Introduction
People who experience psychosis often report high levels of trauma that may arise from adverse childhood experiences; violent and dehumanising treatment along their pathway to care; stigma and discrimination on both a structural and interpersonal level; as well as negative anomalous experiences (e.g., hearing malevolent voices) (Longden & Read, Reference Longden and Read2016; Rodrigues & Anderson, Reference Rodrigues and Anderson2017). Following a psychosis, people may experience profound challenges such as cognitive difficulties; feelings of sadness, guilt, anxiety and fear; an altered sense of self; and disrupted life plans (McCarthy-Jones et al. Reference McCarthy-Jones, Marriott, Knowles, Rowse and Thompson2013). However, people may also experience posttraumatic growth following a psychosis.
Posttraumatic growth refers to the positive, veridical psychological changes that may be experienced following the intense struggle with a negative, adverse or traumatic event and is conceptualised to occur in at least five domains, including a greater appreciation for life; improved relationships with others; greater personal strengths; new life possibilities; and spiritual/existential growth (Tedeschi & Calhoun, Reference Tedeschi and Calhoun2004). People who experience posttraumatic growth may experience it in one, several or all domains and to a small, moderate or great degree (Tedeschi et al. Reference Tedeschi, Shakespeare-Finch, Taku and Calhoun2018). Posttraumatic growth often occurs alongside significant levels of distress and suffering (Dekel et al. Reference Dekel, Ein-Dor and Solomon2012).
Over the past 10 years, an increasing number of studies have examined posttraumatic growth following psychosis. These studies have revealed that posttraumatic growth occurs at the individual level (e.g., living a life that is more congruent with one’s values and passions); interpersonal level (e.g., becoming closer to loved ones) and spiritual/religious level (e.g., stronger belief in God) (Ibrahim et al. Reference Ibrahim, Ng, Selim, Ghallab, Ali and Slade2022; Jordan et al. Reference Jordan, MacDonald, Pope, Schorr, Malla and Iyer2018; Jordan et al. Reference Jordan, Burke, Roe and Davidson2019a, Reference Jordan, Malla and Iyer2019b; Slade et al. Reference Slade, Rennick-Egglestone, Blackie, Llewellyn-Beardsley, Franklin, Hui, Thornicroft, McGranahan, Pollock, Priebe, Ramsay, Roe and Deakin2019b). These changes have been reported among people who have experienced psychosis themselves, as well as their families and friends (Jordan et al. Reference Jordan, MacDonald, Pope, Schorr, Malla and Iyer2018; Thornhill et al. Reference Thornhill, Sanderson and Gupta2022). Posttraumatic growth has been reported among people who have experienced a single or multiple episodes of psychosis (Ng et al. Reference Ng, Ibrahim, Franklin, BLINDED, Lewandowski, Fang, Roe, Rennick-Egglestone, Newby, Hare-Duke, Llewellyn-Beardsley, Yeo and Slade2021), and some evidence also suggests that posttraumatic growth may be stable over time (Jordan et al. Reference Jordan, Ng, Malla and Iyer2022; Lee et al. Reference Lee, Seet, Chua, Verma and Subramaniam2022).
The history of posttraumatic growth is rooted in philosophical and religious traditions as well as in existential, humanistic and cognitive psychology (Tedeschi & Calhoun, Reference Tedeschi and Calhoun2004; Tedeschi et al. Reference Tedeschi, Shakespeare-Finch, Taku and Calhoun2018). In addition, psychoanalytic scholars such Jung (Jung, Reference Jung1967), Liang (Liang, Reference Liang1960), and Perry (Perry, Reference Perry1974, Reference Perry1999) provided detailed accounts of how psychosis can bring about growth and positive psychological change. Of note, Perry argued that psychosis could help people heal old wounds and initiate a process of individuation, eventually leading to a sense of self- renewal, growth, greater authenticity, a new life direction and improved relationships with others (Perry, Reference Perry1974, Reference Perry1999).
