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Research Article

Trauma informed interventions: A systematic review

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Project administration, Resources, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations School of Nursing, The Johns Hopkins University, Baltimore, Maryland, United States of America, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland, United States of America

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Roles Formal analysis, Writing – original draft, Writing – review & editing

Affiliation School of Nursing, Duke University, Durham, North Carolina, United States of America

Roles Data curation, Writing – original draft, Writing – review & editing

Affiliation School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States of America

Roles Formal analysis, Writing – review & editing

Affiliation School of Nursing, The Johns Hopkins University, Baltimore, Maryland, United States of America

Roles Data curation, Writing – review & editing

Affiliation School of Nursing, Vanderbilt University, Nashville, Tennessee, United States of America

Affiliation Medstar Good Samaritan Hospital, Baltimore, Maryland, United States of America

Roles Data curation, Formal analysis, Writing – original draft, Writing – review & editing

  • Hae-Ra Han, 
  • Hailey N. Miller, 
  • Manka Nkimbeng, 
  • Chakra Budhathoki, 
  • Tanya Mikhael, 
  • Emerald Rivers, 
  • Ja’Lynn Gray, 
  • Kristen Trimble, 
  • Sotera Chow, 
  • Patty Wilson


  • Published: June 22, 2021
  • Reader Comments

Fig 1

Health inequities remain a public health concern. Chronic adversity such as discrimination or racism as trauma may perpetuate health inequities in marginalized populations. There is a growing body of the literature on trauma informed and culturally competent care as essential elements of promoting health equity, yet no prior review has systematically addressed trauma informed interventions. The purpose of this study was to appraise the types, setting, scope, and delivery of trauma informed interventions and associated outcomes.

We performed database searches— PubMed, Embase, CINAHL, SCOPUS and PsycINFO—to identify quantitative studies published in English before June 2019. Thirty-two unique studies with one companion article met the eligibility criteria.

More than half of the 32 studies were randomized controlled trials (n = 19). Thirteen studies were conducted in the United States. Child abuse, domestic violence, or sexual assault were the most common types of trauma addressed (n = 16). While the interventions were largely focused on reducing symptoms of post-traumatic stress disorder (PTSD) (n = 23), depression (n = 16), or anxiety (n = 10), trauma informed interventions were mostly delivered in an outpatient setting (n = 20) by medical professionals (n = 21). Two most frequently used interventions were eye movement desensitization and reprocessing (n = 6) and cognitive behavioral therapy (n = 5). Intervention fidelity was addressed in 16 studies. Trauma informed interventions significantly reduced PTSD symptoms in 11 of 23 studies. Fifteen studies found improvements in three main psychological outcomes including PTSD symptoms (11 of 23), depression (9 of 16), and anxiety (5 of 10). Cognitive behavioral therapy consistently improved a wide range of outcomes including depression, anxiety, emotional dysregulation, interpersonal problems, and risky behaviors (n = 5).


There is inconsistent evidence to support trauma informed interventions as an effective approach for psychological outcomes. Future trauma informed intervention should be expanded in scope to address a wide range of trauma types such as racism and discrimination. Additionally, a wider range of trauma outcomes should be studied.

Citation: Han H-R, Miller HN, Nkimbeng M, Budhathoki C, Mikhael T, Rivers E, et al. (2021) Trauma informed interventions: A systematic review. PLoS ONE 16(6): e0252747.

Editor: Vedat Sar, Koc University School of Medicine, TURKEY

Received: July 1, 2020; Accepted: May 23, 2021; Published: June 22, 2021

Copyright: © 2021 Han et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: This is a systematic review. All relevant data were extracted from the published studies included in the review.

Funding: This study was supported, in part, by a grant from the Johns Hopkins Provost Discovery Award (HRH). Additional funding was received from the National Center for Advancing Translational Sciences (UL1TR003098, HRH), National Institute of Nursing Research (P30NR018093, HRH; T32NR012704, HM), National Institute on Aging (R01AG062649, HRH; F31AG057166, MN), Robert Wood Johnson Foundation Health Policy Research Scholar program (MN), and Substance Abuse and Mental Health Services Administration (5T06SM060559‐ 07, PW). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. There was no additional external funding received for this study.

Competing interests: The authors have declared that no competing interests exist.

Despite the United States’ commitment to health equity, health inequities remain a pressing concern among some of the nation’s marginalized populations, such as racial/ethnic or gender minority populations. For example, according to the 2016 National Health and Nutrition Examination Survey (NHANES), 29.1% of Mexican Americans and 24.3% of African Americans with diabetes had hemoglobin A1C greater than 9% (the gold standard of glucose control with levels ≤ 7% deemed adequate), compared to 11% in non-Hispanic whites [ 1 ]. The 2016 survey also revealed that 40.9% and 41.5% of Mexican Americans and African Americans with hypertension, respectively, had their blood pressure under control, compared to 51.7% in non-Hispanic whites. In 2014, 83% of all new diagnoses of HIV infection in the United States occurred among gay, bisexual, and other men who have sex with men, with African American men having the highest rates [ 2 ].

Several factors have been discussed as root causes of health inequities. For example, Farmer et al. [ 3 ] noted structural violence—the disadvantage and suffering that stems from the creation and perpetuation of structures, policies and institutional practices that are innately unjust—as a major determinant of health inequities. According to Farmer et al., because systemic exclusion and disadvantage are built into everyday social patterns and institutional processes, structural violence creates the conditions which sustain the proliferation of health and social inequities. For example, a recent analysis [ 4 ] using a sample including 4,515 National Health and Nutrition Examination Survey participants between 35 and 64 years of age revealed that black men and women had fewer years of education, were less likely to have health insurance, and had higher allostatic load (i.e., accumulation of physiological perturbations as a result of repeated or chronic stressors such as daily racial discrimination) compared to white men (2.5 vs 2.1, p <.01) and women (2.6 vs 1.9, p <.01). In the analysis, allostatic load burden was associated with higher cardiovascular and diabetes-related mortality among blacks, independent of socioeconomic status and health behaviors.

Browne et al. [ 5 ] identified essential elements of promoting health equity in marginalized populations such as trauma-informed and culturally competent care. In particular, trauma-informed care is increasingly getting closer attention and has been studied in a variety of contexts such as addiction treatment [ 6 – 8 ] and inpatient psychiatric care [ 9 ]. While there is a growing body of the literature on trauma-informed care, no prior review has systematically addressed trauma-informed interventions; one published review of literature [ 10 ] limited its scope to trauma survivors in physical healthcare settings. As such, the purpose of this paper is to conduct a systematic review and synthesize evidence on trauma-informed interventions.

For the purpose of this paper, we defined trauma as physical and psychological experiences that are distressing, emotionally painful, and stressful and can result from “an event, series of events, or set of circumstances” such as a natural disaster, physical or sexual abuse, or chronic adversity (e.g., discrimination, racism, oppression, poverty) [ 11 , 12 ]. We aim to: 1) describe the types, setting, scope, and delivery of trauma informed interventions and 2) evaluate the study findings on outcomes in association with trauma informed interventions in order to identify gaps and areas for future research.

Five electronic databases—PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), SCOPUS and PsycINFO—were searched from the inception of the databases to identify relevant quantitative studies published in English. The initial literature search was conducted in January 2018 and updated in June 2019 using the same search strategy.

Review design

We conducted a systematic review of quantitative evidence to evaluate the effects of trauma informed interventions. Due to heterogeneity relative to study outcomes, designs, and statistical analyses approaches among the included studies, we qualitatively synthesized the study findings. Three trained research assistants extracted study data. Specifically, we used the PICO framework to extract and organize key study information. The PICO framework offers a structure to address the following questions for study evidence [ 13 ]: Patient problem or population (i.e., patient characteristics or condition); Intervention (type of intervention tested or implemented); Comparison or control (comparison treatment or control condition, if any), and Outcome (effects resulting from the intervention).


Inclusion criteria..

Articles were screened for their relevance to the purpose of the review. Articles were included in this review if the study was: about trauma informed approach (i.e., an approach to address the needs of people who have experienced trauma) or an aspect of this approach, published in English language and involved participants who were 18 years and older. Also, only quantitative studies conducted within a primary care or community setting were included.

Exclusion criteria.

Exclusion criteria were: studies in or with military populations, refugee or war-related trauma populations, studies with mental health experts and clinicians as research subjects or studies of incarcerated and inpatient populations. Conference abstracts that had limited information on study characteristics were also excluded.

Search strategy and selection of studies

Search strategy..

Following consultation with a health science librarian, peer-reviewed articles were searched in PubMed, Embase, CINAHL, SCOPUS and PsycINFO using MeSH and Boolean search techniques. Search terms included: "trauma focused" OR "trauma-focused" OR "trauma informed" OR "trauma-informed." We also searched for the term trauma within three words of informed or focus ((trauma W/3 informed) OR (trauma W/3 focused), or (traumaN3 (focused OR informed)). Detailed search terms for each database are provided in Appendix 1.

Study selection.

The initial electronic search yielded 7,760 references and the follow-up search yielded 5,207 which were all imported into the Covidence software for screening [ 14 ]. Screening of the references was conducted by 2 independent reviewers and disagreements were resolved through consensus. There were 4,103 duplicates removed from the imported articles and 8,864 studies were forwarded to the title and abstract screening stage. Eight thousand five hundred and twenty-one studies were excluded because they were irrelevant. Three hundred and forty-three abstracts were identified to be read fully. Following this, 311 articles were excluded for focusing on other psychological conditions (n = 120), were non-experimental studies (n = 78) and were in inpatient or incarcerated populations (n = 46). One additional companion article was identified during full text review. Therefore, thirty-three articles met the inclusion criteria and are reported in this review. Fig 1 provides details of the selection process and identifies the reasons why articles were excluded at each stage.


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Quality assessment

We used the Joanna Briggs Institute quality appraisal tools [ 15 ] for randomized controlled trials (RCTs), quasi-experimental studies, and retrospective studies to assess the rigor of each study included in this review. The Joanna Briggs Institute quality appraisal tools [ 15 ] include items asking about methodological elements that are critical to the rigor of each type of study designs. In particular, one of the items for RCTs addresses participant blinding to treatment assignment. Due to the nature of trauma-informed interventions included in our review, it was decided that participant blinding is not relevant and hence was removed from the appraisal list for RCTs. No studies were excluded on the basis of the quality assessment. The quality assessment process was conducted independently by two raters. Inter-rater agreement rates ranged from 56% to 100% with the resulting statistic indicating substantial agreement (average inter-rater agreement rate = 77%). Discrepancies between raters were resolved via inter-rater discussion.

Overview of studies

Table 1 summarizes the main characteristics of the 32 unique studies included in the review, with one companion article [ 16 ] for a study which was later reported with a more thorough examination of findings [ 17 ] totaling 33 articles. More than half (n = 19) of the 32 studies were RCTs [ 17 – 35 ] whereas twelve studies were quasi-experimental [ 36 – 47 ] and one was retrospective study [ 48 ]. Thirteen studies were conducted in the U.S. [ 17 – 19 , 22 , 26 , 27 , 29 , 35 , 39 – 41 , 45 , 47 ]; five in the Netherlands [ 30 , 31 , 33 , 38 , 48 ]; three in Canada [ 23 , 25 , 46 ]; two in Australia [ 21 , 24 ]; two in the United Kingdom [ 36 , 44 ]; two in Sweden [ 42 , 43 ]; on study in Chile [ 20 ]; Iran [ 32 ]; Haiti [ 37 ]; South Africa [ 34 ]; and Germany [ 28 ]. Fourteen of the studies only included females in their sample [ 18 , 20 , 21 , 23 – 25 , 27 , 28 , 38 – 41 , 45 , 48 ]. The average sample size was 78 participants, with a range from 10 participants [ 38 ] to 297 participants [ 48 ]. Of the studies included, 67% had a sample size above 50 [ 18 – 22 , 26 , 29 – 34 , 36 , 37 , 39 – 42 , 46 – 48 ].


The studies included in this review recruited their study populations largely based on the type of trauma they were aiming to address, such as individuals that experienced interpersonal traumatic event such as child abuse, sexual assault, or domestic violence [ 16 – 18 , 20 – 22 , 24 – 26 , 35 , 40 – 43 , 45 , 46 ], individuals with substance abuse disorders [ 19 , 47 , 48 ], couples experiencing clinically significant marital issues [ 23 ], individuals with limb amputations [ 38 ], dental phobia [ 28 ], or fire service personnel suffering from post-traumatic stress disorder [ 44 ]. Trauma was self-reported in eight articles [ 16 , 17 , 20 , 22 , 26 , 34 , 35 , 47 ]. In contrast, nine studies clearly identified a measurement of trauma; the Trauma History Questionnaire [ 19 , 45 ], the Childhood Trauma Questionnaire [ 23 , 25 ], the Childhood Maltreatment Interview Schedule [ 23 ], the Revised Conflict Tactics Scale adapted for sex work [ 39 ], the Traumatic Events Screening Instrument for Adults [ 27 ], the Life Events Checklist [ 46 ], and the Adverse Childhood Experiences [ 18 ]. Two studies used a clinical tool (e.g. eye movement desensitization and reprocessing [ 38 ] and Diagnostic and Statistical Manual of Mental Disorders, 4 th edition [ 41 ] to identify or diagnose trauma. Fifteen studies did not include direct measurements for trauma [ 21 , 24 , 28 – 33 , 36 , 37 , 40 , 42 – 44 , 48 ].

