psychosis and the concept of internal cohabitation
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Psychosis and the concept ofinternal cohabitationJoscelyn Richards Consultant Clinical Psychologist andPsychoanalyst aa Consultant Clinical Psychologist & Psychoanalyst,Psychology and Psychotherapy Services, CNWL MentalHealth Resource Centre , LondonPublished online: 15 Feb 2007.
To cite this article: Joscelyn Richards Consultant Clinical Psychologist andPsychoanalyst (2007) Psychosis and the concept of internal cohabitation,Psychodynamic Practice: Individuals, Groups and Organisations, 13:1, 25-42, DOI:10.1080/14753630601086329
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Psychosis and the concept of internalcohabitation
JOSCELYN RICHARDS
Consultant Clinical Psychologist & Psychoanalyst, Psychology and Psychotherapy
Services, CNWL Mental Health Resource Centre, London
AbstractThis paper was first presented at a conference with the title, ‘Where is the madness?Exploring aspects of the psychotic in ourselves and our clients’. The author exploresthe idea that ‘madness’ exists in us all in the form of an internal other mind thatfrequently operates as an inner voice or adviser. The paper elaborates the concept ofinternal cohabitation that conceptualizes two minds or egos – a psychotic and a non-psychotic – co-existing or cohabiting in the one body from birth. The nature ofpsychosis is discussed and clinical details are given involving two patients with, andone without, an obvious psychosis. Although the experience is writ large for the firsttwo patients, on close examination, all three experience similar internal advice,warnings and threats, causing distress and an undermining of their autonomy. Thepaper illustrates the importance of therapists conducting a dual track analysis ofboth selves and remembering that they, too, can receive poor advice from theirinternal cohabitant. The paper ends by exploring the devastating problems that canoccur when a patient with an obvious psychosis is not helped during the course ofhis therapy to differentiate his perceptions from those of the paranoid internal otherand when the latter’s terror of being annihilated by the analytic process is notrecognized.
Keywords: Internal cohabitation, internal cohabitant, psychotic personality,non-psychotic personality.
Introduction
Major contributors to analytic literature, for example Freud, Klein, Bion
and Herbert Rosenfeld have thought that there are psychotic and non-
psychotic dimensions in all human beings and that what is observed to exist
in patients with a psychotic illness, although extreme, is likely to hold true for
Correspondence: Joscelyn Richards, Consultant Clinical Psychologist and Psychoanalyst, Psychology and
Psychotherapy Services, CNWL Mental Health Resource Centre, Harlesden Road, London NW10 3RY.
Psychodynamic Practice,
February 2007; 13(1): 25 – 42
ISSN 1475-3634 print/ISSN 1475-3626 online � 2007 Taylor & Francis
DOI: 10.1080/14753630601086329
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everyone. Bion particularly emphasized that people who are psychotic also
have a non-psychotic personality that is masked by the psychotic personality
and that people who are considered to be neurotic have a psychotic perso-
nality that the neurosis conceals. Thus, according to these analytic thinkers,
all of us have a psychotic dimension co-existing with our sane resources.
Psychotic and non-psychotic mentalities
In other papers (Richards, 1993, 1999, 2001) I have described my
understanding of the two different mentalities that characterize the
psychotic and non-psychotic personalities.
First, the psychotic mind is characterized by the following:
. hatred of reality, thinking and dependence, there is an assumption that
dependence is dangerous and a sign of weakness and that needs can
never be met, thus there is an idealization of self-sufficiency;
. the conviction that all relationships are exploitative, hierarchical (i.e.
someone is always above and someone below) and based on power only
and that creative intercourse (literally and metaphorically) cannot exist,
the mind with these convictions is essentially paranoid and hates and
dreads any form of psychological investigation;
. extreme narcissistic sensitivity to real and imagined hurts;
. the belief that like-for-like retaliation is fair;
. concrete, absolutist (all-or-nothing) and rigid thinking; or, put another
way, tram-lined thinking where there is no room for doubt or no room
for certainty;
. the use of symbolic equations (Segal, 1981) in which the psychotic mind
cannot truly symbolize but sees two things that have some aspects in
common as being literally the same; this, of course, leads to serious
errors of judgement such as assuming everyone with the same skin
colour is the same in every other way;
. an incapacity to acknowledge mistakes and thereby to learn from
experience.
On the other hand, the non-psychotic mind can learn from experience,
can think, can symbolize and make associations and connections, under-
stands and appreciates complexity, enjoys human relationships and has the
capacity and the desire to empathize, to make useful differentiations and to
recognize and negotiate internal and external realities, including social
relationships. Categories are recognized but are seen as useful tools for
identifying differences and making sense of information and not for
classifying human beings permanently into inferior and superior groups.
The non-psychotic mind needs a facilitating environment if it is going to
develop its full potential. It is the self with the non-psychotic mind that
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seeks therapy and can use the processes of psychoanalytic psychotherapy
and the relationship with the therapist to continue growing and developing.
Introduction to the concept of internal cohabitation
and the inner voice
Bion’s 1957 paper is entitled ‘Differentiation of the psychotic from the non-
psychotic personalities’. It is interesting to note that in the title he refers not
to aspects or parts but personalities (although in the text he is inconsistent).
