All the different ways clients use the word trauma that could confuse your treatment.
We use arbitrarily the term trauma and with different meanings. We could think that it doesn’t matter, but the clinical implications of such confusion are enormous. The significance of traumatization among mental disorders is undeniable, and taking the phenomena seriously is crucial.
We know more and more about what emotional wounds are every day, and therefore we could find better explanations of the trauma phenomena. There are amazing advocates and researchers coming up with new findings on how we get emotionally injured and traumatized. Neurobiology is our best ally in picturing every step of the traumatization process but first, we need to have some clarity on how to use the term trauma.
To describe how the term trauma is used in psychotherapy, I thought it could be useful to include several of the available definitions to help you see my point on how broad its definitions can be:
The American Psychological Association (APA) says that trauma is “an emotional response to a terrible event.”
Freud said that trauma was “the experience of being overwhelmed by an adaptive demand that renders the ego passive, helpless, and unable to anticipate, cope, and integrate.” (Even when he uses the word experience as the first definer, he also includes what renders from the experience.)
The Centre for Addiction and Mental Health (CAMH) in Canada says that “Trauma is the lasting emotional response that often results from living through a distressing event.”
The Cambridge dictionary says that trauma is a “severe and lasting emotional shock and pain caused by an extremely upsetting experience”
The Merriam-Webster dictionary lists several meanings: “a very difficult or unpleasant experience that causes someone to have mental or emotional problems usually for a long time;” “an emotional upset;” “an agent, force, or mechanism that causes trauma.”
Wikipedia displays trauma definition as “damage to a person’s mind as a result of one or more events that cause overwhelming amounts of stress that exceed the person’s ability to cope or integrate the emotions involved, eventually leading to serious, long-term negative consequences.”
Tara Brach states that “Trauma is when we have encountered an out of control, frightening experience that has disconnected us from all sense of resourcefulness or safety or coping or love.”
Bessel van der Kolk wrote that trauma is “an event that overwhelms the central nervous system, altering the way we process and recall memories” adding that “Trauma is not the story of something that happened back then, it’s the current imprint of that pain, horror, and fear living inside people.”
As you can appreciate, definitions of trauma talk somewhat interchangeably about it as an experience, a response, shock and pain, damage, imprint, or experiences that have resulting effects. Let’s start by differentiating the several ways the word trauma is used and why it’s important to find a common understanding of what trauma really is. That could help us avoid calling trauma to every unpleasant experience we have, as it has been happening lately.
The word trauma is used in many publications to define:
as adverse circumstances
a mental disorder
Trauma as emotional distress
Merriam-Webster includes ‘emotional upset’ under their definition of trauma. I find this to be a dangerous inclusion. Placing trauma within the realm of the emotionally upset could lead many to infer that being emotionally unsettled is life-threatening. While emotional distress is an unpleasant experience that may leave us in a negative state, it is as much a part of life as getting bruises. It’s almost impossible to have a life free of distress and only high-risk individuals (low or no-resilience + long-term previous traumatization) may get injured from the feeling of being distressed. To become distressed is to be expected when someone offends us, when we remember that someone offended us, or even when we offend others.
Of course, the distress caused by constant adversity can become an extreme form of emotional suffering that causes feelings of depression, anxiety, or some other emotional issues. But it is not until the distress and additional feelings accumulate and reach a fever pitch that we can observe a psychological trauma disorder. Distress is part of our human condition — if we didn’t have a feeling response to something that affected us, that would mean we have no connection to our emotions or awareness of them. This lack of response would make our human experience duller. The other good news is that it is also part of our human condition to heal from injuries. Being hurt or upset can easily get resolved internally, similar to how an itch heals itself with no help.
Trauma as an emotional wound
An emotional wound is a negative experience(s) that causes pain on a deep emotional level. If trauma originally meant ‘wound,’ it’s fair to include emotional wounds under the different uses of the term trauma. An emotional wound leaves a mark, the same way that an injury leaves a scar even if it’s only made by the tiny puncture of a needle. Even if it doesn’t need stitches, it still leaves a trace.
An emotional wound is interpersonal in nature — it is caused by the relationship with others. In many situations, these wounds relate to shame, guilt, resentment, or emotions that can’t be expressed and, therefore, stay unprocessed.
Memories of emotional wounds play an important role in treatment because the marks left on our psyche carry negative emotions and engender reactions, phobias, avoidance, or long-term hurt. These memories may mirror those described as “traumatic memories” among PTSD symptoms, including flashbacks and nightmares, and can be treated similarly. An important distinction is that emotional wounds are not necessarily connected to shock, threat, and defeat — it’s shock and threat that specifically activate the protective mechanisms that could end up causing a lasting trauma disorder. While many emotional wounds can be as disturbing as traumatic memories, it’s important not to assign a full diagnosis just because they are present, or give them names such as “childhood trauma.” These wounds-as-memories can indeed last a very long time, but they don’t carry the same level of despair and dysfunction that traumatic memories do because they are not connected to survival. Therefore, they don’t need the level of treatment that PTSD or other trauma syndromes do, even though they could be significant.
