Trauma

Trauma is a word used quite liberally in everyday language, typically to identify a highly stressful event.  When we speak about trauma in the clinical sense, we are referring to an event that has completely overwhelmed an individual’s capacity to cope and this, of course, is entirely defined by the survivor. Two people can experience the same adverse event, one may be left severely psychologically traumatized and the other relatively unaffected. Several factors influence an individual’s response to trauma including previous trauma exposure, age, gender, family of origin environment, genetics and level of social support. Many different events can cause a post-traumatic stress response and various aspects of the event can exacerbate the impact of the trauma, including the duration and frequency as well as the nature of the event (e.g., man-made vs. natural). Generally speaking, traumatic experiences that are prolonged, repeated and purposely inflicted by people cause the most severe posttraumatic responses.  With regards to duration and frequency, the term Type I trauma is used to identify a single incident trauma whereas Type II trauma denotes a trauma that is prolonged and repeated. Furthermore, we use the term complex trauma to categorize prolonged and repeated trauma that only occurs in some type of captivity (not necessarily physical), where a person is subjected to systematic methods of coercive control by the perpetrator who wields substantially more power than the victim. Examples include domestic violence, concentration camps, cults, organized sexual exploitation and even childhood abuse.

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The distinction between Type I and Type II trauma is essential as the type of trauma shapes clinical presentation, conceptualization and treatment approach. As trauma psychiatrist, Judith Herman, explains, post-trauma responses really should be understood as a spectrum of conditions rather than as a single disorder. The diagnosis of PTSD that is described in the DSM-V is more reflective of the post-traumatic response inflicted by Type I trauma whereas those that suffer from Type II trauma present with a much more complex myriad of symptoms and problems that may include dissociation, self-harm, addiction, paranoia as well as somatic preoccupations. Importantly, as clinical presentations differ significantly based on type of trauma, so does the appropriate treatment approach. Those that present with Type I trauma are most effectively treated with a more exposure based treatment, such as Prolonged Exposure, EMDR or Cognitive Processing Therapy.  Given the nature and frequency, and duration of Type II trauma, an individual’s basic functioning and fundamental capacities for coping are more significantly disrupted; therefore, an individual presenting with complex trauma or Type II will not benefit initially from exposure based therapies, and may even experience further decompensation.  These individuals are most effectively treated with a three phase approach that begins with interventions targeting safety, stabilization and improved functioning in day to day life. Once this is achieved, processing and exposure to trauma material may be introduced.  Unfortunately, many individuals suffering from Type II trauma or complex PTSD are often misdiagnosed, thus, do not receive effective and comprehensive treatment. This unfortunate trend points to the importance of seeking out a qualified trauma therapist who can accurately diagnose and conceptualize the continuum of post-traumatic stress responses.