Mindfulness and dissociation

I’m coping well with my ‘voices’ these days but still feel very ‘mindless’ and dissociated.

Dissociation and Mindfulness in Patients with Auditory Verbal Hallucinations.

The very few studies relating mindfulness and dissociation have found a negative association between them (depersonalization and absorption). However, all these studies have been done in non-clinical populations and there are no data on the relationship between these variables in psychiatric patients with auditory hallucinations. This study was designed to study the relationship between mindfulness and the two dissociative variables, absorption and depersonalization, as well as their predictive power for the severity of auditory hallucinations and the distress they cause in a clinical population. Fifty-five psychiatric patients with hallucinations were given the following tests: MAAS (Brown & Ryan, 2003), TAS (Tellegen & Atkinson, 1974), CDS (Sierra & Berrios, 2000), PSYRATS (Haddock, McCarron, Tarrier, & Faragher, 1999), and PANSS (Kay, Opler, & Lindenmayer, 1988). A significant negative correlation was found between mindfulness and the dissociative variables, and between mindfulness and the distress caused by the hallucinations. A positive correlation was also found between absorption and distress caused by hallucinations and between depersonalization and their severity. Finally, the variable with the most predictive power for severity of the voices was depersonalization, and the variable with the most predictive power for distress caused by the voices was mindfulness. Interventions addressing training in mindfulness techniques could diminish the distress associated with hearing voices.

Rufus May’s excellent site has interesting articles on mindfulness and dissociation.

I need to work on the following:

●    Acceptance – accepting what is present rather than denying it or wishing it was not there.
●    Non-judging – observing objects and events without evaluating them.
●    Patience – we stay with the present moment and don’t rush towards the next exciting event, we focus on the unique unfolding of what is happening now.
●    Beginners mind – seeing things with an open mind and noticing their unique qualities.
●    Letting go – developing the ability to switch attention and let go of one object of concentration and focus on another
●    Being with – as opposed to trying to fix or control things or achieve constantly
●    Non-striving – by accepting the present moment and its accompanying sensations we let go of constantly striving for better moments.  We focus on the journey rather than just the destination.
●    Non-attachment – this is about relating to things with kindness but not clinging onto them recognising that everything changes.

Mindfulness in schizophrenia: Associations with self-reported motivation, emotion regulation, dysfunctional attitudes, and negative symptoms.

Mindfulness and Metta-based Trauma Therapy (MMTT): Initial Development and Proof-of-Concept of an Internet Resource. 

Mindfulness & Metta Trauma Therapy (MMTT) is a self-help therapy for improving self-regulation in people suffering from trauma and stressor-related disorders that can be practiced online. The therapy was developed by Dr. Paul Frewen, a psychologist at Western University, Canada. MMTT involves learning to apply 6 therapeutic principles to your everyday life through the practice of a reflective journaling exercise we call Mindful and Metta Moments, as well as through the practice of guided meditations. The 6 therapeutic principles of MMTT are: 1) Presence, 2) Awareness, 3) Letting-Go, 4) Metta, 5) Re-Centering and De-Centering, and 6) Acceptance and Change.

Trauma and Stressor-related Disorders

Trauma and stressor-related disorders are psychological problems that are caused by the experience of one or more traumatic life events or relationships. Different researchers and clinicians define traumatic life events in different ways; some definitions are very broad and general, whereas others are more specific. For the purposes of this website, we define traumatic life events and relationships somewhat broadly as any life event or relationship that caused a person psychological harm that continues to be experienced long after the event occurred or the relationship ended. Examples of traumatic life events include:

  • rejection, abandonment or betrayal following the ending of a close and loving relationship;
  • experiences of complicated or extended grieving following the loss of a loved one (complicated bereavement);
  • being physically or sexually assaulted, or witnessing or finding out that this happened to another person you care about;
  • being verbally or emotionally abused or bullied, including as a child;
  • being abused, mistreated or neglected by caregivers when you were a child;
  • being in a life threatening or physically disabling event, for example, as in military combat, a serious car accident, or a fire, workplace accident or natural disaster;
  • experiences of guilt and shame for physical or psychological harm that you have caused another person.

Post-Traumatic Growth Follow Up: What It Takes To Grow From Tough Times

Compassion and the Voice of the Tormentor

See more at Voice Hearers Connect

Auditory verbal hallucinations in schizophrenia and post-traumatic stress disorder: common phenomenology, common cause, common interventions? (2015)

I’ve been thinking along similar lines…

Auditory verbal hallucinations in schizophrenia and post-traumatic stress disorder: common phenomenology, common cause, common interventions?

