in treatment as the symptom of dissociation and the converse of mentali- ..... reflecting status quo and stagnation on the negative side, or unity, harmony, and ..... sifications of dysfunctions (e.g., Diagnostic and Statistical Manual classifica-.
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Journal of Psychotherapy Integration, Vol. 7, No. 3, 1997
Multiple Voices: A Virtual Discussion Moderator: William B. Stiles1,10 Panelists: Lorna Smith Benjamin,2 Robert Elliott,3 Peter Fonagy,4 Leslie S. Greenberg,5 Hubert J. M. Hermans6 Questioners: Wilma S. Bucci,7 Bertram P. Karon,8 Mikael Leiman9
Is there a central organizing entity that brings order to the multiple voices in the person? How can healthy multivoicedness be distinguished from dissociation orfragmentation?What patterns of attachment or dissociation are present in psychosis? How can hallucinated voices be dealt with in treatment? Parents' voices speak in their children, but do children's voices speak in their parents? Can such diverse approaches as attachment theory and object relations be productively combined to understand the development of voices in people? Can theorists distinguish multiple distinct internal characters from multiple psychological functions or processes? Views on these and other
1
Department of Psychology, Miami University, Oxford, Ohio. Department of Psychology, University of Utah, Salt Lake City, Utah. 3 Department of Psychology, University of Toledo, Toledo, Ohio. 4 Sub-Department of Clinical Health Psychology, University College London, London, Great Britain. 5 Department of Psychology, York University, North York, Ontario, Canada. 6 Department of Clinical Psychology and Personality, Catholic University of Nijmegen, Nijmegen, The Netherlands. 7 The Derner Institute, Adelphi University, Garden City, New York. 8 Department of Psychology, Michigan State University, East Lansing, Michigan. 9 Department of Psychology, University of Joensuu, Joensuu, Finland. 10 Correspondence should be directed to William B. Stiles, Department of Psychology, Miami University, Oxford, Ohio 45056, USA; e-mail: stileswb@ muohio.edu. 2
241 1053-0479/97/0900-0241$12.50/0 © 1997 Plenum Publishing Corporation
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questions were exchanged in a virtual discussion, conducted by email over a period of several weeks.
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KEY WORDS: multiple voices; dissociation; fragmentation; attachment; object relations.
Dr. Stiles: In organizing this virtual discussion, I asked three people to write comments or raise questions about the foregoing papers (Benjamin, this issue; Elliott & Greenberg, this issue; Fonagy, this issue; Hermans, this issue) for the panelists to discuss. Dr. Wilma Bucci, Dr. Bertram Karon, and Dr. Mikael Leiman were members of the audience who participated in the discussion following the panel presentations at the Society for Psychotherapy Research meeting in Geilo, Norway, on which this special issue is based (Stiles, 1997). The discussion in Geilo was not recorded; instead, each questioner reviewed the written versions of the papers and sent their written comments and questions to me by email. I circulated each question to each panelist in turn, giving each an opportunity to respond (within a strict overall page limit). Discussions of the points raised by Drs. Bucci, Karon, and Leiman, along with panelists' comments on each other's papers, all proceeded in parallel via email over a period of weeks during November 1997. The first questioner is Dr. Wilma Bucci. Dr. Bucci: These four papers present multiple distinct perspectives on the concept of multivocality. Fonagy (this issue) and Benjamin (this issue) talk, in quite different ways, about multiple voices as pathology. Fonagy straightforwardly and clearly refers to the predominance of multiple voices in treatment as the symptom of dissociation and the converse of mentalization, and provides evidence supporting a link between disorganized early attachment patterns and dissociative disorders. Benjamin addresses the adaptive functions of fantasy systems, including delusions and hallucinations that incorporate imaginary others, but nevertheless sees these in a context of pathology. As she points out, in normal children fantasy play is eventually replaced by more satisfactory real relationships; people who hallucinate, other than bipolar manics during a specific episode, typically are isolated and socially withdrawn. Every psychopathology may be "a gift of love," as Benjamin evocatively asserts, but the maladaptive patterns of multivocality that she describes are pathological nonetheless. In contrast, Elliott and Greenberg (this issue) and Hermans (this issue) focus on multivocality in terms of complexity of personality organization and its continuing resolution and enhancement. Thus Elliott and Greenberg characterize multivocality as "an essential part of being human" and "a therapeutic resource, to be nurtured and valued" (p. 225). Hermans talks
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of the "dialogical self" as a complex, narratively structured self in which the "I" has the capacity to move back and forth among various positions. In disorders of disorganization and dissociation, these dialogical relationships are seriously impaired; in treatment, incompatible positions meet as partners and become integrated in a multi-voiced self. I do not think these papers can be seen as "pro or con" multivocality. I think these perspectives are divergent enough that we may ask whether or to what extent the four authors are looking at the same construct or psychological entity when they talk about "multiple voices." Since this is of course a very general question, I would like to focus on the following critical points: (a) To what extent does each author postulate a central organizing entity in his or her view of psychological organization; what is the nature and role of this entity? (b) To what extent and in what form would each author expect to find multi- vocality in an adaptive, functioning individual? (c) To what extent—for what categories of patient—does treatment focus on enhancement of complexity vs. repair of splitting or fragmentation? For Drs. Elliott and Greenberg, and Dr. Hermans, I think the critical issue is (a); if there are multiple autonomous "I" positions within a single body, how are decisions made concerning how the single body will act? For Dr. Fonagy and Dr. Benjamin, I think the critical issue is (b). I wonder to what extent the diverse views will converge on (c). Dr. Greenberg: In my view the self is a central construct; however, the term "self" refers not to an entity but to an overall organizing process that acts as the integrating agent. In other words, the self is emergent from the interaction of all the currently active self aspects. It operates more like a leaderless group or parliament in debate: the interactions among the parts produces the final result. This occurs by a principle of summation in which, as in voting, it is the summation of the votes, or the combined weights of the constituents in a synthesis, that results in the final product. Thus decisions are made by a self-organizing process, not by an executive entity such as an ego. The self thus operates as a dynamic system organizing the elements of experience into a coherent whole and works by a process of dynamic/dialectical synthesis. By organizing experience it creates what is "me" and separates it from what is "not me." Organismic systems thus are seen as creating experiential stability and continuity by organizing their own experience into what we have called emotion schemes (Greenberg, Rice, & Elliott, 1993). It is these structures that produce a stable sense of self and world. Critical in the infant's ability
