The author would like to express his appreciation to Joyce Catlett, M.A., associate and collaborative writer, who worked closely with me at every stage in the production of this book and added greatly to its intellectual background. I would like to thank Dr. Richard Seiden for his insights in the field of suicidology and his collaboration on two theoretical papers quoted in this work. I am grateful also to Dr. Jerome Nathan, Susan Short, M.A., and Lisa Firestone, M.A., who researched relevant material in the literature; to Anne Baker, Catherine Cagan, Eileen Tobe, and JoEllyn Barrington for their help in producing the final draft; and to Geoff Parr, who helped prepare the documentary film material referenced in this work.
Lastly, but most importantly, I want to acknowledge the Glendon Association, a large group of friends, former patients, and associates, who have employed me for the past ten years, contributed their support to the continuing investigations, and financed the production of documentary films and the dissemination of the many books and articles stating my theoretical views.
I thank them for their devotion to learning in the field of psychology, their personal quest for self-development and individual identity, and their openness and honesty in revealing their personal truths. Of even greater significance, I am appreciative to them for their ongoing participation in the study and growing body of knowledge about the voice process, fantasy bond, and other important concepts. Together they have created a unique psychological laboratory to investigate the psychopathology of everyday life in a normal or relatively healthy population. They have encouraged me to communicate my ideas to the professional community at large and have been strongly motivated to share their insights with others so that they may benefit from their experiences.
The names, places, and other identifying facts contained herein have been fictionalized and no similarity to any persons, living or dead, is intended. In the filmed material, names were not fictionalized, as individuals specifically requested that their names remain unchanged, and first names were retained.
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The author gratefully acknowledges permission to reprint the following:
from Steppenwolf, by Herman Hesse. English translation copyright 1919 by Holt, Rinehart and Winston, Inc. Reprinted by permission of Holt, Rinehart and Winston, Inc.
from “Dear Mom And Dad,” by David Breskin, Rolling Stone, November 8, 1984. Copyright 1984 by David A. Breskin. Reprinted by permission of David A. Breskin.
from Schizoid Phenomena Object-Relations and the Self, by Harry Guntrip. Copyright by Harry Guntrip. Reprinted by permission of International Universities Press, Inc., Mrs. B. Guntrip, and The Hogarth Press.
from The Divided Self: An Existential Study In Sanity And Madness, by R. D. Laing. Copyright 1969 by R.D. Laing. Reprinted by permission of Tavistock Publications Ltd.
from Will Therapy And Truth And Reality, by Otto Rank. Copyright © 1936, 1964 by Alfred Knopf, Inc. All rights reserved. Reprinted by permission of the Author’s Representative, Gunther Stuhlmann.
from “Toward a Theory of Thinking,” by David Rapaport, Organization and Pathology of Thought: Selected Sources, Translated by David Rapaport. Copyright 1951 Columbia University Press. Reprinted by permission of Columbia University Press.
from Definition of Suicide, by Edwin Shneidman. © Copyright 1985 by Edwin S. Shneidman. Reprinted by permission of John Wiley & Sons, Inc.
from “Individual and Mass Behavior in Extreme Situations,” by Bruno Bettelheim, Surviving and Other Essays, by Bruno Bettelheim. Copyright 1952, 1979 by Bruno Bettelheim and Trade Bettelheim as Trustees. Reprinted by permission of Alfred A. Knopf, Inc.
from Transactional Analysis in Psychotherapy by Eric Berne. Copyright 1961 by Eric Berne. Reprinted by permission of Random House, Inc.
from“The Ego and the Id,” by Sigmund Freud, from The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 19, translated and edited by James Strachey. Copyright The Institute of Psycho-Analysis. Reprinted by permission of Sigmund Freud Copyrights Ltd., The Institute of Psycho-Analysis, the Hogarth Press, and W. W. Norton, Inc.
from Self and Others, by R. D. Laing. Copyright 1961, 1969 by R. D. Laing. Reprinted by permission of Tavistock Publications, Ltd.
from “The Human Meaning Of Total Disaster: The Buffalo Creek Experience,” by Robert Jay Lifton and Eric Olson, Psychiatry, Vol. 39, February 1976. Copyright 1976 by The William Alanson White Psychiatric Foundation, Inc. Reprinted by permission of Psychiatry.
from Death Anxiety: The Loss Of The Self, by James B. McCarthy. Copyright 1980 by Gardner Press, Inc. Reprinted by permission of Gardner Press, Inc.
from Masochism in Modern Man by Theodor Reik. Copyright © 1941 by Theodor Reik. Reprinted by permission of Farrar, Straus and Giroux, Inc.
from Existential Psychotherapy by Irvin D. Yalom. Copyright ©1980 by Yalom Family Trust. Reprinted by permission of Basic Books, Inc., Publishers.
