We don't really understand trauma, yet

When I first sat down to write this article, I was planning to title it "An introduction to trauma" and provide a brief overview of what mental health professionals should know if they have not studied or worked with trauma before.

Like all of my articles, I wanted it to be scientific and evidence-based. Unfortunately, this is tricky with trauma because the psychological community is at war with itself over what trauma is and what we do about it. Therefore, I have decided to devote this article to presenting an understanding of where we are with our understanding of trauma.

The medical model

Mental health encompasses a wide range of professionals including psychologists, psychotherapists, psychiatrists (medical doctors), mental health nurses, social workers and many others.

Much of mental health is dominated by the medical model: rather than looking at people as a whole person we classify them by their symptoms into a series of discrete categories: depression, social anxiety disorder, personality disorders, etc.

These classifications come from one of two sources: the International Classification of Diseases (ICD) published by the World Health Organisation and the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. While the ICD is on the rise, the DSM has traditionally been the manual of choice.

Unfortunately, the American Psychiatric Association has been slow on the uptake of accepting trauma. Someone who is traumatised and classified by the DSM will almost inevitably receive a diagnosis of Post-traumatic stress disorder (PTSD).

What's wrong with PTSD?

PTSD is a good starting point but it has three major failings.

The first is that PTSD does not differentiate between simple trauma and complex trauma. Simple trauma comes from a horrific incident that occurs to an adult who otherwise has good attachment and coping styles.

Such incidents are horrible. But they are not the same as a child who has grown up with repeated traumatic events such as abuse, that never allowed them to develop healthy attachment and coping styles in the first place.

The fight to recognise this is detailed in Bessel van der Kolk's book The Body Keeps the Score.

The second major failing of PTSD is that it describes trauma as a mental disorder and not an injury.

If a soldier returns from the war, having seen many of his friends shot, and then jumps for his life when he hears what he thinks is gunfire, that's not a weird thing to do. That's a natural reaction given what has happened to them.

What such an individual needs is a type of therapy that is focused on healing their psychological injury, rather than trying to fix a mental illness. Peter Levine makes the case for this in his book In an Unspoken Voice.

Third, the DSM definition of PTSD only recognises life-threatening situations. In his book, The Myth of Normal Gabor Maté makes the case that while these big-T traumas are important, we also need to consider the many small-T traumas such as parental divorce, bullying, accidents and invasive medical procedures in which life may not be in danger but still leave our psyche damaged.

What do we do about trauma?

Cognitive behavioural therapy has long dominated the world of clinical psychology and it has an extensive evidence base for a range of problems.

Therefore, when addressing trauma, the clinical psychology community did what it always does: came up with a version of CBT designed to help with trauma. In this case, Trauma-Focused Cognitive Behavioural Therapy (TF-CBT).

The problem is that CBT works on a cognitive level. As Albert Wong points out, is that "you Can't think your way out of trauma." Trauma hijacks our nervous system, shutting down our higher cognitive functions, and therefore rendering cognitive strategies ineffective.

What else can we do?

Varies alternatives have been approached. Eye movement desensitisation and reprocessing (EMDR) is now widely used as a type of exposure therapy for those from a CBT background.

Humanistic psychologists often advocate for Person-Centred Therapy or Emotion-Focused Therapy (EFT) as a way to work directly with emotions and bypass the cognitive processes.

However, somatic and body therapists, such as those that practice Sensorimotor Psychotherapy or Somatic Experiencing Therapy, say even working on an emotional level is too high and we need to work directly with the body to heal trauma.

The current state of play

In psychology, we use the scientist-practitioner model: we are both scientists and applied psychologists in one.

This presents a challenge for trauma because the bias towards CBT approaches has led to extensive funding to support CBT-based trauma approaches while body-oriented therapies either lack evidence or in the case of polyvagal theory, outright rejected.

However, the lived experience of so many psychotherapists has taught us that trying to apply CBT to a client who is traumatised simply does not work.

Other areas are still being contested. For example, the ICD now accepts complex trauma whereas the DSM does not.

Conclusion

We know more about trauma than we have ever done before.

This is important to note because in this article I have mostly presented the ongoing confusion and complexity of debate around trauma.

This confusion hurts clients because they do not get the healing they need, and it hurts therapists who can find themselves feeling deskilled and frustrated when traditional psychotherapy tools do not work with trauma.

But things are changing. Knowledge of trauma is expanding all the time and importantly, there is much we can already learn today that will help us be more effective in treating trauma.

References

Levine, P. A. (2010). In an unspoken voice: How the body releases trauma and restores goodness. North Atlantic Books.

Maté, G., & Maté, D. (2022). The myth of normal: Trauma, illness, and healing in a toxic culture. Avery.

Van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Penguin Books.

Wong, A. (2020). Why you can’t think your way out of trauma. Psychology Today.