-How to document the conversations we carry on with ourselves most everyday (in the West at least)
-The importance of inner voices for rebuilding our notion of mental illness
-The role hearing voices (and working with those voices) can play in therapy for schizophrenia
-What it’s like to be without such an inner voice
-The inner voices in addiction.
The post points to how we might rethink clinical practice and laboratory tests in ways that reflect better the natural history of our own voices, and the power of language in our lives. That, in turn, would lead to both conceptual reworkings and applied impact.
I find myself increasingly concerned that people continue to take interdisciplinary efforts like neuroanthropology to mean that everything must be reduced to the biology, as if that’s somehow an explanation. Well, it’s certainly a socially important one right now, but I have my doubts about its scientific validity for humans.
So this post is a reduction to language, it could be said. The overall theme is the conversation we carry on with ourselves, the voices we contain within our minds, and how that is central to how we are – and needs much more research.
I’ll start with the work of inner dialogues by anthropologist Andrew Irving, bring in a post about hearing voices and hallucinations from Ruminations on Madness, address Tanya Luhrmann’s work on schizophrenia and working with inner voices, bring back some great work by Greg on language and neuroanthropology, and then speak about how language, particularly our inner voices, matters deeply in addiction.
Andrew Irving and Documenting People’s Voices
In New York Stories, anthropologist Andrew Irving captures the inner dialogues people carry on with themselves as they walk the streets of the city. He combines visual, linguistic, and psychological anthropology together, using cameras and tape recorders to record people speaking out loud the same interior monologues we carry on with ourselves.
Irving has just been featured in a great write-up by Ferris Jabr over at Scientific American, Mrs. Dalloway in New York City: Documenting How People Talk to Themselves in Their Heads.
[Irving] approached strangers at different points in the city. “Excuse me,” he would say, “this might sound like a strange question, but can I ask you what you were thinking before I stopped you?” If the stranger did not run away, he would ask them to wear a microphone headset attached to a digital recorder and speak aloud their thoughts as he followed closely behind with a camera. He would not be able to hear what they were saying, Irving explained, and they would be free to walk wherever they liked and continue their business as usual…
Irving’s videos are permanent records of fleeting thoughts, of dynamic mental processes unfurling in real time. They give us nearly direct access to a kind of internal communication we usually do not share with one another.
Irving describes this monologue, along with two prior others, in his blogpost New York Stories: The Lives of Other Citizens.
[A]s the person walked through the city narrating their thoughts it soon becomes apparent that there are as many ways of thinking as there are of speaking. Meredith’s thoughts stretch from the trivial to the tragic over a few short steps as she begins by looking for a Staples stationary store to buy CD covers, then shortly after is dwelling on a friend’s cancer diagnosis she learnt about the previous night. Meanwhile, she looks over the road and notices a cafe she likes to watch people in. Thomas is concerned with people’s prospects in the current social and economic climate and his thoughts are organised as a sustained social analysis and argument about the position of working people and the historical migration of black workers from the agricultural south to the industrial north. Tony, a writer and video artist, walking from his boyfriend’s house, his thoughts emerging in staccato bursts: as he walks quicker and his blood circulates faster he begins to get more argumentative with himself as he negotiates a significant life event and keeps returning to the same words suck it up or let it go.
Irving has published on this research, including this 2010 article Dangerous substances and visible evidence: tears, blood, alcohol, pills. Irving also extends this approach to his work with HIV/AIDS in Africa, in his 2011 article Strange Distance: Towards an Anthropology of Interior Dialogue.
The capacity for a complex inner life—encompassing inner speech, imaginative reverie, and unarticulated moods—is an essential feature of living with illness and a principal means through which people interpret, understand, and manage their condition. Nevertheless, anthropology lacks a generally accepted theory or methodological framework for understanding how interiority relates to people’s public actions and expressions. Moreover, as conventional social–scientific methods are often too static to understand the fluidity of perception among people living with illness or bodily instability, I argue we need to develop new, practical approaches to knowing. By placing the problem of interiority directly into the field and turning it into an ethnographic, practice-based question to be addressed through fieldwork in collaboration with informants, this article works alongside women living with HIV/AIDS in Uganda with the aim of capturing the unvoiced but sometimes radical changes in being, belief, and perception that accompany terminal illness.