from Adolescence: The Farewell To Childhood, by Louise J. Kaplan, Ph.D. Copyright © 1984 by Louise J. Kaplan, Ph.D. Reprinted by permission of Simon & Schuster.
from “The Psychological Organization of Depression,” by Silvano Arieti, M.D., and Jules R. Bemporad, M.D., American Journal of Psychiatry, 137(11), 1360-1365 November 1980. Copyright 1980 by American Psychiatric Association. Reprinted by permission of the American Psychiatric Association.
from Cognitive Therapy Of Depression, by Aaron T. Beck, A. John Rush, Brian F. Shaw, and Gary Emery. Copyright 1979 by Aaron T. Beck, A. John Rush, Brian F. Shaw, and Gary Emery. Reprinted by permission of The Guilford Press.
from Attachment and Loss, Volume III: Loss, Sadness and Depression by John Bowlby. Copyright © 1980 by The Tavistock Institute of Human Relations. Reprinted by permission of Basic Books, Inc., Publishers.
from “Sigmund Freud On Suicide,” by Robert E. Litman, Essays in Self-Destruction, edited by E. S. Shneidman. Copyright 1967 by Jason Aronson, Inc. Reprinted by permission of Jason Aronson, Inc.
from Cognitive Therapy And The Emotional Disorders, by Aron T. Beck, M.D. Copyright 1976 by Aaron T. Beck, M.D. Reprinted by permission of International Universities Press, Inc.
from “Rational-Emotive Therapy,” by Albert Ellis in Current Psychotherapies, Second Edition, edited by R. J. Corsini. Copyright 1979 by F. E. Peacock Publishers, Inc. Reprinted by permission of F. E. Peacock Publishers, Inc.
from Effective Psychotherapy: The Contribution Of Hellmuth Kaiser, edited by Louis B. Fierman, M.D. Copyright © 1965 by The Free Press, a Division of Macmillan, Inc. Reprinted by permission of Macmillan Publishing Company.
from Theories of Counseling and Psychotherapy (3rd edition), by C. H. Patterson. Copyright 1980 by C. H. Patterson. Reprinted by permission of Harper & Row Publishers, Inc.
from The Denial Of Death, by Ernest Becker. Copyright © 1973 by The Free Press, a Division of Macmillan, Inc. Reprinted by permission of Macmillan Publishing Company.
from “Civilisation and Its Discontents,” by Sigmund Freud, from The Standard Edition of The Complete Psychological Works Of Sigmund Freud, Vol. 21, translated and edited by James Strachey. Copyright The Institute of Psycho-Analysis. Reprinted by permission of Sigmund Freud Copyrghts Ltd., The Institute of Psycho-Analysis, The Hogarth Press, and W. W. Norton, Inc.
from The Discovery Of Being, by Rollo May. Copyright 1983 by Rollo May. Reprinted by permission of W. W. Norton & Company, Inc.
from EQUUS, by Peter Shaffer. Copyright © 1973 by Peter Shaffer. Reprinted by permission of Atheneum Publishers.
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Note to Readers
Because of the awkwardness inherent in constructing sentences so as to avoid sexist language, the author has chosen to use the generic “he” at those times when “one” or “they” would have been cumbersome.
My life’s work as a psychotherapist has focused on the problem of resistance. In my study of people’s resistance to change, I have been deeply perplexed by a seemingly paradoxical phenomenon: the fact that most people consistently avoid or minimize experiences that are warm, successful, or constructive. I have observed that most of my patients tend to manipulate their environments in order to repeat painful past experiences and to avoid positive emotional interactions that would contradict their negative personal identity within the original family. I have been searching for an answer to the question of why most individuals, in spite of emotional catharsis, understanding, and intellectual insight, still hold on to familiar, destructive patterns of the past and refuse to change on a deep character level.
In our years of study, my colleagues and I observed clinical material that expanded our understanding of human self-destructiveness and its probable sources. Although I was not involved in the field of suicidology as a specific area of specialization, I could not help but apply this growing body of knowledge to the complex problem of suicide and suicide prevention. We were able to generalize from the myriad forms of partial or parasuicide to the extreme manifestations of suicidal individuals. As we addressed the problem of micro-suicidal symptomatology in our patients, we became increasingly involved in the mental or cognitive processes associated with self-destructive behavior.
All along, we were concerned with the stubborn resistance to changing a conception of self that was negative, self-critical, or self-accusatory. In our work with schizophrenia, it became increasingly clear that these seriously disturbed patients were involved in a process of idealizing their parents at their own expense. This tendency to preserve an image of the “good mother” together with an image of being the “bad child” was first elucidated by Arieti in one of his early works (1955). The child, who is so dependent on the mother for satisfaction of his needs and, indeed, for his very survival, must perceive her as being adequate and good. If not, the situation would be truly hopeless. The child then assumes that “if the parent is punitive and anxiety-arousing, it is not because she is malevolent but because he, the child, is bad” (p. 48). In that sense, the critical part of the adult patient’s defense system is an attempt to hold on to the parent by accepting the blame and seeing himself as unlovable. We have come to understand this concept in a broader and enlarged perspective that plays a very significant role in our understanding of psychopathology.
