Conceptualizing and Treating Self-Identity Problems Associa

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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. ID: 425944 Download Presentation

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Conceptualizing and Treating Self-Identity Problems Associa




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Presentations text content in Conceptualizing and Treating Self-Identity Problems Associa

Slide1

Conceptualizing and Treating Self-Identity Problems Associated with Emotionally Dysregulated Personality Disorders

John

Livesley

livesley@mail.ubc.ca

Slide2

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

Slide3

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.

Slide4

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.

Slide5

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.

Slide6

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

Slide7

Clinical Vignette: The Story of Martha

Slide8

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

Slide9

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

Slide10

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

Slide11

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

Slide12

The Personality System

Slide13

The Personality System

Trait System

Environment

Knowledge Systems

Self System

Interpersonal

System

Regulatory

and

Control

Systems

Basic Processes

Memory/Attention

Metacognitive

Processes

DBT

TFT

MBT

CT/SFT

Slide14

Historical Perspective

Slide15

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

Slide16

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

Slide17

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

Slide18

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”

Slide19

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?

Slide20

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

Slide21

Structure of the Self System

Experiential Self

Cognitive Self

Agentic Self

Self-Knowledge

Self-Appraisal

Differentiation

Integration

Slide22

Structure of the Self System

Experiential Self

Cognitive Self

Agentic Self

Self-Knowledge

Self-Appraisal

Differentiation

Integration

Self-ReflectiveThought Processes

Borderline personality involves

Impairments

in

all

components

of the

self

Slide23

Structure of the Self

1. Self as Knower

Experiential or Ontological Self

Slide24

Experiential or Ontological Self

Critical dimensions:

Personal unity, coherence, wholeness

Continuity and historicity

Authenticity and genuineness

Clarity and certainty

Slide25

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

Slide26

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

Slide27

Impaired Experiential Self:

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.

Slide28

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.

Slide29

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.

Slide30

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

Slide31

Structure of the Self

2. Self as Known

Self as a Knowledge System

Slide32

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)

Slide33

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)

Slide34

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

Slide35

Cognitive-Emotional Schema

“A

n 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

Slide36

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

Slide37

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

Slide38

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).

Slide39

Impaired Differentiation

“I am an exceptional person. Exceptional in everyway. There is nothing else I need to say about myself”

Slide40

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

Slide41

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)

Slide42

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

Slide43

Self as Multifaceted

Self as therapist

Struggling

Understanding

Helpful

Competent

Overworked

Self as friend

Sociable

Fun

Slide44

Hierarchical Structure of the Self

C-E Schema

C-E Schema

C-E Schema

C-E Schema

C-E Schema

C-E Schema

C-E Schema

SelfFacet

SelfFacet

SelfFacet

Global Self Schema

Narrative Self

Theory of the Self

Failure to establish link

leading to a fragmented self system and distinct and

poorly integrated self states

Slide45

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

Slide46

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.

Slide47

Gillian: Self States

47

Rage

Falls apart

Abandonment

Despair

Slide48

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)

Slide49

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

Slide50

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

Slide51

Implications for Treatment

Transference-Focused Therapy:

Focus on splitting as it occurs in the transference

Interpretative approach to change

Compromised Integration:

Removal of hindrances to integration

Emotional

lability

Cognitive distortions

Foster connections and links within self-knowledge

Slide52

Case Example

Mother: extremely violent and abusive

and

loving

Patient: high anxiousness and emotional

lability

Fragmented self state: anxious to please and desperate for love especially from mother

and

angry and resentful

Treatment Strategies:

Build self understanding

Build

ability to self-regulation of emotion

Tolerance of neediness

Gradually relinquish hopes of being loved by mother

Promote understanding of how needs originating in early relationships affect current

behaviour

and relationships

Restructure associated schemas

Slide53

Self as a Complex Processing System: Matrix Structure

Self Concept

Identity

Cognitive-emotional schema

Connections that differ in strength

Self is both a structure and a process

Facet of the Self

or self-image

Slide54

Momentary Self

Event A

Momentary

Self

Momentary

Self

Event B

Slide55

Momentary Self

Event A

Momentary

Self

Momentary

Self

Event B

Momentary Self

Context related

Varies

with

the situation

Not simply recalled or

reactivated

Generated and created

to fit the context

Stability with Adaptive Variability

Stability: relatively stable links in the network

Adaptive Variability: capacity to generate a momentary working self that is relevant to the situation

Relationship between Self and Environment

Self as a system that mediates between the internal conditions of the individual and the environment

Environment is partly a creation of the self

Note the importance of emotion in this process

Slide56

Clinical Vignette (1)

Elana

: aged 35 years

Long psychiatric history dating to age 13 years

Currently relatively stable

Completed university

Working in a professional capacity

Severe self-identity problems:

“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.”

