When Voluntary Control Breaks Down

Psychopathology is the study of repeated, dysfunctional errors that are often known to be errors by the person who makes them, “slips” of action or experience that escape attempts to control them over and over again. Most psychopathology in the neurotic range involves a loss of voluntary control over inner speech, feelings, mental images, or overt actions. Loss of control over inner speech is a factor in obsessive or delusional thinking and in some auditory hallucinations; out of control bodily feelings play a role in pathological anxiety, conversion hysteria, and depression; uncontrolled mental images are at the core of phobias; and when actions run out of control we find compulsive or impulse-control pathology.

We can illustrate all these points with a single patient who suffered from a variety of symptoms. Consider Anna O., the classical early patient of Breuer and Freud, who suffered from a very severe case of conversion hysteria. As Erdelyi describes the case:

Anna O. became Breuer’s patient in 1880 at the age of 21 when, under the pressure of nursing her dying father, she suffered a nervous collapse. She developed a veritable museum of symptoms which included a labile [variable] pattern of incapacitating paralyses of the limbs; depression and listlessness; terrifying hallucinations of snakes, which transmogrified into death’s heads and skeletons; painful coughing fits, especially in reaction to music; a period of severe hydrophobia, during which she could not bring herself to drink water; amnesias [blackouts] for recent events; a blinding squint; severe paraphasia [loss of language ability]; anorexia [unwillingness to take food]; and several other serious dysfunctions.

It is the loss of desired control that makes these symptoms pathological. Not moving one’s limbs is quite all right if one doesn’t want to move them; depression and sadness due to a loss is quite normal; strong squinting is a good idea in the middle of a sun-drenched desert; even images of snakes and death’s heads can be quite normal for a reader of Gothic fiction (after all, thousands of people voluntarily go to horror movies or read Gothic tales); even amnesias for recent events can be normal when we want to deliberately forget or ignore them.

These events become pathological when people do not want them. Those who suffer from these symptoms try hard and often to master the involuntary feelings, thoughts, actions, or images, but they fail over and over again, in spite of often desperate efforts. It is not the content of the thoughts, feelings, and actions that is problematic: it is their occurrence out of an acceptable, stable frame, out of the perceived control of the sufferer. Thus the issue of voluntary control is at the very core of human psychopathology, and an understanding of psychopathology must be grounded in an adequate theory of volition.

There is a clinical intervention that is sometimes very effective that seems to act directly on the mechanism of voluntary control. This paradoxical technique is called “negative practice,” or “practicing the symptom.” If a person has a specific phobia, he is told to voluntarily bring forth the fearful images and thoughts; if he is a stutterer, he is to try stuttering voluntarily whenever he stutters spontaneously; and so on.

This technique has been systematically tested for a variety of problems. Some of the results are quite remarkable. Children who have stuttered for years are told to stutter deliberately for 30 seconds each time they do so involuntarily. As a result, they often stop stuttering in a day or two, with a 75 percent success rate. There are many cases in which the paradoxical technique works remarkably quickly to stop anxiety attacks, compulsive actions, tics, involuntary phobic images, LaTourette symptoms and the like. We see here a case in which countervoluntary automatisms are turned into wanted automatisms, just the opposite of the case of “bad” habits. Of course, practicing the symptom is not a cure-all; but it has been reliably observed to stop pathological symptoms with remarkable speed, often after years of helpless struggle.

Of theoretical interest here is the neat contrast between voluntary and involuntary control in the paradoxical technique. A habitual stutterer has typically struggled thousands of times against the tendency to stutter. This repeated attempt to exert voluntary control rarely works. The paradoxical intervention requires him to stutter deliberately, to do voluntarily what normally happens involuntarily, and rather magically, in many cases the problem disappears.

One fascinating possibility is that practicing the symptom, which is, after all, only a switch in the direction of voluntary effort, operates through the voluntary control system. If this is true, then it may be that the symptom itself is an error in voluntary control.

Much psychopathology may involve “errors of the will.”