Clinical, scientific and stakeholders’ caring about identity perturbations

Abstract

In this editorial we comment on the article by Zhang et al published in the recent issue of the World Journal of Psychiatry. We focus on identity diffusion, identity perturbations, their origin and developmental pathways. This is an upcoming problem in the society as not only school children are affected. Adolescents and young people suffer from uncertainty in gender identity, in self-image, migration effects due to chronic crises caused by war, pandemic disruptions or climate change. We show how such chronic uncertainty can be cared for, treated, and contained. The key is affective holding, reflection and to provide adequate affective mentalizing in a close concomitant way. These key features also depend on ambient conditions, such as psychotherapeutic care. In a qualitative interview study carried out in a cyclical research design with a comparative analysis on the basis of thematic coding using Grounded Theory Methodology we found institutionalized defenses in health policies. Professionals request better training and adequat academic knowledge as well as research into unresolved areas for improvement of the ambient conditions for adequat development of the self. Practice points for further clinical and scientific development are given and discussed.

Key Words: Identity diffusion; Trauma; Dissociation; Ambient conditions; Environment; containment; Mentalized affectivity

Core Tip: Research on development of the self and identity disturbance has progressed over the past decade studying memory changes and brain plasticity. However, there are still many unanswered questions related to clinical and ambient, environmental applications. As external stimuli have personal valence and meaning, we investigated efficacy of psychotherapeutic care. Stakeholders provide insight into institutional resistances and solutions for better care- and containment-competence development and training. The goal therefore is to target containment processes in both, in individuals who suffer from mental disorders, and their ambient conditions with real-world consequences.

INTRODUCTION

In the article by Zhang et al[1] the development of the self is addressed. The psychodynamic approach conceptualized behavior as dependent on individual drives (sexual and aggressive). Later, object-relations theory and attachment theory emphasized the importance of interpersonal relationships for personality development, and the conflicts arising between drives and defenses. Internalized and metabolized interactions between the child and others form the ‘Self’ as an identity-preceding structure in early infancy. Mechanisms for Self-preservation and enhancement also develop, referred to as “‘mirroring’ (an object who reflects the infant's ambitious grandiosity), ‘idealizing’ (an object who can be admired, identified with, and whose strength can be shared), and ‘twinship' (a ‘best friend’, a companion of one's heart)”[2].

When answering the question "Why do you think someone has become the person he or she is now?" the developmental aspects often seem to be in the foreground, especially in the case of mentally ill people. Answering this question remains challenging, as it requires reflection not only on the nature of a person, but also on his or her development over time in relation to the context and the individual himself or herself, thus including an interpretation of knowledge about the (relational) memories of others.

The interviewee might come up with an answer that satisfies the need for an explanation-as simply and succinctly as possible. It is usually much easier to recall emotionally relevant memories of oneself and the person, and thus to give examples of a person's "typical" behavior. In certain states, however, even this task becomes a particular challenge. Take the state of acute psychosis, in which the sense of self is certainly impaired. Psychotic states are characterized in psychoanalytic theory by the defense mechanisms of splitting (i.e., positive, and negative remain unintegrated) and projective identification (i.e., projection of one's own intolerable or inexplicable impulses onto others)[3-5]. Associated with this are deficient intrapsychic representations of self and others and, in particular, a lack of ability to differentiate between internalized cognitive and affective representations of self and others[6].

In this understanding, developmentally cumulating self-representations can be conceptualized as localized in the self as a “steady frame of reference”-a frame for comparison with future mental states linked to affects[7,8].

Any mental condition that impairs memory functions or the "sense of self" may impede or compromise these complex thought processes, requiring the description of a "dialectically constituted" subject rather than a fixed entity[9-11]. Here, "dialectically constituted" means that the self can be seen as something that emerges from the relationships and interplay between a variety of interacting systems and processes (both conscious and unconscious) within a subject's mind in time and context.

