Conceptualizing and Treating
Self-Identity Problems
Associated with Emotionally
Dysregulated Personality
Disorders
John Livesley
[email protected]
Components of the Self
Self as a three-component structure:
Centre of reflective self-awareness
Knowledge structure consisting of self-referential
knowledge
Centre of agency and self-regulation
Identity: elements of self-referential
knowledge that defines who the person is in
the context of his or her major social units
and groups
A 40 year-old woman with emotional
dysregulation or borderline traits
I don’t know what to say about myself. It’s difficult. I’m not
sure who I am.
My ideas about myself change all the time. My life is not a
movie. Everything is a series of snapshots. I don’t know
where I am in them.
Sometimes I feel all right and I’m able to cope well but then
it all comes crashing down. I don’t know why. I get
overwhelmed and I can’t think. As a result I give up. I am
not sure about anything else.
Two patients with borderline pathology
I think that I am a nice person. I am moody. I
live alone. I can’t find a job. I am unemployed. I
have a cat that I am very fond of. I don’t know
what else to say about myself. There is nothing
else about me.
There are only a few things that I am sure of
about myself. I would not kill anyone. I like
dogs—in fact all animals. I like music. I like the
color green. This is how I felt when I was four. It’s
as if I have not changed. I got stuck.
A young woman with eating disorder and
emotional dysregulation or borderline personality
I is a fallacy of sorts. I is an infinitely deconstructionable
conglomeration of shreds and patches, the mental picture of
being ‘under erasure,’ as always having an X marked through
it.
I is a piece of abstraction, it is a kind of tense numbness or
void where I seem to willingly hide but am almost unable to
extract myself from.
Summary
Limited knowledge about the self – “I do not
know who I am”
Confusion about self attributes
Uncertainty about whether “self” exists
Sense of inner void or emptiness – “There is
nothing inside”
“Existential angst” – being is painful
Clinical Vignette: The Story of Martha
Summary
 Limited knowledge about the self – “I do not know who I am”
 Confusion about self attributes
 Uncertainty about whether “self” exists
 Sense of inner void or emptiness – “There is nothing inside”
 “Existential angst”
 Lack of continuity to self experience: “No memory”
 Sense of self dependent on others: the “as-if” personality (Deutsch,
1942)
 “Borrowed identity”
 To treat these problems we need a conceptual framework to
understand them
Self Pathology: Does it matter? (1)
 To treat borderline personality do we need to treat self
pathology?
 The evidence suggests we do:
Results of outcome studies: residual pathology
Longitudinal studies and persistent problems with social
adjustment
 Difficult to account for the organization of personality
without a concept of self
 Increasing focus on personality as a complex dynamic
processing system
 Self as a personality sub-system concerned with selfregulation
Self Pathology: Does it matter? (2)
People construct self-narratives (McAdams, 2008) or
a theory about themselves (Epstein) that influences
many aspects of their behaviour:
Operations of the self system
How the self system is elaborated – self regulates its own
development (McAdams et al., 2006; Swann & Buhrmester,
2012)
Acquisition of goals, values, motivations
Interpersonal relationships (Cantor et al., 1991)
Construction of personal niche (Tesser, 2002)
Importance of downward regulation and explanation
Treatment of Self Pathology
Two Components:
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
The Personality System
The Personality System
Environment
DBT
CT/SFT
Self System
Trait System
Knowledge Systems
Interpersonal
System
Regulatory
and
Control
Systems
TFT
MBT
Memory/
Attention
Basic Processes
Metacognitive
Processes
Historical Perspective
Significant Historical Developments (1)
Contemporary study of the self began with
William James (1890) who distinguished
between:
The self as knower
The self as known
Significant Historical Developments (2)
Symbolic interactionists – self as an interpersonal
phenomenon:
Cooley (1902): “the looking glass self”; “self….