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to produce self-coherence is the developing capacity to focalize attention. This ability emerges as the organism organizes experiential constancy and a stable reality. Thus, the self is seen as developing a sense of stability by organizing its own experience into stable wholes. In this dynamic systems view there is no central control, but all elements add weight in an ongoing synthesis in which the resulting self organization—a momentary state, such as feeling shy or being assertive—is the result of the synthesis. Conscious control is but one aspect that can influence the synthesis process and is always itself influenced by tacit knowing processes in a never-ending circular process of mutual influence. The self thus constructs itself developmentally, step by step, through the organization and structuring of experience. The self is dynamically synthesized in this manner into possessing a sense of coherence, agency, continuity, and affectivity (Stern 1985). The self is thus an emergent sense synthesized from more basic elements of experience of which the affectively toned sensorymotor experience of infancy are reference points for the ordering of much later experience and one's developing sense of self. Emotion is the "glue" of identity formation as the self comes into being through the interplay of primary affective responses and the responses and expectations of caretakers to the infant's experience. In this way, the self can thus be thought of as emerging developmentally at the boundary between self and other. The individual is also, however, an agent in forming a coherent sense of self and can thus influence the synthesis process. This is done by consciously adding attentional weight to certain aspects of the synthesis, thereby attempting to boost their influence in the synthesis of a form that successfully organizes aspects of experience into a coherent whole that is a creative adjustment, viable in a given situation. Nevertheless, conscious influence of this sort does not control the process. It only influences the weighting of elements, and this may or may not determine the result. This view attempts to overcome the problem, in both language and thought, of presuming the operation of any unconscious, preexisting, content or meaning (a hidden self) that is accepted into consciousness or into a self-concept. Rather, there is an ongoing process of synthesizing levels of processing and modules of experience in an internal field that provides an internal sense of complexity. We then can attend to this preverbal experience, and synthesize it in awareness. Moving to treatment, and to the question of for whom does one focus on enhancing complexity vs. repairing fragmentation, the issue is one of the nature of the person's organizing processes. For people who have developed the ability to create coherence and stability in their sense of self and world, explicit dialogue between the parts will be helpful. Others with more dissociative experiences, hallucinations, or unwanted "voices in their
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head" suffer in their ability to maintain coherence and will benefit from an empathic, confirming relationship that will help them regulate dysfunctional affect. Because they lack the ability to integrate their experience, having these clients take the positions of different aspects and evoking the feelings associated with internal conflicts between intensely emotional parts may be too disruptive. Two-Chair Work is thus most appropriate for people who possess the ability to synthesize their experience and create stability and coherence in their world. This method is, however, always mediated by a containing relational bond with the therapist, to help deal with what is evoked. The determination of what is containable depends on the strength of the alliance and the safety of the bond as well as on the client's nature and wishes. Dr. Elliott: I agree with Bucci's observation that the authors of these papers are talking about different phenomena. Hermans (this issue) and Greenberg and I (this issue) clearly advocate using the terms "voice" and "multiple self" very broadly as metaphors to talk about important intraindividual psychological differences also characterized in the literature as "states of mind" (Horowitz, 1987), "emotion schemes" (Greenberg et al., 1993), or "experiencing potentials" (Mahrer, 1983). We see dysfunction as coming from a combination of (a) the implicit, unreflected, undifferentiated or inadequately symbolized nature of these self-aspects or sets of experiences; (b) a negative or hostile relationship between them; and (c) isolation or lack of psychological contact between the aspects, resulting from selfprotection or silencing of one part by another. Treatment thus requires evocation and explication of the implicit self-aspects, as well as facilitation of psychological contact, especially tolerant or even friendly contact, among the self-aspects. On the other hand, Benjamin (this issue) and Fonagy (this issue) use the phrases "voice" and "multiple self" in a much narrower, less metaphorical sense, essentially restricting them to psychopathology. Benjamin does describe a spectrum of imaginative internal dialogue, from self-talk to imagined conversation to hallucination; however, she is primarily interested in hallucinatory "voices" whose pathology derives from (a) their being taken as real, and (b) their common persecutory nature. For his part, Fonagy, to the extent that he refers to multiple voices at all, appears to be talking about severe dissociative phenomena. We would find little to disagree with in his presentation if he were to use the phrase "silenced voices" to describe the sources of intrusive memories and transient hallucinatory experiences that result when important aspects of self-experience not allowed to "speak." Because speaking is part of the self-reflection process, that which remains unspoken cannot be reflected upon and therefore must find other ways to manifest itself.
