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The Clinical Implications and Neurophysiological
Background of Useing Self-Mirroring Technique
to Enhance the Identification of Emotional Experiences:
An Example with Rational Emotive Behavior Therapy
Piergiuseppe Vinai •Maurizio Speciale •Luisa Vinai •
Paolo Vinai •Cecilia Bruno •Marianna Ambrosecchia •
Martina Ardizzi •Shonda Lackey •Giovanni Maria Ruggiero •
Vittorio Gallese
Springer Science+Business Media New York 2015
Abstract Many patients have difficulty recognizing their own emotions. The aim
of the ABC framework of Rational Emotive Behavior Therapy (REBT) is to help
patients identify the emotions (the C) connected to dysfunctional thoughts (B) in
critical situations and inferences (the A). Today, new audiovisual recording tech-
niques can provide patients with a ‘‘mirror’’, where they can view their own
emotions and way of thinking. A videotape of a patient’s face during the session and
the subsequent analysis of emotional sequences can help patients gain awareness of
their emotions. In this case, they do not use their self-reflective abilities, related to
the limbic system, that are frequently impaired in patients affected by psychopa-
thologies. Instead, patients use their automatic and intuitive abilities related to the
Mirror Neurons system that are usually used to understand the thoughts and emo-
tions of others. In this paper, we describe the application to the ABC framework of
REBT to a new video-based protocol based on this theoretical perspective: the self-
mirroring technique. We record patients while they are recalling an emotionally
significant episode of their life. Immediately after, we record their faces while they
are looking at their own image on the screen. Then, we show them the effects of
P. Vinai (&)M. Speciale L. Vinai P. Vinai C. Bruno G. M. Ruggiero
Self Mirroring Therapy Unit, GNOSIS No Profit Research Group, v langhe 64,
12060 Magliano Alpi, Italy
e-mail: piervinai@tin.it
P. Vinai M. Speciale
Studi Cognitivi, Post Graduate Psychotherapy School Research Group, Milan, Italy
M. Ambrosecchia M. Ardizzi V. Gallese
Department of Neuroscience, University of Parma, Parma, Italy
S. Lackey
Psychotherapist in NYC, New York, NY, USA
123
J Rat-Emo Cognitive-Behav Ther
DOI 10.1007/s10942-015-0205-z
seeing their own emotions in action. The aim is to improve patients’ ability to
recognize their own emotions.
Keywords Rational emotive behavioral therapy Mirror neurons Alexithymia
Video feedback Self-mirroring technique
Introspective Abilities and Recognition of Emotions
In this paper, we will present an application of the ABC technique of Rational
Emotive Behavior Therapy (REBT). We will describe a new video-based
methodology developed by Maurizio Speciale and Piergiuseppe Vinai (2013). This
technique involves showing patients the emotions conveyed by their facial
expressions while they are recalling a significant life event.
The ABC framework in REBT consists of asking patients to recall an
emotionally meaningful event and to describe the thoughts and emotions they
experienced. The goal is to make the patients aware of the link between their
thoughts and their emotions and of the emotional consequences connected to the
way, they choose to think about an event (Ellis 1962).
The efficacy of this technique, however, can be decreased by the poor
introspective and self-reflective abilities of some patients. According to DiGiuseppe
et al. (2013), failure to accurately identify the client’s C, including emotions, is a
common problem for REBT psychotherapists. ‘‘Problems in identifying C come
(…) because emotions are a difficult and confusing problem for the client to
identify’’ (DiGiuseppe et al. 2013). Difficulty identifying emotions may exist for
several reasons: mixed functional and dysfunctional emotions, guilt, shame, or fear
about recognizing the emotions and telling them to the psychotherapist; clients who
express little or no emotions; confusion and difficulty in discriminating emotions;
mislabeling or unclear labeling of emotions; tendency to express the C only in
behavioral terms, and so on (DiGiuseppe et al. 2013).
Even some people within a non-clinical sample have been shown to have
difficulty assessing their mental states (Wilson 2009; Wilson and Dunn 2004).
However, over 50 % of the patients seeking for psychological help are affected by
alexithymia, a clinical condition characterized by difficulty in identifying and
describing emotions (Sifneos 1973).
Many patients use generic descriptions when describing their emotions. For
example, they might use the word ‘‘sick’’ to describe emotions such as fear,
anger, excitement, anxiety, and shame (Sassaroli et al. 2006). Patients might also
use the word ‘‘sick,’’ to describe their somatic manifestations: tachycardia,
tightness in chest, or excessive sweating. Other patients report emotions that are
inconsistent with their non-verbal behavior. For example, they might say they are
angry while displaying a sad facial expression. Finally, there is a category of
patients who are able to recognize their own emotions, but are unable to express
them in words.