appears in a particular mind”
Each to each a looking glass/Reflects the other that doth
pass”
G.H. Mead (1934): “taking the role of the other”;
“generalized other”
Impact of behaviourism
Significant Historical Developments (3)
Clinical interest in the self:
 Carl Rogers (1951): importance of the self in self-actualization and
fulfillment
 Problem of the homunculus:
 Pseudo-explanation
 Self-agent that “pulls the strings”
 Psychoanalytic contributions:
 Erikson and stages of identity
 Self Psychology:
 Kohut (1971): cohesiveness of the self: importance of mirroring (looking glass self)
 Object relations theory:
 Early work of Fairbairn and Guntrip
 Kernberg (1984): identity diffusion
Significant Historical Developments (4)
Impact of the cognitive revolution:
Social cognition and the self
Growth of research on self as known
Solution to the homunculus problem
Emergence of “self as agent”
Significant Historical Developments (5)
Evolution and the Self:
What does the self do?
Why did it evolve?
How did it enhance adaptation?
What evolutionary pressures brought
about the self system?
Contemporary Approaches to the
Self
1. Self as knower: Experiential or ontological self
2. Self as known: Cognitive or known self (Selfknowledge)
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
Structure of the Self System
Experiential Self
Differentiation
Self-Knowledge
Integration
Cognitive Self
Self-Appraisal
Agentic Self
Structure of the Self System
Experiential Self
SelfReflective
Thought
Processes
Differentiation
Self-Knowledge
Integration
Cognitive Self
Self-Appraisal
Agentic Self
Borderline personality involves
Impairments in all
components of the self
Structure of the Self
1. Self as Knower
Experiential or Ontological Self
Experiential or Ontological Self
Critical dimensions:
Personal unity, coherence, wholeness
Continuity and historicity
Authenticity and genuineness
Clarity and certainty
Impairments to the Experiential Self
 Impaired sense of unity:
 Fragmentation of self experience
 No “inner sense of self”
 Impaired sense of continuity:
 Sense of living only in the moment
 Difficulty integrating the past and past experiences
 Lack of Authenticity:
 Uncertainty about personal qualities
 Doubts about the genuineness of emotions and other experiences
 Lack of clarity and certainty:
 Difficulty defining and describing personal qualities
Authenticity
Authenticity is experienced when
persons feel:
They are the authors of their own actions:
Importance of fostering self-efficacy and
agency
These actions are internally caused
Importance of a collaborative alliance
That there was a choice:
Problem solving and the generation of
alternatives
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.
Session A
P: How do you get from one day to the next? Difficult to connect one
day to the next. I never feel the same person. Having you in my life
provided me with what I did not have before – some kind of connection.
You do not change a lot. Your attitude does not change. This has
helped me … to be more stable. To deal with my loss of my self.
When seeing you, you provided something external that I did not have –
that I have not given myself. You are like a crutch. An identity. Really it is
like a borrowed identity, a borrowed self. This helped me especially
when I felt that I could not get from one day to the next. Or, the next
month. I knew you would be there and the same. Now I can do it for
myself. It is like a basic model – I don’t know about model – motivation –
a way of thinking.
T:
It helped that I was always the same.
Session B: The next session 3 weeks later
P:
I wonder what gets someone form one day to the next. What gets me from one
day to the next is reading. I have no self and no memory of my life. That’s why I see
you. You’re the memory bank. You remember. You recognize me and understand
what I’m saying. You remember. That makes me feel stable. If I am not sure if I
have a self – I begin to feel I have a self in response to you and what you do.
T:
Meeting with me gives you a sense of continuity – you exist across time.
P:
Hmm, it is like reading. I only read to understand. I’m reading about Galileo (as she
walked to the office she showed me a substantial academic tome). I read to
understand --- I’m reading to understand him and his historical context. It helps me
to get from one day to the next.
T:
Your reading is the thread.