Irving’s emphasis that interiority can become a research question, addressed through methods and collaboration, is an important one. It turns us away from inner voices as a philosophical problem, one of trying to discern one’s “true voice”, as well as away from inner voices as a psychological problem, of an isolated mind that we access through some theoretical angle, fixing it with ideas rather than actually doing the reseaarch.
Ruminations on Madness and Inner Voices
Ruminations on Madness is a powerful blog that aims to bring together research, the actual experiences of people, and activism. Nev’s most recent post Limitatations of the Current Phenomenology of Psychosis, a reflection built on her attendance at the week-long International Congress on Schizophrenia Research.
Nev addresses how auditory verbal hallucinations have become naturalized, a nosological category that seems apparent to researchers and clinicians yet misses the actual complexity of the phenomena. People who experience these inner voices report a wider range of experiences than the token “AVH” considered in the literature, and the linking of biological, subjective, and social points to the need for new theory to better understand the role and meaning of these voices both clinically and in people’s everyday lives.
Here is what people actually report:
I regularly listen to descriptions, for example, of “voices” that are in no sense ‘literally’ auditory; that are also “felt” as presences (sometimes in a more tactile way, sometime more ‘affectively’); that are locatable and even agentically moveable or malleable (e.g. can be ‘pushed to one side’); that can occupy very specific parts of the head, brain and/or body; that can be felt passing through membranes, tissue and bones; that may be visual or visualizable; that may alternate or ‘flit’ between modalities; that may derive only from existing sounds, spoken or written words.
Their so-called “verbal” messages may likewise be directly ‘felt’—never taking the form of a spoken or written sentence or word; interpreted verbally or more straightforwardly ‘heard’ or ‘seen’ as words. The ‘hearing’ of messages may be a dream-like experience, phantastic or phantasied, brutal, possessing, but virtually always characterized by a strength and strangeness that defies metaphor and language in the most intractable ways…
[T]he lion’s share of “bizarre” beliefs I hear are instead often verbal descriptions (and precisely not ‘explanations’ although we might quibble over the distinction) of experiences that themselves seemingly resist any attempts at reduction to particular (more basic, primitive, ‘animal’) sensory, perceptual, vestibular, proprioceptive or affective domains.
Over time, layer adds to layer; there is labeling, description, explanation, interpretation; solo ‘acts’ repeatedly intermixed and intermarried with ‘raw’ experience, with clinical and social interactions, with dialogue, with the cultural imaginary.
And finally, so often, all these experiences are doubled in the most frustratingly inarticulable ways: “real worlds” encased in solipsistic realities; simultaneities of familiarity and radical unfamiliarity; perfectly intact logic ‘here’ and its wild negation, suspension or potentiation ‘there’. Fear, isolation, terror. Possibility. All of it.
This naturalistic approach is at odds with a clinical approach that needs definite categories for disease/illness, treatment options, and payment. This approach is also at odds with a biological reductionism, where these voices would become mere epiphenomena, expressions of an underlying and faulty biology. Nev pushes us to take this reality of inner voices as constitutive in itself of the problem we seek to understand. Not something to place to one side, to figure out later, but rather front-and-center in how we will move forward in understanding mental illness.
Undeniably, distinctions, categories, taxonomies, and so forth are needed and necessary. The first question is (yes, rhetorical): have we truly selected the most veridical, the most careful, the most phenomenologically coherent distinctions; those most likely to reveal crucial differences, correlates or indications– biologically, etiologically, epidemiologically, clinically or culturally?
