To develop a thorough understanding of traumatology, a summary of the general understanding of the nature and causes of trauma will be explained. Additionally, a specific type of event that can result in a trauma-related disorder will be discussed. Special emphasis will be placed on the causes, description of symptoms, short- and long-term effects, overview of possible treatment methodologies, and an in-depth look at one recommended treatment. A Scriptural worldview will be integrated, as well as a consideration of future research ideas.
Nature and Causes of Trauma
Defining Traumatology
The field of traumatology is a relatively recent field of study emerging out of a need to address the pain many are currently enduring as a result of the atrocities that occur in this fallen world. Traumatology can be defined as the study of traumatic stress (Morrissette, 2004). Merriam-Webster (n.d.) defines traumatology as “the evaluation and treatment of psychological trauma in individuals affected by severe mental or emotional stress or physical injury.” Additionally, traumatology is also “the academic field that studies the various interdisciplinary aspects of trauma (Gingrich & Gingrich, 2017). Therefore, in essence the field of traumatology seeks to understand the effects of subjectively traumatic events on survivors and the possibility of healing and growth in their aftermath. Although the causes of trauma may fall within a wide range of possibilities, the fundamental characteristics of trauma and its effects on a person are strikingly similar.
Another important word to define is trauma. An initial investigation into the field of traumatology inevitably begs the question of what should be considered trauma. Gingrich and Gingrich (2017) state that trauma does not only refer to tragic external events that occur in life, but also internal responses, individual and shared, to those events. Bad events on their own do not constitute trauma, but rather a “subjective experience of physical, emotional, or relational harm” (Gingrich & Gingrich, 2017, p.9). The abundant life described in John 10:10 has been disrupted by very hurtful life events; the thief has stolen, slaughtered, and destroyed (Gingrich & Gingrich, 2017; The Scriptures, 2018). The key to understanding trauma and truly helping those who have survived it is to understand that responses to it are subjective. In other words, the person defines whether they have endured harm that is debilitating. Many have resilience built into them from their early years and can overcome situations which can be traumatic for others and cause lingering relational and internal problems. The study of traumatology seeks to understand those internal and relational consequences of trauma (Gingrich & Gingrich, 2017).
As the field of trauma has changed over the past three decades, there has been an acceptance of trauma reactions being a normal response to abnormal circumstances (Morrissette, 2004). This perspective is causing the field of traumatology to inadvertently become more aligned with Scripture, as Romans 8:22 states that “For we know that all the creation groans together and suffers the pains of childbirth together until now” (The Scriptures, 2018). All of creation groans because we live in a disaster site brought about after the Fall of mankind (Genesis 3, The Scriptures, 2018; Gingrich & Gingrich, 2017). Therefore, those called to the field of traumatology have been called to help clean up this disaster site (Gingrich & Gingrich, 2017), understanding that in the wake of a disaster, pain and suffering exist as a normal response in a fallen world and that by being present, they can bring understanding and hope to struggling survivors.
History of Traumatology
The history of trauma and its causes lends a rich understanding of the evolution of the field of traumatology. During the Civil War, soldiers returning from war with psychological issues were seen as being weak and having underlying past problems and were therefore perceived as already defected (Morrissette, 2004). Over time, each war represented a period of evaluation of the effects that soldiers were returning with, eventually adopting a psychological understanding of the symptoms being displayed (Morrissette, 2004). It was during the Vietnam war that posttraumatic stress disorder (PTSD) was acknowledged and linked to the experience of severe distress (Morrissette, 2004). In 1980, the Diagnostic and Statistical Manual of Mental Disorders (DSM) first included PTSD (Gingrich, 2020). By the time 2001 came around, the United States was faced with processing the devastating effects of trauma upon first-responder populations as well as civilians. The evolution of the understanding of psychological trauma can be separated into two phases. Phase one challenged the belief that those who endure psychological distress in the aftermath of a traumatic event had a previous susceptibility and were emotionally unstable; phase two included the understanding of vicarious traumatization of the people around those who experienced trauma first-hand, such as family members, significant others, and caregivers (Morrissette, 2004).
