Ego Analysis as a Deeper Form of Cognitive Therapy

What the standard cognitive therapist (CT) does is to be an attorney in this case you are bringing against yourself. The CT takes the charges against you seriously. Although there are ways we disagree with CTs, we especially appreciate the way they respect self-condemnations. They never tell you you’re being too hard on yourself, which risks making you feel bad about feeling bad.

Here you are in the courtroom and the case against yourself seems to have been decided. You have been found guilty, but the charges are vague and poorly substantiated, as Kafka knew. The CT shows that they demonstrate cognitive errors, like overgeneralizing, catastrophizing, all-or-nothing thinking, and jumping to conclusions.

This is negative self talk. When patients first appear they usually are not hearing it. They are just knowing facts. The patient comes in saying “I have trouble finishing projects and I seem to get distracted easily. I thought you might be able to help with that.” It’s just factual; not an unusual problem and one for which it is reasonable to expect to find a solution. What the patient is not hearing what CTs call an “automatic [negative] thought.” In this example, let’s say it is something like, “You are inadequate. You never do anything right.”

Typically the thought is in the form of a one-liner or phrase, as if spoken from one part of the mind to the main part—so it is self talk. As we put it, a subself is talking to the host self. This language of multiple personality disorder is helpful, just as MPD patients are good informants. But the patient is only aware of a fact, that is, of the emotional impact of self talk.

The patient may not even be aware of feeling inadequate, but only of a dull, enervating feeling, which may itself be what makes it hard to finish things and makes him easily distractible. This reversal of the causal arrow is prototypic. We logically assume that our mental state follows from our doings with the world, when psychologically the reverse is often the case.

The genius of CT is to quickly demonstrate to patients how what seems to them to be simply a fact about them, or just a feeling, is a reaction to something they are being told, by an inner voice. Not only that, it is an inner voice that has it in for them, is prejudiced against them, will use the flimsiest of evidence to condemn them.

This is introducing the patient to a whole different paradigm: to the psychological revolution of the 20th century, in which we have come to recognize that there are psychological processes that create our experience. Pre-psychologically, people just thought that how they felt was a direct reaction to the world impinging on them.

In modern times if someone says “I’m inadequate,” we don’t say, “That’s too bad—sorry to hear it.” We know it’s what we call subjective; it’s a feeling. But in pre-psychological times it was taken as so factual that a person would never say it. They would just know it.

We have all seen patients who, when you ask them how they feel, will just describe what happened.

“I just got passed over for a promotion.”

The therapist asks, “How did you feel about that?”

“I didn’t expect it.”

The therapist, frustrated, “But how did you feel about it?”

The patient, equally frustrated, “How would you feel?”

The patient is offended, as if his sanity is being questioned—as if he had said he broke his ankle and the therapist asked, “How did it feel?” It’s a paradigm clash. The a patient lives in a world of facts. The therapist lives in a world of interpretations.

Many people take it for granted that their feelings are an inevitable consequence of what happens to them. The subjective-objective split was a product of the psychological revolution, maybe was the psychological revolution. Before that, there was no model for experiencing your feelings as separate from external events. Your feelings were real. What does it mean to say that?

Think of the self-hate of minority groups, of the underclass in any society. The individual feels abashed in the presence of a social superior, uncomfortable—tries to be as inconspicuous and unchallenging as possible. Even among peers, pride and even strong emotions are seldom felt. We infer self-hate, but the actual experience is more like self-apathy—in other words, feeling unimportant, easily substitutable with anyone else. For such a person there would be no way to bring out a negative voice or subself because, you might say, there is no organized host self. Typically, when such people are in the presence of a therapist—as in a community clinic—the sense of inferiority and shame is so restrictive that the individual can only try to minimize the exposure and to muster whatever deferential behavior they can come up with. “Pardon me for living” is our sarcastic phrase of choice to register a slight, but for these people it captures what they actually feel.

It is also true that the upper class individual in most societies is no better at self representation, as contrasted with most Westerners, since we specialize in consciousness. And it may be fair to say that none of us is so actualized as to be fully conscious (which, to avoid any misunderstanding, I should add would mean being fully aware of the limits of consciousness).

A big insight of the seventies was that people needed to get in touch with their feelings, and that therapists were overlooking this. Janov, the Primal Therapist, said he found it disturbing to walk through a clinic and not hear a sound coming from the offices, no groans, much less screams. The movement to get people into their feelings ran out of steam and is no longer heard from, I think because it did not come up with any good way to accomplish this. Worse that that, it assumed that feelings were just there, so all you had to do to get at them was to ask people what they were feeling or, in hard cases, to overcome their resistance.

