Post-rationalism and mental health

©

Leandro Castelluccio

(Image obtained from: link)

What is it better for our mental health: to think about our problems or not to think about them? ¿To focus and think about our own thoughts, what we are experiencing, our emotions, our behavior, or not to think about them at all and just experience them? ¿Or is it a middle ground?

There is a difference between problems as perceived and as what they are, usually what we think about reality is different from what reality actually is, although this issue is more complex because we could argue that problems arise in the intersection between reality and ourselves, like in perception, it depends on our brain structures and what is out there in reality.

The question is closely related to our metacognitive abilities. One might think that if we do not have the ability to realize what happens to us or what our problematic thoughts are, we would not have the problems we have, but this should not make us think that the absence of metacognition leads us to a healthy path, rather other problems appear, because we cannot, for example, connect our problems with the way we act and think, which makes us have those problems according to how we interact with reality.

According to Lysaker et al. (2005), metacognition relates to the ability to assess and plan action strategies for problems especially those related to mental states. Generally speaking, following articles about metacognition and self regulation, the ability to think about our own mental states, our emotions, what we perceive, what we believe, etc., affects our experience and regulates the emotions themselves, and a diminished metacognition is associated with a wide range of issues. For example, poor insight is regarded to be the commonest symptom in schizophrenia subjects. As Lysaker et al. (2005)point out, the clinical significance of insight deficits is further highlighted by its association with treatment non-adherence (example: McEvoy et al., 1989; David et al., 1992; Perkins, 2002), poor psychosocial functioning (see in: Dickerson et al., 1997; Amador et al., 1994), premorbid functional impairment (Debowska et al., 1998 ), poor prognosis (Schwartz et al., 1997 ), involuntary hospitalizations (Kelly et al., 2004 ), and higher utilization of emergency services (Haro et al., 2001 ).It is for that reason that there is growing interest in studying and exploring, for example, the neurobiology of insight. In that sense, following Lysaker et al. (2005),a potential relationship between prefrontal function and insight has been examined in a number of structural imaging studies (see in: David et al., 1995; Rossell et al., 2003; Takai et al., 1992; Laroi et al., 2000; Flashman et al., 2001; Shad et al., 2004). Let’s consider, for example, the correlation between dorso lateral prefrontal cortex (DLPFC) deficit and unawareness of illness (Flashman et al., 2001; Shad et al., 2004), which has been explained on the basis of a pivotal DLPFC role in self-monitoring and conceptual organization. The orbitofrontal cortex (OFC), on the other hand, a prefrontal sub-region, has direct connections with the limbic structures (see in: Schultz et al., 2000; Wallis et al., 2001), which could integrate information from various limbic areas, and because of its reciprocal connections it may play a critical role in correct attribution of salience, in which events and thoughts control action and influence behavior (Kapur, 2003). It is possible that alteration in OFC function may result in aberrant salience and thus an inability to correctly attribute symptoms to an illness (Lysaker et al., 2005). Additionally, there is some evidence linking both smaller whole brain volume and frontal cortical atrophy to poor insight in this population with schizophrenia. According to Sapara et al. (2007), smaller prefrontal grey matter volume is associated with poor insight of the presence of illness in stable schizophrenia patients. Contrary to this, we see such things as extensive insight meditation experience, which involves focused attention to internal experiences, associated with thicker brain regions linked to attention, interoception and sensory processing, these areas include the prefrontal cortex and right anterior insula (Lazar et al., 2005). In the experiment by these authors, between-group differences in prefrontal cortical thickness were most pronounced in older participants, suggesting also that meditation might offset age-related cortical thinning.

Although we are not saying that with metacognition we are necessarily thinking about our problems, since we think about thought themselves, as one of the possibilities, it is probable that one thing leads to the other, and our thought are linked to the problems and issues we perceive. We could say that metacognition might be more in the level evaluating our mental states in a more rational way. One effective therapy that deals with our thoughts is Cognitive Behavioral Therapy.

