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Big or small, trauma still matters

According to the American Psychological Association (APA), trauma is ‘an emotional response to a terrible event like an accident, rape or natural disaster.’ Survivors typically experience ‘shock and denial in the short term followed by longer term reactions including unpredictable emotions, flashbacks, strained relationships and physical symptoms like headaches, nausea and appetite disruption. There can be other chronic emotional and psychological symptoms.’ I think most people would recognise that these symptoms can be attributed to the aftermath of the traumatic event. But it was not always so.

If you attempt to explore the history of psychological trauma you may find slim-pickings as you delve beyond the 1960s. Trauma only really started to be acknowledged after the Vietnam War, and even then it took many years of argument to make progress on its diagnosis and potential treatment. Before this, Trauma went by other names, or was entirely anonymous.

Many will be aware of ‘shell shock’ as it was described in the Great War. The consensus, encouraged by those in power and authority, was that shell shock was a sign of weak character and that healthy, strong chaps would recover from psychological scarring with time, in the same way they recovered from physical scarring.

There had previously been some acknowledgement of a potential problem during and after the American Civil War, from which there were accounts of veterans suffering from ‘Soldier’s heart.’ (How much more evocative and moving is this label than shell shock?)

Any earlier and you will struggle. Articles and books on the history of trauma that discuss the long-term impact of traumatic events on the mind, body and spirit before the second half of the 19th Century are rare.

So, whilst the problem is not a new one, there has traditionally been some reluctance to acknowledge and codify the impact of major traumatic experiences on people. One of the barriers to accepting many of the symptoms of trauma has sometimes been that they can play out physically, as much as mentally.

Shakespeare offers an uncanny description of the Post-Traumatic response of soldiers in Henry IV, Part 1. Lady Percy is speaking to her husband, Hotspur. He has recently returned from battle and is about to leave again that morning. Her words provide a striking summary of traumatic symptoms.

‘Tell me, sweet lord, what is‘t that takes from thee

Thy stomach, pleasure, and thy golden sleep?

Why dost thou bend thine eyes upon the earth,

And start so often when thou sit’st alone?

Why hast thou lost the fresh blood in thy cheeks…’

This is just a flavour of her speech, but I think it makes the point. Shakespeare’s description of the physical as well as mental effects of trauma are so precise that they have been used as an illustrative checklist by Jonathan Shay, The American Psychiatrist who helped to establish the existence of PTSD in Vietnam Veterans.

Despite Shakespeare’s words over 400 years ago, we still struggle to make the connection between the life of the mind and that of the body. Whilst most people can accept that what happens to us physically can have an impact on our mental or emotional state, many are reluctant to accept that our emotional and psychological responses can result in changes to the workings of our ‘body’.

There is a folk memory of terms such as psycho-somatic illness (literally ‘mind and body’). Psychosomatic issues were of great interest to Freud and like a lot of his ‘Greatest Hits’, they have become part of our vocabulary. Freud linked psychosomatic issues with his interpretation of hysteria (indeed Freud’s characterising of ‘hysterical symptoms’ was applied to the impact of shell-shock.) It’s fair to say that Freud’s interpretation of ‘hysterical’, whilst problematic, wasn’t intended to be dismissive. The term has, however, developed very definite and negative implications over the past century or so. It implies over-reaction, irrationality and a lack of self-control. (It also has obvious links to gender-stereotyping. Isn’t being ‘hysterical’ – literally being influenced by the womb - linked to behaving like a weak woman?) Similarly, I think we often think of psychosomatic issues as being linked to strength of character, of being ‘all in the mind’.

Thankfully, much of this has now changed. We now seem able to accept the idea that psychological trauma is real and can leave a lasting impression on anyone. Only the most emotionally tone-deaf would think someone with the experiences referred to above should simply ‘pull themselves together’. Although there isn’t a common understanding of trauma and its effects, there is awareness.

But there is some way to go. Within the professional community, it is common to refer to two types of trauma. These are ‘Big T’ and ‘Little t’. Much of what I have described so far has been ‘Big T’. Big incidents and events. We are all aware of them, from wars to sports stadium disasters, car accidents to assaults. The importance of ‘Little t’ trauma is often overlooked and in my experience, most people don’t immediately connect it with the tag ‘trauma.’ Perhaps the label ‘Little t’ isn’t helpful. It implies less importance, but that isn’t necessarily the case. ‘Little t’ trauma is probably best summed up as the effect of ongoing grind of misery, deprivation and abuse. Notably, many people who suffer from ‘Little t’ trauma also suffer from ‘Big T’ trauma. If you are abused once it is a ‘Big T’ trauma, if you spend your childhood in a state of heightened anxiety, waiting for it to happen again and not being able to rely on or trust your parents or carers, that is ‘Little t’ trauma. Both are valid causes of distress and despite what the First World War generals thought, neither are likely to simply fade with time.

The reasons for many of the emotional and physical responses to trauma are increasingly put down to the effects of suffering prolongued and/or intense anxiety and fear for your survival. This affects brain development and triggers neuro-chemical and hormonal responses which reverberate around the body for years to come. It isn’t difficult to imagine someone fearing for their existence when faced with a bomb or assault. It is more difficult to accept that the effects of long-term neglect and abuse, poverty and deprivation can amount to a similar threat to existence, with a similar neurological and physiological impact.

As I have written about before, PTSD is now a recognised, diagnosable and (arguably) treatable condition, but the definition attached to this is that of ‘Big T’ trauma. ‘Little T’ trauma leads to many of the same mental, emotional and physical responses, however, it is not formally recognised by the medical community and sufferers are still regularly referred for stand-alone treatment for anxiety, depression, bipolar disorder, personality disorders etc. The inability of the medical establishment to recognise the impact of trauma is itself traumatising for individuals who were often not believed by those charged with caring for them. That’s not just my opinion. The medical community now readily accept that a sense of not being listened to or believed contributed to the PTSD tsunami in Vietnam veterans.

It would be a great step towards a mature society if we were to stop dismissing the experience of others as a failure to ‘pull themselves together’, or suggesting that it's time to 'move on' and started listening to their stories with empathy and a recognition of the strength they show in simply surviving.

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