Auditory verbal hallucinations (AVH: ‘hearing voices’) are found in both schizophrenia and post-traumatic stress disorder (PTSD). In this paper we first demonstrate that AVH in these two diagnoses share a qualitatively similar phenomenology. We then show that the presence of AVH in schizophrenia is often associated with earlier exposure to traumatic/emotionally overwhelming events, as it is by definition in PTSD. We next argue that the content of AVH relates to earlier traumatic events in a similar way in both PTSD and schizophrenia, most commonly having direct or indirect thematic links to emotionally overwhelming events, rather than being direct re-experiencing. We then propose, following cognitive models of PTSD, that the reconstructive nature of memory may be able to account for the nature of these associations between trauma and AVH content, as may threat-hypervigilance and the individual’s personal goals. We conclude that a notable subset of people diagnosed with schizophrenia with AVH are having phenomenologically and aetiologically identical experiences to PTSD patients who hear voices. As such we propose that the iron curtain between AVH in PTSD (often termed ‘dissociative AVH’) and AVH in schizophrenia (so-called ‘psychotic AVH’) needs to be torn down, as these are often the same experience. One implication of this is that these trauma-related AVH require a common trans-diagnostic treatment strategy. Whilst antipsychotics are already increasingly being used to treat AVH in PTSD, we argue for the centrality of trauma-based interventions for trauma-based AVH in both PTSD and in people diagnosed with schizophrenia.

Another recent article highlights how “interventions specifically targeting aspects of self-experience, including self-affection, self-reflection, self-schema and self-concept, may be sufficient to reduce distress and disruption in the context of hearing voices” [1].

See also:

Are some Auditory Verbal Hallucinations trauma/fear memories that are amendable via therapy & pharmacologically enhanced reconsolidation/extinction?

Clinical perspectives on the relationship between psychosis and dissociation: utility of structural dissociation and implications for practice (2015)

Trauma-related dissociation and altered states of consciousness: a call for clinical, treatment, and neuroscience research (2015)

Hallucinations: New interventions supporting people with distressing voices and/or visions

Hallucinations as a trauma-based memory: Implications for psychological interventions.

Trauma-related dissociation and altered states of consciousness: a call for clinical, treatment, and neuroscience research (2015)

Trauma-related dissociation and altered states of consciousness: a call for clinical, treatment, and neuroscience research

The primary aim of this commentary is to describe trauma-related dissociation and altered states of consciousness in the context of a four-dimensional model that has recently been proposed (Frewen & Lanius, 2015). This model categorizes symptoms of trauma-related psychopathology into (1) those that occur within normal waking consciousness and (2) those that are dissociative and are associated with trauma-related altered states of consciousness (TRASC) along four dimensions: (1) time; (2) thought; (3) body; and (4) emotion. Clinical applications and future research directions relevant to each dimension are discussed. Conceptualizing TRASC across the dimensions of time, thought, body, and emotion has transdiagnostic implications for trauma-related disorders described in both the Diagnostic Statistical Manual and the International Classifications of Diseases. The four-dimensional model provides a framework, guided by existing models of dissociation, for future research examining the phenomenological, neurobiological, and physiological underpinnings of trauma-related dissociation.

A summary of the 4-D model that categorizes symptoms of trauma-related psychopathology into (1) those that occur within normal waking consciousness and (2) those that are dissociative and are associated with trauma-related altered states of consciousness (TRASC) along four dimensions: (1) time; (2) thought; (3) body; and (4) emotion. The bottom pink part of the boxes indicates non-dissociative processes and normal waking consciousness, whereas the orange part of the boxes denote dissociative processes and TRASC. The first arrow (infrequency) indicates that the experience of TRASC is hypothesized to be less common than presentations of normal waking consciousness given that states of normal waking consciousness, by definition, are the most common phenomenological state of human beings. It should be noted that the four dimensions of consciousness are not mutually exclusive, but may refer to the same phenomena viewed from different perspectives (e.g., depersonalisation can manifest itself both in the dimension body and emotion). From Frewen and Lanius (2015).

“Psychological trauma may not only affect the perspective of an individual’s narrative but also the plot and the structure of the narrative. Although often able to maintain first-person perspective, trauma survivors may exhibit distinctly negative self-referential thinking, including “I am a bad person” or “I do not deserve to live”

Traumatized individuals may, however, occasionally exhibit alterations in the perspective of their narrative. These alterations can lead survivors to experience voices in the second-person perspective, for example, telling them, “you are bad” or “you deserve to die,” an experience thought to reflect a dissociative process associated with TRASC. When this occurs, the person is no longer the only storyteller of his/her lived experience but rather another or other narrative voice(s) also speak inside his/her head. These voices may present distinctly different goals, motivations, and affects, in the extreme case creating the experience of possessing multiple selves. Research in the area of voice hearing has suggested that this phenomenon is elevated significantly in individuals suffering from trauma-related disorders, including in individuals diagnosed with PTSD, dissociative disorders, and borderline personality disorders as compared to patients with other psychiatric disorders; voice hearing is also related to the experience of dissociative symptomatology and a history of early life adversity”

“From a clinical perspective on trauma-related voice hearing, it is crucial to create a shared narrative by identifying the strengths of each voice or self state in the present and by encouraging awareness and communication among different voices or self states, thereby facilitating collaboration between or among distinctly compartmentalized and contradictory goals, motivations, and affects associated with each voice or self state. The latter is also critical in fostering of self-compassion, which is sorely lacking in many survivors of chronic trauma due to ongoing conflict among different voices or self states.”