Experiential Self: Clinical Strategies
 Impaired sense of unity: INTEGRATE; LINK AND CONNECT
 Fragmentation of self experience PROMOTE SELF REFLECTION
 No “inner sense of self”
 Impaired sense of continuity: THERAPIST AS INTEGRATIVE AGENT
 Sense of living only in the moment “PRESENCE OF THE THERAPIST”
 Difficulty integrating the past and past experiences
 Lack of Authenticity: VALIDATION
 Uncertainty about personal qualities
 Doubts about the genuineness of emotions and other experiences
 Lack of clarity and certainty: DECONSTRUCT GLOBAL EXPERIENCES
 Difficulty defining and describing personal qualities
Structure of the Self
2. Self as Known
Self as a Knowledge System
Self as Known
Self-referential knowledge system
Critical dimensions:
Degree of differentiation of self-knowledge
Degree of integration of self knowledge to form
coherent sense of self
Need for a construct to describe units of selfknowledge (and personality)
Concepts Used to Describe Self Structures
 Object relationships (Fairbairn, 1951; Guntrip, 1962;
Kernberg, 1984)
 Working models (Bowlby, 1980)
 Self and object representations (Gold, 1990a, 1990b; Ryle,
1990, 1997; Wachtel, 1985)
 Cognitive schemas (Beck, et al., 1990)
 Early maladaptive schemas (Young et al., 2003)
 Self or interpersonal schemas (Guidano, 1987, 1991;
Horowitz, 1988, 1998)
 Complexes (Jung, 1932)
Self Structures
 Common feature: personality consists of cognitive structures that
mediate behavioural responses to events
 Essential difference: whether these structures are purely cognitive
or also have an emotional component
 Cognitive therapy: schemas are primarily cognitive
 Object relations and attachment assume they have an emotional
component: Kernberg (1982): self-object-emotion triad
 Social-cognitive approaches to personality also assume they are
cognitive-emotional systems (Mischel & Shoda, 1995)
 Schema as a unifying concept (Piaget, 1926; Bartlett, 1932)
 Cognitive-emotional schema
Cognitive-Emotional Schema
“An organized and
relatively stable
constellation of (selfreferential)
cognitions, emotions,
and memories
constructed to
encode and
appraise internal and
external events and
to guide, regulate,
and direct action”
Self as a Knowledge System
Self-knowledge is organized into multiple
cognitive-emotional schemas
The self develops through simultaneous processes
of differentiation and integration of self-schemas
Dimensions of the experiential self – unity,
continuity, authenticity, and clarify – are the
experiential consequences of differentiation and
integration
Differentiation of the Self System
Progressive increase in self-knowledge
Formation of cognitive emotional
schemas
Origins of self-knowledge:
Impact of heritable traits
Developmental experiences
Self-reflection
Impaired Differentiation
 Two patients with borderline pathology:
 I think that I am a nice person. I am moody. I live alone. I can’t find a
job I am unemployed. I have a cat that I am very fond of. I don’t know
what else to say about myself. There is nothing else about me.
 There are only a few things that I am sure of about myself. I would not
kill anyone. I like dogs—in fact all animals. I like music. I like the color
green. This is how I felt when I was four. It’s as if I have not changed. I
got stuck.
 A seven-year-old girl:
 I am seven years old. I have one sister. Next year I will be eight. I like
colouring. The game I like is hide-the-thimble. I go riding every
Wednesday. I have lots of toys. My flower is a rose, and a buttercup
and a daisy. I like milk to drink and lemon. I like to eat potatoes as well
as meat. Sometimes I like jelly and syrup as well” (Livesley & Bromley,
1973).
Impaired Differentiation
“I am an exceptional person.
Exceptional in everyway. There is
nothing else I need to say about
myself”
Impaired Differentiation
 Poorly delineated interpersonal boundaries:
 Difficulty differentiating self from others
 Uses others to define self experience
 Confuses others feelings with own
 Impoverished self structure; few cognitiveemotional schemas
 Poorly defined and global self schemas
 Simple and rather concrete self-description
Integration of the Self System
 Differentiation of self-knowledge is accompanied by a
simultaneous process of integration
 Levels of integration (and meaning):
 Cognitive-emotional schemas
 Different self-images or facets of the self
 Higher-order self structures:
Autobiographical self or self narrative
Personal self theory (Epstein,1990)
 Cohesiveness of the self arises from the connections within selfknowledge (Toulmin,1978).
