A Position on Trauma

A Position on Trauma

One cannot be in clinical practice without being asked by clients to address and treat trauma.  While the term “trauma” has become an oft cited problem and reason for seeking treatment, there is great variation among clients in their description of the causes of their trauma and the symptoms and effects of trauma.

Without question there is a clinically significant, psychological and physiological/biological disorder labeled “trauma”.

Trauma is understood to result from exposure to an incident or series of incidents or events that were/are emotionally disturbing and life-threatening with lasting and adverse impact on the individual’s functioning and mental, physical, social and emotional well-being.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), trauma is defined as: "Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: 

Directly experiencing the traumatic event(s) 

Witnessing, in person, the event(s) as it occurred to others 

Learning that a close family member or close friend experienced or witnessed the traumatic event(s) 

Experiencing repeated or extreme exposure to aversive details of the traumatic event(s), such as through professional duties (e.g., first responders, cleanup workers, journalists)" 

It's important to note that in the DSM-5, not all stressful events qualify as trauma. The event must meet the criteria of being life-threatening or causing serious injury to be considered traumatic. 

Trauma is known to cause a significant chemical change in the body triggered by extreme stress and anxiety such as the release of adrenaline and cortisol. If the experience is significant in that it is life threatening, stressful and extreme, the person might reexperience those same chemical reactions long after the event when triggered by memories or experiences similar to that original event. When a person chronically or repeatedly experiences a life threatening or deeply disturbing and destabilizing stress they might have those same chemical changes in the body when activated by something akin to the stressor.  

In clinical practice, it is common for clients to refer to trauma as a causal explanation for their current behavior and subsequently the reason they are feeling stuck and unable to make changes. For many clients, trauma has become a ready explanation for any emotional suffering. As an overused self-diagnosis, the contemporary application of the term trauma is frequently used to describe any painful, upsetting or tragic life event and any relationship experience that caused distress.  Defined as such, one would be hard pressed to find a person who has not experienced some trauma. It is also common in situations where individuals feel particularly stuck, that they begin to see trauma as unchangeable and something that they possess internally – “I have trauma, that’s my trauma, and that’s why I can’t do those things”.

An alternative, and perhaps unpopular, position on trauma which I would like to share is that trauma is not a catch-all explanation for why people are stuck.

We have found in fact, that the experience of legitimate trauma is treatable and able to be overcome with diligent work. There are many different clinical approaches and protocols that treat trauma. The most common approach sees trauma-informed therapy as helping people to heal from trauma by creating a safe and supportive environment. This approach is based on the idea that trauma can have a complex impact on a person’s life and that it is critical to understand the root cause of the distress.

 The clinical approach that we take at our practice, as Marriage and Family Therapists (MFTs), is context and relationally based. We endeavor to understand the current, intimate context of the client how the experience of trauma and the resultant symptomatic behaviors function in the person’s life and relationships. Our understanding of healing is then to slowly and methodically retrain the person’s associations, narratives, or frames about the traumatic experiences or memories to gain mastery, voluntary control, over the psychological and physiological experiences they are currently having and reorganize their relationship to the trauma or stressor(s). It is our belief that a person cannot change the past or unlearn what they have learned. They cannot un-experience what they have experienced, therefore the treatment of trauma is not to forget or “heal” from what has happened but rather to gain control and mastery over the current symptoms, so they no longer are central and controlling in the person’s life and relationships. For that to happen, patterns of relating in relationships must be changed so that the trauma is not the central, organizing factor. Whether the experience of trauma is legitimate, or a self-diagnosis used as an excuse for inaction, the frame of the client and the family, and the associated symptomatic behavior becomes controlling in the lives of the client and their family. For the symptomatic behavior to be alleviated, the patterns of relating – the corresponding roles and relationships that have become stabilized around the trauma – must change as well.

A case example:

A young, newly married, man sought individual therapy for trauma and general mental health concerns. His relationship has been rife with issues of major mental illness and substance abuse. In this particular session, he reported feeling overwhelmed from a situation over the previous weekend. The client had become embroiled in a family drama where a cousin seemed to be in a manic episode and reaching out to the client for help. The cousin’s father and the client’s father share an unproductive family narrative about mental health and thus, both adamantly refused to believe that the person could be manic and so the client was also embroiled in trying to teach them and convince them of the severity of the situation. The client reported knowing that he was overextending himself and that this was a pattern of his, but he was not feeling like he could successfully extricate himself from the situation. He eventually chose to travel to take care of the cousin. Over the weekend, he spent significant time and energy on the phone with the cousin’s father and wrote a letter to both his uncle and his own father to share his experiences with his mental health journey in the hopes of convincing them to treat this situation appropriately. He came home exasperated and called a previous provider to do a session of EMDR (Eye Movement Desensitization and Reprocessing (a common treatment for trauma)) and still felt overwhelmed. The client shared all this in his meeting with me, his current psychotherapist, in our meeting early the following week. I asked the client about the reason for his overinvolvement and lack of ability to boundary effectively to which he responded that his behavior was caused by childhood trauma. The client explained a dysfunctional upbringing and a difficult relationship with his unreliable mother.

Certainly, the connection could be made that his lack of reliable parenting in early childhood was related to his historical and current compulsion to be a parental or caretaking figure for others. A typical “treatment” for this clinical situation could be to focus attention on the client’s reported history of “traumatic” parenting and pursue the past, attempting to help the client to safely voice his pain and anxiety on the journey to healing. The approach used asked a few different questions that instead pursued how his behavior that he is seeing as directly caused by his trauma, is functioning in the present.

I asked what the client likes about and what the client gets out of being stuck in caretaker roles.  The client insisted there is nothing to like and nothing to be gained from it, it comes solely from his trauma, and he hates all of it. The clinician respectfully insisted the client dig deeper and consider if there is something positive about caretaking.  The client agreed there is a sense of accomplishment, of feeling and being important and needed by the others, and a sense of purpose in being the person he needed when he was growing up. The clinician agreed with his reflections and continued to challenge. He suggested that the client also arranges to get taken care of whenever he puts himself in these situations. As he overfunctions at his own detriment to the point of exhaustion and overwhelm, he gets multiple providers and family members organized to help him and take care of him. The client was taken aback and surprised but reflected and thoughtfully responded affirming that maladaptively he can see how it functions that way.

The clinician went on to challenge whether or not his trauma is at the root of his behavior in relationships, the client needs to discover adaptive ways to accomplish effective and healthy caring in his intimate relationship, or he will likely never give up the caretaking because it works so well to provide things he desperately needs and is terrified to not have.

The intention of this case example is to highlight how the trauma this client reports might or might not meet the DSM 5 criteria of life-threatening and in fact, it is not important to pursue that as a focus of therapy. It would have been shortsighted and likely ineffective to only focus on the past trauma and miss how his frame/narrative about trauma functions in his life and relationships. It became abundantly clear, and very poignant and painful, to the client that the focal point in moving forward was to address his needs in his relationship with his new wife and make changes to more effectively give and receive caretaking in a way that his relationship is currently not able to provide. Then and only then will the client be able to make more purposeful and voluntary choices about his traumatic triggers and overcome his belief that his childhood relationships, that he understood to be traumatic, define his relationships and his options, and embrace that he has the choice to shape and choose different relationship patterns now.