Cognitive Behavioral Therapy is a psychological therapy with a large component of scientific support for the treatment of problems such as anxiety and depression among others. Psychological disorders are usually expressed in the levels of thoughts, behaviors and emotions, Cognitive Behavioral Therapy focuses on eliminating or modifying thoughts and behaviors so that they do not generate discomfort to the person.

The therapy works on modifying the negative thoughts so that the individual can learn more flexible and positive ways of thinking, specifically, more rational ways, which will affect emotional and affective states of the subject in a positive way. The axis of the question is in the distorted thoughts and beliefs that the person maintains, which are managed and reinforced by the so-called cognitive errors or biases of perception. The question is: is this approach to mental problems always effective? Can there be a more effective way to treat these psychological issues?

Within Cognitive Theory applied to psychotherapy we have approaches such as the Attributional Style Theory, where the kinds of causes we attribute to events seem to have an impact on our health (Peterson & Seligman, 1987; Kamen & Seligman, 1987). In this sense certain mental health issues relate to a specific way in which we think about the causes of our problems. Another approach is that of Beck (1979), in which stressful events activate a certain schemata, plus a bias in cognition, resulting in emotional reactions that permeates our mental problems. All these have implications on how we think about cognition and emotion, since there is a relationship between the two, and Cognitive Behavioral Psychotherapy focus on changing the meaning of beliefs and attributions to reach an emotional change, because it seems, the way we think about things is responsible for our emotions. In this sense, emotional resolution of our issues is an intellectual task, but this appears to have problems of its own, certain gaps that don’t fit the theory. For example, we can experience emotional reactions without being able to identify any prior thoughts that caused them. Also, we can think about emotions without reactions. Currently, authors think that this disparity between thoughts and emotions points to the existence of intellectual and emotional beliefs. This follows the Interacting Cognitive Subsystems Theory (ICS)(Barnard & Teasdale, 1991; Teasdale & Barnard, 1993) where there are two levels of meaning, a propositional one, which has indirect contributions to emotion and an implicational one which is directly related to emotion production. In this sense, we have implicit felt senses, like the feeling that “something is wrong or right”. 

We all know the difference between “knowing with the head” and “feeling it”. In therapy it is common to see and understand our patterns of though as irrational, we can say “yes, this is rational”, but we don’t necessarily feel it that way, that is because there are two levels of meaning, and we have cognitive versus emotional beliefs, so we might recognize and think our thoughts as irrational, but still implicationally and deeply, we might not believe that. In that sense, we might say that we are not fully convinced that the idea or thought is irrational. Therefore, processing emotions through the cognitive route may not always be helpful in resolving emotional concerns, and this can be a problem in Cognitive Behavioral Psychotherapy, where emotional shifts might be at a deeper level, instead of in the cognitive or conceptual level of meaning. We must understand that the emotional beliefs are not more truthful than our rational understandings, that is the effort that implicitly Cognitive Therapy tries to develop, but what we must understand as well is that this cannot be achieved necessarily through cognitive ways and rational understandings, not even through behavioral techniques, and this might be the case very often, so we need to address the issue with an experiential way of processing these beliefs.

But when in Cognitive Therapy we rewire our ways of thinking about something we might be indirectly contributing to not thinking about the problem, we say “this is more rational” and we leave it that way, instead of ruminating constantly in the same pattern of thought. But more efficient might be to not think about the problem and its possible causes, consequences and implications, and just be mindful of it, how it presents itself, how it feels. This puts us in an implicational level, in an experiential and not conceptual way of addressing the issue, which might be more beneficial for our mental health than thinking about the problem, because in the conceptual way we don’t reach all the meanings, just the propositional, and thus we don’t get in touch deeply with the emotional belief.

