ERIC ED368998: Voices in Suicide. The Relationship between the Firestone Voice Scale for Self-Destructive Behavior and Self-Destructive Life-Styles.

16 Pages·1992·0.51 MB·English

by  ERIC

DOCUMENT RESUME
ED 368 998
CG 025 287
AUTHOR
Firestone, Robert W.
TITLE
Voices in Suicide. The Relationship between the
Firestone Voice Scale for Self-Destructive Behavior
and Self-Destructive Life-Styles.
INSTITUTION
Glendon Association, Los Angeles, CA.
PUB DATE
[92]
NOTE
18p.
PUB TYPE
Reports
Evaluative/Feasibility (142)
EDRS PRICE
MF01/PC01 Plus Postage.
DESCRIPTORS
Adolescents; Adults; Behavior DisorderL; *Personality
Traits; *Predictive Measurement; *Self Destructive
Behavior; *Suicide
IDENTIFIERS
*Firestone Voice Scale Self Destructive Behavior
ABSTRACT
This article presents findings from recent research
demonstrating a significant relationship between parental introjects,
or "voices," and self-destructive behavior. The "voice" is defined as
a systematized, integrated pattern of negative thoughts accompanied
by angry affect, that is the basis of an individual's maladaptive
behavior. The development of these negative thought processes often
is attributable to childhood trauma due to inadequate, immature, or
hostile parenting of the individual in question. This theoretical
construct of "voice" led to the development of the Firestone Voice
Scale for Self-Destructive Behavior. Results of administering the
scale to 507 subjects in psychotherapy showed that the instrument
distinguished between individuals with a past history of suicide
attempts ana those without such a history. Factor analysis revealed
three factors of increasing self-destructiveness: low self-esteem or
inwardness; extreme self-hate; and actual impulses toward destruction
of the self. Empirical evidence indicates that the latter category,
"destruction of the self," may contain primary factors distinguishing
actual suicide attpmpters from those individuals who represent a
lesser threat to themselves. Assessing the level and intensity of
destructive "voices" may correlate with suicide potential. (Contains
42 references.)
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VOICES IN SUICIDE
The Relationship Between the Firestone Voice Scale for
Self-Destructive Behavior and Self-Destructive Life-Styles
ROBERT W. FIRESTONE, Ph.D.
Los Angeles, Calgbrnia
ABSTRACT
All aspects of giving up of self, one's sense of
reality, goal-directed activity, and appropriate emo-
This article presents findings from recent re-
tional response represent a defensive, self-destruc-
L. Firestone, 1991) demonstrating a sig-
search
tive orientation toward life that inevitably leads to
nificant relatiopship between parental inffojects or
neurotic or psychotic symptom formation. The ex-
"voices" and self-destructive behavior. The "voice"
tent of emotional deprivation and destructive parent-
is defined as a systematized, integrated pattern of
ing will determine the degree of psychological mal-
negative thoughts. accompanied by angry affect,
adjustment. Inimical thought patterns and emotional
that is the basis of an individual's maladaptive be-
attitudes are introjected or incorporated into the self
havior. The study applied the author's theoretical
system that strongly influence or control the relin-
construct of the voice to the development of the
quishing of one's unique identity and the narrowing
Firestone Voice Scale for Self-Destructive Beha-
of life experiences. Suicide represents the ultimate
vior. Results of administering the scale to 507 sub-
abrogation of self and the extreme end of the con-
jects in psychotherapy showed that the instrument
tinuum of self-destructiveness. Therefore, it is pro-
distinguished between those individuals with a past
ductive to study this phenomenon as it sheds light
history of suicide attempts and those without such a
on the entire spectrum of "mental illness."
history.
