I have 13 draft posts sitting in my WordPress dashboard (including, from 1st June, one entitled ‘Everyday Feminism’. A response to a wave of posts on feminism on other mental health blogs, this article was conceived and drafted well before I learned of the excellent ‘Everyday Sexism‘ project, which highlights exactly the same things as I’d set out to write about. Given the huge success of that site, I clearly missed a trick there 😉 Oh well; it’s entirely my own fault.) So, rather than try and complete one of those, I am of course embarking on an entirely new post. Obviously.
My therapist and I irritated each other today – indeed, he commented at the end of the session that it was “almost like we were arguing.” I responded by quipping, “you should have seen me arguing with my last therapist then.” It was intended as a compliment as it happens; my last therapist had a propensity for being an arsehole, and my current one generally doesn’t. I used to scream at, laugh at, sneer at, insult and on one occasion even threw something (my glasses) at my ex-therapist. I have never felt thus inclined with the current one.
However, as I was walking down the stairs out of the building, I realised that if anything I’d insulted him by reminding him of how volatile I could be with my ex-therapist (and not him). If that sounds perverse, then hear me out. My ex-therapist had (eventually) access to all of me; the good, the bad, and the very, very ugly. My current one often comments that he only occasionally sees any anger in me, yet he knows it’s very fundamentally there. He never sees psychosis, dramatic outbursts, personal attacks, blah de blah, and he wonders why.
Why indeed. He might think it’s about trust; did I trust the ex-therapist completely, to the point where I surrendered everything to him? Arguably so, I suppose, and I can see why that would offend my current therapist – or at least cause him to wonder if we really have the rapport we seem to. I see it differently, of course, but he always accuses me of trying to rationalise or find reasons for things rather than just feel, and this could be one such occasion. Who knows.
One thing my therapist and I will never agree on is the role of psychiatry in the management of conditions like mine. One of the reasons, in my view, that my therapist has never seen any psychotic episodes in his time with me is simply that medication has fended them off. He regards such an explanation as a cop-out, rather than something that might actually be the bloody reality, which is immensely frustrating at times. To me, in general terms anyway, he treats my PTSD; my psychiatrist treats my bipolar/schizoaffective disorder. I view them very much as discreet, separate issues, though of course I accept that the causes and treatments for such ‘disorders’ are complex, varied and deeply individual.
And herein, finally, lies what I’m attempting to get at with this post. What is psychosis, and what is dissociation? Are they one and the same, as he appears to see it? Or are they different manifestations of different types of mental health condition?
Literally the second I sat down today he said:
I’ve been reading a book called Today I’m Alice, which is about a woman who experienced psychosis in the wake of severe trauma. I read it, and thought of you throughout.
I listened to him describing the book, and found myself somewhat bewildered. He was clearly describing a book about dissociative identity disorder, not psychosis.
I mean, it even says it’s about DID(/MPD) on the front of the damn thing!
Now, I can see why some would be confused by the distinction. If alters/parts are talking to you, and you’re not aware of them as individuals sharing your body or of the fact that multiples even exist (and I’m guessing that many not already immersed in this online world of crazy people don’t), then assuming you had schizophrenia or similar might seem like a logical conclusion. I can even see why it would be difficult for a psychiatrist to arrive at the correct diagnosis.
Still, these conditions are not the same, whatever popular opinion and the media may erroneously suggest. For my therapist, a man who has worked with both psychotic and dissociative patients and who is about as close to an expert in this arena as I’ve met, to equate them is astonishing. He would argue that he sees all mental health conditions as existing on a trauma-based continuum and, although I don’t agree with that model, I can see the arguments that give rise to it. But why does that have to mean that psychosis and dissociation are virtually identical sides of the same coin?
Now, I don’t have DID, and as someone once pointed out to me on this blog, I probably don’t have the first clue about what it’s really like. My knowledge of the condition stems, in the main, from reading the blogs of those that do have it – and that is very different. But I have experienced dissociation of some descriptions, stemming from the PTSD, and even once encountered what my therapist and I thought at the time may be a co-conscious alter (though I’m pretty sure she didn’t turn out to be, as such. A fragment, perhaps – a sign that I wasn’t psychologically owning up to all that I needed to own up to.) Psychosis is different, though in a nebulous sort of way. Let me see…
The ‘hearing voices’ thing is at the crux of Today I’m Alice, my therapist’s discussion of which prompted this post. If we assume for a second that the possible alter I mentioned in the last paragraph actually was an alter (again, I don’t think so), then the experience is very different. Your mind clouds, and it feels like someone is ‘pushing in’ to your consciousness. Any words are heard from that pushed area – not your own, but very definitely right there, in your head. And my experience was that they, however alien, came from somewhere.
