When Trauma Leads to Psychosis

1. When Trauma Leads to Psychosis Healing Begins by Finding the Story Presenter: Ron Unger LCSW 4ronunger@gmail.com 541-513-1811

2. For those with psychosis, the role of trauma is often still denied • In 1975 the Comprehensive Textbook of Psychiatry, a respected source of information, estimated the prevalence of incest to be • 1 in a million! • Since then, a lot has changed regarding recognition of the existence and role of trauma, but not for those with psychosis, especially in the U.S.

3. From an official “Illness Management and Recovery” handout: • “What causes schizophrenia? • “Schizophrenia is nobody’s fault. This means that you did not cause the disorder, and neither did your family members or anyone else. Scientists believe that the symptoms of schizophrenia are caused by a chemical imbalance in the brain.”

4. What does the research say? • A body of research now includes many large-scale population-based studies controlling for possible mediating variables • This research provides strong evidence that trauma can be a contributing cause for psychosis See “Childhood trauma and psychosis: Evidence, pathways, and implications”, W Larkin, J Read. J, 2008

5. The Evidence that Trauma can Cause Psychotic Symptoms: • The high incidence of psychotic symptoms in people who have been traumatized • The high incidence of trauma histories in people who have psychotic symptoms • Studies that show the greater the severity of the trauma, the greater likelihood of more, and more intense, psychotic symptoms • Brain changes sometimes linked with psychotic symptoms and “schizophrenia” are also found disproportionately in children who have been abused • There are logical and meaningful connections between psychotic symptoms and normal reactions to traumatic experience

6. Three levels of possible relationship between trauma and psychosis: 1 Trauma, especially childhood sexual trauma, can cause psychosis later 2 Having psychotic symptoms can in itself be traumatizing 3 The response by others to one’s psychosis, such as the response of the mental health system, of friends, of family, and of society, can also be traumatizing • Further trauma can cause more psychosis, in a vicious circle

7. Peter Bullimore – his story Currently, Peter currently facilitates a hearing voices and paranoia support group in Sheffield. He also runs his own training and consultancy agency, Asylum Associates, and is the founder member of the Paranoia Network. Peter delivers teaching on hearing voices and paranoia internationally. He also teaches on the COPE initiative at Manchester University and undertakes a research post at the university looking at a collaborative working between voluntary sector organizations and the university, he is also undertaking research into what recovery means from a service user’s perspective. He co-authored the workbook Asking the Questions with Paul Hammersley and Professor John Read, a guidebook around childhood trauma

8. What is the impact when the possible link between trauma & psychosis is denied? • Trauma is often not even asked about, much less discussed • Potentially, through decades of treatment • Understandable reactions to trauma may be defined as non-understandable • Psychotherapy for trauma is denied • Even self-understanding may be discouraged

9. What’s causing these weird experiences? Therapist: We can diagnose you with the illness called schizophrenia because you have these weird experiences. Therapist: These weird experiences are being caused by your illness, which is schizophrenia Client: How do you know that I have an illness called schizophrenia? Problems occur when a “diagnosis” is used as an explanation of the problem

10. Don’t assume a trauma history: there appear to be multiple roads that can lead to psychosis • Some are primarily biological, or physical (like too much methamphetamine) • Some are directly related to trauma • Some seem more related to a “buildup” of stress & negative emotions that aren’t well dealt with, that becomes overwhelming (even traumatic?) • Some may result from a catastrophic interaction among all the above • See “The catastrophic interaction hypothesis” by Fowler et al in the book “Trauma and Psychosis: New directions for theory and therapy”

11. Does Trauma Always Show as PTSD? • Evidence indicates instead that trauma can lead to a broad spectrum of possible reactions • Including psychosis • This differs from the notion that psychosis often just “co-occurs” with PTSD

12. Understanding why trauma causes much more than just “PTSD” • A PTSD diagnosis requires symptoms that can be identified as revolving around the trauma • There must be at least one of the following: • recurrent recollections, or • distressing dreams that relate to the trauma or • acting or feeling as though it's reoccurring, • or distress at exposure to external or internal cues that symbolize or resemble the event. • But if a person successfully avoids thinking about or processing the trauma in an obvious way, then there will be no symptoms that clearly revolve around the trauma.

