Cross-posted to LessWrong.

Summary

  • The psychotherapy school Internal Family Systems (IFS) is popular among effective altruists and rationalists. Many view IFS as the only therapy school that recognizes that our psyche has multiple ‘parts’.
  • As an alternative perspective, we describe comparatively evidence-based therapy approaches that work with such ‘inner multiplicity’ in skillful ways:
    • Compassion-Focused Therapy, which incorporates insights from many disciplines, including neuroscience and evolutionary psychology.
    • Schema Therapy, which integrates concepts from cognitive behavioral therapy (CBT) and psychodynamic approaches, among others.
    • Chairwork, the oldest psychotherapy technique used for working with the minds’ multiple parts and which inspired IFS.
  • This post may be especially relevant for people interested in ‘internal multiplicity’ and those seeking therapy but who have had disappointing experiences with CBT and/or IFS or are otherwise put off by these approaches.

Introduction

The psychotherapy school Internal Family Systems (IFS) is based on the idea that our minds have multiple parts. IFS therapy focuses on enabling these parts to “communicate” with each other so that inner conflicts can be resolved and reintegration can take place. For brevity’s sake, we won’t discuss IFS in detail here. We recommend this post for an in-depth introduction.

What is ‘inner multiplicity’?

By ‘multiple parts’ or ‘inner multiplicity’, we don’t mean to suggest that the human psyche comprises multiple conscious agents—though IFS sometimes comes close to suggesting that. By ‘parts’, we mean something like clusters of beliefs, emotions and motivations, characterized by a (somewhat) coherent voice or perspective. Many forms of self-criticism, for instance, could be described as a dominant part of oneself berating another part that feels inferior. Different parts can also get activated at different times. Most people behave and feel differently during a job interview than with their closest friends.[1] 

This idea is shared by many theorists of various schools, often using different terminology. Examples include ‘sub-personalities’ (Rowan, 1990), ‘social mentalities’ (Gilbert, 2000), and ‘selves’ (Fadiman & Gruber, 2020).[2] Not only new-agey softies espouse this perspective. The related concept of a modular mind is shared by unsentimental evolutionary psychologists (e.g., Kurzban & Aktipis, 2007; Tooby & Cosmides, 1992).

In any case, this is a complex topic about which much more could be written. For a detailed “gears-level model” of inner multiplicity (and for why working with parts can be helpful), see Kaj Sotala’s Multiagent Models of Mind.

IFS is very popular among EAs and especially rationalists. If you were to only read LessWrong and the EA forum, you might think that there are only two therapy schools: IFS and cognitive behavioral therapy (CBT).

IFS has its own LessWrong Wiki entry. Searching for “internal family systems” on LessWrong yields many more results than any other therapy, besides CBT. IFS is even credited with inspiring influential CFAR techniques like Internal Double Crux. Most of Ewelina’s clients (Ewelina is a psychotherapist mostly working with EAs) know and respect IFS; few have heard of other therapy schools besides CBT, IFS or perhaps traditional psychodynamic approaches. Some EAs even believe that IFS can “revolutionize” psychotherapy.

IFS is often regarded as superior to standard psychotherapy, i.e., cognitive behavioral therapy (CBT), mainly for two reasons. First, while CBT is viewed as treating the psyche as unitary, IFS acknowledges that we have multiple parts. Secondly, IFS treats all parts with empathy and understanding, even if they are irrational or problematic, which ultimately allows them to become integrated. In contrast, CBT is seen as taking the side of rational, analytical parts in order to shut down irrational emotions and thoughts which (if done incorrectly) doesn’t work and might even backfire.

Other therapy approaches emphasize inner multiplicity as well

Overall, we agree that these two criticisms of (many forms of) CBT are mostly accurate and that IFS can offer advantages in both areas. However, there exist several other psychotherapy schools besides IFS which i) emphasize the importance of working with one’s multiple parts (or: “parts work”) and which ii) treat these parts with empathy and understanding, rather than attempting to shut them down with force.[3] 

Making these approaches more widely known is the main reason we wrote this post. Finding a good IFS therapist can be difficult, especially in Europe. It’d thus be unfortunate if people limited themselves to IFS practitioners in the mistaken belief that this is the only way of finding therapists who skillfully work with inner multiplicity.

Another reason for writing this post is that IFS can be off-putting to some: it can give off a new-agey vibe, is somewhat disconnected from academic, evidence-based psychotherapy research, and certain concepts like the “True Self” are implausible. As long as working with inner multiplicity and IFS are viewed as one and the same, people who don’t like IFS will inevitably be skeptical of parts work. This is a pity because we believe that such work can be very helpful.

Generally, people are drawn to the aesthetics of different therapies for a variety of reasons. We hope that at least some readers benefit from the therapy approaches described below. Note that we picked the three approaches we like and studied the most; this is not an exhaustive list of all therapy schools working with inner multiplicity.

Compassion-focused therapy

Developed by Paul Gilbert,[4] compassion-focused therapy (CFT) views the human mind through an evolutionary lens, as being formed of multiple, often conflicting, emotional, motivational, and cognitive systems. CFT groups these systems into three different clusters, depending on their primary evolutionary function: i) threat/protection, and ii) drive/seeking/acquisition, both associated with the sympathetic nervous system, and iii) rest/soothing/attachment, associated with the parasympathetic nervous system (Bell et al., 2021).

