The word “trauma” originated in the late 17th century from the Greek language. The literal translation is to “wound or damage.” The Greek word was specific to physical injury and has been used in medical terminology since. In psychology, psychological trauma or emotional trauma refers to damage to the psyche. Trauma and the painful and sometimes debilitating resulting symptoms are not new. Any study of world history will reveal the presence of traumatic events that include the tragedy of war and cultural mores. Historians have found chronicles of psychological disturbance as far back as ancient Egyptian life.
What is trauma?
The definition I have shared with patients and their families over the years is: trauma is an over whelming emotional experience in which one has a real or perceived threat to their life and/or safety or the life and/or safety of another. The definition can encompass a multitude of experiences. The definition lends to subjectivity and the idea that it is not the event itself which is traumatic, but rather the individual’s experience of the event.
As an example, a divorce may not be traumatic for one, but it may be to another. A child of divorcing parents could experience the divorce as traumatic if she feared for her very survival learning she would be moving back and forth between the two parents, and one parent is someone she feels terrified of. Depending on a child’s age, maturity level, and relationship with each parent, a divorce could feel life threatening.
SAMHSA (Substance Abuse and Mental Health Services Administration) defines trauma as “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” This definition too speaks to the subjectivity and personal experience of an event. There are a myriad of life experiences that an individual could define as being traumatic. We know that those who fare better after experiencing a traumatic event are individuals who did not feel utterly helpless at the time of the event and have been able to make some sense out of what happened.
Some will suffer more than others. Suffering and unresolved trauma are synonymous. Suffering may result from the experience of physically and/or emotionally debilitating events that feature resulting painful responses to undesirable perceived or real harm. Suffering does not discriminate. Trauma does not discriminate. There is no zip code, address, state, or country immune from trauma and suffering.
Current statistics from the National Institute of Health, Department of Veteran Affairs, and the Sidran Institute estimate that 70% of adults in the United States have experienced some type of traumatic event at least once in their lives. They further estimate that 20% of these adults have or will develop Post Traumatic Stress Disorder.
History of Identification of Trauma in The U.S.
The American lexicon when veterans returned home from battle in World War I with emotional and mental disturbances was “shell shock.” After World War II the terminology became “battle fatigue.” As American war veterans returned to society, some with clear physical and emotional scars, despite recognition, the issue was not addressed and sadly, some veterans were viewed as cowards due to their uncontrollable responses to horror.
History also speaks to the suffering of The Revolutionary War and The Civil War. I recently viewed a documentary that followed a group of 9 participants from diverse backgrounds that attended weeklong intensive workshops every three months for a year and were seeking healing from childhood wounds. An African American participant spoke of the multi-generational “slavery trauma” that he still felt effected by today. His pain was profound.
Then in 1952, the first Diagnostic and Statistical Manual of Mental Disorders (DSM) was published. The manual identified “gross stress reaction” which was defined as a stress syndrome resulting from exceptional physical or mental stress. Specifically battle or natural disasters were the criteria provided as events that could cause the stress.
In 1968, the first revision to the manual, DSM-II was published and no longer included any stress disorder diagnoses. Some surmised that this was due to the diagnosis being so closely attached to combat and the second DSM was written during a relatively peaceful era. I argue this explanation however; as 1963 was the year President John F Kennedy was assassinated. In April of 1968 Martin Luther King, Jr. was assassinated, as was Robert F Kennedy in June of 1968. There was no shortage of cultural and political stress in our country.
While recently watching the CNN series American Dynasties: The Kennedys, I was struck by the commentator’s statement while describing Robert Kennedy’s bid for the presidency in 1968. He cited that Jackie Kennedy tried to support him publically as best she could but was suffering severe PTSD as a result of her husband’s assassination in 1963. This diagnosis was not defined until 1980. The footage of Jacqueline Kennedy revealed a woman looking fatigued and minimally present. Her comments and movements seemed to take great effort, her speech measured and slow. I was again reminded of how trauma does not discriminate and how psychological help did not exist at that time.
Sadly, the lack of any stress disorder in the DSM-II also left no accepted diagnosis for returning Vietnam War veterans and as this war became more unpopular, the suffering veterans received no adequate treatment for their psychological disturbances, which were then exacerbated by the contempt many returned home to. Despite the lack of a formal diagnosis however, research increased finding more evidence that a variety of stressful experiences resulted in significant and consistent symptoms for anyone. Thus, the DSM III recognized that after experiencing something so severe and outside of normal human familiarity that any individual could be significantly impacted. The DSM-III was published in 1980 with a new diagnosis:
“posttraumatic stress disorder.”
The diagnosis became widespread and clinicians began to generalize the concept to include what were considered more mild stressors not intended to be included in the PTSD diagnosis by the collaborators of the DSM-III.
In 1987, the DSM- III-R was published and changed the PTSD definition expanding the range of symptoms and emphasized the psychological content of the stressor. The diagnosis no longer included criteria that an event is so severe that it would result in symptomology for anyone. Questions continued to arise however, as did it make sense to use this same diagnosis for someone who had been tortured and imprisoned for years and someone who was a passenger in a vehicular accident with minimal physical injuries? Was another differentiating diagnosis needed?