We could say that emotional wounds precede traumatization without causing it. Still, they could be so significant that a specific survival strategy can be adopted after being wounded, especially if repeated, which may confuse clinicians with being posttraumatic.
I know many people may argue with me. I want to include emotional wounds because they need to be treated and healed, but want to clarify that they don’t need the level of treatment that PTSD or other trauma syndromes do because they are less severe; the nervous system doesn’t get as affected and the person doesn’t shift to live in survival mode chronically after being emotionally wounded.
Let’s imagine that a casual friend hurt and/or betrayed you and you stopped being friends. You may carry that wound and even corresponding distress for a very long time, but at no point in the ‘break-up’ with that friend would you feel that the end of the relationship jeopardized your stability in a way that could affect everything else in your life. You continue living as you were, even if you carry the pain of not having that friend anymore. The emotions assigned to the memory of the betrayal and rejection may come as flashbacks and nightmares as reminders of the friendship and its end, but they won’t become chronic symptoms or cause dysfunction. Even if, let’s say, you start avoiding becoming friends with someone who reminds you of your ex-friend, that’s still not a marker of traumatization and therefore should not be called a ‘trauma.’
Trauma as a Memory
There is a big difference between the memories that being emotionally wounded leave in our brain and the memories stored after being in danger of losing one’s life. Many people refer to both as ‘traumas.’ Since flashbacks are one of the main recognized symptoms of PTSD, it’s easy to incorrectly assume that the existence of flashbacks means one suffers from a trauma disorder. Yes, traumatic events leave memories ‘charged’ with negative emotions that can be stored as reminders of unsafe or upsetting situations. They can appear unsolicited, disturbing our moments, and even create dysfunction. It’s common to store emotions connected to memories as part of our adaptation, but it’s also natural to forget what is irrelevant, and many memories can become irrelevant over time. Still, calling memories ‘traumas’ is narrowing the scope of the phenomenon since disturbing traumatic memories are only one symptom left by traumatization.
Trauma as an Event
Not every distressing event is traumatic, and not every traumatic event is traumatizing.
Events (or circumstances) that are colloquially referred to as trauma don’t always make people feel threatened, highly stressed, terrified, shocked, or frightened. Only when events are situations with the potential to cause physical, emotional, spiritual, or psychological harm does ‘traumatized’ begin to apply. The consequences after experiencing a traumatic event are independent of the event’s potential to traumatize. Let’s use a car crash as a traumatic event: a crash can be lethal, and a crash can also leave the people involved completely unharmed. When ‘trauma’ is used to refer to an event, it should be implied that the event caused an injury. Otherwise, it is just an event. Using ‘trauma’ to name any type of scary event is misleading (as in “small and big t,” where “t” is for trauma) and only a partial view of the whole construct.
An event is traumatic when it has the potential to leave an emotional wound and leave the individual traumatized (a long-lasting dysfunction in your nervous system). Examples: sexual abuse, bullying, oppression, racism, emotional abuse, emotional neglect, car accidents, surgery, natural disasters, foster care, entrapment, betrayal, poverty,…
Trauma as Adverse Circumstances
The term trauma began to be used to refer to adverse circumstances when the results of the Adverse Childhood Experiences (ACEs) study was connected to traumatization. The groundbreaking study–conducted in 1995 by the Centers for Disease Control and the Kaiser Permanente health care organization — exposed the fact that maltreatment and household dysfunction in childhood contribute to health problems decades later. Every day there are new findings that prove that living under the stress of adverse situations, especially during the first years of life, could leave profound wounds in our mind and body. Different types of wounds could make us feel at risk and are therefore traumatizing, but they may be circumstantial wounds as opposed to directly inflicted ones. A good name for these would be ‘adversities’ instead of traumas so that there is a better understanding of the “what” behind the pain. The term ‘adversity’ seems like the perfect term when referring to life hardships — even better, using the terms of the actual afflictions such as ‘a lot of abuse,’ ‘extreme neglect,’ ‘prolonged sexual molestation,’ etc. is preferred to speaking of ‘lots of trauma.’
Trauma as an Experience
Experiences are subjective; some people refer to what they experienced while facing a challenge as trauma. The perception of danger is what sets us up into surviving — and therefore initiates a process that we could identify as traumatization. Experiencing danger could also be traumatizing even without actual danger because someone may feel scared even from an event that’s harmless. Our brain is always trying to anticipate outcomes. Have you noticed how your smartphone or email anticipates what you are going to say while texting? Well, that’s exactly how our brain does it. If we anticipate the worst, our experience will match that expectation. That expectation is what could cause the injury more than the actual event. Traumatization is about the relationship we have with the event. Even if the experience in itself is not a chronic injury, if the shock and the process are felt as extreme and unbearable, our system may have difficulty regulating and going back to baseline, leaving a wound that can endure. An experience can be traumatizing even if the event was not traumatic.
