Didn’t get that job, relationship breakdown, bad loss in the semi-final? These kinds of losses can now colloquially be described using the ‘T’ word. No longer unusual or noteworthy, ‘trauma’ has become common usage for the narration of personal distress.
An interplay of material and cultural forces has promoted this. For example, trauma is being recommended across multiple media platforms as an educated, responsible, even savvy lens through which to interpret intra-physic difficulty. A recent Age newspaper article reported how workers in the arts upended by the effects of COVID-19 are so distressed that they are increasingly contacting a helpline in part due to the financial insecurity so many people are facing but…also [because] a separation from community and purpose, in itself, is causing trauma.
In this telling the term trauma is being used to give weight to the level of difficulty many are experiencing. But acknowledging this, an experience of struggle, of doing it tough, of internal distress should not be conflated with having a ‘mental health issue’. Even more important is maintaining a distinction between the experience of psychological difficulty and a diagnosis of psychiatric illness. To quote an old tune, one might say, ‘I feel a bit roughed up, I feel a bit frightened’, but this is not the same as being reasonably diagnosed or regarding oneself as suffering from the chronic condition known as trauma.
As citizen, potential service user or current client we are all porous. Humans absorb, take in, the metaphors we live by. Over time, who remains able to tease out distinctions between colloquial, literary, faux-technical and formal diagnostic meanings? Overreach, over-inclusivity and conflation in the naming and taming of experience are everyday risks. In this regard the popular media are massaging the trauma trend and readers and viewers cleave to their categories. But is there more to be said about the institutional and other drivers also promoting the ascription of the term trauma to problems of living?
From a minor position less than a generation ago, trauma has come to occupy a central status in psychotherapeutic and mental-health practice. This clinical status finds its echo in the recognition afforded to trauma by funding agencies, host organisations and governance structures, bodies that in turn play a key role in determining what takes place in the consulting room and on emergency helplines. For example, non-government organisations in the Victorian community sector must demonstrate that they provide ‘trauma-informed’ services to be eligible for state funding. A similar situation is present at the federal level, where the Australian government has mandated a specific eligibility condition for those who apply for refugee status: the applicant must prove that they have experienced trauma.
If trauma determines eligibility, a powerful driver is at work, as both professionals and potential service users have an incentive to concentrate, even fixate, on this framing of distress. Rather than start from scratch in how interiority might be articulated or subjectivity addressed, if there is an incentive to identify trauma as the focus this will tend to displace other possibilities. A brief account of the rise of the construct within the professional domain shows how trauma has been positioned significantly to displace less pathologising and neurologically based formulations. As anthropologist and systems theorist Gregory Bateson once remarked, the wave that lasts longest lasts longer than the wave that doesn’t last as long. The surf’s up for trauma right now, so what are the hydraulics generating this prominence?
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Until the 1980s ‘trauma’ was a term with a distinctly medical domain. It was used to refer to accidental violence (for example, road trauma), violence that had been deliberately inflicted (for example, injuries sustained on the battlefield, ‘battlefield trauma’) and the impact of pathogenic physical processes (for example, a misshapen root could lead to ‘dental trauma’). The term was also used to describe particular roles, such as ‘trauma physician’, and the specialised field within which such professionals practised, ‘trauma medicine’. This institutional location and genealogy endowed the term with a substantial authority, even dignity. Since the 1980s, however, the term has come to enjoy a vastly broadened usage.
For example, in the homelessness sector a policy contention is developing that the experience of family and institutional trauma is the cause of many individuals being unable to sustain secure accommodation. That is, it is posited that those who are generally homeless have a personal, even neural, disability. That this formulation psychologises homelessness, and is in stark contrast to the long-held view of many in the sector that homelessness is a social structural problem, goes some way towards illustrating how far trauma has come as an organising principle and conceptual practice.
