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Author: Udeni Appuhamilage, Ph.D, TMH Psychologist 
Trauma has become one of the most common human experiences in the modern world, due not only to personal losses but also to massive adversities caused by both man-made and natural disasters. 2021 was marked by the COVID-19 pandemic which severely disrupted our familiar everyday routines, leaving us with a lingering uncertainty; as of April 2022, it has killed more than 6.15 M people worldwide[1]. Climate-related extreme events like heat waves, forest fires and floods and other natural disasters such as landslides and earthquakes also hit many parts of the world. According to UNHCR, an annual average of 21.5 million people has been forcibly displaced by weather-related events since 2008.[2] If we consider Japan, a country that sits at the nexus of four tectonic plates thus subjected to more than 1,500 seismic events annually, disaster related losses and displacements are familiar experiences to many communities. The 2011 earthquake and Tsunami is one of the more recent disasters that caused catastrophic damage to Northeast Japan, with nearly 20,000 deaths (Nakahara & Ichikawa 2013)[3]. This picture is further complicated by the many man-made adversities around the world that kill, disable, displace and/or disappear thousands of people every year. Globally, an estimated 736 million women are subjected to physical and/or sexual violence at least once in their life.[4] According to the United Nations, more than 79.5 million people have fled war, persecution and conflict in 2019, the highest level recorded since these statistics have been systematically collected.[5] In other words, trauma is not new or unfamiliar to many of us. Even if we are not subjected to any of these calamities directly, we all get an intense-enough daily dosage of traumatic exposure through media.
Table of Contents
What is Trauma?
This is an important question to ask not only because of its forced and/or increasing familiarity to us. The significance of this question is also about understanding its plural meanings. In fact, the term has become so common that it is used for all sort of mental discomfort varying from the impact of child abuse to rape to motor accidents to war to displacement caused by natural disasters. Conceptually differentiating between what trauma is and is not, hence, is not an easy task. While such plurality makes trauma one of the most challenging mental health phenomena to work with, the same plurality also allows flexibility and enables the survivor to creatively work with it, a point to which I will come at the end of this article.
Trauma is clearly a health-related concept; it is directly linked with physical and psychological pathologies, one of the most significant being Post-Traumatic Stress Disorder. However, trauma is also a social, cultural, moral and political concept. After all, society has always debated the merits of allowing suffering people to ‘freely’ express themselves. The idea of collective trauma highlights how cataclysmic events such as a tsunami or massacre can destroy the basic fabric of a society. In doing so, these traumatic events transmit into a collective memory leading to a shared system of meaning that affords the surviving community to redefine who they are; in other words, collective trauma is fundamentally about a crisis of meaning. While the shared system of meaning allows survivors to identify with and adapt as a group, these meanings also hint at existential crisis and propels survivors to search for alternative meanings, especially given that traumatic events such as sudden death and rape lack meaning within established socio-moral frameworks.
Collective trauma and the resulting collective memories are linked with intergenerational trauma, which notes how trauma experienced in one generation affects the well-being of the descendants of future generations. There is robust literature explaining the intergenerational effects of traumatic events including armed conflict, massacres and various kinds of interpersonal abuses and also the mechanisms such as parenting and family interaction styles through which trauma transmits across generations (E.g., Bezo and Maggi 2015; Han 2005; Sangalang and Vang 2017).[6]
Whether it is individual, family or community trauma, present or past trauma or intergenerational trauma, the concept of trauma can be used/abused by many parties for many purposes. Given this complexity, one can even argue that the concept and experience of trauma are both disabling and enabling, based on who defines whose trauma.