Although, it is uncertain how just doing this allows for a change in the emotional belief. Maybe it allows to reach the belief so to associate it to experiences that contradicts it and then change it, in a way that it is easier or more efficient, so maybe when we are at an experiential mode we can better see the irrationality and inaccuracy of the belief, we can then achieve insight: a holistic integration of meanings, with ideas, experiences, thoughts, memories and other emotions, that is far more powerful to resolve and change our emotional concerns. Teasdale (1999) proposed that change in schematic mental models would be facilitated by processing at the implicational level, underpinned by the more direct access and modification of the mental models available in this mode. In this sense, it is predicted within the ICS framework, that self-focused processing of emotional material would be adaptive and facilitate emotional processing in the experiential mode corresponding to the implicational level, but would be maladaptive and prevent effective emotional processing in the conceptual-evaluative mode. Evidence of this is provided by the study performed by Watkins (2004) mentioned later in this essay.

One way that we might reach this experiential mode is through meditation. Mediation is not to be thought as something separate from a conceptual approach, since mindfulness meditation, for example, can be a way for us to stop thinking negatively about our issues, enough so that we can engage in a more rational dialog with ourselves.

Research has provided evidence for meditation-induced improvements in psychological and physiological well-being, including benefits in higher-order cognitive functions altering brain activity (Luders, Toga, Lepore, & Gaser, 2009). According to these author’s research, correlates of long-term meditation were detected, with significantly larger gray matter volumes in meditators in the right orbito-frontal cortex, as well as in the right thalamus and left inferior temporal gyrus when co-varying for age and/or lowering applied statistical thresholds. Meditators showed significantly larger volumes of the right hippocampus as well. These orbito-frontal and hippocampal regions have been implicated in emotional regulation and response control (following Luders et al., 2009). According to the authors the larger volumes in these regions might account for meditators’ singular abilities and habits to cultivate positive emotions, retain emotional stability, and engage in mindful behavior. This is just citing one of hundreds of papers that show lasting effects on brain volume and function, suggesting that the practice of meditation might integrate within ourselves and lead to a way of being that is more often in an experiential mode, with all its argued benefits for resolving emotional concerns.

The goal in mindfulness is to be oriented to on-going events and experiences in a receptive, attentive manner, without judging, this is an experiential mode of processing, which has implications for the way we perceive and respond to stress situations. Mindfulness then would promote more objectively informed ways of acting to stressful situations, which can then be viewed in more benign or neutral terms. This is a way in which mindfulness can also help with emotional problems. Evidence supports this, showing that mindfulness promotes desensitization and reduction in emotional reactivity to potentially threatening stimuli (Weinstein, Brown, & Ryan, 2009). Thus, the technique of mindfulness is a method in which thoughts are experienced as transient, more related to psychological events rather than reflections of absolute reality. This practice may facilitate and strengthen this capacity for positive reappraisal, which goes hand in hand in a way with the idea of an experiential mode of dealing with issues. This is a key point, separating conceptual from experiential awareness.

There are several studies that address this issue of experiential versus conceptual mode.According to Gadeikis, Bos, Schweizer, Murphy and Dunn (2017) thereare indications that engaging in experiential processing (through direct awareness of sensory and bodily experience) bolsters positive emotion experience. In their experiment, greater spontaneous use of experiential processing during a memory task was associated with greater happiness experience. Additionally, experiential processing increased happiness experience relative to other conditions, although not all of them. The results suggest that engaging in experiential processing is an effective way to up-regulate positive emotion experience during positive memory recall.

Let’s consider deeply the study by Watkins (2004), which tries to address the hypothesis that there are adaptive and maladaptive ruminative self-focus during emotional processing, which either increase-maintain depressive symptoms or alleviate them. As it is mentioned in the study, increased self-focus is associated with depression (Ingram, 1990; Pyszczynski & Greenberg, 1987). Also, in experimental studies, rumination intensifies dysphoric mood and negative thinking, whilst impairing problem solving (Lyubomirsky & Nolen-Hoeksema, 1995; Lyubomirsky, Tucker, Caldwell, & Berg, 1999; Watkins & Baracaia, 2002).

