While PATH providers often do not have medical training, they regularly encounter consumers who face health issues. This section of Assessing Health, Promoting Wellness provides an introduction to trauma.

The unexpected loss of a loved one, a car accident, or exposure to a violent experience is familiar to many of us. Everyone reacts to such events, but the responses vary widely, ranging from numbness and withdrawal to crying, nervousness, and agitation.

There is no “right” way to respond to or recover from a traumatic event. Over time, some people are able to integrate these experiences and begin to heal. For others, this process is considerably more difficult. Some responses to trauma are intense and prolonged, and interfere with a person’s ability to function.

Because traumatic events are prevalent, cause profound suffering, and may lead to life-altering responses, it is imperative that caregivers have the knowledge and understanding to respond skillfully and compassionately to people exposed to traumatic stress.

What is trauma?

Trauma involves some sort of overwhelming experience that goes beyond usual day-to-day stressors.

It typically involves some sort of threat either to oneself or to a loved one. This threat can be physical or emotional.

The experience overwhelms our usual systems of coping and results in a profound sense of vulnerability and a loss of control.

This experience leaves people feeling helpless and fearful, and over time, may adversely affect their relationships and ways of thinking about the world.

Traumatic experiences occur in many forms, including:

• Unexpected loss of a loved one
• Loss of job or home
• Accidents
• Community or school violence
• Domestic violence
• Neglect
• Physical and sexual abuse
• Man-made and natural disasters
• War and acts of terrorism

It is important to remember that while there are some life events that most people would describe as “traumatic,” what one person considers traumatic may not be traumatic for someone else. What may leave one person feeling helpless and out of control may not lead to those same feelings in another person.

Trauma generally falls into two categories:

• Single incident traumas (or acute traumas) occur as a one-time event such as an earthquake, bombing, assault, or car accident.
• Multiple traumas refer to the layers of ongoing trauma that people sometimes experience over their lifetimes. Multiple traumatic experiences can occur because of a single event such as a natural disaster that leads to loss of loved ones, loss of home, or separation from family, or from a lifetime of traumatic experiences that may include childhood abuse and adult experiences of domestic violence.

The body’s response to trauma

Our brains have a built in alarm system designed to detect potential danger and help us to respond quickly and effectively to a threatening situation. In general terms, here is what happens when our brains and bodies face threatening or dangerous situations.

How the alarm system works

To understand how the brain responds to stress, we will talk about the doing and thinking parts of the brain. The doing part of our brain acts like a smoke detector. Its purpose is to detect anything that might potentially be dangerous (e.g., hearing a sudden, loud noise). The purpose of the thinking part of the brain is to check things out when the doing brain sounds the alarm, to see if there is actual danger.
Information comes into the brain through the senses (sight, touch, sound, smell, and hearing). At the same time that the doing brain takes in the information it also goes to the thinking brain. It is the thinking brain’s job to evaluate the situation and decide whether the danger is real (e.g., whether the loud noise is just a door blowing closed in the wind or if that noise signals a danger that you have to escape from). If the thinking brain determines that there is no actual threat, it sends this message to the doing brain to shut the alarm off so that you can return to your prior activity.
If the thinking brain decides that there is real danger, it sends this message to the doing brain, and the doing brain takes action. When this happens, the thinking brain gets shut off because it is no longer necessary and the doing brain starts the release of chemicals that prepare you to respond to keep yourself safe.

When our brains perceive danger, we are likely to react in one of three ways:

• Fight
• Flight
• Freeze

Everyone has intense physical and emotional responses to threatening or dangerous experiences. We all feel the rush of adrenalin as our brains release those chemicals and we choose to fight, flee, or freeze. The more intense the situation, the longer it may take those chemicals to come back into balance and for us to feel “normal” again.

An experience becomes “traumatic” when it overwhelms this physiological system of coping. In the face of trauma, we fight, flee, or freeze, and yet, we do not achieve the desired result. The intensity of a person’s emotional response to a threatening event will depend on how overwhelming or “traumatic” the individual perceives the event to be.

Events perceived to be particularly threatening may lead to a longer time for the body to return to normal after facing the threat or danger. In such cases, the release of chemicals and the body’s attempts to fight, flee, or freeze may continue once the threat subsides. Some people may perceive an experience as so “traumatic” that their bodies continue to respond in ways that have an impact on daily functioning, and additional help and support may be necessary in order to recover and regain control. Many factors influence a person’s ability to recover from trauma without developing significant difficulties. We will discuss these factors later in this section.