Trauma: the Medical Model
‘Trauma’ is the Greek word for wound, and hence, was initially used to refer to a physical injury caused by an extrinsic agent. Nowadays, however, it is also used to refer to emotional wounds. Those psychiatrists and clinical psychologists who adhere to the medical model understand trauma as a disordered psychic and/or behavioral state that is caused by severe emotional or physical stress. Both the 11th edition of the International Classification of Diseases (i.e., ICD-11), published by the World Health Organization and 5th edition of Diagnostic and Statistical Manual of Mental Disorders (i.e., DSM-V), published by American Psychiatric Association, follow such a pathological model and categorizes several trauma related disorders. These classifications present a list of symptoms (e.g., consistent patterns of emotional withdrawal, social and emotional disturbances, impulsivity, nightmares, dissociative reactions, etc.) for each of the many disorders which help in forming a diagnosis.
The common factor that binds all these different diagnoses is that all of them are defined primarily by the survivor’s exposure to a traumatic or stressful event. However, what events would count as ‘traumatic’ and thus, could cause a trauma-related disorder, is left for debate: instead, the emphasis is on how survivors react to the trauma and it is the reaction that is pathologized rather than the situation itself.
Beyond The Biomedical Model
While the idea of psychic trauma is familiar to many of us today, we need to understand that it went through several stages of change before it gained wider acceptance at the end of the nineteenth century (Fassin and Rechtman 2009).[7] Among the many implications of these historical developments, I want to emphasize two factors.
- Firstly, these historical developments demonstrate the reluctance of the medical and political authorities to acknowledge and validate the idea of psychic trauma. Concepts like collective trauma and intergenerational trauma still raise doubts among many professionals and are absent from the above diagnostic manuals.
- Secondly, the recognition of trauma as a valid category inadvertently allowed the trauma victim to be culturally, socially and institutionally acknowledged, for her to become respectable and validated. Such acceptance converted trauma to be an indisputable moral category, thereby strengthening the legal and political power of reparation and testimonies of survivors (Fassin and Rechtman 2009).
Acknowledging these historical developments and the said complexity of trauma compels a level of antipositivism; it requires therapists to be comfortable to work with subjective, multifaceted meaning systems that extend beyond lists of symptoms and diagnostic categories. Below, I highlight three aspects that represent this complexity but are not accommodated by the medical model.
Aspect 1: Trauma is a transcending experience.
Trauma transmits between generations, individual and the group and between body and mind. In many cases, trauma starts with, if not involves at some level, physical trauma. Except for cases where the loss or injury of someone else causes trauma on the patient, other causes of trauma such as a motor accident, domestic violence, rape, chronic illnesses and internal or international displacement due to a disaster involve physical injury. The moment this physical damage is transmitted to include invisible injuries inflicted on the mind/self, we not only translate the physical into mental, but also acknowledge how certain external experiences can corrupt and destroy the internal.
Aspect 2: Trauma is one of the most human responses to overwhelming events.
If we look at events such as the loss of a loved one, child abuse, rape and civil war that traumatize people, we can easily see that all these events are out of the ordinary. These are not the kind of mundane, everyday life experiences that we understand, expect or live with. Thus, should it surprise us if survivors’ responses – crying spells, nightmares, anxiety, depression, and stress – to these events are also out of the ordinary? In fact, what should alarm us is if a survivor of a rape, motor accident or someone who lost a loved one to a land slide does not cry, does not have nightmares. As Pupavac (2001)[8] has argued, trauma, at some level, is a normal response to an abnormal situation.
Aspect 3: Trauma is a subjective experience.
Whether an event is traumatic or not is decided by the complexity of the individual/group who faces and endures that event. This is why the same event can traumatize different people in different ways and to different extents. Such understanding, however, is problematic since it enables victim blaming by assigning the survivor as responsible for her trauma. Victim blaming assumes trauma and one’s capacity to endure it as exclusively defined by personal factors. Yet, neither trauma nor the resilience of individuals/groups who survive the trauma is singular; instead, they are plural and defined by factors internal and external to the individual. For instance, it is daily wagers who suffered the most in the COVID-related lockdowns, while the middle class and the rich in the society could survive the situation better. There is a significant association between child maltreatment and stressors such as low family socio-economic status (e.g., Herrenkohl and Herrenkohl 2007).[9] The lower the status of women in a society, the higher the rate of rape is (Martin, Vieraitis and Britto 2006).[10] Ignoring this socio-political context within which trauma occurs blinds us not only to the complexity of the phenomenon but also to the possibility of building effective interventions to address trauma.
