Working with dissociation in the context of first episode psychosis: Guidance for therapists

BackgroundDissociative experiences are common transdiagnostically, and particularly prevalent in psychosis. Such experiences have long been under-recognised in routine clinical practice, despite evidence that dissociation is related to clinical complexity and increased risk of self-harm and suicidality. Adopting a symptom-specific, targeted approach to conceptualisation and intervention of dissociation may help improve outcomes. AimsThe evidence base for psychological treatments targeting dissociation is building, but training and guidance for clinicians remains sparse. This review outlines a preliminary approach to the treatment of a subtype of dissociative experience (‘felt sense of anomaly’ dissociation), based on emerging research evidence and clinical practice. The guidance is tailored to the context of first episode psychosis, and may also have broader clinical relevance.MethodFactors to consider in the assessment, formulation, and intervention of felt sense of anomaly dissociation in the context of first episode psychosis are outlined, including reflections on process issues. We present a cognitive-behavioural model, where affect-related changes are interpreted as an internal threat, driving a maintenance cycle of catastrophic appraisals and safety behaviours. Using this formulation, evidence-based therapy techniques familiar to most readers can then be applied.ConclusionsIt is important for clinicians to consider dissociation. As well as generating new avenues for translational intervention research, we anticipate that the novel insights and specific advice outlined here will be of use to professionals working with dissociation in psychosis (and beyond). Encouragingly, we demonstrate that widely used, evidence-based skills and techniques can be employed to address distress arising from dissociation.