To illustrate, a patient recalled that when she approached adolescence, her father began beating her at night. At frequent intervals, he would come into her bedroom, wake her up, and physically abuse her. She said that at the time, she “knew” he was right in punishing her, that she must have done something to make him angry. The next morning, in spite of her innocence, she would invariably apologize to him for causing trouble and being a problem child.
If the patient had not assumed the blame for the beatings and instead had seen her father as being in the wrong, then she would have felt the full brunt of being in the hands of a highly disturbed, irrational, or even potentially murderous person who was out of control. It was the lesser of two evils for her to make his actions appear of rational character.
Working in Direct Analysis under the auspices of Dr. John N. Rosen, my associates and I challenged the idealization of the parent with schizophrenic patients. We noted that there was considerable resistance to changing both the idealized image of the parent and the negative image of self, and that the two processes were interrelated. In fact, when this idealization process was challenged directly in sessions where the patient was instructed to express negative ideas and critical comments about the parent image, there was a significant reduction in bizarre symptoms and thought disturbance.
Later, in our work with children ages ten to fourteen and with neurotic adults in a feeling release therapy, we were impressed that they possessed a deep-seated conviction that they were “bad.” When asked to make positive statements about themselves with feeling, strong primal emotions were induced, manifested by extreme sadness and sobbing. Statements such as “I’m not bad,” when taken seriously by the patient in an accepting atmosphere, were accompanied by powerfully painful emotions. Other positive statements, i.e., “I’m good,” or “I’m lovable,” brought out similar outbursts when expression of affect was encouraged. We concluded that this core of negative feeling toward self was an important dynamic in neurotic symptomatology and inimical life-styles and was the basis of resistance to therapeutic change. Indeed, separation from the negative conception of self appeared to be related symbolically to a break in the bond with one’s family and therefore tended to create separation anxiety. Even those individuals who were geographically separated or independent of parental ties were afraid, as though a basic change in self-concept would break important bonds or fantasies of connection with their parents.
Interestingly enough, when children are threatened with statements such as, “If you’re bad, you won’t get any presents,” or “You won’t be allowed to go with us,” they frequently cry painfully as though the punishment were a foregone conclusion, as though they were powerless to change. Many neurotic adults exhibit the same characteristics.
In my early work with shizophrenic patients and later in my office practice, I was progressing in my understanding of the dimensions of the self-destructive process, but important aspects were missing. My associates and I were very excited when we came upon several new developments in the early 1970s.
At that time I focused on the emotional pain that patients experienced when they were confronted with certain types of verbal feedback or information about themselves. They would have strong negative responses to selective aspects of this information and feel bad for long periods of time. Initially, I considered the old adage, “It’s the truth that hurts,” but then I realized that evaluations from others, regardless of accuracy, that support or validate a person’s distorted view of himself, tend to arouse an obsessive negative thought process.
From these observations, I discovered that most people judged and appraised themselves in ways that were extremely self-punishing and negative. Thus, their reactions to external criticism were usually out of proportion to content, severity, or manner of presentation. I thought it would be valuable for people to become aware of the areas and issues about which they were the most sensitive, so I began to study this phenomenon with my patients and associates. In 1973, we formed a therapy group, made up of a number of psychotherapists, to investigate this problem and pool our information. This group became the focal point for my ongoing study of the specific thought patterns associated with neurotic, repetitive behaviors and later with self-destructive actions and life-styles.
The participants focused on identifying the negative thoughts they had about themselves as well as discussing their reactions to feedback or criticism. Their observations corroborated my early hypotheses about a well-integrated pattern of negative thoughts, which I later termed the “voice.” When the therapists verbalized their negative thoughts out loud, they began by describing what they were telling themselves about their personal qualities and the events in their lives, such as “My voice is telling me that I’m not really competent,” or that “I’m a mean bastard,” or that “I’m going to be rejected,” or that “I’m no good.” Later they found it useful to separate out their voice attacks in the second person, and they sounded like: “You’re no good”; “You’re a phony”; “You’re incompetent.” They discovered that when they expressed their negative thoughts in this manner, the self-attacks were most easily identified and had a greater emotional impact. Often, deep feelings of compassion and sadness were aroused when an especially sensitive area was explored for the first time.
In my office practice, similar material was being uncovered as patients began to articulate their self-critical thoughts in the second person. At times patients displayed an animosity toward themselves that became very intense. I was shocked at first by the viciousness of these self-attacks and by the derisive tone of voice as my subjects gave words to their negative view of self. I was pained to see how divided people were within themselves and how insidiously they sabotaged their efforts to adapt and cope with their everyday lives.
