Part 1: Theory

​Chapter 1: The Control-Mastery Theory
George Silberschatz, Ph.D.

The control-mastery theory is an integrated theory of how psychopathology develops and how psychotherapy works. According to this model, psychopathology stems from pathogenic beliefs that develop from traumatic life experiences — these may be severe, extraordinary events or ongoing stressful experiences. Pathogenic beliefs, which are usually unconscious, are extremely frightening and powerful because they suggest that the pursuit of important goals will endanger oneself or loved ones.

Patients work in psychotherapy to disconfirm pathogenic beliefs, and there are three primary ways they can do so: Patients may test pathogenic beliefs directly with the therapist, they may use the therapist's interpretations, or they may use the therapeutic relationship per se to disconfirm pathogenic beliefs.

Chapter 2: How Previously Inaccessible Experiences Become Conscious
George Silberschatz, Ph.D.

A fundamental question for psychodynamic and all uncovering therapies is how do previously warded-off thoughts, feelings, or memories become conscious? The control-mastery theory emphasizes that a person exerts considerable control over her conscious and unconscious mental life, and that perceptions of danger and safety play a central role in explaining human motivation and behavior. The theory postulates that a patient may unconsciously decide to bring previously warded-off feelings or thoughts into awareness based on the patient's appraisal of whether he feels he can do so safely. A person's assessment of safety and danger is strongly influenced by his unconscious pathogenic beliefs. Thus any experience or interaction that helps to disconfirm a pathogenic belief will increase a person's sense of safety and thereby allow him to lift defenses against warded-off feelings, ideas, and memories.

Chapter 3: The Role of Safety in Emotional Regulation
Joseph Weiss, M.D.

This chapter discusses the centrality of feelings of safety in human life and in psychotherapy. Over 50 years ago Weiss described the phenomenon of "crying at the happy ending," suggesting that people face painful emotions when they feel they can do so safely. This observation and Weiss's attempts to explain it led to several other concepts in control-mastery theory — namely, that a person has a powerful unconscious wish to solve problems and has unconscious cognitive capacities that enable problem solving. This chapter illustrates the concepts of psychological safety and danger clinically and shows their centrality to his theory of therapeutic process. The chapter concludes with observations about the role of safety in the production of sexual fantasies: specifically, people use sexual fantasies to create conditions that make it safe for them to become sexually aroused.

Chapter 4: The Role of Unconscious Guilt in Psychopathology and in Psychotherapy
Marshall Bush, Ph.D.

This chapter shows the major role of irrational unconscious guilt as a cause of psychopathology and as a central factor in understanding the psychotherapeutic process. The following topics are discussed:

  • the relation of excessive feelings of responsibility for others and the development of irrational guilt
  • unconscious pathogenic beliefs about how one has harmed loved ones and how these beliefs give rise to feelings of deserving to be punished
  • how the control-mastery understanding of guilt differs from the traditional Freudian view
  • how patients work in therapy to master problems with guilt, and how the therapist can best assist the patient in those efforts

An often overlooked but crucial type of unconscious guilt is the guilt which stems from patients' irrational beliefs about their power to hurt others (including the therapist) by pursuing their developmental strivings and life goals.

Part 2: Therapy​

Chapter 5: The Assessment of Pathogenic Beliefs
John T. Curtis, Ph.D. & George Silberschatz, Ph.D.

Psychotherapy is most effective when the therapist helps the patient disconfirm pathogenic beliefs. This chapter presents an empirically validated and clinically tested case formulation approach, termed the plan formulation method, for assessing pathogenic beliefs. The plan formulation contains five elements:

  • the patient's goals for treatment
  • obstructions that impede goal attainment
  • testing strategies that the patient is most likely to use with the therapist
  • insights that are most likely to be helpful
  • traumas most directly connected to the patient's problems

Each of these formulation elements sheds light on the origins and nature of the patient's pathogenic beliefs and provides valuable clinical information regarding how the patient is likely to work in therapy. The chapter includes a detailed clinical illustration of the plan formulation method.

Chapter 6: Successful Treatment of a Major Depression
Polly Bloomberg-Fretter, Ed.D.

A dramatic and intensive psychotherapy of a major depression is presented. The treatment was conducted as part of a research project on long-term, psychodynamic therapies for major depressive disorders. All of the assessment measures indicated that the treatment was very successful. The chapter provides a rich, detailed description of the patient and her treatment. It includes: her presenting problems and history; an integrated formulation of her early traumas, pathogenic beliefs, and goals; and how she worked in therapy to overcome her pathogenic beliefs. In addition to the therapist's case formulation, the chapter includes the patient's own formulation of her problems and pathogenic beliefs, which she completed near the end of the therapy.