In summary, the formation of the self involves unconscious and conscious intrapsychic experience and action and relies on intersubjectivity[12,13]-a realm in which meaning is generated; with the acquisition of language, symbolization mediates dialogue and experience of the world[14]. However, without the function of memory to integrate a multiplicity of experiences, the attempt to construct the infant as a subject with a core self from his or her (social) experience would not be feasible. Social engrams[15] and empathic behavior[16] have been shown to influence higher-order cognition and modulate negative experiences and memories, in part by facilitating new learning[17]. Adaptive integration of language with affect regulation/self-regulation depends on the quality of the parent-child relationship as learned in early interactions[18,19] and is necessary to form an integrated self[19]. The integrated conscious self with its intact memory functions gives a sense of coherence. The sense of coherence is linked to personality traits, especially to low neuroticism and high extraversion, openness to experience, agreeableness, and conscientiousness[20]. Furthermore, these traits were associated also with meaningfulness in life, i.e. the feeling to comprehend and to the trust in one’s capacities to manage life. Besides, shared genetic backgrounds for sense of coherence, mental health, self-esteem, and personality have been proposed just recently[21].

RELATEDNESS TO OTHERS

Psychic development has been described as a "lifelong synergistic interaction between two fundamental dimensions of human experience: Relatedness and self-definition"[22,23]. Personality-related changes imply changes in the self, and it could be hypothesized that barriers to change arise from intense affect experiences, e.g., the fear of losing self and orientation in life when interventions challenge patients' current configuration of self.

Philosophical concepts concerned with the nature of human beings, referred to as "the self," can be traced back to Aristoteles, Plato, and Kant[11]. Hume and Descartes located a "homuncular self" within human consciousness[24,8]. For Sartre the subject emerges in the small gap between reflecting and the reflected consciousness[25,8]. The question of the intersubjective origins of the "self" has a long tradition among philosophers and psychoanalysts[13,26,27]. Winnicott put the focus on affective exchanges in the mother-baby/infant-relationship, with recognition by the other as a self and thus permitting the emergence of a separate infantile subject, actively constructing a perceptual world[8]. The subject's quest for identity along with the object's functions of self-affirmation and mirroring[28] and the role of language in forming the subject within an intersubjective matrix[14,29] have been a focus of theorizing.

The self has traditionally been conceptualized as the subject of a person's mental and physical actions. However, when Freud was confronted with the conscious non-knowledge and simultaneous unconscious knowledge of his patients, he proposed a multiplicity of interacting systems and processes rather than a single entity[11,12].

RELEVANT OUTER CONTEXT

Reconsidering the context, a question arises regarding where affective holding, mirroring, mentalization, and mentalized affectivity can occur to provide an optimal environment for the adequate development of the self. Several shortcomings in the provision of psychotherapeutic treatments and their referral management have been observed and discussed in Austria, its neighbouring regions, and in other middle European countries (e.g., the United Kingdom and Germany) recently and with increasing dynamization. In this context, a health policy controversy has emerged on the occasion of planned legislative changes and the (upcoming) expansion and reorganization of contracts. Definitions of problems regarding psychotherapeutic care situations play an important role, and the implementation of appropriate solution interpretations is being refined. A widespread and prominent description of the problem emphasizes the effectiveness of psychotherapeutic services in the extramural sector.

CONTAINING FACTORS AND THE RESPECTIVE ENVIRONMENT

To investigate the effectiveness of psychotherapeutic care for the optimal development of the self, as well as the implementation of adequate improvements, an observational interview study[30] was carried out using grounded theory methodology with a cyclical design and comparative analysis using thematic coding. A theoretical sampling strategy was used to supplement focus group discussions with targeted sampling by identifying strategically important people with relevant knowledge in the field[30]. Details on the specific research steps and sample selection that resulted in 12 participants from different organizations that were strategically involved in the healthcare system, as well as data analysis according to the methodology and coding paradigm of grounded theory, were presented by the research core group[30]. Prominent specific single perspectives[30], such as the Health Care Administration (Nr. 2 in Table 1) or Health Insurance (Nr. 3), and the Patient Advocacy Perspective (Nr. 11 in Table 1) led to an iterative in-depth discussion in the core research group, resulting in strengthened condensation toward code families.