The concept of posttraumatic growth may compliment alternative conceptualisations of psychosis. These conceptualisations include viewing psychosis as a spiritual emergency that can eventually lead to a spiritual awakening (Grof & Grof, Reference Grof and Grof1991); as well as viewing one’s identity as a Mad person with pride (i.e., Mad Pride) (LeFrancois et al. Reference LeFrancois, Menzies and Reaume2013). Importantly, these alternative frameworks highlight how one can experience growth following psychosis without experiencing trauma, such as in the case when a psychosis is perceived as beautiful, profound, or spiritual in addition to confusing or scary. These perspectives also challenge the dominant medical model of psychosis as a diagnostic entity with negative consequences and shifts the perspective to a more positive and nuanced view to value individual perspectives. For some who have experienced psychosis, this shift in conceptualisation of their experiences of psychosis as deficit to a more hopeful and nuanced conceptualisation may provide hope and better encapsulates lived experience.
Posttraumatic growth shares some similarities and differences with the concept of recovery. Specifically, posttraumatic growth is conceptually distinct from clinical recovery, which is defined as the resolution of symptoms and the restoration of functioning; but overlaps with personal recovery, through experiencing growth via identity transformation, connection with others, meaning making and other areas of improvement (Jordan et al. Reference Jordan, Iyer, Malla and Davidson2020a).
Posttraumatic growth can be fostered in several ways, such as by drawing on personal resources and strategies (e.g., spirituality); engaging in a meaning-making process to actively construe a positive aftermath from psychosis; as well as experiencing a sense of healing and recovery (Jordan et al. Reference Jordan, Malla and Iyer2020b). Loved ones and peers with lived/living experience can foster posttraumatic growth by providing instrumental (e.g., financial) and emotional forms of support (e.g., listening), as well as by providing a sense of solidarity and community which can serve as a base for exploring possible new aspects of the self (Jordan et al. Reference Jordan, MacDonald, Pope, Schorr, Malla and Iyer2018; Jordan et al. Reference Jordan, Ng, Malla and Iyer2022; Ng et al. Reference Ng, Ibrahim, Franklin, BLINDED, Lewandowski, Fang, Roe, Rennick-Egglestone, Newby, Hare-Duke, Llewellyn-Beardsley, Yeo and Slade2021).
Supporting posttraumatic growth may be important for several reasons. First, such support is consistent with policies that guide the provision of recovery-oriented care. These policies recognise that people who have experienced mental health problems like psychosis can live full meaningful lives in the communities of their choice, with or without symptoms, if they are provided with proper supports and accommodations. Recovery-oriented care is often aligned with clients’ needs, preferences, goals and explanatory models of psychosis, as well as with clients’ personal histories and cultural background. Several elements of recovery-oriented care which stem from such policies and foster posttraumatic growth (Jordan et al. Reference Jordan, MacDonald, Pope, Schorr, Malla and Iyer2018; Ng et al. Reference Ng, Ibrahim, Franklin, BLINDED, Lewandowski, Fang, Roe, Rennick-Egglestone, Newby, Hare-Duke, Llewellyn-Beardsley, Yeo and Slade2021) include having a fundamental belief in clients’ capacity to recover and lead a meaningful life of their choosing; treating clients like human beings worthy of dignity, compassion and respect; fostering relationships with clients that are non-hierarchical and based around honesty, openness, compassion and trust and finding ways to support clients’ strengths and talents (Le Boutillier et al. Reference Le Boutillier, Leamy, Bird, Davidson, Williams and Slade2011; Davidson et al. Reference Davidson, Carr, Bellamy, Tondora, Fossey, Stryton, Davidson, Elsmara, Barber and Van Sant2016; Davidson et al. Reference Davidson, Rowe, DiLeo, Bellamy and Delphin-Rittmon2021).
Supporting posttraumatic growth is also in line with policies that guide trauma-informed care. Such policies recognize how trauma intersects with various health and social problems that people experience; aims to reduce the risk of trauma and re-traumatization and promotes healing from trauma (Bowen & Murshid, Reference Bowen and Murshid2016). Within the context of psychosis, work on posttraumatic growth can provide avenues for policies that encourage the recognition that such growth is a possibility for people.