Clearly, suicide, depression, and self-destruc-
Factor analysis revealed three factors of in-
tive actions are multidetermined and biological
creasing self-destructiveness: F I (low self-esteem
components should be considered in determining
or inwardness); F2 (extreme self-hate); and F3 (des-
their etiology, particularly in Bipolar Disorders. In
truction of the self). Empirical evidence showed that
our studies, however, we focus primarily on the
the category "destruction of the self may contain
psychodynamics of suicide and emotional disorders.
primary factors distinguishing suicide attempters
The paper presents findings from a recently
from those individuals who represent a lesser threat
completed research project that demonstrate the
to self.
strong connection between parental irlfrojects or
"voices" and self-destructive behavior. The "voice"
INTRODUCTION
is defined here as a systematized, integrated pattern
Psychopathology or "mental illness" can be
of negative thoughts and attitudes, antithetical to the
more accurately conceptualized as a limitation in
self and hostile toward others, that is the basis of an
living, imposed on the individual by inadequate.
individual's maladaptive behavior. It is important to
immature, or hostile parenting, internalized in the
point out that the voice concept is not restricted to
form of negative thought processes ("voices"), and
cognitive processes, but is generally associated with
later manifested in self-limiting and/or self-destruc-
varying degrees of angry affect.
tive life-styles. In this sense, varieties of so-called
Self-attacks, "voices," vary along a continuum
mental illness are subclasses of suicide rather than
of intensity from mild self-reproach to strong self-
the reverse.
accusations and suicidal ideation. Similarly, self-
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that the goal of "treatment" is "to increase the pa-
destructive behavior exists on a continuum ranging
from self-denial; self-criticism; self-defeating be-
tient's knowledge of himself, others, and the world
about him and hence his freedom of choice and
haviors, i.e., behavior contrary to one's goals, acci-
dent-proneness, substance abuse; and eventually te
responsibility in the conduct of his life" (p. 172). He
direct actions that cause bodily harm. Clinical evi-
is opposed to the progressive medicaliintion of psy-
chotherapy which he sees as deriving from an in-
dence supporting the relationship between internal
creasing adoption of medical formulations about
voices and self-destructive living suggested re-
"symptoms" that are, in reality, manifestations of
search possibilities that would lead to an accurate
prediction of an individual's suicide potential. distutbed ways of living.
Laing and Esterson (1964/1970) share Szasz's
Data obtained during preliminary studies (R.
abhorrence of diagnostic labels and medical models
Firestone. 1988) utilizing Voice Therapy procedures
as applied to emotional disturbances. In Sanity,
led to the following hypotheses. The source of nega-
Madness and The Family, Laing and Esterson argue
tive thought processes and their development within
the personality is related to (a) the projection of
that the term "schizophrenia" was a clinical attribu-
tion "made by certain persons about the experience
negative parental traits onto the child; (b) the child's
and behaviour of certain others" (p. 19). They re-
imitation of one or both parents' maladaptive defen-
serve final judgment about the validity of such at-
ses: and (c) the internalization and incorporation of
parental attitudes of covert aggression toward the
tributions, concluding that:
child. As the degree of trauma experienced in
It is most important to recognize that the diag-
childhood increases, the level of intensity of voice
nosed patient is not suffering from a disease
attacks parallels this progression, and there are in-
whose aetiology is unknown, unless he can
creasingly angry, vicious attacks on the self. These
prove otherwise. He is someone who has queer
voices are manifested in an individual's retreat into
experiences and/or is acting in a queer way, from
inwardness, feelings of extreme self-hate, and even-
the point of view usually of his relatives and of
tually impulses toward self-destructive action (R.
ourselves. (p. 18)
Firestone. 1988).1
Feinstein and Krippner (1988) view psycho-
In summary, the effects of negative early en-
logical maladies as originating in the dysfunctional
vironmental influences are retained in the form of
destructive voices within the adult personality.
personal myths of the patient. A number of major
including
Thus, the voice plays a major role in precipitating
approaches,
philosophically-oriented
and maintaining a wide range of maladaptive be-
those of Frankl, May, Bugental, Rogers, Pens, and
Maslow, are based on the assumption that an Un-
haviors that are mistakenly classified or defmed as
balanced emotional life is the result of a person's
a disease entity or "mental illness."
"cultural beliefs, his philosophy and ethical values,
and his spiritual development" (Zeig & Munion,
REVIEW OF THE LITERATURE
1990, p. 169).
