The relationship The relationship between trauma and between trauma and

psychosispsychosis

Presenter: Ron Unger LCSWPresenter: Ron Unger LCSW

541-513-1811541-513-1811

ronunger@efn.orgronunger@efn.org

Psychosis: the last holdout for Psychosis: the last holdout for those who deny the role of traumathose who deny the role of trauma

In 1975 the Comprehensive Textbook In 1975 the Comprehensive Textbook of Psychiatry, a respected source of of Psychiatry, a respected source of information, estimated the information, estimated the prevalence of incest to be 1 in a prevalence of incest to be 1 in a millionmillion

Since then, a lot has changed Since then, a lot has changed regarding recognition of the regarding recognition of the existence and role of trauma, but not existence and role of trauma, but not for those with psychosis, especially in for those with psychosis, especially in the U.S.the U.S.

From an official “Illness From an official “Illness Management and Recovery” Management and Recovery”

handout:handout: ““What causes schizophrenia?What causes schizophrenia? ““Schizophrenia is nobody’s fault. This Schizophrenia is nobody’s fault. This

means that you did not cause the means that you did not cause the disorder, and neither did your family disorder, and neither did your family members or anyone else. Scientists members or anyone else. Scientists believe that the symptoms of believe that the symptoms of schizophrenia are caused by a schizophrenia are caused by a chemical imbalance in the brain.”chemical imbalance in the brain.”

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 be Having psychotic symptoms can in itself be

traumatizingtraumatizing33 The response by others to one’s psychosis, such The response by others to one’s psychosis, such

as the response of the mental health system, of as the response of the mental health system, of friends, of family, and of society, can also be friends, of family, and of society, can also be traumatizingtraumatizing

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

Peter Bulimore’s story Peter Bulimore’s story illustrates all three levels illustrates all three levels of trauma, as well as why of trauma, as well as why it is so important for the it is so important for the mental health system to mental health system to

begin to understand these begin to understand these issues.issues.

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 are also found in many children and adults with PTSD

There are logical and meaningful connections between psychotic symptoms and traumatic experience

Why the mental health system fails Why the mental health system fails to see the connectionto see the connection

If biological and physical factors explain If biological and physical factors explain some psychoses, it is then hoped they will some psychoses, it is then hoped they will explain them allexplain them all– Especially by the drug companies!Especially by the drug companies!

Historical period where some practitioners Historical period where some practitioners were too quick to assume abuse by were too quick to assume abuse by particular individualsparticular individuals

The difficulty in understanding people with The difficulty in understanding people with psychosispsychosis– And the fear by some that understanding And the fear by some that understanding

“crazy people” means that oneself is “crazy!” “crazy people” means that oneself is “crazy!”

Client: What'scausing theseweirdexperiences?

Therapist: Theseweird experiences arebeing caused by yourillness, which isschizophrenia

Client: How do youknow that I have anillness calledschizophrenia?

Therapist: We candiagnose you with theillness calledschizophrenia becauseyou have weirdexperiences.

How the Stress/Vulnerability model How the Stress/Vulnerability model was hijackedwas hijacked

The idea is that “vulnerable” people, The idea is that “vulnerable” people, when subject to excess stress, when subject to excess stress, become psychoticbecome psychotic– Biological psychiatry quickly adopted Biological psychiatry quickly adopted

this model, with “vulnerability” assumed this model, with “vulnerability” assumed to be always biological, such as genetic to be always biological, such as genetic etc.etc.

But psychological trauma, as well as But psychological trauma, as well as certain other experiences, can also certain other experiences, can also lead to vulnerabilitylead to vulnerability

The PTSD model of how trauma The PTSD model of how trauma “makes psychosis worse”“makes psychosis worse”

Argues that “schizophrenia” is a real Argues that “schizophrenia” is a real illness independent of trauma, but illness independent of trauma, but that trauma can make a mild case that trauma can make a mild case much worsemuch worse

Problems of this model:Problems of this model:– Continues to discuss schizophrenia as if Continues to discuss schizophrenia as if

it were a meaningful construct, when it it were a meaningful construct, when it is notis not

– Ignores evidence that trauma can cause Ignores evidence that trauma can cause psychosis psychosis

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.

The dissociation model of The dissociation model of psychosispsychosis

No significant reliable differences No significant reliable differences have been found between the voices have been found between the voices of those diagnosed with of those diagnosed with “schizophrenia” and discussions “schizophrenia” and discussions between alters in those diagnosed between alters in those diagnosed with dissociative identity disorder with dissociative identity disorder

Hearer of the thought

Speaker of the thought

Normal identity in our culture: we see ourselves both as who is saying or “thinking” the thought to ourselves, and as the person who is registering or hearing the thought. Our identity is not centered in either saying or hearing the thought.