By developing an understanding of, and supporting, posttraumatic growth during clinical care, clinicians may provide hope to people experiencing psychosis; validate personal experiences of growth which may be dismissed as delusional or evidence of a lack of insight into their condition (Slade et al. Reference Slade, Blackie and Longden2019a). Given that posttraumatic growth emphasizes how people can improve or experience positive personal or life changes following adversity, supporting posttraumatic growth challenges aspects of the medical model that hold that some people who experience psychosis may be on a path towards chronic impairment (Canton, Reference Canton and Russo2021).
Additionally, the medical model assumes that people may, through treatment, return to previous levels of functioning. However, a core theoretical component of posttraumatic growth is that people can grow beyond this. Experiencing posttraumatic growth may be a first step towards engaging in generativity, or actions characterized by giving back to one’s community, society and future generations (McAdams, Reference McAdams2013; McAdams & de St Aubin, Reference McAdams and de St. Aubin1992; McAdams et al. Reference McAdams, Hart and Maruna1998), which may be important actions that people who have experienced psychosis may wish to partake in. Understanding that posttraumatic growth is possible may lead clinicians to communicate with clients in a more hopeful manner in a way that acknowledges and validates their potential experiences, perhaps establishing greater trust.
Guidance around how to support posttraumatic following psychosis specifically are needed for at least at least three reasons. First, many who have experienced psychosis often experience multiple intersecting traumas. Any discussions around posttraumatic growth, or attempts to support it, must be done with great tact, compassion, and consideration of the negative impact that trauma may have had on a person. Second, people who experience psychosis are often seen as lacking insight, the capacity for rational thought, or potential for personal development (Slade & Sweeney, Reference Slade and Sweeney2020). Such fallacies are not often applied to people who experience other mental health problems (e.g. depression or anxiety) or have experienced other adversities, (e.g. natural disasters); and such assumptions can impact the ways in which clients are spoken to and treated. This may result in their experiences being invalidated and their rights being violated (Newbigging & Ridley, Reference Newbigging and Ridley2018). Finally, some approaches to supporting posttraumatic growth, such as encouraging the use spiritual resources (as described below), are often discouraged within the context of psychosis. However, given that these practices can support meaning making, there is a specific need to highlight the importance of such practices within the context of posttraumatic growth.
As researchers who have investigated posttraumatic growth following psychosis over the past nine years, we are often called upon by colleagues to present our findings to clinical audiences. Our presentations have garnered a wide range of reactions. Some clinicians have commented that it is impossible to grow following a psychosis, and that people who describe experiencing growth show a lack of insight into their illness or may be actively delusional. Other clinicians have shared that our work has inspired them to think about and support their clients in a “more humane way”. We find both forms of comments disturbing. On the one hand, they can be invalidating to a person’s own understanding of how they’ve changed following a psychosis. On the other hand, these comments suggest that to be seen as human one must be experiencing some form of profound personal development, and that the presence of suffering or disability on their own are not enough to bear witness to clients’ humanity. These comments also suggest that clinicians may lack awareness of posttraumatic growth following psychosis, which is consistent with other work (Jordan et al. Reference Jordan, Malla and Iyer2020c).
Several clinical manuals and guides exist which describe how clinicians can best support posttraumatic growth following adversities in general (Altmaier & Gleason, Reference Altmaier and Gleason2019; Calhoun & Tedeschi, Reference Calhoun and Tedeschi1999; Calhoun & Tedeschi, Reference Calhoun and Tedeschi2013); yet no guidance exists on how clinicians can best support posttraumatic growth following psychosis. Without guidance, clinicians risk invalidating people’s experiences or providing improper support, which may include working with the false expectation that everyone who experiences psychosis should grow (Jordan et al. Reference Jordan, Burke, Roe and Davidson2019a, Reference Jordan, Malla and Iyer2019b). To address this knowledge gap, the aim of this paper is to draw on existing clinical guidelines and our own work on this topic to articulate several strategies that clinicians can adopt to support posttraumatic growth among people who have experienced psychosis.