So how is the category of trauma being practised in the clinical domain? Given the prominence of trauma as a policy concern, might the formal diagnosis of trauma have become overgeneralised? Commenting on practices in psychiatry and clinical psychology, researchers in the sector such as Nick Haslam suggest that the definition of trauma has been subject to a process of ‘concept creep’. That is, operational criteria have become rubbery, with a bias towards inclusion of people and problems in the category, rather than exclusion. Indeed some expert spokespeople are publicly advocating that the experience of trauma has a universal ambit. ‘We all have them [traumatic memories] tucked away in the lower part of our brain, in the cerebellum’, was the opinion recently voiced as a scientific truth by a leading clinical psychologist to an Australia-wide audience on Radio National’s Life Matters. How do you know that you have this dark past? Listeners were told that the evidence is in: each time you overreact, or act out of character, this tells you that you have embedded trauma. This leading comment recalls the argument put forward by philosopher Ian Hacking that there is an unstable relationship between what the mental-health trade terms ‘case finding’ and what he terms ‘people making’.
The ‘infirming’ possibilities of ‘trauma’
In Fragile Nation: Vulnerability, Resilience and Victimhood, Tanveer Ahmed, a Bangladeshi-born, western-Sydney-based psychiatrist, presented details of his work with a resettled Afghani migrant who had experienced multiple traumas during the fifty-year-long tragedy that is the recent history of his country. According to Ahmed, this man had coped remarkably well until he internalised a diagnosis of PTSD, a turn that occurred while he was being therapeutically socialised to become more reflective and emotionally literate. Ahmed concludes that the ‘[PTSD] diagnosis became his identity and rendered him psychologically disabled’.
Rather than the therapeutic process providing relief and greater options, in this (and other cases) Ahmed describes an inadvertent process whereby people can be ‘infirmed’ by their diagnosis. Such an invalidating process can be subtle but powerful. For example, if a person becomes convinced by a bone fide authority figure (such as the Radio National expert above) that it is evidence of a history of trauma to overreact or act out of character—by being tearful, fearful, conflicted or aggressive—this has the potential to alter how everyday events are interpreted. Ahmed offers the following summary:
PTSD is increasingly a synonym for experiencing adversity, measured subjectively, whereas the original meaning of trauma referred to unexpected, life-threatening circumstances that overwhelmed our coping response…PTSD is now an important cultural narrative to process suffering.
Of course, a diagnosis of trauma can have a definite positive moment. Rather than thinking, ‘I am no good, just a useless no-hoper’, it can be enormously reassuring to be told by an expert: ‘You are suffering from trauma. Memories from this event are embedded in your neurology. This causes your emotions and behaviour to become deregulated’. But it is exactly because it has such a positive personal benefit that, as Dennis Saleebey outlines, ‘the diagnosis, the assessment [can]…become the cornerstone of an emergent identity’. For those who are seriously troubled, those with biographies that have wounded and maimed, much is offered by a diagnosis of trauma, but there are also risks if this emergent marker of identity comes to totalise one’s subjectivity in ways that discount one’s sense of agency and accountability.
Consider this double action in which a street outreach program has made contact with Brodie, a forty-year-old with a long history of institutionalisation and primary homelessness. If this man comes to understand that a history of multiple trauma has left him with a chronic impairment, there is a risk that he will conclude that his problem is ‘brainal’: ‘Hey, not only am I a junked-up prison loser; these know-alls are telling me that my wiring has been screwed up. Wow, I guess that makes me a chronic certified neuro’. However well intentioned, practitioners and programs geared to be trauma centred have the potential to leave unwanted legacies.
The process of diagnostic invalidation is familiar to anyone who has witnessed the existential struggle young people experience when told ‘you have schizophrenia’ by an authority. Such events are powerful ceremonies, rituals of transformation, that can inadvertently disrupt and engulf. The conferral of a diagnosis can have a helpful impact, but one of the potential consequences is that a diagnosis of trauma can be interpreted to mean that the needs of my condition revoke my responsibility to think about myself as having agency, or to consider the interests of others. In its privatised iteration, signing up to a diagnosis-specific club can confer a metaphorical entitlement: members get a badge that says, ‘Whose problem am I?’
Post-traumatic stress disorder
One example of the prominent use of ‘trauma’ is the formulation ‘post-traumatic stress disorder’ (PTSD), which, as described and diagnosed during and after the First World War, was once known as shell shock. Clearly, the terminology has shifted, but has the experience behind these changing labels remained the same? It is not self-evident that the shell shock experienced by soldiers who served in the First World War is the same as the PSTD suffered by Australian soldiers serving in Iraq and Afghanistan early in the twenty-first century. In clinical terms, did soldiers in these two groups ‘exhibit the same symptom profile’?
