What is the self?

Many theories referring to the role of the self in depression typically use metaphors (such as a “fragile self,” or discrepancies between the ideal or wished for self and the actual self) to capture the psychological processes that may explain vulnerability for depression. These metaphors are tremendously helpful from a phenomenological perspective but also have led to the reification of these self-experiences, as if we truly “have” a false or fragile self, or that we “have” an ideal and an actual self. Although helpful clinically, they provide a metaphorical description of the phenomenological experience of depression, rather than a true explanation (see Figure 8.1). Most contemporary psychological approaches therefore assume that the self and the sense of self-coherence (i.e., the sense that one has continuity and consistency in thought and behavior) is an illusion (Bargh, 2011, 2014): it is the product of our capacity for social cognition or mentalizing, that is, our capacity to understand ourselves in terms of intentional mental states (i.e., our feelings, wishes, attitudes, and goals) that have some stability over time (Han, Northoff, & Joan, 2009; Northoff et al., 2006).

In the remainder of this chapter, we focus on the differences between theories about the self in depression that are rooted in mental representation versus mental process approaches to the self. While the former typically focus on the content of representations of the self, the latter approaches view impairments in self-structures in depression as being the result of impairments in the process of social cognition or mentalizing (Fonagy, Moran, Edgcumbe, Kennedy, & Target, 1993; Luyten, Blatt, & Fonagy, 2013).

Mental representation models of the self in depression: depression and disruptions of the dialectic between the development of the self and relatedness

Both psychodynamic (Blatt, 2004; Luyten & Blatt, 2012) and cognitive-behavioral (Beck, 1983; Young, Klosko, & Weishaar, 2003) theorists have argued that distortions in the content of mental representations concerning the self (and others) confer vulnerability to depression (see Table 8.1). Beck (1983) described the concepts of sociotropy and autonomy, which refer to broad cognitive-affective schemas that organize the self and are presumed to confer vulnerability to depression, as well as to other types of psychopathology. These dimensions overlap both theoretically and empirically with psychodynamic formulations concerning dependency and self-critical perfectionism, respectively (Blatt, 2004; Luyten & Blatt, 2011, 2013). While sociotropy/dependency refers to a self-organization that is overly focused on others as a source of self-worth and self-esteem, autonomy/self-critical perfectionism refers to a sense of self that is overly focused on achievement and autonomy at the cost of developing a capacity for relatedness. These types of self-organization are considered to reflect a disruption of the normal dialectical interaction between two fundamental developmental lines. These are, first, an anaclitic, relatedness or attachment line, which normally leads to increasingly mature, complex, and mutually satisfying interpersonal relations; and second, an introjective or self-definitional line, which normally leads to the development of a stable, realistic, and essentially positive self and identity (Luyten & Blatt, 2013; Luyten et al., 2011). Disruptions in this dialectic lead to an imbalance between these developmental lines, in which one is overemphasized or exaggerated while the other is neglected.

Empirical research suggests that autonomy/self-critical perfectionism involves one’s identification with high demands from attachment figures and/or represents a defensive compensation for feelings of inferiority resulting from harsh parenting – in particular parental criticism and psychological control (Blatt & Luyten, 2009; Soenens, Vansteenkiste, & Luyten, 2010). Attempts to compensate for these feelings may lead to overcompensation, as is expressed in an exaggerated focus on achievement, often leading to mental and/or physical overexertion, and a so-called “false” self that is seen as strong, autonomous, and self-reliant, but in reality is fragile and vulnerable. These individuals have been described in the self psychology literature as experiencing a strong discrepancy between their “ought” or “ideal” self and their real self, or as characterized by strong conflicts between their ego ideal and/or superego and their ego, or as exhibiting high levels of self-criticism and self-derogation, depending on the specific theoretical approach. Excessive self-sacrificing tendencies may serve the purpose of seeking recognition and praise. Given this tendency for overexertion and self-sacrifice in combination with strong needs for autonomy and control, self-critical perfectionism is also implicated in fatigue- and pain-related exhaustion syndromes (see Chapter 19 in this book), as well as in eating disorders (Boone, Soenens, & Luyten, 2014; Egan, Wade, & Shafran, 2011).

Sociotropy/dependency refers to a self-organization that is overly focused on others as a source of self-esteem and self-worth, to the neglect of feelings of autonomy. This may range from individuals with a very fragile “self-structure” who thus are almost completely dependent on others for their self-esteem; this is, for instance, typically observed in individuals with borderline personality disorder. Indeed, studies suggest the existence of high levels of preoccupied and disorganized attachment in these individuals, which lead to idealization–denigration cycles in relationships and a lack of feelings of stability of the self – so-called identity diffusion (Fonagy & Luyten, 2016; Levy, Beeney, & Temes, 2011). In higher-functioning individuals (e.g., individuals with dependent or histrionic personality disorder), dependency needs are more modulated and are typically associated with a submissive yet passive–aggressive relational style. These individuals typically inhibit anger, as “anger threatens the very hand that feeds” (Blatt, 2004), which often is associated with “self-silencing” strategies (Jack & Dill, 1992), silencing their needs for autonomy and recognition because they fear abandonment and loneliness. Many of these individuals may also develop compulsive caregiving tendencies; that is, they care for others as they would like to be cared for themselves (Blatt, 2004). Developmentally, excessive dependency has been shown to be rooted in attachment figures’ excessive emphasis on dependency, i.e., feelings of love, approval and recognition were excessively contingent upon the child’s dependence, thwarting the development of the capacity for autonomy and self-efficacy.