P. Vinai et al.
123
The Visual Recognition of Emotions: A History
Emotions, can be communicated to other people through non-verbal language:
prosody, posture and facial expressions (Darwin 1872). As stated by Ekman (1985)
‘‘when an emotion arises, facial muscles are activated in an automatic way, they are
directly connected to the areas of the brain involved in regulating emotions, so,
regardless of the degree of awareness of the participant, his face manifests his
emotional state’’. The mimic-facial expression of emotions is a product of evolution,
older than the development of language. Many studies (Ekman 1982,1984) show
that in humans, the basic emotions are marked by specific patterns of genetically
determined expression and that we have an innate ability to recognize the emotional
expressions of others regardless of their age, sex, race and culture. These facial
expressions ‘‘are the richest sources of information about our emotions’’ (Ekman
1984).
Recent studies found that facial mimicry is involved in emotion recognition
(Ponari et al. 2012). Even passive viewing of facial expressions activated a wide
network of brain regions that were also involved in the execution of similar
expressions, including the inferior frontal gyrus/insula and the posterior parietal
cortex (van der Gaag et al. 2007). Wieving emotional facial expressions activate
early somatosensory activity, as opposed to neutral expressions (Ekman 1984; Sel
et al. 2014). This suggests an active and independent role of the somatosensory
cortex during facial emotion discrimination. From a clinical point of view, this
means that for some patients (particularly those with deficits in self-reflective
ability), it is easier to recognize the emotions of others than their own.
The Mirror Neurons System
Mirror Neurons (MNs) (Gallese 2003a,b) discovered for the first time in the ventral
premotor cortex (area F5) of a monkey’s brain (Rizzolatti and Sinigaglia 2007) and
then in other monkey’s motor and premotor brain areas (Gallese et al. 2011;
Vigneswaran et al. 2013) are visuo-motor neurons characterized by a unique firing
pattern. MNs fire both when the monkey performs an action (i.e., goal directed
motor acts) and when the animal observes the same action performed by another.
The existence of MNs in the human brain is now firmly established (Fadiga et al.
1995; Iacoboni et al. 2005). Numerous studies using different techniques like
Functional Magnetic Resonance (fMRI), (Chong et al. 2008; Iacoboni et al. 1999;
Kilner et al. 2009; Leslie et al. 2004; Lingnau et al. 2009) Positron Emission
Tomography (PET) (e.g.; (Decety et al. 2002), and Transcranical Magnetic
Stimulation (TMS). Avenanti et al. (2007), found that in the ventral and dorsal
premotor cortex and in the inferior parietal lobe of the human brain, action
observation and action execution recruit the same neurons. The discovery of MNs
suggests that one possible path to understand others’ actions is based on motor
equivalence between ‘‘what others do’’ and what ‘‘the observer can do’’. The
activity of MNs produces an ‘‘embodied simulation’’ (ES) of observed actions,
(Vittorio Gallese 2013) resulting in a direct, automatic, pre-reflexive and
An Example with Rational Emotive Behavior Therapy
123
unconscious form of action understanding not exclusively dependent upon
mentalistic/linguistic abilities. (Gallese 2003a). Further studies demonstrated that
human MNs, far from being restricted to fronto-parietal motor and premotor
regions, can also be recorded in brain areas involved in other functions such as
somato-sensation and emotions. Both the observation of other people’s hands
(Ebisch et al. 2011), legs (Keysers et al. 2004), neck, or face (Blakemore et al. 2005)
being touched triggers activity in the same brain regions that respond when
participants are touched on these respective body parts.
Emotional brain regions also seem to be vicariously activated while participants
perceive the emotional states of others. While we can directly perceive the actions
of others, we have to deduce their emotions from their actions (e.g. facial
expressions), visible bodily causes (e.g. a syringe penetrating a hand is likely to
trigger pain), or more arbitrary cues such as language (e.g. ‘I’m very sad today’).
Viewing facial expressions that convey emotions, be it disgust (Jabbi et al. 2007),
happiness (Hennenlotter et al. 2005), pain (Botvinick et al. 2005), (Saarela et al.
2007) or a combination of different emotions (Carr et al. 2003), activates regions of
the Anterior Insula and adjacent Frontal Operculum involved in experiencing
similar emotions as triggered by olfactory (Wicker et al. 2003), gustatory (Jabbi
et al. 2007) or painful (Botvinick et al. 2005) stimuli.
It appears, then, that a whole range of different ‘mirror matching mechanisms’
may be present in the human brain. The role of mirror matching mechanisms is
inevitably more extensive than that originally discovered and described in the
domain of action, suggesting that it could well be a basic organizational feature of
our brain, (Gallese 2003a). Embodied Simulation (ES) has become one of the basic
mechanisms through which humans attempt to understand, not only others’
intentional motor behaviours, but also others’ sensations and emotions. ES posits
that like in the case of others’ actions understanding, relied on a basic functional
mechanism which exploits the intrinsic organization of the motor system of
primates (Gallese 2013), others’ sensations and emotions can be ‘empathized’, and
therefore implicitly understood, through the same mirror matching mechanism.
