When Trauma and Psychosis Mix

Presenter: Ron Unger LCSW 541-513-1811 [email protected]

The connection between trauma and psychosis

 Mainstream mental health system understanding: – Serious mental illness such as schizophrenia is biological in origin, does not result from any special sorts of events  Cognitive therapy understanding: – Traumatic experiences can easily lead to problems such as thinking errors which can lead to psychosis

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 cause psychosis – All studies looking for a dose response (more severe abuse leads to more severe trauma) 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 relationship between trauma and psychosis:

1 Trauma, especially childhood sexual trauma, can cause psychosis later 2 Having psychotic symptoms can in itself cause trauma 3 The response by others to one’s psychosis can also be traumatizing Responses by the mental health system, by family & friends, can all add to trauma  Further trauma can cause more psychosis, in a vicious circle See “Relationships between trauma and psychosis: A review and integration” by Anthony P. Morrison, Lucy Frame and Warren Larkin 2003

Psychosis (disorganization or mistaken way of being organized.) Trauma (involves perceived need to reorganize in a radical way.) 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 appear to be multiple roads that lead to psychosis

    Some are purely biological, or physical (like street drugs) Some are directly related to trauma Some seem more related to a “buildup” of stress & negative emotions that aren’t well dealt with, that become 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”

How is “Psychological Trauma” Defined?

  DSM focuses on perceived physical threat – But this is somewhat arbitrary Psychological impact is key – Trauma is created by a combination of sense of overwhelming threat, or terror, with helplessness – It’s not a specific type of event, but our appraisal of the event, which causes psychological trauma  Even if the appraisal is mistaken, the terror & trauma may be real

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

     Hoping for a simple explanation: – since some psychoses have a biological cause, maybe they all do?

Evidence of genetic causation is commonly exaggerated Bias toward believing that if biology is involved at all, it must be primary Pharmaceutical companies & their allies gain power when the explanation is biological Denial of trauma has lessened overall, but this hasn’t yet reached the field of psychosis

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

   Past overly simplistic judgments and assumptions by some of those who did see a role for trauma in causing psychosis Parallel process – Neither the client, nor the mental health system, want to face the facts of the trauma Idea that if trauma causes a mental problem, it will be PTSD

Positive and Negative Symptoms

  Psychosis and PTSD can both be divided into clusters of positive and negative symptoms  (McGorry 1991) Many of what are called the negative symptoms of PTSD – difficulty concentrating, withdrawal, emotional numbing, derealization, estrangement, self neglect – overlap with what are identified with the negative symptoms of psychosis  (Fowler, 1997; Stampfer, 1990)

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 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

 

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)

What happens when a person fears madness?

 When a person fears that intrusive mental phenomena are “madness” they attempt 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.

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

    Trauma is often not even asked about, much less discussed – Potentially, through decades of treatment Understandable reactions to trauma are defined as non-understandable Psychotherapy for trauma is denied Even self-understanding is discouraged

Assessment: Finding out about trauma

 Need to ask – Often clients won’t say if not asked – Seldom harmful to ask, often harmful not to ask  Asking seems common-sense, but research says in our current mental health system, it commonly doesn’t happen for people with psychosis – Read, Hammersley, & Rudegeair, 2007

Slide from presentation by Dr Warren Larkin & Pauline Callcott

How to ask:

 Prepare the person  Move questions from general to specific – Specific questions are much more likely to elicit reports of abuse  Know how to respond

How to respond to reports of abuse:

      

Not necessary gather a lot of details immediately Affirm it was positive to tell you Offer support

– Like access to counseling

Check current safety

– Including if abuser might currently be abusing others

Check emotional state end of session Offer follow-up or check in Has person told anyone before – if so how 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 caused by by mental health treatment

