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Trauma and Psychosis: What Has Happened to You?

Written by Steven Coles on . Posted in Clinical Psychology Bite-Size

Trauma and Psychosis: What Has Happened to You?

Issue 37 – December 2013

Authors: Steven Coles (steven.coles@nottshc.nhs.uk)

Key points

  • There is a growing body of research recognising that a range of traumatic circumstances are a cause of experiences labelled as psychosis or schizophrenia.

 Implications for practice

  • It is important to sensitively ask about difficult experiences, such as childhood abuse, as part of exploring a person’s life story.
  • How we respond and support people following disclosure is as important as asking about abuse.
  • People’s life stories can help make sense of experiences such as hearing voices.

 “Given the role of trauma and adversity, we need to start asking ‘what has happened to you?’ rather than ‘what is wrong with you?’ ”    Hearing Voices Network (2013)1

 Unusual experiences, often labelled as psychosis, are increasingly being recognised as one response to very difficult life experiences and dilemmas. A wide range of difficult life experiences, such as sexual abuse2, loss of a parent5, poverty6 and discrimination7, are connected to the onset of unusual experiences (“psychosis”). Trauma is as strongly related to psychotic experiences, if not more so, than to any other form of mental distress2. A recent review3 of research on trauma and psychosis concluded “exposure to adverse childhood events should be regarded as an important determinant of psychotic disorders” (p. 8). Furthermore, a study following 13-16 year old over one year found that exposure to childhood trauma (including bullying and physical abuse) predicted new incidents of psychotic experiences. They also found that once difficult life events stopped, the psychotic experiences also reduced4.

What has happened to you?

Given the importance of difficult life experiences, it is crucial for staff to be able to open up space so that service users, if they wish to do so, can tell their stories. These stories can include horrifying experiences, as well as tales of survival and hope. Understandably we can feel worried about asking about trauma for fear of upsetting the person, and apprehensive about how to ask and respond to disclosure. However, research suggests the majority of services users favour being asked about difficult life experiences8. In fact services users can be disturbed if they are not asked9. Discussing difficult life experiences can obviously be stressful and painful, and requires sensitivity as to how it is approached, careful pacing of discussions and responsiveness to emotional reactions. Staff also require appropriate clinical supervision, which is of a reflective nature rather than managerially focussed. Read, Hammersley and Rudegeair (2007)10 have outlined some guidelines on how to ask about abuse and respond to disclosure (see for details). They suggest childhood abuse should be asked about as part of a general life history or life story. Questions should move from general questions to specific behavioural questions such as: ‘tell me a bit about your childhood’, ‘best childhood memory? Worst?’, ‘how did you get on with mum and dad?’, ‘how was discipline dealt with?’, ‘did an adult hurt or punish you in a way that left bruises, cuts or scratches?’ (p. 105 – 106). Around sexual abuse more specific questions might include ‘when you were a child did anyone ever do something sexual that made you feel uncomfortable?’ (p. 106)10.

The response to disclosure is as important as asking (see Read et al. 2007)10. Discussions need to be collaborative and service users should have a sense of control over what, how and when trauma is spoken about. For some clients simple acknowledgement and validation of the painful experience and its impact might be all that is needed, and may allow people to focus on more immediate concerns. Others may need, at some point, to discuss issues and experiences over a number of sessions. Simply asking someone, whether what has happened to them is connected to their current distress and difficulties, may help them to make sense of their emotional pain. When abuse is first disclosed, it is unnecessary and perhaps unhelpful to go into details at this point – some people may never want to do this. It is crucial though that people are offered support and are helped to feel safe. This might include: offering space to discuss the issues as part of an ongoing therapeutic relationship; providing a telephone number they call in case of a crisis or if they need to talk. It may also include referral to a counsellor or psychologist, or referral to a self-help group. It is also important to support a person to identify their own resources and social support networks. Issues of note-keeping and safeguarding issues also need to be considered.

Creating the Story

Difficult life events are a crucial part of the story that can help make sense of experiences, such as hearing voices, which on the surface may appear unusual and difficult to understand. The anthology of 50 stories of living with voices11 highlights how hearing voices can often be seen as a survival strategy to traumatic life experiences, such as sexual and physical abuse, emotional neglect and bullying. We need to create space for these stories to be formed and flourish in our conversations with people. Asking about abuse and trauma, listening to and responding sensitively to accounts of suffering and hurt can be the start of a creating a story, and perhaps one that can see someone grow from being a victim, to surviving, through to thriving (see Dillon, 2011)12. We need to ensure we are listening to stories of abuse, rather than inadvertently colluding in the silencing of abuse, so that we can be part of the solution, rather than part of the problem.

REFERENCES[i]

  1. Hearing Voices Network (2013). Position Statement on DSM 5 and Diagnoses. England: HVN.
  2. Read, J., van Os, J., Morrison, A. P. & Ross, C. A. (2005). Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications. Acta Psychiatrica Scandinavica, 112, 330-350
  3. Varese, F. et al. (2012). Childhood adversities increase the risk of psychosis: a meta-analysis of patient-control, prospective-and cross-sectional cohort studies. Schizophrenia Bulletin, 38, 661-671.
  4. Kelleher, I. et al. (2013). Childhood Trauma and Psychosis in a Prospective Cohort Study: Cause, Effect, and Directionality. American Journal of Psychiatry, 170, 734-41
  5. Morgan et al. (2007). Parental separation, loss and psychosis in different ethnic groups: a case-control study. Psychological Medicine, 37, 495-503.
  6. Read, J. (2010). Can Poverty Drive You Mad? ‘Schizophrenia’, Socio-Economic Status and the Case for Primary Prevention. New Zealand Journal of Psychology, 39, 7-19 
  7. Janssen, I. et al. (2003). Discrimination and delusional ideation. British Journal of Psychiatry, 182, 71 -76.
  8. Read, J. (2006). Breaking the silence. In W. Larkin & A. P. Morrison (Eds.), Trauma and Psychosis. London: Routledge.
  9. Lothian & Read (2002). Asking about abuse during mental health assessments: Clients’ views and experiences. New Zealand Journal of Psychology, 31, 98 – 103.
  10. Read, J., Hammersley, P. & Rudegeair, T. (2007). Why, when and how to ask about child abuse? Advances in Psychiatric Treatment , 13, 101-110.
  11. Romme, M., Escher, S., Dillon, J., Corstens, D. & Morris, M. (2009). Living with Voices. Ross-on-Wye: PCCS Books.
  12. Dillon, J. (2011). The personal is political. In M. Raply., J. Moncrieff. & J. Dillon (Eds.), De-Medicalizing Misery. Hampshire: Palgrave MacMillan.
[i] Thanks to Jacqui Dillon whose story and workshop “Trauma, ‘psychosis’ and dissociation” (2013) inspired this article

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