Trauma Prevalence
The importance of the study of traumatology is placed into perspective when considering the statistics regarding PTSD. According to the U.S. Department of Veteran Affairs (2022), 6% of the population will experience PTSD over the course of their life. During any given year, about 12 million adults in the United States may have PTSD, with women being twice as likely as men to develop PTSD (U.S. Department of Veteran Affairs, 2022).
With regards to children, the Substance Abuse and Mental Health Services Administration (SAMHSA) states that (a) more than two thirds of children report experiencing at least one traumatic event by the age of 16, (b) in the past year one in seven children have experienced abuse or neglect, and (c) in the year 2019, 1,840 children in the United States died as a cause of abuse and neglect (2022). Given statistics like these, understanding the nature and causes of PTSD and complex PTSD equip professionals to bring needed help to individual survivors and the community.
Neurobiology of Trauma
A brief description of the way trauma affects the body broadens understanding of the study of traumatology. Uhernik (2017) describes the concept of a triune brain which includes the brainstem, midbrain, and the cerebral cortex. The following description of the triune brain is useful in considering a bottom-to-top (brainstem to cerebral cortex) physiological return to basic functioning after trauma (Uhernik, 2017). The brainstem is in charge of basic functions such as breathing, regulating temperature, sleeping, and movement. Emotions, the fight-flight-freeze response, and memory information storage originate in the limbic system, part of the midbrain. Higher order thinking occurs in the cerebral cortex. Understanding the function of these structures and bottom-to-top return to normal functioning can go a long way in guiding treatments that are used to help survivors of trauma return to a fully integrated brain.
As a result of trauma, the brain dis-integrates itself. The areas of the brain below the cortex take over and the limbic system increases its activity (Gingrich, 2020). In essence, the cerebral cortex, the area of the brain that rationally regulates behavior, is bypassed. Therefore, the limbic system communicates to the body that there is danger, even when the danger has passed, and the body is flooded with the stress hormones cortisol and adrenaline which in turn trigger the fight-flight-freeze response (Gingrich, 2020). The internal feedback system the body uses to regulate itself becomes overactivated, resulting in big responses to reminders of the trauma (AACC, 2017). Therefore, although the body is designed to normally respond in this way in the presence of danger, survivors with PTSD live in an intermittent state of arousal in which trauma reminders in the form of thoughts, dreams, or situations inhibit the body from being able to ascertain the difference between the real traumatic event in the past and the current posttraumatic symptoms (Gingrich, 2020).
Nature and Causes of Trauma- and Stressor- Related Disorders
The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) includes a section for trauma- and stressor-related disorders for which there must be exposure to a traumatic or stressful event as a diagnostic criterion. The disorders included in this section are reactive attachment disorder, disinhibited social engagement disorder, PTSD, acute stress disorder, and adjustment disorder. Reactive attachment disorder and disinhibited social engagement disorder are both diagnosable for children and necessitate the absence of proper caregiving during childhood resulting in serious attachment problems between the child and adult and inappropriate over familiar behavior with strangers, respectively (APA, 2013). Acute stress disorder, although similar to PTSD, is diagnosed within 3 days to 1 month after exposure to a traumatic event and requires the presence of nine or more symptoms from within any of the clusters of intrusion, negative mood, dissociative, avoidance, and arousal symptoms (APA, 2013). Diagnosis of adjustment disorder requires the presence of emotional or behavioral symptoms in response to a stressor within 3 months (APA, 2013).
The major trauma- and stressor-related disorder in this category is PTSD. It is worth noting that Complex PTSD (C-PTSD) is not listed as a separate disorder in the DSM-5. The differentiating between PTSD and C-PTSD in the literature includes strong convictions on either side of the spectrum regarding its inclusion as a separate disorder (Friedman, 2015; Gingrich, 2020). However, counselors with years of experience in treating survivors of trauma have described specific distinctions in the symptomatology of those who have endured different forms of trauma leading to a necessity of separate diagnostic features for the purposes of establishing proper and uniform treatment protocols (American Association of Christian Counselors [AACC], 2017; Gingrich, 2013).