People functionally attribute to others their own mental states or processes
represented in bodily format (Gallese 2003a; Gallese and Sinigaglia 2011;
Niedenthal 2007). This implicit, automatic, and unconscious process of ES enables
the observer to use his/her own resources to penetrate the world of the other without
the need of explicitly theorizing about it (Gallese and Goldman 1998; Goldman and
Gallese 2000; Umilta
`et al. 2001) Mental states or processes are embodied insofar as
they are represented in a bodily format. The same content, such as an action, a
motor intention or a mental state, can be represented in a propositional format or in
an bodily form,
1
but it is the latter one that phylogenetically and ontogenetically
precedes the first. Accordingly, it has been demonstrated that the recruitment of the
motor simulation mechanism provides an input to ‘mentalizing’ (Keysers and
1
Following the embodied simulation theory, the view of a movement induces an automatic micro-
contraction of the same muscles of the body of the observer, that simulate the observed action. The brain
of the observer ‘‘reads’’ the movements of these own muscles to understand the meaning of the observed
movement. More usual are for the observer these movements, more he will be able in reading the
intentions of the person he is observing. (Gallese 2013).
P. Vinai et al.
123
Gazzola 2007). ES neither provides a general Theory of Mind (ToM) reading, nor a
mental simulation covering all types of simulation-based mindreading. ES aims to
explain the MNs and related phenomena, suggesting that there are several ways of
understanding others:
Clinical Implications
In the therapeutic setting, however, patients primarily deal with their own emotions,
trying to recognize and connect each emotion to the thought generating it. Difficulty
in recognizing and managing emotions is a primary problem in many psychopa-
thologies, mainly anxiety disorders (Karukivi et al. 2010; Zeitlin and McNally
1993) depression, (Celikel et al. 2010; Da Ros et al. 2011; Honkalampi et al. 2000),
eating disorders (Guilbaud et al. 2000; Schmidt et al. 1993; Speranza et al. 2007),
somatoform disorders (Pedrosa Gil et al. 2009) and personality disorders (Loas
2012; Loas et al. 2012).
For example, anxious patients may perceive themselves as frail and consider the
world full of danger. Frequently, though, they do not recognize their emotion as
fear, since they have a selective attention to this emotion’s somatic components,
such as an increase in their heartbeat and/or the chest tightness. This creates a
vicious circle in which the emotion is not recognized and is misunderstood as a
symptom of a physical illness, further generating fear (Sassaroli et al. 2006).
Among patients affected by major depression, alexithymia contributes to the
emergence of somatic symptoms (Gu
¨lec¸ et al. 2013). Difficulty in identifying
feelings has been found to be predictive of the severity of residual symptoms of
depression after psychotherapy, over and above the initial levels of depression, the
type of therapy and the use of antidepressant drugs. This suggests that difficulty in
identifying feelings may constrain the ability of patients to effectively utilize
psychotherapy (Ogrodniczuk et al. 2004).
Keating et al. (2013) discovered a relationship among alexithymia, attachment
insecurity and body esteem in women with eating disorders. Moreover, among
patients affected by eating disorders, the levels of alexithymia are related to those of
anhedonia (Deborde et al. 2006) and seem to have an influence on their treatment
choice and level of compliance (Speranza et al. 2011).
Patients with Borderline Personality Disorder (BPD) and Avoidant Personality
Disorder (APD) have higher levels of alexithymia than healthy participants. Patients
with BPD are highly responsive to the feelings of others, but are impaired in
identifying/describing feelings and in taking the perspective of others (New et al.
2012).
Unfortunately, alexithymia is a stable personality trait. In a large sample of
patients affected by different psychopathologies, highly significant correlations
occurred between scores on Toronto Alexithymia Scale-26 before and after
psychotherapeutic treatment (Stingl et al. 2008). The ABC method is a very
powerful tool in helping patients recognize their emotions, sometimes they have
difficulties labeling them, generically state that they ‘‘feel bad’’, while, their faces
synchronously take on a well-defined typical configuration of fear: raised eyebrows
An Example with Rational Emotive Behavior Therapy
123
and eyelids, eyes open and tense, taut lips with mouth half open…. In the
therapeutic setting, since the patient cannot see his face, the only one who receives
this signal is the psychotherapist. To remedy this situation, Ekman (1984) suggested
‘‘to put a mirror in front of the patient to allow him to have a clear information of
the emotion he is feeling’’. A real attempt to explore those innate abilities that allow
understanding the emotions of others has never before been done in REBT.
