Selfhood : A Theory-Derived Relational Model for Mental Illness and Its Applications

The purpose of this chapter is to introduce a theory-derived relational model for Mental Illness and its applications in self-help, health-promotion, sickness prevention, and psychotherapy. Consequently, most of this chapter will be concerned with explaining and expanding on; (1) the basic theoretical derivation of this model, (2) its relational qualities and (3) views of mental health and mental illness, (4) research to validate its construct, convergent, and predictive validities; and (5) its clinical and preventive applications in mental health.


Introduction
The purpose of this chapter is to introduce a theory-derived relational model for Mental Illness and its applications in self-help, health-promotion, sickness prevention, and psychotherapy.Consequently, most of this chapter will be concerned with explaining and expanding on; (1) the basic theoretical derivation of this model, (2) its relational qualities and (3) views of mental health and mental illness, (4) research to validate its construct, convergent, and predictive validities; and (5) its clinical and preventive applications in mental health.

Theoretical origins of the Selfhood Model 11
Selfhood Model 11 is one of the most important models in Relational Competence Theory (RCT).It is also one of the most validated models of RCT, even though all the models of RCT are just as important but perhaps not as important and as validated as Selfhood, as summarized in Figure 1.Furthermore, not all models lead to direct clinical, promotional, preventive, and psychotherapeutic applications as the model Selfhood.To fully explain this Model 11 it will not be necessary to spend as much space and time on the whole RCT.There are plenty of sources where this theory has been explained in greater detail (Cusinato & L'Abate, 2012;L'Abate, 2005;2008a;2009c;L'Abate & Cusinato, 2007;L'Abate, Cusinato, Maino, Colesso, & Scilletta, 2010).It is important to underscore that the 16 model of RCT were created to encompass as many qualities as possible of relational competence relevant to both intimate and non-intimate relationships.The overall scheme is a hierarchical pyramidal flowchart or organizational chart because it needs to differentiate among meta-theoretical (Models 1-3 ) from theoretical ( Model4-6 ) assumptions as well as between developmentally normative (Models 7-12 ) from nonnormative Models 13-15 .Summary Model 16 about Negotiation includes both normative and non-normative charac-teristics that are present in all models ( 1-15 ) of RCT.The historical origins of RCT in general and of the Selfhood Model 11 in particular go back to half a century ago, when behaviorism, psychoanalysis, and eventually humanism were in full force.Less known and less popular was systems theory and information processing formulations.The latter were very influential in starting to think about the family as the 2.1 Requirements for RCT These four requirements are necessary to understand the nature of RCT as: (1) verifiable model by model, like in any human organization, each model has to be accountable and has to be verified from the top down; (2) applicable to individuals, couples, and families as well as functional and dysfunctional conditions and relationships in different Settings (Model 3 ); (3) redundant in linking models together to describe and explain one particular construct, all models are interrelated to support each other by expanding the meaning of a construct from the different viewpoints represented by each model; and (4) fruitful in producing research and applications to validate or invalidate its models, a requirement that implies also longevity.
The requirement of redundancy eventually will be useful to understand the inevitable and necessary overlap among dimensions of functionality-dysfunctionality, as shown at the conclusion of this chapter.Since this requirement is relatively new in psychological theoryconstruction, it might be relevant to expand on its meaning and function within a hierarchical, pyramidal theoretical framework.Redundancy, within the context of RCT, means that human relationships are too complex to be described, explained, or even understood by one single, solitary model.Those relationships can and should be evaluated, described, and perhaps even explained and eventually understood, from multiple but overlapping viewpoints or models.Each model, in and of itself, represents one different way to look at the same construct in relation with different viewpoints.For instance, Model 4 , deals with the ability to love, a multidimensional construct, described first according to a dimension of distance: who and what we approach or avoid, how often and for how long we approach someone or something we love or like and avoid someone or something we do not like.Second, an overlapping construct of love (Figure 1) is also found in Model 7 , using a different set of dimensions in the Triangle of Life.This Triangle was derived from resource exchange theory (Foa, Converse, Tornblom, & Foa, 1993) composed of: (1) emotional and instrumental Being or Presence that includes Importance or Status (Model 11 ) and Love or Intimacy (Model 15 ): (2) Doing or Performance, composed of Information and Services; and (3) Having or Production, composed of Goods or Possessions and Money.In this model, Love is defined by Being Present and available reciprocally to those we love and who love us emotionally and instrumentally.Third, additionally, different meanings of love are visible in the Selfhood Model 11 described in this chapter, on how Importance is bestowed on self and intimates.Fourth, another meaning of love is found in Model 12 about Priorities: what kind of Priorities determine our behavior toward intimates and non-intimates?Fifth, another meaning is found in the Intimacy Model 15 , defined as the sharing of joys and hurts and fears of being hurt.This sharing usually occurs at home and intimate relationships found there, not at work, in the office, or in bars or gyms.The same kind of redundant analysis could be performed with Model 5 about the ability to control self is described by a dimension of speed, how fast or how slow we respond in approaching or avoiding people, responsibilities, or tasks.This Model 5 can be seen from the viewpoint of Model 7 , according to whoever controls Doing and Having has the power to control others, as seen in most despots around the world.Control of self is also relevant to Model 16 about negotiation.One cannot negotiate adequately with others if one is not in full control of oneself.