One important goal of CFT is to balance these three systems, usually by strengthening the rest/soothing/attachment system. Spending too much time in the threat system (e.g., ruminating, feeling anxious) or the drive system (e.g., working hard), and not enough time in the rest/soothing/attachment system seems to contribute to exhaustion and fatigue (e.g., Maslach et al., 2001, p. 411[5]; Russell, 2015, ch. 5).[6] Overstimulation of the threat or drive system can also make one feel threatened or rushed, which makes it difficult to feel empathy, think creatively, act rationally or make good judgments.

Our evolutionary origins, self-deception, and compassion

CFT focuses on developing a thorough understanding of our brain’s evolutionary origins and how they have made us vulnerable to (self-)destructive behaviors, thoughts and emotions. CFT emphasizes that they are not our fault. We didn’t choose to design our minds such that they regularly feel jealousy or envy, for instance. It thus makes little sense to feel shame, guilt and criticize ourselves for parts[7] of our mind we didn’t create in the first place (Bell et al., 2020; Kolts, 2016). Instead, we want to cultivate (self-)compassion.

This attitude makes it easier to acknowledge and clearly see our “dark sides”, rather than engage in self-deception and rationalize our actions by invoking purely benevolent motives, even to ourselves.[8] According to CFT, we have a responsibility to carefully examine our real motives and strengthen our compassionate and prosocial inclinations.

CFT in practice

CFT utilizes insights and techniques from a wide variety of disciplines and therapy schools. Working with one’s multiple parts plays a central role in CFT.[9] To this end, chairwork in its numerous forms, described in more detail below, is used frequently, but whiteboard exercises can be incorporated as well (Bell et al., 2020; 2021).

CFT expands on ‘parts work’ by introducing the notion of a ‘compassionate self’ which is developed and cultivated via various techniques throughout therapy. This ‘compassionate self’ is “used as a ‘secure’ base from which to engage with, and integrate, various other parts [...] that can become segregated and disowned” (Bell et al., 2020, p. 2).[10]

In addition, CFT employs standard cognitive behavioral techniques, more emotions-focused techniques (e.g., expressive letter writing), as well as “meditational practices, guided imagery, body-focused exercises, and method-acting techniques” (Bell et al., 2021), to name just a subset.

Is CFT the right fit for you?

CFT emphasizes the evolutionary origins of our minds more than probably any other psychotherapy school. Consequently, CFT has a less panglossian view of human nature, especially compared to therapy schools emerging from humanistic psychology. (After all, natural selection is all about maximizing inclusive genetic fitness, not benevolence.) Likewise, CFT views many of our unhelpful tendencies and problems as at least partly resulting from our evolutionary past. In contrast, most other therapies see mental health problems as almost exclusively arising from distressing experiences in our lives and (early) development, at least in practice.

If the above doesn’t sound too dark or otherwise mistaken, and you like evolutionary psychology, neuroscience, and are not allergic to secular Buddhism, CFT might be for you. CFT also places great importance on compassion and helping others, which plausibly makes it a good fit for effective altruists. CFT appears to be helpful in alleviating various mental health problems (e.g., Craig et al., 2020) but might be especially effective if you struggle with guilt, shame, and/or self-criticism (Leaviss & Uttley, 2015).

If you want to read more on CFT, we recommend the overview paper by Gilbert (2019). See Gilbert & Simos (2022) for a more in-depth resource, aimed at clinicians.

Schema therapy

Schema therapy (ST) was developed by Jeffrey Young in the 1980s. According to schema therapy, we all share certain needs, such as the need for safety, competence, or belonging.[11] If certain needs are not met, corresponding maladaptive schemas are at risk of developing. Maladaptive schemas are pervasive patterns of thought and emotion regarding oneself and others, causing substantial distress, and are usually developed early in life (Young et al., 2003).[12] 

For example, early experiences with perfectionistic and demanding parents, peers, or teachers whose affection is mostly conditional on achieving high performance might give rise to the ‘unrelenting standards’ schema, characterized by deriving one’s self-worth from meeting overly demanding standards which can result in a sense of inadequacy, frequent feelings of stress and time pressure, difficulty relaxing, being competitive and overly critical of oneself and others.

Schema therapists distinguish between more than a dozen distinct types of maladaptive schemas. See Rafaeli et al. (2011, p. 19 to 28) for a full list. (In our view, any such list is somewhat arbitrary.)

Modes

In schema therapy, one's parts or selves are called ‘modes’. “Modes refer to the predominant emotional state, schemas, and coping reactions that are active for an individual at a particular time.” (Rafaeli et al., 2011, p. 47). Modes are transient states, in contrast to schemas, which are stable traits.

There are four types of modes: child modes, coping modes, dysfunctional parent modes, and the healthy adult mode. Note that these are just broad categories. How these modes manifest exactly can be very different for each person. Schema therapists often encourage their clients to come up with their own names for their own unique constellation of modes.

Child modes include the vulnerable, angry, impulsive and happy child (more on this below). The vulnerable child mode can be seen as the “wounded core” of a person (Rafaeli et al., 2011) and is particularly important. In this mode, one feels sad, frightened, and helpless.