New technologies allow patients to have a virtual mirror in front of them
(Speciale et al. 2014). Observing the video recordings of the sessions, patients
recognize their own emotions (manifested, for example, during an ABC) starting not
‘‘from the inside’’ via the self-reflective and introspective capacity (which, as we
have seen are often impaired), but from ‘‘the outside’’ observing their facial
expressions. The participants use the Mirror Nneuron system, which is normally
involved in understanding the emotions of others. Many studies have found that the
Mirror Neurons system is not impaired in patients who have great difficulties
managing and recognizing their emotions. In a electromyographic study (Matzke
et al. 2014) 28 female BPD patients and 28 healthy controls underwent a facial
recognition task with dynamic facial pictures while facial muscle activity was
recorded. There were no differences in emotion recognition performance or
intensity ratings. Moreover, it has been reported that patients with Borderline
Personality Disorder performed significantly better in the detection of positive and
negative facial expressions compared to the healthy controls (Schulze et al. 2013).
Patients with somatoform disorders (SFD), however, exhibited elevated alexithymia
symptoms relative to healthy controls and recognized significantly fewer emotional
expressions. The difference in emotion recognition accuracy became non-significant
once the influence of alexithymia was statistically controlled, suggesting that the
deficit in facial emotion recognition was mostly a consequence of concurrent
alexithymia (Pedrosa Gil et al. 2009).
These results support the theory that facial recognition in BPD is not impaired
and that there is a reduced facial response to positive social signals and increased
facial response to negative social signals. During a session of Self Mirroring
Therapy, it is easy for patients to see this bias. We propose that gaining awareness
of such a bias can help patients deal with the difficulties in social interactions
frequently reported by patients with this disorder.
Self and Other Recognition: Neurophysiological Background
Viewing our own face is even more effective in activating mirror neurons than
viewing the face of another person. (Uddin et al. 2005). A right fronto-parietal
network is activated specifically when participants view images of their own faces,
rather than the faces of other people (Platek et al. 2006; Serino et al. 2008). This
brain network includes areas that are part of the Mirror Neuron system (Serino et al.
2008). This could be explained by the fact that the mirror system becomes more
active when the participant observes an action that he already knows. For example,
in a classical dancer, mirror neurons are more activated when the participant sees a
classical ballet than when he looks at modern dance (Calvo-Merino et al. 2005). The
P. Vinai et al.
123
observation of facial expressions belonging to the motor repertoire of the observer
induces a higher activity of mirror neurons (Iacoboni 2008). The image of our own
face on the screen perfectly matches the image of our real face, so we hypothesize
that it induces a strong activation of the mirror neuron system. (Serino et al. 2008).
Effect of Videotaped Images On Emotion Recognition
While the image reflected from the mirror is synchronic with the movements of the
participant, the videotaped image is not related to the current behavior of the patient.
The image creates a gap between the observer and its image in the video. This
technique is used in the session to help patients be in an ‘‘external position’’ from
which they can observe their own thoughts and emotions from a new perspective—
as if they are looking at themselves as characters in a movie.
Distance from their emotions and thoughts allow patients to increase their
metacognition, which is necessary to change their behavior (Sassaroli et al. 2006).
In addition, patients looking at the video can compare the image of themselves in
their mind with the real image seen on the screen. This mechanism is well known
and is already used in a video-feedback technique to improve self-perception in
individuals with social anxiety disorder (Harve et al. 2000; Rapee and Lim 1992).
This technique is based on the hypothesis that when people with SAD have to
perform in public (e.g.; give a speech), they have negative perception of themselves
and overestimate their flaws (Clark 2001; Clark et al. 2003). Observing their
performance through video informs them of their actual behavior, ‘‘restructuring’’
the negative image they have of themselves (Clark 2001). Receiving information
that is not compatible with their own schemas allows them to change their own
mental image (Moscovitch et al. 2008).
Self Mirroring Technique involves a similar mechanism (Vinai and Speciale
2013). However, comparison between the self-image and the one seen in the video
is not about a specific kind of performance (such as speaking in public) but focuses
on his way of thinking and feeling emotions. When patients look at themselves
recalling an emotionally engaging episode, they do not just passively remember that
moment, but observe it as it was happening again. This allows patients to look at
themselves from another point of view: suffering is not the same as observing
ourselves while we are suffering. In the latter case, the patient sees the sadness
painted on his face and, at the same time, hears his own voice expressing negative
thoughts. Moreover, even in patients who are already aware of their negative
beliefs, self-observation allows them to achieve deeper insight into their way of
thinking. To think ‘‘rationally’’ that we are not worthy is very different from having
the experience of observing ourselves saying ‘‘I am not worthy!’’ To start to change,
patients must experience an intellectual awareness (Safran 1990). Patients ‘‘see’’
their mental mechanisms ‘‘in action’’ and this allows them to reach a deeper level of
awareness of their own emotions, way of thinking and, more generally, their way of
being in the world. Furthermore, through Self Mirroring- based ABC, patients see
what happens during a session in the ‘‘original version’’ not filtered by the words of
the psychotherapist. Patients evaluate and process everything according to their own
An Example with Rational Emotive Behavior Therapy
123
pattern, without an external interference. As a result, patients can more easily
compare what they ‘‘think’’ of themselves with what they ‘‘see’’ on the screen. If the
video provides dissonant information regarding the vision the patients have of
themselves, patients will be influenced to update their thoughts about themselves
based on the new information seen in the screen.