The problem comes into focus when you recognize that feelings are not just there, but that people have to be enabled to experience them. One way is by suggesting possibilities. This is more relevant than it at first seems. None of us can organize feelings unless we have the idea first. In 1980 or thereabouts the idea of sexual abuse appeared, following the appearance of the idea of physical abuse a decade or so earlier. Suddenly women could have feelings about it. One woman who grew up in a commune and had been molested by a male teacher between the ages of eight and ten and by another man for about seven months at age thirteen, ran out of the room crying when a teacher talked about child abuse. “I’d never heard of it, but realized I’d been living it my whole life.” Suddenly she could have the experience.

Sexual abuse is a good, sobering example because its recognition is such a recent accomplishment, despite its being one of the most profoundly traumatic experiences. Imagine how much of our experience still remains unoccupied territory, as we gradually expand our grasp.

In the seventies, the phrases like “cop out” and “ripped off” suddenly had currency and people were quick to inhabit the experiences they made available. “That brings me down” from the drug experience is another example of the time. More recently, feeling abandoned, unheard of earlier, has become popular (deservedly so), as has not-feeling-empathized-with.

CT has introduced another way to get people in touch with feelings. The CT does not ask, “What are you feeling?” The question is, “What are you telling yourself?” Although this question can be difficult, it is a much easier question to answer—partly because it can be pursued further—and it gets at the same thing.

The CT opens the patient’s eyes to another way of looking at “I am inadequate or unlovable.” Recognizing that it is something you are hearing, that you are being told, rather than simply knowing, puts you in a different relation to it. It brings your adult mind to bear on it.

Of course, there are obsessional or depressed patients who are well aware of the existence of self talk. That may even be their presenting symptom: feeling harangued by an inner voice, nagged, belittled. They are good informants; they are the ones who teach us about self talk. Just as the MPD patients teach us about subselves and about moods.

What Beck made plain is that it is not just obsessional patients who experience self talk—that we all do. But unlike the obsessional we don’t hear it. All we are aware of is the outcome: what we experience as facts.

Just like when we were kids. Our parents would call us stupid, selfish, or lazy and we wouldn’t know we were being abused. We just thought we were learning facts. We were learning what we really were like. The concept of verbal abuse itself is a recent discovery, and we only recently have been paying attention to how kids are subjected to fairly constant verbal abuse. Twenty years ago no one was thinking or talking about it.

Now in one way all therapists make the translation from what the patient thinks is a fact, to a feeling. But they make the translation instinctively. Unlike the CT the standard therapist does not challenge the patient’s experience of facticity. It may be fair to say that many therapists assume that the fact of patients’ experience is less salient than their feelings about it. I think a lot of unpsychologically minded people drop out of therapy because they can’t share this assumption. As I have been saying, they feel challenged, as if their experience is being questioned, as if they are just having feelings. My favorite example is a rather heartwarming story told by Harold Galooshian:

He saw this patient in a consultation session with the referring psychiatrist, who had been getting nowhere with this man. The patient thought he had a contagious disease and was perpetually infecting others, even killing them. Goolishian reported that “Multiple medical consultations and psychotherapies had failed to relieve the man of his conviction and fear.”

Goolishian asked, “How long have you had this disease?” The man “looked astonished,” turning to the referring psychiatrist, who was observing, and exclaiming, “He believed me!” The patient apparently felt greatly relieved and understood, going on in the session to talk at length about his experience.

Goolishian reported that his colleagues were critical. “Many suggested that a safer question would have been, ‘How long have you thought you had this disease?'” They worried that Goolishian’s version of the question would “have the effect of reinforcing the patient’s ‘hypochondriacal delusion. ‘”

The multiple consultations and psychotherapies got nowhere because the patient felt challenged, since his experience was being questioned. “How long have you thought you had this disease” would just mean, “How long have you been crazy?”, as if his experience was itself being questioned. Once his experience was taken as presented— was taken as a fact—he was eager to talk about it, undoubtedly to express just how poisonous he felt himself to be.

Once on this footing, it would be easier to see that he actually was unable to feel poisonous, to use that ego-analytic jargon—which, translated, means that’s how we translate his concretization of the worry, but since he experiences it concretely, this means he is unable to experience it directly, that it is too disturbing and so gets warded off and then comes back in distorted form. (Thus the solution is not for him to get over feeling poisonous, i.e., to “relieve the man of his conviction and fear,” but for him to be able to tolerate the worry in its original everyday form: “I’m afraid I’m a bad influence on people; I seem to make them uncomfortable.”)