  Between 44 and 51% were found to have PTSD induced by psychiatric admission and treatment  (Priebe, Broker, & Gunkel, 1998; Morrison, Bowe, Larkin, & Northard, 1999) Forced drugging, retraint, and seclusion have been identified as inducing fear, victimization and helplessness – Also a factor: Loss of control over identity as one is forced into the role of a “mental patient”

General principles of trauma informed CBT for psychosis:

 Collaborative, – neither imposed structure nor lack of structure  Client prioritizes problems and goals – But address any issues that might interfere with therapy first  Have a clear rationale for each step – And get consent for each step  Also attend to supports outside of therapy

The role of therapist uncertainty:



“People wish to be settled; only as far as they are unsettled is there any hope for them.”

– RALPH WALDO EMERSON, “Circles,” Essays: First Series, 1841

Key skill: soliciting feedback

  Watch for signs you may be going in the wrong direction – Either lack of progress – Or client dissatisfaction If client is unhappy, don’t automatically assume direction is wrong – Might just be need a better rationale – Or perhaps direction is partly wrong, partly right  Sorting that out may require some discussion

The Formulation

 Can map out how reactions to the trauma may be causing the psychosis  Understanding psychosis as a possible reaction to difficult experiences is normalizing, reduces stigma

Effective Therapy: Shifting the Question

 From “What’s wrong with you?”  To: – “What happened to you?” and – “What’s happening with you right now?” and – “What would you like to see happen in the future, and what do you see as your possible role in making that happen?”

The Role of Assembling a Story:

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

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

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

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

Avoid explanations that assume permanent defect

   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

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

Key Vicious Cycle Threat Problematic & Narrow “Safety Strategies” Unintended Consequences

Key “Virtuous Cycle” Reduced Threat Better Integrated Safety Strategies Positive Consequences

Threat relations

Conflicts of Emotions

blocks Anger Anxiety Sadness Each emotion can have a variety of defensive behaviours and memories Slide by Paul Gilbert

Threat Relations

Conflicts of Strategies

blocks Dominant Submissive Care Seeking Each strategy can have a variety of forms, functions and behaviours and memories Slide by Paul Gilbert

Core dynamic in extended or unresolved trauma: intrapersonal conflict is amplified to point of dissociation    Struggle between incompatible reactions or strategies – When one extreme doesn’t work, a tendency to jump to opposite extreme While organizing around one strategy, the other extreme is seen as “the enemy” or an intruder This conflict accounts for much of the dynamics in both PTSD and psychosis

Two extremes, when rational internal dialog is missing:

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.

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.

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

I need to block them out (or drug them away)

The most common, or Primary, Structural Dissociation

 The Apparently Normal Part, or ANP – This part fuses with “daily life” motivations, and avoids or blocks traumatic memories and/or upsetting emotions  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

Three Types of Dissociation

 Two types of “negative” dissociation – ANP attempts to shut out EP  Dissociation attempting to soothe – EP attempts to overwhelm ANP  Dissociation to increase focus on threat  “Positive” Dissociation – Results when formerly dissociated content or parts reconnect in a disorderly way

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

 Attempts to bring together what was formerly kept separate can lead to – disorder – preoccupation with internal realities that may be seen as external  These problems can lead to self and/or others perceiving and fearing madness – Resulting in attempts to shut down the process & return to “negative dissociation

A Paradox

 The same process, positive dissociation, or creatively bringing together what has usually been kept separate, is – A risk for retraumatization & psychosis – A necessary part of healing  Finding successful ways to bring together parts that have been at war requires – Boundaries that also have some openness

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 Feeling, thought, impulse or voice that tries to dominate Resistance to the feeling, thought, impulse or voice 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 Balanced Identity, Balanced View, What’s right in this context?

