Identity is experienced as being aware that one exists and that one has the right to live. The person accepts his limits and is prepared to exert his right to exist. He derives strength and courage from a basic feeling of security, from self-confidence and faith in others. He accepts responsibility for his behaviour. A patient with weakness in the sphere of identity feels insecure, "not O.K."and avoids responsibilities. This often obstructs progress in therapy. Strengthening identity then has a high priority.
A therapist may lack strength and credibility because of a weak or faked identity. If this is the case one can hardly expect a patient to experience basic security in his/her presence.
Humans are social animals. One of the first needs of an individual is to relate closely to one person in particular. This produces bonding between infant and mother. Later in life the intimacy of lovers and close friends develops, one learns to be close to others without losing one's own identity. Intimacy develops on the edge of fusion (identification with the other) and self-assertion. The antithesis: fusion versus autonomy is solved by "sharing". A person who feels supported by a strong feeling of identity can reach out and become intimate with others thereby enriching their lives. The intimacy offered in return, is a reinforcement of one's own identity. If something in the sphere of intimacy is lacking, a patient may experience trouble in developing adequate social coping skills. In a therapist an unrequited need for intimacy may give rise to problems: the transfer of feelings by the patient to the therapist may cause confusion and elicit inadequate responses.
The art of living is making the right choices and decisions. This aspect of human behaviour is studied by motivation theory. It is an important domain for the communication pathologist: many disorders have their beginning in this sphere.
The patient who has lost control over his voice or speech often has to reexamine his priorities in life. Is he satisfied with his work, what can he do to feel better about his family relations, who are his friends, can he depend on them, can he make his choices from a position of self-respect? Before the outbreak of a psychogenic loss of voice there has often been a period of inner confusion. Under the appearance of a perfectly regular and well-organised life, there has been inner dispute, irresolution, or even despondency, there may have been existential crises. In this situation the patient needs a reliable guide to counsel and support him until he is sufficiently "reorganised" to withstand the adversities of life by drawing on his own resources. The "Old" practice of dealing with "these hysterics" by surprise tactics or suggestive exploits is callow or at best naive.
Choosing the right counsellor can be difficult for the patient, especially when he is in emotional disarray. More than one patient with a beginning spastic dysphonia, who could have been healed by adequate psychotherapy and reeducation, has accepted medical help that has piloted him into the quiet harbour of permanent disability (surgery, beds and benefits included). It is a weakness in the health care system that patients are seldom fully informed about cognitive and behavioural therapy. If they are, it is a choice between unequal alternatives. The reeducation therapist is at a disadvantage because he/she can only offer hard work with uncertain outcome instead of surrender to partial disability, with the accompanying tokens of sympathy.
In the process of self-actualisation this is the buffer-zone that people build around their identity and intimacy. Human drives and motivations are consummated in the social sphere: identity is fostered, intimacy has to be actualised in a social context. Interaction takes place with members of the family and other people in the environment, in an ever widening circle. Out of early experiences with socialisation a complex scene of transactions between people will grow, which E.Berne has aptly described as activities, pass-times and "games". A fair number of games get people entangled in risky social habits of which they themselves are hardly aware. A life-scenario with unwholesome games may include some vicious speech- and voice neuroses. Replacing the dominating games and changing the scenario, by role-playing and practising game-free relationships can bring about a profound change. It will bring the person closer to a true feeling of identity (instead of a fake one) and to genuine intimate relationships.
Men and women are often judged by the impression of power they display in carrying out their designs and resolutions, in demanding achievements from themselves and in dominating others or, on the other hand by submitting to others. Phantasy and creative power are important factors in people's lives, and so are ambition and perseverance to carry out one's design.
The fulfilment of most aspirations and expectations needs time. Impatience and haste are widespread disabilities in people who feel insecure. Physical features belonging to this state of mind are hurried superficial breathing, an incontinent rate of speech. Working on these features may be a good point of entry for body-oriented therapy.
On the level of thinking, reasoning, evaluative judgments, people must also learn to take the time it needs. They will do so if they think of themselves as competent and worth while.
In this sphere the person keeps his internal image of the environment and of his own functioning in this environment. Cognition has been collected from and pervades all previous levels: identity, intimacy, emotional self-preservation, relating to others, creativity and willpower, have their involuntary controls as well as a conscious representation. By rational thought the person tries to make sense of what is happening to him and to his environment. Rational though they may seem to be, thoughts may be subject to distortion: Misinterpretations and false expectations may occur as a consequence of exceptionally strong experiences dating far back in time.
The therapist's cognitive skills are his most obvious instrument . Such skills are however powerless if not activated and supported by creative energy (level 5) and guided by social intuitions (level 4). They may become blocked or misdirected if the more central levels, the emotional life, intimacy, identity are inadequately developed. If well developed they enable the therapist to intervene at the right time, by the right gesture. The equilibrium in an individual is never static. Its being dynamic is the reason why well-timed therapy helps an unpoised person to regain his balance.