Watkins (2004) takes into account the Interacting Cognitive Subsystems framework (ICS) (Teasdale & Barnard, 1993), which as mentioned before proposes two qualitatively different levels of meaning: an implicational level (characterized by a non-evaluative, intuitive, direct experiential awareness of experience in the moment) and a propositional level (characterized by conceptual, analytical, evaluative- ‘thinking about the self). This study by Watkins (2004) is testing the hypothesis that repeated and prolonged focus on an upsetting event would result in less recovery from it (conceived by a greater negative mood, for example,) in a conceptual-evaluative mode compared to an experiential mode.

The methodology and procedure of the study involved the participation of seventy-eight people (35 male, 43 female, age M. 30:5, SD 9:7), who volunteered for the study from within a London university. Different instruments were used to gather the relevant information for the study and of the variables analyzed, such as the Impact of Event Scale, the BDI or the ACS.

There was a negative mood induction to the participants, performed by the failure version (McFarlin & Blascovich, 1984) of the Remote Associates Test (RAT; Mednick, 1962), in which participants try to solve 10 problems, in a length of 5 minutes, each of which involves finding a fourth word that relates to a set of three presented words. On average, however, only one problem is answered correctly, effectively inducing negative mood (according to Brown & Dutton, 1995). To enhance the induction, participants were informed that the test was a brief measure of IQ and correlated with successful academic and career performance. The rationale given to participants was that the study investigated how people deal with test stress.

All participants were randomly allocated to one of two essay conditions. They were matched for references to the self, to feelings and to the test, each with the same initial instructions. In the conceptual-evaluative condition, participants were instructed to write about the causes, reasons and meanings for their performance and their feelings, meanwhile in the experiential condition, participants were instructed to write about their direct experience of their performance and their feelings, which included their mental processes and use of their experience as a guide to solutions.

Overall, the methodology and analysis of the study is substantially sound. For example, analyses of variance (ANOVAs) and chi-squared tests were calculated to examine whether there were any differences on background variables between the participants allocated to each writing condition. Positive aspects of the study’s methodology are the careful selection of the tests, which have been proven to particularly acquire information relevant for the study, for example the ACS, which was chosen because it measures tendency to dwell on past events independent of processing mode. Also, precautions were taken to ensure that the instructions for the different conditions were similar enough to not generate differences in clarity, experiential, conceptual-evaluative, nor in emotional impact. However, because the underlying assumption is that the experiential mode is what is acting as a factor of the reduced negative mood compared to the conceptual mode, in order to make such conclusion, one would have to assume that there are in effect different processes happening according to the condition. Therefore, the study’s methodology could have been improved if further analysis would have been performed to assess this point. A writing task could have been used in which participants expressed the observations or thoughts they had of the resulting experience, according to the condition. A quantitative analysis of the number of words referring to the self, experiential or evaluative notions, could have then been useful to determine whether conditions differed in this sense or not.

Regardless of this, results show that for negative mood measured 12 hours after the failure experience, the writing condition interacted with trait tendency towards rumination. In this sense, increasing tendency to ruminate produced more negative mood (less recovery from the failure), but only in participants who wrote in the conceptual-evaluative condition. Both writing condition and tendency to rumination independently influenced intrusions and avoidance about the test for the first 12 hours after the failure experience. Therefore, consistent with predictions of the study, the conceptual-evaluative writing condition was associated with greater intrusions and avoidance about the test than the experiential writing condition.

These results are particularly relevant for the ongoing treatment of negative mood states, indicating that an experiential based approach to negative experiences could facilitate a better regulation of mood compared to an evaluative approach.