In that paper, he states, ‘I do not think real progress with psychotic patients
is likely to take place until due weight is given to the nature of the
divergence between the psychotic and non-psychotic personality’. In other
words he suggests that there are two very different modes of functioning
and relating to others. Bion’s work has influenced me a great deal as has
some aspects of Herbert Rosenfeld’s writings, particularly the concept of
‘the narcissistic omnipotent self’ who adopts bully tactics when that self
feels threatened by the libidinal self’s relationship with the therapist
(Rosenfeld, 1987). Winnicott, too, recognized ‘an active non-communicat-
ing mode of being’ that is different from his other concepts of the true and
false selves (Sinason, 2004b). To Winnicott, this non-communicating self is
also a true self, although profoundly different from the actively commu-
nicating true self. Winnicott thought of the ‘non-communicating self’ as a
central ‘secret self’ that is an isolate who cannot tolerate being known and
who reacts to ‘the threat of being found, altered or communicated with’ by
a further hiding of itself (Winnicott, 1963).
The concept of internal cohabitation, which encompasses some of these
key ideas, conceptualizes two minds or egos – a psychotic and a non-
psychotic – co-existing or cohabiting in the one body from birth.
This concept was introduced into the psychoanalytic literature by
Sinason in a paper entitled ‘Who is the mad voice inside?’ (1993). He
referred to experiences in both the consulting room and in everyday life
where both the observer and the subject use common phrases to recognize
that the subject has acted out of character when he does something violent
or crazy leading a friend to say, ‘he wasn’t in his right mind’ or the subject
to say later, ‘I wasn’t myself’. In this paper, Sinason re-examines the
relationship between the experience of ‘self’ and the experience of an ‘inner
voice’, which he suggests is universal but writ large in the experience of
psychotic patients. He suggests that all of us have an ‘inner voice’ that says
or does things that undermine our autonomy – but in a more hidden or
subtle way than in patients with a formal diagnosis of a psychotic disorder.
Sinason suggests that the identity of this inner voice is a mind that has
certain characteristics that are different from the characteristics of the
mind that can comprehend social reality and form relationships with
other human beings. The designation of which of these minds is sane and
Psychosis and the concept of internal cohabitation 27
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which psychotic is complicated by the fact that each is an authentic
advocate of what ‘really’ matters in life, although what they advocate is often
incompatible. Each mind sees its own approach as ‘sane’ and the approach
of the other as ‘psychotic’. Thus, the concept of internal cohabitation
involves a dual-track analysis of the two co-existing selves, each of whom
has a mind of their own and in which neither mind is considered to be
subsidiary to nor split-off from the other, although one mind is able to
think and relate to the therapist and the other cannot and wishes to
remain hidden.
Having worked with the concept for many years, I have come to the
conclusion that probably all patients benefit from an opportunity to
explore and analyse the other mind that lives with them, however hidden
it may seem at first. Although it may seem hidden, it is usually the
underlying reason that people seek psychotherapy. It is due to the subtle,
or not so subtle, influence of this mind that people feel stuck in
destructive patterns that they cannot control. For example, I remember a
patient saying that she could not believe that she was treating her children
just as her father had, that is, yelling and shouting at them ferociously and
seeing a look of terror in their eyes that reminded her of herself as a child.
She frequently resolved not to treat them in the same way but was unable
to stop. Instead, she felt taken-over by someone in her head who was like
her father.
It is a matter of ongoing debate as to whether this inner experience of
take-overs is due to a split in the ego as a result of early internal and/or
external pressures or is due to the co-existence, from birth, of two different
and autonomous minds that apprehend reality differently. I have enlarged
in previous papers (Richards, 1993, 1999) on the reasons why I began to
find the more usual concepts of splitting, disavowal and internalization of
perverse object relations unsatisfactory in explaining certain phenomena
that I had become increasingly aware of in my analytic work with patients. I
found that these concepts did not sufficiently explain why a number of
patients showed genuine motivation for insight and change and then
behaved as if these had never been desired and seemed to attack the
therapeutic relationship. Patients, too, often expressed an awareness of
alternating experiences that they could not control: ‘it’s like someone turns
on a switch but it isn’t me’. There was something about their bewilderment
and distress at their loss of autonomy that led me to consider that the usual
concepts did not do justice to their experience. Nor did their histories
explain the severity of their disturbance.
In order to see if I could understand the clinical phenomena better, I
began to take an interest in Sinason’s concept of internal cohabitation or
co-residency of two selves or egos in the one body from birth and began to
work with him and other colleagues in developing and exploring the clinical
application of this concept (for example, Jenkins, 1999).
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Terminology
For the purpose of this paper, I will use the following terms interchangeably
to refer to the self that has a mind that is able to relate, think, reflect and
symbolize: ‘well mind’, ‘sane mind’, ‘sane person’ and ‘the patient’. I will
use the terms ‘internal adviser’, ‘internal cohabitant’, ‘psychotic mind’, ‘the
ill self’, ‘the other mind’ or even ‘the other’ interchangeably to refer to
the self who has a mind that is psychotic in the ways described earlier in the
paper.