Even people who have learned to think of themselves as having feelings rather than facts may still, underneath, think they are having facts, maybe getting really convinced only over a long period in therapy. I think CT succeeds because it pointedly challenges the experience that there is no self talk, only facts, hitting this issue right away by bringing out the disapproving, critical, blaming, inner voice. Bringing out the sentences: the automatic thoughts based on pathogenic assumptions or beliefs, the if-then, or should statements, and the schemas (I’m inadequate, worthless; people are dangerous). Patients list them and log them in when they hear them, so it becomes a convincing experience for them. They can feel their impact.

Typically these are thoughts that can only be detected by focusing on feelings first. That’s why calling it “cognitive” therapy can be misleading. The thoughts are retrieved by seeing what phrases and sentences the feelings bring up. And once these phrases and one-liners are made conscious, the feelings they create become clearer.

CT operates at the point that the standard dynamic model blurs over. The standard model goes right to why you think about yourself as you do. CT dwells on that you think about yourself as you do.

CT has shown us how we are in a constant struggle with self blame, with what Sullivan called self-esteem regulation. But CT has brought out only one side of the struggle. The side of the inner voice that takes potshots at the host self.

This is a funny thing about standard CT. CTs are so focused on bringing out and refuting negative inner voices that they ignore the fact that the host self is usually not passive, but argues back. In other words, CTs are so focused on arguing with negative thoughts that they overlook the fact that we usually are already arguing with them. In this light, what the CT is doing is strengthening our arguments against negative thoughts—arguing against them better than patients can.

What you find when you don’t try to refute the automatic thoughts or pathogenic beliefs, is that patients themselves not only have automatic thoughts, they have automatic refutations.

So the patient may hear “You can’t do anything right, ” but he also hears the rejoinder that “I do so do things right.” Although this automatic refutation usually takes a different form. It may take the form of a fantasy of being super-competent. Or actions that are intended to prove that he really is a very competent person, and he may succeed in proving that over and over again.

You have the automatic or negative thought, “I’m inadequate,” and then you have the equally automatic refuting thought, “But look how adequate I was about parking the car, or getting all my books lined up in a row, or getting this item on sale, or look at this license on my wall.” Those refutations only work momentarily; we do a kind of broken-field running.

They can fail and that’s when a cognitive therapist can help you develop better ones. The CT works more effectively by tackling the negative thoughts directly, taking them apart, showing how they misconstrue you, how they are unfair, biased, and how they can’t stand up against everyday evidence.

We find that there always are refuting thoughts, sometimes very well hidden. It is, in effect, a deeper cognitive therapy to bring out this side. In fact, this may be much of the reason that negative thoughts can be so hard to hear. Refuting thoughts block them from awareness, even though they do not eliminate them.

Let’s take an everyday example of how negative self talk typically looks. You find that you feel a little draggy about some chore, let’s say fixing something or attending to some problem with your computer. Something you can put off, but that would be more convenient if you could get it done. And it wouldn’t take that long. But you can’t seem to get around to it. It just seems like a simple case of not feeling like it. We’ve all had that experience.

When you look at it more closely you notice that you feel slightly disheartened. Now if you make an effort to tune in to it a little more deeply, you may find that you actually feel a little apprehensive. Taking that further may reveal that what makes you apprehensive is that if you fail at the task you’ll get harshly criticized, although you may not hear the criticisms. You will lose your good opinion of yourself. But you don’t think you should; after all it’s no big deal. So you don’t know about this black cloud hanging over these chores, this threat.

So you shy away from the task. Maybe you forget about it. But as we see it, that actually is your problem. It’s not the negative thoughts themselves. Many negative thoughts lose all their power when you can actually hear them. Because then you have your whole conscious adult host-self to review them. That often automatically refutes them. You automatically realize that just because you screwed up your VCR doesn’t mean you are a complete washout as a human being.

But, if you don’t or can’t pull up that negative thought, then it has the effect of making you feel like a complete washout. So the real problem is our avoidance of the negative thought—of fear of it— which keeps the thought buried, but leaves us with a continuing apprehension and consequent urge to avoid whatever might trigger it.

Our approach is to bring out the whole internal argument. The whole courtroom scene. That takes us into the whole world of blame that we all struggle with (see The Shame-Blame Reflex) whereas CTs stay focused on just the one side of our struggle for justification. They will argue, as your attorney in this courtroom drama, that just because you screwed up your VCR you are not a total washout. That can be very relieving. But, as I will get to, it can be even more relieving to have the person experience the full impact of the internal condemnation and of the weak internal refutations that only kept it hidden.

The brain is described as a foresight organ, and this may be its most obvious function, but less obviously it is a self-justifying organ, that is, it is constantly hunting for ways to escape self-blame, to argue against negative thoughts. It works all the time to rationalize our experience so as to keep our self-esteem from sinking. We live in the courtroom.