Provide gentle encouragement within a validating, normalising context
Clinicians may support posttraumatic growth by applying gentle encouragement, rather than expecting, or pushing people towards posttraumatic growth (Calhoun & Tedeschi, Reference Calhoun and Tedeschi1999). Pre-existing clinical guidelines specify that supporting posttraumatic growth—especially early on in a person’s recovery—should not be a priority. Rather, the focus of care should be on building a therapeutic alliance and helping people cope with and survive their traumas (Ng et al. Reference Ng, Ibrahim, Franklin, BLINDED, Lewandowski, Fang, Roe, Rennick-Egglestone, Newby, Hare-Duke, Llewellyn-Beardsley, Yeo and Slade2021). As sessions progress, clinicians can encourage posttraumatic growth by noticing and acknowledging experiences of growth as they are mentioned. Any acknowledgement should be led by the client’s own experiences rather than a clinician’s urge to acknowledge the occurrence of posttraumatic growth. Acknowledgements of posttraumatic growth should be well timed, not sound like empty platitudes, and stated in such a way as to emphasize that growth is not produced by the psychosis, but by the struggle to deal with it. Importantly, clinicians should tolerate and respect the validity of clients’ accounts of posttraumatic growth even if clinicians perceive such accounts as illusory.
That stated, clinicians must also be mindful that many clients will not experience posttraumatic growth, nor should they; and clients who do not experience growth are not moral failures unworthy of a clinicians’ efforts. Clients who experience posttraumatic growth are not better people than clients who have not; and experiences of posttraumatic growth are not attestations of their clients’ humanity and potential. After all, dealing with everyday life challenges, stressful experiences that fall outside of consensus reality, and the often-intolerable toll that fitting into a neoliberal political economy takes, can be challenging enough (Rowe & Davidson, Reference Rowe and Davidson2016).
Support the development of an integrated and constructive life narrative
McAdams has argued and demonstrated that people often construct their identity and sense of self around a life story or narrative (McAdams, Reference McAdams2013; McAdams & de St Aubin, Reference McAdams and de St. Aubin1992; McAdams et al. Reference McAdams, Hart and Maruna1998). Psychosis can often lead to significant disruptions to people’s life narratives. Hence, an important way that clinicians can facilitate posttraumatic growth following psychosis may involve helping clients reconstruct a coherent and constructive narrative about their lives. These reconstructions can be framed around redemption sequences or stories. Such stories often frame a difficult or traumatic life experience as one that leads to meaning-making, resolution or growth (McAdams, Reference McAdams2013; McAdams & de St Aubin, Reference McAdams and de St. Aubin1992; McAdams et al. Reference McAdams, Hart and Maruna1998). Although framing life narratives around redemption may not be suitable for people who have experienced psychosis in a positive light, clinicians may consider helping clients frame their narratives to reflect how they have grown in some way (no matter how little or how much) following the struggle with psychosis. To do so, clinicians may gently encourage clients to first recount the events leading up to, and the experience of, psychosis. Then, clinicians can help clients integrate the psychosis within their overall life story, highlighting differences and similarities between clients’ pre and post-psychosis self-narrative. As alluded to earlier, clinicians should provide a space for clients to grieve the losses they experienced, while also support clients as they seek to reconstruct a constructive life story (Jirek, Reference Jirek2017). The narration of one’s life story should encompass not only elements associated with positive change but rather all components of an individual’s life which are of value or meaning.
Interventions to support narrative reconstruction among people who have experienced psychosis exist and may be useful to adopt in this regard. These include Metacognitive Reflection and Insight Therapy (Lysaker & Klion, Reference Lysaker and Klion2017), which aims to help people make sense of and derive meaning from their experiences by supporting meta-cognition; and Narrative Enhancement Cognitive Therapy (Yanos et al. Reference Yanos, Roe, West, Smith and Lysaker2012), which is a group-based narrative treatment helping people cope with internalized stigma.
Be open to different explanatory models of psychosis
A key facilitator of posttraumatic growth is engaging in a meaning-making process whereby people seek to understand the deeper, constructive meaning of their experiences (Jordan et al. Reference Jordan, Malla and Iyer2020b). For instance, some may adopt an explanatory framework highlighting how their psychosis was meant to happen and was needed to fundamentally restructure their lives according to what really matters in the grand scheme of things (Jordan et al. Reference Jordan, Burke, Roe and Davidson2019a, Reference Jordan, Malla and Iyer2019b). Clinicians can therefore support posttraumatic growth by being mindful of, and open to, different explanatory models of psychosis.
