980 likes | 1.13k Views
Conceptualizing and Treating Self-Identity Problems Associated with Emotionally Dysregulated Personality Disorders. John Livesley livesley@mail.ubc.ca. Components of the Self. Self as a three-component structure: Centre of reflective self-awareness
E N D
Conceptualizing and Treating Self-Identity Problems Associated with Emotionally Dysregulated Personality Disorders John Livesley livesley@mail.ubc.ca
Components of the Self • Self as a three-component structure: • Centre of reflective self-awareness • Knowledge structure consisting of self-referential knowledge • Centre of agency and self-regulation • Identity: elements of self-referential knowledge that defines who the person is in the context of his or her major social units and groups
A 40 year-old woman with emotional dysregulation or borderline traits I don’t know what to say about myself. It’s difficult. I’m not sure who I am. My ideas about myself change all the time. My life is not a movie. Everything is a series of snapshots. I don’t know where I am in them. Sometimes I feel all right and I’m able to cope well but then it all comes crashing down. I don’t know why. I get overwhelmed and I can’t think. As a result I give up. I am not sure about anything else.
Two patients with borderline pathology • I think that I am a nice person. I am moody. I live alone. I can’t find a job. I am unemployed. I have a cat that I am very fond of. I don’t know what else to say about myself. There is nothing else about me. • There are only a few things that I am sure of about myself. I would not kill anyone. I like dogs—in fact all animals. I like music. I like the color green. This is how I felt when I was four. It’s as if I have not changed. I got stuck.
A young woman with eating disorder and emotional dysregulation or borderline personality I is a fallacy of sorts. I is an infinitely deconstructionable conglomeration of shreds and patches, the mental picture of being ‘under erasure,’ as always having an X marked through it. I is a piece of abstraction, it is a kind of tense numbness or void where I seem to willingly hide but am almost unable to extract myself from.
Summary • Limited knowledge about the self – “I do not know who I am” • Confusion about self attributes • Uncertainty about whether “self” exists • Sense of inner void or emptiness – “There is nothing inside” • “Existential angst” – being is painful
Summary • Limited knowledge about the self – “I do not know who I am” • Confusion about self attributes • Uncertainty about whether “self” exists • Sense of inner void or emptiness – “There is nothing inside” • “Existential angst” • Lack of continuity to self experience: “No memory” • Sense of self dependent on others: the “as-if” personality (Deutsch, 1942) • “Borrowed identity” • To treat these problems we need a conceptual framework to understand them
Self Pathology: Does it matter? (1) • To treat borderline personality do we need to treat self pathology? • The evidence suggests we do: • Results of outcome studies: residual pathology • Longitudinal studies and persistent problems with social adjustment • Difficult to account for the organization of personality without a concept of self • Increasing focus on personality as a complex dynamic processing system • Self as a personality sub-system concerned with self-regulation
Self Pathology: Does it matter? (2) • People construct self-narratives (McAdams, 2008) or a theory about themselves (Epstein) that influences many aspects of their behaviour: • Operations of the self system • How the self system is elaborated – self regulates its own development (McAdams et al., 2006; Swann & Buhrmester, 2012) • Acquisition of goals, values, motivations • Interpersonal relationships (Cantor et al., 1991) • Construction of personal niche (Tesser, 2002) • Importance of downward regulation and explanation
Treatment of Self Pathology • Two Components: • Explicit model: • This model must inevitably be complex • Personality is a complex system • No reason to assume that disordered personality is any less complex • Conceptual model of the self must also be complex • Set of treatment strategies: • Treatment strategies are usually straightforward • The challenge is to implement these strategies consistently
The Personality System Environment CT/SFT Trait System Self System DBT Knowledge Systems Interpersonal System Regulatory and Control Systems TFT MBT Basic Processes Memory/Attention Metacognitive Processes
Significant Historical Developments (1) • Contemporary study of the self began with William James (1890) who distinguished between: • The self as knower • The self as known
Significant Historical Developments (2) • Symbolic interactionists – self as an interpersonal phenomenon: • Cooley (1902): “the looking glass self”; “self…. appears in a particular mind” • Each to each a looking glass/Reflects the other that doth pass” • G.H. Mead (1934): “taking the role of the other”; “generalized other” • Impact of behaviourism
Significant Historical Developments (3) • Clinical interest in the self: • Carl Rogers (1951): importance of the self in self-actualization and fulfillment • Problem of the homunculus: • Pseudo-explanation • Self-agent that “pulls the strings” • Psychoanalytic contributions: • Erikson and stages of identity • Self Psychology: • Kohut (1971): cohesiveness of the self: importance of mirroring (looking glass self) • Object relations theory: • Early work of Fairbairn and Guntrip • Kernberg (1984): identity diffusion
Significant Historical Developments (4) • Impact of the cognitive revolution: • Social cognition and the self • Growth of research on self as known • Solution to the homunculus problem • Emergence of “self as agent”
Significant Historical Developments (5) • Evolution and the Self: • What does the self do? • Why did it evolve? • How did it enhance adaptation? • What evolutionary pressures brought about the self system?