Simon Wessely, professor of psychiatry and president of the UK Royal College of Psychiatrists, has taken up this question. Together with co-researcher Edgar Jones, he examined the case records of three hundred First World War veterans who had received a diagnosis of shell shock. In the case notes researchers found an almost universal record of somatic symptoms—for example, physical shaking, an inability to talk, and difficulties with mobility and balance. They found only a single record of a soldier who reported that he had experienced flashbacks. Today, the experience of flashbacks is almost ubiquitous for those with a diagnosis of PTSD.
It is highly improbable that, out of three hundred cases, only one person experienced flashbacks. If flashbacks were in fact under-reported, how might this be explained? Broadly speaking, case records reflect the interests and prejudices of the interviewer; more specifically, structured-interview and record-keeping formats prescribe the questions asked—literally, the classes of information that will or will not be recognised. Moreover, interviewees would have been unlikely to insist on admitting to ‘going back in time’ unless this kind of phenomenon had already been convincingly normalised, which it certainly had not been at that time. Whatever the constraints, that only one out of three hundred files made mention of flashbacks is a striking finding. Most likely, as Wessely and Jones argue, the internal experience of trauma—its subjective reality—has altered over time.
If the lived experience of trauma is fungible—so that flashbacks have become more prominent and somatic presentations less so—what might have caused this change in phenomenology? Theorising this shift, the researchers suggested that the rise of cinema after the First World War has played a role, given that ‘many directors used the flashback technique where everyday sounds or settings…transport the protagonist back to their time at war’. As Ken McLaughlin, a UK lecturer in social work, has argued, ‘this cinematic shortcut is now embodied in the lived experience of PTSD sufferers’. Humans are indeed porous. A person’s experience may be uniquely their own, but how this realm is narrated, interpreted and conducted has changed over time.
A considerable literature is available on the changing nomenclature and expression of what is now referred to as trauma. For example, in the seventeenth century Swiss physician Johannes Hofer coined the term ‘nostalgia’ to describe Swiss soldiers who suffered from despair and homesickness, as well as more expected symptoms such as sleeplessness and anxiety. Veterans of the American Civil War reported palpitations, constricted breathing and other cardiovascular symptoms. This condition was understood to be due to an overstimulation of the heart’s nervous system and became known as ‘soldier’s heart’, ‘irritable heart’ or ‘Da Costa’s syndrome’. As with the First World War example studied by Wessely and Jones, it is noteworthy that the symptom profile documented in these reports is somatic in nature and lacks the features of dissociation and memory disturbance that are prominent, even defining, in presentations today. Why is this the case?
Putting the question of stimulus to one side, it seems likely that the subjectivity, the inner life, of those who lived, say, in inner-city Sydney at the time of the First World War had a different ground for the processing of adverse events than the inner life of those who live in the same location today. Given that lived experience is both elemental and mediated, it is possible, even likely, that the interiority of the current self is less earthy and corporeal, and more immersed in, and activated by, media and technology than was the case a hundred years ago. Might this set the stage for—might we be more prone to—dissociation and flights of memory as a consequence? Meaning and materiality, the structures of work and sociality, have altered considerably over this period. Technology is no doubt implicated in these shifts. Whether an instance of adversity strikes in a rush or is experienced incrementally, how duress and suffering—the problems of living—are processed is a significant arena in the changing practices of the self that have emerged over the past hundred years.
Ahmed’s work, discussed above, suggests that there is a transition under way towards greater personal fragility. That such vulnerability is notated within a medico-cinematic register should not come as a surprise. Ahmed’s associated view that medical-psychological prescription may be constructing victimhood as a subject position also has a certain face validity.
The moral and ideological context of trauma
Beyond the possibility that a diagnosis of trauma might either invalidate or excuse, a further question arises: is trauma best understood as a private dysfunction? As Bruce Perry, researcher and practitioner in the field, points out, the circumstances in which an event occurs are crucial in establishing a context of meaning. Childhood trauma where trust has been violated, for example, has a different context of meaning than, say, a lightning strike, a natural disaster or a pandemic.
