The evolution of "trauma"

Once burned. Twice shy.

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When I was learning to be a clinical psychologist back in the 1970s, I don’t think I ever heard the word “trauma”. In the last few decades, trauma has become a foundational concept in our understanding of human nature, relations and suffering. I wanted to understand this better, and so I took a deep dive of exploration. This is what I learned.

NOTE: this essay is long, somewhat technical, and addresses the subject of human violence. Proceed if you wish.

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People say that what doesn’t kill you makes you stronger. This notion fits nicely into a Puritan/Stoic ethic of the character building effects of suffering (“No pain, no gain”).

In fact, near-death experiences leave most people terrified and in pain for the rest of their lives.

One can experience threats to life and limb in a variety of situations:

• Accidents

• Natural disasters

• Severe illness/disease

• Poverty

• Political/state violence

• Interpersonal violence

In the first 4 categories of events, there is usually no human actor to “blame” (except in the case of certain drunk drivers, bad doctors or corrupt politicians!) and so we curse fate/bad luck for our suffering. In the case of political and interpersonal violence, we must account for the human element in any efforts to prevent or alleviate trauma and its suffering.

A Short History of the Concept of Trauma

Observations about the impact of threats to life and limb appear throughout the written record of human history. There has been a surge of attention (as reflected in the written record) to the subject of trauma since World War II and accelerating since the 1970s.

TRAUMA: the cumulative impacts of a situation that a person (or non-human being) experiences as threatening their life and/or bodily integrity

As battlefield medicine improved after the Civil War (prior to and during which most wounded soldiers died of either blood loss or infection), more people survived their injuries and filled the beds of the veterans hospitals. It was there that doctors and nurses began to observe a constellation of symptoms in a significant percentage of their patients:

• High anxiety/fear

• Hyper-vigilance

• Exaggerated startle response

• Emotional disturbance (Irritability/anger, depression, numbing)

• Sleep and appetite disturbance

• Difficulties with “executive functions” (attention, concentration, memory)

• “Psychogenic” symptoms without clear physical etiology (muteness, blindness, paralysis, pain)

• Vivid re-experiencing of the traumatic event (“flashbacks”)

Once this syndrome was formally defined and widely known, health professionals began to notice its appearance in a number of people and situations other than the military. The diagnosis was therefore expanded from “shell shock” and “battle fatigue” to “traumatic neurosis” and finally post-traumatic stress disorder (PTSD). The common causal pathway to PTSD, regardless of the precipitating situation, was understood to be the cumulative impacts of a situation that a person (or non-human being) experiences as threatening their life/survival or bodily integrity.

This diagnostic and etiological clarity in the post-WWII period ushered in a period of greater professional and public interest in the causes and treatment of trauma. The facilitators of this mobilization to define, understand and alleviate traumatic suffering include:

• Expansion (more federal funding) of basic science research on the biological mechanisms of health and dis-ease

• A gradual (and still only partial) shift from tradition/authority driven medical, public and mental health practices and teaching to a more science/evidence-based paradigm

• Social and political movements challenging longstanding power arrangements (and related narratives, norms and beliefs) along lines of class, gender and pigmentation

• Increased representation of historically disempowered groups in academic, professional, political and economic positions of authority

• A mass communication architecture (industrial printing, radio/television/satellite-enabled “broadcasting”, web-based interactive social media) facilitating open access to information and group consolidation based on shared interests

Our accurate understanding of post-traumatic suffering has been advanced by the progress being made in the following sectors of study:

• The psychobiology of fear-based learning and the neurological-hormonal stress/threat management system in human and other beings

• The dynamic process of organismic adaptation, natural selection and genetic transmission (“evolution”)

• The epidemiological prevalence estimates of traumatic injury in the general population, and clarification of its causes

Once Burned … Twice Shy

The mind is a system of organs of computation, designed by natural selection to solve the kinds of problems our ancestors faced in their foraging way of life, in particular, outmaneuvering objects, animals, plants, and other people. — Steven Pinker

Here is a thought experiment:

If you were tasked with designing a fail-safe national security Threat Management System to protect your country against attack, what critical features would you want to include?

