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A broad definition of trauma is useful; an open-ended one isn’t | Psyche

Photo by Tobias Tullius/Unsplash

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A broad definition of trauma is useful; an open-ended one isn’t

Photo by Tobias Tullius/Unsplash

by Ahona Guha + BIO

The concept of trauma now permeates our zeitgeist like never before, with a growing awareness of both the range of events that can be considered traumatic and the tendrils of harm that trauma can send into the lives of victims. As the sexual abuse survivor Grace Tame, winner of the 2021 Australian of the Year award, recently said, we must have an ‘open and honest discussion about trauma and what that can look like. It can be ugly. It can look like drugs. Like self-harm, skipping school, getting impulsive tattoos and all kinds of other unconscious, self-destructive, maladaptive coping mechanisms.’ Her statement will leave clinicians working in the field of trauma nodding, familiar as we are with the darker and more destructive impulses trauma can engender. Abuse and trauma can have far-reaching impacts, sometimes making life itself feel so painful as to be untenable.

The conceptualisation of trauma has changed significantly over time. Historically, much of the clinical thinking about trauma has taken a narrow view, assuming that trauma (derived from the Greek for ‘wound’) necessitated the infliction of physical wounds and harms. In the early 20th century, clinicians recognised manifestations of trauma in soldiers, using terms such as ‘shell shock’ and ‘war neurosis’. Later, a collection of frequently observed after-effects of trauma were reconceptualised as post-traumatic stress disorder (PTSD). PTSD is one of the most well-known mental health conditions arising after trauma, with symptom clusters of trauma intrusions (such as flashbacks and nightmares), avoidance (of memories of the trauma), emotional and cognitive changes (such as persistent negative emotions or distorted beliefs about oneself or others) and changes in arousal and reactivity (such as hypervigilance).

Since the time PTSD first entered the diagnostic lexicon, our conception of trauma – including the causes of traumatisation and how it manifests – has grown more encompassing. There has been easy recognition that a range of experiences, such as exposure to war, assault, rape and anything else that involves a disturbing and life-threatening event can lead to post-traumatic difficulties. We now also know that events that are not directly life-threatening, including behaviours such as emotional abuse, financial abuse, bullying and neglect, can lead to post-traumatic reactions and responses. When traumas compound or occur at key developmental ages, a person may develop complex post-traumatic stress disorder (C-PTSD), which involves difficulties related to a person’s self-concept, emotional development, thinking and interpersonal functioning. The concept of trauma has also been expanded such that witnessing a traumatic event as part of work might qualify one for a diagnosis of post-traumatic disorders, lending recognition to concepts such as the vicarious traumatisation experienced by professionals such as first responders.

There are a number of potential reasons why the conception of trauma has widened. And with the expansion of ways in which the term ‘trauma’ is used, there are also concerns that it is now being overused. The psychologist Nick Haslam suggests that the changing meaning of trauma is underpinned by what he calls ‘concept creep’, reflective of increasing liberalisation of society and a greater focus on moral harms. He notes that concepts that refer to negative aspects of human experience (such as bullying and prejudice) have expanded over time to capture less harmful variants of the same behaviour, as well as qualitatively new phenomena. Michele Cascardi and Cathy Brown have provided a somewhat contrasting view, arguing that the broadening of our understanding of certain psychological concepts often constitutes a meaningful expansion. ‘When meaningful expansion occurs,’ they write, ‘a concept is altered in a thoughtful way to include new behaviours in new contexts,’ which ‘points toward constructive strategies for harm reduction.’

This work is not as simple as concluding: ‘You have anxiety after a difficult experience, ergo you must be traumatised’

A broadened conception of trauma clearly has some key benefits. First is the recognition it provides trauma victims who might have hitherto found it difficult to name their experiences and acknowledge the impact. It is difficult to understand and treat something that remains unacknowledged. Second, recognising the variety of behaviours that can cause trauma has allowed us to seek protection for people from these behaviours, which might not have been recognised as harmful in the past. Marital rape, for example, was long not even acknowledged as an offence. Severe bullying has become enshrined in law as a criminal offence just within the past decade. People have slowly recognised that behaviours that were historically accepted as normal cause significant harm and must be stopped – resulting, overall, in moves toward a fairer and kinder society.