By default, people try to avoid experiencing overly distressing emotions, such as the inherent vulnerability of the vulnerable child mode, by engaging in, usually maladaptive, coping behaviors. When doing so, we usually inhabit three different types of coping styles—surrender, avoidance, or overcompensation—corresponding to the freeze, flight and fight response, respectively. Surrender may take the form of submissive compliance, avoidance usually involves detachment or distraction, and overcompensation may entail self-aggrandizement or perfectionistic striving. Coping modes often have been adaptive in the past but usually tend to become inflexible and maladaptive.

Dysfunctional parent modes take the form of inner critics that denigrate or belittle one when not meeting almost impossible standards. They can originate from having internalized criticism, punishment or abuse by one’s parents, peers, or other role models—including of society at large (the term ‘parent mode’ can therefore be misleading.) These modes’ voices can be cruel and leave one feeling worthless and useless.

A core aim of schema therapy is to empower two adaptive modes: The Healthy Adult and the Happy Child mode. One inhabits the Healthy Adult mode when one feels confident, capable, balanced, and compassionate. Its functions include meeting needs and responsibilities, and handling conflicts between different parts. In the Happy Child mode, one feels care-free, curious and joyful. Regularly inhabiting this mode is relaxing and restorative.

Schema therapy in practice

In schema therapy, like in CFT, chairwork (explained below) in its various forms is used frequently to work with one’s multiple parts, aka modes.

For those interested, this section in the appendix describes in more detail how schema therapy works in practice, as well as its similarities with IFS and coherence therapy.

Is schema therapy the right fit for you?

Compared to CFT and IFS, schema therapy is arguably most similar to traditional CBT. In fact, Young developed schema therapy in collaboration with Aaron Beck, the father of CBT (Rafaeli et al., 2014). But schema therapy also has much in common with psychoanalytic approaches—e.g., its comparative emphasis on childhood experiences—and attachment theory. If you are put off by that, Schema therapy might not be for you. Schema therapy is well-established within academia and supported by a larger amount of empirical evidence (e.g., Masley et al., 2012), at least compared to IFS and, to a lesser extent, compassion-focused therapy (cf. the section on CFT).

If you want to learn more, Rafaeli et al. (2014) provides a short overview on how schema therapy works with modes. See Arntz & Jacob (2017) for a book-length treatment (aimed at clinicians).

Chairwork

Chairwork is not a therapy school but a technique that works with one’s multiple parts. It was chairwork that introduced Richard Schwartz, the founder of IFS, to the idea of having “inner conversations” with one’s multiple parts (Schwartz & Sweezy, 2019).

There are many forms of chairwork (Pugh, 2019, ch. 3-5). In multi-chair techniques, the client is asked to sit in and speak from two or more chairs representing different parts, to allow these parts to communicate with each other. In chair one the client might speak as her internal critic, in chair two as her vulnerable side, and in chair three as her “wise and rational part”. In the empty-chair technique, the client speaks to a part of herself (e.g., her inner critic) imagined sitting in an empty chair.

The term “chairwork” is potentially misleading because there is nothing magical about chairs. Instead of an empty chair, for instance, you could use a puppet or a drawing. The essential ingredients of “chairwork” are not chairs, but rather i) self-multiplicity, ii) personification and embodiment, iii) and dialogue (Pugh, 2018, 2019). A more descriptive name might be “animating and disentangling one’s multiple self-aspects via personification or embodiment, thereby stimulating their interaction, enabling internal dialogue and transforming conflict into integration”-technique though that admittedly doesn’t roll off the tongue quite as smoothly.

  • Self-multiplicity means that the self is conceptualized as being composed of multiple parts, e.g., one’s vulnerable child, compassionate self, or inner critic.
  • Personification and embodiment are two different ways of “animating” these different parts. Personification refers to imagining one’s multiple parts as human-like persons (if possible). Embodiment means acting out a part of oneself. For example, the client might be invited to switch chairs and speak and act as though she was the inner critic herself. Personification and embodiment can help accessing one’s parts and clarify their relationships with each other, among other things. Externalizing distressing thoughts and emotions in this way can also facilitate more rational, reflective processing.
  • Behavioral, cognitive, and emotional changes are more likely to occur if different parts can enter into a dialogue and communicate with each other. This can help to resolve internal conflicts and enables different parts to start “working together”.[13]

Like with most specific psychotherapy interventions, there is limited research on the effectiveness of chair work. However, there is preliminary evidence that chairwork decreases mental health problems such as anxiety, depression, and self-criticism as, or possibly more, effectively than other conventional techniques. (e.g.; Stiegler et al., 2017; de Oliveira et al., 2012; Shahar et al., 2012). For an overview, see Pugh (2017, p. 13-18).

Which therapy schools use chairwork?

Several modern schools have incorporated chairwork as a therapeutic technique (e.g., Kellog, 2012; Pugh, 2019, ch. 2). However, most “standard” CBT therapists rarely use chairwork in their practice (Pugh et al., 2021). Therefore, if you are particularly interested in “parts work”, going to a standard CBT therapist is probably not the best option. As mentioned, Chairwork is especially common in compassion-focused and schema therapy.

Other therapy modalities

Since the ~1980s, working with inner multiplicity has become increasingly common among many therapy approaches.[14] Prominent examples include Dialectical Behavior Therapy (DBT) which distinguishes emotional, rational, and wise mindsets (Linehan, 2014, ch. 7), Acceptance and Commitment Therapy (ACT), which recognises three dimensions of the self: the conceptualized self, the knowing self, and the observing self (Zettle, 2016), Voice Dialogue Therapy (1970s) which describes multiple selves as ”discrete units of consciousness and ways of being, which possesses a will, emotional spectrum and worldview of its own” (Berchik, Rock, Friedman, 2016), and Mindfulness-based cognitive therapy (MBCT) which also emphasizes working with inner multiplicity; a guiding principle of one of MBCT’s founders, John Teasdale, was: “We don’t have one mind, but many” (Teasdale, 1997).