Suicidologist Edwin Shneidman (1989) has
Some Contemporary
emphasized that suicide is not an illness, rather it is:
Views of Mental Illness
a human, psychological orientation toward
The categorization of emotional disturbance as
life, not a biological, medical disease.... Suicide
a medical abnormality or illness has been challenged
is a human malaise tied to what is "on the mind"
by a number of theorists and clinicians (Szasz, 1961,
including one's view of the value of life at that
1963, 1978; Laing & Esterson, 1964/1970). Szasz
moment. It is essentially hopeless unhappiness
(1963) suggests that "mental illnesses...be regarded
and psychological hurtand that is not a medi-
as the expressions of man's struggle with the prob-
cal condition. (p. 9)
lem of how he should live" (p. 16).
In this context, Menninger's view (1938) of
In attacking the "myth of mental illness," Szasz
faults the careless use of language for perpetuating
psychosis deserves special attention: he conceived
beliefs about psychological distress that are as ar-
of schizophrenia as a method of self-destruction:
chaic as the belief in witchcraft. Szasz (1990) argues
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This departure from reality standards enables
The degree of self-hate and self-persecution
the psychotic person to destroy himself in a
going on in the unconscious determines the
degree of the illness, and in severe cases the
unique way not available to anyone else. He can
imagine himself dead; or, he can imagine a part
person can become hopeless, panic-stricken.
of himself to be dead or destroyed. This fan-
and be driven to suicide as a way out. (p. 190)
tasied self-destruction, partial or complete, cor-
Beck (1976), Ellis and Harper (1961/1975), and
responds in its motives to actual self-mutilation
Kaufman and Raphael (1984) present similar con-
and suicide. (p. 187)
cepts in their discussion of maladaptive thought
In their writing, suicidologists Ka Ile Achte
processes. It is apparent that the phenomena des-
(1980) and Norman Farberow (1980) describe in-
cribed by these clinicians are similar to the self--
direct suicidal manifestations in non-medical terms,
attacks identified by our subjects through the labor-
that is, as the methods people use to sabotage their
atory procedures of Voice Therapy. The concept of
the voice and methods of Voice Therapy are more
own success, seemingly preferring to live miserable,
deeply rooted in the psychoanalytic approach than
restricted lives (R. Firestone. 1990b). Space does not
permit more than a brief mention of the author's
in a cognitive-behavioral model. Our theoretical
depiction of "mental illness" as manifestations of focus is on understanding the psychodynamics of
the patient's functional disturbance in the present,
microsuicidal and suicidal behavior (R. Firestone.
and our methods are based on an underlying theory
1986, 1988, 1990a; Firestone & Seiden 1987, 1990).
Our expanding knowledge of negative cognitive
of personality that emphasizes a primary defensive
processes and related affect has been applied to
process (R. Firestone, 1988, 1990c).
sexual dysfunctions, personal limitation, conflict in
marital relationships, faulty parenting practices. and
BACKGROUND OF THE STUDY
more serious child abuse (R. Firestone 1985, 1989.
I990d). Clinical and empirical studies tend to con-
The Development of the Firestone Voice
firm our view that "mental illness" represents a
Scale for Self-Destructive Behavior
narrowing of one's life-space, a constriction of ex-
(FVSSDB)
perience, and a controlled destruction of the per-
sonality.
My primary purpose in initiating an empirical
research project was to predict an individual's sui-
cide potential because accurate prediction could po-
The "Voice"Psychoanalytic and
tentially save lives. Secondarily, I was interested in
Cognitive-Behavioral Appmaches
determining whether the continuum of voice atr2cks
Many theorists, beginning with Freud, have
would actually parallel manifestations of self-des-
identified aspects of a negative thought process and
tructive behavior as had been hypothesized. Would
split ego functions. In Group Psychology and the.
the results of the proposed research be consistent
Analysis of the Ego, Freud (1921/1955) described
with our theoretical orientation and support our ini-
cases of melancholia in which there is "a cruel
tial findings? If so, they would be of significant
self-depreciation of the ego combined with relent-
value because many theorists have proposed the idea
less self-criticism and bitter self-reproaches..." He
of the continuous nature of self-destructive behavior
and restrictive life-styles, yet this concept has not
went on to state, "but these melancholias also show
been subject to empirical research. In addition, the
us something eLse... They show us the ego divided,
fallen apart into two pieces, one of which rages
research could shed light on the relationship be-
against the second" (p. 109).
tween powerful psychological defenses formed in
In Guntrip's (1969) analysis of Fairbairn's
childhood and later personality malfunctions.