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The clinical prescriptions drawn from Benjamin (this issue) and Fonagy (this issue) are very similar to those of Hermans (this issue) and Elliott and Greenberg (this issue): the dissociated or hallucinated experiences must be explicated, understood, and reflected upon in a safe therapeutic environment. Where severe, the therapist would offer more empathic and fewer evocative or uncovering interventions. The disagreement is thus not practical in nature. Instead, it turns on the usefulness and range of convenience of the "voice" and "multiple self" metaphors. In their papers, Fonagy and Benjamin attend primarily to a narrow range of phenomena in which some individuals at times unreflectively convert common human metaphors of voice and multiple self into literal happenings reflecting the action of nonself "entities" (cf. Sarbin & Mancuso, 1980). It is not clear to us whether Fonagy and Benjamin reject the "voice" and "multiple selves" metaphors on aesthetic, scientific, or clinical grounds, or whether they have simply failed to consider the appositeness or utility of these metaphors. Dr. Hermans: I can find myself very well in what Dr. Greenberg has said about the process of self-organization and the superfluity of a central organizing ego. Part of the problem may be that in our language we are using the word "I" indiscriminately for a great variety of states of mind that, despite their varieties, contrasts, and contradictions, are appropriated by the I as if it is somewhere "above" the multiplicity of voices of the self. Certainly, cultural factors are involved that are closely related to linguistic practices. Gloria Wekker (1994) explains that in Sranon Tongo, the language of Afro-Surinam people, there are different words expressing different modalities of the J: Mi Mi kra A misi (f'mi) A masra (f'mi) Mi misi nanga mi masra Mi dyodyo Mi skin Mi geest
I My soul, I My feminine part My masculine part My feminine and masculine part My divine parents My body, I My spirit, I
As this example shows, the word I (Mi) is directly associated with markers of a great variety of persons or voices, including not only singular voices but also plural ones, and not only spiritual but also corporeal ones. Based on this idea I have explored the idea of conceiving traits as characters (Hermans, 1996). Starting from the supposition that people do not have personality traits but they are them, I invited people to tell about
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the world and themselves as if this trait was a character with a specific worldview. Typically, I asked people to describe two opposite sides of themselves and tell their stories and implied meaning units (valuations) from these two positions successively. One of my subjects, Nicole, a 23-year-old woman, indicated that she had two opposite sides, which she described as a "self-assertive" and an "uncertain-anxious" with the first one as more dominant in her everyday life than the second. Next, she performed a selfinvestigation from these two positions: I-self-assertive and I-anxious, respectively. Some of the valuations formulated from the two positions were very different in content, others were even contradictory. For example, from her assertive position she said, "I have a relationship with a man in which I can totally be myself (in both my good and bad moods) and be accepted, and I derive certainty from that." From her anxious position, however, she told about the same relationship: "The fact that my relationship is illegitimate evokes in me feelings of loneliness, powerlessness, dependency, and jealousy." In general, most of the valuations of the uncertain position were associated with positive affect, whereas most of the valuations form the anxious position were associated with negative affect. After the formulation of these valuations I followed this woman during a three-week period in which I invited her to rate her valuations on dominance and meaningfulness at the end of each week. To my surprise the self-assertive position which was dominant at the start of the investigation decreased strongly during the three-week period whereas the less dominant anxious position increased steeply. These changes reflected a so-called dominance reversal, a radical change in the relative dominance of two traits. Apparently, the trait that was considered by Nicole as most dominant in her everyday life, gave up its dominant position in favor of a trait that she perceived as less dominant, a change that took place within a relatively short period of intensive self-reflection. For our discussion the data on meaningfulness are most relevant. The trait (anxious) associated with most negative affect increased not only in dominance but also in meaningfulness. On the other hand, the trait with most positive affect (self-assertive) decreased not only in dominance but also in meaningfulness. After a series of investigations of this type with several people (none of them had a psychiatric history) I concluded that the two sides, conceived as voices telling their specific stories, experienced these stories as mutually complementing and as valuable counterparts of a polyphonic self. The findings reflected the dynamic nature of the self: The upcoming of a neglected or suppressed part of the self was welcomed as belonging to the self although this part of itself was associated with much unpleasant affect. Synthesis, although painful, was meaningful.
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This "happy synthesis of unhappiness" observed in our case studies does not apply to people with disorganized/disoriented patterns of attachment, as Dr. Fonagy's research suggests. As he describes (Fonagy, this issue), parents with unresolved patterns of attachment may present alternating frightened and/or frightening emotional displays to their child. Consequently, the child develops numerous contradictory self-caregiver constructs resulting in a multiple and incoherent unintegrated structure. In fact, the self of these children are resembling the picture I found in Mary and her witch. In keeping with Dr. Elliott's objections against a restricted use of the notion of multivoicedness, I would propose that there is a common denominator in the various phenomena of our discussion (disorganized patterns of attachment, hallucinations, and delusions, Mary and the witch and Nicole with her opposite sides): They all can be studied and understood from the metaphor of multivoicedness. However, elaborating on Dr. Bucci's first question, there is a crucial point to make: When all these phenomena can be seen as reflections of multivoicedness, it should be made clear what the difference is between healthy and unhealthy multivoicedness. Most succinctly, my answer is that the difference is in the nature of the relationship between the voices. In my view there are two basic forces in the organization of the self: centrifugal and centripetal. Centrifugal forces move away from a (hypothetical) integrating center in the self. Fonagy (this issue) sees attachment principally as a mode of affect regulation: (a) the infant signals affect, (b) this affect is perceived and responded to by the caregiver, and (c) these responses make it possible for the infant to return to an equilibrium. I would say that this returning to an equilibrium is a corrective movement which functions as a centripetal force, which creates the conditions for the infant, and later for the adult, to keep shifting and contrasting experiences together as differentiated parts of a synthesizing self. As we have argued earlier, both centrifugal and centripetal forces are necessary for a healthy self. Altman (1987) summarizes his view as follows: I must reiterate that neither centrifugal nor centripetal trends are intrinsically "good" or "bad." One can praise or decry centripetal trends, for example, as reflecting status quo and stagnation on the negative side, or unity, harmony, and stability on the positive side. Similarly, centrifugal trends can be viewed negatively, for example, as indicating divisiveness and disunity, or positively, for example, as allowing for enrichment and exploration of new directions...we should not evaluate either trend as intrinsically good or bad. Rather we should attempt to assess their respective strengths, directions, and characteristics in order to adjust to and capitalize on their qualities. (pp. 1062-1063)
