) has been validated in studies conducted in (Australia: Lee et al., 1999; China: Cui et al., 2011; Korea & Australia: Baranoff et al., 2006; Norway: Hoffart et al., 2005; Turkey: Waller et al., 2001; and the United States: Cecero et al., 2004).
The Young Schema Questionnaire (YSQ) and Schema Mode Inventory (SMI) were developed as tools to assist clinicians to identify which Early Maladaptive Schema (EMS) are present and active within an individual. The first comprehensive investigation of its psychometric properties was conducted by Schmidt et al. (1995). Results from this study produced alpha coefficients of each Early Maladaptive Schema that ranged from .83 (Enmeshment/Underdeveloped Self) to .96 (Defectiveness/Shame) and test-retest coefficients from .50 to .82 in a nonclinical population. The primary subscales demonstrated high test-retest reliability and internal consistency. The questionnaire also demonstrated good convergent and discriminant validity on measures of psychological distress, self-esteem, cognitive vulnerability to depression and personality disorder symptomatology (Young et al., 2003).
Hawke and Provencher (2013) reviewed the research on EMSs in mood and anxiety disorders. Across the studies, elevations on most schema domains were present when comparing depressed patients to individuals who report never having been depressed. Riso et al. (2003) compared depressed and chronically individuals to non-depressed individuals and found that both depressed and chronically depressed individuals scored higher across all schema domains than healthy controls, with chronically depressed individuals scoring highest on the schema in the impaired autonomy and performance, disconnection and rejection, and over-vigilance domains.
Schema Therapy (ST) has been shown to be successful in the treatment of a wide range of mental health conditions in adults, including both affective disorders (Hawke & Provencher, 2013; Wang et al., 2010) and personality disorders (Bamelis et al., 2014; Giesen-Bloo et al., 2006; Nadort et al., 2009). Taylor et al. (2017) conducted a meta-analysis of research studies conducted between 1990 and 2016 which examined the efficacy of schema therapy. From the initial results of 1555, they identified only 12 studies which met their inclusion criteria
- Single‐blind randomized controlled trials (RCTs), open trials (without control groups), and, because of the limited evidence base, case series.
- Studies where schema therapy was the intervention or a component of the intervention being examined (no minimum number of sessions specified).
- Studies where a schema questionnaire (EMS, mode) was used as a measure.
- Studies where a specific Axis I and Axis II mental health disorder were included.
- A measure of symptoms and symptom change was included in the studies. Individual case studies and studies only using self‐help schema therapy books (without therapist sessions) were excluded. Taylor et al. (2017) reported some “low‐quality evidence” of schema change in schema therapy interventions targeting personality disorders. In the personality disorder specific studies, symptom change appeared to accompany schema change. They indicated that they found very limited quality evidence of schema change in schema therapy studies of PTSD eating disorders, chronic depression, agoraphobia. They note that while preliminary evidence suggests that schema might be effective with these disorders, in its current form, the evidence is insufficient to inform evidence‐based intervention.
Any book which attempts to explain Jungian psychology begins with a detailed telling of Carl Gustav Jung’s life. Jung’s understanding of human nature was informed and shaped by the confluence of his introspective nature and his rich imaginative / spiritual life within the crucible of religion, medicine, spiritualism and the occult which permeated his family of origin. (Stevens, 1990). In 1961 Jung concluded his autobiography Memories, Dreams and Reflections, in which he details how his theoretical perspective grew out of life experiences.
Jung described his childhood as solitary, but not lonely. Jung spent as much time as he could on his own. “I remained alone with my thoughts. On the whole I liked that best. I played alone, daydreamed or strolled in the woods alone, and had a secret world of my own” (Jung, 1989, p. 66). Jung describes as a child that he came to experience himself as made up of two separate but distinct personalities, which he referred to as ‘No. 1’ and ‘No. 2’ respectively. Jung (1989) described his number 1 personality as “the son of my parents, who went to school and was less intelligent, attentive, hard-working, decent, and clean than many other boys,” (p. 62). This was the part of Jung’s personality he would later label the “conscious ego.” His number 2 personality was an old man, “skeptical, mistrustful, remote from the world of men, but close to nature, the earth, the sun, the moon, the weather, all living creatures, and above all close to the night, to dreams, and to whatever ‘God’ worked directly in him,” (Jung, 1989, p.62). Ultimately, Jung realized that these two personalities are present in everyone; he was just more aware of them than most. Jung came to rename these two personalities the ego and the Self. He asserted that the interaction between the ego and Self is the crucible in which the individual personality develops, a process Jung termed individuation. Jung believed that his No. 2 personality provided him access to the mind of God.
In addition to his awareness of his two personalities, the nature of Jung’s childhood dreams and visions convinced him that they too must have come from beyond himself. Contrary to the traditional Christian portrayal of God as “all good”, the God Jung encountered in his dreams and visions appeared to contain both light and darkness, good and evil, creation and destruction. According to Jung’s theory, tension and interdependence between the poles of God’s nature, and the tension between all opposites (Male/Female, Wisdom/Foolishness, Body/Spirit) is central. Jung recounts a dream which occurred when he was 3 or 4 years of an underground phallic being which he described as a deity:
“On this platform stood a wonderfully rich golden throne. I am not certain, but perhaps a red cushion lay on the seat. It was a magnificent throne, a real king’s throne in a fairy tale. Something was standing on it which I thought at first was a tree trunk twelve to fifteen feet high and about one and a half to two feet thick. It was a huge thing, reaching almost to the ceiling. But it was of a curious composition: it was made of skin and naked flesh and on top, there was something like a rounded head with no face and no hair. On the very top of the head was a single eye, gazing motionlessly upward.” (Jung, 1989, p. 25).
This dream terrified and haunted Jung throughout his childhood. He later came to
understand the dream as having welled up from what he later termed the collective unconscious as contrast and compensation for the sterile, one-dimensional, monochromatic deity espoused by his father’s church. At age 12 Jung was overwhelmed by another experience from his unconscious, a powerful vision, which he struggled unsuccessfully to resist: “I saw before me the [Basel] cathedral, the blue sky. God sits on His golden throne, high above the world—and from under the throne an enormous turd falls upon the sparkling new roof, shatters it, and breaks the walls of the cathedral asunder. “ (Jung, 1989, p. 57).
Jung considered himself a scientist. He was adamantly opposed to the doctrine of any kind (religious, political or scientific), and yet his interests in the natural sciences were countered by his willingness to investigate experiences and topics which science typically shuns as irrational. The foundational ideas of his teleological theory of human personality development rest on the dreams, visions and fantasies from his childhood, which he believed came from a source beyond himself, nudging, tugging and pulling him toward becoming the unique individual he was meant to be. Throughout his career Jung received harsh criticism from many different fronts including academics and the church and yet he persisted in following the path of truth as he perceived it.
“Not the criticism of individual contemporaries will decide truth or falsity of these discoveries, but future generations. There are things that are not yet true today, perhaps we dare not find them true, but tomorrow they may be.” (Jung, 1966, p. 119).
In the final chapter of his autobiography Jung (1961) acknowledges that he uses the terms “unconscious” and “God” interchangeably, and yet, it would be mistake to assume that Jung is referring to a traditional Christian, theistic conceptualization of God as an omniscient, all-merciful, and omnipotent creator who stepped back from creation to oversee and occasionally intervene in creation. He asserts that the God of the traditional Christian myth is flawed in that God is denied wholeness. God’s dark, destructive side is projected upon Satan, fallen angels, and ultimately humanity. He argues that Christian mythology is not sufficient for contemporary society, because it has not taken monotheism seriously. Christian theology has instead created a dualism “and enthroned an eternal dark antagonist alongside the omnipotent Good.” (Jung, 1989, p. 396). Jung argues that, in order to become whole, both God and humans must become conscious of and integrate the dark shadow aspects of their nature on the journey toward wholeness. He asserts that the “incarnation of God—the essence of the Christian message—can then be understood as [humanity’s] creative confrontation with the opposites and their synthesis in the self, the wholeness of his personality.” (p. 397). Jung asserts that as humans become conscious of and synthesize the opposites within themselves, they are simultaneously reconciling the opposites in God’s nature.
After completing his medical degree from Basel University in 1900, Jung became a psychiatric assistant to Eugene Bleuler (1857–1939) at Burghöltzli Mental Hospital in Zürich. While Jung was at Burghöltzli Bleuler assigned him to work with Sir Francis Galton (1822–1911) word-association test. Bleuler was attempting to demonstrate that patients’ associations with particular words would align with discrete mental “disease states.” The procedure is fairly straightforward: The examiner reads a series of words from a carefully prepared list. The subject is asked to respond with the first word that comes to mind. The examiner records the word, along with the time, in seconds, taken to elicit the response. When all the words have been presented, the procedure is repeated. The subject is asked to respond with the same words as in the first administration. While Bleuler’s hypothesized relationship between specific words and disease states did not materialize, Jung did notice that there existed considerable variation in individual’s response times from one word to another. While most stimulus words (Listed in the appendix) elicited a response in 1 – 2.5 seconds, some words would result in a prolonged time before a response or no response at all. Jung found that the words which triggered an interruption tended to cluster around particular emotionally charged, but mostly unconscious themes, which Jung later identified as complexes (Stevens, 1991).
Jung identified several behaviors which were indicators of complexes: responding with more than one word; longer than average reaction time; repetition of stimulus word by the subject; mishearing the stimulus word as some other word; expressive body movements in response to the stimulus work (laughing, clearing the throat, twitching, awkwardly changing position; twitching), very superficial reaction to stimulus word (rhyming or nonsense words); failure to respond at all; perseveration of response, slips of tongue; stammering and significantly altering the response when the procedure is repeated (Sollod et al., 2009).
Jung’s theory of complexes led to him taking a different approach to case conceptualization than his colleagues at Burghöltzli:
“Dominating my interests and research was the burning question: “What actually takes place inside the mentally ill?” That was something which I did not understand then, nor had any of my colleagues concerned themselves with such problems. Psychiatry teachers were not interested in what the patient had to say, but rather in how to make a diagnosis or how to describe symptoms and to compile statistics. From the clinical point of view which then prevailed, the human personality of the patient, his individuality, did not matter at all. Rather, the doctor was confronted with Patient X, with a long list of cut-and-dried diagnoses and a detailing of symptoms. Patients were labeled, rubber-stamped with a diagnosis, and, for the most part, that settled the matter. The psychology of the mental patient played no role whatsoever.” (Jung, 1989, 141)
Jung reports that during this period Freud’s work became vitally important to him. When Jung read Freud’s The Interpretation of Dreams (1900) he identified a correlation between the complexes he had identified and ‘repressed wishes’ and ‘traumatic memories’ which Freud held to be responsible for neurotic symptoms and for the content of dreams. As Jung began to listen to his schizophrenic patients he found that their hallucinations, delusions, and repetitive behaviors were not random gibberish, but were instead, full of meaning. One of Jung’s female patients, who had been hospitalized at Burghölzli for 50 years, continually made stitching movements, similar to a cobbler sewing shoes. Jung found that the old woman had been jilted by a lover many years ago. He had been a cobbler. Another patient had been diagnosed with schizophrenia. By inquiring about words to which she had delayed or no response on the word association experiment, Jung was also unfolding the tragic story which led to her depression. She had fallen in love with a boy from a wealthy family. She and her family had determined that a marriage proposal from this young man was not possible, so they forced her to marry a man she did not love. After having children with her husband, she heard from a mutual acquaintance that the wealthy boy was quite disappointed to learn that she had married someone else. He had loved her after all. She attempted to repress her disappointment, but two weeks later while bathing her children, she noticed her daughter sucking on a bath sponge. The woman knew she should remove the sponge from her daughter’s mouth because the town’s water supply had been contaminated with typhoid fever, but she did not. Not long thereafter, the girl contracted typhoid and died. (Jung, 1989).
Jung believed that the woman’s act of allowing her daughter to continue to suck the sponge unconsciously represented her wish for marriage and family she could have had with her former love interest. Jung confronted the woman with her unconscious motivation. At first, she had no conscious awareness of what she had done, but after exploring the meaning of her associations with various words, she began to experience guilt and remorse and in a matter of weeks recovered from her depression and was released from the hospital (Jung, 1989). Jung came to think of his schizophrenic patients as dreamers, awake in the world (Stevens, 1991).
After that Carl Jung, published an acknowledgment of Sigmund Freud’s ideas as well as research evidence which seemed to confirm Freud’s hypotheses and findings. Freud was familiar with Jung’s work and began to view Jung as his successor and the one who would “continue and complete” Freud’s work. As time passed, differences between Freud and Jung’s views began to emerge. Jung took issue with Freud’s insistence that human motivation is exclusively sexual. He also disagreed with Freud’s view that the unconscious is composed of forgotten or repressed material from personal experience. Jung found these and other aspects of Freud’s thinking reductionist and too narrow. Instead of understanding psychic energy (which Freud termed libido) as entirely sexual, Jung understood libido as more generalized energy, of which sexuality was one aspect. Jung had come to believe that beneath Freud’s exclusively personal unconscious was a collective unconscious.
During his 9 years at Burgholzli Hospital in Zurich, Jung found that patients’ strange thoughts, ideas and visions, not only resembled each other but also, are closely aligned with mythological and religious themes and images which were common from cultures across the world. This convinced Jung that there must be a collective foundation to the human psyche which is part of the structure of the human brain rather than the product of individual experience or cultural transmission (Stevens, 1991). The idea of a collective unconscious provided an explanation for Jung’s childhood dreams, vision and perceptions.
Freud was resistant to Jung’s ideas. Jung recalls a conversation in which Freud warned him against deviating from Freud’s central ideas, and to defend them at all costs:
“I can still recall vividly how Freud said to me, ‘My dear Jung, promise me never to abandon the sexual theory. That is the most essential thing of all. You see, we must make a dogma of it, an unshakable bulwark’” (Jung, 1989, p. 181).
In this published work and in a lecture series given in New York in September 1912, Jung described his differences with Freud, which resulted in their relationship ending in 1913. Shortly after their relationship ended Jung fell into a 5-year long period of emotional and psychological disequilibrium, which at times bordered on psychosis. Jung referred to this time as his creative illness which was his “confrontation with the unconscious,” (Jung, 1989).
The theoretical perspectives of both Sigmund Freud and Carl Jung rest on a common foundational idea: the unconscious, the notion that human conscious awareness is only the “tip of the iceberg.” They agree that human thoughts, feelings, beliefs and behavior are motivated, influenced, and to some extent, determined by portions of the psyche “not directly accessible to consciousness,” (Stevens, 1990). It’s a mistake to think of the “unconscious” as conceptualized by Freud and Jung as a thing, as having a specific location in space and time. For Jung, the unconscious is more akin to a process, an interrelationship between autonomous aspects of the personality, an interrelationship “on which the conscious ego rides like a jockey (Stevens, 1990, p. 9).
Jung conceptualized complexes as the essential “functional units” (Stevens, 1990, p. 31) of the human mind. In order to understand complexes, one must first understand archetypes. For Jung, archetypes are the psychological equivalent of instincts, the “innate releasing mechanisms” (Stevens, 1994, p. 51) which an animal inherits that predisposes it to a pattern of behavior once the mechanism is triggered, similar to the way that goose is triggered to migrate, or a deer is triggered to seek a mate, or a bear is triggered to hibernate (Stevens, 1994). Archetypes predispose humans to develop as individuals and communities according to patterns already laid down in the psyche (Singer, 1994; Hillman, 1989). Jung asserts that there are as many archetypes as there are typical situations in life. There are archetypal figures (e.g., mother, child, father, God, wise man), archetypal events (e.g., birth, death, separation from parents, courting, marriage, etc.) and archetypal objects (e.g. water, sun, moon, fish predatory animals, snakes) (Stevens, 1994).
According to a Jungian perspective, each part of the genetic endowment, which enables humans to develop and thrive socially, culturally, and psychologically, is expressed archetypally through stories found in religion, myth, ritual, art, music, fairy tales, and dreams (Cambray, 2010).
While the Jungian theory has evolved into a rich diversity of theoretical approaches and clinical practices, they all revolve around the gravitational field created by Jung’s understanding of the unconscious as “purposive.” Stevens (1990) asserted that Jung took the view that the totality of the personality is present at birth, in potentia. One’s environment does not grant personality but merely awakens what was already there through selection and heredity, operating in the context of the previous environments to which the species has been exposed (Stevens, 1990).
The lifelong individuation process, Jung’s term for the process of becoming
conscious of and evolving into one’s whole personality, is under the co-coordinating influence of the Self (Jung, 1989), which is the sum total of the psyche, with all its potential included, as well as the nuclear or core aspect of the psyche (Singer, 1994). The Self contains and directs the movement toward fulfillment and wholeness. Jung conceives of the ego, the conscious personality, as a mediator between the Self and the world. Once a formerly unconscious aspect of the personality has become conscious, the ego mediates and facilitates the integration of the unconscious material into the conscious personally (Singer, 1994).
