Psychological Theories and Psychotherapy of Personality Disorders
Frequently Asked Question # 24
Psychological theories must be all-inclusive (anamnetic), coherent, consistent, logically compatible, insightful (diagnostic), aesthetic, parsimonious, explanatory, predictive (prognostic), therapeutic, imposing, and elastic.
But psychology is constrained because its experiments have to be ethical and are subject to the Psychological Uncertainty Principle: they are unique and lead to undergeneration of testable hypotheses.
The psychological theories underlying psychotherapy, though, are good as organizing principles, integrative principles, and purgatory principles.
By: Dr. Sam Vaknin
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Storytelling has been with us since the days of campfire and besieging wild animals. It serves a number of important functions: amelioration of fears, communication of vital information (regarding survival tactics and the characteristics of animals, for instance), the satisfaction of a sense of order (justice), the development of the ability to hypothesize, predict and introduce theories and so on.
We are all endowed with a sense of wonder. The world around us in inexplicable, baffling in its diversity and myriad forms. We experience an urge to organize it, to "explain the wonder away", to order it in order to know what to expect next (predict). These are the essentials of survival. But while we have been successful at imposing the structures of our mind on the outside world – we are less successful when we try to cope with our internal universe.
The relationship between the structure and functioning of our (ephemeral) mind, the structure and modes of operation of our (physical) brain and the structure and conduct of the outside world have been the subject matter of heated debate for millennia. Broadly speaking, there were (and still are) two schools of thought:
There are those who, for all intents and purposes, identify the substrate (brain) with its product (mind). Some of them postulate the existence of a lattice of preconceived, inborn categorical knowledge about the universe – the vessels into which we pour our experience to be molded.
Others regard the mind as a black box. While it is possible in principle to know its input and output, it is impossible, again in principle, to understand its internal functioning and management of information. Pavlov coined the word "conditioning", Watson adopted it and invented "behaviorism", Skinner came up with "reinforcement". But they all ignored the psychophysical question: what IS the mind and HOW is it linked to the brain?
The other camp fancies itself more "scientific" and "positivist". It speculates that the mind (whether a physical entity, an epiphenomenon, a non-physical principle of organization, or the result of introspection) – has a structure and a limited set of functions.
They argue that a "user's manual" for the mind could be composed, replete with engineering and maintenance instructions. The most prominent of these "psychodynamists" was, of course, Freud. Though his disciples (Adler, Horney, the object-relations lot) diverged wildly from his initial theories – they all shared his belief in the need to "scientify" and objectify psychology.
Freud – a medical doctor by profession (Neurologist) and Josef Breuer before him – came with a theory regarding the structure of the mind and its mechanics: (suppressed) energies and (reactive) forces. Flow charts were provided together with a method of analysis, a mathematical physics (dynamics) of the mind.
But this was a mirage. An essential part was missing: the ability to test the hypotheses derived from these "theories". Still, their theories sounded convincing and, surprisingly, had great explanatory power. But - non-verifiable and non-falsifiable as they were – they could not be deemed to be scientific.
Psychological theories of the mind are metaphors of the mind. They are fables and myths, narratives, stories, hypotheses, conjunctures. They play (exceedingly) important roles in the psychotherapeutic setting – but not in the laboratory. Their form is artistic, not rigorous, not testable, less structured than theories in the natural sciences.
The language used in psychological theories is literary, polyvalent, rich, effusive, and fuzzy – in short, metaphorical. They are suffused with value judgments, cultural preferences, fears, post facto and ad hoc constructions. None of this has methodological, systematic, analytic and predictive merits.
Still, these theories are powerful descriptive instruments, admirable constructs of the mind. As such, they are bound to satisfy some needs. Their very existence proves it.
Peace of mind is an essential need, which was neglected by Maslow in his famous hierarchy of needs. People sacrifice material wealth, resist temptation, ignore opportunities, and sometimes risk themselves and others – just to attain this bliss.
People prefer inner equilibrium to outer homeostasis. It is the fulfillment of this overriding need that psychological theories cater to. In this, they are no different than other collective narratives (myths, for instance).
In some respects, though, there are striking differences:
First, psychology is desperately trying to link up to reality and to scientific discipline by employing observation and measurement and by organizing its results and presenting them using the language of statistics. This does not atone for its primordial sin: that its subject matter is ethereal, ephemeral and inaccessible. Still, it lends it an air of credibility and rigorousness.