Quality ratings

Tables 2 – 4 shows final scores of quality assessment. Quality of the 32 unique studies included in this review varied across individual studies. Twelve of 19 RCTs included in the review were of high quality (i.e., 9 to 11) [ 17 , 18 , 20 , 21 , 24 , 26 , 28 , 29 , 31 , 33 – 35 ] and six were of medium quality (i.e., 5 to 8) [ 19 , 22 , 23 , 25 , 27 , 30 ]. One study scored 4 of 12 [ 32 ]. The low rating study [ 32 ] lacked relevant information to adequately score its methodological rigor. Most RCTs clearly described randomization, group equivalence at baseline, rates and reasons for attrition, study outcomes, and analysis. Blinding of outcomes assessors to treatment assignment was used and described in several RCTs [ 17 , 20 , 21 , 24 , 27 , 35 ], whereas blinding of those delivering treatment was discussed clearly in only one study [ 25 ]. The majority of the quasi-experimental studies were of high quality (i.e., 7 or higher), except two, which scored 2 of 9 [ 37 ] and 6 of 9 [ 39 ], respectively. Six of twelve quasi-experimental studies [ 36 , 41 – 44 , 47 ] had a comparison group to strengthen internal validity of causal inferences by comparing intervention and control groups. Some of these studies, however, noted differences in baseline assessments between groups [ 36 , 43 , 44 ]. Finally, one retrospective study [ 48 ] scored 11 of 11 and hence was rated as high quality.




Characteristics of trauma-informed interventions

Type of intervention..

Table 5 details the trauma informed intervention characteristics included in this review. The two most frequently used interventions were eye movement desensitization and reprocessing (EMDR) [ 28 , 30 , 31 , 33 , 36 , 38 ]—a multi-phase intervention using bilateral stimulation, such as left-to-right eyes movements or hand tapping, to desensitize individuals to a traumatic memory or image—and trauma-focused cognitive behavioral therapy or cognitive behavioral therapy (CBT) [ 26 , 27 , 32 , 46 , 48 ]—a psychological approach to introduce emotional regulation and coping strategies (e.g., deep muscle relaxation, yoga, thought discovery and breathing techniques) to deal with negative feelings and behaviors surrounding a trauma of interest [ 32 , 48 ]. The implementation of CBT varied on the trauma of interest. Other studies implemented interventions using general trauma focused therapy [ 22 , 43 ], emotion focused therapy [ 23 , 25 ], stress reduction programs [ 17 ], cognitive processing therapy [ 24 ], brief electric psychotherapy [ 31 ], present focused group therapy [ 26 ], compassion focused therapy [ 44 ], prolonged exposure [ 45 ], stress inoculation training [ 45 ], psychodynamic therapy [ 45 ], and visual schema displacement therapy [ 30 ]. A number of studies included more than one of these therapies [ 13 , 26 , 30 , 31 , 33 , 36 , 45 ].


Setting, scope, and delivery of intervention.

Twenty of the interventions were identified to occur in an outpatient clinic/setting [ 19 – 21 , 24 , 25 , 27 – 29 , 31 – 34 , 36 , 39 , 40 , 42 , 43 , 46 – 48 ]. Four of the studies took place in a research lab or office [ 23 , 26 , 41 , 45 ], one study occurred in the community [ 17 ], and one study implemented therapy in three locations, two of which were outpatient and one of which was a residential treatment center [ 47 ]. Lastly, one study occurred in internally displaced people’s camps within a metropolitan area in Haiti [ 37 ]. The remaining studies did not identify a specific setting [ 22 , 35 , 38 , 44 ].

The interventions ranged in length and time, but most often occurred weekly. The longest intervention was done by Lundqvist and colleagues [ 43 ], which lasted a total length of 2-years and included 46 sessions. Several other studies included 20 sessions or more [ 18 , 22 , 23 , 25 , 26 ]. The interventions were most commonly delivered by medical professionals, including but not limited to: psychologists or psychiatrists, therapists, social workers, mental health clinicians and physicians [ 16 , 17 , 20 – 29 , 33 , 36 , 38 , 39 , 41 , 44 – 47 ]. The articles frequently noted that the interventionists were masters-level-prepared or higher in their profession [ 21 , 23 , 25 – 27 , 33 , 40 , 47 ]. In addition to standard education and licensure, many of the professionals implementing the interventions were required to obtain further training in the therapy of interest [ 23 – 25 , 27 – 30 , 33 , 36 , 38 – 40 , 46 , 47 ]. Two studies were identified to be delivered by lay persons [ 34 , 37 ].

Fidelity was addressed in 16 of the included articles [ 16 , 19 , 21 , 23 , 24 , 26 – 30 , 33 – 35 , 45 – 47 ]. The manner in which fidelity was addressed varied by study. Videotaping or audiotaping therapy sessions [ 21 , 23 , 24 , 28 – 30 , 33 , 35 ] were most common, followed by deploying regular supervision of the therapy sessions [ 21 , 23 , 27 , 29 , 33 , 46 ], using a training manual or intervention protocols [ 19 , 21 , 33 , 46 ], or having individuals unaffiliated with the study or blind to the intervention rate sessions [ 21 , 26 , 28 , 35 ]. Additionally, three articles utilized fidelity checks/checklists to ensure components of the intervention were addressed [ 16 , 30 , 47 ] or had patients and/or therapists rate therapy sessions [ 26 , 34 , 45 ]. Finally, one study had quality assurance worksheets completed after each session that were later reviewed by the study coordinator [ 34 ].

Effects of trauma-informed interventions

Trauma-informed interventions were tested to improve several psychological outcomes, such as post-traumatic stress disorder (PTSD), depression, and anxiety. The most frequently assessed psychological outcome was PTSD, which was examined in 23 out of the 32 studies [ 17 , 20 – 27 , 31 , 33 , 35 – 39 , 41 , 42 , 44 – 48 ]. Among the studies that assessed PTSD as an outcome, 11 found significant reductions in PTSD symptoms and severity following the trauma-informed intervention [ 17 , 20 , 21 , 24 , 26 , 28 , 34 , 42 , 45 – 47 ], however, one of these studies, which utilized outpatient psychoeducation, did not find significant differences in reduction between the intervention and control group [ 20 ]. Trauma-informed interventions that were associated with a significant reduction in PTSD were a mindfulness-based stress reduction program [ 16 ], two therapies using the Trauma Recovery and Empowerment Model (TREM) [ 47 ], CBT [ 26 , 46 ], EMDR [ 28 ], general trauma-focused therapy [ 42 ], psychodynamic therapy [ 45 ], stress inoculation therapy [ 45 ], present-focused therapy [ 26 ], and cognitive processing therapy [ 24 ]. In addition, an intervention designed to reduce stress and improve HIV care engagement improved PTSD symptoms; however, this intervention was not intended to treat PTSD [ 34 ].

Other commonly assessed psychological symptoms, including depression and anxiety, were examined in 16 [ 17 – 21 , 24 – 26 , 29 , 31 , 32 , 35 , 40 , 44 , 47 , 48 ] and 10 [ 21 , 24 , 25 , 28 , 29 , 35 , 36 , 44 , 47 , 48 ] studies, respectively. Among these, trauma-informed interventions were associated with decreased or improved depressive symptoms in 9 studies [ 17 , 18 , 20 , 21 , 24 , 32 , 35 , 47 , 48 ] and decreased or improved anxiety in 5 studies [ 21 , 28 , 35 , 47 , 48 ]. For example, Vitriol and colleagues found that outpatient psychoeducation resulted in improved depressive symptoms in women with severe depression and childhood trauma [ 20 ]. Similarly, Kelly and colleagues found that female survivors of interpersonal violence experienced a significantly greater reduction of depressive symptoms in the intervention group (mindfulness-based stress reduction) compared to the control group [ 16 , 17 ]. Other therapies that resulted in improved depressive symptoms were TREM [ 47 ], prolonged exposure therapy [ 21 ], CBT [ 32 , 46 ], psychoeducational cognitive restructuring [ 35 ], and financial empowerment education [ 18 ]. Cognitive processing therapy similarly resulted in large reductions in depression symptoms, however this reduction was also observed in the control group [ 24 ]. The same studies showed that TREM [ 47 ], prolonged exposure therapy [ 21 ], CBT [ 48 ], and psychoeducational cognitive restructuring [ 35 ] were associated with improved anxiety. Lastly, in a separate study than the one highlighted above, EMDR was associated with improved anxiety [ 28 ].

A select number of the studies found associations between trauma-informed interventions and other psychological outcomes such as attachment anxiety, attachment avoidance, psychiatric symptoms or dental distress. For example, the trauma-informed mindfulness-based reduction program implemented by Kelly and colleagues was associated with a greater decrease in anxious attachment, measured by the Relationship Structures Questionnaire, compared to the waitlist group [ 17 ]. Similarly, Masin-Moyer and colleagues found that TREM and an attachment-informed TREM (ATREM) were associated with significant reductions in group attachment anxiety, group attachment avoidance, and psychological distress in women with a history of interpersonal trauma [ 47 ]. Additionally, individuals in an outpatient substance abuse treatment program, consisting of psychoeducational seminars and trauma-informed addiction treatment, experienced significantly better outcomes of psychiatric severity, measured by the Global Appraisal of Individual Needs scale, compared to a control treatment group [ 19 ]. Doering and colleagues found that EMDR, compared to the control group, was associated with significantly greater improvement in dental stress, anxiety and fear in patients with dental-phobia [ 28 ].

There was a series of interpersonal, emotional and behavioral outcomes assessed in the included studies. For example, adult females that were sexually abused in childhood experienced a significant improvement in social interaction and social adjustment after receiving trauma focused group therapy [ 43 ]. Similarly, Dalton and colleagues found that couples that received emotion focused therapy experienced a significant reduction in relationship distress [ 23 ] and MacIntosh and colleagues found that individuals that received CBT reported lower interpersonal problems post-treatment [ 46 ]. Trauma-based interventions were also associated with emotional outcomes. Visual schema displacement therapy and EMDR both were superior to the control treatment in reducing emotional disturbance and vividness of negative memories [ 30 ]. In a separate study, CBT was found to reduce levels of emotional dysregulation in individuals that experienced childhood sexual abuse [ 46 ]. Lastly, trauma-informed interventions were associated with behavioral outcomes, including HIV risk reduction [ 26 ], decreased days of alcohol use [ 27 ], and improvements in avoidance of client condom negotiations, frequency of sex trade under influence of drugs or alcohol, and use of intimate partner violence support [ 40 ]. Interventions that were associated with these behavioral outcomes included trauma focused and present focused group therapy [ 26 ], CBT [ 27 ], and a trauma-informed support, validation, and safety-promotion dialogue intervention [ 40 ].

Publication bias

We analyzed three sets of outcome variables for publication bias: PTSD, depression, and anxiety. Based on Begg and Mazumdar test, there was no evidence of publication bias for PTSD (z = 1.55, p = 0.121) and anxiety (z = 0.29, p = 0.769). However, there was some evidence of publication bias for depression (z = 5.19, p<.001). The statistically significant publication bias for depression appears to be mainly due to large effect sizes in Nixon [ 24 ] and Bowland [ 35 ].

According to our database search, this is the first systematic review to critically appraise trauma-informed interventions using a comprehensive definition of trauma. In particular, our definition encompassed both physical and psychological experiences resulting from various circumstances including chronic adversity. Overall, there was inconsistent evidence to suggest trauma informed interventions in addressing psychological outcomes. We found that trauma-informed interventions were effective in improving PTSD [ 17 , 20 , 21 , 24 , 26 , 28 , 34 , 42 , 45 – 47 ] and anxiety [ 21 , 28 , 35 , 47 , 48 ] in less than half of the studies where these outcomes were included. We also found that depression was improved in less than about two thirds of the studies where the outcome was included [ 17 , 18 , 20 , 21 , 24 , 32 , 35 , 47 , 48 ]. Although limited in the number of published studies included this review, available evidence consistently supported trauma-informed interventions in addressing interpersonal [ 23 , 43 , 46 ], emotional [ 30 , 46 ], and behavioral outcomes [ 26 , 27 , 40 ].

Effective trauma informed intervention models used in the studies varied, encompassing CBT, EMDR, or other cognitively oriented approaches such as mindfulness exercises [ 16 , 24 , 26 , 28 , 32 , 35 , 45 , 46 , 48 ]. In particular, CBT was noted as an effective trauma informed intervention strategy which successfully led to improvements in a wide range of outcomes such as depression [ 32 , 48 ], anxiety [ 48 ], emotional dysregulation [ 46 ], interpersonal problems [ 23 , 46 ], and risky behaviors (e.g., days of alcohol use) [ 27 ]. While the majority of the studies included in the review were focused on interpersonal trauma such as child abuse, sexual assault, or domestic violence [ 16 – 18 , 20 – 22 , 24 – 26 , 35 , 40 – 43 , 45 , 46 ], growing evidence demonstrates perceived discrimination and racism as significant psychological trauma and as underlying factors in inflammatory-based chronic diseases such as cardiovascular disease or diabetes [ 4 ]. Future trauma informed interventions should consider a wide-spectrum of trauma types, such as racism and discrimination, by which racial/ethnic minorities are disproportionately affected from [ 49 ].

While the majority of the trauma informed interventions were delivered by specialized medical professionals trained in the therapy [ 16 , 17 , 20 – 29 , 33 , 36 , 38 – 41 , 44 – 47 ], several of the articles lacked full descriptions of interventionist training and fidelity monitoring [ 20 , 22 , 25 , 36 , 38 – 41 , 44 ]. Two studies were identified to be delivered by lay persons [ 34 , 37 ]. There is sufficient evidence to suggest that lay persons, upon training, can successfully cover a wide scope of work and produce the full impact of community-based intervention approaches [ 50 ]. Given such, there is a strong need for trauma informed intervention studies to clearly elaborate the contents and processes of lay person training such as competency evaluation and supervision to optimize the use of this approach.

