John Livesley livesley@mail.ubc

1. Conceptualizing and Treating Self-Identity Problems Associated with Emotionally Dysregulated Personality Disorders John Livesley livesley@mail.ubc.ca

2. Topics • Introductory clinical material • Framework for conceptualizing the self and self pathology • Treatment strategies

3. Treatment of Self Pathology • Two Components: • Explicit model of personality disorder and the self: • 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

4. 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

5. 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.

6. 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.

7. 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.

8. 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

9. Clinical Vignette: The Story of Martha • Models of change in treating personality disorder • Exploratory and Substitutive Change versus Synthetic Change • “I lose myself in other people” • Mental mechanisms and structures

10. 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 doesn’t 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.

11. Session A continued T: It helped that I was always the same. P: Hmm. A dependable consistency that was not easy for me to have. I do not know how you do it. You never get it wrong or make a wrong comment. It has been wonderful having this relationship with you. Without it I would not have survived the break-up of my relationship with Peter. I thought the only way was to die. I would not have survived without this relationship. I would have killed myself. I realized early on with Peter it was not going to work out. The relationship was not good for either of us. But I couldn’t see a way out without dying. Now, I am glad to be alive. I feel happy and contented. I wish things could go on as they are. I think tomorrow will be like today and I don’t think anything is missing.

12. Session A continued T: But you played a part in this – it was a joint venture. P: Yes, I allowed myself to be influenced by you. I came to trust you and not fight you. That was my role. I learned that I did not have to control things. I could just relax. Now I’m glad I was able to do that. It’s not easy for me to trust people. T: You were able to work through that with me. P: Yes. I could probably trust more if I had an intrinsic sense of self value. I do not have that.

13. 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.

14. Session B: Continued T: Your reading is the thread. P: Yes, tomorrow I need to understand more – it works for me but I don’t know why. It seems odd because I can’t do anything with this. I don’t really get more knowledgeable about him. T: But it sounds as if you understand him – understand Galileo’s self. P: Nods. It’s true, it’s true. I feel I trust that. But I can’t trust myself. Others seems so confident and know who they are. I am lucky though that I have something (reading) to get me from one day to the next. I have Galileo and the rest. T: Isn’t this who you are – you are the person who reads about and understands Galileo? And, trusts what you think about him. P: But I cannot just be someone who reads. T: Why not? Although you are not only someone who reads.

15. Session B: Continued T: Why not? Although you are not only someone who reads. P: I can see that. I have been coming here and I have had consistency over time. You are a symbol of that and I am too. T: So there is some “self” to you that continues from one session to the next and through time. P: Yes but people need successes through time like marriage and a job. I failed at everything. T: What about your children? P: Yes, and I am grateful for that. They care about me. T: But you also need recognition. P: Yes – social recognition. T: Like your daughter said about your reading few months ago – ‘you’re a scholar now mum, an academic.’ You understand Galileo and you’re going to teach about him. P: Yes, I like that. It does not matter if people do not like it. What matters is I like it and it can be sustained.

16. 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

17. 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

18. 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

19. The Personality System

20. The Personality System

21. The Personality System Environment

22. The Personality System Environment Trait System

23. Trait System

24. Trait System Emotional Dysregulation/ Anxious-Dependent/ Borderline Dissocial/ Psychopathic Socially Avoidant/ Schizoid-Avoidant Compulsive

25. The Personality System Environment Trait System Knowledge Systems

26. The Personality System Environment Trait System Self System KnowledgeSystems Interpersonal System

27. The Personality System Environment Trait System Self System Knowledge Systems Interpersonal System Regulatory and Control Systems

28. The Personality System Environment Trait System Self System Knowledge Systems Interpersonal System Regulatory and Control Systems Basic Processes Memory/Attention Metacognitive Processes

29. 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

30. Historical Perspective

31. 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

32. 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

33. 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

34. 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”

35. 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?

36. Evolution of the Self • Janksepp & Norhoff (2009). The trans-species core SELF: The emergence of active cultural and neuro-ecological agents through self-related processing within subcortical midline networks. Consciousness and Cognition, 18, 193-215 • Three levels to the self: • Proto-SELF • Core-SELF • Cognitive or idiographic selves

37. Proto-SELF Internal Sensory-Motor Inputs External Sensory Inputs Proto-SELF • Self-related processing: Coherently associating intero- and exteroceptive stimuli within the organism to allow the organism to become integrated with the environment • Establishes what Allport (1961) called the bodily self • Primordial mechanism to differential internal and external stimuli

38. Levels of the Self Internal Sensory-Motor Inputs External Sensory Inputs Proto-SELF Internal Conditions: 1. Needs 2.Emotional State Environmental Conditions Core-SELF • Self is inherently a relational system • Matches internal conditions to external environment • Self in intimately related to emotions • Self and territoriality; related to a sense of place

39. Levels of the Self Internal Sensory-Motor Inputs External Sensory Inputs Proto-SELF Internal Conditions: 1. Needs 2.Emotional State Environmental Conditions Core-SELF Downward Regulation More refined and selective interaction with the environment Creation of personal environment Cognitive or Idiographic Self

40. Evolution, Self, and Culture • Impact of social living • Change from hunter gathering to sedentary farming • Impact of urbanization and modernity • Loss of proscribed identity

41. 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

42. Structure of the Self System Experiential Self Differentiation Self-Knowledge Integration Cognitive Self Self-Appraisal Agentic Self

43. 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

44. Structure of the Self 1. Self as Knower Experiential or Ontological Self

45. Experiential or Ontological Self • Critical dimensions: • Personal unity, coherence, wholeness • Continuity and historicity • Authenticity and genuineness • Clarity and certainty

46. 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

47. 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

48. 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:

49. 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.

50. 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.