The intent of the design of the brain is to keep us as safe as possible. The brain is always finding new ways to adapt and change in order to protect us best from danger. Therefore, when we experience traumatic events, our brains remember many aspects of these events (e.g., sights, sounds, and feelings) so that if we face similar experiences, our bodies can respond very quickly, going into automatic fight, flight, or freeze mode without having to use the thinking brain to check things out.

After experiencing a traumatic event, people may hear, smell, taste, see, or feel something that reminds them of a past traumatic experience. These reminders are “triggers.” When a person faces a trigger, the brain automatically assumes there is danger, because the brain associates these signals with being in danger previously. The thinking part of the brain automatically shuts off and the doing part of the brain takes over and prepares the body to respond.

Chronic exposure to trauma actually changes the way the brain functions. If the world we live in is consistently dangerous, the brain decides that it can more efficiently protect us by assuming that everything is dangerous. In other words, rather than the thinking brain checking things out when the alarm goes off, as we talked about earlier, the doing brain always assumes that the body is in danger and responds accordingly. Because the thinking part of the brain shuts off automatically at the first sign of danger, people lose their ability to assess accurately whether the present danger is real. The alarm system becomes faulty because people lose their ability to tell whether a danger is presently real or is just a reminder from the past. A “false alarm” happens when people’s bodies respond as if they are in danger, even when they are not.

People with experiences of chronic trauma have significant lists of triggers, making the whole world a dangerous and scary place for them. Because chronic trauma survivors learned to pay close attention to signals for danger, these triggers are often subtle and can be difficult to detect. Ordinary things become triggers, which can lead to intense fight, flight, or freeze responses that may appear confusing and out of place to others (intense responses to smells, colors, sounds, etc.).

Effects of trauma

Traumatic experiences are often shattering and life-altering for children and adults. These experiences may affect all levels of functioning and result in an array of distressing responses:

• Physical. Increase in physical complaints such as headaches, stomach aches, nausea, nervousness, fatigue, palpitations, pain, difficulty sleeping, nightmares, and worsening of existing medical problems. Longer-term physical issues such as ulcers, asthma, heart disease.
• Emotional. Fear, anxiety, panic, irritability, anger, withdrawal, numbness, depression, confusion, hopelessness, helplessness. Difficulty managing, understanding, and regulating feelings.
• Cognitive. Difficulty focusing, concentrating, thinking, planning, problem-solving. In the face of chronic threat, people focus on survival, which can lead to problems concentrating, difficulty learning, and struggles at school or work.
• Relational. Difficulty maintaining relationships, trusting others, maintaining a sense of self in relationship to others. Perceive the world and others as unsafe. Includes emotional barriers, distrust, feelings of betrayal, and relationship difficulties (i.e., attachment problems) between parents and children.

Nearly all trauma survivors have acute symptoms following a traumatic event, but these generally decrease over time. Various factors influence the recovery process:

• Previous exposure to trauma. This exposure may include neglect, physical abuse, sexual abuse, or abrupt separation from a caregiver or partner.
• Duration of exposure to trauma. A one-time exposure, such as a car accident, results in very different responses than exposure over several years, such as domestic violence. The longer the exposure, the more complex the healing process.
• Severity of exposure. An incident that happens directly to someone or in a person’s presence will have a different impact than an incident that happened to someone else or that a person learned about later. The more severe the exposure, the more difficult it will be to heal.
• Prior emotional and behavioral problems. Pre-existing behavioral problems or a prior history of depression or anxiety may complicate a person’s response to a traumatic event.
• Strengths/coping skills. The more strengths people identify and the more coping skills they master and are able to use consistently in the face of distress, the greater the likelihood that they will be able to recover from a traumatic event without experiencing long-term difficulties.
• Stage of development. Where we are in our development when we experience trauma can have a significant impact on how we respond and how severe an impact a traumatic experience may have. Adults experiencing trauma throughout their lifespan, beginning in childhood, may not have the opportunity to master certain skills in childhood and adolescence. These adults may struggle to hold jobs, raise children, and manage day-to-day stressors.
• Cultural background. While the brain’s response to trauma is consistent for all trauma survivors, cultural context plays a significant role in the types of trauma experienced, the risk for continued trauma, how survivors manage, express, and make meaning of their experiences, and which supports and interventions are most effective. Violence and trauma have different meanings across cultures, and healing can only take place within one’s cultural and “meaning-making” context.
• Nature of relationships and social supports. The quality of our early relationships with caregivers influences our ability to form relationships in adulthood. Early trauma can make forming adult relationships difficult. It decreases our ability to trust, seek out safe supports, etc. As a result, we are likely to have decreased social support and therefore, the impact of another trauma on our lives can be more disabling.
• Care provider’s response after the exposure. It matters whether a care provider validates someone’s experience or blames the person, or if the worker is able to provide comfort and reassurance instead of having difficulty responding to the person. When a provider of care experiences a high level of distress, the other person often responds similarly. The care provider’s support is one of the most important factors in someone’s recovery from trauma.

