Can Trauma Therapies Unlock the Prison of Psychosis?

New review sheds light on effective trauma therapies for psychosis, revealing how life experiences can lead to onset of symptoms.

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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.

undecided woman does not know which key to chooseHistorically, 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.

 

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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)

16 COMMENTS

  1. In my study and help with friends (I’m 77 with 25 years of sobriety), I basically do this by helping people recognize the voice of their ego versus that of the self. It’s truly amazing what can happen for people when they start living this way. I should write a book! As a matter of fact….

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  2. It’s about time! “When we recognize the pivotal role trauma plays in shaping psychotic experiences, we pave the way for more holistic, empathetic, and effective treatment strategies,” yet there is no mention of the somatic therapies many trauma experts say are crucial for recovery. CBT itself is often contra-indicated for trauma survivors as it can shame and re-traumatize those who suffer from shame and trauma.

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    • I always felt on the defensive in talk therapy of any kind. But I’m convinced weekly body massage played a significant role in gently alleviating the occasional psychosis I was experiencing at the time and that it helped prevent it from completely overtaking my already stressed-out mind and the shame-ravaged emotions I was unable to express, even to myself.

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    • Well, kinda the point may not be about therapies, but about acceptance, if I am not misunderstanding.

      Not changing what therapies try to change with other things therapy changes with no real relief, but submission and false acceptance. And for a price…

      Approaching a clearer, healthier, more enjoyable way to live as one is.

      And by extension to be accepted, even loved by others as one is.

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  3. I’ve read many articles to under stand, female at 46, why phycosis came out of nowhere in February 22, 2022. Three years ago, I watch my brother, at 29, struggle for weeks to regain his health. My mother and father’s health declined at the same time. That traumatic experience changed me. 1 year later, my psychosis came fourth. The local hospital judgement was one of a drug addict. Until my drug test came back, they sent me to a rehab facility for two hours. Then they seen I was sick, then transmited by ambulance to the hospital by stabbing me in the arm. I woke up to a diagnosis of a UTI. I had enough sense to know no antibiotics was given. My doctor now will only say, “no you had no UTI. Never heard voices, I just thought everything was a sign. This has left me clueless on correct diagnosis. I’m now labeled bipolar 1. Thank you, I’m studying all I can.

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  4. I’m a female and 46 years old. I’m studying many articles to educate myself on pycosis. Until 45 February 22, 2023, Id never endoured a misdiagnosis or pycosis. I didn’t hear voices, but it came fast and everything was so bizarre. My local Emergency Room is in small town, and they never waited for my drug test, they simply put me in a security car and placed me in a Rehab. Until my blood test came back 2 hours later I was clean, it was then diagnosed a UTI. I was then transported to Johnson City Medical in TN. Never received an antibiotic, and I suppose they thought I’d never notice for a week’s stay. Trauma came from watching my only sibling at 29, fight to stay on the Earth. It happened so fast and it was hell to watch. 1 year later I broke. My doctor now diagnosed me as bipolar 1, also stated I never had a UTI. Anger, confusion, and heartbroken for how my health went untreated I read a lot This one helped a lot, and rung so true.

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  5. It has been my understanding that a chronic psychotic is difficult to treat basically because he is out of communication with his environment. The recommendation is to use “light” processes, which might include mimicry. Once communication was established, one could start with limited verbal (or cognitive) processes like simple Objectives. You start with therapies that are simple to do and non-threatening. This brings more of attention into present time.

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  6. Often, those who study these types of issues are not allowed to be individuals who may have experienced trauma or psychosis, or both. And if they have, they are typically not permitted to disclose their experiences implicitly or explicitly. Consequently, they tend to conform to the flow of the study which makes these types of study meaningless to those who actually not only experience trauma but recover from fully.

    This is because trauma does not have a clear-cut definition (as everyone experiences it differently, which is not a definition in itself), and separating psychosis from trauma is another belief system, as there is no concrete experimental evidence. Already the study cannot work because there are no universal definition of their hypothesis.

    I will now share my thoughts to further the conversation.

    In my perspective, psychosis can be a path to recovery from trauma (which is absolutely not allowed to be said). When people undergo a profound transformation, recovering from deeply ingrained childhood trauma with the manifestation of adulthood and additional trauma, their minds may undergo a significant shift to reset completely in electrical way that is almost impossible to create in a lab. If talk therapy may take 20yrs, one safe psychosis episode may undo a life time of trauma in a flash!

    The field of psychiatry often views psychosis as the onset of madness (this is the belief I am trying to challenge), but based on my personal and professional experiences, when psychosis is managed with compassion, respect and upmost safety, it can actually be the means for the brain to recover from a long and sustained trauma (better than any drugs). It stands in stark contrast to trauma. If trauma is like breathing in CO2 deeply and quietly for a long time, psychosis is the volcano that allows fertile ground! IMHO, this is not about cause and effect or correlation, this is – psychosis is the recovery of trauma! To medicate people, to arrest them or to involuntarily restrain them is all ways to keep the trauma not recovered naturally and powerfully!

    What is nature’s way of resetting traumatic experiences? If trauma is losing your mind, how does one find the mind?

    Unfortunately, for many, it becomes the onset of a new trauma that is exceedingly difficult to recover from, given its systematic and culturally enforced nature. Some people, unfortunately, become adaptive in the psychosis spectrum and we conveniently give them many more profitable diagnosis to keep them hooked.

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  7. Thank you, Kelli, for this summary of the article. It is of course a very welcome development. I do wonder, however, about the connection you appear to be making between internal family systems and Talking with Voices. It makes it sound a bit as if Talking with Voices was inspired by IFS, which is definitely not my reading of how it all unfolded. May be I am mistaken. But as a long standing active member of the Hearing Voices Movement and practitioner of Talking with Voices – IFS has definitely not featured in my work or even inspired me. My understanding is that this is not an unusual situation. May be you can kindly explain what made you make that connection? I may, of course, have got it entirely wrong and may be lots of people in the HVM were first inspired by IFS and then applied it to voices too. Historically, I think that is not the case for lots of people though. Anyway, happy to be put right and/or enlightened otherwise :).

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