Contemporary Approaches to the Self • Self as knower: Experiential or ontological self • Self as known: Cognitive or known self (Self-knowledge) • Self as agent: Executive self: Self as a centre of self regulatory action (Self as “doer” or decision-maker) Leary and Tangney, (2012). Handbook of Self and Identity. New York, Guilford
Structure of the Self System Experiential Self Differentiation Self-Knowledge Integration Cognitive Self Self-Appraisal Agentic Self
Structure of the Self System Experiential Self Differentiation Self-Knowledge Self-Reflective Thought Processes Integration Cognitive Self Self-Appraisal Agentic Self Borderline personality involves Impairments in all components of the self
Structure of the Self 1. Self as Knower Experiential or Ontological Self
Experiential or Ontological Self • Critical dimensions: • Personal unity, coherence, wholeness • Continuity and historicity • Authenticity and genuineness • Clarity and certainty
Impairments to the Experiential Self • Impaired sense of unity: • Fragmentation of self experience • No “inner sense of self” • Impaired sense of continuity: • Sense of living only in the moment • Difficulty integrating the past and past experiences • Lack of Authenticity: • Uncertainty about personal qualities • Doubts about the genuineness of emotions and other experiences • Lack of clarity and certainty: • Difficulty defining and describing personal qualities
Authenticity • Authenticity is experienced when persons feel: • They are the authors of their own actions: • Importance of fostering self-efficacy and agency • These actions are internally caused • Importance of a collaborative alliance • That there was a choice: • Problem solving and the generation of alternatives
40 year-old woman with emotional dysregulation or borderline personality: I don’t know what to say about myself. It’s difficult. I’m not sure who I am. My ideas about myself change all the time. My life is not a movie. Everything is a series of snapshots. I don’t know where I am in them. Sometimes I feel all right and I’m able to cope well but then it all comes crashing down. I don’t know why. I get overwhelmed and I can’t think. As a result I give up. I am not sure about anything else. Impaired Experiential Self:
Session A P: How do you get from one day to the next? Difficult to connect one day to the next. I never feel the same person. Having you in my life provided me with what I did not have before – some kind of connection. You do not change a lot. Your attitude does not change. This has helped me … to be more stable. To deal with my loss of my self. When seeing you, you provided something external that I did not have – that I have not given myself. You are like a crutch. An identity. Really it is like a borrowed identity, a borrowed self. This helped me especially when I felt that I could not get from one day to the next. Or, the next month. I knew you would be there and the same. Now I can do it for myself. It is like a basic model – I don’t know about model – motivation – a way of thinking. T: It helped that I was always the same.
Session B: The next session 3 weeks later P: I wonder what gets someone form one day to the next. What gets me from one day to the next is reading. I have no self and no memory of my life. That’s why I see you. You’re the memory bank. You remember. You recognize me and understand what I’m saying. You remember. That makes me feel stable. If I am not sure if I have a self – I begin to feel I have a self in response to you and what you do. T: Meeting with me gives you a sense of continuity – you exist across time. P: Hmm, it is like reading. I only read to understand. I’m reading about Galileo (as she walked to the office she showed me a substantial academic tome). I read to understand --- I’m reading to understand him and his historical context. It helps me to get from one day to the next. T: Your reading is the thread.
Experiential Self: Clinical Strategies • Impaired sense of unity: INTEGRATE; LINK AND CONNECT • Fragmentation of self experience PROMOTE SELF REFLECTION • No “inner sense of self” • Impaired sense of continuity: THERAPIST AS INTEGRATIVE AGENT • Sense of living only in the moment “PRESENCE OF THE THERAPIST” • Difficulty integrating the past and past experiences • Lack of Authenticity: VALIDATION • Uncertainty about personal qualities • Doubts about the genuineness of emotions and other experiences • Lack of clarity and certainty: DECONSTRUCT GLOBAL EXPERIENCES • Difficulty defining and describing personal qualities
Structure of the Self 2. Self as Known Self as a Knowledge System
Self as Known • Self-referential knowledge system • Critical dimensions: • Degree of differentiation of self-knowledge • Degree of integration of self knowledge to form coherent sense of self • Need for a construct to describe units of self-knowledge (and personality)
Concepts Used to Describe Self Structures • Object relationships (Fairbairn, 1951; Guntrip, 1962; Kernberg, 1984) • Working models (Bowlby, 1980) • Self and object representations (Gold, 1990a, 1990b; Ryle, 1990, 1997; Wachtel, 1985) • Cognitive schemas (Beck, et al., 1990) • Early maladaptive schemas (Young et al., 2003) • Self or interpersonal schemas (Guidano, 1987, 1991; Horowitz, 1988, 1998) • Complexes (Jung, 1932)
Self Structures • Common feature: personality consists of cognitive structures that mediate behavioural responses to events • Essential difference: whether these structures are purely cognitive or also have an emotional component • Cognitive therapy: schemas are primarily cognitive • Object relations and attachment assume they have an emotional component: Kernberg (1982): self-object-emotion triad • Social-cognitive approaches to personality also assume they are cognitive-emotional systems (Mischel & Shoda, 1995) • Schema as a unifying concept (Piaget, 1926; Bartlett, 1932) • Cognitive-emotional schema