Based on this, we could offer a proposal for continuous research on the basis of this reading. Since mindfulness based meditation can help the person to “retune” the mind to enter the implicationally mode according to Teasdale (1999), it follows that people trained in mindfulness meditation might have a strategic advantage in the processing of negative emotions. From the results obtained by Watkins (2004), we would argue that less negative mood would be present in a mindfulness trained group compared to controls following a negative mood induction. Such proposed study would then expand upon the results obtained by Watkins (2004) and tackle relevant practical applications of his findings. In such experiment for example, participants would be divided into control and meditation condition. In the case of the last one, participants would undergo a previous period of training in mindfulness meditation. If we are to find significant differences on mood according to conditions, in the directions predicted considering Watkins (2004) findings, then this would imply supporting evidence for the study’s conclusions, as well as evidence for practical applications of mindfulness meditations, specifically in the regulation of negative mood following a negative event. More generally, results could make us question current models about the effectiveness of more cognitive or conceptual approaches to treatments of negative mood. 

Overall, we could treat a multitude of thoughts that generate negative consequences for our physical-mental health in the same way that we treat certain common illnesses like the cold, from time to time they come, but as they come they go and we must let them go naturally. Thought is a useful aspect, a more rational thought we would say, but we could also argue that sometimes, or perhaps very often, emotional beliefs are so strong that they overshadow any thought we have and the best way to deal with this is through an experimental or experiential mode. And in a way, to think that we should do that in the face of the beliefs we have is a particular way of thinking, so we do not deny that thought affects or regulates our experience ultimately. The problem is in the types of thinking and in the acceleration that causes, the anxiety they generate, and in a certain way we avoid insight or to think about different things when we give room to the experiential mode.

It could be said in the following way: there is much more than a thought in a thought, because the emotional and sensorial content and the ramifications that extend through different scopes of our cognition go beyond thinking at a conceptual level, so to change an irrational idea appealing to the conceptual mode of thinking can be futile. Not only that, sometimes leaving the idea aside instead of concentrating on it is all that is needed to improve our condition, since this will eventually and naturally disappear with the passage of time and experience of the person. Maybe we can also suggest that just being in the conceptual mode is often the reason for our high anxiety and stress, as it interrupts with the natural flow of our functioning, which would occur in an experimental mode, and because it usually falls in overthinking that can overwhelm us by itself, and it can do so with negative thoughts. Therefore, thinking about our problems as in Cognitive Behavioral Psychotherapy can be a double-edged weapon: it can be beneficial, but also problematic. We must recognize that there are other ways, bottom-up, embodied and insightful-holistic paths to regulate emotion without too much thought involved. Moreover, we could argue that many times it is not that certain thoughts cause things like anxiety, but rather anxiety emerges from implicational meanings of things around us, and it is this that causes certain thoughts that then are a feedback for the anxiety. Sometimes bodily sensations and feelings associated to anxiety are enough feedback for its increase regardless of thought. Certain rational thoughts might help, because of their relationship to emotion, but mindfulness and relaxation techniques might be more effective, or just letting the feelings go away naturally once the body becomes less activated in time and just don’t focus on the issue too much.

We cannot deny that metacognition is an essential aspect for mental health, and Cognitive Behavioral Psychotherapy works with this tool, by thinking about our very own thought and beliefs, trying to come up with more rational views. But experiential approaches might cover other aspects of meaning that are not reached through thinking alone, and insight and implicit meaning integration might be the tool behind the resolution of emotional and mental health issues. This could be why relative new trends such as Mindfulness-Based Cognitive Therapy have been very effective. This has challenged the view of having healthy, positive thoughts, or more rational ones, as a good thing for solving emotional concerns, and has promoted going deeper as a result of research on multi-level models of emotion andcognition. This is the why of the title of this essay, the idea is to explore a way beyond rational thoughts to deal with mental health problems.

References

Amador, X.F., Flaum, M., Andreasen, N.C., Strauss, D.H., Yale, S.A., Clark, S.C., 1994. Awareness of illness in schizophrenia, schizoaffective and mood disorders. Archives of General Psychiatry 51, 826–836.

Barnard, P. J., & Teasdale, J. D. (1991). Interacting cognitive subsystems: A systemic approach to cognitive-affective interaction and change. Cognition & Emotion, 5(1), 1-39.