The nature of psychosis
‘Patients with psychotic illnesses can experience themselves as under the
influence and control of a voice that commands them to perform actions
that they do not want to do (command hallucinations)’ (Sinason, 2004a) or
they see and hear things that others do not see and hear (called visual or
auditory hallucinations) which is disturbing for them.
In an unpublished dictionary definition, Sinason (2004a) says the
following about psychosis:
If the mind of an internal adviser has grown up alongside the patient’s
mind, more or less unseen, then the clinical symptoms manifest in
psychotic depression, mania and schizophrenia are not evidence of a
disintegration of the functioning of a single ego [as is the more usual way
of conceptualizing psychosis]. Instead they are seen as the emergence of
an authentic and passionate belief in the rightness of a profoundly
different view of the world. From this perspective, the body is the habitat
of two minds, one capable of grasping interpersonal social reality and
another mind, whose confident assertions about the world are often
(although not exclusively) based on misconceptions since they ignore
social phenomena. The content of delusions and hallucinations can then
be viewed as the emergence of the deep conviction of an ‘other’ ego that
has always existed, more or less in the background, and who has always
considered himself as having a superior hold on reality.
It is patients with psychotic symptoms, although not exclusively, that
have led me to consider that there is another mind, which human beings are
born with and which grows up with them and makes its presence felt in a
variety of ways. These ways may be more or less direct but are usually
troubling. This other mind is often experienced as an advice giver who
expresses criticism and ridicule if the advice is not taken but, often, also if it
is. For example, I have a patient who has decided that she functions and
feels better both at parties and the next day if she limits how much alcohol
she drinks. However, she experiences an inner voice which is very active in
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persuading her to drink more so that people will not see her as a pathetic
kill-joy who cannot hold her drink. If she recognizes this as ill advice and
puts it to one side and sticks to her plan to drink moderately, the advice gets
more scathing and insistent so she sometimes gives in to shut it up.
However, when she does this, and suffers the inevitable consequences, she
is then given a severe telling-off internally for being so weak and feeble as to
forget her intention not to drink so much.
Clinical examples
I will describe two patients who have been diagnosed by psychiatrists as
suffering from a schizophrenic disorder and who are aware of the influence
of another mind: one calls it ‘the controllers’ and the other ‘the devil’. I will
then present another patient who would not be considered psychotic
according to usual psychiatric criteria but close examination of his material
suggests the existence of an internal other mind that controls and criticizes
him in ways that are not very different from that which occurs with the first
two patients.
Ms X
Ms X was referred for an assessment for psychotherapy by a psychiatrist
when she was 26 years old because she was interested in having
psychotherapy following a partial recovery from an extensive and severe
schizophrenic breakdown.
When we met, Ms X wanted to tell me, in as much detail as she could
remember, the experiences of the last few years and how there had been
recurring signs of disturbance since her adolescence. She partly read from
notes she had made.
From the age of 18 years onwards, she had felt controlled by forces inside
and outside her mind which had made it difficult to face people and almost
impossible to work. For about three years, the terror of outside forces
prevented her from working but terror of her father finding out led her to
pretend to work, which resulted all the more in fearing what her father
would say or do if he did find out. She lived off her savings until forced to
tell her parents the truth of her situation when her father suggested that she
use her savings to join them on holiday. By this time she had little money
left. Before telling her parents, she said she thought references were being
made to her on the TV and radio that both excited and frightened her. She
thought she had become ‘newsworthy’ because her ‘life was out of the
ordinary’. Every day she became more and more scared and checked the
newspapers to see if she had been exposed – ‘they were the most scared days
of my life’. She thought this was when her ‘schizophrenia started – I was
looking at people as if they knew me and what I had done’. She finally felt
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she had to tell her parents before she appeared on TV or in the newspapers.
After telling them, she was less gripped by the voices and was then able to
work in an assistant clerical role (below her ability but manageable). She
explained that she calls the voices ‘the controllers because their aim seems
to be to keep me under their control’.
It seemed to me, from what she described, that, when under the influence
of the ‘controllers’, she often thought that people could read her mind and
that she was a famous person. At times, she said, she particularly
experienced ‘being persecuted by an alien force which controls my words
and actions’. She also heard voices in her head that ordered her about and
which she found herself asking advice and seeking views from about her
future. Also, she continued to have recurring sensations of having her head
crushed by forces that she found unbearable and made her scream in pain.
Ms X started taking medication about a year prior to our interview and
said that this had helped to reduce the head pain. She thought that she had
gradually regained her insight and said that she realized ‘that the voices came
from inside my head and were not an alien force trying to damage me’.
For much of the interview, Ms X was very lucid and insightful and could
even explain that she had not been able to seek help earlier because ‘I
thought I was being controlled by an alien who was the only person who
could make me better and if I sought help I would be punished’. It is
interesting to note that she experienced the inner voice as having the
characteristics of a person. For the first part of the interview, Ms X seemed
relatively free of psychotic voices influencing her and I felt that I was in the
presence of a sane person who could engage with me in an appropriate way.