Second, while historical narratives are "blanket" narratives – psychology is "tailored" or "customized". A unique narrative is invented for every patient (client) in which s/he is the protagonist (hero or anti-hero). This mass customization seems to reflect an age of increasing individualism.
True, the "language units" used in therapy (large chunks of denotates and connotates) are one and the same for every "user". In psychoanalysis, the therapist is likely to always make use of the tripartite structure of Id, Ego, Superego. But these are language elements and need not be confused with the plots. Each client, each person, and his own, unique, irreplicative, plot.
Finally, psychology is biased as a practice owing to the socio-economic (one is almost tempted to say “anthropological”) slant of its practitioners:
“What we think we know about ourselves through science could be skewed, since the majority of psychology studies sample individuals who don't represent the population as a whole. These WEIRD (Western, Educated, Industrialized, Rich, Democratic) samples make up most nonclinical neuroimaging studies as well. Increased awareness of this bias has prompted researchers to actively seek out samples that are more representative; however, there's less discussion or awareness of the potential biases introduced by WEIRD scientists.”
(This Idea Must Die, Edited by: John Brockman, Harper Perennial, 2015, pp. 389-391)
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To qualify as a "psychological" plot, the narrative must be:
In all these respects, a psychological plot is a theory in disguise. Scientific theories must satisfy most of the same conditions. But the equation is flawed. The important elements of testability, verifiability, refutability, falsifiability, and repeatability – are all missing. No experiment could be designed to test the statements within the plot, to establish their truth-value and, thus, to convert them to theorems.
There are four reasons to account for this shortcoming:
So, what are plots good for? They are the instruments used in the procedures which induce peace of mind (even happiness) in the client. This is done with the help of a few embedded mechanisms:
c. The Purgatory Principle – In most cases, the client feels sinful, debased, inhuman, decrepit, corrupting, guilty, punishable, hateful, alienated, strange, mocked and so on. The plot offers him absolution. Like the highly symbolic story of the Savior – the client's sufferings expurgate, cleanse, absolve, and atone for his sins and handicaps. A feeling of hard won achievement accompanies the spinning of a successful plot. The client sheds layers of functional, maladaptive clothing. This is inordinately painful. The client feels dangerously naked, precariously exposed. He then assimilates the plot offered to him, thus enjoying the benefits emanating from the previous two principles and only then does he develop new mechanisms of coping. Therapy is a mental crucifixion and resurrection and atonement for the sins. It is highly religious with the plot in the role of the scriptures from which solace is gleaned.
Dichotomous Classification (Taxonomy) of Psychological Theories
All psychological theories can be classified by one or more of these dichotomies (pairs):
Dualism vs. Monism
The belief that the mind and the body are two separate entities (though in constant interaction via various mechanisms and pathways); OR
The belief that the mind is nothing but an emergent phenomenon or a manifestation of and emanation from or a mislabelling physiological processes and qualities and, therefore, that psychology should be a branch of neuroscience or medicine (medicalization of psychology).
Innate vs. Stimuli-driven
The belief that all psychological traits and processes are innate and autonomous; OR
The belief that psychological processes are triggered by and psychological traits are shaped and conditioned by stimuli emanating from the environment.
Nature vs. Nurture
The belief that genes and, more comprehensively, evolution determine one’s psychological make-up and modus operandi; OR
The belief that one’s psychology is decided by one’s upbringing, human milieu, and personal history.
Reductionist vs. Holistic
The belief that psychology can be analytically reduced to a set of interacting, distinct, atom-like components or constructs; OR
The belief that one’s psychology is the complex, irreducible outcome of shape-shifting network of ceaseless interactions and the synergy of extensive and intensive qualities, parameters of action and boundary conditions.
Fixed vs. Plastic (Childhood vs. Lifespan or Determined vs. Mutable)
The belief that, at a certain age, one’s psychology becomes an immutable fixture, subject only to minor, almost imperceptible modifications; OR
The belief that one’s brain is plastic and reprogrammable from cradle to grave and that, therefore, one’s psychological settings and proceedings are constantly evolving and changing throughout the lifespan.
Static vs. Dynamic (Objective vs. Subjective)
The belief that psychological reactions and processes are rigid and set, allowing for well-demarcated diagnoses based on sharply-delineated clinical entities which are subject to the scientific method; OR
The belief that psychology is a narrative, fuzzy, impressionistic, ever-evolving, and somewhat “artistic”. Diagnosis and treatment require human contact and interaction, mostly subjective and emotional.
