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Selena is a precocious five-year old girl who could not stop sucking her fingers. Her teeth were beginning to protrude. Because she still believes in Santa Claus and the Tooth Fairy, I was positive that she would be very susceptible to hypnosis.
I asked Selena to “move to the magic chair where kids stop sucking their fingers .” Then , at my request, she named each finger. She responded with, “Bunny Rabbit,” “Robin” and other similar titles. I directed her to ask each finger if it liked being sucked. She said, “No.” Then , I asked her to find out what her fingers would rather do instead. After some conversation with her fingers, she told me they would rather play dolls, jump rope and do puzzles.
l suggested, “Let’s see how we can give those fingers more time to play.” With proper ceremony, I showed Selena my “magic wand.” I then asked her to “… think of a magic word that will keep you from sucking your fingers.” With delight, she squealed , “Poof!”
Next, I asked Selena to put each finger in her mouth. “But,” I cautioned her, “before you put your fingers in your mouth, say ‘Poof!’ And I will wave my magic wand.” We repeated this pleasant little ritual with each finger.
Then, I told her she could do that all by herself after she left my office.
The following week, Selena and her mother reported that Selena did not suck her fingers all week except for one short moment as Selena was leaving my office. The mother then mentioned, almost in passing, that she would ask me to help Selena overcome her bedwetting, but she knew Selena was not yet ready to stop that behavior. I began to talk to Selena, reinforcing the previous week’s process, but it seemed not to have any energy left in it. Then I told Selena, “I don’t want you to stop wetting the bed yet. But you will be ready very soon. So let’s do some things for when you are ready. OK? Can we do the same magic for the part of you that wets the bed?”
Selena agreed. I told her I would wave my magic wand and asked her what she would do. She replied that she “would dive, like this.” She stood and did a full body dive onto the couch. As she hit the couch she said, “POOF!”
Selena did several more dives on the couch and then progressed to crawling all over the floor saying she “was swimming like in the Olympics.” I gave her an “Olympic medal ” (a sticker) and told her that the medal was for “all the dry ‘Pull Ups’ you will have now.” A week later, I phoned the mother for a “follow-up.” She reported Selena had not sucked her fingers since the day of our first session and had not wet the bed since our second.Discussion by William Keydel, M.A.
Magical … and fun. This wonderful case illustrates three principles which are at the heart of Ericksonian psychotherapy. First and foremost is the acceptance and honoring of the client’s way of viewing the world. Dr. Williams begins by utilizing the preschooler’s belief in magic to set the stage for change. She deepens Selena’s natural imagery by asking her to name her fingers and creating the imaginary friends so common to children’s play. It is then these friends of Selena’s unconscious who provide motivation for change with reasons meaningful to the child and not even necessary for Williams to know. Williams also evokes Selena’s natural energy and excitement by allowing her to come up with the magical words and acts that would extinguish unwanted behaviors. In these ways, Williams has entered Selena’s world to stimulate change from within.
The second principle which stands out is the interruption of existing patterns through strategic interventions. The beauty of Erickson’s work stemmed from his ability to see the individual’s patterns and his creative responses to those patterns generating change with a minimal amount of effort. By having Selena say, “Poof!” as she put each finger up to her mouth , Williams introduced a change in the old pattern. Then this became a new pattern, reinforced by practice with each finger, and further reinforced by the excitement of creating magic on her own. In this case, it’s easy to imagine that Selena experienced no effort as the strategic intervention created its own reward. Similarly, Selena’s patterns for approaching bedtime were changed with her full-body dives which naturally utilized the playful energy of a child.
The third principle to be honored in William’s handling of the case, is the willingness to let go of theories and “treatment plans” and respond to the client. As Erickson is quoted by Gindhart, “Too many psychotherapists try to plan what they will do instead of waiting to see what the stimulus they receive is, and then letting their unconscious mind respond to that stimulus” (p. 120). While reinforcement is generally good work, Williams responded to her client’s “energy ” and appropriately moved on. Throughout her work with Selena, Williams demonstrates the elegance of responding to her client and thereby allowing Selena, in a general way, to structure therapy in accordance with her needs.