of ego-psychology, he uses
the terms
theory
Subsequently, Lisa Firestone elected to conduct
the research project to fulfill requirements for a
libidinal ego and antilibidinal ego to delineate parts
of the split ego. Guntrip links the punishing ego-
Her
doctoral dissertation in clinical psychology.
funcuon of the antilibidinal ego to depression and
study (L. Firestone, 1991) involved the application
of voice theory to the development of a scale to
suicide:
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assess self-destructive behavior (later termed the
experience negative thoughts or "voices" on a 5-
Firestone Voice Scale for Self-Destructive Be-
point Likert-type scale (see Figure 2). In addition,
havior). Her goal was to establish the validity and
the subjects were asked to complete a battery of nine
reliability of the scale. It was hypothesized that the
other instruments covering diverse areas of self-
scale would reveal valuable information about the
destructiveness in order to provide construct valida-
content of an individual's negative thought proces-
tion for the various levels of self-destructiveness
ses. By identifying where and with what frequency
proposed by R. Firestone (L. Firestone, 1991). The
the individual's thoughts lie along the Continuum of
tests included the Beck Hopelessness Scale (Beck &
Negative Thought Patterns (Figure 1), it was ex-
Steer, 1988), the Suicide Probability Scale (Cull &
pected that one could better assess the seriousness
Gill, 1988), and the Reasons for Living Inventory
or "dangerousness" of suicide intent.
(Linehan, Goodstein, Nielsen, & Chiles, 1983),
among others. Client participants were administered
Description of the Scale
the battery of tests in a private setting with the main
researcher or a research assistant, who was present
The "rational" approach (Jackson, 1970) to
to answer questions or conununicate with those who
scale construction was adopted from the onset in the
might become disturbed by feelings amused during
development of the FVSSDB. The items for the
the testing. Following testing, the Beck Hopeless-
FVSS DB were originally chosen on the basis of the
ness Scale and the Suicide Probability Scale were
author's (1986, 1988; Firestone & Seiden. 1987)
scored within 24 hours, and the therapist was in-
theory of the dynamics underlying suicide. Items
formed if any of the scores were in a range of
were drawn from actual clinical material obtained
concern.
during the author's 18-year longitudinal study of the
It was hypothesized that the scale would be able
voice." Items on the scale were made up of self-
to distinguish between those individuals with a past
critical statements or "voices" gathered from pa-
history of suicide attempts and those without such a
tients and subjects over the course of this clinical
history.Both therapists and subjects provided infor-
It was noted that more extreme
investigation.
mation on the criterion variable (subjects' past sui-
"voice" attacks were manifested by individuals who
cide attempts). It was found that the sample chosen
had made past suicide attempts.
included 93 persons who had made suicide attempts
Based on a pretest administered to individuals
and 414 who had not. We anticipated that the scale
who had made previous suicide attempts and to
would enhance our ability to predict suicide poten-
nonattempters, the sca .e was shortened and revised.
tial as well as identify a wide range of self-destruc-
Items found to significantly discriminate between
tive behavior patterns.
the two groups, attempters and nonattempters, were
In addition, the scale, combined with our theo-
retained. The revised scale consists of 110 items,
retical orientation, would provide clinicians with a
equally drawn fro:
.1 levels of self-destructiveness
comprehensive framework for understanding the
proposed by the author on the Continuum of Nega-
dynamics of alienation, self-attack, and suicide. The
tive Thought Patterns.
majority of scales previously developed to assess
suicide potential focus on data already known to be
Methods
correlated with suicide. In contrast, the FVSSDB is
In the main study, the revised questionnaire was
based on accessing and measuring a partially uncon-
administered to 507 subjects currently in psycho-
scious process hypothesized to underlie suicidal be-
therapy. The subjects' ages ranged from 16 to 73,
havior.`
with an average age of 38. Of the participants, 169
It was expected that items on the scale would
were male (33%) and 338 were female (67%). The
elicit partially unconscious material in respondents,
subjects were predominantly white (89%), even
thereby lending the instrument more discriminatory
though a concerted effort was made to include mi-
power than scales based on descriptive information
nority subjects. Respondents were tested at sites
concerning behaviors known to be correlated with
throughout the United States and western Canada.
suicide.