Consider these highly effective defense mechanisms:

• Continuous hyper-vigilance/scanning for early detection of threat signals

• Hyper-sensitivity to threat signal detection with a threshold allowing multiple false positives (activating to threats that are not present) in order to minimize the false negatives (missing a threat that does exist) that can get you killed

• Intense sensory signaling (bright flashing lights, loud klaxons, etc.) upon threat detection to arouse immediate attention, decision-making and defensive action

• Automation of multiple response systems to reduce uncertainty and accelerate decision velocity

• Massive non-proportional threat response (offensive and defensive) to increase probability of survival

Over thousands of generational experiments and refinements (“evolution”), a BIOLOGICAL threat management system (TMS) was designed and, due to its providing a significant survival advantage over organisms without it, naturally selected for genetic transmission to generations of humans and other beings. It lies generally dormant until the first exposure to a life-threatening event, then it switches on fast and hard (“one-trial learning”), encoding that traumatic memory as a permanent autonomous fail-safe system, continuously scanning and reacting.

When our TMS (made up of an entire symphony of brain, gut, endocrine and sensory-motor operations organized within the sympathetic nervous system) triggers an explosion of fear/energy into fighting, fleeing and freezing strategies depending on the circumstances of the threat, its main goal is of course immediate survival and escape from danger. If the organism survives the threat, the experience is encoded in the memory system for future retrieval, but the nature of the memory playback is DRAMATICALLY different than for non-traumatic scenarios. It is this specialized fear-based learning/memory system that creates all the suffering and dis-ease we call PTSD.

The IMAX/VR experience of traumatic memory

Replaying a memory from a non-life threatening situation is like looking at a picture or watching a movie. Replaying a memory of a situation where life or limb were threatened is like BEING IN the movie. We can afford to be a passive casual observer of a regular memory, but post-traumatic memories are designed to be exponentially louder/brighter, more intensely immersive and emotional/experiential, and impossible to ignore. They DEMAND our attention as if our lives depend (and they do!) on remembering that previous encounter with a similar danger situation so we can fight, flee or freeze sooner and faster and better than in the first exposure.

This specialized post-traumatic memory system (a very fast one-trial fear-based learning program) provides a significant survival advantage, and most of us have it because it has been widely transmitted throughout the population. That is why most beings will experience (with varying degrees of intensity) the symptoms of post-traumatic stress disorder (PTSD) following a situation that threatens their survival or bodily integrity.

With this fuller understanding of the structure and function of the human TMS, research into effective treatments for PTSD is focused on ways to modulate and disrupt it. Standard “mental health” treatments such as psychotherapy, cognitive-behavioral therapy and psychiatric medications have proven largely ineffective in treating the symptoms of PTSD. “Talk therapies” are directed at the verbal/thinking brain systems that have little control over the workings of our TMS. Most medications for mood disorders (anxiety and depression) are hypothesized (we don’t really know) to work on the dopamine and serotonin systems in the brain, and therefore not targeted at the biological systems currently implicated in the TMS.

Traumatic memories are formed/stored under the influence of our TMS’s adrenal-pituitary axis and its hormones (ACTH, norepinephrine etc.). Based on this paradigm, there have been some promising results from administering a beta-adrenergic blocker closely following a traumatic event to disrupt the epinephrine surge that accompanies traumatic memory formation/storage. The goal is to PREVENT the formation of traumatic memories/PTSD and its suffering.

Effective therapies will be designed to stimulate the workings of the parasympathetic nervous system (PNS: rest-and-digest) that is shut down by the fight-flight-freeze mechanisms of the TMS (located in the sympathetic nervous system/SNS). Learning to access the PNS at will can give people a “brake” on the explosive activation of their TMS. A range of “non-traditional” interventions (psychiatry/psychology is a VERY conservative change-averse field!) to strengthen this braking function are being studied in clinical trials with some promising initial findings. These include hallucinogens, hypnosis variants (including EMDR and other “dissociative” techniques), meditation, body work, companion animal (dogs, horses etc.) bonding, dance and expressive therapies (art, music, writing).

The goal of all treatments is to enable the patient to recall the traumatic memory without triggering a full-blown TMS explosion so it can be stored safely in regular long-term memory as a past event. The TMS is not verbal or reason-based, but it can learn (which is how it forms traumatic memories to begin with). Feeding it multiple experiences of memory recall WITHOUT a sympathetic/adrenal chemical cascade (and full IMAX/VR re-traumatization) can “teach” the TMS to deactivate that specific trigger. That’s what is called a “cure”.

