When Trauma and Psychosis Mix Presenter: Ron Unger LCSW [email protected].

When Trauma and When Trauma and Psychosis MixPsychosis Mix

Presenter: Ron Unger LCSWPresenter: Ron Unger LCSW

541-513-1811541-513-1811

[email protected]@gmail.com

The connection between trauma The connection between trauma and psychosisand psychosis

Mainstream mental health system Mainstream mental health system understanding:understanding:– Serious mental illness such as Serious mental illness such as

schizophrenia is biological in origin, schizophrenia is biological in origin, does not result from any special sorts of does not result from any special sorts of eventsevents

Cognitive therapy understanding:Cognitive therapy understanding:– Traumatic experiences can easily lead Traumatic experiences can easily lead

to problems such as thinking errors to problems such as thinking errors which can lead to psychosiswhich can lead to psychosis

What does the research say?What does the research say?

A body of research now includes many A body of research now includes many large-scale population-based studies large-scale population-based studies controlling for possible mediating controlling for possible mediating variablesvariables

This research provides strong evidence This research provides strong evidence that trauma can cause psychosisthat trauma can cause psychosis– All studies looking for a dose response All studies looking for a dose response

(more severe abuse leads to more severe (more severe abuse leads to more severe trauma) found such a responsetrauma) found such a response

See “Childhood trauma and psychosis: Evidence, pathways, and implications”, W Larkin, J Read. J, 2008

Slide from presentation by Dr Warren Larkin & Pauline Callcott

Three levels of possible Three levels of possible relationship between trauma and relationship between trauma and

psychosis:psychosis:11 Trauma, especially childhood sexual trauma, can Trauma, especially childhood sexual trauma, can

cause psychosis latercause psychosis later22 Having psychotic symptoms can in itself cause Having psychotic symptoms can in itself cause

traumatrauma33 The response by others to one’s psychosis can The response by others to one’s psychosis can

also be traumatizingalso be traumatizingResponses by the mental health system, by family & friends, can all Responses by the mental health system, by family & friends, can all add to traumaadd to trauma

Further trauma can cause more psychosis, in a Further trauma can cause more psychosis, in a vicious circlevicious circle

See “Relationships between trauma and psychosis: A review and integration” by Anthony P. Morrison, Lucy Frame and Warren Larkin 2003

Trauma (involves

perceived need to reorganize in a radical way.)

Psychosis (disorganization or mistaken way

of being organized.)

Trauma (involves

perceived need to reorganize in a radical way.)

Psychosis (disorganization

or mistaken way of being organized.)

Don’t assume a trauma history: there Don’t assume a trauma history: there appear to be multiple roads that lead to appear to be multiple roads that lead to

psychosispsychosis Some are purely biological, or physical Some are purely biological, or physical

(like street drugs)(like street drugs) Some are directly related to traumaSome are directly related to trauma Some seem more related to a “buildup” of Some seem more related to a “buildup” of

stress & negative emotions that aren’t well stress & negative emotions that aren’t well dealt with, that become overwhelming dealt with, that become overwhelming (even traumatic?)(even traumatic?)

Some may result from a catastrophic Some may result from a catastrophic interaction among all the aboveinteraction among all the above– See “The catastrophic interaction hypothesis” by Fowler et al in the book See “The catastrophic interaction hypothesis” by Fowler et al in the book

“Trauma and Psychosis: New directions for theory and therapy”“Trauma and Psychosis: New directions for theory and therapy”

How is “Psychological Trauma” How is “Psychological Trauma” Defined?Defined?

DSM focuses on perceived physical DSM focuses on perceived physical threatthreat– But this is somewhat arbitraryBut this is somewhat arbitrary

Psychological impact is keyPsychological impact is key– Trauma is created by a combination of Trauma is created by a combination of

sense of overwhelming threat, or terror, sense of overwhelming threat, or terror, with helplessnesswith helplessness

– It’s not a specific type of event, but our It’s not a specific type of event, but our appraisal of the event, which causes appraisal of the event, which causes psychological traumapsychological trauma

Even if the appraisal is mistaken, the terror & Even if the appraisal is mistaken, the terror & trauma may be realtrauma may be real

Why is the role of trauma in causing Why is the role of trauma in causing psychosis commonly denied?psychosis commonly denied?

Hoping for a simple explanation: Hoping for a simple explanation: – since some psychoses have a biological cause, since some psychoses have a biological cause,

maybe they all do?maybe they all do? Evidence of genetic causation is Evidence of genetic causation is

commonly exaggeratedcommonly exaggerated Bias toward believing that if biology is Bias toward believing that if biology is

involved at all, it must be primaryinvolved at all, it must be primary Pharmaceutical companies & their allies Pharmaceutical companies & their allies

gain power when the explanation is gain power when the explanation is biologicalbiological

Denial of trauma has lessened overall, but Denial of trauma has lessened overall, but this hasn’t yet reached the field of this hasn’t yet reached the field of psychosispsychosis

Why is the role of trauma in causing Why is the role of trauma in causing psychosis commonly denied? psychosis commonly denied?

(continued)(continued) Past overly simplistic judgments and Past overly simplistic judgments and

assumptions by some of those who did see assumptions by some of those who did see a role for trauma in causing psychosisa role for trauma in causing psychosis

Parallel processParallel process– Neither the client, nor the mental health system, want to Neither the client, nor the mental health system, want to

face the facts of the traumaface the facts of the trauma

Idea that if trauma causes a mental Idea that if trauma causes a mental problem, it will be PTSDproblem, it will be PTSD

Positive and Negative Symptoms Positive and Negative Symptoms

Psychosis and PTSD can both be divided Psychosis and PTSD can both be divided into clusters of positive and negative into clusters of positive and negative symptoms symptoms

(McGorry 1991)(McGorry 1991) Many of what are called the negative Many of what are called the negative

symptoms of PTSD – difficulty symptoms of PTSD – difficulty concentrating, withdrawal, emotional concentrating, withdrawal, emotional numbing, derealization, estrangement, numbing, derealization, estrangement, self neglect – overlap with what are self neglect – overlap with what are identified with the negative symptoms identified with the negative symptoms of psychosis of psychosis