We even fight off self-accusations as we sleep, in dreams. Our dreams are ways of justifying ourselves so we can sleep without being awakened by negative thoughts. This is the ego analytic approach to dreams, that is, that dreams are just our way, when asleep, of doing what we have to do when awake.

The mind weighs everything in legalistic terms, looking to see whether it is good or bad. We all see this operating all the time in therapy. Patients are always taking what you say as praise or blame, as meaning something is good or bad, as I have mentioned in a lot of places on this site.

Therapists can make the natural mistake of saying that that’s the wrong way to hear what they said, carrying the message that it’s bad to hear a comment as good or bad. The ego analytic therapist is more likely to say that its natural and expectable to hear the comment that way—maybe unavoidable. That does not, of course, mean to take it for granted, but rather keeping it in mind all the time.

I’ll give you an example of what I mean.

A therapist who consults with me said that a patient he had been seeing twice a week for several years finally asked if it was OK to park in the lot in the back of the building. He said it was OK and asked the patient how he felt about asking. The patient said it made him nervous but he was glad he was able to do it. It came out that he was worried about putting the therapist on the spot. The therapist said, “You feel like people can’t take care of their own feelings.” And then the patient went on to something else.

The next session this therapist brought up the idea that the patient’s worry about putting him on the spot was a symptom of the way he got enmeshed in relationships—how he had trouble separating himself. But the therapist was in the middle of presenting this idea when the patient interrupted and said, “Wait a minute, I don’t want to spend time on this. I’ve got other things on my mind.”

The therapist said to me that at first he was stunned, but then recovered as he realized that this man needed to be able to do what he did, which was like unmeshing himself. So he asked him how it felt to interrupt like that. The patient said again that it was scary but he was pleased with himself for being able to do it. So this time they talked about his problem with guilt.

The therapist thought the patient was being freer to be more assertive, when what actually happened was that he was acting on the idea that it’s been brought out that he’s a wimp and so he feels he’s got to be assertive.

When the therapist said, “It looks like you feel guilty about putting me on the spot,” this triggered the self-blaming voice that makes everything sound like a compliant or a criticism.Typically the patient just takes in the information and doesn’t say anything directly. But he thinks to himself that he will try not to feel so guilty next time.The therapist doesn’t intend it but it’s almost impossible to not hear the message that you shouldn’t feel guilty. Because our minds run on shoulds.

Suppose the patient said, “Do you mean that I should just assume that other people can
take care of their own feelings? That I shouldn’t feel guilty?” A patient rarely brings that out, but it often comes out indirectly. And the therapist is likely to answer, “No, I don’t mean that. I’m just bringing that out as something we need to work on.” Or something like that. Now what the patient is likely to think is that he’s not supposed to think that. So he’s not supposed to feel guilty and he’s not supposed to think he’s not supposed to feel guilty.

Standard cognitive therapy can run into the same problem. If the CT’s attempts at refutation fail, the patient is left feeling “I must really be inadequate to still feel inadequate now that I see how irrational that belief is.” Of course, CTs are well aware of that problem and have their relapse prevention strategies, largely inoculating the patient against that negative thought.

But here is where we think the the CT runs into the limits of refutation. What we call the host self still is pitted against an inner voice or subself. We find that refutation is not necessary for relief and that also it sets up a problematic model for inner growth.

CT, of course, seems to be aiming at self-acceptance, but efforts to promote self-acceptance frequently run into difficulty because such programs miss the necessity to develop self-acceptance about not being self-accepting, meaning to accept negative thoughts.

Here’s an example of what I mean:

This was a depressed patient. When faced with some task or responsibility, he often felt overwhelmed, hopeless. When we got into what he was telling himself it was, “You’re too small. You can’t do this.” He then found, on his own, that when that happened if he put his head down on his arms and said those same words to himself, “I’m too small. I can’t do this,” several times, he then would feel relieved and freer to act.

So this is an example of the relieving effect, not of refuting, but of “agreeing” with, siding with, empathizing with the voice. It can seem like the goal of empathizing with negative thoughts, of having a closer relationship with oneself, would take longer to reach than arguing against negative thoughts and refuting them. But as in this example, the effect was instantaneous.

Going back to the patient who was inhibited by feeling bad if he asked the therapist about the parking. We think that the real accomplishment would be for him to be able to be aware of feeling guilty—of being blocked by guilt, and to allow that, to be able to let that happen, that is, to not have to overcome it. For this patient, it would mean to be comfortable with feeling guilty and worried about putting people on the spot. That’s accepting the non-acceptance. This is relaxing. Because we think that the feeling that you should overcome the guilt is already there. We think of this as the development of greater internal intimacy.

