1. When Trauma Leads to Psychosis
Healing Begins by Finding the Story
Presenter: Ron Unger LCSW

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 , 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
Former miss america, day child, night child

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
Life goes increasingly out of control as preoccupation with the voices goes up
Seeking control & toughness to deal with trauma
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
Life becomes increasingly manageable as preoccupation with voices decreases
Accept vulnerability that exists alongside some toughness
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

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
psychosis/