THE VOICE

Tom groaned involuntarily. It stung, way more than he thought it would, but there were no regrets, and a wave of relief flooded his being as the rich crimson pulsed out, gradually dyeing the water red, his last influence on the material world. He wanted this, longed for it, even: to bleed out into sweet oblivion. And then the deep, throbbing ache, first in his wrists, then spreading and deepening as if the very marrow of his bones was leaking out too. He comforted himself with the thought that it would be over so soon. Nausea and a fuzzy tingle accompanied the throbbing pain, and Tom thought, for the second time, that this was far more uncomfortable than he expected.
"You fool. Do you think you can end this so easily? Do you think I haven't made provision for this?" laughed the voice in his head, but Tom ignored it, guessing it was the last spiteful attempt to deceive him - to make him think he'd failed.
Spots appeared before his eyes as his vision failed and he began to lose consciousness. "Good. If I end, so do you," he said aloud to the voice as he closed his eyes to drift into his eternal sleep. Free at last.
The thud of the front door. "Tom…Tom, where are you? I got off early, so I thought I'd come straight round". The bathroom door pushed wide. "Oh my god! Oh Jesus, Tom, what have you done? Fuck, fuck, fuck!" Jen repeated as she dialled 999."
"J…Jen?" was all Tom could muster in response, and the voice laughed and laughed and laughed as Tom slipped into unconsciousness.

Psychiatric Progress Notes following the first session with Tom:
I concur with both the patient and his MHA that he displays no reduction in his capacity to make his own decisions. So far, he has consented to detention under Section 2, giving me up to 28 days to see progress or change my recommendation; however, whilst the patient has signed the treatment consent form and submitted to my initial assessment, he was generally uncooperative, morose and despondent throughout our first session, describing the sessions as a 'pointless exercise'.
He presents as severely depressed, so this is not at all unusual; however, such a stubborn refusal to participate in any form of therapy is, nonetheless, fairly atypical. If I could only get him to let his guard down for a moment, I may get a glimpse of how I can find a way in. I do not feel, in this case, that CBT would be an appropriate approach; instead, I will focus upon individual Psychotherapy.
Other than diagnosing him as being in a severely depressed state, I am yet to see any other indicators of his suicide attempt; with this in mind, and given the seriousness of the attempt, it is my judgement that he is at high risk of a repeat attempt and it is my recommendation that he remains under regular observation of at least 15-minute intervals.

Partial transcript of a conversation between Tom and his assigned psychiatrist:
Session#2
P: Are you feeling better today, Tom?
T: As good as is possible, considering.
P: Considering what?
T: [inaudible] Well, that's a dumb question, Doc. What do you think?
P: Daniel. it's Daniel. Please, call me Daniel.
T: [laughs] Sure thing Doc – sorry, 'Daniel'
P: Thank you, Tom. So, do you mean everything that's happened, or has something else happened you want to talk about?
T: No, just everything. There's no point talking is there? It's not like it'll change anything. You can't possibly understand.
P: Not to put too fine a point on it, Tom, but you did try to end your own life. Isn't that reason enough for concern? Why don't you… [speaker interrupted]
T: You have no fucking idea do you! No matter what I tell you, you will just put it down to mental illness.
P: Is that so bad?
T: No! See? You can't understand. It's not that it's 'bad'; it's just not the truth.
P: Then what is the truth, Tom?
T: What's the point? As I've already said, not only won't you understand, but you won't believe me either. It's pointless.
P: Isn't it worth a try, Tom? Surely you know that not talking to me is equally as pointless?
T: Well, I [pause] I can't just tell you like that. I would need to explain and it would take too long, then you would just diagnose me as mentally ill anyway.
P: Okay Tom. I understand that you think it's a waste of time, and that you think I will draw the same conclusions whether you explain or not. Have I got that right?
T: yeah.
P: So, it seems to me we need to find a workaround.
T: What do you mean?
P: Well [pause] if there was a way of changing your expected outcome, what might that be?
T: I don't know. Isn't that your job? You tell me.
P: It's my job to facilitate your progress, but how we go about it, well, that's down to you. I can only help you if you work with me. It's your life, Tom. You're still in control. You can spend every session in silence and frustration if you want, or you can try and do something about it.
T: [inaudible] Well, it looks like I'm fucked then, doesn't it.
P: Okay, let's approach this from another angle then. At the moment, you see no point because you believe that the outcome is already decided, so let's pretend that there's a possibility that I might understand and believe whatever it is you think I won't believe, and that possibility, of course, could change everything. Wouldn't you want to take that chance?
T: [laughter] Pretend? Jesus, that's even more pointless!
P: [pause] Think about it, Tom. If, as you say, I will come to the same conclusions regardless of whether you talk to me or not, what have you got to lose? I mean, what's the worst that can happen if you already know the outcome? Humour me.
T: [pause] That's a fair point.
P: Thank you, I thought so too [laughs]
T: Don't get cocky now.
P: Of course, but we'll find a way; that is what I'm here for. [pause] So, imagining that you could actually say something that would lead to a different, let's say more desirable, outcome, one in which I not only believe you but would also understand you, what's actually stopping you?
T: I don't know [pause] It's too hard to explain, I suppose. You'd need my bloody life story.
P: Okay, let's see if I understand. You're telling me that it's complicated, very difficult to explain and hard to believe, and these short sessions together are a bit limiting. Is that about right?
T: "A bit limiting"? [inaudible] That's an understatement! But yeah, that's about it.
P: So, let's find our workaround [pause] in fact, I might just have had an idea. You're a writer - a journalist, right?
T: Yeah, what of it?
P: So you're comfortable with writing, yes?
T: Yeah, I suppose so.
P: Well, there's our workaround. Instead of trying to tell me in these sessions, write it down. Tell me your story on paper.
T: I suppose that might work.
P: I'm going to take that as your most positive response to date, Tom.
T: Yeah well, I don't know. I wouldn't know where to start – how to even begin.
P: You know what? It doesn't matter. Just start anywhere you like, you can always backtrack, start again, or even use footnotes. What matters to me is that you get to tell your story, however you want to - and I think that's what matters to you, too. I absolutely promise I will read it, and who knows, it will probably enable us to have more meaningful conversations.
T: It'll do that all right. You don't know what you're asking for.
P: Perhaps I don't Tom, perhaps I don't, but I look forward to finding out. So, are you in?
T: Fine, I'll give it a try. Like you say, it can't make things any worse [pause] but no promises, mind.