Jung was developmental in that he maintained that personality development continues throughout the lifespan into old age (Edinger, 1991). Jung termed this lifelong developmental process as individuation. Jung understood that humans are indeed shaped by their family of origin and the community and culture in which they live, and yet this conditioning is not acting on a “blank slate, but rather upon a complex set of predispositions and characteristic that make up the individual nature of the child at birth and channels its subsequent development as a unique individual” (Singer, 1994, p. 134). Singer (1994) describes the individuation process as moving along two tracks. One track helps individuals to discover and grow into their unique personality and potential. This consists of differentiating the individual personality from the expectations and constraints imposed by family and culture. The second track requires differentiation from the environment. Each person must ask, “How am I a part of that which surrounds me, and how am I different.” Singer (1994) describes it as “an ability to discriminate between the “I” and the ‘Not I’” (p. 134).
Jung understood individuation as the process of becoming conscious of and integrating, the possibilities contained within the individual. At a young age, Jung experienced God’s nature as both light and dark, creative and destructive, similar to the Brahma, Vishnu and Shiva from the Hindu tradition. The individuation process involves becoming conscious of both the darkness and light in one’s nature. Individuals cannot simply remove, lock away or ignore aspects of their personality that they dislike or that do not seem fit neatly into their life and work. Instead, the individuation process requires that individuals actively seek to become conscious of the disliked or inconvenient aspects of their personality. With work, their energy can be transformed into something creative or at least manageable (Singer, 1991).
Jung utilized the term psyche to refer to the total personality, conscious and unconscious components. In very broad strokes, Jung’s understanding of the psyche can be broken into three main components; Ego, Personal Unconscious and Collective Unconscious. Singer (1994) states that, when an individual thinks or says, “I,” the ego is the one doing the thinking or speaking. The ego includes all sense impressions, thoughts, and awareness of feeling and body sensation. The ego also chooses where attention will be focused and energy will be expended. On a more complex level, the Ego is the mediator between all these different aspects of the personality. The ego is in a constant process of receiving stimuli from the environment and from the unconscious. The unconscious is sometimes collaborating with the ego’s agenda, and at other times is working in opposition to it. The ego is always in the process of making split-second decisions regarding whether and how to respond to the information coming in from the environment as well as the impulses and impression welling up from the unconscious. Once an individual consciously chooses to engage in the individuation process, the ego facilitates the process of allowing and integrating unconscious material into the total personality (Sollod et al., 2009).
Jung’s understanding of the personal unconscious is in many respects similar to Freud’s unconscious. Freud believed the unconscious contains memories, impulses, fantasies, etc. which once was conscious, but has been repressed. This material is repressed because it runs counter to, or threatens the perspective of the conscious ego. Jung agreed, and also included mental content which is not currently conscious, because it is not currently being used, but can be retrieved when needed. Freud labeled this material “preconscious” (Sollod et al., 2009).
Regarding the collective unconscious, it is often tempting to assume that Jung believed in some sort of mystical “ghost in the machine” consciousness to which everyone taps into, like an unconscious aquifer running through the spiritual ether. On the contrary, Jung understood the collective unconscious as biologically based, an innate neuro processing capacity made up of archetypes: inborn, preformed neural structures, which activate in response to experiences and situations which are common (typical) to all people and generate thoughts, images, myths, rituals, stories, feelings, and ideas in people, regardless of culture, ethnicity, class geographic location, creed, race, historical context (Stevens, 1991).
One archetype that is easily recognized and understood is the hero archetype. Hero myths are common in virtually every culture. In A Hero with a Thousand Faces Joseph Campbell (1949/2004) examined the hero myth/narrative as it appears in religions, myths, rituals, and fairy tales throughout history and across cultures. Giving credit to Jung’s understanding of archetypes, as well as Freud’s discovery of the importance of the unconscious, Campbell (2014) identified archetypal themes, characters, and motifs common to all hero stories, regardless of time or culture. The hero is typically of humble origins and is called, summoned or driven onto a journey in order to attain a personal or universal goal. The hero is often a child, orphan, or outcast, and parents are typically absent, cruel, or controlling. Campbell identified typical types of heroes (e. g. Warrior, Lover, King / Queen, World Redeemer) and the stages of the hero’s journey (Departure, Initiation, and Return). Within each stage Campbell identified consistent patterns such as the refusal of the call; receiving supernatural aid; crossing the first threshold; meeting the goddess; seeking atonement with the father; achieving the ultimate boon; refusal of the return; the magic flight; and crossing of the return threshold. Consistent with Jung’s archetypal theory, Campbell (2014) describes mythological themes as symbolic representations of each individual’s psychological journey toward healing and wholeness, and that each character the hero encounters is a representation of an archetypal aspect of the individual personality, of which one is called to become conscious, and integrated into the conscious personality. Each event and character within the hero’s journey is also an archetype in itself.
Hero’ journey stories are ripe with dualities and polarities: good/evil, light/dark, masculine/feminine, persona/shadow; conscious/unconscious. Jung understood the interplay and interdependence of these polarities as an essential feature embedded into the fabric of the physical and psychological universe (Jung, 1989). Jung used the principle of enantiodromia to explain how these polarities function. Enantiodromia is the idea that all things possess an inherent tendency to turn into their opposite, which Jung saw as a characteristic of all dynamic systems. He believed that the human psyche is governed by the same principle of the physical world, in that energy always flows from a more energized pole to the less energized, seeking a state of balance or equilibrium (Singer, 1994).
The principle of enantiodromia applies to archetypes: each archetype has its opposite. The persona is the psychological mask one presents to the world. As a part of learning to function in a family, a community or society at large, humans must learn to strike a balance between their natural inclinations and the expectations and patterns of the community in which they live. Each circumstance, and each relationship, requires subtle or dramatic adjustments in personality, temperament, speech, posture, attitude, etc. This is a way of presenting one’s self to the world. Jung referred to this pubic face as the persona. The persona is orientated toward the expectations of society or culture. The persona is not necessarily negative, and it is absolutely necessary. Personas take multiple and situation- specific forms: parent, lover, friend, boss, student, leader, etc. (Singer, 1994). From a very young age children learn to shift their persona in order to adapt to their immediate social context, be if with parents, or friends, or school, or with teammates.
In contrast to the persona, it is the shadow. The shadow is made up of those aspects of the personality which are considered inferior, that one chooses not to consciously display in public, and often attempts to hide, even from one’s self (Jung, 1966). The more rigid the persona, the more strongly one identifies with it, the more one must deny and repress other important aspects of the personality. For example, many religious leaders who have publicly and adamantly condemned sexuality, sensuality, premarital sex, sex education, and homosexuality as immoral, and who have taken great pains to project a personal persona of sexual purity, have been found to be living secret lives which are diametrically opposed to their public persona. These repressed aspects of one’s nature and personality form an autonomous splinter personality. Alternatively, the shadow finds its own means of expression, particularly through projections. What one cannot admit in oneself, one often finds in others. Jung suggests that the individuals we find the most repugnant and repulsive, those for whom we have the least empathy, and who elicit the most powerful negative emotions, serves as a mirror in which we can see our shadow projected and reflected back at us. Jung (1966) claimed that, through projections, the world is transformed into a replica of one’s unknown face. As with other unconscious aspects of the personality, Jung’s approach to dealing with the shadow is, through dreams and introspection, become conscious of, befriend, and integrate the shadow aspects of our nature into one’s conscious personality.
Over the past century cultural perspectives on gender and sexuality have undergone a seismic shift. Jung was born and raised in the late 19th and early 20th centuries, and some of his language and assumptions reflect that culture and time in which he wrote, and yet the ideas which form his foundational understanding of gender and sexuality still resonate, and at times seem almost prophetic. Jung used the terms anima and animus to identify the twin, contra sexual archetypes of human nature. The anima is the eternal feminine aspect in a man, and the animus is the eternal masculine aspect in a woman (Jung, 1966).
Singer (1994) recalls asking her supervising analyst, “What are the innate differences between the masculine and the feminine?” . Singer (1994) reports his response as follows:
For many generations, people have been pondering his question, and there has been much talk about it in terms of nature versus nurture or heredity versus environment. After all the talk and all the research, the only thing that everyone seems to agree on is that there is a difference!” (p. 179).
The Jungian theory acknowledges that there are inborn, innate aspects of the personality, affirming the evolutionary psychology perspective that our brains and consequently our behavior patterns, our impulses, our attractions and our anxieties are influenced, but not determined by, the biology and psychology we have inherited from our ancestors. Understanding the complex and mysterious, the interplay between biology and the environment is a core construct of Jungian theory (Jung, 1961).
As conscious attitudes about what is feminine and what is masculine vary culture
to culture, family to family, and from one individual to another, what is considered acceptable and unacceptable also varies. Regardless of culture, ideas and qualities which men view as feminine within themselves are often repressed and live in the unconscious as aspects of the anima, while for women the repressed masculine lives a hidden existence as their animus (Singer, 1994).
Depending upon the individual, his or her culture, life experiences and innate personality, anima and animus can be represented by a wide variety of characters (Singer, 1994). A man’s anima may be represented by feminine icons from Marilyn Monroe, a Kardashian, Meryl Streep, Venus Williams, Hillary Clinton to Billie Elish. Similarly, a woman’s animus may appear like Brad Pitt, Lebron James, Justin Beiber, Ryan Gosling or Bill Clinton. The possibilities are endless (Singer, 1994).
Jung (1966) asserted that men are typically most powerfully attracted to women who embody characteristics of their anima, and women to men who embody aspects of their repressed animus. Jung believed that the patterns and characters in the hero’s journey are common to all cultures, religions and mythologies (Jung, 1989). The archetypal themes and characters associated with the hero’s journey can be easily found in fairy tales, comic books, contemporary movies, video games and cartoons. The fact that archetypes permeate all aspects of culture and media provides a ready but typically utilized, pathway to help children, adolescents and their parents begin to explore and understand personality characteristic and behavior patterns as typical, expressions of human growth and development, rather than signs that one is flawed, broken, and pathological.
Hammond et al. (2015) assert that individuals often harness the power of myths to tell the stories of their illness and that ancient cultures often developed healing rituals around creation myths, believing that the myths themselves, with themes of death, rebirth and transformation, contained an intrinsic healing power. Hammond et al. (2015) notes that the repetition of mythological themes in contemporary illness narratives suggests that ancient myths and stories are experienced as retaining their healing properties.
Following are some examples that might be particularly effective when working with adolescent males and their fathers. Stories are written for young readers and viewers often portray a mentor of some sort. These individuals serve as teachers or counselors or role models. Often, they serve as a father or mother figure who prepares, trains and initiates the hero for the journey. Contemporary examples of the mentor are Mr. Miyagi in The Karate Kid, Rafaki in The Lion King, Obi-Wan Kenobi and Yoda in Star Wars, and Uncle Iroh in The Last Air Bender. They often have a trickster quality as well, often teaching with paradox, cynicism, confrontation, deception and self-serving manipulation. These characters often have a history of woundedness or significant loss.
This dissertation will primarily utilize fairy tales. Fairy tales frequently include a trickster character. The fairy tales in the following examples are from The Complete Fairy Tales of the Brothers Grimm (Zipps, 1988). Trickster characters typically have a dual nature, containing contradictory qualities. They are both foolish and wise; creative and destructive; kind and cruel; human and divine (Bassil-Morozow, 2015). Some tricksters are sly and intentionally deceptive or appear oblivious to good and evil, driven purely by appetites and impulses (The wolf in “Little Red Cap”). Other tricksters appear oblivious or destructive, but in reality, their obliviousness conceals deep wisdom and their destructiveness paves the way for a new social order (“The Good Bargain”). Some face and defeat a threat that no one, with any common sense, would face (“A Tale about the Boy Who Went Forth to Learn What Fear Was”). In some stories, tricksters are depicted as unintelligent, simpletons, (e. g. “The Golden Bird ” and “Three Sons”). They are labeled as “stupid” by their families. They approach tasks and problems in ways that seem absurd and doomed to failure but typically, often with the assistance of characters whom the trickster has befriended, the trickster prevails.
Archetypal stories also often contain a “damsel-in-distress,” usually a young woman placed in a dire situation by a villain, monster or life event. Often there is a missing, wounded or evil parent who contributes to the maiden’s circumstances. Historically, she has required a male hero to rescue her, but in recent years, this theme has shifted, often with the maiden “saving” the rescuer by providing him a missing aspect of his life, personality and awareness while he is “saving” her. The relationship between the male and female characters typically represent anima/animus relationships, each character bringing balance and wholeness to the other. More traditional maidens are found in Snow White and Cinderella stories (Singer, 1994). Newer, stronger, versions of the damsel archetype are found in Vivian in Pretty Woman, Fiona in Shrek, Anna in Frozen, Snow White in Snow White & The Huntsman.
Jung asserted that children are born with a predisposition to bond with a female caregiver, which activates and shapes aspects of the child’s inborn personality features.
The mother archetype can take the form of a physical mother figure who is the source of life, nutrition, nurturance, stability, warmth and love. The mother archetype also has a dark side (cold, distant, cruel, and absent). The mother archetype can also take the form of the great or universal Mother, which is associated with generativity, the cyclical patterns in nature (birth, growth, decline, death, rebirth) (Singer, 1994). The great mother can be represented by positive generative divine figures such as the Virgin Mary or mothers with a more bipolar nature such as Kali or Maleficent, who are seen as both a source of nurturance and destruction, the mother who devours her young (Singer, 1994). A similar theme is found in the ancient Greek myth, in which Zeus’s perpetually jealous wife, Hera, learns of Zeus’ dalliance with Lamia, and kills Lamias’ children. In the Mexican folk talk, la llorona, a mother learns of her husband’s infidelity and drowns her children in a fit of rage and in her grief and guilt, drowns herself as well.
Clinicians typically assign mental health diagnoses and develop treatment plans based upon the descriptions and observations of the patient’s symptoms provided by patients and their family members, which are imprecise at best. Clinicians attempting to diagnose and treat physical complaints have sophisticated and precise instruments at their disposal such as blood tests, x-rays, MRI’s and CT scans. Mental health clinicians have to rely on more blunt and subjective tools to determine whether a patient is depressed, delusional or traumatized. Even well- developed and validated psychometric instruments are dependent upon individuals’ ability and willingness to provide accurate data. Once data is collected, clinicians are then limited to the diagnostic labels and categories available in The Diagnostic and Statistical Manual 5 (DSM 5; American Psychiatric Association, 2013), another blunt and imprecise instrument, as it provides broad diagnostic categories which are not able to capture and represent the variety of ways a particular mental health issue may be expressed and experienced in an individual. The DSM-5 attempts to provide a framework and process for identifying and categorizing typical maladaptive behaviors, attitudes, beliefs, patterns which are universal across time and cultures. No version of the DSM, including the most recent, was developed utilizing blood, tests, x-rays, MRI’s or CT scans. The diagnostic categories were established utilizing the available descriptions and observations of patient’s symptoms compiled by clinicians, researchers and other stakeholders. Every few years, in response to research, letters, conferences and lobbying, DSM diagnostic categories are added, deleted, edited and revised, generating an unending stream of disagreement, accusations, demonization and defensiveness. While there is no shortage of disagreement about the DSM-5, there is virtual consensus that is an imperfect tool.
Jung developed his theory of archetypes and complexes utilizing the available descriptions and observations of the patient’s symptoms. He acknowledged that his own subjective experiences informed his understanding as well. With similar goals as the American Psychiatric Association (APA), Jung attempted to provide a framework and process to identify and categorize typical maladaptive behaviors, attitudes, beliefs, patterns which are universal across time and cultures. Jung’s system is imperfect as well, and yet as Sollod et al., (2009) describe:
One of Jung’s most elusive concepts, archetypes, has recently emerged in a different guise in the form of cognitive modules or inherited predispositions to process information and experience in pre-programmed ways. Consideration of this type of hardwiring is becoming a more important part of contemporary neuroscience and evolutionary psychology (p. 175).
Anthropological research has identified dozens of typical (archetypal), universal traits, attitudes and behaviors which are common to all known human cultures throughout history (Brown, 1991). Examples include behaviors associated with childrearing and family life such as adults speaking to infants and children utilizing baby talk; play; customs and rituals associated with birth, transitions into adolescence and adulthood; marriage and death.
All known cultures also exhibit belief in supernatural/religion and utilize daily, monthly and yearly rituals; and routines to enact the beliefs, stories and myths to teach exemplify these beliefs. Other examples of universal behaviors include facial expressions of anger, contempt, disgust, fear, happiness, sadness, surprise, and masking/modifying of facial expression in specific social settings (Brown, 1991).