If we have not (and this, clearly, is my contention), then we are faced with a series of (non-rhetorical) questions. Which distinctions, assemblages, gestalts or taxonomic clusters are in fact most relevant, most important?
Further, which distinctions at which temporal or developmental moments? (How, e.g., can we deconstruct ‘background’ and foreground, generative and consequential, primary, secondary and tertiary.) And at which levels of explanation?
How can we move forward (particularly with measurement) given the very serious limitations of extant vocabulary and the possibility that psychotic experience may, in fact, constitutively trouble even those mental distinctions that have held up in other areas of neurology, psychiatry and cognitive neuroscience?
Is there, here, a potentially critical role for ‘experiencers’ who may not be able to provide precise positive accounts of psychosis, but nevertheless effectively play the ‘negative theologian,’ apophatically indicating what madness is not?
To do this sort of work requires a methodological approach along the lines of Andrew Irving, something that can capture these voices and experiences outside both the clinical categories and clinical settings that so infect our thinking about and research on such phenomena.
Tanya Luhrmann and Hearing Voices
Stanford anthropologist Tanya Luhrmann is one person who has set out to do that sort of work. In the video below she speaks about her cross-cultural work on hearing voices, with research in the United States, India, and Ghana. The video was presented at the Culture, Mind and Brain conference last October. Greg wrote a long description and reflection on Luhrmann’s work, and describes the methods used by her research team:
Luhrmann and her research assistants asked patients about their voices: how many, what sorts of voices, their relationships to the voices, could they identify any of the voices, what sort of control they had. The interviews paid close attention to the experiential quality of the voices: were they stressful and why; were any experiences of hallucination positive; whether the patients thought that the voices were ‘real’; and what they felt the causes of the voices was.
For more on Luhrmann’s methods, jump to around 6:45 in the video.
Luhrmann is also interested in the applied implications of this work, and has worked with the Hearing Voices Movement to better understand how some people might cope with the distress they can experience with inner voices. She describes this work in a 2012 American Scholar essay, Living with Voices. Here’s the movement’s genesis in The Netherlands, birthed through postcards and then a meeting that brought people coping with voices in everyday life together in one spot.
Romme and Escher decided to hold a conference for everyone who had sent in cards. All sorts of people turned up, including people who had struggled with voices and hadn’t been able to do anything about them despite the efforts of psychiatrists and medication.
The people who were comfortable with hearing voices told the same story; their experience had a trajectory. Some voices had started out mean and difficult, and the hearers had first responded with startled fear, but once they had chosen to interact with them, the voices settled down and became more manageable, sometimes even useful.
“They show me the things I do wrong,” one voice-hearer said, “and teach me how to do them otherwise. But they leave the choice to me if I really want to change it or rather leave it as it was.” That was the kernel Romme and Escher took away from the event: if people could accept their voices and create a relationship with them, they could get their voices to change.
The implications of this movement for psychiatric thought and practice around schizophrenia are profound. Rather than auditory hallucinations as the reflection of an underlying pathology, of a brain gone wrong that needs to be treated with pharmacotherapy, the hearing of voices comes front-and-center in clinical practice. Or, to put it in a different way, the clinical practice socially constructs the voices in new ways, changing their meaning and expression.
Its method, to treat voices like people, is almost the inverse of the biomedical understanding of psychotic voices and a completely different perspective on how to handle them. The organization insists that hearing voices is a normal human experience, which indeed it is, although what is common (and thus “normal”) is hearing a voice as you slip into sleep, perhaps calling your name, perhaps your mother’s voice…
The paradoxical assumption here is that if the voice-hearer treats the voices as if they are real, as if they are like the independent, external people in the world they are perceptually experienced as being, the voices will become less real…
The Hearing Voices method not only puts people in groups to encourage them to talk about and then engage their voices, it also asks other people to treat the voices as real. Staff members conduct “voice dialogues,” often working one on one with a client. The staff member asks to speak with the voice. The client will listen for what the voice says and then report it back, in a strangely ventriloquized process. Some staff members invite the voices to attend the group meeting.