One influential psychologist, Martin Seligman, former president of the American Psychological Association, sees trauma as a purely technical matter. Interviewed on Radio National some years ago, Seligman informed listeners that his research had proven that US military drill sergeants were wonderfully adept at inculcating new recruits into the constructive mindset that is positive psychology. If these junior soldiers internalised the correct system of thinking, Seligman said, this course of instruction minimised the risk of soldiers returning home traumatised from their placements in Iraq and Afghanistan. Further, if these recruits were able to master the right regime of thought, it followed that a good proportion would thrive—that is, actually benefit from these difficult experiences.
Seligman’s view can be contrasted with that of Michael White, an Australian narrative therapist. When asked to comment on the effect on Western soldiers of fighting in wars beyond their own borders in circumstances where they were seen by locals as outsiders, even invaders, who did not understand or have the right to participate in local conflicts, White argued that these soldiers witnessed horrors that had an inevitable moral dimension. Rather than filleting these encounters of their moral quality, White argued that they are a crucial element of the soldiers’ distress. Indeed these soldiers experienced what he termed ‘violated compassion’.
In another example, psychoanalyst Chaim Shatan, a prominent trauma researcher and one of the first to describe PTSD, argued that Vietnam veterans were disturbed, at least in part, because they believed they had been
‘deceived, used and betrayed’ by a combination of the military, the government and society at large. Shatan alluded to the veterans’ rage but did not suggest this was a particular reaction to life-threatening battlefield encounters. He described it as what ‘follows naturally from the awareness of being…duped and manipulated’.
Beyond feelings of manipulation and official betrayal, there was also the idea that war veterans might experience PTSD, shifting from a focus on the soldier’s sense of moral worth to include the disturbing character of combat itself. This revision can be seen as progressive, as it contests the traditional military disposition that regarded soldiers who report ‘nervous symptoms’ as transgressive—that these men lacked character and were behaving in an insubordinate and cowardly manner.
The above arguments make the case that PTSD should not be represented as a straightforward private dysfunction. At the least, PTSD needs to be recognised as a meaning-laden, mediated phenomenon. This is easier to see, perhaps, where troops are despatched to a foreign country to execute a dangerous mission for a purpose that is politically and morally contested, but it is also true for the various circumstances in which trauma is experienced. In other words, the circumstances in which a traumatic event takes place are crucial to how this experience is embedded in the person and how therapeutic practitioners approach it.
Clearly, then, this view has implications for how the person’s distress might be treated and resolved. For example, infant experiences of trauma where trust has been traduced dictate a framework of understanding that fundamentally differs from that related to a natural event such as an earthquake or a flood. Other variables, such as temperament and previous experience of trauma, are also relevant. These and other differences amount to a complex matrix of meanings within which trauma is embedded, and constitute its ethical and ideological context. This context retreats, even disappears, from view in approaches that simply ‘psychologise’.
To psychologise is to attribute primacy to psychological explanations in preference to, say, the contextual and the ethical. Mindful that ‘the psychological’ can be defined in more than a dozen mutually incompatible ways—the behavioural, the psychoanalytic, the transpersonal, the neuro-biological and so forth—narrowly psychological formulations are often accorded dominance. Suffice to say that if justice, the external environment and other contextual elements are excluded from consideration, the tendency will be to expect that there can be private, technical and a-contextual solutions to people’s distress.
An allegorical vignette illustrates this point. Frantz Fanon, the political philosopher and psychiatrist, worked as a psychotherapist in Algeria during that country’s violent war of independence. At one point early in his career he become so frustrated with the lack of progress with a patient who experienced panic, suicidal thoughts and what we now refer to as flashbacks that he felt compelled to break with psychoanalytic protocol. He has attended regularly for a long period; my technique is sound, my knowledge too, Fanon fumed. Aware that it was technically incorrect, Fanon asked his patient what he did for a living. The man replied: ‘I am a torturer’. Trauma always has a context.
Personal or relational responses?