13. Common factors in PTSD and psychosis: • High arousal & hypervigilance • Sleep disturbance • Avoidance • Emotional numbing • Selective Attention • Safety behaviors • Dysfunctional thought control strategies • Expressed emotion causes relapse • Dissociation • Intrusive phenomena: thoughts, sensory, emotions

14. From “Relationships between trauma and psychosis” by Warren Larkin & Anthony P. Morrison, in Trauma and Psychosis: New Directions for Theory and Therapy

15. A key common factor: Fear of going mad • 70% of those diagnosed with psychosis reported “fear of going crazy” as the most common “prodromal symptom” out of 30 that were assessed • (Hirsch & Jolley, 1989) • Interpreting initial post trauma symptoms as a sign of impending madness was found in one study • to be common in those who developed PTSD compared to those who didn’t, and • to distinguish those who developed persistent PTSD from those who recovered • (Dunmore, Clark, & Ehlers, 1999)

16. What happens when a person fears madness? • Fears that intrusive mental phenomena are “madness” leads to attempts to avoid experiencing them • Which interferes with exposure, or finding out one can handle them, and putting them in perspective (as memories, etc.) • Instead, person is (re) traumatized, as a desperate attempt to control experience fails.

17. Key Difference between a flashback and a hallucination: • In a flashback, there is the recognition that what one is experiencing now is related to the past trauma • But when a trauma has been especially overwhelming or denied, this recognition itself is blocked • A hallucination is often just a “flashback” type of experience where the connection to the past is overlooked or denied.

18. Decontextualized Experience • Ordinarily, the hippocampus serves to bind individual features of incoming information into a spatial/temporal context • Then info goes to amygdala • But when trauma is too intense, info goes straight to the amygdala • Resulting in memory fragments that contain high affect • With no context See “The catastrophic interaction hypothesis” by Fowler et al., in the book “Trauma and Psychosis: New Directions in Theory and Therapy”

19. Decontextualized trauma flashbacks can easily become “psychotic” • Problematic interpretations of the activation of trauma memories • Like a voice that echoes meanings first encountered during trauma • Might be interpreted as a current presence of the abuser, or as an alien or demon See “Relationship between child abuse and psychosis” by Read, Rudegeair & Farelly, p. 39-41, in the book “Trauma and Psychosis: New Directions for Theory and Therapy”

20. Trauma narrows the focus • In a traumatic experience, a person’s focus & interests narrow to what seems necessary to survive • Possibilities are seen in black & white, • to aid sharp decision making and intense action • Some interests & needs must be sacrificed to carry out the survival strategy

21. BUT • Having a very narrow focus on a particular threat is often itself a threat to the person • Because of that tendency for other needs to be sacrificed • So the person may attempt to deny or tune out the threat in order to meet those additional needs • Leading to a dissociative split

22. The most common, or Primary, Structural Dissociation • The Emotional Part, or EP • This part is fused with particular forms of threat response, and avoids considering the impact of that response on other concerns • The Apparently Normal Part, or ANP • This part fuses with “daily life” motivations, and avoids or blocks traumatic memories and/or upsetting emotions

23. Two contradictory directions to take in attempting to cope with trauma: • Wanting to see threat (EP) • Develop a bias toward seeing danger, and toward thinking about bad memories, in order to be able to take action to avoid bad things happening again. • Wanting to NOT see threat (ANP) • Develop blocks against seeing signs of threat and against remembering trauma, to avoid overwhelming affect and extreme behavior etc. • Being dissociated, doing both at once, can lead to appearing and feeling “crazy”

24. Hypervigilant: Afraid of not seeing a threat that may be present Anxious, aroused, perceiving a threat in the absence of good evidence Blocks out or looks away from signs of danger Interprets self as over-reacting: afraid of going mad or appearing mad Confusion caused by coexistence of hypervigilance and blocking perceptions

25. Relationship between dissociative identity disorders & schizophrenia • The more symptoms considered to be unique to schizophrenia a person has • The more likely that person is to fit criteria for dissociative identity disorder • (Foote & Park, 2008) • Experiences often considered to be the most clear indicators of schizophrenia, like voices conversing • Are actually pretty typical in dissociative identity disorder

26. A Paradox • The same process, exposure to what has been kept separate, or dissociated, is • A risk for retraumatization & psychosis • A necessary part of healing • Finding successful ways to bring together parts that have been at war requires both • Setting boundaries with each part • Finding value in each part, having some openness to each part

27. Where most mental health system approaches to psychosis go wrong: • They put all the focus on attempting to suppress disturbing intrusions etc. • In effect, siding with something like the “apparently normal part” • But integration is impossible without some openness to parts that have been dissociated • The focus on suppression of experience becomes “part of the madness” • The “way out” requires finding some value in disturbing experiences, while also setting boundaries

28. More Vicious Circle Stress Increased emotional arousal hypervigilance, listening harder for more voices Hearing a voice Interpret voice itself as a threat

29. Less Virtuous Circle Stress Accept the voice as a useful signal of stress, take action that reduces the stress Less trouble from Hearing a voice Interpret the voice as an effect of stress or as a source of information about aspects of self

30. Eleanor Longden quote (paraphrased): • Like many I tried to bury my past • The problem was that I tried to bury it alive!