There are methodological issues to be taken into consideration when interpreting the findings in this review. While twenty-three of 32 studies were of high quality [ 17 , 18 , 20 , 21 , 24 , 26 , 28 , 29 , 31 , 33 – 36 , 38 , 40 – 48 ], some studies lacked methodological rigor, which might have led to false negative results (no effects of trauma informed interventions). For example, about one-third (31%) had a sample size less than 50 [ 17 , 23 – 25 , 27 , 28 , 35 , 38 , 43 , 45 ]. In addition, half of the quasi-experimental studies [ 37 – 40 , 45 , 46 ] did not have a comparison group or when they had one, group differences were noted in baseline assessments [ 36 , 43 , 44 ]. In several studies, therapists took on both traditional treatment and research responsibilities (e.g., delivery of the intervention) [ 20 , 25 , 29 , 32 , 33 , 36 , 40 , 46 , 47 ], yet blinding of those delivering treatment was discussed clearly in only one study [ 25 ]. This dual role is likely to have led to the disclosure of group allocation, hence, threatening the internal validity of the results. Future studies should address these issues by calculating proper sample size a priori, using a comparison group, and concealing group assignments.

Review limitations

Several limitations of this review should be noted. First, by using narrowly defined search terms, it is possible that we did not extract all relevant articles in the existing literature. However, to avoid this, we conducted a systematic electronic search using a comprehensive list of MeSH terms, as well as similar keywords, with consultation from an experienced health science librarian. Additionally, we hand searched our reference collections, Second, the trauma informed interventions included in this review were implemented to predominantly address trauma related to sexual or physical abuse among women. Thus, our findings may not be applicable to trauma related to other types of incidence such as chronic adversity (e.g., racism or discrimination). Likewise, there were insufficient studies addressing a wider range of trauma impacts such as emotion regulation, dissociation, revictimization, non-suicidal self-injury or suicidal attempts, or post-traumatic growth. Future research is warranted to address these broader impacts of trauma. We included only articles written in English; therefore, we limited the generalizability of the findings concerning studies published in non-English languages. Finally, we used arbitrary cutoff scores to categorize studies as low, medium, and high quality (quality ratings of 0-4, 5-8, and 9+ for RCTs and 0-3, 4-6, 7+ for quasi-experimental studies, respectively). Using this approach, each quality-rating item was equally weighted. However, certain factors (e.g., randomization method) may contribute to the study quality more so than others.

Our review of 33 articles shows that there is inconsistent evidence to support trauma informed interventions as an effective intervention approach for psychological outcomes (e.g., PTSD, depression, and anxiety). With growing evidence in health disparities, adopting trauma informed approaches is a growing trend. Our findings suggest the need for more rigorous and continued evaluations of the trauma informed intervention approach and for a wide range of trauma types and populations.

Supporting information

S1 checklist..

S1 Appendix. Search strategies.


We would like to express our appreciation to a medical librarian, Stella Seal for her assistance with article search. Both Kristen Trimble and Sotera Chow were students in the Masters Entry into Nursing program and Hailey Miller and Manka Nkimbeng were pre-doctoral fellows at The Johns Hopkins University when this work was initiated.

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Trauma Through the Life Cycle: A Review of Current Literature

  • Original Paper
  • Published: 31 May 2014
  • Volume 42 , pages 323–335, ( 2014 )

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  • Shulamith Lala Ashenberg Straussner 1 &
  • Alexandrea Josephine Calnan 2  

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The past is never dead. It’s not even past. William Faulkner
The conflict between the will to deny horrible events and the will to proclaim them aloud is the central dialectic of psychological trauma. Judith Lewis Herman

This paper provides an overview of common traumatic events and responses, with a specific focus on the life cycle. It identifies selected “large T” and “micro” traumas encountered during childhood, adulthood and late life, and the concept of resilience. It also identifies the differences in traumatic events and reactions experienced by men compared to women, those related to the experience of immigration, and cross generational transmission of trauma. Descriptions of empirically-supported treatment approaches of traumatized individuals at the different stages of the life cycle are offered.

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As recognized by William Faulkner and Judith Herman, as well as by many other writers and mental health professionals, trauma can take a tremendous psychological toll that may not disappear even with the passage of time. The term “trauma” comes from the Greek language meaning a “wound” or “hurt” (Oxford Dictionaries, 2013 ). Psychologically, “trauma” refers to an experience that is emotionally painful, distressful, or shocking, and one that often has long-term negative mental and physical (including neurological) consequence. An event is thought to produce a traumatic response when the stress resulting from that event overwhelms the individual’s psychological ability to cope (McGinley and Varchevker 2013 ).

Although we often think of trauma as being synonymous with the identified objective cause of the trauma, such as a soldier losing his legs to a roadside bomb explosion, the effect of the trauma is always subjective and refers to the impact—the perceived “wound” or “hurt” as identified by the early Greeks—that it has on the individual (Miller 2004 ). Thus what might be a traumatizing, life-shattering event for one individual might have minimal effects on another. Such differential reaction is based on many factors, including the individual’s age, gender identity, pre-morbid ego strength, previous traumatic experiences, the chronicity of the trauma, family history of trauma, current life stressors, social supports, and one’s cultural, religious or spiritual attitude toward adversity (Amir and Lev-Wiesel, 2003 ; Brewin et al. 2000 ; Felitti et al. 1998 ; Foa et al. 2009 ; Stamm and Friedman 2000 ; Straussner and Phillips 2004a ).

Unfortunately, the experience of trauma is not uncommon. Although there is a lack of recent national epidemiological findings about trauma among adults [Centers for Disease Control and Prevention (CDC) 2006 ], studies during the 1990s found that over 60 % of men and 51 % of women in the United States report having experienced at least one traumatic event during their lifetime (Giaconia et al. 1995 ; Kessler et al. 1995 ). Traumatic stress can cause disorganization of thinking, awareness, impaired judgment, altered reaction time, hyper vigilance, and unhelpful attempts at coping. While most people will experience time limited reactions, such as acute stress disorder, a smaller percentage may continue to manifest more severe and often longer lasting trauma-related impacts. These may include panic disorders, depression, sleep disorders, substance use disorders, as well as post-traumatic stress disorder (PTSD) (Kessler et al. 1995 ; Leskin and Sheikh 2002 ; Ringel and Brandell 2012 ).

While trauma can impact an individual at any time in the life cycle, from pre-natal development through old age, the impact and the treatment approaches vary depending on the individual’s developmental needs and the psychosocial environment. The purpose of this article is to provide an overview of common traumatic events and responses with a specific focus on the life cycle—identifying selected traumas encountered during childhood and adolescences, adulthood and late life. The differential impact of trauma on men and women, on immigrants, transgenerational transmission of trauma, the concept of resilience, and the implications for the treatment of traumatized individuals at the different stages of the life cycle are identified.

Nature of Trauma: “Large T” and “Micro-Traumas”

There are many different kinds of traumas, ranging from what Francine Shapiro, the originator of Eye Movement Desensitization and Reprocessing (EMDR) treatment approach (Shapiro 1995 ) has termed “large - T” traumas to “ small - t” or, what Straussner ( 2012 ) refers to as “micro-traumas.” Large-T traumas can impact individuals, families, groups and communities and include natural disasters, such as hurricanes, floods, wildfires, or nuclear disasters, as well as human-caused disasters, such as deadly car accidents, individual and mass violence, and other one-time traumatic events. Large-T traumas can also include, what Judith Herman ( 1997 ) termed as “complex traumas,” and which others refer to as Complex Traumas and Disorders of Extreme Stress (DESNOS- disorders of extreme stress not otherwise specified )—traumas that involve events of prolonged duration or multiple traumatic events (van der Kolk, Roth, Pelcovitz, Sunday and Spinazzola, 2005 ). Examples of complex, large-T traumas [also referred to as Type II trauma by Terr (1991)], include on-going interpersonal violence, child physical or sexual abuse spanning several years, never-ending wars, or constant acts of terrorism.

Small-t or micro-traumas are the more common traumas encountered by many of us. While large-T traumas are easily identified, many micro-traumas, such as being bullied in school or in the workplace (Idsoe et al. 2012 ; Mishna 2012 ), being stalked by someone (Purcell et al. 2005 ), living in severe poverty (Kiser 2007 ), childbirth (Kendall-Tackett 2013 ), or being the recipient of on-going individual discrimination because of one’s race, religion, gender identity, or sexual orientation, often go unrecognized and unacknowledged. Yet these micro-traumas may still cause much psychic pain and life-long damage.

Exposure to and Impact of Trauma

In her classic book Shattered assumptions: Towards a new psychology of trauma , Janof-Bulman ( 1992 ) reflects on the psychological shattering of one’s worldview experienced by traumatized individuals, especially if the trauma is caused through deliberate human acts (Straussner and Phillips 2004a ). Whereas the world was previously viewed as being trustworthy and benevolent, this belief may become transformed into the sense that “people will hurt me, and I can’t trust anyone.” Additionally, trauma survivors might find that the world they used to perceive as being stable and predictable, now seems unpredictable and out of their control. Consequently, their previous sense of empowerment and of being in control of their environment and their lives gives way to one in which they feel disempowered, helpless, and unable to predict and plan for the future. They may even have a sense of being psychologically damaged and defective (Janof-Bulman 1992 ).

The idea that trauma could result in specific clusters of symptoms first became formalized by the inclusion of the diagnosis of PTSD in the third edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM; American Psychiatric Association (APA) 1980 ]. This new diagnostic category was precipitated by awareness of the psychological problems experienced by returning Vietnam War veterans in the late 1970s and the growing literature by European writers who survived their own traumatic experiences during the Second World War—such as Gunter Grass, Primo Levy, and Eli Wiesel among others—and who vividly described the profound impact of mass violence on individuals, families and communities (Straussner and Phillips 2004a ). Studies of survivors of the Nazi-caused Holocaust (Krystal and Niederland 1968 ) and of the Hiroshima atomic bombing by the United States (Lifton 1968 ), introduced the concept of “survivors’ guilt” into our vocabulary.

The more recent recognition that traumatic reactions can result from response to events other than war, such as sexual assault, exposure to child abuse, domestic violence, and accidents has made PTSD a widely recognized disorder throughout the world (Herman 1997 ; van der Kolk et al. 2005 ). The importance of PTSD as a diagnostic category is reflected in the newly revised DSM-5 (APA, 2013 ), where PTSD and related conditions are no longer listed under Anxiety Disorders or Adjustment Disorders as previously, but are located in a separate chapter titled “Trauma- and Stressors-Related Disorders.”

While the experience of trauma is common, PTSD diagnosis is relatively rare. The estimated lifetime prevalence rate of PTSD in the US is thought to range between 6 and 12 %, averaging around 9 % of the population (APA 2013 ; Breslau et al. 1991 ; Kessler et al. 1995 ; Resnick et al. 1993 ). However, the initial prevalence rates among active duty military exposed to war conditions and among survivors of mass trauma, such as the September 11, 2001 World Trade Centers in New York, can range as high as 30 % and more (Galea et al. 2005 ; Susser et al. 2002 ). According to the latest edition of the DSM, the “[h]ighest rates (ranging from one-third to more than one-half of those exposed) are found among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide” (APA 2013 , p. 276). Recent United States- based studies document higher rates of PTSD among African-Americans, Latinos and American Indians than among white or Asian populations (APA 2013 ). International annual prevalence rates are believed to be somewhat lower than those in the US (APA 2013 ; Landolt et al. 2013 ), although studies in areas with on-going conflict, such as in Israel and the Palestinian territories, point to rates that are similar to those in the US among individuals who have been or are still exposed to combat (Dimitry 2011 ; Gelkopf et al. 2008 ; Solomon et al. 1996 ).

As pointed out earlier, trauma has a differential impact depending on age, gender, and psychosocial factors, which are discussed below.

Trauma and Children

As is recognized in the new Diagnostic and Statistical Manual (DSM-5; APA 2013 ), while trauma has a profound impact on all individuals, its impact on young children is unique and particularly pernicious. Millions of children throughout the world are currently growing up amidst traumatic environments—they are being sexually and physically abused at home, bullied at school, and traumatized in their communities (Finkelhor et al. 2009 ). Many lack adequate food and shelter, and some live in unsafe communities and war zones witnessing violence occurring to friends and family, including rape, torture and murder. Numerous studies have shown evidence of long term repercussions of exposure to violence at an early age (Anda et al. 2006 ; Steele 2004 ). The implications of exposure to trauma are now believed to have an effect on the infant even before birth. A more detailed discussion of the impact of trauma on children follows, starting with prenatal impact.

Prenatal Impact

Preliminary research shows that children are impacted even before birth by trauma that is experienced by their mothers. Studies in New York City comparing pregnant women who were close to Twin Towers on September 11 and suffered “post traumatic stress syndrome” (PTSS) with pregnant women who were in different locations, found that newborns of mothers manifesting PTSS had significant smaller head circumference at birth (Engel et al. 2005 ). As we know, decrements in head circumference influence subsequent neurocognitive development. More recent studies, using modern technologies such as Functional MRI, reveal that fetal exposure to maternal stress is significantly associated with a variety of impacts on brain activity, endocrine function, and on autonomic nervous system function (Sandman and Davis 2012 ). While these studies have small sample sizes and need to be validated further, we are recognizing that it is not enough to assess, when appropriate, whether a child was born prematurely or not, or whether the mother was malnourished during pregnancy, but also whether she was being abused by her husband or partner, or lived in a violent community or a war zone during her pregnancy, and how this may be related to the some of the problems exhibited by her children (Lieberman and Van Horn 2008 ; Pine and Cohen 2002 ). It is also worth noting that the biophysiological impact of paternal trauma on the fetus and newborn child has yet to be considered as worth studying, even though there is growing evidence that spontaneous changes in genetic makeup in the sperms of fathers impacts on the mental health of their children (Kandel 2013 ). Whether paternal trauma impacts the sperm, and thus the child, needs to be researched in the future.

