In 1995 I apparently gave a long talk to some meeting or other, after which the content of my talk was published by the BPS Psychotherapy Section. I have no memory whatsoever of giving any talk but I do remember writing the article. It seems worth publishing on this blog, with some updates in terms of one of the practical examples, a much shorter version of the original article as it complements with useful background the Approach to Psychosis sequence I republished some time back: I’ve also tried to reduce the psychobabble, though maybe not enough for everyone’s taste! I’ve in addition included references to later research that sheds further light on, for example, neuroplasticity and the relationship between trauma and psychotic experiences. This is the third of five instalments.
In the last post, I started to explore the next interpretation of thinking through others described by Shweder in his book Thinking through Cultures: (b) `getting the other straight, of proving a systematic account of the internal logic of the intentional world constructed by the other’ for `strong and persistent’ feelings `must after all be based on something real, which it may perhaps be possible to discover.’
It needs a long illustration to convey its relevance so this is why I began to share Ian’s experience last time.
At first he found it difficult to trust me. Within the psychiatric system, trust is an issue which, with people who hear voices, frequently slows down the piecing together of the picture. He asked if he could bring his key-worker from social services with him and I agreed. Even then he found the going very rough. `The questions you asked were painful. And I didn’t want to answer them. I didn’t see the point in answering them.’ Gradually over a period of three or four sessions he became more able to disclose some of what was in his mind both about the voices and about his past.
For him there seemed to be two breakthroughs. One was early on.
I knew there was something wrong with me. But I didn’t know what it was. And it seemed so simple when it was explained to me that it seemed too simple, if you know what I mean. But it worked. I bargained with the voices. I kept my promise to them and talked to you, and things got gradually better.’ It wasn’t a question of shouting them down: `I just talked to them quietly. I told them I knew they were unhappy and that I would do something about it. I said “I know that you’re unhappy. But I don’t know why you’re unhappy, but I’ll talk to Peter about it and see if we can’t get to the bottom of it. And I’ll try to make you happy.” I asked them if they could let me sleep. It took a coupla nights. Then they give me a break.
We wrote him a letter at about this point to help him hold on, in between sessions, to what he was beginning to grasp during the session itself. We said, in part:
We felt there was a pattern in what you were telling us. It looks as though, when life is interesting and/or enjoyable, the voices are either not there or quite friendly. For example, this seemed to be the case most of the time when you were in the army and was true for several years after you were discharged on medical grounds. When things get difficult and lonely however the voices seem to turn nasty.
It doesn’t look as though your feeling that you must have done something to upset them is not correct. It’s more as though they feed off your unhappiness, uncertainty and distrust of other people to cut you off even more from the outside world and tempt you into dangerous courses of action. In fact, they may sometimes even simply be the expressions of those feelings, arising from within you as a result of your emotional state.
Certainly, they often play on your fears and your feelings, and what they say may seem to reflect the way you feel so well that you come to believe it’s true. But it’s only true to your emotional state rather than true to the world as it is. If you can learn to build on the ways you cope with the world so that you deal with your feelings better, the voices may not turn nasty so often: they may even not turn nasty at all.
Remember how we described the way the army teaches people not to be aware of their feelings? When life goes badly wrong and you have no powerful distractions, like parachute jumping, and no close companions to help you pretend you don’t feel bad, then you have only the voices to rely on and they turn very sour. In fact, they turn into tempters and tormentors.
Although it will be hard to unlearn the lessons of the army about how not to feel and about how to look `macho’, as you put it, it is possible to do so over time and with support. In the meantime, it may help to remind yourself, when the voices are at their worst, that they are feeding off your pain and loneliness to make you believe what feels true but is not.
As Ian found pictures easier to absorb than words we captured the core point in the letter in a diagram.
As later understanding revealed, our view of his army life was coloured by his rosy presentation of it at this stage. None the less, the letter eased things forwards somewhat. Our idea that acceptance and integration of difficult feelings would be a possible solution only worked for more manageable negative feelings. As we found later, there were feelings that were too dark for him to contain and so he reverted to repression and hallucinations as preferable ways of coping.
