This entry reviews the definition and history of psychological trauma, some possible effects of psychological trauma (including posttraumatic stress disorder [PTSD] and resilience), treatment, and types of psychological trauma, including collective trauma, national trauma, intergenerational trauma, and international trauma.
Psychological trauma occurs when the human self-defense system becomes overwhelmed and disorganized. Trauma generally involves threats to life, bodily integrity, or psychological integrity; close personal encounters with violence and death; or sudden unexpected disruptions of affiliative bonds and individual frames of reference. Traumatic events are usually accompanied by feelings of intense fear, helplessness, loss of control, and threat of annihilation, which result in emotional, cognitive, and biological changes. The traumatic experience also concurrently depends on an identifiable objective occurrence and one's subjective interpretation and response.
The understanding of the concept of psychological trauma has changed over history. The ability to recognize psychological trauma depends on social, political, and cultural context. Indeed, revisiting the diagnostic criteria of psychological trauma and the populations diagnosed prompts examining psychological trauma in its social context.
The 20th century witnessed a proliferation of interest in psychological trauma, which has developed in a few fairly distinct waves. The first era began with scholarly investigations that found the diagnostic criteria of psychological trauma rooted in the study of hysteria. This first school of analysis arose in 19th century France, in the context of its republican, anticlerical political movement. The neurologist Jean-Martin Charcot was the first to document the neurobiological symptoms of hysteria in his studies of young women who were beggars, prostitutes, or insane. At the time, hysteria was generally regarded as a disease that occurred in women only and originated in the uterus. Charcot's studies were the first to demonstrate that hysteria was actually a psychological state because the symptoms were lessened through the use of hypnosis. Pierre Janet, Sigmund Freud, Josef Breuer, and others who witnessed Charcot's treatment of hysteria attempted to understand the cause of the illness.
The subject of child sexual abuse has played a pivotal and provocative role in the history of psychological thought. Freud's "seduction theory" acknowledged the pervasiveness of sexual abuse in which he posited that the origins of hysteria lie in premature sexual experiences. However, Freud had great difficulty reconciling this theory with his evolving concept of the child's inner fantasy life. Thus, by the beginning of the 20th century, memories of seduction were conceptualized largely as fantasy instead of as actual trauma, and the theory of psycho-sexual development—crucial to Freud's subsequent work and the cornerstone of classical analysis—was born. Although Freud always retained a belief in the reality of sexual trauma, the motivation was shifted from adults to the seductive behavior of the child.
The second wave of trauma investigation constituted an inquiry into the mental state of soldiers who had experienced combat and suffered from what was then known as shell shock. This study originated in England after World War I and reached its peak in the United States after the Vietnam War. The sociopolitical context in which this investigation flourished was the antiwar movement. After witnessing and participating in the atrocities of World War I, many soldiers began to behave like hysterical women. At first, the symptoms of mental breakdown were thought to be a physical reaction to exploding shells. But soon, the same symptoms were found in soldiers who had not been exposed to physical trauma. Thus, shell shock was understood to be a psychological phenomenon.
The recognition of the traumatic effect of combat changed the understanding of hysteria. Still, the long-term psychological effects of combat were not closely studied until after the Vietnam War. At first, the soldiers who suffered from shell shock were thought to be immoral and were accused of laziness and cowardice. In the United States, with the rise of the antiwar movement in the 1960s, soldiers and veterans united, refused to be dishonored or stigmatized, and spoke of their trauma publicly. As the antiwar movement gained legitimization, the PTSD syndrome was recognized by the psychological and psychiatric communities as a valid diagnosis. In 1980, for the first time, the American Psychiatric Association included PTSD as a category in its official manual, the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III).
The third wave of investigation took place in the 1970s and 1980s, with the rise of feminism in North America and western Europe. The reality of trauma caused by sexual and domestic violence entered the public's awareness. The previous wave had focused the understanding and treatment of trauma on the experiences of combat veterans, to the exclusion of widespread sexual abuse and violence against women in the domestic sphere. Women's consciousness-raising groups in the 1970s gave voice to suffering hidden in the private sphere and concealed behind the claim of privacy. The feminist movement produced considerable research concerning sexual assault, which established a hitherto unrecognized prevalence of assaults against women and children: One in four women in the United States had been raped, and one in three sexually abused. Only after PTSD had gained recognition and was legitimized because of studies of combat veterans did it become apparent that the diagnosis once used to describe the psychological wounds initially called hysteria, and later recognized as the result of combat, actually pertains to numerous women and children who are survivors of domestic violence, rape, and incest.
