Clinical Case: Individual
Experiencing Depression
Before describing the clinical case of an individual experiencing
depression, I introduce the theory of individual Voice Therapy.
Theory of the Defenses and the Negative Voice
As mentioned earlier, Firestone theorizes that
to some extent all children form psychological defenses that
originally help children survive emotional deprivation, but
which later underlie emotional problems in adult life.
According to Firestone, the primary defense is the fantasy
bond. This is an imagined connection the infant or child
forms with the primary care giver in the first years of
life. When the young child is feeling alone, frightened,
or emotionally deprived, the child imagines that the care
giver is present, attending to its needs. This fantasy
bond functions as a defense against separation anxiety,
interpersonal pain, and existential dread. It is highly
effective as a defense because a human being's capacity
for imagination provides partial gratification of needs
and reduces tension. Without the fantasy bond, Firestone
contends that the young child would be overwhelmed with
anxiety and fears of annihilation.
Once children are hurt and form the primary defense, the
fantasy bond, they progressively give up reaching out to
their caregivers for nurture and love, and develop a defense
called inwardness. Inwardness refers to a retreat into
oneself, in which children learn to parent or feed themselves,
to take care of their own feelings and emotional needs.
Initially, children do this by thumb sucking. Later, children
learn other ways to gratify themselves: a favourite blanket
or stuffy, masturbation, fantasy, solitary play, excessive
eating, reading, TV and computer play.
As children become inward, learning to feed and gratify themselves
internally, they develop a pseudo independent attitude,
an illusion of self-sufficiency. The core attitude is "I
can take care of myself." The defense of inwardness
protects children against the pain of reaching out for
love-food that may not be forthcoming, but leaves children
emotionally impoverished and alone.
Inward children have a negative conception of themselves
as bad, flawed, and deficient. This negative conception
is also a defense against anxiety. It is only possible
for small, dependent children to maintain the fantasy bond,
the illusion that their parents are more loving and attentive
than they really are, by seeing themselves in a negative
light. When parents are at their worst behavior, children
say to themselves, "Mommy and daddy are right to be
angry. I'm the problem. I'm just, a bad kid!"
Children incorporate this negative view of themselves in
the form of a negative thought process. By the time children
are four or five, they have an identifiable negative thought
process about themselves. A child will think, "I'm
not smart. I'm not good enough. I suck." This negative
thought process is internalized when parents are at their
worst behavior, and express harsh, critical attitudes toward
their children.
To recap, Firestone theorizes that when children are hurt,
to some extent they pull away from a close attachment to
their primary caregivers. In place of a close attachment,
they form the fantasy bond, an imagined connection to their
caregivers. This defense allays anxiety and provides an
illusion of security. The child then goes into an inward
state, characterized by self-feeding behavior and a pseudo
independent attitude. In order to maintain the fantasy
bond, the child develops a negative conception of self,
characterized by a negative thought process, "I'm
bad etc."
According to Firestone, our defenses are regulated by a negative
thought process, called the negative inner voice or 'voice'.
The voice is internalized at a young age. It refers to
a well-integrated pattern of hostile thoughts and attitudes
that generates negative emotional states and self-destructive
behavior, and causes people to reject positive experiences.
The voice has a dual focus: it is critical and hostile
toward the self, predisposing alienation from the self.
It is also hostile and critical toward others, predisposing
mistrust and alienation from others. The voice may be construed
along a continuum of self-destructive thoughts, ranging
from thoughts that are mildly critical of the self ("You
should have worked harder"), to thoughts that are
punitive toward the self ("You're worthless"),
to thoughts of self-annihilation ("You're not fit
to live. Just get rid of yourself").
Firestone postulates that the voice and the defenses constitute
an anti self-system, a destructive part of the personality,
an enemy within. In his view, we have a divided self: on
the one hand, the anti self-system; on the other hand,
the healthy self-system. The anti self-system comprises
our defenses and the voice which regulates the defenses.
The healthy self-system comprises our rational thinking,
our goals, wants, preferences, and our values. Although
people are conflicted internally between these two systems,
the more they operate from the healthy self system, the
more they are able to pursue their goals and tolerate love.
Clinical Case: Individual Experiencing Depression
A middle aged, single, accountant, named Stan, requested
Counselling saying that he was feeling stressed and burned
out on the job.