“…while remembering an event, mental time travel is “partial” in that the present self voluntarily directs attention to the past self, thus maintaining awareness of the present self in the present time. In this case, the “I” is proposed to exist in the present self, which outweighs the representation of the past self in past time. In contrast, during a reliving experience, mental time travel occurs “fully,” generally not by choice, and is usually triggered by internal and/or external stimuli that bear some resemblance to a past self-state. In this case, the “I” is thought to inhabit the past self, which is thought to outweigh the presence of the present self, thus lacking a mental time traveler and the ability to voluntarily position oneself in the past or in the future.”

“…it may be critical to strengthen the self among survivors of trauma, in order to facilitate the emergence of a mental time traveler that is able to remember rather than to relive the past. Processes relevant to this development across all four dimensions of consciousness include the encouragement of safe relationships, including the therapeutic relationship, enhancing mindful awareness of the present through mindfulness exercises, emotion regulation, distress tolerance skills, and building capacity for positive affect tolerance. Based on the theoretical assumptions reviewed here, strengthening the sense of self through the use of present-centered therapies in combination with exposure-based treatments may be crucial to successfully overcoming severe dissociative flashbacks.”

“…among individuals who suffer from the aftermath of trauma, the mind/body connection is often severed, leading to the subjective experience of feeling partially or fully detached from one’s body, or alternatively, as if one’s body does not belong to oneself.”

“It is critical for clinicians to understand the subjective experience from which the traumatized individual experiences his/her body and its relation to the surrounding world. Body-scan meditations, intended to facilitate awareness and the monitoring bodily sensations, form a central part of the mindfulness-based stress reduction program developed by Kabat-Zinn (1990) and provide an important means of assessing states of full or partial depersonalization, while at the same time enhancing the capacity for interoceptive awareness and diminishing detachment from bodily states. It is critical to note, however, that body scans must be carried out in a trauma-sensitive way in order to prevent the traumatized individual from becoming overwhelmed during this exercise”

“In the aftermath of trauma, however, it is well documented that emotion dysregulation can range from states of emotional undermodulation during which the individual experiences painful states of fear, anger, guilt, and shame to states of emotional overmodulation, during which the individual experiences emotional detachment such as states of depersonalization, derealization, emotional numbing, and affective shut-down.”

“Clinical efforts to assist individuals in overcoming emotional numbing and affective shutdown may center around assisting the traumatized individual to shift out of his/her shut-down state in order to be able to feel a full range of emotions, particularly pleasure and joy”

Future directions for research are covered:

“Future research is needed to identify more precisely the neurobiology underlying voice hearing and negative self-referential processing in trauma-related disorders as compared to that underlying voice hearing in psychotic-spectrum and other psychiatric disorders. This will be important to facilitate more accurate diagnosis, thereby guiding the most appropriate treatment interventions. Here, it will also be critical to examine how emotional triggers, for example, positive or negative self-related statements, may affect differently the presentation and underlying neurobiology of voice hearing in trauma-related disorders as compared to psychotic and other psychiatric disorders. Moreover, it will be important to examine the integrity of neural networks, such as the default mode network, which has been associated with an integrated sense of self across time , pre- and post-treatment interventions that target specifically the creation of a shared narrative between or among voices that may be associated with different self states.

From a clinical perspective, treatment outcome studies that focus specifically on interventions designed to affect voice hearing in trauma-related disorders should also be urgent foci of investigation”

See also:

Auditory Hallucinations in Chronic Trauma Disorders: Phenomenology and Psychological Mechanisms

Clinical perspectives on the relationship between psychosis and dissociation: utility of structural dissociation and implications for practice (2015)

Are some Auditory Verbal Hallucinations trauma/fear memories that are amendable via therapy & pharmacologically enhanced reconsolidation/extinction?

A pilot study exploring compassion in narratives of individuals with psychosis: implications for an attachment-based understanding of recovery

‘Hearing voices’, ‘pseudohallucinations’ and ‘lucid dreams’

Journaling as Therapy (2015)

Clinical perspectives on the relationship between psychosis and dissociation: utility of structural dissociation and implications for practice (2015)

Clinical perspectives on the relationship between psychosis and dissociation: utility of structural dissociation and implications for practice

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.”

Clinical implications:

“…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:

  1. that trauma and dissociation may be key to understanding psychosis as a fundamentally emotional problem;
  2. that specific therapies and techniques developed for dissociation will have application in psychosis, and vice versa; and
  3. 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.

See also:

Are some Auditory Verbal Hallucinations trauma/fear memories that are amendable via therapy & pharmacologically enhanced reconsolidation/extinction?

Trauma-related Structural Dissociation of the Personality