Impact on Young Children and Adolescents

The impact of trauma on the brain of traumatized children continues after birth and even during adolescence and young adulthood, as evidenced by recent studies suggesting that the brain continues its development until age 25 (Cicchetti and Curtis 2006 ; Giedd 2008 ). Trauma, particularly complex or ongoing trauma in early life, affects brain development, especially the development of right hemispheric brain functions, which include among other things, regulation of mood and social adjustment. Moreover, “[n]europsychological studies suggest an association between child abuse and deficits in IQ, memory, working memory, attention, response inhibition, and emotion discrimination. Structural neuroimaging studies provide evidence for deficits in brain volume, gray and white matter of several regions, most prominently the … prefrontal cortex but also hippocampus, amygdala, and corpus callosum (CC). Diffusion tensor imaging (DTI) studies show evidence for deficits in structural interregional connectivity between these areas, suggesting neural network abnormalities” (Hart and Rubia 2012 p. 52). While the authors acknowledge the limitations of such studies, particularly the lack of control for co-morbid psychiatric disorders, which make it difficult to disentangle which of the above effects are due to maltreatment, other researchers have found that even indirect exposure to trauma, such as witnessing family or community gang violence, plays an important role in altering brain mechanisms involved in the processing of emotions and may predispose children to problems managing strong emotions and difficulty with emotional regulation. Such children appear to experience changes in stress hormonal regulatory systems and neural patterns that are associated with heightened emotional reactivity as well as weakened emotional resiliency, increasing their vulnerability to problematic behaviors, future traumas, as well as their own potential for violence (Grasso et al. 2013 ; Heide and Soloman 2006 ).

Data from the well regarded Adverse Childhood Experiences (ACE) study (Felitti et al. 1998 ) suggests that ACEs are “related to a greater likelihood of developing a variety of behavioral, health, and mental health problems, including smoking, multiple sexual partners, heart disease, cancer, lung disease, liver disease, sexually transmitted diseases, substance abuse, depression, and suicide attempts” (Lu et al. 2008 p. 1018).

Various authors have identified other negative consequences resulting from exposure to trauma during early life:

Preschool children are likely to exhibit passive reactions and regressive symptoms, such as enuresis, decreased verbalizations and clinging behavior, indicative of anxious attachment (APA 2013 ; Lieberman and Van Horn 2008 ; Steele 2004 ).

School age children may display both more aggression and more inhibition. They also develop somatic complaints, depression, sleep disturbance, cognitive distortions and learning difficulties manifested by impaired concentration and memory problems (Steele 2004 ; Terr 1991 ).

Adolescents exposed to trauma tend to respond by acting-out and self–destructive behavior: substance abuse, promiscuity, delinquent behavior, and life-threatening reenactments of violent episodes (APA 2013 ; Bava and Tapert 2010 ; Brent and Silverstein 2013 ; Garbarino et al. 1992 ; Pat-Horenczyk et al. 2007 ).

Children and adolescents who witness the death of close friends or family members may experience survivor guilt (Herman 1997 ; Steele 2004 ).

Like many traumatized adults, children may exhibit classic symptoms of PTSD without any understanding of what is going on with them (Derluyn et al. 2004 ).

Some children exposed to severe trauma may not show many of the classical trauma symptoms until later in life, reflecting the new DSM-5 specifier of “delayed expression” (APA 2013 ).

Children may exhibit traumatic bonding reflecting maladaptive attachment as well as inappropriate modeling of the behaviors of their abusers (a behavior also seen in adults and known as “identification with the aggressor” or “the Stockholm syndrome”) (Cohen et al. 2006 ; Derluyn et al. 2004 ; Weierstall et al. 2012 ).

Studies show that almost 100 % of those witnessing the murder or the sexual assault of a parent, and 35 % of urban youth exposed to community violence develop PTSD, although some of these highly traumatized children are more resilient than others (Derluyn et al. 2004 ; Garbarino et al. 1992 ; Malmquist 1986 ).

These young people with a history of, or current trauma need to be identified and treated in order to prevent life-long physiological, cognitive, emotional, behavioral, and social sequelae of their traumas (Anda et al. 2006 ).

Impact of Trauma on Adults

Ever since the tragedy of September 11, 2001 much has been researched and written about the impact of trauma on adults, especially in the United States. A exploration of the literature finds a variety of specialized journals devoted to this topic (to wit: Journal of Trauma Practice , Journal of Loss and Trauma , Journal of Traumatic Stress , Traumatology , International Journal of Emergency Mental Health , Journal on Rehabilitation of Torture Victims and Prevention of Torture, among others), as well as various textbooks aimed at different health professions, including social work (e.g., Courtois and Ford 2009 ; Foa et al. 2009 ; Ringel and Brandell 2012 ; Straussner and Phillips 2004b , etc.). What we would like to emphasize in this article are some of the lesser known factors effecting millions of adults by focusing on gender differences Footnote 1 and the impact of trauma on immigrants and refugees.

Gender and Trauma: What Do We Know?

Studies have found that men and women experience trauma in very different ways with somewhat different consequences. For instance, while men are much more likely to experience trauma, women are more likely to develop PTSD (APA 2013 ): for every traumatized man, three women have a lifetime prevalence rate of PTSD (Foa et al. 2009 ). Moreover, men are two times as likely as women to experience trauma due to physical assault, yet women are fifteen times more likely to develop PTSD as a result [World Health Organization (WHO), 2011 a]. While there are a variety of hypothesized explanations for these findings, ranging from the fact that women are more likely to seek professional help than men to possible neurobiological and hormonal differences, to women’s greater exposure to intrusive interpersonal violence (Hien et al. 2009 ), there is a lack of conclusive studies explaining these findings. Moreover, it appears that for men the most common factors associated with a diagnosis of PTSD are: rape, combat exposure, childhood neglect, and childhood physical abuse, while women are most likely be diagnosed with PTSD that is associated with sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse (Janof-Bulman 1992 ). These differences are particularly noteworthy among young adults. Recent data on military veterans show that over 15 % of US women veterans returning from the wars in Afghanistan and Iraq report being sexually traumatized in the military compared to .7 % of the men (Kimerling et al. 2010 ; Risen 2012 ).

Violence against women seems to be a growing worldwide pandemic. According to Key Facts Regarding Intimate Partner and Sexual Violence Against Women in the World , published by the World Health Organization (WHO 2011 a):

Violence against women is a major public health problem and violation of women’s human rights. Approximately 20 % of women report being victims of sexual violence as children.

The WHO multi-country study found that between 15 and 70 % of women reported experiencing physical and/or sexual violence by an intimate partner at some point in their lives, ranging from the extremely high rate of 70 % of women in Ethiopia and Peru to a low rate of 15 % among women in Japan.

First sexual experience for many women is reported as forced, with 40 % of young women in South Africa having such an experience. Such violence results in physical, mental, sexual, and reproductive health problems, and may increase the vulnerability of women to HIV/AIDS.

Population-based studies of relationship violence among young people (i.e., “dating violence” or “date rape”) show that it affects a substantial proportion of youth throughout the world. Moreover, worldwide, 1 in 2 female murder victims are killed by their male partners, often during an ongoing, abusive relationship.

Finally, situations of political conflict, post conflict and displacement may exacerbate existing violence and present new forms of violence against women.

Trauma and Immigration/Migration

In 2010, some 214 million people—3 % of the world’s population—lived outside of their country of origin (Batalova and Lee 2012 ). While many people migrate for positive reasons, the so called pull factors –to seek better education or jobs, to reunite with family, and so on—more and more people today move for negative reasons, or push factors , i.e. they are being pushed from their home communities due to natural disasters, economic situations, or local conflicts and wars (Castex 2006 ). Worldwide, there are currently over 15 million refugees uprooted from their home countries, the highest number since the 1990s Rwandan genocide (McClelland 2014 ). For many of these individuals, trauma is compounded by grief over loss—loss of family members and friends, loss of homes, neighborhoods, language, and even familiar smells. Cultural anchors, such as local religious and educational institutions, familiar medicines, native healers and/or known medical and psychological treatment approaches are missing. For many, particular political refugees and those with undocumented status, migration itself becomes traumatic with numerous obstacles along the way and an uncertain future. For some, prejudice and discrimination, lack of recognition of previously achieved economic and personal status (the micro-traumas) compound the reactions. For those whose migration status is undocumented or illegal, seeking or obtaining help for their big T, much less their micro-traumas is often impossible; thus their trauma may remain unresolved and may carry over to the next generation.

The dynamics of intergenerational transmission of trauma was first identified in studies of adult children of Holocaust survivors (Danieli 1998 ; Yehuda et al. 2001 ). The growing attention in the US on what is being termed “historical trauma”, relating mainly to Native American populations (Heart 1999 ), and “Post Traumatic Slave Syndrome” (DeGruy Leary 2006 ), which focuses on the consequences of slavery on African Americans, point to the increasing recognition and need to address the psychological, social, political, and cultural impact of widespread trauma over time . A study by Mollica et al. ( 1998 ) found that in a group of Cambodian survivors the impact of trauma remains decades after the original experience and that mental health symptoms may increase when individuals experience additional traumas, findings that were confirmed by other researchers studying refugee populations from different parts of the world (Bogic et al. 2012 ; Steel et al. 2002 ). Thus, the frequency of traumatic events (multiple traumatic exposures) is an important predictor of long term mental health outcomes, especially for traumatized refugee populations.

Trauma and Older Adults

The finding that cumulative trauma is more likely to increase the risk of poor psychiatric outcomes is of particular relevance to aging populations. The global population of people aged 60 years and older is expected to reach about 1.2 billion in 2025, more than doubling in the last 30 years (WHO 2011 b). As the world’s population ages, the special issues of trauma among the elderly need to be recognized more widely. The concept of “cumulative life stressors” is well known in the psychosocial literature (Dohrenwend 1998 ), and “cumulative trauma” is seen as reflecting multiple traumas experienced by an individual in multiple situations (Landau and Litwin 2000 ; Mollica et al. 1998 ). Thus the older an individual, the more likely he or she is to have been exposed to a variety of traumatic situations, and the more frequent exposure to life-threatening events has been associated with a lower capability to handling stress and higher risks of PTSD (Brandler 2004 ; Ursano et al. 1995 ). Moreover, the elderly are at a greater risk for psychological distress post- disaster than middle aged adults due to a greater risk for bodily injury, loss of resources, and lack of social networks or supports (Marsella 2008 ; Ursano et al. 1995 ). These issues play an even greater role among disabled older adults who are dependent on others for both physical as well as emotional support.

While the elderly may suffer trauma from the same sources as younger people, like children they are particularly vulnerable to being maltreated or abuse at home and even more so in institutions aimed to protect them, such as nursing homes and hospitals. According to the WHO ( 2011 b), an estimated 4–6 % of elderly people in high-income countries have experienced some form of maltreatment at home. Many of the abusive acts against the elderly in homes or institutions consist of micro-traumas, such as: being physically restrained, deprived of dignity by being left in soiled clothes, being over- or under-medicated, and emotionally neglected and abused. One study found that more than half the residents of intermediate care facilities were receiving psychoactive drugs and 30 % received long-acting drugs not recommended for elderly persons (Beers et al. 1988 ). Some acts against older adults do rise up to the level of large-T traumas of physical abuse that can be life threatening or can result in serious, long-lasting, psychological consequences, including depression, anxiety and PTSD.

While accurate, generalizable data are scarce (Ben Natan and Lowenstein 2010 ), one survey of nursing-home staff in the US, found that (Pillemer and Moore 1989 ):

36 % witnessed at least one incident of physical abuse of an elderly patient in the previous year;

10 % committed at least one act of physical abuse towards an elderly patient;

40 % admitted to psychologically abusing patients.

For those cared for at home, studies indicate that the social isolation of both caregivers and the older adults, and the ensuing lack of social support, is a significant risk factor for elder maltreatment by caregivers. Thus help needs to be provided not only to the elderly, but also to their caregivers.

Moreover, when dealing with community trauma, whether natural, such as earthquakes, or man-made, such as a terrorist attack, or individual micro-traumas, such as having a spouse who has been diagnosed with Alzheimer’s, older adults are particularly vulnerable to what has been termed as “ambiguous loss” (Boss 2009 ) or “disenfranchised grief” (Doka 1989 ). For example, while the parents of an adult son killed in a terrorist attack may be acknowledged and supported by the community, the great-aunt of the murdered young man may be totally ignored, even though for many years he may have been her major source of emotional support. Finally, it is important to recognize that the nature of trauma among older adults varies among different ethnic and racial groups, even in the same community (Marsella 2008 ). For example, Higgins and Park ( 2012 ) in a comparison of African American and Caribbean Black older adults in New York found that African Americans experienced more spousal abuse, incarceration, and combat involvement, while Caribbean Black older adults experienced more natural disasters.

Trauma and Resilience: A Strength-Based Perspective

As George Bonanno ( 2004 ) reminds us, as professional helpers we tend to see people who have difficulties coping with trauma. We thus forget that many people are exposed to traumatic events at some point in their lives, and yet they continue to have positive emotional experiences and show only minor or transient disruptions in their ability to function. The concept of resilience reflects the individual’s ability to effectively use resources in the environment, notably relationships with others, as well as their own internal resources and potentialities (Bonanno et al. 2007 ; Bonanno et al. 2011 ). Hauser ( 1999 ; Hauser et al. 2006 ) point out that resilience is a process, not a state. Doing longitudinal studies of youth, most of whom were physically and sexually abused at home and then put into psychiatric hospitals, the authors found that those young men, who as adults were able to achieve a satisfying life despite horrendous childhoods, reflected three general characteristics:

A belief that one can influence one’s environment (self efficacy),

The ability to handle one’s thoughts and feelings (cognitive-behavioral skills), and

The capacity to form caring relationships.