Anderson (1995) describes advances that resulted from the marriage of connectionist cognitive models and developmental neurobiology which have demonstrated that there cannot be learning without innate neurological circuitry that is predisposed to do the learning. Cognitive theorists and researchers now agree that there are innate learning or information processing networks in the human brain that prepare and predispose individuals to learn and engage in all the patterns of behaviors that are universal and common to all cultures. These information- processing networks are the functional equivalent to Jung’s notion of archetypes, which predisposes people to a particular pattern of behavior once the mechanism is triggered by environmental stimuli. And yet, the notion of biologically based innate, inborn characteristics, tendencies or abilities are still controversial in the social sciences, and researchers who produce evidence for these sorts of predispositions are often lumped in with determinist, reductionists, (Davis, 2020) and “proponents of eugenics [and] Social Darwinism.” (Pinker, 2016, p. 109).
In spite of resistance within the academic community, neuroscience researchers have shown the human mind is not merely a lump of malleable clay, shaped exclusively by social and cultural factors. A significant portion of human behavior and personality is the product of genetic inheritance and the modular ways the brain /mind function. Different modules or systems in the brain cooperate to formulate a specific train of thought or plan of action (Elman et al, 1994). The brain has designated information-processing systems to perform distinct operations such as controlling the body, facilitating spatial awareness, filtering out distractions, remembering facts, acquiring and mastering new skills , temporarily storing information, recognizing faces and noticing, interpreting social cues. A neuropsychological evaluation will consider domains such as sensation/perception; motor skill/construction; attention/concentration; social-emotional functioning; executive functioning; and language (Harvey, 2019). These data-processing systems, domains, or modules coordinate and collaborate in ways that cognitive scientists are only beginning to understand (Gardner, 1983; Hirschfeld and Gelman, 1994). These cognitive modules function in that ways are strikingly similar to Jung’s understanding of archetypes.
Additional support for Jung’s notion of archetypal structures can be found in the field of linguistics. Noam Chomsky (1986) makes the case for similar innate cognitive structures or modules which are responsible for children’s ability to learn the language. Chomsky’s (1986) theory posits that all languages are built upon universal grammar, an unconscious set of constraints that enable humans to determine if sentences are correctly formed. Chomsky’s theory asserts that these linguistic structures are already encoded in the human brain at birth.
The concept of cognitive modules is further supported by evolutionary psychology, which suggests that the human mind is essentially a collection of information processing modules that have evolved to solve specific evolutionary problems. Evolutionary psychology hypothesizes that neural circuits have become specialized to solve specific adaptive problems, and function similarly to our understanding of instincts, in that when an individual encounters a specific stimulus, the brain responds in a way that has been adaptive for the species for millennia (Buss, 1999).
As Roesler (2013) notes, currently there are no randomized controlled trials (RCT) evaluating the efficacy of Jungian therapy. Using RCT’s as the “gold standard” of evidence-based support , compared to cognitive theory as a whole, Jungian theory suffers from a lack of evidence-based support. Roesler (2013) challenges the scientific assumption that RCTs are the only means of demonstrating the efficacy of a psychotherapy method, on the basis that, while RCT’s internal validity is typically high (in a controlled setting), the external validity of often low, due to the impossibility of controlling for individual differences between clients and therapists. Roesler (2013) reviewed studies conducted since 1990, mostly in Europe, which attempted to measure the efficacy of Jungian therapy. Roesler (2013) found that the studies consistently show significant improvements in the areas of externalizing and internalizing symptoms, relationship difficulties, personality structure, and everyday life conduct. Three of the studies Roesler (2013) reviewed (Keller et al. , 1999; Rudolf et al., 2004; Tschuschke et al., 2010) were designed by Jungian training institutes in Zurich, Belin and San Francisco in response to criticism that there is no evidence to support the efficacy of Jungian therapy. The naturalistic outcome and retrospective studies utilized the following standardized instruments: Symptom Checklist 90 Revised Version (SCL-90-R); Interpersonal Problems Inventory (IIP); Trier Personality Inventory (TPF), as well as health insurance data. The studies found consistent symptom reduction in 75% – 80% of the participants with significant effect sizes in both personality and mood disorder symptom improvements as well as positive changes in “everyday life.” These improvements appeared to remain stable after completion of therapy over a period of up to six years. The studies demonstrate continued improvements after the end of therapy. Insurance company data showed that, after Jungian therapy, patients reduced health care utilization to a level even below the average of the total population
Mental health services are consistently underutilized by individuals struggling with mental health difficulties. Even when structural barriers such as cost, lack of health insurance and geographic accessibility are removed, many individuals are reluctant to seek mental health treatment (Wu et. al., 2017). Mackenzie et al. (2014) found that among American university students, negative attitudes toward seeking mental health services have become more prevalent over the past 40 years. They note that this finding is consistent with research which suggests that public stigma about mental illness has either remained steady or worsened over time. They report that while the rate of mental health treatment overall has increased over time, this increase is primarily due to the significant increase in the utilization of psychopharmacological treatments since the 1980 s, while the utilization of outpatient psychotherapy services has decreased over 28% over the past 20 years.
For many individuals, there is still a considerable stigma associated with seeking mental health treatment. Rüsch et al. (2014) found that greater mental health shame and less mental health literacy, along with negative attitudes about mental health providers, predicted that participants in their study would be less inclined to seek mental health services. Mackenzie et al. (2014) proposes that the trend to “medicalize” mental health diagnoses, in the hope of destigmatizing mental illness, has actually had the opposite effect, contributing to the decrease in literacy about and utilization of outpatient therapy. Self-stigma labels such as “insecure, inadequate, inferior, weak and disturbed” (Lannin et al., 2016, p. 351) have also been found to be associated with a disinclination to utilize mental health services. This general stigmatization of mental health treatment is even more impactful for boys and men, in part due to normative practices in therapy which involve encouraging clients to notice and attend to emotions, admit dependency, and disclose vulnerability, behaviors which many men and boys view as particularly un-masculine (Rabinowitz and Cochran, 2002; Rochlen & Rabinowitz, 2014; APA, 2018). Men and boys are more likely to exhibit symptoms of alexithymia (difficulty in experiencing, expressing, and describing emotions) than women (Aust et al., 2013; Minnich et al., 2017). Levant and Parent (2019) proposed the “normative male alexithymia” hypothesis, which suggests that the difficulty men and boys’ exhibit expressing emotions is a typical occurrence which is the product of gender role socialization. This could be reframed as men and boys are socialized to be ill- suited for psychotherapy.
Berke et al. (2017) identified a prevailing view of manhood as a socially constructed status that boys must earn and work diligently to maintain throughout adulthood. Vandello and Bosson, (2011) characterized manhood as, “hard- won and easily lost” (p. 101). They argue that across virtually all cultures womanhood is considered a natural, permanent, biological developmental transition, in contrast to manhood which must be “earned and maintained through publicly verifiable actions,” (p. 101). As a result, they assert that men experience anxiety, ambiguity and stress associated with gender that most women do not, especially when their gender status is challenged or uncertain. This can motivate a variety of maladaptive and risky behaviors, as well as the avoidance of behaviors which are adaptive and beneficial, such as pursuing mental health treatment or encouraging and partnering with sons as they pursue mental health treatment (Vandello and Bosson, 2011; APA, 2020).
No studies were found which indicated that a particular treatment modality was better suited to engage adolescent males in therapy or helping them persist in treatment. The majority of research on schema theory and Jungian theory has examined those theories applicability to specifically adults . The research that does attempt to apply these theories to adolescents and children is sparse. This research will be critiqued in the following section.
While studies have consistently shown that therapy, regardless of theoretical approach, is more effective than no mental health treatment at all (Joyce et al., 2006; Meichenbaum and Lilienfeld, 2018) many clients do not respond to therapy. This is true even with therapeutic approaches that have relatively strong evidence-based support, such as CBT and “Third Wave” cognitive approaches such at Acceptance and Commitment Therapy and Dialectical Behavior Therapy (Arch et al., 2012). Among the 60% of individuals for whom therapy is effective, for 30% of those, the effects are short lived (Young, Klosko, and Weishaar, 2006).
As Arch et al. (2012) describe many clients relapse following a seemingly successful treatment; some go on to seek additional treatment; and others remain susceptible to anxiety and mood disorders throughout their lives. Meichenbaum and Lilienfeld (2018) point out that comparative studies of psychotherapy consistently indicate that non-approach specific factors (e.g., the therapeutic alliance, methodological concerns) account for sizable proportions of variance in treatment outcomes. This perspective echoes Joyce et al. (2006):
“The meta-analytic literature supports 2 main conclusions. Firstly, psychotherapy is indisputably superior to the absence of treatment. Across all reviews, patients treated with psychotherapy exhibit greater improvement than untreated patients. Secondly, the reviews consistently indicate that different approaches to psychotherapy yield equivalent effects. When differences in effectiveness do emerge, they tend to favor cognitive-behavioral approaches over psychodynamic interpersonal approaches. However, it has been invariably demonstrated that these differences are attributable to such confounding variables as investigator allegiance. With statistical adjustment of artifactual effects, the relative effectiveness of different therapy approaches disappears.” (p. 801)
This information is not provided to suggest a one size fits all approach to mental health treatment. As van der Kolk (2014) describes, some treatment modalities are clearly more effective with specific populations than others. It is important to acknowledge that even peer- reviewed, randomized controlled trials which appear to provide evidence that one treatment modality is more effective than another, are not the final word on the matter. Clinicians and researchers aligned with specific treatment modalities make grand claims regarding efficacy and versatility of their approach and yet, subsequent research typically requires stepping back to more measured, modest claims. As Jung (1989) states, in science, modest truth is often regarded as the truth and a minor mistake is equated with fatal error. “Yesterday’s truth is today’s deception and yesterday’s false inference may be tomorrow’s revelation. This is particularly so in psychological matters, of which, if truth were told, we still know very little, (p. 185).
Differing theoretical approaches, rather than working collaboratively to learn from and scaffold each other, seem focused upon demonstrating the efficacy and superiority of their approach while ignoring the knowledge gained by their perceived rivals (Goldfried, 2019). Establishing the efficacy of a theoretical approach is often treated as a zero-sum game. Decades of research has been conducted with the goal of demonstrating that one therapeutic approach is more efficacious than another, with little or no attention paid to the common ground these approaches might share, nor how these supposedly contradictory approaches can complement, strengthen or learn from each other (Goldfield, 2019).
Common factors theory asserts that different theoretical approaches to psychotherapy rely upon similar underlying factors which produce similar outcomes (Bailey and Ogles, 2019; Brown, 2015). Laska et al. (2014) lists them as follows:
- an emotionally charged bond between the therapist and patient,
- a confiding healing setting in which therapy takes place
- a therapist who provides a psychologically derived and culturally embedded explanation for emotional distress
- an explanation that is adaptive (i.e., provides viable and believable options for overcoming specific difficulties) and is accepted by the patient
- a set of procedures or rituals engaged by the patient and therapist that leads the patient to enact something that is positive, helpful or adaptive (p. 469).
Instead of placing primacy on specific theoretical approaches, a common factor approach posits that alignment with a credible theory is only one of many common factors that contribute to efficacy. Common factory theory predicts that if a therapeutic approach contains all of the factors listed above, therapy will be effective for the presenting problem. CF theory also predicts that relationship factors such as the therapeutic alliance, empathy, positive regard, goal consensus and collaboration powerfully impact therapy outcomes, but the CF perspective does not assert that a “relationship” with a therapist, in and of itself is sufficient. The CF approach also asserts that treatments designed to be therapeutic will outperform therapeutic approaches such as supportive control, intent to fail, or placebo treatments (Laska et al., 2014)
While multiple studies suggest that cognitive based approaches are somewhat effective with adolescents, meta-analyses have found that effect sizes decrease in response to more methodological rigor and in clinical, rather than experimental settings. In a meta-analysis, Klein et al. (2008) evaluated randomized studies which evaluated the effectiveness of CBT in treating adolescent depression. Klein et al. (2008) noted that methodological differences between early and recent RCTs likely contribute to discrepancies in the estimates of the effects of CBT for adolescent depression. Klein et al. (2008) suggest that these differences reflect a shift from an early emphasis on demonstrating the efficacy of treatment in controlled research settings to demonstrating the effectiveness of treatment in a clinical setting. Klein et al. (2008) also noted increased statistical and methodological rigor over time. Klein et al. (2008) concluded that CBT may be effective in the treatment of depression in adolescents but noted that treatment effects are likely to be more modest in clinical settings than early studies would suggest. In a meta-analysis of psychosocial treatments for child and adolescent depression, Weersing et al. (2017) found evidence of efficacy in multiple trials for depressed adolescents in both CBT and interpersonal psychotherapy interventions. They noted that their findings were tempered by the small size of the interpersonal psychotherapy literature (N = 6) and concerns that CBT effects may be impacted by clinically complicated samples and when compared against active control conditions. Supporting the common factors perspective, Yang et al. (2019) conducted a meta-analysis of studies that evaluated the treatment of adolescents diagnosed with a social anxiety disorder. The meta-analysis was limited to studies with evaluated manualized or structured psychological interventions including cognitive- behavioral therapy (CBT), behavioral therapy (BT), psychodynamic therapy, exposure, social skills training. They found no differences between the various types of psychological interventions which would support the claim that one intervention is significantly more effective than another. Their subgroup analyses suggested that interventions appeared to offer similar efficacy in individual, group, individual and group combined, internet-assisted treatments for children and adolescents. They did note that group psychological intervention was associated with larger effect size and may be more cost-effective.
Zhou et al. (2019) conducted a meta-analysis of 11 different “types of therapy” and delivery methods for psychological treatments of anxiety disorders in children and adolescents. They treatments included Individual Behavior Therapy (BT); combined individual and group BT; individual BT with parental involvement, group CBT, group CBT with parental involvement, individual CBT, individual and group CBT, individual CBT with parental involvement, Internet-assisted CBT, parent-only CBT, and bibliotherapy CBT, the 4 control conditions (wait list, psychological placebo, no treatment and treatment as usual). They reviewed a total of 101 unique trials. They indicated that the certainty of evidence was rated as low or very low for most comparisons in their study. They reported that most psychotherapies were significantly more effective than the wait list condition posttreatment, however only group cognitive- behavioral therapy (CBT) was significantly more effective than the other psychotherapies and all control conditions posttreatment.
Lending support to the impact of parental involvement in treatment with adolescents, Sun et al. , (2019) conducted a meta-analysis evaluating four treatment features of CBT (i.e., the inclusion of sessions, the addition of booster sessions) to determine if they were associated with posttreatment and follow-up effect size of youth cognitive behavioral therapies (yCBTs) for anxiety, depression, posttraumatic stress disorder and obsessive-compulsive disorder in age groups spanning young children to adolescents. They evaluated 76 randomized clinical trials and found that parental involvement was significantly associated with larger pre to post- treatment effect sizes as well as pre- to follow-up effect sizes.
While there have been fewer studies examining the efficacy of mindfulness-based approaches with adolescents, the existing studies do suggest their utility with this population. Kallapiran et al. (2015) conducted a systematic review of randomized controlled trials to examine the effects of different mindfulness-based interventions on mental health symptoms and quality of life in both clinical and non-clinical samples of children and adolescents. Kallapiran et al. (2015) found that mindfulness‐based cognitive therapy was more effective in stress reduction than nonactive controls in the non-clinical populations. Acceptance Commitment Therapy (ACT) was found to be comparable to active treatments with patients in the clinical range. The authors concluded that mindfulness‐based treatment can be effective in children and adolescents with mental health symptoms, but they noted significant limitations which suggest that more research is needed, and stressed that the current findings should be interpreted with caution. In a meta-analysis, A-tjak et al. (2015) identified a small body of evidence to support the efficacy of ACT for adolescents in the treatment a wide variety of issues including chronic pain, eating disorders, obsessive-compulsive disorder, trichotillomania, aggressive behavior, school attendance, high-risk sexual behaviors, impulsivity, anxiety and suicidal ideation but stressed that additional research is needed.
There are more studies that focus exclusively on dialectical behavior therapy for adolescents. Hunnicutt, Hollenbaugh and Lenz (2018) conducted a meta–analysis to evaluate the effectiveness of dialectical behavior therapy for adolescents in reducing symptoms of depression, anxiety, self-injury and suicide risk. Their results indicated small-to-medium effect sizes for all 4 symptoms compared with alternative treatments and control groups. They concluded that DBT for adolescents is limited in generalizability, primarily due to the small effect sizes available for each analysis. In meta meta‐analyses evaluating DBT as a treatment targeting self-injurious behavior in adolescents, both Cook and Gorraiz (2016) and McCauley et. al. (2018) found that DBT is an effective treatment for self-injury with adolescents, but Cook and Gorraiz (2016) stressed that their findings were tentative and preliminary.