Requirements for models of RCT
In addition to being verifiable and verified and being defined by the same requirements for RCT in general, RCT models can vary along a dimension of functionality/dysfunctionality, developmentally and normatively.Some models, such as Models 4, 5, 6, 7, 8, 9, 10, & 11 are definitively linked to Axis I and II of the DSM-IV, while Models 13, 14, & 15 in and of themselves unrelated to the DSM-IV evaluate and are linked directly to dysfunctional relationships and roles.Furthermore, some models have been supported by independent evidence (face validity), such as secondary references completely unrelated to RCT but with sufficient similarity to RCT models to warrant their presume or suggestive validity (L'Abate, 2009a).Some models are supported by indirect evidence about the validity of the model.This would be the case,

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- --------------------------------------------------------------------------------------------------------   4, 5, & 6 where support is furnished from other sources or measures developed by researchers extraneous to RCT.Some models have produced specific, paperand-pencil self-report measures that evaluate directly the psychometric robustness of each model (construct, concurrent, and predictive validities among others).This is especially the case for Models 1, 2, 3, 7, 11, 15, & 16 .Model 11 was evaluated also with a visual-verbal test for couples that needs further applications (Cusinato & L'Abate, 2005a, 2005b).S o m e m o d e l s h a v e b e e n e x p a n d e d b y r e v i sing original model-derived measures.For instance, the Relational Answers Questionnaire to evaluate Model 1 was revised and expanded from five (Emotionality, Rationality, Activity, Awareness, Context) to seven components of an information processing Model 1 (Cusinato, 2012).The importance of Emotionality as the basis of our humanity has lead to an entire series of studies about alexithymia, that is: the inability to experience feelings and therefore express them as emotions (Cusinato & L'Abate, 2012).Model 2 , composed of two levels of : (1) description, with sublevels of (a) self-presentation/impression management façade and (b) behavior in intimate prolonged relationships; and (2) explanation with two sublevels (a) genotypical and (b) developmental/generational influences, can be evaluated with a revised Selfpresentation scale (Cusinato, 2012).Model 3 about various specific survival and enjoyment settings can be evaluated by a revised R-EcoMap that includes also evaluation of how the immediate relational contexts and intimates are perceived by participants (Colesso, 2012b).Model 8 about identitydifferentiation has been originally evaluated in a face-to-face verbal administration that limited its being available to more than one individual at a time (Cusinato & Colesso, 2008).However, it has been expanded into a written format that allows mass administration at one time (Colesso, 2012a).Model 14 about the Deadly Drama Triangle (DDT) composed by the Victim, Perpetrator, and Rescuer has been expanded in a forthcoming volume that includes similar or related models, such as Parentification, when a child is assigned or assumes the parental role toward one's parents, the Parental Alienation Syndrome (PAS), when one parent demonizes the other, usually divorced parent with the children., 2011).Some PIPEs are completely independent from sources or models of RCT.Some PIPEs are related indirectly to models of RCT.Some PIPES are directly related to models of RCT, as discussed in greater detail below.

Relational qualities of Selfhood Model 11 and their connections with mental illness
This Selfhood Model 11 is based on the notion that a sense of importance is continuously exchanged between and among intimates and non-intimates.This exchange occurs through the bestowal of importance to Self and intimate Others.When this sense of importance is bestowed positively toward Self and Others, a relational propensity called Selfulness emerges, producing cooperative functionality in three major Settings (Model 3 ), home (family), school/work, and surplus time.When a sense of importance is bestowed positively on Self more than negatively on Others, a relational propensity called Selfishness emerges leading to competitive derogation and impulsive devaluation of others based on envy, anger, acting out, aggression, and in its extremes, murder, as exemplified by personality disorders of Axis II Cluster B from the DSM-IV (Fisher & Cox, 2011;Madden && Bickel, 2010).When a sense of importance is bestowed negatively on Self and positively on Others, a relational propensity called Selflessness emerges, leading to sadness, depression, anxiety, and in its extreme suicide, as exemplified by personality disorders of Axis II Cluster C of the DSM-IV.When a sense of importance is bestowed negatively on both Self and Others, a relational propensity called No-self emerges, leading to various psychopathological conditions, as exemplified by Axis I and Axis II Cluster A disorders of the DSM-IV.Possible gender differences were predicted from the very outset of RCT (L'Abate, 1994), with men being trained relatively more than women to behave selfishly and women being trained relatively more than men to behave selflessly.Equal gender ratios are predicted for Selfulness as well as for No-Self.This Selfhood Model 11 , as shown in Figure 2, integrates various degrees of functionality (Selfulness) and different degrees and types of dysfunctionalities, providing a relational, dimensional version of static, non-dimensional psychiatric categories of the DSM-IV.

