Self Concept: Self-Image, Ideal Self, and Self-Esteem

Self-Concept

The term self-concept is a general term used to refer to how someone thinks about or perceives themselves. To be aware of oneself is to have a concept of oneself. One definition of self-concept is: “the individual’s belief about himself or herself, including the person’s attributes and who and what the self is."

Self-concept includes two different experiences of the self:

(1)   The Existential Self

This is the most basic part of the self-scheme or self-concept; the sense of being separate and distinct from others and the awareness of the constancy of the self” (Bee, 1992).

The child realizes that they exist as a separate entity from others and that they continue to exist over time and space. According to Lewis, awareness of the existential self begins as young as two to three months old and arises in part due to the relation the child has with the world. For example, the child smiles and someone smiles back, or the child touches a mobile and sees it move.

(2) The Categorical Self

Having realized that he or she exists as a separate experiencing being, the child next becomes aware that he or she is also an object in the world. Just as other objects including people have properties that can be experienced (big, small, red, smooth and so on) so the child is becoming aware of him or her self as an object which can be experienced and which has properties. The self too can be put into categories such as age, gender, size or skill. Two of the first categories to be applied are age (“I am 3”) and gender (“I am a girl”).

In early childhood. The categories children apply to themselves are very concrete (e.g. hair color, height and favorite things). Later, self-description also begins to include reference to internal psychological traits, comparative evaluations and to how others see them.

Beyond these basic ways of experiencing the self, self-concept encompasses 3 things:

• The view you have of yourself (Self-image)
• How much value you place on yourself (Self-esteem or self-worth)
• What you wish you were really like (Ideal self)

Self-Image

Your self-image is what you see in yourself. It does not necessarily have to reflect reality. Indeed a person with an eating disorder may be thin but have a self-image of being fat. A person's self image is affected by many factors, such as parental influences, friends, the media etc.

Our self-image includes:

1) Physical Description: I’m tall, have brown eyes...etc.

2) Social Roles: We are all social beings whose behavior is shaped to some extent by the roles we play. Such roles as student, housewife, or member of the football team not only help others to recognize us but also help us to know what is expected of us in various situations.

3) Personal Traits: These are a third dimension of our self-descriptions. “I’m impulsive...I’m generous...I tend to worry a lot”...etc.

4) Existential Statements (abstract ones): These can range from "I’m a child of the universe" to "I’m a human being" to "I’m a spiritual being"...etc.

Typically, young people describe themselves more in terms of personal traits, whereas older people feel defined to a greater extent by their social roles.

Ideal Self

Ideal self refers to how you wish you were, and how you think you should be. It is shaped by your life experiences, messages you received from other people about how you should be, cultural values, and things you admired in role models.

Where a person’s ideal self and self-image are consistent or very similar, a state of congruence exists. If there is a mismatch between how you see yourself (your self-image) and what you’d like to be (your ideal self), then this is likely to affect how much you value yourself. Therefore, there is an intimate relationship between self-image, ideal self, and self-esteem. A person’s ideal self may not be consistent with their actual experience, or what is even possible. This is called incongruence.

Self-Esteem and Self-Worth

Self-esteem refers to the extent to which we like, accept, or approve of ourselves; or how much we value ourselves. Self-esteem always involves a degree of evaluation, and we may have either a positive or a negative view of ourselves.

HIGH SELF-ESTEEM: we have a positive view of ourselves. This tends to lead to

• Confidence in our own abilities
• Self-acceptance
• Not worrying excessively about what others think
• Optimism

LOW SELF-ESTEEM: we have a negative view of ourselves. This tends to lead to

• Lack of confidence
• Wanting to be/look like someone else
• Always worrying what others might think
• Pessimism

However, self-esteem is changeable, and varies from situation to situation. For example, in one study, participants waiting for a job interview were seated next to someone they were told was another candidate, but was really working with the researcher. Some of them sat next to “Mr. Clean,” who was dressed in nice suit, carrying a briefcase. Others sat next to “Mr. Dirty,” who was dressed in an old T-shirt and jeans, slouched over a trashy novel.

The self-esteem of participants with Mr. Dirty increased while those with Mr. Clean decreased! No mention made of how this affected subjects’ performance in interview. However, other studies have shown that level of self-esteem affects performance at numerous tasks, so we could expect Mr. Dirty subjects to perform better than Mr. Clean.

Even though self-esteem might fluctuate, there are times when we continue to believe things about ourselves even when there is evidence to the contrary. This is known as the perseverance effect. That means if we believe negative things about ourselves, we are likely to maintain those beliefs regardless of what is really true.

Our early experiences, particularly messages we received from our parents, have a significant influence on our self-esteem. Four aspects of our current experience also influence self-esteem:

1)      THE REACTIONS OF OTHERS. If people admire us, flatter us, seek out our company, listen attentively and agree with us we tend to develop a positive self-image. If they avoid us, neglect us, tell us things about ourselves that we don’t want to hear, we develop a negative self-image.

2)      COMPARISON WITH OTHERS. If the people we compare ourselves with (our reference group) appear to be more successful, happier, richer, better looking than (we think) we are we tend to develop negative self-esteem. BUT if they are less successful, etc., than we are, our self-esteem will be positive.

3)      SOCIAL ROLES. Some social roles carry prestige, e.g. doctor, TV personality, professional athlete, and this promotes self-esteem. Other roles carry stigma, e.g. ex-con, maid, day laborer, garbage collector, and may lower self-esteem

4)      IDENTIFICATION. Roles aren’t just “out there.” They also become part of our personality i.e. we identity with the positions we occupy, the roles we play and the groups we belong to.

Fear of the Unknown

A theme that has been coming up among my clients this week is fear of the unknown. Specifically, several of them who are "stuck," immobilized by their ambivalence about recovery, have identified the fact that they don't know and can't imagine what recovery might be like as the strongest force pulling them away from recovery efforts.

While everyone may experience different versions of it, I think we all share this kind of fear of the unknown. The whole fortune telling industry banks on this anxiety, and our willingness to spend money to make life more predictable. The thing is, life is inherently unpredictable, and seems to delight in proving that to us.

And here is the other thing: even when we have every reason to expect a positive outcome, we still experience the fear. For example, one of the ways I have tried to assuage my clients' fear of recovery is to remind them of other people's stories of what recovery is like - both the stories of people they may know, and stories that have been published in popular recovery books. However, while such stories may temporarily raise overall sense of hope that recovery might be possible and positive, they don't erase the fear.