(Fowler, 1997; Stampfer, 1990)(Fowler, 1997; Stampfer, 1990)

Common factors in PTSD and Common factors in PTSD and psychosis:psychosis:

High arousal & hypervigilanceHigh arousal & hypervigilance Sleep disturbanceSleep disturbance AvoidanceAvoidance Emotional numbingEmotional numbing Selective AttentionSelective Attention Safety behaviorsSafety behaviors Dysfunctional thought control strategiesDysfunctional thought control strategies Expressed emotion causes relapseExpressed emotion causes relapse DissociationDissociation Intrusive phenomena: thoughts, sensory, Intrusive phenomena: thoughts, sensory,

emotions emotions

See “Relationships between trauma and psychosis” by Larkin & Morrison, in the book “Trauma and Psychosis: New directions in theory and therapy” p. 260-261

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

A key common factor: Fear of A key common factor: Fear of going madgoing mad

70% of those diagnosed with psychosis 70% of those diagnosed with psychosis reported “fear of going crazy” as the most reported “fear of going crazy” as the most common “prodromal symptom” out of 30 common “prodromal symptom” out of 30 that were assessedthat were assessed

(Hirsch & Jolley, 1989)(Hirsch & Jolley, 1989) Interpreting initial post trauma symptoms as Interpreting initial post trauma symptoms as

a sign of impending madness was found in a sign of impending madness was found in one study one study – to be common in those who developed PTSD to be common in those who developed PTSD

compared to those who didn’t, and compared to those who didn’t, and – to distinguish those who developed persistent to distinguish those who developed persistent

PTSD from those who recoveredPTSD from those who recovered (Dunmore, Clark, & Ehlers, 1999)(Dunmore, Clark, & Ehlers, 1999)

What happens when a person What happens when a person fears madness?fears madness?

When a person fears that intrusive When a person fears that intrusive mental phenomena are “madness” they mental phenomena are “madness” they attempt to avoid experiencing themattempt to avoid experiencing them– Which interferes with exposure, or finding Which interferes with exposure, or finding

out one can handle them, and putting them out one can handle them, and putting them in perspective (as memories, etc.)in perspective (as memories, etc.)

– Instead, person is (re) traumatized, as a Instead, person is (re) traumatized, as a desperate attempt to control experience desperate attempt to control experience fails.fails.

What is the impact of the mental What is the impact of the mental health system’s refusal to see the health system’s refusal to see the link between trauma & psychosis?link between trauma & psychosis?

Trauma is often not even asked Trauma is often not even asked about, much less discussedabout, much less discussed– Potentially, through decades of Potentially, through decades of

treatmenttreatment Understandable reactions to trauma Understandable reactions to trauma

are defined as non-understandableare defined as non-understandable Psychotherapy for trauma is deniedPsychotherapy for trauma is denied Even self-understanding is Even self-understanding is

discourageddiscouraged

Assessment:Assessment: Finding out about trauma Finding out about trauma

Need to askNeed to ask– Often clients won’t say if not askedOften clients won’t say if not asked– Seldom harmful to ask, often harmful Seldom harmful to ask, often harmful

not to asknot to ask Asking seems common-sense, but Asking seems common-sense, but

research says in our current mental research says in our current mental health system, it commonly doesn’t health system, it commonly doesn’t happen for people with psychosishappen for people with psychosis

– Read, Hammersley, & Rudegeair, 2007Read, Hammersley, & Rudegeair, 2007

Slide from presentation by Dr Warren Larkin & Pauline Callcott

How to ask:How to ask:

Prepare the personPrepare the person Move questions from general to Move questions from general to

specificspecific– Specific questions are much more likely Specific questions are much more likely

to elicit reports of abuseto elicit reports of abuse Know how to respondKnow how to respond

How to respond to reports of abuse:How to respond to reports of abuse:

Not necessary gather a lot of details Not necessary gather a lot of details immediatelyimmediately

Affirm it was positive to tell youAffirm it was positive to tell you Offer supportOffer support

– Like access to counselingLike access to counseling Check current safetyCheck current safety

– Including if abuser might currently be abusing othersIncluding if abuser might currently be abusing others Check emotional state end of sessionCheck emotional state end of session Offer follow-up or check inOffer follow-up or check in Has person told anyone before – if so how Has person told anyone before – if so how

did that go?did that go?

“Why, when and how to ask about childhood abuse“ John Read, Paul Hammersley and Thom Rudegeair (2007)

Also ask about possible trauma Also ask about possible trauma caused by by mental health caused by by mental health

treatmenttreatment Between 44 and 51% were found to Between 44 and 51% were found to

have PTSD induced by psychiatric have PTSD induced by psychiatric admission and treatmentadmission and treatment

(Priebe, Broker, & Gunkel, 1998; Morrison, Bowe, (Priebe, Broker, & Gunkel, 1998; Morrison, Bowe, Larkin, & Northard, 1999)Larkin, & Northard, 1999)

Forced drugging, retraint, and seclusion Forced drugging, retraint, and seclusion have been identified as inducing fear, have been identified as inducing fear, victimization and helplessnessvictimization and helplessness– Also a factor: Loss of control over identity Also a factor: Loss of control over identity

as one is forced into the role of a “mental as one is forced into the role of a “mental patient” patient”

General principles of trauma General principles of trauma informed CBT for psychosis:informed CBT for psychosis:

Collaborative, Collaborative, – neither imposed structure nor lack of neither imposed structure nor lack of

structurestructure Client prioritizes problems and goalsClient prioritizes problems and goals

– But address any issues that might interfere But address any issues that might interfere with therapy firstwith therapy first

Have a clear rationale for each stepHave a clear rationale for each step– And get consent for each stepAnd get consent for each step

Also attend to supports outside of therapyAlso attend to supports outside of therapy

The role of therapist uncertainty:The role of therapist uncertainty:

““People wish to be People wish to be settled; only as far as settled; only as far as they are unsettled is they are unsettled is there any hope for there any hope for them.” them.” – RALPH WALDO EMERSON, “Circles,” Essays: First Series, 1841RALPH WALDO EMERSON, “Circles,” Essays: First Series, 1841

Key skill: soliciting feedbackKey skill: soliciting feedback

Watch for signs you may be going in the Watch for signs you may be going in the wrong directionwrong direction– Either lack of progressEither lack of progress– Or client dissatisfactionOr client dissatisfaction

If client is unhappy, don’t automatically If client is unhappy, don’t automatically assume direction is wrongassume direction is wrong– Might just be need a better rationaleMight just be need a better rationale– Or perhaps direction is partly wrong, partly Or perhaps direction is partly wrong, partly

rightright Sorting that out may require some discussionSorting that out may require some discussion

Can map out how reactions to the Can map out how reactions to the trauma may be causing the trauma may be causing the psychosispsychosis

Understanding psychosis as a Understanding psychosis as a possible reaction to difficult possible reaction to difficult experiences is normalizing, reduces experiences is normalizing, reduces stigmastigma

The FormulationThe Formulation

Effective Therapy: Shifting the Effective Therapy: Shifting the QuestionQuestion

From “What’s wrong with you?”From “What’s wrong with you?”

To:To:– ““What happened to you?” andWhat happened to you?” and– ““What’s happening with you right now?” What’s happening with you right now?”

andand– ““What would you like to see happen in What would you like to see happen in

the future, and what do you see as your the future, and what do you see as your possible role in making that happen?”possible role in making that happen?”

The Role of Assembling a Story: The Role of Assembling a Story:

Forming coherent narratives of the Forming coherent narratives of the past, which help frame the present, past, which help frame the present, and define future possibilitiesand define future possibilities– with flexible capacity to integrate with flexible capacity to integrate

internal & external experienceinternal & external experience The narrative should successfully The narrative should successfully

explain both the traumatic explain both the traumatic experience and the psychosisexperience and the psychosis– And it should do so in a way that And it should do so in a way that

promotes hope and self worthpromotes hope and self worthSee “Narrative CBT for Psychosis” by Rhodes & Jakes, p.117-138

Working toward a narrativeWorking toward a narrative

Slow down the session & gently Slow down the session & gently inquire about areas that seem inquire about areas that seem broken or fragmentedbroken or fragmented

– See “Staying Well After Psychosis” p. 114See “Staying Well After Psychosis” p. 114

Look at both the positive and Look at both the positive and negative side of coping strategiesnegative side of coping strategies– This helps integrate positive and This helps integrate positive and

negative affect about the strategies, and negative affect about the strategies, and about life direction in generalabout life direction in general

Steve, 23 years oldSteve, 23 years old

Several “psychotic breaks”Several “psychotic breaks” Lots of paranoiaLots of paranoia

– Fear related mostly to “the government”Fear related mostly to “the government” No recollection of childhood traumaNo recollection of childhood trauma

– But family members were able to But family members were able to recount stories of physical abuse, sexual recount stories of physical abuse, sexual abuse, and exposure to severe domestic abuse, and exposure to severe domestic violenceviolence

What workedWhat worked

Positive, supportive relationshipPositive, supportive relationship Gently questioning the beliefs about Gently questioning the beliefs about

the governmentthe government Looking at past trauma as possible Looking at past trauma as possible

source for “emotional flashbacks” to source for “emotional flashbacks” to terror that were being blamed on terror that were being blamed on current threat from the governmentcurrent threat from the government– At first, this explanation was more At first, this explanation was more

terrifying than the paranoid beliefsterrifying than the paranoid beliefs

Avoid explanations that assume Avoid explanations that assume permanent defectpermanent defect

NOTNOT “the illness causes…” “the illness causes…” Instead: Instead:

– Consider explaining in terms of coping Consider explaining in terms of coping strategies that backfired, or were too strategies that backfired, or were too extremeextreme

– If there may have been biological If there may have been biological predisposing factors, consider the predisposing factors, consider the possibility of alternative ways of coping possibility of alternative ways of coping with those factorswith those factors

Having a coherent story of what might Having a coherent story of what might have caused the psychosis creates have caused the psychosis creates room to imagine a story of recoveryroom to imagine a story of recovery

Trauma narrows the focusTrauma narrows the focus

In a traumatic experience, a person’s In a traumatic experience, a person’s focus & interests narrow to what focus & interests narrow to what seems necessary to surviveseems necessary to survive– Possibilities are seen in black & white, Possibilities are seen in black & white,

to aid sharp decision making and intense to aid sharp decision making and intense actionaction

– Some interests & needs must be Some interests & needs must be sacrificed to carry out the survival sacrificed to carry out the survival strategystrategy

Key Vicious CycleKey Vicious Cycle

ThreatThreat

Problematic & NarrowProblematic & Narrow““Safety Strategies”Safety Strategies”

UnintendedUnintended ConsequencesConsequences

Key “Virtuous Cycle”Key “Virtuous Cycle”

Reduced ThreatReduced Threat

Better IntegratedBetter IntegratedSafety StrategiesSafety Strategies

PositivePositive ConsequencesConsequences

Threat relationsThreat relations

Conflicts of EmotionsConflicts of Emotions

AngerAnger AnxietyAnxiety

SadneSadnessss

blocks

blocksblock

s

blocks

blocksblocks

Each emotion can have a variety Each emotion can have a variety of defensive behaviours and of defensive behaviours and

memories memories Slide by Paul Gilbert

Threat RelationsThreat Relations

Conflicts of StrategiesConflicts of Strategies

DominanDominantt

SubmissivSubmissivee

Care-Care-SeekinSeekin

gg

blocks

blocksblock

s

blocks

blocksblocks

Each strategy can have a variety of Each strategy can have a variety of forms, functions and behaviours and forms, functions and behaviours and

memoriesmemoriesSlide by Paul Gilbert

Core dynamic in extended or unresolved Core dynamic in extended or unresolved trauma: intrapersonal conflict is amplified to trauma: intrapersonal conflict is amplified to

point of dissociationpoint of dissociation

Struggle between incompatible Struggle between incompatible reactions or strategiesreactions or strategies– When one extreme doesn’t work, a When one extreme doesn’t work, a

tendency to jump to opposite extremetendency to jump to opposite extreme While organizing around one While organizing around one

strategy, the other extreme is seen strategy, the other extreme is seen as “the enemy” or an intruderas “the enemy” or an intruder

This conflict accounts for much of the This conflict accounts for much of the dynamics in both PTSD and psychosisdynamics in both PTSD and psychosis

Fusion:

My emotions or thoughts take over, or tell me what is real: 

If I'm feeling down then I'm doing terrible, if I feel scared, then I’m in danger, etc.

