Introduction

Derek, a 33-year-old single man, employed in sales at a technology retailer, feels lost. He has struggled with feelings of depression and anxiety since early adolescence, and now, 20 years later, he seems to have made little progress with his life. He has suffered two episodes of major depression, one after his first year of university and the other five years ago. The first episode remitted with a trial of pharmacotherapy and the second with a combined treatment of antidepressant medication and cognitive behavior therapy (CBT). However, the effectiveness of the CBT was minimal, and Derek prematurely terminated treatment after 11 sessions. It seemed like the sessions were going nowhere, the treatment goals felt lofty and unattainable, and Derek repeatedly failed to follow through with his homework assignments. The therapy became a mirror reflection of Derek’s approach to life: drifting, aimless, with no real purpose or meaning.

From a diagnostic perspective, Derek’s symptom presentation is consistent with depressive personality disorder (see Clark & Hilchey, 2015). Although not an official diagnostic disorder in the ICD-10 (World Health Organization, 2013) or the DSM-5 (American Psychiatric Association, 2013), Derek’s personality constellation was characterized by persistent unhappiness, belief in his own inadequacy and insignificance, heightened pessimism, lack of interest and goal-directedness, and negativity towards others. He had difficulty forming close, stable relationships with others, and had no real goals, ambitions or meaning. He was chronically underemployed and spent much of his free time gaming or binge-watching online movies. He had a nihilistic outlook on life, and often concluded “why bother?” when it came to taking initiative. He actually felt sluggish much of the time, complaining that he often felt bored and disinterested.

The self is a critical construct in cognitive behavioral formulations. For individuals like Derek, who enter therapy with major personality problems, selfhood issues will be a major focus of the therapeutic enterprise. In fact treatment effectiveness will hinge on an ability to achieve change in biased and dysfunctional self-representation. And yet, work on the self is not only critical for CBT of personality disorders, but it is considered the key change process in CBT for a range of clinical disorders such as major depression, generalized anxiety disorder, eating disorders, and even obsessive–compulsive disorder. For Derek to move beyond his chronic depression, therapy must address his core self-beliefs of worthlessness, insignificance, criticalness, and ineffectiveness. If these fundamental issues of the self are left intact, Derek’s treatment will never provide more than temporary symptomatic improvement.

This chapter focuses on the role of the self in cognitive therapy and CBT of the emotional disorders. Much of the research and theoretical development in CBT has focused on anxiety and depression, so it is reasonable to confine our review to these disorders. In this chapter the term self-concept or self-representation refers to characteristics or attributes that form meaning-based memory for oneself (i.e., self-knowledge), are subject to reflective processing, can be consciously acknowledged through language, and are integral to the regulation of thought, feeling, and behavior (Harter, 1999; Kihlstrom, Beer, & Klein, 2003; Leary & Tangney, 2003). Although self-concept is a multidimensional construct with a multiplicity of corresponding terms, it will be seen that CBT theory and treatment has mainly focused on self-concept content, that is, one’s self-beliefs and self-evaluations, rather than self-concept structure, which is how self-concept is organized in terms of unity, pluralism, complexity, discrepancies, and the like (Campbell, Assanand, & Di Paula, 2003).

The chapter begins with a brief historical review of the role of the self in early theories of CBT. This is followed by a discussion of the self in contemporary CBT models of anxiety and depression. The chapter concludes by speculating on how a greater appreciation of the self might direct cognitive behavioral treatment of difficult emotional disorders, such as that described in the case of Derek with a depressive personality.

The self in early CBT

The self has always been recognized as an integral concept – even in the earliest versions of CBT. Ellis, for example, does not directly mention the self in rational-emotive therapy (RET), but the basic premise of RET, that psychological disturbance is the result of irrational thinking (Ellis, 1962), is predicated on the notion of a self as object. Most of the irrational beliefs identified in RET are beliefs that concern the self as it interacts with the social and even physical world. There is a strong sense of self-evaluation in the irrational beliefs of RET, but again this is not elaborated in the theory. Rather, RET is much more focused on self-relevant belief content, and how modification of these “irrational beliefs” can correct emotional disturbances like anxiety and depression (Ellis, 1962, 1977). Furthermore, RET is silent on how these negative construals of the self might lead to emotional disturbance. It is assumed their very existence and dominance in self-regulation will lead to excessive negative emotion and maladaptive behavior. Of course, the solution promoted in early RET was the adoption of more rational, realistic beliefs about the self and the personal world.