They were asked to endorse how frequently they
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Figure 1
CONTINUUM OF NEGATIVE THOUGHT PATTERNS
Levels of Increasing Suicidal Intention
Content of Voice Statements
Low Self-esteem
Seff-critical thoughts of everyday lite, self-depreciation.
You're incompetent, stupid. You're not very attractive.
1.
You're going to make a fool of yourself.
Voices rationalizing setf-denial. Thoughts praising and
You're too young and inexperienced to apply for this
2.
approving setflessness and asceticism.
job. You're too shy to make any new friends, or Why
go on this trip? It'll be such a hassle. You'll save
money by staying home.
Why go out with her (him)? She's cold, unreliable;
Cynical attitudes toward others combined with seff-at-
3.
tacks leading to alienation and distancing.
she'll reject you. She wouldn't go out with you
anyway. You can't trust men (women).
A Tendency Toward isolation
4. Thoughts influencing isolation. Rationalizations for
Just be by yourself. You're miserable company
time alone, but using time to attack oneself.
anyway; who'd want to be with you? Just stay in the
background, out of view.
Psychological Pain
You idiotl You bitch! You creepl You stupid shitl You
Vicious setf-abusive thoughts and self-accusations
5.
(accompanied by intense angry affect).
don't deserve anything; you're worthless.
Substance Abuse
6. Thoughts urging excessive use of substances fol-
It's okay to do drugs, you'll be more re/axed. Go
lowed by sett-accusations (weakens inhibitions
ahead and have a drink, you deserve it. (later) You
against seffdestructive actions, while increasing guilt
weak-willed jerkl You're nothing but a drugged-out
and seff-recrimination).
drunken freak.
Sense of Hopelessness
7. Thoughts urging withdrawal or removal of oneseff
See how bad you make your family (friends) feel.
completely from the lives of people closest. (Ration-
They'd be better off without you. It's the only decent
al, moral justification of immoral acts, e.g., one's
just stay away and stop bothering them.
thing to do
children would be better off if one left or committed
suicide.)
Progressive Withdrawal from Favored Activities
Voices influencing person to give up priorities and
What's the use? Your work doesn't matter any more.
8.
favored activities.
Why bother even trying? Nothing matters anyway.
Perturbation (Intense Agitation)
9.
Injunctions to inflict injury on setf at an action level (in-
Why don't you just drive across the center divider?
tense rage against seff). (Basis of self-mutilation
Just shove your hand under that power sawl
sometimes observed in seriously disturbed
patients.)
10. Thoughts planning details of suicide (calm, rational,
You have to get hold of some pills, then go to a hotel,
often obsessive, indicating complete loss of feeling
etc.
for sett).
11. Injunctions to carry out suicide plans (extreme
You've thought about this long enough. Just get it
thought constriction),
It's the only way outl
over with.
Any combination of the voice attacks listed above can lead to serious suicidal intent. Thoughts leading to isolation,
ideation about removing onesetf from people's lives, beliefs that one is
a bad influence or has a destructive effect
on others, voices urging one to give up special activities, vicious setf-abusive thoughts accompanied by strong
anger, voices urging self-injury and a suicide attempt are all indications of high suicide potential or risk.
Copyright 1989, The Glendon Association
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Los Angeles, CA 90067 - [phone]
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Figure 2
FVSSDB
1
All people experience "voices" or thoughts that are critical and destructive toward oneself and others.
For example, when about to give a speech or public talk, a person might think to him/herset
"You're going to make a fool of yoursetf."
When a man or woman is about to call someone for a date, he or she might hear or think:
"Why would he (she) want to go out with you?"
Negative thoughts are a part of everyone's thinking process. Please indicate the frequency with which you experience
the following 'Voice."
4
2 5
3
1
FREQUENTLY
MOST ALL OF
NEVER
RARELY
ONCE IN
THE TIME
A WHILE
For example. you think or
say to yoursetf:
"You're so stupid!"
"Just stay in the background."
I.
"People are no damn good."
2.
"Look at all this pain you have
3.
to go through. If you just
weren't here, you wouldn't
have to go through this
pam."
"Why buy a new car? It'll just
4.
get scratched or stolen
anyway."
"You just have to try harder."
5.
"You have to lind a place no one
6.
will find you."