Critique of Schema Theory as Applied to Adolescents
Schema theory posits that, within the context of the family of origin, children form stable cognitive patterns and frameworks (schema) which become the lens through which they view interpret relationships and themselves. Some of these schemas are maladaptive and the source of unproductive, often harmful, behavior patterns (Young et al., 2003). Van Wijk-Herbrink et al. (2018) noted that schema therapy has an increasingly popular treatment for children and adolescents with personality disorder features but did not identify studies demonstrating schema therapy’s efficacy with this population. The majority of the research on schema therapy with children and adolescents has focused on identifying early maladaptive schemas in this population, rather than on treating mental health symptoms related to early maladaptive schemas. The underlying principles of ST (i.e., early maladaptive schemas, schema coping, and schema modes) have been well established in adults (e.g., Jacobs, et. al., 2019; van Van Vlierberghe et al., 2010). The validity of inventories designed to identify EMS, such as the Young Schema Inventory (YSI), requires a level of self-awareness and introspection which is difficult for some adolescents. Even with these challenges, several studies purport to have validated early maladaptive schemas in adolescents (Muris, 2006; Roelofs et al., 2016; and van Wijk-Herbrink et al., 2018). Santos et al. (2018) examined the psychometric properties of the brief form of the Young Schema Questionnaire for Adolescents (B-YSQ-A), a new instrument, still in development, to identify Early Maladaptive Schemas. Results indicated a “satisfying fit” for the 18 original schema factors through confirmatory factor analysis.
Sundag et al. (2018) found that parents’ early maladaptive schemas significantly predicted schemas of their children. Similarly, Zeynel and Uzer (2020) found that mothers’ maladaptive schemas are associated with the development of maladaptive schemas in their children. Additionally, they identified that perceived deficiencies in mothers’ care, protection and love suggests intergenerational transmission of early maladaptive schemas but only when fathers do not provide enough support in child rearing. When fathers are actively involved in their children’s growth process, this involvement appears to compensate for the negative effects of mother’s deficits in terms of maladaptive schema formation. Zonnevijlle and Hildebrand (2019) found significant positive correlations between children’s EMS and perceived parental rearing styles (i.e., rejection, control/overprotection, anxious rearing) and attachment anxiety.
Although the effectiveness of schema therapy with adults to treat a wide range of mental health conditions has been established (Hawke et al. , 2013; Wang et al., 2010; Bamelis et al., 2014; Giesen-Bloo et al., 2006; Nadort et al., 2009; Sempertegui et al., 2013) research is still sparse with respect to adolescent populations. There is some preliminary evidence to suggest that schema therapy is effective in adolescents with behavior issues (Wijk-Herbrink et al., 2016). One multiple case study has found promising effects of schema therapy for adolescents with personality disorder traits and mood disorders (Roelofs et al., 2016). In this study, four outpatients received weekly group schema therapy sessions plus weekly or two-weekly individual ST sessions. Additionally, their parents received separate parent group sessions. All patients improved with respect to schema therapy- related constructs (i.e., early maladaptive schemas and schema modes) and some patients also improved with respect to quality of life and symptoms of psychopathology. This inclusion of parents in this study is a promising step in the right direction. Fassbinder et al. (2018) published a study protocol that will compare the (cost-) effectiveness of DBT and ST in structured outpatient treatment programs in the routine clinical setting of an outpatient clinic. Loose and Pietrowsky (2013) published a collection of essays entitled Schema Therapy for Children and Adolescents, which provides guidance and techniques for utilizing schema therapy with children and adolescents, but does not include research support for the efficacy of its approach. No studies are available which have utilized schema theory to target fathers’ attitudes toward and engagement with mental health treatment for children and adolescents
More research is needed to study and better understand the child/caretaker relationships in which these schemas are formed, specifically how caregiver attitudes and behavior contribute to the development of adaptive and maladaptive schema. This research can then be used to inform caregiver training and interventions which may mitigate or reverse the impact of the early maladaptive schema.
Jungian theory has not been extensively applied to children and adolescents. It is typically considered psychology of adulthood (Green, 2011). Jung wrote very little about the psychology of children and adolescents. Fordham (1994) builds upon Jung’s ideas and asserts that the individuation process actually begins during childhood. Based on his research and clinical observation, Fordham (1994) argued that children tap into the archetypes within the collective unconscious to grow and assimilate into their culture. Fordham and Edinger (1992), both assert that when children are born, their ego is identical with the Self. The individuation process for children, as they understand it, involves the child’s ego gradually separating from the Self. In adulthood, individuation consists of the gradual reintegration and alignment of the ego with the Self.
The vast majority of the literature which applies Jungian theory to children and adolescents is in the realm of play therapy. Jungian Analytical Play Therapy (JAPT) posits that during children’s development, feelings, thoughts and traits of primary caretakers are internalized (Green, 2011). Additionally, any dysfunction or trauma(s) associated with those significant primary relationships creates psychic wounds that take the form of complexes. Fordham (1994) describes Jung’s belief that the human psyche, including the psyches of children, contains a self-healing archetype (the Self) which surfaces through symbols produced by the collective unconscious. Jungian play therapists attempt to create a safe, trusting therapeutic environment, in which the child’s unconscious will spontaneously produce the symbols, stories and images, through which the child processes thoughts, feelings and experiences. These productions are understood as having a self-healing impact upon the child. Jungian play therapists facilitate and observe symbol production through artwork, sand play, fantasies and dreams. Children and adolescents often speak most clearly and meaningfully through the symbols and metaphors they produce. The primary goal of Jungian play therapy is to activate the individuation process by creating an environment in which symbols can be produced freely. Once unconscious aspects of the child’s personality (e. g. feelings, thoughts, traits, beliefs) and are made conscious through play, art and conversation, Jungian oriented play therapist believe children are better able to regulate their impulses by regulating the energy between their interior and outer worlds (Green, 2011).
Green et al. (2013) provided a case study in which a Jungian play therapy / drawing technique was utilized with an adolescent male diagnosed with Attention-deficit/hyperactivity disorder. Green et al. (2013) noted that in Jungian play therapy, healing is not accomplished through specific therapeutic techniques, but through the personal self-healing archetype that emerges within the safety of the therapeutic relationship. In Green et al.’s (2013) case study, the self-healing archetype is activated through the adolescent client’s interaction with mandalas (a bound shape, typically a circle) which is associated with wholeness, healing and integration. Mandalas can be found in the sacred artwork of cultures throughout time, from cave drawing and rock carving to sand painting and stained-glass windows. Green et al. (2013) noted that, at the end of treatment, the client had better awareness of his personal strengths, and less self-reported stress, anxiety, and better self-reported ability to interact effectively with peers. Green et al.’s (2013) description of the client’s progress is typical of the few case studies that are available describing a Jungian approach to working with adolescents. Since the therapeutic process centers upon the symbol production of the child’s unconscious, and efficacy is understood as activation and facilitation of the child’s “self-healing archetype,” it is difficult to imagine how one might manualize this approach with the goal of designing a randomized controlled trial to evaluate the effectiveness of Jungian play therapy.
Green (2011) describes a typical Jungian play therapy session in which the therapist presents 8 to 10 preselected fairy tales which are somewhat aligned with the child’s current challenges and allows the child to select one of the stories. The therapist then reads the fairy tale, and asks the child to notice the aspects of the story that particularly catch their attention. The child is then encouraged to depict a part of the story with figurines on a sand try, or with clay or drawing materials. The therapist simply observes while the child creates. After the child finishes the creation, the therapist might ask some of the following questions: “If you were in this world you created, what would you feel like?” “What might you be worried about, or hoping for?” The therapist might ask questions about specific aspects of the child’s creation (e. g.) What were you feeling when you placed that character here?; If this (animal, object or person) were talking, what might they say? The goal of this work is allowing the child to experience and process feelings, thoughts, memories. The therapeutic process is fluid, and proceeds in response to the child.
In a review of the clinical and research literature examining adolescent and young adult male mental health, Rice et al. (2018) found current approaches do not adequately engage adolescent males who are unwilling, resistant, or aggressive in clinical interactions. They posited that engaging family in the treatment of adolescent males is critical , and noted the particular need for father engagement. In addition to family engagement, Rice et al. (2018) suggested tailoring therapy to better fit the needs of adolescent males, such as utilizing sports, technology, and new media, and addressing the cultural perception that young men are “the problem.”
In 1994, Young and Klosko wrote a self-help book entitled Reinventing Your Life, in which they outlined the theoretical underpinnings of schema theory; specifically, Early Maladaptive Schema (EMS). In that book, they labeled the EMS Life Traps and listed only 11, rather than 1, early maladaptive schema. The book’s goal is to provide individuals a basic understanding of the origins of their harmful, repetitive life patterns and to motivate them to pursue therapy. While the book does not go into the mechanics of schema therapy, it is used as a psychoeducation tool by clinicians trained in schema therapy.
In spite of the fact that schema theory posits that EMS is formed in childhood, no programs or treatment approaches have evolved from Schema Theory which seeks to help parents learn to identify and heal their own personal EMS in order to become more effective parents. Several studies have begun to explore the relationship between parents, primarily mothers, EMS and the formation of schema in children (Sundag et al.,2018; Zeynel and Uzer, 2020). More research is needed to determine if parents’ participation in schema therapy has an impact on parenting style, the parent / child relationship, and child / adolescent mental health. Additionally, since schema therapy aspires to help clients engage in “healthy parent” schema mode, it seems that schema theory researchers would want to investigate the extent to which family systems and intergenerational transmission, results in family schema mode patterns. As described, above, Sundag et al. (2018); Zeynel and Uzer (2020); and Zonnevijlle and Hildebrand (2019) have begun to explore the relationship between mother’s early maladaptive schema and parenting style impact the formation of early maladaptive schema in children. No research was found examining how a father’s early maladaptive schema impacts the formation of early maladaptive schema in children.
In 2010 Murray Stein compiled a selection of essays representing the evolution and diversity of Jungian thought since Jung’s death. The volume contains two essays that address the application of Jungian theory to children and adolescents. Allain-Dupre’ (2011) essay, entitled “The Child’s Side: Genealogy of the Self,” summarizes Neuman (1973) and Fordham’s (1969) expansion on Jung’s understanding of the psyche of the child. The essay, “Adolescence – A Development Perspective,” by Bovenseipen (2011) depicts adolescent development from a Freudian psycho-sexual perspective. No other essays exploring applying Jungian theory to children and adolescents were included in that volume. Some clinicians have explored utilizing Jungian play therapy with adolescents (Green et al. 2013; Green, 2008) but beyond that very specific context, the existing literature focuses on applying Jungian theory exclusively to the adult population. More research is needed to explore the utility of a Jungian developmental perspective for children and adolescents. A search of Jungian journal produced some theoretical articles speculating on archetypal themes in adolescent psychology, but only one case study describing the therapeutic process with an adolescent was found.
Jungian theory understands most psychopathology in terms of complexes. Stevens (1990) described complexes as the vehicle through which archetypes are embodied and expressed in the individual psyche. For a Jungian perspective, persistent, troublesome emotional states and behavior patterns are the product of complexes. Complexes function as autonomous aspects of the personality, which generate emotions and behaviors that run counter to an individual ; conscious intentions. In spite of the fact that Jungian theory posits that complexes are formed in childhood, no programs or treatment approaches have evolved from Jungian Theory that seeks to help parents learn to identify and heal their personal complexes in order to become more effective parents. More research is needed to determine if engaging in Jungian therapy has an impact on parenting style, the parent / child relationship and child / adolescent mental health.
Both Schema theory and Jungian theory operate from Schwartz and Sweezy (2020), the developers of internal family systems theory, described as a paradigm of multiplicity, meaning that an individual’s personality is not a seamless, unified whole but is instead made of many, somewhat autonomous sub-personalities. Both Jungian theory and Schema theory assert that persistent, stable and troublesome emotional and behavior patterns are the product of early psychic wounds which occur within the childhood environment when caregivers do not meet the child’s needs for safety, nurturance, love, stability, attention, acceptance, empathy, validation and consistent, realistic limits. In response, children gradually construct maladaptive, unconscious subpersonalities, which often take control of their thinking and behavior, leading to maladaptive behavior (Young et al. . 2003).
Several recent studies have explored the transgenerational transmission of the early maladaptive schema (Zonnevijlle and Hildebrand, 2018; Zeynel and Uzer, 2019). For this theoretical perspective, one could argue that efforts to increase a parent’s emotional and psychological well-being would have a direct impact upon the well-being of their children. Zeynel and Uzer (2019) found that perceived deficiencies in mothers’ protection, engagement and affection, which lead to the formation of early maladaptive schema, can be mitigated by the father’s consistent involvement in a child’s life. Consistent with the notion of transgenerational transmission of early maladaptive schema, Bowen’s (1978) family systems theory asserts that levels of individuation (Bowen uses the term differentiation), achievement and psychological health are transmitted across generations through the family system. According to Bowen’s (1978) multigenerational transmission theory, the etiology of the most severe human dysfunctions can be found in examining behavior and relationship patterns that have persisted generation after generation. Multiple factors contribute to behaviors, attitudes, relationship patterns and psychopathology being transmitted through a family across generation. 1) Parents purposively shape the development of their children; 2) Children innately respond to, and internalize their parents’ moods, attitudes and actions, and 3) The long developmental dependency period of human children results in children developing attitudes, behaviors, aptitudes and competencies similar to their parents’ levels (Bowen, 1978; Kleisver, 2005; Zeynel and Uzer, 2019).
Considerable scholarly consensus (Steinberg et al., 1994; Fletcher et al., 1999; Cuccì, 2019; Wittig and Rodriguez, 2019) exists to support the assertion that an authoritative parenting style, characterized by parental warmth (also referred to as parental responsiveness) and parental control (also referred to as parental demandingness) predict positive adaptive characteristics in children and adolescents. Warm and responsive parents make a consistent effort to be engaged in their adolescents’ lives and to understand, accept and take seriously their adolescent’s expressed feelings and needs. And yet, socialized masculine gender roles in western societies tend to run counter to the attitudes and behaviors associated with an authoritative parenting approach.
Barker et al. (2017) summarized existing research and reported that parental sensitivity and engagement are consistently associated with reduced child psychopathology and that secure father – child attachment, independently predicts decreased adverse child outcomes. Adolescent boys’ emotional and behavioral difficulties frequently occur within the context of strained father-son relationships (Pitsoane and Gasa, 2018). And yet there is limited research or guidance regarding programs to engage fathers in boys’ mental health treatment (Panter-Brick et al., 2014; Rice et al., 2018). Research and clinical guidance regarding increasing paternal involvement is desperately needed because, boys are more inclined to seek mental health treatment when a warm, engaged and supportive father figure is involved in their lives (Reeb and Conger, 2011).
Mental health diagnoses are complex and laden with negative connotations. Boys in today’s culture are often saddled with stigmatizing labels which may accurately describe one aspect of the behavior but do not begin to represent them as a whole human being (Rice et al. , 2018). Unfortunately, once a boy is labeled as oppositional or inattentive or defiant or hyperactive or antisocial, or dependent or compulsive or autistic or obsessive or depressed or aggressive, then the labels can come to define him and limit him, even within his own family. The stigmatization of mental health diagnosis and treatment is inordinately impactful for boys and men (APA, 2018; Rice et al., 2018). Experiencing mental health concerns is generally perceived as socially undesirable but this is especially true for adolescent boys and young adult men (Lynch et al., 2016; DuPont-Reyes, 2019). Once boys and men do engage in therapy, they often experience the environment and expectation of therapy as foreign and threatening (APA, 2018), which is not conducive to building trust and rapport with a therapist. Ogrodniczuk et al. (2018) found a positive correlation between the level of male patient’s alexithymia (i.e. greater difficulty communicating feelings and greater tendency to engage in externally oriented thinking) and the negativity of therapist’s reactions to the patient.
The following chapter will provide a theoretical framework for future applied research to integrate the structured assessment and therapeutic process of schema therapy with the archetypal focus of Jungian theory. This integration will help destigmatize mental health concerns by providing therapists, adolescent male clients and their fathers a means to conceptualize mental health symptoms through the lens of familiar archetypal themes as they occur in religion, mythology, fairy tales and contemporary media (e. g. movies, books, television shows, comic book characters and historical figures) in order to find a better way to understand and modify the impact of mental health symptoms. Additionally, this new approach will create an environment which does not demand that adolescent boys or their fathers, immediately or directly experience or communicate their emotional affect. This integration will also provide a theoretical framework for future research and clinical practice to aid therapists, fathers and sons in examining the impact of masculine gender roles through an archetypal lens.