Psychiatric Progress notes following session #2:
The second session was much more positive than my first encounter. Although he remains somewhat taciturn, this time the patient was a little more responsive – even lucid and rational rather than the typical brain fog, so not typical indicators of someone so severely depressed, but this, by no means, detracts from my diagnosis.
Given his references to me not being able to 'believe' or even 'understand' him, I may be dealing with someone in a delusional state. My guess is he is clinging to a specific delusion, probably in denial regarding his state of mind and resulting actions. Despite his protestations that I will neither believe nor understand him, he has agreed to tell his story in writing. It's a hunch at the moment, but I suspect he will attempt to convince me of his delusion, and I am prepared to amend my initial diagnosis to either Major Depressive Disorder with psychotic features or a psychotic disorder being the primary condition with co-occurring depression.

Tom's story in his own words: Part one
I'm not alone. That's the first thing you need to know. I don't expect you to understand that, but I will try to explain what I mean. Secondly, I'm not mentally ill. You have to accept those two facts if this is going to work, otherwise, it's pointless.

I'm not sure how to explain - maybe because I don't really understand it myself - but I'll try, and the only way I can think of is by going back to the beginning and telling you my story. Maybe then you'll see.

It started as young as I can remember with dreams, mainly nightmares, and eventually the waking dreams. Yes, I know, that's not particularly unusual, but that's the problem; for most of my life, no one, single aspect is evidence enough, but everything together, especially with hindsight…well, let's say it paints a picture.
Of course, unless you've experienced this, you are bound to interpret it within your own framework of reference, so you'll just have to take my word for it that these are no ordinary dreams. The main thing is that they just don't seem to be generated from my own mind. Now, when I look back, I realise they're an invasion from another mind; something imposed upon me by a completely separate entity. I know you will interpret this as psychosis, but it's not. Believe me, I wish it were. Then there would be some hope.

There were also the thoughts. These gradually became more intense - I think 'intrusive' is the word you would use. At first, there was no reason not to think it was just my own inner dialogue. I think, deep down, I knew something wasn't right, that other people didn't experience their inner dialogue as intensely as me, and that their thoughts weren't like a separate person. You see, for me, they felt like a passenger that was vying for control, one that wanted the steering wheel. When I got into religion, the situation changed. The voice seemed to get quiet, and I thought I was free of it. I wondered if God had freed me or whether the experience was just something I experienced as part of growing up, and had just grown out of it. It was neither. What I actually did was just start misattributing the voice as being the voice of God, but I'm getting ahead of myself.

Addendum To Post session 2 Psychiatric Progress Notes after reading Tom's first instalment of his written account:
Success! The patient has begun to write down his story. My hunch that he is in an active delusional state is correct. His account, such as it is so far, is considered, thoughtful and coherent – if it were not for the underlying delusion. As I suspected, he seems to be building a picture for me – trying to convince me of his delusion. So far, he has established that he is "not alone", believing he is persecuted by the presence of some kind of invisible being. Assigning external culpability to thoughts, dreams and voices in the mind is a sure indicator of an embedded delusion. He describes a voice in his mind as a "passenger…vying for control". My job, now, is to get to the root of this delusion so that he is able to debunk it himself, thereby providing enough hope to begin to see a way forward.