Luhrmann goes on to describe an alternative psychiatric reading of the Hearing Voices movement, that these internalized voices are related to trauma and dissociation, rather than a biologically-produced epiphenomenon.
If it is true that distressing auditory hallucinations are the dissociative consequences of trauma, the implications are enormous. Dissociative disorder has a positive prognosis, one of the most positive in the realm of psychiatric disease, whereas schizophrenia is often thought to have the worst. Dissociative disorder is understood to be a reaction to events in the world; schizophrenia is usually imagined as a largely inherited vulnerability. Dissociation is best treated with therapy and interaction; schizophrenia is assumed to require medication, often heavy.
The new way of thinking opens the possibility that people do not hear voices because they are crazy, but that their apparent craziness may be the result of the brain-numbing chaos that can result from hearing voices. It suggests that we can help by teaching people to cope with their voices, rather than viewing the voices as evidence of organic damnation.
Luhrmann’s long essay Living with Voices is filled with more case studies, more intellectual history, more discussion of implication, so I recommend you go read it. But to wrap up this part, what I want to stress is how inner voices are open to cultural influence, both in a broad sense (Chennai, Accra, US) and in a focused sense (the Hearing Voices movement). By doing cross-cultural research, and working with experts who cultivate particular lines of human variation, we can position ourselves to interrogate current ethnographic and neurobiological theory and to aim to build a better synthesis.
Life without Language Interlude
I want to take a quick meander back to a post Greg wrote in 2010, Life without language. He described there the work of Susan Schaller with people who have grown up without exposure to language, in particular her work with her informant Ildefonso. This research offers us another point of comparison, another dimension that helps set the overall layout of the puzzle we are facing. Howe we fit the pieces of the puzzle together will be quite determined by the borders we draw around the problem as well as the picture we think is painted there.
Greg summarizes his thoughts near the end:
In contrast to the absolute inability Idefenso had getting the idea of ‘idea,’ or his struggles with points in time, he clearly was capable of all sorts of tasks that suggest he was not mentally inert or completely vacant. He had survived into adulthood, crossed into the US, kept himself from being mowed down in traffic or starving to death. Moreover, he and other languageless individuals had apparently figured out ways to communicate without a shared language, which I find both phenomenally intriguing and difficult to even imagine…
I suspect that Ildefonso might be suggesting a way in which certain cognitive skills and communicative channels had actually atrophied with the incursion of language into his life, or even become impossible once language had intruded upon them. Language was not simply an addition to his cognitive repertoire; it may have displaced or disrupted other forms of thought and interaction.
From the perspective of a language-saturated world this seems improbable; we tend to think of ourselves as cognitively complete, profoundly abled, without limit. But clearly Ildefonso and other languageless individuals had to find some way to compensate for their deficits, whether it was through mimetic thinking (which is one possibility) or through some other constellation of adaptations. This languageless cognition would not be simply prelinguistic, childlike thought because adult languageless individuals function much more adeptly than four-year-olds. But how this non-linguistic, adult cognition might operate, what it might include, is a bit of a mystery and seems fragile in the face of language learning…
So can people have thought without words? Well, the evidence-based answer would seem to be, yes, but it’s not the same sort of thought. Some things appear to be easier to ‘get’ without language (such as imitation of action), other things appear to be a kind of ‘all-at-once’ intuition (such as suddenly realizing all things have names), and other ideas are difficult without language being deeply enmeshed with cognitive development over long periods of time (like an English-based understanding of time as quantitative and spatialized). In other words, language is not simply an either/or proposition, but part of a cognitive developmental niche that shapes both our abilities and (unperceived) disabilities relative to the fully cognitively matured language-less individual.
