BPAS:

We are grateful to Dr Sinason for allowing us to reproduce this version of his paper, based on a talk given 6th March 1993 at the APP Conference Psychodynamic approaches to psychosis: survival or revival?
It was published originally as: Sinason M (1993) Who is the mad voice inside? Psychoanal. Psychother. Vol 7 (3) 207-221 but has been revised subsequently.

Who is The Mad Voice Inside?
Dr M Sinason BSc MBBS FRCPsych

1. Summary

This paper will consider the identity of an inner voice that is experienced by everyone but in very different ways. However, when working in the transference with psychotic patients the boundaries of personal identity and the question of choice and volition are so compromised by the illness that the phenomena are so to speak "writ large". This allows the issues to be brought out with great vividness and intensity and it is the struggle with this that has led me to reconsider the identity of the inner voice in a way which I have found useful for the rest of my clinical work.

Prior to 1985 my clinical work with patients with psychotic illnesses was undertaken in the in-patient psychotherapy ward at Shenley Hospital that I was responsible for. With the movement of psychotherapy resources out of Shenley to set up the Willesden Centre our ability to continue with this work was very compromised because the Centre is entirely an out-patient resource. However, a number of us persevered and gradually worked out ways to be able to continue to offer treatment to patients who had psychotic illnesses. This involved the establishment of a case-manager system to enable the therapist to work in the transference. This evolution has occurred in a specialist workshop that I have been running at the Willesden Centre since 1986.

2. The everyday language of internal cohabitation

The experience of an ‘other mind’ speaking with its own ‘inner voice’ seems to be so universal and troublesome that it is not surprising that it has many representatives in aphorisms and saying in common speech. These sayings are worthy of study since they incorporate a wealth of common knowledge about these phenomena. For example the phrase "single minded dedication" includes both a recognition that the state of being single minded is unusual and that it can be useful if you want to get a single job done. On the other hand there is also a recognition that the state of being single minded includes a narrowing of the field of attention so that important phenomena or alternative approaches will not be seen and it is therefore a potential risk to have entered into the state of being "single minded". However, emancipation from the restricted state of being single minded is not straightforward since the phrase "being in two minds" indicates a state of irresolvable paralysis where two minds are opposing each other rather than siding with each other.

These phrases indicate a clear recognition that one body does not mean one mind and that ownership of mind is a much more elusive and problematic matter than having a body. These phrases represent the daily grammar with which we try and keep track of which mind we are in and represents an acknowledgement that the body is cohabited by more than one mind, whatever it says on the birth certificate. There are further phrases illustrating that there can be problems associated with which mind adequately represents the named owner of the body. In connection with a future plan a person can say that they "have a mind" to implement it or that they have "half a mind" to implement it which in fact means that they are in trouble about it. Another example comes when something is said or done which is abusive or damaging and out of character with the persons usual approach to life and this is often acknowledged by saying that they were "not in their right mind" when they behaved that way. As an extension of this, if there has been some profoundly damaging violent action this is commonly referred to as "mindless violence" because I think that there is recognition that even if the person perpetrating the violence claims that it was their choice to do it, it is nevertheless known that this is a false claim and it is in fact a delusion of choice in an out of control mind.

I will now give a short review of the psychoanalytic literature which has contributed to understanding how an autonomous other mind can exist in the inner world.

2.1 The voice as a split-off part of a single ego

Freud proposed in his 1924 paper entitled "The Loss of Reality in Neurosis and Psychosis" that when the ego is overwhelmed by the demands of the external world it effects a cleavage or division of itself by means of which the individual is spared the need and consequences of repression at the cost of a detachment from reality. Freud therefore recognised that there would then be one ego oriented to the demands of reality while the cleaved off other ego lived in a world of delusions. In subsequent years Melanie Klein (1975), Herbert Rosenfeld (1966), Wilfred Bion (1967) and Hanna Segal (1981) have extended the understanding of this process. In the Kleinian model a single ego comes into being during infancy but is overwhelmed by anxiety arising from its own destructive reactions to environmental frustrations and failures. Very early it therefore splits itself with the projection in phantasy of the hostile and destructive parts of the ego which are felt to otherwise be likely to destroy the self. The projection of these parts gives rise to an impoverishment of the ego. It also results in paranoid anxieties since the external object that has become the receptacle for the disowned aspects of the self is expected to retaliate. In this model the mad inner voice is therefore a split off part of the ego which is denied and disowned and which is often projected in phantasy into others who are then identified with these characteristics. Treatment therefore is conceived of as interpreting the motives for the splitting and the disowning of those aspects of the self and the gradual re-integration of these parts into a more coherent less split ego.

