Dissociation and avoidance in psychosis: narratives through the trauma-lens

Abstract

Section A
Research on the relationship between trauma and psychosis continues to grow (Bloomfield et al., 2021), however, a clear understanding of processes involved from trauma-related stress to vulnerability for psychosis has yet to emerge. Processes associated with post-traumatic responses have been suggested to be involved in psychosis-related experiences, such as dissociation and avoidance. There is increasing evidence which depicts an association between dissociation and psychosis-related phenomena (Longden et al., 2020). Additionally, experiential avoidance has been found to relate to voice-related distress (Varese et al., 2016) and to forms of dissociation (Marx & Sloan, 2005). This review aimed to critically evaluate literature that depicts the roles of both dissociation and avoidance in the context of psychosis and to present a metasummary of the emerging themes across studies. Ten quantitative papers and three qualitative papers met the eligibility criteria, which collectively comprised of outcome evaluation data and interview-based research. Sandelowski & Barroso’s (2006) metasummary approach was taken to synthesise the findings, where six themes were found: dissociation and avoidance linking trauma and psychosis, working with dissociation and avoidance in psychosis, associations between dissociation and avoidance with psychosis, conceptualising dissociation and avoidance, using measures of dissociation, and the relationship between dissociation and avoidance in psychosis. Results suggested dissociation and avoidance could be grouped as emotion regulation strategies in the context of psychosis, and demonstrated ways in which these processes may distinctly occur. Combined investigation of both dissociation and avoidance as processes within psychosis requires further investigation considering the limited empirical research available. Implications for practice and further research are outlined.

Section B
Despite evidence, trauma-based explanations for psychosis are often overshadowed by biomedical ones (Harper et al., 2012) and individuals with psychosis remains underrepresented trauma-focused research and practice (Mueser et al., 2010; Hardy, 2017). However, strong links between trauma and psychosis have led to the development of effective trauma-focused therapies (TFT’s) for reducing associated distress (Brand et al., 2018). Furthermore, processes akin to post-traumatic stress, including emotion regulation strategies, are observed in individuals with psychosis (Hardy et al., 2024), such as experiential avoidance (Powers, 2016) and dissociation (Longden et al., 2020). Yet, research jointly exploring dissociation and avoidance as trauma-related processes in psychosis remains limited (Marx & Sloan, 2005; Longden et al., 2020). This study conducted a narrative analysis to investigate individual narratives of TFT for psychosis; whether and how they described experiences of dissociation and/or avoidance in their narratives, and if so, whether and how these were explored in TFT. Additional aims included analysing narrative structure and exploring the presence of biomedical or trauma-related frameworks e.g., comorbidity model. Narratives described the difficulty accepting psychiatric diagnoses and discussed biological versus trauma-informed explanations of psychosis. Dissociation and avoidance were described in the narratives as ways of managing trauma-related distress from early and later life experiences. The therapeutic relationship, eliminating self-blame and shame, and support to sit with emotions were identified as processes which supported overcoming distress. These findings highlight the need to assess for dissociation and avoidance in psychosis and inform trauma focussed clinical and research directions.

Date of Award	2025
Original language	English