Madness and the Family (Part One): The History and Research of Family Dynamics and Psychosis

I was very lucky to have great family dynamics but there were non-family related stressors such as bullying and other traumas in my teenage years. Here’s part one of an interesting topic:

Madness and the Family (Part One): The History and Research of Family Dynamics and Psychosis

There are very few things considered more taboo in the world of mental health than the suggestion that problematic family dynamics can lead to a child developing a psychotic disorder. And yet, when we look honestly at the history and research of psychosis and the broader concept of “mental illness,” it becomes apparent that there are few subjects in the mental health field that are more important. I’d like to invite you, then, to join me on a journey into this taboo territory, dividing our trip into three legs. In the first leg (Part One), we’ll go back in time to explore how such a crucial topic has become so vilified, and then embark upon a flight for an aerial view of some of the most essential findings of the last 60 plus years of research that look at the links between problematic family dynamics and psychosis. In the second leg of the journey (Part Two), we’ll explore a framework that offers us the potential to unify the research on the various problematic family dynamics, trauma, and other factors associated with psychosis, locating the roots of psychosis within two core existential and relational dilemmas that I believe we all struggle with to greater or lesser degrees. Finally, in the third and last leg of our journey (Part Three), we will reap the fruits of our exploration, and consider how what we have learned may guide us as parents, as family members, and as society as a whole in offering genuine support to those who continue to grapple with these extreme states of mind.


Positive disintegration – a path to the resolution of ‘psychosis’?

“Without passing through very difficult experiences and even something like psychoneurosis and neurosis we cannot understand human beings and we cannot realize our multidimensional and multilevel development toward higher and higher levels.”

Positive disintegration – a path to the resolution of ‘psychosis’?

“Suffering, aloneness, self-doubt, sadness, inner conflict; these are our feelings that we have not learned to live with, that we have failed to appreciate, that we reject as destructive and completely negative, but in fact they are symptoms of an expanding consciousness. Dr. Kazimierz Dabrowski has spent 45 years piecing together the complete picture of the growth of the human psyche from primitive integration at birth; the person with potential for development will experience growth as a loosening of the stable psychic structure accompanied by symptoms of psychoneuroses. Reality becomes multileveled, the choices between higher and lower realms of behavior occupy our thought and mark us as human. Dabrowski called this process positive disintegration, he declares that psychoneurosis is not an illness and he insists that development does not come through psychotherapy but that psychotherapy is automatic when the person is conscious of his development. To Dabrowski, real therapy is autopsychotherapy; it is the self being aware of the self through a long inner investigation; a mapping of the inner environment. There are no techniques to eliminate symptoms because the symptoms constitute the very psychic richness from which grow an increasing awareness of body, mind, humanity and cosmos… Without intense and painful introspection and reflection, development is unlikely. Psychoneurotic symptoms should be embraced and transformed into anxieties about human problems of an ever higher order. If psychoneuroses continue to be classified as mental illness, then perhaps it is a sickness better than health.” [1]

“Unless we change our thinking… our understanding of psychogenic emotional and psychosomatic disorders and their therapy  will  remain  superficial,  unsatisfactory, and incomplete. Psychiatry and psychology will be unable to genuinely comprehend the nature and origin of spirituality and appreciate the important role that it plays in the human psyche and in the universal scheme of things. These revisions are therefore essential for understanding the ritual, spiritual, and religious history of humanity,  shamanism, rites of passage, the ancient mysteries of death and rebirth, and the great religions of the world. Without these radical changes in our thinking, potentially healing and heuristically invaluable experiences (“spiritual emergencies”) will be misdiagnosed as psychotic and treated by suppressive medication.” [2]

The phases of recovery from psychosis are detailed here

Understanding Madness: Science, Philosophy, and the Experience of Delusions (2015)

Despite multiple trials with antipsychotics, I really struggle to filter out ‘irrelevant’ information (as this blog clearly demonstrates). Ordinary information becomes ‘hypersalient information’ and I’m compelled to explain ‘it’, whatever ‘it’ is… it’s great for compiling long lists of citations of varying (ir)relevance – thankfully, I don’t struggle with too many delusions. I found the following interesting as an insight into psychosis:

Understanding Madness: Science, Philosophy, and the Experience of Delusions (2015)