Diagnosis: My best diagnosis to date is that he is in the active stage of Paranoid Schizophrenia with associated delusion and hallucinations with co-occurring severe depression.
Questions:
1) What is the nature of the hallucinated voice – how does he hear it?
2) Are the dreams a trauma response?

Partial transcript of a conversation between Tom and his assigned psychiatrist:
Session#3
P: Thank you for sharing your feelings about being here, Tom. I appreciate that you felt you could open up.
T: Right.
P: Now that we've done that, would you like us to discuss what you wrote?
T: I suppose so, though you know I already know what you're thinking, so it's still a pointless exercise.
P: Okay, I understand that's your point of view, but I assure you I intend to take you at your word and proceed with an open mind. [pause] so I would really like to explore what you've written so far, perhaps ask you some questions about it?
T: Whatever, it can't get any worse.
P: Indeed. Can you tell me more about the dreams? What is it about these dreams that first suggested they're not generated by your own subconscious?
T: I can't tell you the details of any of them. They fade like most dreams, but even more quickly. It's how they leave me feeling that's different though. An ordinary weird dream or a nightmare can be disturbing, I know, but these, they're on a whole other level. The best description I can think of is that they have an otherness about them. They feel like a violation, as if my mind has been invaded.
P: That sounds horrible. Thank you for explaining that, I think I understand. Contrary to popular belief, it's how the dreams make us feel that is more insightful than the details, so that's something we can work with. [Pause] I want to be upfront with you, though, Tom; despite the otherness of these dreams, and your feelings of violation, I'm not sure that would be enough for me to draw the conclusion that they're not from my own mind.
T: Oh, I didn't! Not at first [pause] not for a long time. I didn't know any different, so I only gradually realised my experience was different to everyone else. I can only say that now with hindsight, but I assure you, when he invades my sleep too, I can tell.
P: I see. I understand how it must be awful to feel your dreams are invaded as well as your waking thoughts.
P: Perhaps you could now tell me about the intrusive thoughts you mentioned. When did they start?
T: It's hard to say. Like the dreams, it was a gradual thing. I probably had some sense, even as a teenager, that there was something unusual happening.
P: Okay, I understand you believe the voices in your mind were never actually your own thoughts; but in your account, you say you misattributed the voices at first?
T: Not "voices", just voice. It's singular; one voice! You need to listen if this is ever going to work, I mean, really listen.
P: My apolo… [interrupted]
T: No! It's always the same! You people always jump to the same fucking conclusions. I tell you about one distinct voice, and straight away, it's the old 'he's hearing voices' bullshit. I knew this was pointless.
P: I'm very sorry Tom. I assure you I am trying to listen very carefully to you. [pause] I only said 'they' because we had been talking about the dreams as plural.
T: yeah, well, you say that now. [pause] There's no point carrying on if this is going to keep happening.
P: I see that you're frustrated, but it would be a shame to waste our progress now.
T: [inaudible] "progress"! [laughter] That's a joke. [pause] What's the point in telling you any of this? It's not like you can do a single thing about it, I mean, shit, I'm taking your drugs and they aren't having the slightest effect. I'm done for today.
P: I'm sorry you feel that way, Tom. I thought we were beginning to make progress. Will you continue to write your story?
T: I'll see. [Patient leaves the room].

Psychiatric Progress Notes following session #3:
The patient discussed their dreams and their intrusive thoughts a little, but as soon as I enquired about the "voices", he took exception to my use of the plural and closed the conversation down. This is frustrating, but I understand his reactions are rooted in his delusion.
What was revealing was his sense of "violation" and "invasion". Those are certainly interesting word-choices, which may well indicate that his condition is related to some kind of abuse.
Diagnosis: I am now confident his depression is rooted in his delusion; therefore, it is co-occurring with Paranoid Schizophrenia.
I continue to recommend he remain on suicide watch with regular intervals of no greater than 15 minutes.

Tom's story in his own words: Part two
Right, I'm sure you'll be pleased I'm still writing. Maybe it was a little unfair of me to bail on you so quickly because of the whole voice/voices thing. To be fair, for a long time, I thought the one voice was several voices - worse, I thought they were my own thoughts. With hindsight, I can see how the voice masqueraded as various voices, but I know now it is only one voice in the guise of others. So yeah, he acted as all the usual voices of the human mind - inner critic, insecurity, ego etc. So I would naturally assume those to be different aspects of myself. I mean, who wouldn't? It's a normal human experience, right? This is exactly why I said it was hard to explain - why you wouldn't believe me.