However, as the interview progressed, her demeanour changed and she
seemed to be listening to something or someone else. When I asked her if
there was a problem, she began to talk about the ‘controllers’ from the
American and British governments being in the wall and sending messages
through ‘clicks’ in the furniture, ‘the tick of the clock’ and ‘the hum of the
traffic’. She managed to tell me that the message they were sending was,
‘We’re still looking at you girl’. She looked frightened as she said this.
For the remainder of the interview, Ms X was in conflict because she
wanted to talk to me but was afraid to. She kept looking at me warily, as if
having to check with the ‘controllers’ whether it was safe to tell me anything
further, especially anything to do with what they were saying in her head
right now. At one point she looked at me and said warily and hesitantly, ‘it
is safe isn’t it – to talk to you?’. When I said that she was letting me know
that the internal ‘controllers’ had begun to get active and threaten her for
talking to me, which made her feel unsure whether to continue, she said she
didn’t want to listen to these voices but couldn’t help it and she thought
‘that they deliberately say things to make me think they’re still in control’.
Thus, we can see that Ms X described experiences where she was
completely taken over by the psychotic personality and was completely
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identified with this self who believed she was a very famous and newsworthy
person (often called grandiose thinking) but was also terrified of being seen
and thought that people could read her mind (paranoid thinking). At these
times, Ms X had completely lost her hold on reality and could not
differentiate herself from the internal other mind. However, she also
described experiences where she felt more separate from the psychotic self
and this was when she heard the voices of ‘the controllers’ and experienced
herself as on the receiving end of threats and coercion. At times, she
recognized these as coming from an internal source and thought that there
was a powerful internal ‘person’ who knew what was best for her and, at
other times, she believed the voices were external and represented agents of
the American and British governments. I think it may be the case that when
a person hears internal voices, he knows that they are not his own thoughts
but thinks it cannot be the case that another mind exists in his head with
him and so misattributes the voices of an internal agent to that of an
external agent.
Mr L
Mr L was in his mid-twenties when he started therapy 4 years ago. He had
been an in-patient many times and had a diagnosis of schizophrenia. He
cannot remember a time when he did not hear voices or see and hear things
that others did not see or hear. In particular, he has always heard voices that
tell him he belongs to the devil: the visible proof, as far as he is concerned, is
a mark on his hand. The voices also tell him that he causes others to die and
deserves to die himself, especially when he is enjoying himself or getting on
well in relationships. Also, at times, because of the take-over by the
psychotic mind, he sees blood running down walls and gets internally
persuaded that people are following him or that birds in the trees outside his
bedroom are spying on him and so on. I came to observe that every time we
had some meaningful engagement, however brief, it would be followed by
looking at me very suspiciously or looking at his wrist, where he was certain
that the devil had put the mark to show that he belonged to the devil, as if
the voices in his head were warning him that I would reject him because he
was such a bad person and, therefore, it was a mistake to trust me enough to
talk to me.
One of the things that he was able to tell me early on in a moment of trust
was about a recurring dream. In this dream, there are two people walking
beside a railway line. He is not sure what sex they are. One of them
suddenly breaks away and runs towards the line as if to throw him/herself
under the train. The other person tries to stop him/her. The dream ends
without the patient knowing the outcome. The patient himself said that he
felt the dream represented an internal conflict between wanting to live and
wanting to die. He told me that he really wanted to die and that I had to
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help him because being alive was too painful. I felt a tremendous pressure
to agree to help him kill himself. He wanted it to be painless and successful,
as he did not want the job to be botched or he would suffer even more either
through being maimed and/or being rejected by his family.
On this occasion, I said to him the following:
I think you are letting me know that the voices are very strong in
threatening you and making you feel that you are bad, that you deserve to
die and that there is no escape. I think the voices come from a mind that
lives in your head with you, presents itself as the devil and tells you that
you have to do its bidding or you will be punished. I think you are letting
me know that you feel desperate, that you can’t think of any way to deal
with this inner pressure but to plan your death yourself and enlist my
help. You want me to know that when the voices are this active you feel it
would be a relief to die. However, I think your interest in telling me about
your dream – where one person tries to stop the other one from jumping
under a train – means you hope that instead of me joining in with the plan
to kill you, I can help you to find a better way to live with the voices’.
When I stopped speaking he sobbed and sobbed. He said later that he
was surprised at his reaction but said it was a relief to feel that I understood
about the power of the voices and how real they are and how hopeless they
can make him feel. He said he was scared to have hope about his life but this
was what he wanted.
This was the beginning of the patient feeling he could bring these
pressures into the therapy to explore why they were happening rather than
to go along with them. This led to him saying later in his therapy,
I know this may sound strange but I think the voices are jealous of my
relationship with you because they seem to want to punish me whenever
I talk to you (he looked distressed). They threaten that they’re going to
kill me. It’s been like that ever since I can remember – they become very
threatening when I like someone and rely on them – it’s the same with G
(girlfriend).
We gradually moved from referring to ‘the voices’ to ‘the mind behind
the voices’ and began mapping out how, why and when this mind functions
the way it does.