PTSD refers to a disorder experienced by a relatively small proportion of survivors of traumatic events. Those exhibiting this disorder have developed symptoms of intrusion, avoidance, negative alterations in cognitions and mood, and marked alterations in arousal and reactivity all associated with the traumatic event (APA, 2013). These symptoms have persisted beyond a month of the traumatic event and have caused clinically significant distress or impairment in areas of functioning (APA, 2013). The exposure to the traumatic event could have included direct experience, witnessing it occur to another, learning that it happened to a close one, or repeated or extreme exposure to details of traumatic events, such as with first responders (APA, 2013). Although traditionally, PTSD was focused solely on war trauma (Morrissette, 2004), research efforts have expanded this understanding and include such things as physical abuse, sexual violence, torture, severe vehicle accidents, kidnappings, amongst many others (APA, 2013). Not included are life-threatening illnesses or debilitating medical conditions unless they were sudden catastrophic medical incidents (APA, 2013).
C-PTSD includes all symptoms included in the DSM-5 under the PTSD diagnostic criteria, however, many others that are not described tend to dominate the presentation of survivors of complex trauma. Some of those symptoms may include a distorted view of self, self-blame for abuse endured, identity confusion, severely impaired trust levels, difficulties which affect regulation, dissociation, distorted perception of the perpetrator, physical problems related to abuse or medical issues, and alterations in systems of meaning leading to hopelessness about recovery (Gingrich, 2020). These kinds of problems do not respond well to traditional treatments for PTSD which focus on a single traumatic event since these survivors have more than likely endured repeated trauma over a period of time (Gingrich, 2020).
Whereas causes for the development of PTSD tend to be isolated events, C-PTSD usually develops as a result of continuous emotional, physical, or sexual trauma at a young age when basic developmental milestones should be reached (Gingrich, 2020). Another significant distinction between PTSD and C-PTSD is the trauma source. In PTSD, the source of trauma is not usually someone the victim has a relationship with. However, in C-PTSD, the source of trauma is often those closest to the victim, such as parents or significant others (Gingrich, 2020). Therefore, for the survivor of complex trauma, the one hurting them was the same one who claimed to love them and care for them. The perpetrator was the person they were supposed to run to for help.
Comorbid Conditions
It is important to consider other conditions that a survivor with PTSD may be struggling with because according to the DSM-5, individuals with PTSD are 80% more likely to have symptoms that meet diagnostic criteria for at least one other mental disorder (APA, 2013). These are mainly depressive disorder, bipolar disorder, anxiety disorders, and substance use disorders (APA, 2013). With C-PTSD, survivors often also present with dissociative identity disorder (DID), previously known as multiple personality disorder, and borderline personality disorder (Chu, 2011).
Major Treatment Modalities
Several treatments have been found to be empirically supported for the treatment of trauma. The International Society for Traumatic Stress Studies (ISTSS), a leader in trauma research, strongly recommends Cognitive Behavior Therapy – Trauma (CBT-T) as well as Eye Movement Desensitization and Reprocessing for children with posttraumatic stress symptoms (2019). For adults with PTSD, Cognitive Processing Therapy (CPT), Cognitive Therapy (CT), EMDR, Individual CBT with a trauma focus, and Prolonged Exposure (PE) are strongly recommended (ISTSS, 2019). Additionally, CBT without a Trauma Focus, Group CBT with a Trauma Focus, Guided Internet-based CBT with a Trauma Focus, Narrative Exposure Therapy (NET), and Present Centered Therapy (PCT) are standard recommendations (ISTSS, 2019).