Resistance to the feeling, thought, impulse or voice

Simple technique to address polarized experience

 Draw a continuum, showing both extremes – Portray each extreme as potentially useful in the right circumstance  Ask the client to consider – what some more middle of the road options might be - how much of each extreme might fit particular circumstances

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

Focused on defending against interpersonal threats:

Gullible for over reacting to signs of threat

Vigilant for both kinds of threat but not overly so Focused on defending against paranoia or over-reacting to threat:

Gullible for interpersonal betrayal

Get betrayed again, or notice threats that have not been adequately tracked Restore inner equilibrium by minimizing awareness of external threat Get worn out by hypervigilance, mentally overwhelmed Defend against possibility of betrayal through hypervigilance, bias toward perceiving threat

Working Toward Balance

  Need to set limits with intrusive, disturbing, or polarized parts of the psyche While also being open to hearing about, and addressing, the underlying concerns that those parts represent – Note that the second step will seldom be taken if the disturbing part is seen just as a “symptom” of an “illness”

Exercise on Identifying Two Extremes

 “Client” briefly describes struggling with some problematic state or experience  “Therapist” explores the possibility it is one kind of extreme – And asks questions to figure out what an opposite extreme might be  Write it on paper!

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

The Focus Widens in Healing

 A shift occurs, – From  “either/or” – To  “both/and”  Person identifies with both “opposing” forces within self, plus wider 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 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 considered to be the most clear indicators of schizophrenia, like voices conversing – Are actually pretty typical in dissociative identity disorder

Effect of dissociation on self organization of dissociated content

 Whatever is not integrated in some way may take on a life of its own  Content not yet integrated may be simple or complex – From automatic thoughts, emotions, memory fragments – To mood states, perspectives, voices – To complex identity states seen as “alternate personalities” or alien entities

Fixed traumatic associations vs. excess “protective” dissociation

Extreme associations (fusion) based on trauma :

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

Balance between associate and dissociate.

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

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….

Dissociation, and loss of contact with reality

 Dissociation can lead to – Loss of “internal anchors” (the sense of being connected to one’s body, a sense of self or identity, and a sense of ownership over one’s actions)  The result of this may be – Not only impaired reality testing – Also severe confusion, disorganization, & disorientation  (Allen et al 1997)

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

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 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.

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”

Why trauma causes problems in

 

integrating experiences

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”

Decontextualized trauma flashbacks can easily become “psychotic”

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

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

 One study found that over half of the “schizophrenic symptoms” of abused adult inpatients appeared obviously related to the abuse – for example, hearing the voice of a perpetrator commanding them to commit suicide  (Read & Argyle, 1999)

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

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

Get re traumatized & overwhelmed, no integration.

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

Trauma Interpret trauma memories as a threat, attempt to block Voices form to overcome blocks & raise issues related to trauma Voices increase in volume & frequency as emotional distress and blocking increases Interpret voices as a threat, become emotionally distressed, attempt to block or distract from voices

Possible origin of “positive” voices

Trauma “Negative” voices form to raise issues related to trauma Protective dissociation, “positive” voices emerge to protect self from trauma & trauma memories 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 sustains the power of the intrusion

  Trying to get rid of the “madness” is actually part of the madness “The way out of hell is through the center” – Just accepting the intrusion or unwanted trauma reminder or “psychotic” experience, allows us to put it into perspective for what it is – And it’s putting it into perspective, into context, that allows us to move on

Problematic ways of coping with voices:

   Flight: Relying on avoidance and distraction – Issues aren’t dealt with, person feels too weak to face the voice Fight: Arguing with the voice, trying to change it’s mind – Fighting with the voice is a distraction from life Submission: Giving in to the voice – Even if voice demands are not harmful, personal power is diminished

Better way of coping with voices:

 Alternating between attending to, and ignoring, the voices – Can choose the best method for the occasion, or set “appointments” with them  Be both assertive and friendly with the voices – Able to not take voices literally, while seeing them as clues regarding issues that may need attended to

Trauma Life goes increasingly out of control as preoccupation with the voices goes up Seeking control & toughness to deal with trauma 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 Voices appear as an internal representation of what cannot be controlled

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

Beware of narrow goals

 Clients often want to get rid of trauma memories & intrusions, including those that seem “psychotic” – Mental health system often jumps on board, sees that as the goal as well – But focusing on getting rid of intrusions

typically gives them more power!