Mr B
This patient was less obviously psychotic than Ms X or Mr L and had never
been in hospital, did not have a psychiatric history and had been married
(but was now divorced) and had a good job. He had no obvious
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schizophrenic symptoms and did not report hearing voices. He tended
towards depression and anxiety. At our very first meeting (in my private
consulting room), it emerged that he was under the influence of an internal
voice that endlessly gave him negative advice about who he was and what
other people thought of him. As we explored his reasons for wanting
psychotherapy, he said that he had nearly run away without ringing the door
bell because of insistent, uncontrollable thoughts that I would be very
judgmental and unsympathetic and either judge him to be too disturbed to
take him on or, more likely, would not consider his problems to be
sufficiently serious and would accuse him of wasting my time. When I
referred to these thoughts as coming from an internal adviser who presented
himself as having absolute knowledge about a situation and had already
decided that therapy was a waste of time, Mr B was very interested in
exploring the possibility of another mind influencing him. We were
gradually able to explore the extent to which he had lived his life under the
influence of an internal other mind who kept tight control over him by
insisting that he was a failure and that other people believed this too.
He explained that, every time he undertook a project at work, he would
have sleepless nights because of the internal warning that he would fail and
his boss would give him the sack. He would be so convinced of the truth of
this warning that he could not bear to face his boss and was always surprised
to find that his boss was pleased with his work. We noticed that when he
began to develop a capacity to question this advice, the internal adviser
became more insistent that he had made a mistake and that his boss, after
all, was deeply displeased with him. This pattern also occurred with a new
girlfriend whom he thought liked and respected him but, as soon as he
thought this, he would be internally informed that actually she thought he
was a failure as a man. This pattern, of course, had its parallels in our
relationship: I would be seen as the boss who thought he was a failure in the
therapy, was angry with him and thought he should be sacked from therapy
or I was thought to be like the girlfriend and really believed he was a failure
as a man. Also, if we had a good session or good communication within a
session, this would be quickly followed by an even more insistent assertion
that he was a failure and that he had a made a big mistake to think I thought
well of him. Thus, he could leave a session feeling better about himself
because he had differentiated his view from the internal adviser’s, and
return to the next session in the depths of despair, convinced again that he
was a failure and that I would want to get rid of him.
Discussion of clinical cases
It may seem at first glance that the internal situation with Mr B is not
identical to that of the other two patients who had a number of first rank
schizophrenic symptoms. However, I would suggest that some aspects are
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very similar. For example, all three patients experienced internal advice and
warnings that made them feel that they were under the control of an agent
other than themselves (either internal or external) who had a superior grasp
of reality and, through powerful repetition and insistence, persuaded them
to ignore their own judgement and perceptions and believe certain things
about themselves and the world (usually negative) for their own good. All of
them found this experience highly distressing, unpleasant and undermining
of their sense of autonomy. All made similar comments that they felt
tormented by what they were internally informed and that they felt
threatened, coerced and punished if they disagreed with or disobeyed the
inner voice or voices, especially if they sought help from others or made
relationships with people external to themselves. They all expressed a desire
not to listen to, or be influenced by, the inner voice/s, but all felt helpless to
challenge or question the other mind’s authority, believing it knew best and,
despite their suffering, had their interests at heart. All felt that their own
judgement was inferior to that of the other mind until, in the case of Mr B
and Mr L, they had been in therapy for sometime (Ms X did not go into
therapy).
Mr B did not actually hear voices but experienced thoughts that seemed
very like the voices of the other two in that they were powerful, insistent and
convincing. He was an intelligent and able person who held down a
demanding job but was persuaded internally that, at any moment, he would
be found out to be a fraud. He could not trust other people’s views of his
capabilities and could not trust his own observations of his achievements in
the external world. Again and again, he fell for the internal persuasion that
either he had failed or others believed he had. This was an identical process
to what happened with Mr L who would be persuaded again and again that
he was bad and the devil owned him or with Ms X who was persuaded again
and again not to seek help because ‘the alien force’ was the only person who
could help her.
I have presented three patients who have experienced and been aware of
an inner voice or other mind much of their lives. With other people the
psychotic mind stays more hidden and may only emerge into the open under
certain conditions. For example, with one of my psychotherapy patients, it
was only when she became engaged, that is, seriously involved with someone
else, that the other mind emerged in an obvious way. In this case, it emerged
in a hypomanic state that resulted in the patient being hospitalized and the
fiance eventually breaking off the engagement which, of course, destroyed
the very relationship that the patient had valued. For some patients, the
other mind never emerges in a dramatic way but influences the patient in
more subtle ways and can be recognized through dreams and language.
Careful mapping can help a person to identify and get to know and
understand the partially hidden other mind. In parallel, in my experience,
the other mind opposes these exploratory, mapping processes and attempts
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to remain hidden and to obfuscate any investigation. I think it is the other
mind’s fear and hatred of being seen and recognized that lies behind the
negative therapeutic reaction (Richards, 1993).
There are other patients who start therapy with very little awareness of
another mind but get interested when I pick up and comment on any
experiences where they have felt out of control. Usually people do get
interested in exploring and getting to know the existence of another mind
whose basic assumptions about life have been adversely influencing them
for a long time without them realizing. For example, I have a patient who
thought it was her own thought and a good one to aim to be a zombie, that
is, not feel anything or engage with anything or anyone and thus avoid pain.