The fact that fear continues regardless of efforts to cognitively talk oneself out of it suggests that this kind of anxiety is not cognitive at all. In fact, although I rarely subscribe to Freudian theory, I think he may have been onto something when it comes to anxiety. Freud identifies five types of anxiety, associated with stages of development:

1. The first kind of anxiety which infants experience Freud called automatic anxiety. It is a reaction to stimuli that are perceived as threats beyond the infant's control - things that cannot be escaped or regulated. Ego psychologists have renamed this kind of anxiety annihilation anxiety. They argue that "infants experience these terrifying moments at the level of excruciating organic distress, accompanied by inchoate fears that overwhelm them" (Berzoff et al., p. 81), in large part because they have not yet developed a structure of defense mechanisms to assuage their anxiety.
2. The next form of anxiety that develops, in early childhood, is separation anxiety, or fear of abandonment. It is less intense than annihilation anxiety, but still quite intense, since young children depend upon adults for their very survival.
3. The next level of anxiety involves fear of loss of a caregiver's love and esteem (fear of rejection). It shapes children's behavior by motivating them to adhere to rules and limits set by caregivers.
4. The fourth level of anxiety Freud termed "castration anxiety," but modern theorists have renamed fear of bodily harm, or loss of valued physical or mental capacities. It is understood as "projected fear of retribution for hostile wishes against a parent" (p. 82).
5. Finally, the fifth stage recaps the four earlier stages, this time triggered not by interactions with the caregiver, but by internal interactions between the superego and ego.

While I have some skepticism about the latter two stages, I have observed the first three to be common ongoing concerns for people at various ages and stages of development; therefore, I can easily believe that they might be universal.

I also suspect that they have something to do with our fear of the unknown. My theory is that the unknown becomes a projective test of our deep-seated anxieties. In the absence of evidence or data about the nature of what will come (which is, after all, the definition of the unknown), our psyche runs through its repertoire of worst fears. Thus, when clients are able to explore their fear of the unknown, common themes that come up include abandonment, rejection, loss of capacity, and even annihilation.

So, where does that leave us - clients and therapists alike? Recognizing these core fears and their developmental basis does not necessarily make the fear go away. And when it comes to fear of the unknown, the only true antidote is to turn the unknown into the known. That means "feeling the fear and doing it anyway" - accepting the experience of fear, exposing oneself to fear without avoidance, and guiding our choices and actions by our values and goals rather than our emotions or worry thoughts (sounds a lot like ACT, right?).

How do you think about the fear of the unknown? How do you respond to clients' fear of the unknown?

The Cognitive Model

Cognitive Therapy is based on the so-called cognitive model - a theory that conceptualizes emotions and behaviors as resulting from the content of people's thoughts. Instead of seeing situations as triggers for emotions and behaviors, thoughts are seen as the mediator between situation and reaction.

All of us have thoughts rattling around in our heads all of the time. After all, the brain's job is to think. We are not aware of all of these thoughts - if we were, we would never be able to focus on anything! And, not all of our thoughts are "true" or "accurate" - that is not a natural property of the human brain.

When we experience... well, anything, really...it triggers a series of "automatic thoughts" - whatever words or images begin running through our minds. We may be aware of these thoughts...but we may not. According to the cognitive model, these thoughts produce our emotions and behaviors (of which we are more likely to be aware).

A starting point of CBT is often teaching clients to identify automatic thoughts. In fact, some symptom improvement can happen very quickly when a client starts to identify automatic thoughts. This happens because identifying the thoughts begins to unearth cogntive distortions. By recognizing distortions and ceasing to accept distorted thoughts as Truth, they lose some of its power over emotions and actions.

The cognitive model does not stop there, however. It asks: where are these automatic, distressing and/or distorted thoughts coming from? The answer provided by the cognitive model is that automatic thoughts arise from another category of thoughts: beliefs.

We all develop beliefs about ourselves, other people, and the world we live in, beginning in early childhood. Some of these beliefs are so fundamental to how we view...everything...that we see them as absolute truths. The cognitive model calls these "core beliefs." We may not be consciously aware of our core beliefs - they are kind of like the water fish swim in. However, they have a significant impact (like water does for fish): situations can activate core beliefs, which then shape our perception and interpretation of the situation. In fact, we tend to filter incoming information to accept information that fits the core belief, while discounting anything that contradicts our belief.

The way that core beliefs influence our perception, interpretation, and response to a situation is through what is called "intermediate beliefs." This category includes our attitudes, assumptions, and rules. Attitudes are evaluative statements ("It would be terrible if..."), assumptions tend to be "if...then..." statements, and rules are "shoulds" (or musts, or oughts). These intermediate beliefs arise from core beliefs, either as logical extensions thereof, or as attempts to cope with a painful core belief (often that one is inadequate and/or unloveable): I am inadequate so I need to work harder than everyone else. I am unloveable, so I should expect rejection. Etc.

If CBT begins with automatic thoughts, it's only a matter of time before beliefs start popping up. Themes may start to appear among automatic thoughts that cause distress. Some thoughts may even be direct expressions of a belief. These beliefs then become the substance of therapy - evaluating their usefulness (pros/cons), examining evidence for and against, and considering possible modification or replacement of unhelpful beliefs. Of course, this is not nearly as easy as it sounds, but a full description of the process is beyond the scope of this post.

So, this, then, is the cognitive model: early life experiences shape core beliefs, which give rise to intermediate beliefs. A given situation activates relevant beliefs, resulting in automatic thoughts, which in turn shape emotions and behaviors. Changing automatic thoughts can lessen distressing emotions and maladaptive behaviors, while changing core beliefs can prevent the automatic thoughts in the first place.

Do you buy into the cognitive model? How do you use it, or why do you not? What seems useful and less useful about it?

"Underlying Issues"

When people seek therapy to address a problem behavior, whatever that behavior may be (e.g., addictions, eating disorders, impulsive or compulsive behavior), they also usually bring up the issue of "underlying issues" early in treatment.