The publication of Michael Mahoney’s Cognitive and Behaviour Modification in 1974 was a major contributor to the “cognitive revolution” that was emerging in behavior therapy. The main thesis of this work was an impassioned, empirically based argument for the importance of cognitive mediation in understanding the etiology and treatment of psychological disorders. Of course, an argument for cognitive mediation in the context of emotional disturbance is also an acknowledgment of the importance of the self in understanding psychopathology. Later in this publication, Mahoney provides an eloquent critical analysis of the construct of belief, concluding that concepts like beliefs, counter-control and choice do have a place in a scientific theory of human change. All of these constructs require a notion of self as both the knower (self as subject; I-self) and the object of being known (Me-self; James, 1890). Mahoney concludes by proposing a therapeutic orientation he called the personal scientist paradigm. One of the critical components of this approach is the acquisition of adaptive self-evaluative skills. Mahoney argues that evaluative self-reactions are predominant in the life of individuals, but unfortunately much of this self-evaluation is negative or dysfunctional. We see here an explicit recognition of the importance of self-representations in emotional disturbance, but the discussion is narrowly focused on the evaluative aspect of the self. Twenty years later, Mahoney (1995) embraced the constructivist perspective. In delineating future directions for constructivism psychotherapy, he noted that a greater appreciation of the centrality of the self is needed with recognition that psychotherapy is a participation in “selving processes” and that development of the self occurs through our most intimate relationships.

The original cognitive theory of emotional disorders formulated by Aaron T. Beck makes explicit reference to the importance of self-concept in depression. In his pioneering book Depression: Causes and Treatment (1967), Beck refers to a 1960 experiment in which he found that depressed patients endorsed more socially undesirable traits and fewer positive traits. He then proposed that a constellation of negative generalizations about the self constituted a specific vulnerability to depression, along with negative attitudes about the world and future. He further emphasized the importance of self-evaluation, noting that the depressogenic self not only possesses negative self-descriptions but also places high value or judgment on these traits. Thus, the belief “I am stupid” is only pathogenic if the person places high value on being intelligent. As well, Beck argued that self-blame is a key component of the depressogenic self, such that the person holds herself responsible for her deficiencies. In Cognitive Therapy and the Emotional Disorders (1976), he appears to again emphasize the self-evaluative aspect of the pathogenic self, noting that low self-esteem and self-criticalness derive from a tendency to compare oneself with others. Beck’s seminal treatment manual on depression coined the term “cognitive triad” to refer to the three major negative cognitive patterns in depression: negative views of the self, the personal world, and the future (Beck, Rush, Shaw, & Emery, 1979). Once again, negative self-evaluation was emphasized as both a predisposition to, and characterization of, depression.

Publication of the cognitive therapy manual for anxiety disorders revealed that Beck also considered a pathogenic self to be applicable to generalized anxiety (Beck & Emery, 1985). Here the notion of “self” vulnerability to anxiety involved ideas of inadequacy, helplessness, and weakness so that individuals are susceptible to fears of negative evaluation and rejection by others. This belief that one is incompetent in dealing with problematic situations results in lowered self-confidence and increased likelihood of anxiety in relevant situations. Beck also noted that the self-view of the anxious person fluctuates with the degree of risk or danger perceived in a situation. The lowered self-confidence and self-criticism in anxiety is selective, activated only in anxious situations, whereas in depression the negative self-view is more global and pervasive.

Of the early cognitive clinical theories, Guidano and Liotti (1983) provided the most extensive elaboration of the role of the self or personal identity in psychological disorders. Drawing on both attachment and cognitive theories, Guidano and Liotto discuss how the development of a distorted self-knowledge structure (i.e., personal identity) will result in a rigid and defensive attitude toward oneself, and problems interacting with the real world. This disparity will cause a failure to distance and decenter from the negative, distorted ideas that constitute the self-concept. The failed distancing leads to an emotional self-knowledge that is undifferentiated and poorly controlled, which is evident in the dogmatic thinking often seen in emotional disorders.

Guidano and Liotto (1983) viewed personal identity in terms of the development of a complex cognitive structure that begins as a primitive, undifferentiated, largely intuitive self-conceptualization, and becomes progressively more elaborated through play, fantasy, and early attachment relationships. They noted two key aspects of personal identity relevant to psychopathology. The first, self-identity, refers to the traits and attitudes that individuals utilize to define the self. It is the interrelated beliefs one has about the self across various domains like attachments, duty, values, attributions of causality, and the like. Self-esteem is the second component of personal identity and refers to our tendency to engage in self-evaluation. The degree of congruence between beliefs about one’s value and estimates of one’s behavior and emotions will determine level of self-acceptance and self-esteem. In sum, representations of the self in the form of self-identity and self-esteem interact and influence how we perceive or understand our experience. To understand psychological disturbance, like obsessive compulsive disorders (OCD), one had to determine the aberrant personal identity and distorted self-evaluative component (Guidano & Liotto, 1983). In OCD, an ambivalent or contradictory self-identity leads to a form of interaction with the external world in which one feels forced to search for certainty and the perfect solution in order to rectify a state of indecision caused by the ambivalent self (see Chapter 12 by Ahern and Kyrios in this volume).