Another approach to the dissociation from the ego of an ill ego fragment was developed by Carl Jung who had experience of the whole range of severe psychiatric disorders when working at the Burgholzli Psychiatric Hospital in Zurich. Despite initial co-operation with Freud they had such major divergences of opinion about the structure of the psyche that they eventually could no longer work together. Jung thought that there was an important demarcation line between neurosis and psychosis and that Freud was over-stretching the personalistic interpretation of the psychic events within schizophrenia in his analysis of the Schreber case. He thought that neurosis could be satisfactorily explained by analysis of personal biographical data whereas psychotic mental contents defied reduction to a personalistic causality. Instead he thought that there was a second psychic system of a collective, universal and impersonal nature which is identical in all individuals and it is from this that a pathological ego complex is formed.

2.2 The voice as a destructive narcissistic organisation within the ego

Herbert Rosenfeld (1971) extended our understanding of the destructive aspects of narcissism and illustrated how an internal psychic organisation can be built up within the ego which usurps the functions of the ego and turns them to destructive ends. Intelligence is thereby turned to the service of destructiveness and achievement is conceived of solely in terms of domination and subjugation of others to the narcissistic aims of the ill ego. Rosenfeld described how this mental structure functioned internally like a controlling gang or Mafia which kept the well aspects of the ego kidnapped and trapped by seduction, coercion and intimidation. Treatment is conceived of as carefully disentangling the hopes and aspirations of the residual sane parts of the ego from the destructive narcissistic parts. This assists the well aspects of the ego to be able to stand up against the subjugation and abuse that they are otherwise doomed to suffer.

2.3 The voice as a differentiated Psychotic Personality co-existing with the Non-Psychotic Personality.

Wilfred Bion has described how the difficulty of dealing with psychic pain can give rise to the development of two parts of the personality each with a very different way of coping. The psychotic part, intolerant of frustration, gets rid of its perceptions and the part of the mind that registers them. The non-psychotic part of the personality which retains a capacity for tolerating psychic pain is able to experience jealousy or envy or disappointment without denying the experience and without attempting to change his attitude to the object in order to avoid these experiences.

Although Bion was clear in some of his writing that the psychotic personality functioned in an entirely autonomous manner which initially is quite beyond the understanding and influence of the non-psychotic personality, he also extensively used the concepts of the splitting of the ego and projective identification. Treatment is conceived of as firstly the process of helping the remaining diminished and impoverished non-psychotic personality of the patient to recognise the defensive and evasive motivations operating within the psychotic personality. If this is achieved then the second step is to understand the strength that comes from acknowledging personal mutual interdependence and to use the support of others to enhance the strength and sphere of influence of the reality oriented non-psychotic personality.

One of the insights shared by Bion and Rosenfeld was that the ostensive patient, the named owner of the body, was by no means to be always considered the senior partner in regard to the splitting of the personality. However, they continued to use the language of "parts of the personality" although this produces a major technical problem. The term "part" allows one part to be super ordinate or subordinate or an equal part in relation to another part. However, use of the term "part" also carries an automatic subsidiarisation of that part beneath "the personality" which is thereby treated as a unitary whole. In the Psychosis Workshop at Willesden we have found that it is extraordinarily difficult to not be drawn back into this linguistic subsidiarisation of the psychotic personality as being a sub-part of "the personality". One common way that it creeps back in, is in relation to the term "the patient". In our inter-professional dialogues we are so used to talking as if one body meant one patient that it is almost impossible to get away from referring to what "the patient said", "the patient felt", "the patient did" etc. If there is to be any hope of carefully investigating which mind is which in the inner world then we will have to learn how to specify which "the patient" we are referring to when we speak to each other.