Self Mirroring-Based ABC: The Clinical Protocol
SMT is not a form of psychotherapy in itself but a technique that can be used in
many types of psychotherapy including the REBT. It was not created as an
alternative to classic psychotherapy or as a tool that has to be used in all the sessions
for the entire course of the psychotherapy. It is designed to be used when it is
needed and its main purpose is to help patients who have difficulty recognizing
emotions.
Setting
SMT is performed in a face-to-face setting. Psychotherapists have a PC in front of
them, (we suggest using a laptop, because placing a bigger screen between the
patient and the psychotherapist could induce a sense of division between the two),
near the psychotherapist, in front of the patient, there is a bigger screen in which
patients can see the recorded videos. On the screen there is a webcam used to record
the patient’s face. A sound recording system with two speakers is placed next to this
screen to allow patients to hear their recorded words.
General Instructions to the Patients
At the beginning of the session, we inform patients that they will be videotaped. We
explain the rationale, obtain consent and say them that the video will be deleted at
the end of the session, however, if they want, they can take home the recorded
material. At the end of each session, if patients don’t ask to bring the videos at
home, we delete them in front of the patient To explain the rationale of our method,
we usually use sentences like these:
As you can see, here we have a webcam—two speakers and a screen. We are
using this setup to test and improve the efficacy of psychotherapy. We will video
record the sessions because we are able to recognize the emotions of others better
than we understand our own emotions. Haven’t you ever said to someone, ‘‘Look at
your face! You don’t really believe what you are saying!’’ People can lie, but their
face will often reveal the truth. Sometimes our faces reveal emotions that are
unknown also to ourselves. In these cases, the video is of great help. Do you agree to
use this method? If you do not agree, we will perform our sessions as usual, but it is
my duty to inform you that even if there are not yet randomized control studies on
this technique, in my experience this method improves the efficacy of psychother-
apy. I can do as you prefer.’’ In our personal experience, no one has either refused
our approach or claimed to have any difficulties in understanding the rationale of
P. Vinai et al.
123
our method. Last but not least, psychotherapists have to comply with any laws or
ethical guidelines that exist in the jurisdiction within which they practice concerning
this digitally recorded material in the sessions.
Phase 1: Creation of VIDEO #1
If the patient accepts to be video recorded, the session begins as usual. As the
psychotherapist identifies an unresolved issue in which the patient is not fully aware
of his feelings and thoughts, the psychotherapist asks the patient to recall a specific
episode related to that issue. The psychotherapist then uses the ABC schema (Ellis
1962) and the patient is video recorded while recalling the episode. This recorded
material is VIDEO #1.
We say to the patient:
Think back to an episode relevant to the issue of which you have just spoken
and describe it.
At the end of the re-enactment, we perform an ABC on the event that was just
described by asking: ‘‘Which emotions are you feeling?’’ ‘‘What are you thinking at
this moment?’’
While the patient is speaking, the clinician focuses on discrepancies between the
patient’s words and the emotions conveyed by facial expressions. The psychother-
apist invites patients to clarify those discrepancies. If he asks patients to remember
specific scenes they have lived, this will be useful in helping them to feel the
emotions similar to the emotions they felt at that time. For example:
A patient said that he was happy when his mother left him alone when he was
5 years old, because he could watch the TV all day, But his face did not convey
happiness while recalling those episodes. So the psychotherapist said:
‘‘You told me that you were happy when your mother left you alone, but what did
you feel when she closed the door and turned the key into the lock? What did you
think in that moment?’’ At this point, the psychotherapist asked the patient to
perform an ABC on that episode.
If discrepancies arise in the patient’s speech or between his words and his
emotions, psychotherapists can use phrases like:
‘‘Excuse me, but I did not understand…first told me that…and now he says I
wanted to understand better…’’ or (to a patient expressing clear signs of anger who
is affirming to be calm and serene): ‘‘So theseare your facial expressions when you
are calm and quiet?’’
When we recall an event, we do it based on our current beliefs and emotions, and
then, inevitably, we tend to enhance certain aspects and exclude others (Stern 2004).