I could have focused on Williams’ effective use of permissive therapy and embedded commands; or my focus could have fallen on the value of using a naturalistic trance to avoid the awkwardness a formal trance induction is likely to have on a child. But, as Richard Dimond points out in “Trials and Tribulations of Becoming an Ericksonian Psychotherapist,” (Zeig, 1985), Ericksonian psychotherapy requires more than learning Erickson’s techniques. There are fundamental principles about entering in and trusting the unconscious system of the child across from us.
Dimond, R. (1985). “Trials and Tribulations of Becoming an Ericksonian Psychotherapist.” In Zeig (Ed.), Ericksonian Psychotherapy, Vol. 1: Structures. NY: Brunner/Mazel
Gindhart, L. (1985). “Hypnotic Psychotherapy.” In J. Zeig (Ed.), Ericksonian Psychotherapy, Vol. 1: Structures. NY: Brunner/ Mazel
Our life is what our thoughts make it. ~ Marcus Aurelius, Meditations
The critical inner voice is made up of a series of negative thoughts and attitudes toward self and others, which is at the core of a person’s maladaptive behavior. It can be conceptualized as the language of a defensive process that is both hostile and cynical. The voice is not limited to cognitions, attitudes, and beliefs; it is also closely associated with varying degrees of anger, sadness, shame, and other primary emotions. It can be thought of as an overlay on the personality that is not natural or harmonious, but rather learned or externally imposed.
The voice is a form of internal communication – usually critical, yet sometimes self-nurturing and self-aggrandizing, but in either case opposed to one’s self interest. It is experienced as though one were being spoken to. It includes attacks such as, “You’re so stupid!” “You’re a failure!” “No one could ever love you.” “You can’t trust anyone.” “They don’t appreciate you.”
Critical inner voices are often experienced as a running commentary that interprets interactions and events in ways that cause a good deal of pain and distress. The voice defines situations in alarming and pessimistic terms. It is analogous to a lens or filter that casts a gloomy light on the world which, in turn, has a profound negative effect on one’s mood and feelings.
The critical inner voice can be distinguished from a conscience or constructive moral influence because it interprets moral standards and value systems in an authoritarian manner, in the form of strict “should,” that leads to harsh criticism and self-recrimination. It increases one’s self-hatred, rather than motivating one to alter behavior in a constructive manner. Seemingly positive, self-nurturing voices that appear on the surface to be supportive, can be hurtful, misleading, and dysfunctional. Self-aggrandizing voices encourage an unrealistic build-up that sets the stage later for attacks on the self.
The voice not only serves the function of attacking the self; it is also directed toward others. These oppositional viewpoints are symptomatic of the deep division that exists within all of us. Sometimes people view their loved ones with compassion and affection, but other times they think of them in cynical or disparaging terms.
Voice attacks are sometimes consciously experienced, but more often than not, one experiences them partially conscious or even totally unconscious. In general, people are largely unaware of the extent of their self-attacks, and the degree to which their behavior is influenced or controlled by the voice.
Critical inner voices vary in intensity along a continuum, ranging from mild self-reproach to strong self-accusations and suicidal ideation. They precipitate a wide range of self-limiting, self-destructive actions, from giving up on goals, to physically hurting oneself, or even committing suicide. In a very real sense, what people tell themselves about events and occurrences in their lives is more damaging and contributes to more misery than the negative episodes themselves.Early Investigations into the Critical Inner Voice
In early investigations of the voice, participants in our pilot study attempted to express self-attacks in a rational, cognitive manner and tone. They articulated self critical thoughts in the first person, as “I” statements about themselves. For example: “I am so stupid.”; “I can never get along with people.”; “I am no good.” Etc. So I suggested that they verbalize these same thoughts as statements spoken to them in the second person, “you” statements, such as, “You are so stupid.” “You never get along with anyone.” “You are no good.” When the participants complied with this new method, I was shocked by the malicious tone of their self-attacks, and the intensity of the anger with which they condemned themselves. It was surprising to observe even mild-mannered, reasonable individuals being so intensely self punishing and cruel.