What is important to note is that these traumatized yet resilient youth did not show a normative development. Their lives had not been easy; they made seemingly unwise choices and often got into social and legal troubles. What characterized them was, however, an ability to learn from experience . The authors point out is that “Resilience does not lie in either the competence or relationship; it lies in the development of competence or relationship where they did not exist before” (Hauser et al. 2006 , p. 261). It is this ability to learn from one’s traumatic experience and to achieve what we now refer to as Post - Traumatic Growth (PTG) (Tedeschi and Calhoun 2004 ; Zoeller and Maercker 2006 ) that is the ultimate goal of effective trauma treatment.

Treatment Approaches with Traumatized Individuals

The last few decades have brought extensive research and innovative treatment approaches to helping traumatized individuals. Since, as indicated previously, the experiencing and the consequences of trauma are highly subjective, there is no single treatment approach for helping all individuals who have experienced and suffered trauma, and particularly those suffering from chronic PTSD. Moreover, as trauma can occur at different ages, interventions must be age appropriate as well as gender and culturally relevant.

Interventions with Traumatized Children

As with traumatized adults, the main goal of treatment with traumatized children is to engage them in activities and experiences that allow them to safely express feelings, regulate their emotions and manage overwhelming sensations. The natural language of young children is play. Play therapy, and related expressive arts therapies (Harris 2007 ), provide a way for the child to reenact the traumatic event through symbolic play and movement, and is an empirically-based intervention for working with traumatized children from the age of 3–11 (Bratton et al. 2005 ; Malchiodi 2008 ; Ryan and Needan 2001 ; Webb 2011 ). Play therapy with a caring, empathic adult allows the traumatized child to develop a sense of trust and provides an opportunity to achieve a sense of control over their trauma (Steele 2004 ; Webb 2011 ). While play therapy is usually conducted with an individual child, other approaches focus on involving the parents, and include:

Child-Parent Psychotherapy (CPP) (Lieberman and Van Horn 2008 ). CPP is a psychodynamically based therapeutic approach has shown to be very effective in treating trauma in young children while working with parents to repair the impact of the trauma to the family system. CPP is a flexible, culturally sensitive intervention that can be utilized in unstructured weekly session over the course of a year. It focuses on helping the child to rebuild trust by creating a trauma narrative where the caregiver can act out the protective role through the use of play. CPP has been supported by a number of randomized trials showing efficacy in increasing attachment security and maternal empathy (Berlin et al. 2008 ).

Parent–Child Interaction Therapy (PCIT; Eyberg and Bussing, 2010 ). While not specific to traumatized children, it is an empirically-based behavioral short term intervention for children age 2–7 who are experiencing emotional and behavioral disorders. PCIT draws on both attachment and behavioral theories and is provided over the course of 12 1-h weekly sessions. PCIT involves the parent interacting with the child with the therapist observing through a one-way mirror and coaching through a hearing aid device. The coaching consists of helping the parents to utilize two sets of skills: a. Child Directed Interaction, which teaches parents to use traditional play therapy techniques, and b. Parent Directed Interaction, which teaches the parents skills to address disruptive behaviors while increasing compliance by the child. These skills include establishing rules, praising compliance, using time-out chair for non-compliance, and so on (Ware et al. 2008 ).

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Cohen and Mannarino 2008 ).

TF-CBT is a psychosocial intervention found to be effective in treating PTSD and other behavioral and emotional problems related to a variety of traumatic experiences in children and adolescents. It can be used with children and parents in individual and conjoined sessions, as well as in multi-family groups. TF-CBT usually lasts from 12 to 16 sessions. The treatment model focuses on applying the acronym PRACTICE, which summarizes the nine components of this model: Psychoeducation and parenting skills; Relaxation skills; Affect expression and regulation skills; Cognitive coping skills and processing; Trauma narrative; In-vivo exposure (when needed); Conjoint parent–child sessions; and Enhancing safety and future development (Cohen and Mannarino 2008 ; Cohen et al. 2006 ).

Intervention with Traumatized Adults

Many different treatment approaches have been shown to be effective for traumatized adults. They include: Psychoeducation, cognitive behavioral therapy, exposure therapy, desensitization and imaginal flooding, Eye Movement Desensitization and Reprocessing (EMDR), narrative therapy, group therapy and medications.


Psychoeducation is the “process of teaching clients with mental illness and their family members about the nature of the illness, including its etiology, progression, consequences, prognosis, treatment and alternatives” (Barker 2003 , p. 347). While there has been limited empirical evidence proving the importance of psychoeducation (Lukens and McFarlane 2004 ), clinical experience has shown that understanding the physiological responses to trauma can help individuals develop new coping strategies in dealing with others and learning to calm oneself physically (Creamer and Forbes 2004 ). It has also been shown to improve the quality of life for family members traumatized by others or to better understand the sometimes irrational behaviors of their traumatized loved one (Solomon et al. 2005 ).

Cognitive Behavioral Therapy [CBT]

CBT has been shown to be very effective at helping individuals who have experienced trauma by dealing with their thoughts and beliefs, as well as with their behavior patterns. Among the various empirically-based CB treatments are:

Exposure/Desensitization, which consists of direct confrontation with trauma by having individuals visualize the event, talk about it, and expose themselves gradually to stimuli which reminds them of the trauma. This is repeated several times until the person becomes accustomed or desensitized to these thoughts and images. Through these repeated exercises, the traumatic memory becomes just a regular memory, allowing the individual to have a sense of control rather than feeling helpless over the past traumatic event. One particular approach is known as “Prolonged Exposure” (PE; Foa et al. 2007 ), and is rooted in the tradition of exposure therapy for anxiety disorders and emotional processing for PTSD. PE uses both imaginal exposure (confront feared trauma memories and thoughts via imagining the feared object, event, or situation), and in vivo (experience/confront feared objects, places, events, and situations in real world settings). Individuals also are provided with psychoeducation on trauma reactions and on the use of PE to reduce symptoms, as well as breathing training to manage their anxiety. PE may not be appropriate for individual who have a history of multiple traumas (particularly in childhood), those with anger problems, and those who dissociate (Foa et al. 2007 , 2009 ).

Another empirically supported cognitive-behavioral treatment for PTSD is Dialectical Behavior Therapy (DBT) (Linehan 1993 ), which was developed for individuals diagnosed with borderline personality disorder (BPD). The emotional dysregulation that is the hallmark of BPD is also associated with symptoms of complex-PTSD (DESNOS). The treatment combines group skill training sessions, individual psychotherapy, and phone coaching. It is designed to help individuals label and regulate arousal, tolerate emotional distress, and trust their emotional reactions. Emotional regulation, interpersonal effectiveness, and self-management skills, including mindfulness and meditation skills are core skills in DBT. Validation and dialectical strategies are used to balance acceptance and change during treatment.

A different treatment model found to be effective in treating traumatized adults is Eye Movement Desensitization and Reprocessing (EMDR) (Shapiro 1995 ). For many traumatized individuals, remembering an event can feel as real as if it were happening again before their eyes. EMDR uses the person’s eye movements to help the natural processing and relaxation mechanisms available in the brain. During treatment, people are asked to think of a picture, emotion or thought relating to their trauma and at the same time to watch the therapist’s moving finger or listen to a repeating sound of a drum or a bell, leading to cognitive dissonance and a diminished power of the intrusive traumatic memory. EMDR can be delivered in a short series of sessions and does not involve detailed narrative of the traumatic event.

Narrative Therapy

This approach is based on the belief that trauma disrupts the normal narrative processing of everyday experiences by interfering with psychophysiological coordination, cognitive processes, and social connections, and such incomplete narrative leads to symptoms of posttraumatic distress (Wigren 1994 ). Narrative therapy thus allows for the completion and reframing of the traumatic event. While there is some evidence showing the effectiveness of this approach (Amir et al. 1998 ; Schaal et al. 2009 ), there seems to be no single narrative treatment model. Further research is needed in order to identify the best narrative approaches.

Group Therapy

While group therapy has been found to be effective at providing support for individuals in many circumstances, the use of certain group approaches, such as Critical Incidence Stress Debriefing (CISD) has been shown to have the potential for retraumatization. This is a particular danger for some individuals who are mandated to participate in such a group and listen to other people’s stories of their traumatic events before they had a chance to process their own trauma (Rose et al. 2002 ). Thus caution must be taken when utilizing any group approaches to trauma treatment.

One highly effective treatment model, used mainly in group settings, is Seeking Safety , developed by Lisa Najavitis ( 2006 ), The Seeking Safety Model is a present-focused therapy to help people attain safety from both trauma/PTSD and substance abuse. Treatment is flexible and utilizes 25 different topics that focus on both cognitive and behavioral areas. Seeking Safety is based on five central ideas: Safety as the priority of treatment; integrated treatment of trauma and substance use; a focus on ideals; content addressing cognitive, behavioral, interpersonal skills and case management; and attention to the clinician. Originally developed as an empowerment model for women, it is now recognized as being an effective and widely used approach for many others, including traumatized US veterans (Boden et al. 2012 ). The program focuses on teaching traumatized individuals to view themselves in more positive ways and helping clients build their self-esteem and self-confidence.


While there are no medications specific for trauma or PTSD, some medications have been shown to be effective at treating certain symptoms of PTSD, such as depression, anxiety or sleeping disorders. Currently the US Federal Drug Administration (FDA) has approved only two anti-depression medications for use with patients diagnosed with PTSD: sertraline (Zoloft) and paroxetine (Paxil), although other medications are being used off-label (Jeffreys 2013 ). It is worth noting that some medications have been found to be dangerous for those using or recovering from a substance use disorder, or those who are potentially suicidal (for a full review of medication use for those with PTSD, see Jeffreys 2013 ).

In general, when working with traumatized adults, the most important task is the establishment and maintenance of a physical and emotional sense of safety. It is critical to determine if the individual is at risk for imminent interpersonal violence or other maltreatment in their psychosocial environment, if they are suicidal or homicidal, and if they are psychologically stable and capable of caring for themselves (Briere and Scott 2012 ).

Interventions with Older Adults

While there is a growing acknowledgement of the need for psychosocial interventions with this population, the literature tends to focus more on programs and policies devoted to identification and reporting of elder abuse than actual clinical interventions (Brandler 2004 , Donovan and Regehr 2010 ). Literature on empirically supported interventions with traumatized older adults seems to be almost non-existent, although some believe that CBT may be effective (Foa et al. 2009 ). Obviously, more needs to be done to identify effective clinical approaches to this growing population.

Unfortunately, traumatized children and adults comprise a significant number of individuals in our communities and will continue to be with us in the foreseeable future. Many remain untreated. It is therefore critical for clinicians to be familiar with the various traumas encountered by individuals, families and communities, and to become knowledgeable about the most effective treatment approaches for a given population. Despite the growing research that is providing us with a base of scientific knowledge regarding promising interventions, there is much to be learned about effective interventions with traumatized children and adults—to make sure that we “do no harm.” Particularly important is research focusing on the resilience that many traumatized individuals’ exhibit and learning how best to encourage clients to access their strengths and abilities both in and out of the treatment process. Finally, because of the risk of experiencing secondary trauma, clinicians also need to be aware of the risk of working with high caseloads of traumatized individuals and to learn to take care of themselves so that they do not become part of the problem, but are an effective part of the solution.

While this article discusses the available research focusing on trauma among individuals with traditional gender identities, the authors recognize that transgender individuals experience disproportionate levels of trauma. Since a comprehensive discussion on this topic is beyond the scope of this paper, readers are referred to Mizock and Lewis ( 2008 ) for further information.

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This paper is based on a keynote presentation by the senior author at the international conference on Trauma Through The Life Cycle From a Strengths Perspective: An International Dialogue, Hebrew University, Jerusalem, January 8, 2012. The authors would like to thank Drs. April Naturale, Miriam Schiff and Shlomo Einstein for their helpful critiques of an earlier draft of this paper.

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Straussner, S.L.A., Calnan, A.J. Trauma Through the Life Cycle: A Review of Current Literature. Clin Soc Work J 42 , 323–335 (2014).

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  • Published: 20 May 2024

Targeted temperature control following traumatic brain injury: ESICM/NACCS best practice consensus recommendations

  • Andrea Lavinio 1 , 2 ,
  • Jonathan P. Coles 1 , 2 ,
  • Chiara Robba 3 ,
  • Marcel Aries 4 , 5 ,
  • Pierre Bouzat 6 ,
  • Dara Chean 7 ,
  • Shirin Frisvold 8 , 9 ,
  • Laura Galarza 10 ,
  • Raimund Helbok 11 , 12 ,
  • Jeroen Hermanides 13 ,
  • Mathieu van der Jagt 14 ,
  • David K. Menon 1 , 2 ,
  • Geert Meyfroidt 15 ,
  • Jean-Francois Payen 6 ,
  • Daniele Poole 16 ,
  • Frank Rasulo 17 ,
  • Jonathan Rhodes 18 ,
  • Emily Sidlow 19 ,
  • Luzius A. Steiner 20 ,
  • Fabio Silvio Taccone 21 , 22 &
  • Riikka Takala 23 , 24  

Critical Care volume  28 , Article number:  170 ( 2024 ) Cite this article

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Aims and scope

The aim of this panel was to develop consensus recommendations on targeted temperature control (TTC) in patients with severe traumatic brain injury (TBI) and in patients with moderate TBI who deteriorate and require admission to the intensive care unit for intracranial pressure (ICP) management.