Further clarification of the biology of the TMS (in particular its specialized fear-based learning/memory storage systems) using better scanning tools and bio-assays will hopefully enable the development of ever more effective biotherapeutics for alleviating and even preventing the severe suffering of PTSD. The science-fiction scenario of someday being able to locate and REMOVE specific traumatic memories from the brain would be a Nobel-prize winning achievement.

A short history of violence

We stopped looking for monsters under our bed when we realized that they were inside us. — Charles Darwin

The standard definition of trauma as the result of a situation perceived as threatening one’s life or bodily integrity has generally included the statement that traumatic events are “rare and outside the range of normal human experience”. For most of their history, the medical-, mental- and public health professions did not include any inquiry about traumatic events (assault, rape, torture, life-threatening illness or accidents) in their research or standard intake/diagnostic interview, so the true prevalence of trauma was never ascertained.

This ignorance (and denial) was due to the members of these professions being largely protected from the main risk factors for trauma:

• Female gender

• “Darker” pigmentation

• Childhood status

• Poverty

As most physicians and mental health professionals have historically been (until quite recently) “white” middle-class males, they have controlled the narrative and determined what normal human experience looks like. In their experience, trauma is perhaps a rare event. For other populations, not so much.

History (and its cousin “reality”) is a story we tell ourselves, rather than a purely objective accounting of events. Historians are often enthralled by sweeping grand narratives of great empires and great men and their achievements. The colonial empires of Rome, Eurasia, Spain, France, Great Britain, Japan and The United States of America have been extolled for bringing the benefits of “civilization” to the native peoples they invaded and conquered.

A more accurate fact-based reporting reveals that what the invaders brought was TRAUMA to millions of people in the form of disease, enslavement, torture and death. If we also include the genocides perpetrated within countries (Germany, Turkey, North Korea, Rwanda, Bosnia-Herzegovina, Soviet Union, USA etc.) on segments of their own population, it becomes clear that the notion of trauma as “rare and outside the bounds of normal human experience” depends entirely on which humans are writing the history or the diagnostic manual.

While many of the leaders of these marauding hordes were no doubt pure psychopaths with no moral sense or capacity for guilt/shame, most garden-variety invaders were “normal” people who simply employed well-honed strategies to prevent the triggering of the compassion reserved for their blood kin and tribe. This process involves the creation of a fiction that the people (and non-human beings) to be used and abused are “less than” (lacking a mind, feelings or a “soul”) and therefore not deserving of ethical consideration. By reducing other beings to the level of a spiritual outcast or a dumb insensate “thing”, no form of violence is beyond the moral pale. Every holocaust/genocide has been built on a foundation of dehumanizing debasement.

Instances of violence toward non-human beings are enabled by the same strategy (“animals” have no soul/feelings) and lead to behavior such as training horses using gross torture to break their spirit by inducing a form of PTSD to ensure terror, submission, passivity and compliance. Only recently have equine and other animal behaviorists made the effort to understand the intelligence and “psychology” of these living beings with the purpose of developing more respectful and ethical training methods to achieve desired ends.

The Reckoning

The process of liberation of oppressed traumatized people consists of

• ending the denial of their historical reality and writing an accurate (fact-based) history

• rejecting and rewriting the “less than” narratives fed to them by their conquerors to justify and rationalize their cruelty and abuse

• political empowerment and advocating for redress and restitution for past harms by economic, legal, legislative and educational remedies

People who were formerly excluded from the halls of academia and government and business can then insist on their more representative inclusion. As the proportion of those at higher risk of traumatic suffering has increased in those venues of influence and power, a tipping point is reached where THEIR experiences and insights and narratives can begin to compete with and ultimately change the dominant ones. These are the stories of the workers rights, civil rights, women’s rights, LGBT rights, and patients rights movements of the post-WWII period during which, as mentioned above, there has been a correlated increase in the attention to and attempts to alleviate traumatic suffering.

The scholarship (serial waves of feminist critique, factual teaching of history, real-world economics etc.) and activism (Act Up, Black Lives Matter, Me Too, Occupy Wall Street) of these various liberation movements have challenged and revised the dominant narratives of history and reality to reveal a deeply disturbing truth:

Throughout human history, many dominant regimes built and maintained their control and dominance by the intentional inflicting of TERROR as a means of subjugation to advance a variety of economic, political and psychological aims.