 The more the person is able to organize “multiple self schemas
into a coherent whole, the more likely the individual is to
experience a sense of identity cohesiveness and continuity
over extended periods of time (Horowitz, 1998, p. 87)
Multi-Facetted Self
 Facet: cluster of self schemas that are activated
together
 Reflect different aspects of the self that are relevant
to the major roles and recurrent situations of the
person’s life
 Part of the basic structure of the self
 Adaptive self structure: facets are linked to form a
coherent network
 Borderline personality: facets are relatively distinct
and unrelated giving rise to different self-states
Self as Multifaceted
Competent
Understanding
Fun
Self as therapist
Struggling
Self as friend
Helpful
Overworked
Sociable
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
C-E
Schema
C-E
Schema
Self
Facet
C-E
Schema
C-E
Schema
Self
Facet
C-E
Schema
C-E
Schema
C-E
Schema
Problems of Integration
Fragmented and unstable self system
Sense of self varies across time and situations
with few links between self states
Self-state:
 A particular way of experiencing the self and the
world
 Constellation of characteristics attributed to the self
 A given affective tone that is often intense
 Associated behaviours and ways of relating
40 year-old woman with emotional
dysregulation or borderline personality:
I don’t know what to say about myself. It’s
difficult. I’m not sure who I am. My ideas
about myself change all the time. My life is
not a movie. Everything is a series of
snapshots. I don’t know where I am in
them. Sometimes I feel all right and I’m
able to cope well but then it all comes
crashing down. I don’t know why. I get
overwhelmed and I can’t think. As a result I
give up. I am not sure about anything else.
47
Gillian: Self States
Falls apart
Abandonment
Despair
Rage
Structure of the Cognitive Component of
the Self Explains the Experiential Self
Experiential self:
Impaired sense of unity
Impaired sense of continuity
Lack of Authenticity
Lack of clarity and certainty
Unity, cohesion, authenticity, and certainty are
experiential consequences of a well
differentiated and integrated self structure (links
within self-knowledge)
Cognitive-Structural Model of the Self
 The self as a stable and cohesive structure
 Traditional model of mental health professions
 Current social-cognitive model: the self is a complex
processing and meaning system
 With this model, the self:
 A structure and a process
 Stable and variable
 Generates temporary “selves” related to the situation –
momentary working self
 The model has interesting clinical implications and
applications
Reflections on Alternative Conceptions
of the Fragmentation of the Self
 Alternative conceptions:
 Transference-focused therapy (Kernberg, 1984):
Origins in splitting that arises as a defence against aggression
 Compromised integration
Not defensive
 integration is a developmental process
 Failure arises from:
 Disparity in informational input that exceeds the integrative
capacity the cognitive apparatus:
Impaired integrative mechanisms
Extreme emotional lability
Extremely disparate behavior by significant others
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
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
Self as a Complex Processing System:
Matrix Structure
Cognitive-emotional schema
Connections that differ in strength
Self Concept
Identity
Facet of the Self
or self-image
Self is both a
structure
and a
process
Momentary Self
Momentary
Self
Event B
Momentary
Self
Event A
Event B
•Context related
•Varies
Momentary
Selfwith the
situation
•Not simply recalled
or
Momentary
reactivated
Self
•Generated and
created
to fit the context
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
Stability with
Adaptive Variability
•Stability: relatively
stable links in the
network
•Adaptive Variability:
Momenta
capacity
to
generate
ry a
momentary
Self working
self that is relevant to
the situation
Event A
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.”