Sociotropy/dependency and autonomy/self- critical perfectionism have also been shown to be associated with increased stress sensitivity and stress generation processes, particularly through their impact on close interpersonal relationships, which are expressed in dysfunctional interpersonal transactional styles (Luyten, Blatt, Van Houdenhove, & Corveleyn, 2006; Luyten et al., 2011; Shahar & Priel, 2003). Highly dependent individuals tend to elicit rejection and abandonment by others because of excessive demands for love and care. They thus show hypervigilance for rejection and abandonment, leading to continuous doubts about the self, which hampers the development of feelings of autonomy, integrity and agency. Self-critical perfectionistic individuals tend to evoke criticism and disapproval in others as a consequence of their high standards and critical attitudes. Hence, others tend to confirm dependent individuals’ fears of rejection and abandonment, and self-critical individuals’ fears of disapproval, leading to interpersonal vicious cycles. Self-critical individuals therefore show hypervigilance for experiences of failure, typically leading to strong feelings of self-doubt and often even the conviction that, deep down inside, they are completely worthless. Needless to say, these feelings and fantasies seriously hinder the development of positive feelings of self-regard. These findings are in line with major models of depression linking the disorder to increased stress sensitivity and the active generation of stress (Hammen, 2005; Heim, Newport, Mletzko, Miller, & Nemeroff, 2008).

Despite these similarities in various theoretical formulations concerning these two types of self-organization in depression, there are also some interesting differences between theoretical orientations. For instance, there is a greater emphasis on the function of these types of self-construal within psychodynamic approaches. As an example, cognitive-affective schemas centered on sociotropy/dependency are not seen solely as reflecting an individual’s high dependency needs resulting from a history of deprivation, but also as his/her best attempt, given his/her biological endowment and environmental context, to establish some sense of stability in the sense of self and others – however maladaptive the attempt may in fact be. This perspective has recently also been incorporated in schema therapy – for example, through the notion of experiential avoidance and the view that schemas (and modes) may reflect compensatory strategies (Eurelings-Bontekoe, Luyten, Ijssennagger, van Vreeswijk, & Koelen, 2010; Young et al., 2003).

Mentalizing and the self in depression: depression and disruptions in the capacity for reflecting about the self

More recent psychodynamic and cognitive-behavioral approaches have increasingly adopted a process approach to the disorganization of the self-experience and vulnerability for depression. Specifically, there is increasing interest in the role of impairments in metacognition – literally “thinking about thinking” – or mentalizing (also referred to as reflective functioning) in depression (Luyten, Fonagy, Lemma, & Target, 2012; Segal, Williams, & Teasdale, 2013; Watkins & Teasdale, 2004). These approaches center on the metacognitive processes that are involved in reflecting on the self and others (see Table 8.2). This approach is consistent with the so-called “third-wave” cognitive-behavioral approaches that focus on the roles of metacognitive awareness and mindfulness in the treatment of depression.

These approaches complement views focusing on distorted cognitive-affective schemas in depression outlined earlier in this chapter. Specifically, they provide a better account of the disintegration of the feeling of self that is typical of many depressed patients and which is perhaps at the core of the depressive experience. These more phenomenological process-oriented approaches also provide more direct, and perhaps more effective, avenues for intervention with patients who are severely depressed: “lifting” these patients’ depressed mood is often a prerequisite before they can engage with their therapist in any meaningful work relating to the content of their depressive experiences. This may be one of the reasons why mindfulness-based cognitive therapy has been shown to be effective in chronic depression (Kahl, Winter, & Schweiger, 2012; Mathew, Whitford, Kenny, & Denson, 2010). Similarly, the mentalizing approach originated in the treatment of patients with borderline personality disorder, who commonly experience intense, long-standing feelings of depression as well as serious disorganization of the self (Luyten & Fonagy, 2014).

Both mindfulness and mentalizing approaches to depression place emphasis on the influence of depressed mood on a person’s metacognitive abilities. These approaches start from the point of view that, irrespective of the cause of a person’s low mood and depression, he or she may well be completely unable to reflect on the self and others when depressed; when he or she does engage in reflective processes, they are very likely to be biased by his/her depressive thoughts. Hence, mindfulness and mentalizing approaches tend to avoid interventions that rely on insight and reflective capacities, particularly in the early stages of treatment, when patients are more likely to be severely depressed and to lack these capacities. Such interventions run the risk of the patient experiencing further pessimistic thoughts, for example, feeling helpless and hopeless, perceiving the therapist as lacking in empathy – or even as persecutory or accusatory – depending on the content of the patient’s cognitive-affective schemas (that is, whether they tend toward sociotropy/dependency, or autonomy/self-critical perfectionism, as outlined earlier). A patient whose self-organization is strongly dependent may feel that the therapist fails to recognize his/her suffering or even blames the patient for his/her problems. In contrast, a patient who is more self-critical may feel that the therapist attempts to force interpretations on them and thwarts the patient’s strivings for autonomy; these patients often drop out of treatment prematurely for this reason.