Some want to focus on behavior change, and bring up "underlying issues" only to request that they not become the focus of treatment, either because "there aren't any," or they're irrelevant to the problem at hand. They are highly skeptical of the stereotype of therapy delving into one's childhood, and assume that changing behavior will be sufficient. Others take the opposite stance, expressing frustration with a focus on behavior change, and asserting that the problem is not the behavior itself, but the "underlying issues" that have caused it. They assume that behavior change will happen automatically if underlying issues are resolved, but intentional behavior change will be transient if these issues are not addressed.

While such requests immediate arouse my curiosity/suspicion about what the person may be avoiding or defending against, or what past experiences are informing their request, I also understand the dilemma. After all, therapeutic approaches have been similarly divided on the most appropriate and efficacious focus for treatment. Psychodynamic and analytical approaches take the latter stance, that behaviors are simply markers of underlying issues, which should be the focus of treatment, with the assumption that resolving underlying issues will also resolve any problematic behaviors. Consequently, interventions focus on uncovering whatever the "underlying issues" may be (for example, via free association, transference/countertransference, etc), and resolving them through analysis, interpretation, and the resulting development of "insight." 

Behaviorism developed in reaction to psychoanalysis, almost as an antithesis. It is no surprise, therefore, that its descendants (e.g., Cognitive Behavioral Therapy) have a reputation for "no-nonsense," short-term interventions targeting behavior change, either by focusing on the behavior itself, or the thought process in which it is embedded. The assumption is that changing behavior, either on its own, or by changing thinking, is sufficient to achieve symptom relief (and avoids the lengthy and therefore costly therapy required to resolve those pesky "underlying issues").

However, most therapists I know (including myself) subscribe to a both/and, rather than either/or, approach - in other words, many of us espouse an approach that integrates the faster symptom-relief of approaches such as CBT, with the longer-term but longer-lasting resolution that comes from addressing "underlying issues." We've probably adopted this stance because we've seen incomplete or transient improvement as a result of a behavioral focus, but also witnessed clients' frustration or discouragement at the slow rate of behavior change when the focus is exclusively on underlying issues.

Because I subscribed to this kind of integrate stance, I was intrigued by the following defense of CBT as a potential access point to "underlying issues."

CBT's focus on symptoms is not meant to be a superficial intervention that has no implications for what lies beneath. Instead, by beginning with the symptoms that are present and accessible, the therapy process has access to what is fundamental and significant in determining the emotional and psychological health of the individual and thereby has the potential to facilitate meaningful and profound change. If CBT were merely a superficial intervention, it would be like weeding a garden by snipping off the top leaves. Instead, CBT interventions begin with the top leaves and follow the organic connections until the roots of the problem have been identified and weeded out. (Pike, Devlin & Loeb, 2004)

What do you think about this question of behavior change vs. underlying issues? How do different approaches you've learned navigate the question? What does it really take to "facilitate meaningful and profound change?"

Stages of Group Development

Groups are fascinating - truly "more than a sum of their parts." It's almost like the group itself becomes a living, breathing organism. And, like any organism, groups also have a life cycle, and go through predictable stages of development. 

There are various descriptions out there for these stages of development. Perhaps the most famous is the so-called Boston model, and while this is also the version I like the most, it's not the one that I use the most. Instead, perhaps because I learned it first, but more likely because it is...catchy, for lack of a better word, I frequently refer back to Bruce Tuckman's stages. 

Like the Boston model, Tuckman identifies five stages, which he calls: Forming, Storming, Norming, Performing, and Adjourning (see? catchy!). 

Forming refers not only to the physical act of initially getting the group together and arranging logistics, but also to all the inter- and intra-personal dynamics that go along with it. People come to groups with a lot of baggage, including goals, expectations, past experiences, and related anxieties. Everyone wonders whether they will fit in, whether people will like them. They wonder if their needs will be met. They wonder who these strangers are. Therefore, forming involves a mutual process of feeling each other out, and trying to present oneself in the best possible light. People tend to be polite, but independent; the group has not yet become more than a sum of its parts.

Of course, as imperfect humans, we can only be polite and present our best sides for so long. It is inevitable that competing expectations, goals, and differences of opinion will come to light. Enter the Storming stage. In the Boston model, this stage is referred to as "Power and Control" because it often involves some degree of jockeying for position, including status and roles within the group, along with testing or challenging behavior. The group leader is frequently the target of such challenges as members test the leader's authority; one or more group members may even take over authority in the group. The group environment can feel charged, like a storm. But, while this stage is uncomfortable, it's inevitable and necessary to turn the group's parts into a cohesive whole.

Once issues of power and controol (i.e., Storming) have been resolved, the group can finally proceed to the purpose for which it was organized. However, before real progress can be made in working on that purpose, the group has to determine how it will go about its work. The group establishes a group identity and group narrative, rituals, and social norms (hence, Norming). Members are assigned or take on roles, and fall into a comfortable groove, more secure in how the group sees them, and trusting of the group dynamic as a whole. The result is a sense of cohesion.

With this foundation, the group addresses its purpose in the Performing stage. Real, tangible progress is made, and members typically feel like the group has finally begun to meet their needs or be productive. The cohesion that has developed continues, but slowly, members begin to also differentiate from the group, which makes room for the individuality of its members, including diversity of needs and interests.

Both doing the work of the group, and differentiating of individual members set the stage for the ultimate move into the group's final stage: Adjourning, also known as termination. This is a time for naming and consolidating gains, affirming the value of the group experience, and each member taking what they can from the experience for their everyday lives. The group changes back into parts as people say goodbye, but each part is still more than it was before the experience.

So, what do you think about this model? Do you see this process at work in groups you're involved with? How else do you understand the evolution of a group?

Nuances in Countertransference

In school, we learn a little about countertransference - basically, enough to know that it's normal for therapists to have emotional reactions to clients, which are called countertransference, and that these reactions can provide us with important information about the client's internal experience, and how others may relate to him/her. While that's useful knowledge for beginning therapists, countertransference is actually much more complex.

There are two ways of distinguishing various countertransference reactions that I find helpful. The first is subjective vs. objective. Subjective countertransference comes out of our own issues and histories, rather than the client's. One possible source of subjective countertransference is our past relationships - for example, when a client reminds us of our mother or daughter, a childhood friend or bully, and therefore elicits feelings from these relationships. Another source of subjective countertransference is emotional difficulties, traumas, or other vulnerabilities we've experienced. For example, someone who has had depression may find the experience of treating a client with depression more distressing due to fear of being sucked back into that state, or someone who has experienced rape may have strong reactions to a client describing a rape, let alone a client who has been a perpetrator, or even makes general comments that seem to justify sexual aggression.