2.4 The voice as an "identificate"

Leslie Sohn, my predecessor in running Woodside Ward at Shenley Hospital, has given particular attention to a number of problems in the conceptualisations of Rosenfeld and Bion about the nature of the psychotic personality structure. Sohn suggests that acknowledgement of connection with others is so profoundly opposed by the narcissistic organisation within the ego that it considers itself a new object not a part of the ego of the patient. He coins the term "identificate" for this usurping part of the ego which operates in a hidden and covert way to mimic a variety of apparently positive situations. He points out that the commonest example of this is seen in analysis where it suddenly takes up a collusive pseudo-alliance with the analyst and criticises the hated dependent parts of the personality which are felt to be ill, and helps the analyst in the inquiry into the illness treated as if it were a crime, but with complete callow hypocritical indifference to the fate of the "ill part".

Leslie Sohn's formulation of the nature of the psychotic personality has a number of features which I would like to highlight. It goes a lot further than other formulations in acknowledging that the mad voice inside sees him or herself as the true owner of the body and the appropriate spokesperson for that individual. This allows for some of the truly personal aspects of the inner voice to be addressed and what a personal affront it is to that usurper that anyone would think of him as a usurper when from his point of view he is like a new chief executive brought in to manage the ego and turn it into a going concern when the previous manager was manifestly incompetent. Leslie Sohn does, however, maintain that this character is an elaborate malformation of the structure of the ego. Treatment is therefore conceived of as assisting the sane ego remnants towards their restitution as the original personality. This involves the exposure of the identificate as a phantasied construction shaped from profound envious hatred of the pain and loss of dependent object relations.

3.0 Problems with previous conceptualisations

In the conceptions of Klein and her followers psychoanalytic treatment is aimed at helping the patient to mitigate the force and violence of destructive processes by acknowledging the destructiveness as their own and developing concern for the victims. However, it is easy for a such a model to evidence a lack of concern for the experience of the psychotic personality. This dilemma will be illustrated in an extract from an allegory written by C S Lewis called "The Great Divorce - a dream". This story addresses Lewis’s concern about the perennial wish to make a marriage between Heaven and Hell. This ambition Lewis believes to be a disastrous error and aims to illustrate the importance of achieving instead divorce between the two. In his story, an Angel, who for our purposes we can consider to represent the therapist, is in a dialogue with a Ghost representing the patient, and there is a Lizard who represents the versatile voice of the psychotic personality.

" I saw coming towards us a Ghost who carried something on his shoulder - a little red lizard, and it was twitching its tail like a whip and whispering things in his ear. The Ghost turned his head to the reptile with a snarl of impatience. 'Shut up, I tell you!' he said. It wagged its tail and continued to whisper to him. He ceased snarling, and presently began to smile. Then he turned and started to limp westward, away from the mountains.