The worst thing about it is that I didn't know it wasn't me for so many years, but now I know, the clues were there all along. Look, you have my notes, you know I understand how it works – which is a big reason why I think our sessions are pointless.

Anyway, I started to jump ahead a little last time, so I need to backtrack a little – provide some context. You see, when I was a kid, just pre-teens I guess, new neighbours moved in next door. These were religious people, like, your full-blown 'born again' Christian fundamentalists – especially the woman. My mum got involved with her, and before long she was a convert and would drag us along to their weird church for a while. Stay with me, you'll see why the preamble is relevant. One day, in the aftermath of a family row, the voice kind of took control. On that occasion, the voice became my voice, then supplanted my voice altogether. I had lost all control and was behaving and saying things out of character. So, what did my Mum do? Only fetch her mentor neighbour! I remember crouching behind a chest of drawers in my bedroom feeling angry and afraid…and out of control, as if someone else was making me say the things I was saying. You need to understand that I don't hold any religious beliefs, but I have to admit, the woman's beliefs did one thing for her: they enabled her to recognise the voice wasn't my own. She concluded I was being oppressed by demons, even naming them. You see, she listened to what the voice was saying and recognised it wasn't me. Her specific belief in demons may be nonsense, but it meant she could recognise something in what I was saying that was uniquely, distinctly, not the voice of a troubled child – something 'other'.
Remember I described the voice as a passenger? I suppose another way to describe it is that he piggy-backed on my human psyche, mimicking human consciousness - hiding in plain sight, you might say. The difference, though, is that, over time, I began to recognise his voice as much more intense than my own - an exaggeration of my psyche. And when I got into religion, (yeah, the religious neighbour and being dragged along to church and youth groups eventually got under my skin) well, he took advantage of that, too, upping his game and masquerading as the voice of God. I know what you're thinking: that believing I can hear the voice of God is a common psychotic delusion, but I remind you, lots of religious people believe God speaks to them, and whilst they may be deluded, it's a far cry from psychosis. Also, as I said, I don't even believe in God anymore - haven't done for years, so it is certainly not a delusion I suffer from any longer. Back then, though, it was a different story. At a low point, I reached out and Jesus seemed to answer me – not just some voice in my mind, or wishful thinking, but a clear, audible voice reassuring me he was there and that he'd be with me. So, from that point on I was your typical zealous convert, a hundred per cent convinced; a hundred per cent committed – I mean, why wouldn't I be? I literally heard the voice of God! So, it successfully fooled me into thinking I was hearing god's voice. I became a missionary, then a minister. My whole life and identity became entirely entwined with my faith. Despite all that, I'm a rational guy, so, deep down, all the reasons for not believing all that crap were there. I ignored them, pretended they weren't there, but they were, and they were piling up, held back by the dam that was this bloody voice. Gradually, however, the cracks in the dam started to appear as he began to over-play his hand. As the years went by, he increasingly began to say things inconsistent with what I understood God to be. That, coupled with burning out, finally put too much pressure on the dam, and once I realised the voice really wasn't the voice of God, my belief in God shattered, and my life as I knew it completely fell apart.

That was the turning point. I finally knew what I'd half suspected for most of my life - but had buried deep in my psyche - was true: it wasn't my own mind, and it certainly wasn't the voice of Christ, it was someone, or something else entirely. I was broken, lost; everything that I had built my identity upon came crashing down around me and I had no idea who I was anymore. I descended into a deep depression and the voice capitalised on this breakdown. With my sense of self in ruins, he took control of the steering wheel and my life was no longer my own.

Addendum To Post session 3 Psychiatric Progress Notes after reading Tom's second instalment of his written account:
Despite his protestations at my apparent faux pa, I have received Tom's second instalment. Rather than flesh out what he hears from the voice, he has moved forward with his autobiographical account. It's interesting how he flips early signs of psychosis around to be "clues" of his oppression by the imagined voice.
The account of the religious neighbour and her diagnosis [is that the right word?] of demonic oppression is interesting. Is there religious trauma at the root of his delusion? Having also revealed that he spent years in christian work believing he was literally hearing the voice of god, only to lose that faith, could be a second trauma with religion at the centre of it, and as such, is the influence of religious fanatics the crux of his delusion? He describes the experience as losing his sense of purpose and identity, which I believe, could well be instrumental in him redefining, not only his own self-image, but his view of the nature of his reality as he experienced it. It is, therefore, quite possible that there is a trauma related to this experience and the delusion lies at the heart of it. I would like to explore this in the next session (if he allows me), but it is also important we discuss the suicide attempt that brought him here. The challenge is moving at an appropriate pace whilst navigating his evasiveness and inclination to control information.

