Resilience and PTSD: Are we overusing the term Trauma?

A response to The Check Up with Doctor Mike podcast featuring Prof. George Bonanno

This podcast was shared with me a while back by a colleague. It was really interesting to listen to and held my attention for the whole episode! I found myself hooked to what Bonanno had to say and thought I would share some of that here. You can listen to the podcast on Spotify or wherever you find your podcasts and visit Doctor Mike online here.

The ideas I found myself reflecting on are the abuse of trauma language in popular culture, that humans are an incredibly resilient, darn tough species for creatures with little teeth and no claws, and that our bodies are not repositories for all of our experiences, they are the means of expressing how our experiences have shaped us.

This podcast also had me reflecting on the question could Trauma-Informed Care somehow be dangerous?

Right off the hop Bonanno dove in to the current trend of defining every difficulty as traumatic. And it's true, a lot of people use the word "trauma" to describe set backs, frustrations, and upsetting experiences that they are not deeply or irrevocably changed by. The problem with this trend that Bonanno noted was that it could potentially undermine the very real psychological injuries people were left with after surviving things they thought would certainly be their end. On this I found myself agreeing.

In addition to misuse of trauma language is, I suppose, a mistaken assumption among the public -- and probably many health professionals as well -- that horrible experiences are automatically traumatic. According to Bonanno, not so. He uses the phrase "potentially traumatizing experiences" or PTE's, which I found refreshing. The truth is, most of us are NOT traumatized, even when we do go through truly life altering horrors. When the Adverse Childhood Experiences (ACEs) study came out it was really shocking for people to discover that some 75-90% of the population had gone through at least one of the really difficult experiences on the ACEs list (you can learn more here). The study was looking at long term adult health outcomes from childhood experiences and found, that, well yeah a lot of people who had higher ACE scores tended to also have poorer health outcomes in adulthood. But, according to the World Health Organization (WHO), of those people who have experienced PTEs, only about 5% of them go on to live with persistent trauma disorder symptoms and of those, some 40% see resolution within 1 year. So a rather small segment of the population lives with persistent symptoms related to trauma disorders. As Bonanno put it, there are multiple trajectories people can find themselves on post trauma and, most of the time, it is a trajectory of short term recovery and long term well-being.

Having said that, my TIC training tells me that it's not the experience we focus on but the impact of it. That the experience itself may not be the traumatizing ingredient; rather that person's ability to respond to it constructively, is. So while I hold that, yes, there are people describing things as "traumatic" without experiencing actual trauma, there are people who likely are experiencing trauma in relation to things that others would not identify as trauma. There are people who are more sensitive to overwhelm who experience repeated blows to their sense of safety in the world. Autistics come to mind and there is growing discussion about the experience of unidentified autistics developing trauma symptoms or adaptations in response to constant sensory overload. Within the concept of Potentially Traumatizing Events I would hope there is room for this. And if there is not, if trauma is now and will always be about life threatening, horrifying experiences, then we very much need to attend to the numbers of people fundamentally affected by experiences like verbal abuse and bullying, poverty, autistic burnout, and other experiences that leave scars.

Later in the episode Bonanno talks about "The Body Keeps the Score" and the idea that trauma memories are stored outside of the brain somewhere in the body. His point is simply that trauma relates to memory and memory is something that happens in our brain. There is no where in the body outside of the brain that can do this. Scientifically and physiologically it just doesn't make sense.

I have pushed back on this idea for years. I have not read the book (it's too graphic in the beginning for me) but the gist of it is that your body remembers the things that happened to you and stores those memories in your body tissues. I don't know if Van Der Kolk meant this literally or if he was speaking in metaphor but it has been interpreted literally by the public and those selling various trauma recovery programs and tools. You can read more about my thoughts on that here.

Ultimately I agree with Prof. Bonanno on this topic as well. Trauma is, in my opinion, predominantly a cognitive problem that has physiological impacts. The past is not stored in your fascia, your grief or anger are not stored in your psoas or your jaw. The past is gone and what remains with you is the skills and bodily functions you developed in adaptive response to the environment you were living in. Your nervous system is constantly defining the world around it and responding for survival. Your NS's map of the world and the most appropriate path through it will influence (strongly, maybe) how you think and feel about the world, and how your physiology needs to be in order to survive in the world. These come together to form our behaviours.

I can't find it in the play back so I am not certain I have their attribution correct but they dropped a GREAT quote, "The brain keeps the score, the body is the scorecard." Leah Benson has a great blog post unpacking this that you can read here.

There was one part I disagreed on, though and that is Bonanno's assertion that Trauma-Informed Care is a very dangerous practice. I was actually kind of surprised that he felt so strongly about it being dangerous. In my learning and understanding, Trauma-Informed Care practices are about leaving space for someone to have a traumatic past that is potentially still influencing them today. In my opinion, we can not look at someone and say "oh this is related to trauma in the past." You can't know someone's story just by looking at them. So it's not about identifying people who have traumatic histories or PTSD in the present, but rather leaving space for it and developing whatever care plans you are collaborating on with that person to achieve goals they have set.

Bonnano described TIC as assuming you may be working with someone who has trauma in their story that they either don't want to talk about or don't know about and thus the practitioner should be very careful in how they speak to that person. He goes on to say more specifically that the assumption someone may have a trauma that they don't know about, that framing their current struggles as trauma reactions or PTSD is dangerous because it may leave people questioning themselves and wondering... "was I traumatized, did something happen to me that I don't remember that explains xyz?" It also risks robbing people of the truth, that PTE's are not a guaranteed pipeline to PTSD but rather resilience and total recovery is much more likely, and removing from them their agency and ability to respond to their life circumstances. And, yes, I can see how that specifically is problematic, but I don't think that in inherently a problem with TIC and perhaps my understanding and application of TIC is different from how Bonanno describes it in this podcast.

It's possible I have strayed from the Rule of TIC in that I do not assume everyone has trauma - I assume I do not know unless they tell me. I conduct myself with the principles of TIC because I know, even for people who are not traumatized, it's easier to deal with a person who is transparent, builds rapport, values your trust and safety, and works to understand your social context in the world. I don't need to know about the things that have disturbed you to provide that to you. For me, the real issues are knowing how you do and do not want me to handle your body, regardless of your history.

Perhaps in the sphere of psychiatric diagnostics and psychological care, this concern may have more weight, as labels are applied, treatment plans developed, and insurers are billed. As an RMT who respects her scope of practice, this isn't a huge concern for me. I don't need to label someone as traumatized nor do I need to identify traumas in their past. It's just not relevant to my work. That said, I think the principles of TIC make the foundations for robust informed consent and rapport building with patients and clientele. More broadly, being appropriately transparent, conducting yourself with trustworthiness, building rapport, respecting the needs and limits of others, and having some awareness of the social contexts at play, both your own and those of the other, is just good personhood. To consider that as dangerous, "very dangerous," seems kind of ludicrous to me. Perhaps I'm not TIC-ing perfectly but I apply TIC to ME. I apply it to how I am going to conduct myself and for the most part it asks me to just be open to someone else's definition of who they are and how they are and why they are the way they are.

Overall this was such an interesting talk and I was delighted by the resilience discussions as it was an excellent reminder for me that even in the worst situations humans typically come out on top. Perhaps a little worse for wear but still fully capable of happiness and health. And I hope that brings you some inspiration as well, whether you are struggling or others in your life are struggling, as a human being you have the capacity for recovery. Statistically speaking, you are far more likely to recover and live your life happily, than any other possibility.