A group of 18 international neuro-intensive care experts in the acute management of TBI participated in a modified Delphi process. An online anonymised survey based on a systematic literature review was completed ahead of the meeting, before the group convened to explore the level of consensus on TTC following TBI. Outputs from the meeting were combined into a further anonymous online survey round to finalise recommendations. Thresholds of ≥ 16 out of 18 panel members in agreement (≥ 88%) for strong consensus and ≥ 14 out of 18 (≥ 78%) for moderate consensus were prospectively set for all statements.

Strong consensus was reached on TTC being essential for high-quality TBI care. It was recommended that temperature should be monitored continuously, and that fever should be promptly identified and managed in patients perceived to be at risk of secondary brain injury. Controlled normothermia (36.0–37.5 °C) was strongly recommended as a therapeutic option to be considered in tier 1 and 2 of the Seattle International Severe Traumatic Brain Injury Consensus Conference ICP management protocol. Temperature control targets should be individualised based on the perceived risk of secondary brain injury and fever aetiology.


Based on a modified Delphi expert consensus process, this report aims to inform on best practices for TTC delivery for patients following TBI, and to highlight areas of need for further research to improve clinical guidelines in this setting.


Traumatic brain injury (TBI) is a complex and heterogeneous disease, and a major cause of death and disability globally [ 1 , 2 , 3 ]. Amongst other common neurological diseases, TBI is estimated to have the highest prevalence and incidence, impacting up to 60 million people worldwide annually and representing a substantial public health burden [ 4 ].

TBI is defined as an alteration in brain function or other evidence of brain pathology caused by an external force [ 5 ], and requires immediate and sustained management strategies to optimise clinical outcome. The injury processes that follow from a TBI are divided into two stages: primary and secondary [ 6 ], where primary injury refers to the damage caused by the original physical impact, which can trigger a pathophysiological cascade resulting in secondary injury with deleterious effects on neurological outcome and survival [ 7 , 8 ]. In order to prevent or mitigate secondary injury, immediate treatment following severe TBI focuses on the prevention of further brain damage. As the brain remains susceptible to secondary injury from processes that extend beyond the zone of primary injury such as ischaemia, oedema, herniation, seizures and altered metabolism [ 9 ], immediate treatment following severe TBI focuses on prevention or mitigation of such injury. This is achieved through the control of intracranial pressure (ICP), and prompt treatment of systemic insults such as hypoxia, hypercapnia, and systemic hypotension [ 10 ].

In the neuro-intensive care unit (NICU), fever is a prevalent occurrence with heterogenous underlying causes, and it may contribute to secondary injury. Across patients with TBI, subarachnoid haemorrhage and stroke [ 11 , 12 , 13 ], hyperthermia has been found to increase the risk of complications and is believed to be associated with unfavourable clinical outcome including death [ 9 , 11 , 14 , 15 ].

Targeted temperature control (TTC) is a complex intervention that aims to control body or brain temperature to prevent further brain injury and improve neurological outcome [ 9 ]. The term TTC may refer to different degrees of temperature control, from fever prevention, maintenance of normothermia to the induction of hypothermia, at different levels [ 9 , 16 ]. In TBI, TTC can be used to modulate a range of important physiological parameters such as cerebral metabolism and ICP. However, its role in improving long-term outcome, as well as the appropriate indications, targets and duration of TTC in severe or moderate TBI are currently unknown.

This work aims to utilise a Delphi approach to develop best-practice consensus recommendations from international experts for the real-world application of TTC in severe TBI with ICP guided treatments.

Review of the literature and evidence quality assessment

Statements and questions were informed by a systematic review of the literature, which identified observational studies, meta-analyses and randomised controlled trials (RCTs) relevant to the topics under discussion. This review search focused on evidence released since 2013. Following this first review, the methodology group of ESICM conducted an independent systematic review of the literature, considering only published RCTs regarding TTC in TBI patients with ICP monitoring. This review confirmed the paucity of RCTs and the substantial clinical heterogeneity between them, which precluded meta-analytical combination. The outputs from the reviews were shared with the expert panel members ahead of the Delphi process. A detailed reporting of the literature reviews is provided as Additional files 1 and 4 .


The 18 expert attendees for the Delphi process were chosen from members of three professional societies: the Neuro Anaesthesia and Critical Care Society (NACCS), the European Society of Intensive Care Medicine (ESICM), and the European Society of Anaesthesiology and Intensive Care (ESAIC). Selection was based on a documented history of publications in the fields of traumatic brain injury and/or targeted temperature management, as well as their established professional profiles and expertise as leading intensive care practitioners in teaching university hospitals. We endeavoured to ensure balanced representation, covering the geographic areas of the EU, Switzerland, and the UK.

Delphi rounds

A modified Delphi consensus method was employed, involving a combination of an online survey (Round 1), a face-to-face meeting (Round 2), an additional online survey containing the refined questions from the previous steps, (Round 3) and post-meeting reviews of the consensus results. The questions asked at Round 1 can be found in the Additional file 2 , and the results following Round 3 are shown in Table  1 . Round 1 was conducted via the SmartSurvey® online platform, and Round 2 was held as a hybrid meeting in London, UK, on Tuesday 10th October 2023. AL acted as Chair, with an independent facilitator (ES) moderating the meeting. After the results from the final survey of Round 3 were received, the recommendations and final manuscript were developed, with documents shared by e-mail and feedback collected independently from each participant by the facilitator. The predefined agreed cut-off for strong consensus was to have ≥ 16 out of 18 (≥ 88%) of panel members in agreement, and for moderate consensus was to have ≥ 14 out of 18 (≥ 78%) of panel members in agreement. The Delphi methodology and process was adopted from the manuscript published by Lavinio et al. [ 17 ]. In a Delphi process, conflicting opinions are addressed through a structured framework that promotes consensus-building among experts. Initially, participants are asked to provide their views anonymously, which are then summarised and shared with the group. This approach facilitates open and unbiased input, as the anonymity helps mitigate the influence of dominant personalities or hierarchical pressures. When conflicting opinions emerge, they are documented and presented back to the participants, along with any common ground that has been identified. In subsequent rounds, individuals are encouraged to reconsider their positions in light of the collective feedback, which often leads to a convergence of opinions. If discrepancies persist, these are explored through further iterative rounds, with an emphasis on clarifying rationale and seeking areas of agreement. The Delphi method's iterative nature, combined with the feedback mechanism, effectively manages conflicting opinions by fostering a gradual move towards consensus, or at least a clearer understanding of the points of divergence. The process for the Delphi panel and subsequent manuscript development is visualised in Fig.  1 . A detailed overview of the iterative Delphi process is provided in the Additional files 2 and 3 .

figure 1

Summary of the Delphi process. ESAIC European Society of Anaesthesiology and Intensive Care, ESICM European Society of Intensive Care Medicine, NACCS Neuro Anaesthesia and Critical Care Society


To guide discussions during the Delphi process, clinical terms were defined with the values as shown below.

Declarations and conflicts of interest

The face-to face meeting in London was supported by Becton, Dickinson and Company (“BD”) through the provision of travel costs, meeting space and refreshments. Representatives from BD were allowed to silently observe the conference, without any interaction with the panellists or the process. No donors or other outside parties influenced any portion of these recommendations. There was no industry input into recommendation development, and no panel member received honoraria for their involvement. Panellists completed conflict of interest forms relevant to TBI management. There were no conflicts mandating recusal of any participant. No funding was provided by the societies involved.

The results of the final consensus are presented in Table  1 . We highlight and expand upon statements in which consensus was reached in the discussion section. Some consideration is added to statements in which consensus was not reached, proposing them as potential areas for valuable future research.

To date, there is a lack of definitive evidence regarding the use of TTC with an automated feedback-controlled device for managing temperature in severe TBI. This underlines the importance of consensus discussion in identifying areas of uncertainty where evidence is lacking, and in encouraging harmonised care delivery across different settings.


Temperature measurement and control is an essential aspect of high-quality care in patients with severe TBI

In patients with impending cerebral herniation, temperature control is essential

As an introduction to the discussions, the group debated the recommendation for temperature measurement and control following severe TBI and, after extensive discussion, concluded that core temperature measurement and control is essential for the provision of high-quality care, especially in patients perceived to be at high risk of secondary brain injury. Noting the phrasing of ‘temperature control’ in the recent guidelines for temperature control following cardiac arrest [ 18 ], the group agreed that as an entry point into high-quality care following TBI, the notion of temperature measurement and control is key, opening the door to the full practice of targeted temperature management. This nuanced phrasing was intended to set the scene for the group’s work, with the specifics of the TTC process such as temperature ranges and duration of control being addressed throughout the remainder of the discussions.

Highlighting the wealth of physiological data available on the management of temperature in stroke and cardiac arrest, the group noted that the guidelines for temperature management in TBI are less specific. Fundamentally, the group agreed that high-quality TBI care does include monitoring temperature and implementing some form of temperature control, recognising its potential role in optimising outcome. The group highlighted the importance of treatment titration based on an individualised risk–benefit assessment and stratification. In particular, it was noted that in patients with exhausted intracranial compensatory reserve and at risk of cerebral herniation or ischaemia—there exists an extreme susceptibility to secondary brain injury precipitated by suboptimal temperature control.

Cerebral herniation is a life-threatening event that requires early diagnosis and prompt management in order to prevent irreversible pathological cascades that can lead to death [ 19 ]. Increases in brain temperature have been linked to a linear rise in ICP, with the relationships between temperature, ICP and cerebral perfusion pressure (CPP) becoming more apparent with rapid temperature changes. The impact of temperature on ICP supports the recommendation from the group that temperature control is an essential aspect of care in patients at risk of herniation [ 20 ]. The group agreed that while control of ICP and prevention of herniation were important reasons for TTC in TBI, benefits of TTC in the acute phase of TBI also extended to patients without intracranial hypertension.

During the discussions the group highlighted that different pathologies often dictate different patient management. For example, patients in whom fluctuations in ICP are well-tolerated (e.g., patients with high intracranial compliance) will be managed differently to patients with obliterated basal cisterns, obliterated cortical sulci, and midline shift (e.g., intracranial mass effect). In patients with exhausted intracranial volume-buffering reserve, strict control of physiological parameters such as CO 2 and temperature, is strongly recommended.

Continuous temperature monitoring is preferable over intermittent temperature measurements in patients with severe TBI.

Monitoring core temperature (e.g., bladder, oesophageal, brain) is strongly recommended over measuring or monitoring superficial temperature (e.g., skin, tympanic) in severe TBI.

When brain temperature monitoring is in place, it is advisable to assess an additional source of core temperature monitoring (i.e. oesophageal, bladder).

The group widely agreed, in line with supporting literature, that continuous temperature monitoring is preferable over intermittent temperature measurements with severe TBI. Intermittent monitoring and recording of temperature can result in large fluctuations in temperature being missed, as highlighted by supporting literature investigating the use of TTC following cardiac arrest, TBI and stroke [ 17 , 21 , 22 ].

Discussions amongst the group drew attention to the fact that inaccurately measured temperatures can negatively impact patient care and outcome. Several temperature monitoring sites are available for TTC, and the group widely agreed that core temperature measurements, i.e., bladder and oesophageal sites, are strongly preferred over superficial measurements such as those taken at skin and tympanic sites. Following acknowledgement of their limitations [ 23 ], bladder and oesophageal were singled out as favoured core temperature measurements. The group acknowledged the widespread use of oesophageal probes due to their relative ease of insertion and the challenges of finding MRI compatible bladder probes. Confirmation of preference between the two was acknowledged as being beyond the scope of the group due to these nuances. Rectal temperature monitoring was widely regarded as impractical for reasons such as the lag time and a high rate of dislocation [ 16 , 23 ]. Peripheral sites were unanimously deemed to be insufficiently accurate to guide temperature treatment [ 16 ].

Some panel members argued that monitoring target organ (i.e. brain) temperature could add a layer of clinical safety, improve pathophysiological understanding and allow selective and individualised titration of treatment (i.e. selective brain cooling). It was, however, agreed by the group that more research is needed into optimum methods for measuring brain temperature and its interpretation from both a clinical and resource-availability perspective. In particular, it was highlighted that temperature thresholds for harm are less well defined for brain temperature than core temperature. When brain temperature monitoring is available and in place, the group advised that core temperature should also be assessed with bladder or oesophageal probes since this is part of routine practice and has been studied to a greater extent than brain temperature. The group noted the importance of having a dual source of temperature monitoring when using automated TTC devices to reduce the risk of probe malfunction and subsequent over or undercooling [ 24 ].

After TBI, brain temperature has often been shown to be higher than systemic temperature and can vary independently, with literature noting a difference of as much as 2 °C depending on the individual characteristics of brain pathology and/or probe location, making a consistent and accurate link between the two challenging and possibly inaccurate [ 25 , 26 ]. The group highlighted that targeting brain temperature may allow precise titration of treatment dose, including titration of selective brain cooling with brain temperature management technologies, theoretically reducing side effects associated with systemic hypothermia, whilst delivering neuroprotection and brain temperature management. However, it was concluded that further research is needed in this regard and that not enough evidence exists to support practical recommendations.

ICP management

Temperature control is a key component of ICP management in severe TBI.

Controlled normothermia (i.e., target core temperature 36.0–37.5 °C) should be included as an addition to the Tier 1 and Tier 2 treatments defined within the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC) 2019 guidelines.

Therapeutic hypothermia (i.e., target core temperature ≤ 36.0 °C) should be considered in cases where tier 1 and 2 treatments (as per SIBICC guidance) have failed to control ICP.

If hypothermia is considered to control ICP, target temperature should be managed as close to normothermia as possible.

ICP monitoring remains a critical component in the management of severe TBI [ 27 , 28 ]. The group unanimously agreed that temperature control is a key aspect of managing ICP, highlighting that an increase in temperature can lead to an increase in cerebral metabolism and augmented cerebral blood flow, and a simultaneous increase in cerebral blood volume. In cases of exhausted compensatory mechanisms, these factors can precipitate intracranial hypertension [ 20 ], which in turn can have a deleterious effect on overall outcome.

