“The past is never dead.
It’s not even past.”
– William Faulkner – Requiem for a Nun (1951)
This blog examines a recent systematic review and meta-analysis by Diamantis Toutountzidis et al., (2026), which investigates trauma-focused interventions, such as Trauma-Focused Cognitive Behavioural Therapy (TF-CBT), Eye Movement Desensitisation and Reprocessing (EMDR) and Exposure Therapy to help face past traumas. The reviewers aimed to evaluate the effects of these interventions on symptoms associated with psychosis, notably symptoms including delusions, hallucinations and negative symptoms.
The quote starting the blog epitomises Trauma-Focused Interventions (TFI), in which people continue to have living experiences of their trauma(s) despite the exposure(s) being in the past. Much evidence exists that people exposed to trauma, such as in their childhoods, face an increased likelihood of experiencing psychosis in later life, normally exhibiting symptoms in their late teens for males and early twenties for females. Approximately one-third of psychosis cases may be attributable to childhood adversity, and ~39% of people with schizophrenia report past physical abuse. Via learning to address these past adverse events, it may lessen the impact of psychotic phenomena, for example, by reducing distress. However, the relationship between trauma and psychosis is not straightforward. For some people, the experiences of psychosis itself, including paranoid beliefs and frightening hallucinations such as seeing things others cannot, may also be a source of trauma (Giannopoulou et al., 2023).
TFIs address a broad spectrum of physical, sexual, and emotional traumas, focusing on how experiences involving abuse, neglect, violence, disasters, and systemic oppression impact individuals. In terms of the latter, this can involve trauma through institutionalised means, such as from schools (e.g., prejudicial disciplinary procedures), places of worship (e.g., concealed sexual abuse) and/or the care home system (e.g., feeling unwantedness) (Centre of expertise on child sexual abuse, 2023).
To address such traumas, TFIs have become increasingly prominent in mental health care over the last two decades. These evidence-based approaches aim to reduce trauma-related distress, including the distressing re-experiencing of past traumatic events (Roberts et al., 2010). Given the correlation of trauma to experiences of psychosis, such as the hearing of malevolent voices of abusers, TFIs are increasingly seen as useful approaches to lessen the distress of psychosis. However, as this article points out, evidence of the effectiveness of these interventions still requires certifying to ensure their beneficial impact on those who experience psychotic phenomena (Toutountzidis et al, 2026).
Childhood trauma is strongly linked to psychosis, making trauma-focused interventions an increasingly important part of mental health care.
Methods
The study is a systematic review and meta-analysis. The authors pre-registered with PROSPERO (CRD42024508790) and followed PRISMA guidelines. Their methodology involved searching and selecting relevant quantitative research, and the sample size was expanded by bringing all the studies together in the meta-analysis.
The literature search employed the following databases: CINAHL Ultimate, Cochrane reviews, Education Research Complete, MEDLINE, PsycArticles, PubMed and SCOPUS using a combination of search terms relating to the aim of the review. The articles were screened through inclusion/exclusion criteria to identify relevant research papers.
Data from the final papers in the review were extracted into a table to ascertain the effectiveness of the TFIs on psychotic symptoms such as hallucinations. All studies were reviewed to assess quality, but no study was excluded based on quality issues. Meta-regression was employed in the meta-analysis, which is a statistical technique to investigate why study outcomes vary by linking effect sizes to study-level characteristics. Whereas other findings were synthesised in terms of the type of TFI and their impact on psychosis.
Results
Thirty-six studies were included with a sample size totalling 1,384 participants. Eighteen studies contributed to the meta-analyses, which ran separate analyses for uncontrolled pre-post designs and randomised controlled trials (RCTs). TFIs identified are in the following table:
|
TFI type |
Beneficial impact |
| Eye movement desensitisation reprocessing (guided eye movements while recalling traumatic events, which can help reprocess memories to lessen their distress) | Delusions and some evidence on reduction of hallucinations found in case series; however, no significant results were found in the RCT included |
| Prolonged exposure (helping individuals gradually approach trauma-related memories and situations) | Mixed results; no significant advantage over the control condition |
| Eye movement desensitisation reprocessing compared to prolonged exposure | Both reduced paranoia, but neither significantly reduced hallucinations; prolonged exposure effects on paranoia sustained longer at follow-up |
| Trauma-focused cognitive behavioural therapy (targeted treatment to help process specific traumatic memories and experiences) | Reported a decrease in hallucinations and delusions |
| Trauma-informed cognitive behavioural therapy (focused on safety to avoid re-traumatisation) | No significant impact, but lessened symptoms associated with Post Traumatic Stress Disorder |
| Other trauma-focused interventions (e.g., imagery rescripting – addressing flashpoints relating to trauma/ trauma management therapy – generic term for controlling trauma distress/phasic trauma treatment – establishing safety before processing traumatic memories, followed by reintegration). | Positive effect on some hallucinations and paranoia associated with delusions |
Small reductions in hallucinations and a medium reduction in delusions were noted. However, in the RCTs, no significant reduction in hallucinations was identified following the intervention and at follow-up. The RCTs did find that delusions were significantly reduced at both points. Younger participants benefited the most from TFIs, while daily functioning and reduction of negative symptoms (e.g., flat affect) improved on follow-up. TFIs also produced small but significant reductions in PTSD symptoms at both the end of treatment (g = -0.36) and follow-up (g = -0.31). This is an important secondary outcome confirming TFIs were therapeutically active even when psychosis symptoms did not shift significantly.
In terms of quality, most RCTs were examined to be of a higher rigorous value than the other quantitative studies.
Younger people showed the greatest gains from trauma-focused interventions, and the benefits for delusional thinking held up for months after treatment ended.