DSM-IV was published in 1994. Like the previous two DSM the diagnosis remained open to interpretation. The definition was expanded however to include the experience of “a threat to the physical integrity of self or others”. The diagnosis now was no longer limited to an event only personally experienced by the individual. In addition, the diagnosis of Acute Stress Disorder was added which focused on criteria in which the individual had three out of five dissociative symptoms; numbing, reduced awareness of surroundings, derealization, depersonalization, and dissociative amnesia. Acute Stress Disorder is characterized by presentation of symptoms within 4 weeks after the stressor and is resolved within this same 4-week period. If symptoms continue after one month, the diagnosis is then changed to PTSD.
In 2013, the DSM-V came out with increased criteria and specific differentiation for those 6 years of age and older and those under 6 years of age. Acute Stress Disorder remains and a conglomerate of disorders are also included under a chapter titled Trauma and Stressor-Related Disorders.
Trauma and Addiction
In the mid 1990’s I was privileged to develop my career at Sierra Tucson, an acute care licensed psychiatric hospital with both level one and level two units. Early on I was involved in the development of a program focused on the treatment of trauma and trauma recovery. Myself and 3 colleagues were given a blank slate on which to develop a program that supported the treatment of patients with history of sexual, physical, emotional, and mental abuse as well as neglect, abandonment and more with resulting symptoms of PTSD, alcohol and/or drug addiction, sexual addiction, relationship addiction, and other behavioral health issues. The four of us had no differing opinions as to our understanding of unresolved trauma manifesting itself in these unhealthy behaviors. We also developed a family component in which family members came to the facility and engaged in open and honest communication about the traumas, which included facing the shame of incest, neglect, abandonment and more. The program rolled out in 1997.
The ACE (Adverse Childhood Experience) study was facilitated at Kaiser Permanente from 1995 – 1997. The study was conducted by The American Health Maintenance Organization, Kaiser Permanente, and the Center for Disease Control and Prevention. The study involved 17,000 plus participants surveyed on childhood experiences. Each was asked to identify if they experienced any of 10 pre-identified Adverse Childhood Experiences. The ACE score results demonstrated a high correlation of adverse childhood experiences with adult high-risk behaviors, and poor physical and mental health. Participants continued to be periodically evaluated over time. In short, the Ace Studies provide testament to the philosophy that addictions and other behavioral health issues are symptoms of underlying trauma. In 1996, my colleagues and I became familiar with the ACE studies and followed the research as it evolved.
I mention this because I have found that addiction treatment has not kept pace with the research. Only in the past few years have many clinicians begun discussing the ACE studies and how the results should be considered in the provision of treatment. Although on going, this study took flight over 20 years ago.
How Trauma Affects Us
Trauma can impact every aspect of one’s life. Behaviorally, we know that someone with unresolved trauma may over react to situations and under react as well. Anyone who is repeatedly exposed to frightening experiences and is unable, for whatever reason, to process the experience, receive understanding, or be provided comfort for their fears can become wired for extremes, leaving the individual either over-reacting or under-reacting to experience. Thus, unprocessed trauma can be seen in emotional, behavioral and psychological extremes. So, when something occurs that most would consider benign, a trauma survivor might present with an exaggerated response to the occurrence. Something seemingly small may result in a trauma survivor’s eruption as it may mimic a trigger or reminder of something terrorizing. In contrast, if a sudden unexpected crisis occurs, the trauma survivor might be the person presenting as calm and able to best manage the frightening situation. Why?
Trauma can result in dysregulation of our physiology. Extreme stress and traumatic experience wreak havoc on the body and cause emotional, physical, and psychological pain. After exposure to a traumatic event or events, biological changes occur that can interfere with our respiration and digestion, immune function, perception, cognition, changes in limbic system functioning, and other areas of the brain involved in learning and memory. Trauma affects our autonomic nervous system. Trauma distorts and dramatizes every aspect of a person’s world. For those exposed to repeated frightening experiences, the state of psychological arousal and dealing with crisis becomes normal for the individual. Despite not liking how they feel, crisis becomes familiar and there is safety in familiarity. Someone with a high level of traumatic exposure often knows instinctively how to manage crisis. As treatment providers, it is essential that we forgive the extreme behaviors of the trauma survivor, as they do not choose these reactions. Good treatment must include empathy, nurturing, kindness, and compassion and target the treatment toward the trauma roots; not by having survivors verbalize the stories and details, but by working with the beliefs the survivor has created and how trauma has become stored within the body.
In Part 2 we will talk about the Underlying Causes of Trauma
Nancy Jarrell O’Donnell specializes in addiction and trauma treatment. She has spent most of her 25-year career working in residential and in-patient facilities. Her experience ranges from Psychotherapist to Clinical Director to President of Clinical Services/Operations. She is a licensed therapist in Arizona and a Neuropsychotherapist currently in private practice and provides clinical consulting for treatment facilities in the U.S. She developed The Sabino Model: Neuroscience Based Addiction and Trauma Treatment™ www.nancyjarrellodonnell.com
©Nancy Jarrell O’Donnell 2018