The Voice as a Curative Factor in Psychotherapy
By Susan Lee Bady, LCSW, BCD
SusanLeeBady, MSW, author, Psychoanalyst in private practice and a supervisor at the Corona Elmhurst Guidance Clinic of Catholic Charities in New York.
The cry of the newborn baby activates his breathing mechanism and heralds his arrival into the world. It also constitutes his first vocalization-a wordless communication of new life that later evolves into a complexity and a pattern according to the culture which shapes him.
This paper discusses the vocalization that occurs in psychotherapy and suggests ways it contributes to the healing process. My ideas are based on clinical experience as a psychoanalytic psychotherapist, psychological and medical research on the voice, and my experiences as an amateur singer and voice student.
Leo Stone (1961) states that the vocalization which is patterned into speech is the medium, the technical instrument, by which therapists carry out their work. It is a vehicle of object relationship which arises at a time when intimate contact with the mother is coming to an end. In the psychotherapeutic situation, he says,
the communication of insight, the neutralizing of instinctual energies, the conversion of primary-process elements into directed thought, the extension of the integrating scope of the ego, all are mediated in good part through the indispensable function of speech, (p. 100)
It is also interesting to note that all the various forms of psychoanalysis that have evolved since its inception as well as the myriad different types of therapy that have newly developed maintain a striking similarity: virtually all methods involve two or more persons talking together.
I will not be focusing on that aspect of speech involving the particular words that are uttered. The importance of the well-chosen word is fully acknowledged by psychotherapists and has received much attention by other writers. Rather, I will consider the medium by which words are expressed —the human voice —and suggest some ideas on other aspects of healing the practitioner might find useful as he engages in that practice we call “the talking cure.”
The first section of the paper considers the voice as a reflection of the emotional state of the speaker and as a form of nonverbal communication that is heard, not seen. As such, it allows the listener (be he patient or therapist) to achieve empathic understanding of the speaker. Further the quality of the speaker's voice appears to influence the emotional state of the listener.
The second section considers the voice as a motoric instrument which gives concrete qualities to one's thoughts and which possesses therapeutic impact when the patient hears his own spoken words and experiences physically and psychologically the process of verbalization both in himself and from the therapist.
I. The significance of the voice is not a new concept for psychotherapy. Shirley Weitz (1979) devotes a chapter of her book on nonverbal communication to research on paralinguistic communication. Several psychoanalytic writers have mentioned the voice as a highly expressive instrument that not only conveys thought, but is an exquisite representation of emotion. Racker (1966) suggests that the patient knows his therapist's inner state from various nonverbal cues, including the quality of his voice. Karpf (1980) mentions voice tone among other nonverbal cues as reflecting intrapsychic conflict in the patient and alerting the therapist to opportune times for intervention.
Paul Moses (1954) considers the voice to be the primary expression of the individual, revealing general personality structure as well as momentary emotional states.
Moses describes the effect of emotions on body functions such as depth or speed of respiration or shrinking or swelling of the mucous membranes of the nose, which influences in turn such vocal qualities as tone, breathiness, length of phrases, resonant quality of the voice. Similarly volume, intensity, rhythm of speech, range of pitch, the lowering or raising of the voice at the end of a sentence all reflect the individual's emotional state.
Moses specifies various neurotic personality types by vocal characteristics and differentiates by voice the neurotic from the schizophrenic.
Although Shirley Weitz does not agree with as full a correlation of vocal quality and emotions as does Moses, she states that researchers do find that there are specific measurable vocal characteristics of various emotional states, as well as distinctive vocal characteristics of seriously disturbed persons.
Medical specialists are finding the voice an increasingly useful diagnostic tool. Certain infant abnormalities can be detected according to the characteristics of the cry, for example (Ostwald & Peltzman, 1974). It is becoming increasingly possible to determine by volume, speed, and plosiveness of the voice those persons with Type A behavior pattern who are most susceptible to coronary disease (Shucker & Jacobs, 1977).