A Review of The Measure of Madness: Philosophy of Mind, Cognitive Neuroscience, and Delusional Though

At the beginning of my training in psychiatry, I encountered an attitude that psychosis was inherently beyond human understanding, as if schizophrenia were an alien thing, and that the mad were unreachable, at least until medicines restored something of their humanity. I later learned that such abhorrent, even dangerous, views may have originated from a misinterpretation and generalization of what Karl Jaspers had written about the “ununderstandability” of certain delusions— psychic experiences that were not meaningful and precluded empathy. A partial antidote to this perspective, I discovered, came from mid-century psychoanalytic approaches to psychosis through which a method in madness could be discerned, albeit limited and imperfect…

“…[Gerrans] proposes that delusions result from the operations of a “default cognitive processing” mode under twin conditions of reduced “supervision” by higher level decontextualized (prefrontal) processing, and dominance of “hypersalient information” mediated by dopaminergic systems.

Gerrans works through key aspects of the literature concerning the salience system and reward prediction, the role of dopamine neurotransmission in these neural processes that are concerned with novelty and motivation, and culminates with the work of Kapur (2003) and others who have proposed a central role for enhanced dopamine transmission in producing a state of hypersalience (or “aberrant salience”) in which stimuli acquire heightened significance—intense phenomenal events that compel explanation. Decontextualized processing refers to hypothesis-testing-like cognitive processes for verifying interpretations or conclusions about experience of the world and inner life. It relies on several cognitive functions that involve activation of the dorsolateral prefrontal cortex. Gerrans argues that this system is absent, diminished, or compromised in delusional states, or somehow not operative in “supervision” of the dominating effects of hypersalient information.

The most interesting element introduced by Gerrans centers on what has been called the default mode network, a cognitive system involving the ventromedial prefrontal cortex that simulates “fragments of autobiographical/personal narratives.” It is an imaginative process, sometimes with dream-like qualities, a “default state” to which the mind reverts in the absence of a salient problem on which to focus. Gerrans proposes that delusions emerge from the hyperactivation of this cognitive system in which, rather like acts of creative imagination, highly salient thoughts, untrammeled by top-down decontextualized processing, are incorporated into autobiographical narrative fragments and achieve “subjective adequacy.” By this is meant a kind of story that “fits” with the person’s psychology, rather than publicly shared beliefs, and that seems to emerge spontaneously and with a compelling intensity.

Using this model, the author offers a critique of a leading doxastic theory of delusion formation, particularly the two-factor theory that proposes an initial anomalous perceptual experience, which generates a quasi-rational but delusional explanation for the experience, followed by a failure to reject that explanation due to a faulty reasoning or “belief evaluation” system, related in turn to damage or dysfunction in the right frontal hemisphere (e.g. Coltheart, 2005). The problem with this theory, Gerrans proposes, is that it treats delusions as hypotheses, to be tested and confirmed or disconfirmed, when they are no such thing, but rather “narrative elements [that] go on to play a role in structuring the agent’s psychology”…

An interesting implication of Gerrans’ view that the default thinking involved in delusion formation is “essentially an imaginative process” with a result that achieves “subjective adequacy” is that it introduces the notion that a creative process is involved, perhaps leading to an aesthetic effect in the subject (Carr, 2010). As such, the processes of delusion formation not only bear similarities to dreams, daydreaming, and reverie, but to creative processes generally, including artistic expression and scientific insight.”

“…madness is a human experience. Delusion is not alien and unfathomable if we have the tools required, make the effort to understand it, overcome the barriers to empathy, and engage with the person gripped by delusion…”

“My hope, however, is that psychiatrists will read it, think about its subject matter deeply, and how it might better inform their view of the person and the mind/brain behind madness, thereby perhaps helping to counter the enormous contemporary pressures towards biomedical reductionism in our profession. Delusions are more than antipsychotic deficiency states; there is more to understanding madness than dopamine receptors, and there is more to delusions than madness itself.”
See also:

Journaling as Therapy (2015)

I’ve recently had the pleasure to get to somewhat know a special friend who has, to say the least, inspired me to reconsider the therapeutic potential of words and the act of writing. I see so much potential in this young woman and deeply connect with what she writes and the parts of her soul she shares in doing so. I hope she continues to share her gifts.

