Presentation is loading. Please wait.

Presentation is loading. Please wait.

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

Similar presentations


Presentation on theme: "Conceptualizing and Treating Self-Identity Problems Associated with Emotionally Dysregulated Personality Disorders John Livesley"— Presentation transcript:

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

2 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

3 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.

4 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.

5 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.

6 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

7 Clinical Vignette: The Story of Martha

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”  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

9 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

10 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

11 Treatment of Self Pathology  Two Components: 1.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 2.Set of treatment strategies:  Treatment strategies are usually straightforward  The challenge is to implement these strategies consistently

12 The Personality System

13 Trait System Environment Knowledge Systems Self System Interpersonal System Regulatory and Control Systems Basic Processes Memory/ Attention Metacognitive Processes DBT TFT MBT CT/SFT

14 Historical Perspective

15 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

16 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

17 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

18 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”

19 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?

20 Contemporary Approaches to the Self 1.Self as knower: Experiential or ontological self 2.Self as known: Cognitive or known self (Self- knowledge) 3.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

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

22 Structure of the Self System Experiential Self Cognitive Self Agentic Self Self-Knowledge Self-Appraisal Differentiation Integration Self- Reflective Thought Processes Borderline personality involves Impairments in all components of the self

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

24  Critical dimensions:  Personal unity, coherence, wholeness  Continuity and historicity  Authenticity and genuineness  Clarity and certainty

25 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

26 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

27 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.

28 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.

29 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.

30 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

31 Structure of the Self 2. Self as Known Self as a Knowledge System

32 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)

33 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)

34 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

35 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”

36 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

37 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

38 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).

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

40 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

41 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)

42 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

43 Self as Multifaceted Self as therapist Struggling Understanding Helpful Competent Overworked Self as friend Sociable Fun

44 Hierarchical Structure of the Self C-E Schema Self Facet Self Facet Self Facet 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

45 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

46 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.

47 Gillian: Self States 47 Rage Falls apart Abandonment Despair

48 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)

49 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

50 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

51 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

52 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

53 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

54 Momentary Self Event A Momentary Self Momentary Self Event B

55 Momentary Self Event A Momenta ry 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

56 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.”

57 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

58 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

59 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  ed the administrator

60 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

61 Structure of the Self 3. Self as Agent Executive self Self as a centre of self regulatory action Self as “doer” or decision-maker

62 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

63 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

64 Negative Feedback Loop Goal Standard Reference Value Input Function Comparator Output Function Effect on Environment After: Carver & Scheier, 1998, 2011; Carver, 2012

65 Negative Feedback Loop Thermostat Setting Sensed Temperature Comparator Switch on Heater Effect on Environment After: Carver & Scheier, 1998, 2011; Carver, 2012

66 Negative Feedback Loop Goal Standard Reference Value Input Function Comparator Output Function Effect on Environment After: Carver & Scheier, 1998, 2011; Carver, 2012

67 Hierarchical Structure of Goals Superordinate goal Comparator Lowest Level Output Input

68 Hierarchical Structure of Goals Superordinate goal Comparator Lowest Level Output 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

69 Hierarchical Structure of Goals Superordinate goal Comparator Lowest Level Output 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

70 Treating Self Pathology

71  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

72 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”

73 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” Integration arises from: i.Connections within self referential knowledge ii.Self-directedness

74 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

75 Integrated Modular Treatment: Phases of Change Phase 1: Safety, Containment, and Engagement Phase 2: Control and Modulation: Unstable and dysregulated emotions Phase 3: Exploration and change: Maladaptive schemata and interpersonal patterns, consequences of trauma and adversity Phase 4: Synthesis: Self pathology Most readily changed Most stable

76 Components of Treatment 1.Formulation: Setting the Stage for Integration 2.Necessary Prerequisites 3.Generic Change Mechanisms 4.Specific Integrative Interventions

77 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

78 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

79 Emotions and Self (1)  Emotions inform self-understanding  Emotions are “the basic prerequisite for a person to feel situated in the world” (Stanghellini & Rosfort, 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

80 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

81 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

82 Developing Emotional Stability  Two main features: 1.Skills training: developing emotional regulation and self-management skills:  Focus of DBT, CBT, STEPPS 2.Building the capacity for emotional processing:  Focus of MBT, TFT

83 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

84 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

85 General Treatment Modules 1.Structure: Establish and maintain the structure of treatment 2.Relationship: Build and maintain a collaborative working relationship 3.Consistency: Maintain a consistent treatment process 4.Validation: Promote a validating process 5.Motivation: Build motivation and a commitment to change 6.Self-reflection: Encourage self-observation and self- reflection Livesley, in press

86 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

87 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

88 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

89 Promoting Differentiation  Development of boundaries:  Consistency  Modeling  Collaborative description of problems and psychopathology  “Unpacking the meaning of experience

90 4. Specific Integrative Strategies 1.Integrating self states 2.Establishing goals 3.“Getting a life of one’s own” 4.Establishing personal niche 5.Constructing a new self-narrative

91 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

92 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

93 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

94 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”

95 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

96 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

97 5. Constructing a New Self-Narrative  Formulation and reformulation  Regular narrative summaries  Setting a new self narrative as a treatment goal

98 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


Download ppt "Conceptualizing and Treating Self-Identity Problems Associated with Emotionally Dysregulated Personality Disorders John Livesley"

Similar presentations


Ads by Google