Cognitive Therapy and Research

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

REVIEW

The Theory of Modes: Applications to Schizophrenia and Other

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

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

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

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

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generally in a withdrawn state.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

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significant signs of psychosis. Importantly, David received
a fulfilling position in a restaurant, in which his main duty
was to prepare food.
This individual’s clear and drastic shift in personality,
which resulted in a presentation of adaptive functioning, is
common. In fact, we have observed this periodic transforma-
tion in many of the severely mentally ill individuals whom
we treat in hospitals and group homes. The occurrence of
these episodes raises several questions: Is there a theoretical
framework that describes these episodes of personality shift-
ing and what are the mechanisms involved in the improve-
ment we see in individuals like David? Despite the lack of
established responses to these questions within the field
of schizophrenia research and treatment, similar episodic
shifting between depression and mania is well documented
in individuals with bipolar disorder. In addition, analogous
transient shifts have been observed in Dissociative Identity
Disorder (DID) whereby a complete change in identity is
observed during the activation of the various “alters”.
Similar types of personality transformations have been
noted through the ages, and have formed the substance of
folklore, philosophies and religious ideologies about the
self. For example, one parable propounded by the Cherokee
Indians is as follows:
“Two Wolves”: A Cherokee Legend
An old Cherokee is teaching his grandson about life.
“A fight is
going on inside me,” he said to the boy.
“It is a terrible fight and it is between two wolves. One
is evil—he is
anger, envy, sorrow, regret, greed, arrogance, self-pity,
guilt,
resentment, inferiority, lies, false pride, superiority,
and ego.” He
continued, “The other is good—his is joy, peace, love,
hope, serenity,
humility, kindness, benevolence, empathy, generosity,
truth,
compassion, and faith. The same fight is going on
inside you—and
inside every other person, too.”
The grandson thought about it for a minute and then
asked his
grandfather, “Which wolf will win?”
The old Cherokee simply replied, “The one you feed.”
It is apparent from the passage that two different states
encompass the personality but are alternately activated.
Descriptions similar to the Native American legend above
have surfaced in philosophy as well. David Hume’s Bundle
Theory of human nature explicates that any object consists
of a collection or bundle of elements (Hume 1969). This
theory has been applied to the concept of the self in that a
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Cognitive Therapy and Research
person is composed of a collection of mental states at any
given time. Per this theory, there is a waxing and waning
of these states so that as one mental state is activated, it
replaces the previously activated mental state and therefore
the self as a whole is changed (Pitson 2005).
Within the field of psychology, several theories share an
understanding of the self as multiple and distinctive ele-
ments that can be activated depending on circumstance,
culture, or identity. Alfred Adler’s early works The Prac-
tice and Theory of Individual Psychology (Adler1924) and
Understanding Human Nature (Adler 1954), described the
notion of the self as being directly related to and affected
by one’s self-image, one’s environmental surroundings, and
social interactions. Further, some humans overcompensate
for feelings of inferiority which then leads to a superiority
complex. Later relevant theories regarding the self include
E. Tory Higgins’s self-discrepancy theory (Higgins 1987),
Karen Horney’s theoretical concepts of the real self and the
ideal self (Horney 1991) and Hazel Markus’s ideas regarding
the independent self and interdependent self, and the signifi-
cance of culture in understanding these distinct identities
(Markus 1977; Markus and Kitayama 1991).
Other contemporary theorists within the field of person-
ality have also contemplated the notion of multiple selves.
Such theories include David Lester’s work on multiple self
theory of personality which postulates that each individual
self consists of intricate psychological processes includ-
ing thoughts, emotions and behaviors and details a for-
mal description of 10 postulates and 49 corollaries (Lester
2010, 2012, 2017), Robert Lifton’s concept of the Protean
Self which takes inspiration from ancient Greek mythol-
ogy (Lifton 1993), and Rita Carter’s writings of the major,
minor, and micro sub-selves, which stem from parental influ-
ence, past versions of individuals childhood self, and stereo-
typical societal roles that individuals model such as that of
a caregiver or teacher (Carter 2008). Mendlovic (2008) has
taken a psychoanalytic approach to theorizing about multiple
selves as sub-structures of the ego and traces the origin of
multiples selves to individuals’ childhood interactions with
their primary caregivers. While these theories have not been
widely applied in the clinical realm, other theories such as
Jeffrey Young’s schema theory have shown more clinical
relevance. Young’s theory incorporates the notion of indi-
viduals having multiple mental states labeled “modes” (for
example, the Vulnerable Child mode) that include cognitive
schemas and coping styles in response to these schemas.
However, these maladaptive modes are only thought to form
if an individual’s basic needs and demands in childhood are
not met (Young et al. 2006; Rafaeli et al. 2010).