Chapter 7: Treatment by Attitudes
Harold Sampson, Ph.D.

This chapter illustrates how the therapist's attitudes toward the patient may help the patient disconfirm longstanding and debilitating pathogenic beliefs. Sampson points out that all therapists inevitably convey attitudes about themselves and about their patients throughout therapy. Attitudes are conveyed by the therapist's interpretations, silences, non-interpretive interactions, and by the therapist's manner, personality, and style. They are conveyed implicitly as well as explicitly, unintentionally as well as deliberately, and unconsciously as well as consciously. Patients readily detect therapist attitudes and construe them in terms of their own particular psychology, immediate concerns, and specific pathogenic beliefs. Attitudes that disconfirm the patient's pathogenic beliefs produce internal changes in the patient's expectations, feelings, behaviors, symptoms, and self-image. Sampson argues that these changes are not simply "transference cures;" he views these as structural changes that take place gradually and incrementally over long periods of time.

Chapter 8: A Long-Term Therapy Case Illustrating Treatment by Attitude
Kathryn Pryor, Ph.D.

A skillfully conducted psychotherapy of a very traumatized patient is presented to illustrate how the therapist's stance and attitudes may disconfirm certain powerful pathogenic beliefs. The patient, a middle-aged woman with a life-long history of suffering, chronic unhappiness, and personality disorder, showed major improvement during the course of treatment. She went from an insecure, anxious attachment style to becoming more securely attached in her relationships (including the therapeutic relationship); chronic anxiety and panic states at work, to a fulfilling career; isolated and lonely, to being happily married and becoming a loving mother. In addition to manifesting attitudes that disconfirmed pathogenic beliefs, the therapist consistently passed the patient's tests and provided valuable insights that helped the patient to understand early traumatic experiences and to disconfirm the destructive beliefs connected to the traumas.

Chapter 9: How Patients Coach Their Therapists
John Bugas, Ph.D. & George Silberschatz, Ph.D.

This chapter focuses on the different ways and reasons patients coach their therapists. Throughout therapy patients are actively engaged in prompting, instructing, and educating the therapist to relevant aspects of the patient's plan for disconfirming pathogenic beliefs and attaining treatment goals. Patients may employ coaching strategies at any time during therapy. However, there are three specific occasions when coaching tends to be prominent: at the beginning of therapy; before, during, and after significant testing sequences; and when patients want to change the therapeutic relationship. These three kinds of coaching behavior are illustrated with clinical vignettes.

Part 3: Research and Integration

Chapter 10: A Developmental Basis for Control-Mastery Theory
Robert Shilkret, Ph.D. and Sara Silberschatz

Many of the important ideas in control-mastery theory are supported by research and theory from developmental psychology. One of the key developmental assumptions of the theory is that early experiences, including those during infancy, exert a strong (and generally unconscious) influence on later personality and psychopathology. Beyond this basic assumption, several other ideas in control-mastery theory also reflect important concepts from developmental psychology. The chapter is organized around four broad areas: (1) social interactions and expectations in infancy; (2) attachment theory; (3) early cognition and the development of pathogenic beliefs; and (4) pro-social behavior, empathy, and the development of guilt.

Chapter 11: An Overview of Research on Control-Mastery Theory
George Silberschatz, Ph.D.

One of the distinctive features of control-mastery theory is the extensive program of research that has been an integral part of theory development. This chapter provides an overview of 30 years of rigorous empirical studies of control-mastery theory. Emphasizing findings and results rather than methodological issues, this chapter covers research on:

  • the unconscious regulation of behavior
  • the emergence of warded-off themes in therapy
  • how therapist attitudes, behaviors, and interventions influence the therapeutic process
  • the assessment of the patient's pathogenic beliefs
  • how pathogenic beliefs are disconfirmed in therapy

These research findings provide strong scientific support for the control-mastery theory.

Chapter 12: The Control-Mastery Theory: An Integrated Cognitive-Psychodynamic-Relational Theory
George Silberschatz, Ph.D.

The control-mastery theory is a model of how psychopathology develops and how psychotherapy works. The theory was originally developed within a psychoanalytic framework but has subsequently been expanded to a wide variety of treatment modalities. The main strengths of this theory are 1) it provides a clinically useful model of how psychopathology originates and how the therapist can help the patient; 2) its central hypotheses are clearly stated and empirically testable; and 3) there is a considerable body of research supporting this theory. This chapter moves the control mastery theory beyond its psychoanalytic roots and presents it as an integrated cognitive-psychodynamic-relational theory.

Chapter Summaries

Transformative Relationships