Table 1 Code family: Environmental conditions and problem descriptions according to expert perspectives.

Thematic codes	Perspectives
	Health policy advice	Health care administration	Health insurance top-management perspective	Economic advocacy and social insurance expert	Health policy - workforce perspective	Health care research and health policy advice	Health care research and psychosocial strategy development	Psychotherapy care and professional representation	Psycho-social-psychiatric services and professional representation	Legal affairs of health insurance	Patient advocacy		Patient (representation)
Training/skills acquisition	7		1		10	5	6	16	14		7	4
Health sector and mental health	7	2		5	13	2	8	5	2	1	2
Stigma	10	1	1	2	3		6	3		4	2	3
Effectiveness and quality assurance	6		3	1	4	2	2	3	8		3
Environmental change and mental stress		3	2	5	4	1	3	1	1		2
Working and economic conditions	1				7		1	4	2	3		1
Law and law enforcement		6	1		7			4			1
Access to pension benefits				9	3			2				2
Federal-state scaling	4		2	3		1	3	5	1	3	3	2
Vocational rehabilitation				2				3				5
Medical system	1			2			1

An overview of the condensed results of the code family for environmental conditions and problem descriptions based on expert perspectives was presented. The topics of the code family and their quantitative distribution according to expert perspectives are presented in tabular form (Table 1). We achieved the functional areas of financing, health administration, and policy (Perspective 5); perspectives of professional representation and care in psychotherapy; and perspectives of professional representation and care in psychiatry in the area of professional and training representation (Perspective 9). These perspectives place the most weight on environmental and ambient conditions when containing effectiveness. Notably, an institutional and institutionalized defense is observed from the politics and policies concerning the health sector and mental health and formulated as: ‘But I can well imagine, especially from the point of view of those affected, that some things are simply not seen and considered sufficiently’ (Perspective/Interview 5). Furthermore, it was stated that a problem of responsibility can be observed when prevention and/or adequate indication for specific interventions are needed: ‘That is the fundamental issue of what you cannot really control in private treatment anyway, whether psychotherapy is necessary due to an illness-worthy condition and whether that is also or should be the competence of social insurance. Is it used only to treat illnesses? Therefore, there are family problems, school problems, or things that do not fall within the remit of social insurance’ (Interview 5).

This is interesting because those working in the field in direct contact are not the only ones aware of the inefficiency of identity perturbation containment.

To summarize, there is a need at the individual level and institutional levels for adequate indication procedures for psychotherapy, including iterative evaluation and empirical, practice-oriented research, and a need for care pathways. Providing the best point of service for an individual problem is an environmental issue; stepped care procedures require the interplay, commitment, and cooperation of all affected.

CLINICAL IMPLICATIONS

Social modulation of identity formation, development of the self, learning, and memory is a field of research in neuro-science, resilience, psychodynamic theories, and behavioral and social sciences. However, the study of socialization effects, and their genetic, ambient, and environmental aspects, including their associated effects must be considered.

The ontogeny and socialization of emotions (c.f. primary affects)[31] are most likely closely linked; cross-cultural aspects have been illustrated, but many questions remain open[32-36]. Popular or folk role models of personhood, affectivity, and development differ between cultures and influence local child-rearing practices and educational strategies, resulting in a culturally specified emotional repertoire. Affective core elements form the basis of an ego/self-core-element[37]. Psychotherapeutic interventions such as confrontation, interpretation, and working through target expressions of intense socialized negative effects have been shown to be highly effective[38].

‘Because what various therapists working in this field have not internalized, and I say this independently of the profession, is that if someone has taken a certain path of mental processing, this path is taken again more easily and iteratively in both ways good or bad’ (Interview 9).

