Psychosis and dissociation are usually considered independently in their phenomenology, aetiology and treatment within mainstream psychiatry and psychology. Recently, research has suggested a relationship that may be more consistent with historical views of them as related phenomena. Unfortunately, the implications for the practising therapist have often been overlooked and the result is a challenging clinical landscape, with limited guidance. Yet, due to first-hand experiences with clients, therapists are already intervening and arriving at their own understandings. This article presents a qualitative research project that explored such practice-based perspectives. The findings are conceptualised within a model of Structural Dissociation of the Personality, supporting the clinical validity of this model in understanding psychosis and dissociation as related yet distinct constructs, and provide an account of the complex clinical work that follows.
“…the emerging research seems to broadly support the historical account of a relationship between trauma, dissociation and psychosis.”
Theory and practice
“In the clinical realm, these developments can be broadly translated into two camps, “psychosis-as-PTSD” and “psychosis-as-dissociation”. The first camp relies on information-processing models of PTSD (post-traumatic stress disorder), with positive symptoms of psychosis essentially decontextualised variations of PTSD intrusions, and negative symptoms akin to PTSD numbing. The suggestion is that various factors, including dissociation, might influence the phenomenology of the symptoms. However, these models lack a theoretical coherence about such processes, struggle to define or accommodate dissociation, and assume that traditional treatments for PTSD will be applicable. Alternatively, the second camp aims to integrate the emerging evidence within dynamic traditions where dissociation is more familiar. Here, the perspective is from a structural model of the psyche and problems of ego-development and self-experience, where psychotic symptoms represent interplay between deeply fragmented and incohesive ego-states, and the deterioration of the ego. Treatment focuses on rebuilding ego-deficits, or learning to live with existing ego-potential. However, it could be argued that these models are less direct in explaining causal relationships with trauma than PTSD models, and lack the associated, empirically supported treatments.
… it is argued that The Theory of Structural Dissociation of the Personality (TSDP) offers a genuine means of integrating these perspectives, and offers the best framework for understanding views and experiences of practising therapists. Rooted heavily in the seminal work of Pierre Janet, the model assumes that trauma results from dissociation between two evolutionarily derived parts of the personality. Broadly, these parts can be broken down into their underlying systems (and corresponding action tendencies) dedicated to approach and avoidance. Usually integrated through “good enough” development, certain experiences such as fatigue, illness or trauma lower mental level (the range of available actions which facilitate integration) and emotionally overwhelm the individual, impeding integration. The fallout is a “structural dissociation” of the personality between the “apparently normal part” (ANP) that tries to go on, or approach, everyday life, and the “emotional part” (EP), fixated in the memory and defensive actions present at the trauma(s). From this we observe the prototypical intrusion-avoidance paradigm. Through respective patterns of avoidance and reinforcement, these parts can accrue distinct mental levels of their own, grow apart, divide and multiply, sometimes to include psychotic presentations. Treatment involves promoting more global, adaptive action, raising overall mental level (including processing of traumas), and ultimately integrating the personality. Thus, this model accommodates a dissociative perspective of disruption to self-experience and a focus on resource-building, and adds to a PTSD-based model the importance of integrative capacity (mental level).”
Results and discussion
“The superordinate theme, “A Question of Semantics”, illustrates how it was possible to observe, conceptualise and treat specific psychotic symptoms in others as trauma-derived, and a kind of dissociation.
…The second superordinate theme, “Spot the Difference”, described a shift from the discrete to the general, symptoms to disorders, and reflection on relationship, in order to understand what felt like different classes or types of difficulties.”
Superordinate theme 1: A question of semantics
Psychosis as dissociation: understanding emotions and multiplicity of self
“…it was important that participants’ clinical approaches accommodated this multiplicity of self, and facilitated attempts to help the client reconnect with these parts, in order that their associated emotional content could be open to processing, and ultimately integration. Specific therapies endorsed included Schema-Focussed Therapy, Cognitive Analytic Therapy, Compassion-Focussed Therapy and TSDP, all of which accommodate this multiplicity of self.”
Targeting distress and dysfunction, not pathology
“…participants emphasised the importance of a trauma-informed approach which was more concerned with promoting functioning and reducing distress than abolishing symptoms. This perspective is in keeping with contemporary cognitive-behavioural therapy (CBT) approaches to psychosis, the TSDP’s focus on promoting adaptive action, and modern third-wave CBT approaches which focus on acceptance and distress tolerance”
Core client needs: a phase-based approach
“The ultimate aim, however, was to develop an autonomous sense of safety. From this, a second stage was discernable focussing on processing and integration, where symptoms were explored, and re-associated with emotion and identity. The methods of achieving this were quite diverse, but the key seemed to be establishing communication. Sometimes this was via literal conversation (e.g. voice dialogue), written communication (e.g. in therapeutic letters), or interview, and sometimes more visceral (e.g. Sensorymotor). However, it usually involved establishing a more helpful relationship with alien parts of self in order to process problematic emotions.”