Research to validate the Selfhood Model 11
Most of the research to evaluate the psychometric validities of this model has been conducted with various versions of the Self-Other-Profile Chart (SOPC).The latest version is shown in Figure 3.Most of the research to validate this SOPC has been conducted at the University of Padova under the leadership of the second author (Cusinato & L'Abate, 2012;L'Abate et al., 2010, pp. 163-188).
The convergent and construct validities of this model were evaluated with the SOPC in 19 different studies, using instruments already validated in English, mostly in USA.Seven studies evaluated the construct validity of the SOPC.Five studies supported the hypothesis of possible gender differences, with men appearing more selfish than women.Fourteen studies evaluated also the convergent/divergent validity of the SOPC.The questionnaire was administered during the months of April 2011.The correct procedure was observed with appropriate letters of invitation, informed consent, instructions to perform the answer-sheets and collect the fulfilled questionnaires.The collected data were processed in May 2011 with the check of sample distribution, the reliability of the scales, the correlation analyses between profiles and areas, the analysis of variance with independent variables, the translation of the two profiles Self on Other in the propensities selfhood.

Results of the study
After determining the existence of a normal distribution in the data (Self Profile: asym.-. 08, Curt..7;Other Profile: asym.-.27, Curt..26), the analysis focused on the reliability of the profiles, the areas of personal qualities, and the people subdivided by settings.The results (Table 1) show coherent and consistent trends.The correlations between the profiles and the quality areas meet the expectations driving the construction of the instrument (Table 2 and Table 3).The correlation between the two profiles is positive and statistically significant (r = .41**).Therefore, the new version of SOPC seems to be reliable, even though further tests of reliability and validity (concurrent and differentiating in particular) will be performed in the future.The time spent to compile the two profiles seems to be acceptable: mean = 17 min.(range 8-30 min).

The step from propensity to selfhood propensities
A particularly interesting aspect of these results deserves to be proposed for applications in training and clinical practices.On a formal level, the derivation of selfhood propensities of the two profiles has been chosen according to the criteria shown in Figure 4.At the operational level, percentiles 16th and 84th are identified (in theory correspondent to one SD less and more to mean in the standardized Gauss curve) as a cut-off point into three parts.This procedure can obtain 9 types of which 4 correspond to the earlier model of selfhood propensities and the others are intermediate positions, except for the central that could be considered as indecision.
- The intersection of the three levels of Self and Other Profiles with the significance calculated using log-linear analyses gave the results shown by As a consistent result with this procedure, data are distributed mainly in the intermediate range; the two propensities selfless and selfish appear somewhat extreme because 47% of the processed data is not oriented towards specific propensities.The orientation towards selfish, selfless, and selfull is significantly present.

Self
The new version of the Self-Other-Profile Chart seems at first blush more complex and more complicated than the original version.On the other hand, it seems to cover many more relevant areas of Selfhood, including also relationships to Mode l2 , where a distinction was made between servival and enjoyment settings.The acceptable psychometric properties of this revision allow an expansion of the original Model 11 that seems closer to the real-life realities of everyday living.The transformation from inert paper-and-pencil self-report instruments and measures into active and interactive workbooks (L'Abate, 2011c) is obtained by asking participants to define items in any list of behaviors or symptoms, using the dictionary (L'Abate, 2007) if necessary, and then giving two examples from the definition, a nomothetic step.After completing this first step, participants are asked to rank-order items according to their importance to them, an idiographic step.This rank-order is used to administer following PIPEs according to a standard format that includes specific questions about the developmental origins, frequency, intensity, duration, rate and personal and relational outcomes of that particular behavior.This transformation allows to change most evaluative instruments into active and interactive workbooks, thus linking and matching evaluation with intervention in ways that would be difficult if not impossible to achieve as long as face-to-face talk based on personal contact is the norm for most clinical, promotional, preventive, rehabilitative, and therapeutic practices.This transformation was specifically applied to a previous and simpler version of the SOPC thus linking directly a model of RCT to evaluation and to intervention (L'Abate, 2011c).This latest version could be transformed by any mental health professional into a interactive practice exercise using the guidelines given in the previous paragraph.The usefulness of these PIPEs has been evaluated in various studies (L'Abate, 2004b) and in a meta-analysis by Smyth and L'Abate (2001), where the effect-size of these workbooks was found to be .44.In addition to clinical experience and case studies included in L'Abate (2011c), this effect size indicates that it is possible to change behavior for the better through programmed distance writing without ever seeing or talking with a participant face-to-face, provided that the interactive practice exercises match the condition in need of improvement (L'Abate, 2008b(L'Abate, , 2008c)).

