Personality Disorder
I was at a conference the other day, which was about how different therapies understand people labelled as having a personality disorder. After watching a video of an actress, advocates of CAT, Psychodynamic Interpersonal Therapy, Mentalization and MBCT all made there different accounts of how they would formulate and what intervention would involve. I was thinking about how in ACT the case would be formulated.
If my understanding is correct, it strikes me that from a functional contextual perspective, the origin of the person’s behavioural patterns would not be taken into consideration, it would focus on the relationship between symptoms and the overt behaviour.
This leaves me a little confused in how the model would be applied in the case I observed. The lady in the film was most distressed by her difficulties in maintaining relationships with people, she scares people off as she becomes aggressive in response to feelings of jealousy or insecurity. So I’m thinking as I'm writing this, in an ACT formulation, maybe the function of aggression would be analysed, which is that she uses aggression to avoid feelings of jealousy, fear of rejection etc, which prevents her from meeting her values of forming meaningful relationships.
I guess I’m wondering if ACT would help to understand her history of behaviour? So, from childhood, since being rejected by her mother and father, she has associated relationships with being rejected and pain. It seems maybe if it did, it has some similarities with CAT, in helping her understand her patterns of behaviour to understand the current function of her behaviour.
Secondly I’m quite new to ACT, I’ve done the online tutorial, although some time ago now and my memory is not so good, but I’m a little confused about the ACT view on thoughts that thoughts and beliefs do not influence behaviour. To me and my limited understanding, it suggests that people do not have a conscious/ decision making control over their behaviour. I don’t quite understand this bit and need to do some more reading. To illustrate my confusion, take a simple example that somebody regularly takes a vitamin pill and then they choose to stop taking it to see if they notice any difference in how they feel. Is that not a generated thought influencing a person’s behaviour?
So, if anybody could help add a little clarification that would be great.
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I know you wrote this quite awhile ago...
I hadn't looked on this site in several weeks...too busy...maybe you've figured out some of this stuff by now. Obviously, what Dr Hayes wrote is correct; you probably need to read some more. However, some of the obvious is 1) I don't think anyone would suggest that thoughts and feelings don't influence behavior. The point is that they don't have to influence behavior. There's a choice you can make and this choice is easier when you are mindful and step back from the drama you think is your life. It doesn't happen instantly; it requires practice but you will realize that your thoughts create your feelings and you can do a couple things - change your thoughts, for one,(that's more the CBT thing), accept your thoughts and be ok with them, or (this might be my Yogic training, I'm not sure...not identifying with the thought. It's just a sensory thing running through my mind. Just like I see an object through my eyes doesn't make it mine, the same could apply to thoughts. Just random things my mind is sensing. Maybe not at all true, maybe a little true...whatever. But certainly, nothing you have to act on.
Your vitamin example showed a clear choice. The thought that maybe the vitamin wasn't helping led the person to choose to do a little experiment. Everyone wouldn't do the same thing; hence, choice.
Also, you don't really need to understand your history of behavior in any particular detail for acceptance to take place. This could just lead to intellectualization and not change. A woman in a situation such as you described could stay present focused on her values - what is it she considers important in life, for instance, and what is she doing right now to make that a reality? Sometimes, people are quite shocked to see that their behavior is in complete opposition to that which they consider to be of value. Sure, she would have to go through the pain of risking rejection, risking in general is painful. But consider that "life unlived" vs. going out and risking, accepting whatever happens and being okay with the results. For me, this is where ACT is most similar with Buddhism; do your best, do what needs to be done but let go of any expectations of your preferred results. Don't get attached to the results. Some people (authors, actors) get rejected many, many times, and sure, it's not great, but it's not the end of the world either.
I know this is a very superficial explanation but I hope it's helped a little. Certainly reading books/articles by people with much more experience would help you gain a much deeper insight.
Very brief PD / Mentalization / ACT thoughts
Thanks for all the work, site etc.
I'm a psychiatrist deeply interested in Borderline Personality Disorder, understanding the aetiology and treatment of PD, and also in general psychological disorder and Mindfulness based and especially ACT approaches.
It seems to me that Fonagy and Bateman's Mentalization understanding, explicated preclinically in "Affect Regulation, Mentalization and the Development of the Self," 2002, Other Press, and clinically in "Psychotherapy for BPD - a Mentalization Based Approach," 2004, Oxford, allows appreciation and clinical focus upon the PREVERBAL developmental psychopathology, something RFT / ACT doesn't approach, nor claims to.