It became evident that the self-attacks isolated by these individuals from both populations were only the tip of an iceberg in terms of the underlying anger and hostility toward the self. Clues began to emerge that pointed to the depth and pervasiveness of this thought process. For example, when the participants attempted to trace the cause of an erratic mood change to a precipitating event, they were able to uncover the pervasive self-attacks that controlled their lives. When these strong self-attacks were then expressed in the “voice,” or second person, there was generally a good deal of angry affect accompanying their expression. However, these dramatic emotional sessions were usually followed by an improvement in mood and a return of good feeling.
As various aspects of the voice were elicited in both populations, my thinking about the concept of the voice unfolded and evolved. In the process of searching for the probable sources of this antithetical voice process, my associates and I expanded our study of a variety of procedures that could be utilized to elicit the voice.
As we refined our techniques, and participants began to loosen their controls while vocalizing their inner thoughts, we learned that the expressions of intense anger against the self that had been noted in our earlier studies were not isolated occurrences. It became quite apparent that most people hated themselves with an intensity that surpassed by far anything they conciously thought they felt toward themselves.
As material of this nature accumulated, it became a logical extension of our work to study this voice process in more depressed patients and in patients who had a history of suicidal thoughts and attempted suicides. We explored the self-destructive thought patterns that appeared to influence their life-threatening behaviors and life-styles. When my colleagues and I interviewed depressed and/or suicidal individuals, we found that they were able to expose and identify the contents of their hostile way of thinking about self. Even though they had no previous knowledge of the concept of the “voice,” they generally related to the concept with ease and familiarity. We concluded that the thought process which we had observed in “normal” or neurotic individuals was essentially the same mechanism that leads to severe depressive states and self-destructive behavior.
This book is the outcome of several years of fruitful explorations into the dynamics of the “voice,” which we consider to be an unnatural overlay on the personality. The voice appears to be an integrated, systematized, cognitive process, interwoven with varying degrees of negative affect, that is capable of influencing a person’s behavior to the detriment of physical and mental health.
Our purpose in writing this book is to elucidate and demonstrate manifestations of the voice or alien point of view and thereby to advance our knowledge of suicide and other forms of human self-destructiveness. In proposing a correlation between the voice and self-destructive behavior, we will describe laboratory procedures (Voice Therapy) which have been used to elicit this hostile thought process, thereby bringing it more directly into consciousness.
In developing the concept of the voice, we have drawn upon findings of previous investigators to develop hypotheses which, on the one hand, are continuously and organically connected to prior formulations and, on the other hand, provide new insights. Our hypotheses are empirically based on experiences in a wide variety of settings, including hospitals, inpatient and outpatient clinics, individual and group psychotherapy, and population survey studies. Our population ranged from severely regressed schizophrenic patients to the average patient population encountered in private practice. It included colleagues and associates who participated in our preliminary investigations into manifestations of the “voice.” In addition, we have excerpted from interviews with a number of individuals who, having made serious suicide attempts, wished to share their experiences in the hope that others might benefit. While the pilot studies that we have undertaken to examine and analyze this destructive point of view are still in the early stages, we believe that continuing research will further clarify the close relationship between the voice and the self-destructive process.
Voice Therapy is essentially a laboratory procedure that can be utilized to elicit and identify a person’s negative thoughts and attitudes toward self, bringing them more into consciousness. Voice Therapy as a psychotherapeutic methodology is still in its early phases, yet the procedures have thus far proven to be effective in gaining access to patients’ core defenses and in facilitating changes in their maladaptive behaviors.
In developing preliminary hypotheses about the voice and procedures to isolate the self-destructive patterns of thought, the author has had many opportunities to observe this process in a wide range of patients and volunteer subjects. As described earlier, my associates and I have been investigating the various dimensions of the voice in group sessions for many years. In addition, Voice Therapy procedures have been utilized as part of a multidimensional approach to individual psychotherapy.
In the following pages, we will describe the techniques of Voice Therapy and discuss clinical material derived from voice therapy sessions. We will analyze significant findings and illustrate the type of resistance encountered in the therapeutic process. In the next chapter, Voice Therapy as a treatment for emotional and mental illness will be evaluated on its own merits, and we will compare and contrast our technique and theory with important cognitive approaches.