Early cognitive theories readily recognized the importance of a negative and biased self-view in the etiology and maintenance of emotional disturbance. However, with the exception of Guidano and Liotto (1983), there was little consideration of the development of biased self-representation or the mediating processes responsible for its influence on psychopathology. Also, there was a rather simplistic view of the self that overemphasized self-evaluation or self-esteem as the chief progenitor of psychological disturbance. Other aspects of the self, such as aberration in structure, organization, function, access, and change, were rarely mentioned.

The self in current CBT theories

Theory, research, and treatment have continued to evolve since those early years of the “cognitive revolution.” The self has continued to play an important role in the cognitive-behavioral perspective, but it has not taken center stage in our conceptualizations. Advances in psychological theories about the self have had minimal impact on more contemporary cognitive behavioral theories. Despite some apparent “shunning” of the self by cognitive behavioral researchers, there are some glimmers of progress. The first is the continued development of Beck’s cognitive theory, the concept of mode and the centrality of the self-schema. Second, certain selfhood theories have been mentioned in the CBT literature, notably Markus’ self-schema research, Higgins’ self-discrepancy theory, Linville’s concept of self-complexity, and the influence of contradictory or feared elements of the self. We now examine a selection of these self-related topics in current CBT formulations.

The elaborated cognitive theory

The schema construct is central to Beck’s (1996) cognitive model. Schemas are relatively enduring internal structures of stored information that guide and organize the processing of new information in a manner that determines how phenomena are perceived and interpreted (Clark & Beck, 1999). The critical schemas in the emotional disorders are biased in content and distorted in their structure and organization (Beck, 1967, 1987). In depression, schematic content is excessively focused on negative self-referent material, whereas in anxiety the schemas are oriented around threat, danger, and helplessness. Beck (1996) noted that there are different types of schemas, with the cognitive-conceptual schemas being most relevant to the current discussion. According to Beck, these schemas are critical to the selection, storage, retrieval, and interpretation of information. The cognitive-conceptual schemas provide an internal representation of the self, or self-concept, which constitutes our self-identity, personal goals and values (Clark & Beck, 1999). Together with other schema types, an interrelated schematic array or mode is constituted that relates to particular demands placed on the organism (Beck, 1996). In depression, a loss mode predominates, whereas in anxiety the threat mode is activated.

In their elaboration of the cognitive model of depression, Clark and Beck (1999) proposed that the cognitive-conceptual schemas of self-knowledge form an interrelated array of schemas we call the self-concept. They identified a number of characteristics that may be important to consider in the dysfunctional self such as (a) the importance or centrality of specific self-representations, (b) whether beliefs represent actual or idealized aspects of the self, (c) the temporal orientation of the beliefs, (d) the valence of the beliefs, (e) the degree of certainty or efficiency associated with the schema, (f) the self-schema’s basis in few or varied external referents, (g) the degree of self-belief accessibility, (h) the level of self-schema complexity, and (i) the extent of the interpersonal orientation of self-beliefs. However, as cognitive clinical researchers have tended to focus on schematic content and valence, the importance of these other self-schema characteristics still remains speculative at this time.

Two self-report measures especially important to the measurement of self-schema content are the Beck Self-Concept Test (BSCT; Beck, Steer, Epstein, & Brown, 1990) and the Dysfunctional Attitudes Scale (DAS; Weissman & Beck, 1978). The BSCT was developed to assess characteristics of self-concept relevant to Beck’s cognitive triad. Individuals rate themselves on 25 self-relevant domains (e.g., appearance, knowledge, popularity, personality, etc.) in comparison to other people they know, with high scores indicating a more positive self-view. As expected, the BSCT evidenced significant negative correlations with measures of depressive but not anxious symptoms, and depressed patients scored significantly lower than non-depressed individuals. Unfortunately, the BSCT has not been widely used in CBT research, so not much is known about the specific selfhood elements assessed by this measure.