The second-person dialogue technique is what brought these powerful emotions to the surface. The participants were able to separate their own viewpoint from the internalized negative parental view of themselves that has been superimposed on their self-image. In addition, the emotional release that accompanied the expression of the voice uncovered core dysfunctional beliefs and brought about a more positive feeling and compassionate attitude toward self and others.The Development of the Self System and Anti-Self System
As children develop expressive language and verbal skills, they attempt to give meaning to, or make sense of, the primal emotions they have internalized (Tronick & Beeghly, 2011). They apply negative labels and specific verbal attacks to themselves, based on their interpretation of painful interactions they experienced early in life. This internalized voice becomes a fixed part of the child’s core identity and labeling his or herself, even though initially there was no essential validity to the label. As children continue to grow and develop, they refine and elaborate on their self-critical attitudes and thoughts, and apply new labels to themselves. These destructive attitudes or voices form a distinct and separate aspect of the personality that I have termed the “anti-self system.”
The anti-self system is composed of an accumulation of these internalized destructive thoughts, attitudes, and feelings directed toward the self. When children are confronted with hurtful experiences in the family, they tend to absolve their parents or other family members from blame, and take on the attitude that they themselves are bad, unlovable, or a burden. Gradually, personal trauma and separation anxiety combine to turn children against themselves. The anti-self can be characterized as the “enemy within.” (Firestone, 2018)
In contrast, the self system is made up of one’s biological temperament, genetic predisposition, parents’ admirable qualities, and the ongoing effects of experience and education. Parents’ lively attitudes, positive values, and active pursuit of life are easily assimilated through the process of identification and imitation, and become part of the child’s developing personality. In addition, the self system represents a person’s wants, desires and goals, and his/her individual manner of seeking fulfillment. Throughout life, these two systems become well-established and are in direct conflict. How this conflict is resolved over time powerfully affects the course of the individual’s life and his or her happiness or unhappiness.
To summarize, the voice consists of: (1) the internalization or introjection of destructive attitudes toward the child held by parents and other significant adults in the early environment; (2) a largely unconscious imitation of one or both parents’ maladaptive defenses and views about life; and (3) a defensive approach to life, based on emotional pain experienced during the formative years. The greater the degree of trauma experienced in childhood, the more intense one’s voice attacks become.Voice Therapy
Voice therapy is a cognitive/affective/behavioral methodology that brings internalized destructive thought processes to the surface with accompanying affect, in a dialogue format that allows a client to confront alien components of the personality. The method involves expressing one’s self-attacks and the accompanying feelings, developing insight into their causality, answering back to self-attacks from one’s own point of view, and collaboratively planning strategies with the therapist to counter specific voice attacks.
With its focus on emotions and on the expression of deep feelings, voice therapy differs significantly from other cognitive-behavioral models. The methods are aligned with certain aspects of emotion-focused therapy (EFT), which primarily concentrates on eliciting emotion by directing clients to amplify their self-critical statements (Greenberg et. al., 1993). Voice therapy is also more deeply rooted in psychoanalytic/ psychodynamic approaches than it is in a cognitive-behavioral model.
In conclusion, the purpose of voice therapy is to help individuals achieve a free and independent existence, remain open to experience and feelings, and maintain the ability to respond appropriately to both positive and negative events in their lives. The process of identifying the voice and its associated affect, combined with corrective strategies of behavioral change, significantly expand the client’s boundaries and bring about a more positive sense of self.References
Firestone, R.W. (2018) The enemy within: Separation theory and voice therapy. Phoenix. AZ: Zeig, Tucker, & Theisen, Inc. Publishers.
Greenberg, L. S., Rice, L. N., & Elliott, R. (1993). Facilitating emotional change: The moment-by-moment process. New York: Guilford Press.
Tronick, E., & Beeghly, M. (2011). Infants’ meaning-making and the development of mental health problems. American Psychologist, 66(2), 107-119. http://dx.doi.org/10.1037/a0021631
People who are hit with panic attacks have a common response. They feel compelled to fight the symptoms with all their available resources. They brace for the fight as they approach any feared situation. And if they predict this on-guard approach will fail, they avoid entering the scene as the only way they can guarantee their safety. But this resistance and avoidance comes with a price: a restricted lifestyle, anxious hypervigilance and often depression.