Because there is often no single pathophysiological pathway of ICP elevation, its management is complex. The most recent versions of the Brain Trauma Foundation TBI guidelines do not contain treatment protocols, in part due to a lack of solid evidence around the relative efficacy of available interventions [ 27 ]. To address this, the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC) developed a consensus-based practical algorithm for tiered management of severe TBI guided by ICP measurements [ 28 ].

One of the most impactful outcomes from this consensus meeting was the acknowledgement of the essential role of temperature control for ICP management in severe TBI, and the recommendation that controlled normothermia (i.e., target core temperature 36.0–37.5 °C) should be considered in addition to Tier 1 and Tier 2 treatments. The group was keen to harmonise this output with SIBICC by suggesting a more aggressive and specific management with the addition of controlled normothermia in Tiers 1 and 2, adding a layer of clinical safety beyond merely the avoidance of fever over 38.0 °C in Tier 0, as shown in Fig.  2 . In cases when hypothermia is considered (i.e., SIBICC Tier 3), the group recommended that target temperature be managed as close to normothermia as possible, based on an individualised risk–benefit assessment [ 29 ].

figure 2

Intracranial pressure management algorithm for severe TBI edited from SIBICC 2019 [ 28 ]. * Including TTC in tiers 1 and 2 is the suggested addition from the TTC-TBI group to the original SIBICC tiers (green bars). *When possible, the lowest tier should be used. It is not necessary to use all modalities in a previous tier before moving to the next tier. Consider repeat CT and surgical options for space occupying lesions. CPP cerebral perfusion pressure, CT computed tomography, EEG electroencephalography, Hb haemoglobin, kPa kilopascal, mmHg milimetre of mercury, PaCO 2 arterial partial pressure of carbon dioxide, SpO 2 arterial oxygen saturation

No consensus was reached on whether hypothermia was a viable temporising strategy in patients with impending cerebral herniation, in patients awaiting haematoma evacuation or decompression, or before consideration of barbiturate coma. Whilst the group acknowledged that therapeutic hypothermia can be effective in reducing ICP, there was no consensus on whether this could be induced rapidly enough in these circumstances, and it was felt that insufficient evidence was available to provide pragmatic recommendations on its indication in these extreme clinical circumstances.

Whilst the majority of experts indicated 35.0 °C as the lowest target temperature to be considered in these circumstances, no consensus was reached. The discussion highlighted that insufficient evidence exists to support practical recommendations and highlighted the importance of an individualised risk–benefit assessment. It was also noted that centres might have a varying degree of familiarity with different therapeutic options, including ease of access to neurosurgical options (i.e. ventricular drainage, decompression) and this may have an impact on clinician preference for hypothermia as a temporising therapeutic modality.

The group also discussed the indication of barbiturates in the context of ICP control following severe TBI, not reaching consensus on whether therapeutic hypothermia should be attempted before considering barbiturates. The group noted that both barbiturate-induced burst-suppression and therapeutic hypothermia have distinctive side effects and concluded that no recommendations for standard clinical practice could be made beyond what was already stated in SIBICC guidance.

Neurogenic fever (core temperature > 37.5 °C) driven by neurological dysregulation in the absence of sepsis or a clinically significant systemic inflammatory process is relatively common in TBI, and it should be promptly detected and treated (i.e., with controlled normothermia targeting 36.0 °C to 37.5 °C), irrespective of ICP level.

Controlled normothermia should be considered when pyrexia is secondary to sepsis or inflammatory processes, and when the patient is perceived to be at risk of secondary brain injury, especially in the acute phase of TBI.

Uncontrolled fever (neurogenic or secondary to inflammation or infection) can precipitate secondary brain injury in patients with severe TBI.

It was widely agreed that neurogenic fever, defined here as core temperature > 37.5 °C driven by neurological dysregulation in the absence of sepsis or a clinically significant inflammatory process is common in intensive care and it has been found to be associated with an increased risk of complications and unfavourable outcome [ 9 , 14 , 15 ]. In the setting of neurogenic fever developing in comatose patients with acute traumatic encephalopathies, controlled normothermia targeting 36.0–37.5 °C was recommended in tier 1 and 2 of the ICP management algorithm.

Correctly differentiating central fever against fever of infectious origin is both challenging and clinically important due to the impact of failing to identify a treatable condition, the negative consequences of antibiotic overuse, and the detrimental effect of hyperthermia on brain-injured patients [ 17 , 30 , 31 ]. However, the group noted that physiological processes such as brain metabolic rate of oxygen, CO 2 control, brain tissue oxygenation (P bt O 2 ) and ICP are directly related to temperature, and that the deleterious effects and likelihood of secondary injury may occur irrespective of whether temperature is raised due to infection or impaired thermoregulation. This therefore highlights the need for acute management of temperature regardless of the source of the pyrexia, although added focus must be placed on the management of nuanced patient characteristics such as those with severe TBI with impending herniation and/or obliterated basal cisterns, as opposed those with low ICP and preserved intracranial compliance.

In line with current research [ 9 , 11 , 32 ], it was agreed that the development of fever is common in TBI cases, and that it can precipitate secondary brain injury and adversely affect patient outcome. It is therefore of utmost importance to prevent or promptly treat fever when detected. The group agreed that while some degree of controlled pyrexia may be allowed during the subacute phase of disease, ‘uncontrolled’ fever requires urgent management in the acute phase as long as the patient is still perceived to be at significant risk of secondary brain injury.

Fever control is recommended in patients with severe TBI who have seizures or are perceived to be at high risk of seizures.

In patients with severe TBI who are sedated and ventilated, controlled normothermia, irrespective of ICP, should be initiated reactively when fever is detected.

When neurogenic fever is detected in TBI cases, controlled normothermia should be continued for as long as the brain remains at risk of secondary brain damage.

The group strongly recommended that fever control and controlled normothermia are of particular relevance in patients perceived to be at high risk of seizures and, more in general, secondary brain injury. The assessment of whether an individual patient should be considered ‘at risk of seizures’ or ‘at risk of secondary brain injury’ remains the responsibility of the managing physician. The group defined risk factors for seizures as a history of seizures, the presence of temporal contusions or depressed skull fractures. Features associated with a higher ‘risk of secondary brain injury’ included labile ICP, obliterated basal cisterns, midline shift or subfalcine herniation, and other signs of exhausted intracranial volume buffering reserve. While no consensus was reached on a specific temperature range to target during controlled normothermia, the group agreed that the reactive initiation of temperature control was important in sedated and ventilated TBI patients, with agreement on a pragmatic setting of a target core temperature range of 36.0–37.5 °C to accommodate expected fluctuations of ± 0.5 °C while avoiding spikes over 38.0 °C [ 28 ].

Hypothermic TTC induction

It is recommended that the rapid induction of hypothermia in traumatic brain injury cases should be achieved with automated feedback-controlled temperature management devices.

In line with current research [ 17 ], the group widely agreed on the reactive use of an automated feedback-controlled device for the application of optimal TTC. The TTC process can be divided into three phases: induction, maintenance, and rewarming [ 9 , 16 ]. As explained in existing literature, varying availability of devices and financial aspects may dictate choice, and while non-automated methods of temperature control are cheaper and easier to apply, the level of control offered is poor and their use should be limited to the induction phase, as adjuncts to automated devices. [ 17 , 33 ] Whilst antipyretics such as acetaminophen (paracetamol) or nonsteroidal anti-inflammatory drugs (NSAIDs) are widely acknowledged in intensive care unit (ICU) settings for their role in fever management, it is recognised that in the context of severe TBI, the efficacy of antipyretics in controlling fever and minimising temperature variability is limited. The application of therapeutic hypothermia requires constant monitoring of core body temperature in order to achieve an accurate target temperature during induction to prevent overcooling, to assess variations during the maintenance phase, and to ensure a steady, controlled rewarming phase [ 16 ].

There was no agreed recommendation from the group as to whether ICUs should stock readily available ice-cold NaCl solutions of different concentrations for the management of ICP crises, citing a lack of clear evidence to draw upon. The group did however highlight the fact that the rapid infusion of ice-cold saline is an inexpensive and readily available option for lowering core body temperature [ 9 ], with the rapidity of response to ice-cold infusions being regarded as a valuable aspect of TTC induction.

TTC maintenance

An automated feedback-controlled TTC device that enables precise temperature control is desirable for the initiation of TTC and maintenance at target temperature in patients with severe TBI.

The maximum temperature variation that a patient should experience during normothermia is less than or equal to +/− 0.5 °C per hour and ≤ 1 °C per 24-hperiod

When hypothermia is indicated, treatment should be continued for as long as the brain is considered to be at risk of secondary brain injury.

Automated feedback-controlled devices for TTC are powerful tools, encouraging the delivery of quality care and aiming to improve neurological outcome [ 13 , 17 ], minimising the chances of temperature variability. Temperature variability is the deviation of patient temperature outside of the goal, typically reported as mean deviation or percent of time outside of target [ 9 ]. The group noted that there is a level of pragmatism to be adopted in TTC maintenance, discussing that while more time spent in fever can negatively impact neurological outcome, fluctuations in temperature may also affect outcome [ 17 ], and consensus was reached on the importance of maintaining temperature at as consistent a level as possible with the group settling on a fluctuation range of less than or equal to ± 0.5 °C per hour and ≤ 1 °C per 24-h period. In instances where an automated feedback-controlled device is not available, the group noted the importance of increased staff awareness of patient status to ensure fluctuations outside of this range are appropriately managed. The group highlighted that a dedicated protocol for sedation, analgesia and shivering management might be helpful to ensure consistent application of optimal TTC.

The group agreed that when indicated, hypothermia should be continued for as long as the individual practitioner considers the brain to be at risk of secondary injury. These considerations were supported with a suggestion that it should be maintained for as short a time as possible.

Rewarming following hypothermic TTC

Obtaining an interval scan and/or an alternative assessment of intracranial compliance, in addition to the absolute number of ICP, is recommended before rewarming.

Rebound hyperthermia should be prevented whenever possible or promptly treated in cases when the brain is perceived to be at risk of secondary brain injury.

In cases in which the patient is being rewarmed from therapeutic hypothermia (core temperature lower than 36.0 °C), the group agreed that once ICP has been maintained within controlled limits and de-escalation of treatment intensity is considered, it is sensible to ensure the patient has sufficient intracranial volume buffering reserve through the use of an interval scan and/or an alternative measure of intracranial compliance, before commencing the rewarming process. The group also noted the high prevalence and potential risks associated with rebound hyperthermia when TTC is discontinued following therapeutic hypothermia, highlighting the importance of continued vigilance and careful temperature control in the rewarming phase.

Whilst no consensus was reached on recommended rewarming rates, the group agreed that controlled rewarming with an automated feedback-controlled device may reduce the risk of rapid temperature variations and rebound pyrexia that can precipitate secondary brain injury and compromise care [ 16 , 33 ]. The group highlighted how controlled rewarming may improve the ability of clinicians to more effectively control important inter-dependent clinical variables such as PaCO 2 , ventilation settings and depth of sedation.

TTC for shivering

It is important to assess, document and manage shivering in severe TBI patients.

Whenever ICP is labile and shivering is detected, neuromuscular blockers should be considered after ensuring appropriate depth of sedation.

In self-ventilating patients in the subacute phase of severe TBI, an individualised risk–benefit assessment should be undertaken regarding the strict indications of controlled normothermia.

Permissive hyperthermia should be considered in cases where risk of secondary brain injury resulting from pyrexia is thought to be low, and when shivering cannot be controlled with first line treatments such as NSAIDs, opiates, magnesium or counter warming.

In line with current literature, it was widely agreed that shivering should be managed in patients following severe TBI. Shivering can reduce brain tissue oxygenation leading to cerebral metabolic stress, which may therefore negate the neuroprotective benefits of TTC [ 9 , 34 , 35 , 36 ].

Titration of sedation and the use of neuromuscular blocking agents provides intensivists with readily available and effective options for shivering control in critically ill patients [ 37 ]. To ensure appropriate and effective use however, treating staff must be aware of the nuances of selecting the correct agent, monitoring the depth of neuromuscular blockade, and ensuring adequate skeletal muscle recovery once therapy with neuromuscular blockers has ceased. In cases of shivering when ICP is labile, the group agreed in line with current literature that ensuring depth of sedation before administering neuromuscular blockers is of utmost importance [ 37 , 38 ]. When using pharmacologic agents for shivering management, treating staff must consider potential pharmacokinetic and pharmacodynamic variation and monitor for efficacy (i.e. shivering control) and safety (i.e. adverse events and drug-drug interactions) [ 9 ].

The group agreed that in patients who are perceived to be at relatively lower risk of secondary brain injury (i.e. self-ventilating patients in the sub-acute phase of severe TBI), permissive hyperthermia may be considered over TTC, especially if the latter therapeutic option would require sedation or other invasive interventions. The group agreed that an individualised risk–benefit assessment should ultimately be undertaken before commencing controlled normothermia in such patients.

‘Time within target range’, ‘burden of fever’ and similar metrics can be considered as indicators of quality of temperature management.

‘Time within target range’ and ‘burden of fever’ were considered by the group to be appropriate metrics of quality temperature management. It was widely acknowledged that these metrics should be weighed by patient length of stay and/or duration of monitoring for appropriate statistical interpretation. The group was also careful to note that the administrative burden on physicians is already high and acknowledged the fact that some centres may not have access to electronic patient data management systems, so it was agreed that it was unrealistic for this group to issue prescriptive recommendations on auditing practices. In light of the high heterogeneity across centres [ 9 ], here the group were keen to clarify that wherever possible, documenting metrics such as ‘time within target range’ and ‘burden of fever’ may improve their ability to deliver data-driven service improvement and temperature control.