Slide57

Clinical Vignette (2)

Self-Identity problems continue

Core cognitive-emotional schema: “I am incompetent”

Contributes to a self-narrative linking incompetence, submissiveness, fear of being assertive, fear of humiliation, shame, fear of abandonment, low self esteem, and what she considered a cognitive disability – the inability to multi-task including inability to do two simple things at the same time e.g., walking and talking

Forms the basis for a momentary working self that is similar across situations – lack of adaptive variability

Slide58

Clinical Vignette (3)

Optional therapeutic strategies:

Standard cognitive therapy approach of restructuring core cognitive-emotional schema “I am incompetent”

Viable option

May be a necessary component of any effective approach

But is it sufficient?

Problem is the schema is part of a complex narrative

Lasting change may require restructuring the narrative – in effect the construction of a new narrative

Developing a more adaptive momentary self and constructing a new narrative

Slide59

Clinical Vignette (4)

In-session,

Elana

described an event that occurred the day before

Course cancelled

Reacted strongly and the decision was reversed within hours

In a very short time, she:

Determined policy and regulations

Legal considerations

Emailed the administrator

Slide60

Factors Influencing the Development of Integration and Coherence

Information that exceeds capacity of integrative and regulatory mechanisms to process information due to:

Neuropsychological limitations on ability to process and integrate information

Emotional impact that overwhelms cognitive mechanisms

Inconsistent informational that exceeds ability to integrate

Effects of extreme levels of affective traits such as anxiousness and affective

lability

Slide61

Structure of the Self

3. Self as Agent

Executive

self

Self

as a

centre

of self regulatory

action

Self

as “doer” or decision-maker

Slide62

Agentic or Self-Directed Self

Sense

of agency and

directedness contributes to cohesion and integration

Goals:

Energize

D

irect action

Give meaning and purpose to lives (

Baumeister

, 1989; Carver &

Scheier

, 1998;

Pervin

,

1992)

As

Allport

(1961) noted:

Striving

towards a goal confers integration by linking abilities, wants, needs, and traits needed to achieve

the goal

Goals form a hierarchy

Slide63

Impaired Sense of Agency in Personality Disorder

Low self-directedness (

Cloninger

, 2000)

Difficulty setting and attaining long-term goals

Problems with direction and purpose

Difficult to set goals without a sense of clarity about personal wants and desires and sense of authenticity

Many goals are often “ought goals” imposed by others

People only work consistently to attain personal goals

Slide64

Negative Feedback Loop

GoalStandardReference Value

Input Function

Comparator

Output Function

Effect on Environment

After: Carver &

Scheier

, 1998, 2011; Carver, 2012

Slide65

Negative Feedback Loop

ThermostatSetting

Sensed Temperature

Comparator

Switch on Heater

Effect on Environment

After: Carver &

Scheier

, 1998, 2011; Carver, 2012

Slide66

Negative Feedback Loop

GoalStandardReference Value

Input Function

Comparator

Output Function

Effect on Environment

After: Carver &

Scheier

, 1998, 2011; Carver, 2012

Slide67

Hierarchical Structure of Goals

Superordinate goal

Comparator

Comparator

Comparator

Lowest Level Output

Input

Input

Input

Slide68

Hierarchical Structure of Goals

Superordinate goal

Comparator

Comparator

Comparator

Lowest Level Output

Input

Input

Input

System is self-regulating

No central control

centre

or unit

Overcomes the problem of the homunculus – a central causal agent

The only thing left to explain is the origin of a superordinate goal

Slide69

Hierarchical Structure of Goals

Superordinate goal

Comparator

Comparator

Comparator

Lowest Level Output

Input

Input

Input

System is self-regulating

No central control

centre

or unit

Overcomes the problem of the homunculus – a central causal agent

The only thing left to explain is the origin of a superordinate goal

Most goals are not established using a self-reflective process

Most goals established through an implicit process

Emotional aspect of this process motivates for action

Slide70

Treating Self Pathology

Slide71

Treating Self Pathology

Limitations of current therapies

Modest effect on core personality pathology

Integration as a major treatment goal

Although integration is often a task for the later stages of therapy, it needs to be kept in mind from the outset