31. Effective Therapy: Shifting the Question • From • “What’s wrong with you?” • To: • “What happened to you?”

32. Vicious Circle Trauma Seeking control & toughness to deal with trauma Life goes increasingly out of control as preoccupation with the voices goes up Voices appear as an internal representation of what cannot be controlled Voices “feed” off the tension involved in efforts to control them: they increase Voices are interpreted as a threat to sense of control, so attempts are made to control them

33. Virtuous Circle Less Trauma Accept vulnerability that exists alongside some toughness Life becomes increasingly manageable as preoccupation with voices decreases When voices appear, accept them as clues about areas of vulnerability Due to lack of tension around them, voices become less noticeable Voices are not interpreted as a threat to sense of control, so it does not seem necessary to eliminate them

34. Being curious about how ”psychotic” beliefs and perceptions might meet needs • Possible functions: • Might allow into awareness the existence of the threat • While also distorting it • Might help protect against perception of threat • As in grandiose beliefs etc. • Common factor is difficulty tolerating affect and associations around threat sufficiently to put the threat into perspective

35. Relationship between tolerating affect, and developing helpful narratives • It’s kind of a chicken and egg thing • Developing more ability to tolerate strong disturbing affect allows for the development of more coherent and constructive stories • Developing coherent and constructive stories allows even strongly disturbing affect to become grounded within the story

36. Tips on how to identify the emotional issues behind the “psychosis • Explore the person’s story up till the point when the “psychosis” emerged • Look for themes within it • If person has persecutory beliefs or perceptions • Explore how it feels to have that happening • And earlier times they felt that way • If person has more grandiosity etc. • Explore how they might feel if the grandiose stuff was not there

37. A less extreme story leaves more room for growth & development Evolving Human Story:As I reflect on things, I can develop stories that meet my emotional needs while also allowing me to relate well to others “Psychotic” story: I have to believe this story for important emotional reasons, even if it gets me into serious trouble Psychiatric story:my beliefs and experiences are caused by my disease, for example, schizophrenia

38. Developing Self-Affirming Narratives • Not psychotic stories, and • NOT “the illness causes…” • Instead: • Consider explaining in terms of coping strategies that backfired, or were too extreme • If there may have been biological predisposing factors, consider the possibility of alternative ways of coping with those factors • Having a coherent story of what might have caused the psychosis creates room to imagine a story of recovery

39. The Role of Assembling a Story: • Forming coherent narratives of the past, which help frame the present, and define future possibilities • with flexible capacity to integrate internal & external experience • The narrative should successfully explain both the traumatic experience and the psychosis • And it should do so in a way that promotes hope and self worth See “Narrative CBT for Psychosis” by Rhodes & Jakes, p.117-138

40. Working toward a narrative • Slow down the session & gently inquire about areas that seem broken or fragmented • See “Staying Well After Psychosis” p. 114 • Look at both the positive and negative side of coping strategies • This helps integrate positive and negative affect about the strategies, and about life direction in general

41. Emphasis on how the story is being told in the present moment • “Those who do not have power over the story that dominates their lives, the power to retell it, rethink it, deconstruct it, joke about it, and change it as times change, truly are powerless.” — Salman Rushdie

42. Steve, 23 years old • Several “psychotic breaks” • Lots of paranoia • Fear related mostly to “the government” • No recollection of childhood trauma • But family members were able to recount stories of physical abuse, sexual abuse, and exposure to severe domestic violence

43. What worked • Positive, supportive relationship • Gently questioning the beliefs about the government • Looking at past trauma as possible source for “emotional flashbacks” to terror that were being blamed on current threat from the government • At first, this explanation was more terrifying than the paranoid beliefs

44. “Madness” that leads to fun, changes seen as positive, and/or notable cultural influence – how different is it from madness that just causes trouble and is labeled “sick?”

45. The “Renewal Process” • 1. Construct system breaks down • Common cause of that: trying to solve a problem not solvable within existing constructs • 2. Temporary suspension of constructs • Encounter with the “transliminal” • 3. Construct restructuring If done under high stress etc., errors are more likely, leading to getting attached to defective constructs, and/or back into….. • If done under low stress etc., more likely to result in new vision that enriches the person & possibly the culture!

46. The bottom line: • We need to study, rather than deny, the connection between trauma and psychosis • We need to recognize that there is generally a story to how people came to be mentally troubled • Then we can join with them in creating a story of recovery, rather than retraumatization and chronic “illness”

47. To learn more about this topic: • Check out the online course, “Working With Trauma, Dissociation, and Psychosis: CBT and Other Approaches to Understanding and Recovery” • This comes with 6 CE credits for most US professionals! • For more information, or to register, go to • http://recoveryfromschizophrenia.org/working-with-trauma-dissociation-and-psychosis/