Boys and men are not a homogenous group. Differences in ethnicity, socioeconomic status, race, culture, migration status, sexual orientation, ability status, age, gender identity, and religious affiliation inform and shape how boys and men experience, define and live out their masculinities (APA, 2018). When working with boys and fathers, it is important to keep in mind the complex role that navigating the construct of masculinity itself plays in the lives of diverse boys and men. It is essential to acknowledge that gender is not a binary construct and that it is distinct from, although interrelated to, sexual orientation (APA, 2018). The majority of boys and men are steeped in heteronormative cultures which typically confuse and conflate sexual and masculine identity for boys and men (APA, 2018). Similarly, the religious, cultural and social environment boys and men live in shapes their assumptions about family roles and parenting approaches, some of which socialize boys and fathers to avoid intimacy and deep connections with others (APA, 2018). Consequently, fathers and sons can perceive being asked to identify and express their vulnerable feelings feels “wrong.” It is essential that the new integrated theory of this dissertation consider the influence of social, cultural and religious differences upon boys seeking to consider and honor the diverse ways gender and sexuality is experienced and expressed and seek to promote gender empathy and to raise awareness about sexual and gender diversity.
While the objective of this integrated approach is to involve fathers in their son’s mental health treatment, there will be circumstances in which involving fathers is not possible or appropriate (e. g. the father is absent; is not willing to participate; is the perpetrator of abuse). Fathers who do not align with the dominant construct of Caucasian, heterosexual and able, are likely to encounter additional barriers to involvement in their son’s mental health treatment (language, transportation, working multiple jobs, financial constraints, educational level, legal concerns (APA, 2018). It is also important to note that some boys simply do not have a father, or father figure in their lives.
It is important to acknowledge that some boys may not want their father to be involved in treatment. The relationship may be so strained or conflicted or the son may feel so wounded by that relationship, that he is unwilling to consider reestablishing that relationship. Conversely, some fathers may not want to be engaged in their son’s treatment, or it might not be in the son’s best interest to attempt to engage the father in therapy, due to the father’s history of speaking or behaving in a demeaning or abusive manner toward the son. In these circumstances, another adult may be an appropriate surrogate.
Throughout human evolutionary history, until the industrial revolution, the vast majority of humans lived in rural homogeneous communities and with a few exceptions, rarely traveled outside those communities (Wilkinson, 2020). Families spent a lot time together. Anthropologist Frank L’Engle Williams (2019) found evidence to suggest a history of father-child bonding, even in early childhood, throughout human evolutionary history. Fathers were mentors and teachers, training, molding and shaping their sons with the goal of preparing them for the roles and responsibilities expected of adult males in their communities. As boys transition into manhood, fathers and other adult men led boys through rites and rituals to embody the transition from boyhood to manhood. (Bly, 1991; Campbell, 2012; Gillette and Moore, 1990; Eliade, 1959). In those small, pre-industrialized cultures, there was community consensus regarding the requirements for manhood. Sons’ lives and vocations were typically continuations of the paths their father, grandfathers and great-grandfathers had walked before them (Wilkinson, 2020).
As discussed in Chapter 2, there is no longer a cultural consensus to guide fathers in their attempts to prepare their sons for the roles and expectations of manhood. The molding and shaping process, traditionally associated with fatherhood, is virtually impossible to perform because there is no community consensus as to what constitutes a “good man.” As Bly (1991) and Scherrer (2020) noted, the loss of cultural consensus regarding appropriate roles and behaviors for men and boys, has led to men, particularly fathers, being depicted as increasingly incompetent, baboonish and bumbling in the entertainment media. Many fathers and sons, seem lost. If one has the opportunity to observe adolescent boys with their fathers, it is not unusual for the son to have headphones in his ears and a hoodie pulled up over his head. The sons’ body language is clearly communicating, “I am not open to having a conversation with you.” This is likely due in part to the fact that fathers are still trying very hard to “mentor, mold and shape. ” their sons but not very skillfully and without clear purpose and direction. Things are not going well. The boys typically seem sullen and a little angry. It seems that many boys have come to expect that, regardless of what they do or say, their father’s response will include criticism, correction and a volley of you shoulds. This dissertation is proposing a new theoretical approach to engaging fathers in their son’s mental health treatment, by also proposing a new and yet not so new, model for thinking about the role of fathers in their relationships with their adolescent sons.
Jungian analyst James Hillman (1996) labeled Jung’s idea that each person is born with unique and innate abilities, preferences, tendencies, affinities, and peculiarities the Acorn Theory (Hillman, 1996). While individuals are to some extent shaped by their families of origin and life experiences, this “shaping” does not happen in the same way that a potter shapes clay. Instead of that, individuals are shaped by their experiences and relationships, much as an oak sapling is shaped by the soil in which it germinates, the amount and type of moisture it receives, the strength, consistency and direction of the wind it encounters, the amount of sunlight it receives. These environmental factors can certainly influence the growth of the oak tree but not so dramatically that the oak will turn into an apple tree or an asparagus. According to Jung’s (1966) perspective, the basic pattern forming elements of an individual’s deepest identity are innate to one’s biological and psychological structure. There is something inside of the human personality that is greater than the sum of the parts, something which transcends conscious awareness. Jung (1989) termed this something, the Self. Within the context of families of origin and environmental influences, the Self is nudging, tugging and pulling, with the goal of shaping the individual into the unique oak that the acorn was created to be. Within the context of Jung and Hillman’s perspective, symptoms, aches, pains, anxieties, depressions, fears and phobias are the language the Self uses to prompt individuals to change course in the direction of their true Selves (Jung, 1989).
This dissertation will propose that a father’s ideal role with his son is to catch glimpses of his son’s acorn and to reflect this image back to his son, to create space, and light, and warmth for his son to catch glimpses too, and grow into the oak he was created to be. This model proposed in this dissertation will provide space and structure for fathers’ to be present with their son’s without the expectation that they guide or correct their son. Instead, in this model, the father’s role will be listening and reflecting. Jung’s notion of the “self-healing archetype,” is crucial here. Just as the human body knows how to heal itself when it is injured or sick, Jung argues that the human psyche, given the right environment, will do the same. A medical doctor might suture a laceration, set a bone or prescribe an antibiotic but ultimately, the body does the work of healing. Similarly, therapists might provide tools to help sons and fathers put behaviors, cognitions and emotions into better alignment but ultimately, the self-healing properties of the psyche does the work of healing.
It seems that fathers are still trying to live within the ancient “mentor/teach” role, when there is no cultural consensus regarding what needs to be taught. Fathers often see their sons’ difference or uniqueness as a flaw or a threat and scramble to “correct it,” without knowing himself what “correct” looks like. If fathers can learn to simply be with their sons, let go of the compulsion to teach, coach, shame, guilt and shape their sons and learn to listen and hear them, the will be better able to look and listen with their full attention, until they see and hear the acorn that foreshadows the oak their son can become.
While both schema theory and Jungian theory conceptualize mental health symptoms as the product of autonomous, somewhat split-off, aspects of the personality, they have divergent understandings of the goals of mental health treatment. Schema Theory characterizes early maladaptive schema and dysfunctional schema modes as enemies, and therapy as “doing battle” with ultimately eliminating these aspects of the personality (Young et al., 2003). In contrast, Jungian theory conceptualizes complexes as wounded and currently dysfunctional, but essential aspects of an individual’s psyche. The Jungian approach to complexes is to create a therapeutic environment in which clients can become conscious of, understand, heal and integrate the complexes into the conscious personality (Singer, 1991).
Existing theories do not provide a framework or therapeutic approach which acknowledges and addresses both the conflicting cultural expectations traditionally associated with manhood, and the biological and genetic factors which impact men and boys. Integrating Schema theory with Jungian theory can guide and inform future research and practice to help destigmatize mental health diagnosis and treatment for boys and men, provide a therapeutic space for fathers and sons to be in each other’s presence without judgment or criticism and encourage fathers to become more engaged in their son’s mental health treatment.
Schema theory has strong evidence-based support, validated assessment tools and a standardized approach to treatment (Jacobs et. al., 2019; Roelofs et al., 2016). There is a general assumption that psychodynamic approaches do not have evidence based support but in a review of multiple meta-analysis evaluating the efficacy of psychodynamic approaches, Shedler (2010) found that across the meta-analyses, “effect sizes for psychodynamic therapies are as large as, and sometimes larger, than those reported for other approaches which that have been promoted as “empirically supported” and “evidence based.” Shedler (2010) concluded that across studies the evidence indicates that the benefits of psychodynamic therapy are lasting and appear to extend well beyond simple symptom remission, suggesting that psychodynamic therapy may help individuals harness inner resources and capacities that lead to more fulfilling lives.
It is difficult to imagine how one might design a randomized, controlled trial to explore the efficacy of Jungian therapy, because the essence of a Jungian approach is to allow the unique “acorn” of an individual to emerge and guide the therapeutic process. In fact, Carl Jung espoused, “highly mercurial” attitudes toward method and technique (Weiner, 2010, p. 87). “Psychotherapy and analysis are as varied as are human individuals. I treat every patient as individually as possible, because the solution to the problems is always an individual one. Universal rules can be postulated only with a grain of salt” (Jung, 1963, p. 153).
Since schema theory and Jungian theory identify the same psychological processes as the source of mental health concerns and use similar tools and techniques in treatment, it is likely that the established tools and process of schema therapy can be married with “highly mercurial” / “heal and integrate” model of Jungian therapy, in a way to destigmatize adolescent mental health concerns for fathers and increase fathers’ willingness to seek mental health support for their sons. Jungian theory also acknowledges that psychological traits of both males and females that provided survival and procreational benefits in the past are biologically based and are still present and impactful in humans today, influencing perceived psychological and behavioral differences in males and females (Buss, 1999; Ozkan, 2017; Campbell et al., 2001). Acknowledging the influence of innate, biological traits by no means implies that men and boys are powerless to make choices about their cognitions, emotions, and behaviors. On the contrary, becoming conscious of acknowledging and understanding these ancestral influences empowers boys and men nurture, harness, and enlist their total personalities into their growth and development. A central tenet of both schema theory and Jungian theory is that becoming conscious of the currently unconscious aspects of one’s personality enables individuals to manage, rather than mindlessly, reflexively and unconsciously reacting to powerful unconscious aspects of one’s personality.
Jung’s understanding of archetypes offers an approach to conceptualizing human behaviors, individual differences, and mental health symptoms which can be applied across a broad spectrum of cultural contexts to normalize and destigmatize aspects of the personality which are typically judged and rejected. Jung asserts that there are as many archetypes as there are typical situations in life. One simply opens a book, scrolls through their news feed or binge watches a popular series and characters and behaviors from our inner world, greet us there. The dissertation proposes that, if fathers can come to see their son’s personality characteristics, behaviors and mental health symptoms as universal expressions of the human condition and human development, they will be better positioned and more open, to understand , empathizing and engaging with their sons’ mental health treatment.
The proposed solution to the shortcomings of the theories described above, as applied to engaging fathers in mental health treatment with their adolescent sons, is fairly straightforward: affirm the important role that fathers play in their son’s development and mental health; create opportunities for sons and fathers to be in each other’s presence as they experience and respond to archetypal stories; and merge the mythopoetic framework of Jungian theory, with the more manualized structure of Schema theory, to create a therapeutic environment in which fathers and sons are invited conceptualize mental health symptoms in a more accessible, less stigmatizing way, while examining and challenging traditional masculine gender role expectations as they impact adolescent male mental health.
A typical psychological evaluation process for an adolescent male culminates with the examiner presenting the parents (but more typically, just the mother), with a written document that purports to describe the origins of, the diagnostic label for, and recommended treatment modalities to address the presenting concerns. Boys are given pejorative, often stigmatizing diagnostic labels: depressed, anxious, oppositional, avoidant, hyperactive, addicted, autistic, inattentive. Recommendations and treatment plans describe changing behaviors, correcting thoughts, learning skills, and eliminating symptoms. While evidence-based treatments exist which, reportedly, can achieve some of these goals, for some clients, some of the time, mental health services are underutilized among adolescents in the United States, particularly among boys (APA, 2018; DuPont-Reyes et al., 2019; Rice et al., 2018) . While multiple studies indicate that paternal participation in mental health treatment for children and adolescents is associated with positive treatment outcomes, fathers are less likely than mothers and other female caregivers to participate in psychological treatment for children and adolescents (Lindsay et al., 2011; Tiano and McNeil, 2005; Walters et al., 2001).
Both Jungian theory and Schema theory describe autonomous, unconscious aspects of the personality which often take control of individuals’ thinking and behavior. Young et al. (2003) describe dysfunctional schema modes as facets or parts of the self that have become disassociated or cut-off from other aspects of the individual’s personality. Dysfunctional schema modes are described as “erupting” and “taking control” of an individual’s thinking and behavior when triggered by life-situations to which one is “overly sensitive.” According to a Jungian perspective, these autonomous, persistent, troublesome emotional states and behavior patterns are considered the product of complexes. Complexes, like schema modes, are autonomous, splinter aspects of the personality, which generate emotions and behaviors which run counter to an individual’s conscious intentions (Singer, 1979).
Utilizing the paradigm of splinter aspects of the personality, Schema theory and Jungian theory provide a way to conceptualize problematic behaviors and attitudes as expressions of one, wounded part of the personality, allowing the individual, and the father, to think of the attitude, behavior or symptoms as emanating from a wounded part of the son’s personality, rather than his entire being. This will, hopefully facilitate compassion and empathy in father and allow him to engage with aspects or parts of their son’s personality, each having different abilities, levels of development and needs. Additionally, as parent mental /emotional health issues are significantly correlated with the mental /emotional health concerns of their children (Bowen 1978; Sherman et al., 2019; Sundag et al.,2018; Zeynel and Uzer, 2020 ), helping fathers gain understanding, empathy and compassion for the autonomous aspects of their son’s personality responsible for mental health symptoms, also creates an opportunity for fathers to gain understanding, empathy and compassion for their own, likely similar, symptoms and behaviors patterns.
Vic is a 17-year-old Caucasian male who is a high school senior in an affluent suburb of Minneapolis, MN. He was referred to an outpatient mental health clinic for therapy following an assessment and psychological testing to determine if Vic met the diagnostic criteria for Attention Deficit/Hyperactivity Disorder. As a product of the evaluation Vic was diagnosed with Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD) and provisionally with AD/HD. The provisional diagnosis was due to the possibility that Vic’s difficulties with attention and distractibility are the product of his anxiety and depression symptoms, rather than a neurodevelopmental disorder. Vic’s mother expressed concern that Vic has intermittently used cannabis. Vic reported that he has not used cannabis in the past 8 months. Vic’s mother reported that “tests” him regularly to make sure he is not using. Vic said that feels less self-conscious when using cannabis but knows that he needs to work on his anxiety and depression without relying on cannabis. Vic reported a high level of motivation to participate in therapy.
Vic has exhibited depression and anxiety symptoms, academic difficulties and difficulty with peer relationships, since 5th grade, the year his parents separated and divorced. Vic’s mother reported no academic or social concerns or difficulties with inattention and distractibility, for Vic prior to 5th grade. Vic’s mother noted that Vic always manages to pass his classes, in spite of the fact that he is constantly late submitting his work. “Due dates do not mean anything to Vic.” Vic indicated that he has difficulty motivating himself to complete school work prior to the due dates. He indicated that it is often easier to complete work after the due date has passed.
During middle school, Vic was often picked on / bullied at school. Vic’s mother stated that Vic was sensitive, easily overwhelmed and struggled socially and academically. In response to this experience, Vic’s mother enrolled Vic in an online middle school. Vic had difficulty with motivation while attending the online school and returned to the traditional school setting in 8th grade. Vic’s mother reported that Vic’s depression and social difficulties worsened in 9th grade. Vic stated that 9th grade was a particularly difficult year because he began to isolate himself socially, in response to increased anxiety. Vic reported that still has difficulty making friends and maintaining peer relationships because vic continually worries about how to perceived by peers, and adults. Vic added that he “never knows what to say,” and that he is always second guessing and criticizing himself.
Vic has changed school settings multiple times since 5th grade. His depression and anxiety symptoms have been continually present during that time. The symptoms increased dramatically when Vic was prescribed Prozac by his primary care provider during his 9th– grade year. Vic stated that, while on Prozac, he experienced frequent nightmares and increased suicidal thoughts. Vic described feeling “dead inside” while taking Prozac. During the summer prior to his 10th– grade year, he was prescribed Wellbutrin following a consultation with a psychiatrist. Vic indicated that his depression symptoms and suicidal ideation decreased with Wellbutrin but were still present. Vic has recently been prescribed Zoloft in response to a recent increase in reported anxiety symptoms. Vic reported that he has not noticed any changes since beginning Zoloft. Vic stated that is not sure if the Wellbutrin is helping because he still feels the “depression I have felt since I was a kid.” He stated that he suspects that his depression has an impact on his motivation and that this is the major contributing factor to his difficulty completing academic work.