The process of identifying the voice can be approached intellectually as a primarily cognitive technique or approached more dramatically using cathartic methods. In the former procedure, the patient attempts to identify and analyze self-criticisms and self-attacks and learns to restate negative thought patterns in the second person as “voices” experienced from the outside. In the latter technique, there is an emphasis on the release of the affect accompanying the voice attacks on the self. In this abreactive method, the patient is asked to amplify his self-attacks and express them more emotionally, with instructions to: “Say it louder,” “Really feel that,” or “Let go and blurt out anything that comes to mind.” In our early studies, patients and subjects frequently adopted this style of expression of their own volition. When asked to formulate their negative thoughts in the second person, they spontaneously began to speak louder and with more intensity of feeling. The participants revealed the patterns of derogatory self-accusations that held special meaning for them. Utilizing this method, much information spilled out, along with a powerful emotional release. For this reason, we began to focus on the cathartic method.
As we described earlier, we were surprised and concerned at the intense anger and sadness expressed by patients and subjects in our initial investigations. Intensely painful feelings were aroused as people learned to articulate their self-attacks and distorted views of self. The powerful feelings of self-loathing and anger against self that quickly emerged during these early sessions gave us an indication of the depth and pervasiveness of the voice process in the personality.
Lastly, in discussing the abreactive method, it is of major importance to note that as an individual released powerful feelings of sadness and rage, he expressed clear insights into the source of these self-attacks, without assistance or interference from the therapist. The participants became aware of the specific nature of their self-attacks and the extent of their self-destructive consequences.
I. Identifying the contents of the patient’s negative thought process is the first step in a three-step procedure in which patient and therapist collaborate in understanding the patient’s distorted ways of thinking. Articulating the self-attacks in the second person facilitates the process of separating the patient’s own point of view from the hostile thought patterns that make up an alien point of view toward self. Prior to actually articulating the voice, most patients generally accepted their negative thoughts as true evaluations of themselves and implicitly believed them. These critical attitudes had been part of their identity since early childhood. However, with continued participation, our patients and subjects found that they were better able to distinguish their own viewpoints from introjected parental views and distortions. We found this to be evident when utilizing analytic approaches to the voice, as well as abreactive methods.
To illustrate the first step, a twenty-five-year-old male subject verbalized his voice about his relationship to women in a group session:1
You are so disgusting. You are so low. You’re beneath a woman. No woman could ever feel anything for you. What makes you think a woman could be attracted to you?
You have no features that could be attractive to a woman. You’re ugly. You’re short. You’re small. You’re just not an at-tractive-looking person.
In this example, note that the subject brought out his hostile selfattacks in the second person. Later in the same session, he expressed considerable anger at being limited by this destructive form of thinking about himself.
II. In the second step, patients discuss their spontaneous insights and analyze their reactions to verbalizing the voice. Then they attempt to understand the relationship between their voice attacks and their self-destructive behavior patterns. They subsequently develop insight into the limitations that they impose on themselves in everyday life functions. Incidentally, becoming aware of one’s self-imposed restrictions reduces paranoid reactions to others and feelings of being victimized.
Here, the same subject discusses his reactions to the self-attacks he had just verbalized:
Immediately after I finished saying my voice, I had another quick thought, a voice that said:
“Okay, so now you’ve said your voice, but what difference is it going to make in your life? It isn’t going to change anything.”
I didn’t really go with that feeling. I realized what it was—that it was a voice attacking what I’d just said, and I didn’t think it was a real point. But I did notice how quickly it came up, trying to invalidate everything I’d just said.
I also realized that since the session last week, I’ve generally felt better. I felt like taking more positive steps in my life, and it always seems like when I feel that way, positive things tend to happen. I had more to do with girls, and I felt I was making more friends in general. I just felt more alive overall.
III. Thirdly, the therapist asks the patient to formulate an answer to the voice. In the analytic approach, the patient is asked to respond with a more realistic, objective self-appraisal. In the cathartic method, patients are encouraged to talk back to the voice and challenge it directly as though they were addressing an actual person. Since people tend to identify the voice in relation to parental figures early on, many times they end up talking back directly to their parents in a form of psychodrama.
In the following segment, the same subject articulated his response to the voice attacks concerning his feelings about women. In the course of separating and strengthening his own point of view, he clearly differentiates between his view and that of his parents. It is important to note that the subject responded to his voice with considerable forcefulness, mobilizing deep feelings of anger and sadness as he answered back:
“I’m not that way. I’m not that person you’re talking about. I care a lot for women.”
Another thought that comes to mind, “I’m not like you! [Loud] I’ve got some feelings. I care! I want something. You never wanted anything. [Mournful] I want something in my life.” [Angry]
Responding to one’s self-attacks or “answering the voice” is not the same as an actual confrontation with one’s parents, with real consequences in interpersonal relationships. It avoids some of the problems, guilt, and responsibilities involved in challenging one’s parents directly; however, expressing one’s point of view is an attack on the introjected parental images and, as such, can still cause considerable anxiety and guilt reactions.
In conclusion, when patients utilize the more dramatic style of giving utterance to their voices and answering back, they usually experience strong feelings similar to the emotions experienced by patients in Feeling Release Therapy. The result is a powerful emotional catharsis, with accompanying insight and understanding.
