Many shapes of trauma, many forms of pain

I was reminded this afternoon that there is still work to be done, in the media and in our therapy offices, to remind one another (and make the case) that trauma (and its cousin, pain) can take many forms.

PTSD, the diagnostic label under which most trauma is captured, was historically a diagnosis most commonly given to men, in particular soldiers returning home after experiencing or witnessing the fear and violence of battle. (George Carlin speaks brilliantly (and with his typical provocativeness--fair warning!) about the evolution of the clinical language--from "shell-shock" to PTSD--used to describe their very real experience).

While there is still not enough being done to treat PTSD for soldiers (not to mention preventing it) the trauma associated with war as nearly-universally regarded as a legitimate cause of emotional suffering. We've also done some work, culturally speaking, on adding victims of violent crime, including sexual assault, to the ranks of those we consider legitimately vulnerable to trauma.

Pain is pain, trauma is trauma: Making more room

There are other sets of experiences that tend to not be so well honored as "legitimate" sources of trauma. The consequence is that we leave a good number of people alone in their suffering. While diagnosing pain isn't the only way to respect it (or treat it), diagnosis tends to be the gatekeeper to formal treatment (and a non-negotiable obstacle to insurance reimbursement, government services, admission to certain kinds of out-patient treatment, etc.). Formal diagnosis also has a "trickle down" effect with regard to how we legitimize (or fail to legitimize) suffering in everyday conversations. It affects the questions we ask and, perhaps more notably, the questions we don't ask.

Take for example a serious illness that results in an extended stay in the I.C.U. If you've experienced a catastrophic injury or had major surgery, there's no better place to be than the I.C.U. of a major American research hospital. And yet if you find yourself in one, you've no doubt gone through a serious life event. We attend very well in those spaces to physical suffering, and often look at the cause of that suffering (an accident, an act of violence) for evidence of trauma. But what about the experience in the hospital itself? Even with the best of intentions (and often directly because of those intentions) the steps doctors and nurses take to keep a patient alive in the I.C.U. can cause trauma themselves. But because we are (understandably) focused on the physical recovery, and because we don't typically associate these experiences with trauma, medical providers and friends and family alike tend not to investigate this terrain for emotional fodder in the same manner we would with other sorts of suffering more commonly associated with trauma.

Chronic childhood neglect is another such matter. I have worked in my therapy practice, for example, with adults who had a parent who struggled with serious mental illness or abused alcohol and was unable to adequately care for and be emotionally available to his or her child. In other cases unhealthy relationships among parents or parental loss result not necessarily in violence (or not only in violence) but in a traumatic, chronic neglect that may not look like an acute, episodic event (a rape, a fire, a car crash) of the sort that we tend to associate with trauma.

Bullying, divorce, the loss of a loved one--these are all common life experiences that can have not-so casual consequences.

If we call that trauma, does it make my trauma (his/ her trauma) less meaningful?

At the risk of sounding snarky (and I'm going to slightly overstate my case), the question seems to me roughly equivalent to the so-called traditional marriage argument that allowing same-sex couples to marry will somehow devalue the marriages of straight couples. As it turns out, that hasn't happened, and I don't think making room for a broader appreciation of the sorts of experiences that can traumatize needs to take away from an appreciation of any other sort of experience. Not all trauma is the same, to be sure, but need we create a hierarchy of the legitimacy of suffering (as some propose we should do with the legitimacy of certain types of love)?

Trauma: Not a lifetime sentence

In my experience, the greater risk is in leaving people who are in pain alone. And that's a risk I'm not willing to take. There is no hierarchy of suffering, and suffering sometimes needs us to go looking for it because those who are in pain might be experiencing that pain in a way that makes it hard for them to know they need help. An experience of trauma doesn't need to be a sentence for a lifetime of suffering. Of course it doesn't. What we do know (and what we experience, as therapists who work with trauma everyday), is that trauma and pain need attention, need to be honored, and when we do so, we can begin to help it get better.