Psychosis and The Traumatised Self

Understanding and Change

John Rhodes

• Publisher: Routledge
• Year: 2022
• ISBN:
  9781000554717
• Edition: 1
• Topic: Psychology
• Subtopic: Post-Traumatic Stress Disorder (PTSD)
• Index: Psychology

Psychosis and the Traumatised Self explores what it is like to experience psychosis for individuals with histories of childhood physical and sexual abuse.

The book additionally explores how meaning expressed in psychosis might originate from the effects of abuse, but also long-term life difficulties, motivations, memories, social history, and struggles to narrate and understand. One chapter focuses on refugees who suffered trauma as adults and later became psychotic. Another chapter examines how trauma leads to the destruction of certainty and trust, thereby opening a pathway to persecutory ideas. Drawing on a developmental model of trauma, it is proposed that dissociated parts of the self that developed during childhood contribute to psychosis in adults when undergoing difficulties and stress.

Presented with case illustrations, the book will be useful for those who work in the area of psychosis and abuse to understand the experiences of individuals, and how we might develop appropriate therapy and care.

1 Psychosis and trauma

DOI: 10.4324/9781003044956-1

After just a few years of working with psychosis, two new clients began therapy with me and asked to talk about the abuse and trauma that had occurred in their lives. One had experienced extreme physical abuse in childhood and the other had been in a war as an adult. Of course, I had known about the possibility of abuse and trauma beforehand, but meeting individuals who were motivated to talk through this, and who later said that the therapy had helped, changed my way of understanding and doing therapy. It taught me that some clients were able to explore such issues, could benefit from this, and would not deteriorate or somehow come apart. This book presents research and therapeutic applications which came out of such initial explorations and draws on the growing body of relevant findings and theory. In this chapter, I will discuss types of trauma, the general effects of trauma, and consider the relationship between trauma and psychosis in terms of long-term effects and causation. Finally, I will describe how the research for the various chapters was carried out and give a brief overview of the book.

Types of abuse and trauma

There is a range of types of abuse and trauma: the Child Trauma Questionnaire (Bernstein & Fink, 1998) lists physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect. While the term ‘trauma’ includes the impacts of abuse, it can also result from a wide range of events such as parental death, loss, becoming ill with physical or mental conditions. Sometimes the word ‘adversity’ is used to include wider phenomena such as poverty or living in difficult environments.

This book explores the experiences of three groups of individuals experiencing psychosis: those who have suffered sexual abuse or physical abuse in childhood and those impacted by trauma in the context of political violence such as torture or war. The wider range of traumas is not covered. In this section, however, I wish to make some comments on the relevance of two sorts of trauma which have typically also occurred in the lives of the three groups looked at in the book, that is, child emotional abuse and the trauma of the onset of psychosis and hospitalisation.

Child emotional abuse and neglect

Child emotional abuse and neglect (Glaser, 2002) can involve any of the following: parental emotional unavailability, parental negative attributions about a child, developmentally inappropriate interactions, failure to recognise individuality and psychological boundaries, using the child for fulfilment of the parents’ psychological needs, and failure to promote the child's social adaptation. It has been consistently found (e.g., Cawson et al., 2000; Mason et al., 2009) that some form of emotional abuse usually accompanies other severe forms of child abuse such as sexual and physical abuse. It was assumed that this would probably be true of those participating in the research reported in this book.

Hospitalisation and the onset of psychosis

The onset of psychosis may in itself be such an extreme and negative event that it constitutes a form of trauma. Hutchins, Rhodes, and Keville (2016) noted a very wide range of powerful emotions including shame and guilt following the trauma of breakdown and hospitalisation. The personal meaning of experiencing a mental health crisis can substantially impact an individual's identity, with long-term consequences. In addition to experiencing the disturbing effects of psychosis, a person is often put under the care of the psychiatric system or hospitalised against their will. It is perhaps not surprising that some patients describe their experiences as incarceration, and the fact they are being detained in hospital adds negative meaning to their already heightened concerns.

A review by Berry et al. (2015) showed high levels of post-traumatic stress disorder (PTSD) resulting from the trauma of psychosis or hospitalisation or both, with prevalence rates for PTSD resulting from these traumas varying from 11% to 67%. They also noted that there was some evidence that the severity of psychosis-related PTSD is influenced by the person's previous trauma history. Inpatient psychiatric experience often features disempowerment, coercion, and the restriction of liberty, which can echo conditions of childhood adversity. Given this finding, it is possible that those who have experienced child abuse might find involuntary treatment particularly distressing.

Lu et al. (2017) carried out qualitative work using semi-structured interviews to examine the experience of sixty-three people on an inpatient psychiatric unit who had experienced either a first or multiple episodes of hospitalisation. The main finding was that both the experience of having psychosis and being hospitalised were potentially traumatic. Some features of psychosis which were found to be traumatic included frightening hallucinations, suicidal thoughts, thoughts about harming others, delusions, and unusual behaviours. The patients reported that the psychosis itself also induced anger, sadness, confusion, anxiety, and numbness. In terms of the actual treatment they experienced, the patients mentioned: being kept in hospital for a long time; forced medication; upsetting side effects; coercive treatments involving the use of restraints; being exposed to aggressive patients; and mistreatment by professionals. It is an extremely vivid and worrying picture but, I believe, will be one recognised by those who have worked on wards. Of course some patients somehow cope better with psychosis and many patients do seek help and find their care helpful. It is certainly the case, however, that some patients have a terrible struggle as they are admitted to hospital, particularly during a first episode; and even the most compassionate care may be involuntary and thus constitute a severe challenge to an individual's sense of autonomy and personhood.

