What is Considered Trauma in Therapy?
Updated: Apr 18, 2021
As a trauma therapist, faculty, and in charge of the curriculum of one of the best postgraduate trauma studies programs in the US, I struggle to convey the correct response to this question. There are many different definitions and the word is used to refer to different things even by the most renowned professionals and academics. Sharing a common understanding of what trauma really is, has relevance in terms of psycho-education and normalization of the disease. It’d be great if we therapists agree on the terminology of trauma in order to avoid confusing our clients, refrain from over pathologizing them and help them heal sooner.
The recognition of psychological trauma is a recent development. It was not until after the Vietnam War, when the evidence for the mental consequences on veterans was overwhelming, that PTSD was accepted as a mental disfunction, included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a disorder, and its treatment started to be funded.
Even when trauma goes way beyond the consequences of war or extreme events, and takes many more forms than only PTSD, insurance companies don’t cover much more than “tragic” events, and dismiss all the other faces of traumatization.
There are amazing advocates and researchers coming up with new findings of trauma every day. At this point, the significance of trauma among mental disorders is undeniable, but there is still a long way until we fully comprehend all its ramifications and consequences.
Let’s start by differentiating the several ways the word trauma is used.
The word trauma appears in many different publications defining:
a mental disorder
Trauma as an event
Traumatic events are those that make people feel threatened, anxious, or frightened because it’s potential to cause physical, emotional, spiritual, or psychological harm.
Examples: rape, bullying, oppression, racism, emotional abuse, emotional neglect, car accidents, surgery, natural disasters, foster care, entrapment, betrayal, poverty,…
Trauma as an experience
Any event could end up causing trauma if the reaction to it exceeds the capacity of the person to stay regulated.
How someone experiences the event is what will determine if it’s traumatizing or not. A traumatic experience depends on your perception of risk and is very individual. For a baby, being wet, cold, or hungry for “too” long can seem life-threatening. For an adolescent, flunking an academic year or being expelled from the team can seem life-threatening; for a mother with children breaking up from a romantic relationship can seem the end of the world.
Trauma as a reaction
Our innate survival mechanisms trigger a series of reactions with the sole purpose of keeping our system running. The best known is the fight-flight response, and many people call this reaction trauma.
Fight-flight is only one of the reactions triggered by a traumatic event that can end up traumatizing the system, but there are several others: Orienting, Attentive immobility, Social-engagement, Freeze, Tonic Immobility, Collapse Immobility, and Quiescent Immobility. I have a very extensive description of each in my blog in case you are interested.
Trauma as a response
When danger is perceived, fear triggers a series of mechanisms that act without our consent, generating all sorts of changes in ordinary functioning because the brain interprets fear as an indication that there is the possibility of “not making it” — not only staying alive but also maintaining one’s health, social position, family, jobs, assets, freedom, autonomy, stability, etc. The obvious response to such an impact in our system is to feel overwhelmed. Under the trauma lens, being overwhelmed means that we experience many emotions at the same time, or a few of them in an extremely intense way. That response takes us out of the “Window of Tolerance” which means that we lose control over our behavior, thoughts, reactions, etc. This level of reactivity is called dysregulation and will keep the cascade of changes in the system to continue in charge. If we don’t regain control over our response, we will probably stay traumatized. But if we deactivate the survival mechanisms by activating the executive functions of our brain, we would have really won the battle. The response by itself, even if never becomes trauma, may present symptoms that may leave marks. The response to a shocking event will keep very vivid memories with some emotional charge, and may leave you hypervigilant for a while. But most of the effect of the response will fade away on themselves. Still, few symptoms could stay as a consequence of the response of the nervous system; many people call this PTS as in post-traumatic stress. Some of them may sound almost identical as the ones on PTSD but the difference is that PTS will not be as debilitating and they will be winding down as days pass.
Example: Hyperactivation, hypoactivation, dissociation, flashbacks, alertness, restlessness, etc.
Trauma as a mental disorder
PTSD, C-PTSD (complex), Developmental trauma, Attachment trauma, Intergenerational trauma, are some of the most common terms used to describe the mental disorder.
The difference between a reaction and a disorder is worth expanding. The way we react to danger has been in our systems since before we were humans. These reactions assume a danger that fortunately, we don’t have to endure anymore. Still, we are wired to react as preys and consider anyone that attacks us, as a predator. That of course, assuming that we have not evolved at all. But we have, and besides the primitive responses of our autonomic nervous system (ANS), we count on with a very developed neocortex (prefrontal cortex specifically) that gives us the capacity to control the primitive responses.
Not everyone that suffers a traumatic event, develops a mental disorder. We may go through traumatization, but we may not develop trauma. here is the difference between both:
This is the process that your system goes into after perceiving danger. The cascade of reactions makes changes in your functioning to keep the body alive. That process is really tolling to the system and can leave complications in your memory, perception, physiology, etc.
Traumatization can end when the danger is gone, or can continue after, depending on how your mind deals with the event. If you are still scared even when the situation turned in your favor and you are safe, the traumatization will continue.
Traumatization can end up as a mental disorder, but not always. It can dissipate in hours, days, or weeks if you are safe and feel safe. Once your cortex sends the signal to the amygdala that the risk os over, the body will naturally try to go back to normal. The brain prefers equilibrium over chaos. According to the bible of psychiatry (DSM), if symptoms last for longer than 1 month, the diagnosis of PTSD can apply.
Suffering from trauma assumes that the disorder has developed fully and it has become “permanent.” All the changes suffered during the traumatization have left sequelae and the system now functions in a dysregulated way on a regular basis. It will not disappear by itself; it will need interventions in order to heal.
The most significant changes are:
Loss of homeostasis
Dysregulated nervous system: tendency to stay hyperactivated, hypoactivated, or having both sympathetic and parasympathetic in override
Loss of tolerance to affect; easily overwhelmed and overreactive.