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What is trauma? Types, symptoms, and treatments

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A person can experience trauma after any situation that they find distressing or threatening. Learn the causes, symptoms, and treatments.

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Overview

Post-traumatic stress disorder (PTSD) is a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event.

Most people who go through traumatic events may have temporary difficulty adjusting and coping, but with time and good self-care, they usually get better. If the symptoms get worse, last for months or even years, and interfere with your day-to-day functioning, you may have PTSD.

Getting effective treatment after PTSD symptoms develop can be critical to reduce symptoms and improve function.

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Symptoms

Post-traumatic stress disorder symptoms may start within one month of a traumatic event, but sometimes symptoms may not appear until years after the event. These symptoms cause significant problems in social or work situations and in relationships. They can also interfere with your ability to go about your normal daily tasks.

PTSD symptoms are generally grouped into four types: intrusive memories, avoidance, negative changes in thinking and mood, and changes in physical and emotional reactions. Symptoms can vary over time or vary from person to person.
Intrusive memories
Symptoms of intrusive memories may include:

Recurrent, unwanted distressing memories of the traumatic event

Reliving the traumatic event as if it were happening again (flashbacks)

Upsetting dreams or nightmares about the traumatic event

Severe emotional distress or physical reactions to something that reminds you of the traumatic event

Avoidance
Symptoms of avoidance may include:

Trying to avoid thinking or talking about the traumatic event

Avoiding places, activities or people that remind you of the traumatic event

Negative changes in thinking and mood
Symptoms of negative changes in thinking and mood may include:

Negative thoughts about yourself, other people or the world

Hopelessness about the future

Memory problems, including not remembering important aspects of the traumatic event

Difficulty maintaining close relationships

Feeling detached from family and friends

Lack of interest in activities you once enjoyed

Difficulty experiencing positive emotions

Feeling emotionally numb

Changes in physical and emotional reactions
Symptoms of changes in physical and emotional reactions (also called arousal symptoms) may include:

Being easily startled or frightened

Always being on guard for danger

Self-destructive behavior, such as drinking too much or driving too fast

Trouble sleeping

Trouble concentrating

Irritability, angry outbursts or aggressive behavior

Overwhelming guilt or shame

For children 6 years old and younger, signs and symptoms may also include:

Re-enacting the traumatic event or aspects of the traumatic event through play

Frightening dreams that may or may not include aspects of the traumatic event

Intensity of symptoms
PTSD symptoms can vary in intensity over time. You may have more PTSD symptoms when you're stressed in general, or when you come across reminders of what you went through. For example, you may hear a car backfire and relive combat experiences. Or you may see a report on the news about a sexual assault and feel overcome by memories of your own assault.
When to see a doctor
If you have disturbing thoughts and feelings about a traumatic event for more than a month, if they're severe, or if you feel you're having trouble getting your life back under control, talk to your doctor or a mental health professional. Getting treatment as soon as possible can help prevent PTSD symptoms from getting worse.
If you have suicidal thoughts
If you or someone you know has suicidal thoughts, get help right away through one or more of these resources:

Reach out to a close friend or loved one.

Contact a minister, a spiritual leader or someone in your faith community.

Contact a suicide hotline. In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline, available 24 hours a day, seven days a week. Or use the Lifeline Chat. Services are free and confidential.

Make an appointment with your doctor or a mental health professional.

When to get emergency help
If you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately.

If you know someone who's in danger of attempting suicide or has made a suicide attempt, make sure someone stays with that person to keep him or her safe. Call 911 or your local emergency number immediately. Or, if you can do so safely, take the person to the nearest hospital emergency room.

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Causes

You can develop post-traumatic stress disorder when you go through, see or learn about an event involving actual or threatened death, serious injury or sexual violation.

Doctors aren't sure why some people get PTSD. As with most mental health problems, PTSD is probably caused by a complex mix of:

Stressful experiences, including the amount and severity of trauma you've gone through in your life

Inherited mental health risks, such as a family history of anxiety and depression

Inherited features of your personality - often called your temperament

The way your brain regulates the chemicals and hormones your body releases in response to stress

Risk factors

People of all ages can have post-traumatic stress disorder. However, some factors may make you more likely to develop PTSD after a traumatic event, such as:

Experiencing intense or long-lasting trauma

Having experienced other trauma earlier in life, such as childhood abuse

Having a job that increases your risk of being exposed to traumatic events, such as military personnel and first responders

Having other mental health problems, such as anxiety or depression

Having problems with substance misuse, such as excess drinking or drug use

Lacking a good support system of family and friends

Having blood relatives with mental health problems, including anxiety or depression

Kinds of traumatic events
The most common events leading to the development of PTSD include:

Combat exposure

Childhood physical abuse

Sexual violence

Physical assault

Being threatened with a weapon

An accident

Many other traumatic events also can lead to PTSD, such as fire, natural disaster, mugging, robbery, plane crash, torture, kidnapping, life-threatening medical diagnosis, terrorist attack, and other extreme or life-threatening events.

Complications

Post-traumatic stress disorder can disrupt your whole life - your job, your relationships, your health and your enjoyment of everyday activities.

Having PTSD may also increase your risk of other mental health problems, such as:

Depression and anxiety

Issues with drugs or alcohol use

Eating disorders

Suicidal thoughts and actions

Prevention

After surviving a traumatic event, many people have PTSD-like symptoms at first, such as being unable to stop thinking about what's happened. Fear, anxiety, anger, depression, guilt - all are common reactions to trauma. However, the majority of people exposed to trauma do not develop long-term post-traumatic stress disorder.

Getting timely help and support may prevent normal stress reactions from getting worse and developing into PTSD. This may mean turning to family and friends who will listen and offer comfort. It may mean seeking out a mental health professional for a brief course of therapy. Some people may also find it helpful to turn to their faith community.

Support from others also may help prevent you from turning to unhealthy coping methods, such as misuse of alcohol or drugs.

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Post-traumatic stress disorder (PTSD) - Symptoms and causes

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Post-traumatic stress disorder (PTSD) is a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety.

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Post-traumatic stress disorder (PTSD) is a mental health condition that some people develop after they experience or witness a traumatic event.

What are the symptoms of PTSD?

To receive a PTSD diagnosis, symptoms must last for more than a month and must cause significant distress or issues in your daily functioning. The symptoms of PTSD fall into four categories:
Intrusion:

Intrusive thoughts, such as repeated, involuntary memories.

Nightmares.

Flashbacks of the traumatic event, which can be very vivid and feel real.

Avoidance:

Avoiding reminders of the traumatic event, like people, places, activities, things and situations.

Avoiding remembering or thinking about the traumatic event.

Avoiding talking about what happened or how you feel about it.

Changes in thinking and mood:

Ongoing fear, horror, anger, guilt or shame.

Memory loss of important aspects of the traumatic event.

Ongoing negative and distorted thoughts and feelings about yourself or others.

Distorted thoughts about the cause or effects of the event that lead to wrongly blaming yourself or others.

Feeling detached from others.

No longer enjoying activities you once did.

Being unable to experience positive emotions.

Changes in arousal and reactivity:

Irritability and angry outbursts.

Reckless or self-destructive behavior.

Being overly watchful of your surroundings (hypervigilance).

Being easily startled.

Problems concentrating or sleeping.

Symptoms of PTSD in children

Children with PTSD may have difficulty expressing how they're feeling or they may have experienced trauma that you don't know about. They may seem restless, fidgety, or have trouble paying attention and staying organized.

These symptoms can be confused with symptoms of attention-deficit/hyperactivity disorder (ADHD). Because of this, it's important to take your child to a specialist (like a child psychologist) who has experience in diagnosing PTSD.

Complications of PTSD

The following conditions are common in people with PTSD, which can make PTSD symptoms worse:

People with PTSD also have an increased risk of suicidal thoughts and attempts.
If you or a loved one is thinking about suicide, call or text 988 to reach the Suicide and Crisis Lifeline. Someone is available to help you 24/7.
What causes PTSD?

Approximately 61% to 80% of people experience a traumatic event at some point in their lives. PTSD develops in about 5% to 10% of this population.

It's unclear why people respond differently to trauma. But studies show that people with PTSD have abnormal levels of certain neurotransmitters and hormones. They also experience brain changes.

Neurotransmitter and hormone changes

Studies show that people with PTSD have normal to low levels of cortisol (the "stress hormone") and elevated levels of corticotropin-releasing factor (CRF) despite ongoing stress. CRF triggers the release of norepinephrine, which leads to an increased sympathetic nervous system response. This "fight or flight" response leads to increased:

In addition, some studies show altered functioning of other neurotransmitter systems, including:

Brain changes

PTSD is associated with changes in the functioning and anatomy of your brain:

The size of your hippocampus (a part of your brain that regulates motivation, emotion, learning and memory) decreases.

The amygdala (the part of your brain that processes emotions and fear responses) is overly reactive in people with PTSD.

The medial prefrontal cortex, which partly controls the emotional reactivity of your amygdala, appears to be smaller and less responsive in people with PTSD.

What are the risk factors for PTSD?

There's no way to predict who will develop PTSD after a traumatic event. But PTSD is more common in people who have experienced:

Certain types of trauma, particularly military combat or sexual assault.

Trauma during childhood.

Injury during the event.

Horror, helplessness or extreme fear at the time of the event.

Lack of social support after a traumatic event.

Long-lasting or repeated trauma.

Mental health conditions and/or substance use.

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PTSD (Post-Traumatic Stress Disorder): Symptoms & Treatment

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PTSD (post-traumatic stress disorder) is a mental health condition that some people develop after they experience or witness a traumatic event. It's treatable.

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Post-traumatic stress disorder (PTSD) can develop after a very stressful, frightening or distressing event, or after a prolonged traumatic experience.

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Causes of Post Traumatic Stress Disorder

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Causes of Post Traumatic Stress Disorder

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a community for everyone in the UK affected by Post Traumatic Stress Disorder

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Trauma is an emotional response to a terrible event like an accident, crime, or natural disaster. Reactions such as shock and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, strained relationships, and physical symptoms.

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Childhood Antecedents of Exposure to Traumatic Events and Posttraumatic Stress Disorder

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Childhood Antecedents of Exposure to Traumatic Events and Posttraumatic Stress Disorder

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A traumatic event is an incident that causes you physical, emotional, spiritual, or psychological harm. You may feel physically threatened or extremely frightened as a result.

In some cases, you might not know how to respond or may be in denial about the effect such an event has had. You'll need support and time to recover from the traumatic event and regain emotional and mental stability.

Examples of traumatic events include:

physical pain or injury (e.g. severe car accident)

serious illness

war

natural disasters

terrorism

witnessing a death

rape

domestic abuse

incarceration within the criminal justice system

While this article is focused on the causes and effects of physical or life threatening trauma, emotional and psychological stress can feel as strong to those experiencing it.

Complicated grief can occur as a result of the death of a loved one or a difficult divorce. Life changes like moving to a new location, parental abandonment, or family conflicts can trigger adjustment disorder.

Faced with these kinds of events, some people may experience shock that feels equivalent to the traumatic events listed above.

People respond to traumatic events in different ways. Often there are no visible signs, but people may have serious emotional reactions.

Shock and denial shortly after the event are normal reactions.

Shock and denial are often used to protect yourself from the emotional impact of the event. You may feel numb or detached. You may not feel the event's full intensity right away.

Moving past the initial shock usually takes 4-6 weeks from the event. This is seen as the difference between an acute stress reaction (within 4 weeks from the event) or a post-traumatic reaction (usually after 4-6 weeks).

Once you have moved past the initial shock, responses to a traumatic event may vary. Common responses include:

repeated memories of the event or flashbacks

nightmares

intense fear that the traumatic event will recur, particularly around anniversaries of the event (or when going back to the scene of the original event)

withdrawal and isolation from day-to-day activities

continued avoidance of reminders of the event

shifts in mood or changes in thought patterns

irritability

sudden, dramatic mood shifts

anxiety and nervousness

anger

denial

depression that can commonly occur along with traumatic stress

difficulty concentrating

altered sleeping or insomnia

physical symptoms of stress, such as headaches and nausea

worsening of an existing medical condition

A condition known as post-traumatic stress disorder (PTSD) can sometimes occur after you experience a life-threatening event or witness a death.

PTSD is a type of anxiety disorder that affects stress hormones and changes the body's response to stress. People with this disorder require strong social support and ongoing therapy.

Many veterans returning from war experience PTSD.

PTSD can cause an intense physical and emotional response to any thought or memory of the event. It can last for months or years following trauma.

Experts do not know why some people experience PTSD after a traumatic event, while others do not. A history of trauma, along with other physical, genetic, psychological, and social factors may play a role in developing PTSD.

Many experts do suspect that high levels of avoiding things in life and continued self-blame or shame for a personal role in the event are a few key signs that a person may go on to experience PTSD after a traumatic event.

There are several ways to help restore your emotional stability after a traumatic event:

Notice if you feel a pull to avoid things in your life and try to stay engaged in routines like work and social life

Spend time with others to avoid becoming withdrawn, even if you do not feel up to it.

Pursue hobbies or other interests.

Communicate the experience with family or close friends or in a diary or online journal.

Give yourself time and recognize that you can't control everything.

Ask for support from people who care about you or attend a local or online support group for people who have had a similar experience.

Find a support group led by a trained professional who can facilitate discussions.

Try to eat a well-balanced diet, exercise, get adequate rest, and avoid alcohol and drugs.

If you believe you have symptoms of substance use disorder, talk with a healthcare professional who can help you create a treatment plan and connect you with supportive resources.

Maintain a daily routine with structured activities.

Avoid major life decisions, such as changing careers or moving, soon after the event.

You should seek professional help if symptoms persist and interfere with day-to-day activities, school or work performance, or personal relationships.

Experiences with traumatic stress can appear much different for children. Signs that a child may need professional help to cope with a traumatic event include:

emotional outbursts

aggressive behavior

withdrawal

persistent difficulty in sleeping

continued obsession with the traumatic event

serious problems at school

Psychologists and mental health professionals can work with people to help find ways to cope with stress. They can help both children and their parents understand how to cope with the emotional impact of a traumatic event.

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A traumatic event is an incident that causes you physical, emotional, spiritual, or psychological harm. You may feel physically threatened or extremely frightened as a result. In some cases, you might not know how to respond or may be in denial about the effect such an event has had.

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Trauma: definition, types, causes, symptoms, effects, and treatment

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Trauma: definition, types, causes, symptoms, effects, and treatment

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AUTHOR:Asif Baliyan, MD Last edited on 06-17-2025

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Trauma: definition, types, causes, symptoms, effects, and treatment - The Diamond Rehab Thailand

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Trauma refers to the psychological harm resulting from going through deeply distressing or disturbing events. What’s traumatic to someone is often personal,

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Helping Abused and Traumatized Children: Integrating Directive and ...

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Helping Abused and Traumatized Children: Integrating Directive and ...

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Presenting an integrative model for treating traumatized children, this book combines play, art, and other expressive therapies with ideas and strategies drawn from cognitive-behavioral and family therapy. Eliana Gil demonstrates how to tailor treatment to the needs of each child by using both directive and nondirective approaches. Throughout, practical clinical examples illustrate ways to target trauma-related symptomatology while also helping children process painful feelings and memories that are difficult to verbalize. The book concludes with four in-depth cases that bring to life the unique situation of each child and family, the decision-making process of the therapist, and the applications of developmentally informed, creative, and flexible interventions.

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The Effects of Psychological Trauma on Children and Adolescents

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The Effects of Psychological Trauma on Children and Adolescents

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Trauma-informed care (TIC) involves a broad understanding of traumatic stress reactions and common responses to trauma. Providers need to understand how trauma can affect treatment presentation, engagement, and the outcome of behavioral health services. This chapter examines common experiences survivors may encounter immediately following or long after a traumatic experience.

Trauma, including one-time, multiple, or long-lasting repetitive events, affects everyone differently. Some individuals may clearly display criteria associated with posttraumatic stress disorder (PTSD), but many more individuals will exhibit resilient responses or brief subclinical symptoms or consequences that fall outside of diagnostic criteria. The impact of trauma can be subtle, insidious, or outright destructive. How an event affects an individual depends on many factors, including characteristics of the individual, the type and characteristics of the event(s), developmental processes, the meaning of the trauma, and sociocultural factors.

This chapter begins with an overview of common responses, emphasizing that traumatic stress reactions are normal reactions to abnormal circumstances. It highlights common short- and long-term responses to traumatic experiences in the context of individuals who may seek behavioral health services. This chapter discusses psychological symptoms not represented in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013a), and responses associated with trauma that either fall below the threshold of mental disorders or reflect resilience. It also addresses common disorders associated with traumatic stress. This chapter explores the role of culture in defining mental illness, particularly PTSD, and ends by addressing co-occurring mental and substance-related disorders.

TIC Framework in Behavioral Health Services-The Impact of Trauma

Sequence of Trauma Reactions

Survivors' immediate reactions in the aftermath of trauma are quite complicated and are affected by their own experiences, the accessibility of natural supports and healers, their coping and life skills and those of immediate family, and the responses of the larger community in which they live. Although reactions range in severity, even the most acute responses are natural responses to manage trauma- they are not a sign of psychopathology. Coping styles vary from action oriented to reflective and from emotionally expressive to reticent. Clinically, a response style is less important than the degree to which coping efforts successfully allow one to continue necessary activities, regulate emotions, sustain self-esteem, and maintain and enjoy interpersonal contacts. Indeed, a past error in traumatic stress psychology, particularly regarding group or mass traumas, was the assumption that all survivors need to express emotions associated with trauma and talk about the trauma; more recent research indicates that survivors who choose not to process their trauma are just as psychologically healthy as those who do. The most recent psychological debriefing approaches emphasize respecting the individual's style of coping and not valuing one type over another.

Foreshortened future: Trauma can affect one's beliefs about the future via loss of hope, limited expectations about life, fear that life will end abruptly or early, or anticipation that normal life events won't occur (e.g., access to education, ability to have a significant and committed relationship, good opportunities for work).

Initial reactions to trauma can include exhaustion, confusion, sadness, anxiety, agitation, numbness, dissociation, confusion, physical arousal, and blunted affect. Most responses are normal in that they affect most survivors and are socially acceptable, psychologically effective, and self-limited. Indicators of more severe responses include continuous distress without periods of relative calm or rest, severe dissociation symptoms, and intense intrusive recollections that continue despite a return to safety. Delayed responses to trauma can include persistent fatigue, sleep disorders, nightmares, fear of recurrence, anxiety focused on flashbacks, depression, and avoidance of emotions, sensations, or activities that are associated with the trauma, even remotely. Exhibit 1.3-1 outlines some common reactions.

Common Experiences and Responses to Trauma

A variety of reactions are often reported and/or observed after trauma. Most survivors exhibit immediate reactions, yet these typically resolve without severe long-term consequences. This is because most trauma survivors are highly resilient and develop appropriate coping strategies, including the use of social supports, to deal with the aftermath and effects of trauma. Most recover with time, show minimal distress, and function effectively across major life areas and developmental stages. Even so, clients who show little impairment may still have subclinical symptoms or symptoms that do not fit diagnostic criteria for acute stress disorder (ASD) or PTSD. Only a small percentage of people with a history of trauma show impairment and symptoms that meet criteria for trauma-related stress disorders, including mood and anxiety disorders.

The following sections focus on some common reactions across domains (emotional, physical, cognitive, behavioral, social, and developmental) associated with singular, multiple, and enduring traumatic events. These reactions are often normal responses to trauma but can still be distressing to experience. Such responses are not signs of mental illness, nor do they indicate a mental disorder. Traumatic stress-related disorders comprise a specific constellation of symptoms and criteria.

Emotional

Emotional reactions to trauma can vary greatly and are significantly influenced by the individual's sociocultural history. Beyond the initial emotional reactions during the event, those most likely to surface include anger, fear, sadness, and shame. However, individuals may encounter difficulty in identifying any of these feelings for various reasons. They might lack experience with or prior exposure to emotional expression in their family or community. They may associate strong feelings with the past trauma, thus believing that emotional expression is too dangerous or will lead to feeling out of control (e.g., a sense of "losing it" or going crazy). Still others might deny that they have any feelings associated with their traumatic experiences and define their reactions as numbness or lack of emotions.

Emotional dysregulation

Some trauma survivors have difficulty regulating emotions such as anger, anxiety, sadness, and shame-this is more so when the trauma occurred at a young age ( van der Kolk, Roth, Pelcovitz, & Mandel, 1993). In individuals who are older and functioning well prior to the trauma, such emotional dysregulation is usually short lived and represents an immediate reaction to the trauma, rather than an ongoing pattern. Self-medication-namely, substance abuse-is one of the methods that traumatized people use in an attempt to regain emotional control, although ultimately it causes even further emotional dysregulation (e.g., substance-induced changes in affect during and after use). Other efforts toward emotional regulation can include engagement in high-risk or self-injurious behaviors, disordered eating, compulsive behaviors such as gambling or overworking, and repression or denial of emotions; however, not all behaviors associated with self-regulation are considered negative. In fact, some individuals find creative, healthy, and industrious ways to manage strong affect generated by trauma, such as through renewed commitment to physical activity or by creating an organization to support survivors of a particular trauma.

Traumatic stress tends to evoke two emotional extremes: feeling either too much (overwhelmed) or too little (numb) emotion. Treatment can help the client find the optimal level of emotion and assist him or her with appropriately experiencing and regulating difficult emotions. In treatment, the goal is to help clients learn to regulate their emotions without the use of substances or other unsafe behavior. This will likely require learning new coping skills and how to tolerate distressing emotions; some clients may benefit from mindfulness practices, cognitive restructuring, and trauma-specific desensitization approaches, such as exposure therapy and eye movement desensitization and reprocessing (EMDR; refer to Part 1, Chapter 6, for more information on trauma-specific therapies).

Numbing

Numbing is a biological process whereby emotions are detached from thoughts, behaviors, and memories. In the following case illustration, Sadhanna's numbing is evidenced by her limited range of emotions associated with interpersonal interactions and her inability to associate any emotion with her history of abuse. She also possesses a belief in a foreshortened future. A prospective longitudinal study ( Malta, Levitt, Martin, Davis, & Cloitre, 2009) that followed the development of PTSD in disaster workers highlighted the importance of understanding and appreciating numbing as a traumatic stress reaction. Because numbing symptoms hide what is going on inside emotionally, there can be a tendency for family members, counselors, and other behavioral health staff to assess levels of traumatic stress symptoms and the impact of trauma as less severe than they actually are.

Case Illustration: Sadhanna

Sadhanna is a 22-year-old woman mandated to outpatient mental health and substance abuse treatment as the alternative to incarceration. She was arrested and charged with assault after arguing and fighting with another woman on the street. At intake, Sadhanna reported a 7-year history of alcohol abuse and one depressive episode at age 18. She was surprised that she got into a fight but admitted that she was drinking at the time of the incident. She also reported severe physical abuse at the hands of her mother's boyfriend between ages 4 and 15. Of particular note to the intake worker was Sadhanna's matter-of-fact way of presenting the abuse history. During the interview, she clearly indicated that she did not want to attend group therapy and hear other people talk about their feelings, saying, "I learned long ago not to wear emotions on my sleeve."

Sadhanna reported dropping out of 10th grade, saying she never liked school. She didn't expect much from life. In Sadhanna's first weeks in treatment, she reported feeling disconnected from other group members and questioned the purpose of the group. When asked about her own history, she denied that she had any difficulties and did not understand why she was mandated to treatment. She further denied having feelings about her abuse and did not believe that it affected her life now. Group members often commented that she did not show much empathy and maintained a flat affect, even when group discussions were emotionally charged.

Physical

Diagnostic criteria for PTSD place considerable emphasis on psychological symptoms, but some people who have experienced traumatic stress may present initially with physical symptoms. Thus, primary care may be the first and only door through which these individuals seek assistance for trauma-related symptoms. Moreover, there is a significant connection between trauma, including adverse childhood experiences (ACEs), and chronic health conditions. Common physical disorders and symptoms include somatic complaints; sleep disturbances; gastrointestinal, cardiovascular, neurological, musculoskeletal, respiratory, and dermatological disorders; urological problems; and substance use disorders.

Somatization

Somatization indicates a focus on bodily symptoms or dysfunctions to express emotional distress. Somatic symptoms are more likely to occur with individuals who have traumatic stress reactions, including PTSD. People from certain ethnic and cultural backgrounds may initially or solely present emotional distress via physical ailments or concerns. Many individuals who present with somatization are likely unaware of the connection between their emotions and the physical symptoms that they're experiencing. At times, clients may remain resistant to exploring emotional content and remain focused on bodily complaints as a means of avoidance. Some clients may insist that their primary problems are physical even when medical evaluations and tests fail to confirm ailments. In these situations, somatization may be a sign of a mental illness. However, various cultures approach emotional distress through the physical realm or view emotional and physical symptoms and well-being as one. It is important not to assume that clients with physical complaints are using somatization as a means to express emotional pain; they may have specific conditions or disorders that require medical attention. Foremost, counselors need to refer for medical evaluation.

Advice to Counselors: Using Information About Biology and Trauma

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Frame reexperiencing the event(s), hyperarousal, sleep disturbances, and other physical symptoms as physiological reactions to extreme stress.

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Communicate that treatment and other wellness activities can improve both psychological and physiological symptoms (e.g., therapy, meditation, exercise, yoga). You may need to refer certain clients to a psychiatrist who can evaluate them and, if warranted, prescribe psycho-tropic medication to address severe symptoms.