 Focus instead on reducing distress, & be curious about what might work

Command Hallucinations

 Reducing compliance is often essential  Compliance comes from a dominant/subordinate schema – Often first created during trauma  Surrender to the “higher power” of the voice may be helpful during trauma – But 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 command hallucinations:

  Assess details, beliefs, habits Work on beliefs that support appeasement & compliance – Establish that only something physical can hurt the body – Focus on the fact that voices and words are not physical – Point out voices rely on people to act, they just talk – Challenge the voice to hurt the therapist – Establish 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 voices

 Therapist plays client, client plays the voice – Therapist responds in calm, detached, Socratic way  Then client plays a person the client likes & respects, therapist plays voice – Client practices calm detached response  Finally, client plays self, therapist plays voice See “Person-Based Cognitive Therapy for Distressing Psychosis” by Paul Chadwick, p. 101-102

Exercise

  One person will role play being a therapist, another will role play a client who hears a persecutory &/or commanding voice Within the role play, the therapist will role play the client, while the client role plays the voice – Therapist responds in calm, detached, Socratic way – Be curious & friendly  Notice & comment on any concerns that seem to underlie the comments of the voice

Interpret the destructive consequences of appeasement as proof that the best strategy is avoidance Avoid a difficult emotion, impulse, or voice Never engaged with, the emotion, impulse or voice becomes larger, more intense, more autonomous Decision is made to give in to or appease the emotion, impulse or voice, but the consequences are destructive Emotion, impulse, or voice finally breaks through barriers and is experienced as overwhelming

Layers of Healing

 “Setting Limits” Combined with “Acceptance & Appreciation” – Externally  Between others and the person with psychosis – Internally  Between the person and his/her voices  Between the person and his/her memories of trauma  Between the person and the missing emotions & parts of the self that had been buried under the trauma

Controversial Option: Therapist Talking to the Voices

 Explicitly talking directly to the voices may be helpful, to – Understand voice goals or viewpoints – Increase cooperation between adult self and voice  To meet joint, negotiated life goals One source: http://www.en.transformationalpsychology.com/index.php?cmd=page&id=2676

2006

Two directions in good stress management

 Empowerment – Helping a person get power over one’s own life  “Courage to change the things I can” part  Detachment – Reducing the perceived need to do something even when that leads to overwhelm  “Letting go of what I cannot change” part

Vicious Circle of Trauma and Paranoia

Interpersonal betrayal, trauma Develop beliefs, self as weak, others as bad Automatic thoughts and/or voices reinforce negative view of self Hypervigilance for threat leads to seeing more of it Efforts to defend self against perceived threat are seen as inappropriate by others, Aggressive response by others is perceived as…….

Problems result from excess attention to, or obedience to, voices In state of confusion, person becomes gullible, easily influenced by voices, which naturally emerge at such times Inability have adequate basis of trust leads to becoming overwhelmed and confused Person becomes suspicious, distrustful, paranoid

Both being oblivious to metaphor and using metaphors without being aware they are metaphors may be trauma related

  Metaphor can be an attempt to integrate perceptions that have as yet no words The key to integrating metaphorical content is to see it as metaphor – partly fitting and partly not  But when things are polarized, it’s more likely the metaphor will be seen as – 100% literally true – or as nonsense

Finding a balance with metaphor

Excessive focus on similarities, metaphor seen as literal truth:

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

“Wave”

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”

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”

Ways to work with psychotic content that may be metaphorical

 Watch for themes – You can ask about possible experiences that relate to the theme you detect  Just ask, “What other experiences in your life have been like that?