As we have seen, trauma now attracts significant interest across disparate fields of practice. Narrowly formulated, this interest incites a particular kind of query: can we find an intervention that will fix the consequences of trauma? In this light a range of solutions is currently being presented that claim effectiveness in readjusting those individuals seen to have faults in self-regulation, hyper-arousal and the like. Among various techniques, EMDR (eye-movement desensitisation and reprocessing), ‘tapping’/EFT (emotional freedom techniques), ‘havening’ or, slightly broader in their provenance, cognitive behavioural therapy, mindfulness and positive psychology are presented as candidate prescriptions. Acknowledging that some people find relief in ‘therapo-centric’ interventions, and that such techniques may be genuinely offered as beneficial, a broader issue is in question here: just what is the aim of therapy?
The above approaches typically seek to minimise, control or extinguish symptoms. A larger project aims to realise recovery and healing. In the contest between these stances there is considerable tension: the former advocates instrumental, individual treatment; the latter the importance of connectedness, accountability and context. A key difference is in how trauma is theorised—as neural or as socio-neural. The former is associated with the siren-like appeal of quick-fix privatised solutions and the so-called ‘high fidelity’ replications of evidence-based methods. The latter rejects the fetish of technique and reaches into an indeterminate social and ethical domain.
One example is Michael White’s clinical insight that ‘violated compassion’ is a feature in some cases of PTSD. In this formulation ethical transgression—an absence of accountability—is a defining context. A parallel formulation holds for childhood sexual abuse. In these cases caregivers betray their role as guardians, and harm rather than protect. In this circumstance ‘violated trust’ can be understood as the context that has had a determinant effect on the meaning of the event. In this situation the individual’s symbolic order has been sundered and trust has been deregulated—and not just for the moment. A minimal understanding of such abuse holds that a technically sound intervention will minimise, control or extinguish symptoms. A more complex formulation sees that while it is necessary to attend to symptoms, a sufficient response requires a process of recovery. Key to this process is establishing practices of belonging and accountability where trust may be learned and earned.
Patricia Deegan, a foundational thinker in the recovery movement, has argued that the aspiration ‘to live, work and love in a community in which one makes a significant contribution’ is essential to the possibility of recovery. Another early contributor, Judith Herman, argues that a precondition for recovery is ‘the creation of new connections’, ‘capacities for trust…and intimacy’ to complement the ‘autonomy, initiative, competence (and) identity’ dimensions that also have to be reforged. For such thinkers, neat privatised techniques are not enough. If trust has been disordered, if the possibilities of reliable accountability have been negated, the steps forward are necessarily social and interpersonal, and the process uncertain.
When it is reported that a ‘mother says she and her young daughter are traumatised after opening packet of Sponge Bob Square Pants biscuits…and finding a dead mouse inside’, as in the Melbourne Age a year or two ago, it is clear that ‘trauma’ has found a very broad constituency. Trauma talk has infiltrated the popular imagination, and seems to register a very generalised sense of fragility. More seriously, as the discussion above has shown, the subjective experience of individuals for a range of complex events has been both redescribed and seems increasingly to be lived as ‘traumatic’, with varying effects.
One of the most worrying of these effects is that framed by governmental and other imperatives: trauma—like depression and anxiety—has become overgeneralised as a category, pathologising what in other times were considered problems in living. Even in cases of severe trauma, as in PTSD, the application of the category may have inadvertent consequences for the person, with the trauma label becoming self-fulfilling. This dynamic recalls Pierre Bourdieu’s well-known aphorism: ‘it is all too easy to slip from your model of reality into the reality of your model’; or in Ahmed’s more subjective description, it may lead you to become ‘infirmed’ by the identity that trauma talk creates for you. Whether in everyday life or within the clinic, overgeneralisation devitalises an important construct, and undermines its proper usage in cases of clinical severity. Trauma should not be incited; stressed interiority is not synonymous with trauma; but let us also consider therapeutic responses to significant trauma that set such trauma within larger contexts of meaning. It is clear that we are porous in our recent take-up of trauma in self-descriptions and in broad clinical practice; it is also clear that the experience of trauma is porous to forms and suggestions from the culture and history that are its context.