23 Future directions in examining the self in psychological disorders
As has been demonstrated throughout this book, the concept of the “self” opens up many opportunities for advancing our understanding of human psychological functioning and dysfunction. It is also apparent that the use of this concept gives us multiple options to facilitate developments in the treatment of disorder and, perhaps, could improve the efficacy and effectiveness of therapy for a broad range of psychological conditions. Despite such potential advantages, numerous issues have been identified, inclusive of the disparities in the definition and operationalization of the term “self” itself, and also in discrepant foci on aspects of the self (Katzko, 2003).
Starting with issues relating to the definition and operationalization of the “self,” researchers have recently provided a simple characterization:
… the term self often refers to a warm sense or a warm feeling that something is “about me” or “about us.” Reflecting on oneself…requires that there is an “I” that can consider an object that is “me.” The term self includes both the actor who thinks (“I am thinking”) and the object of thinking (“about me”).
However, the “self” remains a fuzzy concept. Leary and Tangney (2012) identified five distinct ways in which the self has been used by researchers (self as the total person, self as personality, self as experiencing subject, self as beliefs about oneself, self as executive agent). Their review of the literature reveals 66 self-related constructs, processes, or phenomena, although this is likely to be an underestimate, and they acknowledge that there is little research exploring their interrelationships. Despite such “conceptual morass” (Leary & Tangney, 2012, p. 5), the notion of the “self” has shown itself to have great persistence for a range of reasons including its utility, its face validity, its ability to be integrated with other frameworks (e.g., cognitive, psychoanalytic, social), and because of the opportunities it allows for empirical investigation.
The usage of “self” varies depending on one’s preferred psychological paradigm. The psychoanalytic approach focuses on internal structures and the dynamics between them, but there is variation even within this approach from Freud’s traditional egopsychology through to interpersonal object relations theory and beyond (Fosshage, 2009; Guntrip, 1977; Kohut, 1971, 1977). The cognitive approach, which has been influential most recently in the clinical domain, has also embraced the self. Self-concepts are considered to be cognitive structures incorporating content, attitudes, evaluative judgments and attentional processes that aim to facilitate goal achievement and self-protection (Oyserman & Markus, 1998).
Throughout this volume, we have seen a number of approaches to understanding the role of self in psychological disorders. In some instances, authors have emphasized that the self is part of the core phenomena of the disorder (e.g., ipseity in schizophrenia). Other times, the self is considered an etiological underpinning of the clinical phenomena (e.g., moral self in OCD). Other authors see the self as part of both core phenomena and processes that maintains the disorder (e.g., self processing in social anxiety). In some instances, a bidirectional relationship with symptoms has been emphasized (e.g., disruptions in attachment and the capacity to mentalize in depression and its subsequent impact on mentalizing). In most cases, however, authors have highlighted the complex transactional relationships between ruptures in self and symptoms of disorder.
A key theme throughout a number of chapters is that the self is not a static construct and that the experience of self is not a property of the individual, but, as Liotti and Farina (Chapter 17) put it, “an emergent, intersubjective property of human relatedness” (p. 175). All authors have emphasized general aspects of the self that require targeting in treatment, as well as the need for ongoing research to better identify aspects of the self that are related to specific disorders and that require targeting in treatment. Calls for theoretical integration, using the self and related concepts such as attachment as central tenets, have been made throughout the book in order to better understand psychological processes underpinning specific disorders. Moreover, paying greater attention to the self as a therapeutic target has been proposed across the board as a way forward in improving therapeutic outcomes and in decreasing relapse and vulnerability to disorder.
What is the direction that the study of self should proceed to in the future? Given such diverse perspectives, how can a common language about the self be reached? Can the construct of self, as understood through a psychoanalytic perspective, be at all similar to the notion as understood through cognitive and social perspectives? Throughout this book, we have seen that the self as understood by proponents of different theoretical orientations may appear to reflect radically differing constructs. Yet, can there be a common theme or an overarching narrative that encompasses such divergent perspectives on this thing called “self”? If so, would a consensus in depicting the self be useful for research or for psychotherapy?