Worth noting are treatments such as those mentioned in Uhernik (2017) which involve somatic approaches to treatment with a basis on neurophysiology. In alignment with the bottom-to-top approach of the brain, treatments such as art therapy, dance therapy, and aromatherapy address parts of the brain that feel emotions before the treatments which require cognitive processing such as CBT, the most recommended treatment for trauma (Uhernik, 2017). Another treatment garnering attention is based on the Trauma Resiliency Model (TRM) which first focuses on teaching the survivor to regulate their own nervous system, and then once the client is comfortable with doing so, the therapist can help them reprocess the traumatic experience (Miller-Karas, 2015). With TRM, the emphasis is on traumatic symptoms that affect nervous system regulation – rather than in cognitions and emotions – and especially immediately after a traumatic incident, TRM has the ability to significantly reduce psychological symptoms (Leitch et al., 2009).
Treating complex trauma presents a different set of challenges as it has been found that survivors with C-PTSD do not respond as well to recommended treatments for PTSD (Gingrich, 2020). A three-phase treatment for C-PTSD is followed among clinicians who treat survivors with complex trauma, with the understanding that phase one may take the longest amount of time as survivors develop trust and safety in the therapeutic relationship (Chu, 2011; Sanderson, 2013). Phase two includes the processing of trauma, which is only begun once the survivor has the skills to handle the difficult trauma reactions that emerge (Gingrich, 2020; Sanderson, 2013). The goals of phase three may include helping the survivor to develop healthy relationships, learn to live as an integrated whole, and practicing forgiveness (Gingrich, 2020).
Working with Trauma from a Scriptural Worldview
Working with trauma survivors brings a greater awareness of the dichotomy of good and evil presented in Scripture from the very beginning chapters. Evil presents itself in the form of loss of safety and assurance in people and sometimes, YHVH Himself. Survivors struggle with “why” questions that have no easy answer. Therapists would do well in avoiding easy answers, instead choosing to sit with the survivor through their pain, demonstrating empathy and genuineness (Gingrich, 2020). Hebrews 4:15-16 states, “For we do not have a High Priest unable to sympathize with our weakness, but One who was tried in all respects as we are, apart from sin. Therefore, let us come boldly to the throne of favour, in order to receive compassion, and find favour for timely help” (The Scriptures, 2018). Therapists who love and obey YHVH have a calling to imitate Messiah in the way He walked. Therefore, when helping a survivor, the very presence of the therapist conveys His compassion and empathy.
Noting the reliance on the medical model in the field of trauma, and mental health in general, the question of whether the basic underlying belief that something is wrong and needs to be fixed is compatible with Scripture is viable. There are many therapists who prefer not to adhere to this model, including using books such as the DSM-5 and empirically supported treatments (ESTs), such as CBT and EMDR, citing that they are part of a system of oppression and reductionistic in nature (Conti, 2018). There is truth to the belief that ESTs have been verified under sterilized conditions not truly representative of the real world (Conti, 2018), however, many therapists who use treatments such as these report improvement for the majority of clients, especially in the trauma field when treating PTSD (Edmond & Voth Shrag, 2017).
Therapists who hold Scripture to be the ultimate truth do not hold the DSM-5 and ESTs as the ultimate authority, but instead rely on Scripture and the Spirit of YHVH as the standard to which all that claims to be truth must measure up (John 17:17, The Scriptures, 2018). Additionally, a basic understanding of the sinful nature which needs to be redeemed is compatible with the belief that something is wrong and there is a solution. For therapists who rely on the Spirit of YHVH and the truth of Scripture, the hurting person is in need of Yahusha, the Son of YHVH, the only One who is able to bring wholeness (1 Peter 5:10, The Scriptures, 2018). This foundational belief shapes the character of the therapist in a way that demonstrates the life of the Son through their very presence (1 John 5:12, The Scriptures, 2018). They make room to allow a hurting person to experience His compassion, love, and empathy. Techniques, models, and labels are used, not robotically, but as necessary, guided by the Ultimate Counselor Himself, The Spirit of YHVH (John 14:26, The Scriptures, 2018).
Specific Event that can Result in Trauma Related Disorder
As it has been discussed above, the development of a trauma-related disorder is based on the subjective experience of the survivor. There are many different situations that could result in a traumatic experience, including but not limited to war, sudden accidental death of a loved one, repeated abuse, natural disasters, and sexual trauma (APA, 2013). In the following section, sexual trauma will be further elaborated on, and a possible treatment will be examined.