Integration resides in the mind of the therapist

Slide72

Treating Self Pathology: Goals

Promote a sense of unity and coherence

Facilitate the differentiation of self-knowledge

Construct a more integrated and adaptive self system:

Establish links and connections within self-knowledge

Develop a more adaptive life script or self narrative

Construct a more adaptive and rewarding personal niche

Promote self directedness

Help the patient to “get a life”

Slide73

Treating Self Pathology: Goals

Promote a sense of unity and coherenceFacilitate the differentiation of self-knowledgeConstruct a more integrated and adaptive self system:Establish links and connections within self-knowledgeDevelop a more adaptive life script or self narrative Construct a more adaptive and rewarding personal nichePromote self directednessHelp the patient to “get a life”

Integration arises from:

Connections within self referential knowledge

Self-directedness

Slide74

Structure of Therapy: Integrated Modular Treatment

Integrated: Uses an eclectic array of interventions drawn from all effective therapies:

Common factors approach: treatment is organized around common change mechanisms

Technical eclecticism: uses specific interventions from all therapies (See Norcross

& Newman,

1992)

Treatment methods are divided into:

General treatment methods based on common change mechanisms

Specific treatment methods selected to treat specific problems

Treatment methods are organized into modules:

General treatment modules: used with all patients throughout therapy

Specific treatment modules: selected on the basis of a given patients problems and the problems that are the current focus of treatment

Slide75

Integrated Modular Treatment: Phases of Change

Phase 1: Safety, Containment, and EngagementPhase 2: Control and Modulation:Unstable and dysregulated emotionsPhase 3: Exploration and change:Maladaptive schemata and interpersonal patterns, consequences of trauma and adversityPhase 4: Synthesis:Self pathology

Most readily changed

Most stable

Slide76

Components of Treatment

Formulation: Setting the Stage for Integration

Necessary Prerequisites

Generic Change Mechanisms

Specific Integrative Interventions

Slide77

1. The Role of Formulation

Formulation provides the blueprint for therapy and constructing an adaptive self system

This requires:

Formulation in narrative form (see Ryle, 1997 & reformulation letter)

Developed collaboratively

Available to the patient

Revised collaboratively throughout therapy (

Dimaggio

et al., in press)

Therapist provides regular summaries that are discussed with the patient

Process designed to facilitate construction of a self narrative or autobiographical self

Slide78

2. Prerequisites: Conditions Necessary to the Construction of an Adaptive Self System

Elements of borderline pathology that hinder self development:

Unstable emotions

Inconsistent relationships

Self-invalidating ways of thinking

Limited self reflection and metacognition

Slide79

Emotions and Self (1)

Emotions inform self-understanding

Emotions are “the basic prerequisite for a person to feel situated in the world” (

Stanghellini

&

Rosfort

, 2013.

Emotions and personhood

)

Emotions structure experience

Give significance and meaning to objects and events

Without emotions our world is merely filled with objects and events that do not differ in importance or significance

Emotions motivate for action

Slide80

Emotions and Self (2)

Much of self knowledge is acquired in an interpersonal context:

Understanding of others depends on capacity to understand their emotions

This depends on the capacity to modulate one’s own feelings

That is, ones understanding of the other is not driven by one’s own emotions

Slide81

Emotional Stability

Prerequisite for self development

Helps ensure a consistency and stability in environmental inputs

Contribute to a stable interpersonal landscape:

Importance of reflected interpersonal appraisal (Looking glass self or Cooley, 1902)

Contribute to stable wants and preferences – the early raw material of the self:

Young children’s self concept is organized around concrete features and likes and preferences

Slide82

Developing Emotional Stability

Two main features:

Skills training: developing emotional regulation and self-management skills:

Focus of DBT, CBT, STEPPS

Building the capacity for emotional processing:

Focus of MBT, TFT

Slide83

Emotional Regulation and Modulation and Intervention Modules

Regulation and Modulation

Awareness & Recognition

Re-structuring Escalating Cognitions

Acceptance & Tolerance

Psycho-education

Self-Regulation Skills

Re-structuring Cognitive Appraisal

Slide84

3. Contribution of Generic Change Mechanisms

Common factors account for substantial amount of outcome change

Treatment should seek to optimize the effects of non-specific factors

Castonguay

L.S., &

Beutler

L.E. (2006).

Principles of therapeutic change that work.

