Traditionally, individuals experiencing both trauma and psychosis have had limited treatment options. Trauma survivors with symptoms of psychosis have faced challenges accessing appropriate care because trauma and psychosis were often treated as separate issues. This approach has metaphorically imprisoned trauma survivors with psychosis, putting significant hurdles in their path to care. However, recent research highlights the efficacy of a trauma-informed approach for those experiencing psychosis, opening up new possibilities for those with complex trauma histories.
In a new study, Amy Hardy, from King’s College London, and her colleagues reviewed integrative therapy approaches to address survivors of PTSD with psychosis. The research assessed various treatments, including EMDR for psychosis (EMDRp), trauma-focused Cognitive Behavioral Therapy for psychosis (tf-CBTp), and dialogic approaches targeting voice hearing. These innovative therapies, such as Talking with Voices (TwT) and AVATAR, aim to foster more positive relationships with voices. While TwT emphasizes building constructive voice interactions, AVATAR uses digital means to facilitate dialogue with these voices.
Hardy and her coauthors write: “…these findings, incorporating lived experience perspectives, will support the implementation of safe and effective psychological interventions for people with psychosis and a history of trauma.”
The new research by Hardy, from the Institute of Psychiatry, Psychology & Neuroscience, King’s College London, in collaboration with a global team of experts, offers a profound glimpse into the intertwined relationship between trauma and psychosis. This new review comes at a crucial juncture, highlighting both the role traumatic events play in triggering psychotic symptoms and the current disparity in access to trauma-based therapies for those living with psychosis in the US.
Historically, the onset of psychosis was primarily understood through a biogenetic lens. However, contemporary research is pivoting towards a more comprehensive trauma-informed approach, recognizing the profound implications of traumatic experiences, especially those suffered in early childhood, on the emergence and progression of psychosis.
These traumatic events don’t merely coexist alongside psychosis; they influence its very nature. The study reveals how traumatic occurrences, especially those rooted in childhood interpersonal victimization, are not just correlated with but might play a causal role in the emergence and persistence of psychosis. Such experiences often echo in the nature of psychotic episodes, where the content and perception of these experiences reflect past traumas.
Yet, despite the compelling connections between trauma and psychosis, individuals diagnosed with the latter have been historically sidelined from trauma therapy trials and treatments. The study suggests that this exclusion stems from fears of causing further harm or the risk of relapse due to the emotional strain of processing traumatic memories.
This oversight is more than just a clinical misstep; it’s an issue of justice. Given the evidence showing that those with both trauma and psychosis histories often face exacerbated clinical challenges and reduced medication efficacy, the lack of access to trauma-informed therapies is a significant healthcare inequality.
Thankfully, the tide is turning. Researchers and practitioners are now beginning to address this oversight. The review sheds light on the groundbreaking developments in this domain, introducing seminal cognitive-behavioral models of psychosis that unravel the mechanisms through which trauma may precipitate psychotic experiences. Furthermore, it delves into emerging therapies like EMDR for psychosis (EMDRp), trauma-focused Cognitive-Behavioural Therapy for psychosis (tf-CBTp), and dialogic approaches, underscoring the potential of co-produced therapies like “Talking with Voices” and digitally augmented “AVATAR” therapies.
Cognitive Behavioral Therapy for people with psychosis (CBTp)
The authors write that Cognitive Behavioral Therapy for people with psychosis (CBTp) can be an effective trauma-informed therapy but may not fully address the full integration of emotions.
“Even when trauma-informed CBTp is delivered,” the authors write, “it may not sufficiently address the trauma-related mechanisms that could play a role in maintaining problems. Trauma-focused CBT for psychosis (TF-CBTp) targets trauma, including psychosis. By including psychosis as a traumatic experience, this therapy is flexible and emphasizes survivor engagement.”
EMDR for psychosis (EMDRp)
EMDR therapy has long focused on PTSD and has recently been used to address the trauma effects of psychotic experiences (EMDRp). Evaluation of EMDRp results is limited but is underway in the Netherlands as an integrative process to treat and care for survivors of PTSD with psychosis. Traditional EMDR focuses on the processing of traumatic memories. Unprocessed traumatic memories can lead to significant mental health challenges, and targeting psychosis as a trauma experience is the focus for creating greater access to care.
Targeted Interventions for Trauma-Related Voices: Talking with Voices
Similar to Internal Family Systems (IFS), a relatively “new” approach in the United States (founded in the early 1980s) based on addressing a person’s various “parts” created through trauma, new dialogical treatments directly addressing auditory voices are emerging as effective treatments. Through IFS, individuals work with their different “parts” with a trained therapist who helps facilitate dialogue.
Hardy and her coauthors examine Talking with Voices (TwV) and AVATAR as emerging therapies to address symptoms of psychosis as a trauma response. TwV focuses on creating symbiotic dialogue internally, while AVATAR treatment uses digital technology to create an external dialogue for the survivor.
The authors do not address mainstream inequities prevalent in mental health care, such as limited access for underrepresented communities or those experiencing poverty in the United States. The authors note that trauma survivors who experience psychosis have limited treatment options within the mental health care paradigm, creating inequity for PTSD survivors with psychosis.
Service users rarely have adequate support systems or access to treatment. The trauma therapies for psychosis start a meaningful conversation about this overlooked population. Previous research has examined the reality of trauma-based psychosis and the importance of a support system that does not view the survivor as “crazy” or “mad.” Supportive environments with a trauma-focused lens are becoming an essential conversation surrounding psychosis survivors.
The study demonstrates that transformational and integrative solutions are beginning to come online. However, clinicians remain reluctant to treat survivors who also experience psychosis. Framing the solutions presented in the study for mainstream consumption is a natural step toward improving access to those living in a psychosis prison where inequity related to treatment is seen.
Individuals facing multiple layers of barriers, such as those with mental health crises, minority communities, and LGBTQ+ communities, deserve adequate health care and access to treatment. Treatments such as Internal Family Systems are becoming more accessible in the United States. While these important treatments appear to be on the horizon, significant work remains to fully open the doors related to the metaphorical prison created through the experience of psychosis.
It’s not just about integrating trauma therapies into the treatment regimens for psychosis but also about rethinking our understanding of psychosis itself. When we recognize the pivotal role trauma plays in shaping psychotic experiences, we pave the way for more holistic, empathetic, and effective treatment strategies.
Hardy, A., Keen, N., van den Berg, D., Varese, F., Longden, E., Ward, T., & Brand, R. M. (2023). Trauma therapies for psychosis: A state-of-the-art review. Psychology and Psychotherapy: Theory, Research and Practice, 00, 1–17. https://doi.org/10.1111/papt.12499 (Link)