Vic recalled that he has been anxious and a worrier as long as can remember. Vic stated that cannot tell whether he has ADHD or anxiety. Vic reported that sometimes “I cannot focus on anything. Sometimes I get really stuck.” Vic stated that has felt increased anxiety associated with his girlfriend. With his mother’s encouragement, Vic explained that has trouble understanding why his girlfriend likes him. Vic reported that Vic’s girlfriend texts him “all the time ” and is always interested in doing things with him but Vic fears that Vic’s girlfriend will “stop liking me.” Vic stated that has not shared this concern with his girlfriend. He stated that when he feels really anxious, he tends to “hold it in and stay quiet.” Vic described heightened anxiety, excessive worry, ruminations, difficulty concentrating and nervousness, feeling restless, irritability and difficulty concentrating.
Vic lives with his mother and his 18-year-old brother, who has been diagnosed with an autism spectrum disorder. Vic’s mother supports the family with a small business she started several years ago. Vic’s mother also receives “inconsistent” child support from Vic’s father. Vic described his family as “middle class.” “We live in a neighborhood of ‘richer-than-us’ white people.” Vic stated that his favorite thing is being with his girlfriend but Vic also likes to skateboard, snow board and design, build and fix things. Vic said that always has “about 20 projects in my head all the time.” He reported that has built skateboard ramps, bicycles, a go- cart, furniture, and a miniature skate park for the miniature skateboards that he makes. Vic pulled out his phone to show pictures of some of the things Vic has made. The first picture was of a workbench he built in the garage. Vic was particularly proud of the way the bench legs were attached to the work surface. When Vic talked about his projects, his entire demeanor changed. He smiled, he was more engaged, alert, focused and his physical and verbal energy level increased. Vic also showed pictures of the miniature skateboards and skateboard park he built. He described in detail how he 3D printed a mold to press the layers of plywood together for the skateboard decks. Vic stated that he is currently rebuilding an old Toyota SUV. Vic’s mother added that Vic is also “an amazing artist.” Vic acknowledged that he really likes to draw.
Vic’s mother reported that, prior to their divorce, when Vic was 11 years old, she and Vic’s biological father had a volatile relationship. Vic’s mother indicated that finally asked Vic’s father to leave, when Vic’s mother could no longer deal with how Vic’s father treated Vic and his brother. Vic’s mother reported that has physical custody and that Vic’s mother and Vic’s father have shared legal custody. Vic reported that, when his parents first separated, Vic saw his father every other weekend and on Fridays. Vic’s mother stated that, over the past 2-3 years, Vic has seen his father only intermittently. Vic’s mother indicated that seeing his father has “sort of fallen off Vic’s radar.” She said that Vic’s dad “is letting it go.” Vic stated that, when saw his father regularly, Vic’s brother “did not feel safe around him because was always yelling at Vic’s brother, so Vic trying to not see him that much.”Vic’s mother reported that there has been a lot of tension and conflict in Vic’s relationship with his father. Vic’s mother noted that Vic’s father was never physically abusive to Vic but Vic was physically abusive to Vic’s mother and to Vic’s brother.
Vic’s mother reported that Vic played baseball when he was younger. Vic added, “just because Dad wanted me to. He coached my team until I was in 4th– grade.” When Vic’s parents separated, Vic stopped playing baseball and began skateboarding. Vic said that never felt comfortable skateboarding when his father was living in the house, because he knew his father disapproved of skateboarders. Vic also started snowboarding during the first winter after his parents separated. Vic said, “I was better at snowboarding after one day, than I was after 4 years of playing baseball.” Vic said his father was angry at him when he stopped playing baseball, and told him that skateboarding and snowboarding were “stoner sports.”
Vic stated that would like to snowboard professionally. Vic described an elaborate plan for the coming snowboarding season. Vic hopes to go snowboarding every day after school and all day on weekends. Vic reported that worked a lot over the summer at an oil change center so that does not have to work in the winter. Vic said that plans to record himself snowboarding so that can send the videos to potential sponsors. Vic stated that he has purchased an old camcorder because Vic thinks “it will be cool to have an old school look to my videos.”
Vic’s mother indicated that Vic’s father has made critical and shaming statements toward Vic regarding Vic’s anxiety and depression symptoms. Vic’s mother indicated that Vic’s father has communicated the belief. Vic is weak or defective because Vic experiences anxiety, worry and depression. Vic’s father has also made disparaging comments about the fact that Vic needs help to manage his mental health symptoms.
Vic’s mother stated that Vic occasionally tells her that Vic is thinking about killing himself. Vic’s mother indicated that this is most prevalent when Vic is overwhelmed or confused. Vic described the suicidal ideation as, “I do not like the inside of my head.” Vic reported that his suicidal ideation was sometimes connected to thoughts and feelings regarding his father. Vic indicated that, at other times, it was related to “school stuff – feeling overwhelmed.” Vic said, “Most of the time I can deal with it – keep everything inside.” During the intake session, Vic stated that the last time he recalled suicidal ideation more than 2 years ago, when Vic was taking Prozac, but during the course of therapy, Vic admitted that thoughts of killing himself “pop into my head,” 1-2 times a week, particularly when thinks like he has failed, or has disappointed someone. Vic denied hallucinations. Vic reported that occasionally has nightmares, but these were much worse before he began taking Wellbutrin. Vic also said that he often has “vivid dreams” . Vic said that wakes up and it seems like the dream really happened, “like it happened yesterday.” No issues with appetite were reported for Vic.
Vic said that has never shown any of his projects or artwork to his dad, for fear that his dad will criticize them. Vic said that there have been several times that he wished that could call his dad and ask his help. Vic went into some detail about having difficulty replacing the ball joints on the SUV he was working on. He stated that he knew that his dad had a tool that would help, but he was afraid to call him. Vic has not said even told his dad that he is rebuilding the SUV. Vic said that sometimes wants to have a relationship with his dad and sometimes does not. Vic explained that his father has been so unkind to his brother and his mother that he thinks, “I should not want to see him: I am embarrassed that I still want to seem but sometimes I think it would be really fun to work on things with him.” Vic said his father texts him regularly and tries to get Vic to make plans to come to see him. Vic said, “I usually do not respond.”
Vic stated that used to have “a couple friends” with whom Vic skateboarded and snow boarded, but “we are not as closed as we used to be.” Vic explained that his cannabis use started with those friends. Vic was clear that does not want to hang out with them anymore. He said that, “If we are not stoned, I feel really weird and awkward around them.” Vic was clear that he does not want to smoke any more and noted that his former friends “are into some stuff now, that I got to stay away from.” When asked about other things he enjoys Vic stated that he like music, also, listens primarily to hip hop music, but stressed that the likes hip hop that is about “real life for real people, not that, ‘I got more money than you, crap.’” Vic mentioned Juice World and Lil’ Peep specifically.
During the first few therapy sessions Vic had a lot of difficulty maintaining his train of thought and completing sentences. Vic was very self-conscious and anxious. Vic had said so many things that Vic wanted to talk about that he did not know where to start. When encouraged to pick a starting place, Vic could not. Vic said “Could we start with you asking me questions. That will get me going.” Over the course of several sessions, Vic appeared to relax a little but he was still very easily distracted by his thought process. At times Vic sustained eye contact but only for a few seconds. Vic mostly looked at the floor or off to the side. In the 4th therapy session Vic said that was afraid that the therapist “did not really want to” work with him and was just doing it because he “had to.” When asked to talk more about this concern, Vic said that his dad often acted like he was really excited to see him, but when they were together, his dad always seems “bummed and disappointed, or angry.” “When my father texts me and says we should do something, now I do not respond, because I do not believe him.”
Vic is very insecure, and puts a lot of energy into anticipating / mind reading what people are thinking and how they will react. Vic demonstrated some insight into the origins of his anxiety and depression. He indicated that he knows a lot of his anxiety has to do with his dad, “being a dick to me, my brother, and my mom.” Vic described his father as “bi-polar,” in the sense that he “switches personalities” unexpectedly. Vic stated that sometimes it seems like his father is nice, and interested in spending time with him, but then Vic’s father switches into “dick mode.”
When Vic was talking about his father, Vic appeared calmer and more grounded, and made better eye contact. He did not lose his train of thought, and the tone and volume of his speech was more consistent. After several sessions with Vic being distracted and anxious, except when he spoke about his father, I asked Vic if it would be okay if we invited his father to attend a therapy session. Vic became very anxious and said he was not sure that that was a good idea. Vic agreed to allow his father to meet with the therapist, but was adamant that Vic did not want to be present when his father was present. Vic warned the therapist that his father will try to act “all nice and shit,” and will blame everything on Vic’s mother.
Meeting with Vic’s Father
After consulting with Vic, the therapist reached out to Vic’s father and to schedule a meeting. Vic’s father was reluctant at first. Vic’s father stated that did not believe in the “psychology crap.” The therapist affirmed that, given the volume of misleading, conflicting, and inaccurate information available, the perspective of Vic’s father is understandable. The examiner explained that his goal is to gain an accurate and comprehensive picture of Vic, and given that the therapist has only heard Vic’s mother’s perspective, it is important that Vic’s father’s experiences and perspective be taken into consideration. Vic’s father agreed to meet for 30 minutes.
The examiner began the session by inviting Vic’s father to tell the examiner what he should know in order to know and understand Vic. Vic’s father began by asserting that from the time their children were babies,Vic’s father felt like his opinion did not matter. Vic’s father stated that when Vic’s father attempted to “do anything with the kids,” his wife told him Vic’s father was doing it wrong. Vic’s father said that“I eventually just stopped trying.” Vic’s father stated that knows something “is not right” with Vic’s older brother, but Vic’s father does not “buy into the whole autism thing.” Vic’s father explained that Doug does what he wants, and then pretends cannot do what he does not want to do.
The examiner said, “Tell me about Vic.” Vic’s father said, “Vic is a great kid, but his mom has made him scared. She coddled him. Every time he struggled with something, she jumped in and did it for him. The weaker he became, the more he struggled, the more she smothered him. I read something about this thing called, ‘learned helplessness.’ That’s Vic. His mom has ruined him and turned him against me. Vic thinks I’m an asshole, because I try to help him learn to do things on his own, suck it up and keep going when he’s scared or tired. He just shuts down, then goes home to his mom, and she tells him I am an angry asshole. That’s what she always called me when he would fight: angry asshole.”
The examiner told Vic’s father that Vic’s mother said that Vic was his favorite. Vic’s father said, “Well, he is one I understand the best. Vic played baseball when was in elementary school. He was good and a shortstop like me. I was hitting ground balls to him one day, and one popped up and hit Vic in the lip. He was bleeding like hell. His mom accused me of hitting the ball too hard , and managed to turn Vic off baseball after that. Now he skateboards and snowboards. Those are ‘stoner sports.’ That’s what I told Vic when he first started skateboarding. Turned out to be true. I think the pot is a part of the reason they brought him to see you.”
The therapist stated that Vic’s father has heard that Vic is very good at both snowboarding and skateboarding. Vic’s father acknowledged that he thinks he’s okay with them , but stated, “What the kids are really good at is building shit. You should see the ramps he has built in the backyard . He has done some pretty complicated shit; and it looks good.” The therapist asked Vic’s father if he had told Vic how impressed was with the ramps. Vic’s father said, “I do not think so.”
The examiner asked, “What else should I know?” Vic’s father said, “I want to spend time with Vic, but it seems like everything I say or do scares him or makes him sad. Vic just shuts down around me. It does not matter what I say or suggest, Vic hears it as a criticism, so I am kind of giving up.” The examiner said, “If you knew how to make it better, it sounds like you would.” Vic’s dad said, “Of course I would. I guess you are going to tell me how to make it better.” The examiner said, “I do not know how to make it better. That’s what I am trying to figure out. If I get any good ideas, would you be willing to work with me to give them a try?” Vic’s father said, “I might.”
On the Young Schema Questionnaire (YSQ-3), Vic showed elevations on the following domains: Abandonment/Instability (i. e. The perception that others will not be able to provide emotional support, connection, strength or protection because they are emotionally unstable and unpredictable): Emotional Deprivation (i. e. The expectation that that one’s desire for emotional support will not be adequately met by others); Defectiveness/Shame (The belief that one is defective, bad, unwanted, inferior or invalid in important ways or that he would be perceived as unlovable if his flaws were exposed); and Negativity/Pessimism (i. e. A pervasive focus on the negative aspects of life (e. g. pain, death, loss, disappointment, conflict, guild, resentment, unsolved proles, potential mistakes and things that could go wrong).
According to a strictly cognitive perspective, Vic would be encouraged to eliminate and extinguish problematic cognitions; challenge his automatic thoughts; identify and challenge his core beliefs with rational responses; and follow through on behavioral assignments to test his thoughts and beliefs and develop new behavior skills. The cognitive approach would not necessarily explore the dynamics within the family environment which contributed to the formation of his automatic thought and core beliefs . It also will not encourage him to experience, tolerate and learn from troublesome emotions, nor create a pathway for the client’s father to better understand and engage with his son’s developmental and healing process.
According to a strictly schema theory perspective, Vic would be assessed to identify and label his early maladaptive schema, and his active schema modes through standardized assessments tools. The therapist will explore the origins of the maladaptive modes in childhood and family of origin experiences, link current problems and symptoms to maladaptive schema modes; use imagery to conduct dialogues between modes; attempt to diminish or extinguish maladaptive modes; and generalize the results of schema mode work to his daily life.
The Schema Mode work will not explore the utility and potential value in the maladaptive modes. It also will not de-pathologize the maladaptive schema modes by helping Vic identify the schema mode’s equivalent manifestations in stories, myths, movies, comic books, video game characters etc. Finally, the Schema Mode work will not provide an avenue for Vic’s father to understand and engage in Vic’s psychological treatment.
According to Jungian perspective, a therapist would spend considerable time developing a safe, trusting therapeutic relationship, in which Vic’s self-healing archetype could activate through dreamwork, art, sand play, and active imagination. The therapist would facilitate the process of the Vic connecting with meaningful stories, myths, fairy tales and characters that capture and resonate with his personal struggles or the source of their emotional pain. Once Vic becomes aware of the stories, symbols and characters he is living out, it is assumed that his self-healing archetype will guide him in developing coping mechanisms to understand and transform pain and suffering.
The structure, focus and mechanics of Jungian therapy vary, depending upon the therapist and his or her perception of the client’s needs. As noted above, Jung understood psychotherapy and analysis to be varied as human individuals (Jung, 1963). Regardless of the therapeutic approach, Jungian therapy does not have standardized tools for identifying they particular type of complex which has been activated; nor does it have a consistent, uniform means of explaining / communicating how complexes and archetypes function within the personality and how the autonomous, split-off aspects of the personality function autonomously, creating mental health symptoms. Jungian therapy also does not have psycho-education tools to guide the client and therapist through the process of communicating with and integrating the complexes. Finally, Jungian theory does not have a mechanism for helping fathers better understand their son’s and their sources of their mental health symptoms. Nor does it have a process or structure for engaging fathers, engaging fathers in the therapeutic process, or impacting a father’s relationship with his son .
An integrated approach would adopt the standardized assessment tools of Schema therapy to align early maladaptive schema and schema modes with archetypal themes utilized in Jungian theory, and found in fairy tales, as well as contemporary / familiar stories, novels, movies and television shows, myths and religious stories. Both schema theory and Jungian theory conceptualize mental health symptoms as the product of unconscious, autonomous, split-off, aspects of the personality, but they have divergent understandings of the goal of mental health treatment. Schema Theory characterizes early maladaptive schema and dysfunctional schema modes as enemies, and therapy as “doing battle” with, and ultimately eliminating these aspects of the personality (Young et al., 2003).
In contrast, Jungian theory conceptualizes complexes as wounded and currently dysfunctional, but essential aspects of an individual’s psyche. The Jungian approach to complexes is to create a therapeutic environment in which clients can become conscious of, understand, heal and integrate the complexes into the conscious personality (Singer, 1991).
Schema therapy has a book utilized as a psychoeducational tool entitled Reinventing Your Life (Young and Klosko, 1993). Schema therapy also has a standardized treatment framework to assist clinicians in familiarizing clients with the concepts of the early maladaptive schema. These can be adapted and expanded to incorporate archetypal themes into the more manualized schema therapy process. Once early maladaptive schemas are aligned with archetypal themes, this existing schema therapy structure can be utilized (described in Chapter 2 and below) can be utilized.