New York: Oxford University Press

Analyses

of the empirical literature by the joint Task Force of the Society for Clinical Psychology (Division 12 of the American Psychological Association) and the North American Society for Psychotherapy

Research

Slide85

General Treatment Modules

Structure: Establish and maintain the structure of treatment

Relationship: Build and maintain a collaborative working relationship

Consistency: Maintain a consistent treatment process

Validation: Promote a validating process

Motivation: Build motivation and a commitment to change

Self-reflection: Encourage self-observation and self-reflection

Livesley

, in press

Slide86

Generic Treatment Strategies

Treatment relationship:

Importance of a consistent experience of the self in relationship with the therapist

Therapist as “keeper of the self”

Validation and “strengthening” the ontological self:

Validation and the authenticity of experience

Increasing self-knowledge:

Repetitive linking of different components of personality at all levels of the personality system

Promoting self-reflection:

Critical mechanism in the formation of the self system

Slide87

Self-Reflection

Fundamental to the development of the self

Capacity for a reflective loop to thought – we are not only aware but can reflect on this awareness

Self refection differs from self awareness and self focus

Self focus without self reflection may create additional problems

Research shows that a self focus is results in greater distress associated with:

Physiological sensations

Emotional reactions

Many patients with borderline pathology are intensely self-focused but not

necessaryily

self-reflective

Self

refection is necessary for experience to be therapeutic

Slide88

Key Point

Synthesis of a more adaptive self does not necessary require complex or specific interventions

Simply requires an understanding of what is required to construct an adaptive self and consistent use of the numerous opportunities that inevitably arise during therapy

An explicit model of the self heightens the therapist’s awareness of these opportunities and enables the therapist to make maximum use of them

Example:

suicidality

and formulation of self-harming behavior

Slide89

Promoting Differentiation

Development of boundaries:

Consistency

Modeling

Collaborative description of problems and psychopathology

“Unpacking the meaning of experience

Slide90

4. Specific Integrative Strategies

Integrating self states

Establishing goals

“Getting a life of one’s own”

Establishing personal niche

Constructing a new self-narrative

Slide91

1. Integrating Self-States

Therapy as a sequence of scenarios

Management of scenarios changes as therapy progresses

Using scenarios to facilitate integration

Using diagrams to promote understanding and integration

Slide92

Core Self States

Not understand someone’s behaviour or wants

Unpredictable, thinks the worse

Frightened, terrified FEAR OF ABANDONMENT

FALLS APART

CANNOT SPEAK

Other Person

is frightened

Withdraws

Cyclical

Pattern

ANGRY

Unloved

Slide93

2. Establishing Goals and Self-Directedness

Few patients have a sense of direction and purpose

Most organize their lives on the basis of negative goals

Positive goals integrate personality and

behaviour

and create a sense of purpose

Importance of therapists showing an active interest in goals, wants,

aspirations

Using real life events e.g., vignette: seeking a quiet life

Slide94

Importance of Wants and Preferences

Likes

and wants

are important elements of the self in young children

Often the beginnings of motivation and interests; define salient parts of the self

Validate wants as appropriate

Discuss interests; take an active interest in new interests e.g.,

“Do not do anything”

“Interested in ‘bugs”

Slide95

3. “Getting a life”

The importance of the idea:

Many patients have not thought of their problems in this way

Sense of relief from discussing the idea

Validates the patient’s autonomy

Validates the person not part of the person e.g., a feeling

Often this is sufficient if the timing is right

“What would you like to do with your life?”

E.g., fitness instructor and dependence on partner

Slide96

4. Establishing Personal Niche

Importance of a personal

niche:

Inter-relationship between self and

envirPnment

Source of structure and integration

Supports adaptive functioning

Most patients fail to create a congenial niche

Help identify a suitable niche that supports adaptive rather than maladaptive

behaviour

Slide97

5. Constructing a New Self-Narrative

Formulation and reformulation

Regular narrative summaries

Setting a new self narrative as a treatment goal

Slide98

Sources

Leary, M.R., &

Tangney,

J.P. (2012

).

Handbook of Self and

Identity 2

nd

Ed.

New York, Guilford

Vohs

, K.D.,

Baumeister

, R.F., (2011).

Handbook of Self Regulation 2

nd

Edition.

New York, Guilford

Carver, C. S., &

Scheier

, M. F. (1998).

On the self-regulation of behavior

. Cambridge, UK: Cambridge University

Press

Stanghellini

, C., &

Rosfort

, R. (2013).

Emotions and personhood. Oxford; Oxford University Press

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