If the current emotion is congruent whit that felt in that moment, there is an increase
in the intensity of the remembered emotion. rThe emotions we experience
remembering the slice of Sacher torte
eaten in Wien 1 year ago is different if we
are hungry versus while we are vomiting. Psychotherapists’ task is to bring out the
details that are incongruous with the mental image of a specific episode. Awareness
of these incongruences has a great therapeutic role in helping the patient to discover
the lies he is telling to himself: ‘‘it is often a discrepancy between words and voice,
An Example with Rational Emotive Behavior Therapy
123
gestures and facial expression, to betray a lie’’ (Ekman 1985). This helps patients
look at the episode from a point of view closer to reality. Patients can then change
the image they have of themselves and others. The psychotherapist has to be very
attentive to both the patients’ verbal and the non-verbal communication, identifying
both the contradictions and the inconsistencies between words and non-verbal
messages.
Then the psychotherapist, starting from what the patient says while looking at the
video, makes a laddering, in order to identify the patient’s core beliefs. The phrases
typically used are:
What do you not like if…?
What happens if…?
As soon as psychotherapists complete the laddering, they stop recording the
patient. This point ends the creation of VIDEO # 1.
Phase 2: The patient looks at VIDEO #1 and creates VIDEO # 2
Now the psychotherapist invites the patient to look at the just recorded VIDEO #1.
Delivery to the patient:
Look at the screen and try to observe yourself as you were looking at a friend.
The setting is designed to maximize the decentralization and the discrepancy
between patients and their image seen in the video, thus enhancing the therapeutic
effect of video-feedback (Harve et al. 2000).
As soon as the patients have watched VIDEO #1, they are asked to perform an
ABC, where A is the experience of watching VIDEO #1. In addition, the
psychotherapist encourages the patient to reflect on the meaning of the discrepancies
found between the emotions listed in the ABC and those actually observed in the
screen. More generally, the psychotherapist discusses the inconsistencies between a
patient’s words and facial expression.
Delivery to the patient:
Which emotions did you feel watching the movie?
What did you think seeing yourself on the screen?
Did you recognize on your face emotions that you had not perceived before?
Then the psychotherapist can ask:
What would you say to the guy on the screen?…What would you advise him?
These questions try to induce patients to give themselves suggestions and self-
instructions, like:
You have to get your point across …you cannot go on like this…you have to
react…
P. Vinai et al.
123
While patients are watching VIDEO #1 (including the subsequent ABC and any
other questions asked by the psychotherapist) the psychotherapist videotapes their
face. This second recorded part of the session is VIDEO #2.
Phase 3: The patient looks at the VIDEO #2
As soon as the patient finishes commenting on VIDEO #1, the psychotherapist
shows VIDEO #2 to the patient, usually introducing it with a sentence like this:
Now I’ll show you your face when you were looking at the screen.
Then patients look at the screen, showing their face as they were looking at
VIDEO #1 (and listening to the words they were saying in the VIDEO #1). In this
way, patients can see the different emotions caused by seeing and listening to
different parts of their speech.
Looking at these emotions helps patients become more aware of their feelings
recalling that episode. During this phase, emotions differ from those seen in VIDEO
#1. For example, a patient in VIDEO # 1 was very sad recalling when her husband
left her, but in VIDEO #2 she displayed an emotion of compassion towards herself
and of anger towards the partner. The awareness of her angry (that she for the first
time has seen in the VIDEO #2) informed the patient about her feelings toward the
partner, she became aware of how she despised him and wondered how she could
have maintained a relationship that was so unpleasant. This helped her to discuss the
dysfunctional beliefs driving all her relationships: ‘‘I am not able to live alone, I
need a man to sustain me!’’
Phase 4: Discussion and Elaboration of the Emerged Material and Prescription
of Home Work
Finally, the psychotherapist asks the patient to perform an ABC where A is the
experience of watching VIDEO #2. The psychotherapist asks the patient to reflect
on what emerged so far. Moreover, the psychotherapist and the patient discuss
together what happened during the session. At the end of the session the
psychotherapist assigns homework consisting of responding in writing to questions
like those listed below. Questions are chosen based on the content of the session.
Did you learn new information about yourself? If so, what?
Did you learn new information about your way of seeing things? If so, what?
Did you learn new information about your way of thinking? If so, what?
Did you learn new information about your way of expressing your emotions?
If so which ones?
Did you learn new information about your way of reacting to certain situa-
tions? If so, what?
Did you learn new information about your way of looking to others? If so,
what?
Do you think that in the future you could use what you learned to deal with
similar situations?
An Example with Rational Emotive Behavior Therapy
123
The answers to these questions are discussed in the following session. Studies on
memory processing suggest that in order for new information to be internalized,
images have to be interpreted at a deep level in order to derive new meanings (Craik
and Tulving 1975). This process of elaboration and reflection is carried out in order
to consolidate and strengthen the internalization of new information that emerged
from viewing the videos (Orr and Moscovitch 2010).