The case of Ildefonso suggests that not all ‘thought’ is either neurologically or practically similar. Ildefonso had managed to survive, and clearly had thoughts, but he was also obviously confused by some basic qualities of the language-saturated world in which he had to live, not least of which was social interaction. Even without very basic capacities – like, apparently, naming itself, the seemingly first act of applying a symbolic icon to a recurring element in perceptually reality – he managed in day-to-day life and was emphatically ‘human,’ although operating with unusual cognitive capacities.
The evidence that Schaller presents on the relationship of language to different cognitive skills correlates also with the evidence from child development, widely recognized as demonstrating a progression through skills of varying complexity. For example, Western children seem to understand the concept of ‘pretending’ or ‘imagining’ a couple of years before they understand the concept of ‘believing,’ although to an adult, the concepts might seem to be logically linked. These concepts are not pre-established in a ‘language of thought,’ nor are they just the result of language socialization shaping cognition as, in both cases, we would not expect them to emerge at staggered time intervals. Not all words are equally easy to learn, nor is every cognitive ability equally dependent upon language (although some functions might be accomplished both pre-linguistically and post-linguistically using different mechanisms, so that continuity of function masks discontinuity of means).
To be honest, I wish I could write something deeper and more interesting about the case. I find myself pondering without much success what life would be like without language, how I might learn to compensate or develop other ways of accomplishing the same tasks, but I’m stopped short by the realization that language has been knit into my neurological functioning to such a significant degree that words are my constant inner companion. Even when I find that I have not been engaged in an inner dialogue, it is like waking from a sleep, unable to recall a dream that fast slips away. Perhaps like Ildefonso, I cannot talk about a languageless ‘dark’ once in the linguistic ‘light,’ even though there is a rich potential for action and perception in the dark.
How does language knit into neurological function? What are its differential relations with our cognitive skills and developmental trajectories? These are complex questions. Greg has a series of older posts that get at this domain in a broad fashion: (1) Sapir-Whorf hypothesis is right… sort of?, (2) Sapir-Whorf hypothesis was right… about adults, and (3) The new linguistic relativism: Guy Deutscher in the NYTimes.
Lera Boroditsky is a leader in this area, and has a nice Scientific American article, How Language Shapes Thought. This 2012 paper Linguistically Modulated Perception and Cognition: The Label-Feedback Hypothesis looks similar to some of what Greg is proposing about how language might interact with thought, perception, and action. Nick Chater and Morten Christiansen are leaders in developing an alternative approach to Chomsky’s univeral grammar, and have a recent chapter entitled Language as an Adaptation to the Human Brain. And Stephen Levinson and Nicholas Evans offer up a co-evolutionary model in Time for a Sea-change in Linguistics: Response to comments on ‘The Myth of Language Universals’. For those looking for a good overview, this 2010 review article Linguistic Relativity (pdf) by Phillip Wolff and Kevin Holmes is quite good.
Addiction: Talking Yourself into It and Out of It
To many, addiction seems like the prototypical biologically-based mental illness. Drugs change the brain, leading to compulsive craving and lots of problems. Certainly this view is promoted that way by the US government, for example, NIDA calling addiction a “brain-based disease.” So, what role for language here?
My ideas about addiction changed one day in Bogotá, Colombia as I watched the head therapist in action at the counseling program where I also worked. This moment was before I ever returned to grad school to studying action. I was simply trying to do my best at therapy for young addicts.
Gloria was overseeing the Monday morning session with the boys who had returned from a weekend at home. I worked at a therapeutic community, where the adolescent boys stayed for months of treatment. Near the end they started returning to spend their weekends at home, to see how they adjusted and to give them time to adapt back to their family setting while also dealing with the inevitable problems that cropped up.
It seemed a routine session, the counselor in charge admonishing some and praising others, boys confessing various transgressions and difficulties. But Gloria stepped in when one boy tried to skate through the moment too easily.