Contemporary trauma researchers and practitioners have embraced an interdisciplinary approach toward better understanding the psychology of the traumatic experience. It is now recognized that trauma results in biological, psychological, and social changes, and a diagnostic classification that only lists symptoms is insufficient. Hence, today it is understood that the individual experience of trauma must be contextualized, as psychological trauma differs depending on the distinct instances that cause the trauma. For example, people who have suffered prolonged interpersonal violence, such as sexual abuse and domestic violence, tend to react differently than do those who have suffered a single traumatic incident such as a car accident. Furthermore, survivors of collective violence react differently to human-made events (such as terrorism, mass murder, mass torture, genocide, and ethnic cleansing) than to natural disasters (such as earthquakes and hurricanes).
Reactions to trauma vary widely. Whether a specific event elicits a traumatic response depends on both subjective and objective variables such as personality, past traumatic experiences, psychological resilience, degree of social support, extent of physical injury, and material loss. The personal, social, or political circumstances of the event are also highly influential factors. The responses to potentially traumatic events generally consist of cognitive, behavioral, and psychological experiences, as well as avoidance of the trauma. Responses vary between the extremes of a spontaneous recovery from the traumatic symptoms (marked by returning to equilibrium, both emotionally and functionally), to symptoms persisting more than a month and a possible diagnosis of posttraumatic stress disorder.
PTSD refers to severe anxiety that develops after exposure to any event that results in psychological trauma. This event may involve the threat of death to oneself, to someone else, or to one's own or someone else's physical, sexual, or psychological integrity. The absence of a spontaneous return to equilibrium within 4 weeks after the traumatic event often prompts a diagnosis of PTSD. Because the diagnostic criteria adopted for defining PTSD have widespread ramifications in disciplines such as law, psychology, and psychiatry, their formulation has generated considerable theoretical, political, and academic debate and controversy. Furthermore, these criteria, and the very definition of PTSD, have evolved (and are still evolving) in relation to historical context. The definition of PTSD is currently being revised for inclusion in the fifth edition of the Diagnostic and Statistical Manual (DSM-V; in preparation and due to be published in May 2013).
The current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines PTSD by the fulfillment of certain criteria, which include the following:
Exposure to a traumatic event (see the earlier definition of a traumatic event).
Suffering from intrusive recollection (such as images, thoughts, and dreams that create a sense of reliving the experience) as well as from illusions, hallucinations, and dissociative flashback episodes. This includes intense psychological distress and reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
Avoidance/numbing, which includes avoidance of stimuli associated with the trauma and numbing of general responsiveness, indicated by efforts to avoid thoughts, feelings, conversations, activities, places, or people that arouse recollections of the trauma. These symptoms may be accompanied by an inability to recall an important aspect of the trauma and are followed by a sense of foreshortened future. Furthermore, feelings of detachment or estrangement from others might arise, such as feelings of abandonment, alienation, and deep loneliness. Simultaneously, the range of emotions is narrowed.
Hyperarousal, characterized by persistent symptoms of increasing arousal (which were not present before the trauma), indicated by difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response.
A pronounced disturbance in daily functioning, which results in significant distress or impairment in social, occupational, or other important areas of functioning.
When the duration of symptoms is less than 3 months, the disorder is deemed acute; more than 3 months is considered chronic.
Most people experience a traumatic event at some point in their lives, yet the majority will not develop PTSD or other mental health problems. The emotional and neurobiological responses to psychosocial stressors and trauma vary widely among individuals following exposure to a potentially traumatic event. Yet resilience, as manifested in spontaneous recovery, is the most common outcome.
Psychological resilience can be characterized by the ability to bounce back from negative experiences. Most people experience an initial, brief spike in distress after a potentially traumatic event and may struggle for a short period to maintain psychological equilibrium. For example, they may experience several weeks of sporadic difficulty concentrating, intermittent sleeplessness, or daily variability in levels of well-being while still managing to function.
Resilience has been linked to the continued fulfillment of personal and social responsibilities and the capacity for positive emotions and generative experiences (e.g., engaging in new creative activities or new relationships), both immediately and in the months following exposure to a potentially traumatic event.