In our opinion, such endeavors towards defining self are worthwhile. The task of reaching a consensus definition brings with it the potential for an integrative approach to the construct that is inclusive of various theoretical perspectives, and that is clarifying of whether differences in the definition are substantial or simply semantic. With such inclusivity, cross-theory collaborative efforts in research are more likely. Researchers from various orientations may be more likely to work together if there can be some agreement about the construct under study. The self no longer needs to be a divisive concept between different theoretical camps, but conversely could become a construct that brings such camps together. The consensus definition of self could also be theoretically clarifying, as differences in language will need to be distinguished from differences in inferences about the self. For example, when the self is described as “compartmentalized,” “conflicted,” and/or “complex,” are such descriptions simply semantically different, but alluding to the same mulitifaceted properties of self-concept? Such debates will – in our opinion – serve to clarify what is common but potentially described differently by researchers of the self.
In sum, we need a clearer operationalization of the “self”; and further, perhaps what is needed is a consensus language around terms such as self-concept, self-esteem, self-structure, self-integration, and so forth. The Common Language for Psychotherapy initiative may be a place to start in bridging across diverse theoretical orientations to reach a common language in psychotherapy and psychological research in relation to the self.
Turning to the perspective of a practicing clinician, a number of questions need to be considered. How can a clinician seek leverage in the notion of self-concept in therapy – and in what ways does this already occur within various schools of therapy? From various theoretical standpoints and paradigms, the self already occupies a central position in the formulation of disorders, yet how do therapists tailor their treatment strategies and techniques around such self-based formulations? To what extent is treatment within these perspectives informed by an understanding of the self-concept of the patient? Do therapists have the skills and training required to accommodate such formulations? These are issues for further research and consideration.
At a more “macro” level, an obvious future direction is the development of evidence-based preventative, early intervention, treatment, or relapse-prevention programs that target self-construals, presuming we are correct that such construals make individuals vulnerable to psychological disorder, resistant to treatment, or prone to relapse. As self-narratives are potentially redemptive, in that they are useful for buffering against distress, they have importance for prevention, treatment outcomes, and relapse prevention across disorders. Therapists can address attachment insecurities to assuage damaged or irreconcilable self-concepts, emphasizing their potential importance in therapeutic alliance and engagement, and in motivational and treatment processes. Specifically considering self-concept as a therapeutic target for focused psychological techniques could be an important way forward in augmenting current treatments, in the hope of achieving improved outcomes; therapy for social anxiety disorder is a prototypical example where self-processing techniques have already led to improved outcomes. Consideration of self-construals would also be useful in case formulations, as therapists can incorporate developmental, functional, and symptomatic information to develop treatment plans. All this is consistent with the bidirectional need to integrate our understanding of phenomena and theory within a scientist–practitioner framework (Salkovskis, 2002). Understanding symptoms or related phenomena from the emerging theoretical and empirical literature on the self appears to have enormous potential across the range of disorders.
What is interesting, however, is that despite several examples of specificity in some self-disorder associations, interventions have several components that are shared, for example, these include reparenting, rescripting, reflecting on and making sense of one’s experiences (i.e., mentalizing), creating narratives that link maladaptive beliefs to their external sources and origins rather than reflections of reality, etc. The commonality of these therapeutic strategies could be explained by an attachment framework and the therapeutic alliance in psychotherapy. Alternatively, given the importance of specific models of disorder in evidence-based treatment, targeting disorder-specific aspects of self could inform further development in treatment. Irrespective, the proposed ruptures in self-structures that are at the heart of disorder hold important implications more generally for scientist-practitioners, whatever their psychotherapeutic orientation.