-

Discuss traumatic stress symptoms and their physiological components.

-

Explain links between traumatic stress symptoms and substance use disorders, if appropriate.

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Normalize trauma symptoms. For example, explain to clients that their symptoms are not a sign of weakness, a character flaw, being damaged, or going crazy.

Support your clients and provide a message of hope-that they are not alone, they are not at fault, and recovery is possible and anticipated.

Biology of trauma

Trauma biology is an area of burgeoning research, with the promise of more complex and explanatory findings yet to come. Although a thorough presentation on the biological aspects of trauma is beyond the scope of this publication, what is currently known is that exposure to trauma leads to a cascade of biological changes and stress responses. These biological alterations are highly associated with PTSD, other mental illnesses, and substance use disorders. These include:

Changes in limbic system functioning.

Hypothalamic-pituitary-adrenal axis activity changes with variable cortisol levels.

Neurotransmitter-related dysregulation of arousal and endogenous opioid systems.

As a clear example, early ACEs such as abuse, neglect, and other traumas affect brain development and increase a person's vulnerability to encountering interpersonal violence as an adult and to developing chronic diseases and other physical illnesses, mental illnesses, substance-related disorders, and impairment in other life areas ( Centers for Disease Control and Prevention, 2012).

Hyperarousal and sleep disturbances

A common symptom that arises from traumatic experiences is hyperarousal (also called hypervigilance). Hyperarousal is the body's way of remaining prepared. It is characterized by sleep disturbances, muscle tension, and a lower threshold for startle responses and can persist years after trauma occurs. It is also one of the primary diagnostic criteria for PTSD.

Hyperarousal is a consequence of biological changes initiated by trauma. Although it serves as a means of self-protection after trauma, it can be detrimental. Hyperarousal can interfere with an individual's ability to take the necessary time to assess and appropriately respond to specific input, such as loud noises or sudden movements. Sometimes, hyperarousal can produce overreactions to situations perceived as dangerous when, in fact, the circumstances are safe.

Case Illustration: Kimi

Kimi is a 35-year-old Native American woman who was group raped at the age of 16 on her walk home from a suburban high school. She recounts how her whole life changed on that day. "I never felt safe being alone after the rape. I used to enjoy walking everywhere. Afterward, I couldn't tolerate the fear that would arise when I walked in the neighborhood. It didn't matter whether I was alone or with friends-every sound that I heard would throw me into a state of fear. I felt like the same thing was going to happen again. It's gotten better with time, but I often feel as if I'm sitting on a tree limb waiting for it to break. I have a hard time relaxing. I can easily get startled if a leaf blows across my path or if my children scream while playing in the yard. The best way I can describe how I experience life is by comparing it to watching a scary, suspenseful movie-anxiously waiting for something to happen, palms sweating, heart pounding, on the edge of your chair."

Along with hyperarousal, sleep disturbances are very common in individuals who have experienced trauma. They can come in the form of early awakening, restless sleep, difficulty falling asleep, and nightmares. Sleep disturbances are most persistent among individuals who have trauma-related stress; the disturbances sometimes remain resistant to intervention long after other traumatic stress symptoms have been successfully treated. Numerous strategies are available beyond medication, including good sleep hygiene practices, cognitive rehearsals of nightmares, relaxation strategies, and nutrition.

Cognitive

Traumatic experiences can affect and alter cognitions. From the outset, trauma challenges the just-world or core life assumptions that help individuals navigate daily life ( Janoff-Bulman, 1992). For example, it would be difficult to leave the house in the morning if you believed that the world was not safe, that all people are dangerous, or that life holds no promise. Belief that one's efforts and intentions can protect oneself from bad things makes it less likely for an individual to perceive personal vulnerability. However, traumatic events-particularly if they are unexpected-can challenge such beliefs.

Cognitions and Trauma

The following examples reflect some of the types of cognitive or thought-process changes that can occur in response to traumatic stress.

Cognitive errors: Misinterpreting a current situation as dangerous because it resembles, even remotely, a previous trauma (e.g., a client overreacting to an overturned canoe in 8 inches of water, as if she and her paddle companion would drown, due to her previous experience of nearly drowning in a rip current 5 years earlier).

Excessive or inappropriate guilt: Attempting to make sense cognitively and gain control over a traumatic experience by assuming responsibility or possessing survivor's guilt, because others who experienced the same trauma did not survive.

Idealization: Demonstrating inaccurate rationalizations, idealizations, or justifications of the perpetrator's behavior, particularly if the perpetrator is or was a caregiver. Other similar reactions mirror idealization; traumatic bonding is an emotional attachment that develops (in part to secure survival) between perpetrators who engage in interpersonal trauma and their victims, and Stockholm syndrome involves compassion and loyalty toward hostage takers ( de Fabrique, Van Hasselt, Vecchi, & Romano, 2007).

Trauma-induced hallucinations or delusions: Experiencing hallucinations and delusions that, although they are biological in origin, contain cognitions that are congruent with trauma content (e.g., a woman believes that a person stepping onto her bus is her father, who had sexually abused her repeatedly as child, because he wore shoes similar to those her father once wore).

Intrusive thoughts and memories: Experiencing, without warning or desire, thoughts and memories associated with the trauma. These intrusive thoughts and memories can easily trigger strong emotional and behavioral reactions, as if the trauma was recurring in the present. The intrusive thoughts and memories can come rapidly, referred to as flooding, and can be disruptive at the time of their occurrence. If an individual experiences a trigger, he or she may have an increase in intrusive thoughts and memories for a while. For instance, individuals who inadvertently are retraumatized due to program or clinical practices may have a surge of intrusive thoughts of past trauma, thus making it difficult for them to discern what is happening now versus what happened then. Whenever counseling focuses on trauma, it is likely that the client will experience some intrusive thoughts and memories. It is important to develop coping strategies before, as much as possible, and during the delivery of trauma-informed and trauma-specific treatment.

Let's say you always considered your driving time as "your time"-and your car as a safe place to spend that time. Then someone hits you from behind at a highway entrance. Almost immediately, the accident affects how you perceive the world, and from that moment onward, for months following the crash, you feel unsafe in any car. You become hypervigilant about other drivers and perceive that other cars are drifting into your lane or failing to stop at a safe distance behind you. For a time, your perception of safety is eroded, often leading to compensating behaviors (e.g., excessive glancing into the rearview mirror to see whether the vehicles behind you are stopping) until the belief is restored or reworked. Some individuals never return to their previous belief systems after a trauma, nor do they find a way to rework them-thus leading to a worldview that life is unsafe. Still, many other individuals are able to return to organizing core beliefs that support their perception of safety.

Many factors contribute to cognitive patterns prior to, during, and after a trauma. Adopting Beck and colleagues' cognitive triad model ( 1979), trauma can alter three main cognitive patterns: thoughts about self, the world (others/environment), and the future. To clarify, trauma can lead individuals to see themselves as incompetent or damaged, to see others and the world as unsafe and unpredictable, and to see the future as hopeless-believing that personal suffering will continue, or negative outcomes will preside for the foreseeable future (see Exhibit 1.3-2). Subsequently, this set of cognitions can greatly influence clients' belief in their ability to use internal resources and external support effectively. From a cognitive- behavioral perspective, these cognitions have a bidirectional relationship in sustaining or contributing to the development of depressive and anxiety symptoms after trauma. However, it is possible for cognitive patterns to help protect against debilitating psychological symptoms as well. Many factors contribute to cognitive patterns prior to, during, and after a trauma.

Feeling different

An integral part of experiencing trauma is feeling different from others, whether or not the trauma was an individual or group experience. Traumatic experiences typically feel surreal and challenge the necessity and value of mundane activities of daily life. Survivors often believe that others will not fully understand their experiences, and they may think that sharing their feelings, thoughts, and reactions related to the trauma will fall short of expectations. However horrid the trauma may be, the experience of the trauma is typically profound.

The type of trauma can dictate how an individual feels different or believes that they are different from others. Traumas that generate shame will often lead survivors to feel more alienated from others-believing that they are "damaged goods." When individuals believe that their experiences are unique and incomprehensible, they are more likely to seek support, if they seek support at all, only with others who have experienced a similar trauma.

Triggers and flashbacks

Triggers

A trigger is a stimulus that sets off a memory of a trauma or a specific portion of a traumatic experience. Imagine you were trapped briefly in a car after an accident. Then, several years later, you were unable to unlatch a lock after using a restroom stall; you might have begun to feel a surge of panic reminiscent of the accident, even though there were other avenues of escape from the stall. Some triggers can be identified and anticipated easily, but many are subtle and inconspicuous, often surprising the individual or catching him or her off guard. In treatment, it is important to help clients identify potential triggers, draw a connection between strong emotional reactions and triggers, and develop coping strategies to manage those moments when a trigger occurs. A trigger is any sensory reminder of the traumatic event: a noise, smell, temperature, other physical sensation, or visual scene. Triggers can generalize to any characteristic, no matter how remote, that resembles or represents a previous trauma, such as revisiting the location where the trauma occurred, being alone, having your children reach the same age that you were when you experienced the trauma, seeing the same breed of dog that bit you, or hearing loud voices. Triggers are often associated with the time of day, season, holiday, or anniversary of the event.

Flashbacks

A flashback is reexperiencing a previous traumatic experience as if it were actually happening in that moment. It includes reactions that often resemble the client's reactions during the trauma. Flashback experiences are very brief and typically last only a few seconds, but the emotional aftereffects linger for hours or longer. Flashbacks are commonly initiated by a trigger, but not necessarily. Sometimes, they occur out of the blue. Other times, specific physical states increase a person's vulnerability to reexperiencing a trauma, (e.g., fatigue, high stress levels). Flashbacks can feel like a brief movie scene that intrudes on the client. For example, hearing a car backfire on a hot, sunny day may be enough to cause a veteran to respond as if he or she were back on military patrol. Other ways people reexperience trauma, besides flashbacks, are via nightmares and intrusive thoughts of the trauma.

Advice to Counselors: Helping Clients Manage Flashbacks and Triggers

If a client is triggered in a session or during some aspect of treatment, help the client focus on what is happening in the here and now; that is, use grounding techniques. Behavioral health service providers should be prepared to help the client get regrounded so that they can distinguish between what is happening now versus what had happened in the past (see Covington, 2008, and Najavits, 2002b, 2007b, for more grounding techniques). Offer education about the experience of triggers and flashbacks, and then normalize these events as common traumatic stress reactions. Afterward, some clients need to discuss the experience and understand why the flashback or trigger occurred. It often helps for the client to draw a connection between the trigger and the traumatic event(s). This can be a preventive strategy whereby the client can anticipate that a given situation places him or her at higher risk for retraumatization and requires use of coping strategies, including seeking support.

Source: Green Cross Academy of Traumatology, 2010.

Dissociation, depersonalization, and derealization

Dissociation is a mental process that severs connections among a person's thoughts, memories, feelings, actions, and/or sense of identity. Most of us have experienced dissociation-losing the ability to recall or track a particular action (e.g., arriving at work but not remembering the last minutes of the drive). Dissociation happens because the person is engaged in an automatic activity and is not paying attention to his or her immediate environment. Dissociation can also occur during severe stress or trauma as a protective element whereby the individual incurs distortion of time, space, or identity. This is a common symptom in traumatic stress reactions.

Dissociation helps distance the experience from the individual. People who have experienced severe or developmental trauma may have learned to separate themselves from distress to survive. At times, dissociation can be very pervasive and symptomatic of a mental disorder, such as dissociative identity disorder (DID; formerly known as multiple personality disorder). According to the DSM-5, "dissociative disorders are characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior" ( APA, 2013a, p. 291). Dissociative disorder diagnoses are closely associated with histories of severe childhood trauma or pervasive, human-caused, intentional trauma, such as that experienced by concentration camp survivors or victims of ongoing political imprisonment, torture, or long-term isolation. A mental health professional, preferably with significant training in working with dissociative disorders and with trauma, should be consulted when a dissociative disorder diagnosis is suspected.

Potential Signs of Dissociation

Sudden flattening of affect

Responses not congruent with the present context or situation

Excessive intellectualization

( Briere, 1996a)

The characteristics of DID can be commonly accepted experiences in other cultures, rather than being viewed as symptomatic of a traumatic experience. For example, in non-Western cultures, a sense of alternate beings within oneself may be interpreted as being inhabited by spirits or ancestors ( Kirmayer, 1996). Other experiences associated with dissociation include depersonalization-psychologically "leaving one's body," as if watching oneself from a distance as an observer or through derealization, leading to a sense that what is taking place is unfamiliar or is not real.

If clients exhibit signs of dissociation, behavioral health service providers can use grounding techniques to help them reduce this defense strategy. One major long-term consequence of dissociation is the difficulty it causes in connecting strong emotional or physical reactions with an event. Often, individuals may believe that they are going crazy because they are not in touch with the nature of their reactions. By educating clients on the resilient qualities of dissociation while also emphasizing that it prevents them from addressing or validating the trauma, individuals can begin to understand the role of dissociation. All in all, it is important when working with trauma survivors that the intensity level is not so great that it triggers a dissociative reaction and prevents the person from engaging in the process.

Behavioral

Traumatic stress reactions vary widely; often, people engage in behaviors to manage the aftereffects, the intensity of emotions, or the distressing aspects of the traumatic experience. Some people reduce tension or stress through avoidant, self-medicating (e.g., alcohol abuse), compulsive (e.g., overeating), impulsive (e.g., high-risk behaviors), and/or self-injurious behaviors. Others may try to gain control over their experiences by being aggressive or subconsciously reenacting aspects of the trauma.

Behavioral reactions are also the consequences of, or learned from, traumatic experiences. For example, some people act like they can't control their current environment, thus failing to take action or make decisions long after the trauma (learned helplessness). Other associate elements of the trauma with current activities, such as by reacting to an intimate moment in a significant relationship as dangerous or unsafe years after a date rape. The following sections discuss behavioral consequences of trauma and traumatic stress reactions.

Reenactments

A hallmark symptom of trauma is reexperiencing the trauma in various ways. Reexperiencing can occur through reenactments (literally, to "redo"), by which trauma survivors repetitively relive and recreate a past trauma in their present lives. This is very apparent in children, who play by mimicking what occurred during the trauma, such as by pretending to crash a toy airplane into a toy building after seeing televised images of the terrorist attacks on the World Trade Center on September 11, 2001. Attempts to understand reenactments are very complicated, as reenactments occur for a variety of reasons. Sometimes, individuals reenact past traumas to master them. Examples of reenactments include a variety of behaviors: self-injurious behaviors, hypersexuality, walking alone in unsafe areas or other high-risk behaviors, driving recklessly, or involvement in repetitive destructive relationships (e.g., repeatedly getting into romantic relationships with people who are abusive or violent), to name a few.

Self-harm and self-destructive behaviors

Self-harm is any type of intentionally self-inflicted harm, regardless of the severity of injury or whether suicide is intended. Often, self-harm is an attempt to cope with emotional or physical distress that seems overwhelming or to cope with a profound sense of dissociation or being trapped, helpless, and "damaged" ( Herman, 1997; Santa Mina & Gallop, 1998). Self-harm is associated with past childhood sexual abuse and other forms of trauma as well as substance abuse. Thus, addressing self-harm requires attention to the client's reasons for self-harm. More than likely, the client needs help recognizing and coping with emotional or physical distress in manageable amounts and ways.

Resilient Responses to Trauma

Many people find healthy ways to cope with, respond to, and heal from trauma. Often, people automatically reevaluate their values and redefine what is important after a trauma. Such resilient responses include:

Increased bonding with family and community.

Redefined or increased sense of purpose and meaning.

Increased commitment to a personal mission.

Increased charitable giving and volunteerism.

Case Illustration: Marco

Marco, a 30-year-old man, sought treatment at a local mental health center after a 2-year bout of anxiety symptoms. He was an active member of his church for 12 years, but although he sought help from his pastor about a year ago, he reports that he has had no contact with his pastor or his church since that time. Approximately 3 years ago, his wife took her own life. He describes her as his soul-mate and has had a difficult time understanding her actions or how he could have prevented them.

In the initial intake, he mentioned that he was the first person to find his wife after the suicide and reported feelings of betrayal, hurt, anger, and devastation since her death. He claimed that everyone leaves him or dies. He also talked about his difficulty sleeping, having repetitive dreams of his wife, and avoiding relationships. In his first session with the counselor, he initially rejected the counselor before the counselor had an opportunity to begin reviewing and talking about the events and discomfort that led him to treatment.

In this scenario, Marco is likely reenacting his feelings of abandonment by attempting to reject others before he experiences another rejection or abandonment. In this situation, the counselor will need to recognize the reenactment, explore the behavior, and examine how reenactments appear in other situations in Marco's life.

Among the self-harm behaviors reported in the literature are cutting, burning skin by heat (e.g., cigarettes) or caustic liquids, punching hard enough to self-bruise, head banging, hair pulling, self-poisoning, inserting foreign objects into bodily orifices, excessive nail biting, excessive scratching, bone breaking, gnawing at flesh, interfering with wound healing, tying off body parts to stop breathing or blood flow, swallowing sharp objects, and suicide. Cutting and burning are among the most common forms of self-harm.

Self-harm tends to occur most in people who have experienced repeated and/or early trauma (e.g., childhood sexual abuse) rather than in those who have undergone a single adult trauma (e.g., a community-wide disaster or a serious car accident). There are strong associations between eating disorders, self-harm, and substance abuse ( Claes & Vandereycken, 2007; for discussion, see Harned, Najavits, & Weiss, 2006). Self-mutilation is also associated with (and part of the diagnostic criteria for) a number of personality disorders, including borderline and histrionic, as well as DID, depression, and some forms of schizophrenia; these disorders can co-occur with traumatic stress reactions and disorders.

It is important to distinguish self-harm that is suicidal from self-harm that is not suicidal and to assess and manage both of these very serious dangers carefully. Most people who engage in self-harm are not doing so with the intent to kill themselves ( Noll, Horowitz, Bonanno, Trickett, & Putnam, 2003)-although self-harm can be life threatening and can escalate into suicidality if not managed therapeutically. Self-harm can be a way of getting attention or manipulating others, but most often it is not. Self-destructive behaviors such as substance abuse, restrictive or binge eating, reckless automobile driving, or high-risk impulsive behavior are different from self-harming behaviors but are also seen in clients with a history of trauma. Self-destructive behaviors differ from self-harming behaviors in that there may be no immediate negative impact of the behavior on the individual; they differ from suicidal behavior in that there is no intent to cause death in the short term.

Advice to Counselors: Working With Clients Who Are Self-Injurious

Counselors who are unqualified or uncomfortable working with clients who demonstrate self-harming, self-destructive, or suicidal or homicidal ideation, intent, or behavior should work with their agencies and supervisors to refer such clients to other counselors. They should consider seeking specialized supervision on how to manage such clients effectively and safely and how to manage their feelings about these issues. The following suggestions assume that the counselor has had sufficient training and experience to work with clients who are self-injurious. To respond appropriately to a client who engages in self-harm, counselors should:

Screen the client for self-harm and suicide risk at the initial evaluation and throughout treatment.

Learn the client's perspective on self-harm and how it "helps."

Understand that self-harm is often a coping strategy to manage the intensity of emotional and/or physical distress.

Teach the client coping skills that improve his or her management of emotions without self-harm.

Help the client obtain the level of care needed to manage genuine risk of suicide or severe self-injury. This might include hospitalization, more intensive programming (e.g., intensive outpatient, partial hospitalization, residential treatment), or more frequent treatment sessions. The goal is to stabilize the client as quickly as possible, and then, if possible, begin to focus treatment on developing coping strategies to manage self-injurious and other harmful impulses.

Consult with other team members, supervisors, and, if necessary, legal experts to determine whether one's efforts with and conceptualization of the self-harming client fit best practice guidelines. See, for example, Treatment Improvement Protocol (TIP) 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders ( Center for Substance Abuse Treatment [CSAT], 2005c). Document such consultations and the decisions made as a result of them thoroughly and frequently.

Help the client identify how substance use affects self-harm. In some cases, it can increase the behavior (e.g., alcohol disinhibits the client, who is then more likely to self-harm). In other cases, it can decrease the behavior (e.g., heroin evokes relaxation and, thus, can lessen the urge to self-harm). In either case, continue to help the client understand how abstinence from substances is necessary so that he or she can learn more adaptive coping.

Work collaboratively with the client to develop a plan to create a sense of safety. Individuals are affected by trauma in different ways; therefore, safety or a safe environment may mean something entirely different from one person to the next. Allow the client to define what safety means to him or her.

Counselors can also help the client prepare a safety card that the client can carry at all times. The card might include the counselor's contact information, a 24-hour crisis number to call in emergencies, contact information for supportive individuals who can be contacted when needed, and, if appropriate, telephone numbers for emergency medical services. The counselor can discuss with the client the types of signs or crises that might warrant using the numbers on the card. Additionally, the counselor might check with the client from time to time to confirm that the information on the card is current.

TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment ( CSAT, 2009a), has examples of safety agreements specifically for suicidal clients and discusses their uses in more detail. There is no credible evidence that a safety agreement is effective in preventing a suicide attempt or death. Safety agreements for clients with suicidal thoughts and behaviors should only be used as an adjunct support accompanying professional screening, assessment, and treatment for people with suicidal thoughts and behaviors. Keep in mind that safety plans or agreements may be perceived by the trauma survivor as a means of controlling behavior, subsequently replicating or triggering previous traumatic experiences.

All professionals-and in some States, anyone-could have ethical and legal responsibilities to those clients who pose an imminent danger to themselves or others. Clinicians should be aware of the pertinent State laws where they practice and the relevant Federal and professional regulations.

However, as with self-harming behavior, self-destructive behavior needs to be recognized and addressed and may persist-or worsen-without intervention.

Consumption of substances

Substance use often is initiated or increased after trauma. Clients in early recovery- especially those who develop PTSD or have it reactivated-have a higher relapse risk if they experience a trauma. In the first 2 months after September 11, 2001, more than a quarter of New Yorker residents who smoked cigarettes, drank alcohol, or used marijuana (about 265,000 people) increased their consumption. The increases continued 6 months after the attacks ( Vlahov, Galea, Ahern, Resnick, & Kilpatrick, 2004). A study by the Substance Abuse and Mental Health Services Administration ( SAMHSA, Office of Applied Studies, 2002) used National Survey on Drug Use and Health data to compare the first three quarters of 2001 with the last quarter and reported an increase in the prevalence rate for alcohol use among people 18 or older in the New York metropolitan area during the fourth quarter.

Interviews with New York City residents who were current or former cocaine or heroin users indicated that many who had been clean for 6 months or less relapsed after September 11, 2001. Others, who lost their income and could no longer support their habit, enrolled in methadone programs ( Weiss et al., 2002). After the Oklahoma City bombing in 1995, Oklahomans reported double the normal rate of alcohol use, smoking more cigarettes, and a higher incidence of initiating smoking months and even years after the bombing ( Smith, Christiansen, Vincent, & Hann, 1999).

Self-medication

Khantzian's self-medication theory ( 1985) suggests that drugs of abuse are selected for their specific effects. However, no definitive pattern has yet emerged of the use of particular substances in relation to PTSD or trauma symptoms. Use of substances can vary based on a variety of factors, including which trauma symptoms are most prominent for an individual and the individual's access to particular substances. Unresolved traumas sometimes lurk behind the emotions that clients cannot allow themselves to experience. Substance use and abuse in trauma survivors can be a way to self-medicate and thereby avoid or displace difficult emotions associated with traumatic experiences. When the substances are withdrawn, the survivor may use other behaviors to self-soothe, self-medicate, or avoid emotions. As likely, emotions can appear after abstinence in the form of anxiety and depression.

Avoidance

Avoidance often coincides with anxiety and the promotion of anxiety symptoms. Individuals begin to avoid people, places, or situations to alleviate unpleasant emotions, memories, or circumstances. Initially, the avoidance works, but over time, anxiety increases and the perception that the situation is unbearable or dangerous increases as well, leading to a greater need to avoid. Avoidance can be adaptive, but it is also a behavioral pattern that reinforces perceived danger without testing its validity, and it typically leads to greater problems across major life areas (e.g., avoiding emotionally oriented conversations in an intimate relationship). For many individuals who have traumatic stress reactions, avoidance is commonplace. A person may drive 5 miles longer to avoid the road where he or she had an accident. Another individual may avoid crowded places in fear of an assault or to circumvent strong emotional memories about an earlier assault that took place in a crowded area. Avoidance can come in many forms. When people can't tolerate strong affects associated with traumatic memories, they avoid, project, deny, or distort their trauma-related emotional and cognitive experiences. A key ingredient in trauma recovery is learning to manage triggers, memories, and emotions without avoidance-in essence, becoming desensitized to traumatic memories and associated symptoms.

Social/Interpersonal

A key ingredient in the early stage of TIC is to establish, confirm, or reestablish a support system, including culturally appropriate activities, as soon as possible. Social supports and relationships can be protective factors against traumatic stress. However, trauma typically affects relationships significantly, regardless of whether the trauma is interpersonal or is of some other type. Relationships require emotional exchanges, which means that others who have close relationships or friendships with the individual who survived the trauma(s) are often affected as well-either through secondary traumatization or by directly experiencing the survivor's traumatic stress reactions. In natural disasters, social and community supports can be abruptly eroded and difficult to rebuild after the initial disaster relief efforts have waned.