When we apply these insights to the development of the self, I would propose that multivoicedness, as a metaphor, has the potential to under-
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stand both the dangers and the chances for the developing self. A danger is when multivoicedness goes off track as a result of an overemphasis of centrifugal forces. Insecure attachment seems to be an important developmental condition that may involve such an overemphasis. On the other hand, multivoicedness may a powerful force in the development of different, contrasting, and contradicting aspects of one's personality and in the unveiling of neglected or suppressed aspects of the self. As so many examples of creative artists, scientists, and spiritual people have demonstrated, a strong synthesizing self, and much courage, is needed for the centrifugal exploration of the opposites and extremes of our experiential worlds. This exploration is potentially enriching but one may get lost. To answer Dr. Bucci's first question most briefly: A psychological theory of multivoicedness does not need the postulation of a central organizing entity, but it needs a dynamic theory of mutually complementing centrifugal and centripetal forces. Dr. Benjamin: I think it is most useful therapeutically to think of an "executive self" that can access "reality" as well as the various inner selves. The therapist speaks usually to that strong part. Together, the therapist and the strong self access, hear, mediate aspects of the less adaptive internalized representations. Well-functioning individuals engage regularly in self-talk and fantasy. Normal and pathological copy processes are identical. The difference is only in what is copied and internalized. Normals internalize well-socialized patterns, while disordered folks devote themselves to distorted and maladaptive "rules." I suspect that people who are desperate to avoid blame are more likely to have hallucinations, because hallucinatory fantasy is marked by separation from the self. I think that treatment focuses mostly on repair of splitting or fragmentation. I would not reject other terms or descriptions for different forms or functions of imagination. I simply picked three fairly common ones and concentrated on the one (hallucinations) for which I happened to have some relevant data. I would like to add that the data show that hallucinations can be loving as well as persecutory. Their quality differs with diagnosis (Benjamin, 1989). Dr. Stiles: We now move to a different line of inquiry. The next questioner is Dr. Bertram Karon. Dr. Karon: I have related questions for two of the panelists. First, Dr. Fonagy, if the attachment pattern you describe underlies dissociative disorder, what is the attachment pattern underlying more serious pathology,
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like psychosis or schizophrenia? Certainly this attachment pattern seems very serious. Second, Dr. Benjamin, I think you have written an excellent paper. Among other things, it demonstrates how misguided are those clinicians who think that discussion of the meaning of hallucinations should not be part of the treatment process with hallucinating patients. Can you say more about how such discussions might proceed in therapy? Dr. Fonagy: Dr. Karon raises a most interesting question. To my knowledge, there are no data available on the attachment patterns associated with psychosis. However, I would be surprised if there was a specific attachment pattern associated with schizophrenia. Attachment, theoretically and empirically, is at best "loosely coupled" with the severity of psychopathology. For example, autistic children, tested in the strange situation, appear to be securely attached to their caregiver (Capps, Sigman, & Mundy, 1994). In general, the relationship between attachment and psychopathology is a complex one. Many of us believe that attachment patterns may predispose to specific psychological problems but do not cause them. Thus conduct disorder in children in some longitudinal studies has been shown to follow avoidant attachment patterns in infancy (Renken, Egeland, Marvinney, Mangelsdorf, & Sroufe, 1989). The majority of avoidant children are not behaviorally disordered and there may be many children with conduct problems with resistant or even secure patterns of infant-mother attachment. Nevertheless, we may conceive of a transactional developmental process whereby an individual's specific adaptation to an insensitive early caregiving environment predisposes them to oppositional, conduct disordered, and ultimately delinquent behavior. Let me illustrate. Let us assume that certain temperamentally difficult boys have mothers whose past experiences, the mental representations in which these are encoded, and current mental state make it hard for them to relate in an attuned way to a male child. Perhaps as a consequence of unresolved experiences of trauma, they are frighteningly intrusive, and are certainly relatively unresponsive. This creates a particular risk in that nonresponsive parenting we know exacerbates the irritability or demandingness of the infant (Shaw, Owens, Vondra, Keenan, & Winslow, 1996), which in turn increases the mother's difficulty in parenting. Anxious-avoidant attachment develops to the mother as part of a strategy to avoid being blocked from access to her, and approaches decline in frequency in the middle of the second year. Thus a holding environment that could contain the child's, perhaps constitutionally determined impulsivity or hyperactivity is absent. With increased mobility come more frequent episodes of undirected anger and negative reactions which may provoke mothers of these infants to view their child's behavior as demanding and difficult.
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The disengagement in the mother-child dyad, which is reflected in the infant's reduced expectation of security from her, also disrupts the child's opportunity to learn about mental states in the normal course of interaction. Mentalizing, conceiving of interpersonal experience in terms of mental states or minds, we believe, gives coherence to the self-representation. Without it, the self is experienced as at risk of disintegration. Oppositional, and at times aggressive, behavior serves the function of protecting a fragile side of ourselves so, expectably, the child's behavior will become increasingly negative in approaching the mother yet simultaneously shielding himself from her. (At this stage difficult children are only difficult with their attachment object.) By 24 months the dyad may be predisposed to a coercive style of interaction. It is hard to control a child whose bond to the caregiver is deeply insecure, as a major means of control (the threat of loss of love) has significantly reduced potency. Gradually, the characteristics of the dyadic process will be generalized to others. For example, the child may extend his expectations of interaction to a preschool situation. Coercive intervention strategies become more extreme and therefore almost by necessity less consistent (Patterson, DeBarysh, & Ramsey, 1989); harsh or threatening punishments cannot be employed to address every instance of rule violation. The child's motivational system has become extrinsic. Self-control, based on sensitivity to internal signals, fails to emerge. Ultimately, under the influence of peer group pressures and subsequent