"Go ahead and have a drink,
7.
you deserve it."
Copyright © 1991 by Robert W, Firestone and Lisa Firestone
6
7
the questionnaire made comments such as "I see that
my pattern is to be inward and isolated" or "I didn't
The results of Lisa Firestone's empirical inves-
realize I was talking to myself so much." These
tigation provided support for the reliability and va-
comments and others strengthened our informal hy-
lidity of the Firestone Voice Scale for Self-Destruc-
pothesis that items on the scale were closely related-
tive Behavior. Through evaluating the structure of
to internalized thought patterns that were only par-
the FVSSDB [by estimating Cronbach's (1951)
tially conscious. Indeed, answering qurstions in this
alpha coefficientl
it was determined that the internal
,
format gave respondents a feeling of being under-
consistency of the total scale was very high (alpha
stood. Moreover, therapists reported that their cli-
= 0.98) as well as for the subscale alpha, ranging
ents brought up topics not previously mentioned in
from 0.78 for Level 2 (self-denial) to 0.97 for Level
their sessions and expressed their emotions more
11 (injunctions to commit suicide) (see Hays &
openly and freely in the weeks following testing.
Hayashi, 1990). The FVSSDB total score correlated
significantly with the Suicide Probability Scale, =
LEVELS OF INTENSITY OF THE VOICE
.05). The FVSSDB total also correlated
0.77 (12
significantly with therapists' overall evaluation of
Clinical Studies
the self-destructiveness of the clients,
= 0.40 (12
In laboratory procedures (Voice Therapy) in
.05). A Guuman Scalogram Analysis confirmed the
their
self-critical
hypotheses regarding the interrelatedness and con- verbalized
subjects
which
thmous nature of self-limitation and self-destruc-
thoughts, we were able to identify three levels of the
tiveness (see Figure 3).
voice in terms of intensity and content: (1) at the first
Perhaps the most promising results were ob-
level, we discovered that every individual was able
tained in establishing the criterion-related validity
to identify a self-critical thought process or internal
of the scale. It was demonstrated that scores on the
dialogue; (2) when subjects verbalized their self-at-
tacks in a dramatic or cathartic manner, they often
scale correlated significantly higher than the Beck
launched into an angry diatribe against themselves
Hopelessness Scale or the Suicide Probability Scale
that was shocking in its intensity; (3) on a deeper
with subjects' prior suicide attempts for this par-
level, we observed intense rage toward the self,
ticular sample. For example, the Beck Hopelessness
expressed as suicidal impulses or commands to in-
Scale showed only 13 of the 93 suicide attempters
scoring in the range of severe concern. In contrast,
jure oneself (R. Firestone, 1986).
the FVSSDB was found to have 41 individuals of
The levels of intensity correspond to different
the 93 attempters scoring in the highest ranges of
aspects or functions of the voice that progressively
influence maladaptive behaviors along the contin-
concern, while only 17 individuals scored in either
the no or mild range of concern. The FVSSDB's
uum of self-destructiveness. There are two essential
correlation with subject's previous suicide attempts
modes of operation. The first refers to thought pro-
cesses that lead to self-denial, attitudes that are
was
= 0.31 (12 .<05), compared with the SPS, 1=
0.26, and the BHS, i= 0.18. Logistic regression
restrictive or limiting of life experience, while the
analysis showed that the FVSSDB could add sig-
latter, self-attack, refers to self-destructive propen-
sities and actions. Some overlap clearly exists be-
nificantly to our ability to determine suicide poten-
tween these two aspects of the voice; however, the
tial. The difference between logic coefficients when
the FVSSDB, BHS, and SPS were compared was
prohibitive quality appears to be based on the child's
= 383) = 7.268,
X(1,
< .05. A short form, the
imitation of, and adaptation to, the parental defense
system, while the malicious aspect of the thought
Firestone Voice Scale for Suicide, was also found to
have a significantly higher correlation with prior
process is more closely related to repressed or overt
suicide attempts than other instruments in the bat-
parental aggression.
tery of tests.