'Off so soon?' said the Angel.
'Yes. I'm off'. 'Thanks for all your hospitality. But it's no good, you see. I told this little lizard that he'd have to be quiet if he came - which he insisted on doing. Of course his stuff won't do here: I realise that. But he won't stop. I shall just have to go home'.
'Would you like me to make him quiet?' said the Angel.
'Of course I would', said the Ghost.
'Then I will kill him,' said the Angel, taking a step forward.
'Oh-ah-look out! You're burning me. Keep away,' said the Ghost, retreating.
'Don't you want him killed?'
'You didn't say anything about killing him at first. I hardly meant to bother you with anything so drastic as that'.
'It's the only way,' said the Angel, whose burning hands were now very close to the lizard. 'Shall I kill it?'
'Well, that's a further question. I'm quite open to consider it, but it's a new point, isn't it? I mean, for the moment I was only thinking about silencing it because it's so damned embarrassing.'
'May I kill it?'
'Well, there's time to discuss that later.'
'There is no time. May I kill it?'
'Please, I never meant to be such a nuisance. Please - really - don't bother. Look! It's gone to sleep of its own accord. I'm sure it'll be all right now. Thanks ever so much.'
'May I kill it?'
'Honestly, I don't think there's the slightest necessity for that. I'm sure I shall be able to keep it in order now. I think the gradual process would be far better than killing it.'
'The gradual process is of no use at all.'
'Don't you think so? Well, I'll think over what you've said very carefully. I honestly will. In fact I'd let you kill it now, but as matter of fact I'm not feeling frightfully well today. It would be silly to do it now. I'd need to be in good health for the operation. Some other day, perhaps.'
'There is no other day. All days are present now.'
'Get back! You're burning me. How can I tell you to kill it? You'd kill me if you did.'
'It is not so.'
'Why, you're hurting me now.'
'I never said it wouldn't hurt you. I said it wouldn't kill you.'
'Oh, I know. You think I'm a coward. But it isn't that. Really it isn't. I say! Let me run back by tonight's bus and get an opinion from my own doctor. I'll come again the first moment I can.'
'This moment contains all moments.'
'Why are you torturing me? You are jeering at me. How can I let you tear me in pieces? If you wanted to help me, why didn't you kill the damned thing without asking me - before I knew? It would be all over by now if you had.'
' I cannot kill it against your will. It is impossible. Have I your permission?'
The Angel's hands were almost closed on the Lizard, but not quite. Then the Lizard began chattering to the Ghost so loud that even I could hear what it was saying.
'Be careful,' it said. ' He can do what he says. He can kill me. One fatal word from you and he will! Then you'll be without me for ever and ever. It's not natural. How could you live? You'd be only a sort of ghost, not a real man as you are now. He doesn't understand. He's only a cold, bloodless abstract thing. It may be natural for him, but it isn't for us. Yes, yes. I know there are no real pleasures now, only dreams. But aren't they better than nothing? And I'll be so good. I admit I've sometimes gone too far in the past, but I promise I won't do it again. I'll give you nothing but really nice dreams - all sweet and fresh and almost innocent. You might say, quite innocent ...'
'Have I your permission?' said the Angel to the Ghost.
'I know it will kill me.'
'It won't. But supposing it did?'
'You're right. It would be better to be dead than to live with this creature.'
'Then I may?'
'Damn and blast you! Go on can't you? Get it over. Do what you like,' bellowed the Ghost: but ended, whimpering, 'God help me, God help me.'
Next moment the Ghost gave a scream of agony such as I never heard on Earth. The Burning One closed his crimson grip on the reptile: twisted it, while it bit and writhed, and then flung it, broken backed, on the turf.

Lewis's allegory can be used to illustrate some features of the relationship between therapist as Angel and patient as Ghost which need to be more thoroughly encompassed in our clinical formulations. I will itemise some of these:-

1. The Ghost never expected to be able to be truly free of the influence of the Lizard because he thought that the liberating process would kill him. There was really no expectation that a new life without the domination of illness could be achieved and that the attempt would cost the patient his life and that he thought it better therefore to be resigned to the impairments that accompany the cohabitation.

2. The Angel does not seem to realise that the Ghost cannot express his wish to be free of the Lizard because the Lizard hears everything that is said and will thus be alarmed at hearing that there is a plan afoot to be rid of him. In the end he does ask for the Angel’s help in extricating him from his trapped position. However, even terms like "the psychotic personality" or "the mad voice inside" are going to be heard by that ‘other’ cohabitant of the body and can be experienced as insulting undermining and life-threatening. This is a fundamental technical problem which will be illustrated later with clinical material.

3. The Angel was a newcomer and the Ghost was more used to listening to the advice of the Lizard than the words of the Angel. It cannot be immediately apparent to a patient why he should start listening more to a therapist than to someone who has presented themselves as a close adviser for most of the patient's life. At the beginning of the story, although the Ghost is telling the Lizard to shut up he ends up laughing at what he is being told.

4. The Ghost is very explicit that it is not cowardice which is governing his attempts to prevaricate and back out of getting the help that is offered and in the end he shows that he is not governed by "affect avoidance" and does accept help. This has important implications for formulations which emphasise the death instinct roots of the psychotic personality. These can easily be heard by the patient as impugning his courage and integrity and denigrating the character of the other mind instead of considering all the reasons why it might not seem to be a realistic option to the patient to change his view of the ‘other’ cohabitant of his body as a useful advisor.

5. There is one area where this allegory exposes an important clinical issue which is difficult to address. The Angel appears to have murderous intentions towards the Lizard and shows no concern or interest in the lifelong involvement of the Ghost with the Lizard. All concern for the Lizard is left to the Ghost who in fact shows quite a lot of concern which is overridden by the Angel's refusal to consider a gradual way of dealing with the Lizard. This has all the hallmarks of an abuse situation where for example a therapist would get fed up with the slowness of the progress of a patient and the frequency of the negative therapeutic reactions and be driven to propound some much more radical action treatment.