Acknowledgements

We thank Amber Dawn, Kaj Sotala, and Damon Pourtahmaseb-Sasi for helpful comments.

Appendix

Schema therapy and its similarities with IFS and coherence therapy

Rafaeli et al. (2014, emphasis ours) describes some important principles of working with modes, much of which seems reminiscent of “parts work” in IFS (note that there is more to Schema therapy than mode work even though mode work is quite essential):

In collaboration with the client, the therapist labels [various] modes, explores their origin, and links them to current problems. [...] A unique aspect of ST is its emphasis on deliberately inviting or activating all of a client’s modes, including the maladaptive ones, in session. Schema therapists seek to give voice to various modes, to differentiate them, and to use experiential techniques to set up deliberate interactions between these normally dissociated self-states. This “hot” emotional activation of the client’s neural and cognitive circuitry is seen as essential for affecting change for deeply rooted, long-standing problems.

Noticeably, Rafaeli et al. (2014) explicitly describe similarities between ST and structural (family) therapy:

We use the metaphor of structural therapy here, as it emphasizes the idea that in ST, we view the person as a system, comprising multiple and mutually interacting modes. Our aim is to change the way these parts work together. In broad terms, this requires three key processes: clarifying what the modes are; giving voice to adaptive and vulnerable modes; and creating adaptive boundaries between the modes. One technique often used in ST to facilitate all three of these processes is chairwork (Kellogg, 2004), and in particular, two-chair dialogues [...] but ST mode work may at times involve three, four, or even more chairs.

The following dynamic described by Rafaeli et al. (2014) parallels IFS explanations of how “exiles” (corresponding to child modes) can be suppressed by “firefighters” or “protectors” (corresponding to coping modes):

Among many clients, even those with ample reasons for hurt or angry feelings, the Vulnerable and Angry Child modes often sound very muffled or cannot be heard at all. These modes hold most of the client’s distress and negative affect, but are often buffered or obscured by coping modes, or overpowered by internalized parental modes.

Interestingly enough, some prominent coping modes in schema therapy have names like “Detached Protector” or “Avoidant Protector”. 

Schema therapy’s approach to healing the vulnerable child mode also seems similar to how IFS (or coherence therapy) approach “healing” exiles and traumatic memories, respectively. All three approaches posit that one needs to stop pushing traumatic memories / our vulnerabilities away and in fact experience and activate distressing memories first, then nurture and sooth them/present them with disconfirming evidence in a compassionate manner, in order to integrate/reconsolidate them.

From Rafaeli et al. (2014, emphasis ours):

The [vulnerable child] mode [...] can often be triggered in an adult’s life. “Triggers” are situations that bear varying degrees of similarity to the originating experience (e.g., aversive or ambiguous interpersonal interactions). When these situations occur, clients essentially reexperience an earlier trauma [...and] concomitant distress (e.g., fear, shame, loneliness). Typically, the client is not aware that the distress is linked to earlier experiences [...] ST aims to help clients make their VC mode present and visible, allow it to receive care (at first, from the therapists themselves), and, over time, learn how to internalize and generalize this care. This process, in which therapists identify and partially gratify the unmet needs of the VC, is the central therapeutic stance within ST, and is referred to as limited Reparenting.

Importantly, the nurturance of the Vulnerable Child mode, and the access to the mode that it requires, are often quite difficult to achieve. The experiences of vulnerability and distress that are inherent to this mode are painful and patients often expend great effort to avoid or combat the mode. Most commonly, the patient would engage in some coping behaviors to escape the mode. Ironically, these maladaptive coping efforts and reactions only increase and prolong the distress. The schema therapist's role is to gently encourage the patient to accept, and participate in, a counterintuitive process of recognizing and experiencing the vulnerability rather than pushing it away. If the vulnerability is kept hidden or obscured, no such process can take place [...]. If it is allowed to come to the surface, the slow process of addressing it can occur.

References

Arntz, A., & Jacob, G. (2017). Schema therapy in practice: An introductory guide to the schema mode approach. John Wiley & Sons.

Bell, T., Montague, J., Elander, J., & Gilbert, P. (2020). “Suddenly you are King Solomon”: Multiplicity, transformation and integration in compassion focused therapy chairwork. Journal of Psychotherapy Integration.

Bell, T., Montague, J., Elander, J., & Gilbert, P. (2021). Multiple emotions, multiple selves: compassion focused therapy chairwork. the Cognitive Behaviour Therapist, 14.

Berchik, Z. E., Rock, A. J., & Friedman, H. (2016). Allow me to introduce my selves: An introduction to and phenomenological study of voice dialogue therapy. Journal of Transpersonal Psychology, 48(1).

Craig, C., Hiskey, S., & Spector, A. (2020). Compassion focused therapy: a systematic review of its effectiveness and acceptability in clinical populations. Expert review of neurotherapeutics, 20(4), 385-400.

de Oliveira, I. R., Hemmany, C., Powell, V. B., Bonfim, T. D., Duran, É. P., Novais, N., ... & Cesnik, J. A. (2012). Trial-based psychotherapy and the efficacy of trial-based thought record in changing unhelpful core beliefs and reducing self-criticism. CNS spectrums, 17(1), 16-23.