I’m no wordsmith – these days my thoughts are very fragmented, as is the stream of words manifesting on this screen as I try to write. That generally doesn’t stop me from slowly piecing together a somewhat coherent picture when writing and conveying what I intended to communicate, despite any ‘cognitive deficits’.

Verbally, my words have never flowed… I imagine I either come across as disinterested or plain boring when I do attempt to talk. Socially, that has left me struggling and to this day, I still rely on writing to communicate to a deeper level, which so far has mostly been to doctors and psychologists… I’d like to expand that to friends.

Someone else has successfully put words to therapeutic use and detail their journey in the following article. It’s worth a read.

Journaling as Therapy

Journaling about my issues with metaphysics and psychoanalysis were paramount in my recovery from schizoaffective disorder. I have gone to talk therapy for 1h/week for the past 4 years and after my third year of therapy I began writing in a metacognitive journal where I have psychoanalyzed myself and learned a great deal about my psyche and everything else in my life. During episodes and other points in my life there were many traumatic experiences from the past that affected me in the present that I needed to face and analyze. There have also been normal life experiences that have been new to me which I have written about and have hashed out to gain a better understanding of or make better decisions regarding them. Talk therapy was an important tool for coming to terms with the experiences I was most afraid of facing. I started at a point where I didn’t want to speak even the slightest of sentences and progressed to being able to talk frankly about any of my experiences in my life. I don’t always share experiences with others but being able to face them on my own has been immensely beneficial. I know the only way I can improve is being honest with myself about my experiences because the past is ingrained in my mind and if I lie about it to myself I’ll never truly understand the reasons and ways trauma is currently affecting me. When I haven’t accurately addressed a past issue it has had a way of still affecting me. I know when I’ve found mistakes I’ve made or areas I could have done better I only need to share this information with myself. Once I developed the ability to freely analyze my experiences I started working with the meaning I had surrounding them and the meaning they had within my life. I discovered I have to find the truth that makes me function as well as I can because ultimately my goal has been to function at my optimal levels. In any well functioning mind there’s a balance of eliminating rigidity in thought and developing mental flexibility but also in having some set of parameters from which to work. The best minds are able to accordingly adapt to the particular set of circumstances they are working within or change situations to their advantage. 


“…it has been suggested that through our personal story, or narrative we attempt to bring coherence to “the chaos of existence” However, for those in society that lack power, narratives available may be narrow and negative and such views may be internalised into an individuals’ personal story. The opportunity to construct alternative narratives, to “re-story”, can therefore be a powerful tool in integrating and making sense of experiences and challenge stigmatised views, which may have become part of their personal story” [1]

Emotion-focused therapy (EFT):

” …includes narrative construction and reconstruction ‘in which symbolized feelings, needs, self-experience, thoughts and aims are clarified and organized into a coherent story’ ‘Here, complex experiences, such as conflict or puzzling reactions, are organized into stories that are understandable and often new’. ‘Promoting reflection on emotional experience, as well as helping people make sense of their experience, promotes its assimilation into their ongoing self-narratives’. EFT also includes ‘Transformation of emotion and story outcomes’ where the therapist helps the patient create ‘new explicit meanings and story outcomes’. Modifying life-story narratives is understood to cause emotional change. ‘As such, emotional change, by definition, involves narrative change’. EFT also includes ‘identity reconstruction’. ‘A critical change process occurs when the client’s most important personal stories and their emotional plotlines change. This final process involves different forms of identity transformation that result in the emergence of new self-narratives’. ‘Importantly, the integration of emotion processes and narrative structure facilitates the construction of a stored explanation of what happened, which can then be told to others and reflected on for further understanding and personal meaning construction. Therapy then is a process of clients coming to know and understand their own lived stories and articulating them as told stories – and in doing so changing their stories’. ‘The term autobiographical reasoning refers to this type of narrative meaning-making activity’. [2]

If writing interests you, consider getting involved in a new collaborative blog: “You do not need to be a good writer, but merely have an interest in writing. …write how you feel”

That said, I must stop adding to this collection of articles, copy and pastes and citations – all mere dissociation from the pain, fear and yes love in my mind and become reacquainted with myself. Maybe try journaling offline. Become a friend to all those parts of me that hurt and heal… Start with healing myself and as I do, evolve and hopefully heal others. …and revise some of my study material, too.