Beck, A. T. (1979). Cognitive therapy and the emotional disorders. Penguin.

Brown, J. D., & Dutton, K. A. (1995). The thrill of victory, the complexity of defeat: self-esteem and people’s emotional reactions to success and failure. Journal of Personality and Social Psychology, 68, 712–722.

David, A., Buchanan, A., Reed, A., Almeida, O., 1992. The assessment of insight in psychosis. British Journal of Psychiatry 161, 599– 602.

David, A., van Os, J., Jones, P., Harvey, I., Foerster, A., Fahy, T., 1995. Insight and psychotic illness: cross-sectional and longitudinal associations. British Journal of Psychiatry 167 (5), 621– 628.

Debowska, G., Grzywa, A., Kucharska-Pietura, K., 1998. Insight in paranoid schizophrenia—its relationship to psychopathology and premorbid adjustment. Comprehensive Psychiatry 39 (5), 255–260.

Dickerson, F.B., Boronow, J.J., Ringel, N., Parente, F., 1997. Lack of insight among outpatients with schizophrenia. Psychiatric Services 48, 195– 199.

Flashman, L.A., McAllister, T.W., Johnson, S.C., Rick, J.H., Green, R.L., Saykin, A.J., 2001. Specific frontal lobe subregions correlated with unawareness of illness in schizophrenia: a preliminary study. Journal of Neuropsychiatry and Clinical Neurosciences 13 (2), 255– 257.

Gadeikis, D., Bos, N., Schweizer, S., Murphy, F., & Dunn, B. (2017). Engaging in an experiential processing mode increases positive emotional response during recall of pleasant autobiographical memories. Behaviour research and therapy, 92, 68-76.

Haro, M. J., Ochoa, S., & Cabrero, L. (2001). Insight and use of health resources in patients with schizophrenia. Actas espanolas de psiquiatria, 29(2), 103-108.

Kamen, L. P., & Seligman, M. E. (1987). Explanatory style and health. Current Psychology, 6(3), 207-218.

Kapur, S., 2003. Psychosis as a state of aberrant salience: a framework linking biology, phenomenology and pharmacology in schizophrenia. American Journal of Psychiatry 160 (1), 13–23.

Kelly, B.D., Clarke, M., Browne, S., McTigue, O., Kamali, M., Gervin, M., Kinsella, A., Lane, A., Larkin, C., O’Callaghan, E., 2004. Clinical predictors of admission status in first episode schizophrenia. European Psychiatry 19 (2), 67– 71.

McEvoy, J.P., Apperson, J., Appelbaum, P.S., Ortilip, P., Brecosky, J., Hammill, K., Geller, J.L., Roth, L., 1989. Insight in schizophrenia: its relationship to acute psychopathology. Journal of Nervous and Mental Disease 177, 3– 47.

McFarlin, D. B., & Blascovich, J. (1984). On the Remote Associates Test (RAT) as an alternative to illusory performance feedback: a methodological note. Basic and Applied Social Psychology, 5, 223–229.

Mednick, S. A. (1962). The associative basis of the creative process. Psychological Review, 26, 220–232.

Ingram, R., & Appelbaum, Mark I. (1990). Self-Focused Attention in Clinical Disorders: Review and a Conceptual Model. Psychological Bulletin,107(2), 156-176.

Laroi, F., Fannemel, M., Ronneberg, U., Flekkoy, K., Opjordsmoen, S., Dullerud, R., Haakonsen, M., 2000. Unawareness of illness in chronic schizophrenia and its relationship to structural brain measures and neuropsychological tests. Psychiatry Research: Neuroimaging 100, 49– 58.

Lazar, S. W., Kerr, C. E., Wasserman, R. H., Gray, J. R., Greve, D. N., Treadway, M. T., … & Rauch, S. L. (2005). Meditation experience is associated with increased cortical thickness. Neuroreport, 16(17), 1893.