Religions have also focused on the concept of the self in
similar ways. For example, the term Anatta in Buddhism
pertains to the idea of a “non-self” (Philip and Smith 2004).
Here, it is understood that a permanent or stagnant self does
Cognitive Therapy and Research
not exist but rather the self is an illusion (Carlisle 2006;
Fulton 2008). In Christianity, there are also dueling versions
of the self, namely the true and false selves. In this case,
the true self speaks to the moral, socio-centric qualities of
a person while the false self pertains to the immoral and
egocentric aspects, which are connected to the concept of
sin (Vaden 2016).
What the Cherokee legend, Hume’s philosophy, psycho-
logical theories of the self, and religious views all have in
common are their perspectives on the different aspects or
structures of the central identity of the self. We consider
that these different expressions are the result of the activa-
tion of different structures within the personality that we
label as modes. In this paper, we will define a theory of
modes, which clarifies the apparent oscillations in personal-
ity in psychopathology and non-pathological behavior. We
will also attempt to show the mechanisms responsible for
the activation and shift of the components of personality in
schizophrenia and demonstrate how the theory provides a
basis for a new psychotherapy for schizophrenia and other
disorders.
The Evolution of the Theory of Modes
The idea of modes first occurred when I (ATB) was working
with patients diagnosed with depression. It seemed that the
following observation required an explanation. I noted that
the individuals were very different when depressed and non-
depressed. Not only was there a profound shift in behavior
towards withdrawal and avoidance when individuals were
depressed, but there was also a system of corresponding
beliefs such as “Life is hopeless” in the depressive phase.
However, these maladaptive behaviors and beliefs seemed
to disappear when the depression was lifted. Another indi-
vidual compared himself quite unfavorably to other profes-
sionals in his field when depressed but tended to dismiss
these ideas as silly when the depressive symptoms were alle-
viated. The changes in the individuals between depressed
and non-depressed phases were pronounced and required
an explanation. It seemed possible that unique facets of the
personality are activated in these unique phases.
I later realized that similar dynamics occurred in cases
of anxiety in which the anxiety was largely situational. The
individual, for example, experienced anxiety in a social situ-
ation but not in a non-social situation. This seemed to war-
rant the consideration of an anxiety organization (or mode)
that was activated by anxiety-driving stimuli. These observa-
tions then led to a preliminary theory of modes that could be
extended to all of psychopathology (Beck 1996), including
a depression mode, an anxiety mode, a phobic mode, an
OCD mode, and so on. Additionally, there were valid cases
of multiple personality disorder (now labeled Dissociative
Identity Disorder (DID)) that fit the idea of modes, whereby
the “separate personalities” could be seen as an extreme rep-
resentation of the activation of different modes. The alter-
nate identities/personalities each display cognition, affect,
motivation and behavior that is unique and untethered from
the host identity/personality. Despite similarities between
the construct of modes and the presentation of DID, no arti-
cles pertaining to the concept of modes in DID were ever
published. Further refinements of the theory of modes fol-
lowed in a volume on depression (Clark and Beck 1999) and
a more recent article regarding the Generic Cognitive Model
(Beck and Haigh 2014).
The current iteration of the theory of modes and the
simultaneous development of a clinical program entitled
Recovery Oriented Cognitive Therapy (CT-R) was a result
of several observations that our schizophrenia research and
clinical team made while working with individuals living
in psychiatric hospitals or group homes in the community.
First, we noted an interesting phenomenon that was not pre-
dicted by any of the current theories of schizophrenia. As
mentioned in the above in the case of David, we observed
that individuals would make drastic, periodic shifts in their
personality from being socially withdrawn, actively psy-
chotic and aggressive to being energetic, communicative,
friendly and totally in touch with reality. Additionally, we
determined that consistently implementing certain therapeu-
tic strategies, such as providing opportunities for individuals
to engage in personalized, meaningful activities, facilitated
the shift from a state of maladaptation to adaptation, and
thus had significant positive impact on the individuals.
Throughout this discussion, we continue to focus on how
the theory of modes has been inspired by and was adapted
based on recent work with individuals diagnosed with
schizophrenia, since their shift from the maladaptive psy-
chotic and/or negative symptom mode to an adaptive mode
has yet to be holistically theorized. Additionally, the theory
of modes constitutes an essential aspect of the therapeutic
intervention for this population (CT-R). However, we begin
by introducing the basic definitional and structural concepts
within the theory of modes in order to clarify the theory
and its applications to psychopathology and non-clinical
functioning.