While these kinds of subjective countertransference are normal, they do not give us information about the client, and can hinder rather than help therapeutic work. As a result, it's important for us to learn to recognize, manage, and contain our subjective countertransference, to keep it from negatively influencing the work. If we are unable to contain it, the ethical decision would be to transfer the case to someone who might be more objective, and if the reaction is to a certain client population (e.g., perpetrators of sexual abuse) we should seek out a field of practice or practice setting where we won't be working with that population.

Objective countertransference is elicited by the client, out of their own issues and histories. It gives us information about their emotional state, unconscious material, and/or how they may be experienced by others. For example, if we become irritated by a client, they may be experiencing irritation - even if they are not expressing it. If we feel distanced or dismissed by the client, they may also distance or dismiss others, or feel distanced and dismissed by others. Awareness of objective countertransference can be a useful tool in therapy, both by informing our own clinical hypotheses, and through carefully constructed comments sharing our observations, make implicit clinical material explicit.

The other useful distinction between types of countertransference is common vs. idiosyncratic. Common countertransference refers to the reactions that we always or usually have to a particular clinical situation. For example, sitting with someone who is depressed makes me feel like I'm in a black hole, and the feeling is so consistent that I can use it as a diagnostic tool. These reactions can be helpful (e.g., when they are a diagnostic tool), or unhelpful (e.g., if my lethargy when sitting with a depressed client interfered with effective intervention), depending on how we manage and use them.

Idiosyncratic countertransference is the unique reaction we have to a particular client and/or a particular clinical encounter. For example, experiencing a surge of anger toward a client with whom we have not felt angry in the past can point to their own anger, and/or to how they might elicit antagonism from others, while anxiety without a known cause likely reflects the client's level of anxiety. Such idiosyncratic reactions are the most informative kind of countertransference because they provide a window into this client at this moment in time, and may even reveal things that client is not yet consciously aware of. Of course, like all forms of countertransference, the utility of such reactions depends upon our being aware of them and managing them effectively so that we reflect on, rather than enacting, them.

How do you understand, manage, and use countertransference in your work?

Systems at Work

A dominant theoretical foundation of social work is Systems Theory, which uses biological or ecological systems as a metaphor for understanding human behavior. As you may remember (from biology, or from human behavior courses), a system is made up of interdependent parts that adapt to each other in order to maintain equilibrium - a state of balance, or the status quo.

We can gain insight into human behavior by considering how this concept applies to different levels of human functioning:

• An individual person functions as a system, with biological, psychological, emotional, cognitive, and spiritual "parts" of the self interact to maintain a stable ego state.
• Families (of all shapes and sizes) function as systems, with each member influencing and influenced by the others, functioning interdependently to maintain the family's identity, meet its material needs, and function in relation to the outside world.
• Other small groups also function as systems, including therapy groups, clubs, committees, etc. The members function interdependently and adapt to one another in order to effectively carry out the group's purpose.
• Organizations function as systems, with interplay between individual staff, between different teams and departments, between management and employees, with funding sources and outside constituents, all in the service of fulfilling the organization's mission.
• Communities function as systems, with each of the previous levels of systems existing within communities as parts that interact to maintain the overall functioning of the community.
• Societies, cultures, states and nations are also systems, with each of the preceding levels of systems functioning as pieces thereof.

We are most likely to intentionally draw on systems theory if we're practicing macro social work, focusing on the systemic functioning of the community, society, state, or nation; doing family therapy, focusing on the functioning of a family system; or doing group therapy, establishing and maintaining the group as a functioning system. We're also likely to notice how we fit into our organizations as systems. In contrast, it can be easy to forget about systems when we're doing individual therapy.

However, perhaps especially in individual therapy, it's a mistake not to think about systems. In the macro, family, or group work, we intervene with an entire system. However, with individual work, we intervene with one person, as both an individual system, and part of larger systems (family, group, organization, community). It behooves us to remember that systems strive to maintain equilibrium, and therapy often functions to destabilize the system's balance. When we work with someone to change their thinking, there are going to be ripple effects in their emotions and behavior. When our work with a client changes their behavior, it's going to effect the other systems of which they are a part. Sometimes these ripples facilitate and expand the changes clients are trying to make. Sometimes, however, there is a push-back from other parts of a system as the system seeks balance through the status quo. Therefore, when our efforts in individual therapy aren't leading to the desired effects, we have to consider what other forces might be operating to maintain our client's existing role in the functioning of a system.

How do you think about systems and their role in your work? What level(s) of systems do you work with?

The Power of Observation

As every student learns in introductory science (and psychology) classes, all research has a caveat: the act of measuring or observing a phenomenon changes the phenomenon. These unintended observation effects, called Hawthorne Effects, are both unavoidable, and hard to distinguish from the rest of the data.

Now, you may not be interested in research, but you should still be interested in the Hawthorne effect. Why, you ask? Well, as therapists, we are in the business of both observing people, and bringing about change. If observation itself has the potential to create change, it warrants serious thought.

I'm pretty sure the police have been using this idea to their advantage for years. Think about it: everyone is a great driver...when there's a police cruiser in sight. Observation creates change. A trooper only has to hang out in a particular location for a little while, every now and then, in order to get drivers to consistently slow down just in case. Of course, when the police want to catch people being less cautious drivers, they have to stay out of sight - but that's another story.

So, how might this apply to therapy?

1. As we all know, people aren't always accurate self-reporters. There are many reasons for this, but at least one of them is that people adjust their self-presentation when they're with other people, especially when they want the other person to perceive or respond to them in certain ways. This process is usually subconscious, rather than intentional, but it means that we should consider the possibility that we're not hearing the absolute truth. This is most important with actively suicidal or homicidal clients who may be telling us they are fine, in order to have the freedom to act.
2. On a more positive note, expressing a desire or intention for change (whatever the target behavior) increases action toward change. Even simply signing up for treatment can lead to progress, without any other intervention. In fact, a premise of brief treatment is that people tend to have more momentum to pursue a circumscribed change within a limited time period after starting treatment.
3. Wherever someone is the treatment process, we can harness the Hawthorne Effect by judiciously adding more direct observation. For example, having a client observe and track a target behavior, thoughts, feelings - whatever - is likely to change the frequency of the target. You do have to think it through, though - observation has the potential to increase the desired behavior...or the undesired behavior. For example, in the work I do with eating disorders, we sometimes ask clients to track their eating. Some of them find it helpful to have the accountability of tracking it. However, for others, tracking is triggering and leads them to eat less rather than more. This is also another great argument for individualizing treatment - the same intervention can have different effects with different people.