Survivors may readily rely on family members, friends, or other social supports-or they may avoid support, either because they believe that no one will be understanding or trustworthy or because they perceive their own needs as a burden to others. Survivors who have strong emotional or physical reactions, including outbursts during nightmares, may pull away further in fear of being unable to predict their own reactions or to protect their own safety and that of others. Often, trauma survivors feel ashamed of their stress reactions, which further hampers their ability to use their support systems and resources adequately.

Many survivors of childhood abuse and interpersonal violence have experienced a significant sense of betrayal. They have often encountered trauma at the hands of trusted caregivers and family members or through significant relationships. This history of betrayal can disrupt forming or relying on supportive relationships in recovery, such as peer supports and counseling. Although this fear of trusting others is protective, it can lead to difficulty in connecting with others and greater vigilance in observing the behaviors of others, including behavioral health service providers. It is exceptionally difficult to override the feeling that someone is going to hurt you, take advantage of you, or, minimally, disappoint you. Early betrayal can affect one's ability to develop attachments, yet the formation of supportive relationships is an important antidote in the recovery from traumatic stress.

Developmental

Each age group is vulnerable in unique ways to the stresses of a disaster, with children and the elderly at greatest risk. Young children may display generalized fear, nightmares, heightened arousal and confusion, and physical symptoms, (e.g., stomachaches, headaches). School-age children may exhibit symptoms such as aggressive behavior and anger, regression to behavior seen at younger ages, repetitious traumatic play, loss of ability to concentrate, and worse school performance. Adolescents may display depression and social withdrawal, rebellion, increased risky activities such as sexual acting out, wish for revenge and action-oriented responses to trauma, and sleep and eating disturbances ( Hamblen, 2001). Adults may display sleep problems, increased agitation, hypervigilance, isolation or withdrawal, and increased use of alcohol or drugs. Older adults may exhibit increased withdrawal and isolation, reluctance to leave home, worsening of chronic illnesses, confusion, depression, and fear (DeWolfe & Nordboe, 2000b).

Neurobiological Development: Consequences of Early Childhood Trauma

Findings in developmental psychobiology suggest that the consequences of early maltreatment produce enduring negative effects on brain development ( De Bellis, 2002; Liu, Diorio, Day, Francis, & Meaney, 2000; Teicher, 2002). Research suggests that the first stage in a cascade of events produced by early trauma and/or maltreatment involves the disruption of chemicals that function as neurotransmitters (e.g., cortisol, norepinephrine, dopamine), causing escalation of the stress response ( Heim, Mletzko, Purselle, Musselman, & Nemeroff, 2008; Heim, Newport, Mletzko, Miller, & Nemeroff, 2008; Teicher, 2002). These chemical responses can then negatively affect critical neural growth during specific sensitive periods of childhood development and can even lead to cell death.

Adverse brain development can also result from elevated levels of cortisol and catecholamines by contributing to maturational failures in other brain regions, such as the prefrontal cortex ( Meaney, Brake, & Gratton, 2002). Heim, Mletzko et al. (2008) found that the neuropeptide oxytocin- important for social affiliation and support, attachment, trust, and management of stress and anxiety-was markedly decreased in the cerebrospinal fluid of women who had been exposed to childhood maltreatment, particularly those who had experienced emotional abuse. The more childhood traumas a person had experienced, and the longer their duration, the lower that person's current level of oxytocin was likely to be and the higher her rating of current anxiety was likely to be.

Using data from the Adverse Childhood Experiences Study, an analysis by Anda, Felitti, Brown et al. (2006) confirmed that the risk of negative outcomes in affective, somatic, substance abuse, memory, sexual, and aggression-related domains increased as scores on a measure of eight ACEs increased. The researchers concluded that the association of study scores with these outcomes can serve as a theoretical parallel for the effects of cumulative exposure to stress on the developing brain and for the resulting impairment seen in multiple brain structures and functions.

The National Child Traumatic Stress Network ( http://www.nctsn.org) offers information about childhood abuse, stress, and physiological responses of children who are traumatized. Materials are available for counselors, educators, parents, and caregivers. There are special sections on the needs of children in military families and on the impact of natural disasters on children's mental health.

Subthreshold Trauma-Related Symptoms

Many trauma survivors experience symptoms that, although they do not meet the diagnostic criteria for ASD or PTSD, nonetheless limit their ability to function normally (e.g., regulate emotional states, maintain steady and rewarding social and family relationships, function competently at a job, maintain a steady pattern of abstinence in recovery). These symptoms can be transient, only arising in a specific context; intermittent, appearing for several weeks or months and then receding; or a part of the individual's regular pattern of functioning (but not to the level of DSM-5 diagnostic criteria). Often, these patterns are termed "subthreshold" trauma symptoms. Like PTSD, the symptoms can be misdiagnosed as depression, anxiety, oran other mental illness. Likewise, clients who have experienced trauma may link some of their symptoms to their trauma and diagnose themselves as having PTSD, even though they do not meet all criteria for that disorder.

Combat Stress Reaction

A phenomenon unique to war, and one that counselors need to understand well, is combat stress reaction (CSR). CSR is an acute anxiety reaction occurring during or shortly after participating in military conflicts and wars as well as other operations within the war zone, known as the theater. CSR is not a formal diagnosis, nor is it included in the DSM-5 ( APA, 2013a). It is similar to acute stress reaction, except that the precipitating event or events affect military personnel (and civilians exposed to the events) in an armed conflict situation. The terms "combat stress reaction" and "posttraumatic stress injury" are relatively new, and the intent of using these new terms is to call attention to the unique experiences of combat-related stress as well as to decrease the shame that can be associated with seeking behavioral health services for PTSD (for more information on veterans and combat stress reactions, see the planned TIP, Reintegration-Related Behavioral Health Issues for Veterans and Military Families; SAMHSA, planned f).

Case Illustration: Frank

Frank is a 36-year-old man who was severely beaten in a fight outside a bar. He had multiple injuries, including broken bones, a concussion, and a stab wound in his lower abdomen. He was hospitalized for 3.5 weeks and was unable to return to work, thus losing his job as a warehouse forklift operator. For several years, when faced with situations in which he perceived himself as helpless and overwhelmed, Frank reacted with violent anger that, to others, appeared grossly out of proportion to the situation. He has not had a drink in almost 3 years, but the bouts of anger persist and occur three to five times a year. They leave Frank feeling even more isolated from others and alienated from those who love him. He reports that he cannot watch certain television shows that depict violent anger; he has to stop watching when such scenes occur. He sometimes daydreams about getting revenge on the people who assaulted him.

Psychiatric and neurological evaluations do not reveal a cause for Frank's anger attacks. Other than these symptoms, Frank has progressed well in his abstinence from alcohol. He attends a support group regularly, has acquired friends who are also abstinent, and has reconciled with his family of origin. His marriage is more stable, although the episodes of rage limit his wife's willingness to commit fully to the relationship. In recounting the traumatic event in counseling, Frank acknowledges that he thought he was going to die as a result of the fight, especially when he realized he had been stabbed. As he described his experience, he began to become very anxious, and the counselor observed the rage beginning to appear.

After his initial evaluation, Frank was referred to an outpatient program that provided trauma-specific interventions to address his subthreshold trauma symptoms. With a combination of cognitive- behavioral counseling, EMDR, and anger management techniques, he saw a gradual decrease in symptoms when he recalled the assault. He started having more control of his anger when memories of the trauma emerged. Today, when feeling trapped, helpless, or overwhelmed, Frank has resources for coping and does not allow his anger to interfere with his marriage or other relationships.

Although stress mobilizes an individual's physical and psychological resources to perform more effectively in combat, reactions to the stress may persist long after the actual danger has ended. As with other traumas, the nature of the event(s), the reactions of others, and the survivor's psychological history and resources affect the likelihood and severity of CSR. With combat veterans, this translates to the number, intensity, and duration of threat factors; the social support of peers in the veterans' unit; the emotional and cognitive resilience of the service members; and the quality of military leadership. CSR can vary from manageable and mild to debilitating and severe. Common, less severe symptoms of CSR include tension, hypervigilance, sleep problems, anger, and difficulty concentrating. If left untreated, CSR can lead to PTSD.

Common causes of CSR are events such as a direct attack from insurgent small arms fire or a military convoy being hit by an improvised explosive device, but combat stressors encompass a diverse array of traumatizing events, such as seeing grave injuries, watching others die, and making on-the-spot decisions in ambiguous conditions (e.g., having to determine whether a vehicle speeding toward a military checkpoint contains insurgents with explosives or a family traveling to another area). Such circumstances can lead to combat stress. Military personnel also serve in noncombat positions (e.g., healthcare and administrative roles), and personnel filling these supportive roles can be exposed to combat situations by proximity or by witnessing their results.

Advice to Counselors: Understanding the Nature of Combat Stress

Several sources of information are available to help counselors deepen their understanding of combat stress and postdeployment adjustment. Friedman (2006) explains how a prolonged combat-ready stance, which is adaptive in a war zone, becomes hypervigilance and overprotectiveness at home. He makes the point that the "mutual interdependence, trust, and affection" (p. 587) that are so necessarily a part of a combat unit are different from relationships with family members and colleagues in a civilian workplace. This complicates the transition to civilian life. Wheels Down: Adjusting to Life After Deployment ( Moore & Kennedy, 2011) provides practical advice for military service members, including inactive or active duty personnel and veterans, in transitioning from the theater to home.

The following are just a few of the many resources and reports focused on combat-related psychological and stress issues:

Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery ( Tanielian & Jaycox, 2008)

On Killing ( Grossman, 1995), an indepth analysis of the psychological dynamics of combat

Haunted by Combat ( Paulson & Krippner, 2007), which contains specific chapters on Reserve and National Guard troops and female veterans

Specific Trauma-Related Psychological Disorders

Part of the definition of trauma is that the individual responds with intense fear, helplessness, or horror. Beyond that, in both the short term and the long term, trauma comprises a range of reactions from normal (e.g., being unable to concentrate, feeling sad, having trouble sleeping) to warranting a diagnosis of a trauma-related mental disorder. Most people who experience trauma have no long-lasting disabling effects; their coping skills and the support of those around them are sufficient to help them overcome their difficulties, and their ability to function on a daily basis over time is unimpaired. For others, though, the symptoms of trauma are more severe and last longer. The most common diagnoses associated with trauma are PTSD and ASD, but trauma is also associated with the onset of other mental disorders-particularly substance use disorders, mood disorders, various anxiety disorders, and personality disorders. Trauma also typically exacerbates symptoms of preexisting disorders, and, for people who are predisposed to a mental disorder, trauma can precipitate its onset. Mental disorders can occur almost simultaneously with trauma exposure or manifest sometime thereafter.

Acute Stress Disorder

ASD represents a normal response to stress. Symptoms develop within 4 weeks of the trauma and can cause significant levels of distress. Most individuals who have acute stress reactions never develop further impairment or PTSD. Acute stress disorder is highly associated with the experience of one specific trauma rather than the experience of long-term exposure to chronic traumatic stress. Diagnostic criteria are presented in Exhibit 1.3-3.

The primary presentation of an individual with an acute stress reaction is often that of someone who appears overwhelmed by the traumatic experience. The need to talk about the experience can lead the client to seem self-centered and unconcerned about the needs of others. He or she may need to describe, in repetitive detail, what happened, or may seem obsessed with trying to understand what happened in an effort to make sense of the experience. The client is often hypervigilant and avoids circumstances that are reminders of the trauma. For instance, someone who was in a serious car crash in heavy traffic can become anxious and avoid riding in a car or driving in traffic for a finite time afterward. Partial amnesia for the trauma often accompanies ASD, and the individual may repetitively question others to fill in details. People with ASD symptoms sometimes seek assurance from others that the event happened in the way they remember, that they are not "going crazy" or "losing it," and that they could not have prevented the event. The next case illustration demonstrates the time-limited nature of ASD.

Differences between ASD and PTSD

It is important to consider the differences between ASD and PTSD when forming a diagnostic impression. The primary difference is the amount of time the symptoms have been present. ASD resolves 2 days to 4 weeks after an event, whereas PTSD continues beyond the 4-week period. The diagnosis of ASD can change to a diagnosis of PTSD if the condition is noted within the first 4 weeks after the event, but the symptoms persist past 4 weeks.

ASD also differs from PTSD in that the ASD diagnosis requires 9 out of 14 symptoms from five categories, including intrusion, negative mood, dissociation, avoidance, and arousal. These symptoms can occur at the time of the trauma or in the following month. Studies indicate that dissociation at the time of trauma is a good predictor of subsequent PTSD, so the inclusion of dissociative symptoms makes it more likely that those who develop ASD will later be diagnosed with PTSD ( Bryant & Harvey, 2000). Additionally, ASD is a transient disorder, meaning that it is present in a person's life for a relatively short time and then passes. In contrast, PTSD typically becomes a primary feature of an individual's life. Over a lengthy period, PTSD can have profound effects on clients' perceptions of safety, their sense of hope for the future, their relationships with others, their physical health, the appearance of psychiatric symptoms, and their patterns of substance use and abuse.

There are common symptoms between PTSD and ASD, and untreated ASD is a possible predisposing factor to PTSD, but it is unknown whether most people with ASD are likely to develop PTSD. There is some suggestion that, as with PTSD, ASD is more prevalent in women than in men ( Bryant & Harvey, 2003). However, many people with PTSD do not have a diagnosis or recall a history of acute stress symptoms before seeking treatment for or receiving a diagnosis of PTSD.

Case Illustration: Sheila

Two months ago, Sheila, a 55-year-old married woman, experienced a tornado in her home town. In the previous year, she had addressed a long-time marijuana use problem with the help of a treatment program and had been abstinent for about 6 months. Sheila was proud of her abstinence; it was something she wanted to continue. She regarded it as a mark of personal maturity; it improved her relationship with her husband, and their business had flourished as a result of her abstinence.

During the tornado, an employee reported that Sheila had become very agitated and had grabbed her assistant to drag him under a large table for cover. Sheila repeatedly yelled to her assistant that they were going to die. Following the storm, Sheila could not remember certain details of her behavior during the event. Furthermore, Sheila said that after the storm, she felt numb, as if she was floating out of her body and could watch herself from the outside. She stated that nothing felt real and it was all like a dream.

Following the tornado, Sheila experienced emotional numbness and detachment, even from people close to her, for about 2 weeks. The symptoms slowly decreased in intensity but still disrupted her life. Sheila reported experiencing disjointed or unconnected images and dreams of the storm that made no real sense to her. She was unwilling to return to the building where she had been during the storm, despite having maintained a business at this location for 15 years. In addition, she began smoking marijuana again because it helped her sleep. She had been very irritable and had uncharacteristic angry outbursts toward her husband, children, and other family members.

As a result of her earlier contact with a treatment program, Sheila returned to that program and engaged in psychoeducational, supportive counseling focused on her acute stress reaction. She regained abstinence from marijuana and returned shortly to a normal level of functioning. Her symptoms slowly diminished over a period of 3 weeks. With the help of her counselor, she came to understand the link between the trauma and her relapse, regained support from her spouse, and again felt in control of her life.

Effective interventions for ASD can significantly reduce the possibility of the subsequent development of PTSD. Effective treatment of ASD can also reduce the incidence of other co-occurring problems, such as depression, anxiety, dissociative disorders, and compulsive behaviors ( Bryant & Harvey, 2000). Intervention for ASD also helps the individual develop coping skills that can effectively prevent the recurrence of ASD after later traumas.

Although predictive science for ASD and PTSD will continue to evolve, both disorders are associated with increased substance use and mental disorders and increased risk of relapse; therefore, effective screening for ASD and PTSD is important for all clients with these disorders. Individuals in early recovery-lacking well-practiced coping skills, lacking environmental supports, and already operating at high levels of anxiety-are particularly susceptible to ASD. Events that would not normally be disabling can produce symptoms of intense helplessness and fear, numbing and depersonalization, disabling anxiety, and an inability to handle normal life events. Counselors should be able to recognize ASD and treat it rather than attributing the symptoms to a client's lack of motivation to change, being "dry drunk" (for those in substance abuse recovery), or being manipulative.

Posttraumatic Stress Disorder

The trauma-related disorder that receives the greatest attention is PTSD; it is the most commonly diagnosed trauma-related disorder, and its symptoms can be quite debilitating over time. Nonetheless, it is important to remember that PTSD symptoms are represented in a number of other mental illnesses, including major depressive disorder (MDD), anxiety disorders, and psychotic disorders ( Foa et al., 2006). The DSM-5 ( APA, 2013a) identifies four symptom clusters for PTSD: presence of intrusion symptoms, persistent avoidance of stimuli, negative alterations in cognitions and mood, and marked alterations in arousal and reactivity. Individuals must have been exposed to actual or threatened death, serious injury, or sexual violence, and the symptoms must produce significant distress and impairment for more than 4 weeks ( Exhibit 1.3-4).

Case Illustration: Michael

Michael is a 62-year-old Vietnam veteran. He is a divorced father of two children and has four grandchildren. Both of his parents were dependent on alcohol. He describes his childhood as isolated. His father physically and psychologically abused him (e.g., he was beaten with a switch until he had welts on his legs, back, and buttocks). By age 10, his parents regarded him as incorrigible and sent him to a reformatory school for 6 months. By age 15, he was using marijuana, hallucinogens, and alcohol and was frequently truant from school.

At age 19, Michael was drafted and sent to Vietnam, where he witnessed the deaths of six American military personnel. In one incident, the soldier he was next to in a bunker was shot. Michael felt helpless as he talked to this soldier, who was still conscious. In Vietnam, Michael increased his use of both alcohol and marijuana. On his return to the United States, Michael continued to drink and use marijuana. He reenlisted in the military for another tour of duty.

His life stabilized in his early 30s, as he had a steady job, supportive friends, and a relatively stable family life. However, he divorced in his late 30s. Shortly thereafter, he married a second time, but that marriage ended in divorce as well. He was chronically anxious and depressed and had insomnia and frequent nightmares. He periodically binged on alcohol. He complained of feeling empty, had suicidal ideation, and frequently stated that he lacked purpose in his life.

In the 1980s, Michael received several years of mental health treatment for dysthymia. He was hospitalized twice and received 1 year of outpatient psychotherapy. In the mid-1990s, he returned to outpatient treatment for similar symptoms and was diagnosed with PTSD and dysthymia. He no longer used marijuana and rarely drank. He reported that he didn't like how alcohol or other substances made him feel anymore-he felt out of control with his emotions when he used them. Michael reported symptoms of hyperarousal, intrusion (intrusive memories, nightmares, and preoccupying thoughts about Vietnam), and avoidance (isolating himself from others and feeling "numb"). He reported that these symptoms seemed to relate to his childhood abuse and his experiences in Vietnam. In treatment, he expressed relief that he now understood the connection between his symptoms and his history.

Certain characteristics make people more susceptible to PTSD, including one's unique personal vulnerabilities at the time of the traumatic exposure, the support (or lack of support) received from others at the time of the trauma and at the onset of trauma-related symptoms, and the way others in the person's environment gauge the nature of the traumatic event ( Brewin, Andrews, & Valentine, 2000).

People with PTSD often present varying clinical profiles and histories. They can experience symptoms that are activated by environmental triggers and then recede for a period of time. Some people with PTSD who show mostly psychiatric symptoms (particularly depression and anxiety) are misdiagnosed and go untreated for their primary condition. For many people, the trauma experience and diagnosis are obscured by co-occurring substance use disorder symptoms. The important feature of PTSD is that the disorder becomes an orienting feature of the individual's life. How well the person can work, with whom he or she associates, the nature of close and intimate relationships, the ability to have fun and rejuvenate, and the way in which an individual goes about confronting and solving problems in life are all affected by the client's trauma experiences and his or her struggle to recover.

Posttraumatic stress disorder: Timing of symptoms

Although symptoms of PTSD usually begin within 3 months of a trauma in adulthood, there can be a delay of months or even years before symptoms appear for some people. Some people may have minimal symptoms after a trauma but then experience a crisis later in life. Trauma symptoms can appear suddenly, even without conscious memory of the original trauma or without any overt provocation. Survivors of abuse in childhood can have a delayed response triggered by something that happens to them as adults. For example, seeing a movie about child abuse can trigger symptoms related to the trauma. Other triggers include returning to the scene of the trauma, being reminded of it in some other way, or noting the anniversary of an event. Likewise, combat veterans and survivors of community-wide disasters may seem to be coping well shortly after a trauma, only to have symptoms emerge later when their life situations seem to have stabilized. Some clients in substance abuse recovery only begin to experience trauma symptoms when they maintain abstinence for some time. As individuals decrease tension-reducing or self-medicating behaviors, trauma memories and symptoms can emerge.

Advice to Counselors: Helping Clients With Delayed Trauma Responses

Clients who are experiencing a delayed trauma response can benefit if you help them to:

Create an environment that allows acknowledgment of the traumatic event(s).

Discuss their initial recall or first suspicion that they were having a traumatic response.

Become educated on delayed trauma responses.

Draw a connection between the trauma and presenting trauma-related symptoms.

Create a safe environment.

Explore their support systems and fortify them as needed.

Understand that triggers can precede traumatic stress reactions, including delayed responses to trauma.

Develop coping strategies to navigate and manage symptoms.

Culture and posttraumatic stress

Although research is limited across cultures, PTSD has been observed in Southeast Asian, South American, Middle Eastern, and Native American survivors ( Osterman & de Jong, 2007; Wilson & Tang, 2007). As Stamm and Friedman (2000) point out, however, simply observing PTSD does not mean that it is the "best conceptual tool for characterizing post-traumatic distress among non-Western individuals" (p. 73). In fact, many trauma-related symptoms from other cultures do not fit the DSM-5 criteria. These include somatic and psychological symptoms and beliefs about the origins and nature of traumatic events. Moreover, religious and spiritual beliefs can affect how a survivor experiences a traumatic event and whether he or she reports the distress. For example, in societies where attitudes toward karma and the glorification of war veterans are predominant, it is harder for war veterans to come forward and disclose that they are emotionally overwhelmed or struggling. It would be perceived as inappropriate and possibly demoralizing to focus on the emotional distress that he or she still bears. (For a review of cultural competence in treating trauma, refer to Brown, 2008.)

Methods for measuring PTSD are also culturally specific. As part of a project begun in 1972, the World Health Organization (WHO) and the National Institutes of Health (NIH) embarked on a joint study to test the cross-cultural applicability of classification systems for various diagnoses. WHO and NIH identified apparently universal factors of psychological disorders and developed specific instruments to measure them. These instruments, the Composite International Diagnostic Interview and the Schedules for Clinical Assessment in Neuropsychiatry, include certain criteria from the DSM (Fourth Edition, Text Revision; APA, 2000a) as well as criteria from the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10; Exhibit 1.3-5).

Complex trauma and complex traumatic stress

When individuals experience multiple traumas, prolonged and repeated trauma during childhood, or repetitive trauma in the context of significant interpersonal relationships, their reactions to trauma have unique characteristics ( Herman, 1992). This unique constellation of reactions, called complex traumatic stress, is not recognized diagnostically in the DSM-5, but theoretical discussions and research have begun to highlight the similarities and differences in symptoms of posttraumatic stress versus complex traumatic stress ( Courtois & Ford, 2009). Often, the symptoms generated from complex trauma do not fully match PTSD criteria and exceed the severity of PTSD. Overall, literature reflects that PTSD criteria or subthreshold symptoms do not fully account for the persistent and more impairing clinical presentation of complex trauma. Even though current research in the study of traumatology is prolific, it is still in the early stages of development. The idea that there may be more diagnostic variations or subtypes is forthcoming, and this will likely pave the way for more client-matching interventions to better serve those individuals who have been repeatedly exposed to multiple, early childhood, and/or interpersonal traumas.

Other Trauma-Related and Co-Occurring Disorders

The symptoms of PTSD and other mental disorders overlap considerably; these disorders often coexist and in clude mood, anxiety, substance use, and personality disorders. Thus, it's common for trauma survivors to be underdiagnosed or misdiagnosed. If they have not been identified as trauma survivors, their psychological distress is often not associated with previous trauma, and/or they are diagnosed with a disorder that marginally matches their presenting symptoms and psychological sequelae of trauma. The following sections present a brief overview of some mental disorders that can result from (or be worsened by) traumatic stress. PTSD is not the only diagnosis related to trauma nor its only psychological consequence; trauma can broadly influence mental and physical health in clients who already have behavioral health disorders.

The term " co-occurring disorders " refers to cases when a person has one or more mental disorders as well as one or more substance use disorders (including substance abuse). Co-occurring disorders are common among individuals who have a history of trauma and are seeking help.

Advice to Counselors: Universal Screening and Assessment

Only people specifically trained and licensed in mental health assessment should make diagnoses; trauma can result in complicated cases, and many symptoms can be present, whether or not they meet full diagnostic criteria for a specific disorder. Only a trained assessor can distinguish accurately among various symptoms and in the presence of co-occurring disorders. However, behavioral health professionals without specific assessment training can still serve an important role in screening for possible mental disorders using established screening tools ( CSAT, 2005c; see also Chapter 4 of this TIP). In agencies and clinics, it is critical to provide such screenings systematically-for each client-as PTSD and other co-occurring disorders are typically under diagnosed or misdiagnosed.

People With Mental Disorders

MDD is the most common co-occurring disorder in people who have experienced trauma and are diagnosed with PTSD. A well-established causal relationship exists between stressful events and depression, and a prior history of MDD is predictive of PTSD after exposure to major trauma ( Foa et al., 2006).