Definition of a Mode
We define a mode as a specific internal construction of per-
sonality. We propose that the role of the personality is adap-
tation and thus the function of the mode is to automatically
modify a person’s adaptation to a specific context. More
specifically, the mode attempts to create a fit between the
internal desires, needs, and impulses of an individual and
the external demands of the stimulus situation. Ordinarily,
13

there is a reasonable fit and the selection of a specific mode
is adaptive to the situation (for example, anxiety when there
is a real threat; anger in response to an insult; sadness in
response to a loss; or pleasure in response to a gain). How-
ever, when the fit between the internal forces and external
situational demands is poor, there is interference of success-
ful adaptation and therefore inappropriate or maladaptive
behavior is expressed.
Two examples from non-clinical experiences of adaptive
or “well-fitting” modes corresponding to demand character-
istics are as follows. During a symphony concert, adapting
to the demands of the situations might include inhibiting
self-expression, intently watching the musicians and listen-
ing quietly. Conversely, while attending a baseball game,
expressing one’s self through psychical exertion such as
clapping and cheering loudly is considered adaptive. Clearly,
the context of these two situations are vastly different and
thus, adaptive behavior for each situation is similarly dis-
tinct. Importantly, the activation of a mode also relies on
social and cultural expectations in addition to the fit between
the self and the external environment.
Important to the definition of this construct is the idea that
a given mode encompasses all of the personality domains
including cognitive, affective, motivational and behavioral
components. This element of the definition sets the modal
construct apart from earlier work on depression by Beck
et al. regarding negative/ maladaptive cognitive schemas
(Beck 1967, 1971; Dozois and Beck 2008), which generally
only consist of the cognitive components (both content and
process) that are systematically grouped to form the patterns
of maladaptive cognitions. While, these cognitive schemas
are a critical component of a mode, the mode more holisti-
cally includes cognition and any subsequent changes to the
affective, motivational and behavioral domains of person-
ality. Throughout the historical iterations of the theory of
modes (Beck 1996, Beck 1999, Beck and Haigh 2014), this
core feature of the definition has remained present and is
vital to the understanding of how modes become activated.
These individual components of the personality react in syn-
chrony during the activation of a given mode. For example,
when in a maladaptive angry mode, an individual may have
the thought “They hurt me, and I should retaliate against
them” and simultaneously experience a negative, angry
affective response. A corresponding motivational response
of taking action against the person who hurt them might
follow, and a behavioral response of acting out retaliation
or revenge could then ensue. This example demonstrates
that while a person may have other more positive attributes,
emotions and thoughts, during the activation of the angry
mode, only the functions of personality that are activated to
satisfy this mode are expressed. However, when the individ-
ual deems a particular behavior to be situationally or mor-
ally maladaptive or inappropriate in a particular situation, a
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Cognitive Therapy and Research
higher-level process which we call the superordinate process
is then activated to inhibit this maladaptive response.
Structure of the Mode
The personality functions of cognition, affect, motivation
and behavior, along with physiological responses, work syn-
chronously for the operation of a mode. The processes of
activation, shifting of modes and deactivation is automatic.
Cognition, affect, motivation and behavior, provide unique
and necessary functions for adaptation including providing
context, understanding and meaning to stimulus situations
and activating or suppressing behavioral responses when
indicated.
Cognition
In response to an external stimulus or event, the first func-
tion to be activated in a given mode is generally cognition
(automatic or preconscious) that then activates other person-
ality functions such as affect, motivation and behavior. The
mode consists of beliefs and attitudes that act as formulae
for making rapid and automatic appraisals. The content of
these cognitions is largely based on an appraisal of the cur-
rent situational demands, the perceived efficacy and dura-
bility of the self within that specific context (self-concept),
past learning experiences (memories), attitudes and social
and cultural norms. Therefore, cognitions are often subject
to many personal biases. These cognitions, whether biased
or not, form structures that we label schemas (Beck and
Haigh 2014). Depending on the particular situations that
individuals face, different schemas may be activated that
can then induce a pattern of activated beliefs regarding one’s
view of the self, the outside world/others and the future (the
Cognitive Triad) (Beck 1967). Therefore, a mode is often
maladaptive when persistent negative cognitive schemas are
present, irrespective of the variability of external situations.
Similarly, we note that adaptive cognitive schemas (which
were significantly less discussed in earlier work on cogni-
tive therapy) are vital to the activation of an adaptive mode.
Importantly, the intensity of particular beliefs directly cor-
responds to the degree of activation of a particular mode,
as beliefs have direct effects on other personality domains
within the mode.
Affect
The subjective experience that we label affect—such as
sadness, happiness, pleasure, anger, and excitement—is
generally stimulated after the activation of an automatic or
preconscious thought. However, when affect is particularly
salient, the preceding cognition may be overshadowed, and
Cognitive Therapy and Research
the individual may not be aware of the cognition. Affect
plays an important role, not only in adding richness to an
individual’s life, but also being involved in the process of
motivation and memory. Additionally, the intensity of the
affective reactions signifies the significance of an event for
both the person experiencing the affect and observers.