Unfortunately, enforcing biomedical explanatory models onto people who experienced psychosis and invalidating their meaning-making process has been adopted as mainstream practice in many jurisdictions (Cohen, Reference Cohen1993; Handerer et al. Reference Handerer, Kinderman, Timmermann and Tai2021). Despite the dominance of the biomedical model, many people who have experienced psychosis insist those experiences are meaningful and can provide insight into their path to recovery (O'Keeffe et al. Reference O'Keeffe, Keogh and Higgins2021; Ritunnano et al. Reference Ritunnano, Kleinman, Oshodi, Michail, Nelson, Humpston and Broome2022). Framing psychosis as a biomedical process gone awry can generate expectations of chronicity and feelings of hopelessness, while pathologizing psychosis is often overly reductive and fails to acknowledge, and thus respond to, the wider context and social determinants of distress (Kirmayer et al. Reference Kirmayer, Corin and Jarvis2004). Rendering meaningful experiences as merely symptoms of illness devoid of meaning can impede recovery and hinder growth and agency (LeFrancois et al. Reference LeFrancois, Menzies and Reaume2013; Seikkula & Trimble, Reference Seikkula and Trimble2005). Clinicians may fear exacerbating delusions and hallucinations, but research suggests that acknowledging psychotic utterances and the perspectives and experiences of those in florid psychosis can be therapeutic and inform pathways out of suffering (Razzaque & Stockmann, Reference Razzaque and Stockmann2018). Many people feel their experiences of psychosis are deeply meaningful and even spiritual and are benefited by approaches and frameworks that “restore the meaning in madness” p.31 (Johnstone, Reference Johnstone2018), or even find benefit in psychosis (O'Keeffe et al. Reference O'Keeffe, Keogh and Higgins2021). These approaches can include, but are not limited to, Open Dialogue, Hearing Voices groups, and psychological formulation that acknowledge the individual’s worldview and belief systems. These frameworks for interpreting and approaching psychosis do not need to negate biomedical treatment but can work in conjunction with psychiatric approaches while addressing the spiritual, psychological, cultural and social elements of distress (Tamm, Reference Tamm1993). Acknowledging and respecting how a person interprets and makes meaning out of their experiences of psychosis is a critical step in facilitating posttraumatic growth following psychosis.
Support spirituality and religiosity
Many people who experience posttraumatic growth following psychosis experience spiritual forms of growth and rely on spiritual or religious resources to support their growth (Ng et al. Reference Ng, Ibrahim, Franklin, BLINDED, Lewandowski, Fang, Roe, Rennick-Egglestone, Newby, Hare-Duke, Llewellyn-Beardsley, Yeo and Slade2021). Yet, clinicians may be less likely to notice spiritual or religious forms of growth relative to growth in other domains (Jordan et al. Reference Jordan, Malla and Iyer2020c).
In some settings, such as in early intervention services for psychosis, both clinicians and service users have reported stigma around spirituality and a reluctance to discuss spiritual issues (Larsen, Reference Larsen2004). Spirituality and religion, which are important for many people, are often not discussed, and there is a tendency to view spiritual or religious content within therapeutic encounters unfavourably (Yamada et al. Reference Yamada, Lukoff, Lim and Mancuso2020), particularly within societies that emphasize secularism (Venkataraman et al. Reference Venkataraman, Jordan, Pope and Iyer2018). There is a concern among clinicians that engaging with spiritual or religious resources or practices may support the development of, or perhaps reinforce, religious or spiritual delusions or hallucinations (Larsen, Reference Larsen2004; Mohr, Reference Mohr2004). While engaging in spiritual practices such as intense meditation may contribute to the development of psychosis for some (Sharma et al. Reference Sharma, Mahapatra and Gupta2022), spirituality and religion are important aspects of people’s lives that should not be neglected (Milner et al. Reference Milner, Crawford, Edgley, Hare-Duke and Slade2019). To support posttraumatic growth, clinicians can to learn more about spiritual or religious worldviews, as well as develop greater humility and competence around their clients’ spirituality.