Dimaggio, G., & Stiles, W. B. (2007). Psychotherapy in light of internal multiplicity. Journal of clinical psychology, 63(2), 119-127.

Gilbert, P. (2000). Internal ‘social’conflict and the role of inner warmth and compassion in cognitive therapy. Genes on the couch: Explorations in evolutionary psychotherapy, 118-150.

Gilbert, P. (2005). Social mentalities: A biopsychosocial and evolutionary reflection on social relationships. In M. Baldwin (Ed.), Interpersonal cognition (pp. 299–333). New York, NY: Guilford.

Gilbert, P. (2010). Compassion focused therapy: Distinctive features. Routledge.

Gilbert, P. (2014). The origins and nature of compassion focused therapy. British Journal of Clinical Psychology, 53(1), 6–41.

Gilbert, P. (2019). Psychotherapy for the 21st century: An integrative, evolutionary, contextual, biopsychosocial approach. Psychology and Psychotherapy: Theory, Research, and Practice, 92(2), 164-189.

Gilbert, P., & Simos, G. (2022). Compassion Focused Therapy: Clinical Practice and Applications. Routledge.

Kellogg, S. (2012). Using chairwork dialogues in schema therapy. The Wiley-Blackwell handbook of schema therapy: Theory, research, and practice, 197-207.

Kolts, R. L. (2016). CFT made simple: A clinician's guide to practicing compassion-focused therapy. New Harbinger Publications.

Kurzban, R., & Athena Aktipis, C. (2007). Modularity and the social mind: Are psychologists too self-ish?. Personality and Social Psychology Review, 11(2), 131-149.

Leaviss, J., & Uttley, L. (2015). Psychotherapeutic benefits of compassion-focused therapy: An early systematic review. Psychological medicine, 45(5), 927-945.

Linehan, M. (2014). DBT Skills training manual. Guilford Publications.

Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual review of psychology, 52(1), 397-422.

Masley, S. A., Gillanders, D. T., Simpson, S. G., & Taylor, M. A. (2012). A systematic review of the evidence base for schema therapy. Cognitive behaviour therapy, 41(3), 185-202.

Pugh, M., Bell, T., Waller, G., & Petrova, E. (2021). Attitudes and applications of chairwork amongst CBT therapists: a preliminary survey. The Cognitive Behaviour Therapist, 14.

Pugh, M. (2017). Chairwork in cognitive behavioural therapy: A narrative review. Cognitive Therapy and Research, 41(1), 16-30.

Pugh, M. (2018). Cognitive behavioural chairwork. International Journal of Cognitive Therapy, 11, 100–116.

​​Pugh, M. (2019). Cognitive behavioural chairwork: Distinctive features. Routledge.

Rafaeli, E., Bernstein, D. P., & Young, J. (2011). Schema therapy: Distinctive features. New York: Routledge.

Rafaeli, E., Maurer, O., & Thoma, N. C. (2014). Working with modes in schema therapy. Working with emotion in cognitive behavioral therapy: Techniques for clinical practice, 263-287.

Rowan, J. (1990). Subpersonalities: The people inside us. London: Routledge.

Russell, B. (2015). The conquest of happiness. Routledge.

Schwartz, R. C., & Sweezy, M. (2019). Internal family systems therapy. Guilford Publications.

Shahar, B., Carlin, E. R., Engle, D. E., Hegde, J., Szepsenwol, O., & Arkowitz, H. (2012). A pilot investigation of emotion-focused two-chair dialogue intervention for self-criticism. Clinical Psychology & Psychotherapy, 19(6), 496-507.

Stiegler, J., Molde, H., and Schanche, E. (2017). Does an emotion-focused two-chair dialogue add to the therapeutic effect of the empathic attunement to affect? Clinical Psychology and Psychotherapy, 25, 86-95.

Teasdale, J. D. (1997). The relationship between cognition and emotion: The mind-in-place in mood disorders. In D. M. Clark & C. G. Fairburn (Eds.), Science and practice of cognitive behaviour therapy (pp. 67–94). Oxford, UK: Oxford University Press.

Tooby, J., & Cosmides, L. (1992). The psychological foundations of culture. In J. Barkow, L. Cosmides, & J. Tooby (Eds.), The adapted mind: Evolutionary psychology and the generation of culture (pp. 19–136). Oxford University Press.

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. New York: Guilford Press.

Zettle, R. D. (2016). The self in acceptance and commitment therapy. The Self in Understanding and Treating Psychological Disorders. (Section 2, ch. 6). Cambridge University Press.

 

  1. ^

     Generally, people differ in the degree to which they experience such inner multiplicity. On the one end of the spectrum, there might be people who almost never experience psychic multiplicity, on the other end you could have people with full-blown dissociative identity disorder.

  2. ^

     See Dimaggio & Stiles (2007) for a non-comprehensive overview.

  3. ^

     One example out of many is Psychotherapy in Light of Internal Multiplicity, in which Dimaggio & Stiles (2007) argue that it’s crucial to treat one’s different parts with empathy and understanding: “As respect and empathy are offered to each voice individually, conflicting internal voices can hear and begin to understand each other, a crucial step toward developing internal meaning bridges. [...] Accurate empathy can thus be understood as facilitating conversation and hence mutual understanding among the client’s internal voices.”