Many survivors with severe mental disorders function fairly well following trauma, including disasters, as long as essential services aren't interrupted. For others, additional mental health supports may be necessary. For more information, see Responding to the Needs of People With Serious and Persistent Mental Illness in Times of Major Disaster ( Center for Mental Health Services, 1996).

Co-occurrence is also linked with greater impairment and more severe symptoms of both disorders, and the person is less likely to experience remission of symptoms within 6 months.

Generalized anxiety, obsessive-compulsive, and other anxiety disorders are also associated with PTSD. PTSD may exacerbate anxiety disorder symptoms, but it is also likely that preexisting anxiety symptoms and anxiety disorders increase vulnerability to PTSD. Preexisting anxiety primes survivors for greater hyperarousal and distress. Other disorders, such as personality and somatization disorders, are also associated with trauma, but the history of trauma is often overlooked as a significant factor or necessary target in treatment.

The relationship between PTSD and other disorders is complex. More research is now examining the multiple potential pathways among PTSD and other disorders and how various sequences affect clinical presentation. TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders ( CSAT, 2005c), is valuable in understanding the relationship of substance use to other mental disorders.

People With Substance Use Disorders

There is clearly a correlation between trauma (including individual, group, or mass trauma) and substance use as well as the presence of posttraumatic stress (and other trauma-related disorders) and substance use disorders. Alcohol and drug use can be, for some, an effort to manage traumatic stress and specific PTSD symptoms. Likewise, people with substance use disorders are at higher risk of developing PTSD than people who do not abuse substances. Counselors working with trauma survivors or clients who have substance use disorders have to be particularly aware of the possibility of the other disorder arising.

Co-Occurring PTSD and Other Mental Disorders

Individuals with PTSD often have at least one additional diagnosis of a mental disorder.

The presence of other disorders typically worsens and prolongs the course of PTSD and complicates clinical assessment, diagnosis, and treatment.

The most common co-occurring disorders, in addition to substance use disorders, include mood disorders, various anxiety disorders, eating disorders, and personality disorders.

Exposure to early, severe, and chronic trauma is linked to more complex symptoms, including impulse control deficits, greater difficulty in emotional regulation and establishing stable relationships, and disruptions in consciousness, memory, identity, and/or perception of the environment ( Dom, De, Hulstijn, & Sabbe, 2007; Waldrop, Back, Verduin, & Brady, 2007).

Certain diagnostic groups and at-risk populations (e.g., people with developmental disabilities, people who are homeless or incarcerated) are more susceptible to trauma exposure and to developing PTSD if exposed but less likely to receive appropriate diagnosis and treatment.

Given the prevalence of traumatic events in clients who present for substance abuse treatment, counselors should assess all clients for possible trauma-related disorders.

Timeframe: PTSD and the onset of substance use disorders

Knowing whether substance abuse or PTSD came first informs whether a causal relationship exists, but learning this requires thorough assessment of clients and access to complete data on PTSD; substance use, abuse, and dependence; and the onset of each. Much current research focuses solely on the age of onset of substance use (not abuse), so determining causal relationships can be difficult. The relationship between PTSD and substance use disorders is thought to be bidirectional and cyclical: substance use increases trauma risk, and exposure to trauma escalates substance use to manage trauma-related symptoms. Three other causal pathways described by Chilcoat and Breslau's seminal work ( 1998) further explain the relationship between PTSD and substance use disorders:

1. The "self-medication" hypothesis suggests that clients with PTSD use substances to manage PTSD symptoms (e.g., intrusive memories, physical arousal). Substances such as alcohol, cocaine, barbiturates, opioids, and amphetamines are frequently abused in attempts to relieve or numb emotional pain or to forget the event.

2. The "high-risk" hypothesis states that drug and alcohol use places people who use substances in high-risk situations that increase their chances of being exposed to events that lead to PTSD.

3. The "susceptibility" hypothesis suggests that people who use substances are more susceptible to developing PTSD after exposure to trauma than people who do not. Increased vulnerability may result from failure to develop effective stress management strategies, changes in brain chemistry, or damage to neurophysiological systems due to extensive substance use.

PTSD and substance abuse treatment

PTSD can limit progress in substance abuse recovery, increase the potential for relapse, and complicate a client's ability to achieve success in various life areas. Each disorder can mask or hide the symptoms of the other, and both need to be assessed and treated if the individual is to have a full recovery. There is a risk of misinterpreting trauma-related symptoms in substance abuse treatment settings. For example, avoidance symptoms in an individual with PTSD can be misinterpreted as lack of motivation or unwillingness to engage in substance abuse treatment; a counselor's efforts to address substance abuse-related behaviors in early recovery can likewise provoke an exaggerated response from a trauma survivor who has profound traumatic experiences of being trapped and controlled. Exhibit 1.3-6 lists important facts about PTSD and substance use disorders for counselors.

Case Illustration: Maria

Maria is a 31-year-old woman diagnosed with PTSD and alcohol dependence. From ages 8 to 12, she was sexually abused by an uncle. Maria never told anyone about the abuse for fear that she would not be believed. Her uncle remains close to the family, and Maria still sees him on certain holidays. When she came in for treatment, she described her emotions and thoughts as out of control. Maria often experiences intrusive memories of the abuse, which at times can be vivid and unrelenting. She cannot predict when the thoughts will come; efforts to distract herself from them do not always work. She often drinks in response to these thoughts or his presence, as she has found that alcohol can dull her level of distress. Maria also has difficulty falling asleep and is often awakened by nightmares. She does not usually remember the dreams, but she wakes up feeling frightened and alert and cannot go back to sleep.

Maria tries to avoid family gatherings but often feels pressured to go. Whenever she sees her uncle, she feels intense panic and anger but says she can usually "hold it together" if she avoids him. Afterward, however, she describes being overtaken by these feelings and unable to calm down. She also describes feeling physically ill and shaky. At these times, she often isolates herself, stays in her apartment, and drinks steadily for several days. Maria also reports distress pertaining to her relationship with her boyfriend. In the beginning of their relationship, she found him comforting and enjoyed his affection, but more recently, she has begun to feel anxious and unsettled around him. Maria tries to avoid sex with him, but she sometimes gives in for fear of losing the relationship. She finds it easier to have sex with him when she is drunk, but she often experiences strong feelings of dread and disgust reminiscent of her abuse. Maria feels guilty and confused about these feelings.

Sleep, PTSD, and substance use

Many people have trouble getting to sleep and/or staying asleep after a traumatic event; consequently, some have a drink or two to help them fall asleep. Unfortunately, any initially helpful effects are likely not only to wane quickly, but also to incur a negative rebound effect. When someone uses a substance before going to bed, "sleep becomes lighter and more easily disrupted," and rapid eye movement sleep (REM) "increases, with an associated increase in dreams and nightmares," as the effects wear off ( Auerbach, 2003, p. 1185).

People with alcohol dependence report multiple types of sleep disturbances over time, and it is not unusual for clients to report that they cannot fall asleep without first having a drink. Both REM and slow wave sleep are reduced in clients with alcohol dependence, which is also associated with an increase in the amount of time it takes before sleep occurs, decreased overall sleep time, more nightmares, and reduced sleep efficiency. Sleep during withdrawal is "frequently marked by severe insomnia and sleep fragmentation...a loss of restful sleep and feelings of daytime fatigue. Nightmares and vivid dreams are not uncommon" ( Auerbach, 2003, pp. 1185-1186).

Confounding changes in the biology of sleep that occur in clients with PTSD and substance use disorders often add to the problems of recovery. Sleep can fail to return to normal for months or even years after abstinence, and the persistence of sleep disruptions appears related to the likelihood of relapse. Of particular clinical importance is the vicious cycle that can also begin during "slips"; relapse initially improves sleep, but continued drinking leads to sleep disruption. This cycle of initial reduction of an unpleasant symptom, which only ends up exacerbating the process as a whole, can take place for clients with PTSD as well as for clients with substance use disorders. There are effective cognitive-behavioral therapies and nonaddictive pharmacological interventions for sleep difficulties.

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Trauma-informed care (TIC) involves a broad understanding of traumatic stress reactions and common responses to trauma. Providers need to understand how trauma can affect treatment presentation, engagement, and the outcome of behavioral health services. This chapter examines common experiences survivors may encounter immediately following or long after a traumatic experience.

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Acute and Chronic Mental Health Trauma - StatPearls - NCBI Bookshelf

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The word “trauma” derives from the Greek word for “wound” or “hurt.” Mental health or psychological trauma has since become more broadly defined as an experience that is subjectively perceived as painful or distressing and results in acute or chronic mental and physical impairment or dysfunction.[1][2] The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), defines a traumatic event as the exposure to “death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence.” Trauma may be experienced either through direct involvement or by witnessing or learning of such an event happening to others and is often accompanied by a sense of shock, helplessness, or loss of control.

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Trauma: definition, types, causes, symptoms, effects, and treatment

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Trauma: definition, types, causes, symptoms, effects, and treatment

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AUTHOR:Asif Baliyan, MD Last edited on 06-17-2025

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Trauma: definition, types, causes, symptoms, effects, and treatment - The Diamond Rehab Thailand

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Trauma refers to the psychological harm resulting from going through deeply distressing or disturbing events. What’s traumatic to someone is often personal,

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A traumatic event is an incident that causes you physical, emotional, spiritual, or psychological harm. You may feel physically threatened or extremely frightened as a result.

In some cases, you might not know how to respond or may be in denial about the effect such an event has had. You'll need support and time to recover from the traumatic event and regain emotional and mental stability.

Examples of traumatic events include:

physical pain or injury (e.g. severe car accident)

serious illness

war

natural disasters

terrorism

witnessing a death

rape

domestic abuse

incarceration within the criminal justice system

While this article is focused on the causes and effects of physical or life threatening trauma, emotional and psychological stress can feel as strong to those experiencing it.

Complicated grief can occur as a result of the death of a loved one or a difficult divorce. Life changes like moving to a new location, parental abandonment, or family conflicts can trigger adjustment disorder.

Faced with these kinds of events, some people may experience shock that feels equivalent to the traumatic events listed above.

People respond to traumatic events in different ways. Often there are no visible signs, but people may have serious emotional reactions.

Shock and denial shortly after the event are normal reactions.

Shock and denial are often used to protect yourself from the emotional impact of the event. You may feel numb or detached. You may not feel the event's full intensity right away.

Moving past the initial shock usually takes 4-6 weeks from the event. This is seen as the difference between an acute stress reaction (within 4 weeks from the event) or a post-traumatic reaction (usually after 4-6 weeks).

Once you have moved past the initial shock, responses to a traumatic event may vary. Common responses include:

repeated memories of the event or flashbacks

nightmares

intense fear that the traumatic event will recur, particularly around anniversaries of the event (or when going back to the scene of the original event)

withdrawal and isolation from day-to-day activities

continued avoidance of reminders of the event

shifts in mood or changes in thought patterns

irritability

sudden, dramatic mood shifts

anxiety and nervousness

anger

denial

depression that can commonly occur along with traumatic stress

difficulty concentrating

altered sleeping or insomnia

physical symptoms of stress, such as headaches and nausea

worsening of an existing medical condition

A condition known as post-traumatic stress disorder (PTSD) can sometimes occur after you experience a life-threatening event or witness a death.

PTSD is a type of anxiety disorder that affects stress hormones and changes the body's response to stress. People with this disorder require strong social support and ongoing therapy.

Many veterans returning from war experience PTSD.

PTSD can cause an intense physical and emotional response to any thought or memory of the event. It can last for months or years following trauma.

Experts do not know why some people experience PTSD after a traumatic event, while others do not. A history of trauma, along with other physical, genetic, psychological, and social factors may play a role in developing PTSD.

Many experts do suspect that high levels of avoiding things in life and continued self-blame or shame for a personal role in the event are a few key signs that a person may go on to experience PTSD after a traumatic event.

There are several ways to help restore your emotional stability after a traumatic event:

Notice if you feel a pull to avoid things in your life and try to stay engaged in routines like work and social life

Spend time with others to avoid becoming withdrawn, even if you do not feel up to it.

Pursue hobbies or other interests.

Communicate the experience with family or close friends or in a diary or online journal.

Give yourself time and recognize that you can't control everything.

Ask for support from people who care about you or attend a local or online support group for people who have had a similar experience.

Find a support group led by a trained professional who can facilitate discussions.

Try to eat a well-balanced diet, exercise, get adequate rest, and avoid alcohol and drugs.

If you believe you have symptoms of substance use disorder, talk with a healthcare professional who can help you create a treatment plan and connect you with supportive resources.

Maintain a daily routine with structured activities.

Avoid major life decisions, such as changing careers or moving, soon after the event.

You should seek professional help if symptoms persist and interfere with day-to-day activities, school or work performance, or personal relationships.

Experiences with traumatic stress can appear much different for children. Signs that a child may need professional help to cope with a traumatic event include:

emotional outbursts

aggressive behavior

withdrawal

persistent difficulty in sleeping

continued obsession with the traumatic event

serious problems at school

Psychologists and mental health professionals can work with people to help find ways to cope with stress. They can help both children and their parents understand how to cope with the emotional impact of a traumatic event.

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A traumatic event is an incident that causes you physical, emotional, spiritual, or psychological harm. You may feel physically threatened or extremely frightened as a result. In some cases, you might not know how to respond or may be in denial about the effect such an event has had.

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Trauma Explained: How It Impacts Mind, Body, and Society

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Trauma Explained: How It Impacts Mind, Body, and Society

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Trauma Explained: How It Impacts Mind, Body, and Society

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Trauma Explained: How It Impacts Mind, Body, and Society

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Trauma Explained: How It Impacts Mind, Body, and Society

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Trauma Explained: How It Impacts Mind, Body, and Society

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Understanding Trauma: Causes, Symptoms, Wellbeing Strategies

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Understanding Trauma: Causes, Symptoms, Wellbeing Strategies

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Understanding Trauma: Causes, Symptoms, Wellbeing Strategies

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Understanding Post-Traumatic Stress Disorder - Symptoms, Causes, and Treatments

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Understanding Post-Traumatic Stress Disorder - Symptoms, Causes, and Treatments

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Understanding Post-Traumatic Stress Disorder - Symptoms, Causes, and Treatments

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Trauma dumping: how sharing experiences on social media can cause distress for other users

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Trauma dumping: how sharing experiences on social media can cause distress for other users

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Have you ever asked someone how their day was, or been chatting casually with a friend, only to have them tell you a horrific story that has left you feeling distressed or emotionally exhausted yourself?

This is called " trauma dumping ". It's when someone shares something traumatic or distressing without checking in first if the person they're talking to has the capacity or willingness to take on that information.

Trauma dumping is not new, and you've probably experienced it (or inadvertently done it yourself) at some stage in your life.

But now, with the rise of social media platforms such as TikTok, the risk of experiencing trauma dumping has increased exponentially.

People often turn to TikTok for support or validation. And because TikTok's algorithm is based on attention, it's not uncommon for highly emotional stories to gather traction and go viral.

My colleagues and I wanted to understand more about trauma dumping on TikTok. In a recent study, we found people often share their trauma on TikTok. And this is usually done without a trigger warning.

TikTok and mental health

It's estimated around 75% of the population have experienced a traumatic event at some point in their lives. This could include exposure to abuse or neglect in childhood, violence, natural disasters, the death of a loved one, or any other event which is unexpected, distressing, and causes long-term impacts on physical or mental health.

TikTok can be an important source of support and validation, especially for young people who have faced trauma, and who may not have sufficient support offline.

Previous research has shown TikTok provides a platform for talking about things like body image concerns, seeking support and information about gender and sexual diversity, and tackling stigma.

But while TikTok can be a great place for community, support and validation, at the same time it can be a hotbed for trauma dumping.

Importantly, sharing trauma on social media runs the risk of exposing other users to vicarious traumatisation, which is when a person is traumatised by someone else's trauma.

Vicarious trauma is most common in people who work in " frontline" jobs, such as paramedics or therapists, who deal with trauma regularly. However, anyone can be at risk. Factors including personal experiences, personality traits (such as empathy), support systems and coping strategies all play a role in whether someone might experience vicarious trauma.

In our study, we set out to explore the top videos on TikTok with one or more of five hashtags related to trauma: #traumatok, #trauma, #traumatized, #traumatic and #traumabond.

We looked the most viewed 50 videos from each hashtag. At the time we carried out our analysis in December 2022, these 250 videos had a total of 296.6 million likes, 2.3 million comments and 4.6 million shares.

#TraumaTok

We found the majority of videos (about 67%) were from people sharing their trauma. In many cases severe trauma was discussed, including child maltreatment, violence and death.

Our study also showed some videos (about 22%) were from people who claimed to be "experts" in trauma. They were using the platform to speak about the symptoms and treatment for trauma-related mental health conditions.

Worryingly, most "experts" (84%) did not disclose their credentials. And only a small proportion (2%) said they were licensed psychologists, counsellors or medical professionals (who are trained to provide evidence-based treatment or advice for mental health).

The remaining videos were either more general mental health content with a mix of hashtags such as "anxiety" and "depression", or were meant to be humorous, using memes or jokes about trauma.

One of the most concerning things we found in our study was that only 3.7% of videos had some form of trigger warning. A trigger warning, often a verbal statement by the creator, text within the video or a caption, is meant to alert the audience that potentially distressing content is discussed in the video.

One of the limitations of our study was that we didn't look at users' experiences of viewing these videos. We also didn't explore discourse on the app, such as comments and video replies.

We can't say for sure what it's like for people, especially young people or people with lived experience of trauma, to watch and interact with these videos. Exploring this should be a focus for future research.

Trigger warnings are important

None of this is to say that sharing stories, even traumatic ones, should never happen. In fact, we know support from others is essential for healing from trauma. This can be facilitated, among other avenues, through sharing stories on social media.

But to make this safer for everyone, TikTok should encourage trigger warnings, and creators should use them on videos where trauma is shared. This can give users the option to "opt out" and scroll on if they think they might not have the capacity to listen at that time.

For people consuming videos on TikTok and other platforms, it's important to be wary of misinformation and think critically about the information they see, seeking further advice from other sources.

If you feel distressed by content you see on social media, seek support from a health-care professional.
If this article has raised issues for you, or if you're concerned about someone you know, call Lifeline on 13 11 14.

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Trauma dumping: how sharing experiences on social media can cause distress for other users

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Do you 'trauma dump' on social media? Read this first.

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Not everyone who experiences severe trauma develops PTSD. But here's why many people do.

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Not everyone who experiences severe trauma develops PTSD. But here's why many people do.

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Not everyone who experiences severe trauma develops PTSD. But here’s why many people do.

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Here’s what PTSD is, what causes it and how it’s usually treated.

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BBC Audio | The Reith Lectures | Gwen Adshead - Four Questions about Violence | Does Trauma Cause Violence?

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Forensic psychiatrist Dr Gwen Adshead asks if trauma causes violence.

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Generational Trauma Might Explain Your Anxiety and Depression

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Generational trauma passes down through generations in families. Read on to learn how trauma passes between family members and how to seek treatment.

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Traumatic injury is a term which refers to physical injuries of sudden onset and severity which require immediate medical attention. The insult may cause…

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National Institute of Mental Health (NIMH)

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What is post-traumatic stress disorder, or PTSD?

It is natural to feel afraid during and after a traumatic situation. Fear is a part of the body's "fight-or-flight" response, which helps us avoid or respond to potential danger. People may experience a range of reactions after trauma, and most will recover from their symptoms over time. Those who continue to experience symptoms may be diagnosed with post-traumatic stress disorder (PTSD).

Who develops PTSD?

Anyone can develop PTSD at any age. This includes combat veterans and people who have experienced or witnessed a physical or sexual assault, abuse, an accident, a disaster, a terror attack, or other serious events. People who have PTSD may feel stressed or frightened, even when they are no longer in danger.

Not everyone with PTSD has been through a dangerous event. Sometimes, learning that a relative or close friend experienced trauma can cause PTSD.

About 6 of every 100 people will experience PTSD at some point in their lifetime, according to the National Center for PTSD, a U.S. Department of Veterans Affairs program. Women are more likely than men to develop PTSD. Certain aspects of the traumatic event and biological factors (such as genes) may make some people more likely to develop PTSD.

What are the symptoms of PTSD?

Symptoms of PTSD usually begin within 3 months of the traumatic event, but they sometimes emerge later. To meet the criteria for PTSD, a person must have symptoms for longer than 1 month, and the symptoms must be severe enough to interfere with aspects of daily life, such as relationships or work. The symptoms also must be unrelated to medication, substance use, or other illness.

The course of the disorder varies. Although some people recover within 6 months, others have symptoms that last for 1 year or longer. People with PTSD often have co-occurring conditions, such as depression, substance use, or one or more anxiety disorders.

After a dangerous event, it is natural to have some symptoms. For example, some people may feel detached from the experience, as though they are observing things as an outsider rather than experiencing them. A mental health professional-such as a psychiatrist, psychologist, or clinical social worker-can determine whether symptoms meet the criteria for PTSD.
To be diagnosed with PTSD, an adult must have all of the following for at least 1 month:

At least one re-experiencing symptom

At least one avoidance symptom

At least two arousal and reactivity symptoms

At least two cognition and mood symptoms

Re-experiencing symptoms

Flashbacks-reliving the traumatic event, including physical symptoms, such as a racing heart or sweating

Recurring memories or dreams related to the event

Distressing thoughts

Physical signs of stress

Thoughts and feelings can trigger these symptoms, as can words, objects, or situations that are reminders of the event.

Avoidance symptoms

Staying away from places, events, or objects that are reminders of the experience

Avoiding thoughts or feelings related to the traumatic event

Avoidance symptoms may cause people to change their routines. For example, some people may avoid driving or riding in a car after a serious car accident.

Arousal and reactivity symptoms

Being easily startled

Feeling tense, on guard, or on edge

Having difficulty concentrating

Having difficulty falling asleep or staying asleep

Feeling irritable and having angry or aggressive outbursts

Engaging in risky, reckless, or destructive behavior

Arousal symptoms are often constant. They can lead to feelings of stress and anger and may interfere with parts of daily life, such as sleeping, eating, or concentrating.

Cognition and mood symptoms

Trouble remembering key features of the traumatic event

Negative thoughts about oneself or the world

Exaggerated feelings of blame directed toward oneself or others

Ongoing negative emotions, such as fear, anger, guilt, or shame

Loss of interest in previous activities

Feelings of social isolation

Difficulty feeling positive emotions, such as happiness or satisfaction

Cognition and mood symptoms can begin or worsen after the traumatic event. They can lead people to feel detached from friends or family members.

How do children and teens react to trauma?

Children and teens can have extreme reactions to traumatic events, but their symptoms may not be the same as those seen in adults. In children younger than age 6, symptoms can include:

Wetting the bed after having learned to use the toilet

Forgetting how to talk or being unable to talk

Acting out the scary event during playtime

Being unusually clingy with a parent or other adult

Older children and teens usually show symptoms more like those seen in adults. They also may develop disruptive, disrespectful, or destructive behaviors. Older children and teens may feel guilt over not preventing injury or death, or have thoughts of revenge.

Find more information on helping children and adolescents cope with traumatic events.

Why do some people develop PTSD and other people do not?

Not everyone who lives through a dangerous event develops PTSD-many factors play a part. Some of these factors are present before the trauma; others play a role during and after a traumatic event.

Risk factors that may increase the likelihood of developing PTSD include:

Exposure to previous traumatic experiences, particularly during childhood

Getting hurt or seeing people hurt or killed

Feeling horror, helplessness, or extreme fear

Having little or no social support after the event

Dealing with stressors after the event, such as the loss of a loved one, pain and injury, or loss of a job or home

Having a personal history or family history of mental illness or substance use

Resilience factors that may reduce the likelihood of developing PTSD include:

Seeking out and receiving support from friends, family, or support groups

Learning to feel okay with one's actions in response to a traumatic event

Having a coping strategy for getting through and learning from a traumatic event

Being prepared and able to respond to upsetting events as they occur, despite feeling fear

How is PTSD treated?

It is important for people with PTSD symptoms to work with a mental health professional who has experience treating PTSD. The main treatments are psychotherapy, medications, or a combination of psychotherapy and medications. An experienced mental health professional can help people find the best treatment plan for their symptoms and needs.

Some people with PTSD, such as those in abusive relationships, may be living through ongoing trauma. In these cases, treatment is usually most effective when it addresses both the traumatic situation and the symptoms of PTSD. People who experience traumatic events or who have PTSD may also experience panic disorder, depression, substance use, or suicidal thoughts. Treatment for these conditions can help with recovery after trauma. Research shows that support from family and friends also can be an essential part of recovery.

Find tips to help prepare and guide you in talking to your health care provider about your mental health.

Psychotherapy

Psychotherapy, sometimes called talk therapy, includes a variety of treatment techniques that mental health professionals use to help people identify and change troubling emotions, thoughts, and behaviors. Psychotherapy can provide support, education, and guidance to people with PTSD and their families. Treatment can take place one on one or in a group setting and usually lasts 6 to 12 weeks but can last longer.

Some types of psychotherapy target PTSD symptoms, while others focus on social, family, or job-related problems. Effective psychotherapies often emphasize a few key components, including learning skills to help identify triggers and manage symptoms.

A common type of psychotherapy called cognitive behavioral therapy can include exposure therapy and cognitive restructuring.