Motivation
Along with the cognitive processing and affective responses
that coincide in a given mode, motivation is also activated.
Similar to automatic thoughts and affect, motivation often
occurs automatically and spontaneously. These automatic
motivations have their roots in the primary schemas and
include protection (fight/flight reaction), reproduction, appe-
tite, and the need for social connection and love. Impor-
tantly, motivations, whether adaptive or maladaptive to a
particular situation, determine the subsequent behavioral
responses.
Behavior
The expression or inhibition of behavior is typically the last
component of personality to be activated in a given mode.
Thus far, we have stated that adaptive cognitive processing
and relevant cognitions lead to adaptive affect, and adaptive
motivation. From this understanding one could imply that
the behavioral response indicated by the adaptive motivation
would also be adaptive (a “good” fit between the internal
needs and external circumstances). While this is generally
the case, there are some unique circumstances whereby the
intended adaptive behavior is not expressed and instead the
behavior is maladaptive despite prior adaptive motivation.
For example, if the intended, adaptive behavioral response
induces a fear of negative consequences such as in the cases
of social anxiety or test anxiety, this adaptive behavior will
be suppressed. A non-clinical example would be if an adap-
tive motivation to be assertive is activated, yet this motiva-
tion may trigger an interfering belief such as “If I am asser-
tive, the other person may be angry at me and that will be
terrible”. In this case, the adaptive behavioral response may
be suppressed. These clinical and non-clinical examples
show the critical, chain-like movement between personal-
ity functions of cognition, affect, motivation and behavior.
Superordinate/Reflective Processing
We conceptualize that above the automatic processes of a
mode, which includes the thread of cognition, affect, motiva-
tion, and behavior, lies an overlapping conscious and delib-
erate function that we have named superordinate processing.
This function can be compared to the Superego element of
the Freudian psychic apparatus in that it acts as a moral and
social compass guiding us into appropriate behaviors (Freud
1923). In the cognitive psychology and cognitive therapy
literatures, metacognition, or the ability to have awareness
and cognition regarding one’s own thought processes, is one
example of this higher-level cognitive processing at work
(Metcalfe and Shimamura 1994; Moritz and Woodward
2007; Dunlosky and MetcalfeS 2008). In terms of cogni-
tion, the superordinate function acts as oversight, leading
individuals to reflect on the appropriateness of automatic
cognitions. Similarly, this conscious cognitive process also
includes problem solving, decision making, deliberation and
reasoning.
There are unique circumstances where this superordinate
process does not function adaptively. For example, when an
individual is intoxicated or engaging in substance use, he/she
may make maladaptive decisions that defy logic or reason.
This may be due to the inability to access one’s cognitive
resources and take part in reflective adaptive thoughts pro-
cesses as well as a loosening of inhibition. Motivation is also
relevant within the superordinate function. In other words,
superordinate processing is responsible for the restraint or
disinhibition of an action when an individual consciously
considers the appropriateness of that action in a particular
situation.
Because the modes are initiated and operate automati-
cally, the superordinate component to modes is crucial to
function adaptively. In psychopathology, such as in cases of
suicidal individuals or those with substance use disorders,
there is often a lack of adaptive reflective oversight by the
superordinate function to inhibit these behaviors. These neg-
ative or maladaptive modes need to be moderated in order
for the individual to survive. Therefore, strengthening these
higher-level processes is imperative to block the operation
of a maladaptive mode or at least curtail its implementation
by blocking the impulse and instead, initiating an adaptive
response. Additionally, the reflective, higher level processing
is typically available to an individual in an adaptive mode.
Thus, a therapeutic target also becomes activating these
adaptive modes more readily and frequently. In summary,
the superordinate function acts as reality testing, perspec-
tive-taking, objectivity, and logical and analytic thinking.
Theory of Modes and Psychopathology
Modal Conceptualization of Schizophrenia
The current understanding of the role of modes stemmed
from working with individuals diagnosed with schizophre-
nia. It is well established in the literature that symptoms
of schizophrenia are grouped into clusters labeled posi-
tive and negative symptoms (Andreasen and Olsen 1982;
Cutting 2003). We have relabeled the positive symptoms
13

as psychotic symptoms to avoid confusion with our thera-
peutic emphasis on the positive aspects of personality. The
psychotic symptoms include delusions, hallucinations,
disorganized speech and delusion-based behaviors such as
unwarranted aggression (Andreasen 1984). The negative
symptoms include anhedonia, asociality, anergia, amotiva-
tion /avolition, and alogia along with the behavioral mani-
festations of withdrawal and expressions such as flat affect
(Andreasen 1982; Kirkpatrick et al. 2006). The questions
arise: how does one account for the emergence of these
symptoms and how can professionals in the mental health
field target these symptoms effectively using psychosocial
methods. One can begin to make sense of the development
of schizophrenia as well as the psychotherapeutic interven-
tions by considering the symptoms domains as representing
various modes: the psychotic mode, the negative symptoms/
withdrawn mode, and the adaptive mode, which represents a
distinct shift away from the two symptomatic modes.