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
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
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
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
Structure of the Self
3. Self as Agent
Executive self
Self as a centre of self regulatory action
Self as “doer” or decision-maker
Agentic or Self-Directed Self
 Sense of agency and directedness contributes to cohesion and
integration
 Goals:
 Energize
 Direct 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
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
Negative Feedback Loop
Goal
Standard
Reference Value
Comparator
Input Function
Effect on
Environment
Output Function
After: Carver & Scheier, 1998, 2011; Carver, 2012
Negative Feedback Loop
Thermostat
Setting
Comparator
Sensed
Temperature
Effect on
Environment
Switch on
Heater
After: Carver & Scheier, 1998, 2011; Carver, 201
Negative Feedback Loop
Goal
Standard
Reference
Value
Comparator
Input
Function
Effect on
Environment
Output
Function
After: Carver & Scheier, 1998, 2011; Carver, 2012
Hierarchical Structure of Goals
Superordinate
goal
Comparator
Input
Comparator
Input
Comparator
Input
Lowest
Level
Output
System is self-regulating
Hierarchical Structure of Goals
No central control
centre or unit
Overcomes the problem
of the homunculus – a
central causal agent
Superordinate
goal
Comparator
Input
The only thing left to
explain is the origin of a
Comparator
superordinate goal
Comparator
Input
Input
Lowest
Level
Output
System is self-regulating
Hierarchical Structure of Goals
No central control
centre or unit
Overcomes the problem
of the homunculus – a
central causal agent
Superordinate
goal
Comparator
The only thing left to
explain is the origin of a
Comparator
superordinate goal
Comparator
Most goals are not established
using a self-reflective process
Input through
Most goals established
an implicit process
Emotional aspect of this process
motivates for action
Input
Input
Lowest
Level
Output
Treating Self Pathology
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
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”
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
arises from:
Construct a more adaptive andIntegration
rewarding personal
i. Connections within
niche
self referential
Promote self directedness
knowledge
Help the patient to “get a life”
ii. Self-directedness
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
Integrated Modular Treatment: Phases of
Change
Phase 1: Safety,
Containment, and
Engagement
Phase 2: Control and
Modulation:
Most readily
changed
Unstable and dysregulated
emotions
Phase 3: Exploration and
change:
Maladaptive schemata and
interpersonal patterns,
consequences of trauma and
adversity
Phase 4: Synthesis:
Most stable
Components of Treatment
1. Formulation: Setting the Stage for Integration
2. Necessary Prerequisites
3. Generic Change Mechanisms
4. Specific Integrative Interventions
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
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
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
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
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
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
Emotional Regulation and Modulation and
Intervention Modules
Regulation
and
Modulation
Psycho-education
Awareness & Recognition
Acceptance & Tolerance
Re-structuring Escalating
Cognitions
Self-Regulation Skills
Re-structuring Cognitive
Appraisal
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
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 selfreflection
Livesley, in press
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
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 selffocused but not necessaryily self-reflective
 Self refection is necessary for experience to be therapeutic
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
Promoting Differentiation
 Development of boundaries:
 Consistency
 Modeling
 Collaborative description of problems and
psychopathology
 “Unpacking the meaning of experience
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
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
Core Self States
Other Person
is frightened
FALLS APART
CANNOT SPEAK
Withdraws
ANGRY
Unloved
Cyclical
Pattern
Frightened, terrified
FEAR OF ABANDONMENT
Unpredictable, thinks the worse
Not understand someone’s behaviour or wants
2. Establishing Goals and SelfDirectedness
 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
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”
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
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
5. Constructing a New Self-Narrative
Formulation and reformulation
Regular narrative summaries
Setting a new self narrative as a treatment
goal
Sources
 Leary, M.R., & Tangney, J.P. (2012). Handbook of Self
and Identity 2nd Ed. New York, Guilford
 Vohs, K.D., Baumeister, R.F., (2011). Handbook of Self
Regulation 2nd Edition. New York, Guilford
 Carver, C. S., & Scheier, M. F. (1998). On the selfregulation of behavior. Cambridge, UK: Cambridge
University Press
 Stanghellini, C., & Rosfort, R. (2013). Emotions and
personhood. Oxford; Oxford University Press