Exposure therapy helps people learn to manage their fear by gradually exposing them, in a safe way, to the trauma they experienced. As part of exposure therapy, people may think or write about the trauma or visit the place where it happened. This therapy can help people with PTSD reduce symptoms that cause them distress.

Cognitive restructuring helps people make sense of the traumatic event. Sometimes people remember the event differently from how it happened, or they may feel guilt or shame about something that is not their fault. Cognitive restructuring can help people with PTSD think about what happened in a realistic way.

Learn more about psychotherapy.

Medications

The U.S. Food and Drug Administration (FDA) has approved two selective serotonin reuptake inhibitors (SSRIs), a type of antidepressant medication, for the treatment of PTSD. SSRIs may help people manage PTSD symptoms, such as sadness, worry, anger, and feeling emotionally numb. Health care providers may prescribe SSRIs and other medications along with psychotherapy. Some medications may help treat specific PTSD symptoms, such as sleep problems and nightmares.

People should work with their health care providers to find the best medication or combination of medications and the right dose. Read the latest medication warnings, patient medication guides, and information on newly approved medications on the FDA website .

How can I find help?

The Substance Abuse and Mental Health Services Administration has an online treatment locator at to help you find mental health services in your area. Learn more about getting help on the NIMH website.

What can I do to help myself?

You can get better with treatment. Here are some things you can do to help yourself:

Talk with your health care provider about treatment options and follow your treatment plan.

Engage in exercise, mindfulness, or other activities that help reduce stress.

Try to maintain routines for meals, exercise, and sleep.

Set realistic goals and focus on what you can manage.

Spend time with trusted friends or relatives and tell them about things that may trigger symptoms.

Expect your symptoms to improve gradually, not immediately.

Avoid the use of alcohol or drugs.

How can I help a loved one with PTSD?

If you know someone who may be experiencing PTSD, the most important thing you can do is to help that person get the right diagnosis and treatment. Some people may need help making an appointment with their health care provider; others may benefit from having someone accompany them to their health care visits.

If a close friend or relative is diagnosed with PTSD, you can encourage them to follow their treatment plan. If their symptoms do not improve after 6 to 8 weeks, you can encourage them to talk about it with their health care provider. You also can:

Offer emotional support, understanding, patience, and encouragement.

Learn about PTSD so you can understand what your friend is experiencing.

Listen carefully. Pay attention to the person's feelings and the situations that may trigger PTSD symptoms.

Share positive distractions, such as walks, outings, and other activities.

Where can I find more information on PTSD?

The National Center for PTSD, a program of the U.S. Department of Veterans Affairs, is the leading federal center for research and education on PTSD and traumatic stress. You can find information about PTSD, treatment options, getting help, and additional resources for families, friends, and providers on the center's website .

Are there clinical trials studying PTSD?

NIMH supports a wide range of research, including clinical trials that look at new ways to prevent, detect, or treat diseases and conditions-including PTSD. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct clinical trials with patients and healthy volunteers. Talk to a health care provider about clinical trials, their benefits and risks, and whether one is right for you. Learn more about  participating in clinical trials.

Reprints

The information in this publication is in the public domain and may be reused or copied without permission. However, you may not reuse or copy images. Please cite the National Institute of Mental Health as the source. Read our copyright policy to learn more about our guidelines for reusing NIMH content.

For more information

MedlinePlus (National Library of Medicine) ( en español )

ClinicalTrials.gov ( en español )

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 23-MH-8124
Revised 2023

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This brochure provides information about post-traumatic stress disorder (PTSD) including what it is, who develops PTSD, symptoms, treatment options, and how to find help for yourself or someone else who may have PTSD.

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Injuries result from road traffic crashes, falls, drowning, burns, poisoning and acts of violence against oneself or others, among other causes.

Of the 4.4 million injury-related deaths, unintentional injuries take the lives of 3.16 million people every year and violence-related injuries kill 1.25 million people every year. Roughly 1 in 3 of these deaths result from road traffic crashes, 1 in 6 from suicide, 1 in 10 from homicide and 1 in 61 from war and conflict.

For people age 5-29 years, 3 of the top 5 causes of death are injury-related, namely road traffic injuries, homicide and suicide. Drowning is the sixth leading cause of death for children age 5-14 years. Falls account for over 684,000 deaths each year and are a growing and under-recognized public health issue.

Tens of millions more people suffer non-fatal injuries each year which lead to emergency department and acute care visits, hospitalizations or treatment by general practitioners and often result in temporary or permanent disability and the need for long-term physical and mental health care and rehabilitation. For example, there has been a significant rise in road traffic injuries in the African region since 2000, with an almost 50% increase in healthy life-years lost.

Beyond death and injury, exposure to any form of trauma, particularly in childhood, can increase the risk of mental illness and suicide; smoking, alcohol and substance abuse; chronic diseases like heart disease, diabetes and cancer; and social problems such as poverty, crime and violence. For these reasons, preventing injuries and violence, including by breaking intergenerational cycles of violence, goes beyond avoiding the physical injury to contributing to substantial health, social and economic gains.

Injuries and violence are a significant cause of death and burden of disease in all countries; however, they are not evenly distributed across or within countries - some people are more vulnerable than others depending on the conditions in which they are born, grow, work, live and age. For instance, in general, being young, male and of low socioeconomic status all increase the risk of injury and of being a victim or perpetrator of serious physical violence. The risk of fall-related injuries increases with age.

Twice as many males than females are killed each year as a result of injuries and violence. Worldwide, about three quarters of deaths from road traffic injuries, four fifths of deaths from homicide, and two thirds of deaths from war are among men. In many low- and middle-income countries, however, women and girls are more likely to be burned than men and boys, in large part due to exposure to unsafe cooking arrangements and energy poverty. Across all ages, the three leading causes of death from injuries for males are road traffic injuries, homicide and suicide, while for females they are road traffic injuries, falls and suicide.

Poverty also increases the risk of injury and violence. About 90% of injury-related deaths occur in low- and middle-income countries. Across the world, injury death rates are higher in low-income countries than in high-income countries. Even within countries, people from poorer economic backgrounds have higher rates of fatal and non-fatal injuries than people from wealthier economic backgrounds. This holds true even in high-income countries.

The uneven distribution of injuries that makes them more prevalent among the less advantaged is related to several risk factors. These include living, working, travelling and going to school in more precarious conditions, less focus on prevention efforts in underprivileged communities, and poorer access to quality emergency trauma care and rehabilitation services. These issues are explained in more detail below.

Risk factors and determinants:

Risk factors and determinants common to all types of injuries include alcohol or substance use; inadequate adult supervision of children; and broad societal determinants of health such as poverty; economic and gender inequality; unemployment; a lack of safety in the built environment, including unsafe housing, schools, roads and workplaces; inadequate product safety standards and regulations; easy access to alcohol, drugs, firearms, knives and pesticides; weak social safety nets; frail criminal justice systems; and inadequate institutional policies to address injuries in a consistent and effective manner, in part due to the availability of sufficient resources. In settings where emergency trauma care services are weak or there is inequitable access to services, the consequences of injuries and violence can be exacerbated.

Injuries and violence are predictable and there is compelling scientific evidence for what works to prevent injuries and violence and to treat their consequences in various settings. This evidence has been collated into technical documents that can serve as a guide to support decisions for scaling up injury and violence prevention efforts - see:

Analysis of the costs and benefits for several selected injury and violence prevention measures shows that they offer significant value for money, making investment in such measures of great societal benefit. For example, with regard to child injury prevention, a study found that every US$ 1 invested in smoke detectors saves US$ 65, in child restraints and bicycle helmets saves US$ 29, and in-home visitation saves US$ 6 in medical costs, loss productivity and property loss. In Bangladesh, teaching school-age children swimming and rescue skills returned US$ 3000 per death averted. The social benefits of injuries prevented through home modification to prevent falls have been estimated to be at least six times the cost of intervention. It is estimated that in Europe and North America, a 10% reduction in adverse childhood experiences could equate to annual savings of 3 million Disability Adjusted Life Years or US$ 105 billion.

For all injuries and violence, providing quality emergency care for victims can prevent fatalities, reduce the amount of short-term and long-term disability, and help those affected to cope physically, emotionally, financially and legally with the impact of the injury or violence on their lives. As such, improving the organization, planning and access to trauma care systems, including telecommunications, transport to hospital, prehospital and hospital-based care, are important strategies to minimize fatalities and disabilities from injury and violence. Providing rehabilitation for people with disabilities, ensuring they have access to assistive products such as wheelchairs, and removing barriers to social and economic participation are key strategies to ensure that people who experience disability as the result of an injury or violence may continue a full and enjoyable life.

WHO supports efforts to address injuries and violence in many ways, including by:

developing and disseminating guidance for countries on evidence-based policy and practice including those listed above;

providing technical support to countries through programmes such as the Bloomberg Initiative for Global Road Safety and the Global Partnership to End Violence against Children;

documenting and disseminating successful injury prevention approaches, policies and programmes across countries;

monitoring progress towards achieving the Sustainable Development Goal targets linked to injury, violence prevention, mental health and substance use - namely targets 3.4, 3.5, 3.6, 5.2, 5.3, 16.1 and 16.2 - through global status reports on road safety and violence prevention, and on alcohol and health, and world reports on preventing suicide;

through informal networks chaired by WHO such as the UN Road Safety Collaboration and the Violence Prevention Alliance, and others towards which WHO contributes like the Global Partnership to End Violence against Children, coordinating global efforts across the UN system including decades of action, ministerial conferences and weeks and days dedicated to injury-related topics to improve road safety and end violence;

clarifying the role of Ministries of Health as part of multi-sectoral injury-prevention efforts, as reflected in Preventing injuries and violence: a guide for ministries of health, including its role in collecting data; developing national policies and plans; building capacities; facilitating prevention measures; providing services for victims, including emergency trauma care; promulgating legislation on key risks; and training journalists to improve reporting on these issues with a focus on solutions and by co-hosting biannual global meetings and regional meetings of Ministry of Health focal points for violence and injury prevention; and

co-hosting and serving on the International Organizing Committee for the series of biannual World Conferences on Injury Prevention and Safety Promotion, the 14th edition of which will take place in Adelaide, Australia, in 2022.

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Injuries result from road traffic crashes, falls, drowning, burns, poisoning and acts of violence against oneself or others, among other causes. Of the 4.4 million injury-related deaths, unintentional injuries take the lives of 3.16 million people every year and violence-related injuries kill 1.25 million people every year.

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Social, Cultural, and Other Diversity Issues in the Traumatic Stress Field

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Social, Cultural, and Other Diversity Issues in the Traumatic Stress Field

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Social, cultural, and other diversity issues in the traumatic stress field

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This chapter describes how the impact of psychological trauma and posttraumatic stress disorder (PTSD) differ, depending on individual differences and the social and cultural context and culture-specific teachings and resources available to…

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Social, cultural, and other diversity issues in the traumatic stress field

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Social, cultural, and other diversity issues in the traumatic stress field

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Social, cultural, and other diversity issues in the traumatic stress field

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This chapter describes how the impact of psychological trauma and posttraumatic stress disorder (PTSD) differ, depending on individual differences and the social and cultural context and culture-specific teachings and resources available to…

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Historical trauma | Research Starters | EBSCO Research

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Historical trauma is a psychological concept that explores how the traumatic experiences of a cultural group impact subsequent generations. It recognizes that events such as slavery, genocide, and forced relocation can leave lasting effects on the descendants of those who directly experienced these traumas. Initially developed in the context of American Indian communities, the concept has broader applicability to any group that has faced systemic oppression or violence. Historical trauma is categorized as transgenerational, meaning its effects can ripple down through generations, influencing the mental health and social behaviors of descendants even if they did not directly experience the original events.

The ongoing impact of historical trauma may manifest in various forms, including low self-esteem, substance abuse, and difficulties in forming trusting relationships. These issues are often compounded by cultural dislocation, such as the loss of ancestral languages and traditions. Social workers and mental health professionals recognize the significance of addressing historical trauma in therapeutic settings, emphasizing the need for culturally sensitive approaches. While some debate the appropriateness of the term "trauma" for historical events long past, the consensus remains that understanding these legacies is crucial for healing and fostering resilience in affected communities.

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Trauma-related cultural concepts of distress: A systematic review of qualitative literature from the middle east and North Africa, and Sub-Saharan Africa

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Trauma-related cultural concepts of distress: A systematic review of qualitative literature from the middle east and North Africa, and Sub-Saharan Africa

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Many individuals who seek treatment in behavioral health settings have histories of trauma, but they often don't recognize the significant effects of trauma in their lives; either they don't draw connections between their trauma histories and their presenting problems, or they avoid the topic altogether. Likewise, treatment providers may not ask questions that elicit a client's history of trauma, may feel unprepared to address trauma-related issues proactively, or may struggle to address traumatic stress effectively within the constraints of their treatment program, the program's clinical orientation, or their agency's directives.

By recognizing that traumatic experiences and their sequelae tie closely into behavioral health problems, front-line professionals and community-based programs can begin to build a trauma-informed environment across the continuum of care. Key steps include meeting client needs in a safe, collaborative, and compassionate manner; preventing treatment practices that retraumatize people with histories of trauma who are seeking help or receiving services; building on the strengths and resilience of clients in the context of their environments and communities; and endorsing trauma-informed principles in agencies through support, consultation, and supervision of staff.

This Treatment Improvement Protocol (TIP) begins by introducing the scope, purpose, and organization of the topic and describing its intended audience. Along with defining trauma and trauma-informed care (TIC), the first chapter discusses the rationale for addressing trauma in behavioral health services and reviews trauma-informed intervention and treatment principles. These principles serve as the TIP's conceptual framework.

Before You Begin

This TIP endorses a trauma-informed model of care; this model emphasizes the need for behavioral health practitioners and organizations to recognize the prevalence and pervasive impact of trauma on the lives of the people they serve and develop trauma-sensitive or trauma-responsive services. This TIP provides key information to help behavioral health practitioners and program administrators become trauma aware and informed, improve screening and assessment processes, and implement science-informed intervention strategies across settings and modalities in behavioral health services. Whether provided by an agency or an individual provider, trauma-informed services may or may not include trauma-specific services or trauma specialists (individuals who have advanced training and education to provide specific treatment interventions to address traumatic stress reactions). Nonetheless, TIC anticipates the role that trauma can play across the continuum of care-establishing integrated and/or collaborative processes to address the needs of traumatized individuals and communities proactively.

Individuals who have experienced trauma are at an elevated risk for substance use disorders, including abuse and dependence; mental health problems (e.g., depression and anxiety symptoms or disorders, impairment in relational/social and other major life areas, other distressing symptoms); and physical disorders and conditions, such as sleep disorders. This TIP focuses on specific types of prevention ( Institute of Medicine et al., 2009): selective prevention, which targets people who are at risk for developing social, psychological, or other conditions as a result of trauma or who are at greater risk for experiencing trauma due to behavioral health disorders or conditions; and indicated prevention, which targets people who display early signs of trauma-related symptoms. This TIP identifies interventions, including trauma-informed and trauma-specific strategies, and perceives treatment as a means of prevention-building on resilience, developing safety and skills to negotiate the impact of trauma, and addressing mental and substance use disorders to enhance recovery.

This TIP's target population is adults. Beyond the context of family, this publication does not examine or address youth and adolescent responses to trauma, youth-tailored trauma-informed strategies, or trauma-specific interventions for youth or adolescents, because the developmental and contextual issues of these populations require specialized interventions. Providers who work with young clients who have experienced trauma should refer to the resource list in Appendix B. This TIP covers TIC, trauma characteristics, the impact of traumatic experiences, assessment, and interventions for persons who have had traumatic experiences. Considering the vast knowledge base and specificity of individual, repeated, and chronic forms of trauma, this TIP does not provide a comprehensive overview of the unique characteristics of each type of trauma (e.g., sexual abuse, torture, war-related trauma, murder). Instead, this TIP provides an overview supported by examples. For more information on several specific types of trauma, please refer to TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues ( Center for Substance Abuse Treatment [CSAT], 2000b), TIP 25, Substance Abuse Treatment and Domestic Violence ( CSAT, 1997b), TIP 51, Substance Abuse Treatment: Addressing the Specific Needs of Women ( CSAT, 2009d), and the planned TIP, Reintegration-Related Behavioral Health Issues in Veterans and Military Families (Substance Abuse and Mental Health Services Administration [SAMHSA], planned f).

This TIP, Trauma-Informed Care in Behavioral Health Services, is guided by SAMHSA's Strategic Initiatives described in Leading Change: A Plan for SAMHSA's Roles and Actions 2011- 2014 ( SAMHSA, 2011b). Specific to Strategic Initiative #2, Trauma and Justice, this TIP addresses several goals, objectives, and actions outlined in this initiative by providing behavioral health practitioners, supervisors, and administrators with an introduction to culturally responsive TIC.

Specifically, the TIP presents fundamental concepts that behavioral health service providers can use to:

Become trauma aware and knowledgeable about the impact and consequences of traumatic experiences for individuals, families, and communities.

Evaluate and initiate use of appropriate trauma-related screening and assessment tools.

Implement interventions from a collaborative, strengths-based approach, appreciating the resilience of trauma survivors.

Learn the core principles and practices that reflect TIC.

Anticipate the need for specific trauma-informed treatment planning strategies that support the individual's recovery.

Decrease the inadvertent retraumatization that can occur from implementing standard organizational policies, procedures, and interventions with individuals, including clients and staff, who have experienced trauma or are exposed to secondary trauma.

Evaluate and build a trauma-informed organization and workforce.

The consensus panelists, as well as other contributors to this TIP, have all had experience as substance abuse and mental health counselors, prevention and peer specialists, supervisors, clinical directors, researchers, or administrators working with individuals, families, and communities who have experienced trauma. The material presented in this TIP uses the wealth of their experience in addition to the available published resources and research relevant to this topic. Throughout the consensus process, the panel members were mindful of the strengths and resilience inherent in individuals, families, and communities affected by trauma and the challenges providers face in addressing trauma and implementing TIC.

What Is Trauma?

According to SAMHSA's Trauma and Justice Strategic Initiative, "trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual's functioning and physical, social, emotional, or spiritual well-being" ( SAMHSA, 2012, p. 2). Trauma can affect people of every race, ethnicity, age, sexual orientation, gender, psychosocial background, and geographic region. A traumatic experience can be a single event, a series of events, and/or a chronic condition (e.g., childhood neglect, domestic violence). Traumas can affect individuals, families, groups, communities, specific cultures, and generations. It generally overwhelms an individual's or community's resources to cope, and it often ignites the "fight, flight, or freeze" reaction at the time of the event(s). It frequently produces a sense of fear, vulnerability, and helplessness.

See Appendix C to read about the history of trauma and trauma interventions.

Often, traumatic events are unexpected. Individuals may experience the traumatic event directly, witness an event, feel threatened, or hear about an event that affects someone they know. Events may be human-made, such as a mechanical error that causes a disaster, war, terrorism, sexual abuse, or violence, or they can be the products of nature (e.g., flooding, hurricanes, tornadoes). Trauma can occur at any age or developmental stage, and often, events that occur outside expected life stages are perceived as traumatic (e.g., a child dying before a parent, cancer as a teen, personal illness, job loss before retirement).

It is not just the event itself that determines whether something is traumatic, but also the individual's experience of the event. Two people may be exposed to the same event or series of events but experience and interpret these events in vastly different ways. Various biopsychosocial and cultural factors influence an individual's immediate response and long-term reactions to trauma. For most, regardless of the severity of the trauma, the immediate or enduring effects of trauma are met with resilience-the ability to rise above the circumstances or to meet the challenges with fortitude.

For some people, reactions to a traumatic event are temporary, whereas others have prolonged reactions that move from acute symptoms to more severe, prolonged, or enduring mental health consequences (e.g., posttraumatic stress and other anxiety disorders, substance use and mood disorders) and medical problems (e.g., arthritis, headaches, chronic pain). Others do not meet established criteria for posttraumatic stress or other mental disorders but encounter significant trauma-related symptoms or culturally expressed symptoms of trauma (e.g., somatization, in which psychological stress is expressed through physical concerns). For that reason, even if an individual does not meet diagnostic criteria for trauma-related disorders, it is important to recognize that trauma may still affect his or her life in significant ways. For more information on traumatic events, trauma characteristics, traumatic stress reactions, and factors that heighten or decrease the impact of trauma, see Part 1, Chapter 2, "Trauma Awareness," and Part 1, Chapter 3, "Understanding the Impact of Trauma."

Trauma Matters in Behavioral Health Services

The past decade has seen an increased focus on the ways in which trauma, psychological distress, quality of life, health, mental illness, and substance abuse are linked. With the attacks of September 11, 2001, and other acts of terror, the wars in Iraq and Afghanistan, disastrous hurricanes on the Gulf Coast, and sexual abuse scandals, trauma has moved to the forefront of national consciousness.

Trauma was once considered an abnormal experience. However, the first National Comorbidity Study established how prevalent traumas were in the lives of the general population of the United States. In the study, 61 percent of men and 51 percent of women reported experiencing at least one trauma in their lifetime, with witnessing a trauma, being involved in a natural disaster, and/or experiencing a life-threatening accident ranking as the most common events ( Kessler et al., 1999). In Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, 71.6 percent of the sample reported witnessing trauma, 30.7 percent experienced a trauma that resulted in injury, and 17.3 percent experienced psychological trauma ( El-Gabalawy, 2012). For a thorough review of the impact of trauma on quality of life and health and among individuals with mental and substance use disorders, refer to Part 3 of this TIP, the online literature review.

Rationale for TIC

Integrating TIC into behavioral health services provides many benefits not only for clients, but also for their families and communities, for behavioral health service organizations, and for staff. Trauma-informed services bring to the forefront the belief that trauma can pervasively affect an individual's well-being, including physical and mental health. For behavioral health service providers, trauma-informed practice offers many opportunities. It reinforces the importance of acquiring trauma-specific knowledge and skills to meet the specific needs of clients; of recognizing that individuals may be affected by trauma regardless of its acknowledgment; of understanding that trauma likely affects many clients who are seeking behavioral health services; and of acknowledging that organizations and providers can retraumatize clients through standard or unexamined policies and practices. TIC stresses the importance of addressing the client individually rather than applying general treatment approaches.

TIC provides clients more opportunities to engage in services that reflect a compassionate perspective of their presenting problems. TIC can potentially provide a greater sense of safety for clients who have histories of trauma and a platform for preventing more serious consequences of traumatic stress ( Fallot & Harris, 2001). Although many individuals may not identify the need to connect with their histories, trauma-informed services offer clients a chance to explore the impact of trauma, their strengths and creative adaptations in managing traumatic histories, their resilience, and the relationships among trauma, substance use, and psychological symptoms.

Two Influential Studies That Set the Stage for the Development of TIC

The Adverse Childhood Experiences Study ( Centers for Disease Control and Prevention, 2013) was a large epidemiological study involving more than 17,000 individuals from United States; it analyzed the long-term effects of childhood and adolescent traumatic experiences on adult health risks, mental health, healthcare costs, and life expectancy.

The Women, Co-Occurring Disorders and Violence Study ( SAMHSA, 2007) was a large multisite study focused on the role of interpersonal and other traumatic stressors among women; the interrelatedness of trauma, violence, and co-occurring substance use and mental disorders; and the incorporation of trauma-informed and trauma-specific principles, models, and services.

Implementing trauma-informed services can improve screening and assessment processes, treatment planning, and placement while also decreasing the risk for retraumatization. The implementation may enhance communication between the client and treatment provider, thus decreasing risks associated with misunderstanding the client's reactions and presenting problems or underestimating the need for appropriate referrals for evaluation or trauma-specific treatment. Organizational investment in developing or improving trauma-informed services may also translate to cost effectiveness, in that services are more appropriately matched to clients from the outset. TIC is an essential ingredient in organizational risk management; it ensures the implementation of decisions that will optimize therapeutic outcomes and minimize adverse effects on the client and, ultimately, the organization. A key principle is the engagement of community, clients, and staff. Clients and staff are more apt to be empowered, invested, and satisfied if they are involved in the ongoing development and delivery of trauma-informed services.

An organization also benefits from work development practices through planning for, attracting, and retaining a diverse workforce of individuals who are knowledgeable about trauma and its impact. Developing a trauma-informed organization involves hiring and promotional practices that attract and retain individuals who are educated and trained in trauma-informed practices on all levels of the organization, including board as well as peer support appointments. Trauma-informed organizations are invested in their staff and adopt similar trauma-informed principles, including establishing and providing ongoing support to promote TIC in practice and in addressing secondary trauma and implementing processes that reinforce the safety of the staff. Even though investing in a trauma-informed workforce does not necessarily guarantee trauma-informed practices, it is more likely that services will evolve more proficiently to meet client, staff, and community needs.

Advice to Counselors: The Importance of TIC

The history of trauma raises various clinical issues. Many counselors do not have extensive training in treating trauma or offering trauma-informed services and may be uncertain of how to respond to clients' trauma-related reactions or symptoms. Some counselors have experienced traumas themselves that may be triggered by clients' reports of trauma. Others are interested in helping clients with trauma but may unwittingly cause harm by moving too deeply or quickly into trauma material or by discounting or disregarding a client's report of trauma. Counselors must be aware of trauma-related symptoms and disorders and how they affect clients in behavioral health treatment.