People have been so impressed with the clinical successes of CT that its main contribution is easily overlooked. As we see it, its main contribution is what could be called the “microanalysis” of a problem. It exposes how glib are much of our standard ways of diagnosing and understanding problems.

The best example of what I mean comes not from CT but from EMDR, a case I present in more detail in Vignettes. This woman was dying of cancer—had only a few months to live. Her husband threatened to leave her. She kept a gun to shoot herself with if he did. It seems clear enough that under these catastrophic circumstances she couldn’t bear having him desert her.

Although this was her obvious problem—on the macro level—her real problem was hidden—on the microanalytic level, on the cognitive level.

Through EMDR work she was able to feel, not only OK about the possibility of his leaving her, but even positively cheerful about it. EMDR theory has it that the therapy actually modified neural circuits, but I see it as an extraordinary example of how a microanalysis can turn our understanding of a problem completely around.

On the macroanalytic level it looked like a straightforward case of a catastrophic reality. This woman was on her deathbed and her husband was on the verge of leaving her. It would be hard to imagine how to help her in any substantial way. But it turned out that, on the microanalytic level, there not only was the obvious problem, panic about being abandoned, there was a subtle problem that emerged as the primary one, humiliation at feeling so panicked.

EMDR worked because it reduced her panic about how she would feel about being abandoned. By relaxing while visualizing him taking off, she became confident that she could cope with it. Which proved that this women was afraid, not primarily of her husband leaving her, but of how she would feel if he did. Consequently, there was this unexpected and amazing outcome. She even got cheerful about the possibility of his leaving her. The clue that explained this surprising turn of events was her saying, once she no longer felt panicked about it, “Now I can die with dignity.”

There had been no sign, on the macroanalytic level, that she was feeling humiliated. It only came out when she felt confident about not panicking.

REFUTING NEGATIVE SELF TALK VERSUS HAVING A MORE INTIMATE CONNECTION WITH IT

Now notice another thing about this case. No one disputed her negative thoughts, or even knew they were there, much less brought them out. But we can infer that she had thoughts like “I’m being a big baby,” or “I’m being repulsive by clinging to him this way,” or “He hates me.” So the case shows that negative thoughts need not be argued with.

As I said, part of our problem with CT is the whole focus on arguing. On debating negative self-attributions. We think an unfortunate side effect is that it preserves an adversarial relationship with oneself.

Next are two detailed examples of what it looks like to encourage rather than refute negative thoughts, first bringing them out, much as the standard CT would. Then, rather than arguing with them, bringing them out even more fully, which has the effect of expanding internal intimacy.

This was a 42 year-old single man who suffered from bouts of severe restlessness and difficulty concentrating. He reported that his stomach was “jumping” at those times and his thoughts sped up. But this was only on certain days, like about every third day. On other days he felt relatively normal. On the bad days as soon as he woke up his mind would be “churning:”

“I’ll go over things I did wrong years ago. It could be something embarrassing I did as a child. Something I felt bad about. Or ways I screwed up at work. It could have been months ago. Then I get disgusted with myself, thinking Why do I keep going over these things? It’s so stupid!

“I’ll be shaving and I’ll look at myself in the mirror, and I’ll say ‘Roger, how could you have done that!'”

Pause for a commercial break: Many therapists, hearing that, think to themselves, this is pretty deep-seated, a long-term case—nothing much I can do at the moment. Just as “negative self talk” can seem like self-hate lite. In this regard, it may help to think of an embitttered warring couple. In such cases we think that being enabled to talk (in the sense of communicate) is a way for them to begin to get a handle on their relationship. Similarly, even when self hate is intense, perhaps especially when it is, being able to establish some internal dialogue is a way to get a purchase on one’s self organization. Back to the case.

He has already answered the question, “What are you telling yourself.” Our next usual question is “What kind of person is that?” (who does all these embarrassing and screwed up things). Or, “What kind of a person is your mind telling you you are?”

“That I’m not a good person. That I’m incapable, inadequate.”

This approach perked him up. He had just been thinking how stupid it was to obsess on these things in the morning, but now it was a project we were working on.

The next session he said that as he watched these thoughts, he found that he hit “a speed bump,” by which he meant it went to another level. He said his mind will go to “sharp disgust:” He’d hear, “God, Roger, what an asshole!” Then it would call up anecdotes confirming that judgment.

The next question is “How does that make you feel?” “Dejected, defeated. Beat up. Punched in the stomach. Why even try. This is your destiny. The way you’ve always been. You’ll never learn.”

“You’re being scolded?”