There are probably other ways that the Hawthorne Effect could be a resource (or a liability) in therapy? Are there other examples that spring to your mind?

What's My Motivation?

Before launching into a new role, the stereotypical actor will ask the director: "What's my motivation" - meaning, what is driving this character? what is the character thinking and feeling in this scene?

Therapists ask a similar question when they meet a new client - what is this client's motivation? We need to know what's getting someone in the door in order to figure out how to "meet them where they are," and harness their existing motivation to help them move toward personally meaningful goals. 

Social psychologists talk about "intrinsic" and "extrinsic" motivation. Intrinsic motivation comes from within, fueled by personal desire, interest and appreciation of the task for its own sake. Extrinsic motivation comes from external outcomes - engaging in a task to obtain a rewarding outcome, or avoid a negative consequence. So, for example, some children choose to read or draw during free time because they enjoy these activities (intrinsic motivation). However, if they are rewarded for doing these activities (extrinsic motivation), the intrinsic desire to engage in the activity decreases.

The clinical parallel to intrinsic motivation might be the desire for growth or self-actualization. When this desire is strong, some theorists (e.g., Adler and Maslow) have contended that self-actualization will happen naturally once more basic needs are met and barriers are removed. We might infer that adding some sort of extrinsic motivation when a client is already intrinsically motivated might inadvertently reduce the drive toward self-actualization - something I, for one, would not want to do. 

The truth is, however, that most of my clients come in with some form of extrinsic motivation. Sometimes there is a reward on the horizon for positive change (more independence, the ability to progress toward personal and vocational goals, functioning more effectively in personally significant roles...). More often, the motivation is stopping or avoiding a negative consequence of not changing. Most simply, the client is often suffering and wants the suffering to stop (be that depression, anxiety, dope-sickness...whatever). There may also be the threat of losing things that are important to the client - a relationship, a job, custody, financial support, housing...for some problems, even fear of losing their lives. 

The answer to "what's this client's motivation" is rarely either/or - more often it's both/and: the desire to change coming in part from hope for a better life, and the expectation of positive results, and the wish for suffering to lessen, and the fear of what might happen in the problem continues or gets worse. By learning what the specific combination of factors is for each individual client, I can help them harness and build on their existing motivation to get and keep them engaged in the treatment process. 

How do you think about motivation? How do you work to build motivation?

Shadowed

So many problems in life seem to be caused by our inability to face some truth about ourselves - a deeply rooted unwillingness to acknowledge those parts of ourselves we've tried (but failed) to renounce. Often, these are things we learned in early childhood were unacceptable to the people around us (parents, caretakers): anger and aggression, rebellion, intense emotion or crying, dependency (or independence)....

However, just renouncing them doesn't make these parts of ourselves really go away. Instead, they just go underground - into the unconscious mind, where we are unaware of their continued presence...and thus shocked when they jump out from time to time, and catch us by surprise. Jung called these parts of the self "Shadow." 

Jung writes: "Unfortunately there can be no doubt that man (sic) is, on the whole, less good than he imagines himself or wants to be. Everyone carries a Shadow, and the less it is embodied in the individual’s conscious life, the blacker and denser it is. If an inferiority is conscious, one always has a chance to correct it. Furthermore, it is constantly in contact with other interests, so that it is continually subjected to modifications. But if it is repressed and isolated from consciousness, it never gets corrected and is liable to burst forth suddenly in a moment of unawareness. At all events, it forms an unconscious snag, thwarting our most well-meant intentions."

If we refuse to acknowledge the Shadow parts of ourselves, instead of going away, these parts tend to leak out at inopportune moments. We find ourselves acting them out (for example, by lashing out at, belittling, or betraying a loved one), or we project them, seeing the renounced negative trait in those around us, but not ourselves.

Jung wasn't the first to recognize the Shadow; people have known this fact of human nature for millennia. Even Paul writes in Romans (7:18-19): "I have the desire to do what is good, but I cannot carry it out. For I do not do the good I want to do, but the evil I do not want to do—this I keep on doing." However, Jung made this truth more accessible...along with another truth: that by embracing and reintegrating our Shadow parts, they become sources of creative power and energy, rather than liabilities.

Now, diving into the darkness to reclaim the Shadow is not an activity to be undertaken lightly, or alone. It takes courage to face our Shadows, and a safe environment. There are therapists specialize in facilitating this process. It is too threatening for some people, and at some times or places - after all, it requires us to relinquish a fiercely held view of ourselves. On the other hand, for others the cost is too high to continue to deny the Shadow and allow it to wreak havoc on its own terms. 

Have you encountered your own Shadow? Have you seen the Shadow in a client (perhaps when it's projected onto you)? Or does this all sound too bizarre to be considered?

If you dare:

Flexible Thinking...Let's Streeeetttch!

Therapists from diverse theoretical orientations seem to agree that a major goal in treatment is increasing flexibility of thought.

It's a weird concept, right? We can tell if someone's body is flexible if they can master gymnastics or yoga, but how do we know if their mind is flexible?

I find it easier to identify when someone's thinking is NOT flexible - in other words, when it's rigid. Rigid thinking is fixed - it doesn't adjust to accommodate new or conflicting information. It assumes universality - that there is only one accurate way to view things. Other perspectives are only considered in order to refute them.

Taking this as a reference point, then, flexible thinking actively considers alternative perspectives - not just to oppose them, but to really consider them as possibilities. Instead of insisting on one Right Answer, flexible thinking recognizes that there can be multiple truths, and they can change over time - that much of what we collectively identify as truth is simply our current best guess, and by nature provisional. As a result, new and sometimes contradictory information is welcomed.

So why is flexible thinking such an important goal of treatment? Well, for one thing, it tends to be more accurate simply because it considers contradictory information and alternate viewpoints. It also leads to innovation - new scientific discoveries and creative or technical inventions don't come from rigid thinking! On the other hand, rigid thinking tends to cause emotional pain - for example, most depression, anxiety, and self-harm are fueled by fixed beliefs about self, others, the world, and/or the future.