Our subjects tend to “answer back” to their voice attacks spontaneously. They sense the need to reaffirm their own individual points of view after articulating hostile, destructive attitudes and feelings toward themselves. Answering the voice is beneficial for those patients who display sufficient ego strength to cope with the anxiety created by disrupting basic defenses, but is not necessary as part of the overall procedures. Indeed, dramatic methods are specifically contraindicated for patients with weak egos or marginal adjustments, unless applied with considerable care and therapeutic expertise. We will discuss this issue in more depth when we delineate the specific advantages and problems involved in Voice Therapy in the next chapter.
Most patients easily acquire the technique of verbalizing their self-attacks; however, this should not be interpreted to mean that the procedure is necessarily a form of short-term or brief psychotherapy. To the contrary, Voice Therapy is generally, although not exclusively, a long-term dynamic methodology because it attempts to cope with major character defenses. Voice Therapy procedures draw immediate attention to core issues of the patient’s personality structure. For this reason, the application of these techniques should be undertaken with sensitivity and considerable attention to patient selection.
The procedures of Voice Therapy elucidate the basic split in patients’ thinking and feeling about themselves and their fundamental ambivalence about people and events. The goal of Voice Therapy is effectively to separate out those elements of the personality that are antithetical toward the person, that affect him adversely, and that support the compulsion to repeat deleterious patterns of the past. Voice Therapy increases the patient’s awareness of the self-destructive internal dialogue and of the particular events, circumstances, and situations that are likely to activate self-attacks. Most importantly, in exposing these self-attacks, the voice comes more under the patient’s control, and he gradually moves toward behavioral choices that are in the direction of his stated goals.
Since the procedures of Voice Therapy challenge core defenses and one’s basic self-concept, the process of initiating behavioral changes that expand one’s boundaries and expose misconceptions about oneself are a vital part of our overall treatment. Collaborative interventions that effect changes in an individual’s behavior in his everyday life functions are a necessary part of any effective therapeutic procedure. The author believes that the potential for therapeutic progress is not merely a function of identifying negative thought patterns and uncovering repressed material; indeed, personal growth ultimately must involve constructive behavioral changes that oppose self-limiting or self-destructive patterns and life-styles.
Our corrective experiences2 bear a direct relationship to the maladaptive behavior patterns that are influenced and controlled by the patient’s negative cognitive processes. In analytic discussions, the therapist and patient identify the specific behaviors regulated by the voice that are self-destructive and constricting, and both participate in formulating ideas about altering routine responses and habitual patterns of behavior. Corrective suggestions are arrived at through a collaborative effort and are in accord with patients’ personal goals and ambitions. They specifically apply to those problem areas that the patient wishes to correct or improve.
Initiating changes that help to alter or control the patient’s self-nourishing, addictive habit patterns; that disrupt destructive bonds; that attempt to overcome fears; that control provoking, withholding responses; and that lead to a more positive self-image are included in our overall treatment strategy. Until patients learn to take definitive actions that are in opposition to the prohibitions of the voice, they tend to repeat early patterns of maladaptive behavior and continue to live in a narrow range with significant limitations.
Corrective suggestions act as a catalyst to help patients approach new, unfamiliar, or open-ended situations where they will be more vulnerable and less defended. In general, our patients and subjects have shown considerable insight and sensitivity into their resistance about moving toward positive experiences and an expanded world. They recognize their stubbornness about changing habitual responses even when they are known to be maladaptive and self-defeating.
Corrective suggestions, if consistently followed, bring about changes in the emotional atmosphere and often lead to a corrective emotional experience. For example, patients whose style of relating offended their friends, mates, or associates and who characteristically provoked angry responses will make a concerted effort to control their noxious behavior. Once they stop manipulating the interpersonal environment in this manner, they generate a new set of circumstances. This, in turn, creates an unfamiliar, albeit more positive, emotional climate.
Perhaps the most simple and straightforward examples of the use of corrective suggestions are those that are instituted in relation to substance abuse. It is apparent that most self-nourishing habits are directly related to the neurotic process of symbolically gratifying oral needs. Continued substance abuse numbs the patient’s feelings of emotional pain and anxiety; however, these addictions also keep him insulated from positive as well as negative experiences. Until patients give up their self-feeding habit patterns, they will continue to maintain a false sense of security and an illusion of self-sufficiency that severely impairs their competency in the interpersonal world. Suggestions to stop addictive behaviors leave patients vulnerable to painful feelings they have been suppressing for years. As they give up a particular habit they have used as a painkiller, they expand their lives and move toward a healthier overall adjustment.