The need for trauma-informed services

The effects of repeated exposure to traumatic experiences can be long-term and pervasive. The impacts can involve all areas of a person’s life, including biological, cognitive, and emotional functioning, social interactions and relationships, and identity formation. Simply stated, people who experience multiple traumas tend to relate differently to the world than those without significant trauma histories.

Many people endured multiple traumas prior to being homeless and because of becoming homeless. These experiences significantly affect their understanding and perception of themselves, their environment, and the people around them. Consequently, these individuals require specific types of services that are sensitive to their status as trauma survivors. In addition, individuals need to have access to therapeutic relationships and experiences to promote trust, coping, and healing.

What services providers can do

• Adopt a “trauma-informed” approach to service provision and care. This approach means viewing the lives of people through a “trauma lens” that provides a way to understand their behaviors, responses, attitudes, and emotions as a collection of survival skills developed in response to traumatic experiences. Otherwise, the impact of trauma gets lost amid other mental health, substance use, health, employment, and housing issues in people’s lives.
• Within shelters, all aspects of programming require examination to ensure sensitivity to the needs of traumatized individuals including atmosphere and environment; policies and procedures; assessment and service planning; and staff development and training.
• Involve consumers who are survivors in the development and implementation of programs and services.
• Shelters and service delivery sites should be trauma-informed spaces for individuals. Such spaces meet basic needs and create a safe environment in which routines and responses are consistent and predictable. Along with creation of a safe service setting is the need to create an emotional environment that enhances the consumer’s sense of safety. This environment includes a demonstrated tolerance for the consumer to express a range of emotions. Tolerance for emotional expression enhances the survivor’s internal sense of security and ability to regain self-control.
• Regardless of the response that a trauma survivor exhibits under stress, the provider must understand the individual’s reactions in order to provide support. Providers working with trauma survivors should have an understanding of how traumatic experiences affect the brain and the body, and how trauma survivors exhibit different reactions in the present due to their experiences in the past.
• Providers need to be able to recognize how extreme responses of dissociation or overreaction are in fact adaptations helpful to trauma survivors while managing their traumatic experiences, but may be ineffective and unhealthy in the present. This recognition requires ongoing training and trauma education for providers that allows them to identify someone’s experience and understand why the person may respond in particular ways.
• When providers understand trauma responses, they can help survivors better understand their experiences, provide opportunities for them to practice regaining self-control, and utilize techniques to de-escalate difficult situations. Important components of support for trauma survivors involve helping them:
  -identify specific triggers
  -understand how their brains and bodies respond
  -ground themselves in the reality of the present situation
  -develop self-soothing techniques and coping skills to manage feelings associated with past traumatic experiences
• By keeping in mind the potential triggers for trauma survivors, providers can examine their agencies and programs to identify and eliminate daily practices, policies, or ways of responding to people that might result in loss of control or power and feeling re-traumatized.  

Points to remember

• All people respond to traumatic events
• Responses range from numbness and withdrawal to crying, nervousness, and agitation
• There is no “right” way to react to or recover from a traumatic event
• Over time and with support, most people heal

Adapted from: Bassuk, E., Konnath, K., & Volk, K. T. (2006). Understanding traumatic stress in children. Newton, MA: The National Center on Family Homelessness. Retrieved from www.nhchc.org/2008conference/workshops/28docs/NCFH_Understanding_Trauma_Booklet.pdf