“Exposed and humiliated. You get so impulsive and hurt people’s feelings. You talk too much. Mr. Know-it-all.”

I said that it looked like he was trying to tell himself something that he was resisting hearing. That he wasn’t saying to himself, “I feel foolish and like a showoff.” But this voice wouldn’t let up until he did.

That gave him some sense of there being a point to it all. That it was going somewhere he needed to go. He reported that tuning in to the voice this way had the effect of his hearing the same things, but it didn’t make him nervous and jumpy. The way he put it was that, “I didn’t feel nervous because I was thinking.”

We also found that on his good days he had some project in mind that he felt would impress people, like a lecture he had to give, or a meeting to chair, or being a consultant. He realized that these activities worked as refutations. They proved that he was not an asshole, was not inadequate, was not stupid, or an embarrassment, or a big showoff.

It is easy to go right past the pathogenic experience and into the background causes for it. Like why this patient felt inadequate or why the other patient felt too small. There is a place for that, of course, and I did that in both cases, but if you go for it too soon you can miss getting patients more deeply into what they are experiencing.

What I’m saying is that the cognitive approach has the potential for getting the patient into feelings more quickly even than approaches that go for feelings directly. But the CT approach misses that opportunity by focusing on refuting negative thoughts. In this next example, I’ll give you another illustration of how the cognitive approach can be used to get into feelings and deal with them. This patient said,

My girl friend is very reserved and never shows affection unless I do first. It makes me feel hurt and resentful, but when I complain she gets even more withdrawn. So I try not to. I tell myself that’s just the way she is—that she’s shy— but that doesn’t work. Or when it does, it’s temporary. So how can I not get hurt and upset about how cold she can seem? It would be a lot better if I could not take it so personally.

My comment was that that was the trouble. In trying to talk himself out of feeling slighted, it was like he was stifling the voice that was telling him that she was being cold and hurtful. In encapsulating a feeling the voices already intensify it, as if getting more insistent. This partly accounts for their abusiveness. So to try to drown out a voice can make it more insistent, even mantra-like.

But, and this is a big but, this is exactly what the standard CT tries to do. To drown out the negative voice. So according to what I’m saying, standard CT shouldn’t work. It should just intensify the internal argument. I think the reason it works so well is that the line of argument is much more objective. Our own internal arguments are often just name-calling, just exchanges on the level of wisecracks. Whereas the CT does an unemotional, authoritative job.

This patient’s presentation was tailor made for the standard CT approach. He wanted to be able to not take it so personally and not get hurt and upset when his girl friend seemed cold. The therapist would bring out what the patient told himself when his girl friend seemed cold. And it would be things like, “She really doesn’t love me.” The therapist would go over the evidence for that. Another automatic thought might be, “I’m not warm enough to her.” And the CT might argue that that is much too global an attribution, etc.

If this approach worked, the patient would feel relieved and better able to be accepting of his girl friend. But this would be at the cost of strengthening his belief that he shouldn’t take things personally. This might be hard to notice if the therapist agrees, as I think many CTs would, that you shouldn’t take things personally. But the trouble with shoulds is that they can backfire: then if you do feel hurt or slighted you can’t avoid being self-condemnatory about that.

Another drawback to the standard CT approach is that he would be no more intimate with himself and he would be no more intimate with her. But it won’t be clear what I mean by that until I give you my approach to this case. The ego analytic alternative was, instead of strengthening the argument against taking things personally, to help the patient to be better at taking things personally. So what I said to him was,

Think of it this way. One voice is telling you “She really cares for you. She’s just shy.” Another voice is telling you “She’s cold and hurtful.” And this way the two voices are interfering with one another. So let’s try to keep them separate. Let’s see if we can bring out the voice that says “She’s cold.”

This freed him to get into how she was just using him—that she stayed in the relationship only because she was too shy. That she would have left him if she was more self-confident. Because actually she was a 7.5 and he was only a 6, and people always want to be with someone who is at least half a point to a point higher than they are.

As he warmed up to the topic he went on about how in relationships people don’t know or want to know one another—they just use one another. That no one cares about anyone else beyond what good they are to them.

I’m presenting this more smoothly than he did, because he kept interrupting himself to say, “I’m exaggerating,” or, “This isn’t really how I see things” (that was him doing a “really” interpretation to himself). I had to keep saying that he was cutting off the voice— or that he was strangling the voice. He also would look at me apprehensively.

And when he got to this point, he looked at me like he felt I had really set him up. Now his goose was cooked. I probably had gotten more than I bargained for. So now I was going to tell him he was a nut case—not in so many words, but by implication, like by saying, “Let’s think about where these attitudes came from.”