  4. ^

     See Gilbert (2014) for more details about the origins and nature of compassion focused therapy.

  5. ^

     The paper by Maslach et al. (2001) is about burnout. But exhaustion is one of the core symptoms of burnout.

  6. ^

     As an aside, many individuals seem to have the impression that such feelings of exhaustion and fatigue have exclusively non-psychological origins. At least this has been the case for David and several of Ewelina’ clients. Of course, exhaustion and fatigue can have non-psychological origins. In fact, they are, as most things, often the result of a combination of mutually reinforcing factors. Last, it’s not always easy to neatly separate psychological and physiological factors. For example, psychological factors can alter the function of one’s immune system, and sickness can change one’s mood and cognition.

  7. ^

     Of course, some amount of guilt or shame can be adaptive and might help to prevent us from committing immoral actions. E.g., feeling ashamed of murderous thoughts helps to keep such impulses in check. Stalin, for instance, could have certainly benefited from feeling more guilt. (See also the next footnote.) But overall, most people who seek therapy because of depression, anxiety and self-criticism probably experience too much guilt and shame, for their own good and that of the world at large. (Thanks to Kaj Sotala for raising this point.)

  8. ^

     A complete inability to admit to anything less than purely benevolent motives is probably most common among narcissists. It’s certainly possible that some of the most malevolent individuals in history actually believed that they were perfectly altruistic heros.

  9. ^

     See also this quote by Gilbert (2010, ch. 4): “[..] we are not an integrated coherent whole self, but are rather made up of a variety of motives and competencies that combine and interact in complex ways. [...] This turns us to the question of [...] what enables us to open up and explore new potentials within us and integrate them into our sense of self [...]. One answer is compassion, because compassion creates conditions that facilitate openness, caring, safeness and integration.”

  10. ^

     The 'compassionate self' could be viewed as a parent providing a secure base for a child’s development (cf. attachment theory). Bell et al. (2020, p. 2) continue: “[...T]he use of compassion to create a sense of safeness and a capacity for inner exploration and coordination links closely to the role of attachment in creating the neurobiological and emotional context for mentalization, mental integration and pro-sociality [...]”.

  11. ^

     Of course, people differ in the strength of certain needs.

  12. ^

      We like this quote by Rafaeli et al. (2011, p. 17): “Schemas are cognitive-affective traits, and as such, are dimensional: each exists on a continuum ranging in severity and pervasiveness.”

  13. ^

     Pugh (2019, ch. 8) lists several more reasons for the effectiveness of such dialogue: “Firstly, ‘speaking to’ one’s distressing thoughts and feelings is considerably more evocative than merely ‘speaking about’ these experiences, thus enabling more productive cognitive-affective modification [...]. Secondly, speaking from the perspective of self-parts promotes ownership of these experiences: when individuals enact distressing intrapersonal events through chairwork (e.g. self-criticism), they recognise these processes are said and done to oneself (e.g. self-to-self-criticism) [...]. Thirdly, speaking from the perspective of dysfunctional thoughts and feelings allows therapists to assess both the content and the tone of these experiences. In doing so, parallels with other (external) voices are established (Therapist: “Did speaking as your inner critic remind you of anyone in your life?”). Finally, dialogue by its very nature assumes a plurality of perspectives (Perls, 1969), thus challenging singular explanations and responses to events (Therapist: “Although you believe this negative thought a great deal, does any part of you view this situation differently? Can you change seats and speak from that perspective?”).”

    Similarly, Dimaggio & Stiles (2007) write: “Problems seem to arise not because the self has many parts but because communication between the parts is poor. [...] when there is no dialogue of the various parts of the self, behavior may seem incoherent. Individuals may swing between anger aimed at getting their way, guilt feelings at the idea of harming others, and the idea of not deserving anything. As the positions shift, their actions also change, with the result that none of them is pursued long enough to be effective.”

  14. ^

     In the 1980s, various CBT-related psychotherapy schools emerged, often referred to as the “third wave” of cognitive therapy. These approaches tend to share two core principles: i) the importance of non-judgmental acceptance and metacognitive awareness (being aware of one’s thoughts and emotions and learning to accept them while not “getting lost” in them) and ii) a growing emphasis on (various forms of) inner multiplicity. (Cf. Pugh, 2019, ch. 2).

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Good point that CFT is a more science-grounded alternative to IFS. Tim LeBon is a therapist in the UK who has seen community members, does remote sessions, and offers CFT.

Thanks to both of you for writing this! Very valuable resource to have on hand, and a great review of different aspects of therapeutic modes of thought/self-help processes.

Strong upvote! Thank you for making these important distinctions. 

Here is an add-on from effectiveness research.
Some studies show that approaches integrating different types of techniques might be more effective than approaches using just one type, such as just CBT or just inner parts work. This makes sense if it is true that different individuals at different times in different situations benefit most from different methods. 
These are exemplary meta-analyses:
 
* Integrative approaches even can help with very difficult problems and cases: such as Dialectical Behavioral Therapy and schema therapy can help people with Borderline Personality tendencies (Cristiea et. al, 2017); Mindfulness-based approaches can help with treatment-resistant depression (Chen, et. al, 2021).
* Integrating different evidence-based methods might work a little better in coaching for improving wellbeing (Wang et. al, 2021).
* Transdiagnostic (mostly also integrative) treatment approaches such as ACT or mindfulness-based treatments  might work a little better for reducing depression than disorder-specific CBT (Newby, 2015)

Personal note: What might limit the effectiveness of IFS is the lack of evidence-based structure offered for separating the parts in a meaningful and helpful way. Both the approaches explained in this article do this well, drawing from what we already know from science about how the human mind works.
 