Luders, E., Toga, A. W., Lepore, N., & Gaser, C. (2009). The underlying anatomical correlates of long-term meditation: larger hippocampal and frontal volumes of gray matter. Neuroimage, 45(3), 672-678.

Lysaker, Carcione, Dimaggio, Johannesen, Nicolò, Procacci, & Semerari. (2005). Metacognition amidst narratives of self and illness in schizophrenia: Associations with neurocognition, symptoms, insight and quality of life. Acta Psychiatrica Scandinavica,112(1), 64-71.

Lyubomirsky, S., & Nolen-Hoeksema, S. (1995). Effects of self-focused rumination on negative thinking and interpersonal problem solving. Journal of Personality and Social Psychology, 69, 176–190.

Lyubomirsky, S., Tucker, K., Caldwell, N., Berg, K., & Diener, Ed. (1999). Why Ruminators Are Poor Problem Solvers: Clues From the Phenomenology of Dysphoric Rumination. Journal of Personality and Social Psychology,77(5), 1041-1060.

Perkins, D.O., 2002. Predictors of noncompliance in patients with schizophrenia. Journal of Clinical Psychiatry 63 (12), 1121– 1128.

Peterson, C., & Seligman, M. E. (1987). Explanatory style and illness. Journal of personality, 55(2), 237-265.

Pyszczynski, T., & Greenberg, J. (1987). Self-regulatory perseveration and the depressive self-focusing style: a selfawareness theory of reactive depression. Psychological Bulletin, 102, 122–138.

Rossell, S.L., Coakes, J., Shapleske, J., Woodruff, P.W., David, A.S., 2003. Insight: its relationship with cognitive function, brain volume, and symptoms in schizophrenia. Psychological Medicine 33 (1), 111– 119.

Sapara, A., Cooke, M., Fannon, D., Francis, A., Buchanan, R. W., Anilkumar, A. P., … & Kumari, V. (2007). Prefrontal cortex and insight in schizophrenia: a volumetric MRI study. Schizophrenia research, 89(1), 22-34.

Schultz, W., Tremblay, L., Hollerman, J.R., 2000. Reward processing in primate orbitofrontal cortex and basal ganglia. Cerebral Cortex 10 (3), 272– 284.

Schwartz, R.C., Cohen, B.N., Grubaugh, A., 1997. Does insight affect long-term impatient treatment outcome in chronic schizophrenia? Comprehensive Psychiatry 38 (5), 283–288.

Shad, M.U., Muddasani, S., Sahni, S.D., Keshavan, M.S., 2004. Insight and prefrontal cortex in first-episode schizophrenia. NeuroImage 22 (3), 1315– 1320.

Takai, A., Uematsu, M., Ueki, H., Sone, K., Kaiya, H., 1992. Insight and its related factors in chronic schizophrenic patients: a preliminary study. European Journal of Psychiatry 6, 159–170.

Teasdale, J., & Barnard, P. (1993). Affect, cognition and change: Re-modelling depressive thought. Hove: Erlbaum.

Teasdale, J. (1999). Emotional processing, three modes of mind and the prevention of relapse in depression. Behaviour Research and Therapy,37, S53-S77.

Wallis, J.D., Dias, R., Robbins, T.W., Roberts, A.C., 2001. Dissociable contributions of the orbitofrontal and lateral prefrontal cortex of the marmoset to performance on a detour reaching task. European Journal of Neuroscience 13 (9), 1797–1808.

Watkins, & Baracaia. (2002). Rumination and social problem-solving in depression. Behaviour Research and Therapy,40(10), 1179-1189.

Watkins, E. (2004). Adaptive and maladaptive ruminative self-focus during emotional processing. Behaviour Research and Therapy,42(9), 1037-1052.

Weinstein, N., Brown, K. W., & Ryan, R. M. (2009). A multi-method examination of the effects of mindfulness on stress attribution, coping, and emotional well-being. Journal of Research in Personality, 43(3), 374-385.