The good news is that flexible thinking can be learned (actually, per Piaget, it has to be learned, since it requires abstract reasoning skills). How therapists help clients develop more flexible thinking varies depending on the approach. Modeling, examining the evidence, noticing patterns, working through underlying conflicts.... How do you approach it?

Attachment in Therapy

Underneath the theory and technique, the heart of therapy is the relationship - a special kind of relationship that is formed between therapist and client. The incredibly personal nature of what is shared in therapy gives the relationship a very intimate quality. As a result, clients tend to relate to the therapist in a way that reflects the patterns and expectations they bring to intimate relationships. 

We call it "transference" when the client layers a specific relationship from their past or present life onto the therapeutic relationship - for example, relating to the therapist as if she were the client's actual parent/partner/child, etc. However, even without this kind of transference, we are getting flavors of how the client feels about and relates to important other people. 

This process is both incredibly important and incredibly complicated for clients who have experienced relational traumas - when they have been hurt by those who were most supposed to love and protect them. Particularly when these traumas occur early in life, people may develop enduring patterns of "insecure attachment" - basically, relational templates that assume instability, unpredictability, and/or threat within close relationships. 

While there has been plenty written about attachment styles, I have been thinking more about how insecure attachment styles reveal themselves in therapy, and wanted to write a bit about the subject from this perspective. There are three kinds of insecure attachment, described in adults as preoccupied, dismissive, and unresolved:

1. Persons with a preoccupied attachment style are anxious about relationships, and cope with their anxiety by seeking reassurance. In romantic relationships, they may call often, ask if their partners love them or are mad at them, and so on. In therapy, they may need frequent reassurance that the therapist is "there," and will continue to be there. For example, one client of mine needs reassurance that each new adjunct service (case management, day treatment, etc) is not going to replace therapy, and is not an attempt to "get rid of her." Clients with this attachment style tend to find vacations and other cancellations or disruptions in treatment especially distressing and anxiety-provoking. They may also hold back what they consider to be the most unacceptable parts of themselves for an unusually long time, believing the therapist wouldn't continue working with them if they "really" knew them. As a result, continuity and unconditional positive regard in treatment can be immensely healing.
2. In contrast, people with dismissive attachment styles cope with their anxiety about relationships by dismissing the importance of relationships in general, and by minimizing the significance of particular relationships by leaving the other person before that person can leave them. These clients may be extraordinarily reluctant to engage in the therapeutic relationship. For example, I have one client with some risk issues who didn't want to schedule a follow-up appointment. She needs treatment, but I was sure that encouraging her to come would be the surest way to prevent that from happening. I waited two weeks, but she finally did call to request an appointment, and I am much more confident that she will come precisely because I stepped back and didn't try to pull her in. These clients may also be inclined to drop out without warning if things start to feel too intense. However, if they can hang in their through whatever is triggering the impulse to bolt, it's another potential for significant healing.
3. Finally, individuals with unresolved attachment styles are not consistent in a pattern of relating - they are (predictably) unpredictable. Sometimes preoccupied, sometimes dismissive, sometimes clinging while dismissing...you get the general idea. One client of mine copes with her fear of her partners leaving her by holding them hostage, or by leaving them first, depending on relative size and power. She abruptly dropped out of treatment with her last therapist when she sensed that the therapist was "tired" of her. The challenge for the therapist is to both be predictable in the face of unpredictability, and NOT realize the negative predictions (abandonment, rejection, or whatever).

As this last example suggests, I find it incredibly informative to ask about clients' past experiences with therapy, and how they ended. If someone seems to have dropped out just when they were getting to the heart of thing, I talk to them about relationship patterns, and how they may at some point feel like doing the same thing with me - but that they can make some real progress if they can stick with our relationship anyway. 

How do you assess for and understand the relational patterns that your clients bring to therapy? What have been the best and worst examples for you?

Don't Believe Everything You Think!

Whatever their theoretical orientation, most clinicians have learned at least a little about Cognitive Behavioral Therapy (CBT). After all, CBT is hallmark "evidence-based treatment," and favorite of insurance companies.

Perhaps the most widely known element of CBT is the process of identifying and replacing cognitive distortions. Often occurring underneath the surface of our awareness, as "automatic thoughts," distortions are irrational thoughts that tend to be negative, and negatively impact our mood and ability to cope. We all have them. By learning to become more aware of our thoughts, and to recognize and dispute irrational thoughts, we gradually find ourselves feeling better and responding to the world more adaptively.

Sounds pretty straight forward, right? Well, if you've been on either side of this process, you probably know that it's much harder to achieve than it sounds. A difficulty arises when the client firmly believes that a "distorted" thought is "true."

Now, I could discuss postmodernism and the social construction of truth, but I think it's more helpful to go further into CBT - because congitive distortions are only the most surface level of a more complex therapeutic approach. According to the cognitive model, automatic thoughts arise out of deep and fundamental core beliefs (assumptions about self, others and the world that are formed in childhood and regarded as absolute truths), and the attitudes, rules and assumptions (intermediate beliefs) they engender.

However, these core and intermediate beliefs are harder to access, so automatic thoughts offer a starting point through which to begin conceptualizing and ultimately changing dysfunctional beliefs. Modifying automatic thoughts often results in symptom relief, but to prevent the reemergence of symptoms in the future, it's important to also work on the underlying beliefs.

Problematic core beliefs often fall into two categories: 1) I am helpless (inadequate, a failure, defective, trapped, needy, weak, etc.), and 2) I am unlovable (unworthy, different, rejected, alone, bad, unwanted, undesirable, etc.).

CBT's approach to changing such core beliefs is a topic for another day. I'll just leave you today with the invitation to wonder, when you or your client seem to be holding tight to a cognitive distortion, what core beliefs are at work.

(For more, see Cognitive Behavior Therapy, Second Edition: Basics and Beyond)

9/11, Defining Moments, and Paradigm Shifts

Social Jerk describes her experiences of 9/11 quite movingly on her blog this week, talking about the significance it had for her as a lifelong New Yorker who had just left home for the first time to begin college. She contextualizes this narrative by pointing out that social work practice involves helping people to tell their stories, and all too often, helping people cope with the aftermath of trauma.

