Tomorrow is another story Tomorrow is another story Working with life-scenarios in personality Working with life-scenarios in personality disorders

disorders Jean Cottraux MD, PhD Anxiety Disorder Unit University Lyon 1
Cottraux@univ-lyon1.fr

Invited Lecture, ICCP Gteborg June 16, 2005 , 13:00 -14:15

Aims of this presentation

Clinical practice and theory
Bring some flesh to the concept of schema People are not coming to change schemas but because their are not satisfied with their lives Life scenarios (or life-scripts) : attempt to bridge the gap between theory and CT practice

Topics
1. Life scenarios presentation 2. Bipolarity of the schemas 3. Counter-transference issues and resistance 4. Changing life scripts : a four steps approach 5. Application in CT

Life Story and life scenarios

Starting point
What the patient says about his or her life ? How and when is it possible to conceptualize the life-story told by the patients ? When is it possible for the therapist to have a global picture of the patients life-story ? What is the relation of the life-story with the schemas? Do the stories told by the storytellers (movies, novels) have a relation with CT?

My life is a soap

Life-scenarios : a clinical view

Some patients in CT compare their lives to a movie or a soap The plots of most of the movies, novels, operas or soap operas tell the story of a character or describe a personality The number of possible scripts are limited A movie script tells the story of the interaction of two or more personalities (or personality disorders) Is psychotherapy a kind of drama with a possible happy ending ?

Life-scenarios : definition The pursuit of unhappiness

A trap the subject is trying to escape but remains prisoner of Doing more of the same thing while thinking it might bring new outcomes The person is attracted into a downward spiral and lives an unsuccessful life marked by repetition Same partners again and again : alcoholic husbands, etc. Same conflicts at work Same accidents Same repeated failures

Life-scripts : characteristics
Repetition of relationships that are detrimental
Love Work relationships, career Impulsive behaviors Re traumatization

Negative emotions : anxiety, depression, anger Active hidden plot to discover : leading to core schemas Feeling of being caught into a "Cob-web" or trapped into a plot the patient does not understand

Life-scripts as remakes
Remakes of basic screenplays, narratives, or myths Every fictional or true story tells about a personality Every story refers to a bipolar construct : Good-Evil, Trust-Deception, Great expectations-disappointment, Sense and SensibilityCinderella-Princess Persecutorvictim These constructs are found in the patients interpretation of his or her own life The patient may find some explanations in the movies

Life-scenarios history : the psychologists Freud (1920) : destiny neurosis related to masochism
and death instinct

Laforgue (1939) : failure-neurosis (nvrose dchec)

Those who failed when they reach the success Self-punishing behaviors

Eric Berne (1961) : life-scripts : a game that people play

Related to infantile needs Ego states : child, adult or parent

Life-scenarios in cognitive therapy

George A Kelly (1955) : personal constructs and fixed role therapy Guidano and Liotti (1983) : Cognitive processes and emotional disorder : plan of life, life theme, guiding track or script Aaron T Beck (1990) : scenarios in personality disorders; cognitive theory of personality Christopher Muran et al. (1994) : life-scripts related to selfschemas Jean Cottraux (2001) : book on life-scenarios (in French) Robert Leahy (2003) : life-scripts and resistance

Life-scenarios history : the writers and essayists Gozzi, Goethe, Polti (1920) : limited number of dramatic situations 36 situations according to Gozzi as reported by Goethe in conversations with Eckermann Identical structure of the folk tales : Propp, Greimas Questions :
Are individual stories mere repetition or remake of archetypal stories ? Repetition of types of personality living the same ordeal ? Is life a film ? And how to use films in therapy ?

Life-scripts: hypotheses
Behavioral expression of self-schemas Related to early experiences Rooted in culture, family or idiosyncratic experience Emotionally rooted belief Control the behavioral repetition The patient is partly aware of it The patient do not attempt to punish her or himself The patient is controlled by the implicit negative ends of cognitive schemas Discovering the life-scripts and modifying the schema may change the life

Life scripts : the move towards change

External attribution Attributed to destiny : external attribution Attributed entirely to biology Internal attribution Sometimes the patient is aware he or she is (in part) the author, scenarist and director of his or her own drama Taking some part of responsibility for it Ask for help First therapeutic step is clarification of the life-script

I can't help it, it's my character!