Additionally, it is notable to state that most authors have come from the clinical arena. Given that the focus of this book has been on psychopathology, this is not surprising. However, research and theoretical work on the self is actually primarily conducted by social and cognitive psychologists. This is not atypical of the way in which clinical researchers, in search of ways to augment their existing models, integrate alternative frameworks from allied areas of psychology that have face validity or potential utility, rather than solely on the basis of true and comprehensive theoretical discourse. The advantages of clinicians using such constructs is that they are easily able to translate them into the clinical arena in a manner that is meaningful to practitioners and clinical researchers. However, often this development is then recast – the resulting revised models are considered to be theoretically derived in their own right, rather than pragmatically derived. As such, there is a potential disadvantage to clinical researchers using self-constructs in that they run the risk of omitting important theoretical nuances that cognitive and social psychologists hold in understanding their methodology and the results (and of course, conflicting results) within their research field. That is not to say that the clinical and social or cognitive psychological fields are anathema to each other. There is a growing effort in psychology to integrate clinical and both social and cognitive psychology constructs and methodologies; indeed journals such as the Journal of Social and Clinical Psychology explicitly aim to bridge this gap. This book also represents a step towards integration and it is hoped it will spur future research also incorporating true collaboration and the development of a “shared language” between clinical and social or cognitive psychologists investigating the “self.” Conversely, it could also be argued that a focus on specific self constructs has emerged from an understanding of clinical phenomena and that a clinical perspective can advance understanding of the self.
With respect to future research, a number of additional options can be identified. Longitudinal research in psychopathology tracking the development of self processes and construals against the emergence of symptoms reflective of specific disorders would provide useful data for the etiological association between self and psychopathology. In addition, the impact of developmental processes, such as parenting and attachment patterns, on the emergence of the self would be of particular utility in understanding psychopathology; indeed, attachment research – spanning from a background in biological, developmental, and psychodynamic theory but incorporating cognitive and affective theoretical formulations – could serve as a focal point for integrative work on the self. Similarly, experimental psychopathology would also help elucidate etiological associations between self and symptoms. It is entirely possible that self construals as measured in adult research are the result of psychopathology which tends to emerge in adolescence or early adulthood or even, in many cases, childhood.
Furthermore, considering our overarching discussion of the organization of the self, we believe that research needs to move away from being one-dimensional – focusing just on the beliefs held about self – to being two-dimensional – focusing on both the structure of the self-concept and the cohesion of such self-beliefs. Ironically, such an approach may imply moving “back to the future” – incorporating notions such as those from theoretician/clinician George Kelly’s Personal Construct Theory (1966/2003). Within the “Fragmentation Corollary,” Kelly noted that individuals’ belief systems are so large that a “person may successively employ a variety of construction subsystems which are inferentially incompatible with each other” (p. 13); as one’s self-system comprises one’s most developed belief system, its structure and consistency bears the greatest opportunity for inconsistency and fragmentation. Clearly, then, what one thinks of one aspect of self needs to be studied in the context of other competing beliefs one has about oneself. We need research methods to capture both foci. Another useful distinction is between physical and psychological aspects of the self, as was explicated with regards to a number of disorders (e.g., autism, bipolar disorder, chronic fatigue syndrome). This distinction can, however, be applied across a number of disorders where physiological aspects of, for example, anxiety are likely to impact upon constructions of self and other cognitive functions. In addition, research using implicit measures is also instructive, because it goes beyond the explicit declarative statements consciously made about self to study more automatic processes, and potentially taps into alternative ways that such knowledge about self is stored. However, as noted above, given the complex theoretical underpinning of implicit vs. explicit views of self, and the numerous contradictions and complications of research and theory in the area (e.g., see Hughes, Barnes-Holmes, & Vahey, 2012; Nosek, Hawkins, & Frazier, 2011), explicit involvement of social psychologists would be welcomed to assist such endeavors. Similarly, of course, work from cognitive scientists and cognitive neuroscientists will also give shape to this discourse about self, as exemplified by work in this book with respect to psychotic disorders and autism.
In conclusion, we can see that a large challenge awaits us as theoreticians and clinicians. However, we believe that the work in this book highlights the enormous advances we are making in our knowledge and use of techniques regarding the “self” in the understanding and treatment of psychological disorders. We remain optimistic about the future of work in this field, given the relative youth of this work, and considering further the relatively recent emergence of psychology itself as a science when compared to its philosophical roots. We hope this important task is taken up with vigour, and hope that our enthusiasm is infectious, particularly when we are looking forward to the next generations of researchers and practitioners moving into the field.