Hearer of the thought:another“alter”

Speaker of the thought: an “alter”

Dissociative identity: person may have a conversation with “alternate personalities” within themselves. At any given moment, a person may see themselves as a particular personality or self sharing a body with other personalities or selves.

Hearer of the thought:Identified

“self”

Speaker of the thought: a “voice”

Hearing voices: Person sees thought as coming from outside themselves. They may be “heard” as though spoken aloud, or just heard “inside one’s head” but there is the sense or the belief that they are coming from something completely outside the self.

Basic split that happens with Basic split that happens with traumatrauma

One part of self wants to clearly see One part of self wants to clearly see the dangerthe danger

One part wants to block perception One part wants to block perception of the danger in order to prevent the of the danger in order to prevent the over-arousal that will shut down the over-arousal that will shut down the system and make higher functioning system and make higher functioning impossibleimpossible– This leads to the terror/numbing cycle This leads to the terror/numbing cycle

common in PTSD etc.common in PTSD etc.

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

Key Difference between a Key Difference between a flashback and a hallucination:flashback and a hallucination:

In a flashback, there is the recognition that In a flashback, there is the recognition that what one is experiencing now is related to what one is experiencing now is related to the past traumathe past trauma– But when a trauma has been especially But when a trauma has been especially

overwhelming or denied, this recognition itself overwhelming or denied, this recognition itself is blockedis blocked

– A hallucination is often just a “flashback” type A hallucination is often just a “flashback” type of experience where the connection to the past of experience where the connection to the past is overlooked or denied.is overlooked or denied.

Confusion caused by co-existence of hypervigilance and blocking perceptions

Hypervigilant: Afraid of not seeing a threat that may be present

Anxious, aroused, perceiving a threat in the absence of good evidence

Interprets self as over-reacting: afraid of going mad or appearing mad

Blocks out or looks away from signs of danger

Dissociation, memory disturbance, Dissociation, memory disturbance, and delusionsand delusions

Implicit memory that gets triggered Implicit memory that gets triggered could lead to mistaken attributions to could lead to mistaken attributions to the present contextthe present context– To someone who doesn’t understand the To someone who doesn’t understand the

context (which can include the client context (which can include the client when memory is not explicit) behaviors when memory is not explicit) behaviors can seem bizarre and disorganizedcan seem bizarre and disorganized

Bizarre delusions, such as thought Bizarre delusions, such as thought withdrawal and/or insertion, withdrawal and/or insertion,

delusions of controldelusions of control These sort of “delusions” occur in These sort of “delusions” occur in

one-third to two-thirds of individuals one-third to two-thirds of individuals diagnosed with Dissociative Identity diagnosed with Dissociative Identity DisorderDisorder

Can easily be understood in terms of Can easily be understood in terms of interactions between “alters” or interactions between “alters” or subsystems created by dissociationsubsystems created by dissociation

Paranoia can be seen as Paranoia can be seen as hypervigilance around issues of hypervigilance around issues of

betrayalbetrayal

I’ve seen most commonly in people I’ve seen most commonly in people who were seriously abused at a who were seriously abused at a young ageyoung age– Their trust was never very strong, then Their trust was never very strong, then

something shattered itsomething shattered it– ExampleExample

Is trauma responsible for all psychotic symptoms?

Lots of factors, not just trauma, contribute to vulnerability– Most of these factors, like trauma, have a disorientating

effect Such as drug use, lack of sleep, brain damage for some,

mistaken beliefs, even lack of good social support can be understood to be

disorientating But trauma also contributes to many of the above

factors– Such as a traumatized person is more likely to use

substances, or to lose sleep, or to have damaged support systems

And as vulnerability increases, stresses in the environment become increasingly traumatizing, which is what sends people “over the edge”

Catastrophic Interaction ModelCatastrophic Interaction Model

That there are a number of routes by That there are a number of routes by which severe trauma may tip someone which severe trauma may tip someone toward psychosistoward psychosis– When various processes occur together, then When various processes occur together, then

there is a bifurcation into psychosisthere is a bifurcation into psychosis For example:For example:

– Intrusive trauma memoriesIntrusive trauma memories– Processing biases like overestimation of Processing biases like overestimation of

danger, or jump to conclusionsdanger, or jump to conclusions– Negative opinions about self lead to greater Negative opinions about self lead to greater

distress about hallucinations that occurdistress about hallucinations that occur

The bottom line:The bottom line:

We need to study, rather than deny, We need to study, rather than deny, the connection between trauma and the connection between trauma and psychosispsychosis

We need to recognize that there is We need to recognize that there is generally a story to how people came generally a story to how people came to be mentally troubledto be mentally troubled

Then we can join with them in Then we can join with them in creating a story of recovery, rather creating a story of recovery, rather than retraumatization and chronic than retraumatization and chronic “illness”“illness”

Finding out about traumaFinding 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 How to ask:How to ask:

– Prepare personPrepare person– Make questions specificMake questions specific– Know how to respondKnow how to respond

Consider the possibility of self-Consider the possibility of self-imposed traumaimposed trauma

Where the clients beliefs and attitudes Where the clients beliefs and attitudes caused a situation to be traumatic that caused a situation to be traumatic that otherwise would not have beenotherwise would not have been

Physical trauma definitions allow for Physical trauma definitions allow for possibility that trauma was self inflicted, possibility that trauma was self inflicted, by accident or otherwiseby accident or otherwise– Why not psychological trauma definitions?Why not psychological trauma definitions?