The study of resilience has focused on identifying the critical factors affiliated with it. These studies have examined risk and the protective factors associated with emotional distress, in quest of isolating factors that may strengthen or diminish spontaneous recovery.
These factors include genetics, neurobiological factors, childhood development, type of trauma or stressful life event, personality characteristics, cognitive style, prior history of exposure to stressful events, gender, age, capacity for affect regulation, social support, and ego defenses.
The traumatic event causes people to confront and contend with overwhelmingly hurtful and powerful forces. Consequently, the treatment of psychological trauma is a complex multilayer task of unraveling and healing such an existential encounter. The traumatic event attacks the human psyche by breaching human relatedness, interpersonal connections, and psychic wholeness. Thus, the healing process aims to recover the capacity for psychological integrity through reestablishing a safe and authentic bond with others and with oneself. The process of recovery must be an interactive one, between the survivors and others, including their family members, the community, and their therapists. Simultaneously, recovery must focus on relief from posttraumatic symptoms so the survivor can return to optimal functioning and regain a strong sense of agency and stability.
To date, no treatment program for PTSD has received universal acceptance among clinicians. Treatment outcome studies have found that although some approaches do lead to symptom reduction, the full range of clinical problems caused by PTSD is not addressed by any of the existing treatment programs. Trauma-focused therapy is typically described as progressing in a series of steps, the first of which focus on symptom reduction, with subsequent steps focusing on building a new understanding and cohesive narrative that integrate the traumatic experiences into the survivor's life story and world schema.
Acute interventions are those that take place within the first 48 hours, or during the first days or even weeks following the traumatic event. Acute interventions are predominantly aimed at maintaining everyday functioning, emotional stabilization, and diminution of symptoms. Moreover, the purpose of acute intervention is to prevent adverse affects of trauma, educate trauma survivors about what to expect in the near future, and facilitate recovery. This is accomplished through methods such as debriefing, defusing psychological first aid (PFA—developed by the Terrorism Disaster Branch of the National Child Traumatic Stress Network and the National Center of PTSD), and eye movement desensitization and reprocessing (EMDR).
Trauma survivors who are still suffering from traumatic symptoms 4 weeks or more after a traumatic event may be diagnosed with PTSD. Treatment methods for PTSD include cognitive-behavioral therapy (CBT), psychoanalysis and different kinds of psychotherapy. CBT is the most empirically supported effective treatment for alleviating trauma symptoms; other treatments may be as effective, but efficacy may be more difficult to establish for methodological reasons. CBT may include a combination of exposure therapy, anxiety management training, cognitive therapy, and EMDR. Emotional regulation can also be addressed by using pharmacotherapy (e.g., psychiatric medication) with more psychodynamic approaches.
Treatments differ primarily in the techniques that are used by therapists to create a safe environment that allows the patient to manage reactions to traumatic recollections. Commonly, the processing of traumatic events includes (a) the patient defining the scope of the damage inflicted by the trauma, (b) analyzing the traumatic memories into different layers of meaning, (c) exploring the meaning of the events in the context of the patient's prior and current experiences, and (d) accepting responsibility for actions taken during the event. Once a sense of mastery is gained over intrusive recollections and mood states, the survivor can begin to initiate relationships. Trauma-focused treatment can be effective in different types of therapeutic settings, such as group therapy, family therapy, individual therapy, art therapy, music therapy, and so forth.
Empirical research has found that there are different types of traumatic events, such as natural disasters, childhood abuse, warfare, torture, domestic violence, ethnic cleansing, and so forth. Each evokes different types of stress (e.g., physical or emotional injuries) and contains distinct psychological repercussions at both the individual and societal levels. Several such distinct categories of trauma are addressed in the subsections that follow.
Aside from the psychological trauma suffered individually, traumatic events can be experienced collectively by groups of people, such as countries, ethnic groups, geographical communities, and families. With the growing awareness of the social component of trauma, collective trauma has garnered wider attention and research.
Collective trauma may occur as a result of a shared catastrophe, which creates a disturbance of the institutional underpinnings of the social order. The consequences of such events include abrupt changes in the qualities of social relationships, the destabilization of social life, interference with the predictability of social conduct, and the questioning of social values. Collective trauma may also occur as a result of an enduring structural oppression of a group, such as colonization (e.g., aboriginal peoples), slavery (e.g., African Americans), poverty, sexism, racism, homelessness, human trafficking, and so forth. The concept of structural trauma has been introduced by historians such as Dominick LaCapra and investigates the notion that certain social structures are inherently traumatizing to those who endure them.