Causes
Sexual trauma can take the form of child sexual abuse, rape, sexual assault, and threat of sexual assault (Edmond & Voth Schrag, 2017). Sexual trauma can be perceived as along a continuum, with one extreme representing a one-time assault or threat of assault; while the other extreme may represent repeated, long-term, sexual abuse. As it pertains to child sexual abuse, almost 90% of children are abused by either a family member or an older child they know (Clinton & Langberg, 2011). Typically, the abuser engages because he/she sees the child as an adult, thinks of themselves as a child, or may be a sociopath (Clinton & Langberg, 2011). An important cultural consideration regards gender. Although women are more likely than men to endure sexual trauma (Clinton & Langberg, 2011), this does not imply that men are mostly safe from it or will not endure lasting consequences. The reality that sexual abuse of males results in a different set of issues such as masculine gender socialization, issues regarding homosexuality, and the fear of becoming predators themselves must be addressed (Gartner, 2018).
Symptom Descriptions
Survivors of sexual trauma may have the following symptoms:
- “physical injuries evidence of the sexual assault
- recurrent intrusive memories, nightmares, and/or thoughts of the assault
- avoidance of situations related to the assault
- anxiety, subjective sense of numbing, helplessness, fear, irritability, afraid to be in public spaces or crowds alone since the assault
- feelings of vulnerability, powerlessness, guilt, or shame
- insomnia, difficulty concentrating, motor restlessness, depression, restricted range of affect
- abstaining from intimacy, pain during intercourse, avoidance of sexual encounters since the assault” (Kolski et al., 2014, p.185)
Short- and Long-Term Effects
Consequences of sexual trauma may include PTSD, depression, anxiety, and substance abuse, with PTSD being the most commonly experienced (Edmond & Voth Schrag, 2017). Due to vulnerability of survivors of sexual trauma with regards to coping strategies such as substance abuse, they are almost 14 times more likely to experience re-victimization (Edmond & Voth Schrag, 2017). Linked to PTSD after sexual trauma is a feeling of disgust associated with the assault that may be turned internally and cause the survivor to feel dirty or contaminated (Badour & Feldner, 2015). Further, in a study comparing sexual trauma with combat trauma, sexual trauma revealed greater PTSD symptom severity than combat trauma (Jakob et al., 2017).
Another effect often missing from treatment protocols are sexual problems. Survivors of sexual trauma are four times as likely to report sexual problems than those survivors of non-sexual trauma (O’Driscoll & Flanagan, 2016). Prevalence rates of sexual problems for women who have experienced sexual abuse or assault is approximately 60% (O’Driscoll & Flanagan, 2016). Although this effect of sexual trauma is so incredibly pronounced in survivors, O’Driscoll and Flanagan (2016) found that among their analysis of randomized controlled studies that attempted to measure sexual problems as an outcome of various PTSD treatments, there was no improvement in sexual concerns and dysfunctional sexual behavior. It is therefore important for therapists to assess for sexual problems and incorporate a direct intervention for sexual problems as needed (O’Driscoll & Flanagan, 2016).
Specific to child sexual trauma, effects may include long lasting physical symptoms and illness; a slew of psychological consequences such as disbelief, denial, and withdrawal as well as PTSD, depression, emotional detachment, suicidal behavior, and substance use; as well as social consequences such as engaging in risky sexual behavior and future negative effects on relationships (Clinton & Langberg, 2011).
Possible Treatment Methodologies
Strongest support for treatment of sexual trauma includes CPT, PE, EMDR, narrative exposure therapy, imagery rescripting, and stress inoculation training (Edmond & Voth Schrag, 2017; Rajan et al., 2022). However, although the most likely places for a survivor of sexual trauma to look for help are Rape Crisis Centers, it has been shown that counselors there are not likely to use these ESTs (Edmond & Voth Schrag, 2017). Exposure therapy is another treatment that has been efficaciously applied for the treatment of anxiety in survivors of sexual trauma, however, Badour and Feldner (2015) found that it did nothing for the feelings of disgust that survivors of sexual trauma feel.
