Command hallucinations and self destructiveness

Sometimes people can engage in suicidal behaviour due to command hallucinations. They report hearing voices that are telling them to be suicidal in some way.

There are two schools of thought on this. One school says that you should confront the crazy beliefs in this case the auditory hallucinations. Saying in a clear and direct way that the voices are not real and endeavoring to get the the person into Adult ego state.

The other school of thought says that you don’t confront the irrational belief, instead you engage the voices with questions such as

Ask - do you recognize the voices? 

Ask - what are they saying?

Then one can talk to the voices in an effort to defuse their destructiveness. The problem in doing this is the therapist is colluding with the crazy part of the Child ego state which believes the voices are real when in fact they are not. So in this way one is supporting the problem.

My personal view is that when you have a crisis situation one talks with the voices in an effort to defuse them. In the longer term the treatment goal is to confront the hallucinations and the delusion that there are voices talking, when there are not. 

I used to do this when I worked for an organization that assisted people who were primarily suffering from chronic schizophrenia, bipolar, psychotic depression and borderline personality disorder. When they reported feeling distress about the voices I leant to address the voices directly. Fortunately I had a coworker who was a psychiatric nurse and I learnt a great deal from her on how to do this.

However, even more interestingly these people just described would be diagnosed as psychotic and in transactional analysis terms that means there is a severe disturbance of the Adult ego state which can occur in two ways as shown in the diagrams. 




When I worked in a prison there were a number who I dealt with who also reported hearing voices. Most of these would not have been diagnosed as psychotic and this raises the question of does a person who hears voices have to be diagnosed as suffering auditory hallucinations. In recent times there has been a lot written on this and it is now accepted that voice hearing does not have to equate to a psychotic symptom.

Such as this from the mental health foundation

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Hearing voices can be a very disturbing experience, both for the person who hears voices and family and friends. Until recently voices were regarded as a symptom of a mental illness and not talked about because of fear of stigma.

Hearing voices are still considered by psychiatry as an auditory hallucination and as a symptom of conditions such as schizophrenic disorders, manic depression and psychosis. The orthodox treatment is with major tranquilizers. These do not get rid of the voices.

In the past mental health professionals were taught not to let voice hearers talk about their voices as this was thought to be colluding with the person’s delusions and not helpful. Most often professionals sought to distract the voice hearer from their voices.

Research has shown that many people hear voices, and some cope well with their voices, without psychiatric intervention. It has also been found that many people who hear voices regard them as a positive part of their lives.

Throughout history and even today there are people who hear voices who find their voices inspirational and comforting. Many researchers, practitioners and voice hearers believe it is mistaken to regard voice hearing as part of a psychopathic disease syndrome. Rather, they consider it to be more akin to a variation in human experience - a special faculty or difference that definitely does not need a cure.

This means it is no longer a sustainable position to think of voices as part of a disease syndrome, such as schizophrenia. Instead hearing voices can be regarded as a meaningful, real (although sometimes painful, fearful and overwhelming) experience that speak to the person in a metaphorical way about their life, emotions and environment. For instance, people experiencing distress as a consequence of abusive or commanding voices can often recognize their voices as those of their 

actual abusers and the voices have the effect of attacking their sense of self esteem and worth.

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Thus some voices are auditory hallucinations and some are not. Which raises a most interesting question. If they are not auditory hallucinations, then what are they? 

These people often have quite good functioning Adult ego states and at the same time they hear voices 
the voice may be experienced as coming from inside your head or from outside the head or even outside the body
the voice may talk about you or to you
the voices maybe distressing and abusive
you don’t know what they are going to say next
at times there can be more than one voice and sometimes the voices are from people you know and sometimes they are unknown

Either way if there are command hallucinations that are directing the person to kill self then my suggestion is the therapist engages the voices whether they are hallcinations or not. The goal is to diffuse the current crisis even if it means colluding with the crazy Child in the short term.

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Ego syntonic and ego dystonic

Something is said to be ego dystonic when the person perceives it to be foreign to them, outside them or not belonging to them. Something is ego syntonic when the person sees it to be part of them, belonging to them or forms part of who they are

These are two important concepts in psychotherapy. Is the problem ego syntonic or ego dystonic for the client?

A client may present with agoraphobia or perhaps insomnia. The therapist needs to ascertain in his own mind does the client see self as

1. A person who can experience agoraphobia, (ego dystonic)

2. An agoraphobic (ego syntonic)

Does the client experience self as  

1. A person who can suffer insomnia, (ego dystonic)

2. An insomniac (ego syntonic)

Unfortunately in most circumstances by the time the client gets to therapy the problem has become ego syntonic.