Conclusion
If just one Selfhood Model 11 from RCT can accomplish this much, one cannot help wondering what the other 15 models of RCT can be accomplish.As mentioned repeatedly during the course of this chapter, practically every model of RCT attempts to cover functional and dysfunctional conditions.For instance, Model 8 , about identity differentiation covers functional and dysfunctional conditions derived directly from the developmental notion of "samedifferent" (Figure 1).Using the requirement of redundancy introduced at the beginning of this chapter, the six ranges of the Likeness continuum in Model 8 (symbiosis, sameness, similarity/differentness, oppositeness, and alienation), were expanded into three relational Styles in Model 9 , Conductive-Creative (CC), Reactive-Repetitive (RR), and Abusive-Apathetic (AA), and in six types of interactions in an arithmetical Model 10 : multiplicative, additive, static positive, static negative, subtractive, and divisive.An interesting feature of Model 10 relates to the ratio of these six interactions with the presence of hurt feelings and intimacy defined earlier in this chapter (Cusinato & L'Abate, 2012;L'Abate, 2011a;L'Abate et al., 2010).These ratios are relevant to both mental health and mental illness.For instance, in multiplicative interactions the ratio of joys to hurts would be 6 to 1, in additive interactions the ratio would be 5 to 2, in static positive interactions the ratio would be 4 to 3, in static negative 3 to 4, in subtractive 2 to 5, and in divisive interactions 1 or 0 to 6.This model, therefore, views mental illness as the outcome of hurts offsetting joys and mental health as the outcome of joys offsetting hurts.These models overlap redundantly with the Selfhood Model 11 in producing a classification of relationships, as shown in Figure 6. Figure 6 shows how human relationships can be classified according to relational (rather than intrapsychic and non-relational), dimensions that cover and encompass the whole gamut of mental health and mental illness.This classification of relationships among human No-self ---------------------------------------------------------------------------------------------------------------  beings can be applied to individuals separate from couples, or to couples separate from families.We do not need separate and different tests or theories to understand separately individuals, couples, or families because in one way or anther these relationships can be understood in terms of these and other dimensions of the RCT models.This classification, of course, implies learning a completely new vocabulary that is based on models evaluated empirically in many different ways and found valid and reliable in observing and understanding mental health and mental illness on various dynamic continua or dimensions rather static categories.

Fig. 2 .
Fig. 2. Integration of Psychiatric Categories with Relational Dimensions and Expansion to Superior Functioning

-theoretical Assumptions about Relationships
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Applications of the Theory
Fig. 1.Summary of Relational Competence Theory www.intechopen.comfor instance, of Models Results from these studies tend to confirm the convergent, criterion, and construct validities of this instrument and, therefore, of the Model 11 underlying it.Current research(Cusinato & L'Abate, 2012)is validating a newer and more complete version of this instrument, as shown in Figure3.

Table 1 .
Means, Standard Deviation, and Internal Consistency of Profiles and Areas/Settings ** = p .01Table 2. Correlations between Profiles and Quality Areas www.intechopen.com

Table 3 .
Correlations between Profiles and Quality Areas

Table 4 .
Derivation of extreme and intermediate propensities in Selfhood

Selfhood Model 11 in mental health
Clinical and preventive applications of the Selfhood Model 11 are based on programmed distance writing occurring through computers and the Internet (L'Abate, 2011c, 2012; L'Abate & Sweeney, 2011) through replicable workbooks or programmed or interactive practice exercises (PIPEs).These exercises can be administered either as substitutes for or in addition to face-to-face talk in the promotion of mental and physical health, prevention of mental illness, or treatment and rehabilitation of mental illness.These PIPEs have been developed from a variety of sources, including research on anxiety, depression, Clusters B and C conditions, and from most dysfunctional conditions available in Axis I of the Diagnostic and Statistical Manual for Mental Illness-IV, including also factor analyses, single-and multiple score tests, such as the Beck Depression Inventory, and the Minnesota Multiphasic Personality Inventory, among many other tests and questionnaire This figure integrates most normative and non-normative PIPEs, regardless of theoretical orientation, gender, and educational level.