Although he was trying to maintain his usual compulsive work
ethic, he was accomplishing little. He reported feeling less
motivated,
having disrupted sleep, having difficulty concentrating,
being less interested in activities, and feeling empty. He
indicated that he
had been spending more time than usual watching TV and surfing
the net at night. As well, he had been drinking up to four
glasses of
wine at night to relax. It was evident that he was depressed,
and that his depressive episode had developed shortly after
he had been
promoted in his company.
When asked to describe his parents through the eyes of himself
as a five to seven year old, Stan, an only child, stated
that his father
was a "great guy" and that his mom was "always
there". Deeper probing indicated that his dad had been
largely absent because of his job
as a salesman, and not very involved in Stan's life. Deeper
exploration indicated that although his mother was a omemaker,
she had been
unhappy, critical, and self-absorbed.
Through the eyes of himself as little Stan, he couldn't
recall his parents showing affection to him. He remembered
how frightened he
felt when his parents were angry and out of control. When
he felt hurt, afraid, or alone, he didn't recall either of
his parents helping
him with his feelings.
When asked to describe what his childhood was like, he stated
he had had a normal childhood. Deeper exploration indicated
he had felt
lonely as a child and lacked confidence, except in school
where he excelled. When asked how he spent his time, he reported
playing alone
a lot. He could entertain himself for hours talking to imaginary
characters he had created. He preferred to play alone rather
than with
neighbourhood kids.
An exploration of his childhood experiences, then, indicated
the tendency to idealize his parents. This is reflective
of the fantasy
bond. This exploration also indicated the tendency to take
care of his own feelings and to gratify himself internally.
This is
reflective of the defense of inwardness, a self-protective
state in which children gratify themselves.
In adulthood, an inward, defended lifestyle leaves an individual
vulnerable to emotional difficulties, such as depression.
Emotional
difficulties may be triggered by positive or negative life
events. According to Firestone, both positive and negative
life events stir
up a negative thought process or "voice" toward
the self and others. Whereas before Stan's promotion his
negative voice was typically at
the lower end of the continuum of self-destructive thoughts
(i.e., mildly self-critical), the voice was now more punitive.
He was
telling himself, "My employers are going to see I'm
incompetent. It's only a matter of time before I'm sacked.
I'm incompetent, an
idiot." Stan didn't realize that his recent promotion
had triggered these intense voice attacks in part because
in being promoted he had
surpassed his father's career success (Firestone surmises
that surpassing one's same-sex parent often arouses anxiety).
The more Stan listened to this destructive thought process,
the more depressed he felt. The more depressed he felt, the
more he clung to
his inward, defended lifestyle. His drinking increased (from
moderate use to abuse), and he became more inward, giving
up hiking and
spending more time numbing himself in front of the television
and computer.
Stan listened to voices that mediated his self-feeding behavior.
He would rationalize drinking more by telling himself, "I'm
going to be
discovered as incompetent and sacked anyway. What does it
matter if I have another drink." He would also rationalize
a less active life
by telling himself, "What's the point of hiking, I'll
just feel more exhausted." When he thought of talking
to his parents about his
emotional state, he would tell himself, "They're old.
Why worry them. Suck it up and deal with it."
The negative voice not only rationalized his self-feeding
behavior, but also left him feeling guilty after engaging
in the behavior.
After abusing alcohol, Stan would berate himself, "I
have no self-control. I'm a drunk." Or, after spending
a sunny weekend confined to
his apartment, he would tell himself, "I've wasted another
weekend. I have nothing in my life."
The more Stan's negative thought process dominated his thinking,
the more depressed and hopeless he felt. He began to lose
feeling for
himself. Although not actively suicidal, he began to fantasize
about escaping, about getting away from everything. He would
tell
himself, "I'm not important to anyone. What's the point
of being here." From the perspective of Firestone's
theory of the divided self,
the more depressed Stan became, the more his anti self-system
took over his personality, cutting off Stan's healthy point
of view about
himself.
To recap, to some extent, we form psychological defenses
that underlie emotional problems such as depression. We have
a negative thought
process, the voice, which regulates our defenses. If this
is the human condition, how do we become less defended, more
ourselves? It
goes without saying that there is no magic bullet, no quick
fix. Becoming a healthier self is a process, a journey of
maturation.