Process vs. Behavior
The belief that psychological processes constantly occur in the mind and underlie behaviors, cognitions, and choices and that they can be subject to meaningful and informed introspection; OR
The belief that, since we can never, in principle observe or measure inner processes in the mind (the intersubjective agreement is not falsifiable), we should only monitor, observe, and analyze behaviors.
Categorical vs. Dimensional
The belief that human behaviors, both normal and pathological (aberrant), can be categorized, distinguished, and demarcated with a minimum of ambiguity and overlap; OR
The belief that human behaviors constitute a spectrum and can be described only using interacting multi-purpose dimensions.
Statistical-Normal vs. Descriptive-Spectrum
The belief that human behaviors cluster around a mean or average which constitutes “normalcy”; OR
The belief that all human behaviors, preferences, drives, urges, traits, and orientations are “normal” (though they may be socially unacceptable or even illegal) and are part of a spectrum, even when there is only anecdotal evidence for their existence.
Analogous vs. Standalone
The belief that modelling human psychology by using analogies to various technologies provides real, testable insights into the human mind; OR
The belief that the human mind and its products are sui generis and cannot be studied by analogy. Getting to know the mind requires its own models and theories, independent of models and theories in other fields of science and knowledge.
Occult (Multipartite) vs. Overt (Monolithic)
The belief that the human mind is comprised of several interacting parts, some of which are accessible trivially while the awareness to and knowledge of other parts require special efforts and knowledge; OR
The belief that the mind is a monolithic, indivisible “black box”, which can be observed and analysed only via its effects on the world and interactions with reality.
Mechanical vs. Stochastic/Emergent
The belief that the mind is a machine which, like other machines, is subject to the laws of Nature and can be deciphered and contextualized objectively and even mathematically; OR
The belief that the mind is a cloud, the emergent outcome of numerous intertwined and fuzzy processes in constantly self-assembling and redundant networks and that the underlying math is stochastic rather than deterministic.
Theoretical vs. Experimental
The belief that psychology is a philosophy of the mind, not a rigorous science and that, consequently, it cannot be falsified and the results of its experiments cannot be repeated or replicated.
The belief that psychology is a science whose theories can yield falsifiable predictions and whose experiments are repeatable and replicable.
Reactive vs. Teleological
The belief that behaviors are reactions to external stimuli; OR
The belief that behaviors are goal-oriented and are selected or deselected by their familiar or anticipated consequences.
Nomothetic vs. Idiographic
Theories that study populations based on analyses of test results vs. theories that study individuals in depth with the use of interviews and psychological tests.
is centered around and focused on the restoration of the individual’s
functionality and autonomy and the attainment of happiness.
Only a small minority of humanity adhere to these values and principles. The majority emphatically and often vociferously reject them. Western psychology is vehemently castigated as decadent and a colonial instrument.
Consider the most basic social unit: the family.
In most societies and cultures in the world, the family is sacred and centred around procreation, not recreation: children and property are by far more important than the pursuit of happiness which is considered both selfish and risky.
Why risky? Because to pursue contentment and gratification is to assiduously avoid making the long-term sacrifices required to maintain a harmonious and productive cooperative.
Everything is secondary to these long-term goals. Women tolerate abuse and domestic violence and act meek and subservient to accommodate their bullying husbands. They undergo harmful medical procedures to conform to their ideals of beauty. Spouses - both wives and husbands - accept extramarital affairs and infidelity as inescapable: you are permitted to secure love, intimacy, and sex outside the marriage as long as you sleep at home and make children and business only with your spouse.
Everyone in such societies mocks the more individualistic and rebellious as egotistical exceptions, or casts them as sacrilegious or insane. To maintain the status quo, reactionary forms of medieval religion (the Church) join forces with oppressive patriarchy, inane "psychiatry", and stifling political authoritarianism in most of these territories.
Our experience of reality is comprised of data from both the external and the internal environments.
These inputs are mediated, structured, and reframed via constructs which activate introjects to produce automatic thoughts. These thoughts affect behaviors intended to modify the environment to conform to a self-state, buttress, and validate it.
Constructs also select memories in order to prevent dissonance and anxiety between recall and self-state. They dissociate memories, alter their emotional content and correlates via attribution and reframing, and impose selectivity.
The construct organizes the output from the introjects according to an algorithm (“identity”) which provides, for each specific environment, selection criteria of self-states and corresponding introjects.
A scientifically rigorous psychology should start with the external environment: stimuli conveyed to the brain via sensa, the ecosystem of information, 95% of which remains unconscious.
The internal environment is comprised of reactions to the external environment and interactions between processes such as cognitions and emotions.