In reading her reflections, and those of others, I find myself turning to two additional theoretical constructs to better understand what folks went through. I'll share them in the context of my own reflections on that day.


1) Paradigm Shifts
I'm a few years older than SJ. On 9/11/01, I was a 19 year old college senior in Boston. I didn't have a landline phone, and nobody was watching television that morning, so the first inkling I got that something might be wrong was my cellphone had no service...and continued to have no service.

Mid-morning, I had a meeting at the college chapel, where I was involved in student leadership. When I got there, everyone looked somber. One of the chaplains pulled me aside:

"Do you know what happened?" 

"No...what happened?"

"There's been an attack on the World Trade Center, and there was just another one on the Pentagon." 

I couldn't figure out what she was talking about. "What do you mean?" 

"There was an attack. A plane flew into the building. A lot of people have died."

I was still lost, couldn't make sense of what she was saying - or didn't want to believe it. "How do they know it was an attack? Could it have been an accident?" 

"Oh, honey. No, they're sure. Come into the study, we have the news on."

There were a handful of other students sitting there. We all stared somewhat blankly at the television, and watched the planes fly into the towers, and the towers later collapse, over and over again on the news. Nobody went to class. Eventually, the chaplain prompted us to call our families, who would want to know we were ok. Late in the day, I stumbled back to my dorm, still dazed - numb.

Looking back, I know that my confusion and disconnection was largely because what had happened didn't fit into any of my existing cognitive schemas. In Piagetian terms, I was trying to assimilate the information with what I knew about the world - for example, wondering if it had been a plane crash or accident. I didn't have any past experiences that would help me understand it.

Things started to sink in fairly quickly, though. During the night of 9/11, I jerked awake several times at small noises, in response to a subconscious sense of danger. As I got un-numb over the next few days, I became consciously aware of a profound sense of being unsafe in the world. To move forward, I had to figure out what it meant to live in a world where such things happen. Piaget labeled this process of shifting schemas to fit new information "accommodation."

2) Defining Moments
This second theme has become clearer to me more from how people experience the anniversaries of 9/11 than from the original experience. We've known for a long time that there is a cohort effect - that people seem to interpret world events similarly to others in their age group, but differently from other age groups. We've tried to describe these differences by naming generations: "greatest generation," "silent generation," "baby boomers," "generation x," "millennial generation."

I fall at the beginning of the millennials, a group described as trusting, collaborative, and energetic, perhaps the a result of a largely protected childhood. The only period of war during our lifetimes had been the Persian Gulf war in the early 1990s. We believed the world to be safe, and to feel as positively toward us as we felt toward it.

For us, 9/11 will probably always feel significant as the day we learned the world isn't safe. In contrast, my mother pinpoints Kennedy's assassination as the moment she lost the illusion of safety. For my grandparents, that moment was Pearl Harbor.

One of the news programs today interviewed young people who came of age after 9/11, and they all acknowledge 9/11 as a defining moment. But they also refused the interviewer's attempt to label them the "9/11 generation." They and I hope that in the decades ahead of us, there will be opportunities to define ourselves by strengths and achievements rather than tragedies.

Externalizing the Problem

One of my favorite interventions, taken from Narrative Therapy, is externalizing the problem. It can be used with adults and children, in individual, family, and group therapy, to help people broaden their perspectives on what have often become narrow problem-centric life stories.

Psychodynamic theories have used the term "externalizing" to refer to the ego defense of blaming problems on an external person or entity rather than taking responsibility for them. Obviously, externalizing from this perspective is not an asset to treatment.

However, Narrative Therapy defines externalizing quite differently. Rather than assuming people will try to avoid taking responsibility for their problems, Narrative theory suggests that people have come to see their problems as TOO intrinsic to the self. As a result, they may have developed a "problem-saturated" self-image, and feel helpless and hopeless about the possibility of change. When this has happened, an important first step in the change process is separating out the person from the problem.

This is achieved not by identifying someone ELSE as the problem, but by recognizing the problem as an entity unto itself, and seeing the problem (rather than any person) as the problem. Using some imagination and creativity, people can be encouraged to objectify, and even personify, the problem in a way that allows them to consider new ways of responding to it.

It also can be a way of beginning to identify exceptions to the problem. The therapist can invite the client to talk about times the problem was more or less strong or active, and times when the client got the upper hand over the problem. New solutions start to crystallize out of this kind of exception.

It's also an opportunity to begin to explore the client's preferred relationship with the problem.  While it may not be possible to eliminate every problem, it may be possible to establish a different relationship with the problem so that it's less...problematic.

I've been trying to use this intervention with a 10 year old boy, who stutters, and has been told (according to his mother) that it is incurable due to the physiological mechanism causing it. When asked about his goal for treatment, he says that he wants the stuttering to stop, while his mom wants him to be less frustrated by the stuttering, and more able to accept it.

My first attempt at externalizing with this client was to ask him to draw the problem as if it were a thing, creature, or person. This intervention did not work - he drew himself, stuttering. Instead, I decided to try something more personally relevant to him, and asked him to bring in his favorite video game. He brought in a WWE wrestling game, and described his favorite characters, as well as the "bad guys." When asked which character would represent his stuttering, he readily identified one of the bad guys, with a tag-team partner who could represent frustration. Since my client could describe all of the characters' favorite strategies, he was quite willing to do some observatory research for me this week, and try to figure out what the favorite moves of stuttering and frustration are. (We'll see how successful the intervention was based on what he comes back with this week!)

Have you ever tried externalizing the problem with a client, with either a positive or negative response?

Reference:

Avoiding Avoidance

Clinicians and scholars across the spectrum of theoretical perspectives seem to agree on quite a bit. Indeed, both cognitive behavioral therapists and psychoanalysts will tell you that their clients' problems have often been caused by some form of avoidance.

To be sure, they use different language. Cognitive behavioral therapists may actually say "avoidance." More specifically, they might say "experiential avoidance," referring to efforts to avoid any distressing internal stimuli (thoughts, feelings, memories, sensations) For example, a behaviorist may suggest that a phobia develops through habitual avoidance of a feared object, or a dialectical behavioral therapists may argue that self-injurious behavior has developed as a way to avoid distressing emotions. In the short term, avoidance is negatively reinforcing (i.e., it results in short-term relief from discomfort, which strengthens the avoidance behavior), so it can be a hard pattern to break, even when it begins to cause harm in the long-run. 