These findings have paralleled my own experience as a voice student. My singing teacher could determine my general personality and various mood changes, plus intrapsychic conflicts that unknown to her I was then working on in my own analysis, all according to the way I was singing that day.
As I have developed an awareness of my own voice I have begun to listen more acutely to those of my patients. Medical analysts and psychological researchers use a variety of instruments to detect, measure, and graph vocal characteristics, a procedure obviously not feasible for therapists. Moses describes a technique that he calls “creative hearing” for perceiving voice quality apart from the words. It involves three main elements: (1) knowledge of the various qualities to listen for; (2) detachment from verbal content in order to concentrate on the voice itself; (3) the listener's awareness of his muscular sensations within his own vocal apparatus, which occur unconsciously in many people in imitation of the muscular movements of the speaker. The listener may relax his jaw in response to the speaker's relaxed speech, for example, or tighten his throat if the speaker constricts his. This phenomenon occurs in large gatherings when one person's cough stimulates the throat muscles of others and an epidemic of coughing fills the room. The great orators such as Franklin Delano Roosevelt or Adolf Hitler, he says, carried their audiences along with their superior breathing techniques that the listener tends to duplicate.
The best explanation of this phenomenon, Moses says, comes from Bernfield's theories on fascination.
Primitive perception is close to motor reaction. The primitive ego imitates what it perceives in order to master intense stimuli. Perceiving and changing one's own body according to what is perceived were originally one and the same thing. (Moses, p. 11)
The listener, Moses says, who can simultaneously be aware of his own muscular movements and separate his own idiosyncratic motions from those that occur in response to the speaker, gains a valuable tool. He will not only hear, but will experience physically the voice patterns of the other person and can then interpolate from that what is occurring in the speaker's vocal apparatus.
This method is especially interesting because it involves not only the ears and the brain, but the use of the body, a noncognitive way of responding to the patient, which I will discuss in greater detail in the second section of the paper.
In addition to Moses's techniques I often visualize my patientss' voices to help me hear them better. One patient speaks in a flat, monotonous voice that looks to me like a straight line. Another usually talks in clear bell tones. One session, however, she spoke in a gravelly texture about her intense fatigue and her difficulty fending off an unwanted suitor. “But I wanted to say no!” her voice shot out straight as an arrow, then resumed its gravelly quality. In the same way Karpf recommends the use of nonverbal cues to help with interpretation, I commented on her two different voice qualities. She responded by discussing the conflict she feels in making choices, for fear of making a mistake.
Since I have been listening to my patientss' voices I have also noted that changes in vocal quality accompany their progress. One patient achieved a lighter, less ponderous voice as he became more comfortable with his emotions. Another slowed down his rapid pace. A third achieved a less grating and more fluid tone.
Patients listen to the therapist's voice also, and I feel that the emotional states reflected in the therapist's voice is an important therapeutic factor. Auditory stimuli, after all, can have an important impact on the human psyche, as indicated by the development of music therapy. Niederland (1958) discusses the influence of sound on some of his patients in psychoanalysis. A distinctive noise (slamming of the door or breaking of glass) stimulated many associations in some patients. Others experienced sound as something substantial and concrete, touching them. One of my own patients also reports a strong physical response to sound. On several occasions she experienced the angry voice of a female authority figure as cutting right through her.
Kohut's (1957) discussion on the psychological aspects of listening to music notes that the same musical piece will affect different people differently, the same person differently at various times, and the same person in different ways according to the various layers of his personality it activates. He suggests we might in time isolate within a musical piece those factors responsible for affecting various layers of the personality in order to apply our knowledge of music to a variety of personality types.
It seems important to expand his idea of the impact of music on the psyche to the impact of the musical quality (or lack of it) of the therapist's voice.
Both Leo Stone (1961) and Martin Nass (1971) state that sound and speech form a connecting link between mother and child. The child can hear the mother's voice or footsteps in the next room and experience her presence, even though he cannot hear her or feel her arms around him, Nass says. Stone suggests that speech is a form of human contact that the child learns while achieving actual physical separation from the mother. It forms for the child a psychobiological bridge between them, similar to the link of verbal intimacy which is formed in the therapeutic setting.