She set to down to grill him in the most kindly yet forceful of therapeutic ways. This was a woman who brooked little foolishness, most of all from young men who thought they could get away with it. Getting away with it, in her mind, was the slippery slope towards addiction in the first place – boys and families alike were too “permisivos,” too permissive, letting things slide that should otherwise be confronted.
More often that not, that simple confrontation was the main point of Gloria’s intervention in moments like that, to show both boy and therapist alike that small “broken window” moments need to be confronted. But today she put on a virtuoso display.
[And there ends my dramatization – I’d really like to, but this post is already way too long. So I am going to cut to the chase.]
The boy had hemmed and hawed about how things went at home. But under Gloria’s careful question, it became apparent that he was “bored” at home, that things weren’t easy. His family wasn’t like treatment; his friends were waiting outside. He made his bed and did his chores and then had little to do. He was bored.
And then Gloria led him through how he was trying to talk himself into going using, into why he really should. His mother was on his case. He was fed up with being bored. Who would know if he just slipped out for a bit? His friends were there, waiting; they wouldn’t say anything.
“So you were trying to talk yourself into it?” Gloria asked.
“Sí,” the boy answered. Yes.
That moment has stuck with me through the years. Talking yourself into it?!! That went against so many things I had read and heard about addiction. But it took on an important clinical relevance there. Gloria knew enough about these boys, and about their problems, to recognize the conversation going on inside their heads. And that’s where she chose to focus her energies that day, on bringing that conversation into public light and confronting that level of permisividad, of permissiveness.
For me, the lesson has been larger, though to be honest I haven’t quite known what to do with it. My work has focused on compulsive desire and habitual use, on the linking of the neurobiological with the subjective and the contextual. But language too is there. Likely in ways more profound than I can imagine.
Drinking: A Love Story
Journalist Caroline Knapp’s memoir Drinking: A Love Story illustrates this articulated element of addiction, of words and feelings and desires and conflicts playing out inside our heads and how that plays into drinking or not.
First, early in the development of her drinking, Knapp describes her rising urge to go for a drink right after work.
At some point I began to notice how edgy I’d start to get every afternoon… I’d get up from my desk and wander around the office until I found someone who looked ready to wrap up for the day. I forced a tone of nonchalance. “Any interest in a quick drink at Aku?” “How ‘bout a quick drink?” It was always a “quick drink,” as if I had things to do, places to rush off to afterward.
I was conscious of this, conscious of the feeling of need behind the words, but I managed to ignore this for a long time. I suppose a part of me meant it – just a quick drink: no big deal. The need, and its intensity, was a secret I kept from everybody, myself included (27).
Later, she describes how language – how an inner voice – mediates between urges and anguish and identity.
When I sat there at the table with my aunts and uncles and parents, when I lifted the glass to my lips and watched the people around me swirl the liquid in their glasses, it felt right. I felt as though I’d made the right transition and that gave me a feeling of relief…
Drinking always worked that way, at least it did until the end. There was a logic to it, an easy liquid logic that resolved some deep puzzle of need and wanting. Ah! That’s how it feels. Ah! Here it is; I’ve found the way.
Tennessee Williams describes this feeling in Cat on a Hot Tin Roof, when Big Daddy asks Brick why he drinks. His answer: “I do it for the click.” Click: it’s right, it’s me (70).
But it’s not just in the self-affirmations, in the mediation on how functional drinking might be, on how it seems – told in a certain way – like the right kind of answer. Other parts of how language works for people come to the fore as well.
No is an extraordinarily complicated word when you’re drunk. This isn’t just because drinking impairs your judgment in specific situations, like parties or dates (which it certainly may); it’s because drinking interferes with the murkier, larger business of identity, of forming a sense of the self as strong and capable and aware. This is a difficult task for all human beings, but it’s particularly difficult for women and it’s close to impossible for women who drink…
There was something about drinking, something about getting drunk and sleeping with men [Meg] didn’t know, that gave free rein to a host of buried feelings, to an undercurrent of neediness and longing she’d kept compressed in the darkest corner of her soul for years.