In contrast, psychoanalysts and psychodynamic therapists speak of conscious and unconscious intrapsychic conflicts, and defense mechanisms that allow the individual to avoid whatever is unacceptable or threatening to them. Problems arise when defense mechanisms cause harm, or don't work (i.e., allow inner conflicts to cause distress). Common defense mechanisms include:

• denial - ignoring or disavowing the reality and implications of a painful event
• projection - attributing an unacceptable impulse or painful thought to another person
• acting out - avoiding conscious recognition of distress by immediately acting on wishes, impulses, and fantasies
• dissociation - separating a thought or memory from associated feelings, thereby altering its emotional meaning and impact
• regression - retreating to an earlier level of psychosexual functioning in the face of anxiety or a challenge that cannot be mastered
• repression - removing upsetting thoughts, feelings, or memories from the conscious mind
• reaction formation - transforming an unacceptable wish or impulse into its opposite
• displacement - directing wishes and impulses away from the person with whom they originate, who is perceived as inappropriate or dangerous, to someone else, who is perceived as appropriate or safe
• undoing - acting in ways that symbolically or actually make amends for unacceptable thoughts, feelings, or behaviors
• sublimation - transforming unacceptable wishes and impulses into socially acceptable behaviors 
• humor - using humor to minimize discomfort when expression painful or unacceptable wishes or feelings

While therapists practicing from each of these theoretical perspectives conceptualize treatment differently, they agree that ending the pattern of avoidance is an important part of the process. For psychoanalytical and psychodynamic practitioners, the goal is to integrate parts of the client's inner experience that have been conflicted or disowned. Practitioners using CBT or DBT work to stop the avoidance behavior and replace it with more adaptive alternatives.

The common thread is a process of learning to accept the full range of internal experiences and respond in ways that are consistent with one's values and long-term goals, including mental and emotional health. Would you say that this is a goal of your clinical work? If so, how do you go about it?

Is Therapy a Luxury?

My boss is something of a therapy purist. Having explored various schools of practice, he settled upon Lacanian psychoanalysis as his theoretical orientation. Although he doesn't get to do analysis as an administrator at our agency (he does it on the side), he supervises from that foundation.

A core feature of his approach is that neurosis and psychosis are inherently different, and should be treated in very different ways. Grossly oversimplified, the therapist invites projection and transference when treating neurotic clients, and tries to avoid contaminating the therapy by allowing his/her own ego (self) to be felt by the client. However, if this approach is used with psychotic clients, it may trigger a psychotic break. Instead, the therapist allows him/herself to be more present in therapy, providing more feedback, support and direction to facilitate consolidation of the client's ego. Incorrectly using the latter approach with a neurotic client causes less damage than the reverse error, but detracts from the efficacy of treatment (according to this psychoanalytic perspective).

A problem with this conceptualization of treatment is that it fails to consider the psychosocial (rather than intrapsychic) factors contributing to the so-called "neurosis." In an urban clinic where most clients are insured by Medicaid and/or Medicare, many of my clients find the impetus to seek treatment not because of an underlying mood or anxiety disorder (although those are present), but because they are overwhelmed by the struggles they face to meet their basic needs. If I were to follow the treatment dichotomy described above, I would provide tangible support for my psychotic client who has no financial resources and one change of clothes, but not for my neurotic client who was deemed ineligible for housing assistance after fleeing domestic violence. I fear the latter client would find my withholding of support invalidating and out-of-touch - the product of my own socioeconomic privilege.

Psychologist Abraham Maslow argued that human needs can be arranged on a hierarchy; people do not move on to a higher level until the needs on the level(s) below it have been adequately met. Thus, one cannot give one's full attention to psychological needs without having met basic needs such as food, clothing, shelter, and physical safety.

If we think about my "neurotic" and homeless client, I suspect that providing the psychoanalytical treatment appropriate for neurosis (i.e., not responding to her lack of shelter and security) would interfere with the efficacy of treatment just as much as "incorrectly" providing a more supportive response. It seems to me that ego restructuring is a luxury that just doesn't matter if you're hungry, preoccupied with where you're going to stay tonight, or where you're going to find bus fare to get to the clinic in the first place.

What do you think?

For more information on Lacanian theory and practice, see  Fundamentals of Psychoanalytic Technique: A Lacanian Approach for Practitioners For information on Maslow's Hierarchy of Needs, see Hierarchy of Needs: A Theory of Human Motivation

The Facilitative Conditions

One of the wisest therapists of the last century was Carl Rogers. He went beyond the "blank screen" approach of earlier psychoanalysts to suggest that a human relationship between therapist and client creates the best climate for real change and healing to occur.

Rogers identified the most important qualities of effective therapeutic relationships, which he called "facilitative conditions." They include:

• Empathy
• The therapist's ability to accurately understand what the client is experiencing (thinking, feeling, sensing, perceiving) from the client's own frame of reference, AND the therapist's ability to communicate that understanding back to the client both verbally and nonverbally
• Feeling heard and understood strengthens rapport, and makes it more likely that the client will share sensitive information in the future.
• The most advanced empathic responses involve accurately surmising more than the client has said, based on past experiences with the client, theoretical knowledge, and practice wisdom.
• Positive Regard
• Unconditional respect, acceptance, and a nonjudgmental attitude that reflects the client's inherent dignity and worth, irrespective of the client's choice, characteristics, or outcomes
• Paradoxically, feeling accepted however s/he is in the moment allows the client to take steps toward change.
• Congruence
• The therapist's verbal and nonverbal communication, affect, and behavior are aligned, conveying sincerity 
• When one of more of these elements is not aligned with the others, it at best creates confusion, and at worst can be hurtful (as with sarcasm)
• Genuineness
• The therapist conveys the sincere desire to work with and help the client, without seeming fake
• The therapist seems comfortable in the helping role, and interventions do not feel rehearsed or contrived
• The therapist is spontaneous and willing to engage in appropriate self-disclosure (that is, self-disclosure that furthers the therapeutic relationship and the client's goals, rather than the therapist's needs or agenda)

Which of these do you see as most important? Which one is hardest to maintain?

For more information of Roger's approach and the facilitative conditions, see Corsini and Wedding (2010) Current Psychotherapies