These are the issues which have been taxing us in the psychosis workshop at Willesden and we anticipate that it will fruitfully occupy us for the next 20 years. However, I will now present a new theoretical approach and some illustrative clinical material.

4.0 The cohabitation of two minds in one body

The concept of internal cohabitation or co-residency of two minds in one body which I have evolved with the help of my colleagues at Willesden aims to be consistent with the experiences of two minds in our patients. In order to be able to discuss the differences between the two minds it is necessary to follow some naming convention in the descriptions below. The convention I will follow is to describe the person who comes for treatment and wants the help of the therapist as "the patient" and to describe the other mind whose voice the patient hears as "his cohabiting other mind". This is only for the purpose of exposition since the cohabiting other mind in a woman will be female and that in a man will be male but I will only refer to the male variant. Similarly the name that is used in practice in the treatment setting for the cohabiting other mind is one which usually arises from some particular repetitive issue or experience.

The concept of the cohabitation of two different minds includes the expectation that this is the choice of neither person and is a permanent arrangement that there is no way out of. They will co-habit till death do they part. In this concept any notions of modification of the personality of the other cohabiting mind are ignoring the evidence that he does not learn from experience and cannot change in any way. The patient is markedly different in this regard and is the potential partner in the therapeutic alliance with the analyst or therapist. Changes that occur do so within the understanding and capabilities of the patient and not in the mind of his cohabitant. The treatment alliance will not be expected to be established at the outset no matter how much it might appear so since much of the transaction between patient and analyst will be filtered through a censorship system or transformational processes operated by the cohabiting other mind through his internal advice to the patient.

It is only when the prior alliance between the patient and his cohabiting other mind is replaced with a new alliance between the patient and the analyst that treatment proper can begin. This involves an analytic process being allowed to proceed of the two minds concurrently. This is not an easy matter because our various trainings have instilled in us the impossibility and impropriety of trying to analyse two patients at the same time in the same sessions. And yet within the one body of the patient, if there are two minds which require analysis then the analyst has no option but to proceed to learn how to conduct this dual track analysis. The only way to avoid this would be to deny the mind of the cohabitant a status equivalent to the mind of the patient.

It could be argued that this is precisely what has been done with some of the alternative conceptualisations. If the cohabiting other mind is seen for example as a narcissistic structure in the ego or some other pathological mental aberration then the status of person-hood can be denied to him. However, the effect of doing this is going to be very different depending on whether he is, in truth, an aberrant psychic construction or is a separate person. If he is a mental construction but not a person then the denial of his person-hood will not matter because the aim of the analysis will be to subsume all his characteristics within "the personality" of the patient anyway. However, if he is a separate sentient mind then this conceptualisation of him and the aim to subsume him within the personality of the patient becomes an horrific one of neglect, denial of significance and abuse.

Clinical illustrations

A paranoid schizophrenic patient came for his session with his face and the palms of his hands badly scratched. He told me that he had been playing football with some of the boys from the school that he was teaching in. He had run the length of the pitch avoiding being tackled and had an open goal ahead of him when suddenly his legs became entangled and he fell and slid along the ground for many yards, painfully grazing his hands and face. He fell just an instant before he was to have scored and he told me that in his mind there had already been the cheers and praise of the other members of his team when he was cast violently to the ground. He also told me that a spectator had come up to him afterwards to ask what had happened and had told him that it looked as if an express train had hit him from behind the way he suddenly was seen to career across the ground. In this situation there was no foot of an opponent to trip him up and cast him down - he didn't even blame a lump in the pitch. He was quite clear that it was something in him that had tripped him up and turned an excited expectation of victory and acclaim into a humiliating defeat. He recognised that he carried within himself an agency which could violently interfere with and undermine any achievements or goals that he or I might have.

Prior to the therapy his correct knowledge that there was such an agency combined with the wish that it was not within led to the elaboration of a complex system of persecutory beliefs. Thus, in the absence of help with getting to know what is on the mind of the other cohabitant of the body it is inevitable that the patient will mistake that other mind for his own and will then be looking outside himself for who could be undermining him in such a profound way.