environmental assaults, disorder of conduct and, with age, delinquent behavior starts to emerge. A major measurement problem arises in explorations of the relationship of attachment and psychopathology. A measure that is perfectly valid in classifying a normal population in terms of attachment may be less than adequate in a clinical setting. For example, in the coding of adult attachment types narrative coherence is regarded as an important marker of attachment security. However, certain diagnoses pretty much preclude coherent narratives—an example would be schizophrenia. This certainly does not mean that all schizophrenics are insecure in terms of their attachment relationships. The field requires a number of alternative measures of attachment that intercorrelate highly in a normal population but that are sufficiently diverse in method to permit disentangling the internal working model from the symptom and thus permit comprehensive studies of attachment, psychopathology and psychological treatments. Dr. Benjamin: Dr. Karon asks a quintessentially relevant question. However, I have no idea how to answer it briefly. Does it help to say that you would discuss the relationship with the hallucination the same way you would discuss relationships with other "key figures"—clarify; note connec-
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tions, motivations; explore affect, thoughts, behaviors; work toward friendly differentiation. Dr. Karon: I would like to underscore Dr. Fonagy's (this issue) observation of the importance of parents' mentalizing about their infant. This shows how wrong those psychologists, pediatricians, and even psychoanalysts have been when they encouraged parents to think that infants do not have complex mental lives and discouraged parents from mentalizing about their children, which if successful was hurtful to the infant. Moreover, the attachment and mentalizing of the good parent, even before birth, underscores what we have learned clinically, that spontaneous miscarriages need to be mourned as real losses and not minimized, as so often has happened in the past. I wonder if other panelists have thoughts about the role of the voices of children in the mental life of their parents. Dr. Elliott: Dr. Karon raises the important issue of parents' mental representations, or emotion schemes, of their children, including their very young and even unborn, deceased, or miscarried children. These powerful representations can and should be the focus of clinical intervention with clients who come to therapy to deal with parenting difficulties or to work through their grief at the loss of a child from death (e.g., sudden infant death syndrome), miscarriage or even divorce. The "possible other" represented by the miscarried child may be very psychologically real for the bereaved parent, because it implies the loss of an associated "possible self" (Markus & Nurius, 1986) and an incipient attachment bond. Key processexperiential tasks in work with such traumas would include (a) empathic understanding for the felt meaning of the deceased or lost child, (b) creation of meaning work (Clarke, 1989; involving the contradiction between cherished beliefs and the loss), and (c) perhaps Empty-Chair Work, in which the parent addressed their imagined representation of the child. Finally, we have also found clients' experiences with their older children to be a frequent source for problematic reaction points (for systematic unfolding), as well as for a particular form of Two-Chair Work in which the conflict involves a split between self and an other (here understood as an attributed aspect of self) to whom the person consistently overreacts, for example, a "difficult" child—or one's teenager! Dr. Stiles: The next questioner is Dr. Mikael Leiman. Dr. Leiman: I would like to ask Dr. Fonagy how he is able to combine attachment theory with his object relations account so smoothly (Fonagy, this issue). I find it quite difficult to see how these views can be related because, to me, there seem to be quite profound differences. In my understanding, attachment theory rests on assumptions derived from ethology and behavioral psychology. The first is the division of self and other into two primarily separate entities whose relationship is then
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described in terms of the attachment patterns. As he says in the beginning of his presentation, the key assumption is that the individual constructs mental models of social relationships of his or her early interaction with the caregiver. The interaction is usually described in observable terms. The four basic attachment patterns follow this principle and are deduced by using the behavioral responses of infants to the strange situation experiment. Attachment theory also seems to have adopted some cognitive notions. In an initial, more extended version of his paper, Dr. Fonagy said: "Internal working models are mental schemata, where expectations about the behavior of a particular individual toward the self are aggregated. The expectations are themselves abstractions based on repeated interactions of specific types with that individual." When he moves on to the object relations understanding of the origin of internal voices, another aspect of looking at early development comes to the fore. There is a matrix of joint activity that is mediated by the caregiver. The salient mediatory process is the caregiver's interpretation of the infant's activities and utterances. As Dr. Fonagy's research shows, this aspect can be brought into the context of attachment theory, which is illuminating. The process of interpretation is, however, understood quite differently in cognitive psychology and object relations theory. The relevant technical term is containment, emphasizing how the act of interpretation is related to the quality of the infant's utterances in addition to its content. Different modes of subject-object relationships are played out, including situations in which the boundaries of those involved are experientially dissolved, and a joint sign, or even a concrete object, expresses the meaning in the joint experience. I am thinking here of Ogden's (1994) recent elaboration of the concept of containment. These notions allow for all the subtleties in the self-other articulation that our patients bring into psychotherapeutic relationships. Usually this articulation is also linked with the quality and content of the symbolic mediation available to the patient. In my view "metacognitive control" is quite an impoverished account of this developmental complexity. I get the feeling that Dr. Fonagy's conclusion regarding the necessary preconditions for the development of the sense of agency ("the normal integration of intention and behavior that generates self-agency requires the presence of a caregiver capable of mentalizing the child's intentional state and bringing the external state of affairs in line with his rudimentary action. In the absence of such early experience, the self will feel no true ownership of its acts . . .", p. 190) is elaborated by using the object relations notions and not the attachment theory, which has very little to say