Negotiating with Voices
At first he used a pattern of negotiation with the voices which took a vague form: it became more precise and specific as time went on. He told the voices that if they left him alone for a time in the day, he would give them all his attention in the evening. It worked. They gave him a break.
. . . not having the voices talking to me so much enabled me to think. And I could think for periods of time. And I could think about what I was going to say to the voices because they’d give me time to think about it. And it also give me time to think about exactly what I was going to talk to you about. Once I could see where the problem was I could bargain with the voices. And talking to you showed me where the problem was. So, I was able to deal with the voices in a positive way.’ He felt that earlier advice from staff had not been helpful: `They kept discouraging me and said I shouldn’t talk to the voices. I should ignore ’em. And I kept saying “Well, I should talk to them because I can get in touch with them” I’d felt that all along.
He had not felt though that it would turn out to be as easy as it was:
I didn’t think I could get in contact with the voices so easily. I thought it would take a lot longer. But I found that it happened pretty quickly.
The Effect of Emotional Pain
The other breakthrough, built upon early work to get him more in touch with his emotions, came a dozen sessions later. This is the one which relates most strongly to the issue of creating a `systematic account of the internal logic of the intentional world constructed by the other’
I knew something was bothering the voices. And I think it was over the split up with my partner. And the pain that that caused which I hadn’t dealt with. I just pushed it to one side. I hadn’t come to terms with it. I still loved my partner. And I was still hoping that somehow we could get together. But I’ve give up that idea now. And I’ve put her in the past. Because I was sad inside and because I was still hanging on, really, the voices kept plaguing me. They were feeding on my unhappiness.
This was not an easy process. At the beginning, he explained:
I hurt so much that I thought it wasn’t worth being well. I didn’t want to go on with it at first because I thought it hurt too much but I knew that I had to go on with it, if I wanted to have peace of mind.’
Later it seemed `a price worth paying. Getting your feelings back is a painful thing and it really hurts. Makes you cry. But once you done your crying and you’ve realised that that’s real, then you come to terms with it. You can put it in the past without worrying about it.’
In fact there was still a great deal of work to do at this stage. None the less he was able to describe very clearly the way emotionally-loaded events or actions were related to the voices for him:
I had to deal with the feelings. Feelings were something I’ve always suppressed. [The voices] kept feeding on my suppression. I kept saying `No. I didn’t do that’ or `No. This hasn’t happened’ and they kept getting worse and worse until it got unreal.’
And even though a painful process of emotional re-education still lay before him, the voices had almost completely gone:
I haven’t had ’em for eight weeks. I’ve had ’em for a short period, calling my name. But they soon went.
He summarised his progress in the following way:
I didn’t recognise myself that the problem lay there [i.e. in the way he was dealing or failing to deal with his emotions]. I thought it was just schizophrenia. Jumping under a train was looking very attractive. But it doesn’t look attractive now. I haven’t got any voices at all. I’m not taking any medication for the voices. And I’m sleeping better. I’m eating better.
At the time of my talk Ian had been voice-free for up to three months at a time, only had relapses for a day or so at a time and was on reducing levels of medication. He had bought a car and was driving again. He had not had a hospital admission for almost a year, in contrast to the previous pattern of four or so per year. A voicework group, which was set up largely at his instigation, had been instrumental in facilitating and consolidating his gains. The group exemplified the characteristics I am describing to an even greater degree than the individual work.
We later discovered that there were two anniversary effects that triggered a resurgence of the hostile voices: these related to two traumatic army experiences whose pain he was never able re-experience and integrate, preferring instead for the voices to get worse at that time of year. It was the lesser of two evils for him, even though it risked relapse and consequent hospitalisation sometimes.
What these later discoveries revealed was that the loss of his partner was triggering his awareness of an earlier pool of pain he seemed to know nothing about at that point, and couldn’t bring himself to deal with later even when he knew it was there.
I learned to respect people’s choices in this respect. He was not the only person I worked with who chose admission to hospital in preference to re-experiencing unbearable pain.