The long-term effects of abuse and trauma

Reviewing the experiences of those who have suffered child abuse and protracted trauma in adult years, Herman (1992) suggested a series of criteria for what she termed ‘Complex Post-Traumatic Stress Disorder’. Whether this is a useful specific diagnostic category or not, the list of symptoms is certainly an illuminating overview of the effects of abuse. She states that abuse affects a person's ability to regulate and live with their emotions and involves experiencing extreme negative emotions. There can be effects upon consciousness itself such as amnesia or derealisation and specific features of PTSD such as reliving. It affects the person's perception of the self and is associated with feelings of shame, guilt, and self-blame. Herman noted how a person may feel themselves to be completely different from others. There are changes in relationships such that a person can become isolated, withdrawn, and experiences persistent mistrust. There can be a loss of meaning and a sense of hopelessness and despair. In situations of being held captive (e.g., domestic abuse) there can be alterations in the perception of the perpetrator.

A great deal of research has examined the specific long-term effects of early abuse. A review by Anda et al. (2006) noted that the more childhood adversities a person had suffered, the greater the incidence and severity of negative outcomes. Outcomes included the risk of panic reactions, depressed affect, anxiety, and hallucinations; sleep disturbance, severe obesity, and multiple somatic symptoms; substance use and abuse; smoking, alcoholism; risk of early sexual intercourse, multiple sexual partners, and sexual dissatisfaction; impaired memory of childhood; high perceived stress, difficulty controlling anger, and the risk of perpetrating intimate partner violence. A review by Heim et al. (2010) described a similar picture, noting the long-term prevalence of a range of mood and anxiety disorders, schizophrenia, attachment disorder, eating disorders, and personality disorders. They underlined that childhood trauma also dramatically increases the risk for later substance abuse and suicide attempts.

There is now a growing body of research looking at changes that may occur in terms of the brain and nervous systems of persons who have survived childhood abuse (Van der Kolk, 2014). A review by Teicher and Samson (2016) suggests that not only are these changes long lasting, but that there may be specific changes in the brain according to the type of abuse suffered. The authors concluded that ‘structural and functional abnormalities initially attributed to psychiatric illness may be a more direct consequence of abuse’. Some reviews have focused specifically on the effects of physical or sexual abuse, and these are given in chapters two and three. From the many pieces of research we can say with confidence that experiencing abuse in childhood is one of the most destructive things possible in a person's life, and leads to a wide range of psychopathologies and other forms of suffering.

Does childhood abuse lead to psychosis?

A great deal of research has now shown that various forms of childhood abuse are highly prevalent in the histories of those diagnosed with psychosis: a review by Read et al. (2005) suggested that 48% of female participants reported sexual abuse and 48% physical abuse, while 29% of male participants reported sexual abuse and 50% physical abuse. The results of a meta-study examining the relation between psychosis and childhood abuse (Varese et al., 2012) suggested that those who had suffered childhood adversity were 2.8 times more likely to have psychosis than those who had not. Matheson et al. (2013) in their meta-study reached the same conclusions. Read and colleagues (Read et al., 2005; Skehan, Larkin & Read, 2012) have argued that such evidence points to the probable causal role of abuse.

Longden et al. (2016) added to the evidence for a causal effect of abuse by demonstrating a dose-response relationship between childhood adversities and psychotic symptoms. They used randomly selected records from New Zealand community mental health centres and found that the higher the number of childhood adversities in a patient's history, the higher the number of psychotic symptoms they later experienced, including hallucinations, delusions, and negative symptoms. Longden and colleagues did not find evidence for specific links of sexual abuse with hallucinations or physical abuse with delusions, although these had been suggested in previous reports. The data were consistent with a model of global and cumulative adversity, in which multiple exposures may intensify the risk of psychosis beyond the impact of single events.

Social and psychological features of those with psychosis and abuse histories

What social or psychological features might be commonly found in adults who have suffered childhood abuse and who have a diagnosis of psychosis? In terms of social problems, Skehan et al. (2012) pointed to higher levels of homelessness, impaired intimacy, and extensive use of psychiatric services. These patients were also more likely to have attempted suicide than patients with psychosis who had not been abused. A recent meta-analysis of features by Rodriguez et al. (2021) noted a wide range of cognitive alterations in working memory, attention, social cognitive processes, and emotional perception.

As well as mapping the psychological profiles of those with psychosis and a history of abuse, research has tried to identify specific features which might perpetuate a person's difficulties, and potentially even constitute causal pathways between childhood trauma and psychosis. Such features have included: 1) post-traumatic sequelae including dissociation, 2) affective dysfunction and dysregulation, and 3) maladaptive cognitive factors such as negative beliefs about self and others. Williams et al. (2018) in a meta-study found evidence for all three of these features mediating the trauma-psychosis link. Another meta-study by Alameda et al. (2020) has in general confirmed the findings of Williams et al., demonstrating particularly solid evidence concerning pathways from childhood abuse to psychosis via post-traumatic symptoms including dissociation, and via negative cognitive schemas about the self, the world, and others.

Isvoranu 2016 et al. (2016) examined evidence for an affective pathway using s...