From Trauma to Failed Dissociation to Psychosis

I'm a professor of clinical psychology and in my profession there is a raging debate.

Should we redefine psychosis and psychotic disorders as dissociative post-traumatic conditions? Or not?

History militates against this.

Psychosis is one of the first mental health disorders described in literature well over 150 years ago. And throughout this period, it has been conceptualized and reconceptualized as something totally separate from dissociation.

Actually, many of the main theoreticians of psychosis refuse to acknowledge the very existence of dissociation and dissociative processes.

So as you can see, it's a war, as bad as the war between Israel and Hamas, only without the compassion and empathy. This is academia for you.

What I want to do today is in my typical immodest fashion to propose a framework which could reconcile the two camps in a two-state solution.

And here we go.

But first we have to define the boundary conditions, the opening parameters.

Nothing happens without childhood abuse, adversity, and trauma. This is known as adverse childhood experiences, ACEs.

Now abuse, trauma, adversity, that's a very open field there's the classical forms of sexual abuse physical abuse verbal abuse psychological abuse we're all acquainted with those they feature in the media in movies and so forth.

But there are many other pernicious, subterranean, stealthy forms of abuse.

For example, instrumentalizing the child, using the child to accomplish the parents' dreams, to realize them.

For example, parentifying, when the child is forced to act as a parent to the parent, pedestalizing and idolizing the child, thereby denying the childaccess to reality and to peers, being overprotective, spoiling, pampering, any breach of the child's boundaries, not allowing the child to separate and to become an individual.

All these are forms of abuse and trauma.

And those are the active forms.

We have many passive forms.

For example, abandonment, neglect, rejection, indifference, these are all forms of abuse.

Even when the child is forced to witness violent events, it's a form of abuse and it creates trauma.

To summarize this part, it is extremely, extremely easy to traumatize a child.

And you need to be ultra careful and to walk on your eggshells and on your toes as a parent in order to not traumatize a child.

Children are very delicate creatures with minimal defenses, if any, and they are becoming, they're in the process of formation.

That's why we call the early years, formative years, because the child is being formed and molded and shaped, and it's very, very easy to disrupt the process.

So, childhood, trauma, adversity, and abuse. These are the preconditions for what I'm about to discuss.

How do children react to prolonged, protracted, regular trauma and abuse which last for years? How do they react?

There is a cascade. There is a progression of reactions, starting with splitting through dissociation and into psychosis.

I call it the failure cascade or the progression cascade.

All children start by splitting they divide the world intoall bad and all good.

Mami, the maternal figure, the first person who cares for the child, mommy is automatically divided to good mommy and bad mommy.

Bad mommy is a mommy who frustrates the child, doesn't cater to the child's needs. The mummy who leaves the room when the child cries doesn't change the child's diapers on time. That's a bad mummy.

Of course, a bad mummy is intolerable. It's threatening because if your mommy is bad, you are liable to end up as a dead baby.

So what children do, they internalize bad mommy. They absorb bad mommy. And they idealize mother. Mother becomes all good and the child temporarily becomes all bad.

Now, if the trauma is extensive, if the abuse is all pervasive, if the adversity is ubiquitous, if there's no escape and no sanctuary and no refuge and respite, then the child remains stuck in the splitting stage. Remains stuck in the splitting stage and the splitting becomes a post-traumatic defense.

In order to avoid the trauma, the child devalues itself. The child internalizes a bad object. The child develops a constellation of voices or introjects that keep informing the child that he is unlovable, unworthy, inadequate, ugly, stupid, in short, deserving of mother's misconduct and misbehavior. The child had it coming.

And so the child develops enormous guilt and even bigger shame in this process.

At some point, the guilt and shame are so dangerous, so life-threatening that they are dissociated, they're buried deep inside.

And so this is the stage where there is a transition from splitting to dissociation.

Splitting is the first line of defense against trauma and abuse, and it usually doesn't hold too well because the child is liable to develop emotions or affects which threaten the child's survival. The shame is so overwhelming, so disregulated, so life-threatening that the child would rather pretend that there is no shame.

Now when you pretend that there is not, that something that exists does not exist, that's a great definition of dissociation.

Dissociation, as we shall see, is comprised of a variety of techniques, all of them intended essentially to deny reality.

So this is the second phase. Dissociation is a defense against trauma.

Now there are three ways to defend against trauma dissociatively.

And by the way, the word is not disation. Many self-styled experts online use the word disassociation. It's wrong. There's not such word. The word is dissociation.