Socialization of affect and the emergence of affectivity and self-competence are reciprocal processes that depend on children’s affectivity, temperament, and level of arousal, as well as parents’ mirroring reactions to children’s expression of affect[39]. In the social learning approach, learning occurs in ambient social contexts and is motivated there[15]. Neurologically, the mirror neurone system, which is important for motor and observational learning, is activated in social learning contexts[40].

Although many basic conditions and foundations are known, the composition and components of effective teaching, education, and learning strategies are limited in cultures. Predispositional priming, reliability of experience, approval/disapproval, and operating with high levels of affective arousal while teaching and educating are the most effective strategies[33,41] to focus more on the individual level: ‘There are conditions of mental illness where psychotherapy in the narrow sense (i.e., individual therapy) really does not work or is not yet possible. But there are few. High-quality psychotherapy is not always a solo therapy, but it can be used and applied in many areas. But how do I put it? It is a prerequisite that those who practise it know what the other person is suffering from. Moreover, they recognize the dimensions of difficulty. Yes, I understand this. They received training to deal with it, and from my point of view, this is also an unmet need’ (Interview 9).

The regional structural planning of care (e.g., via the Austrian structural plan for health), including inpatient and outpatient facilities (e.g., bed measurement digits), indication positions, transdiagnostic measurements (e.g., levels of personality and reflecting functioning scales), plan for integrated care (e.g., multimodal, multiprofessional change-effective offer and work for individualized care over adequate dose and time), interprofessional work, and acknowledgement of boundaries are needed. The assigned professional abilities must be strengthened and trained in all healthcare workers and a roadmap for specific applications must be drawn based on an international public mental health plan (European Union-conform implemented through the Ministry of Health/Gesundheit Österreich Gesundheit Oesterreich GmbH). Respect, empathy, and acknowledgement of the other with his/her competencies, information and confrontation[38], transparency, and close scientific evaluation, such as mixed-method designs, including translational research[31], are necessary to achieve excellence within a framework that allows the individual to never abandon their values (a demand and needs-oriented care) and that is scientifically based to include biological, psychic, and socio-cultural environmental needs.

CONCLUSION

Changes in memory, who we think we are, and possibly what we aspire to in life and how we will or will not achieve it, change with unknown consequences. Care must be taken in determining how a life should be lived. Therapy is certainly indicated when stress and suffering lead to subjective limitations and individuals ask for help. Psychotherapy provides a framework that leads to slow but lasting change-so the patient is part of that experience and especially part of the definition of the goal of therapy. Considering recent research confirming the potential of memory modification and identity consolidation, psychoanalytic and -therapeutic approach offers a viable method to work with patients suffering from diseases related to disturbances in the way memories impact their current live (e.g., trauma-related disorders, anxiety disorders, substance abuse). In mental disorders as identity perturbations associated with functional memory impairment, one might assume that maladaptive patterns have become established as a means of regulating intense negative affect via ambient conditions. However, this regulation comes at a price. The sufferer loses access to his or her motives and central aspirations, and thus the ability to truly connect with self and the world, which can lead to a sense of inner emptiness and a meaningless in life. Modifying various aspects of memory rather than erasing and replacing existing memories seems to be the more promising approach today. In addition, the patterns and processes that lead an individual to "affectively color" and retrieve his or her memories can be influenced if necessary. Although research on memory changes and brain plasticity has progressed over the past decade, especially in the area of basic science, there are still many unanswered questions related to clinical and ambient, environmental applications. Human perception of internal and external stimuli results in subjective memories that have highly personal valence and meaning. By influencing further cognitive and affective processing, shaping self-perception, and affecting the way we think, memories contribute to the core of human existence in very dynamic ways. The long-term goal, therefore, is to target these processes in both, individuals who subjectively suffer from mental disorders, and their ambient conditions with real-world consequences. A further step is to implement research-driven evaluation of these processes and prepare future doctors by developing specific curricular training procedures.

ACKNOWLEDGEMENTS

The author thanks Dagmar Steinmair for her help in literature search and Gavin Lord as native speaker for correcting for style.