His language choices are interesting. In a face-to-face session, I would consider them revealing and use them to dig deeper, as all good therapists might, but the question remains whether, in his writing, he has thought carefully about his language choices and is consciously using them for effect, for example: "…she heard something in what I was saying that was uniquely, distinctly, not the voice of a troubled child." The almost throwaway use of "troubled child" is interesting; is he consciously letting me know his childhood was troubled or is it a subconscious slip?

Diagnosis: Given the length of time he has suffered from auditory hallucinations and delusions with a sense of persecution, it is clear he is in an active phase of Paranoid Schizophrenia. His belief in the delusion is firmly held. My only way in, at this stage, might be to focus on his feelings and unhelpful responses.

Partial transcript of a conversation between Tom and his assigned psychiatrist:
Session#4
P: Thank you for continuing to write your story, Tom. I found it very interesting indeed. Is there anything else you wish to discuss, or would you like us to get straight into what you wrote?
T: Nothing new, so fire away.
P: I would like to know a little more about your childhood, Tom. You described yourself as a 'troubled child', have I understood that correctly?
T: I didn't describe myself that way; I simply said the things I was hearing and said were not the voice of a troubled child, but a separate voice.
P: Ah, of course, I see. So your childhood wasn't troubled?
T: I didn't say that either! Jesus, you're going to have to do better than this.
P: I'm very sorry Tom, I'm just trying to clarify my understanding. I hope you can be patient with me.
T: Well, I don't have a lot of choice. If I don't cooperate with you, I have zero chance of getting out of here anytime soon.
P: Is that the only reason you're cooperating? I'd like to think I might genuinely be able to help you.
T: "Help me"? Then you really are missing the point. There is no helping me; the voice is with me, and you can't possibly know how to get him to leave – hell, I have no fucking idea if he will ever leave me alone. The only way you can help me is by getting me out of here.
P: How do you see that working, Tom?
T: Simple. I don't. That's why this is so fucking pointless!
P: Okay, we seem to have talked ourselves into a corner here. As we have already established, you feel like you have no choice but to participate in these sessions, so perhaps we can focus on how you feel. Maybe I can help with how you are responding to your situation?
T: I think you know how I feel. It changes nothing, so there's no point repeating it.
P: I understand you feel very despondent and hopeless, but don't we both agree, at the very least, that there's nothing to lose?
T: I'm not repeating how I feel, but you can ask about what I've written.
P: Thank you Tom; I really do appreciate it.
T: yeah, well.
P: So for clarity, rather than making any assumptions, I'm asking you directly: do you consider your childhood to have been troubled?
T: [laughing] ok, let's go there. Yes, sometimes, sometimes not. I consider my whole life to be troubled, given that he's always with me.
P: That's understandable. Apart from the voice, though, are there other elements of your childhood you'd consider problematic?
T: Sure, my parents' constant fighting, the consequent emotional manipulation and neglect, just fairly common shit like that.
P: How do you feel about your parents now?
T: Look, this line of questioning is pointless and predictable. There's no point in going on if you can't think outside the 'therapy 101' box. I'm done for today. [Patient leaves the room].
Psychiatric Progress Notes following session #4:
My approach in our fourth session was unsuccessful, with little to no progress being made. The patient continues to find ways to be evasive and end the session, this time complaining that my line of questioning was pointless. The patient is smart and is engineering a situation in which he not only has full control of what he does and does not reveal in his writing, but also controls the length and productivity of our face-to-face sessions, purposefully closing them down. This behaviour is in direct contradiction to his willingness to write his story, is atypical and is impinging my ability to help him; this behaviour, given his high-risk status, leads me to consider acquiring a second opinion. It remains paramount that I find a way to reach him and for him to move forward as soon as possible.

Tom's story in his own words: Part three
Ok, so I bailed on you again, but you have to understand that if you approach this like you would a mental illness, I'll just lose patience. The voice is real. Not imagined or hallucinated. You absolutely have to make that your starting point or the sessions will be pointless, and there won't be much point in my writing it all down for you either. One more chance.

So, there I was, lost without the faith, community and purpose that had defined me, and the voice in full control. As I fell into a depression, his influence seemed to grow, and that was when I first entertained the idea of ending my own life. The difference then, though, was that it was a result of the depression, and there was still a spark that fought to live. Looking back, I think it was actually my anger. I was so incensed that I'd wasted so many years on a belief that simply wasn't true – that the voice had reinforced this - that some part of me finally decided to fight back. I worked hard at recovery, tried therapy, and did everything I could to recover. Ultimately, just the fact that I fought back meant that I had a chance. So, gradually I took back a little control, improved my education, reinvented myself, and found myself stumbling into a relatively successful career in journalism. That is until the voice revealed his influence even in my so-called recovery and self-reinvention. There I was thinking that I had taken back some modicum of control, when all along he was just allowing me to think that. It was as if he had learned to disguise his voice as my own thoughts better than ever. That's when I realised: I'm stuck in this living nightmare, so utterly trapped that my life is not my own. Could you live with that?
Think about what I'm telling you. Can't you see, now, why I think our sessions are pointless; why I see no escape other than death?