The psychotic/positive symptom mode is one example of
a mode which falls under the broader categorization of mala-
daptive. The expression of these symptoms often reflects the
usual fears and worries of non-psychotic individuals but are
expressed in a symptomatic, maladaptive framework. For
example, psychotic symptoms such as paranoia reflect the
individual’s sense of vulnerability to danger and the percep-
tion of other people as hostile, controlling, and/or intrusive.
Thus, the delusion of being poisoned by one’s family may
reflect a deeper belief of being diminished or ostracized by
them. The delusion of being followed, having one’s mind
read, or being observed by cameras, reflects the self-con-
scious belief of being evaluated, judged, or controlled. The
grandiose delusions for the most part, are an extreme over-
compensation for the belief in one’s own inferiority, weak-
ness or immorality. We have found that bizarre delusions
sometimes represent the fulfillment of a wish or drive. For
example, the delusion of pregnancy in males often has the
underlying meaning of the desire to have someone to take
care of, having a close friend or relationship, or being “nor-
mal” like other people. In this mode, individuals often can-
not express their underlying fears, challenges, and concerns
via adaptive communication, affective expression, or behav-
ior, and thus we label this psychotic mode maladaptive.
The function of the negative symptom mode is far more
easily comprehensible. In this maladaptive mode, the indi-
viduals often endorse the following beliefs: “I don’t have
the energy to do anything” (amotivation), “I can’t connect
with other people” (asociality), and “I don’t enjoy any-
thing” (anhedonia) (Beck et al. 2009, 2018; Campellone
et al. 2016). These negatively biased beliefs are dysfunc-
tional attempts to protect the person from future experi-
ences that they anticipate will lead to failure, social rejec-
tion, powerlessness, and so on. These negative beliefs aid in
the strength, durability, and frequency of activation of the
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Cognitive Therapy and Research
maladaptive/ negative symptom mode and thus the therapeu-
tic target becomes activating an alternative adaptive mode.
The term adaptive mode is used to indicate that the pre-
dominance of the personality, including cognition, affect,
motivation, and behavior, appears to be adaptively respond-
ing to both internal needs and external factors. Addition-
ally, in the adaptive mode, individuals seem to have greater
access to reflective cognitive processing, effective decision-
making and problem-solving skills (superordinate organiza-
tion). In the beginning of treatment, the adaptive mode may
be rather weak and thus the activation is usually short-lived.
In this case, individuals’ powerful negative beliefs often lead
them to revert to the psychotic and/or withdrawn modes.
Due to the positive outcomes observed when individuals are
in the adaptive mode, the therapeutic goal is to incorporate
interventions that will aid in increasing the frequency, dura-
tion, and durability of the adaptive mode until this becomes
the individual’s primary mode.
Application of the Theory of Mode to the Treatment
of Schizophrenia
The critical observations of individuals with schizophrenia
shifting between maladaptive and adaptive modes aided in
conceptualizing and developing Recovery Oriented Cog-
nitive Therapy (CT-R). With these observations in mind,
the developers of CT-R and their clinical team attempted
to understand what factors accounted for this transition and
indirectly, contributed to the theory as indicated. Generally,
we have come to understand that individuals have strong yet
latent needs to be effective, accepted, respected, competent,
and connected to others. Importantly, we found that when
individuals shift into an adaptive mode, these critical needs
and meanings in their lives can be met. Therefore, we con-
ceptualized that one overarching therapeutic target would
be a consistent activation of the adaptive mode and a cor-
responding deactivation of the maladaptive (psychotic and
withdrawn) modes. Of course, the broader therapeutic target
would be to facilitate a pathway towards recovery. In order to
activate and maintain an individual’s adaptive mode, clini-
cians and other members of a clinical team can use a number
of successful therapeutic interventions that are included in
Recovery Oriented Cognitive Therapy (CT-R) treatment.
The therapeutic style of the CT-R clinician is quite differ-
ent from the typical therapeutic approach to schizophrenia
within the medical model. CT-R shies away from a focus
on symptom reduction and observable behavioral strategies
such as reinforcement, and cognitive remediation. CT-R
must also be distinguished from traditional cognitive ther-
apy. Cognitive Therapy is generally more narrowly focused,
problem-centered and symptom-oriented in that it deals with
highly specific maladaptive automatic thoughts/ attitudes
such as, “Since I failed this test, I am worthless”. Once these
Cognitive Therapy and Research
specific maladaptive misinterpretations about the self, the
outside world and the future are identified, logic and reason-
ing are used to correct these cognitions.