The therapist, in introducing the idea of corrective experiences into the therapeutic alliance, must pay special attention to the proper timing of suggestions. Careful follow-up is needed of the patient’s reactions, including the identification of intensified voice attacks, which are generally activated by the patient’s move toward expressing his individuality. This is especially evident in marital therapy when, for example, one partner begins to relinquish withholding patterns or excessively dependent or submissive behavior as a result of carrying out therapeutic suggestions. In these cases, the partner who is initiating changes may face increased self-attacks, as well as punitive responses from his mate that support his voice. Corrective suggestions in marital therapy challenge the false security of the fantasy bond. Both partners progressively adapt to a growing independence and sense of separateness and at the same time learn to develop greater tolerance for genuine love and friendship without reverting to parent/child modes of relating.
By disrupting dependency bonds and breaking down defenses that have protected the patient against emotional pain and anxiety, corrective suggestions effectively move patients to a new level of vulnerability and openness. If they are able to withstand the strong voice attacks that are activated by their movement toward positive goals, progress will be maintained. Indeed, patients report that their self-attacks gradually diminish after they have maintained the new behavior over an extended period of time without regressing to old habit patterns.
The importance of “sweating out” important changes in one’s style of relating and thereby holding on to the psychological territory gained by patients at each new level cannot be overemphasized. Only through a willingness to risk living without one’s customary defenses, routines, deadening habit patterns, and bonds can one learn that survival is possible without these psychological crutches. In this sense, corrective suggestions teach patients, on a deep emotional level, that by using self-discipline, they can gradually increase their freedom of choice without being overwhelmed by primitive fears and anxiety states. They learn that the anticipatory anxiety involved in following through on a corrective suggestion is often more intense than the actual emotional response to the action of changing one’s behavior. They learn that if they are persistent about their resolve, they will accommodate to the new circumstances, and there will be therapeutic movement. However, if they submit to their voices and retreat, they tend to remain fixated at a lower level of development, and therapeutic progress is attenuated or may be halted altogether.
Corrective suggestions are very valuable at crucial points in the therapy process and may be applied as follows: (1) the patient formulates his personal goals, thereby establishing his priorities and underscoring his life’s purpose and sense of meaning; (2) he plans, with the therapist, corrective experiences that support these goals and that are opposed to the dictates of the voice; (3) there is movement toward risk situations, openness, and a new level of vulnerability; and, finally, (4) the patient learns to tolerate the anxiety of positive change and is able to expand his life space.
In summary, corrective suggestions function to challenge the voice and attempt to alter the patient’s self-destructive or nonfunctional behavior outside the office setting. They assist the patient in his initial efforts to develop a greater tolerance for “a better life.” Patients learn gradually to accommodate to the anxiety, guilt reactions, and voice attacks aroused by the process of individuating themselves and adopting a strong, goal-directed point of view.
The first two case studies illustrate the analytic method of isolating and identifying hidden patterns of thinking that were related to each patient’s presenting problem and symptomatology. We will describe the development of insights achieved by these individuals over the course of their therapy, as well as the constructive behavioral changes they instituted as a result of these insights. In the course of our case descriptions, we will describe the crucial points at which the patient’s resistance came into play and the form that the resistance took.
Dave was referred to me for therapy by a colleague who had become intimidated by his paranoid ideation and rage. My associate, who had seen the patient’s family in family therapy, had told me: “Dave is one of the strangest individuals I’ve ever met, and his parents are among the most rejecting parents I’ve ever worked with.”
Dave’s disturbance consisted of a well developed system of paranoia, an orientation of deep distrust and cynicism toward other people that was extremely difficult to challenge. For example, the patient was particularly paranoid in relation to his boss, obsessively worrying that he would be fired or that his performance would be severely criticized. His negative anticipations created real problems in relating and acted as a self-fulfilling prophecy. His irrational fears also extended to imagining impending assault by strangers; he would cross the street to avoid walking past a group of adolescent boys, because he was afraid they might physically attack him.
Dave lived on two distinct levels: on one level he thought logically and coherently; on another level, he had bizarre thoughts, usually accompanied by intense anger. He spoke in words that painted vivid pictures for his listener, yet his communications were often hopelessly tangled expressions of the two levels on which he thought. Indeed, it was often difficult to determine if Dave’s words or his emotions came out the way he had intended. When he spoke, his eyes sometimes teared up, revealing the presence of his regressed child-self, continually under attack from his introjected parental voices.
One of the major reasons Dave sought therapy was because he and his wife were thinking of having a child, and the thought filled him with dread. The couple had no close friends, and Dave was deeply concerned about the effect that his social isolation would have on a child. His Scroogelike tightness and lack of warmth typically caused people to avoid him or dislike him. These factors contributed significantly to his isolation. He complained strenuously about having no memory of his childhood prior to adolescence and expressed a desire to recover these memories through therapy.
