What’s Called Trauma in Therapy
All the different ways clients use the word trauma when looking for help.
We know more and more about emotional wounds every day. There are amazing advocates and researchers coming up with new findings on how we get emotionally injured and traumatized. 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 and why it’s important to differentiate them. The word trauma is used in many publications to define:
a mental disorder
Trauma as emotional distress
When people say "let me tell you about my traumas" they are probably talking about emotional wounds but not necessarily traumatizing ones. Being emotionally distressed is a highly unpleasant emotional reaction or states like when we feel anguish, humiliated, or furious. We can become distressed when someone offends us, when we remember someone offending us, or even when we offend others. Distress can become emotional suffering and it can evolve into depression, anxiety, or some other emotional issues. It’s part of our human condition and can leave emotional wounds. If trauma means 'wound,' we could say that an emotional wound is a negative experience(s) that could cause pain on a deep psychological level. It is a lasting hurt that often involves someone close like a family member, lover, mentor, friend, or other trusted individual. Emotional wounds are not necessarily connected to fear, threat, and defeat, which are the activators of the survival cascade that ends up as a posttraumatic stress disorder. They may be more related to shame, guilt, resentment, or emotions that can't be expressed and therefore stay unmetabolized.
Trauma as an event
Traumatic events are those that make people feel threatened, highly stressed, terrified, shocked, or frightened because of their potential to cause physical, emotional, spiritual, or psychological harm. A traumatic event has the potential to leave an emotional wound and also traumatization, but not always cause a mental disorder or 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 an experience
Any event could end up causing trauma if the reaction we experience exceeds the capacity of the person to stay regulated. How someone experiences the event is what will determine if it ends up traumatizing the individual or not. A traumatic experience depends on your perception of risk and is very individual. For a baby, being wet & cold and shivering, or hungry with a stomach growling for “too” long can seem life-threatening. For an adolescent, flunking an academic year and the fear of punishment, or being expelled from the team and the rejection that follows can seem life-threatening; for a mother with children, breaking up from a supportive and providing romantic relationship can seem the end of the world. The experience in itself is not the illness. It's just the shock and the process we feel in our system that is overwhelming but it could last only the duration of the event.
Trauma as a reaction
Our innate survival mechanisms trigger a series of physiological reactions with the sole purpose of keeping our whole system running. The best known reaction is the fight-flight response, and many people call trauma to this reaction. 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 and more than one need to be activated before the system crashes into a long term dysregulation: Orienting, Attentive immobility, Social-engagement, Freeze, Tonic Immobility, Collapse Immobility, and Quiescent Immobility are some names included in the survival reaction cascade. For the system to stay traumatized, the cascade needs to get activated beyond fight-flight; that's why traumatization should not be defined only in terms of the reaction.
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 and the traumatization process could remain. But if we deactivate the survival mechanisms by activating the executive functions of our brain, assessing the real level of risk, and controlling the fear and emotional reactions, we would have really won the battle and there will be no “trauma.” The response could stay for a while, but the brain will try to go back to normal. When this response goes away in less than a month, it is not considered trauma. In the DSM-5 this disturbing response could meet the criteria for Acute Stress disorder, but it's not the same as PTSD.
Trauma as a mental disorder
PTSD, C-PTSD (complex), Developmental Trauma, Attachment Trauma, Intergenerational Trauma, Racism Trauma, are some of the most common terms used to describe mental disorders even when only PTSD is included in the DSM-5 and C-PTSD in the coming ICD-11.
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: the risk of being devoured by a predator. Still, we are wired to react as prey and consider anyone that attacks us, a predator. That of course, assuming that we have not evolved at all and that we will always react from a very primitive place without assessing our possibilities. But besides the primitive responses of our autonomic nervous system (ANS), we count with a very developed neocortex (prefrontal cortex specifically) that gives us the capacity to control the primitive responses and regulate our reactions.
Not everyone that suffers from a traumatic event, develops a mental disorder. We may go through traumatization, but we may not develop trauma because resilience helps us bouncing back from the damage in a similar way that our body closes wounds by building up new tissue.
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 stoped. 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 is over, the body will naturally try to go back 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 sequela of alterations and the system now functions in a dysregulated way on a regular basis. If we compare it with a physical injury, instead of scaring, it will be similar to have the wound continue bleeding, probably infected, and even developed 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.