Recent years have seen an influx of numerous studies providing an undeniable link between childhood/chronic trauma and psychotic states. Although many researchers (i.e., Richard Bentall, Anthony Morrison, John Read) have been publishing and speaking at events around the world discussing the implications of this link, they are still largely ignored by mainstream practitioners, researchers, and even those with lived experience. While this may be partially due to an understandable (but not necessarily defensible) tendency to deny the existence of trauma, in general, there are certainly many political, ideological, and financial reasons for this as well.Many have called for the trauma and psychosis fields to join forces. So many valuable findings have come out of the trauma field that could inform practitioners and lay people alike in understanding how one might come to be so overwhelmingly distressed and behave in such seemingly strange ways (see Read, Fosse, Moskowitz, & Perry, 2014, for an informative overview of how trauma affects our bodies). Studies looking at how the non-
BRIEF HISTORY OF TRAUMA RESEARCH
Over 100 years ago, Pierre Janet became the first major figure to identify and treat the vast array of the effects of trauma. In fact, he considered almost all ‘psychopathology’ to be the result of childhood trauma and dissociation (Janet, 1919/25). Under the large umbrella term of ‘hysteria’, Janet identified the following symptoms: hallucinations in all senses, fugue states, amnesia, extreme suggestibility, an odd disposition, nightmares, psychosomatic and conversion symptoms, reenactments, flashbacks, paranoia, subjective experiences of possession, motor agitation, mutism, catatonia, thought disorder (or disorganised speech), and/or double personalities (Janet, 1907/1965). He believed that treatment consisted of a phase-
For the next eight decades or so, the mental health field became more and more narrow in its focus on and recognition of trauma to the point of neglecting it completely in the more biological domains. It was not until the late 1970s, when a massive influx of veterans gained political clout and women began to speak out and be heard, that trauma was once again recognised as a major factor in extreme emotional distress. This also was the time when the DSM became psychiatry’s new bible; and so, while trauma was once again recognised, it was also separated into narrowly defined disorders that included PTSD, adjustment disorders, and dissociative disorders (including multiple personality disorder, as it was then known). It was then that the modern-
So what are people talking about when they speak of ‘dissociation’? Well, not too many people agree on this. It also appears as though the more professionals attempt to come to a consensus on what this term means, the more they do so in an effort to delineate it from any possible association with ‘psychosis’; their attempts to define dissociation are done by disassociating.
Wikipedia defines dissociation (in the broad sense) as: ‘an act of disuniting or separating a complex object into parts.’ I do not believe that many mental health professionals, particularly dissociation researchers, would entirely disagree with this definition. Rather, it is the interpretation of this meaning that is a hotly debated topic within psychiatry (a general term I use to describe the entirety of the mental health field). In general, it may be used to describe a process, a multitude of symptoms, specific disorders, a division of the personality (or lack of integration), and/or a psychic defence. Many believe that it refers to disconnection from one’s thoughts, feelings, environment, self, others, etc. The term is also used to refer to a process of entering a trance-
If nobody agrees on what it means, then why do we really care? Because the political implications and resulting effects on treatment options are directly related to how one interprets this meaning. We can see how this might work by looking at the DSM.
DSM AND ALL ITS FANCY TERMS
Akin to many religions throughout time, psychiatry makes up many technical terms and then creates circular and eccentric definitions to confuse lay people into believing that mental health issues can only be dealt with by an educated professional. Putting this political manoeuvring aside, I would like to focus for a moment on key terms related to the topic at hand: trauma, dissociation, dissociative symptoms, psychosis, psychotic symptoms, dissociative disorders, and schizophrenia.
Trauma: Trauma is technically defined as an event that provokes death-
Dissociation: As stated previously, very few professionals in psychiatry agree on what this term means. Instead of just saying ‘absorption’, ‘feeling unreal’, ‘feeling one’s surroundings are not real’, ‘lack of integrated sense of self’, or ‘detachment’ (all considered in different circles as varied forms of dissociation), scholars instead argue over its meaning until it has no meaning at all. Often, it is an ideological term that is used to say ‘trauma’ versus ‘not trauma’, whether this is explicitly acknowledged or not. Therefore, when one’s ‘symptoms’ are considered non-
Dissociative symptoms: Although dissociative symptoms are acknowledged as existing in a multitude of different DSM categories, they mostly are usurped by the dissociative disorder classifications. In this case, as I will discuss in a moment, dissociative symptoms often seem to take on the meaning of ‘not psychotic’ rather than having any distinct meaning in and of themselves.