The problem with this solution was that she did not feel human and, in fact,
felt exactly like a zombie which reinforced her belief that she was not like
other human beings. Thus, she was relieved to find herself crying and
experiencing a feeling of loss over her young nephew going to live with his
grandmother after living with her for some months, when we worked out
that she did not, in fact, agree with the internal advice that it was best to
feel nothing.
Not all patients show an interest in exploring the existence and mentality
of another mind that lives with them. Some think I am accusing them of
being schizophrenic and strongly oppose any differentiation. I usually think
this opposition comes from the other mind who dreads being exposed and
so it requires time and tactful interpretations to see if the patient can risk
getting interested in such an exploration.
Dual-track analysis of the two selves
The implication for the work in the therapy is to carry out what Sinason
calls a dual-track analysis. This involves the therapist having to think about,
understand and analyse both selves in relation to each other, especially
when the sane self begins to change and develop a relationship with the
therapist, as these changes impact on and disturb the other mind.
Mr B’s therapy illustrates this process very well. We had to give thought
as to why the internal adviser berated the patient when he demonstrated
that he was separate and autonomous and had a mind of his own. We
realized that the patient had not had a close relationship with either parent
and, from an early age, had begun to rely on the internal adviser as a kind of
parent who gave him direction, even though he also felt criticized and
undermined. In an early session, Mr B said, ‘there is a voice going on all the
time – it comments on everything I do and think – it has the upper hand – it
stops me from doing and acting and expressing myself in every sphere of my
life – it leaves me feeling powerless – I feel totally unable to act sometimes
because it is so highly critical and undermining of me yet without it I feel I
wouldn’t know what to do’.
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Gradually, we worked out that this internal adviser felt possessive of Mr B
and was jealous of all his other relationships, especially people he valued
and wanted to be in a relationship with such as the boss, the girlfriend and
the therapist. These relationships threatened the internal adviser’s influence
and status. Mr B said, ‘I think the internal adviser is frightened of change, of
me changing – I think he feels he owns me and worries about what will
become of him if I don’t rely on him any more’. Subsequently he said, ‘I’ve
always thought he’s trying to protect me – it’s like warning me that things
out there are dangerous so I must never expect anything to be all right and
I’ve always believed him. I’ve begun to realize that he may be more
interested in rescuing himself than me’. Further on in the therapy, Mr B
said, ‘I think he’s frightened that you want to get rid of him because you
think he’s a bad influence’. This led us to think further about the internal
adviser’s predicament and to realize that he expected to be in charge of the
patient for the rest of his life and was now getting deeply worried at being
ousted from this role.
We began to have concern for the internal adviser and to acknowledge
that he was terrified of being made redundant. We became clearer that the
internal adviser was a person in his own right who had feelings and so could
feel hurt at having his advice ignored and, because of his paranoia, was
convinced that if he were not in control of Mr B, the latter would not only
want to get rid of him but also could succeed in doing so. Thus, we came to
understand that, in opposing the therapy, the internal adviser was fighting
for his life.
Through the process of accepting the existence of the internal adviser as a
separate self with a mind different from Mr B’s and, by understanding the
significance of his desire to keep control over Mr B, he (Mr B) became
more able to use his mind to weigh up the reality of his abilities and
achievements and to use his own judgement in assessing his personal, social
and work relationships. Whenever Mr B differentiated himself from the
internal adviser, he could then be clear about the accuracy of his own
perceptions and could put the internal adviser’s views to one side.
Acknowledging that the internal adviser felt threatened by this process
seemed to calm down the internal advisor rather than irritate him further.
Using his mind to differentiate himself from, understand and anticipate the
internal adviser rather than fight him or comply with his views, provided
Mr B with a better way of living with the internal adviser.
Keeping in mind the therapist’s other mind
Once therapists realize that they have another mind in their head that
operates in parallel in the therapy sessions, they are then in a position to
monitor their own internal adviser so that it does not intrude inappropri-
ately into the session. The internal adviser in my head often gives me advice
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that would be far better ignored, or rather, registered, thought about and
either monitored to help me to understand a patient’s inner world or put to
one side. Sometimes, however, I fail to do any of these things and instead
get persuaded, just like my patients, that I am being given good internal
advice and must act on it quickly. Sometimes, I know it is not good advice
but it intrudes before I can stop it and, sometimes, I have been taken over
before I have even realized. Examples of take-overs are suddenly ending a
session early or going over time without realizing, feeling very sleepy, falling
asleep, answering a question without thinking, making an impatient or
retaliatory comment and so on. When I realize that a take-over has
happened, it is necessary to think how to help the patient know that I, too,
have someone in my head who has a mind of her own, who has just made an
appearance in the session, and to do this in a way that does not alarm the
patient. Patients seem relieved when I can acknowledge that a take-over of
my mind has occurred and I think this is because I am confirming their
observations rather than denying or ignoring them. I have learnt the hard
way that, if I ignore an intrusion and agree with the internal advice that the
patient has not noticed and allow no space to talk about it, the situation gets
worse: it is usually interpreted by the patient’s other mind as confirmation
that he/she has been right all along to suspect me of being either useless or a
hypocrite and the patient withdraws emotionally.