In Vic’s case, once he and his father are engaged in therapy, (Getting Vic’s father to engage is going to be the most challenging part: more on this in a moment), the evidence-based structure and process of schema therapy, married with archetypal, heal and integrate approach of Jungian therapy, can provide a rich, robust treatment approach, that will benefit both Vic and his father. Ideally, Vic’s father would agree to take the YSQ-3, in order to identify the early maladaptive schema which are impacting him and in particular, and the unconscious aspects of his personality which are impacting his feelings toward and response to Vic. If Vic’s father can become conscious of these aspects of his personality, and begin to understand how they were formed in his family of origin, he can learn to manage and integrate them into his conscious personality and engage with Vic in a more self-aware manner, with more compassion for Vic, for himself. Given Vic’s father’s attitude toward “the psychology crap,” getting him to simply be present with Vic, without verbalizing criticism or judgment, will be the first, more realistic, step.
Rather than focusing on the diagnostic categories which align with Vic’s symptoms (depression, anxiety and possibly AD/HD) or even the early maladaptive schema identified on the YSQ-3, in the new integrated approach, the therapist would translate those diagnostic criteria and schema into themes from stories, myths, fairy tales, and movies which contain characters whose lives, behaviors, traits or personalities that mirror or are attuned to the dynamics of Vic’s (and his father’s) personality, life circumstances, behavior patterns and relationships. The therapist would create opportunities for Vic and his father to experience these stories together and then respond, through conversation or play or creative collaboration. The theoretical underpinnings of Jungian theory posit that the stories, experiences, emotions and events which align with Vic and his father’s complexes, will provide a pathway for the unconscious, autonomous, splinter aspects of the personality to emerge into consciousness.
If Vic and his father first develop the ability to notice the patterns and dynamics in stories, as well as their emotional and cognitive reactions to these stories, it will allow them to begin to develop a working relationship with these, formerly unconscious, aspects of their personalities.
Schema therapy and Jungian both seek to help clients become conscious of the unconscious but autonomous, aspects of their personality which frequently derail and sabotage their conscious intentions. Both approaches seek to help clients interact with these aspects of their personality but with conflicting goals. The new integrated approach will not adopt the schema therapy perspective that these splinter personalities are enemies and approach therapy as “doing battle” with, and ultimately eliminating these aspects of the personality (Young et al., 2003). This new integrated approach will engage the complexes as wounded and currently dysfunctional but essential aspects of an individual’s psyche. The Jungian approach to complexes is to create a therapeutic environment in which clients can become conscious of, understand, heal, and integrate the complexes into the conscious personality (Singer, 1991).
Schema therapy has a formalized, sequenced treatment approach which includes exploring the origins of the maladaptive modes in childhood and family of origin experiences, linking current problems and symptoms to maladaptive schema modes; using imagery to conduct dialogues between modes; attempting to diminish or extinguish maladaptive modes; and then generalizing the results of schema mode work to daily life. The integrated approach outlined in this dissertation will utilize schema therapy’s formalized structure but guided by the client’s response to the archetypal material shared during the sessions, rather than the therapist’s manual driven agenda. Once Vic and his father are able to recognize and interact with the formerly unconscious aspects of Vic’s personality, Vic can begin to harness and intergrade his innate gifts, strengths and abilities which were locked away in the unconscious complex.
The theoretical underpinnings of Jungian theory posit that the stories, experiences, emotions and events which align with Vic and his father’s complexes, will provide a pathway for the unconscious, autonomous, splinter aspects of the personality to emerge into consciousness. Zoja (2010) states that the goal of therapy is to help the client enter into a psychological state through which the unconscious can express itself and then follow the client’s lead regarding what comes next. For this perspective, the therapist does not need to direct the process and the client’s response to archetypal themes and stories will typically provide guidance to the therapist regarding next steps.
Vic’s responses on the YSQ-3 indicated that Vic is impacted by the following early maladaptive schema (EMS): Abandonment/Instability; Emotional Deprivation; Defectiveness/Shame; and Negativity/Pessimism. From the information that Vic and his mother shared, it is not surprising that these schemas are prominent for Vic. One might assume that stories of fathers and sons or parents rejecting, criticizing and abandoning children would be the most applicable to Vic and his father but in practice, this sort of heavy-handed, therapist driven, allegorical alignment is not the objective and is not helpful. When fairy tales are utilized in Jungian play therapy, the therapist presents several fairy tale titles to the client, and allows the client to choose the story that will be read. It is critical that the client unconscious, not the therapist, directs the process.
Humans love, and need stories. Regardless of culture, or geography, or historical context, the same stories, with the same themes and characters, are told over and over again (Campbell, 1949/2004). In her introduction to the 2004 commemorative edition of Joseph Campbell’s (1949/2004) The Hero with a Thousand Faces, Clarissa Pinkola Estés writes,
No matter how urbanized a people may become, no matter how far they are living from family or how many generations away they are born from a tight-knit heritage group – people everywhere nonetheless will form and reform “talking story” groups. There appears to be a strong drive in the psyche to be nourished and taught, but also to nourish and teach the psyche’s of as many others as possible, with the best deepest stories that can be found. (p. xxv).
Erich Fromm (1951) argued that dreams, fairy tales and myths are a universal language which gives rise to sensory perceptions and bodily associations which bring people to “the deepest sources of worldly wisdom”, which resonate with and awaken “the depths of our personality” (p. 17). Joseph Campbell (1949/2004) wrote, “It would not be too much to say that myth is the secret opening through which the inexhaustible energies of the cosmos pour into the human cultural manifestation. . . The wonder is that the characteristic efficacy to touch and inspire deep creative centers dwells in the smallest nursery fairy tale – as the flavor of the ocean is contained in a droplet or the whole mystery of life within the eff of a flea.” (p. 3).
Stories in the form of fairy tales have been utilized in a variety of mental health settings: in the treatment of eating disorders (Hill, 1992); as a tool in clinical supervision (Smith, M. E., and Bird, D. (2014); in supporting families of gifted children (Volker (1995); in treating childhood trauma (Carr and Hancock, 2017); and in the mental health treatment of young adult cancer patients (Hammond et al., 2015). In discussing Jungian sand tray therapy, Zoja (2010) states that the goal of therapy is to help the client enter into a psychological state through which the unconscious can express itself, and then following the client’s lead regarding what comes next. The client might need to talk or draw, dance, shout, cry, play, or simply sit in silence.
The integrated theoretical approach described in this dissertation will utilize stories, initially in the form of fairy tales and later myths, movies and television shows, as a means of creating a therapeutic space in which this psychological state can occur. That approach asserts that when Vic and his father are able to see and experience Vic’s symptoms and the tension in their relationship and embodied in fictional characters, they will feel as if a mirror has been held up in front of their faces. The therapist can use the characters and language of the stories to help normalize and destigmatize Vic’s symptoms, with the goal of helping Vic and his father understand their origins and approach the symptoms with the intent of embracing and healing the wounded aspects of Vic’s personality.
Given the brief portrait of Vic’s father presented in the case study, encouraging him to engage in the therapeutic process may seem like an unrealistic pipe dream. Where should the therapist start? Vic’s depression and difficulties with school and peer relationships became noticeable to Vic’s mother during Vic’s 4th grade year, a time of significant volatility in Vic’s parent’s relationship, prior to their divorce. Vic’s father stated that, from the time Vic and his brother were babies, he felt like his opinion did not matter. He stated that when he attempted to “do anything with the kids,” his wife told him he was doing it wrong. “I eventually just stopped trying.” Vic’s father believes that Vic’s mom “has ruined Vic, and turned him against me.” He stated that “Vic thinks I’m an asshole.”
Vic’s father reported that when he attempts to engage with Vic, to “help him learn to do things on his own, suck it up and keep going when he’s scared or tired, he just shuts down, then goes home to his mom, and she tells him I am an angry asshole.”
Vic’s father clearly expressed a desire to be involved in Vic’s life. While expressing appreciation for many of Vic’s gifts and abilities, he was highly critical of Vic’s chosen sports, and his friends. Vic’s father said, “I want to spend time with Vic, but it seems like everything I say or do scares him, or makes him sad. He just shuts down around me. It does not matter what I say or suggest, he hears it as a criticism, so I am kind of giving up.”
Baumrind’s (1993) research identified two aspects of parental behavior which have been found to predict positive adaptive characteristics in children and adolescents: parental warmth (also referred to as parental responsiveness) and parental control (also referred to as parental demandingness). Warm and responsive parents make a consistent effort to be engaged in their adolescents’ lives and to understand, accept and take seriously their adolescent’s expressed feelings and needs. Warm and responsive parents also make a point of explaining their own actions, especially when they enforce boundaries and limits with the adolescent. Parental control or demandingness involves having mature expectations for children. Parents who exhibit high levels of parental control set and enforce rules, consistently monitor their children and confront and provide meaningful consequences when their children do not meet parental expectations.
Levant et al. (2018) summarized research which found that paternal emotional and behavioral acceptance is an especially important contributor to mental health and well-being in boys, and argued that many boys’ behavior and emotional difficulties are impacted by negative relationships with emotionally distant and rigid father figures. Barker et al. (2017) summarized existing research and reported that parental sensitivity and engagement are consistently associated with reduced child psychopathology and that secure father – child attachment, independently predicts decreased adverse child outcomes.
Vic desperately needs to experience warmth from his father, rather than criticism and judgment. Vic’s father believes that his job is to mold and shape Vic, to identify Vic’s flaws and correct them. Is it even possible to get Vic’s father to understand, accept and take Vic’s expressed feelings and needs? Would he be willing to consider the possibility that Vic was born with biologically endowed abilities, preferences, and affinities, which do not need to be molded and shaped, but rather simply discovered?
Vic’s depression symptoms have improved while taking Wellbutrin. If Vic were to engage with any of the therapeutic processes described above (i. e. cognitive, schema, or Jungian), and persists in the therapeutic process, Vic’s level of self-awareness, his ability to understand and regulate his emotions and his ability to manage and navigate his familial, school, and peer relationships would likely improve. But, if Vic’s relationship with his father remains tense and volatile and if they drift away from each other and become cutoff, Vic will remain at high risk for depression, anxiety, suicidal ideation and substance abuse.
The goal of this dissertation is to provide a theoretical approach for engaging fathers successfully. Once fathers are engaged, any therapeutic approach could bring significant benefit to Vic and father, but the critical question is, how to we get fathers to take that first step, which is sitting with their son, and the therapist, with a willingness to trust the process and an openness to learning more about their son? Getting fathers to take that first step requires fathers to let go of the notion that the father’s job is to mold and shape his son, “set him straight,” and get him on the right path.
Carl Rogers (1961) asked the following questions of himself as a therapist:
Can I let myself enter fully into the world of his feelings and personal meanings and see these as he does? Can I step into his private world so completely that I lose all desire to evaluate or judge it? Can I enter it so sensitive that I can move about it freely, without trampling on meanings which are precious to him? Can I sense it so accurately that I can catch not only the meaning of his experience which are obvious to him but those meanings which are only implicit, which he sees only dimly or as confusion? (p. 53)
The attitude that Rogers (1961) described, is what Vic desperately needs from his father. Yes, this would be a tall order for Vic’s father, or any parent for that matter. In reality, this attitude is an aspirational goal, even for the most well trained, seasoned therapists but imagine how different Vic’s view of himself, his father and his world could be, if his father could make even small strides toward Roger’s (1961) vision of empathy. Vic and his father are imaginary but the relationship dynamics between them are quite common. If one spends any time at all with teenagers and their fathers, it is rare to hear the teenager say anything to which the father does not respond with some sort of criticism, coaching, correction or judgment. Many fathers know no other way to be with their sons, other than molding and shaping them.
What if a therapeutic space were created in which fathers could, briefly, let go of the obligation to mold and shape? What if Vic’s father was given permission and encouragement to just be present with his son, with the goal of learning a little more about him? What if Vic had the opportunity to spend time with his father without feeling judged and criticized. This would be a new experience for both of them. In order for this to happen, Vic’s father must develop the ability to demonstrate warmth and responsiveness toward Vic. Vic’s father will need time, and considerable support to develop his ability to understand, accept and take Vic’s expressed feelings and needs. As a first step, Vic’s father will need to be willing to look past his distrust of the “psychology crap,” and enter into a therapeutic space, with Vic and be emotionally open and present. Vic’s father left the door to this possibility open, when the therapist asked, “Would you be willing to work with me?” and Vic’s father said, “I might.”
For Vic and his father, the process would begin by gaining their commitment to participate in 5 brief, and unusual therapy sessions, which will last approximately 15-30 minutes each. The goal of these first 5 sessions is to provide Vic and his father the experiences of being each other’s presence, without speaking or hearing, words of criticism or judgment.
A proposed model for these 1st 5 sessions is described below, including suggestions for particular stories to be shared. The therapist will attempt to create an experience for Vic and his father, during which they will listen together to archetypal stories (fairy tales) and have the opportunity to share their reactions, thoughts and emotions in response to the stories, while the other simply listens. The therapist will model summarizing and reflecting what he heard, from Vic and his father.
During the first two sessions, Vic, his father and the therapist will sit together at a table. There will be objects and art supplies available, Vic and his father are invited to utilize if they choose (paper and charcoal pencils for drawing; a non-drying sculpting material, a sand tray and figurines, plain wooden blocks). It will be important that these creative supplies do not look like children’s art supplies or toys. When they first sit together the therapist will say, something like this:
Our goals today are to begin to feel comfortable and safe here in this room together, and to begin to listen to and understand each other better. That’s it. We want to avoid anything that feels like judgment or criticism. I am allowed Vic to choose a couple of stories that I will read aloud. While I am reading, and after, you are welcome to use any of the materials in the room, or you can just sit. When I finish reading the story, if there is a character or an event in the stories that really got your attention, I want to hear about it. I will just listen. When you are done, I make sure that I accurately heard and understood what you said. If I got it right, great. If I missed something, you can tell me what I got wrong. I will not offer any opinion about what you said. I won’t ask any questions. My only goal is to understand what you felt and what you thought. I want you to pay close attention during the times when I summarize what I hear, because in later sessions, you will be doing that for each other: just listening and summarizing.
If one of you or both of you, chooses to use the materials during the session, I won’t ask you about what you are doing. I won’t come over and look at it. It’s yours. It’s not private or secret, because we are working on things here in the open but I will not ask you to talk about it. If you want to talk about it, you can and I will listen, and summarize what I heard you say, but I will not ask questions or make comments. If you choose to sit, and do nothing, that is absolutely okay too. If one of you chooses to utilize any of the objects in the room, it is very important that the other does not comment, or ask questions, or respond to it in any way. We are practicing simply being together. That’s it.
There are three goals to this exercise. 1). For Vic and his father to be in each other’s presence without saying or doing anything hurtful, judgmental or critical. 2) For Vic and his father to notice each other, feel each other’s presence, without feeling the immediate need to react to each other’s presence. 3) To introduce archetypal stories into their shared space and to allow space for Vic and his father to experience, absorb and respond to the stories.
During the 3rd or 4th session, Vic and his father will be encouraged to assume the role of reflective listener, if they appear ready. The therapist will guide and coach them through the process. They will be reminded to just reflect and to avoid questions, comments, suggestions, or opinions. This process will continue through the first 5 sessions. At the end of the 5th session, time will be allowed to offer possible next steps for therapy.
During these first 5 sessions, stories do not necessarily need to be chosen to align with themes that are prevalent in Vic or his father’s life and relationships. Fairy tales are an excellent starting place, because they are brief, easily accessible, and touch on universal themes relevant to children and their fears, questions and anxieties, as well as their hopes and dreams. Children and adolescents, typically lack the ability or comfort, to voice to their deepest and persistent fears and anxieties. Fairy tales, start where the child really is in his psychological and emotional being. They speak to his severe inner pressures in a way that the child unconsciously understands and – without belittling the most serious inner struggles which growing up entails – offers examples of both temporary and permanent solutions to pressing difficulties,” (Bettelheim, 1976, p. 6.).
These include fears and anxieties associated with parents (their absence, their disappointment, their flaws); uncertainty regarding whom to trust; having to prove one’s worth and failing, and what is possible after one fails; fear of abandonment; the awareness that the world is not safe (regardless of what the adults say); the reality that the people whom you love and depend upon will sometimes disappoint hurt you; wishing that things were different that they (one’s self, one’s life, one’s family).