Instead I said that it all made sense to me, that that was one fairly well known existential position—that he sounded like Heidigger. And nobody ever suggested that Heidigger should think about where these attitudes came from.

This opened the way for him to get into the hurt and the anger implied by this view, although often, as in this case, he mainly enjoyed being allowed to look at things this way. It was a lot of fun to feel entitled to his cynicism. We think of this as expanding his relationship to himself.

Since his relationship to himself was less adversarial, this carried over into his relationship with his girl friend. He now was able to bring up feeling hurt by her reserve in such a neutral, nonblaming way that she felt safe enough to bring out how she felt guilty about not being able to be more easily affectionate, and also how she felt that even though he never expressed it, he must have been hurt and resentful—which made her feel all the more unable to be affectionate. But this kind of conversation apparently made her feel more forgiven.

That kind of outcome is what I meant about how a drawback of the standard CT approach is that he would be no more intimate with himself or with his girl friend.

NEGATIVE SELF TALK AND SELF HATE

I said that “negative self talk” can seem like self-hate lite, and then dismissed this objection by arguing, essentially, that beginning to be able to talk to oneself—or to hear or even overhear the talk that is already going on—is at least a beginning. I also said, in discussing Roger’s abusive relationship with himself, that in encapsulating a feeling, the voices intensify it, meaning that self hate, like any other feeling, is intensified the more we react to it phobically and try to push it away.

This is to say that experience is stubborn. The prototype for this insight is Freud’s concept of a derivative: when an experience is repressed it returns (return of the repressed) in a derivative form, as a symptom, e.g., when shame is repressed it may return as blushing. (People who blush do have something to hide: shame.) I add that when the derived form is also repressed it returns in an even more symbolic way, e.g., the even more removed form of shame can be agoraphobia. And if that is repressed, as in this example, by the agoraphobic making a special point of being extraverted in public places, then you might get nightmares of being humiliatingly exposed. And if that is repressed, as by using soporifics, you might get persecutory delusions, and so on, up to auditory hallucinations, that is, literal inner voices.

What I am getting at here is that if you can effect a rapprochement between the host self and the self-hating subself, the more pushed-away, derived, and hence more intense form of self hate is ameliorated. But what about when you can’t find the host self? In the cases I have discussed so far, the problem has been buried subselves. Much harder cases are those in which the host self is not on the scene.

In psychopathic, sociopathic self organization, you can think of the self as projected outward. It is like there is no one there to talk to. Internal experience is so intolerable there is no means of support for self talk. This is somewhat similar to the underclass self-abasement I touched on earlier, but the causal texture is entirely different and even group support is lacking. What we are more likely to run in to is the internalized version of the buried host self. This is often is the kind of person I mentioned earlier who suffers from highly insistent and obstructive subselves. Let’s cut to a case.

This twenty-nine year old man, sometime student and musician, said that he needed help to strengthen his will power, and that he could only afford one session. I said OK, maybe that would be enough.

“If I could just do a few things right, then maybe I’d feel better about myself. Success breeds success and failure breeds failure. All I need is the will power. It’s just a matter of self-discipline. I just don’t make the effort. Maybe if I had been in the military…”

He listed drinking and drugs, at the casual user level, and not practicing his instrument. I asked what gave him the will power to come in. He said it was a last straw kind of thing, that he’s had it up to here with himself, given this latest lapse. He had not paid his bills in three months, which maybe by itself was no big deal, but he had written all the checks, and had put them in their envelopes, stamped and ready to mail. That was two weeks ago. He knew that he would feel much better if he mailed them. It would be a relief. He pointed out that there was a mailbox on his corner, and it was just a matter of taking the envelopes there and dropping them in. He said this was an obvious example of the kind of person he was.

“What kind of person is it?”

“Somebody who’s just worthless, who doesn’t do the simplest things.”

I could have said what a friend would say, “How much will power does it take to walk to the corner? There must be some reason you really don’t want to do it,” but, aside from being knee-jerk obvious, it also had to be that he was feeling acutely ashamed—the evidence being that he showed no sign of it, if you will permit me that solecism—and so any such comment would come across as a scolding.

I said I could see how that would be terrifically frustrating (cf. “How long have you had this disease?”), to have gotten it together to get the bills done and ready to go, only to find himself not taking the last little step. That seemed to warm him to the subject and he described these other “bad habits” (the using and the not practicing).

What I then said was, “It looks like you talk to yourself in a tone that takes the heart out of you and makes you not feel like doing anything. That’s the way you talk to yourself about the drinking and the drugs, when it seems to me you need the drinking and drugs to turn off this nagging inside. You blame yourself for not practicing your instrument, even though whenever you do, you get so angry at yourself it isn’t worth it.”