Acknowledging that I too have someone else in my head who can mislead
me helps patients to know that I do not harbour the notion that I am a
superior being free of an internal other and that I, too, know that I have to
monitor and think about my internal adviser for the rest of my life.
I have found that monitoring and processing the internal adviser’s
reactions to my patients (which is equivalent to monitoring the counter-
transference) nearly always provides useful clues about indirect commu-
nications from their other minds. For example, the sudden urge to fall
asleep can be a reaction of my other mind to the hidden hostility in a
patient’s comment.
What happens to patients if the concept of internal cohabitation
is not used?
Clinical material can give clues but cannot prove in any absolute sense that
a concept is underpinned by a matching psychological reality. However, if
we explore the concept that two selves are cohabiting from birth within the
same body, then, as therapists, the task we will engage in is that of helping
the patient to differentiate his or her thoughts and actions from those of the
internal cohabitant. This will mean that both therapist and patient will not
attribute to one mind the thoughts and behaviour that actually belong to the
other mind and the therapist will not try to get patients to own and integrate
radical and unilateral modes of functioning as if they were unwanted
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split-off parts of the patient’s ego. The task instead, in psychoanalytic
psychotherapy, will be to take an interest in getting to know the other: its
view of the world, its beliefs, how its mind works and what situations trigger
disturbance.
Thus, if internal cohabitation is a valid hypothesis for the clinical
phenomena we observe, we can then ask what happens to patients in
psychotherapy when their therapist or analyst does not use that concept. I
think that patients who are not assessed to be actively experiencing the
intrusion of psychotic thoughts or symptoms are often helped by other
models of the mind. However, when it comes to observable and identifiable
psychosis, I think it is essential that the patient be helped to conduct a dual-
track analysis of both selves. Otherwise the therapy is likely to reach an
impasse or end badly, even tragically through suicide.
In one of my papers (Richards 1999), I have described my work with a
patient with bi-polar illness, where, for a long time, I did not use the
concept of internal cohabitation and she remained unchanged until I was
able to alter my approach. However, I thought for this occasion, I would
present a different situation that also throws light on the question of what
can happen if the concept of internal cohabitation is not used. I was asked
to see a patient, Mr A, who had 30 months of psychoanalysis five times a
week brought to an abrupt halt by the analyst, Mr C, when the patient
disclosed that he was carrying a knife into sessions in his jacket. Mr C
arranged for Mr A to see a psychiatrist who prescribed medication and
referred him to me, knowing that I work with psychotic patients.
According to Mr C, Mr A did not reveal in the preliminary interview that
for years he had heard voices that made derogatory and threatening
comments about him or gave him commands he felt compelled to follow
and had experienced uncontrollable switches in his identity. During the
course of the analysis, the other mind was inevitably exposed and the
appearance of very disturbed thinking and behaviour emerged.
Mr C sent me a helpful and detailed report of how the analysis had
unfolded and we also spoke on the telephone. He was very sorry about what
had happened but felt for his own sake, and that of the patient, that he had
to end the analysis as soon as he realized, as he saw it, that Mr A was
planning to attack him with a knife. He did not feel safe and he felt that he
could not say anything without a furious outburst occurring. From his point
of view, Mr A had become obsessed with him and had formed an intense
psychotic transference which involved either wanting to be with him all the
time or hating him for not being available and speaking to him in a scathing
and denigratory way. In his report, and from our conversation, it was clear
that he did not think of the patient as having two minds and that, even
though he recognized very disturbed, hostile and paranoid thinking, he did
not consider that this came from a mind that was different from the
patient’s mind or that comments and interpretations that he made could
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have been heard by another mind as maligning, insulting and life
threatening.
In my early interviews with Mr A, I formed the view that his internal
adviser had felt maligned and attacked by the analyst and he thought that
Mr C was going to kill him. It was apparent that Mr A had no language or
concepts for differentiating himself from another self with a disturbed mind.
Thus, he thought the analyst disapproved of behaviour that they both
thought of as his (but in my view was very likely to have been driven by the
personality of the internal other) such as waiting for the analyst to tell him
what to do and think, finding himself thinking about Mr C all the time,
experiencing severe anxieties before and during sessions and having
powerful urges to hide from people and keep them at a distance, including,
at times, the analyst. Mr A reported that he became completely preoccupied
with what Mr C thought of him and thought he was reproaching and
accusing Mr A for being either too intensely dependent on him or too
suspicious and rejecting of him. He was convinced that Mr C hated him
and thought of him as a nuisance. He finally heard voices saying that the
analyst was going to kill him. Mr A dared not tell him but thought he should
take a knife to sessions in case he had to protect himself from Mr C’s attack.
Finally, he did reveal that he was carrying a knife.
As I have stated, from what I could make out, based on the analyst’s
report, our conversation and what Mr A has said in his therapy with me,
neither Mr C nor Mr A were attempting to differentiate his mind from the
mind of the internal other. In my view, this resulted in the interpretive work
leading to the patient becoming completely identified with the personality
of the internal other and that personality’s terror of and rage at what the
analyst was saying. Thus, the patient was completely vulnerable to the other
mind’s concrete conviction that the analyst was going to murder him and
thus decided to take a knife to the sessions to attack back when necessary.
