The debate about the origin of schizophrenia being genetic, social, biological, drug induced etc rumbles on and on. But what of the spaces where the person with so called schizophrenia, voices, hallucinations, paranoia etc. inter-relates in a safe, constructive and validating relationship and the prominence, distress and threat no longer take priority?
Is the person in an altered state presenting a narrative of fear and response to fear, that he or she experiences in unsafe relationships and the world around them? What might happen when the person who is sitting facing them, who has labelled and described their legitimate functional adaption to cumulative interpersonal trauma as an ‘illness’, ceases to label and instead offers their own self in relationship with the person in a so called psychotic state?
Recently I have been noticing a lot less ‘psychosis’ in the consulting room. Perhaps more important, noticing less and less interest by the person that may have been labelled or self-labelled as psychotic, in talking about or even experiencing the ‘psychosis’. This may potentially be a good thing, but If psychosis itself is not the priority to the ‘psychotic person’, then what might be the difficulty? Could it be that the psychosis, altered state was simple an expression of unsafe relationship and when that relationship becomes safe the ‘messenger’ or altered state does not need to speak so loud to maintain safety?
Not seeking to buy into the biological, reductionist frogmarch of diagnosis and rid the ‘symptoms’ from the person, one could be seen to be most welcoming of the voices, visions and experiences that a person brings to the room, as a small representation of the realities that the person experiences in daily life: taking an interest in what has and is happening on the persons journey as their narrative, their legitimate expression of story?
In doing so, and welcoming the realities as messages, metaphors, guides, spiritual encounters and even for some the ‘illness’, the altered state often does not join us. It becomes less of a concern, or at least the altered state or protective reality ceases to become the priority…Or perhaps the priority that the reality occupied does not seem so overwhelming?
The reality has not gone, it has not been banished or ‘treated’, in deed it likely cannot be treated for it is a person’s legitimate reality, ‘a perfectly rational adjustment to an insane world’ (Laing 1965). It has not even been intentionally or meaningfully explored on most prior occasions. Why not? Because, sometimes other things become more important to explore in a relationship – perhaps the meanings and messages that are being expressed in the ‘psychotic’ state are what is important to experience in relationship? Whether implicit or explicit, other energy, content or distress becomes the most prominent thing for the person attending ‘therapy’ (being in relationship). When this occurs, and the person listening does so with justice and honour of the person in distress, as legitimately ‘being’ in the world, there is potential for other priorities can emerge. How does that happen? There I sit with my hearing voices movement ideas, psychodynamic training, influences from great supervisors, Buddhist teachers and a good number of years of education from the individuals that I have been fortunate to witness as ‘fellow beings’ and the problem that we all want to talk about doesn’t demand the focus: where has the psychosis gone?
Most recently Trauma informed care and Trauma focussed approaches have emerged and continue to do so: approaches, guidelines that prioritise safety in relationship. However, this isn’t a new idea. Bion, for example, talked about the ‘safe container’ many years ago, but the modern language of trauma informed care has a more accessible structure. What has been heard in the trauma informed approaches are concepts around people being in a state of attachment confusion, people being triggered by memories in situations, people dissociating, and at times, not being, or having the experience of not being, in contact with mind and body as a whole system that relates together - we might think of this as dissociation. What I have been taught by people identified as being ‘psychotic’, is that a person is often very much able to be in their bodies, in their minds, and in their bodies and minds together and in relationship with their whole; and all this in relation to another person. Sometimes, this requires working with the body, working with the mind, working with spirit, working with both, all three or sometimes working with the nothing of it all. What is certainly required is the relationship: loving, compassionate and acceptance of selves in relation to one another.
The process can involve talking about life events and experiences, about trauma, about a good life that a person has experienced, the interpersonal realities including fear, threat, love, joy, connection, disconnection, confusion, happiness, safety, unsafety, overwhelm, empowerment, hope, anxiety, awareness, distress, arousal, experiences of violence, gratitude and kindness by others, compassion…the list goes on. The reality that we know, is that a person brings them self or selves to a relationship (‘psychotherapy’ session) – this is not the doing of the therapist.
Witnessing many people who have been identified as psychotic not actually appearing psychotic is a great education and privilege. Often, we talk about psychosis as what the story and the person has become, but psychosis is often not in the room. So, are we really talking about psychosis as all?
With the modern understanding of complex trauma and the challenges of interpersonal safety that might be experienced in reflection of such trauma, so too we might observe a mirror of psychosis: The person in an ‘extreme’ state skilfully holding the person (them self) behind such a state in a safe relational distance from the other [therapist], while the safety is considered, established or disproved. This is a wonderfully skilful adaptation. The person deemed psychotic and to have something so call ‘Schizophrenia’, laden with the prejudice that accompanies such a label, may be displaying the greatest skill and ability of all in their use of the mirror of the other.
For many people that experience and are labelled as being psychotic their journey…their story… often includes significant experiences of interpersonal conflict. Interpersonal conflict that has often been cumulative and has been traumatic: Interpersonal, cumulative conflict of often physical violence, sexual or other traumatic reality.
In recent years, we have learned (accepted) to understand the impact of trauma on the developing person and that the health problems, the interpersonal dilemma and the adult experience are legitimate and functional adaptations by the person who has experience cumulative, sustained, interpersonal adversity.