Although I will describe the steps of this process in a linear
fashion, in actuality they are overlapping and recursive.
The Process of Change
The first step in becoming a healthier self is to confront
oneself by acknowledging the defenses that underlie emotional
problems.
Through exploration of Stan's early childhood experiences,
he confronted himself about having formed a fantasy bond
with his mother, his
primary care giver. He realized that as a small child he
had had legitimate needs to be fed, held, and responded to,
and that when his
mother had been unresponsive because of her own emotional
difficulties, he had imagined she was there attending to
his needs. By using
his imagination in this way, he had relieved partially his
anxiety and tension. He had developed a negative conception
of himself,
seeing himself as a difficult and demanding child, doubting
the legitimacy of his feelings and needs.
Because he had derived a measure of security from an idealized
view of his parents and his childhood, Stan found it painful
to let go of
the fantasy bond with his parents. As he developed a more
realistic view of his parents and his childhood, he started
to feel better
about himself. He realized that his mother's perception of
him as difficult was a statement about her and not about
himself. As he
relinquished the fantasy bond, he began to feel more himself
in relation to his parents. He continued to have contact
with them, but
when he wanted to rather than out of duty or obligation.
Stan also confronted himself by recognizing how he had retreated
into himself, into a state of inwardness in which he looked
to himself
rather than to other people for gratification. Whereas as
a child he had fed himself by playing alone and using fantasy,
now he was
self-feeding in more sophisticated ways. As an adult, he
spent long hours at work, priding himself on opening up the
office and closing
it down at night. In the evening, he would unwind by drinking
as he watched TV or surfed the net. He had several friends,
but none whom
he talked to on a personal level. His only hobby was hiking,
which he preferred to do alone.Stan recognized gradually that
his excessive work, his use of alcohol, his reliance upon
habitual routines such as TV
and surfing the
net, were defenses. He realized that he gratified himself
internally rather than risking real gratification through
close connections
with others and the pursuit of meaningful personal goals.
Having begun to confront oneself by acknowledging the defenses
that underlie one's emotional problems, the second step in
becoming a
healthier self is to confront the negative thought process
that regulates one's defenses. As previously stated, the "voice" refers
to a
well-integrated pattern of hostile thoughts and attitudes
about self and others. The voice is construed as a destructive
overlay on the
healthy self, an alien point of view about the self and others.
Because it is internalized at a young age, people experience
it as
compelling, highly convincing, even comfortable. Because
the voice is only partially in awareness, people are often
unaware of it or its
adverse impact.
Confronting the voice requires separating this destructive
thought process out from one's healthy point of view about
self and others.
What is required is a paradigm shift from uncritically listening
to the voice and failing under its influence, to separating
it out and
holding on to one's healthy point of view. Firestone has
developed a procedure for doing this. He suggests "saying
the voice" in the 2nd
person, "You", as if someone else is talking to
the person. He also suggests saying the voice in the 2nd
person with the affect or
emotional tone that it has in one's head. By following this
procedure, people have an experience of the voice as a hostile,
alien point
of view about themselves that is not in their best interest
to listen to. Once people separate out the voice, they are
encouraged to
counter the voice from their healthy point of view in the
Ist person singular, "I." The steps in this procedure,
then, are:
- awareness
of the negative voice,
- separating the voice out by saying
it with associated feelings in the 2nd person, "You",
and
- affirming one's healthy point of view in the Ist person, "I."
Rather than telling himself in the Ist person, "I'm
incompetent, an idiot. It's only a matter of time before
I'm fired", Stan learned to
say, "You're incompetent, an idiot. It's only a matter
of time before you're fired." When Stan was asked to
identify the emotional tone
that this voice had in his head, he identified it as angry
and contemptuous toward himself. When Stan was asked to "dramatize
the voice" by expressing the voice's
angry affect as an attack on himself in the session, initially
he was unable to do this. Instead,
he stated
what the voice was saying without affect (emotion) in an
intellectual way.
Firestone contends that dramatizing the voice is an important
factor in the process of change. He believes that expressing
the often
intense anger and hostility associated with the voice not
only produces insight into hithertofore unconscious core
beliefs, but also
promotes an integration of these affects (feelings) and beliefs
(cognitions) that results in people feeling more whole.