In my conversation with the Mr C, he clearly had concern about Mr A and
had done his best to help him but it was also clear that he did not
contemplate the possibility that his interpretations could have contributed
to the perception of himself as a murderer. Of course, he had no intention
literally to murder the body that the two personalities shared. However, to
the psychotic mind that cannot think symbolically, interpretations aimed at
either changing that mind or subsuming it within the mind of the patient
would have been experienced in a concrete way as murderous intent. Thus,
to perceive the analyst as a literal murderer who had to be literally defended
with a knife was a misperception and a misunderstanding but it was also a
correct perception because the aim of the analysis was to integrate or
change the psychotic mind’s ways of thinking and relating rather than help
the sane person differentiate from, understand and contain this other mind.
I had sympathy for the analyst as well as the patient because they both felt
their lives were in danger. Mr C said that he would not have taken on the
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patient if he had known about his schizophrenic symptoms. I think the
situation that developed confirms the probability that an analytic process
that does not recognize that, as well as there being a patient in the
consulting room with sane resources and capabilities, there is another self
with a mind that cannot symbolize, is paranoid, believes in retaliation if
attacked and is highly sensitive to denigratory or pathologizing comments,
may lead to uncontainable and tragic consequences.
It took both selves a long time to recover from the analysis itself and the
abrupt ending. Mr A felt very misunderstood, rejected and confirmed as a
bad, mad person who had no future. The other self seemed to be in a rage
and terror at being rejected, as well as fearing that I too was a murderer that
would also abandon and reject this self who could swing from feeling like a
helpless baby thrown out into the cold to feeling like a revengeful murderer.
For the first year of seeing me, Mr A reported vivid, terrifying nightmares
with bleak landscapes and annihilating, ruthless images. I sometimes found
them almost too painful to listen to. The other self seemed to inhabit a
mental world where benign objects quickly turned into relentless
persecuting demons and where there was no escape from torture.
Gradually, Mr A became less dominated by these stark and terrifying
images and the nightmares lessened and, gradually, he began to recognize
and think about another mind that was not the same as his. For a long time,
we met once a fortnight only, as I formed the view that anything more
frequent could provoke and inflame the other mind. Eventually, we moved
to meeting once a week without any serious disturbance occurring.
Although there was often an insistence that there was only one mind, we
were able to work slowly and sensitively in differentiating the two minds.
Gradually, Mr A became very interested in identifying and recognizing the
thoughts and reactions of the other mind and moved from fearing that
mind and wanting to get rid of it to becoming interested in how to
understand and have concern for this other mind, his life-long internal
cohabitant. During his psychotherapy Mr A continued to see his
psychiatrist regularly but was eventually able to come off the anti-psychotic
medication. He was able to work in the mental health field and use his
understanding of his internal other to help clients to understand their
internal worlds.
One of the conclusions I have drawn from Mr A’s experience is that
analysis five times a week is probably too frequent and inflaming for the
other mind when that one is dominant and behaving in a way that results in
a diagnosis of a psychotic disorder. This is the case, even when a therapist
works with the concept of internal cohabitation. In my own practice in the
NHS, although resources limit the number of sessions that patients can be
seen each week, once or twice weekly therapy actually seems to be about the
right frequency in relation to patients’ own resources to manage the internal
disruption that inevitably occurs in psychoanalytic work. This lesser
Psychosis and the concept of internal cohabitation 41
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frequency seems to allow for some change to take place without excessive
inflammation and disturbance of the internal other.
References
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personalities. In Second thoughts. London: Heinemann, 3 – 22.
Jenkins, M. (1999). Clinical applications of the concept of internal cohabitation. British Journal
of Psychotherapy, 16, 27 – 42.
Richards, J. (1993). Cohabitation and the negative therapeutic reaction. Psychoanalytic
Psychotherapy, 7, 223 – 239.
Richards, J. (1999). The concept of internal cohabitation. In S. Johnson, & S. Ruszczynski
(Eds.), Psychoanalytic psychotherapy in the independent tradition. London: Karnac Books.
Richards, J. (2001). What does psychosis have to say about racism? Journal of the British
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Rosenfeld, H. (1987). Impasse and interpretation. London: Tavistock.
Segal, H. (1981). The work of Hannah Segal. New York: Jason Aronson.
Sinason, M. (1993). Who is the mad voice inside? Psychoanalytic Psychotherapy, 7, 207 – 221.
(Note: A revised version of this paper can now be downloaded from the BPAS website:
www.psychoanalysis.org.uk/sinasonmv2004.htm). Accessed 11 December 2005.
Sinason, M. (2004a). Dictionary entry and FAQs: Internal cohabitation. Unpublished paper.
Sinason, M. (2004b). Key psychoanalytic issues concerning R. D. Laing and his legacy. Paper
given at the Annual Conference of the Herts and Beds Pastoral Foundation, June 2004.
Winnicott, D. W. (1990 [1963]). Communicating and not communicating leading to a study
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