We know that the physical and mental wellbeing is impacted by adversity and trauma in childhood, and we know that there is a dose response between adversity in childhood and impaired physical and mental health, including reduced life expectancy of 20 years. We even know that the cost to the health system of the resulting challenges for people who have experience childhood adversity and trauma is enormous, and we know that the economic cost to productivity is even more significant. Although, by measuring economic cost we are, perhaps unintentionally, placing blame and shame in the experience of a person who has experienced trauma being perpetrated against them, for which no blame can be apportioned to the individual. The guidelines on working with trauma are consistently about the person being able to work through and overcome the harm of interpersonal cumulative trauma in becoming the unique human beings that they have always been, but had an interruption in the freedom to live in the light of their own uniqueness due to the impact of the actions of others.
The emerging diagnostic labels of CPTSD and complex trauma have begun to provide a framework by which the shame, victim blaming and re-traumatisation can begin to be reduced and hopefully cease. The trauma informed understanding is still developing, but the absolute reality that people can and do recovery, and that a person can define recovery in the way that leads to their own priorities for a good life is clear and illuminous.
Despite understanding that psychosis is likely for many people to be a meaningful response to life events, the person who is identified as having schizophrenia somehow, and often continues to be seen to have a bio-genetic disease and primarily in need of a biological treatment. This is supported by unfathomable prescribing rates of antipsychotics in Australia, including a rate of 30,000 per 100, 000 of the population in several major cities. We might argue that the role of environment is a contributor to a person being label as have schizophrenia, but the prevailing and dominant approach to treatment is drugs and disorder.
If we look at the context of trauma in the lives of people who are labelled as experiencing complex trauma, and those labelled as experiencing schizophrenia, we see significant correlations and this might lead us to experience hope, understanding, meaning, acceptance of the human being towards personal empowerment of the person formerly labelled as having schizophrenia towards recovery from adversity.
The dose response rate for people experiencing trauma, adversity and childhood abuse is the same in the group of people experiencing complex trauma and the group of people diagnosed as experiencing schizophrenia. The same double bind of victim blaming is present in the group of people experiencing complex trauma in the misunderstanding and labelling of ‘behaviour’ leading to discrimination and exclusions, as the group of people diagnosed as experiencing schizophrenia, including when a person is legally compelled to accept ‘treatment’. This represents not a meaningful response to life events, but an oppressive misunderstanding and labelling of the person.
So, what of the person identified as having schizophrenia and ongoing psychosis? On most occasions the person experiencing ‘psychosis’ has experienced cumulative, interpersonal trauma (AKA - complex trauma)? The ‘psychosis’ that protects a person from the threat of others is the same functional adaptation experienced by a person with complex trauma that becomes hyper aroused when experiencing an unsafe interpersonal dynamic (even when they may not be able to identify why, what, how they came to feel that way)? The life expectancy and quality of life, the risk of physical health problems (as well as the mental distress) is consistent for the group of people said to be experiencing schizophrenia with the data on the group of people experiencing complex trauma? But most important of all, we witness the same courageous, incredible, powerful and wonderful human beings emerge when the same trauma informed approaches, that develop a safe and healthy relationship for a person to emerge into their body and mind, with a person experiencing complex trauma or labelled as experiencing schizophrenia?
Professionals and systems often speak in an all knowing ‘truth’ and re-traumatise through often oppressive approaches, supported by often bias and limited ‘treatment’ options. This creates dissonance between the legitimate experience of the person and the professional. The person is only partially believed or accepted in their description and reality of the effect and harm a person might experience from the ‘treatment’, amplified when being forced or coerced into ‘treatment’ for their ‘own good’. It is this moment that the professional may well be [re]traumatising the person due to the bio genetic informed labelling of a person as experiencing schizophrenia. This despite the explicit reality of the data demonstrating the likely shared experience for individuals that have experienced adversity, trauma and abuse in interpersonal and cumulative dynamics in both complex trauma and schizophrenia. It appears that the difference that modulates the response by the professional is that the symptom of ‘psychosis’, despite this potentially presenting as a legitimate functional adaptation to the threat.
Reflecting on the lack of presentation of psychotic phenomena in the spaces in which I quietly sit with the other person, I wonder not, why is the person no longer psychotic, but why do we see the psychosis as anything other than a legitimate and functional response to the threat the other person poses to a person who has experienced cumulative, interpersonal trauma (complex trauma)? And then I realise that it starts with the label that ‘others’ the person experiencing extreme states is the problem. The other may not be experiencing ‘psychosis’, ‘extreme states’, ‘altered realities’ or any other label… I am experiencing the label and projecting that onto the person. The person is experiencing the legitimate threat that is remembered implicitly, explicitly, in the body and / or mind and is affecting the person’s sense of safety and spirit. The person is being re-traumatised in the relationship with me when I see and use labels.
The memory, wherever and however it is experienced, is being remembered and my role is not to re - traumatise with the labels of schizophrenia, but to accept the enactment and become the facilitator of a safe space, a witness to the story, a companion in the distress and the inevitable recovery as the person emerges in safety.
It is the moments and spaces of safety that allow the ‘psychosis’ to be non-psychosis, still present (often), still important messengers, metaphors and keepers of the persons intuitive and neurologically developed safety nurturer, but no longer needing to take up the whole space, leaving open the pathway for the individual to emerge, grow and be; not a new person but a person that has always been, been protected by the psychosis until such time that the person has found safety within their own courage and survival and within safe relationship with the other and the environment.
Schizophrenia is interpersonal: It exists between the person and threat, from which the necessary fear and adaption, which we call psychosis, has emerged. If we embrace psychosis as the functional adaptation, and schizophrenia the mirage that evaporates in safe relationship with another person the messages can be heard rendering the existence of an altered state or ‘psychosis’ and no longer require as the person is witnessed and she or he emerges in to their own unique being and sense of safety.