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about the interdependency of subjectivity and the early modes of intersubjective activity. Dr. Fonagy: I very much welcome Dr. Leiman's informed and reasonable criticism. There is a certain sense of satisfaction to be had from being caught red-handed having performed an intellectual sleight of hand, which tempts one to say (as villains of yore are said to have done to London Bobbies), "It's a fair cop, Gov." I have just finished writing an extremely long and correspondingly dull chapter for the Cassidy and Shaver handbook of attachment on the relationship of attachment theory and modern psychoanalytic approaches. I am tempted to produce a summary of that chapter here but will resist the temptation. There are many answers to Dr. Leiman's question. The most important is that attachment theory is developing and in many respects is moving toward object relations theory. In particular, those of us who are interested in the origins of internal working models (Inge Bretherton, Morris Eagle, Jeremy Holmes, to name but a few) are using concepts from Bowlby, Fairbairn, Winnicott, and Bion almost interchangeably. Are we doing this at the expense of a "levels of analysis" transgression? I believe not. In Alan Sroufe's formulation attachment is principally a mode of affect regulation. The infant signals affect, this affect is perceived and responded to by the caregiver, and the response acquires meaning in the context of returning to an equilibrium. The caregiver's response signifies the affect but also its containment. We suggest that it is this response that is internalized to become the meta-representation of the meaningless, chaotic internal state that preceded it. This description of containment can be stated in behavioral terms. The caregiver's response in part mirrors but in part distorts the infant's affect. Mothers who are able to soothe their babies rapidly mirror the child's anxiety and distress on their face but mix this affect with another emotion, e.g., humor, irony, incompatible with the child's signal yet reflecting coping as well as understanding. In achieving affect regulation, the child internalizes the mother's response, which becomes the symbol of his, up to this point, unmentalized internal state. If the mother's reflection is too accurate, this symbolic function is jeopardized. The internal state is exaggerated rather than attenuated by the caregiver's response. One might imagine that individuals with generalized anxiety disorder have inadequate symbolic representations of their internal states based upon inadequate, or rather overadequate, mirroring. But what of the notion of experientially dissolved boundaries? I think there is an important clarification that is required here. Dan Stern (1985) drew our attention to the qualitative differences in the developmental course of the physical and psychological self. Infants are well aware of their physical separateness yet may not experience their mind as necessarily lim-
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ited to the space defined by their body boundary. In fact, it is an essential aspect of our understanding of self-development that the child acquires knowledge of himself from the perception of his own mental state in the behavior (and particularly facial expression) of the caregiver. A representation of mind is a representation of the other engaged in understanding the self. This is not so much internalized, introjected, or incorporated as object relations theory generally presupposes. Rather, it is experienced as happening within, since the boundaries of mind are not clearly drawn probably until the second year of life. The developmental strategy of attempting to find oneself in the other as a psychological being is retained throughout life and I believe lies at the root of the entire psychotherapeutic enterprise. I agree with Dr. Leiman that metacognitive control is a hopeless term in this context and I promise never to use it again. Dr. Greenberg: I am not sure I follow clearly the discussion of containment in Leiman and Fonagy's discussion, but my reaction from a dialectical constructivist perspective is that the self is created by a co-constructive process that synthesizes the child's affective experience with the caregivers response. There are always two sources that are combined to make the whole; thus, it is not the parents' mentalization of the child alone that creates the child's mind. It seems to me, drawing on such sources as Piaget and Pascual-Leone, that the child is an independent source of agency in the creation of its mind. Dr. Stiles: I believe Dr. Bucci has some further comments. Dr. Bucci: I see an issue of what I might call vertical vs. horizontal organization in characterizing multiple voices, where there might be an ambiguity to be addressed. The vertical organization would refer to different entities represented within the self—mother, father, therapist, spouse, partner; or Mary and the witch; or imaginary playmates—each more or less fully formed with different agendas, different needs, emotional states, capacity for reason. When Lorna Benjamin (this issue) talks about hallucinatory fantasies as including a mixture of patterns and as highly organized according to normal social rules, as indicated by Structural Analysis of Social Behavior ratings, she seems to be talking about this sort of vertical organization. In contrast, when Elliott and Greenberg (this issue) talk about interaction between critical and experiential self-aspects they are implying a more horizontal organization, i.e., the different types of functions or processes (in my terms, "multiple codes") operating within a more or less integrated self. I know this could be seen as a matter of degree, with each approach including some degree of vertical or horizontal organization, not wholly one or the other, but it seems to me that Elliott and Greenberg (this issue) shift very far toward emphasizing the horizontal when they talk about "two
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different aspects of the self, one more 'external' or conceptual, the other more 'internal' or emotional," (p. 231) with the external corresponding to the client's perception of the situation in which the puzzling reaction occurred, including external details; while the internal involves the client's subjective emotional reactions. This is a far cry from the independent, ideologically authoritative characters, authors of their own contrasting views of the world and so forth, of whom Hermans (this issue) writes, or from the organized relationships that Benjamin (this issue) refers to. I think Elliott and Greenberg particularly need to distinguish between multiple voices as multiple processing codes in the basic psychological sense, on the one hand, vs. multiple voices as independent characters involving distinct well-organized relationships. Many people with more conventional or traditional views, even psychodynamic views, who may have trouble with a notion of multiple autonomous I positions could accept the concept of multiple different types of processing systems continuing throughout life, in more or less integrated forms (Bucci, 1997). I suggest that the notion of horizontal vs. vertical configurations might be helpful in explicating this distinction in approach. Dr. Elliott: Dr. Bucci's characterization is interesting and raises the important issue of how self-aspects or psychological modules are related to each other. From my point of view, the important thing is that the self has a modular structure, and this modularity can be organized on multiple dimensions, including "horizontal" (i.e., "depth of processing") and "vertical" (i.e., "multiple selves"). In some therapeutic tasks, the modules involved are unambiguously "horizontal" in Bucci's terms, e.g., focusing (internal felt sense vs. symbolization) and unfolding (perceptions of situation vs. internal feelings). On the other hand, the "Critic" and the "Experiencer" in Two-Chair Work are clearly what Bucci would refer to as "vertically organized entities"—"characters" in Hermans' sense, or "organized relationships" in Benjamin's view. (Note, however, that we continue to have difficulty with the use of the reifying "entity" metaphor to describe mental phenomena.) In Two-Chair Work, the two aspects of self are each structured around one or more "emotion schemes," which in turn are comprised of networks of interconnected memories, feelings, thoughts, wishes, and action tendencies (Greenberg et al., 1993). It is true that in this therapeutic task, the two self-aspects begin with an additional "horizontal" structure, relying primarily on different modes of processing (as demonstrated by their varying Experiencing Scale ratings). However, resolution of conflict splits requires that the critic aspect shift from purely conceptual to more affectively based processing, so that the nature of the dialogue moves from cross-horizontal layers (deep/emotional vs. shallow/conceptual) to cross-vertical organiza-