This leads to the concern of what the sound of the therapist's voice conveys. Does it create a strong, secure psychobiological bridge or a rough, swaying one? Further, in relation to Kohut's thoughts, how can the therapist attempt through his voice to activate the various layers of the patient's personality?
In my work I will intentionally use my voice along with my words. Sometimes I attempt through vocal tones to soothe an anxious, agitated patient. Other times I use my voice to stimulate a depressed and hopeless one. On still other occasions I talk to give the patient a human response and my words are less important than the vocal indication of my presence. Sometimes I remain silent in order to encourage separation from me. Occasionally my voice backfires on me, as when a patient notices my anger or my anxiety through the sound of my voice.
Several researchers have begun to explore this area in a more systematic way. Bugental and Love (1975) found that mothers of non-disturbed children had more assertive voices while expressing approval or disapproval than while making neutral statements than did mothers of disturbed children. There was no difference between the two groups of mothers in affective quality of the voice.
Milmo, Rosenthal, Blane, Chafetz, and Wolf (1967) found that physicians who displayed an “anxious” vocal quality while talking of alcoholics had been more successful a year earlier in referring alcoholics to a treatment program than those with an “angry” vocal quality. The relationship between anger and ineffectiveness accorded with many clinical reports of doctor-alcoholic encounters, the authors felt. The anxious effective relationship, they said, may relate to the idea that healers with an anxious, nervous voice may be perceived by others as showing greater concern.
Duncan, Rice, and Butler's (1968) analysis of therapistss' voices found distinctive differences between “peak” and “poor” therapy hours. (The quality of the hour was designated by the therapists.) Vocal characteristics during peak sessions demonstrated normal stress with an open voice, lower pitch, and softer intensity than during poor hours. Pauses during the therapistss' speech tended to be unfilled by “urns” and “ahs.” All these factors combined to give the impression of warmth, seriousness, relaxation, and closeness from the therapist.
We will need further research to fully understand those specific factors of the voice that contribute to various responses in the listener and will need also to determine the extent to which the voice quality affected the listener's behavior or whether the listener's behavior influenced the speaker's voice. However, it seems important as therapists to pay attention to our voices for several reasons.
First, it does seem probable that the voice influences the listener. Second, most persons are unaware of how they sound to others. Our own voice is conducted to us through a medium of both bone and air. It thus sounds different from the air-conducted sound that others hear. It is helpful to know how we sound both in normal conversation and in times of stress. I am generally satisfied to hear my voice during tape-recorded sessions. However, I have often been startled and chagrined listening to myself talk during countertransference reactions and hearing the contrast between the therapeutic words I was speaking and the emotions my voice conveyed.
Considering the increasing recognition therapists are giving to countertransference as an important therapeutic tool that can either enhance or harm the therapeutic process, the voice which conveys it deserves much attention.
II. Thus far I have presented the voice as an expressive instrument, a carrier of emotions, reflecting one's inner state. In this second section I will examine it in another context as a motoric instrument possessing important therapeutic functions. Several theorists and researchers suggest that the act of vocalization gives active and concrete properties to words. Further, I believe that vocalization constitutes an important form of action in itself and that it stimulates the healing process in the individual.
Words, and words via speech, serve an important role in human society. Without words thoughts are slippery and diffuse and will slip from our minds unorganized and unusable. Klein (1965) points out that whenever one finds a word for an impression, the impression crystallizes and the experience changes. Further, there is an important difference between the silent and spoken word. Obviously one must be far more organized, focused, and irreversible in expressing one's ideas in conversation than in thinking to oneself, a factor having obvious implications to the verbalization that occurs in psychotherapy.
Lowenstein (1956) stresses that the spoken word can provide strong relief or can hurt more than a physical blow. He also comments that resistances can occur in treatment, not only in the process of making the unconscious conscious, but in the difficulty a patient may experience verbalizing a conscious thought. This may occur due to either the discharge or binding functions of speech. The patient fears being carried away by his emotions and thus eliciting the dislike or disapproval of the therapist. Conversely he may want to remain within his emotions and not allow words to “break the spell” through the reality orientation that words provide.