The drink released this current, let it stream up and out. There was a fuck-you element to it: a feeling of fuck you, I am going to get what I want, even if I don’t believe I deserve it. Frustration and shame and fear and self-loathing and release, all wrapped into one, all liquefied and drained away by drink. She drank and she did just that, just said fuck you to her own complicated mix of feelings and did it (80-81).
Knapp repeats this same theme later in the book.
Abby drank a lot before [the rape] happened, and she smoked pot daily, but afterward, something within her shifted. The impulse to control, and to worry, abated. Fuck it. It’s like the deepest part of your soul just says that – fuck it – and you plunge, justification in hand like a passport to self-destruction…
Janet took the leap after her marriage ended. Something clicked the same way, something very deep said, Nope. Just can’t tolerate any more pain, and her alcohol intake went off the charts. She moved from Vermont to Boston and after a very short time found herself looking up at the clock every night at ten-fifty or ten fifty-five and thinking: Oh, shit. Then, no matter what she was doing, she’s race out to the liquor store before it closed to pick up one more bottle, one more bottle to get her through the night, to get her to sleep (213-214).
Even in recovery the inner voices continue to do their work.
A few nights before the two-year anniversary of my mother’s death, I found myself at home, alone, with an unplanned evening ahead. I stood there in my living room at one point and I could sense it, an edge of emptiness and grief tugging at me, and I wanted to run, eradicate it. This is why I drank. This is why I drank. The feeling is immediate and laced with panic, and so is the response: Anesthetize me. Fuck it.
In the end I lit a cigarette, another great antidote for strong emotion, and I made myself a cup of tea. The feeling abated, as it always does despite your unshakeable conviction that it won’t, and then the feeling passed. Another moment, gotten through without a drink (266).
Knapp brings these words inside ourselves to light, tying them to our experiences and our emotions and the everyday occurrences around us. In her writing I’ve found that she provides a great deal of raw material – of description – that is good to think with, even if one might not always agree with her final assessment. That gives the potential to rework what she describes in new ways.
Inner voices are there in the mediation of drinking, in the why’s we drink and the why’s we don’t. These are a different type of inner voice, one already a part of oneself, yet triggered in specific moments, an articulation of need, a permission to do, a sense of why concretized in an inchoate voice, often confused yet powerful. Deeply powerful.
Later that night, back at Michael’s and sitting around his living room chatting with his parents, I found an excuse to go out to my car. I think I told Michael’s mom I had a book out there I wanted to lend her. In fact, I had a bottle of Scotch stashed under the front seat, and when I got to the car, I grabbed it and I sat there in the dark and drank a good two or three inches of it straight out of the bottle. I just remember the hunger, the need. I need this. I might have actually said it aloud; I can’t remember, but it wouldn’t surprise me, it felt as strong as words (59).
Rethinking Motivational Interviewing as a Linguistic Practice
Motivational Interviewing is one of the few proven clinical interventions for addiction. In the official documents, including the recently released 3rd edition of Motivational Interviewing: Helping People Change (Applications of Motivational Interviewing), and in their extensive training sessions, Motivational Interviewing is presented as a clinical technique that promotes people’s internal motivations in positive ways. Therapists should listen empathically and roll with client resistance, all the while engaging clients in “engaging, focusing, evoking, and planning” on those positive statements that clients make about changes they’d like to make in their lives.
The basic point of Motivational Interviewing is to not get into debates with addicts about the negative side of things; start scolding them, and inevitably they’ll start defending themselves. Rather, therapists should focus on reinforcing the reasons addicts have to make changes in their lives. They inevitably have them. Addiction is no walk in the park, and people are not stupid – heavy alcohol and/or drug use comes with costs, and often wishes on the part of users that things could be different. But they say those things tentatively. Motivational Interviewing works by re-phrasing statements in a more active and positive fashion, a powerful system of feedback from the therapist.