Resistance

Resistance to change : the personal dilemma

Changing the belief is perceived as significant others deception : especially in the stories of early sexual abuse (Pathogenic secrets : Moriz Benedikt, 1868) Changing the belief arise negative emotions and cognitions Not changing the belief and behavior arise negative emotions and cognitions The life-script is detrimental but changing it seems impossible Such dilemmas may lead to suicide

Origins of life-scripts
Three unconscious levels
Biological : temperamental influences Environmental : scenarios built by familial, social learning or cultural influences Cognitive self- schemas rooted in life-events and specific experiences

Three levels of unconscious and life-scenarios life-scenarios

Cognitive unconscious schemas

Life scenarios

MEMORY

Neural networks

Environmental unconscious

Conditioning

Biological Unconscious

Life-scripts and schemas

Biographical narrative

Automatic Thoughts

Image

Emotion

Life-scripts
Self-schema Cultural schema Myths
Life events

Familial schema

Information processing model (BECK, 1990; Cottraux & Blackburn, (1995)

Information content : postulates Cognitive schemas Cognitive process Distortions Schema : reinforcement Cognitive operations Cognitive events Cognitive products

Automatic thoughts Images Behavior

Bipolarity of the schemas

Personal constructs (Kelly,1955) Construing = placing an interpretation on events Personality is made of bipolar constructs Emergent and implicit poles Anticipations : replication of events Convenient for a finite range of events Choice ( good vs.. bad, lovable vs.. unlovable) is made to enhance the anticipations Learning may modify constructs

Life-scripts: LIR model (Cottraux, 2001)

Explicit pole Logic

Logical thinking

Impulsivity
Self-control

Relation
Dependence

Autonomy

Magical thinking impulsivity

Implicit pole

LIR : A brief rating scale for CT in personality disorder : Cottraux, 2001: Logic, Impulsivity, relation of dependence
1. The logic of my thoughts
0.1..234.5678

Fully rational
2. The control of myself and my actions

Fully Illogic

0.1..234.5678

I always control myself

3. My independence

I never control myself

0..1..234.5678

Fully autonomous

Fully dependent

LIR correlation with S.Q II (Young)

Logic : no significant correlation Significant correlations for:
Impulsivity : Insufficient control (IS) : .25 Relation of dependence : Dependence (ID) Subjugation (SB) Enmeshment (EM) Lachenal-Chevallet (2002) .35 .34 .31

Bipolarity of the schemas

Two ends : one positive, one negative Only one end is observable, the other is implicit
_ Avoidant Narcissistic +

I am weak Humiliated

Explicit Implicit Narcissistic

I am superior and special

Avoidant

Bipolarity of the schemas

Obs.comp

dependent

no mistake Explicit Implicit I cant Control myself

I need (love) you

happiness is not for me, I am a failure depressive

borderline

How to manage the schema bipolarity (1) ?

Do not use a psychoanalytic attitude The explicit end of the schema does not represents the false-self of a person The implicit negative end of the schema does not represent the definite true self" of a person Cognitive conceptualization is based on careful assessment of the functional relations between implicit and explicit ends of the schema A synthesis of both ends of the schema is generally useful

How to manage schema bipolarity (2) ?

Historical justification of the schemas : to be acknowledged Importance of past history and events when dealing with implicit and explicit parts of schemas Early experiences play a significant part : strong emotions are here when they are recalled Examples : mistrust and un lovability schemas
abandonment for a brother who is ill for one or two years untrustworthy adults : seducing father in law Being the parent of an alcoholic mother and cooking for the family when Mom is on the wagon

Bipolarity of the schema Mrs. P. : mistrust schema in a borderline patient

Dichotomous relations
Victim / persecutor (bastards) Victim / protector (therapist, friends, husband etc) Victim / protector becoming persecutor

I am
-

Protector
+

Victim

he of she is

Persecutor

Counter transference issues

Life is lived forwards but understood backwards
Sren Kierkegaard

Kierkegaard, Soren Kierkegaard, Soren Kierkegaard, Soren

The Bettmann Archive The Bettmann Archive The Bettmann Archive

Counter transference issues and resistance

The therapist may be acting as a character in a plot written by the patients schemas Plot : repetition of life-scripts inside the therapy Patients and therapists are acting according to the patients rules of the game : life-script Patients and therapists are trapped into a repeated and sterile interaction