By contrast, the central focus in CT-R is on activating
the adaptive mode rather than directly deactivating the
maladaptive modes. CT-R employs a holistic and humanis-
tic approach to ferret out the individual’s values, interests,
capacities, skills, provide collaborative experiences that
cater to these attributes and provide new learning, and help
individuals draw positive conclusions that will support their
pathway towards recovery. These fundamental aspects of
CT-R show resemblance to the basic tenets of positive psy-
chology (Seligman and Csikszentmihalyi 2000) and more
specifically, some of the beliefs held by the field of positive
clinical psychology (Wood and Tarrier 2010). In addition
to understanding activities that may activate an individual’s
adaptive mode, it is also crucial to understand why this acti-
vation occurred. More specifically, the underlying meanings
of skills, hobbies, or activities hold great therapeutic value
and often pertain to themes of connection, control, confi-
dence, empowerment, and safety. When clinicians and indi-
viduals work collaboratively together to draw conclusions
regarding the meanings of events that activate the adaptive
mode, future activities and aspiration setting can be focused
around these meanings.
Individuals might have different opportunities for activity
while in treatment versus in the community. It is important
to recognize the unique challenges that individuals face in
the community such as social isolation, lack of support and
disengagement. However, the hope is for individuals to find
a similar meanings and purpose in the community. Thus, for
example, an individual who helped to organize plays put on
by the individuals in an inpatient unit of a hospital eventu-
ally received a job in the community as a stagehand. The
former and the present activity both led to the individual’s
feeling worthwhile and productive. Below we discuss some
of the core therapeutic strategies of Recovery Oriented Cog-
nitive Therapy (CT-R) that are aimed to shift individuals
from the maladaptive modes to the adaptive mode and sup-
port a pathway towards recovery.
Activating the Adaptive Mode/ the “Sweet Spot”
We attempt to activate individuals’ adaptive modes by
facilitating their participation in enjoyable and meaningful
activities. The selection of an individualized and meaningful
activity is based on a collaborative discussion about the indi-
viduals’ interests, past enjoyments, skills, and values. Addi-
tionally, energizing experiences such as going for a walk
or listening to music can activate an individual’s adaptive
mode. Clinicians must be truly interested and engaged in the
activity that the individual agrees upon and be cognizant of
any content during the discussions in which positive affect,
memories, or communication come about. In therapy, we
call the elements that activate energy and passion in indi-
viduals the “sweet spot”. Of course, the sweet spot varies
from one individual to another—which allows for ultra-
individualized treatment plans.
When individuals are in the adaptive mode, it is impor-
tant to help them notice the positive meaning of a learning
experience. With each successive positive experience, the
clinician and individuals collaboratively draw conclusions
that indicate that the individuals are safe, effective, in con-
trol, confident, and accepted. To return to the case of David
at the hamburger restaurant, a few very significant meanings
aided in the switch to the adaptive mode. For him, the suc-
cessful experience of ordering his food and interacting with
the cashier at the restaurant meant that he was an effective
and sociable person.
Aspirations
Whereas the interventions listed above help to activate the
adaptive mode, placing significant focus on an individual’s
aspirations is important in order to ground the adaptive
mode and maintain its activation throughout the course of
treatment. This focus on aspirations in the treatment of the
severely mentally ill is akin to “valued goals” in Acceptance
and Commitment Therapy (ACT) (Bach and Hayes 2002).
However, a vital difference in the treatment of CT-R is the
focus on cognition. In CT-R, once the individual is in the
adaptive mode, it is then possible to identify their aspirations
and reinforce positive beliefs about their ability to achieve
these aspirations. Sometimes, the aspiration is not appar-
ent but a therapist and individual search for meaningful and
gratifying activities that will bring purpose and meaning to
the individual’s life and thus shift or keep them in the adap-
tive mode. For the aspiration to resonate with the individual
throughout the course of therapy, the following is required:
a) it must be authentic, individualized and meaningful, b)
reflecting on the aspiration must be accompanied by positive
affect, and c) the path towards the aspiration must incorpo-
rate successive steps. Important strategies to determine the
aspiration and build positive affect and confidence around
the idea of aspiration attainment include the use of imagery
and guided discovery regarding the meaning of the aspi-
ration. The treatment then continues to provide activities
and experiences for the individual that either moves them
toward their aspiration or, when the aspiration is not yet
attainable or unrealistic, provide the same purpose or mean-
ing as achieving the aspiration.
Setbacks & Resilience Building
Individuals should also be prepared to cope with the differ-
ent challenges, frustrations and disappointments that they
13

are likely to encounter as they move through treatment and
eventually assume a more adaptive life in the community.