Motivational Interviewing involves attention to natural language about change, with implications for how to have more effective conversations about it, particularly in contexts where one person is acting as a helping professional for another (4).
Motivational Interviewing is presented at a therapeutic approach, a type of talk-based therapy, and is increasingly framed in psychological terms. Clients experience ambivalence, they having varying motivations, they can assess costs and benefits. For counselors, the job is to, first, engage them in a conversation that isn’t oppositional, but after that, largely cognitive – all that “engaging, focusing, evoking, and planning.”
From one perspective MI is complete when there is a change plan in place to which the client is committed. Viewed in this way, MI is something that might be done at the beginning of a treatment process to prime the pump for change… [However] change is often not a linear process. Motivation to initiate and persist in change fluctuates over time regardless of the person’s stage of readiness.
But in writing this post, I’ve come to develop another perspective on what Motivational Interviewing might do. It works because it helps develop certain inner voices over others, giving voice to desired selves and conflicted feelings and hoped-for outcomes. Motivational Interviewing works because it changes the conversations a person has with himself or herself.
In part, those conversations change by being articulated in new ways, in ways that don’t reinforce common stereotypes and negative feelings in the person and that change the very language used. Hearing that affirmation from another – you really do want to cut back on your drinking – changes how the internal conversation happens outside the therapeutic setting. Rather than saying “fuck it” or talking themselves into going out to use, people learn to listen less to their most negative voices and to give space to others inside themselves.
While Motivational Interviewing is largely ramed as changing internal motivations, it really is a linguistic performance. It concretizes things in language – changes the “voice” of it – and helps change the inner voices that the person carries around as they move through their world. That’s the basic point I want to make. It’s not really more complicated than that.
In Conclusion(or Lieu of?!)
Oh, lots more I could say. Here are just two topics I left out:
-Cultural neuroscience and its curious results about bilingual individuals and the differing patterns of brain activation based on which language gets used (for example, this paper on dynamic bicultural brains). Use Chinese, and the interdependent self becomes the better framework to interpret brain imaging results, since both “mother” and “self” are activating similar areas. Switch to English, and the independent self comes to the fore, complete with differing patterns of neural activation.
-How isolated most psychological approaches to “language” are within the framework of linguistic relativity, often taking the Sapir-Whorf hypothesis as meaning just the language one speaks and little more. But languages come attached to cultures. When I speak Spanish here in Tampa, it’s just not quite the same as when I speak Spanish in Colombia. Language without social context and history is, in the end, easily painted into a universal grammar corner. The things that make it actually matter to people are washed away. For better reflections on this than I am capable, see Duranti’s Language as a non-neutral medium and Michael Silverstein on the Language-Culture Nexus.
So that’s not much of a conclusion. But this is very much a first draft of thoughts.
Photo Credit: Donna Mulholland, Our Inner Voices, appearing in The Aquinian post Expressing your inner voice through creativity and yoga
Update: I just want to add in this 2007 piece I came across, Exploring how deaf people ‘hear’ voice-hallucinations, describing the work of Joanna Atkinson with hearing and non-hearing individuals diagnosed with schizophrenia. It points to the sensory modality (and mediation) side of things, and highlights also how “inner voices” can vary.
Participants born profoundly deaf reported non-auditory, clear and easy to understand voices. They were all confident that they did not hear any sounds, but knew the gender and identity of the voice. They reported seeing an image of the voice signing or lips moving in their mind.
By contrast, only participants who had early experience of hearing speech described their experiences in auditory terms. Others with partial awareness of sound were uncertain whether they were really hearing sound when the voices were present. Individuals with severe language deprivation and incomplete acquisition of either speech or sign, were remarkable in that they did not experience either auditory characteristics or perception of subvisual imagery of voice articulation, suggesting that language acquisition within a critical period may be necessary for voice-hallucinations that are organised in terms of how spoken or signed utterances are articulated.
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