Posts Tagged ‘md’
Oct 07
The Critical Inner Voice
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 VoiceIn 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 SystemAs 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 TherapyVoice 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.
ReferencesFirestone, 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
Oct 02
Facing Panic
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.
When asked about James Braid, Ernest Rossi said, “Braid is the true father of hypnosis (personal communication, Dec. 7, 2001). His work forms the basis of what I’m doing today.” This praise becomes understandable after a quick look at Braid’s contributions. He not only popularized the terms hypnosis and hypnotist; he first explained trance states as the interplay of physiology and psychology.
Historians credit Braid (1795-1860) as both the first researcher of psychosomatic medicine and the father of modern theories of hypnotherapy.
Braid’s work marked the end of Mesmerism, which held that a hypnotist emanated magnetic fluids to invoke trance. Mesmer believed he could ‘mesmerize’ trees in order to hypnotize passersby, reasoning that the magnetic fluid would pass from the trees to the subjects.
Braid debunked Mesmer’s theory by utilizing a simple ocular fix as an induction technique. He had subjects stare at common, household objects and within minutes, they entered a trance state. His studies proved that hypnosis occurs naturalistically within the subject and wasn’t dependent on the showmanship of the hypnotist. He wrote, “The whole (of the induction) depended on the physical and psychical condition of the patient… and not at all on the volition, or passes of the operator” (Braid, as cited in Tinterow, 1970, p. 283).
Erickson often echoed this theme, “Once you really know…that you don’t do it, your subject does it, you can have unlimited confidence…that your patient is going to go into a trance” (Argast, Landis & Ruelas, 2000, p. 55).
Braid asserted that everyone can be hypnotized, assuring his contemporaries that, “success is almost certain.” (Braid, as cited in Tinterow, 1970, p. 287). Braid described trance as a “universal phenomenon” and “a law of our species” (p.288). Erickson was later to concur, stating, “As long as your subject is alive, you can expect some developed trance state” (Argast et al., 2000, p. 55).
In 1843, Braid conceptualized trance as a, “shift of the nervous system into a new condition,” (Braid, as cited in Tinterow, 1970, p. 271) marked by excitement and the mind’s fascination with a single idea. “It is this very principle, of over-exciting the attention, by keeping it riveted to one subject or idea which is not of itself of an exciting nature… and (a) general repose which excites in the brain and whole nervous system that peculiar state which I call Hypnotism” (p. 301).
Similarly, Braid characterized psychopathology as a mind fascinated with a single, negative idea.
“Abnormal phenomenon are due entirely to this influence of dominant ideas over physical action, and point to the importance of combining the study of psychology with that of physiology, and vice versa” (p. 369). He added that, “all the natural functions may be either excited or depressed… according to the dominant idea existing in the mind of man… whether that has arisen spontaneously, had been the result of previous associations, or the suggestion of others” (p. 369).
Braid regarded hypnotism as a “valuable addition to our curative means,” describing it as “a powerful and extraordinary agent in the healing art,” while cautioning that it wasn’t a “universal remedy” (p. 272). About hypnotherapy, he believed that “the imagination has never been so much under our control or capable of being made to act in the same beneficial and uniform manner by any other mode of management hitherto known” (p. 272).
Braid also detailed the first list of naturally occurring, hypnotic phenomenon: eye movements, pulse and respiratory changes, and catalepsy. He stated that, “All the (hypnotic) phenomena are consecutive” (p. 307). He reported an “extreme acuteness of hearing during the first stage of hypnotism” and advised “allow(ing) the hearing to disappear, by which time all of the other senses will have gone to rest…I allow all of the senses to become dormant and then rouse only the one I wish to exhibit in the state of exalted function, when operating carefully” (p. 312).Braid wrote poetically about how subjects find a somatic balance so they do not topple over. “They acquire (a) center of gravity, as if by instinct, in the most natural and therefore in the most graceful manner ” (p. 305). He added that because of this “faculty of retaining any position with so much ease, I have hazarded the opinion that the Greeks may have been indebted to hypnotism for the perfection of the sculpture” (p. 305)
References:Argast, T., Landis, R. & Ruelas, G. (2000) Now You Wanted A Trance Demonstrated Today. Laguna Nigel, CA: SCSEPH
Tinterow, Maurice M. (1970) Foundations of Hypnosis: From Mesmer to Freud. Springfield, IL: Charles C. Thomas
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