Experiential Avoidance:

I reject my feelings or thoughts, or see them as my enemy: 

I need to block them out (or drugthem away)

Mindful Dialogue:

I include all of my emotions & the thoughts associated with them in an ongoing internal dialogue.

Decisions about what to do emerge from this process.

Two extremes, when rational internal dialog is missing:

The most common, or Primary, The most common, or Primary, Structural DissociationStructural Dissociation

The Apparently Normal Part, or ANPThe Apparently Normal Part, or ANP– This part fuses with “daily life” This part fuses with “daily life”

motivations, and avoids or blocks motivations, and avoids or blocks traumatic memories and/or upsetting traumatic memories and/or upsetting emotions emotions

The Emotional Part, or EPThe Emotional Part, or EP– This part is fused with particular forms of This part is fused with particular forms of

threat response, and avoids considering threat response, and avoids considering the impact of that response on other the impact of that response on other concernsconcerns

Three Types of DissociationThree Types of Dissociation

Two types of “negative” dissociationTwo types of “negative” dissociation– ANP attempts to shut out EPANP attempts to shut out EP

Dissociation attempting to sootheDissociation attempting to soothe

– EP attempts to overwhelm ANPEP attempts to overwhelm ANPDissociation to increase focus on threatDissociation to increase focus on threat

““Positive” DissociationPositive” Dissociation– Results when formerly dissociated Results when formerly dissociated

content or parts reconnect in a content or parts reconnect in a disorderly waydisorderly way

““Positive” Dissociation Can Be an Positive” Dissociation Can Be an Attempt to Heal That BackfiresAttempt to Heal That Backfires

Attempts to bring together what was Attempts to bring together what was formerly kept separate can lead to formerly kept separate can lead to – disorder disorder – preoccupation with internal realities that preoccupation with internal realities that

may be seen as externalmay be seen as external These problems can lead to self and/or These problems can lead to self and/or

others perceiving and fearing madnessothers perceiving and fearing madness– Resulting in attempts to shut down the Resulting in attempts to shut down the

process & return to “negative dissociationprocess & return to “negative dissociation

A ParadoxA Paradox The same process, positive dissociation, The same process, positive dissociation,

or creatively bringing together what has or creatively bringing together what has usually been kept separate, isusually been kept separate, is– A risk for retraumatization & psychosisA risk for retraumatization & psychosis– A necessary part of healingA necessary part of healing

Finding successful ways to bring Finding successful ways to bring together parts that have been at war together parts that have been at war requiresrequires– Boundaries that also have some opennessBoundaries that also have some openness

Feeling, thought, impulse or voice that tries to dominate

Resistance to the feeling, thought, impulse or voice

The problem…. or even, something from the outside attacking me.

The way I want to be…..or even, this is the only way I ever am

Person may “jump” from identifying with resistance to something, to identifying with it & acting it out.

Feeling, thought, impulse or voice that tries to dominate

Resistance to the feeling, thought, impulse or voice

Balanced Identity, Balanced View, What’s right in this context?

Simple technique to address Simple technique to address polarized experiencepolarized experience

Draw a continuum, showing both Draw a continuum, showing both extremesextremes– Portray each extreme as potentially Portray each extreme as potentially

useful in the right circumstanceuseful in the right circumstance Ask the client to considerAsk the client to consider

– what some more middle of the road what some more middle of the road options might beoptions might be

-- how much of each extreme might fit how much of each extreme might fit particular circumstancesparticular circumstances

Focused on defending against interpersonal threats:

Gullible for over-reacting to signs of threat

Focused on defending against paranoia or over-reacting to threat:

Gullible for interpersonal betrayal

Vigilant for both kinds of threat but not overly so

Drawing a continuum to illustrate the possibility of going too far in either direction:

Defend against possibility of betrayal through hypervigilance, bias toward perceiving threat

Get worn out by hypervigilance, mentally overwhelmed

Restore inner equilibrium by minimizing awareness of external threat

Get betrayed again, or notice threats that have not been adequately tracked

Working Toward BalanceWorking Toward Balance

Need to set limits with intrusive, Need to set limits with intrusive, disturbing, or polarized parts of the disturbing, or polarized parts of the psychepsyche

While also being open to hearing While also being open to hearing about, and addressing, the about, and addressing, the underlying concerns that those parts underlying concerns that those parts representrepresent– Note that the second step will seldom be Note that the second step will seldom be

taken if the disturbing part is seen just taken if the disturbing part is seen just as a “symptom” of an “illness”as a “symptom” of an “illness”

Exercise on Identifying Two Exercise on Identifying Two ExtremesExtremes

““Client” briefly describes struggling Client” briefly describes struggling with some problematic state or with some problematic state or experienceexperience

““Therapist” explores the possibility it is Therapist” explores the possibility it is one kind of extremeone kind of extreme– And asks questions to figure out what an And asks questions to figure out what an

opposite extreme might beopposite extreme might beWrite it on paper!Write it on paper!