Trauma Interventions
Therapeutic approaches used with survivors of trauma, in general, focus on 1) somatic, 2) emotional and 3) cognitive (i.e., higher order information processing capacities) aspects. Trauma leaves bodily memories and pent up bodily intensities; thus physical release is therapeutic. This may mean natural bodily releases such as crying or sweating when triggered; therapy can also involve guiding the survivor within a safe and empathetic relationship to recognize, acknowledge and work with the bodily sensations connected to trauma through intentional practices of breathing and bodily relaxation exercises. One of the most common approaches used with trauma is cognitive behavioral therapy (referred to as CBT henceforth), which aims to guide the survivor to process and evaluate her thoughts and behaviors about a traumatic memory/experience. CBT believes in changing automatic thoughts and bodily, behavioral and emotional reactions triggered by trauma, by recognizing and changing the dysfunctional assumptions that shape the survivor’s understanding of trauma. Eye Movement Desensitization and Reprocessing, or EMDR, is a combination of cognitive and somatic approaches. EMDR incorporates the basic premises of CBT about changing thoughts as a way to change emotions and behaviors, with eye movement or other rhythmic left-right movements to ‘unfreeze’ traumatic memories. Humanistic and existential therapy understands trauma as a normal response to an existentially threatening event. These approaches place a lot of emphasis on the subjective meaning of the traumatic experience rather than ‘symptoms.’ Given how trauma-related disorders such as PTSD result not from the event itself, but from the way one constructs meanings from that event, Humanistic approaches can be quite effective in working with survivors to unpack their incongruent patterns of meaning attribution.
Key Insights about Trauma Care
One of the first cases of trauma that I worked with, and a case that made an ever-lasting impact on me, was a 12 yrs old girl, who had been sexually assaulted by several family members over a period of several years. I was new to the field at the time and thus, had no confidence that I would be able to help her in any way. We had a small clay pot in the therapy room, which she used as a container of her secrets; whenever she had a flashback that disturbed her, and did not want to share it with anyone, she whispered it into the pot and sealed it with a lid. One particular day, she did the same except that she also wanted to share her secret with me. She started describing an incident where she was molested, naming some of her abusers for the first time in therapy. In the middle of the narrative, her breathing changed, her body started to shrink and her voice faded away. She started hitting and kicking the thin air around her, screaming, pulling her clothes, but all the time holding on to the edge of my skirt with one hand. As agonizing as it was to ‘be’ with her through that process, I also knew that I had to let her fight her fight. We had several of those episodes during our work. Each time it happened more and more secrets were disclosed. And each time she had those flashbacks, she held onto my clothes. The intensity of her flashbacks gradually went down. She slowly rebuilt her capacity to heal herself and left therapy. Whatever effect I had on her during that process, her effect on me was greater. She taught me fundamental lessons about trauma and trauma care: that trauma binds us (to a disturbing memory or an empathetic listener) as much as it divides us and that witnessing and ‘being’ with the survivor as she relives her trauma has therapeutic value.
The dynamic balance between containment and expression is at the forefront of trauma care; while therapy believes in expression as the way to free the survivor from the grips of silent memories and secrecy that surrounds trauma, containment offers survivors predictability and hence, a sense of safety. Therapy needs to carefully thread between these two poles, recognizing the strengths and limits of both ends. On the one hand, mere expression can fail in a majority of trauma cases; for many, healing from rape, child abuse, war, domestic violence or an assault at work would require a change in established systems, institutions and cultural belief systems that enable and maintain abuse and disempower selected groups. Moreover, unconstrained disclosure by individual survivors can drain the person herself, and could lead to a loss of her functionality. On the other hand, excessive containment can lead to denial and dysfunctional secrecy.