Thanks, Inga! 


Some studies show that approaches integrating different types of techniques might be more effective than approaches using just one type


Yeah, a major reason why I like CFT and ST is that they are highly integrative therapies that use many different types of techniques and insights adapted from other therapies or disciplines (e.g., CBT, attachment theory, Gestalt therapy, evolutionary psychology, neuroscience, meditation, etc.).

What evidence is there that any of these are more effective than CBT? If they are better, why haven't they been more widely adopted by mainstream medicine?

First of all, I’d say that schema therapy (ST) and CFT ( to some extent) are part of the mainstream. (It’s  fair to say that IFS is not part of mainstream medicine. This is also a major reason for why we wrote this post: To introduce readers to more “mainstream” therapy approaches that work with inner multiplicity.) 

  • You can find dozens of articles about CFT and ST published in mainstream psychology and psychotherapy journals, often with hundreds of citations.
  • CFT and ST are taught in many CBT schools. For example, Ewelina learned about these CFT and ST in her 4-year CBT training (accredited by The European Association for Behavioural and Cognitive Therapies, probably the largest and most mainstream CBT organization in Europe). 
  • As we write in the post, schema therapy was developed by a CBT therapist (Young) in close collaboration with Aaron Beck, the founder of CBT (see also Beck’s review of this standard ST book). Paul Gilbert, the founder of CFT, also collaborated with Aaron Beck who was supportive of his work

Generally, there isn’t a “clash” between ST, CBT and CFT and many other often called “third-wave” CBT schools (like, e.g., ACT and DBT). ~No expert in this area thinks that CBT is the only therapy school that is “evidence-based” and that there is no reason to explore or work with other therapy modalities.

My sense is that most CBT scholars respect CFT and ST and other CBT-affiliated schools and view them as complimentary (more on this below). It’s very common that major CBT figures recommend CFT and ST and incorporate techniques from these (and other!) schools. Just as an example, Judith Beck, the daughter of Aaron Beck and perhaps one of the most respected and well-known living CBT therapists had this to say about the standard CFT book for clinicians: 

This excellent and comprehensive volume contains a biopsychosocial model, informed by evolutionary theory. It is an important resource, systematically exploring compassion from many vantage points. It has certainly motivated me to put an increased focus on incorporating principles of compassion-focused therapy into my cognitive behavior therapy practice. I highly recommend this book!

Second, as we mention in the post, there is (tentative) evidence that CFT and ST work as effectively as CBT and for certain problems more effectively. For example, ST seems to work better for personality disorders (Bamelis et al., 2014), particularly borderline personality disorder (Jacob & Arntz, 2013, p.175 -178) than standard CBT. [1]This is not too surprising because ST was developed particularly for clients with long-standing emotional problems and personality disorders, for whom CBT doesn’t seem to work so well. 

Likewise, there is tentative evidence that CFT works better for patients high on self-criticism and shame (Leaviss & Uttley, 2015). Again, this makes sense because Gilbert developed CFT when he realized that standard CBT therapy doesn’t work that well for such clients. 

Of course, the evidence base isn’t as strong as one might like (it never is). Kaj discusses some of the reasons for this.

  1. ^

    It should be mentioned that for borderline in particular, the evidence base for DBT is probably even stronger (Lynch et al., 2007); we mention DBT briefly in the last section.

This might get us off track but it’s easy to not sufficiently understand the nature and importance of interindividual variability in this area. Most effectiveness studies can only show you how effective a therapy (or drug) is for the average individual suffering from a given syndrome. (More sophisticated studies and meta analyses include moderator analyses; they might look at personality variables such as high self-criticism, personality variables, and so on. More on this below.)

This is all good and informative. If you suffer from a mental health problem, say, depression, you should just try the therapy or antidepressant that works the best for the average person. You should just go with the prior that you are like the average person (unless you have evidence to the contrary). 

However, once you tried out the first line treatment (be it a drug or a therapy) and it didn’t work for you, you can either i) give up or ii) try other treatments or drugs. I generally recommend step ii). This post was written, as mentioned in the summary, primarily for people who are interested in therapy (and inner multiplicity) but have had disappointing experiences with IFS and/or CBT. What is your advice? That they try the same approach repeatedly even if it hasn’t worked for them in the past? 

I’d like to explain in more detail how it is possible that i) most studies find that CFT, ST and CBT are comparatively effective and ii) some people might see bigger therapeutic improvements from seeing a CFT or ST therapist than from a CBT therapist—and the reverse

For the sake of illustration, let’s use a completely hypothetical and unrealistic scenario: Assume that all clients suffer from depression but only differ in two aspects: Some are high on self-criticism, some are low; some are good at mental imagery, some are poor. 50% of clients are low on self-criticism and poor at mental imagery, 25% high on self-criticism and good at mental imagery, and 25% fall in the other two categories. Researchers run a perfectly designed and administered RCT that tests the effectiveness of two different therapies on this sample: therapy A and therapy B. The results are as follows.