Cognitive-Emotional Schema “An organized and relatively stable constellation of (self-referential) cognitions, emotions, and memories constructed to encode and appraise internal and external events and to guide, regulate, and direct action”
Self as a Knowledge System • Self-knowledge is organized into multiple cognitive-emotional schemas • The self develops through simultaneous processes of differentiation and integration of self-schemas • Dimensions of the experiential self – unity, continuity, authenticity, and clarify – are the experiential consequences of differentiation and integration
Differentiation of the Self System • Progressive increase in self-knowledge • Formation of cognitive emotional schemas • Origins of self-knowledge: • Impact of heritable traits • Developmental experiences • Self-reflection
Impaired Differentiation • Two patients with borderline pathology: • I think that I am a nice person. I am moody. I live alone. I can’t find a job I am unemployed. I have a cat that I am very fond of. I don’t know what else to say about myself. There is nothing else about me. • There are only a few things that I am sure of about myself. I would not kill anyone. I like dogs—in fact all animals. I like music. I like the color green. This is how I felt when I was four. It’s as if I have not changed. I got stuck. • A seven-year-old girl: • I am seven years old. I have one sister. Next year I will be eight. I like colouring. The game I like is hide-the-thimble. I go riding every Wednesday. I have lots of toys. My flower is a rose, and a buttercup and a daisy. I like milk to drink and lemon. I like to eat potatoes as well as meat. Sometimes I like jelly and syrup as well” (Livesley & Bromley, 1973).
Impaired Differentiation “I am an exceptional person. Exceptional in everyway. There is nothing else I need to say about myself”
Impaired Differentiation • Poorly delineated interpersonal boundaries: • Difficulty differentiating self from others • Uses others to define self experience • Confuses others feelings with own • Impoverished self structure; few cognitive-emotional schemas • Poorly defined and global self schemas • Simple and rather concrete self-description
Integration of the Self System • Differentiation of self-knowledge is accompanied by a simultaneous process of integration • Levels of integration (and meaning): • Cognitive-emotional schemas • Different self-images or facets of the self • Higher-order self structures: • Autobiographical self or self narrative • Personal self theory (Epstein,1990) • Cohesiveness of the self arises from the connections within self-knowledge (Toulmin,1978). • The more the person is able to organize “multiple self schemas into a coherent whole, the more likely the individual is to experience a sense of identity cohesiveness and continuity over extended periods of time (Horowitz, 1998, p. 87)
Multi-Facetted Self • Facet: cluster of self schemas that are activated together • Reflect different aspects of the self that are relevant to the major roles and recurrent situations of the person’s life • Part of the basic structure of the self • Adaptive self structure: facets are linked to form a coherent network • Borderline personality: facets are relatively distinct and unrelated giving rise to different self-states
Self as Multifaceted Understanding Competent Fun Self as therapist Self as friend Struggling Helpful Sociable Overworked
Hierarchical Structure of the Self Failure to establish link leading to a fragmented self system and distinct and poorly integrated self states Global Self Schema Narrative Self Theory of the Self Self Facet Self Facet Self Facet C-E Schema C-E Schema C-E Schema C-E Schema C-E Schema C-E Schema C-E Schema
Problems of Integration • Fragmented and unstable self system • Sense of self varies across time and situations with few links between self states • Self-state: • A particular way of experiencing the self and the world • Constellation of characteristics attributed to the self • A given affective tone that is often intense • Associated behaviours and ways of relating
40 year-old woman with emotional dysregulation or borderline personality: I don’t know what to say about myself. It’s difficult. I’m not sure who I am. My ideas about myself change all the time. My life is not a movie. Everything is a series of snapshots. I don’t know where I am in them. Sometimes I feel all right and I’m able to cope well but then it all comes crashing down. I don’t know why. I get overwhelmed and I can’t think. As a result I give up. I am not sure about anything else.
Gillian: Self States Rage Falls apart Abandonment Despair
Structure of the Cognitive Component of the Self Explains the Experiential Self • Experiential self: • Impaired sense of unity • Impaired sense of continuity • Lack of Authenticity • Lack of clarity and certainty • Unity, cohesion, authenticity, and certainty are experiential consequences of a well differentiated and integrated self structure (links within self-knowledge)
Cognitive-Structural Model of the Self • The self as a stable and cohesive structure • Traditional model of mental health professions • Current social-cognitive model: the self is a complex processing and meaning system • With this model, the self: • A structure and a process • Stable and variable • Generates temporary “selves” related to the situation – momentary working self • The model has interesting clinical implications and applications
Reflections on Alternative Conceptions of the Fragmentation of the Self • Alternative conceptions: • Transference-focused therapy (Kernberg, 1984): • Origins in splitting that arises as a defence against aggression • Compromised integration • Not defensive • integration is a developmental process • Failure arises from: • Disparity in informational input that exceeds the integrative capacity the cognitive apparatus: • Impaired integrative mechanisms • Extreme emotional lability • Extremely disparate behavior by significant others