A second patient, Mr X, had experienced numerous separations from home throughout his childhood and entered therapy with a strong sense of it being an indulgence and being very sceptical about whether therapists could be trusted since he had heard of so many accounts of therapists who abused their patients. In the first few years of therapy he brought family and work problems and it became clear that he was often precipitated into ill-conceived and undermining actions by injunctions from within, to take urgent action or suffer terrible consequences. As we worked on these recurrent situations we considered the advice he was following and he could see that this was ill-advice that was coming from inside him and I began to refer to the source of this misinformation as being from his "ill-advisor".

There was considerable internal opposition to this description. He could understand the reference to ill-advice as long as he saw it as his own mistakes but he could not countenance that it could come from an "ill-advisor". I was told that the reason that I was interpreting those problematic aspects of himself in that way was that I was trying to take the edge off his guilt about them by implying it was not in his control. I was also told that it was not a good idea to do that since he felt that in the end he had to face up to the fact that it was his responsibility. I did not agree with this interpretation of my behaviour and its consequences and I interpreted that it was making his ill-advisor ill to hear that with my patient’s help I had been able to see him. I went on to say that my patient's "ill-advisor" was trying to become invisible again by persuading me that everything that went on in my patient was to be attributed to my patient's mind and that there was nobody there except the patient. The issue was then dropped by my patient although occasionally, when he was telling me of having done something which he regretted I would be told "I suppose you would say that was my ill-advisor at work" with barely concealed derision and contempt.

After a while I began to notice two phenomena. I had continued to interpret the differences between what was the product of using his mind from what had come from the mind of his ill-advisor and each time I did this I could see his head nodding in silent agreement with what I was saying. However, when the patient began to speak again he talked as if everything that I said about his ill-advisor had been referring to my patient. I gradually realised that there was a continuous covert translation process going on which my patient thought was helpful since it circumnavigated the peculiar inclination he thought I had to invite him to disown all his responsibility. Meanwhile the only way my patient was able to tell me that he understood what I was saying was a very slight nodding of his head during my interpretations which was never accompanied by any verbal agreement or murmur of agreement.

It was a completely silent nodding which I could easily have missed seeing. For the next few months I found myself turning to look at his head when I began my interpretations so that I could see something of whether he agreed with me from whether his head nodded or didn't. Meanwhile my interpretations continued to be silently translated and transmuted inside him into what amounted to criticisms of him. This transformation in effect turned what I said into rubbish because they became things I would never say both because of the misatribution of motives that would be involved and also because pointing out peoples' faults to try and make them shape up and take responsibility for themselves certainly isn't interpretation and is in fact a rather clueless sort of injunction to get well by pulling your socks up. After first noticing these two processes I considered the implications for some months and then interpreted the situation in the following way.

I said that I thought that his "ill-advisor" had so hated being seen by me and so hated that I could find a way to refer to him separately that he had taken to silently translating all my interpretations into ones that I would never say to him. I said that at the same time I had been allowed to know when he, my patient, agreed with me by the initiation of silent nodding which had begun at the same time as the translation.

This interpretation resulted in a significant shift in the relationship since the patient began to be able to be aware of when he was doing the silent nodding and began to put into words what he agreed with and what he didn't. With regard to the translation process there was initially a renewed outburst of assertions that he had to face up to his faults and that the reason he had been doing the translation was to make sense of my interpretations. However, he began to have dreams which he could remember for the first time whereas before he had been deeply frustrated by having dreams which he felt were very significant but which he had forgotten by the time he got to his sessions. The dreams were indeed significant and I will give you one of them and some of the session that followed.

"I was in a hotel and I was looking for a friend of mine who I knew was in the hotel somewhere but I couldn't find him. I came across this young child in a bare room. I didn't like the child. It was clinging onto my arm and I didn't want to have anything to do with it. It was peculiar looking. It was half like a child and half like some sort of ugly misshapen creature - like one of those Gothic sculptures. I just wanted to get away from it and went out of the room and as I left I looked back and saw that it had gone into the corner of the room and it was urinating and shitting in the corner of the room and I felt disgusted."

After reporting the dream he was silent but there followed a series of ostentatious yawns. It was clear that if anyone was going to think about the dream it was me and not him. I then made the following interpretation.