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tions. In other words, successful Two-Chair dialogues become conversations between different "deep" aspects of self, such as needs/wants vs. values/standards or vulnerability vs. compassion. Thus, I see the vertical-horizontal distinction as potentially useful, but risking oversimplification. First, because different depths of processing are often associated with different highly organized aspects of self, vertical organizations can also vary horizontally. Second, all of these modular selfprocesses are likely to vary over time, even within a particular therapeutic task within a particular session. From the process-experiential perspective, the important thing is that there should occur some form of internal dialogical process in which different internal "selves," "voices," or "processing layers" are clarified and brought into psychological contact with one another. Dr. Fonagy: I think Dr Bucci's point is enormously constructive and clarifying. To me she is suggesting that our papers fall into two categories: those that address what she calls vertical separation between selves or identities and those that suggest horizontal separations. This point is related to, but not the same as, the distinction between vertical and horizontal splits in traditional psychoanalytic thinking. To recap, psychoanalytic theory distinguishes between defensive separations of different levels of functioning and defensively imposed separations at the same level both as means of forestalling the recognition of incongruities. Although within psychodynamic theory healing both kinds of splits is a therapeutic goal, I can well appreciate that there is a qualitative difference between the therapeutic tasks implied by the two. Dr. Elliott, in his comments, points to the risk of oversimplification. Clearly, these axes are not orthogonal and stable over time. Dr. Bucci's point, however, stands: The integration between different codes—different modes of representation—is a qualitatively different task (therapeutic or personal) than integration of representations within the same code, where separate levels of representation may be more clearly maladaptive and not intrinsic to the system. On reflection, I think in my paper I was discussing the dangers of multiple representations within the same code and the need to develop a representational code, that of the language of intentionality, which is able to encompass, place side by side, overview, and integrate self-representations at the same level of analysis. Conversations between different levels of analysis, between different codes, may indeed be healthy and productive. Maintaining the integrity of these levels seems to me to be relevant and important as a therapeutic goal, while the creation of artificial integration is a foolhardy task doomed to failure. I also see the way in which creativity is facilitated through the maintenance and recognition of the distinction between different codes.
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Dr. Stiles: Finally, we have left a little space for the panelists' comments about each other's papers. Dr. Benjamin: This is a very interesting series of papers. I am more impressed with the convergences than the divergences. Certainly the topics move the Society for Psychotherapy Research in a new direction. This kind of exchange makes coming to meetings especially useful. The idea of continuing on the internet is groundbreaking. Thank you, Dr. Stiles. Dr. Hermans: There is one point which I experience as an empty spot when looking back at our discussion. This point has to do with the nature of the assessment and research procedures typically used in psychotherapy research. To what extent is it reasonable to assess a person with neglect of the specificity of the situation in which the person lives. For example, what are the implications if we classify children as securely attached or insecurely attached on the basis of a test situation. In a similar way, we may speak of hallucinating people as representatives of a category. If we are posing questions based on classifications of people or dysfunctions, we may neglect the question: In which situation does a dysfunction become manifest and in which situation not? Or, even stronger, are dysfunctions dysfunctional in every situation? For example, if an insecure attachment is found on the basis of a strange situation test, and if this insecure attachment has important consequences for later life, is this personality problem then expressed in later life irrespective of the nature of the situation in which the person will become involved? Or, if a person has hallucinations, do these hallucinations appear in a great variety of situations or, rather, in specific situations, and what is the meaning and influence of the hallucinations in this specific situation? I pose this question, because I was impressed by the fact that in Mary's case there was one situation that showed an exceptional affective structure: her work situation (see valuation 4 of Table I of my paper; Hermans, this issue). Whereas the other three situations (contact with her mother, being at home, and the moments in which she could permit herself to receive) evoked affective responses implying considerable discrepancies between Mary and the witch, the affective profiles of Mary and the witch were remarkably similar (correlation = .74). Note that the degree of this similarity was equal to the degree that was found, one year later in the second investigation, when Mary's valuation system as a whole was much improved. Whereas the witch was a serious threat in the intimate relation with her husband, she perceived the witch as an efficient partner in her work situation where she had to defend her interests against her superiors. The situation issue is part of a more comprehensive discussion that concerns the nature of basic metaphors or, in Pepper's (1942) terms, world hypothesis. It may be useful to compare two of them, formism and con-
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textualism. Formism is applied to views that stress the organization of the world on the basis of the form of objects, that is, on the basis of their perceivable similarities and differences. Personality trait theories and classifications of dysfunctions (e.g., Diagnostic and Statistical Manual classifications) are typical examples of formism. The central element in contextualism is the historical event providing the basis for a story or narrative. An event can only be understood when it is located in the context of time and space. Sarbin (1986) argues that contextualism presupposes an ongoing texture of elaborated events, each being influenced by preceding and following episodes, and by multiple agents who engage in actions. Contextualism assumes a constant change in the structure of situations and in positions occupied by spatially located actors who are, as intentional beings, oriented to the world and toward one another. Typically, these actors have opposite positions as if functioning on a stage as protagonists and antagonists, entertaining relationships of love, hate, agreement, or disagreement, and reality is co-constructed in often unpredictable ways. In sum, contextualism may be a relevant metaphor if we want to give attention to the specificity of the situation in which clinical problems are expressed. Moreover, taking space and time into account, we are forced to deal with the associated problem of unpredictability of human behavior. Dr. Greenberg: I have two general reactions to the