So dissociation has three components, three tactics, three strategies of coping with the unbearable, with the intolerable, with the ominous, and with the inescapable.

The first tactic is to simply forget the traumatic events. Forget, slice them off, pretend they've never happened. Delete all records, erase the file, nothing, nada.

So forgetting the traumatic events. This is known as amnesia, or more technically, clinically speaking, retrograde amnesia.

The second tactic is to deny that external reality is external. To say, this all is happening in my head. This is not real. None of it is real. The abuse, the trauma, the adversity, the neglect, the beatings, the hatred, the sex, none of it is real. It's all happening in my head. I can pretend that none of this has happened or is happening.

And this is known as de-realization when the child pretends that, and later the adult pretends that reality is not real. It's a tactic of dissociation.

And the third tactic in dissociation is to blur, to eliminate the boundary between self and world, between external and internal.

So the inner landscape, the psyche, become indistinguishable from reality, from the world out there, from the universe. The boundary is eliminated, erased.

And so this is a third tactic.

And one of our manifestations of this tactic is to deny one's existence.

So the child says, something is happening here, but it's not happening to me.

The abuse, the trauma, the adversity, the incest, the beatings, the breaching of my boundaries, the emotional blackmail, the emotional incest, all these things are happening. The child accepts the reality of these behaviors or misbehaviors, of these events. The child does not reject reality, but the child removes itself from reality by denying his or her own existence within the traumatic setting.

The child says, this is happening, but I'm not here. This may be my body, but it's not me. This may be occurring, but I'm far removed. I am not a part of this.

And so this is known as depersonalization.

Let us summarize the three strategies.

To forget that the events have happened, and so this is known as amnesia.

To pretend that the events haven't happened in reality, but only in your mind. That is de-realization. And to acknowledge that the events have happened, but not to you. And this is depersonalization. Now, as you can see, all three strategies are very convoluted. They require a lot of self-deception, a lot of energy. You need to fend off countervailing information from reality, you need to filter out information from reality that contradicts or challenges or undermines the dissociative defenses.

In short, dissociation is a lot of hard work. And that is precisely why it sometimes fails.

Now you remember, we are talking about the failure cascade, the progression cascade, starts with splitting.

When splitting fails, move on to dissociation. When dissociation fails, there are only two options left.

One is psychosis, and one is suicide.

Now let's start with psychosis.

When dissociation fails, as you recall, one of the main features of dissociation is the blurring, the elimination of the boundary between self and world, between external and internal. So when dissociation fails, this particular strategy of dissociation undergoes a malignant transformation. Rather than deny external reality, de-realization, there is a denial of internal reality. In psychosis, the psychotic denies internal reality.

Let us be clear. The psychotic does not deny external reality. He accepts it. He is aware of it. He acknowledges it. He senses it. There's nothing wrong as far as sensory input, except for hallucinations, which we will discuss in a minute. But generally speaking, the psychotic is well embedded in reality. But the psychotic denies the existence of his or her internal reality. What the psychotic does, the psychotic externalizes internal reality. The psychotic says, this is not happening to me. This is happening outside me. These voices that are talking to me, they are not my voices, even if I experience them inside my mind internally. They're not my voices. They are someone else's voices, God's voice, my neighbor's voice. They're not my voice.

This denial of ownership of internal processes, this is at the core of psychosis. So whereas in dissociation, the dissociative person denies his or her existence in the traumatic event, the dissociative person denies his or her existence in the traumatic event. The dissociative or dissociated person denies his or her presence in the abuse, in the trauma. The psychotic does not deny it. He simply says, I don't exist as an internalized or in inner entity. Everything that's happening that allegedly is happening in my mind is actually happening outside or coming from the outside as an external source. So in dissociation, the blaring or elimination of the boundary between self and world, between external and internal has to do with the removal of the mind from the sin. The dissociative person says, this is happening, but not to me, because I'm not there. I'm not there. I'm far away. The psychotic also blurs the boundary between self and world, between external and internal, but the psychotic says, this, everything in my mind, the voices that talk to me, the images, the visuals I see, the sounds I hear, the smells I smell, all these are actually coming from the outside. They are external. They are not in my mind. My mind is here.

The psychotic does not deny that his or her mind are there. Unlike the dissociated person, the psychotic does not pretend that he is not on the scene.

Psychotic says, of course I'm here. Of course I'm here.

But everything that's happening inside my mind is not happening inside my mind. It's actually happening outside me. He externalizes, or if you wish, outsources is internal reality. Now, in psychosis, exactly like dissociation. They are dissociated or dissociative internal voices. Voices are very critical in psychosis, in dissociation, and these voices, they are introjects. There are voices of significant figures and role models in the patient's life, mother, father, teachers, authority figures, influential peers, and so on so forth.