I said that I thought that as a result of my helping him understand the way his "ill-advisor" had been silently rubbishing my interpretations by translating them he had been able to let me "see" his "ill-advisor" for the first time by remembering and bringing this dream. I said that in the dream his "ill-advisor" was depicted as a combination of a clinging child and a Gothic monster and that he had been disinclined to have anything to do with him in the same way that he had when I first found a name for his "ill-advisor". I went on to say that the dream showed how his reluctance to be with his "ill-advisor" and his walking out on him had so seriously disturbed that person that he had gone into the corner of the room and was shitting and urinating but again this had only evoked disgust in him not concern. I said that I thought that his "ill-advisor" expected this indifference and often promoted it despite the fact that he was hurt by it and that it was his "ill-advisor" promoting this attitude of indifference by giving the series of yawns that had followed his bringing the dream.

My patient said that he agreed about the yawning because it had come on suddenly when he wasn't feeling tired but that he would never have thought of this child creature as being significant because his main concern in the dream was to find his friend and this creature was a nuisance interfering with what he was trying to do. I said that I thought that when he had been involved in translating my interpretations he had also thought that he was trying to be a friend to me but that in so doing he had been stopping his "ill-advisor" from being seen and that this had been hurtful to that person even though it was promoted and advised by his "ill-advisor" as the best way to proceed.

He was silent for a while and then he said that a memory had returned of a time he was away with his girlfriend on a holiday they had been planning for some time. They had been getting on really well when he had become suddenly ill with stomach pains and on going into the kitchen had suddenly had a bout of diarrhoea and had soiled himself. He was almost never ill and yet on this holiday he had been ill through most of it. I said that I thought it was precisely when he had been in prospect of an enjoyable time with his girlfriend that his "ill-advisor" had become ill and that I thought the memory told us how ill it was making his "ill-advisor" now for us to be getting on better and sharing a language for understanding the differences between them. I added that it not only made his "ill-advisor" feel ill it actually made him be "ill" .

The next session the patient started by saying that he had been thinking about the difference between feeling ill and being ill because he had got some sort of stomach bug and had been up most of the night with nausea and vomiting. He said that he had been thinking that it must be his "ill-advisor" being ill again in a way which was linked with the episode of sudden diarrhoea that he had recalled in the previous session. After a pause he went on to say that he didn't understand how people came to terms with long term disability and illness. He had a friend who had developed diabetes and had to change her whole life to be able to deal with all the tests and checkups and treatments that were needed and yet she had gone ahead and learned all she could about it and taken it on board whereas my patient felt he would just want to try and forget about it and think about it as little as possible.

I said that I thought that he did still have some reluctance to take on board all the work that was involved in getting to know his "ill-advisor" and how he had come to be ill and what the illness meant in practice and that I thought that he was amazed that his analysis had turned out to be able to help him with this. I also said that I thought that he had already changed his attitude somewhat over this since he had not left it to me as he did previously to work out the connection between diarrhoea and the vomiting illness but had thought that through and raised it himself.

The Treatment Model required for cohabitation of two minds in one body.

The treatment approach puts analytic researches at the centre of the enterprise and the analyst will not be drawn out of the analytic frame in any way. All actions are abrogated and resistance to free association examined carefully since it is usually mediated by the patient being fed paranoid propaganda by his cohabiting other mind. He is advised by his cohabiting mind of the dangerous outcomes of letting the analyst know of matters that he would prefer to keep in the dark. There is careful examination of the different emotional, perceptual and motivational systems operating in the mind of the patient and in the mind of his cohabitant. This approach allows many unexpected characteristics of the cohabiting mind to be elaborated. For example that the cohabiting other mind is quite content to join in and facilitate any errors or difficulties that the therapist has and to maximise any opportunity for misunderstanding because this adds to his ability to reside unseen in obscurity. Another unexpected finding is that the cohabiting mind can experience hurt if the therapist actually uses the very value laden denigratory or criticising terms which are promulgated and invited by the other mind.

Treatment is conceived of as fostering the development in the patient of a genuine capability for making decisions in life which adequately take account of the needs of his own mind and that of his cohabiting other mind. This is complicated by the fact that the other mind never wants what he needs and hates anyone having his needs met including his own. This does not preclude having those needs met but it does mean that the process of working out how to do this requires a great deal of detailed knowledge of both minds. This cannot be achieved by premature injunctions for the patient to "be responsible" and will not occur if the patient has an attitude of wishing to be rid of the cohabiting mind or of condemnation and resentment of this internal other. One important part of the development of genuine interest and concern for the other mind comes through attention to the ways in which the mind of the cohabitant is often using concrete symbolic equations instead of symbolism and is therefore unable to think symbolically which constitutes a significant degree of thought disorder and disability. This in turn leads to a recognition that destructive consequences do not always arise from destructive aims. A mind that is incapable of symbolic functioning can be urgent, ruthless and expedient and thereby injure others directly as a result of these disabilities.