papers. The first is to Hermans's earlier comments (in response to Dr. Bucci's first question) on viewing of the voices or parts in a trait manner. I agree with his preceding comments on the importance of seeing these as occurring in contexts. I generally like to keep the parts highly fluid in the moment rather than see them as structural entities. In marital therapy for example people often refer to going crazy or entering states that they later know not to be "true"—states in which they feel desperately abandoned or intrusively punctured by their partners. In these states they rage or wall off in ways they later see as not really them. These states seem to have a mind of their own, but they are most often seen as states of mind rather than as separate "I"s." Possibly the degree of structuralization of parts or states is a measure of dysfunction. In addition, in my view, integration and harmony between parts is a sign of health. Second, with reference to both Benjamin's (this issue) and Fonagy's (this issue) papers and responses, I think the internalization of the other as an introject is often a source of one of the voices. I often work explicitly with the face of the other in the critic chair in Two-Chair Work. Here the face carries the contempt, disinterest, or disapproval, "in the face of" which the self feels shame, worthless, or bad. Thus, the voices of internalized others are often important sources of voices in the internal dialogue, and,
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much as Benjamin says, these voices obey the rules of interpersonal dialogue. This view of internalization would, I believe, also would be in line with the attachment notion that we internalize how we are treated by others. Not only do we expect others to treat us that way, but we treat ourselves in the same way we were treated. This, however, is often a highly tacit process, and therapy helps by bringing this fundamentally body-based emotion/imagery process into awareness. Voices, in the final analysis, are not simply in verbal language but are complex emotion-based states of mind. Dr. Elliott: For my final response, I have three points to make. First, Benjamin's (this issue) discussion of the continuum of imaginative behavior has left me with an interest in examining the role of imagination as a therapeutic process. Two-Chair and Empty-Chair work highlight this issue, as do other therapeutic methods that work with active imagination, such as guided imagery and traditional imaginai exposure methods. However, the role of imagination in narrative processing and metaphor bear examining as well. In addition, some clients experience chair work as quite difficult because they feel silly entering into the imaginative "play" of speaking to an objectified alter self. Others are reluctant to do so because they fear that it will reveal that they have a "split personality." Perhaps it would be worth examining clients' difficulties with these therapeutic tasks as situational or characteristic problems with imaginative performance. Second, I was fascinated by Hermans's description of the lingustics of first-person discourse in Sranon Tongo. It would be very interesting to examine the same phenomenon in therapeutic discourse. For example, it is common for clients to refer to "my critic," "the old me," "the rebellious adolescent in me," "my inner child," or "my felt sense." It seems to me that many forms of psychotherapy promote agentification of self-aspects for various purposes, including both self-empowerment and self-control. I think that it would be intriguing to explore the issues and processes involved here. My final point has to do with the process of this exchange: I was struck by the difference between this virtual conversation and the "live" conversation that originally took place (Stiles, 1997). At the conference, we spoke more spontaneously and as part of a public performance. This process appeared to highlight differences and conflicts between what we were saying. In contrast, the slower, more reflective pace of this virtual conversation has served to highlight agreement at the same time as it brought out new ideas and understandings. Far from reproducing the conference discussion experience, it created a very different process, one that was, from my point of view, much more productive. I think this has some interesting implica-
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tions for SEPI and this journal, both of which are dedicated to promoting dialogue and understanding across different theoretical orientations. I would like to congratulate Bill Stiles for his imaginative construction of this process and for the rigorous shepherding and nagging he used to bring it off. Dr. Stiles: Moderating the multiple electronic voices in this virtual discussion has been fun for me as well as enlightening. I thank the panelists and questioners for their very thoughtful contributions, which were within the page limits and completed ahead of schedule. I invite readers to continue the discussion. REFERENCES Altman, I. (1987). Centripetal and centrifugal trends in psychology. American Psychologist, 42, 1058-1069. Benjamin, L. S. (1989). Is chronicity related to the quality of the relationship with the hallucination? Schizophrenia Bulletin, 15, 291-310. Bucci, W. (1997) Psychoanalysis and cognitive science: A multiple code theory. New York: Guilford Press. Capps, L., Sigman, M., & Mundy, E (1994). Attachment security in children with autism. Development and Psychopathology, 6, 249-261. Clarke, K. M. (1989). Creation of meaning: An emotional processing task in psychotherapy. Psychotherapy, 26, 139-148. Greenberg, L. S., Rice, L. N. & Elliott, R. (1993). Facilitating emotional change: The moment-by-moment process. New York: The Guilford Press. Hermans, H. J. M. (1996). Opposites in a dialogical self: Constructs as characters. Journal of Constructivist Psychology, 9, 1-26. Horowitz, M. J. (1987). States of mind: Analysis of change in psychotherapy (2nd ed.). New York: Plenum. Mahrer (1983). Experiential psychotherapy: Basic practices. New York: Brunner/Mazel. Markus, H., & Nurius P. (1986). Possible selves. American Psychologist, 41, 954-969. Ogden, T H. (1994). Subjects of analysis. Northvale, NJ: Jason Aronson Patterson, G. R., DeBarysh, B. D., & Ramsey, E. (1989). A developmental perspective on antisocial behavior. American Psychologist, 44, 329-335. Pepper, S. (1942). World hypotheses. Berkeley: University of California Press. Renken, B., Egeland, B., Marvinney, D., Mangelsdorf, S., & Sroufe, L. A. (1989). Early childhood antecedents of aggression and passive-withdrawal in early elementary school. Journal of Personality, 57, 257-281. Sarbin, T. R., & Mancuso, J. C. (1980). Schizophrenia: Medical diagnosis or moral verdict. New York: Pergamon. Sarbin, Th. R. (1986). The narrative as a root metaphor for psychology. In Th. R. Sarbin (Ed.), Narrative psychology: The storied nature of human conduct (pp. 3-21). New York: Praeger. Shaw, D. S., Owens, E. B., Vondra, J. I., Keenan, K., & Winslow, E. B. (1996). Early risk factors and pathways in the development of early disruptive behavior problems. Development and Psychopathology, 8, 679-699. Stern, D. N. (1985). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. New York: Basic Books. Stiles, W. B. (Moderator). (1997, June). Multiple voices in psychotherapy clients. Plenary panel presented at the Society for Psychotherapy Research meeting, Geilo, Norway.
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Wekker, G. (1994). Eindelijk kom ik tot mezelf: Subjectiviteit in een Westers en een Afro-Surinaams universum [Finally, I find myself: Subjectivity in a Western and an Afro-Surinam universe]. In J. Hoogsteder (Ed.), Etnocentrisme en communicatie in de hulpverlening [Ethnocentrism and communication in the community service] (pp. 45-60). Utrecht: Stichting Landelijke Federatie van Welzijnsorganisaties voor Surinamers.