An instance illustrating the first example occurred with my patient described above who reacted strongly to the voice of a female authority figure. She once presented a dream where she was rendered powerless to defend herself from an attacker by a loud voice from behind that said, “Don't scream.” Often when I asked a question intended to elicit awareness of aggressive impulses she either drew a blank or responded, “I know what I feel, but I don't want to say it to you.”
Lowenstein says that the vocalization of thought makes it more real. Speech turns ideas into a social reality. They become something you can turn over in your hand and look at, so to speak, especially when spoken to a witness who might remember them or, as my patient feared, might disapprove. It encourages the discovery of hidden material to arise so that the patient comes to his own insight or is ripe to grasp the therapist's interpretation. “Isn't it amazing how ideas occur to me when I'm talking to you,” one of my patients said, “and not when I'm thinking by myself.” Often it provides relief to speak one's thoughts to a sympathetic person. Another patient commented: “Talking helps. It gives my thoughts air. They were smothering inside.”
Thus far I have discussed the psychological aspects of talking that appear to contribute to the therapeutic cure. In addition there is, I believe, another aspect of vocalization that has a curative effect—the physical action of creating audible sounds and the physical impact on the individual when he hears —and feels his own and another's speech.
Klein discusses the impact of hearing one's own voice while talking. The feedback from the sound of our own voice serves an important developmental function, he says, in facilitating distinction between one's covert and one's overt speech, as well as one's own speech from that of others —important distinctions the individual must achieve in order to separate himself from others.
This suggests why my patient who dreamed of a voice saying “Don't scream,” was so reluctant to speak the angry thoughts her mother prohibited and thus separate from her. It also suggests why some persons lower their voice when stating important issues or lift their voice in a questioning tone at the end of a declarative statement. Both actions detract from one's forcefulness and autonomy and they want neither themselves nor others to hear it.
Klein also cites an experiment carried out in Russia by Luria and associates on another important developmental function of hearing oneself talk. The experimenters found that children of three and four years of age could better control their behavior— to push a colored balloon only when a light flashed — when they verbalized loudly the words “stop” and “go” than when responding to visual stimuli alone. Only after a period of verbalization could the children use silent signals to help them control their behavior.
Klein feels this experiment suggests an extended basis for Freud's statement that the commands of the parents become “the voice of conscience.” The superego forms not only through the receptive function of the auditory sphere hearing the parental commands, but also through the action of verbalization. The words the child listens to become words he says aloud and hears and the sound of his own voice helps reinforce the self-other distinction which is the basis for a firm superego.
The idea carries interesting implications in psychotherapy when our patients discuss personality or behavior changes they wish to achieve. The act of vocalization makes thoughts concrete and real not only to a witness, but to the patient. He hears himself. He owns his thoughts with his own ears as an individual separate from his parents, capable of forming his own opinions and controlling his own behavior. As one of my patients said as she came to a new realization, “Did I just say that? Now I know that I have to change.”
Furthermore, voice quality becomes a significant indicator of the strength of a patient's verbalization. When weak, flat, or grating, it can indicate conflict needing further exploration. When strong and consistent with the words spoken, it indicates that speech is not only an abstract phenomenon “mediating” the healing aspects of therapy, as suggested by Stone, but an active and integral part of therapeutic change.
Thus far I have presented a psychological explanation of the active and concrete qualities of the spoken word. However, if we consider the actual mechanics of voice production, we realize that when we speak, something really is happening, an experience every singer knows, feeling in his body the movement of the diaphragm, the relaxing of jaw and throat, the vibration of airwaves in the chest and head. In other words, the spoken word is not only heard by the speaker, but is felt by the speaker who knows that something very real is happening inside his body while producing that invisible phenomenon called voice.
Thus when an individual verbalizes he is not only giving his thoughts a social reality, speaking to a witness and separating himself from the outside world, but through the action of his vocal apparatus and sensory perception of his body, he provides his thoughts with an unseen, yet actual physical existence. The action of speech is not just semantic, but is real.