Psychosis: Psychosis is another technical term with no precise meaning. It tends to refer to a state in which a person appears to not be aware of or in touch with consensual reality. This can be for five minutes or five years, but the term itself is non-
Psychotic symptoms: Most people tend to think that psychotic symptoms clearly refer to things such as hearing voices, seeing visions, having strange beliefs, or disorganised thinking/speech. However, ‘psychotic symptoms’ specifically refers to symptoms of psychosis. What is psychosis? Having psychotic symptoms. If you don’t have psychosis, then you may have ‘psychotic-
Dissociative disorders: While there are five dissociative disorders, the one that is most intertwined with the idea of psychosis is dissociative identity disorder (DID). People who might meet the criteria for DID often experience what is unarguably the core of the term ‘dissociation’; namely, having a fragmented sense of self. In addition, they also experience periods where they cannot remember large gaps of time. This amnesia is certainly not an experience that is universal to many or even most individuals suffering extreme states; however, the other experiences common in DID are definitely non-
Schizophrenia: The category of schizophrenia, and all its sister disorders, is one that is assumed to be a largely biological, genetic brain disease. What differentiates it from DID? No one seems to be able to define where this distinction lies, but those in the dissociative disorder field will state that the difference is based on the existence of ‘delusions’ and/or ‘thought disorder’. A delusion, of course, is a belief that society deems unacceptable. Yet, nobody seems to be able to explain where the line is, separating a delusion from an acceptable belief. More specifically, nobody will explain what the difference is between believing ‘I have a bunch of people living inside of my body who are not me’ (DID) and ‘I am god’ (psychotic). But questionnaires that measure dissociation use this very distinction to say whether one has dissociation or not. And then they say ‘delusions are not related to dissociation’ because they just ruled out dissociation by the fact that a person did not endorse an interpretation of their experience that the questionnaire-
‘Thought disorder’ has been convincingly described by Richard Bentall as a problem in communication, rather than an indication of any true cognitive impairment (Bentall, 2003). Yet, the theory adopted by mainstream psychiatry remains that ‘thought disorder’ is a neurological disease. And so, if one is considered to have DID, any indication of thought disorder is instead interpreted as ‘intrusions’ or ‘rapid-
On the other hand, psychosis researchers solve the problem by simply saying that DID just does not exist. People who present with altered identity states and memory problems (not attributed to an actual neurological problem) are considered as just ‘borderline’ or ‘attention-
In spite of these ideological battles, studies still have shown that individuals meeting criteria for schizophrenia endorse a greater level of dissociative symptoms than any other clinical group, discounting PTSD and dissociative disorders (Ross, Heber, Norton, & Anderson, 1989). Approximately two-
On the other hand, it has been found that dissociatively-detached individuals are not necessarily chronically psychotic and can function at a high level (Allen et al., 1997). Individuals diagnosed with DID are often able to maintain reality testing despite experiencing ‘psychotic’ phenomena (Howell, 2008). Another difference is that persons diagnosed with DID also report higher levels of dissociation, and more child, angry, persecutory, and commenting voices (Dorahy et al., 2009; Laddis & Dell, 2012). They also generally report a higher rate of more severe childhood trauma than any other clinical group (Putnam et al., 1986).
WHAT DOES THIS ALL MEAN?
It is often purported that ‘delusions’ and ‘schizophrenia’ are not dissociative, when using the narrow definition of dissociation: when dissociation means dis-
I do not believe it is possible to separate psychosis and dissociation; to me this is like attempting to separate a headache and a fever when I have the flu. Where does the headache begin and the fever end? And should I focus on ‘treating’ my headache, fever, or maybe the virus that infected me and is creating an interconnected process of events in my body? While psychosis and dissociation are not the same thing, I believe that one does not have psychosis without dissociation or dissociation without psychosis. Often the difference simply boils down to who can frame things the way that the professional wants to hear or agrees with.
Certainly not all those who experience altered identity states experience strange beliefs, voices, or incoherence, but most do. Not all those who experience extreme states also experience altered identity or memory loss, but some do. These experiences are not separate, even if they are different. Although one may appear more reality-
Of course, this belief comes with the caveat that some presentations of emotional distress (whether it is psychosis, depression, dissociation, or any other term or category one might like to think of) are dietary, biological, and/or neurologically based. These are not psychological or psychiatric problems, then, and should be dealt with in the medical realm. All individuals suffering from extreme states should evaluate their diet, exercise, and overall physical health; when these are shown to be a non-
I do not have all the answers. But, I do ask why it is that mental health professionals do not start with just saying what they mean? We can talk about altered identity states, memory loss, feeling unreal, not knowing what is real or not, being terrified of others, etc. Mental health professionals can own the fact that ‘I do not understand this person’ instead of taking this as unequivocal evidence of some brain-
At the end of the day, extreme states and anomalous experiences are terrifying; they are terrifying to the people experiencing them and to all those around those people. Doctors are human beings (much as many might like to state otherwise) and they too often act out of that fear. Certainly, nobody wants to get labelled with being psychotic, and there is benevolence in the efforts of those who try to save many from being so doomed. Being recently labelled with ‘schizophrenia’ appears to be enough to increase the likelihood somebody will commit suicide (Fleischhacker et al, 2014).
Instead of trying to understand people through labelling and insisting on enforcement of an authoritarian dictation of what the experience ‘really’ is, perhaps psychiatry can listen to those who have actually been there. The Hearing Voices Network has given us tools to work with voices and other anomalous experiences; the National Empowerment Center has given us tools on how to work with crises and extreme states; I am working to try to get first-
Why does psychiatry then continue to insist on abiding by a broken and invalid system of disease mongering? Why do we not allow the experiencer to make sense of their experience through their own framework? Why must we be so evangelical and insist that they see things our way? There is nothing that can truly, scientifically say that one diagnosis is more ‘accurate’ than another. All of these diagnoses are just checklists of behaviours—there is nothing that anybody ‘has’ and, until some biological test shows otherwise, nobody can claim that there is. What matters is being with a person in their world where they are at and understanding the meaning behind the experience, not attempting to define the experience itself in a way that makes sense to us. This is nothing more than social control and perpetuation of the status quo, not science.
Even the most biologically-
Noel Hunter lives in America and is a clinical psychology doctoral student, exploring the link between trauma and various anomalous states and the need for recognition of states of extreme distress as meaningful responses to overwhelming life experiences.
Reprinted with permission. First published at www.madinamerica.com in August 2014.
References: click here.