Whether he uses overt influence or tricks me into believing I'm thinking for myself, his power over me is pretty much complete. I don't even know if killing myself is his or my own idea, really; all I can cling to is that if I die, he dies with me, and I'm pretty sure he doesn't want that.

Addendum to Psychiatric Progress Notes following session 4 on reading Tom's third written instalment:
Yet again, the patient is doubling down on his delusion. I remain convinced that antidepressant and antipsychotic medication alongside Individual Psychotherapy (rather than CBT ) is the right approach, especially given his willingness to write his story for me; however, it is disappointing that he remains totally convinced of his delusion and the belief that death is his only escape. His belief that every aspect of his thought life and decision-making could be the influence of his imagined oppressor's influence represents a serious infringement on his perceived autonomy and explains his view that death is the only escape. His delusion and his suicidal ideation have certainly not diminished in the weeks he has been here; thus, I have no choice but to continue to class him as high risk with no reduction of suicide watch observations.

Partial transcript of a conversation between Tom and his assigned psychiatrist:
Session#5
P: I believe your partner has visited?
T: Yeah, a big part of me didn't want to see her [pause] not in here.
P: That's understandable and certainly not an unusual sentiment, Tom. [Pause] Would you like to talk about how it went?
T: [Inaudible] [patient nods]. I have to admit, it went better than I expected. I thought it might be the last time I see her. I thought she was unlikely to want to stick around after finding me like that, so assumed she was coming to say her goodbyes, but I also planned on ending the relationship and telling her not to come again. All of this, it's not fair on her and I just wanted her to not get messed up by my issues, but [pause] she was so happy to see me, so supportive that I didn't go through with it. [Pause] We haven't been together long. We've been colleagues and friends much longer, but the relationship just kind of evolved into something else recently. I wouldn't have got involved, but I thought it was just, like, a casual thing more than anything – even just a convenient no-strings relationship, you know? But she clearly cares way more than I thought, and that took me by surprise.
P: That's really good news, Tom. I'm very happy the visit transpired the way it did. Having someone who is supportive is a big help.
T: Yeah, I get that but [Long pause]
P: But what, Tom?
T: Well, ultimately, it changes nothing about my situation. I think I'm being selfish in keeping her around. The best thing for her would be to forget me and move on. My life isn't normal, so hers wouldn't be.
P: Well, firstly, that's her decision to make, and secondly, couldn't having someone alongside you despite your situation provide a different perspective; something, or someone, to keep living for, for example?
T: Ha! I see what you're doing there. Nice one. Honestly, you're kind of right. I'm really taken aback by her commitment to me, and as much as I tried to deny it, I really enjoy spending time with her, and my feelings for her are pretty strong.
P: That's wonderful. This feels like real progress, Tom.

Psychiatric progress Notes following session 5:
The visit from his partner, this week, has worked wonders. The patient was both more positive and more communicative, and it sounds like he's realised it's worth exploring options other than suicide. This could be the breakthrough that was so desperately needed.

Tom's story: Part four
Ok, so I attempted to end it all again. If you really understood my dilemma, you wouldn't be the least bit surprised. Anyway, I'm not at all surprised you don't understand, but you know that. I briefly entertained the idea that maybe it was worth hanging on, that Jen would make it worth it, but it was a fantasy. There is no one, nothing, that can make this stop. You see, it's getting worse. Just when I thought there might be a glimmer of hope, he unleashed a full offensive, both in my dreams, but also badgering me constantly, non-stop, so I could barely hear myself think, making sure my existence is as miserable as possible, and even threatening Jen. I can't risk him infecting her. Basically, he's ensuring I know beyond a shadow of a doubt that he is in control.

So, you want me to make you understand? I don't know what else I can tell you. I mean, I've been pretty upfront about it. And said it numerous times. You need to accept that the voice is real. It's not me, not a hallucination, and it's certainly not the voice of god. It's…well, I have no idea what it is, call it a demon if you like, call it an alien entity, all I know is that it's a being, somehow attached to me, influencing my whole life with increasing potency, and I have absolutely no escape. Can you imagine how that feels? Sure, I fight, I resist, and sometimes I do pretty well at ignoring it, but it's always there - if not overtly dominating me - subtly influencing me. My life isn't my own and never will be, so the only way to end this is to end me. It's as simple as that, and I cannot see how you, Jen, or anyone else can help. But hey, for now, we're stuck in this dysfunctional relationship, so yes, for what it's worth, while I'm still here, I'll continue telling my story.

