Working with the Self in Clinical Practice

Our view of our self and who we are has a huge impact on the life we live. As practitioners and/or researchers interested in human behaviour, we cannot ignore issues to do with the self as every person has a sense of self. From an Acceptance and Commitment Therapy (ACT) perspective, how we view and relate to our self is often limited and fails to capture much of who we are. Often, we view our self as being a collection of labels, evaluations, descriptions, and experiences. However, these are not stable parts of our self, and inflexibility with our view in this regard is highly problematic. Rather than viewing ourselves as literally this content, stepping back and viewing our self as the witness of these experiences promotes better long-term outcomes. Self-as-context is one of the six core processes of ACT and refers to this container view. Specifically, self-as-context is the perspective from which our self content and moment to moment ongoing experiences of self are observed.

A modern scientific approach to understanding human behaviour. CBS is an approach to psychology and to science more generally that takes action in context as its core focus and sees the prediction and influence of behaviour as a key goal. While this approach has its roots in behaviour analysis, it extends beyond the latter in its emphasis on a functional approach.

When dealing with an individual client its hard to separate any issue they are having from their self. Key problems in clinical practice are a lack of values clarity, self-righteousness, operating on auto-pilot, one's own experiences feeling threatening, a lack of perspective, hyper-attentiveness to views of others, personal rigidity, a sense of emptiness, painful self-judgements.

In order to understand how a healthy self repertoire is acquired a number of key processes need to be well developed. A critical one is learning to engage in deictic relational responding (that is, perspective taking) on the basis of a distinction between one’s own and others’ behaviour. An optimal environment for this will involve frequent interactions with many examples of distinctions between I and others. The skill of being able to talk about ourselves is not something we are born with, It is a repertoire that is developed. Ideally, adults and peers should talk to and ask children about themselves and encourage children to ask and answer questions involving deictic relational cues. Such questions asked to children about themselves should span three dimensions: Interpersonal; “I’m the different to you” or “Do you like the same one teddy has?” Spatial; “Do you like it here at the park?” or “Is that you there hiding behind the couch?” and Temporal; “You finished your colouring really quickly!” or “Did you remember where you put your lego?” Adults and peers should also talk and ask children questions about their emotions, about what they like and don’t like, what they want and don’t want. For example, imagine a child is showing obvious signs of being tired (i.e., going quite, yawning, struggling to keep their eyes open ), their caregiver might ask “Are you tired?” If the child is not able to discriminate that they are tired they may reply “No.” In such a case the child may be permitted to stay up. However, if he then starts to have a tantrum, he might receive socially mediated consequences (i.e., such as no treats the next day). In this case the caregiver might say, “When you’re tired, you get cranky—you cannot stay up so late anymore.” Such consequences result in more accurate reporting by the child of the their own behaviour in the future. More accurate reporting of our behaviour in turn allows for more accurate prediction of our behaviour, both by the ourselves and by others.

Helping the client develop a broader sense of self that is more than their evaluations, judgements and comparisons is important here. From the Acceptance and Commitment Therapy perspective this is referred to as Self as Context. There is a suite of metaphors and exercises available to train self-as-context in the ACT literature. For example, the Observer You Exercise.

The Observer Exercise helps the client become aware that they are present in this space at this moment and that they are the one noticing. The typical format of the exercise involves inviting the client to bring a number of past memories from their lives (e.g., three) to their awareness. As each memory is brought to mind explicit cues such as ‘who notices this?’ are introduced to illustrate the observer perspective. Before exploring the memories with the client the therapist grounds the client in the present by guiding them to direct their attention inwards. This can involve instructions on how to sit and to close the eyes or find a spot to focus their gaze and to direct their attention on the five senses or bodily experiences such as the breath, sitting in a chair, feeling their feet on the floor, or their arms on the armrest or on their lap. Once the client is grounded a number of memories can be explored. An example of how to guide the client to notice the observer perspective for a past memory is as follows:

I want you to remember something that happened last summer. Raise your finger when you have an image in your mind. Good. Now just look around that image. Remember all the things that were happening then. Remember the sights . . . the sounds . . . your feelings . . . and as you do that, see if you can notice that you were there then noticing what you were noticing. See if you can catch the person behind your eyes who saw, and heard, and felt. You were there then and you are here now. I’m not asking you to believe this. I’m not making a logical point. I am just asking you to note the experience of being aware and check and see if it isn’t so that in some deep sense the you that is here now was there then. The person aware of what you are aware of is here now and was there then. See if you can notice the essential continuity — in some deep sense, at the level of experience, not of belief, you have been you your whole life.

The negative self identity is the same as the last question. A lack of self-identity is a bit different. In this case the therapist may want to do work helping the client connect to the present moment and learn to discriminate their current experiences in order to start to contact a self identity. If I can discriminate my current experience it is much easier for me to know what I want and I don't want, what is important to me and not.

There is great work out there in the Compassion Focused Therapy literature on cultivating more compassion. From the Acceptance and Commitment Therapy (ACT) perspective developing a Self-as-Context repertoire will facilitate the development of more compassion towards the self. When I am the witness of my experiences rather than being entangled in my experiences it is easier to respond with kindness to myself.

We would want to look functionally at what is maintaining the behaviours leading to that diagnosis. It may be an over attachment to a positive story about the self and a defensiveness around that. Or there my be a lack of taking perspective due to a lack of fluency in perspective taking. That is, it may be the result of not rehearsing taking the perspective of others when it does not involve referencing the self (i.e., ‘I’). It would be important to look at the presenting individual to do a functional assessment of the particular behaviours in question.

Yes, this is an interesting question. Again it depends on the individual and their history. The repertoire might not be in place or it might not be rehearsed and fluent. There also could be an avoidance around taking the perspective of others as it may bring up unwanted experiences. When we take perspective the experience of the other becomes present for us. This can be painful to do.

In some ways this is a by-product of the way language is. We can relate ourselves to others and we can compare ourselves to others. The way we relate is arbitrary which means I can even compare myself to an ideal Louise I am not living up to. These gaps between how we view ourselves now and how we want to be can result in harsh judgements. When we are operating from believing the stories, judgements, evaluations we make about our self as 'true' rather than witnessing them as just stories, judgements, evaluations this can result in a very harsh relationship with our self. Of course it is always important to look at the individual clients history to detect what is functionally maintaining a harsh or punitive relationship with the self.