Appendix C – Historical Account of Trauma

Historically, symptoms of traumatic stress have been recorded in both military and civilian populations (). Early accounts described the effect of battle conditions on soldiers; “soldier’s heart” and “nostalgia” were the terms for traumatic stress reactions used during the American Civil War. As warfare techniques and strategies changed, so did the depiction of soldiers’ traumatic stress reactions. The advent of heavy explosives in World War I led to the attribution of symptoms to “shell shock,” giving a more physiological description of the effects from explosions (). On the civilian side, the industrial revolution gave rise to larger and more dramatic catastrophes, including industrial and railway accidents. These, as well as other disasters, are noted in occupational health histories, newspapers, and contemporary literature.

Even with a more physical explanation of traumatic stress (i.e., shell shock), a prevailing attitude remained that the traumatic stress response was due to a character flaw. For instance, a soldier’s pain at that time was often seen as a symptom of homesickness. In spite of the efforts of Charcot, Janet, and Freud, who described the psychogenic origin of symptoms as a response to psychological trauma (), World War II military recruits were screened in attempt to identify those “who were afflicted with moral weakness,” which would prevent them from entering military service.

At the same time, there were new treatment innovations for war-related trauma during World War II. One approach treated soldiers in the field for what was then called “battle fatigue” by allowing some time for rest before returning to battle. During the Korean and Vietnam wars, approaches began to focus more on the use of talk therapy. It was not until the post-Vietnam era that interest in developing treatment alternatives started to take hold. During this time, the U.S. Department of Veterans Affairs (then called the Veterans Administration) developed group therapy for posttraumatic stress disorder (PTSD). Beyond being cost-effective, the technique was well suited to the symptoms of the veterans and fostered socialization and reintegration ().

The publication of the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III), in 1980 marked the introduction of PTSD as a diagnosis, inspired by symptoms presented by veterans of the Vietnam War (). The diagnosis in this iteration required the identification of a specific stressor—a catastrophic stressor that was outside the range of usual human experience ()—and classified PTSD as an anxiety disorder (). Beginning with this definition, the body of research grew, and the scope of application began to broaden, but not without considerable debate on what constituted a trauma.

Historical Approaches to Trauma Healing and Recovery

First Generation of Approaches to Trauma Healing and Recovery

The first generation approaches to trauma healing and recovery focused on individual and clinical interventions to address the symptoms of PTSD and moved toward integration of trauma effects into ongoing life activities. The rapidly developing recognition of additional groups with violence and trauma histories—beyond those with war and captivity experiences (e.g., survivors of natural disasters and terrorism, refugees and immigrants fleeing homeland violence and persecution)— presented issues and needs that incited a second generation of approaches to trauma healing and recovery.

Second Generation of Approaches to Trauma Healing and Recovery

The second generation approaches focused on psychosocial education and empowerment models designed to tap into self-healing forces to energize personal and social movement. These approaches often are based on group and peer support models, and provide both support and education on the management of trauma and its affects. These approaches are not designed to replace clinical or alternative therapies; rather, they provide a social context for care.

Concurrent to the development of psychosocial educational empowerment approaches, we also learned that if the approaches are not implemented in organizations or programs that are trauma-informed, they will not take root and may lose effectiveness.

Trauma-Informed Care: A New Paradigm for Public Health Services

Trauma-informed care is a new paradigm for organizing public mental health and human services. Trauma-informed care changes the opening question for those seeking services from “What is wrong with you?” (patient or consumer) to “What has happened to you?” (survivor). Trauma-informed care is initiated by assumption that every person seeking services is a trauma survivor who designs his or her own path to healing, facilitated by support and mentoring from the service provider.

In a trauma-informed environment, survivors are empowered to proactively set goals and to manage progress toward those goals. For most existing organizations or programs, that requires movement from a traditional “top down” hierarchical clinical model to a psychosocial empowerment partnership that embraces all possible tools and paths to healing. In a pluralistic public health system with many levels and types of services and treatment, this is coming to be accepted as a “sine qua non,” or “without which not,” for humane, dignified, cost-effective, genuinely person-centered support and assistance in moving forward.

Source: , p. 18.

The social revolution that began in the 1960s, combined with the women’s movement and the call for more attention to diverse and disenfranchised groups, set the stage for an increase in the acknowledgement and treatment of victims of interpersonal violence and crime-related trauma (). The introduction of rape trauma syndrome as a condition highlighted the psychological consequences of sexual assault and the subsequent lack of support from society and the social services system (). Subsequently, research began to focus more on interpersonal violence, thus leading to the identification of risk factors and treatment approaches unique to this form of violence and trauma ().

With input from international and national mental health organizations and research, the DSM-IV further modified the definition of trauma to include a broader interpretation of the identified stressor (). DSM-5 has maintained the modified definition of trauma, but the criterion requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly ().

Paralleling the change in DSM criteria, cognitive–behavioral therapy for traumatic stress was developed along with other skills-based approaches ().

Researchers, such as Foa, Resick, D’Zurilla, and Michenbaum, added to the body of knowledge and gave clinicians a variety of tools; these approaches continue to develop and show efficacy even today. There was also renewed interest in the long- and short-term effects of childhood sexual abuse and domestic violence. Interest in documenting the effects of trauma expanded further, including traumatic brain injury, significant orthopedic injuries, and multiple traumas (). So too, the consumer movement in health care began. Consumers insisted on patient rights, humane treatment, and involvement in the treatment process; as a result, the paternalistic approach to health care began to change. As consumers set the initial stage and Federal agencies (e.g., the Substance Abuse and Mental Health Services Administration and its centers) and national organizations promoted the need for trauma-informed policies and care, national studies began to demonstrate the prevalence of traumatic experiences. Research including the Adverse Childhood Experiences and the Women, Co-Occurring, and Violence studies clearly demonstrated the pervasive long-term impact of trauma, reinforcing the call for trauma-informed policies and care. (For more information on the development of trauma-informed care, see , as well as .)


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