From the mentalizing perspective, three types of so-called prementalizing modes – modes of thinking that antedate full mentalizing – may be observed in individuals with depression (Lemma, Target, & Fonagy, 2011a; Luyten et al., 2012). These modes of experiencing subjectivity seriously distort the patient’s feeling of coherence of the self, which leads to increasing pressure to externalize unintegrated, unmentalized features of the self – a feature well known to anyone who has worked with seriously depressed patients.

In a psychic equivalence mode, inner and outer reality are equated, such that what the patient thinks or feels becomes hyper-real for them. For example, if a depressed patient thinks he is worthless, it means that he truly is worthless. Any attempt to correct these “dysfunctional thoughts” is itself meaningless – particularly when the patient is severely depressed – and only serves to reinforce psychic equivalence thinking. Psychic equivalence thinking can also lead the patient to equate psychological and physical pain, or emotional and physical exhaustion. The general concreteness of these patients’ experiences can mean that psychological pain literally feels like bodily pain, and depressive thoughts may feel as if they are actually pressing down on the self. This may go some way to explaining the high comorbidity between pain, fatigue, and depression (Luyten & Van Houdenhove, 2013). These individuals may also perceive negative remarks or criticism from others as a literal attack on the integrity of the self, which can lead to feelings of disintegration. This may result in hyperembodiment – a state in which all subjective experiences are experienced as too real; this often leads the individual into a “psychic retreat” because thoughts and feelings, in particular feelings of shame, are literally too painful for the patient to bear (Luyten, Fontaine, & Corveleyn, 2002). The so-called “depressive realism” that some depressed patients show also seems to be related to psychic equivalence thinking: while it may be “realistic” in some respects, reality simply is what it is, which leads to a sense of meaninglessness and apathy.

The teleological mode refers to a mode of functioning in which the patient recognizes a role for mental states as motivating the actions of the self and others, but this understanding is limited to goal-directed behaviors (hence the term “teleological”) that can be directly attributed to observable (physical or biological) causes. In this mode, depressed patients may only feel loved or recognized when someone demonstrates love or recognition by observable, physical means, such as keeping them constant company. These patients may well engage in desperate strategies to get their attachment figures – including medical and mental health professionals – to show that they care for the patient. This is most notable in more dependent patients (e.g., by demanding that a loved one never leaves them alone, or by expecting their therapist always to be available for them). Another consequence of thinking in the teleological mode is that patients may deny that psychological factors play a role in their depressive illness, and steadfastly believe that there is a biological cause, as only biological factors can be recognized as real; this is often typical of more self-critical patients.

Depressed patients often seem to function in an extreme pretend mode, or hypermentalizing mode. This may appear on the surface to be genuine mentalizing, just as depressive realism may come across as appropriate realism. However, hypermentalizing can be distinguished from genuine mentalizing in a number of ways. Hypermentalizing accounts (a) are mostly overly analytical and lengthy; (b) are likely to be heavily focused on depressive themes and self-conscious emotions in particular (i.e., guilt, shame); (c) are often self-serving (e.g., they are constructed to encourage others to show empathy or compassion to the patient, or they may even be used to control or coerce others); and (d) may lack true affective grounding or, at the other extreme, may completely overwhelm the patient and others affectively. In addition, (e) the patient may show an inability to “switch perspectives” (e.g., from a focus on the self to others) when asked to; in contrast, genuine mentalizing is characterized by the ability to consider the mind of others at the same time as the self. Hypermentalizing is thus often accompanied by what is called rumination in cognitive-behavioral terms.

Depressed individuals’ use of prementalizing modes typically gives rise to a pressure to externalize alien self-parts, that is, self-experiences that the individual cannot mentalize. As discussed previously, the capacity for mentalizing creates a feeling of coherence and stability of the self; thus, in an individual whose capacity to mentalize is impaired, this integrative process will be weak, and the incoherence in their self-representation is likely to become dominant. Torturous feelings of being “bad” or “worthless,” for instance, will come to dominate the person’s self-experience. They may deal with these experiences by externalizing them – that is, behaving toward others as though the others are responsible for the unmentalized self-experiences, and sometimes even generating the same experiences in others – that is, others then tend to engage in the same punitive or persecutory behaviors that the person internally inflicts upon themself (Fonagy & Target, 2000). Some patients instead engage in substance abuse, excessive eating or fasting, or other types of behavior that (in the teleological mode) temporarily relieve their tension and arousal (Fonagy & Target, 2000). Hence, the disintegration of the experience of coherence of the self because of the failure of mentalizing that is a result of depressed feelings appears to play an important role in explaining the association between depression and suicidal behaviors (Fonagy & Target, 1997, 2000; Luyten et al., 2013).