Counselors with primary treatment responsibilities should also have an understanding of how to recognize trauma-related reactions, how to incorporate treatment interventions for trauma-related symptoms into clients' treatment plans, how to help clients build a safety net to prevent further trauma, how to conduct psychoeducational interventions, and when to make treatment referrals for further evaluations or trauma-specific treatment services. All treatment staff should recognize that traumatic stress symptoms or trauma-related disorders should not preclude an individual from mental health or substance abuse treatment and that all co-occurring disorders need to be addressed on some level in the treatment plan and setting. For example, helping a client in substance abuse treatment gain control over trauma-related symptoms can greatly improve the client's chances of substance abuse recovery and lower the possibility of relapse ( Farley, Golding, Young, Mulligan, & Minkoff, 2004; Ouimette, Ahrens, Moos, & Finney, 1998). In addition, assisting a client in achieving abstinence builds a platform upon which recovery from traumatic stress can proceed.

Trauma and Substance Use Disorders

Many people who have substance use disorders have experienced trauma as children or adults ( Koenen, Stellman, Sommer, & Stellman, 2008; Ompad et al., 2005). Substance abuse is known to predispose people to higher rates of traumas, such as dangerous situations and accidents, while under the influence ( Stewart & Conrod, 2003; Zinzow, Resnick, Amstadter, McCauley, Ruggiero, & Kilpatrick, 2010) and as a result of the lifestyle associated with substance abuse ( Reynolds et al., 2005). In addition, people who abuse substances and have experienced trauma have worse treatment outcomes than those without histories of trauma ( Driessen et al., 2008; Najavits et al., 2007). Thus, the process of recovery is more difficult, and the counselor's role is more challenging, when clients have histories of trauma. A person presenting with both trauma and substance abuse issues can have a variety of other difficult life problems that commonly accompany these disorders, such as other psychological symptoms or mental disorders, poverty, homelessness, increased risk of HIV and other infections, and lack of social support ( Mills, Teesson, Ross, & Peters, 2006; Najavits, Weiss, & Shaw, 1997). Many individuals who seek treatment for substance use disorders have histories of one or more traumas. More than half of women seeking substance abuse treatment report one or more lifetime traumas ( Farley, Golding, Young, Mulligan, & Minkoff, 2004; Najavits et al., 1997), and a significant number of clients in inpatient treatment also have subclinical traumatic stress symptoms or posttraumatic stress disorder (PTSD; Falck, Wang, Siegal, & Carlson, 2004; Grant et al., 2004; Reynolds et al., 2005).

Trauma and Mental Disorders

People who are receiving treatment for severe mental disorders are more likely to have histories of trauma, including childhood physical and sexual abuse, serious accidents, homelessness, involuntary psychiatric hospitalizations, drug overdoses, interpersonal violence, and other forms of violence. Many clients with severe mental disorders meet criteria for PTSD; others with serious mental illness who have histories of trauma present with psychological symptoms or mental disorders that are commonly associated with a history of trauma, including anxiety symptoms and disorders, mood disorders (e.g., major depression, dysthymia, bipolar disorder; Mueser et al., 2004), impulse control disorders, and substance use disorders ( Kessler, Chiu, Demler, & Walters, 2005).

Traumatic stress increases the risk for mental illness, and findings suggest that traumatic stress increases the symptom severity of mental illness ( Spitzer, Vogel, Barnow, Freyberger & Grabe, 2007). These findings propose that traumatic stress plays a significant role in perpetuating and exacerbating mental illness and suggest that trauma often precedes the development of mental disorders. As with trauma and substance use disorders, there is a bidirectional relationship; mental illness increases the risk of experiencing trauma, and trauma increases the risk of developing psychological symptoms and mental disorders. For a more comprehensive review of the interactions among traumatic stress, mental illness, and substance use disorders, refer to Part 3 of this TIP, the online literature review.

Trauma-Informed Intervention and Treatment Principles

TIC is an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health services from prevention through treatment. There are many definitions of TIC and various models for incorporating it across organizations, but a "trauma-informed approach incorporates three key elements: (1) realizing the prevalence of trauma; (2) recognizing how trauma affects all individuals involved with the program, organization, or system, including its own workforce; and (3) responding by putting this knowledge into practice"( SAMHSA, 2012, p. 4).

TIC begins with the first contact a person has with an agency; it requires all staff members (e.g., receptionists, intake personnel, direct care staff, supervisors, administrators, peer supports, board members) to recognize that the individual's experience of trauma can greatly influence his or her receptivity to and engagement with services, interactions with staff and clients, and responsiveness to program guidelines, practices, and interventions. TIC includes program policies, procedures, and practices to protect the vulnerabilities of those who have experienced trauma and those who provide trauma-related services. TIC is created through a supportive environment and by redesigning organizational practices, with consumer participation, to prevent practices that could be retraumatizing ( Harris & Fallot, 2001c; Hopper et al., 2010). The ethical principle, "first, do no harm," resonates strongly in the application of TIC.

"A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for healing; recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings."

( SAMHSA, 2012, p. 4)

TIC involves a commitment to building competence among staff and establishing programmatic standards and clinical guidelines that support the delivery of trauma-sensitive services. It encompasses recruiting, hiring, and retaining competent staff; involving consumers, trauma survivors, and peer support specialists in the planning, implementation, and evaluation of trauma-informed services; developing collaborations across service systems to streamline referral processes, thereby securing trauma-specific services when appropriate; and building a continuity of TIC as consumers move from one system or service to the next. TIC involves reevaluating each service delivery component through a trauma-aware lens.

The principles described in the following subsections serve as the TIP's conceptual framework. These principles comprise a compilation of resources, including research, theoretical papers, commentaries, and lessons learned from treatment facilities. Key elements are outlined for each principle in providing services to clients affected by trauma and to populations most likely to incur trauma. Although these principles are useful across all prevention and intervention services, settings, and populations, they are of the utmost importance in working with people who have had traumatic experiences.

Advice to Counselors: Implementing Trauma-Informed Services

Recognizing that trauma affects a majority of clients served within public health systems, the National Center for Trauma-Informed Care (NCTIC) has sought to establish a comprehensive framework to guide systems of care in the development of trauma-informed services. If a system or program is to support the needs of trauma survivors, it must take a systematic approach that offers trauma-specific diagnostic and treatment services, as well as a trauma-informed environment that is able to sustain such services, while fostering positive outcomes for the clients it serves. NCTIC also offers technical assistance in the implementation of trauma-informed services. For specific administrative information on TIC implementation, refer to Part 2, Chapters 1 and 2, of this TIP.

Promote Trauma Awareness and Understanding

Foremost, a behavioral health service provider must recognize the prevalence of trauma and its possible role in an individual's emotional, behavioral, cognitive, spiritual, and/or physical development, presentation, and well-being. Being vigilant about the prevalence and potential consequences of traumatic events among clients allows counselors to tailor their presentation styles, theoretical approaches, and intervention strategies from the outset to plan for and be responsive to clients' specific needs. Although not every client has a history of trauma, those who have substance use and mental disorders are more likely to have experienced trauma. Being trauma aware does not mean that you must assume everyone has a history of trauma, but rather that you anticipate the possibility from your initial contact and interactions, intake processes, and screening and assessment procedures.

Even the most standard behavioral health practices can retraumatize an individual exposed to prior traumatic experiences if the provider implements them without recognizing or considering that they may do harm. For example, a counselor might develop a treatment plan recommending that a female client-who has been court mandated to substance abuse treatment and was raped as an adult-attend group therapy, but without considering the implications, for her, of the fact that the only available group at the facility is all male and has had a low historical rate of female participation. Trauma awareness is an essential strategy for preventing this type of retraumatization; it reinforces the need for providers to reevaluate their usual practices.

Becoming trauma aware does not stop with the recognition that trauma can affect clients; instead, it encompasses a broader awareness that traumatic experiences as well as the impact of an individual's trauma can extend to significant others, family members, first responders and other medical professionals, behavioral health workers, broader social networks, and even entire communities. Family members frequently experience the traumatic stress reactions of the individual family member who was traumatized (e.g., angry outbursts, nightmares, avoidant behavior, other symptoms of anxiety, overreactions or under reactions to stressful events). These repetitive experiences can increase the risk of secondary trauma and symptoms of mental illness among the family, heighten the risk for externalizing and internalizing behavior among children (e.g., bullying others, problems in social relationships, health-damaging behaviors), increase children's risk for developing posttraumatic stress later in life, and lead to a greater propensity for traumatic stress reactions across generations of the family. Hence, prevention and intervention services can provide education and age-appropriate programming tailored to develop coping skills and support systems.

So too, behavioral health service providers can be influenced by exposure to trauma-related affect and content when working with clients. A trauma-aware workplace supports supervision and program practices that educate all direct service staff members on secondary trauma, encourages the processing of trauma-related content through participation in peer-supported activities and clinical supervision, and provides them with professional development opportunities to learn about and engage in effective coping strategies that help prevent secondary trauma or trauma-related symptoms. It is important to generate trauma awareness in agencies through education across services and among all staff members who have any direct or indirect contact with clients (including receptionists or intake and admission personnel who engage clients for the first time within the agency). Agencies can maintain a trauma-aware environment through ongoing staff training, continued supervisory and administrative support, collaborative (i.e., involving consumer participation) trauma-responsive program design and implementation, and organizational policies and practices that reflect accommodation and flexibility in attending to the needs of clients affected by trauma.

Recognize That Trauma-Related Symptoms and Behaviors Originate From Adapting to Traumatic Experiences

A trauma-informed perspective views trauma-related symptoms and behaviors as an individual's best and most resilient attempt to manage, cope with, and rise above his or her experience of trauma. Some individuals' means of adapting and coping have produced little difficulty; the coping and adaptive strategies of others have worked in the past but are not working as well now. Some people have difficulties in one area of life but have effectively negotiated and functioned in other areas.

Individuals who have survived trauma vary widely in how they experience and express traumatic stress reactions. Traumatic stress reactions vary in severity; they are often measured by the level of impairment or distress that clients report and are determined by the multiple factors that characterize the trauma itself, individual history and characteristics, developmental factors, sociocultural attributes, and available resources. The characteristics of the trauma and the subsequent traumatic stress reactions can dramatically influence how individuals respond to the environment, relationships, interventions, and treatment services, and those same characteristics can also shape the assumptions that clients/consumers make about their world (e.g., their view of others, sense of safety), their future (e.g., hopefulness, fear of a foreshortened future), and themselves (e.g., feeling resilient, feeling incompetent in regulating emotions). The breadth of these effects may be observable or subtle.

Once you become aware of the significance of traumatic experiences in clients' lives and begin to view their presentation as adaptive, your identification and classification of their presenting symptoms and behaviors can shift from a "pathology" mindset (i.e., defining clients strictly from a diagnostic label, implying that something is wrong with them) to one of resilience-a mindset that views clients' presenting difficulties, behaviors, and emotions as responses to surviving trauma. In essence, you will come to view traumatic stress reactions as normal reactions to abnormal situations. In embracing the belief that trauma-related reactions are adaptive, you can begin relationships with clients from a hopeful, strengths-based stance that builds upon the belief that their responses to traumatic experiences reflect creativity, self-preservation, and determination.

This will help build mutual and collaborative therapeutic relationships, help clients identify what has worked and has not worked in their attempts to deal with the aftermath of trauma from a nonjudgmental stance, and develop intervention and coping strategies that are more likely to fit their strengths and resources. This view of trauma prevents further retraumatization by not defining traumatic stress reactions as pathological or as symptoms of pathology.

View Trauma in the Context of Individuals' Environments

Many factors contribute to a person's response to trauma, whether it is an individual, group, or community-based trauma. Individual attributes, developmental factors (including protective and risk factors), life history, type of trauma, specific characteristics of the trauma, amount and length of trauma exposure, cultural meaning of traumatic events, number of losses associated with the trauma, available resources (internal and external, such as coping skills and family support), and community reactions are a few of the determinants that influence a person's responses to trauma across time. Refer to the " View Trauma Through a Sociocultural Lens " section later in this chapter for more specific information highlighting the importance of culture in understanding and treating the effects of trauma.

Trauma cannot be viewed narrowly; instead, it needs to be seen through a broader lens-a contextual lens integrating biopsychosocial, interpersonal, community, and societal (the degree of individualistic or collective cultural values) characteristics that are evident preceding and during the trauma, in the immediate and sustained response to the event(s), and in the short- and long-term effects of the traumatic event(s), which may include housing availability, community response, adherence to or maintenance of family routines and structure, and level of family support.

To more adequately understand trauma, you must also consider the contexts in which it occurred. Understanding trauma from this angle helps expand the focus beyond individual characteristics and effects to a broader systemic perspective that acknowledges the influences of social interactions, communities, governments, cultures, and so forth, while also examining the possible interactions among those various influences. Bronfenbrenner's (1979) and Bronfenbrenner and Ceci's (1994) work on ecological models sparked the development of other contextual models. In recent years, the social-ecological framework has been adopted in understanding trauma, in implementing health promotion and other prevention strategies, and in developing treatment interventions ( Centers for Disease Control and Prevention, 2009). Here are the three main beliefs of a social-ecological approach ( Stokols, 1996):

Environmental factors greatly influence emotional, physical, and social well-being.

A fundamental determinant of health versus illness is the degree of fit between individuals' biological, behavioral, and sociocultural needs and the resources available to them.

Prevention, intervention, and treatment approaches integrate a combination of strategies targeting individual, interpersonal, and community systems.

This TIP uses a social-ecological model to explore trauma and its effects ( Exhibit 1.1-2). The focus of this model is not only on negative attributes (risk factors) across each level, but also on positive ingredients (protective factors) that protect against or lessen the impact of trauma. This model also guides the inclusion of certain targeted interventions in this text, including selective and indicated prevention activities. In addition, culture, developmental processes (including the developmental stage or characteristics of the individual and/or community), and the specific era when the trauma(s) occurred can significantly influence how a trauma is perceived and processed, how an individual or community engages in help-seeking, and the degree of accessibility, acceptability, and availability of individual and community resources.

Depending on the developmental stage and/or processes in play, children, adolescents, and adults will perceive, interpret, and cope with traumatic experiences differently. For example, a child may view a news story depicting a traumatic event on television and believe that the trauma is recurring every time they see the scene replayed. Similarly, the era in which one lives and the timing of the trauma can greatly influence an individual or community response. Take, for example, a pregnant woman who is abusing drugs and is wary of receiving medical treatment after being beaten in a domestic dispute. She may fear losing her children or being arrested for child neglect. Even though a number of States have adopted policies focused on the importance of treatment for pregnant women who are abusing drugs and of the accessibility of prenatal care, other States have approached this issue from a criminality standpoint (e.g., with child welfare and criminal laws) in the past few decades. Thus, the traumatic event's timing is a significant component in understanding the context of trauma and trauma-related responses.

The social-ecological model depicted in Exhibit 1.1-2 provides a systemic framework for looking at individuals, families, and communities affected by trauma in general; it highlights the bidirectional influence that multiple contexts can have on the provision of behavioral health services to people who have experienced trauma (see thin arrow). Each ring represents a different system (refer to Exhibit 1.1-3 for examples of specific factors within each system). The innermost ring represents the individual and his or her biopsychosocial characteristics. The "Interpersonal" circle embodies all immediate relationships including family, friends, peers, and others. The "Community/Organizational" band represents social support networks, workplaces, neighborhoods, and institutions that directly influence the individual and his/her relationships. The "Societal" circle signifies the largest system-State and Federal policies and laws, such as economic and healthcare policies, social norms, governmental systems, and political ideologies. The outermost ring, "Period of Time in History," reflects the significance of the period of time during which the event occurred; it influences each other level represented in the circle. For example, making a comparison of society's attitudes and responses to veterans' homecomings across different wars and conflicts through time shows that homecoming environments can have either a protective or a negative effect on healing from the psychological and physical wounds of war, depending on the era in question. The thicker arrows in the figure represent the key influences of culture, developmental characteristics, and the type and characteristics of the trauma. All told, the context of traumatic events can significantly influence both initial and sustained responses to trauma; treatment needs; selection of prevention, intervention, and other treatment strategies; and ways of providing hope and promoting recovery.

Case Illustration: Marisol

Marisol is a 28-year-old Latina woman working as a barista at a local coffee shop. One evening, she was driving home in the rain when a drunk driver crossed into her lane and hit her head on. Marisol remained conscious as she waited to be freed from the car and was then transported to the hospital. She sustained fractures to both legs. Her recovery involved two surgeries and nearly 6 months of rehabilitation, including initial hospitalization and outpatient physical therapy.

She described her friends and family as very supportive, saying that they often foresaw what she needed before she had to ask. She added that she had an incredible sense of gratitude for her employer and coworkers, who had taken turns visiting and driving her to appointments. Although she was able to return to work after 9 months, Marisol continued experiencing considerable distress about her inability to sleep well, which started just after the accident. Marisol describes repetitive dreams and memories of waiting to be transported to the hospital after the crash. The other driver was charged with driving under the influence (DUI), and it was reported that he had been convicted two other times for a DUI misdemeanor.

Answering the following questions will help you see how the different levels of influence affect the impact and outcome of the traumatic event Marisol experienced, as well as her responses to that event:

1. Based on the limited information provided in this illustration, how might Marisol's personality affect the responses of her family and friends, her coworkers, and the larger community?

2. In what ways could Marisol's ethnic and cultural background influence her recovery?

3. What societal factors could play a role in the car crash itself and the outcomes for Marisol and the other driver?

Explore the influence of the period of time in history during which the scenario occurs-compare the possible outcomes for both Marisol and the other driver if the crash occurred 40 years ago versus in the present day.

Minimize the Risk of Retraumatization or Replicating Prior Trauma Dynamics

Trauma-informed treatment providers acknowledge that clients who have histories of trauma may be more likely to experience particular treatment procedures and practices as negative, reminiscent of specific characteristics of past trauma or abuse, or retraumatizing-feeling as if the past trauma is reoccurring or as if the treatment experience is as dangerous and unsafe as past traumas. For instance, clients may express feelings of powerlessness or being trapped if they are not actively involved in treatment decisions; if treatment processes or providers mirror specific behavior from the clients' past experiences with trauma, they may voice distress or respond in the same way as they did to the original trauma. Among the potentially retraumatizing elements of treatment are seclusion or "time-out" practices that isolate individuals, mislabeling client symptoms as personality or other mental disorders rather than as traumatic stress reactions, interactions that command authority, treatment assignments that could humiliate clients (such as asking a client to wear a sign in group that reflects one of their treatment issues, even if the assignment centers on positive attributes of the client), confronting clients as resistant, or presenting treatment as conditional upon conformity to the provider's beliefs and definitions of issues.

Clients' experiences are unique to the specific traumas they have faced and the surrounding circumstances before, during, and after that trauma, so remember that even seemingly safe and standard treatment policies and procedures, including physical plant operations (e.g., maintenance, grounds, fire and safety procedures), may feel quite the contrary for a client if one or more of those elements is reminiscent of his or her experience of trauma in some way. Examples include having limited privacy or personal space, being interviewed in a room that feels too isolating or confining, undergoing physical examination by a medical professional of the same sex as the client's previous perpetrator of abuse, attending a group session in which another client expresses anger appropriately in a role play, or being directed not to talk about distressing experiences as a means of deescalating traumatic stress reactions.

Although some treatment policies or procedures are more obviously likely to solicit distress than others, all standard practices should be evaluated for their potential to retraumatize a client; this cannot be done without knowing the specific features of the individual's history of trauma. Consider, for instance, a treatment program that serves meals including entrees that combine more than one food group. Your client enters this program and refuses to eat most of the time; he expresses anger toward dietary staff and claims that food choices are limited. You may initially perceive your client's refusal to eat or to avoid certain foods as an eating disorder or a behavioral problem. However, a trauma-aware perspective might change your assumptions; consider that this client experienced neglect and abuse surrounding food throughout childhood (his mother forced him to eat meals prepared by combining anything in the refrigerator and cooking them together).

Advice to Counselors and Administrators: Sending the Right Message About Trauma

How often have you heard "We aren't equipped to handle trauma" or "We don't have time to deal with reactions that surface if traumatic experiences are discussed in treatment" from counselors and administrators in behavioral health services? For agencies, staff members, and clients, these statements present many difficulties and unwanted outcomes. For a client, such comments may replicate his or her earlier encounters with others (including family, friends, and previous behavioral health professionals) who had difficulty acknowledging or talking about traumatic experiences with him or her. A hands-off approach to trauma can also reinforce the client's own desire to avoid such discussions. Even when agencies and staff are motivated in these sentiments by a good intention-to contain clients' feelings of being overwhelmed-such a perspective sends strong messages to clients that their experiences are not important, that they are not capable of handling their trauma-associated feelings, and that dealing with traumatic experiences is simply too dangerous. Statements like these imply that recovery is not possible and provide no structured outlet to address memories of trauma or traumatic stress reactions.

Nevertheless, determining how and when to address traumatic stress in behavioral health services can be a real dilemma, especially if there are no trauma-specific philosophical, programmatic, or procedural processes in place. For example, it is difficult to provide an appropriate forum for a client to address past traumas if no forethought has been given to developing interagency and intra-agency collaborations for trauma-specific services. By anticipating the need for trauma-informed services and planning ahead to provide appropriate services to people who are affected by trauma, behavioral health service providers and program administrators can begin to develop informed intervention strategies that send a powerful, positive message:

Both clients and providers can competently manage traumatic experiences and reactions.

Providers are interested in hearing clients' stories and attending to their experiences.

As a treatment provider, you cannot consistently predict what may or may not be upsetting or retraumatizing to clients. Therefore, it is important to maintain vigilance and an attitude of curiosity with clients, inquiring about the concerns that they express and/or present in treatment. Remember that certain behaviors or emotional expressions can reflect what has happened to them in the past.

Foremost, a trauma-informed approach begins with taking practical steps to reexamine treatment strategies, program procedures, and organizational polices that could solicit distress or mirror common characteristics of traumatic experiences (loss of control, being trapped, or feeling disempowered). To better anticipate the interplay between various treatment elements and the more idiosyncratic aspects of a particular client's trauma history, you can:

Work with the client to learn the cues he or she associates with past trauma.

Maintain a supportive, empathetic, and collaborative relationship.

Encourage ongoing dialog.

Provide a clear message of availability and accessibility throughout treatment.

In sum, trauma-informed providers anticipate and respond to potential practices that may be perceived or experienced as retraumatizing to clients; they are able to forge new ways to respond to specific situations that trigger a trauma-related response, and they can provide clients with alternative ways of engaging in a particularly problematic element of treatment.

Create a Safe Environment

The need to create a safe environment is not new to providers; it involves an agency-wide effort supported by effective policies and procedures. However, creating safety within a trauma-informed framework far exceeds the standard expectations of physical plant safety (e.g., facility, environmental, and space-related concerns), security (of staff members, clients, and personal property), policies and procedures (including those specific to seclusion and restraint), emergency management and disaster planning, and adherence to client rights. Providers must be responsive and adapt the environment to establish and support clients' sense of physical and emotional safety.

Beyond anticipating that various environmental stimuli within a program may generate strong emotions and reactions in a trauma survivor (e.g., triggers such as lighting, access to exits, seating arrangements, emotionality within a group, or visual or auditory stimuli) and implementing strategies to help clients cope with triggers that evoke their experiences with trauma, other key elements in establishing a safe environment include consistency in client interactions and treatment processes, following through with what has been reviewed or agreed upon in sessions or meetings, and dependability. Mike's case illustration depicts ways in which the absence of these key elements could erode a client's sense of safety during the treatment process.

Neither providers nor service processes are always perfect. Sometimes, providers unintentionally relay information inaccurately or inconsistently to clients or other staff members; other times, clients mishear something, or extenuating circumstances prevent providers from responding as promised. Creating safety is not about getting it right all the time; it's about how consistently and forthrightly you handle situations with a client when circumstances provoke feelings of being vulnerable or unsafe. Honest and compassionate communication that conveys a sense of handling the situation together generates safety. It is equally important that safety extends beyond the client. Counselors and other behavioral health staff members, including peer support specialists, need to be able to count on the agency to be responsive to and maintain their safety within the environment as well. By incorporating an organizational ethos that recognizes the importance of practices that promote physical safety and emotional well-being, behavioral health staff members may be more likely to seek support and supervision when needed and to comply with clinical and programmatic practices that minimize risks for themselves and their clients.

Case Illustration: Mike

From the first time you provide outpatient counseling to Mike, you explain that he can call an agency number that will put him in direct contact with someone who can provide further assistance or support if he has emotional difficulty after the session or after agency hours. However, when he attempts to call one night, no one is available despite what you've described. Instead, Mike is directed by an operator to either use his local emergency room if he perceives his situation to be a crisis or to wait for someone on call to contact him. The inconsistency between what you told him in the session and what actually happens when he calls makes Mike feel unsafe and vulnerable.

Beyond an attitudinal promotion of safety, organizational leaders need to consider and create avenues of professional development and assistance that will give their staff the means to seek support and process distressing circumstances or events that occur within the agency or among their clientele, such as case consultation and supervision, formal or informal processes to debrief service providers about difficult clinical issues, and referral processes for client psychological evaluations and employee assistance for staff. Organizational practices are only effective if supported by unswerving trauma awareness, training, and education among staff. Jane's case illustration shows the impact of a minor but necessary postponement in staff orientation for a new hire-not an unusual circumstance in behavioral health programs that have heavy caseloads and high staff turnover.