 Average reduction in depression score
 Low self-criticism & poor mental imagery (50%)High self-criticism & good mental imagery (25%)Remaining population (25%)Overall
Therapy A-400-2
Therapy B0-80-2

If you average across all people, therapy A and B are equally effective. They both reduce depression scores by 2 points, on average. 

A person that doesn’t know whether she is high or low on self-criticism or mental imagery, should be indifferent between the two therapies or go with the therapy that is cheaper, easier, or more widely used. BUT, if you have tried therapy A and it didn’t work for you, you should try therapy B (and vice versa). Likewise, if you know that you are high on self-criticism, you should try out therapy B, and vice versa.

Coming back to the real world. More and more studies start to include such moderator analyses (e.g., the study by Leaviss & Uttley (2015) mentioned above). However, in reality, people differ in hundreds of potentially therapy-relevant aspects, not all of which can be studied. For example, a therapist might work well for most people but doesn’t work well for committed atheists who are high on conscientiousness, low on neuroticism and extraversion, high on self-criticism, low on mental imagery, have a family history of schizophrenia and bipolar disorder, like Bayesianism, and who were bullied early in their lives. 

I think there are actually good reasons to expect such relevant interindividual differences. One can already observe them in the case of antidepressants, for example. Generally, there is enormous variability between humans in all sorts of psychological and physiological traits. A few individuals do perfectly fine with 5 hours of sleep, some need 9 or more hours (I think Bostrom and Brian Tomasik are among those). For most people, whole grain bread is probably fine and even healthy. But some have Coeliac disease. Some people swear to benefit from meditation, others claim to have suffered enormous negative consequences. The list goes on.

Of course, I’m not saying one should now totally give up on evidence-based medicine. If you start out and haven’t done a lot of self-experimentation, go with the first-line treatment and recommendations that work for the majority of people (e.g., CBT, SSRIs, 8 hours of sleep, etc.). But if a therapy, food, lifestyle choice or antidepressant isn’t working for you, take an empirical approach, and try out alternatives that might work better for you.

I acknowledge that there is a failure mode here of trusting your own experience and experiments too much and, e.g., start swearing on the effectiveness of energy crystals, tarot cards, and so on. I’d say that trying out CFT and ST (and IFS) is still far removed from this failure mode; for the reasons listed in the post and my above comment. 

To me, this post sounds like individual differences of the patient and the mode of therapy are the only key ingredients. Therapists who practice the same mode of therapy differ widely. 

If two doctors both give me Bupropion that's going to have a similar effect. If two therapists both do CBT or CFT the effectiveness will be different depending on their empathy and the relationship I have with them.

To me, this post sounds like individual differences of the patient and the mode of therapy are the only key ingredients.

We definitely did not want to suggest that. I strongly agree that the individual skills, traits and “general style” of therapists vary widely even within a single therapy school and that these variables are extremely important. Research has shown that the individual relationship between a client and a therapist (the ‘therapeutic alliance’) is one of the most important variables in predicting therapy success. (One of the reasons I like ST and CFT is the strong emphasis they put on the therapeutic alliance.)

One can probably rank therapists in terms of overall skill/empathy, and this matters perhaps even more than to which therapy school they belong to. (That being said, people vary in their preferences so there isn’t a therapist that is optimal for everyone.)

If they are better, why haven't they been more widely adopted by mainstream medicine?

Part of it is that the effectiveness of therapy is often hard and slow to study, so it's hard to get unambiguous evidence of one being better than another. E.g. many therapists, even if working within a particular school of therapy, will apply it in an idiosyncratic style that draws upon their entire life/job experience and also knowledge of any other therapy styles they might have. That makes it hard to verify the extent to which all the therapists in the study really are doing the same thing.

My impression is that CBT got popular in part because it can be administered in a relatively standardized form, making it easy to study. But that means that it's not necessarily any better than the other therapies, it's just easier to get legible-seeming evidence on.

Another issue is that therapy can often take a long time, and lots of the quantitative measures (e.g. depression questionnaires, measures of well-being) used for measuring its effects are relatively crude and imprecise and it can be hard to know exactly what one should even be measuring.

So overall it can just be relatively hard to compare the effectiveness of therapies, and particular ones get more popular more slowly, e.g. by therapist A hearing that therapist B has been doing a new thing that seems to get better results that A does and then getting curious about it. Or by word of mouth through therapy clients when a new approach is found that seems to work better than conventional therapies, as has been happening with IFS.

Why should a disinterested third party, without firsthand experience, recommend these therapies over CBT given the relative lack of evidence?

E.g. Other than those who practice them and their clients, do they have any reputable backers? Has it been shown by disinterested parties to work better on certain types of people? Is there any other source of evidence that backs the notion that they are predictably superior for at least a subset of the population?

I'm not sure if there is any reason that should be strongly persuasive to a disinterested third party, at the moment. I think the current evidence is more on the level of "anecdotally, it seems like a lot of rationalists and EAs get something out of things like IFS". 

But given that one can try out a few sessions of a therapy and see whether you seem to be getting anything out of it, that seems to be okay?  Anecdotal evidence isn't enough to strongly show that one should definitely do a particular kind of therapy. But it can be enough to elevate a therapy to the level of things that might be worth giving a shot to see if anything comes out of it.