These challenges have the potential to induce a setback in
the individual’s treatment. In terms of the theory of modes,
we define setback and resilience as follows:
A setback is represented by an exacerbation of the indi-
viduals’ symptoms and a partial regression from the adaptive
mode to the maladaptive mode. However, major elements of
the adaptive mode may still be still energized.
Resilience is represented as either a continual activation
of the adaptive mode despite a challenge or a return to the
adaptive mode following a setback or relapse.
Often the setback and activation of the maladaptive
modes occur when there is a shift in care, when individuals
are confronted with a series of problematic tasks, or when
they have been involved in one or more unpleasant social
experiences. These stressors impinge on a congruent nega-
tive belief and set in motion the reactivation of a maladaptive
mode. Increasing constructive thinking through role-play or
in-vivo activities after a setback can be helpful in re-initiat-
ing the adaptive mode. Another strategy for building up the
adaptive mode after a setback is identifying previous suc-
cess experiences that can be used in the current treatment as
examples of the individual’s strength, control, and resilience.
Finally, it is important for clinicians to explain the normality
of setbacks and challenges along the pathway to recovery. In
fact, we believe that certain cognitive and behavioral skills
can be enhanced only by experiencing challenges and suc-
cessfully overcoming them. With proper application, these
CT-R interventions serve to enhance the individual’s adap-
tive qualities including competence, self-confidence, and
control, and simultaneously reduce negative aspects such
as insecurity, low self-esteem, and dysfunctional attitudes.
Application of Theory of Modes to Other Conditions
Following the successful work using the theory of modes as
a framework with individuals diagnosed with schizophrenia,
another interest was in determining whether the principles of
the theory of modes applied to non-psychotic populations.
Indeed, we found that there is a wide variety of disorders
for which the concept of modes is applicable. The various
non-psychotic disorders tend to be partially characterized
by the presence of specific biases in cognitive processing
which permeates the entire mode. For example, in anxiety,
the bias is often related to vulnerability. In depression, it is
self-devaluation. The cognitions that create the dominant
biased beliefs are largely drawn from internal information
such as memories of past failures and expectations of future
failure. The biases created by focusing on such information
extends to attention, information processing and interpreta-
tion (or rather misinterpretation). Depending on the degree
of activation, the attentional, processing and interpretative
13
Cognitive Therapy and Research
biases can range from mild to extreme and thus directly
predict the intensity, charge and durability of a maladap-
tive mode. Because of the powerful effect of egocentrically
biased information processing, individuals display subjectiv-
ity toward their present situation. They fail to discern that
they are engaged in jumping to unreasonable conclusions,
making snap judgments about themselves, others, and their
future, and selectively focusing on significant negative
events to the exclusion of neutral and/or positive events.
They also may be incapable of gaining perspective, that is,
seeing present challenges as catastrophic or representative
of their character in a holistic way rather than as setbacks
within the broader context of their lives.
Conversely, when people are engaged in adaptive think-
ing, they are aware of the irrational or dysfunctional ele-
ments of a particular maladaptive mode. This kind of aware-
ness is often called cognitive insight (Beck et al. 2004; Riggs
et al. 2010). When individuals can see or imagine a reality
outside of the content of this biased mode, they may gain
perspective by distancing themselves from the content of the
mode and be able to take in information in a broader context.
Therefore, one of the most vital elements in the treatment
of all disorders is the attempt to shift from a biased, subjec-
tive, egocentric maladaptive mode to an unbiased, broad and
perspective-taking adaptive mode.
Standard cognitive behavior therapy has achieved great
popularity in academic and clinical realms, as well as excel-
lent results for its conceptual validity and efficacy for a num-
ber of clinical populations(Hofmann and Smits 2008; Beck
and Alford 2009; Bisson et al. 2013; Cuijpers et al. 2014;
Öst et al. 2015 (for general reviews see Butler et al. 2006
and Hofmann et al. 2012)). Traditional techniques include
the use of reasoning and logic to modify the negative misin-
terpretations of individuals’ experiences. These techniques
have been well outlined in the volume Cognitive Therapy:
Basics and Beyond by Judith Beck (Beck 2011). Despite the
efficacy of these interventions for many individuals, they are
often insufficient for individuals who are chronically afflicted
with mental health disorders. We believe that CT-R, with
its person-centered, holistic approach, would be particularly
effective with these individuals, who tend to be poorly inte-
grated and have a variety of challenges other than their out-
ward symptomatology (including lack of confidence, beliefs
about being ineffective, difficulties in relationships and/or
interpersonal interactions, and a general lack of enjoyment
in life (See Beck et al. (in press), which describes CT-R for
individuals diagnosed with serious or complex mental health
conditions and Beck (in press) for a blending of traditional
and recoveryCarlisle -oriented techniques for higher func-
tioning clients). CT-R directly addresses these challenges by
emphasizing the positive aspects of personality (the adap-
tive mode) and increasing pleasurable, efficacious and social
experiences to build up the individual’s morale and sense
Cognitive Therapy and Research
of security. As an indirect benefit of treatment, individual’s
maladaptive modes (which include maladaptive thinking,
affective reactions, motivation, and behavioral expressions)
deactivate, and the impact of the disorder on their lives
decreases. Of course, we acknowledge that further research
is required to substantiate these clinical findings.