Another critical issue about trauma care involves empathy; ‘being’ with the trauma survivor provokes us. Trauma hits us at our core since trauma reveals our fundamental vulnerabilities. Thus, effective trauma work is an intentional and mindful practice of compassion and dispassion, an informed commitment not to prematurely confirm healing and a readiness to recognize one’s own biases and resulting judgments of ‘weak’ and ‘strong’ people (as Johnson and Lubin [2015][11] notes, ‘cowardice’ was one word used until mid-1800s to refer to what we now know as PTSD).
In Conclusion
Trauma is a plural construct with multiple meanings, (many if not most unconfined to psychiatry and neuroscience), and each type of meaning is worth examining. Trauma is more than the sum of the many specific events that lead to it; instead, it is defined by reciprocal relationships between the events, the subjectivity of the survivor who experiences, questions and lives those events and the complex ecology within which both the survivor and her experiences are interpreted. This plurality is confusing and can be overwhelming to the client and the therapist; it makes trauma complex and abstract, thus hard to work with. However, it is the same plurality that makes trauma unbound in time and space, thereby opening it to interpretation and reinterpretation. Acknowledging and working with this plurality allows therapy to foster a fertile space that enables the survivor to challenge established narratives of victimhood, to make new meanings, and re-write her own narrative- a narrative in which she becomes the author.
References
- https://www.statista.com/statistics/1093256/novel-coronavirus-2019ncov-deaths-worldwide-by-country/ retrieved on 2/4/2022.
- https://www.unhcr.org/uk/news/latest/2016/11/581f52dc4/frequently-asked-questions-climate-change-disaster-displacement.html retrieved on 2/4/2022
- Nakahara, S. and M Ichikawa (2013) Mortality in the 2011 Tsunami in Japan. Journal of Epidemiology 23(1): 70-73.
- https://evaw-global-database.unwomen.org/en retrieved on 4/4/2022. The United Nations defines violence against women as “any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life” (General Assembly of Resolution 48/104 Declaration on the elimination of Violence against Women, 1993). The term women refers to females of all ages, including girls (UN General Assembly, 2006).
- https://unstats.un.org/sdgs/report/2020/goal-16/ retrieved on 4/4/2022.
- Bezo, B and S. Maggi. (2015) Living in “survival mode:” Intergenerational transmission of trauma from the Holodomor genocide of 1932–1933 in Ukraine. Social Science and Medicine 134:87–94; Han, M (2005) Relationship among perceived parental trauma, parental attachment, and sense of coherence in Southeast Asian American college students. Journal of Family Social Work. 9(2):25–45; Sangalang, C. and C. Vang (2017). Intergenerational trauma in refugee families: A systemic review. Journal of Immigrant and Minority Health 19(3): 745-754
- Fassin, D. & R Rechtman (2009). The Empire of Trauma: An Inquiry into the Condition of Victimhood. NJ: Princeton University Press. This blog post does not allow the space to discuss the historical processes through which trauma gained such acceptance. For critical discussion on the historical developments of the concept of trauma, please read Young, A. (1997). Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. NJ: Princeton University Press.
- Pupavac, V. (2001). Therapeutic governance: Psycho-social intervention and trauma risk management. Disasters 25(4): 358-372
- Herrenkohl, T. and Herrenkohl R (2007). Examining the overlap and prediction of multiple forms of child maltreatment, stressors, and socioeconomic status: A longitudinal analysis of youth outcomes. Journal of Family Violence 22: 553-562.
- Martin, K., L. Vieraitis and S. Britto (2006). Gender equality and women’s absolute status: A test of the feminist models of rape. Violence Against Women 12(4): 321-339.
- Johnson, D. and H. Lubin (2015) Principles and Techniques of Trauma-Centered Psychotherapy. Washington DC: American Psychiatric Publishing.
