John Livesley livesley@mail.ubc.ca

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

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: • 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

12. The Personality System

13. 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

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 • 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

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

22. 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

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

24. Experiential or Ontological Self • 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. 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:

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

44. 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

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 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