– Asks “client” how he or she might be able Asks “client” how he or she might be able to identify a healthy middle groundto identify a healthy middle ground

The Focus Widens in HealingThe Focus Widens in Healing

A shift occurs, A shift occurs, – From From

““either/or”either/or”

– ToTo““both/and”both/and”

Person identifies with both Person identifies with both “opposing” forces within self, plus “opposing” forces within self, plus wider context and concernswider context and concerns

Two types of hallucinations and/or delusions:

Those whose function is to get the person to see the danger that they may have been blocking out– These are on a spectrum with “flashbacks” that

are common after trauma Those whose function is to protect the

person from being overwhelmed by what they are afraid of– These are on a spectrum with dissociation, the

ability to separate from experience that is overwhelming

All types of grandiosity can be understood as having a protective function

Relationship between dissociative Relationship between dissociative identity disorders & schizophreniaidentity disorders & schizophrenia

The more symptoms considered to The more symptoms considered to be unique to schizophrenia a person be unique to schizophrenia a person hashas– The more likely that person is to fit The more likely that person is to fit

criteria for dissociative identity disordercriteria for dissociative identity disorder– (Foote & Park, 2008)(Foote & Park, 2008)

Experiences considered to be the Experiences considered to be the most clear indicators of most clear indicators of schizophrenia, like voices conversingschizophrenia, like voices conversing– Are actually pretty typical in dissociative Are actually pretty typical in dissociative

identity disorderidentity disorder

Effect of dissociation on Effect of dissociation on self-self-organizationorganization of dissociated content of dissociated content

Whatever is not integrated in some Whatever is not integrated in some way may take on a life of its ownway may take on a life of its own

Content not yet integrated may be Content not yet integrated may be simple or complexsimple or complex– From automatic thoughts, emotions, From automatic thoughts, emotions,

memory fragmentsmemory fragments– To mood states, perspectives, voicesTo mood states, perspectives, voices– To complex identity states seen as To complex identity states seen as

“alternate personalities” or alien entities“alternate personalities” or alien entities

Extreme associations (fusion) based on trauma:

For example, my abuser was tall with a beard, now all tall bearded men are threatening

Dissociation (experiential avoidance) to protect from trauma associations:

I avoid traumatic over-reactions by shutting them out, but then I fail to protect myself from future threats….

Balance between associate and dissociate.

I can think through whether associations with the trauma are relevant or irrelevant in a given situation.

Fixed traumatic associations vs. excess “protective” dissociation

Dissociation, and loss of contact Dissociation, and loss of contact with realitywith reality

Dissociation can lead to Dissociation can lead to – Loss of “internal anchors” (the sense of Loss of “internal anchors” (the sense of

being connected to one’s body, a sense of being connected to one’s body, a sense of self or identity, and a sense of ownership self or identity, and a sense of ownership over one’s actions)over one’s actions)

The result of this may beThe result of this may be– Not only impaired reality testingNot only impaired reality testing– Also severe confusion, disorganization, & Also severe confusion, disorganization, &

disorientationdisorientation(Allen et al 1997)(Allen et al 1997)

I put everything into airtight categories or compartments:

Everything is completely separate and has nothing to do with anything else. It’s very orderly.

Dissociated

I see the world without any categories at all:

I have no way to organize my perceptions or make any sense out of them.

Dysregulated, or “positive dissociation”

I see everything as different in some sense yet also the same in some sense:

I’m willing to explore different senses, different ways of organizing information or not.

Over-compartmentalized or overly dissociated vs. no categories at all

Why trauma causes problems in Why trauma causes problems in integrating experiencesintegrating experiences

Ordinarily, the hOrdinarily, the hippocampus serves to bind ippocampus serves to bind individual features of incoming information individual features of incoming information into a spatial/temporal contextinto a spatial/temporal context– Then info goes to amygdalaThen info goes to amygdala

But when trauma is too intense, info goes But when trauma is too intense, info goes straight to the amygdalastraight to the amygdala– Resulting in memory fragmentsResulting in memory fragments

that contain high affectthat contain high affect With no contextWith no context

See “The catastrophic interaction hypothesis” by Fowler et al., in the book “Trauma and Psychosis: New Directions in Theory and Therapy”

Decontextualized trauma Decontextualized trauma flashbacks can easily become flashbacks can easily become

“psychotic”“psychotic”

Problematic interpretations of the Problematic interpretations of the activation of trauma memoriesactivation of trauma memories– Like a voice that echoes meanings first Like a voice that echoes meanings first

encountered during traumaencountered during traumaMight be interpreted as a current presence Might be interpreted as a current presence

of the abuser, or as an alien or demonof 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”

Effects of trauma & child abuse Effects of trauma & child abuse is often apparent in “symptoms”is often apparent in “symptoms”

One study found that over half of the One study found that over half of the “schizophrenic symptoms” of abused “schizophrenic symptoms” of abused adult inpatients appeared obviously adult inpatients appeared obviously related to the abuserelated to the abuse– for example, hearing the voice of a for example, hearing the voice of a

perpetrator commanding them to perpetrator commanding them to commit suicidecommit suicide(Read & Argyle, 1999)(Read & Argyle, 1999)

Let the experience intrude so vividly it seems to be happening right now:

Get re-traumatized & overwhelmed, no integration.

Refuse to let the experience intrude:

Stop the experience from re-traumatizing, but also fail to integrate it.

I let the experience occur, but I have ways of reducing its intensity by changing my reaction to it:

With calm, integration occurs.

Spectrum of ways de-contextualized experiences/memories can be dealt with

Possible origin of some voices in effort Possible origin of some voices in effort to block trauma related intrusionsto block trauma related intrusions

Trauma

Interpret trauma memories as a threat, attempt to block

Voices form to overcome blocks & raise issues related to trauma

Interpret voices as a threat, become emotionally distressed, attempt to block or distract from voices

Voices increase in volume & frequency as emotional distress and blocking increases

Possible origin of “positive” voicesPossible origin of “positive” voices

Trauma

Protective dissociation, “positive” voices emerge to protect self from trauma & trauma memories

“Negative” voices form to raise issues related to trauma Interpret

“negative” voices as a threat, increasingly turn to “positive” voices for relief

“Negative” voices increase in volume & frequency to overcome blocking by “positive” voices

It is the “blocking” itself that It is the “blocking” itself that sustains the power of the intrusionsustains the power of the intrusion

Trying to get rid of the “madness” is Trying to get rid of the “madness” is actually part of the madnessactually part of the madness

