Trauma and Psychosis

I just attended an interesting seminar on trauma and psychosis and CBT. 

Psychosis is almost exclusively explained as a biological vulnerability.  Trauma is often assumed to be linked to depression and anxiety but causality is not openly as linked to psychosis.

One researcher and psychiatrist Dr. Bill MacEwan, found that among those in the Downtown Eastside of Vancouver in a population that is highly addicted to substances there is a higher comorbidity of psychosis and childhood trauma than anxiety and childhood trauma.  One explanation is that drug use mediates/masks the anxiety symptoms that trauma can produce and that increased drug use can trigger or exacerbate psychotic symptoms.

Notably Tony Morrison of the UK reported a study that found that in one study institutional care was especially significantly associated with paranoia and rape was associated with audio-visual hallucinations.  Physical abuse alone was significantly linked to both paranoia and audio-visual hallucinations.  Numerous other studies found the same link between psychosis and traumatic events, especially those in early childhood.  Also: people can experience psychosis itself as traumatic and may go on to develop PTSD after having PTSD from the psychosis or institutional care.

This is particularly significant because it means a couple of things.

1) Preventing abuse of children could diminish those who experience psychosis

2) Understanding this link can help someone gain insight into their illness  and through addressing trauma.

3) Our care should acknowledge this and seek to diminish further trauma and increased sense of safety.

For me going starting into a field working with people with psychosis and also with a huge passion for helping people with trauma this brought a new meaning to my work with those with psychotic illnesses and more perspective and ideas on how to understand those of my neighbors in the DTES with psychosis.

Suffering and Trauma

A few days ago I picked up Trauma and Recovery by Judith Herman a book that has been recommended by various people I’ve met in the field of trauma.  Herman uses a feminist narrative to understand the history of trauma, responses to trauma, and recovery.  Right now I’m entrenched into the gory details of human suffering.  As I read the descriptives of what people have suffered in concentration camps, through rape, kidnapping, and child abuse I begin to feel that I cannot bear taking in any more stories of such pain.  It is at these moments that I feel the weight of working in the profession that I do.

In reading this book and hearing the reams of horrible nightmare-like events that people survive I’m drawn back to Job.  How in the world did he manage to cling to his faith in God during that time?  Herman in her book claims that only the smallest minority can survive intense war/kidnapping/abuse without experiencing symptoms of trauma.  She develops a hypothesis that for all there is a breaking point although that is different for some than others.

I was speaking to a colleague today and I challenged her to find a client with a significant persistent mental health issue who has not suffered family neglect/abuse or some sort of trauma inflicted by others.

It is interesting that the line of treatment for mental health issues is cognitive behavioral therapy something which is aimed at understanding and restructuring thoughts and negative core beliefs, but does not centre on pain and suffering as a central part of its framework.  However, for the severely traumatized/mentally ill most clinicians likely agree that this is rarely adequate or enough.  Many cases we file away as hopeless, at least within the bounds of a brief therapy/managed care setting.

I tend to hope that even a short-term therapy interaction that can provide a person a sense of safety, a holding place to process their emotions and begin to understand their thoughts and feelings could be helpful.  I believe this because I have faith that most of the change in people’s life happens outside of the therapy session, through the community, extended family, and social engagement.  However this change may not be initiated or engaged when a person continues to be captive to the negative and false beliefs about themselves that were necessitated by an oppressor (especially one who they loved).  How can we give the fit of beginning on the path to change and healing without falling off that path all together?

For many we do not do enough and some will leave the opposite feeling disappointed and abandonned again, by us as mental health professionals.

Some, however, I hope (with God’s grace and care) are carried onward by a significant experience of care and understanding in therapy.  For this these individual are able to begin to acknowledge their pain, sit with it, process it, and then through re-imagine the world based on new experiences  and then regain a realistic trust in the world and see themselves as worthy and lovable human beings.

Through the eyes of a Friend

I want to tell you about the most interesting thing that happened in therapy with a client. I was working with a man who has experienced significant trauma in his life and we were doing a safe place visualization where he imagines a safe place and I ask him questions to enrich the visualization.

One of the questions I asked was “who is there with you”. He answered a friend, a childhood friend. This man reports having no friends and no close family, and no social support in his life but was able to go back to his childhood and find a loving and kind friend. When I asked him about this friend after the visualization I found out that he and his childhood friend both had a similar name.

What a discovery! Inside of himself was not just a friend, but a kinder, gentler, more accepting part of himself an alter ego of sorts, a companion to the blaming, negative “self” that has crept in to dominate his vision of himself accusing  of failure day in and day out. It is incredible what an experience with a good friend can do for a person, even if the friendship is no longer present. It is similar to the experience of the therapeutic relationship; it gives a person a chance to build an alternate reality than they are accustomed one that is trustworthy, and stable that can disrupt older patterns of thinking that have gotten a person or family stuck.

It reminds me of my and my friends personal journey with people in our neighborhood who struggle with addiction and have had abusive childhoods.  For many years we plod along, not perfectly, but trying our best to be loving friends to those who are not always easily befriended, and who need a lot more than we can give.  It can be easy to dismiss these relationships as of such a small value in their overall healing journey.

Afterall, our love for one another pales in comparison to the amazing love and forgiveness that God offers to each of us.  But for some reason or another God chose us to live in relationship with one another and be the bearers of His love for the world to each other.  It would seem a lot more effective that he could appear in visions with bright light and angels announcing his love to each person, but instead he works in mysterious, gentle, and sometimes quiet ways through our broken selves.

Let us find encouragement that through the loving gaze of a friend this man could feel love and acceptance that he would not otherwise feel toward himself, and that our commitment to love can go a long way.

A Vision

Today I had a vision/idea. I have had this idea in my head for some time, but it is now taking shape.

I’m very interested (like most social workers) in the influence of trauma in a person’s life.  The ACE study (Adverse Childhood Experiences- http://www.acestudy.org/) found that adverse Childhood experiences correlate with negative long-term health in generally, poor mental health and even a shorter life expectancy.

In the Downtown Eastside it is hard to find a person who has not experienced trauma.  It seems like drug addiction has become an ingrained coping method that effectively masks the emotional hurt of the past.  We have many health clinics, and outreach teams, and church missions in our area.  However, I wonder how much treatment for trauma is actually taking place.  Pharmaceuticals help with the pain, but I think there is more that can be done.

One of the obstacles in providing any kind of help here is the chaotic nature of people’s lives- which begs the question how much healing can take place within an environment that often recreates trauma (like our neighborhood).  I have a neighborhood friend who I have spent time on and off for the past 4 years.  It is hard to even make an appointment with her to do something fun like go swimming.  How hard would it for her to go to counselling, or even focus in a session?

I wonder about clinically skilled, but harm reduction outreach counselling for those at the margins?  Also: I would love to do this from a Christian perspective as I believe that God has an amazing unpredictable power to heal and comfort that even the best counsellor cannot provide.  I will have to do some research but for now I’m getting in touch with friends who are knowledgeable in this area of work in the neighborhood, and researching online.

I think especially the integration of horticultural and art therapy would be really neat to accompany first stage trauma treatment. When I say first stage trauma treatment I mean teaching skills like grounding, containment, and journalling (see Lori Haskell’s book http://www.camh.net/Publications/CAMH_Publications/first_stage_trauma_treatment.html).  This step is one that some suggest to provide a sense of safety and self-awareness  before they are ready to tackle intensive therapy for trauma like Cognitive Processing Therapy or EMDR with a skilled therapist.

An idea.  Let’s see where God takes it.  I love dreaming.