There are three major stages of self-awareness along the path to well-being, as summarized in Table 1, based on extensive work by many people, as I have described in more detail elsewhere (7). The absence of self-awareness occurs in severe personality disorders and psychoses, in which there is little or no insightful awareness of the preverbal outlook or beliefs and interpretations that automatically lead to emotional drives and actions. Lacking self-awareness, people act on their immediate likes and dislikes, which is usually described as an immature or "child-like" ego state.
The first stage of self-awareness is typical of most adults most of the time. Ordinary adult cognition involves a capacity to delay gratification in order to attain personal goals, but remains egocentric and defensive. Ordinary adult cognition is associated with frequent distress when attachments and desires are frustrated. Hence the average person can function well under good conditions, but may frequently experience problems under stress. Most people ordinarily think in ways that are defensive, so they frequently struggle to justify why they are right and others are wrong. However, at this stage of self-awareness, a person is able to make a choice to relax and let go of negative emotions, thereby setting the stage for acceptance of reality and movement to higher stages of coherent understanding.
The second stage of self-aware consciousness is typical of adults when they operate like a "good parent". Good parents are allocentric in perspective - that is, they are "othercentered" and capable of calmly considering the perspective and needs of their children and other people in a balanced way that leads to satisfaction and harmony. This state is experienced when a person is able to observe his own subconscious thoughts and consider the thought processes of others in a similar way to his observing his own thoughts. Hence the second stage is described as "meta-cognitive" awareness, mindfulness, or "mentalizing". The ability to the mind to observe itself allows for more flexibility in action by reducing dichotomous thinking (26). At this stage, a person is able to observe himself and others for understanding, without judging or blaming. However, in a mindful state people still experience the emotions that emerge from a dualistic perspective, and so they must struggle effortfully to discipline and control their emotional responses. Such effort is tiring and only partially successful, so mindfulness is only moderately effective in improving well-being (7).
The third stage of self-awareness is called contemplation, because it is the direct perception of one's initial perspective - that is, the preverbal outlook or schemas that direct our attention and provide the frame that organizes our expectations, attitudes, and interpretation of events. Direct awareness of our outlook allows the enlarging of consciousness by accessing previously unconscious material, thereby letting go of wishful thinking and the impartial questioning of basic assumptions and core beliefs about life, such as "I am helpless", "I am unlovable", or "faith is an illusion". The third stage of self-awareness can also be described as "soulful", because in this state a person becomes aware of deep pre-verbal feelings that emerge spontaneously from a unitive perspective, such as hope, compassion, and reverence (7). Soulfulness is much more powerful in transforming personality than is mindfulness, which often fails to reduce feelings of hopelessness (33). However, most people never achieve a stable contemplative state in contemporary societies, which are replete with materialistic and anti-spiritual messages.
Extensive empirical work has shown that movement through these stages of development can be described and quantified in terms of steps in character development or psychosocial development, as in Vaillant's work (34) on Erikson's stages of ego development. Such development can be visualized as a spiral of expanding height, width, and depth as a person matures or increases in coherence of personality. Likewise, the movement of thought from week to week or month to month has the same spiral form regardless of the time scale. Such "self-similarity" in form regardless of time scale is a property characteristic of complex adaptive systems, which are typical of psychosocial processes in general (7). The clinical utility of this property is that therapists can teach people to exercise their capacity for self-awareness, moving through each of the stages of awareness just described. Their ability to do so, and the difficulties they have, reveals the way they are able to face challenges in life.
Based on studies of stages in character development and emotional consistency, I have developed a psychotherapy program that involves a sequence of 15 intervention modules to guide a person along the path to wellbeing (Table 2). These are described as scripts of a dialogue with a patient going through therapy to become more healthy and happy. This therapeutic sequence corresponds to the natural sequence by which a person grows in selfawareness, adapted to provide therapeutic guidance and self-help exercises in a way that will provide systematic progress toward well-being. Each module is about 50 minutes long, suitable for use in a self-help format or as an adjunct to individual or group therapy. It is designed as a universal intervention that can be enjoyed by anyone regardless of his or her level of physical and mental health as long as they have the reading comprehension of an average 14 year old (i.e., eighth grade education). The therapist does not have to repeat instructions or go through standard material, but is free to discuss individualized issues with the patient and suggest applications and homework that is especially appropriate to their particular situation. The pacing of intervals between modules in the series can be determined by the motivation and situation of the patient, and orchestrated by the therapist.
All of the techniques have been tested in clinical work (18), and most have been tested in randomized controlled trials described earlier in this article. A randomized controlled trial of the interventions as a complete set is being planned. It is interesting to note that the first set of modules emphasizes behavioral methods focused on positive emotions along with basic concepts of cognitive processing. The second set of modules goes beyond mindfulness to stimulate deeper meta-cognitive awareness of the perspectives that underlie subconscious thoughts. The third set of modules involves contemplative access to and recognition of the meaning of preverbal symbols by which internal and external influences that are usually unconscious communicate by framing subconscious expectations, as in dreams and some forms of advertising, social movements, and other powerful situations. These stages of therapy correspond to stages of spiritual development but are based on explicit psychobiological principles, as I have described in detail elsewhere (7).
It is my hope that providing an explicit description of a sequence of interventions will help therapists overcome their unfortunate reluctance to attend to their patient's spiritual needs. I have found it possible to be non-judgmental in raising questions about spiritual values for my patients. I emphasize that each person must question all authorities, including me, and focus on providing private exercises by which they can obtain answers for themselves. This allows attention to spirituality based on principles of psychobiology with roots in compassion and tolerance, rather than on the basis of dogmatic judgments that are rooted in fear and intolerance. My experience has been that this has made my therapy more effective and more enjoyable for both my patients and myself. Only by addressing spirituality in a scientific and non-judgmental manner can we make psychiatry into a science of wellbeing that is able to reduce the stigma and disability of mental disorder.
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