Sadly, a year or two later Ian’s continuing cigarette habit exacerbated his emphysema, the same illness as had killed his grandfather. It strangely echoed his mother’s death from tuberculosis: she died before he was two years old. (See below for a brief history of his life up to the point at which we worked together on his difficulties.)
I visited him in the hospice in his last weeks of life. As he lay on the bed with his oxygen cylinder close by, I asked him the same question again as I had asked him during our video recording.
‘Was the gain from our conversations worth the pain you had to go through during them?’ In the video he gives an unqualified affirmation. When I spoke to him in the hospice, as he was dying, he said the opposite. The gain had not in the end been worth the pain. I shall return to that issue in the last of this sequence of posts.
What remains true though is that without all this additional information it would have been impossible to make sense of Ian’s psychotic experiences.
Next time I’ll be exploring further examples of ‘thinking through others.’
For those interested in the full back ground to his psychotic experiences and how far back in his life traumatic events and situations began helping to shape his sensibility I have included at the end here a brief summary, which I helped him write, of his life up to the point I worked with him. It took a lot more time than I describe to glean all this information. It also indicates that Ian’s initial portrayal of army life was not as rosy as our letter to him suggested, based as it was on his earlier accounts of himself.
By the time I was 14 months old my mother was dying of tuberculosis and I was failing to thrive. I was abandoned by my dad. My aunt rescued me and took me to live with her. She applied to the courts to adopt me. My dad, at the 11th hour, began to contest this. The proceedings dragged on until I’d started school. My situation with my aunt was not secure until I was six years old.
When I was seven my grandfather died suddenly. I was extremely close to him. The pain of that still haunts me.
When I was nine I was walking to school through a farmyard, when I saw the farmer hanging in his barn. Shortly after that, the voices started, but they were nice and friendly, and kept me company as I walked the hills near home.
I went down the mines as soon as I left school. I wasn’t happy with that and joined the army. Within the first couple of years, I think, I was stationed in Hong Kong. A bullying sergeant major triggered a psychotic episode. The voices turned nasty. I heard the voice of the sergeant major mocking and insulting me all the time. I faked my way out the army hospital by denying I was hearing voices any longer.
The army didn’t know what to do with me. As they reckoned people with schizophrenia were antisocial, they decided a solitary job within the army would be the best thing for me. They came up with what they felt was the ideal solution: they’d train me to be a sniper. You spend long periods alone and when anyone comes along to disturb you, you kill them – a great idea in their view. There’d be none of that stressful social contact!
At least two incidents in which I was involved in the army left me with strong feelings of guilt. The pain of the deaths I caused, I know now, set up the later experiences of psychosis.
I was discharged from the army after I was seriously injured walking towards a bomb in Northern Ireland. I did this deliberately. It was part of a pattern. From time to time I felt I didn’t deserve to live so I put myself in danger. If I lived I felt I was meant to live and maybe I deserved to do so. When the feeling built up again, as it kept on doing even in civvy street because the guilt about the deaths never left me, I’d play the same kind of Russian Roulette.
Once out of the army I used to do this by lying down on a railway line in the early hours of the morning. If no train came within a certain period of time, I reckoned I deserved to continue living.
After leaving the army my marriage broke up and I ended up living with someone with a serious drink problem. I held down three jobs, working all hours, in order to make ends meet and finance her habit. Eventually, I got completely exhausted and depressed. I couldn’t cope any longer and threw her out.
That didn’t finish it though. I was so convinced that she would die on the streets, I felt like I’d killed her. I became tortured by guilt. I shut himself away in my room with my dog. I survived on frozen chips for six weeks, until my boss became so concerned he got the police to break in. They found me completely psychotic, they say. I think I was determined to die this way. They sectioned me. That began an eight year history of sections, medications, with long and frequent admissions, until I felt that life had nothing to offer me.
[At the end of this eight year period the video interview, from which I took the extracts I quote in the posts, took place. He didn’t want to be fully in shot because of the tremor the medication had caused him.]