Trauma as a Response
With the sole purpose of keeping our whole system running and protecting us from impending damage, our body counts on hard-wired circuits that get activated automatically as a response to danger. The best-known initial response is fight-or-flight, but it’s only one of a series that follows a certain hierarchy. The fight-flight response is extremely common; it gets activated even when we are not under threat but, rather, only stressed or upset, which years back was thought of as equivalent to traumatization and was called trauma. The identified protective responses that intervene during the struggle for survival are Freeze, Fawn, Fight, Flight, Tonic Immobility, Collapse Immobility, and Quiescent Immobility. There are sophisticated processes designed to protect us. Even when they appear obvious during and after experiencing something threatening, they are not synonymous with trauma; they are only elements of the phenomena. Some trauma definitions include ‘lasting response,’ which differs greatly from the immediate response to the traumatic event. When the response lasts or becomes programmed to repeat when confronting similar events, it refers to a posttraumatic symptom.
When 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 on our system is to feel overwhelmed. Under the trauma lens, being overwhelmed means 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., and the way our nervous system responds to stimuli. This level of reactivity is called dysregulation and will keep the autonomic nervous system to continue in charge of our reactions. If we don’t regain control over our responses, we will probably stay traumatized and the traumatization process could remain. Therefore, only when our response to traumatic events stays long, it could be called ‘trauma’ because it’d mean there is a long-lasting wound with enduring consequences. Otherwise, it is just a natural response to feeling threatened.
Trauma as a Reaction
Our innate protective mechanisms set off a series of physiological reactions, which are the direct consequences of the body’s response to danger. The reactions are as natural as the responses because they are manifestations connected to them. For example, fight-flight manifests as shaking, heart racing, sweating, shortness of breath, etc., while ‘submit’ and ‘collapse’ show reactions such as numbing, amnesia, disconnection, coldness, etc. They don’t mean trauma because they are not wounding on their own. Again, they are just part of how the trauma phenomena manifest.
Trauma as the Sequela of Traumatization
The term trauma is also used when a set of symptoms start appearing after experiencing shock from a traumatic event or from having experienced long-term exposure to traumatic stress. It may be misleading calling trauma to the presentation of symptoms because the over-identification with them could cause the traumatization to get prolonged.
Trauma as a mental disorder
The term trauma is used to refer to PTSD (or any other type of traumatization) that leaves lasting alterations in the system. Those alterations result from how our system and emotions relate to the traumatic event or circumstance. The way we react to danger may be a combination of 1) how we have learned to think about what’s dangerous and 2) the information genetically encoded in our systems since before we were homo sapiens. When the brain assumes danger, one reacts as if one were at risk of being devoured by a predator, or of being killed by an enemy.
Is this just because we are predisposed to react as prey and consider attackers predators, or are we acting and reacting to what we consider dangerous based on our experiences — and the information we learn from those around us?
Think about this in terms of whether the police is “dangerous” or not: One person may have learned to feel safe in the presence of a law enforcement official while another may feel completely defenseless and afraid when encountering one. That’s not our caveman’s brain — that difference comes from the information that the brain stores from experience to better anticipate danger and activate a protective reaction. Those protective reactions will take over in direct proportion to the assumed risk. In terms of understanding the “why” behind what injures our system, it’s important to know that the way we react is what matters and what can keep our system running in survival mode, causing us to suffer a disorder.
Traumatization: This is the process that your system goes into after perceiving danger and feeling hopeless. 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, sense of self, reactivity, emotional regulation, behavior, cognition, etc.
Traumatization can stop 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 therefore safe, the traumatization will continue.
Traumatization can end up as a mental disorder if it’s not stopped. It can dissipate in hours, days, or weeks if you are safe and feel safe. Once your cortex signals to the amygdala that the risk is over, the body will naturally try to return to normal. The brain prefers equilibrium over chaos.
Trauma (the long-lasting wound)
Suffering from trauma assumes that the alterations experienced during the traumatization period have developed fully into a ‘disorder’ and it has become the new way for your brain to operate. After the traumatic experience, the traumatization stays as a maladaptation. All the changes suffered during the traumatization leave a sequel of alterations and the system now functions in a dysregulated way on a regular basis. Let's compare it with a physical injury, instead of scaring. It will be similar to having the wound continue bleeding, probably infected, and even develop into an ulcer that won’t close until more severe interventions are in place to heal the open wound.
The “open wound” that uncontrolled or unaware extreme stress creates in our system can really spoil your life if you leave it unattended. It creates all sorts of dysfunction in your cognition, mood, identity, behavior, health, relationships, and performance. That’s why it’s important to differentiate it from a painful memory, or from distress. It needs to be treated as a serious issue that needs professional interventions to heal.