Conclusions
The authors concluded that TFIs are beneficial for delusions but less so for hallucinations, while there appeared to be limited secondary gains from the TFIs. Interventions were found to lead to small improvements in PTSD symptoms, but did not improve depression, anxiety, or overall quality of life. Daily functioning did not improve immediately after treatment, but there were some modest improvements over time.
Overall, this meta-analysis suggests that TFIs may work for delusions. They address maladaptive threat-based appraisals, but not hallucinations, because these may be rooted in perceptual/dissociative processes.
The authors proposed that addressing past trauma via some TFIs aids how people cognitively process troubling ideas (classifiable as delusions) by reducing their distress, and suggest that future research explores TFIs in terms of distress reduction associated with hallucinations.
TFIs are effective for delusions but offer limited benefit for hallucinations, pointing to the need for symptom-specific approaches.
Strengths and limitations
The strengths of this review involve the systematic approach to searching and identifying relevant papers and accumulating the sample size of corresponding study designs. Whilst the blog has not gone into depth about the statistical analysis for reader accessibility, the statistical approach to expand sample size (e.g., for power analysis to detect a significant effect(s)) appeared to be a suitable approach.
However, there were limitations to this review. Most notable was perhaps how trauma was defined, in that it focused on past adverse events and not the manner in which experiencing psychotic phenomena may be traumatic in itself (Mueser et al, 2010). As such, this may have limited the scope of the research papers in the review.
Another limitation is the focus on only quantitative studies. Whilst appropriate for meta-analysis purposes, qualitative data might have brought about further understanding in terms of experiences of TFIs (Alessi & Kahn, 2023). Arguably, the title is also a little confusing, given that more than trauma focused studies were included in the search while there seemed a focus on diagnostic symptomology. That is, how individuals express their experiences of what is medically classed as psychosis can vary from the objective aridity of classifying symptoms.
The paper acknowledged some of its limitations while also noting a focus on distress reduction might be a way forward for future research. Nevertheless, it must be acknowledged that authors such as Chadwick and Birchwood (1994) noted this with their seminal work in reducing the distress of malevolent voices (owing to their omnipotence) over thirty years ago.
A rigorous and well-designed review, though its exclusive focus on quantitative studies leaves the lived experience of TFIs underexplored.
Implications for practice
The paper helped to inform and establish further how TFIs can lessen some psychotic symptoms, hence these approaches must be taken seriously to assist a person experiencing psychotic phenomena. The paper also identified a good impact of TFIs on people who were younger. This is not to propose TFIs only work on young people, but it suggests that when TFIs are employed around experiencing a first episode of psychosis, it might have a better effect (Williams et al, 2024). This is vital, given services such as Early Interventions in Psychosis exist to limit relapses of the condition.
Whilst the paper focused on symptomology, it does not mean that trauma related interventions cannot occur prior to a person becoming unwell. Indeed, lessening the distress of past adverse events may curtail the trauma of experiencing psychotic phenomena while limiting the ‘stress cycle’ that feeds into worsening experiences of psychosis. In terms of TFIs and increasing evidence of situations and contexts which result in trauma, it is imperative that TFIs are considered as early as possible, such as in schools, to lessen the risk of deteriorating mental health in the future (Meiser‐Stedman et al, 2025).
Early intervention matters, as addressing trauma before or during a first episode of psychosis may interrupt the cycle before it becomes entrenched.
Statement of interests
Kris Deering has no conflict of interests to report. Kris used AI to help with grammar.
Edited by
Dr Dafni Katsampa.
Links
Primary Paper
Diamantis Toutountzidis, Emily Ricketts, and Keith R. Laws (2026) Trauma-focused psychological interventions for psychosis: Meta-analytic evidence of differential effects on delusions and hallucinations. Psychological Medicine 56 1-19.
Other references
Alessi E.J and Kahn, S. (2023) Toward a trauma-informed qualitative research approach: Guidelines for ensuring the safety and promoting the resilience of research participants. Qualitative Research in Psychology 20(1) 121-154.
Centre of expertise on child sexual abuse. (2023) Key messages from research on child sexual abuse in institutional contexts. Available at: https://www.csacentre.org.uk/research-resources/key-messages/institutional-csa/ [accessed 7 April 2026].
Chadwick P and Birchwood, M. (1994) The omnipotence of voices: A cognitive approach to auditory hallucinations. The British Journal of Psychiatry 164(2) 190-201.
Faulkner W. (1951) Requiem for a Nun. New York: Random House.
Flinn A, Hefferman-Clarke R, Parker S. et al. (2025) Cumulative exposure to childhood adversity and risk of adult psychosis: a dose–response meta-analysis. Psychological medicine 55 1-10
Giannopoulou I, Georgiades S, Stefanou M.I. et al. (2023) Links between trauma and psychosis. Experimental and Therapeutic Medicine 26(2) 1-8.
Meiser‐Stedman R, Allen L, Ashford P.A. et al. (2025) A pragmatic randomized controlled trial of cognitive therapy for post‐traumatic stress disorder in children and adolescents exposed to multiple traumatic stressors: the DECRYPT trial. World Psychiatry 24(3) 422-434.
Mueser K.T, Lu W, Rosenberg S.D et al. (2010) The trauma of psychosis: posttraumatic stress disorder and recent onset psychosis. Schizophrenia research 116(2-3) 217-227.
Roberts N.P, Kitchiner N.J, Kenardy J. et al. (2010) Early psychological interventions to treat acute traumatic stress symptoms. Cochrane Database of Systematic Reviews 3 1-61.
Williams R, Ostinelli E.G, Agorinya J. et al. (2024) Comparing interventions for early psychosis: a systematic review and component network meta-analysis. EClinicalMedicine 70 1-11.