The idea of an immutable core identity is, therefore, counterfactual: no fixed entity can efficaciously cope with a shapeshifting and ever-transforming reality.
Instead of a unitary lifespan-long Self, in the footsteps of the likes of Philip Bromberg, I propose an ensemble of self-states, each one of which is optimized for a specific environment.
The self-states are automatically triggered. The one best adapted to the exigencies and demands of an idiosyncratic milieu becomes dominant while the others are rendered latent and dormant.
The self-states are not dissociated. They share resources and assets such as the individual’s intelligence and memories.
Some autonomous or continuous background mental processes might conflict with the self-state. To avoid dissonance and the ensuing anxiety, they are silenced with the aid of constructs. Each construct is unique to a specified self-state.
The constructs are stable organizing and hermeneutic-exegetic (interpretative) principles. Constructs mediate, structure, and filter external reality (experience) by reframing it while also regulating the internal environment.
Constructs make sense and impose a meaningful narrative on raw sensa as well as on internal data. They are like theories: they yield predictions. But all the output is censored to conform to the self-state (cognitively and emotionally distorted).
The ego and the persona are instances of constructs.
Like defense mechanisms, constructs impair reality testing in order to buttress the self-state and maintain its coherence and cohesion. Like membranes, constructs selectively suppress any input that challenges the self-state or undermines it.
Constructs, therefore, ensure ego congruency and ego syntony by generating a database of information that is both relevant to the self-state and supportive of it.
Constructs also tackle memories that vitiate or contradict the self-state and thus engender dissonance and anxiety.
The construct either silences such memories or reframes them into compatibility with the self-state.
It accomplishes this feat in one of three ways: 1. By dissociating the memories; 2. By altering the emotional content and correlates of the memory to conform to that of the self-state; and 3. By weighing memories differently and selectively (selective memory).
To accomplish the reconciliation of the self-state to both the external and the internal environments, the constructs call upon (interpellate) introjects (internalized voices of meaningful others, such as parents, teachers, peers, and society at large). The conscience is an example of a cluster of introjects that is often made use of by constructs.
In order to avoid dissonance and anxiety, we make peace with our introjects by misidentifying them as our own authentic voices (attribution error).
The introjects generate automatic thoughts, both positive and negative. They are always on standby. They interfere with daily functioning once they are triggered.
The constructs organize the introjects’s output according to a set of selection criteria and principles (“identity”).
“Identity” is an algorithm which maps self-states and their attendant constructs to specific environments. It determines which introjects are activated. It is a set of principles and operating routines which regulate the emergence and submergence of self-states.
Identity changes only slowly and so gives the illusory impression of stability and continuity.
The “personality” is comprised of the selection criteria (aforementioned algorithm) combined with the resultant self-states.
The individual is cathected (emotionally invested) in the self-state. S/he wants to validate it and thus preserve the comfort zone.
One of the functions of the automatic thoughts is to drown out the processes which negate the self-state or conflict with it. The other function is to affect and modify behaviors.
Some behaviors are inhibited or negatively reinforced by the construct, using the automatic thoughts spewed out by the introjects. Other actions are positively reinforced.
This way, the construct induces or fosters only behaviors whose consequences modify the environment to fit the self-state even as it suppresses all other forms of conduct.
The construct is goal-oriented. The choice of behaviors is secondary and rationalized. Self-efficacy is the overriding aim. The construct leverages external inputs to regulate the internal landscape.
The construct creates a paracosm, a virtual reality to fit and uphold the self-state. It is a harmonizing central authority.
This model sheds new light on basic concepts in psychology.
“Defense mechanisms” render palatable the outcomes of positively reinforced behaviors and prevent secondary anxiety, shame, and guilt.
“Mental illness” occurs when the self-states are mutually exclusive or oppositional or incompatible and the transition from one self-state to another is disrupted for a variety of reasons (mainly when the self-state is suboptimal).
The principle of non-contradiction in the repertory of self-states and the smooth transmission of power between self-states are the bedrocks of mental health. Conflicting self-states coupled with constructs compete for resources in a host of mental health disorders.
With every new environment, the algorithm selects an optimal self-state which takes over the individual. There is a momentary disorientation in the dissociative gaps between consecutive self-states.
In other words: the continuity of memory, identity, and personality is a myth or, at best, a convenient and idealized abstraction.
Self-states are anxiolytic and therapy is anxiogenic. But gradually, therapy helps the client evolve a new algorithm which selects for self-states which are less self-defeating or self-destructive and more functional.
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