Seeing a story where the client adopted Seeing a story where the client adopted beliefs that led to a trauma experience, beliefs that led to a trauma experience, suggests client could adopt different suggests client could adopt different beliefs & handle situations differently in beliefs & handle situations differently in the futurethe future– Unlike in “mental illness” explanationsUnlike in “mental illness” explanations

Integrating trauma and cognitive Integrating trauma and cognitive theorytheory

All psychological trauma can be All psychological trauma can be understood in terms of mistakes made in understood in terms of mistakes made in responding to experiencesresponding to experiences– Understandable, and difficult to avoid making, Understandable, and difficult to avoid making,

but still mistakesbut still mistakes– Which accounts for why some are Which accounts for why some are

“traumatized” and some not, by the same “traumatized” and some not, by the same experienceexperience

Recovery involves learning alternative Recovery involves learning alternative ways of seeing and respondingways of seeing and responding

Trauma and extreme statesTrauma and extreme states

A key mistake in responding to A key mistake in responding to trauma is going to an extremetrauma is going to an extreme– Which may be necessary at the time, Which may be necessary at the time,

but then a person may get stuck in itbut then a person may get stuck in itAn example: either trying to block out an An example: either trying to block out an

experience, or recalling it so vividly it seems experience, or recalling it so vividly it seems overwhelming in the presentoverwhelming in the present

When both of these happen at once, the When both of these happen at once, the person may make a psychotic interpretationperson may make a psychotic interpretation

Mental Health System goes to Mental Health System goes to extremes in response…..extremes in response…..

When clients are effective enough in When clients are effective enough in blocking out distress that its source blocking out distress that its source is no longer obvious, then the mental is no longer obvious, then the mental health system often joins with them health system often joins with them in not seeing the source eitherin not seeing the source either–

Giving in to, or appeasing, the voices

Fight or flight: arguing with voice or running from them, such as through distraction

Mindfulness: being aware of the voices but not responding one way or the other, or feeling a clear ability to choose how to respond to them based on multiple factors

Picture world as good and positive, to comfort self and feel relaxed.

Picture world as dangerous, so that one won’t be overwhelmed by any risks that weren’t anticipated

Notice dangers that are prominent but also possible areas of safety. Try to picture world accurately in regards to safety versus danger.

Block out the trauma or distress…it just doesn’t exist…numb.

The trauma or stress intrudes into everything, it seems to be happening right now and is overwhelming

The trauma or stress is accepted as part of the story, but the story is still ongoing and is free to move in positive directions

I think or feel it – therefore it is true, even if everyone else says it isn’t.

My thoughts and feelings are unreliable, and others have so many different opinions – there is no way to decide what is true

I can check in with myself and with others, and make a conclusion based on what I notice. If I find later there is a problem with my decision, I will change my mind.

If something is worthwhile, I must keep working towards it no matter how much I suffer.

Working towards things leads to disaster and impossible stress, so it’s better to give up before I start.

I can work toward things and see what happens. If the stress is too much, I can let go, at least for awhile, then I can resume where I left off.

I define myself completely independently of others. If I say I am captain of a spaceship, then I am.

I am mentally ill or incompetent, I cannot define myself. Others tell me who and how I am.

I negotiate my identity with others. My identity emerges out of the mix of what I propose and what I do, and how others see what I propose and what I do.

I define myself completely independently of others. I am invulnerable.

I am completely vulnerable to how others see and define me. Often I can’t stand to be looked at because of what might happen to me.

I negotiate my identity with others. In general I care how others see me but I am not a captive of the perspective of others. I decide what to make of how they see me.

Consumer: I think or feel it, therefore it is correct.

Mental Health system: This person is wrong and mentally ill, therefore we must take control away from her and decide for her.

Cognitive approach: let’s share some perspectives on where the distress here may be coming from & how to resolve it. Each of us may be making some mistakes ……

Totally focused on autonomy: self defining, others have no input or connection.

Totally focused on belonging: has no self definition, completely defined by others.

Some mix of autonomy with a sense of belonging, sometimes self asserting, other times relaxes and lets others define self. Comfortable intimacy with coexisting sense of independence.

That which one

consciously identifies

with

Impulse

Emotion

Voice

Thought

External World

Internal representations of others

Our culture expects us to define anything that is not “the external world” as part of our self.

Memories