He, of course, took this as a scolding (I didn’t mean to imply that by some specially artful comment I would be able to avoid that effect). “That’s just weaseling out. I’m responsible that my life’s a mess. I’m just going to have to live with the fact that this is the kind of person I am.”

This had the sound of a kid protecting his image of an abusive parent, but I didn’t have the grounds to go there, and without that it would just sound like more special pleading, wild analysis. What I needed to do was to get to his logic. His rejoinder was that he wouldn’t be nagging himself if there wasn’t something to be nagging himself about. I answered that by saying that the nagging was like prejudice, only against yourself.

“That’s just making excuses.” He said, again, that all he needed to do was to get himself together to make a little effort and get these things mailed. Making excuses for him was not going to do it.

He was making it harder and harder not to say, “How much effort could it possibly take to get yourself to the mailbox. Listen, you could even leave them out for the carrier to pick up.” This meant that he was thinking this himself, so why was he so determined to avoid raising the why question?

So I said, “It seems to me that if I were you, the fact that I let the first day go by without getting the bills off I might get really depressed and think ‘That’s my life, right there. I’m going nowhere.’ But it also might be scary —or even more depressing to think that.”

He was silent and deadpan.

After several minutes I said, “More excuses?” and he nodded. So I went on, “You tell yourself you should just have mailed these things, but there it stops. You tell yourself you need more will power, but as it is now all you’re going on is will power. You force yourself to do everything.”

That got him to the bottom line: “Yes, but if I don’t blame myself, I’ll never get anything done.” I said that was really clarifying—that he must have hated it when I said that his blaming himself was preventing him from getting the job done. I added that it seems right, that sometimes people need to be spurred to do something, and that he might have wished that instead of excusing him I had scolded him, just as a friend might have done: “For God’s sake, man, just do it!” He again nodded. I then remarked, “Now I see why one session seemed like it would be plenty.” I went on to say that I also realized now that he probably thought I couldn’t stand recognizing just how worthless he was, what a mess his life really was, what a pit of futility.

Going on, I said, “You’re whole position is based on the assumption that these bills have to be mailed. Suppose, for whatever reason, your impulse is not to mail them at all. Suppose you’re mad at them. Suppose that what you would really like to do is to rip them up. How would you ever discover that?”

He laughed. I said that laughing like that is a sign of relief from repression —that this must have been an idea he was suppressing. Following up on this, I said, “Boy, it’s a good thing you didn’t mail those envelopes. Then we never would have found out that you might want to shred them. It seems to me now pretty straightforward. It looks like to save your own life you needed to resist the compulsion to always do the right thing.”

He left the session looking to me like whether or not he mailed the bills had become a non-issue, and I was further encouraged by the fact that he did not leave me a message saying he had mailed them or that he had not.

Let me quickly add here that some therapists, like many friends, would have said right away, “Look, how much effort are we talking about here? You must really not want to mail these things.” But in saying this they would mean something entirely opposite from what I was getting at. Their implication would be that he must not want to enough. They would be taking it for granted that bills have to be mailed—especially when they are all ready to mail. This would be to buy in to the self-hating set from which the patient frames his problem.

It would also mean to miss the buried host self, that is to say, his identification with his negative self talk—the way he embraced it. To have tried to badger him into mailing the bills would have been to reinforce his negative self talk—to confirm his belief that he was a worthless person who was incapable of doing the simplest little thing.

SUMMARY

1. Since we live in the courtroom, self-blame (negative self talk) is experienced as knowing facts about ourselves, just as parental blame is often (typically?) experienced as learning facts about ourselves.

2. The question, “What are you telling yourself when …?” is admirably suited to bringing out feelings.

3. Cognitive therapy has introduced us to negative self talk in the form of automatic thoughts and beliefs, but they are just one side of the internal arguments that characterize our adversarial relationship with ourselves. In focusing so exclusively on refuting negative thoughts, cognitive therapists neglect the other side of the argument, automatic refutations (talk, actions, fantasy).

4. We find that automatic refutations are “deeper” than automatic negative thoughts in that they typically keep us from hearing negative thoughts, which keeps us stuck with the feelings they generate. When negative thoughts can get through our automatic counter-arguments, it can be immediately relieving to see them in a conscious perspective and to see where our feelings come from. On this basis we propose that being able to accept negative, self-rejecting thoughts is more powerful than learning to be better at rejecting them.

5. Encouraging negative self talk, rather than invalidating it, makes patients feel connected to negative thoughts, and so permits sharing them with a partner.

6. Negative self talk, in the form of self hate, can be a central organizing influence, embraced by the host self, with the result that the problem is framed in a way that invites a solution that reinforces self hate.

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