Who is the Mad Voice Inside?

Although I will leave you to find your answer to the question I posed in my title I would like to give you a brief sketch of my own answer. I think that the mad voice inside is someone who is conceived at the same time as the patient and shares the same sex as the patient since they share the same body. Living all of his life out of sight and out of the mind of others the cohabiting other mind becomes attached to his isolation and hates to be seen. He never has his own name and will hate any name that anyone gives him. The profound isolation and abandonment which is intrinsic to his experience gives rise to autoerotic preoccupation with bodily sensations and an extreme negativism in relation to the human interpersonal environment. The mind of the cohabiting other is impaired by his preference for relating to body experiences rather than the interpersonal world. This leads to difficulties in language development and emotional processing so that this internal other being has a very different childhood from the patient.

The cohabiting other mind has needs which can be met but he would sooner die than acknowledge that he has any needs to meet and he is exercised wherever possible to interfere with the joining of need with provision. Hate is directed equally at people who meet his needs or who fail to provide for them. His hate and negativism never changes and he is therefore totally reliant on the patient for his safety. The cohabiting other mind will live as long as the patient but has no interest in the life of the patient or his own except as a conduit for sensual experiences. Left to his own devices he will keep the patient subjugated to the service of sexual and physical abuse and its extensions into maiming and death since these are the only ways of relating that he knows about .

The problem for the patient of learning how to look after the other mind cohabiting in his body is substantial but not as insuperable as his cohabitant would have him believe. With patience and hard work a genuine interest in the otherness of this being can be fostered in the patient to replace the attitudes of confrontation, condemnation and impugning of character and integrity with which he starts and which so exacerbate and inflame the problem.

ACKNOWLEDGEMENTS

I am grateful to my colleagues Joscelyn Richards, Manek Bharucha, Lorenzo Bacelle and Janine Sternberg who have helped me, over many years, to evolve and refine the ideas outlined in this paper by their participation in the Psychosis Workshop that I run at the Willesden Centre. I obtained valuable help from Renu Patel and Mona Wilson in discussions about the paper and from preliminary information they collected for me by asking some people the question "Who is the mad voice that you hear inside you?" I would also like to thank Deborah Farrell for helping me to choose the clinical material needed to illustrate the reality of internal cohabitation and its interpretation.

REFERENCES

Bion, W (1962) Learning from Experience, London:Heinemann; reprinted in Maresfield Reprints, London: H, Karnac Books (1984).

Bion, W (1967) Second Thoughts - Selected Papers on Psychoanalysis. New York: Jason Aronson.

Freud, S (1920) Beyond the Pleasure Principle SE 18.

Freud, S (1924) The loss of reality in neurosis and psychosis', SE 19: 183-7.

Klein, M. (1975) The writings of Melanie Klein, vols 1-4 London:Hogarth Press

Lewis, C S (1946) "The Great Divorce" First published Geoffrey Bles, 1946. Fount paperbacks 1983.

Rosenfeld H (1987) Impass and Interpretation. London: Tavistock Publications.

Rosenfeld H (1971) A Clinical approach to the psychoanalytic theory of the life and death instincts: an investigation into the agressive aspects of narcissism. Int. J. Psycho-Anal. 52 169-178.

Segal, H (1957) Notes on symbol formation' in The Work of Hanna Segal, New York:Jason Aronson (1981), 49-65.

Sohn, L (1985) Narcissistic organisation, projective identification and the formation of the identificate. Int. J. Psycho-Anal. 66 201-214.

This paper is based on a talk given 6th March 1993 at APP Conference "Psychodynamic approaches to psychosis: survival or revival?" It was published as: Sinason M (1993) Who is the mad voice inside? Psychoanal. Psychother. Vol 7 (3) 207-221 but has been revised subsequently.

Contact email address: drmsinason@doctors.org.uk

12 June 2004