The DAS is a widely researched measure of cognitive vulnerability for depression. Because most, but not all, of the DAS belief statements have a self-referent orientation, the questionnaire can be viewed as a proxy measure of self-concept (“Who I think I am”), although the items reflect an extreme and maladaptive perspective on the self. Some items are highly self-referent (e.g., “I do not need other people’s approval for me to be happy,” “I should set higher standards for myself than other people”), whereas others are more generalized beliefs about life (e.g., “People will reject you if they know your weaknesses,” “If a person is not a success, then his life is meaningless”). Given this ambiguity and complexity in item structure (i.e., use of “if–then” propositional statements), the DAS can be considered only a retrospective self-report measure of some relevance to the self-concept.

A large research literature has shown that clinically depressed individuals have higher DAS scores, that high pre-treatment scores predict poorer response to treatment, that dysfunctional attitudes can be primed by negative mood state in those vulnerable to depression, and that dysfunctional attitudes interact with negative life events as causal factors in depression onset (for reviews see Brown & Beck, 2002; Clark & Beck, 1999). However, there has been little research into the actual selfhood pathology tapped by the DAS. For example, are some DAS self-beliefs more pathological than others, or are some of these beliefs more central to the self-concept than others? Currently respondents rate their level of agreement or disagreement with each statement, but does this metric accurately capture the level of belief or the centrality of the belief to the person’s self-concept? In sum there is a greater need for item-level analysis of the DAS in order to disentangle the selfhood aspects of the measure.

One of the best examples of selfhood research within CBT is work published on self-schema organization in depression by Dozois and colleagues. Dozois and Dobson (2001a) utilized a procedure called the Psychological Distance Scaling Task (PDST) where individuals position positive and negative trait adjectives within a two-dimensional space defined by a self-descriptiveness x-axis and a valence y-axis. The coordinate point (x- and y-axis) for each adjective is calculated and the average interstimulus distance among the positive schematic adjectives and negative schematic adjectives is determined. These averages reflect the degree of interconnectedness among the schematic adjectives, with lower average values reflecting greater interconnectedness. The PBST negative stimulus distance was correlated with depressive symptoms, and other indices of self-referent processing such as endorsement and recall on the Self-Referent Encoding Task (Dozois & Dobson, 2001a). In their first study, Dozois and Dobson (2001a) found that depressed patients had fewer interconnected positive schema adjectives than anxious patients, but both clinical groups had greater interconnectedness for negative adjectives than the non-clinical controls. A later study found that negative cognitive structure may persist even when depressive symptoms remit, whereas remitted depressed individuals showed an increase in positive self-schema interconnectedness (Dozois & Dobson, 2001b).

More recent research has indicated that stronger interconnectedness of negative self-schema may be particularly prominent in the interpersonal domain, that negative self-schema organization interacts with negative life event occurrence to predict increase in depressive symptoms, and negative interpersonal self-schema organization remains stable beyond symptom amelioration (Dozois, 2007; Seeds & Dozois, 2010). Furthermore, in a treatment outcome study, only the cognitive therapy plus medication group showed significant improvement in positive and negative interpersonal self-schema connectedness compared to a medication-only group (Dozois et al., 2009).

The PDST research is an excellent example of the deeper understanding and clinical utility associated with selfhood research within a CBT framework. This research provides important new insights into cognitive vulnerability for depression as well as influences on response to treatment. At the very least, it demonstrates that an exclusive focus on self-view content or the self-evaluative process might miss important features of the role that selfhood pathology plays in psychological disorders. And yet, it also reminds us that the role of the self can be complex. For example, should CBT therapists be more concerned about the dominance of negative self-beliefs or the coherence of the negative self-structure? Regardless of depression status, self-concept will comprise an array of negative and positive self-beliefs. Possibly clinicians should be more concerned with the presence of a well-structured negative self-system than the nature of the depressed person’s self-beliefs. Likewise, researchers have still not determined the relative functional significance of highly dominant negative self-beliefs versus a poorly developed positive self-system. From a clinical perspective, should therapists be more concerned with weakening negative self-beliefs or strengthening a positive self-view? The core treatment elements of CBT, such as cognitive restructuring, were developed to modify negative self-beliefs. There is considerable research evidence that the interpersonal domain is especially important in depression. Consequently, mastery or achievement may be less important, although it is possible that other self-relevant domains are key constructs in other disorders. For example, appearance would be more central to eating disorders and control might be more critical in the anxiety disorders. Clearly, what is needed is a greater degree of content-specificity in selfhood research because of the congruence between specific selfhood domains and particular disorders. Although many key questions remain, the fundamental importance of self-schema organization has been established.