 Or, for clients who are capable – Explain how the mind uses metaphor – Speculate together about what metaphorical meaning might be

When the reported “trauma” may be imaginary:

 Two pronged strategy: – Help improve coping with the memories and related paranoia and psychosis  Just as you would for any reported trauma – Explore in detail what is known about that time period in person’s life  Adding details may help sort fact from fiction – As well as discern underlying themes that may be feeding any delusional beliefs

Becoming more “open minded” when no solution is apparent

 When people are trying to control something – And there is no direct way to do it  Then they become more likely to see unlikely patterns – Including seeing images in noise, perceiving conspiracies, and believing in superstitions

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

Schizotypy, creativity & illusory pattern perception, & trauma

  People who are schizotypal habitually – have more creative associations (Nettle, 2006) – see more illusory patterns – & seem to have weakened contextual integration (Marzillier & Steel, 2007) People who are schizotypal are more easily traumatized (Marzillier & Steel, 2007) – Also true that people who have been traumatized are more likely to become schizotypal (Berenbaum, Valera, & Kerns, 2003)

Do you see any conflict between these two statements?

 “Rates of schizophrenia worldwide are pretty stable at about 1% of the population, and this is due to schizophrenia being mostly genetic in origin”  “People with schizophrenia are only about 20% as effective as the average person at reproducing”

Psychosis and Spirituality

 Who are we….

– Beyond the way we are defined by our mundane context?

 Mystical mental states involve letting go of one’s conventional orientation – Brain scan research confirms this  “The mystic swims in the same ocean in which the psychotic drowns.”

Joseph Campbell said something like this.



Oscillating from too open-minded to too closed….

Excess dogma or fixed metaphor:

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

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.

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.

Model of the “Renewal Process”

   1. Construct system breaks down – Due to an impairment or trying to solve a problem not solvable within that system 2. Temporary suspension of constructs – Encounter with the “transliminal” 3. Construct restructuring – If done under stress, errors are more likely, leading to…… (See HERIOT-MAITLAND, Charles P. 2008)

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

Shared and Non-shared Reality reasonable mind Ordinary thinking Shared reality.

emotion mind or open to other ways of experiencing wise Mind – in touch With both Non-shared reality

Slide by Isabel Clarke and Donna Rutherford

in the present in control

Current Vs. Long Term Focus

 Start out by addressing current distress – Look for solutions  But be wary of solutions to current distress that may interfere with long term recovery – If an intervention has negative side effects and/or long term consequences, discuss the problem & need to have caution in its use up front

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

Key role of pacing in facing difficult experience

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 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.

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.

Areas for Interventions

 Three basic areas – current problems – Longer term factors such as vulnerability, schemas, values – trauma  Often address in that order – But sometimes a different order makes sense  Or it makes sense to skip around

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

  Research suggests that when people focus on their values, symptoms diminish – Or at least, ability to act despite symptoms increases Recovery is about regaining the ability to move in a meaningful way toward person’s values – Full recovery, with no remaining disability or need for treatment, is always a possibility

Integrating other methods when addressing trauma directly

   The rationale for all methods used should fit with the formulation Many trauma therapies can integrate easily with CBT for psychosis Often start with a cognitive approach to trauma, to reduce distortions & increase grounding – Then more experiential or desensitizing approaches – And/or more depth oriented approaches

When desensitization is effective:

 Trauma flashbacks and/or psychotic intrusions become simply memories or thoughts – That are put into an understandable and manageable context – That are neither avoided nor overly attended to  Once they are put into context no “illness” remains

How Rescripting Works:

 Person remembers the traumatic episode  Then imagines themselves as an adult, going back to the traumatic event & intervening as they see fit – First dealing with the perpetrator – Then communicating with the child self  In later sessions, the focus is just on communication with the child self (Smucker & Dancu, 1999)

Parting words….

May you have the commitment To heal what has hurt you To allow it to come close to you And, in the end, become one with you A Gaelic blessing