So both the psychotic and the dissociated person have to cope with a panoply, a multitude of voices, introjects that are out of control, interjects that keep talking to them, keep attacking them, usually. Usually these voices are harshly critical and very dangerous to survival. And they're a key feature of dissociation and psychosis.

One reason to reconceive of psychosis as a form of mutated dissociation, a subspecies of dissociation.

So these voices, these introjaze, the dissociated person perceives them as authentic. The dissociated person owns these voices. He acknowledges that these voices are internal.

While the psychotic denies the internality of these voices, even when he perceives them as internal, he claims that they have come from the outside. Psychotic externalizes everything.

Now, this dissociated aspect of psychosis, the fact that psychosis is simply an escalation of dissociation is common in many, many mental health issues, pathologies and disorders.

Consider, for example, bizarre and non-bizarre delusions, including paranoia, persecutory delusions, referential ideation, erotomania, and grandiosity.

In all these cases, in all these instances of delusional disorders, there is an internal voice. The voice can be explicit or the voice can be implicit, a hidden text. But this voice falsifies reality somehow.

These delusions, these convictions that are not amenable to any modification with new information. The delusions are resistant to learning and to change. You can't convince a delusional person that his delusion is a delusion as simple as that.

And why is that? Because the delusion is perceived as external, not internal. The delusion is confused with reality. This is a psychotic feature.

Delusions are psychotic in nature, which is a confusion between internal and external.

Also, for example, in narcissism, in dissociative identity disorder, in cases of identity confusion, in cases of identity alteration, in flashbacks during post-traumatic stress disorder, in all these cases, there is a massive confusion between memory and reality, for example, in flashbacks, between reality and internal reality, for example, in flashbacks, between reality and internal reality, for example, in narcissism and in classic psychosis, etc.

The boundary between self and world is demolished. And from that moment on, it's very difficult for the individual to tell where he stops and the world starts. Where the world stops and she starts. There are no boundaries there.

And so it's a form of desperate attempt to cope with trauma and abuse, because if you claim to not have an internal reality, how could you experience pain? By denying internal reality, the psychotic person avoids the experience of pain, of hurt, and of trauma.

Because only someone who has an internal world, an internal model, only someone with an interiority, only someone with an internal landscape can experience emotions, can experience pain, can experience hurt and rejection and abandonment.

If you deny that anything is happening inside you, if you say everything is happening outside, not inside, nothing is happening inside, everything is happening outside, then of course this is a defense against trauma and against abuse and against pain and against hurt, because there's nobody there to experience all these.

And of course, narcissism is a special case of psychosis.

Because what the narcissists does, he denies the external world. He accepts only the existence of the internal world.

By denying the external world, the narcissists says, no one can hurt me. No one can cause me pain. No one can traumatize me. No one can cause me pain. No one can traumatize me. No one can abuse me simply because there's nobody there. Their external world does not exist. Other people are merely my extensions. They are merely figments of my imagination, they are nothing but internal objects.

So you see the two solutions.

The psychotic says nothing is happening inside me, everything is happening outside, so I cannot experience pain and trauma.

The narcissist says nothing is happening outside. Everything is happening inside me, so there's nobody there to traumatize me and to cause me pain.

These are two solutions which are mirror images of each other, but both of them are desperate attempts to cope with trauma and pain and hurt and life-threatening shame and guilt, desperate attempts after splitting and dissociation have failed. These are all post-traumatic conditions exactly like borderline personality disorder.

Finally, of course, if everything fails, if the entire cascade completely loses its efficacy and the person can no longer manage or control the shame, the pain, the hurt, the negative affects, then the only last remaining solution is to reject life.

And if you're religious, to reject the afterlife.

Because by committing suicide, you will never enter the kingdom of heaven.

Okay, it's a rejection of life and the afterlife. And it's a rejection of life by becoming one with the world.

Again, suicide is an elimination of the boundary between self and world. If you kill yourself, then you become one with the world. Your body is recycled into the world.

So suicide is a way to deny the existence of oneself to such an extreme that one becomes integrated, fully assimilated in the huge womb, huge matrix of the world.

It's like going back to the womb. It's like being unborn. It's like saying, I regret having been born. I want to go back to my mother's womb, to my mother's uterus. I want to go back to the matrix.

And I'm going to do this by eliminating myself and letting myself become one with the fabric of reality, merging and fusing finally with this ultimate maternal object, the universe.