Addendum:

After What seemed like the first positive shift in his outlook, I'm extremely disappointed to find out my patient has made another attempt on his life. Thankfully, he was unsuccessful. There will need to be an inquiry into how this has occurred in what is meant to be a place of safety, but I have already discovered that his observations had been reduced against my express wishes. Safeguarding issues for this institution aside, this turn of events places him at the highest risk of another attempt. I feel a sense of urgency to bring him back from the brink, and am increasingly concerned and frustrated that I am failing to do so.

Despite his second suicide attempt, the patient has left me with another instalment of his written account. He is resolute in his belief that he is oppressed by some kind of being that speaks to him and that his only escape is death. Unless he can see another way out, I fear he will continue to make attempts on his life.
Even without the suicide attempts, the patient's indicators are clear, and my diagnosis remains paranoid schizophrenia with co-occurring depression. He is being appropriately medicated, but there is no evidence to date that there is any positive effect whatsoever. His hallucinations and psychosis should be diminishing, but they're not. The auditory hallucinations form the basis of the delusion that he is possessed by an entity and is being persecuted and controlled by it. This is a typical indicator of the active stage of Schizophrenia; but what is atypical is just how long ago he moved from the prodromal stage to active, yet still managed to maintain, at least to the onlooker, a relatively normal life. I am unaware of any sufferer ever being able to manage the increase in severity for anywhere close to as long without a complete breakdown. Whatever the true nature of his condition, the only option that can be discounted is that his delusion is real. It is realistic to expect him to shut down again, but we shall see in our session. It is not clear, as yet, when this will be; it may be expedited but could equally be delayed to allow for physical recovery time.

My immediate priority remains the same: enable him to see it is worth staying alive, and then, hopefully, an improvement in his mental and emotional state will mean I can begin leading him to a pathway of successfully managing his condition. The difficulty is that the harder I push, the harder he pushes back with his delusion, and if I try to just focus on managing his thoughts and feelings, he shuts the conversation down. We seem to be at an impasse, and I'm beginning to think the only way in is to humour him, to let him think I believe him and see where that takes us.