The Differentiation of Psychosis and Spiritual Emergency (2008)

While I keep myself grounded in a biopsychosocial model of psychosis and schizophrenia these days (mainly because of my almost pathological tendency to seek an overly mechanical wordview that lets me analyse the shit out of it…), my late prodromal/FEP days pulled me in a different direction – towards the spiritual. While I didn’t think it was well received by psychiatrists at the time, I don’t see spiritual interpretations and approaches to dealing with psychosis to be bad. That said, I don’t want to stop anyone from continuing under the care of a doctor/psychiatrist, on the condition that they have respect for one’s spiritual beliefs. Here is a thesis from Adelaide of all places…

The differentiation of psychosis and spiritual emergency.

Psychosis has long been recognised as a severe mental disorder characterised by derangement of personality, disorganised thought, and a loss of contact with reality. Certain mystical and alternate states, which have been practiced throughout history by various cultures, have also been deemed as pathological through the lens of western psychiatry even though many of these states provide beneficial contributions to the individual and their community. A number of similar states have been found in modern society and have been termed “Spiritual Emergencies”. The aim of this research was to determine whether “spiritual emergency”. (SE) is a valid concept and to outline the differences between SE and psychosis. One-hundred-and-nine participants from the general public completed a questionnaire developed for this research, comprised of measures of psychosis and ten spiritual emergency subscales. Results indicated that participants who were prescribed medication or previously experienced a psychotic episode scored higher on the SE subscales. One strong factor was found to underlie all the SE subscales and a significant relationship was found between this factor and the measure of psychotic experience. It is open to interpretation as to whether psychosis is nothing more than SE or whether SE is nothing more than psychosis. The implications of these findings are discussed.

Well worth checking out is the Spiritual Competency Resource Center

From LESSON 6.1 Therapeutic Interventions: Spiritual Crises

The Mystical, Near-Death, Meditation and Spiritual Practice, Visionary and Shamanic types of spiritual problems have been associated with crises (“spiritual emergencies”) where a person has difficulty functioning. Each of these problems has a section on Therapy

Mystical experiences
Near-death experiences
Meditation and Spiritual Practice
Visionary experiences
Shamanic experiences

There are also a number of therapeutic strategies that apply to all spiritual crises. Stanislav Grof, MD, and Christina Grof, founders of the Spiritual Emergence Network, describe a spiritually-sensitive approach:

“The most important task is to give people in crisis a positive context for their experiences and sufficient information about the process that they are going through. It is essential that they move away from the concept of disease and recognize the leading nature of their crisis…

Whether attitudes and interactions in the narrow circle of close relatives and friends are nourishing and supportive or fearful, judgmental, and manipulative makes a considerable difference in terms of the course and outcome of the episode…

[Therapy] should not be limited to talking and should allow full experience and direct release of emotion. It is absolutely essential to respect the healing wisdom of the transformative process, to support its natural course, and to honor and accept the entire spectrum of human experience”

(Spiritual Emergency: When Personal Transformation Becomes a Crisis, p. 195)

Interventions can range from support for a time-limited crisis, with possible involvement of relatives, friends, support groups, and medical persons, to intensive long-term psychotherapy. Choice of specific interventions depends on the intensity, duration, and type of spiritual problem, and also on the individual and their support network.

Therapeutic Interventions for Acute Crises

Therapy with spiritual emergency patients in crisis (“spiritual emergency”) can include the following 9 interventions.

An exploration of “how further spiritual development can occur when the spiritual ideal and the linear nature and trajectory of the practitioner’s ego structure are disrupted and their foundations destroyed, making space for the individual to live in an expanded state of consciousness” can be found here and how “variation in an individual’s characterisation of anomalous experiences is nuanced by pre-existing beliefs and affective factors” here

I was profoundly depressed (to the point of ECT two times) for many years and can relate to this “Spiritually integrated treatment of depression: a conceptual framework

Depression Research and Treatment
Table 1 outlines a general framework for intervening at the interfaces between emotional, existential, and spiritual distress in the domains of depressed individuals’ core concerns, to foster a more healthy spirituality. Whereas insight-oriented and cognitive behavioral approaches can help depressed individuals to distinguish distressing emotions from their actual basis in life experience, spiritually oriented interventions can help them use their knowledge and experience of their spirituality (in its ultimate sense, where God or morality are involved) to put these experiences into a larger perspective.