Phase 5: Creation of VIDEO #3
In the next session, after commenting on the patient’s homework, the psychother-
apist makes a new video, recording the patient when recalling again the episode
described in VIDEO #1. Then, the patient is asked to do an ABC assessing emotions
and thoughts induced in the ‘‘‘Here and Now’’ by the memory of the episode. All of
this recorded material will be the VIDEO #3.
Delivery to the Patient
Could you please describe again the episode that you told me in the last
session…which emotions are you feeling thinking about it now? How would
you behave in that situation now?
Then the psychotherapist shows the patient VIDEO #1 and immediately after,
VIDEO #3. The patient is asked to compare what is seen in both videos and the
ABC performed in VIDEO #1 and #3, both related to the same event. These
procedures will be repeated during the course of the psychotherapy until patients
acquire better knowledge of the influence of their dysfunctional beliefs on their life.
Viewing these videos allows patients to see with their own eyes ‘‘the inconsistency
of the evidence in which dysfunctional beliefs are based.
Practical Considerations on the Use of the SMT
Maurizio Speciale and Piergiuseppe Vinai, developed and use the SMT with their
patients since 2011. They consider it for all the patients having difficulties in
recognizing and managing their emotions. Until 2013, they used the SMT mainly
for patients affected by anxiety, mood disorders, eating disorders, obsessive
compulsive disorders, post traumatic disorders and relational problems.
To date, no patient has refused it, on the contrary, in the last year, many patients
requested SMT. In the last 6 months, they began to use it with selected patients
affected by personality disorders, and had promising clinical results. However, there
are not enough of data on efficacy and safety of SMT in this field, so they do not
suggest the use of SMT with these patients.
In the authors’ clinical experience one session of SMT usually increases patients’
self-awareness and induces them to change their vision of the episode, but more
sessions of SMT are needed may to have a stable and significant effect. Usually we
use the SMT method once a session, to avoid an excessive interference with the rest
P. Vinai et al.
123
of psychotherapy. However, in several cases, we used it twice and occasionally
three times in the same session. This choice has to be carefully evaluated because
there might not be enough time for the other part of the psychotherapy in the
session. During the course of the psychotherapy we use the SMT all the times we
need to help the patients in managing/recognizing, their emotions: in average once/
twice a month.
We have noticed that the effectiveness of SMT is based on the personality of the
patient, the severity of the psychopathology and wether patients have lower levels of
emotional awareness or more difficulties in managing emotions using a verbal
approach. Patients with both types of emotional difficulties affirm that the use of
SMT enabled them to see on their faces emotions that they didn’t know they had.
To date our clinical judgment is the only instrument we had used to decide when
to include the SMT in the psychotherapy. We used it when we thought: ‘‘How can I
show you the emotions that you are denying?!’’ In the same way, we stopped using
it when the patients became aware of their emotional states and of the beliefs
inducing them. Our decision is guided by criteria similar to those we use in deciding
when to apply the ABC method in the psychotherapeutic setting.
Efficacy of the SMT: Current Knowledge and Future Research’s Fields
Since 2010, Speciale and Vinai (proceedings of the 15th national conference of the
Italian society of Cognitive, Beavioral Therapy (SITCC)) compared the effect of a
single session of SMT (15 min long without any input from the psychotherapist)
versus a session of 1 h performed by a teacher of the (SITCC) using the classic ABC
technique in improving the ability of twelve students volunteers, six males and six
females, with anxiety disorders to recognize their own emotions. They were asked
to recall an emotionally significant event: (the first episode in which they
experienced a high level of anxiety. The psychotherapist then asked them to label all
the emotions they felt in that moment. Then they were divided in two groups
comparable for age, sex and years in college and levels of anxiety evaluated via the
self-rating anxiety scale, Then the groups were randomly assigned to an individual
treatment using the classic ABC technique or to a SMT individual setting. Both the
groups had the same psychotherapist. In the second session each of them was asked
to recall the episode again: one group made an ABC on it, while the other group
completed a session of SMT. After the sessions both the groups of patients were
able to recall a greater number of emotions, but patients treated in the ABC
condition reported significantly fewer emotions and were less accurate (p\0.005)
in labeling them than were patients treated with SMT (SITCC 2010).
Further empirically based case studies of SMT are needed to test the efficacy and
the efficiency of the method. It would be useful to record psychotherapy sessions
and measure whether the accuracy of patients’ reports of their emotions matches
their facial expression before and after the use of SMT. Researchers should also
determine whether accuracy is higher in those who have had SMT compared to
those who have not.
An Example with Rational Emotive Behavior Therapy
123
Self Empathizing: A Possible New Field of Applications of the SMT: A Case
Study
The application of the SMT that has the most potential is using it to help patients
recognizing their own emotions. In this case study, we show another possible
application of SMT using it to help clients improve self-compassion.