“…this approach seems consistent with a phased therapy which has become best practice for complex trauma and dissociation. Because this was a general principle described by participants, it implies this approach may have clinical utility in treating psychotic symptoms. However, in order to achieve this, it was also necessary to think about differences in presentation.”
Superordinate theme 2: Spot the difference
The self: organised dysfunction vs. functional disorganisation
“Collectively, it is difficult to understand these observations within a PTSD framework. A dissociative model, where ego-structure is key, is more successful. In particular, Scharfetter’s (2008) concepts of disruption to the self via ego-demarcation, ego-consistency and coherence, and ego-identity are perhaps most applicable, although the relevance of functionality is less clear. However, the TSDP can accommodate all of the observations. It would predict that higher mental level of ANP and EP in dissociative disorders would account for higher degrees of functionality (in ANP), more pronounced compartmentalisation, and discontinuity as parts alternate. In psychotic disorders, it may be the case that lower mental level of ANP and EP restrict the possibilities for outright compartmentalisation and alternation, leaving a more consistent yet less functional ANP.”
“…working with psychosis involved more carefully helping the individual to open up to a world of emotion and relationships and raise mental level. Conversely, the process in dissociative disorders was more often about building on existing emotional coping strategies, and relying less on effective, yet ultimately maladaptive, dissociative defences.”
“The idea that mentalising deficits are a central feature of florid psychosis is long-established and generally well accepted. Additionally, because mentalising is a developmentally derived skill, influenced by attachment activation and emotional arousal, it would seem to fit well with the principles of mental level. From a TSDP perspective, it may be the case that mentalising deficits of this type characterise the breakdown of vulnerable ANP into florid psychosis, something dissociative clients were often protected from because of their more successful compartmentalisation. Thus, the chief task seemed to be to raise mental level sufficiently in ANP to help re-establish mentalising. ”
“…participants seemingly personify the psychosis, as intentional and aiming to sever links with reality. This view is exceptionally consistent with Bion’s (1959) view of psychosis as an “attack on linking” as well as the analytic view of psychosis as a “primitive defensive operation”. Here, thought disorder and hallucinations were understood as diversions that were thematically and implicitly associated with, yet explicitly dissociated from, traumatic experiences and overwhelming emotions. The intentional and defensive nature of this interaction is best understood from a TSDP perspective, where EPs containing the traumatic material intrude heavily on ANP. Given that extreme arousal impedes high-order mental functions, the potentially chronic nature of this interaction may well deteriorate the ANP over time, reducing synthetic (linking) capacity and contributing to a florid state of disorientation. This could lead to delusional elaborations of intrusions, consistent with models of CBT for psychosis. In this context, the defensive nature of this dissociation was respected, and approached slowly as mental level was raised.”
“…participants were able to conceptualise psychosis as a response to trauma and, fundamentally, the result of dissociation. There was clearly value in PTSD models and interventions, particularly in processing the overwhelming emotions at the heart of psychosis. However, these ultimately failed to capture the dynamic and structural aspects of disruption to self that seemed key. For this, dissociative models and clinical approaches which accommodated multiplicity of self were essential, and implied that a more accepting and adaptive relationship with current self-structure must be established to facilitate processing. A phased therapy with a primary focus on safety and stability was evident, and this included attending to differences in mental level, which meant that clients had to be engaged and treated in different ways.”
“…We argue that a model of TSDP offers a way to conceptualise the breadth of these experiences, more broadly than has previously been suggested”
[this research] “…validates suggestions of a continuum-based approach to psychosis and dissociation as traumatic reactions, and supports calls for a paradigm-shift in our conceptualization of psychotic symptoms. It accommodates the utility of information-processing based accounts of psychosis-as-PTSD, as well as insights about the nature of self in dissociative models, yet overcomes the limitations of both by providing an additional focus on integrative capacity, which has important clinical and research implications.”
Overall, this research illustrates the disparity between a medical model which isolates psychosis from dissociation, and the reality of working as a therapist with people, who defy such distinctions. It implies a way forward in conceptualising and working with these difficult problems and this should be subject to further scrutiny. Key suggestions from these findings seem to be:
- that trauma and dissociation may be key to understanding psychosis as a fundamentally emotional problem;
- that specific therapies and techniques developed for dissociation will have application in psychosis, and vice versa; and
- that psychosis and dissociation may be related, yet distinct outcomes on the trauma spectrum.
Ultimately, issues with emotion and sense of self emerge as central to both groups of patients, and a key area of interest for clinicians and researchers alike.