The auditory hallucinations I experienced when psychotic came entirely from out of the blue. You’d be sitting minding your own business, and from somewhere, someone would say, “hi Karen, how are you?” (Note that this voice was one of the nice ones. There’s this perception, I think, that all hallucinatory voices are bad – but they’re not necessarily. Indeed, quite a few people choose to happily live with their voices without seeking treatment of any sort.) That particular voice was outside my head, like an actual voice – a person sitting there, five feet away. I believe, though I cannot find a source offhand, that this is a ‘classic’ sign of psychosis. However, I’ve had them inside my head too. Like the ‘alter’, they take up a nebulous space – but they just appear. They have no source; they’re just suddenly there. It’s a bit like how I’d imagine telepathy to be; you look at someone, and his or her thoughts just pop into your head (maybe internal voices exemplify thought insertion? Still psychotic, whatever the case.)
Of course, there’s more to both psychosis and dissociation than voices. I’ve had genuinely amnesiac episodes of dissociation – the horrible realisation that you’ve just woken up, but not in your bed. Oh no. You’re alone in your car, well on the other side of town, your last memory being joining the motorway maybe 40 minutes ago (that’s a good bit more than highway hypnosis, before someone suggests it!) Does one suffer from amnesia during a psychosis? I suppose there’s no reason why not – indeed, the psychosis itself may be traumatic enough to cause memory loss – but I don’t think it comes as part of the deal per se.
Derealisation and depersonalisation are types of dissociation which, respectively, involve a sense of ‘unreality’ about the world around you, and about yourself. Both, in my experience, are like looking at things though a figurative veil. The world, your body, whatever…they don’t seem real. They’re strange and alien, and you feel like you exist in a bizarre fog that keeps you two steps away from reclaiming them as legitimate parts of your life.
The operative clause in the above paragraph is they don’t seem real. Note the use of the word ‘seem’. You’re highly disconnected from things when depersonalised or derealised, but much as things don’t seem real, you retain an awareness that, on some objective level, they are.
That doesn’t usually happen in psychosis. When in the throes of an episode, you’re (mostly) genuinely convinced that your world – the world of the voices, visions, delusions – is real, and that the objective world is something for others. Now, I should clarify that I have had psychotic symptoms and known them to be psychotic – it doesn’t not happen. However, such an awareness (for me anyhow), comes from experience: “oh, that four foot spider on the wall – it very much resembles that thing I saw a few years ago when ill. I’m probably hallucinating.”
And then we have delusions. Beliefs that are false and often fantastical. I don’t recall having experienced this as a by-product of dissociation at any point; as I noted above, when in a dissociated state (one that you remember, anyway), you still retain some semblane of knowledge of objective reality. If you’re delusional, almost by definition, you don’t. If the sign is there to send surreptitious messages to you, then let me assure you that it is. You – or those around you – can rationalise that all you like, but regardless of the objectivity and logic of any counter-argument, for as long as the delusion lasts you truly believe that it is real. Anyone saying otherwise simply isn’t in on the joke; all you can do is humour their delusion that the sign isn’t an instrument of psychic communication. Poor sods, you might think, missing out on the fun.
There are other facets to psychosis – thought disorder, word salad, catatonia, thought theft – though certainly not everyone gets all of them. I’m sure there are other facets to dissociation too – ones I haven’t experienced, but that others have. Please feel free to share any and all accounts in the comments 🙂
So. What am I saying, ultimately? My therapist contends that dissociation and psychosis are borne of the same thing. As noted way up above, although I disagree, I can see that there’s an argument to be made there – that the trauma-model is certainly worthy of discussion as a possible contributor to, potentially, all mental illnesses. However, regardless of what causes psychosis and dissociation, the actual experience of the two phenomena are, in my experience at least, very different, and I’m rather annoyed at my therapist’s clumsy conflation of the two vis a vis Alice Jamieson’s book.
But I’m just one person out of millions who has gone through one or both of these conditions. What are your experiences? Are psychosis and dissociation the same thing? How do they feel to you – in what ways are they the same, and how do they differ? Does it piss you off that they’re often considered as being the same thing (eg. the fact that most people think schizophrenia equals a ‘split’ personality), or is it fine by you? Sound off below. Enquiring minds – and this one 😉 – would love to know.
Picture credits: see outgoing links.