““The way out of hell is through the The way out of hell is through the center”center”– Just accepting the intrusion or unwanted Just accepting the intrusion or unwanted

trauma reminder or “psychotic” trauma reminder or “psychotic” experience, allows us to put it into experience, allows us to put it into perspective for what it isperspective for what it is

– And it’s putting it into perspective, into And it’s putting it into perspective, into context, that allows us to move oncontext, that allows us to move on

Problematic ways of coping with Problematic ways of coping with voices:voices:

Flight: Relying on avoidance and Flight: Relying on avoidance and distractiondistraction– Issues aren’t dealt with, person feels too Issues aren’t dealt with, person feels too

weak to face the voiceweak to face the voice Fight: Arguing with the voice, trying to Fight: Arguing with the voice, trying to

change it’s mindchange it’s mind– Fighting with the voice is a distraction from Fighting with the voice is a distraction from

lifelife Submission: Giving in to the voiceSubmission: Giving in to the voice

– Even if voice demands are not harmful, Even if voice demands are not harmful, personal power is diminishedpersonal power is diminished

Better way of coping with Better way of coping with voices:voices:

Alternating between attending to, Alternating between attending to, and ignoring, the voicesand ignoring, the voices– Can choose the best method for the Can choose the best method for the

occasion, or set “appointments” with occasion, or set “appointments” with themthem

Be both assertive and friendly with Be both assertive and friendly with the voicesthe voices– Able to not take voices literally, while Able to not take voices literally, while

seeing them as clues regarding issues seeing them as clues regarding issues that may need attended tothat may need attended to

Trauma

Seeking control & toughness to deal with trauma

Voices appear as an internal representation of what cannot be controlled

Voices are interpreted as a threat to sense of control, so attempts are made to control them

Voices “feed” off the tension involved in efforts to control them: they increase

Life goes increasingly out of control as preoccupation with the voices goes up

Less Trauma

Accept vulnerability that exists alongside some toughness

When voices appear, accept them as clues about areas of vulnerability

Voices are not interpreted as a threat to sense of control, so it does not seem necessary to eliminate them

Due to lack of tension around them, voices become less noticeable

Life becomes increasingly manageable as preoccupation with voices decreases

Beware of narrow goalsBeware of narrow goals

Clients often want to get rid of trauma Clients often want to get rid of trauma memories & intrusions, including memories & intrusions, including those that seem “psychotic”those that seem “psychotic”– Mental health system often jumps on Mental health system often jumps on

board, sees that as the goal as wellboard, sees that as the goal as well– But focusing on getting rid of intrusions But focusing on getting rid of intrusions

typically gives them more power!typically gives them more power! Focus instead on reducing distress, & Focus instead on reducing distress, &

be curious about what might workbe curious about what might work

Command HallucinationsCommand Hallucinations

Reducing compliance is often Reducing compliance is often essentialessential

Compliance comes from a Compliance comes from a dominant/subordinate schemadominant/subordinate schema– Often first created during traumaOften first created during trauma

Surrender to the “higher power” of Surrender to the “higher power” of the voice may be helpful during the voice may be helpful during traumatrauma– But becomes a problem later onBut becomes a problem later on

See "A Casebook of Cognitive Behaviour Therapy for Command Hallucinations: A Social Rank Theory Approach" by Byrne, S., Birchwood, M., Trower, P., & Meaden

Common steps in therapy with Common steps in therapy with command hallucinations:command hallucinations:

Assess details, beliefs, habitsAssess details, beliefs, habits Work on beliefs that support Work on beliefs that support

appeasement & complianceappeasement & compliance– Establish that only something physical Establish that only something physical

can hurt the bodycan hurt the body– Focus on the fact that voices and words Focus on the fact that voices and words

are not physicalare not physical– Point out voices rely on people to act, Point out voices rely on people to act,

they just talkthey just talk– Challenge the voice to hurt the therapistChallenge the voice to hurt the therapist– Establish the unreliability of the voicesEstablish the unreliability of the voices

See "A Casebook of Cognitive Behaviour Therapy for Command Hallucinations: A Social Rank Theory Approach" by Byrne, S., Birchwood, M., Trower, P., & Meaden

Role plays with voicesRole plays with voices

Therapist plays client, client plays the Therapist plays client, client plays the voicevoice– Therapist responds in calm, detached, Therapist responds in calm, detached,

Socratic waySocratic way Then client plays a person the client Then client plays a person the client

likes & respects, therapist plays voicelikes & respects, therapist plays voice– Client practices calm detached responseClient practices calm detached response

Finally, client plays self, therapist plays Finally, client plays self, therapist plays voicevoice

See “Person-Based Cognitive Therapy for Distressing Psychosis” by Paul Chadwick, p. 101-102

ExerciseExercise

One person will role play being a One person will role play being a therapist, another will role play a client therapist, another will role play a client who hears a persecutory &/or who hears a persecutory &/or commanding voicecommanding voice

Within the role play, the therapist will Within the role play, the therapist will role play the client, while the client role role play the client, while the client role plays the voiceplays the voice– Therapist responds in calm, detached, Therapist responds in calm, detached,

Socratic waySocratic way– Be curious & friendlyBe curious & friendly

Notice & comment on any concerns that seem to Notice & comment on any concerns that seem to underlie the comments of the voiceunderlie the comments of the voice

Avoid a difficult emotion, impulse, or voice

Never engaged with, the emotion, impulse or voice becomes larger, more intense, more autonomous

Emotion, impulse, or voice finally breaks through barriers and is experienced as overwhelming

Interpret the destructive consequences of appeasement as proof that the best strategy is avoidance

Decision is made to give in to or appease the emotion, impulse or voice, but the consequences are destructive

Layers of HealingLayers of Healing ““Setting Limits” Combined with Setting Limits” Combined with

“Acceptance & Appreciation”“Acceptance & Appreciation”– ExternallyExternally

Between others and the person with Between others and the person with psychosispsychosis

– InternallyInternallyBetween the person and his/her voicesBetween the person and his/her voicesBetween the person and his/her memories of Between the person and his/her memories of

traumatraumaBetween the person and the missing Between the person and the missing

emotions & parts of the self that had been emotions & parts of the self that had been buried under the traumaburied under the trauma