Identify Recovery From Trauma as a Primary Goal

Often, people who initiate or are receiving mental health or substance abuse services don't identify their experiences with trauma as a significant factor in their current challenges or problems. In part, this is because people who have been exposed to trauma, whether once or repeatedly, are generally reluctant to revisit it. They may already feel stuck in repetitive memories or experiences, which may add to their existing belief that any intervention will make matters worse or, at least, no better. For some clients, any introduction to their trauma-related memories or minor cues reminiscent of the trauma will cause them to experience strong, quick-to-surface emotions, supporting their belief that addressing trauma is dangerous and that they won't be able to handle the emotions or thoughts that result from attempting to do so. Others readily view their experiences of trauma as being in the past; as a result, they engage in distraction, dissociation, and/or avoidance (as well as adaptation) due to a belief that trauma has little impact on their current lives and presenting problems. Even individuals who are quite aware of the impact that trauma has had on their lives may still struggle to translate or connect how these events continue to shape their choices, behaviors, and emotions. Many survivors draw no connection between trauma and their mental health or substance abuse problems, which makes it more difficult for them to see the value of trauma-informed or trauma-specific interventions, such as creating safety, engaging in psychoeducation, enhancing coping skills, and so forth.

Case Illustration: Jane

Jane, a newly hired female counselor, had a nephew who took his own life. The program that hired her was short of workers at the time; therefore, Jane did not have an opportunity to engage sufficiently in orientation outside of reviewing the policies and procedure manual. In an attempt to present well to her new employer and supervisor, she readily accepted client assignments without considering her recent loss. By not immersing herself in the program's perspective and policies on staff well-being, ethical and clinical considerations in client assignments, and how and when to seek supervision, Jane failed to engage in the practices, heavily supported by the agency, that promoted safety for herself and her clients. Subsequently, she felt emotionally overwhelmed at work and would often abruptly request psychiatric evaluation for clients who expressed any feelings of hopelessness out of sheer panic that they would attempt suicide.

As a trauma-informed provider, it is important that you help clients bridge the gap between their mental health and substance-related issues and the traumatic experiences they may have had. All too often, trauma occurs before substance use and mental disorders develop; then, such disorders and their associated symptoms and consequences create opportunities for additional traumatic events to occur. If individuals engage in mental health and substance abuse treatment without addressing the role that trauma has played in their lives, they are less likely to experience recovery in the long run. For example, a person with a history of trauma is more likely to have anxiety and depressive symptoms, use substances to self-medicate, and/or relapse after exposure to trauma-related cues. Thus, collaboration within and between behavioral health agencies is necessary to make integrated, timely, trauma-specific interventions available from the beginning to clients/consumers who engage in substance abuse and mental health services.

Support Control, Choice, and Autonomy

Not every client who has experienced trauma and is engaged in behavioral health services wants, or sees the need for, trauma-informed or trauma-specific treatment. Clients may think that they've already dealt with their trauma adequately, or they may believe that the effects of past trauma cause minimal distress for them. Other clients may voice the same sentiments, but without conviction-instead using avoidant behavior to deter distressing symptoms or reactions. Still others may struggle to see the role of trauma in their presenting challenges, not connecting their past traumatic experiences with other, more current difficulties (e.g., using substances to self-medicate strong emotions). Simply the idea of acknowledging trauma-related experiences and/or stress reactions may be too frightening or overwhelming for some clients, and others may fear that their reactions will be dismissed. On the other hand, some individuals want so much to dispense with their traumatic experiences and reactions that they hurriedly and repeatedly disclose their experiences before establishing a sufficiently safe environment or learning effective coping strategies to offset distress and other effects of retraumatization.

As these examples show, not everyone affected by trauma will approach trauma-informed services or recognize the impact of trauma in their lives in the same manner. This can be challenging to behavioral health service providers who are knowledgeable about the impact of trauma and who perceive the importance of addressing trauma and its effects with clients. As with knowing that different clients may be at different levels of awareness or stages of change in substance abuse treatment services, you should acknowledge that people affected by trauma present an array of reactions, various levels of trauma awareness, and different degrees of urgency in their need to address trauma.

Appreciating clients' perception of their presenting problems and viewing their responses to the impact of trauma as adaptive-even when you believe their methods of dealing with trauma to be detrimental-are equally important elements of TIC. By taking the time to engage with clients and understand the ways they have perceived, adjusted to, and responded to traumatic experiences, providers are more likely to project the message that clients possess valuable personal expertise and knowledge about their own presenting problems. This shifts the viewpoint from "Providers know best" to the more collaborative "Together, we can find solutions."

How often have you heard from clients that they don't believe they can handle symptoms that emerge from reexperiencing traumatic cues or memories? Have you ever heard clients state that they can't trust themselves or their reactions, or that they never know when they are going to be triggered or how they are going to react? How confident would you feel about yourself if, at any time, a loud noise could initiate an immediate attempt to hide, duck, or dive behind something? Traumatic experiences have traditionally been described as exposure to events that cause intense fear, helplessness, horror, or feelings of loss of control. Participation in behavioral health services should not mirror these aspects of traumatic experience. Working collaboratively to facilitate clients' sense of control and to maximize clients' autonomy and choices throughout the treatment process, including treatment planning, is crucial in trauma-informed services.

For some individuals, gaining a sense of control and empowerment, along with understanding traumatic stress reactions, may be pivotal ingredients for recovery. By creating opportunities for empowerment, counselors and other behavioral health service providers help reinforce, clients' sense of competence, which is often eroded by trauma and prolonged traumatic stress reactions. Keep in mind that treatment strategies and procedures that prioritize client choice and control need not focus solely on major life decisions or treatment planning; you can apply such approaches to common tasks and everyday interactions between staff and consumers. Try asking your clients some of the following questions (which are only a sample of the types of questions that could be useful):

What information would be helpful for us to know about what happened to you?

Where/when would you like us to call you?

How would you like to be addressed?

Of the services I've described, which seem to match your present concerns and needs?

From your experience, what responses from others appear to work best when you feel overwhelmed by your emotions?

Likewise, organizations need to reinforce the importance of staff autonomy, choice, and sense of control. What resources can staff members access, and what choices are available to them, in processing emotionally charged content or events in treatment? How often do administrators and supervisors seek out feedback on how to handle problematic situations (e.g., staff rotations for vacations, case consultations, changes in scheduling)? Think about the parallel between administration and staff members versus staff members and clients; often, the same philosophy, attitudes, and behaviors conveyed to staff members by administrative practices are mirrored in staff-client interactions. Simply stated, if staff members do not feel empowered, it will be a challenge for them to value the need for client empowerment. (For more information on administrative and workforce development issues, refer to Part 2, Chapters 1 and 2.)

Case Illustration: Mina

Mina initially sought counseling after her husband was admitted to an intensive outpatient drug and alcohol program. She was self-referred for low-grade depression, resentment toward her spouse, and codependency. When asked to define "codependency" and how the term applied to her, she responded that she always felt guilty and responsible for everyone in her family and for events that occurred even when she had little or no control over them.

After the intake and screening process, she expressed interest in attending group sessions that focused primarily on family issues and substance abuse, wherein her presenting concerns could be explored. In addition to describing dynamics and issues relating to substance abuse and its impact on her marriage, she referred to her low mood as frozen grief. During treatment, she reluctantly began to talk about an event that she described as life changing: the loss of her father. The story began to unfold in group; her father, who had been 62 years old, was driving her to visit a cousin. During the ride, he had a heart attack and drove off the road. As the car came to stop in a field, she remembered calling 911 and beginning cardiopulmonary resuscitation while waiting for the ambulance. She rode with the paramedics to the hospital, watching them work to save her father's life; however, he was pronounced dead soon after arrival.

She always felt that she never really said goodbye to her father. In group, she was asked what she would need to do or say to feel as if she had revisited that opportunity. She responded in quite a unique way, saying, "I can't really answer this question; the lighting isn't right for me to talk about my dad." The counselor encouraged her to adjust the lighting so that it felt "right" to her. Being invited to do so turned out to be pivotal in her ability to address her loss and to say goodbye to her father on her terms. She spent nearly 10 minutes moving the dimmer switch for the lighting as others in the group patiently waited for her to return to her chair. She then began to talk about what happened during the evening of her father's death, their relationship, the events leading up to that evening, what she had wanted to say to him at the hospital, and the things that she had been wanting to share with him since his death.

Weeks later, as the group was coming to a close, each member spoke about the most important experiences, tools, and insights that he or she had taken from participating. Mina disclosed that the group helped her establish boundaries and coping strategies within her marriage, but said that the event that made the most difference for her had been having the ability to adjust the lighting in the room. She explained that this had allowed her to control something over which she had been powerless during her father's death. To her, the lighting had seemed to stand out more than other details at the scene of the accident, during the ambulance ride, and at the hospital. She felt that the personal experience of losing her father and needing to be with him in the emergency room was marred by the obtrusiveness of staff, procedures, machines, and especially, the harsh lighting. She reflected that she now saw the lighting as a representation of this tragic event and the lack of privacy she had experienced when trying to say goodbye to her father. Mina stated that this moment in group had been the greatest gift: "...to be able to say my goodbyes the way I wanted... I was given an opportunity to have some control over a tragic event where I couldn't control the outcome no matter how hard I tried."

Create Collaborative Relationships and Participation Opportunities

This trauma-informed principle encompasses three main tenets. First, ensure that the provider-client relationship is collaborative, regardless of setting or service. Agency staff members cannot make decisions pertaining to interventions or involvement in community services autocratically; instead, they should develop trauma-informed, individualized care plans and/or treatment plans collaboratively with the client and, when appropriate, with family and caregivers. The nonauthoritarian approach that characterizes TIC views clients as the experts in their own lives and current struggles, thereby emphasizing that clients and providers can learn from each other.

The second tenet is to build collaboration beyond the provider-client relationship. Building ongoing relationships across the service system, provider networks, and the local community enhances TIC continuity as clients move from one level of service to the next or when they are involved in multiple services at one time. It also allows you to learn about resources available to your clients in the service system or community and to connect with providers who have more advanced training in trauma-specific interventions and services.

The third tenet emphasizes the need to ensure client/consumer representation and participation in behavioral health program development, planning, and evaluation as well as in the professional development of behavioral health workers. To achieve trauma-informed competence in an organization or across systems, clients need to play an active role; this starts with providing program feedback. However, consumer involvement should not end there; rather, it should be encouraged throughout the implementation of trauma-informed services. So too, clients, potential clients, their families, and the community should be invited to participate in forming any behavioral health organization's plans to improve trauma-informed competence, provide TIC, and design relevant treatment services and organizational policies and procedures.

Trauma-informed principles and practices generated without the input of people affected by trauma are difficult to apply effectively. Likewise, staff trainings and presentations should include individuals who have felt the impact of trauma. Their participation reaches past the purely cognitive aspects of such education to offer a personal perspective on the strengths and resilience of people who have experienced trauma. The involvement of trauma survivors in behavioral health education lends a human face to subject matter that is all too easily made cerebral by some staff members in an attempt to avoid the emotionality of the topic.

Consumer participation also means giving clients/consumers the chance to obtain State training and certification, as well as employment in behavioral health settings as peer specialists. Programs that incorporate peer support services reinforce a powerful message-that provider-consumer partnership is important, and that consumers are valued. Peer support specialists are self-identified individuals who have progressed in their own recovery from alcohol dependence, drug addiction, and/or a mental disorder and work within behavioral health programs or at peer support centers to assist others with similar disorders and/or life experiences. Tasks and responsibilities may include leading a peer support group; modeling effective coping, help-seeking, and self-care strategies; helping clients practice new skills or monitor progress; promoting positive self-image to combat clients' potentially negative feelings about themselves and the discrimination they may perceive in the program or community; handling case management tasks; advocating for program changes; and representing a voice of hope that views recovery as possible.

Familiarize the Client With Trauma-Informed Services

Without thinking too much about it, you probably know the purpose of an intake process, the correct way to complete a screening device, the meaning of a lot of the jargon specific to behavioral health, and your program's expectations for client participation; in fact, maybe you're already involved in facilitating these processes in behavioral health services every day, and they've become almost automatic for you. This can make it easy to forget that nearly everything clients and their families encounter in seeking behavioral health assistance is new to them. Thus, introducing clients to program services, activities, and interventions in a manner that expects them to be unfamiliar with these processes is essential, regardless of their clinical and treatment history. Beyond addressing the unfamiliarity of services, educating clients about each process-from first contact all the way through recovery services-gives them a chance to participate actively and make informed decisions across the continuum of care.

Familiarizing clients with trauma-informed services extends beyond explaining program services or treatment processes; it involves explaining the value and type of trauma-related questions that may be asked during an intake process, educating clients about trauma to help normalize traumatic stress reactions, and discussing trauma-specific interventions and other available services (including explanations of treatment methodologies and of the rationale behind specific interventions). Developmentally appropriate psychoeducation about trauma-informed services allows clients to be informed participants.

Incorporate Universal Routine Screenings for Trauma

Screening universally for client histories, experiences, and symptoms of trauma at intake can benefit clients and providers. Most providers know that clients can be affected by trauma, but universal screening provides a steady reminder to be watchful for past traumatic experiences and their potential influence upon a client's interactions and engagement with services across the continuum of care. Screening should guide treatment planning; it alerts the staff to potential issues and serves as a valuable tool to increase clients' awareness of the possible impact of trauma and the importance of addressing related issues during treatment.

Nonetheless, screenings are only as useful as the guidelines and processes established to address positive screens (which occur when clients respond to screening questions in a way that signifies possible trauma-related symptoms or histories). Staff should be trained to use screening tools consistently so that all clients are screened in the same way. Staff members also need to know how to score screenings and when specific variables (e.g., race/ethnicity, native language, gender, culture) may influence screening results. For example, a woman who has been sexually assaulted by a man may be wary of responding to questions if a male staff member or interpreter administers the screening or provides translation services. Likewise, a person in a current abusive or violent relationship may not acknowledge the interpersonal violence in fear of retaliation or as a result of disconnection or denial of his or her experience, and he or she may have difficulty in processing and then living between two worlds-what is acknowledged in treatment versus what is experienced at home.

In addition, staff training on using trauma-related screening tools needs to center on how and when to gather relevant information after the screening is complete. Organizational policies and procedures should guide staff members on how to respond to a positive screening, such as by making a referral for an indepth assessment of traumatic stress, providing the client with an introductory psychoeducational session on the typical biopsychosocial effects of trauma, and/or coordinating care so that the client gains access to trauma-specific services that meet his or her needs. Screening tool selection is an important ingredient in incorporating routine, universal screening practices into behavioral health services. Many screening tools are available, yet they differ in format and in how they present questions. Select tools based not just on sound test properties, but also according to whether they encompass a broad range of experiences typically considered traumatic and are flexible enough to allow for an individual's own interpretation of traumatic events. For more information on screening and assessment of trauma and trauma-related symptoms and effects, see Chapter 4, "Screening and Assessment," in this TIP.

View Trauma Through a Sociocultural Lens

To understand how trauma affects an individual, family, or community, you must first understand life experiences and cultural background as key contextual elements for that trauma. As demonstrated in Exhibit 1.1-2, many factors shape traumatic experiences and individual and community responses to it; one of the most significant factors is culture. It influences the interpretation and meaning of traumatic events, individual beliefs regarding personal responsibility for the trauma and subsequent responses, and the meaning and acceptability of symptoms, support, and help-seeking behaviors. As this TIP proceeds to describe the differences among cultures pertaining to trauma, remember that there are numerous cross-cutting factors that can directly or indirectly influence the attitudes, beliefs, behaviors, resources, and opportunities within a given culture, subculture, or racial and/or ethnic group ( Exhibit 1.1-4). For an indepth exploration of these cross-cutting cultural factors, refer to the planned TIP, Improving Cultural Competence (SAMHSA, planned c).

Culture and Trauma

Some populations and cultures are more likely than others to experience a traumatic event or a specific type of trauma.

Rates of traumatic stress are high across all diverse populations and cultures that face military action and political violence.

Culture influences not only whether certain events are perceived as traumatic, but also how an individual interprets and assigns meaning to the trauma.

Some traumas may have greater impact on a given culture because those traumas represent something significant for that culture or disrupt cultural practices or ways of life.

Culture determines acceptable responses to trauma and shapes the expression of distress. It significantly influences how people convey traumatic stress through behavior, emotions, and thinking immediately following a trauma and well after the traumatic experience has ceased.

Traumatic stress symptoms vary according to the type of trauma within the culture.

Culture affects what qualifies as a legitimate health concern and which symptoms warrant help.

In addition to shaping beliefs about acceptable forms of help-seeking behavior and healing practices, culture can provide a source of strength, unique coping strategies, and specific resources.

When establishing TIC, it is vital that behavioral health systems, service providers, licensing agencies, and accrediting bodies build culturally responsive practices into their curricula, standards, policies and procedures, and credentialing processes. The implementation of culturally responsive practices will further guide the treatment planning process so that trauma-informed services are more appropriate and likely to succeed.

Use a Strengths-Focused Perspective: Promote Resilience

Fostering individual strengths is a key step in prevention when working with people who have been exposed to trauma. It is also an essential intervention strategy-one that builds on the individual's existing resources and views him or her as a resourceful, resilient survivor. Individuals who have experienced trauma develop many strategies and/or behaviors to adapt to its emotional, cognitive, spiritual, and physical consequences. Some behaviors may be effective across time, whereas others may eventually produce difficulties and disrupt the healing process. Traditionally, behavioral health services have tended to focus on presenting problems, risk factors, and symptoms in an attempt to prevent negative outcomes, provide relief, increase clients' level of functioning, and facilitate healing. However, focusing too much on these areas can undermine clients' sense of competence and hope. Targeting only presenting problems and symptoms does not provide individuals with an opportunity to see their own resourcefulness in managing very stressful and difficult experiences. It is important for providers to engage in interventions using a balanced approach that targets the strengths clients have developed to survive their experiences and to thrive in recovery. A strengths-based, resilience-minded approach lets trauma survivors begin to acknowledge and appreciate their fortitude and the behaviors that help them survive.

"Trauma-informed care recognizes symptoms as originating from adaptations to the traumatic event(s) or context. Validating resilience is important even when past coping behaviors are now causing problems. Understanding a symptom as an adaptation reduces a survivor's guilt and shame, increases their self-esteem and provides a guideline for developing new skills and resources to allow new and better adaptation to the current situation."

( Elliot et al., 2005, p. 467)

Advice to Counselors and Administrators: Using Strengths-Oriented Questions

Knowing a client's strengths can help you understand, redefine, and reframe the client's presenting problems and challenges. By focusing and building on an individual's strengths, counselors and other behavioral health professionals can shift the focus from "What is wrong with you?" to "What has worked for you?" It moves attention away from trauma-related problems and toward a perspective that honors and uses adaptive behaviors and strengths to move clients along in recovery.

Potential strengths-oriented questions include:

The history that you provided suggests that you've accomplished a great deal since the trauma. What are some of the accomplishments that give you the most pride?

What would you say are your strengths?

How do you manage your stress today?

What behaviors have helped you survive your traumatic experiences (during and afterward)?

What are some of the creative ways that you deal with painful feelings?

You have survived trauma. What characteristics have helped you manage these experiences and the challenges that they have created in your life?

If we were to ask someone in your life, who knew your history and experience with trauma, to name two positive characteristics that help you survive, what would they be?

What coping tools have you learned from your _____ (fill in: cultural history, spiritual practices, athletic pursuits, etc.)?

Imagine for a moment that a group of people are standing behind you showing you support in some way. Who would be standing there? It doesn't matter how briefly or when they showed up in your life, or whether or not they are currently in your life or alive.

How do you gain support today? (Possible answers include family, friends, activities, coaches, counselors, other supports, etc.)

What does recovery look like for you?

Foster Trauma-Resistant Skills

Trauma-informed services build a foundation on which individuals can begin to explore the role of trauma in their lives; such services can also help determine how best to address and tailor interventions to meet their needs. Prevention, mental health, and substance abuse treatment services should include teaching clients about how trauma can affect their lives; these services should also focus on developing self-care skills, coping strategies, supportive networks, and a sense of competence. Building trauma-resistant skills begins with normalizing the symptoms of traumatic stress and helping clients who have experienced trauma connect the dots between current problems and past trauma when appropriate.

Nevertheless, TIC and trauma-specific interventions that focus on skill-building should not do so at the expense of acknowledging individual strengths, creativity in adapting to trauma, and inherent attributes and tools clients possesses to combat the effects of trauma. Some theoretical models that use skill-building strategies base the value of this approach on a deficit perspective; they assume that some individuals lack the necessary tools to manage specific situations and, because of this deficiency, they encounter problems that others with effective skills would not experience. This type of perspective further assumes that, to recover, these individuals must learn new coping skills and behavior. TIC, on the other hand, makes the assumption that clients are the experts in their own lives and have learned to adapt and acquire skills to survive. The TIC approach honors each individual's adaptations and acquired skills, and it helps clients explore how these may not be working as well as they had in the past and how their current repertoire of responses may not be as effective as other strategies.

Advice to Administrators: Self-Assessment for Trauma-Informed Systems

NCTIC has developed a self-assessment package for trauma-informed systems to help administrators structurally incorporate trauma into programs and services. The self-assessment can be used by systems of care to guide quality improvement with the goal of establishing fully trauma-informed treatment and recovery efforts (NCTIC, Center for Mental Health Services, 2007). Behavioral health treatment program administrators can use these materials and NCTIC as resources for improvement in delivering TIC.

Demonstrate Organizational and Administrative Commitment to TIC

Becoming a trauma-informed organization requires administrative guidance and support across all levels of an agency. Behavioral health staff will not likely sustain TIC practices without the organization's ongoing commitment to support professional development and to allocate resources that promote these practices. An agency that wishes to commit to TIC will benefit from an organizational assessment of how staff members identify and manage trauma and trauma-related reactions in their clients. Are they trauma aware-do they recognize that trauma can significantly affect a client's ability to function in one or more areas of his or her life? Do the staff members understand that traumatic experiences and trauma-related reactions can greatly influence clients' engagement, participation, and response to services?

Agencies need to embrace specific strategies across each level of the organization to create trauma-informed services; this begins with staff education on the impact of trauma among clients. Other agency strategies that reflect a trauma-informed infrastructure include, but are not limited to:

Universal screening and assessment procedures for trauma.

Interagency and intra-agency collaboration to secure trauma-specific services.

Referral agreements and networks to match clients' needs.

Mission and value statements endorsing the importance of trauma recognition.

Consumer- and community-supported committees and trauma response teams.

Workforce development strategies, including hiring practices.

Professional development plans, including staff training/supervision focused on TIC.

Program policies and procedures that ensure trauma recognition and secure trauma-informed practices, trauma-specific services, and prevention of retraumatization.

TIC requires organizational commitment, and often, cultural change. For more information on implementing TIC in organizations, see Part 2, Chapter 1 of this TIP.

Develop Strategies To Address Secondary Trauma and Promote Self-Care

Secondary trauma is a normal occupational hazard for mental health and substance abuse professionals, particularly those who serve populations that are likely to include survivors of trauma ( Figley, 1995; Klinic Community Health Centre, 2008). Behavioral health staff members who experience secondary trauma present a range of traumatic stress reactions and effects from providing services focused on trauma or listening to clients recount traumatic experiences. So too, when a counselor has a history of personal trauma, working with trauma survivors may evoke memories of the counselor's own trauma history, which may increase the potential for secondary traumatization.

The range of reactions that manifest with secondary trauma can be, but are not necessarily, similar to the reactions presented by clients who have experienced primary trauma. Symptoms of secondary trauma can produce varying levels of difficulty, impairment, or distress in daily functioning; these may or may not meet diagnostic thresholds for acute stress, posttraumatic stress, or adjustment, anxiety, or mood disorders ( Bober & Regehr, 2006). Symptoms may include physical or psychological reactions to traumatic memories clients have shared; avoidance behaviors during client interactions or when recalling emotional content in supervision; numbness, limited emotional expression, or diminished affect; somatic complaints; heightened arousal, including insomnia; negative thinking or depressed mood; and detachment from family, friends, and other supports ( Maschi & Brown, 2010).

Working daily with individuals who have been traumatized can be a burden for counselors and other behavioral health service providers, but all too often, they blame the symptoms resulting from that burden on other stressors at work or at home. Only in the past 2 decades have literature and trainings begun paying attention to secondary trauma or compassion fatigue; even so, agencies often do not translate this knowledge into routine prevention practices. Counselors and other staff members may find it difficult to engage in activities that could ward off secondary trauma due to time constraints, workload, lack of agency resources, and/or an organizational culture that disapproves of help-seeking or provides inadequate staff support. The demands of providing care to trauma survivors cannot be ignored, lest the provider become increasingly impaired and less effective. Counselors with unacknowledged secondary trauma can cause harm to clients via poorly enforced boundaries, missed appointments, or even abandonment of clients and their needs ( Pearlman & Saakvitne, 1995).

Essential components of TIC include organizational and personal strategies to address secondary trauma and its physical, cognitive, emotional, and spiritual consequences. In agencies and among individual providers, it is key for the culture to promote acceptability, accessibility, and accountability in seeking help, accessing support and supervision, and engaging in self-care behaviors in and outside of the agency or office. Agencies should involve staff members who work with trauma in developing informal and formal agency practices and procedures to prevent or address secondary trauma. Even though a number of community-based agencies face fiscal constraints, prevention strategies for secondary trauma can be intertwined with the current infrastructure (e.g., staff meetings, education, case consultations and group case discussions, group support, debriefing sessions as appropriate, supervision). For more information on strategies to address and prevent secondary trauma, see Part 2, Chapter 2 of this TIP.