Through this lens and paradigm, human history is in significant measure a history of strategic violence/trauma perpetrated by a privileged class to enforce their supremacy over other people, non-human beings and the planet’s ecosystem itself by means of

• Colonial terrorism (war, genocide, enslavement)

• Gender terrorism (sexual violence, barriers to basic human rights/opportunity)

• “Race” terrorism (genocide/enslavement, judicial/legislative domination)

• Class terrorism (oligarchic capitalism, labor abuse)

• Political terrorism (authoritarian rule, corruption, courts and legislatures as enforcement mechanisms for minority interests)

• Species terrorism (non-human beings as commodities; factory farm model)

• Ecological terrorism (pollution/climate heating, unsustainable natural resource extraction, industrial terraforming)

Violence/trauma is NOT a rare human event

The first step to the knowledge of the wonder and mystery of life is the recognition of the monstrous nature of the earthly human realm. — Joseph Campbell

Breaking from the past practice of denial and minimization of traumatic suffering by public, mental and medical health professionals, a growing cadre of professionals has begun to conduct a fresh inquiry into the prevalence and impact of trauma and violence. Their findings are alarming and contradictory to conventional narratives, and have profound implications for our politics, law, economics and health. The first and perhaps most important discovery is that contrary to earlier formulations, violence/trauma is NOT a rare human event at all.

As violence is largely a pathology of unequal power dynamics, studies of historically disempowered groups (women, people of “color”, children, the poor, ethnic minorities etc.) reveal that a significant proportion of their members has suffered at least one incident of physical or emotional abuse or neglect. For example, focused inquiry (just ASK people) into the prevalence and impact of so-called “adverse childhood experiences” (ACE) reveals that

• Almost two-thirds of study participants reported at least one ACE, and more than one in five reported three or more ACEs

• Certain populations (esp. girls, people of “color”, living in poverty) are more vulnerable to experiencing ACEs because of the social and economic conditions in which they live, learn, work and play

• There is a graded dose-response relationship between ACEs and negative health and well-being outcomes. As the number of ACEs increases, so does the risk for negative health outcomes (esp. depression, anxiety/PTSD, suicide, addiction, “accidents”, sexually transmitted diseases, and educational/occupational underachievement with its economic impacts)

A previously under-reported population of male trauma victims is recently coming into clearer focus as well.

The perpetrator of sexual violence, mass or serial killings, and the assault/murder of strangers is almost always male. The gender balance of “domestic” non-sexual violence toward partners and children also leans toward a male perpetrator, though recent analyses suggest that the prevalence of female-initiated violence may be higher than previously estimated.

This research reveals that contrary to the longstanding cultural and professional practice of denial and minimization (“Nothing to see here”), there are MILLIONS of children and adults world-wide suffering from traumatic levels of suffering due to violence and neglect.

PREVENTION is the “cure”

Given the magnitude and prevalence of traumatic violence, there will NEVER be enough resources to “treat” (therapy, medications etc.) our way out of this pandemic of suffering. Any effective program to reduce post-traumatic suffering in a population must invest heavily in PRIMARY prevention strategies i.e. stop violent trauma before it occurs. Primary prevention will require a massive investment in a “Moonshot” approach to a “War on Violence” (hard to resist our violent metaphors!) like the war on drugs, cancer, pandemic viruses and other scourges.

Violence must be called out as Public Enemy #1. An effective violence prevention program will require the comprehensive integrated mobilization of resources and good-faith actors in the educational, communications, entertainment, business, civic/religious, health, legislative and judicial sectors to successfully address the long-standing but still largely silent and invisible pandemic of traumatic suffering.

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SUGGESTED READING

Judith Herman, Trauma and recovery

Bessel van der Kolk, The body keeps the score

Marc-Antoine Crocq and Louis Crocq, From shell shock and war neurosis to post-traumatic stress disorder: a history of psychotraumatology

History of PTSD

Hans Selye, The stress of life

Esther Sternberg, The balance within

Centers for Disease Control and Prevention, Violence prevention

Centers for Disease Control and Prevention, Adverse childhood experiences resources

Samantha Power, A problem from hell

Ernest Becker, The denial of death

Howard Zinn, A people’s history of the United States

Derrick Bell, Faces at the bottom of the well: The permanence of racism

Jean Baker Miller, Toward a new psychology of women

Steven Pinker, How the mind works

Charles Darwin, On the origin of species

Charles Darwin, The expression of emotions in man and animals

Buck Brannaman, The faraway horses

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