Ego dystonic I believe

A person sleeps normally and then for some reasons starts to sleep poorly. Initially this will feel abnormal to the person and the problem is seen as ego dystonic. They perceive self as someone who sometimes does not sleep well but not as an insomniac.

Over time if the insomnia continues the person’s view of it changes. It becomes something that they expect to happen because it has happened many times before. They tend to start to view it as part of who they are - an insomniac. When this change occurs the problem then becomes ego syntonic. The insomnia is perceived by the person as part of who they are and how they live.




The shift from ego dystonic to ego syntonic can be seen to have at least three aspects.

1. It becomes habitual

If a person has slept poorly most nights for the past year then the insomnia is partly a habitual way of being for the person regardless of any other causes for it.

2. It becomes part of the persons life style

As it becomes a habitual pattern of being the person will adjust the practicalities of their life style to fit for it. They will tend to do the same things like get up and do such and such and then go back to bed and then wake up again. They develop a routine at night time that incorporates the wake times.

3. It becomes part of the person’s self perception or part of their identity.

Finally it becomes how the person sees self and a sense of who they are as a person. I am an insomniac is part of the person’s sense of identity.

If a person has slept poorly three nights in the last four months then it wont be habitual, they have no routine when being awake and it is not part of who they see they are.


Eunuch



How long does it take a problem to shift from being ego dystonic to ego syntonic?

In trauma debriefing research indicates that therapy should start within 6 weeks of the trauma. The earlier you start the better. After 6 weeks it is harder to treat the problem (PTSD) as it has become ego syntonic.

Research on the formation of new habits indicates that it takes 66 days for a new habit to fully form. After that the person will behave habitually in the new way. Of course this varies on how often the new behaviour occurs and if there are any relapses along the way.

This suggests that it will take about 1.5 to 2 months for a problem to move from being ego dystonic to ego syntonic if the new problem occurs regularly.

If it is ego syntonic then not only does one have to treat the insomnia, but also the habit of not sleeping and the routine involved, along with the self perception of the client as an insomniac.

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The loneliness of the long distance therapist

I can recall back in high school, in literature, we studied a book called “The loneliness of the long distance runner”. The title always stuck in my mind for some reason and I am not sure why. I always thought it was a good name for a book.

The title here refers not to a therapist who is a long distance from the client but the therapist who goes the long distance, that is, is a therapist for many years. Therapy is an odd profession in a number of ways. A long time ago I wrote an article on psychotherapy and prostitution and some of the similarities between them. Both professions require the person to sell them self.

This is unlike the plumber or an accountant. When they are employed by a client it does not matter what they are like as a person just as long as they do a good job plumbing or accounting, at least that matters the most. When a psychotherapist is employed they are employed for their skills as a therapist but also as a person who the client is going to relate to. Indeed the relationship is a significant part of the therapy along with the therapeutic techniques. You can not really separate them in this way.

This has its down side in some ways. Over the years I have seen various therapists who may be changing profession or moving try and sell their practice. And it never is really successful. A therapist can not sell his practice in the same way a plumber could sell their plumbing business. One reason for this, is it is the therapist as a person who relates to the client that makes the practice successful or not. And obviously you can not sell that along with the business.

The majority of new clients who come to me are referred by someone who knows me in some way. Word of mouth is by far the most effective marketing technique for a therapist doing counselling. I do sometimes get randoms or people who found me by looking on the internet but this is a small group. 




They may say they found my name on LinkedIn or came across my blog or these days even more so they say they found my website. I don’t know if I should let out my trade secrets here, but what the heck! My website is not the usual style of website for a psychologist or a therapist. One particularly odd part is the pictorial history which can be seen here.

I can not recall ever seeing a similar thing on another therapist’s website. If a client reports they have seen my website I will ask them what was their reaction to it and invariably they will talk about the pictorial history. Of course they do, as that is where they can get some insight into me as a person. BTW, that was not the reason why I put it their in the first place. It was just something that felt right when I was constructing it. However it is very unusual for a therapist’s website and now I find that it is a good idea from a marketing point of view. Oh well, these things happen.

So I can never really sell my practice, because most of the clients come to me as a person not to the practice as an entity in its own right.