However, as with many phenomena that draw popular focus, when viewed through the lens of social media, the concept of trauma has started to warp in counterproductive ways. Even as attention is drawn to some of the darker and more difficult ways trauma can manifest, the social media landscape demonstrates a concomitant lightening of trauma – focusing on purported symptoms such as perfectionism, high-functioning anxiety, people-pleasing and difficulty relaxing. It is also now common to see social media channels characterising relatively innocuous behaviours and habits as symptoms of trauma – eg, watching a show repeatedly, struggling to make small decisions, overpreparing, overanalysing, and becoming defensive. To be clear, none of these are clinical symptoms of trauma disorders as per current diagnostic criteria. They might be habits derived from the ways that some people have learned to adapt and function after experiencing trauma, but they might also simply be temperamental quirks, or even adaptive ways people have learned to function in a fast-paced world.

Understanding when certain behaviours are truly underpinned by trauma requires careful psychological exploration and understanding of the nuances of psychopathology. The more common trauma responses for which survivors seek psychological therapy are much more severe than the behaviours listed above: suicidal thoughts, self-harm, drug use, self-hatred, disabling anxiety, eating disorders, aggression and violence are the ones I commonly see. Trauma is a complex phenomenon, made even more so by the wide variety of clinical difficulties associated with a history of trauma and the number of overlapping diagnoses (such as major depressive disorder, generalised anxiety disorder, and borderline personality disorder) that someone with a trauma history might present with. Clinical work involves re-diagnosing someone through the lens of trauma, and determining an appropriate treatment modality, such as cognitive processing therapy for PTSD.

The complexities of trauma also include the fuzzy divisions between events that are truly wounding to the psyche and those that might be aversive and difficult, but are not traumatic. Exactly where these boundaries lie is unclear. But this work is not as simple as concluding: ‘You have anxiety after a difficult experience, ergo you must be traumatised.’

There are many challenging human experiences that we do not need to pathologise

‘Traumabait’ is what I call the overinclusive use of the construct of trauma. Often, it appears to be generated by those who wish to sell a product or an idea, or who want to position themselves as relatable social media influencers and have recognised simply that trauma sells.

The overuse of the concept of trauma could come with some risks. It has the potential to promote overdiagnosis or inaccurate self-diagnosis, which can lead to other difficulties (eg, a misdiagnosis of PTSD might lead to delays in accessing appropriate treatment); redirection of limited treatment resources away from those with more severe need; intolerance of experiences that are difficult but not disabling, resulting in reduced psychological flexibility and resilience; and a hyper-focus on one problem or set of symptoms to the exclusion of others. I have worked with clients in my practice who sought assistance for PTSD after self-diagnosing. In some cases, careful clinical assessment eventually revealed that they did not meet the diagnostic criteria for PTSD, and that therapy interventions other than trauma-based ones were required. On a number of occasions, other pertinent conditions have explained symptoms that people attributed to trauma – such as sensory overwhelm caused by autism spectrum disorders.

Interestingly, though, while I often find that the overuse of ‘trauma’ plays out loudly in the social media sphere, my experiences in the therapy room are frequently quite different. Many clients find it difficult to name the aversive things that happened to them, and they say things like: ‘Well, it wasn’t that bad/as bad as X.’ It is common to have to point out that certain ways of coping (eg, social anxiety) might indeed be reflective of trauma, a learned response when they were faced with a world that was dangerous.

In my practice, I find it helpful to use a reasonably broad definition of trauma. There are no firm, clear-cut boundaries between the kind of event that causes traumatic responses and the kind that doesn’t. I typically use the formal diagnostic criteria for PTSD and C-PTSD as initial guides, and then explore the range of adversities experienced by clients, including the impact of these events on a developing personality and the meaning someone derives from these events. I largely find it helpful to allow clients to use the terminology that they wish to use, including the word ‘trauma’.

Therapists commonly use the word ‘trauma’ when talking about bullying just as we do when talking about rape. However, there are many challenging human experiences that we do not need to pathologise. We can allow clients to notice that some things are aversive and difficult without necessarily entering the realm of trauma (such as being teased by a sibling, or cheated on by a spouse). It is possible to acknowledge, note and soothe distress without needing to legitimise it by assigning it the trauma label. Similarly, it is normal to encounter difficult interpersonal situations such as marital affairs, fights with friends or sibling rivalries, and it might even be helpful to learn to build resilience and interpersonal skills through facing these situations.

Understanding the difference between the traumatic and the distressing is essential to helping people develop healthy identities that are characterised by psychological flexibility and resilience. While bringing mental health terms into common parlance is valuable for awareness-raising, it is important to employ these terms sensibly in order to ensure that people develop useful conceptualisations of their difficulties. A conception of trauma that is well off the mark could end up harming more than it helps.

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9 May 2022