Over the past three decades, specialists in the treatment of panic disorder have helped their clients move from a commitment to resist their symptoms to one of acceptance. By allowing the racing heart and spinning head and wobbly legs to continue in a permissive mental environment, clients discover that they don’t actually have a heart attack, go crazy or faint. As they adopt this new permissive attitude – “It’s OK to be anxious here.” “I can handle these symptoms.” “I’m willing for people to notice my nervousness.” – then each panic attack runs a more limited course with far less intensity.
While this permissive approach has been standard, there also has been a secondary approach to treatment: to voluntarily, purposely seek to increase the uncomfortable physical symptoms. This paradoxical approach, dating back at least to Dr. Victor Frankl’s logotherapy, is now set to take center stage. The chief reason is a pragmatic one: the more provocative treatment is the briefest of treatments.
This winter, the Anxiety Disorders Association of America will release Facing Panic: Self-help for People with Panic Attacks. This guide is a synthesis of the work of this field’s foremost clinician-researchers. Here is the central therapeutic strategy, expressed as five instructions to the reader:
Get anxious on purpose. Once you are anxious, encourage the symptoms to continue for a long time. During this time, stop worrying and start supporting yourself. Let go of your safety crutches. Do this over and over again, in all your fearful situations.
Let’s look at each of the five directives:
Get anxious on purpose. The key here is not just to become anxious, but to purposely choose to get anxious. It is the seeking of the anxiety state that distinguishes this step from the more common approach of tolerating or putting up with the symptoms. It is a shift in one’s relationship toward anxiety, and it is a critical distinction. “Having” anxiety is insufficient; “wanting” anxiety is the central goal.
Once you are anxious, encourage the symptoms to continue for a long time. Here is an extension of the first step: invite your distress to stay around as long as possible. Try to keep it. If it subsides, feel disappointed, and look for ways to bring it back. We know from our studies of flooding that prolonged exposure leads to habituation. But this only occurs if the person drops his guard and allows the anxiety to exist during that time. I am proposing that we challenge the foundation of this flooding protocol. We can greatly shorten the required length of exposure if we emphasize the person’s therapeutic stance: first, to seek out the uncomfortable symptoms, and then, to consciously desire for them to remain for as long as possible.
During this time, stop worrying and start supporting yourself. While we encourage clients to feel scared and to feel the uncomfortable physical sensation of panic, we discourage worried thoughts (there is an appropriate therapeutic time to encourage worried thoughts, too, but I won’t cover that in this brief article.). We are battling two fronts here. First, panic sufferers will worry about just how uncomfortable the symptoms will feel. But, more importantly, they will worry about the catastrophic outcomes: fainting, having a heart attack, making a fool of themselves. We want them to learn, through specific exercises, that the panic attack will be uncomfortable but not horrible. Once they can downgrade their interpretation of the symptoms, then they can accept their symptoms instead of fear them. This stance is reflected in such supportive statements as, “I’m scared, and I’m safe.”
Let go of your safety crutches. Safety crutches are actions that help prevent or mute the symptoms of panic. We have identified over seventy behaviors, such as carrying an anti-anxiety medication in their pocket, practicing breathing skills, monitoring their pulse rate, sitting close to an exit, leaning against a wall, staying somewhere only briefly, turning the radio up, never passing a car, and always avoiding crowds. While these are understandable, protective strategies, they all are based on the fundamental misperception that panic symptoms result in catastrophe. We help clients identify their safety crutches and gradually reduce their reliance on them. As they realize that they can manage the sensations of panic without these restrictions, they are willing to take more risks in the provoking situations.
Do this over and over, in all your fearful situations. To overcome panic, people need to practice their skills again and again, in as many different locations and circumstance as possible. Primary in this effort is to want to feel anxious and to desire to remain uncomfortable for as long as possible. As they change their attitude in this manner, they discover that going face-to-face with panic eventually reduces their symptoms and gives them back their freedom.