Feelings of alienation, isolation, abandonment, and exclusion are the hallmarks of trauma. Collective trauma is exceptional in that these feelings are experienced as a group. This shared experienced often builds a sense of solidarity or shared fate and may result in a supportive community. However, within the traumatized group, there may simultaneously be an array of different reactions and feelings as a result of the trauma, which do not always constitute a sense of solidarity. Feelings of abandonment and disappointment may be directed toward people of the same group who have experienced the same traumatic situations.
Advances in neurobiology have shown that, in accordance with psychological theory, humans are innately relational. These findings suggest that, although individual trauma can be seen as a fundamental breach of relationship with another person, a group of people, a higher force, or an internal schema, collective trauma can be conceptualized as a breached relationship between a group of people and their social environment as, for example, in the Holocaust and the Armenian genocide, which were widely experienced by members of the persecuted group as betrayal by other ethnic groups or nations. In contrast, natural disasters are often accepted as fate or as acts of God.
National trauma is a collective trauma that influences national identity. Some instances of national trauma result in a stronger sense of national unity and social cohesiveness, but other events may cause an assault on the fiber of society. The outcome of a national trauma depends on a combination of the nature of the disaster (e.g., its magnitude, and its physical and psychological ramifications) and the systematic response of the national authorities, together with the effort of the organic social network to recuperate. It has been observed that a well-organized systematic response accompanied by social support in a community, and coupled with material resources, can create collective resilience that may prevent collective PTSD.
Intergenerational trauma was first observed in 1966 by practitioners treating children of Holocaust survivors in Canada, the United States, and Israel, who were seeking treatment. Intergenerational trauma is the transmission of the traumatic experience from one generation to another through verbal or nonverbal communication. The need for this transmission arises when the initial trauma has not been psychologically processed and integrated. Furthermore, when the trauma is not fully acknowledged, rejected, or denied by society, survivors feel that they cannot be fully heard and understood. They then retreat into conveying their trauma to the next generation through nonverbal communication because of a socially imposed silence. This often results in a "conspiracy of silence" in which the survivors' families and communities do not ask about the traumatic event, and the survivors avoid speaking about their suffering yet simultaneously convey their experience in silence. This often results in the vicarious traumatization of people surrounding the survivor. Hence, children and grandchildren of survivors may experience traumatic symptoms such as survivor's guilt, deep unexplained emotional loss, anxiety, and fear of annihilation.
Intergenerational trauma has been observed in numerous second-generation communities of World War II veterans, Japanese survivors of the atomic bomb, Armenians who suffered the Turkish genocide, Holocaust survivors, Cambodian survivors of the Khmer Rouge genocide, Eastern Europeans after the fall of communism, persecuted indigenous peoples (e.g., Native Americans, Australian Aborigines, and Black Africans), and victims of oppressive regimes (e.g., in Chile, Argentina, South Africa under apartheid, and the former Soviet Union under Joseph Stalin).
No established definition of international trauma exists at present. Trauma at the national level has been extensively researched. However, cross-national trauma has yet to be conceptualized and formally defined. The need for developing a framework within which organizations can relate to international trauma has only recently been acknowledged, notably with the publication of Guidelines on Mental Health and Psychosocial Support in Emergency Settings by the 2007 Inter-Agency Standing Committee, which represents the key agencies of the United Nations and other non-UN humanitarian organizations. This report was compiled as part of an effort to establish the capacity for such organizations to systematically coordinate humanitarian activities, develop policy, promote psychological resilience, and support accountability among humanitarian organizations that aim to answer the needs of traumatized communities.
Building a framework and definition for international trauma would include the cross-cultural research of psychological trauma and PTSD. It would need to recognize that, although trauma has a few core characteristics common to all nations, there must also be an effort to understand and to be attentive to the culture of the communities suffering from trauma, to their history, and to their complex relationships with other national entities and global disparities. Furthermore, such a framework should acknowledge the importance of a multidisciplinary approach that can provide a wide contextualized perspective.
See also Biological Effects of Physical and Psychological Trauma; Dissociation; Shared Trauma; Victim, Survivor, Thriver
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