Mary was a 40-year-old girl seeking treatment for depressive symptoms, which
were caused by the sudden death of her 9-year-old daughter. Mary was alone at
home with her daughter when te daughter began to complain of headache. The
mother did not initially believe her daughter; she thought it was an excuse not to go
to school and scolded her. Within few minutes, moreover the daughter passed out
and died. Her death was due to a ruptured brain aneurysm. Mary blames herself for
not believing her daughter and for not calling a physician immediately. Mary started
psychotherapy more than 2 years after the death of her daughter. ‘‘I have a sin so
great that my life will not so long enough to forgive me!’’ She said. In early
sessions, the psychotherapist worked on the guilt of the patient, attempting to
change her dysfunctional thinking. ‘‘I am responsible for the death of my daughter, I
did not believe her and I did not help her’’, the patient thought. She had no particular
difficulty in recognizing her own emotions, so the psychotherapist decided not to
use the SMT in early sessions. However, during the first session, the psychotherapist
suggested to the patient the possibility of using SMT in subsequent sessions.
After three sessions the psychotherapy was stalled. The patient stated: ‘‘I
understand that even if I immediately asked for help for my daughter, it would not
have changed anything. But in my hurt, I am unable to forgive myself!’’ At this
point in psychotherapy, the psychotherapist decided to use SMT to test if the image
of Mary’s suffering face could be useful in helping her to stop judging herself. The
psychotherapist asked Mary if she wanted to be filmed as she told again the story of
the death of her daughter. She agreed and began to speak in a tone of voice that was
cold and detached. She displayed a very angry look, emphasizing more of her
alleged sins: ‘‘I should have realized right away! A child does not scream like that
for a headache!’’ When she saw the video recording, a look of intense astonishment
came over her face and, immediately after, her eyes filled with tears. In phase 3 of
the SMT, again she saw her face and began to sob and then to cry very hard, to the
point that the psychotherapist asked her if she wanted to stop watching the video.
Surprisingly, she said ‘‘No! Indeed, it does me good!’’and begged him not to
interrupt. At the end of the session of SMT, the patient explained that her tears were
not due to the thought of her daughter’s death: ‘‘I’m used to that, I’ve been living it
for over 2 years!’’, but because, ‘‘I had never seen my face so sad!’’ The
psychotherapist made a still image of Mary’s sad face in the video and asked her to
talk to the person on the screen as if it were a dear friend. She said, ‘‘Enough! You
have suffered enough! Torment you do not have more, do it for your husband and
your son. You cannot expose them to this pain every day!’’ In the following
sessions, the patient realized that even though she had attributed her pain only to the
sorrow for the death of her daughter and the sense of guilt for having scolded her a
few moments before she died, there was another reason behind her sadness: ‘‘I force
myself to suffer because it is not right that I returned to living a normal life while
P. Vinai et al.
123
my daughter is no longer here.’’ Seeing in the first video the hardness in her face and
in the second the pain in her own words, she felt guilty about what she was doing to
herself. ‘‘Seeing my eyes hard and the guilt, I felt like an executioner. But not this is
what I want for myself and my family!’’
The rest of the psychotherapy focused on understanding and changing Mary’s
dysfunctional thinking: ‘‘I cannot survive my serious error.’’ Psychotherapy helped
Mary accept her mistakes, a necessary step in order to improve herself. SMT was
not used again with this patient. However, when she was having trouble accepting
herself the memory of her face on the screen was recalled several times by the
patient during the psychotherapy.
Conclusion
If a psychiatrist gives a drug to a patient, he or she will typically be able to answer
the question: ‘‘How do you think this pill will interact with my brain?’’ In the same
way, if we think that the psychotherapy is a scientific approach to the psychological
pain, any new therapeutic approach should be able to answer to the question: ‘‘How
will this affect the brain of your patient?’’
Understanding the neuropsychological mechanisms underlying the efficacy of
psychotherapy was one of the intentions of psychotherapy since its beginning. At
the end of the 19
th
century, Sigmund Freud, a neurologist, theorized his model of the
brain divided into three parts instinctual, rational and ethical in perpetual conflict
but subsequent research did not confirm that model. In following years, researchers
rarely followed this road, probably because their knowledge of brain functioning
was not sufficiently accurate to allow understand what happens in our brains when
we speak with psychotherapists. Today, increased knowledge of brain functioning
allows us to try to answer this question.
In summary, the SMT is the one of the first attempts of helping patients to
recognize their own emotions using the neuro-scientific knowledge on MNs. The
technique can be used to further improve the efficacy of well-known psychother-
apies, as the REBT. Randomized control trials are needed to test the power of SMT
in supporting classical therapeutic approaches.
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An Example with Rational Emotive Behavior Therapy
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