The Impact of Trauma

Trauma is similar to a rock hitting the water's surface. The impact first creates the largest wave, which is followed by ever-expanding, but less intense, ripples. Likewise, the influence of a given trauma can be broad, but generally, its effects are less intense for individuals further removed from the trauma; eventually, its impact dissipates all around. For trauma survivors, the impact of trauma can be far-reaching and can affect life areas and relationships long after the trauma occurred. This analogy can also broadly describe the recovery process for individuals who have experienced trauma and for those who have the privilege of hearing their stories. As survivors reveal their trauma-related experiences and struggles to a counselor or another caregiver, the trauma becomes a shared experience, although it is not likely to be as intense for the caregiver as it was for the individual who experienced the trauma. The caregiver may hold onto the trauma's known and unknown effects or may consciously decide to engage in behaviors that provide support to further dissipate the impact of this trauma and the risk of secondary trauma.

Advice to Counselors: Decreasing the Risk of Secondary Trauma and Promoting Self-Care

Peer support. Maintaining adequate social support will help prevent isolation and depression.

Supervision and consultation. Seeking professional support will enable you to understand your own responses to clients and to work with them more effectively.

Training. Ongoing professional training can improve your belief in your abilities to assist clients in their recoveries.

Personal therapy. Obtaining treatment can help you manage specific problems and become better able to provide good treatment to your clients.

Maintaining balance. A healthy, balanced lifestyle can make you more resilient in managing any difficult circumstances you may face.

Setting clear limits and boundaries with clients. Clearly separating your personal and work life allows time to rejuvenate from stresses inherent in being a professional caregiver.

Provide Hope-Recovery Is Possible

What defines recovery from trauma-related symptoms and traumatic stress disorders? Is it the total absence of symptoms or consequences? Does it mean that clients stop having nightmares or being reminded, by cues, of past trauma? When clients who have experienced trauma enter into a helping relationship to address trauma specifically, they are often looking for a cure, a remission of symptoms, or relief from the pain as quickly as possible. However, they often possess a history of unpredictable symptoms and symptom intensity that reinforces an underlying belief that recovery is not possible. On one hand, clients are looking for a message that they can be cured, while on the other hand, they have serious doubts about the likely success of any intervention.

Clients often express ambivalence about dealing with trauma even if they are fully aware of trauma's effects on their lives. The idea of living with more discomfort as they address the past or as they experiment with alternative ways of dealing with trauma-related symptoms or consequences is not an appealing prospect, and it typically elicits fear. Clients may interpret the uncomfortable feelings as dangerous or unsafe even in an environment and relationship that is safe and supportive.

How do you promote hope and relay a message that recovery is possible? First, maintain consistency in delivering services, promoting and providing safety for clients, and showing respect and compassion within the client-provider relationship. Along with clients' commitment to learning how to create safety for themselves, counselors and agencies need to be aware of, and circumvent, practices that could retraumatize clients. Projecting hope and reinforcing the belief that recovery is possible extends well beyond the practice of establishing safety; it also encompasses discussing what recovery means and how it looks to clients, as well as identifying how they will know that they've entered into recovery in earnest.

Providing hope involves projecting an attitude that recovery is possible. This attitude also involves viewing clients as competent to make changes that will allow them to deal with trauma-related challenges, providing opportunities for them to practice dealing with difficult situations, and normalizing discomfort or difficult emotions and framing these as manageable rather than dangerous. If you convey this attitude consistently to your clients, they will begin to understand that discomfort is not a signal to avoid, but a sign to engage-and that behavioral, cognitive, and emotional responses to cues associated with previous traumas are a normal part of the recovery process. It's not the absence of responses to such triggers that mark recovery, but rather, how clients experience and manage those responses. Clients can also benefit from interacting with others who are further along in their recovery from trauma. Time spent with peer support staff or sharing stories with other trauma survivors who are well on their way to recovery is invaluable-it sends a powerful message that recovery is achievable, that there is no shame in being a trauma survivor, and that there is a future beyond the trauma.

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Many individuals who seek treatment in behavioral health settings have histories of trauma, but they often don't recognize the significant effects of trauma in their lives; either they don't draw connections between their trauma histories and their presenting problems, or they avoid the topic altogether.

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PTSD and Trauma: New APA Guidelines Highlight Evidence-Based Treatments

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PTSD and Trauma: New APA Guidelines Highlight Evidence-Based Treatments

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PTSD and trauma: New APA guidelines highlight evidence-based treatments

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Frameworks help clinicians broaden their practice and personalize treatment .

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Mind–body intervention for post-traumatic stress disorder in adolescents: a systematic review and network meta-analysis

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Mind–body intervention for post-traumatic stress disorder in adolescents: a systematic review and network meta-analysis

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Mind–body intervention for post-traumatic stress disorder in adolescents: a systematic review and network meta-analysis - BMC Psychiatry

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Background Post-traumatic stress disorder (PTSD) is a potentially disabling condition that can lead to long-term impairments, with a significant proportion of adolescents being affected by trauma. Studies have suggested that trauma-focused cognitive behavioral therapy (TF-CBT) is an effective treatment for PTSD in adolescents, however, little is known about the relative advantages of different mind–body interventions. The network meta-analysis aims to evaluate and compare the efficacy of various mind–body interventions in alleviating PTSD symptoms in adolescents. Methods A systematic search was conducted across multiple databases including PubMed, Embase, Web of Science, Scopus, The Cochrane Library, CNKI, WFDSP, and VIP databases. Randomized controlled trials (RCTs) evaluating the effects of mind–body interventions on PTSD in adolescents were included. A network meta-analysis (NMA) was conducted to evaluate the effectiveness of various mind–body intervention therapies using the Surface Under the Cumulative Ranking curve (SUCRA). SUCRA calculates the mean of the cumulative percent area under the curve for each therapy, providing a comprehensive ranking of treatment efficacy. The primary outcomes measured were changes in PTSD symptom scores post-treatment and at follow-ups ranging from 1 to 12 months. Results A total of 20 studies involving 5 interventions and 2085 adolescents were included in the analysis. No inconsistencies were found between direct and indirect evidence. TF-CBT consistently demonstrated the most significant effect in reducing PTSD symptoms compared to routine care and no-treatment groups. The ranking of intervention efficacy from highest to lowest was as follows: TF-CBT (SUCRA = 87.3%), meditation, CBT, yoga combined with meditation and mindfulness (SUCRA = 32.3%). Due to limited evidence, the follow-up results for PTSD symptom changes remained inconclusive. Conclusion Five mind–body interventions were found to be effective in treating PTSD symptoms in adolescents, with TF-CBT emerging as the most effective treatment. Findings suggest that yoga combined with meditation and mindfulness may have promising effects, however, further research is needed to confirm these results due to the limited evidence available.

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The effectiveness of a remote intensive trauma-focused treatment programme for PTSD

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The effectiveness of a remote intensive trauma-focused treatment programme for PTSD

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The effectiveness of a remote intensive trauma-focused treatment programme for PTSD

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Background: Limited research has addressed the efficacy of remote intensive trauma-focused treatment programmes.Objective: This study aims to assess the effectiveness of a remote intensive treatmen…

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Efficacy of an internet-based guided trauma-focused intervention in reducing ICD-11 posttraumatic stress disorder symptoms: study protocol of a randomized controlled trial

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Efficacy of an internet-based guided trauma-focused intervention in reducing ICD-11 posttraumatic stress disorder symptoms: study protocol of a randomized controlled trial

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Efficacy of an internet-based guided trauma-focused intervention in reducing ICD-11 posttraumatic stress disorder symptoms: study protocol of a randomized controlled trial - BMC Psychiatry

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Background Posttraumatic stress disorder (PTSD) is a common mental disorder. However, many cases of PTSD remain untreated because of limited healthcare resources and other treatment-seeking barriers. Effective internet-based interventions could help to improve access to PTSD treatments. Therefore, the main objective of the planned randomized controlled trial is to evaluate the efficacy of the Lithuanian version of the guided internet-based self-help programme (Spring) in reducing ICD-11 PTSD symptoms. Methods The planned sample size is 50 participants exposed to different traumatic experiences. Participants eligible for the study will be randomized into two study groups: the immediate treatment group and the delayed treatment control group. Both groups will receive guided trauma-focused ICBT intervention, but the delayed treatment group will receive access to the programme five months after randomization. The International Trauma Interview (ITI) will be used for the assessment of ICD-11 PTSD symptoms at pre-treatment, post-treatment, and at a 3-month follow-up. Changes in disturbances in self-organization, depression and anxiety levels, as well as posttraumatic cognitions and trauma-related shame, will also be evaluated. In addition, associations between changes in symptoms of PTSD and readiness for treatment, treatment expectations and working alliance will be explored. Changes in treatment outcomes will be evaluated using multiple Latent Change Models. Discussion This study is expected to contribute to valuable knowledge on the efficacy of internet-based interventions for posttraumatic stress disorder. Trial registration ClinicalTrials.gov NCT06475716. Registered on 25 June 2024.

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Diagnostic profiles and trauma history among treatment-seeking young adults with positive post-traumatic stress disorder screens: Findings and implications for public mental health care

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Diagnostic profiles and trauma history among treatment-seeking young adults with positive post-traumatic stress disorder screens: Findings and implications for public mental health care

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Trauma Explained: How It Impacts Mind, Body, and Society

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Trauma Explained: How It Impacts Mind, Body, and Society

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Trauma Explained: How It Impacts Mind, Body, and Society

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Psychological abuse is a complex and prevalent issue that can go unnoticed unless clinicians learn to recognize the signs and use appropriate interventions to support clients.

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A cultural framework for generational trauma

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A cultural framework for generational trauma

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A cultural framework for generational trauma

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With the right clinical framework, counselors can help clients identify and process the complex experiences of intergenerational trauma.

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Treatment strategies for race-based traumatic stress

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Treatment strategies for race-based traumatic stress

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Treatment strategies for race-based traumatic stress

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Treating stress that stems from racial discrimination and oppression can help address the mental health inequities Black clients face.

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A trauma-informed approach benefits both counselors and clients, yet more work needs to be done to ensure these principles are adopted across health care systems.

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Best Practices for Managing Trauma-Related Disorders Related to WTC Psychological Exposures

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Best Practices for Managing Trauma-Related Disorders Related to WTC Psychological Exposures

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Best Practices for Managing Trauma-Related Disorders Related to WTC Psychological Exposures

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Post-Traumatic Stress Disorder: Signs & Treatment Options For PTSD | Stanford

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Post-Traumatic Stress Disorder: Signs & Treatment Options For PTSD | Stanford

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Post-Traumatic Stress Disorder: Signs & Treatment Options For PTSD | Stanford

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Addressing Childhood Trauma through Trauma-Informed Care

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Addressing Childhood Trauma through Trauma-Informed Care

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Addressing Childhood Trauma through Trauma-Informed Care

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Identifying and Treating Post-Traumatic Stress Disorder | Chivonna Childs, PhD

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Identifying and Treating Post-Traumatic Stress Disorder | Chivonna Childs, PhD

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Identifying and Treating Post-Traumatic Stress Disorder | Chivonna Childs, PhD

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You really can recover from a painful experience—and be better than before

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You really can recover from a painful experience—and be better than before

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You really can recover from a painful experience—and be better than before

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It’s called post-traumatic growth. Scientists explain the keys to achieving it.

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The protective role of self compassion in trauma recovery and its moderating impact on post traumatic symptoms and post traumatic growth

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The protective role of self compassion in trauma recovery and its moderating impact on post traumatic symptoms and post traumatic growth

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The protective role of self compassion in trauma recovery and its moderating impact on post traumatic symptoms and post traumatic growth - Scientific Reports

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Scientific Reports - The protective role of self compassion in trauma recovery and its moderating impact on post traumatic symptoms and post traumatic growth

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Post-traumatic growth in young and middle-aged patients with stroke: a qualitative systematic review and meta-synthesis

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Post-traumatic growth in young and middle-aged patients with stroke: a qualitative systematic review and meta-synthesis

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Post-traumatic growth in young and middle-aged patients with stroke: a qualitative systematic review and meta-synthesis - BMC Psychology

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Background With the increasing incidence of stroke among young and middle-aged individuals, addressing their psychological well-being has become a critical concern. Negative emotional states such as depression, anxiety, and conditions like post-traumatic stress disorder (PTSD) can hinder recovery and increase the risk of recurrence. Therefore, this study aims to conduct a meta-synthesis of qualitative research on post-traumatic growth (PTG) in this population, examining the factors that contribute to PTG, its developmental trajectory, and the coping mechanisms involved. Methods A systematic search of 14 databases was conducted, with reference tracking, to ensure comprehensive literature retrieval. A total of 1,753 articles were initially identified. After removing duplicates and excluding articles that did not meet the criteria, 11 studies were included, involving 156 participants in total, with 5 studies conducted in China and the remaining from other regions. The review followed the Joanna Briggs Institute (JBI) approach: systematic search with predefined criteria, critical appraisal of study quality using the JBI Checklist (assessing rigor in data collection/analysis), and meta-synthesis via iterative theme development (coding, categorizing findings) and validation (cross-checking by reviewers) to derive integrated results. Results A total of 42 research findings were synthesized into 9 new categories, further grouped into 3 integrated results: (1) trauma and stress period, which includes physical, psychological, and social stress; (2) adjustment and reconstruction period, involving seeking support, cognitive processing, self-mobilization, and life reorganization; and (3) growth period, characterized by new possibilities and self-actualization. Limitations The limited time frame of the studies and the predominance of research from China (5 out of 11 included studies) may restrict the generalizability of the findings. Excluding non-English and non-Chinese studies introduces a potential language bias. Furthermore, as the review only included qualitative studies with generally small sample sizes (total 156 participants), the findings should be interpreted with caution. Conclusion This meta-synthesis is the first to systematically synthesize qualitative evidence on PTG in young and middle-aged stroke patients, offering a novel three-stage framework (trauma and stress, adjustment and reconstruction, growth) that integrates physical, psychological, and social dimensions of recovery. By clarifying distinct emotional, cognitive, and behavioral features at each stage, this study advances existing research—previously fragmented in exploring PTG elements—by providing a holistic developmental trajectory. In clinical practice, this framework informs targeted interventions (e.g., stage-specific emotional support, cognitive guidance, and social reintegration strategies) to facilitate PTG and enhance patients’ reintegration into society.

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recovery: qualitative study of narratives

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The complicated truth of post-traumatic growth

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The complicated truth of post-traumatic growth

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Eranda Jayawickreme was born in London but grew up in Sri Lanka during the 80s and 90s, in one of the most turbulent periods in its history. He witnessed the insurrection by the People's Liberation Front, and the ongoing civil war with the Liberation Tigers of Tamil Eelam.

"There was a lot of violence," he says. "But growing up with so much adversity and trauma going on around me, I was often struck by the extent to which people somehow managed to 'keep on keeping on' in the wake of all these bad experiences."

When he moved to the US to study psychology at university, it was perhaps only natural that he would be drawn to the science of human resilience. Jayawickreme was particularly fascinated by the concept of "post-traumatic growth". This is the idea that many people not only recover from life-shattering events, but also experience a positive transformation in their values, actions and relationships. The research seemed to affirm Nietzsche's aphorism that "what doesn't kill me makes me stronger".

The intuitive appeal of the concept is obvious - and it has been promoted in numerous magazine articles and books, including Sheryl Sandberg and Adam Grant's best-selling book Option B. As Jayawickreme delved into the research, however, he found that the truth was much more complicated than some of the media coverage would suggest - and that many of the scientific studies themselves may have serious flaws.

Jayawickreme's conclusions are nuanced, but it now seems increasingly likely that the reported prevalence of post-traumatic growth has been exaggerated. This is not just nit-picking or pessimistic naysaying: it might have serious consequences.

"In some cases, this narrative around the potential to grow could be oppressive," says Jayawickreme, who is now a professor of psychology at Wake Forest University in North Carolina, US. "It creates the expectation that not only do I have to recover from what happened to me, but apparently, I'm supposed to become better than ever before." And this pressure, he thinks, could lead to worse mental health outcomes for some individuals.
The phoenix from the ashes
Nietzsche may have hinted at the existence of post-traumatic growth (PTG) in the 19th Century, but the scientific study of the phenomenon only emerged in the 90s, with pioneering research by the psychologists Richard Tedeschi and Lawrence Calhoun. To measure PTG, they asked participants to consider how they felt now, compared to how they felt before their trauma, in five domains: appreciation of life, relationships with others, new possibilities in life, personal strength and spiritual change. They then had to estimate how much of that change was linked to the trauma itself.

As one example, they cited the words of Rabbi Harold Kushner, describing his life after the death of his son:
I am a more sensitive person, a more effective pastor, a more sympathetic counsellor because of Aaron's life and death than I would ever have been without it. And I would give up all of those gains in a second if I could have my son back. If I could choose, I would forego all of the spiritual growth and depth which has come my way because of our experiences... But I cannot choose.

The assumption that we'll experience positive change after trauma could have negative impacts on mental health, experts say (Credit: Getty Images)

Such accounts suggest a positive transformation that goes far beyond recovery and coping. "Post-traumatic growth is not simply a return to baseline - it is an experience of improvement that for some persons is deeply profound," Tedeschi and Calhoun wrote in one of their early papers.

Subsequent research found evidence of post-traumatic growth in the survivors of many different crises - including relationship break-ups, bereavement, cancer diagnoses, sexual abuse and immigration from war zones. And it seemed to be astonishingly common, with some estimates suggesting that as many as 70% of trauma survivors might experience PTG.

Along the way, the researchers have had to understand how post-traumatic growth emerges. Amy Canevello, a psychology professor at the University of North Carolina, US, describes it as a constructive process. "Trauma shatters your worldview and disrupts your core beliefs," she says. "And post-traumatic growth, at least theoretically, is the result of you trying to put your worldview back together in a way that incorporates that traumatic event. You come out the other side looking different in some way."

Supporting this hypothesis, Canevello has found that levels of post-traumatic growth tend to correlate with levels of rumination after the event: the more people think about it, the more likely they are to see a positive transformation. At first, these thoughts may be intrusive and unwanted, she says, but over time the thinking can become more controlled and reflective. "It allows you to start cognitively putting those pieces together and make sense of the event."

Some people reporting post-traumatic growth describe enormous grit and determination to come to terms with their adversity. Ann Wild was born with a congenital spine condition and describes experiencing a series of traumas as a result of her disability and the medical procedures that she has endured - the last of which has resulted in complications that may prove fatal in the years to come. She competed in five Paralympics, has an OBE and works as an occupational therapist.

"I was constantly growing as a person and always held the principles of independence optimism, gratitude and kindness," she adds. "Although I don't follow an organised religion, I have a deep unwavering spirituality and faith in what I do in the world and what I can achieve past the limitations of my impairments... I think for some people it takes trauma to make us realise our potential." Wild recognises that many people do not see that growth, however.

Positive illusions?

The researchers studying post-traumatic growth have been careful not to dismiss the pain of overcoming adversity. "It certainly isn't all sunshine and rainbows," says Canevello. "It means that you have come out the other side of this thing - that you are having these growth experiences, despite the stress."

This message is sometimes lost in the media coverage and public understanding of post-traumatic growth, however, which can focus on the inspirational elements of the phenomenon. "The concept lends itself to a pretty 'Pollyannaish' understanding of recovering for adversity," says Jayawickreme.

Jayawickreme's main concern, however, regards the specific scientific methods behind the research and the way that post-traumatic growth is most commonly measured - problems that he recently outlined in a book for Oxford University Press. He does not doubt that some people experience a positive transformation after trauma, but believes that these flaws have led us to overestimate how likely that is to happen.

One issue is the phrasing of the survey items. Almost all studies use the "Post-traumatic Growth Inventory" (PTGI), in which participants are asked to consider a series of statements describing potentially positive changes and then report how often they have experienced them, from 0 ("I did not experience this change as a result of my crisis") to 5 ("I experienced this change to a very great degree as a result of my crisis").

"You can't report a change for the worse," says Jayawickreme. This could prime people to report growth, he says. (In general, participants may be reluctant to circle 0 for every single question.)

He points to one study from 2015 that looked at people's responses to the earthquakes in Canterbury, New Zealand, in 2010 and 2011. In these surveys, the participants were given the option of reporting negative as well as positive change - and the evidence for widespread post-traumatic growth was much less convincing than the standard studies.

One study involving soldiers suggested that false perceptions of post-traumatic growth reflected a dysfunctional coping strategy (Credit: Getty)

Then there is the potential for memory bias to skew the results. To complete the PTGI, the participants have to look back and compare how they were before the trauma with their current state. They must then evaluate how much of that change was due to the adversity they had faced. "It's assuming that someone can accurately calculate their change, and its cause, and my guess is that most people aren't able to do that," he says.

Human memory is notoriously unreliable, after all, and previous research suggests that most people are naturally inclined to find improvements in their personalities over time - even when there is little reason to think it has actually occurred.

The best way of demonstrating actual growth would be to survey people before and after the traumatic event. Unfortunately, very few studies of post-traumatic growth have done this - but the results of those that have are telling.

Consider a paper by Patricia Frazier, a professor of psychology at the University of Minnesota, which examined a sample of more than 1,500 students. At the beginning and end of the study, the participants completed various in-depth questionnaires that measured the domains that are thought to be positively affected by adversity, such as appreciation of life and the state of their relationships.

One hundred twenty-two of the participants reported some kind of trauma, such as experiencing a life-threatening accident or the death of a close friend, over the two months the study took place. By comparing their responses at the start and end of that period, the researchers were able to work out if any actual psychological transformation occurred, and compared this to the participants' perceived growth, measuring at the end of the study with the PTGI.

Despite the fact the study had only lasted a couple months, many of these people did indeed report positive change using the PTGI. Yet those responses did not generally reflect an improvement in any of the psychological measures taken at the beginning and end of the study period.

Such a discrepancy would seem to support Jayawickreme's suspicion that many of our estimates of PTG prevalence may be flawed, and do not reflect the number of people experiencing real psychological transformation.

You might wonder whether the perception of growth after a trauma could help people to cope; perhaps it's healthy to try to see some positive outcome from adversity. In reality, PTG may be associated with a higher risk of mental illness. One study examined soldiers deployed in Iraq for 15 months after they had returned home from service. The soldiers who reported greater post-traumatic growth five months after their return tended to show worse symptoms of PTSD at the end of the study.

This suggests that for some people, the false perception of growth may be an unhelpful way of processing trauma. If so, we should be especially wary of encouraging people to see positive transformations resulting from their trauma.

Shades of grey

Jayawickreme is not alone in these concerns, though many researchers continue to believe the standard questionnaires measuring post-traumatic growth have captured something meaningful. "There's a split view in the literature," says Dr Matt Brooks, a lecturer in psychology at Manchester Metropolitan University in the UK.

In his own work exploring PTG, Brooks has found that some people who report experiencing post-traumatic growth in questionnaires also describe ongoing difficulties arising from their adverse experiences. They might still struggle to leave the house, for example, or report suicidal ideation. In such cases it is natural to wonder whether the perception of positive change is illusory or may even reflect a dysfunctional coping strategy, he says. "But for some people certainly, there is a transformative change," he adds. He describes people who have come to reassess their basic values, so that they change jobs, travel the world or commit themselves to charity work. "They've channelled [their distress] into something positive."

Dr Hanna Kampman, a senior lecturer in psychology at the University of East London, takes a similarly nuanced view. "We have a major responsibility in how we present the theory," she says, "so that it doesn't come with additional pressure for somebody who has already gone through a very difficult time." It could be particularly damaging, she says, if the discourse on post-traumatic growth means that others start to expect people to recover too quickly.

Kampman is also concerned about our culture veering in the opposite direction, however - so that the potential for resilience and growth is completely neglected. Her research investigates post-traumatic growth in people with acquired disabilities, which many people may only associate with vulnerability and weakness. "It's very important that we also show the other side - that some people are excelling and challenging themselves - rather than just focusing on the expectation of suffering."

Future research - using better designed experimental methods - should help to resolve the uncertainty about the real prevalence of post-traumatic growth, and the factors that might help people to process their crises. With this knowledge, therapists should be better able to tailor their conversations with their clients and to guide them through their recovery.

In the meantime, we need to remember each individual's experience is going to be very different and must be judged on its own terms. The priority should be providing whatever support they personally need to come to terms with their trauma, whether they are reporting distress or growth - or both at the same time - without imposing a narrative on their recovery.
David Robson is a science writer and author of The Expectation Effect: How Your Mindset Can Transform Your Life, published by Canongate (UK) and Henry Holt (USA) in early 2022. He is @d_a_robson on Twitter.

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The complicated truth of post-traumatic growth

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We are often told about people's capacity to thrive after trauma - but these claims may put unnecessary pressure on survivors.

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A mixed methods experience sampling study of a posttraumatic growth model for addiction recovery

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A mixed methods experience sampling study of a posttraumatic growth model for addiction recovery

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A mixed methods experience sampling study of a posttraumatic growth model for addiction recovery - Scientific Reports

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Scientific Reports - A mixed methods experience sampling study of a posttraumatic growth model for addiction recovery

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Facilitating Recovery & Post Traumatic Growth with the People We Serve

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Facilitating Recovery & Post Traumatic Growth with the People We Serve

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Facilitating Recovery & Post Traumatic Growth with the People We Serve | 14 April 2021