Discussion & Future Directions
This updated formulation of the theory of modes and the
conceptualization of psychopathology based on this theory
was inspired by clinical observations of individuals diag-
nosed with schizophrenia, who could temporarily shift
within seconds from a remote, withdrawn state, replete with
voices and delusions, into an apparently adaptive state, hav-
ing full command of their faculties. We have also observed
this paradox in non-clinical behavior where, for example, an
individual can move within seconds from being gentle and
kind, into a rage, striking out at the person whom they love.
Our work with individuals diagnosed with a serious men-
tal health condition involved expanding our thesis of how
beliefs, affect, and motivation lead to behavior. We found
that underlying the inappropriate or dysfunctional behav-
ior, which we describe as maladaptive, was a sequence. The
sequence begins with the activation of maladaptive cogni-
tions (for example, cognitive distortions such as overgeneral-
ization, selective abstraction, tunnel vision, etc.). Often, the
strength and durability of these maladaptive beliefs overrode
the individual’s capacity to take an adaptive, reality-based
view, which would include accurate self-observation and
perspective taking. These durable maladaptive cognitions
then quickly affect individuals’ affective expressions, access
to motivation and behavioral responses, thus encompassing
a holistic adaptive mode. With specific Recovery Oriented
Cognitive Therapy (CT-R-) interventions, we find it possible
to modify maladaptive beliefs or entire maladaptive modes
indirectly by accessing more positive, adaptive modes. More
importantly, frequent activation of adaptive modes seems to
promote a significant reduction of individuals’ symptoms
and progressive movement toward their aspirations and a
state of recovery.
There are many possible directions for future research
related to the theory of modes. First, it would be valuable to
develop instruments that measure different components of
the theory of modes, for example, the intensity or speed of
activation of a given mode. Another measure could exam-
ine specific cognitions and attitudes that may signal a shift
from one mode to another. Outcome studies are also needed
to more deeply understand the components of the theory
of modes and the significance of specific mediators and
moderators in greater depth. Because the theory of modes
is heavily incorporated into Recovery Oriented Cognitive
Therapy (CT-R), randomized controlled trials are needed
to compare standard Cognitive Therapy, treatment as usual,
and CT-R (for uncomplicated diagnoses and treatment resist-
ant diagnoses).
Other interesting avenues of future research should
explore neurophysiological changes in the brain that cor-
respond with the activation of adaptive and maladaptive
modes. For example, a headset can be used to record an
individual’s EEG when they are in a maladaptive mode and
again when the individual’s adaptive mode is activated.
EEGs and neuroimaging could also be used to assess the
individual’s progress as a result of the interventions. It may
also be relevant to research the mechanism of constriction
in visual fields that may be associated with “tunnel vision”
biases in maladaptive modes.
The theory of modes and its application to research and
treatment have important implications as we look toward the
future of cognitive theory and therapy. These include: (1)
refining treatment for inpatient and outpatient populations
with treatment-resistant conditions using Recovery Oriented
Cognitive Therapy (CT-R), (2) a continuing emphasis on
enhancing the positive and adaptive features of individuals,
and (3) reconceptualizing cognitive treatments based on an
overarching, trans-diagnostic theory of modes, rather than
ultra-specific, manualized approaches to treat different forms
of psychopathology.
Author Contribution Credit for original conceptualization of the manu-
script given to A.T.B with significant contributions in idea formulation,
writing, editing and design of manuscript given to M.R.F. Literature
review conducted by M.R.F. The first draft of the manuscript was writ-
ten by A.T.B and M.R.F. Supervision, critical commentary and signifi-
cant revisions provided by J.S.B. All authors edited and commented
on previous versions of the manuscript. All authors read and approved
the final manuscript.
Compliance with Ethical Standards
Conflict of Interest Aron T. Beck, Molly R. Finkel and Judith S. Beck
declare that they have no conflict of interest.
Ethical Approval No procedures were used in this study, no humans
or animals participated in this study. The writing of this manuscript
was in accordance with the national and international ethical standards.
Informed Consent No informed consent had to be obtained from any
subjects.
Animal Rights No animal studies were carried out by the authors for
this paper.
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