CT for PD : Counter transference issues

The therapist may be acting as a character in a plot written by the patients schemas Counter transference may be a mere subjective reflection of the therapists casting Therapists own schemas may be activated To know the part the therapist and the patients are playing is important This may help identify the patients schemas and meta-communicate with him or her about it Types of countertransference plots

Casting :role attributed to the therapist (1) Cottraux (2001)

Personality Paranoid Schizoid Schizotypal Antisocial Borderline Therapists Casting continua Protector Persecutor Supporter Intruder Scientist Wizard Judge Victim Rescuer Incompetent person Problem areas Trust Distance Logical thinking Violence and law Competence and reliability

Casting :role attributed to the therapist (2) Cottraux (2001)

Personality Histrionic Therapists Casting Problem areas continua Neutral Love and seduction professional Seducer Admirer Egocentrism Critic Domination Dominance Help or submission Attachment figure Dependence Unreliable person or abandonment Rationalism Duty or Hedonism pleasure

Narcissistic Avoidant Dependent Obsessivecompulsive

4. Four steps to changing life-scripts

First step :
Understanding the life-script Eliciting the schemas Conceptualization Pentagon

Why Guided Discovery ?

Socratic questioning of the the Patients attitudes To facilitate a cognitive reformulation and conceptualization of his/her problems To modify schemas, emotions and behaviors Changing life-scripts Changing life
A life worth to live

Specific cognitive techniques

o o o o o o Changes in therapeutic relationship: impatience, anxiety, tears, critical attitude, submission etc Dreams Activation of memories of past experiences Images, analogies & metaphors in relation with the schemas Books or movies related to the schemas Socratic discussion of the schemas at the start of the therapy

Cognitive conceptualization : the pentagon Event Unconditional belief

Behavior

Conditional belief

Rule
Emotion Automatic thoughts

Conceptualization :Self-defeating vicious circle. Mlisande : borderline patient

Event: exam, social

Unconditional belief
I am inferior

Behavior Avoidance Addiction Self-mutilation

Conditional belief If I dont succeed in Everything I am worthless Avoid Rule

Emotion Depression Anxiety

Automatic thoughts I am a failure

Greimass paradigm (1966) Six functions of a narrative: Mlisande : life story

Destiny maker Mother

My daughter Is over gifted

Object Success

Recipient Mothers Social values

Helper Therapists

Subject

Opponent Father who left home The patient

The Melisandes scenario: confusion and life without meaning in a borderline patient
Arkel : What are you saying ? I dont understand you Melisande : I dont understand what I am saying either, you see. I dont know what I am saying. I dont what I know. I am no longer able to say what I want to Maurice Maeterlinck Pelleas and Melisande

Four steps to changing life-scripts

Second step :
Meta-communicate with the patient about the life-script Empathy Confrontation to the script Socratic discussion about its value for the patients life

Four steps to changing life-scripts

Third step : Propose a film, novel, opera etc. comparable to the patients script Goals: provoke emotions enhance the understanding of the script Find the origin of the script Early experiences Early schemas History of the schema building

Personality types and films (1)

Paranoid : Play misty for me (Clint Eastwood) Schizoid : Histrionic : Antisocial : Borderline : A heart in winter (Claude Sautet) Gone with the wind (V. Fleming) The Godfather (F. Ford Coppola) Betty Blue (JJ. Beneix) Schizotypal : Matrix ( Wachowski Bros)

Narcissistic : Disclosure (Barry Levenson)

Personality types and films (2)

Dependent : Buddy, Buddy (Billy Wilder) Avoidant : Deconstructing Harry (Woody Allen) Obsessive-Compulsive Aviator ( Martin Scorcese)

Four steps to changing life-scripts

Fourth step : changing the rules of the scenario Rewrite a positive script Problem solving Building of a new schema Use a form (homework) to discuss validity of the old and new schemas (J. BECK) The golden mean : reduction of the schemas bipolarity Plan for a better life Behavioral experiments Reevaluation of the behavioral experiments Maintenance of the change

Conclusion
Borderline personality disorder is one the new frontiers of Cognitive Therapy Life scenarios may represent
A way to conceptualize the patients existential problems A way for the patients to understand the meaning of their lives It may also help to teach CT And bridge the gap between research and clinic