Controversial Option: Controversial Option: Therapist Talking to the VoicesTherapist Talking to the Voices

Explicitly talking directly to the Explicitly talking directly to the voices may be helpful, tovoices may be helpful, to– Understand voice goals or viewpointsUnderstand voice goals or viewpoints– Increase cooperation between adult self Increase cooperation between adult self

and voiceand voiceTo meet joint, negotiated life goalsTo meet joint, negotiated life goals

One source: http://www.en.transformationalpsychology.com/index.php?cmd=page&id=2676

2006

Two directions in good stress Two directions in good stress managementmanagement

EmpowermentEmpowerment– Helping a person get power over one’s Helping a person get power over one’s

own lifeown life““Courage to change the things I can” partCourage to change the things I can” part

DetachmentDetachment– Reducing the perceived need to do Reducing the perceived need to do

something even when that leads to something even when that leads to overwhelmoverwhelm““Letting go of what I cannot change” partLetting go of what I cannot change” part

Vicious Circle of Trauma and ParanoiaVicious Circle of Trauma and Paranoia

Interpersonal betrayal, traumaInterpersonal betrayal, trauma

Develop beliefs, self as weak, others as badDevelop beliefs, self as weak, others as bad

Automatic thoughts and/or voices reinforce negative view of selfAutomatic thoughts and/or voices reinforce negative view of self

Hypervigilance for threat leads to seeing more of itHypervigilance for threat leads to seeing more of it

Efforts to defend self against perceived threat are seen as Efforts to defend self against perceived threat are seen as inappropriate by others, inappropriate by others,

Aggressive response by others is perceived as…….Aggressive response by others is perceived as…….

Person becomes suspicious, distrustful, paranoid

Inability have adequate basis of trust leads to becoming overwhelmed and confused

In state of confusion, person becomes gullible, easily influenced by voices, which naturally emerge at such times

Problems result from excess attention to, or obedience to, voices

Both being oblivious to metaphor and Both being oblivious to metaphor and using metaphors without being aware using metaphors without being aware

they are metaphors may be trauma they are metaphors may be trauma relatedrelated

Metaphor can be an attempt to Metaphor can be an attempt to integrate perceptions that have as integrate perceptions that have as yet no wordsyet no words

The key to integrating metaphorical The key to integrating metaphorical content is to see it as metaphor content is to see it as metaphor – partly fitting and partly notpartly fitting and partly not

But when things are polarized, it’s more But when things are polarized, it’s more likely the metaphor will be seen as likely the metaphor will be seen as

– 100% literally true 100% literally true – or as nonsenseor as nonsense

Excessive focus on similarities, metaphor seen as literal truth:

Everything is connected, and everything is everything else; I’m dreaming while awake.

“Wave”

Excessive focus ways the metaphor does not fit:

I fail to see connections and similarities, if it’s not literally true then it is nonsense.

“Particle”

Metaphor is seen as meaningful but not taken as literal truth:

I can both see both the way that it is true, and the way it is not the literal truth.

“Particle and Wave”

Finding a balance with metaphor

Ways to work with psychotic Ways to work with psychotic content that may be metaphoricalcontent that may be metaphorical

Watch for themesWatch for themes– You can ask about possible experiences You can ask about possible experiences

that relate to the theme you detectthat relate to the theme you detect Just ask, “What other experiences in Just ask, “What other experiences in

your life have been like that?your life have been like that? Or, for clients who are capableOr, for clients who are capable

– Explain how the mind uses metaphorExplain how the mind uses metaphor– Speculate together about what Speculate together about what

metaphorical meaning might bemetaphorical meaning might be

When the reported “trauma” may When the reported “trauma” may be imaginary:be imaginary:

Two pronged strategy:Two pronged strategy:– Help improve coping with the memories Help improve coping with the memories

and related paranoia and psychosisand related paranoia and psychosis Just as you would for any reported traumaJust as you would for any reported trauma

– Explore in detail what is known about Explore in detail what is known about that time period in person’s lifethat time period in person’s lifeAdding details may help sort fact from Adding details may help sort fact from

fictionfiction– As well as discern underlying themes that may be As well as discern underlying themes that may be

feeding any delusional beliefsfeeding any delusional beliefs

Becoming more “open minded” Becoming more “open minded” when no solution is apparentwhen no solution is apparent

When people are trying to control When people are trying to control somethingsomething– And there is no direct way to do itAnd there is no direct way to do it

Then they become more likely to see Then they become more likely to see unlikely patternsunlikely patterns– Including seeing images in noise, Including seeing images in noise,

perceiving conspiracies, and believing in perceiving conspiracies, and believing in superstitionssuperstitions

Whitson, J. A., & Galinsky, A. D. (2008). Lacking control increases illusory pattern perception. Science, 322(5898), 115-117.

Schizotypy, creativity & illusory Schizotypy, creativity & illusory pattern perception, & traumapattern perception, & trauma

People who are schizotypal habituallyPeople who are schizotypal habitually– have more creative associations - have more creative associations - (Nettle, (Nettle,

2006)2006)

– see more illusory patterns see more illusory patterns – & seem to have weakened contextual & seem to have weakened contextual

integration - integration - (Marzillier & Steel, 2007)(Marzillier & Steel, 2007)

People who are schizotypal are more People who are schizotypal are more easily traumatized -easily traumatized - (Marzillier & Steel, 2007) (Marzillier & Steel, 2007)

– Also true that people who have been Also true that people who have been traumatized are more likely to become traumatized are more likely to become schizotypalschizotypal - - (Berenbaum, Valera, & Kerns, 2003) (Berenbaum, Valera, & Kerns, 2003)

Do you see any conflict between Do you see any conflict between these two statements?these two statements?