The restrictive quality of the voice functions to
One interesting finding was that subjects re-
limit one's experience and stifle one's enthusiasm,
ported that it was easy to identify with negative
spontaneity, spirit, and sense of adventure. These
thoughts stated in the second person format on the
completely
block
restrain
or
an
self-attacks
scale. On a number of occasions, clients answering
individual's wants and desires before they can be
The Glendon Association
[phone]
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9
5); and thoughts engendering hopelessness and ur-
translated into action. Negative thoughts provide
ging the withdrawal or removal of oneself from
seemingly rational reasons for self-denial, isolation,
significant others (Level 7). Voice statements from
and alienation from other people.
The malicious aspect of the inimical thought
both these levels represent a strong self-hating point
of view. Factor 2 may include areas of overlap
process issues directives to mutilate the self emo-
between voices that mediate self-restrictive life-
tionally and/or physically (R. Firestone, 1988).
styles and those underlying more serious destruction
These thought patterns are accompanied by intense
of self. This level of intense self-hatred appears to
anger and even rage against the self. When verbal-
ized out loud, in the second person, voices, com-
be an important step in the proE,7ession toward overt
posed of vicious, degrading self-accusations and
self-destructive acts because it leads to considerable
perturbation and psychological pain.
injunctions to injure oneself, are very powerful and
Factor 3, Destruction of the Self, includes Le-
dramatic. It is important to emphasize that, in almost
vels 8 through 11 on the Continuum Chart, thoughts
every case, emotional catharsis appealed to decrease
associated with giving up one's priorities and fa-
the need l',)r action. Facing up to the enemy within
vored activities or points of identity, injunctions to
acted to relieve the pressure, and individuals gained
harm oneself, thoughts planning suicide, and injunc-
a measure of control over self-destructive impulses.
tions to commit suicide. This cluster includes acting
Empirical Findings Related to the
out the destructive level, both psychologically and
Continuum of Intenstty of Voice Attacks
physically. For example, Level 8 includes thoughts
influencing the individual to give up points of iden-
The results of a confirmatory factor analysis
tity and his/her investment in life by indicating that
( see Figure 4) of the assessment scale revealed three
"nothing matters." This type of thought process (the
factors of increasing self-destructiveness that appear
divestment of energy or de-cathexis) leads to aliena-
to correspond to increasing levels of angry affect
tion from the self and extinction of the personality
accompanying voice attacks (L. Firestone. 1991).
(psychological suicide). Level 11 includes actual
When the factor analysis was completed. Factor 1
commands to commit suicide or murder oneself and
was initially named "Low Self-Esteem." It includes
directly predisposes action.
the first four levels of the Continuum of Negative
Thought Patterns: everyday self-criticism, self-de-
Case Report
nial, cynicism, and isolation. I contend that Factor 1
An example of these three factors is illustrated
should more accurately be termed inwardness.3 It
in an interview with a woman who made a serious
includes self-critical thoughts (Level 1); self-denial
suicide attempt and who barely survived through a
(Level 2); cynical or hostile attitudes toward others
( Level 3); and gradual withdrawal into isolation
last minute call for help (R. Firestone, 1986).4 At the
time of her attempt, she was unaware that a destruc-
(Level 4). Subjects in our pilot studies identified this
tive thought process was gradually gaining ascen-
aspect of the voice as influencing them to be self-
critical, to deny themselves pleasurable experien-
dence over her rational thinking and assuming con-
trol of her actions. Later, utilizing the procedures of
ces. to think cynically about others, to avoid becom-
Voice Therapy, she was able to clearly recall the
ing invested in relationships, and to spend more time
thoughts she experienced duririg that period of her
alone and isolated from others. Negative thoughts
from the first four levels on the Continuum Chart
life.
In the transcript that follows, one can observe
were endorsed with a high frequency by subjects,
indicating the universality of these particular pat-
the progression of thoughts and the increasing inten-
terns. Indeed, there is a split in every individual
sity of her murderous rage toward self. The inter-
view begins with Susan describing thoughts as-
psyche: each person is subject to self-destructive
sociated with feelings of low self-esteem, cynical
voices and manifests varying degrees of inwardness
thoughts toward others, and those urging her to
and self-hatred.
Factor 2. Extreme Self-Hate, includes vicious,
isolate herself.
self-abusive thoughts, obsessive ruminations, often
accompanied by intense rage against the self (Level
The Glendon Association
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9
1 1