“Table 2 suggests ways that specific spiritually informed interventions can address the existential dimension of depressive concerns. For example, patients whose existential concerns center around identity, and who are therefore vulnerable to experiencing doubt or disorientation when depressed, may benefit from a humanistic emphasis on connecting with what most fulfills and best defines them. If religious, they may also benefit from grounding their identity in their relationship to God, for example, through a process of spiritual direction.”

Sex differences, hormones, and fMRI stress response circuitry deficits in psychoses (2015)

Sex differences, hormones, and fMRI stress response circuitry deficits in psychoses

Response to stress is dysregulated in psychosis (PSY). fMRI studies showed hyperactivity in hypothalamus (HYPO), hippocampus (HIPP), amygdala (AMYG), anterior cingulate (ACC), orbital and medial prefrontal (OFC; mPFC) cortices, with some studies reporting sex differences. We predicted abnormal steroid hormone levels in PSY would be associated with sex differences in hyperactivity in HYPO, AMYG, and HIPP, and hypoactivity in PFC and ACC, with more severe deficits in men. We studied 32 PSY cases (50.0% women) and 39 controls (43.6% women) using a novel visual stress challenge while collecting blood. PSY males showed BOLD hyperactivity across all hypothesized regions, including HYPO and ACC by FWE-correction. Females showed hyperactivity in HIPP and AMYG and hypoactivity in OFC and mPFC, the latter FWE-corrected. Interaction of group by sex was significant in mPFC (F=7.00, p=0.01), with PSY females exhibiting the lowest activity. Male hyperactivity in HYPO and ACC was significantly associated with hypercortisolemia post-stress challenge, and mPFC with low androgens. Steroid hormones and neural activity were dissociated in PSY women. Findings suggest disruptions in neural circuitry-hormone associations in response to stress are sex-dependent in psychosis, particularly in prefrontal cortex.

• Using fMRI, sex differences exist in stress circuitry deficits in psychoses.
• Male cases were hyperactive across subcortical and cortical stress circuitry.
• Female cases were hypoactive in prefrontal cortex.
• Brain activity deficits in medial prefrontal cortex were significant by sex.
• Neural-steroid hormone associations under stress are sex-dependent in psychosis.

“Brain regions that respond to negatively valenced stimuli also regulate the hypothalamic-pituitary-adrenal (HPA) and HP-gonadal (HPG) systems, which are dysregulated in schizophrenia. Gonadal hormones, such as estradiol, modulate risk of psychotic illness across the lifespan. Likewise HPA dysregulation, at the adrenal, pituitary and central nervous system levels, contribute to the pathophysiology and etiology of schizophrenia. Hippocampus, amygdala, hypothalamus, and anterior cingulate cortex are linked to endocrine function and neuroprotective and neurotoxic responses to reproductive steroid exposures. Glucocorticoid receptors are located in the hippocampus, hypothalamus, prefrontal and anterior cingulate cortices, areas that are dense in sex steroid hormone receptors. The hypothalamus, hippocampus and amygdala are involved in the regulation of HPA and HPG hormones, and anterior cingulate, medial, and dorsolateral prefrontal cortices influence autonomic and endocrine function integrating bodily states and goal-directed behavior. These brain regions are some of the most highly sexually dimorphic regions in the brain, demonstrating in vivo sex differences in brain volumes and brain activity in healthy populations, and schizophrenia.

Compared with control males, males with psychoses expressed hyperactivity in most of the hypothesized stress response regions, demonstrating substantial effect sizes that were present regardless of psychosis type. In contrast, females with psychoses compared with healthy females showed hyperactivity in subcortical stress response regions and anterior cingulate cortex, and hypoactivity in orbital and medial prefrontal cortices, the latter of which were significantly different from males. We had adequate statistical power to test for sex differences in psychoses, and the sample presented here was generally representative of the population from which they were drawn…

