[N.B. this is a bit disorganized; I’m on a plane. I might edit letter, but require the fiction of an audience--I'm already speaking to you.]
I have an upcoming presentation at the Society for Psychological Anthropology biennial in early April (loosely focused on the role of agency in the experience of psychosis) and hence have been thinking through recent experiences—shadowing community support and outreach teams, “working” half the week at a drop-in center in Chicago, facilitating voice hearing groups, and interviewing participants for multiple (different but overlapping) projects—with an eye to this topic.
I sometimes feel like a truly terrible bore for repeating the sentiment—again and again–that psychosis is profoundly heterogeneous (and the experience of voices perhaps more than any other named symptom cluster). In large part, I think, this heterogeneity—masked rather than aided by the ‘apparent’ obviousness and understandability of “hearing a voice that others do not”—stems from the fundamental ambiguity between ‘voice,’ as the privileged perceptual vehicle of discourse, and thought, as well as their parallel (socio-spatial) mapping onto a self/internal versus other/external continuum (auditory speech is at least superficially or literally social in a way that ‘thought,’ classically conceived, is not). (Certainly, in my experience thus far, once one probes (or pushes) people to a certain level of detail, the easy distinctions fall apart and experience comes to seem “queerer and queerer,” whether the individual is a service user or “healthy” community member.)
Historically I’ve felt (and expressed) more than a little skepticism regarding the recent emphasis (in mental health advocacy and CBTp) on “normalization” (many of us hear voices, voices are part of a continuum of normal human experience, etc.) but lately have been rethinking this position and, with a view to better understanding agency in psychosis, thinking more about the complexity of thought and dialogue in general. Many of my (normal) friends, for instance, report talking to themselves, reading textbooks out-loud, rehearsing & replaying conversations, as well engaging in multiple forms of ‘silent’ (but often ambiguously ‘personified’ and even imaginatively ‘perceptualized’) internal dialogue. Auditory vocalization not only forces us to physically articulate (and embody) speech, but also to become the perceptual recipients of something, some message, some meaning, that is ‘external’. Why? Certainly internal ‘fluency’ (as any presenter knows) is not the same as oral fluency, but self-directed vocalization (real or imagined) seems motivated by other benefits as well—a tacit othering of the self, whereby we are made the recipients of mediated rather than ‘direct’ communications, and in the course of which the fundamental sociality of all discourse, all thought, is continuously performed.
Even if particular individuals cannot (immediately) articulate exactly why they do these things, there is presumably a robust spectrum of awareness, choice and subjection in general; at least at some point, most of us, I suspect are aware of the effects (or, if not the effects, the oblique value) of self-directed talk, internal dialogue and personification, in which the self is made an other or (interpersonal or cultural/institutional) other(s) the self but also, at other times, all but completely unaware of the extent to which our own inhabitation of these internal/external relationships has come to structure our lives. And likewise the extent to which these processes of othering and selving play off broader cultural associations with silence, sound and vocalization, spatial and perceptual internality and externality. Although there has recently been a strong focus on voice hearing (in particular) as a form of dissociation (strongly tied to trauma) rather than psychosis, I would proffer that trauma is only one of many possible motivations for the implicit-explicit division and diversification of streams and modes of internal narrative and mental ‘working through.’
My (admittedly rambling) point is not that ‘voice hearing’ is common in the general population (per se), but rather to highlight the commonality of the heterogeneous and perhaps surprisingly strange relationships nearly everyone has with respect to their “own” thoughts; relationships that (like virtually all mental phenomena) develop over time, and stratify and concretize through a dynamic mix of agency, habit, motivation, and effect. Back to ‘voice hearing’ proper, better understanding the temporal dimensions of voices, and trajectories of change over time, as well as past and present (obvious and oblique) motivations is clearly essential. So too, however, is understanding service users’ and voice hearers’ relationships to thought and dialogue in general. I am thinking here not of cognitive behavioral self-monitoring or social cognitive rehabilitative ‘strategies,’ but rather of teasing out styles of thinking (and their relationship to experience) without the usual a priori assumptions (or fictions) regarding ‘healthy’ ego unity or self-integration. How many ‘others,’ how many forms of dialogue, do we need to think, both in general and in the course of navigating a particular social or intellectual ‘problem’? What are the physical and spatial structures that we create in order to work through thought? And how do these change in reaction to, but also more subtly and simply ‘adapt’ to, the psychotic ‘event’ of a profound perceptual reconfigurations of experience? Finally, how can we navigate any distress such experiences might engender, without automatically concluding that “integration” or ego-unity is the goal?
To be continued….