What about the long distance therapist? Well therapists spend their working days relating to people and often the relating can be quite intense. Every person has relational needs, they need to have a sense of being in relationship with others and those relationships must be lived out first hand at least semi regularly. If this does not happen (and thus the person is isolated) then psychological deterioration will occur quite rapidly and can lead to quite severe consequences. Accordingly then therapists must be well supplied in terms of getting their relational needs met and indeed they are, one could say. That could be seen as a positive of being a therapist over time. 

Does this have an impact on relationships in other areas of their lives?
If their relational needs are met in their work maybe they are less motivated to have relationships in other areas of their lives?

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Life script type - 3

Hello KYLady

Thanks for your comments about the percentages of winners, losers and non winners and on how does one define a winner you made in the previous post on this topic.

The percentages cited are somewhat arbitrary. The main point being made is there needs to be a large number in society who basically keep the society functioning as do ‘worker bees’ in a bee hive. If these people do their work then there also needs to be a group who do not follow the customary rules. These people thus give the society an edge, or a continual creative and growth momentum. Without this a society would stagnate and falter sooner or later.

Both the winners and the losers do this. They provide a society with a quality of creative growth. A good example of this in Australia is some what topical at the moment with the American example of the batman movie shootings. It involves a person called Martin Bryant who was in his early 20s at the time. In the mid 1990s he randomly shot and killed 35 people at a popular tourist resort with no motive. The government at the time used this to give Australian society a new direction on the issue of gun control. Laws were significantly tightened to make the purchase of guns more difficult. If Martin Bryant had not done what he did that would not have happened at least then. So this ‘loser’ (for want of a better word) had a significant impact on the direction of Australian society because he broke the rules and in one way forced the society to grow and develop in the way it did.

As you can see from the chart there are a number of similarities between the characteristics of the winner and the loser. The winner has little to do with success in terms of wealth, fame and so on. The key features of a psychological winner are;

Set out and achieve life goals
Things work out well in the end

For most despots throughout history this is not the case and in that sense they would not be considered winners in the way the term is being used here.




In terms of psychological theory to achieve self actualization or psychological health, there is only a small group who do this - the winners. All the others don’t. The losers have tragic life scripts and the non winners achieve only banal lives. Neither of these in terms of psychological theory are the optimum state of psychological health and thus they could then be called neurotic states.

So all this is good and well for the winners who can only achieve this if the non winners do their job. And as I said before this does not seem very fair for the non winners. It is one of those examples where the health of the individual collides with the health of the group (society).

A prime example of this is in the area of child sexual abuse. The research on this is unequivocal. A child who reports being abused and goes through the legal process of the perpetrator being charged, tried and so forth, they will be significantly psychologically worse off at the end, than if they did not go through the legal process. This occurs for whole variety of different reasons including the child being retraumatized a number of times throughout the process. If the child does not go through the legal process the child is better off and the society is worse off. If the child goes through the legal process the child is worse off and the society is better off.


Is the group more important than the individual or the individual more important than the group?




The same kind of situation applies for the winner and the non winner. The winner can only avoid the life of a banal existence and self actualize if the non winners do their job and remain banal. The non winners suffer for the sake of the group and the winners show how the individual can benefit as they do.

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Life script type - 2

The previous post talked about script payoffs being banal or tragic. Under the classification system shown here the loser life script is the tragic outcome and the banal outcome is the non winner and there is a third outcome that of the winner. So this system defines what is the healthy position. This classification system however raises some interesting moral and philosophical questions. 

In almost every society the percentages of each life script type is:

Winner = 20%

Non winner = 60%

Loser = 20%

The non winner would never do this. The winner or the loser might. In some ways the line between winner and loser can be very thin.

The vast majority of people in a society are ‘worker bees’ or non winners. They live out a life that society expects and indeed society requires in order for it to survive. In this way it is only the winners who achieve what could be considered psychological health. And they can only achieve such a thing if the non winners stay as non winners and do their job of keeping a society going.

If all the non winners some how became winners then the society would collapse. Any society needs a large group of people to live out banal lives as these are the ones that form the back bone of any society. They never really achieve any self actualization or significant psychological fulfillment but their lives are tolerable.

The 20% of winners are the ones who achieve self actualization and significant psychological fulfillment but they can only do this if the non winners live the mediocre lives that a functioning society requires them to do. This does not seem all that fair but then who ever said life was fair! (There is another whole set of posts to be written on life being fair or not, and the psychological ramifications of that - but maybe at a later time).



Two will be non winners, one will be a loser and one will be a winner, but which ones? 