We further found that differences across group (psychoses vs. healthy controls) and sex were differentially associated with steroid hormone abnormalities. Hypercortisolemia was present in male and female cases compared to their healthy counterparts, but had a differential effect on brain activity deficits in prefrontal cortex in males and females. Hypercortisolemia was associated with hyperactivity across stress response regions in men with psychoses, including prefrontal cortices. In contrast, hypercortisolemia was associated with hypoactivity in medial prefrontal (and orbitofrontal) cortices in females with psychoses, a difference that was not present among male and female controls. Not surprising, hypercortisolemia in cases was associated with low gonadal hormone expression regardless of sex (i.e, for male cases, low free androgen, and for female cases, low estradiol). The impact of low androgens on explaining hyperactivity in prefrontal cortex in male cases was only, in part, explained by hypercortisolemia, whereas the variance accounting for hypoactivity in prefrontal cortices in female cases was explained through its relationship to hypercortisolemia. These findings suggest adrenal and gonadal hormone abnormalities are associated with brain activity deficits in stress response regions but have differential effects on brain dependent on sex.

Neural-hormone deficits are not surprising given that stress response circuitry regions, such as anterior hypothalamus, amygdala, and hippocampus, are governed by the coordinated action of HPG and HPA axis hormones. They are regions dense in estrogen, progesterone, androgen, and glucocorticoid receptors In fact, as evident in the cases in this study, HPA dysregulation, i.e., hypercortisolemia, had a significant impact on attenuating HPG response (i.e., lower gonadal hormone expression). There is a long history to the idea that HPA dysregulation is implicated in schizophrenia, described as hypercortisolemic and hyper-responsive to stress, physiologic responses attributed to bipolar psychoses as well. Previous work, including our own, also demonstrated abnormalities in gonadal hormone levels (lower in cases) and endocrine function.

Stress response circuitry deficits in psychoses in male (A) and female (B) cases vs. healthy controls, A and B: activations of hypothesized regions of interest were derived using the small volume correction tool in SPM8, restricted to anatomical borders defined by a manually segmented MNI brain. Peak voxel activations were significant at p<.05, FWE-corrected. (A) Male psychosis cases (PSY) showed significant hyperactivity compared to male controls in right hypothalamus (HYPO) and anterior cingulate cortex (ACC), and hypoactivity in left hypothalamus (HYPO). (B) Female cases showed hyperactivity in subcortical arousal regions, and hypoactivity in medial prefrontal cortex (mPFC) by FWE-correction and orbitofrontal cortex (not shown here, given trend-level significance) [source]

fMRI and PET studies of emotional arousal in schizophrenia, particularly response to negatively-valenced stimuli or the so-called stress response, have consistently shown increased activation in hippocampus, amygdala and anterior cingulate cortex, coupled with decreased activation in prefrontal cortex

The magnitude of hyperarousal varied across the menstrual cycle in women, with attenuation of hyperactivity in response to stress during mid-cycle compared with early follicular and increased prefrontal and anterior cingulate cortices during the luteal phase, when progesterone was heightened

Hyperactivity of hypothalamus in healthy men vs. women was consistent across studies, controlled for menstrual cycle status and negatively correlated with estradiol levels.

Low estradiol was associated with hypercortisolemia in female cases with little correlation among the controls (Spearman׳s r=−0.49 vs. −0.07, respectively). However, low estradiol did not account for variance in the impact on prefrontal cortex over and above hypercortisolemia in female cases vs. controls.

Impact of low free androgen levels on hyperactivity in medial prefrontal cortex among the male cases vs. controls was significant (β=0.10, p<0.05), an effect that was, in part, accounted for by the high cortisol:DHEAS levels in male cases.

Other findings:

Jacobs et al. [1] have found that 17β estradiol was significantly related to attenuation of BOLD activity in key subcortical stress response regions in healthy women, but no modulation by 17β estradiol in depressed women was found.

A recent study has found that progesterone mediates brain functional connectivity changes during the menstrual cycle [2].

Sex differences in depressive and socioemotional responses to an inflammatory challenge have been investigated [3].

Hernaus et al. have investigated psychotic reactivity to daily life stress and the dopamine system [4] and found that there is no evidence for attenuated stress-induced extrastriatal dopamine signaling in psychotic disorder [5].

Sex-specific restoration of MK-801-induced sensorimotor gating deficit by environmental enrichment has been reported in rats [6].

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