To do so, Calhoun and Tedeschi (Calhoun & Tedeschi, Reference Calhoun and Tedeschi1999) recommend that clinicians listen attentively to clients when they discuss spiritual themes and attend to them when they occur (p. 117). Models highlighting the importance of spirituality to mental health recovery have been developed, such as the MISTIC framework, and can also guide discussions around spirituality and religion (i.e., the Meaning-making, Identity, Service-provision, Talk about it, Interaction with symptoms, Coping framework). This model has also been adapted into a clinical toolkit aimed at helping clinicians support spirituality during care (Milner et al. Reference Milner, Crawford, Edgley, Hare-Duke and Slade2019). Specifically, the toolkit encourages clinicians to reflect on six spiritual domains in clinical care, including meaning (e.g., how spirituality can help clients make sense of their lives and mental health); identity (e.g., how spirituality can support clients’ identity development); service provision (e.g., which spiritual sources of support clients can access); talk about it (e.g., who clients can speak to about spirituality); interruption (e.g., the spiritual challenges or crises that may have experienced) and coping (e.g., spiritual sources of coping that are available).
Conclusion
Posttraumatic growth may be an unfamiliar construct and phenomenon to clinicians who support people who have experienced psychosis. Despite its potential importance and increasing relevance, there is a lack of guidance on how clinicians can best facilitate posttraumatic growth following psychosis. Drawing on our own research, experiences and pre-existing guidelines, we recommend that to support posttraumatic growth following psychosis, clinicians can gently encourage posttraumatic growth when appropriate, support narrative construction and development, remain open to different explanatory models of psychosis and support spirituality.
The ability of clinicians to follow these recommendations may depend on different factors. These may include rules governing each professional’s clinical roles and their respective professional unions and bodies; the specific foci of services where clinicians are employed as well as institutional buy-in to support posttraumatic growth; each clinician’s specific background, interests, orientation and training; as well as the availability of time and resources.
Several of these recommendations can be followed by any member of a multidisciplinary team. For instance, all clinicians can treat clients with dignity, respect and compassion. All clinicians can be open to various explanatory models of distress and react to non-medical understandings of psychosis with a degree of interest, curiosity and openness. Any clinician can similarly react without judgement towards a client who is openly spiritual or religious and draws on spiritual resources to support their recovery. However, some of our recommendations can be more easily followed by certain professionals. For instance, clinicians with the time, ability and space to support emotional needs, such as psychologists, psychiatrists, mental health nurses and counsellors may be particularly well suited to help clients develop new life narratives following their psychosis or encourage clients to draw on particular spiritual resources.
Worth mentioning is that peer support workers may play an important role in supporting posttraumatic growth. People often feel profound hopelessness following a psychosis (Watkins et al. Reference Watkins, Denney‐Wilson, Curtis, Teasdale, Rosenbaum, Ward and Stein‐Parbury2020). Peers, who draw on their own lived experience to support others, are powerful living examples of how the aftermath of a psychosis may not necessarily be permentantly characterised by despair (Davidson et al. Reference Davidson, Bellamy and Guy2012). Peer support workers may experience posttraumatic growth through their profession, which may be modelled in interactions with people in need (Moran et al. Reference Moran, Russinova, Gidugu, Yim and Sprague2012; Russo-Netzer and Moran, Reference Russo-Netzer and Moran2018). Many peers also role model how one can chart new meaningful life directions and improve the lives of others, following psychosis, thereby demonstrating what posttraumatic growth may in fact resemble (Moran et al. Reference Moran, Russinova, Gidugu, Yim and Sprague2012).
That said, it is incumbent upon services that hire peer support workers to ensure that peers do the actual work of peer support and not fall into clinical roles where the power of their lived experience may be reduced. Peer-run organisations and mutual support groups that fall outside the healthcare system may be particularly well suited in this regard (Moran et al. Reference Moran, Russinova and Stepas2012).
With these recommendations, our hope is that clinicians can better support posttraumatic growth following psychosis when appropriate. However, future research should evaluate how people who have experienced psychosis themselves feel posttraumatic growth should best be fostered.
Financial support statement
This research has received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflicts of interest
None.
Ethical standard statement
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.
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