Fairy tales inevitably trigger responses that are personal and related to themes in human’s lives. Intentionally selecting stories that have overt themes relevant to Vic and his father’s relationship should be saved for later in the treatment. The following stories from The Complete Fairy Tales of the Brothers Grimm are good possibilities for the first 5 sessions: #1 “The Frog King, about a princess who makes a deal with a frog, and then tries not to keep her promise; # 7 “The Good Bargain,” a tale about a farmer who loses everything due to his tendency to want to prove that he is right, when no one is really saying he is wrong; #12 “Rapunzel” is a tale of a mother and father who trade their daughter to a sorceress for some very good lettuce and the daughter eventually saves the prince who unsuccessfully tried to rescue her. #16 “The Three Snake Leaves,” the story of a boy who leaves his father, who can no longer provided for him, falls in love with selfish princess, who tries to kill him; #17 “The White Snake,” the story of a man who snuck a bite of the king’s magic food and gained the ability to understand the language of animals, fell in love with a princess who, at first did not love him, was tricked and betrayed, but eventually won her love, with the help of is animal friends; # 21 “Cinderella,” a tale of a girl whose mother dies and when her father remarries, he allows his new wife and step-daughters to turn his daughter into a poorly treated slave. With the help of some animal friends, she overcomes her father’s neglect and her step sisters cruelty; #29 “The Devil with Three Golden Hairs,” the story of a boy born to a poor mother, but destined to marry the king’s daughter. They king tries everything in his power to prevent the boy from marrying his daughter, but through the persistence and cunning of his mother, he achieved his destiny; # 50 Brier Rose; the story of a king and queen who finally gave birth to a daughter, but did not have enough dishes to invite all the wise women in the kingdom to the party celebrating the birth. The one uninvited wise woman cursed the daughter to fall into a deep sleep on her 13th birthday, which would last 100 years. She awakens after 100 years, because the spell is broken, not because the prince rescued her, but marries the prince anyway; #64 “The Golden Goose,” is about the youngest of three sons, described as a simpleton, whose parents think he is too stupid to even chop wood, so they send his older “smart” brothers, who fail miserably, due to their unkindness to a dwarf. The 3rd son is kind to the dwarf and has an adventure that results in his marrying the king’s daughter. Virtually any fairy tale with work for the first 5 sessions, but these are more complex and engaging than some of the others in the collection.
The proposed integrated theory is an initial step toward future research and practice, because it addresses gaps in the existing research and practice and expands existing theories in a way that has the potential to destigmatize mental diagnosis and treatment for boys and men, as well as engage fathers in their son’s mental health treatment. This type of integrated theoretical approach also has the potential to expand dialog between researchers and clinicians in the cognitive and psychoanalytic traditions.
CHAPTER 5. DISCUSSION AND CONCLUSIONS
Goldfield (2019) asserts that the field of psychology and psychotherapy in particular, suffers from a lack of scientific consensus. Goldfield (2019) attributes this failure to find common ground to psychologists’ tendency to silo themselves into one theoretical orientation, choosing to remain oblivious to other perspectives and best practices. This silo-ing leads to a disconnect between research and practice and missed opportunities to build on existing knowledge. Consequently, Goldfried (2019) describes resources and time are wasted as psychologists work to “rediscover what we already knew, or – even worse –ignore past work and replace it with something new” (p. 484).
Differing theoretical approaches, rather than working collaboratively to learn from and scaffold each other, seem focused upon demonstrating the efficacy and superiority of their approach, while ignoring the knowledge gained by their perceived rivals. Decades of research has been conducted with the goal of demonstrating that one therapeutic approach is more efficacious than another, with little or no attention paid to the common ground these approaches might share, nor how these supposedly contradictory approaches can complement, strengthen or learn from each other. Sanders and Hunsley (2018) compared the current state of research regarding the efficacy of mental health intervention to the “Caucus-race” in Alice’s Adventures in Wonderland. The Dodo bird oversees a contest in which, contestants begin at different starting points , run in different directions and end whenever they please.
The Dodo concludes the race and declares: “Everybody has won, and all must have prizes.” The Dodo Bird Verdict (DBV) has been used to describe a particular conclusion about psychotherapy outcomes-namely, that all types of psychotherapy are equivalently effective (p. 387).
In order to avoid the Dodo Bird Verdict in future studies, Sanders and Hunsley (2018) advocate for more rigorous collaboration, communication, consensus and standardization in the research methodologies and therapeutic approaches evaluated. But, the very nature of mental health therapy, even in highly manualized approaches, makes standardization difficult. Even the most rigorous sampling practices cannot produce identical subjects. Even highly scripted, procedural treatment approaches cannot control for individual differences in therapists and clients. Psychological constructs such as depression, anxiety, attention, hyperactivity , social reciprocity, stress and trauma are difficult to define, let alone measure in a consistent meaningful way.
The proposed integrated theory in this dissertation attempts to upset the apple cart of current theoretical and research practices by suggesting that the ideal goal is to identify and build upon the common ground between theoretical and clinical approaches. Understanding human nature and psychopathology, and developing effective treatment approaches is not a zero-sum game. More is to be gained from partnership and collaboration, than competition and polarization.
Considerable research suggests that schema theory and Jungian theory lead to positive outcomes and symptoms reduction for many clients, but they do not work for all individuals. The most glaring gaps in these theories are that they do not currently address the stigma associated with mental health diagnosis and treatment, especially for men and boys, and they do not effectively engage fathers in their son’s mental health treatment. No current theoretical model exists to help fathers and sons explore, understand and navigate the complex, and often contradictory expectations men and boys face in contemporary society, and no model exists for incorporating fathers into mental health treatment for adolescent boys (APA, 2018; Clauss-Ehlers, 2017; DuPont-Reyes et al., 2019; Rice et al., 2018). In order to bridge these gaps, a new theoretical approach is proposed to marry the assessment tools and evidence-based treatment structure associated with schema theory, with the mythopoetic, transpersonal focus of Jungian theory.
The focus of the new, integrated theory is to blend the structure and evidence-based concepts and processes of Schema theory with the transpersonal focus and healing/integration approach of Jungian theory, to inform and research and clinical practice. This new integrated theory will provide a pathway to engage fathers in their son’s mental health treatment, and deepen and expand both fathers’ and sons’ self-awareness, as well as their relationship with each other. Teaching fathers and sons to view mental health symptoms as representations of wounded, unconscious aspects of their personality will help destigmatize mental illness and mental health treatment, and enable fathers and sons to view mental health concerns through the lens of culturally relevant, and universal, stories, rituals, characters and experiences.
Fictional Vic and his father were virtually cut-offs from one another. At times Vic felt an overwhelming desire to accommodate and please his father and tries to think of ways to make his father proud. At other times, Vic fears his father and is afraid to allow himself to get close (physically or emotionally), because he is confident that he will be hurt, disappointed, shamed or abandoned again. When Vic thinks about how his father has treated his mother and brother, he feels hated toward his father and fantasizes about retaliating against his father, for all the times his father has Vic, his mother and brother. As with most adolescent males, Vic is only partially conscious of these conflicting feelings. When Vic and his father have spent time together, Vic’s father likely senses subtle differences from day to day in Vic’s mood, attitude, and behavior, but attributes the inconsistency to Vic’s weak or manipulative or angry or oppositional nature.
Conceptualizing the Vic’s personality and behavior from the perspective of the new integrated theoretical approach provides a pathway for Vic’s father to move toward a more empathetic, compassionate, and ultimately, effective approach to identifying and addressing Vic’s needs. Understanding Vic’s personality as containing unconscious, autonomous ego-states, allows the father, and the therapist, to acknowledge that there is indeed one part of Vic that still feels a strong need to be nurtured, seen and protected by his father, while another part has been deeply wounded by the father and does not trust that the father will ever be able provide the needed nurturance and love. In an effort to protect itself and the needy dependent aspect of Vic personality, fearful of being hurt again, pushes his father away and defies the father’s wishes. Another wounded part of Vic’s personality is angry, angry at his father and also angry at and ashamed of the venerable, needy and fearful parts of his own personality.
This new integrated theory suggests that these separate parts of the adolescent can be identified, understood, approached and healed individually. The perspective allows fathers, clinicians and adolescents themselves to acknowledge the reality of the harmful, dysfunctional aspects of their personality, living alongside parts that are strong , determined, thoughtful, compassionate, industrious, etc. The theory also suggests that, if fathers can come to know and understand some of the divergent, autonomous aspects of their sons’ personality, they will feel less baffled, threatened and angered by their son’s behavior, and more likely to experience empathy, compassion and love for their son. If fathers can also be taught that they , like their sons, have wounded, fearful and angry parts that often take over and dominate their emotions and behavior, the fathers can begin to heal, as they help their son heal.
Another goal of this new integrated approach is to help clients and their fathers understand that unconscious, autonomous aspects of their personalities are often triggered by situations which touch wounded aspects of their personality, similar to how one might react when someone inadvertently touches a fresh physical injury. Clients and their fathers can eventually learn to recognize when this is happening and learn to turn attention inward to develop a working relationship with these wounded, splinter aspects of the personality. If Vic’s father can begin to think of Vic’s distance, anxiety, depression, and emotionality liability as reflexive reactions to emotional wounds being touched, he can begin to feel less threatened by Vic’s words and behavior and respond more thoughtfully and compassionately.
To help clients and their fathers understand this concept, clips from movies and television shows can be very helpful. Two examples that might be helpful for Vic and his father are provided here. These examples were chosen because they are easily accessible and understandable. The first example will likely be familiar to most adolescents and the latter will likely be familiar to most fathers. In the popular animated series, “The Avatar – The Last Airbender,” the character Zuko has frequent emotional outbursts in response to conversations or events which touch the wounds associated with his relationship with his father. Early in the series, Zuko boldly voiced his disagreement with a tribal elder in a public meeting. The elder is proposing that the tribe go to war. Zuko offers an alternative perspective. Zuko’s insubordination is seen as bringing dishonor upon his family. In response, Zuko’s father challenged Zuko to a duel . Zuko refused to fight his father, which prompted Zuko’s father to banish him, until he accomplished a seemingly impossible task. Throughout the series Zuko regularly makes very poor decisions and says and does harmful things to his mentor and friends when his father’s wound is metaphorically touched. A prime example is a scene with almost 3,000,000 views on YouTube, in which Zuko is confronted about his behavior, by his mentor Iroh (Avatar: The Last Airbender: Iroh’s Speech to Zuko).
A similar dynamic occurs in the movie “Good Will Hunting.” The protagonist, Will, was abused and abandoned by his father. His neighborhood friends are his only real family. Will is incredibly intelligent. Will works as a custodian at a prestigious science and mathematics university, and secretly solves mathematical problems on a public chalkboard with stump the faculty and graduate students at the university. Will’s mathematics abilities are discovered by a profession at MIT and Will is given the opportunity to pursue a career in mathematics. Will is torn between the safety, comfort, and familiarity of his old neighborhood and childhood friends, and this new world opens to him as a product of his amazing intellectual gifts. In the midst of all of this, Will falls in love. Will does not tell his girlfriend about the more painful aspects of his past. With her he is running , king, warm, gentle and loving. As their relationship grows, she invites him to move with her to San Francisco. During the scene Will shifts into a screaming, threatening, violent, aspect of his personality. His fear of abandonment, his inability to believe that anyone could love him if they really knew him, takes over. He in many ways shifts into the personality of the father who so wounded him. (Scene between Will and Skylar).
The scenes from “Avatar” and “Good Will Hunting” depict individuals undergoing radical personality shifts, saying things they would not normally say and doing things they would not normally do. A separate, split off, part of their personality suddenly takes over. These scenes and scenes like these, can be utilized to help fathers understand their sons’ emotional responses to painful, threatening situations. Scenes like these can be used to help fathers learn to see their sons as wounded, in need of compassion and support, rather than stubborn, obstinate, willful, weak, or anxious.
The primary strength of this theory and application is its recognition of the importance of engaging fathers in their son’s mental health treatment. Barker et al. (2017) found that father involvement during childhood and adolescence can significantly influence developmental outcomes, including reduced child psychopathology. Barker et al. (2017) found that the existing research also suggests that secure father–child attachment predicts decreased adverse child outcomes and that while parental engagement in interventions targeting child and adolescent mental health is known to improve beneficial outcomes, parenting programs generally do not successfully engage fathers. Studies consistently demonstrate that men are less likely than women to seek help in general (Kealy et al., 2020; Juvrud and Rennels, 2017), including mental health treatment (Cole and Ingram, 2020). Fathers are less likely than mothers and other female caregivers to participate in psychological treatment for children and adolescents (Cabrera et al., 2018; Clauss-Ehlers, 2017; Barker et al., 2017; Lindsay et al., 2011; Tiano and McNeil, 2005; Walters et al., 2001). Consequently, it is not surprising that fathers and other male caregivers are also less likely to engage in psychological treatment for children and adolescents.
Rather than focusing on the diagnostic categories which align with adolescent males’ mental health symptoms (e. g. depression, anxiety, oppositional behavior) in the new integrated approach, the therapist will translate diagnostic criteria into themes from stories, myths, fairy tales and movies which contain characters whose lives, behaviors, traits or personalities that mirror, or are attuned to the dynamics of the client and his father’s, personality, life circumstances, behavior patterns and relationships. The therapist will create opportunities for the client and his father to experience these stories together, and then respond, through conversation, play or creative collaboration. The stories, experiences, emotions and events which align with the client and his father’s symptoms will provide a pathway for the unconscious, autonomous, splinter aspects of the personality to emerge into consciousness.
This theory also integrates recent research findings from learning theory, information processing theory, anthropology, neuroscience, linguistics and evolutionary psychology which indicate that personality and behavior are powerfully influenced by innate , biologically based predispositions. Anderson (1995) describe advances from the marriage of connectionist cognitive models and developmental neurobiology which have established that there cannot be learning without innate neurological circuitry that is predisposed to do the learning. Cognitive theorists and researchers now agree that there are innate learning or information processing networks in the human brain that prepare and predispose individuals to learn and engage in all the patterns of behaviors which are universal and common to all cultures (Pinker, 2014). The innate, biological basis of these processing networks, provided a foundational bridge upon which to build upon which to begin to build the scientific consensus what Goldfried (2019) identifies as sorely lacking in contemporary psychology.
This new integrated theory does have several limitations which will inform and guide future research. Jungian theory has not been extensively applied to children and adolescents. It is typically considered a psychology of adulthood (Green, 2011). While there are studies which support the efficacy of Jungian therapy with adults (Roesler, 2013), when compared to the literature supporting the efficacy of cognitive approaches in general, and schema theory in particular, the literature supporting Jungian theory is quite limited. A related limitation is that this new integrated theory proposes that Jungian theory and schema theory assume and work with identical psychological processes, research is needed to validate this relationship. Early Maladaptive Schemas (EMS), schema modes and the standard means of assessment for schema have been validated by multiple studies (Van Vlierberghe et al., 2018; Jacobs et al., 2019). Archetypes and complexes do not have equivalent research-based validation, but the archetypal themes discussed in this dissertation are ubiquitous in religious, mythological, folk and contemporary stories. Research which establishes alignment between EMS with archetypal themes will be useful in clinical practice.
This integrated theory also proposes reframing DSM-5 diagnostic categories to align early maladaptive schema and schema modes with archetypal themes utilized in Jungian theory and found in contemporary / familiar stories, novels, movies and television shows, as well as myths, fairy tales and religious stories, in order to destigmatized current mental diagnostic labels which are influenced by a medical model. Mackenzie et al. (2014) propose that the trend to “medicalize” mental health diagnoses, in the hope of destigmatizing mental illness, has actually had the opposite effect, contributing to the decrease in literacy about and utilization of outpatient therapy. Research is needed to align symptoms associated with schema modes and complexes with DSM-5 diagnostic criteria. Similarly, the process of identifying archetypal themes, practices, and characters in the ever-evolving world of contemporary media will be an ongoing process for researchers, clinicians and clients, was well as the development and improvement of educational materials for this population.
Adolescence, by definition, is a difficult time for families. During this chaotic time, parents frequently struggle to understand and effectively communicate with the adolescents in their lives, which can result in volatility, emotional distance and isolation, for the parents and the teen. Within the context of this challenging time for adolescents and their families, depression, anxiety problems and behavioral/conduct problems are common among adolescents. In contrast to the increased prevalence of anxiety and behavioral/conduct disorders, mental health services are underutilized among adolescents in the United States, particularly among boys (DuPont-Reyes et al., 2019). While multiple studies indicate that paternal participation in mental health treatment for children and adolescents is associated with positive treatment outcomes, fathers are less likely than mothers and other female caregivers to participate in psychological treatment for children and adolescents (Lindsay et al., 2011; Tiano and McNeil, 2005; Walters et al., 2001).
While cognitive theory has informed a rich and diverse body of research on adolescent development and adolescent mental diagnosis and treatment, neither cognitive theory, nor any other theoretical approach has not produced an effective model for engaging fathers in their son’s mental health treatment. The integrated theory proposed in this dissertation aspires to provide a theoretical scaffold for future research and program development for engaging fathers in adolescent male mental health treatment.
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