Partial transcript of a conversation between Tom and his assigned psychiatrist:
Session#6
P: Would you like to talk about why you made the attempt on your life?
T: Do I have a choice?
P: You always have a choice, Tom, but I would very much like to help you and that is difficult to do if you won't talk to me. You say you don't want to be here, but having made another suicide attempt, I can hardly recommend your release any time soon, can I?
T: It's hard [pause] I don't think I can. Besides, I feel like I've already said all that needs to be said in my writing.
P: I understand. That's a perfectly normal response, Tom. Would it help if I asked you specific questions?
T: like what?
P: Well, let's give it a go, and see how we get on.
T: Whatever.
P: OK. So, rather than taking all your medication when it was given to you, you were secretly managing to save some over a period of weeks. It begs the question, Tom, if you have been planning this suicide attempt.
T: [inaudible] You think?
P: Ok, I'll take that as confirmation. I'm going to be very direct Tom, and I'm going to ask pertinent and uncomfortable questions. You know you don't need to answer me, but please understand, getting to the bottom of how you're feeling and what you're thinking is the only way I have of trying to help you.
T: I'm writing my fucking story for you!
P: Yes, you are, and that is hugely helpful in understanding your situation, but we have to have the right conversations about it if we are to make progress,
T: [Inaudible]
P: The obvious question, given that you seem to have been planning to take your own life again, is why bother to engage with me at all? Why even begin writing your story?
T: [laughter] Wow, really shooting from the hip today, doc [laughter]. Oops, I mean Daniel. Basically, It's just not that simple.
P: How so? Explain it to me then.
T: For fuck's sake, are you really a professional? [laughter]
P: I'm sorry Tom. I understand that my questions may give the impression I don't understand, but I have to ask even the most basic questions in order to ensure I understand exactly where you're coming from, even if they seem a little simplistic or naive.
T: Yeah [inaudible]. Ok, go on then.
P: Thank you. So, it's not that simple, I get that. Are you able to explain it from your own perspective?
T: [Deep inhalation of breath. Pauses] So, yeah, you could say I planned it, but only as a possible option. It wasn't a definite plan, as such, just keeping my options open.
P: A rather final option.
T: Well, yeah, but I felt like shit [pause] was having a bad day, so it was as much a spur-of-the-moment thing as it was a plan.
P: Thank you, Tom. I understand [interruption]
T: [inaudible] Do you though? I wonder if you have any idea what this is like. Sure, you get mental illness, but you don't get what it's like living with him.
P: With the voice?
T: Yeah.
P: Did the voice have something to do with the attempt?
T: Well duh! That's why I'm here, isn't it?
P: You think you're here because of the voice?
T: I know I am. Look, just knowing I'm stuck with him is enough to end it all, but [long pause]
P: But what, Tom?
T: Nothing [long pause]
P: I suspect it's not "nothing" at all.
T: yeah well [pause] I told you it's not that simple, and I also told you it was pointless. You can't help.
P: That may be true, Tom, but I would like to continue trying if that's OK. You may think it's pointless - and maybe it is - but there's a point to trying anyway.
T: It's just that I [pause] I can't live with it anymore. He will never leave me alone, and there's no other escape. I'm [pause] I'm left with no choice. So yeah, I know what I did is what put me in here, but if I'd been successful, I wouldn't be here, would I; I'd be gone, at peace in sweet oblivion [pause] so you can hardly blame me for trying again.
P: I see. Feeling there is no other option - no other means of escape but death - is a common driving force behind suicide attempts [pause] but I'm here to help you find another way forward – to see that the situation isn't hopeless.
T: [Inaudible] And there it is! That's the problem! You're still looking at this as if you're dealing with a mental health issue. What is the fucking point of telling you it's not, that the voice is real, if you just ignore what I'm saying! That's why I tried again - because it's fucking pointless.
P: I'm sorry Tom. We are only at the very start of this process, and I have to proceed, at least for now, according to my training and expertise. I'm a psychiatrist, Tom. What other approach could I take? I have to believe we will discover a way forward for you [pause] that's what we're doing with you writing your story. Giving up now can only mean I will never get the chance to truly understand your predicament, but if we keep going, we might find a solution together.
T: Yeah, well, I just don't believe it will change anything.
P: I get that, I really do, but we both agreed, whilst you don't believe it will help, trying can't do any harm either. Let's be absolutely clear, Tom; at the moment, we're going around in circles. If you want me to believe you - to take a different approach - convince me in these sessions, not just in your writing, make me see. Even if, as you say, there's absolutely nothing I can do to change your situation, perhaps just getting me to understand would be something?
T: [Inaudible]
P: Look, you're back on suicide watch, and under strict supervision; Use this time to make me understand what you're experiencing. Let's continue on the basis that there might be a way to be free from the voice. Surely there's no harm in exploring the idea?
T: [Inaudible] Possibly.
P: Look, in our second session, if memory serves me, we said we'd pretend I could understand and believe what you're telling me. Let's try and continue on that basis and also look for a solution other than your own death?
T: I see what you're saying, and I appreciate the effort, and hey, if there is another way, I'll try it. Honestly though, I really don't hold out much hope.
P: All I can ask is that we try, Tom, and at the very least, put the suicide attempts on hold?
T: [Laughing] That's fair enough, but no promises.
P: Thank you, Tom. Your written accounts are extremely helpful in this process; I hope you will continue your story?
T: To be honest, it's quite therapeutic writing it all down, so yeah, I don't mind continuing.

Psychiatric Progress Notes following Session 5
My post-suicide session was more positive than I'd dared hope it would be. Whilst making a point that he isn't promising anything, the patient has agreed to continue working with me for a solution other than ending his own life. It is quite possible he might try to kill himself again should the means arise; however, I am cautiously optimistic he also wants to pursue an alternative.

Suicide note left by Tom for Jen:

Jen, I'm so sorry, truly I am. I know, now, that this will hurt you deeply, but in the long run, it's for the best. You will see that one day. Eventually, you'll be happy again. You deserve so much better than me and my shit. I'm sorry.

Tom x

Suicide note left by Tom for Daniel:

Daniel, I want to thank you for trying. I'm sorry I couldn't be what you hoped. It has to be this way. I can't stand it any longer. The voice makes life unbearable, and it's getting stronger. I genuinely fear for the safety of others if I stay alive and let it grow in power. Don't be too sad, you did as good a job as anyone could and, honestly, you were better than I gave you credit for.

Tom

Final Psychiatric Progress Note:
Last night, my patient succeeded in killing himself on his third try, this time using a dressing gown cord as a ligature. This should not have been allowed to happen. Had he been sufficiently monitored, as per my recommendation, he would likely still be alive. I cannot express how deeply saddened and disappointed I am by his unnecessary death. A report to the CQC had already been submitted after his failed attempt, but lessons were not learned. Now this SUI will be investigated in a necessary enquiry and I do not intend to hold back in my statement. Tom was a desperate man in the midst of a deep-rooted active psychosis. His de

"Hello Daniel", said his own voice as clearly as if it were coming from someone else in the room.
Daniel sat, hands frozen, poised above the keyboard…