Dave not only held paranoid and distrustful attitudes toward others, he also felt extremely self-critical and self-hating. He graphically described his voice as follows: “A demon sits on my shoulder, constantly ridiculing me.” Dave was fully aware of what this “demon” was saying to him:
You little creep, you’re too stupid to have a child. Look, you’re even too stupid to do a good job at work. Sooner or later, you’re going to make a terrible mistake; then all your fancy ideas of success will come crashing down on your head. And you’ll deserve everything you get, you miserable shit!
Dave’s voice, while not an actual auditory hallucination, nevertheless approached the level of an external sensation in the sense that it interrupted and almost drowned out his rational thoughts.
During the first phase of therapy, Dave’s hostility and paranoia focused on his distrust of the therapist. Early in the course of treatment, he developed strong negative transference feelings. Although he had sought my help and trusted me to a certain extent, on another level he was deeply cynical, and his behavior was very unpleasant and provoking in his sessions. His resistance in therapy took the form of guarded, vague ramblings and a seeming unwillingness and fearfulness about bringing out his attacks on me directly. He also refused to verbalize them as “voices.” Despite the fact that he readily expressed his self-critical thoughts and feelings, he stubbornly played “dumb” about revealing his external anger. Instead, he tended to blurt out angry questions: “Why are you looking at me like that?” or “What did you mean by that last statement?” Eventually Dave learned to put his suspicions and hostile thoughts in terms of a voice directed against the therapist:
Look, Davie, this man is going to influence you in the wrong direction. He’s going to sit you down and reeducate you and you’ll have no opinions of your own after he’s through with you. You can’t trust him, you’d better listen to me, Davie, if you know what’s good for you. You were always a gullible, stupid kid.
At other times, Dave’s “voice,” which he identified as sounding very much like his father, questioned my character and qualifications as a therapist:
This man is out to get your money. What does he know about people? You think he’s read all these books on his shelves? For all you know he’s a quack, a fake. If he’s so darn good, why isn’t he more well-known?
After approximately 2 years of therapy, Dave began to develop positive feelings that intruded on his paranoid distortions. At this point, he became fearful of being separated from me for a 3-week vacation period. His fear was compounded by the fact that he was planning to undergo minor surgery during my absence. In our last session before the vacation, Dave verbalized these fears in the form of a voice:
See, Davie, now you’re hooked. Take that man, for instance. What right does he have to go away? [sad] He’s always been around, so now he’s going to go away. He knows you’re going to have that operation, that’s just when you need him.
What do you mean you’re just scared? Of course, you’re scared, you need somebody to take care of you. That’s what you’re paying him for, isn’t it?
Much later in therapy, when Dave started his own business, his cynical, judgmental voice about other people was translated into belittling, sarcastic one-liners aimed at his employees. He noticed that by berating others, he sometimes was able to reduce the voice attacks “in his own head”; on the other hand, he hated himself for mistreating the people in his office.
As Dave slowly and painstakingly isolated his distorted attitudes toward other people and controlled his tendency verbally to abuse his employees, he began to break down his fundamental resistance to changing deep-seated character defenses. Both Dave and I thought it would be valuable at this juncture to challenge his characteristic tightness and lack of generosity, so together we discussed a number of possible corrective suggestions in the form of bonuses to his employees and simple acts of generosity toward his friends.
Initially, Dave was afraid and reported a number of voices telling him that he was a sucker. Later, he found that these actions gave him pleasure and led to friendly responses from others. He discovered that his acts of generosity surprisingly enough acted to dispel his deep-seated fear of being exploited. Dave reported this period as being the “happiest time in my life.”
The fact that people responded favorably to the results of Dave’s corrective experience, as they often do to corrective suggestions, moved him beyond the limitations he had previously imposed on himself. He then had to cope with the anxiety aroused by disturbing his “psychological equilibrium.” He had to adjust to the feeling of closeness and increased sense of vulnerability brought about by these unfamiliar positive experiences.
Dave eventually was able to work through basic paranoid beliefs that had been a fundamental part of his resistance. Much later, when he made the decision actually to have a child, his voice escalated its attacks on him and his wife:
You won’t know what to do with a baby. You certainly won’t know how to talk to a kid. What an incompetent, lousy father you’re going to be!
Look at this woman. She’s got you where she wants you now. I’ve always told you that women were tricky, that they’d swallow you up. Once you make a commitment like this, you’re going to have to be devoted to her and the kid for the rest of your life.
In summary, it required several years of psychotherapy for Dave to separate out his paranoid distortions from his more rational ways of thinking. Interestingly enough, throughout the long therapy process, Dave did not substantially recover memories of his childhood. However, following the birth of his son, he recalled an incident that had occurred when he was a young teenager, a humiliating experience that he had repressed for years. He remembered his father severely berating and chastising a high-school friend of his in a style very similar to the way he had mistreated Dave. His outraged feeling for his friend prevailed, whereas he could not feel directly for himself.