Other treatment methodologies have been tested and shown promising results for survivors of sexual trauma. One such approach called Modified Lifespan Integration (MLI), a single session PTSD treatment, was tested on survivors of one sexual assault and demonstrated efficacious reduction in PTSD symptoms at three-week follow up compared to a wait list control (Rajan et al., 2022). This is an interesting treatment since it does not require adherence to a treatment protocol (Rajan et al., 2022).
Cognitive Behavioral Conjoint Therapy for PTSD
In a study investigating the association between social support and resulting depression and PTSD among sexual abuse survivors, it was found that female survivors of rape who were either married or cohabitating with an intimate partner had significantly lower symptoms of depression and PTSD (Mgoki-Mbalo et al., 2017). Additionally, there is evidence that couples therapy for survivors of childhood sexual abuse (CSA) can be just as effective for the treatment of trauma as individual ESTs and yield better results in improvement of communication, relationship quality, and positivity between partners (Taylor, 2017).
One treatment available for couples in which one partner has survived sexual trauma is Cognitive-behavioral Conjoint Therapy (CBCT) for PTSD (Taylor, 2017). CBCT for PTSD has not only been shown to improve PTSD symptoms and mental health, but also depression, panic and anxiety, substance use, and anger (Taylor, 2017). CBCT for PTSD is a manualized, three-phased, 15 session, standalone treatment (Taylor, 2017). Before treatment begins, the couple meets with the therapist for three assessment sessions, two with each individual and one together (Taylor, 2017). Once treatment begins, the first session focuses mainly on psychoeducation on trauma while subsequent sessions teach and make room for practice of skills to “increase relationship satisfaction, undermine the avoidance that maintains both the PTSD and the relationship problems, and make meaning of the traumatic events that caused the PTSD” (Taylor, 2017, p.130).
The three phases of CBCT for PTSD can be described with the acronym R.E.S.U.M.E. Living (Monson & Fredman, 2012). In the manual for CBCT for PTSD, Monson & Fredman (2012) explain the following regarding the phases of treatment. Phase one includes Rationale for Treatment (R) and Education about PTSD and relationships (E). During this phase, the rationale for treatment, overview of the protocol, and psychoeducation is provided. Phase two is composed of Satisfaction Enhancement (S) and Undermining avoidance (U). Goals for this phase are learning about the role of avoidance and communication skills to address PTSD and relationship problems. Lastly, phase three includes Making meaning of the trauma(s) and End of therapy (E). Since in phase three communication skills have been rehearsed and improved, the resolution of problematic appraisals and core beliefs is addressed within the domains of trust, control, emotional closeness, and physical intimacy. Therapy ends as posttraumatic growth is discussed and a review of the gains of therapy and possible future challenges are addressed.
CBCT for PTSD is just one of the therapies available for therapists willing and able to work with couples of which one person has endured sexual trauma. Taylor (2017) eloquently explains the benefits of couples therapy for sexual trauma as she reflects on the ending of the therapeutic relationship. In individual therapy, when it has come to an end, the survivor is then on their own as they continue on their journey. However, in couples therapy, the survivor has learned to develop a stronger relationship with their significant other and can use that relationship as a secure base while continuing to work through challenges as well as growth.
Conclusion
The study of traumatology is an exciting field constantly growing in depth of knowledge that can be used in helping hurting survivors of trauma. Continuing research in the areas of treatment addressing the bottom-top-approach of the brain would be helpful as treatments may be combined to achieve the best results for the survivor. In a similar way as treatment for C-PTSD and sexual trauma is phase oriented, further understanding of treatments that first address bodily responses and how necessary they are for cognitive processing to proceed accordingly, can be implemented in a phase format. Further research into possible phase oriented somatic and cognitive treatment may be warranted. Equipped with understanding from biological, environmental, psychological, social, and spiritual perspectives of trauma, a therapist who loves, obeys YHVH, and is guided by the Spirit of Truth can be used mightily in the lives of trauma survivors.
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Discerning Trauma 