Jon Allen from the Menninger explicates it well for clinicians at this site: http://www.menningerclinic.com/resources/Mentalizingallen.htm
Anthony Bateman's Unit in Halliwell describes something of their approach at this NHS site: http://www.beh-mht.nhs.uk/services/directory_of_services/haringey/halliwick/default.shtm
Final links to post, Fonagy's and Bateman's homepages, which give an idea of their thinking, and more importantly provide links to, for instance, MBT, Mentalization Based Treatment training resources, including a great downloadable PowerPoint on Bateman's page.
http://www.psychol.ucl.ac.uk/psychoanalysis/peter.htm
http://www.psychol.ucl.ac.uk/psychoanalysis/anthony.htm
It seems to me that ACT (which analyses and clinically focusses magnificently upon psychopathology as, and after, Language, and the VERBAL self develops) lends itself beautifully to daily clinical work with highly disturbed people with Borderline PD, a la DBT only with psychopathological and clinical mechanisms deeply considered and explicated in testable, clear concepts and language.
I have imagined a Mentalization informed ACT program (or ACT informed Mentalization Based Psychotherapy) as likely to a lead to a real step forward for the care of these troubled patients. The success of DBT from the perspective of Care Providers, Managers etc appears to be in it's manualised format, amongst other reasons.
It would be absolutely fantastic to hear of Steven Hayes or other key RFT/ACT theoreticians discussing these possibilities and theoretical and clinical aspects with Peter Fonagy and / or Anthony Bateman.
I note that there are international BPD conferences coming up; March 4th in Houston, and especially April 6-7th in London, at which these folks will be present - any chance of an ACT dialogue with these eminent BPD thinkers?
I look forward to further discussion of these complex ideas in this PD page. I hope to contribute more meaningfully once I've digested the 2 areas more fully and clarified my thinking better on the area. It encompasses of course a huge realm of knowledge!
Thanks to Eric Fox for his work in allowing this forum.
cheers rob p
re: attachment theory
Irene Javors
I am very interested in the relationship of ACT to attachment theory. From my clinical experience, many clients experience certain thoughts and feelings as connected to significant persons in their lives; sort of codes for feeling or ideational states associated with parents, siblings, etc. Such Proustian moments often become all pervasive and dominant.
Also, letting go of the thoughts or feelings is experienced as a loss of the attachment. And integration is often experienced as threatening to identity,"I'm not like my mother!"
Hmm
Hmmm
This post raises so many issues it is just not possible to react easily. A lot of what it raises are general issues abut behavioral thinking and especially the philosophy of science that underlies ACT. Hard to put in answers in capsule form.
All behavioral principles are historical. We are most interested in is the history alive and in the present, but its all history.
As for the nature of behavioral causes, the argument is complex.
Start with Hayes and Brownstein, 1986 in the reference section. Consider also Hayes, Hayes, & Reese, 1988, also in the reference section.
Sorry to answer that way but your questions are about things that took years to work out and that are central to ACT / RFT. The reading is just necessary as a start if you want to understand the position.
Steven C. Hayes, University of Nevada
Aha!
Or should that be d'oh!
Hayes and Brownstein 1986 was sufficient to essentially "get it". 'The scientific unacceptabililty of literal dualism' in there, relating to 'mentalism', ought have caused the entire psychoanalytic field to pause and consider. Likewise 'cognitive' accounts. The richness of the philosophy of science in there and the '88 paper clarifies the issues, although each being quite difficult reads. I'm intrigued as to why they haven't impacted the whole field of psychology more comprehensively.
It's been fascinating for me to begin understanding behaviorist history, and thus far better understanding human behavior, and also how we might fruitfully go about this endeavour.
The recent MP3's of the Canonical Works - in the Audio section to the left on this page - walks through Skinner '45 and '50, wherein these ideas begin. I've gone to Jay Moore's stuff - he appears a fan more of Kantor? the '86 paper notes a lack of a research program from Kantor's work - did Kantor lack the intuitive functional contexualism of Skinner?
Skinner '50 noted - "Research designed with respect to theory is also likely to be wasteful. That a theory generates research does not prove its value unless the research is valuable. Much useless experimentation results from theories, and much energy and skill are absorbed by them. Most theories are eventually overthrown, and the greater part of the associated research is discarded."
This would appear to include much, if not all, attachment, 'cognitive' and other mentalistic theorising - hypothetical deductive vs ABA's analytic abstractive theorising which underlies RFT (and hence ACT) (per Hayes account of the '50 paper in the WorldCon lecture)
Aside from astonishment at the clarity of thought, and so many decades of careful scientific incremental progressive endeavour, I'm amazed with the patience of those imbued in this approach with those very many indeed with relatively simplistic mechanistic accounts - and am ever reminded to 'hold it (all) lightly', and consider how I relate to others about all this wonderful stuff with 'successful working' as a key (self-monitoring) criteria!
I no longer refer to Personality Disorder, but instead to (as Kirk Strosahl and Steve Hayes pragmatically describe this area) to Multiproblem, or Challenging Patients.
Thank you for the help in understanding and being of use to my fellow humans.
Robp.