With this in mind, I continued over a number of sessions
to encourage Stan to dramatize the voice. By suggesting gently
to Stan that he "
try not to be afraid" and "really let go and get
into the feelings associated with the voice", Stan gradually
learned to express the
intensity of feeling that the voice had in his head. For
example, he was surprised to discover himself saying in a
loud, angry tone,
"
Stop bothering me! You're always wanting something from me.
You're ruining my life. You shouldn't be here." He immediately
identified
this voice as belonging to his mother when she had been most
out of control. Coming to the realization that when his mother
was at her
worst, she had not wanted him around, helped him to feel
more accepting of himself. Experiencing the intensity of
the affect that
belonged to his mother caused him considerable sadness about
how he was treating himself. Recognizing the hostility of
the voice toward
himself, helped him to feel compassion for himself and to
rebut the voice in the Ist person. He countered, "It's
not my fault that mom
was overwhelmed. I was just a little kid. I was okay then
and I'm okay now."
The third step in becoming a healthier self is to act on
corrective suggestions for behavioral change that counter
one's defenses. Stan
was encouraged to counter his self-feeding behavior by giving
up alcohol and limiting his hours of work. As Stan made these
changes, he
experienced increased voice attacks and associated anxiety.
For example, the voice catastrophized by saying, "You'd
better not put in
less time at work. They will see that you've been promoted
beyond you're level of competence. You'll never succeed!" With
the support of
the "holding environment" I provided, and the realization
that the intensity of this voice attack stemmed from his
having surpassed his
father's career, Stan was able to "sweat out" his
voice attacks and maintain these changes. He did this by
separating out the voice in
the 2nd person (experiencing it as an alien point of view),
and soothing himself by affirming his healthy point of view
about himself.
At the same time that Stan was giving up self-feeding behavior,
he acted on corrective suggestions to counter his inwardness
by moving
toward people for greater connection. For example, I encouraged
him to join a hiking group rather than hiking alone. As he
did this,
initially he experienced an increase in voice attacks and
anxiety. He identified a negative voice, "You're going
to be uncomfortable,
the odd man out. Why bother hiking with anyone else. Just
hike by yourself." Stan persisted in sweating out voices
such as this and
soothing himself. Gradually, he began to feel more comfortable
with the hiking group and to look forward to it.
The more difficult challenge for Stan occurred when he met
a woman through the hiking group who genuinely seemed to
like him. Stan had
been engaged in his mid 20s to a woman he loved very much,
and had felt devastated when she ended the engagement to
be with another man.
Since this painful rejection, Stan had had other women show
an interest in him but had been unwilling to try again. With
encouragement,
Stan started to spend time with the woman from the hiking
group and developed a nice friendship. Although this friendship
did not
progress further, Stan saw it as a positive experience and
the stepping stone to having an emotionally committed relationship
eventually.
As Stan countered his defenses by going against his negative
inner voice and acting on corrective suggestions, his symptoms
of
depression lifted and he began to feel himself again. He
noticed other changes in addition to the improvement in his
mood. He reported
that although his negative voice did not disappear, it had
receded. As a result, he felt less conflicted internally
and more capable of
countering the voice when it attacked him.
As he felt less conflicted internally, he reported that
his life expanded. Rather than leading a restricted, inward
life, he became more
outward, investing himself in rewarding activities and interactions.
As this happened, he also reported developing a more positive
view
of himself.From the perspective of Firestone's theory of the
divided self, the changes Stan reported reflect a shift from
being
dominated by his
anti self-system when depressed to operating more of the
time from his healthy self-system as his mood improved. When
operating from his
healthy self-system, his thought process was more rational,
he felt more himself (less conflicted), and he felt more
free to invest
himself in personal goals and relationships for real gratification
rather than feeding himself internally through fantasy and
addictive
behavior.
Conclusion
Becoming a healthier self is a process,
a journey of maturation. By confronting oneself by acknowledging
the defenses that underlie emotional problems, by confronting
the voice that regulates the defenses, and by acting on
corrective suggestions for behavioral change, one does make
progress.
It is helpful to remember that our defenses were formed
at a time when we really were helpless and dependent. As
adults,
we are neither helpless nor dependent. What is required
is that we draw on the best in ourselves, our healthy self-system,
throughout the journey.
Individual Voice Therapy
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