““Rates of schizophrenia worldwide Rates of schizophrenia worldwide are pretty stable at about 1% of the are pretty stable at about 1% of the population, and this is due to population, and this is due to schizophrenia being mostly genetic schizophrenia being mostly genetic in origin”in origin”

““People with schizophrenia are only People with schizophrenia are only about 20% as effective as the about 20% as effective as the average person at reproducing”average person at reproducing”

Psychosis and SpiritualityPsychosis and Spirituality

Who are we….Who are we….– Beyond the way we are defined by our Beyond the way we are defined by our

mundane context?mundane context? Mystical mental states involve letting Mystical mental states involve letting

go of one’s conventional orientationgo of one’s conventional orientation– Brain scan research confirms thisBrain scan research confirms this

““The mystic swims in the same ocean The mystic swims in the same ocean in which the psychotic drowns.”in which the psychotic drowns.”

Joseph Campbell said something like this.Joseph Campbell said something like this.

Excess dogma or fixed metaphor:

Metaphor or mental content is taken as real, rather than as pointing at something else beyond it.

Drowning in mysticism, lacking any metaphor:

Seeing no metaphor for experience, no way to express it or put it into words or images, it is overwhelming.

Healthy dialogue between images & that which is beyond image:

I can come up with metaphors, images and words for things, but also recognize that reality goes beyond those containers.

Oscillating from too open-minded to too closed….

Model of the “Renewal Process”Model of the “Renewal Process”

1. Construct system breaks down1. Construct system breaks down– Due to an impairment or trying to solve Due to an impairment or trying to solve

a problem not solvable within that a problem not solvable within that systemsystem

2. Temporary suspension of 2. Temporary suspension of constructsconstructs– Encounter with the “transliminal”Encounter with the “transliminal”

3. Construct restructuring3. Construct restructuring– If done under stress, errors are more If done under stress, errors are more

likely, leading to……likely, leading to……

(See HERIOT-MAITLAND, Charles P. 2008)

DIALECTICAL BEHAVIOUR THERAPY: DIALECTICAL BEHAVIOUR THERAPY: Linehan’s STATES OF MIND applied to Linehan’s STATES OF MIND applied to

PSYCHOSISPSYCHOSIS

reasonable mind

Ordinary thinking

Shared reality.

wiseMind –in touch With both

in the presentin control

emotion mind

or open to other ways

of experiencing

Non-shared reality

Shared and Non-shared Reality

Slide by Isabel Clarke and Donna Rutherford

Current Vs. Long Term FocusCurrent Vs. Long Term Focus

Start out by addressing current Start out by addressing current distressdistress– Look for solutionsLook for solutions

But be wary of solutions to current But be wary of solutions to current distress that may interfere with long distress that may interfere with long term recoveryterm recovery– If an intervention has negative side If an intervention has negative side

effects and/or long term consequences, effects and/or long term consequences, discuss the problem & need to have discuss the problem & need to have caution in its use up frontcaution in its use up front

Pro

gre

ss

Time

People encountering trauma, & our mental health system, tend to evaluate based on short term results that may be misleading

Works better in short term, but……

More

difficu

lt to

start

with,

but bette

r long te

rm…

.

I don’t want to understand myself or my past experience:

Please distract me from myself, or numb me out, no matter what the cost!

I am willing to face anything about myself, even that which I’m not ready to handle:

I don’t have any sense of preparedness or pacing, so I overwhelm myself.

I get to know myself gradually:

I make sure I have resources to fall back on so that I can handle the difficult experiences that I am eventually willing to face.

Key role of pacing in facing difficult experience

Areas for InterventionsAreas for Interventions

Three basic areasThree basic areas– current problemscurrent problems– Longer term factors such as Longer term factors such as

vulnerability, schemas, valuesvulnerability, schemas, values– traumatrauma

Often address in that orderOften address in that order– But sometimes a different order makes But sometimes a different order makes

sensesenseOr it makes sense to skip aroundOr it makes sense to skip around

Don’t wait for problems to go away Don’t wait for problems to go away before addressing the futurebefore addressing the future

Research suggests that when people Research suggests that when people focus on their values, symptoms focus on their values, symptoms diminishdiminish– Or at least, ability to act despite Or at least, ability to act despite

symptoms increasessymptoms increases Recovery is about regaining the Recovery is about regaining the

ability to move in a meaningful way ability to move in a meaningful way toward person’s valuestoward person’s values– Full recovery, with no remaining Full recovery, with no remaining

disability or need for treatment, is disability or need for treatment, is always a possibilityalways a possibility

Integrating other methods when Integrating other methods when addressing trauma directlyaddressing trauma directly

The rationale for all methods used The rationale for all methods used should fit with the formulationshould fit with the formulation

Many trauma therapies can integrate Many trauma therapies can integrate easily with CBT for psychosiseasily with CBT for psychosis

Often start with a cognitive approach Often start with a cognitive approach to trauma, to reduce distortions & to trauma, to reduce distortions & increase groundingincrease grounding– Then more experiential or desensitizing Then more experiential or desensitizing

approachesapproaches– And/or more depth oriented approachesAnd/or more depth oriented approaches

When desensitization is effective:When desensitization is effective:

Trauma flashbacks and/or psychotic Trauma flashbacks and/or psychotic intrusions become simply memories intrusions become simply memories or thoughtsor thoughts– That are put into an understandable and That are put into an understandable and

manageable contextmanageable context– That are neither avoided nor overly That are neither avoided nor overly

attended toattended to Once they are put into context no Once they are put into context no

“illness” remains“illness” remains

How Rescripting Works:How Rescripting Works: Person remembers the traumatic Person remembers the traumatic

episodeepisode Then imagines themselves as an Then imagines themselves as an

adult, going back to the traumatic adult, going back to the traumatic event & intervening as they see fitevent & intervening as they see fit– First dealing with the perpetratorFirst dealing with the perpetrator– Then communicating with the child selfThen communicating with the child self

In later sessions, the focus is just on In later sessions, the focus is just on communication with the child selfcommunication with the child self

(Smucker & Dancu, 1999)

Parting words….Parting words….

May you have the commitmentMay you have the commitment

To heal what has hurt youTo heal what has hurt you

To allow it to come close to youTo allow it to come close to you

And, in the end, become one with youAnd, in the end, become one with you

A Gaelic blessingA Gaelic blessing