Over time each of these four women will make a series of decisions such that their lives end up in one of the three ways. Most are unaware of this process and it will just seem natural and right for them to make such a series of decisions over such an extended period of time so they end up either a loser, non winner or winner.

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Life script

There have been a number of different life script classifications systems devised over the years. This one is quite popular and is the tripartite system of loveless, mindless and joyless. 

It shows some of the main features of this system. As with all life scripts it is really about the theme of your life. We all have different twists and turns in our lives but we all tend to have a theme or path that we are on which plays out to the end. By the time the person has reached mid to late adulthood one is getting the first hand version of the person’s life script.



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ICPT newsletter

The most recent newsletter of the International Council of Professional Therapists (ICPT) is out. Find it here.

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New workshop

The young therapist - Part 2

Life experience is an interesting thing which older therapists have more of than younger therapists. Most view it as a positive but it can also be a negative especially if one is a psychotherapist. Without a doubt life experience can be a positive thing for a therapist to have. A person who is 45 will obviously have more life experience than a person who is 25 years old. If they are a practicing therapist this can influence how they work. The older person has extra knowledge about life that the younger person does not have.

If one has been married and divorced they have first hand knowledge of that. Some one who has never been married and divorced can not know about it in the same way which is more likely for the younger therapist. If a client presents who is currently going through a divorce then the therapist who has been divorced knows more about the process and more importantly more about the psychological process one goes through when getting divorced.

If the therapist tells the client they have been divorced then the client can have a feeling of more confidence in the therapist and can have a sense of increased connection with the therapist. The client feels that he and the therapist have a commonality in that way, which they do. In this way the life experience of the therapist can assist the therapeutic process.

However it is not always so sunny. If a couple come to counselling because of marital disharmony and learn the therapist has been divorced this may result in a lack of confidence in the therapist. They have the view that if the therapist cannot sort out his own marital problems how can he ever help others to do so. The young therapist who has never been married or divorced can not have this problem.

Similar to this is the client who seeks counselling for parenting difficulties. They are having difficulty managing their own children or adolescents. I have heard people say they would never seek assistance for their parenting with a therapist who is not a parent them self. However what if the therapist’s children are not all that well adjusted and may be causing all sorts of difficulties for the therapist. Will that be a positive or a negative for the therapist in the eyes of the client. All parents stuff up some where along the line and all children have emotional difficulties to some degree. The young therapist who has no children does not have this on their resume.

In my new book to come out next month - Working with drug and alcohol users - I discuss this very topic. If a drug counsellor has had a history of drug issues is that a positive or a negative. If a client asks a drug counselor directly if they have ever used drugs, does the therapist answer the question, and if so how. How it is dealt with by the therapist can result in the personal life experience of the therapist (whether they have used drugs or not) being a positive or a negative for the therapy.

However there are more things to consider in the life experience conundrum. When one has a major life experience like a divorce that will psychologically impact on them. Their own Child ego state will be effected by the experience and that may be a negative psychological experience. The Child ego state of the young never divorced psychotherapist has never been negatively effected in that way.

Some come out of a divorce feeling bitter and pessimistic about the opposite gender. If the therapist has been impacted like this, is their extra life experience going to be a positive in the therapeutic process especially if the client is of the opposite gender? The young therapist is never going to have this dilemma. 

Is the ex smoker (or smoker) going to be better at helping people give up?

Life experience does afford the therapist an extra knowledge or deeper level of understanding of the client who is going through the same experience. This can then allow more of a connection between the client and therapist. However the therapist’s Child ego state may be negatively effected by that experience which may negatively impact on how effectively they work as a therapist on this issue.

Related to this is the idea of the hot potatoe. It is observed sometimes in the field of psychology that some therapists gravitate to counselling in those areas that have been part of their own life experience. The woman who suffer PND herself ends up counselling other women suffering PND. The person who was sexually abused as child ends up counseling others who have been through the same. The man who had a significant drug problem ends up counseling in a drug rehab centre.

In all these areas the therapist’s personal life experience can be a good help in the ways I have described above. However the question needs to be asked - what’s in it for the therapist to work with clients who have similar issues? What is their own Child ego state getting out of it? For most there is no problem, however the phenomena of the hot potatoe is real and does exist for some.

In this instance the therapist is in some way living through the client because they have not dealt with their own difficulties about their similar life experiences. The therapist can pass their own issue (the hot potatoe) onto the client. If this happens all sorts of counter transference problems can develop. The young therapist who has never had children can never have suffered PND and thus can never have these sorts of difficulties like the hot potatoe.