This idea is especially pertinent when affect matches verbal content. A truly sad communication is felt differently in the body than a happy one or an angry one, in the shape of the vocal cords, the pattern and rate of breathing, the movement of diaphragm, facial muscles, etc. Perhaps the relief that comes from catharsis stems from the physical action of a strong outpouring of words. It may actually feel to the person as though he is ejecting an angry or sad thought from his body. Furthermore, to expand on the idea mentioned earlier, perhaps our patients own their spoken thoughts not only with their ears, but with their entire body, which both produces sound and hears it. We all know instances when a patient evidences strong physical distress while verbalizing a disturbing thought and then feels much relief afterwards. In these circumstances the “neutralization of instinctual energy” may not just be “mediated” by speech, as Stone views it, but also accomplished by speech. Perhaps my patient's comment that talking gives her thoughts air was not only a metaphor for a psychological experience, but also a description of the stream of air that flows through the vocal apparatus in order to produce a sound.
This possibility relates to Niederland's (1958) discussion of his patients who experienced sound as something concrete and touching them. The acoustic apparatus of fetus and newborn are constructed differently from the adult's, he says. Possibly sound to the fetus and infant is experienced as contact. The adult in a regressed state in psychotherapy may return to that earlier perception of sound. But even without that possibility, he says, the fact is that sound is indeed a contact experience. Sound waves from a person's voice or other sources are transmitted through a medium of air to create tiny, yet definite impressions on the skin and eardrum. A loud noise is thus felt as well as heard. At lower frequencies there is a gentle but definite vibration distinct from and superimposed on the sound.
These ideas return us again to the voice of the therapist whose speech can create both a psychological and physical bridge between himself and his patient and stress the importance of the way we touch another with the sound of our voice.
The physical action of voice production raises a final issue in the speaker-listener relationship. As mentioned earlier, Paul Moses states that many listeners unconsciously duplicate within their vocal apparatus the physical movements of the speaker. James Lynch (1979), a researcher, also comments on the bodily coordination between two persons. His book, which presents research showing greater incidence of heart disease among men who live alone, also cites several experiments monitoring heart rates of patient and therapist during sessions. All experiments found a close coordination in increase or decrease of heart rate between the two persons according to the material being discussed. One experiment also found that the cardiac relationship was closest in those sessions where the therapist reported he felt least distracted by personal concerns or countertransference responses to the patient.
If we consider it possible that one person can physically affect another, then vocal intonations of the therapist take on further importance. Perhaps the therapist's use of his voice to soothe or stimulate a patient, discussed earlier, occurs not only through the patient's psychological reaction to the sound of his therapist's voice, but because the patient may begin to duplicate within his own voice and body the physical movements of the therapist. In the same way that Moses described, a voice that reflects the relaxed and self-confident manner of the therapist may calm the agitated voice and emotions of the patient. The assertive, self-assured voice of the therapist may stimulate hope and courage into the timid voice of the patient.
This thought connects with that expressed in my earlier paper on countertransference (Bady, 1984). There I suggest that the patient knows his therapist's inner state and capacity for curing himself of countertransference reactions not only through his words, but through the various nonverbal cues such as voice tone, breathing patterns, and small body movements. I also suggest that the patient unconsciously uses his experience of the therapist's capacity for cure as a model for handling his own conflicts. To continue this thought, as our patients observe our nonverbal cues, infer our inner states, and copy them within their psyche, perhaps they simultaneously —or even initially —copy them within their own body and own vocal apparatus. It is certainly similar in concept to those instances where patients buy similar clothing or smoke the same cigarette as their therapist. This possibility would constitute a very concrete way in which the therapist becomes for the patient a model for his own growth. If so, the voice of the therapist along with other forms of nonverbal communication reflecting the inner state of the therapist becomes an important factor, along with our words, to help our patients find within themselves the capacity for change.
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Psychoanalytic Review, 1985; v.72 (3), p479 (12pp.)