Life experience it seems, is a double edged sword. As with so many things in human psychology its not a matter of having a particular trait or feature (in this case life experience) its what you do with it when you have it. The older person who has more life experience can use those experiences to impede their work as a therapist or to improve their work as a therapist. The younger person has less life experience and therefore in their work as a therapist they do not have this same dilemma.

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The young therapist - Part 1

Jay Haley

“When a therapist is young, he should not try to appear wiser than he is. The beginning therapist is often young and even unmarried. Faced with a couple married for 25 years, the beginner may be tempted to act as if he understands that stage of marriage as well as they do. It is not so. Instead, the therapist should find a stance to work from that is acceptable to the older couple. For example, the beginner can say, “Obviously you know more about marriage than I do since you’ve been married for a long time, and certainly you know more about your marriage than I do. But as an outsider, I can offer you an objective view of some of your problems.””

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This has some personal significance for me because I began as a very young therapist. I began running my first therapy groups with a cotherapist when I was 22 years old. Probably about a year later I started seeing clients individually and has done so ever since. My circumstances were unusual in that both my parents were psychologists and they ran one of the first ever private therapy training institutes in the city where I lived.

I started my original psychology degree when I was 20 years old and began in my parents training institute when I was 21. In those days in a university psychology degree you would study psychology for three or four years before you actually got to work directly with any clients. In the private training institute it was very hands on. Starting with being a therapist with another student as a client in the training group with the supervisor there. Then as a cotherapist with ‘real’ clients and then finally in individual therapy, all under supervision of course until one passed the exam and was qualified.

When I began in the private training institute I was the youngest by far and remained the youngest student in it for a number of years. I experienced the situation of an early to mid 20 year old therapist working with adult clients who were at time many years older than me.

My mother with Bob Goulding on workshop - holiday. The person sitting with the long hair in front is myself (early 20s year old at the time)

Obviously I was aware of this and at times I did think of it but not really all that often. I can only recall one situation where a client stated it to me that I was young. It is highly likely that some talked about my age to others in their life when they talked about the therapy they were doing with me. 

However in the early years I always worked in private practice which meant the clients who came to see me, they selected me and paid me money to counsel them. They were not assigned to me which can happen in a counselling agency where the client does not get to choose which therapist they see. This I imagine allowed for some self selection by clients. If they felt my age was a problem they would have never selected me in the first place and this may account for the fact that only one client ever said anything to me.

I can recall talking about it with other trainee therapists and thinking about it my self. This is why I have quoted Haley above. What view can one take of this, as young therapists are not all that uncommon. Haley’s point seems to be quite a good one and what I used to say was a bit similar. My view was:

“I have learnt the basic theory and the basic techniques so I just do what I do. If people get something out of it they will come to see me and if they don’t then they wont.” 

I think this is similar to what Haley says. There is no attempt to justify or explain away the age issue. No attempt to say that age does not matter or some similar kind of thing. It is a statement of I am who I am and the input I can provide. This is available if you want it and if you do not, that is OK.

Young adults.

What is the problem?

Obviously the problem for the young therapist is a lack of life experience. But does this mean anything. As a young therapist I lacked more (at times much more) life experience that almost all of my clients. However people still voluntarily came to see me and obviously got something out of being my client. 

At that age I did not understand what effect lesser life experience would have on me as a therapist. Now as an older person I do understand. This lack of understanding actually helped I think because at that age I had belief in myself. It was not until later that I realized maybe my belief in self was a bit unrealistic. However I had a confidence in what I was doing and most people respond favorably to a person who has confidence and particularly a person who just is who they are which my statement above tends to say. I never tried to show my self as being more experienced than I was and never felt the need to justify myself. I accepted myself as a 22 year old therapist doing what he had been trained to do with the personal and professional resources he had at that time.

Clearly young therapists can and do work effectively, so life experience is by no means a necessity for an effective therapist. Having said that life experience can help. Having been a very young therapist and now an older therapist I am of the view that it can help in the practice of therapy.

All new therapists are technicians, no matter how old they are. They have been taught the basic theory and practical techniques of the therapy they are trained in. When they meet their first clients they apply those techniques were it is appropriate. The practice of therapy can have a mechanical feel in this way. After time as they get life experience as a therapist they can stop being a person who just applies the technique and they can relate more to the client as a person who also does therapy with them. You can’t make that shift without the life experience as a therapist no matter how much other life experience one may have. Thus it is my view that life experience as a therapist is more important than life experience in general.

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