This consensus review was undertaken to evaluate current evidence on the application of TTC in the management of severe TBI in a critical care setting, and to develop a set of practical recommendations to address identified gaps in current published evidence.

As highlighted by the SIBICC 2020 group, the gap between published evidence and management protocols is bridged by expert opinion [ 39 ]. The optimal method for the provision of high-quality TTC remains unknown, and barriers to its consistent implementation include the lack of evidence-based treatment protocols, knowledge deficiencies, limited access to equipment, lack of financial resources and staff workload. This document aims to address key practice gaps and optimise patient care through multimodal assessment following TBI.

Strengths and limitations

The Delphi process has a number of strengths. Participants are able to reconsider their views in light of the evolving discussions, allowing for an element of reflection that isn’t regularly seen in other studies involving a single time point such as interviews or focus groups [ 40 ]. The element of anonymity offered to the panellists in the survey rounds avoids group conformity and promotes honesty, and the controlled and iterative discussions offer a flexible approach to gathering expert viewpoints on the set research questions. The Delphi method is an iterative process allowing the anonymous inclusion of a number of individuals across diverse locations and areas of expertise and avoiding dominance by any one individual. It uses a systematic progression of repeated rounds of voting and is an effective process for determining expert group consensus where there is little or no definitive evidence and where opinion is important [ 41 , 42 ]. The modified Delphi approach used here combined the early flow of structured information and submission of anonymous responses with the (hybrid) face-to-face discussion and further voting to gain consensus (or establish lack thereof) and expert insight into usual practice regarding non-pharmacological TTC with an automated feedback-controlled device. As cited in existing literature however [ 13 , 17 ], the Delphi process has limitations. The process is vulnerable to drop-outs and technical issues, with the online voting process during our meeting seeing some participants unable to cast their votes on a number of questions, leading to the need for a final anonymous survey round. The group opinions during the meeting may have been impacted by social bias, and the voices across the in-person and online participants may not have been equally heard, highlighting a potential need to ensure consistency in attendance in the same format in future panel meetings.

Our recommendations for the use of automated feedback-controlled TTC devices are based on expert consensus and theoretical benefits, such as precise temperature control and reduced temperature variability, which are thought to potentially improve outcomes in severe TBI management. We acknowledge the current evidence gap and strongly emphasise the need for rigorous research to evaluate the effectiveness of these devices, especially in diverse healthcare settings, including lower-income countries where resource limitations are critical. Future updates to these best-practice recommendations will incorporate emerging evidence to ensure relevance and applicability across different healthcare contexts, aiming for the highest standards of care within the constraints of available resources. While automated feedback-controlled TTC devices represent a significant advancement in the management of temperature in severe TBI patients, offering potential benefits in terms of precision and consistency, it is imperative to recognise the value and applicability of a wide range of temperature management approaches. These include both manual methods and simpler devices, which remain vital in many clinical settings around the world. Our guidelines advocate for the adaptation and implementation of TTC principles based on the specific resources, capabilities, and needs of each clinical setting.

This report has been developed by an expert panel comprised of specialists in neuro-critical care experienced in the management of severe TBI, therefore the recommendations focus on patients managed in a critical care environment. An individualised risk–benefit assessment should be undertaken for each domain to accommodate the high levels of heterogeneity seen across TBI patients, local practice settings, staff training and equipment availability [ 9 ].

TTC is a therapy that has a role in ICP management and may reduce secondary injury and improve long-term neurological outcome for victims of TBI [ 9 ]. Appropriate methods for the implementation of TTC across widely heterogenous clinical settings and patient populations are relatively understudied, and due to a lack of consistent and high-quality evidence, remain largely unknown. Areas of consensus emerging from the Delphi process included TTC being recognised as an essential aspect of high-quality TBI care. Controlled normothermia (36.0–37.5 °C) was strongly recommended as a therapeutic option to be considered in Tier 1 and 2 of the SIBICC ICP management protocol. Temperature management targets should be individualised based on the perceived risk of secondary brain injury and fever aetiology.

Availability of data and materials

All data generated or analysed during this study are included in this article and its supplementary information files.


Cerebral perfusion pressure

Computed tomography


European Society of Anaesthesiology and Intensive Care

European Society of Intensive Care Medicine


  • Intracranial pressure

Intensive care unit

Neuro Anaesthesia and Critical Care Society

Sodium chloride

Neuro-intensive care unit

Nonsteroidal anti-inflammatory drugs

Arterial partial pressure of carbon dioxide

Brain tissue oxygenation

Randomised controlled trial

Seattle International Severe Traumatic Brain Injury Consensus Conference

Arterial oxygen saturation

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The group would like to acknowledge the support of Page & Page, London UK in facilitating the Delphi meeting.

The Delphi Panel meeting in October 2023 was facilitated (through the provision of travel costs, meeting space and refreshments) by Becton, Dickinson and Company. The development of these consensus recommendations was conducted with strict measures to ensure independence from its sponsor. The research team independently conducted all data analyses and drafted the manuscript. The role of BD was limited to providing logistical support for the Delphi panel meeting held in London, including travel costs, meeting space, and refreshments, without any influence over the study's content or conclusions. The Delphi voting process was conducted anonymously, ensuring that panel members could freely express their professional opinions without bias or influence from the sponsoring body or among panel members. The manuscript's drafting, review, and revision processes were carried out independently of BD. The sponsor had no editorial control, ensuring that the recommendations are based on the authors’ independent, professional expertise in targeted temperature management following traumatic brain injury. This article contains the personal and professional opinions of the individual authors and does not necessarily reflect the views and opinions of Becton, Dickinson and Company (“BD”) or any Business Unit or affiliate of BD. If drugs and/or medical devices are cited in the article, please consult package insert and instructions for use of them to know indications, contraindications, and any other more detailed safety information.

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Andrea Lavinio, Jonathan P. Coles & David K. Menon

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IRCCS Policlinico San Martino, Genoa, Italy

Chiara Robba

Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands

Marcel Aries

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All authors took part in the Delphi process. All authors read, revised and approved the manuscript.

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Supplementary Information

Additional file 1.

. Evaluation of five randomized controlled trials by the ESICM Methodology Group evaluates evulating cooling strategies against traditional interventions. The evaluation highlights methodological heterogeneities and evidential challenges.

Additional file 2

. Delphi questionnaire: Round 1.

Additional file 3

. Delphi questionnaire. Round 3.

Additional file 4

. Systematic review of the literature on targeted temperature control in traumatic brain injury, covering clinical studies from 2013 to 2023.

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Lavinio, A., Coles, J.P., Robba, C. et al. Targeted temperature control following traumatic brain injury: ESICM/NACCS best practice consensus recommendations. Crit Care 28 , 170 (2024).

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When Oversharing Turns into Trauma Dumping, and How to Stop

Healthy venting can turn into something else

Cathy Cassata is a freelance writer who specializes in stories around health, mental health, medical news, and inspirational people.

trauma research articles

Aaron Johnson is a fact checker and expert on qualitative research design and methodology. 

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Social Media Breeds Trauma Dumping

Why trauma dumping can push people away, signs you might be a trauma dumper and how to stop, how to set boundaries.

Sharing our stress, anxiety, and worries with others can help process difficult feelings. And, no doubt, the pandemic has brought on a lot of reasons to vent. 

But when does venting turn into trauma dumping—oversharing of traumatic experiences ? 

“Some people may feel the need to share about traumatic experiences to a friend, family member, coworker, or acquaintance, but may not always fully grasp the severity or intensity of what they are about to share,” says Brittany Becker , LMHC and director at The Dorm.

This is especially true if the person oversharing has not identified specific areas of their life as being a traumatic experience.

When a person experiences a traumatic event or ongoing trauma, Becker says they might compartmentalize or create distance from the events in order to protect themselves and function in their day-to-day life. 

“This can become confusing to [listen to] as they may speak about [trauma] as matter of fact or in the same manner of everyday surface level venting, when in actuality the words they are stating are actually very opposite from tone or affect that they may be presenting the information in,” Becker says. 

The fine line between venting and trauma dumping comes down to this, says Gina Moffa , LCSW, psychotherapist: with trauma dumping, the purpose is to solicit sympathy and feedback. 

It's simply making your painful experiences, and devastating emotional setbacks the point to your conversations, wherein you do not have the ability to self-reflect or bring responsibility or accountability to your side of the story.

However, in venting, most of the time, she says people are aware they are expressing pent up emotions, and that their venting is a one-time thing.

“[They are] not soliciting sympathy, as much as simply the need to ‘get this off their chest,’” says Moffa.

Writing about your feelings on social media can feel easier than talking about them in person sometimes. 

“It's much safer to share your pain on a platform, behind a screen. With more and more people on social media, it has become a safer place to share personal stories and information more readily,” says Moffa. 

Plus, Becker says the ability for social media to reach many people makes it likely you will get validating responses, differing opinions that allow you to reframe your thinking, and a test audience to see how people react to your story before sharing it with those closest to you.

While sharing traumatic experiences can be helpful, if you trauma dump incessantly to garner attention or sympathy, Moffa says people may become immune to it.

We have to be careful that we are not sharing deeply personal information, while looking for people to respond over and over again with the same level of sympathy and concern.

Doing so can push people away and encourage them to distance themselves because they may feel the following, notes Becker.

  • Uncomfortable with hearing details about the trauma
  • Unsure how to respond appropriately to the traumatic experience
  • Resentment and frustration toward you for not realizing your trauma could affect their life 

Moffa says those who trauma dump are usually people who feel alone and want to feel heard and validated, “but who also wind up isolating themselves further because they dump on people without…awareness, which in turn, creates more of a chasm for them. Connection is therefore, unfortunately, never reached, although it's what they yearn for most.” 

If you’re pushing people away and not sure if it’s due to trauma dumping, Becker says consider the following signs: 

  • You “vent” about the same feelings and triggers repetitively and do not reframe, learn to cope more effectively to a trigger, or move forward.
  • You don’t allow others to give their opinions or point of view about your experience.
  • You find yourself in one-way relationships, in which you vent to people, but hardly or never hear from them about their life.
  • You don’t ask others about their lives or make room for them to ask you for advice.

Once you realize you are trauma dumping and understand the consequences it has on your relationships and your own wellness, Becker says identify a list of people who you can reach out to when you need to discuss your trauma.

Before contacting them, ask yourself what your motivations and goals are for discussing the trauma with them. Then consider starting your conversation with statements like: 

  • “I’ve experienced something that is really hard for me to process and may be hard for you to hear, are you in a place to talk about something like this with me at the moment?”
  • “Hey, can you help me out by letting me know if I ever step over a line between venting or trauma dumping, in case I ever go somewhere in our conversation that we haven’t discussed?"

Additionally, Becker recommends learning about the different types of support for trauma such as EMDR, and seeking out individual or group therapy held by a trained mental health professional.

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We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

She says practicing mindfulness and activities that engage the five senses can also help process trauma. 

Moffa suggests journaling or letter-writing, “which allows your brain to process the story you’re telling yourself in a potentially new way.”

If you’re the one getting dumped on, Becker suggests validating the person’s feelings and showing empathy, but telling them you do not feel comfortable being in the conversation. 

“[Then offer] to help them secure the more helpful person or professional to talk to about this,” she says. 

Moffa agrees, stressing that friends and online communities are not substitutes for professional help , which a person who trauma dumps may need.

“They need someone to gently guide them through their narrative and help them find a place where they can safely self-reflect, therefore, garnering more of a sense of empowerment over their life, and story,” she says.

While venting to friends, family and social media followers can feel helpful, sometimes oversharing your trauma can turn people away. Understanding what trauma dumping is and why you do it can help you maintain relationships and find the help you need.

Carbone E, Loewenstein GF. Dying to divulge: the determinants of, and relationship between, desired and actual disclosure . SSRN Electronic Journal . Published online 2020. doi:10.2139/ssrn.3613232

Marmarosh CL, Forsyth DR, Strauss B, Burlingame GM. The psychology of the COVID-19 pandemic: A group-level perspective . Group Dynamics: Theory, Research, and Practice . 2020;24(3). doi:10.1037/gdn0000142

Raun T. “Talking about his dead child, again!” Emotional self-management in relation to online mourning . First Monday . 2017;22(11). doi:10.5210/fm.v22i11.7810

By Cathy Cassata Cathy Cassata is a freelance writer who specializes in stories around health, mental health, medical news, and inspirational people.

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The weekly Research Update contains the latest news, journal articles, and useful links from around the web. Some of this week's topics include: ● The potential value of brief waitlist interventions in enhancing treatment retention and outcomes: a randomised controlled trial. ● Trauma-focused therapy retention among military sexual trauma survivors: relationship with veterans’ sexual or gender minority identification.. ● Posttraumatic cognition change trajectories in veterans with PTSD who completed an intensive Cognitive Processing Therapy treatment program. ● Impact of three variants of prolonged exposure therapy on comorbid diagnoses in patients with childhood abuse-related PTSD.

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What are adverse childhood experiences?

Adverse childhood experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years). Examples include: 1

  • Experiencing violence, abuse, or neglect.
  • Witnessing violence in the home or community.
  • Having a family member attempt or die by suicide.

Also included are aspects of the child’s environment that can undermine their sense of safety, stability, and bonding. Examples can include growing up in a household with: 1

  • Substance use problems.
  • Mental health problems.
  • Instability due to parental separation.
  • Instability due to household members being in jail or prison.

The examples above are not a complete list of adverse experiences. Many other traumatic experiences could impact health and well-being. This can include not having enough food to eat, experiencing homelessness or unstable housing, or experiencing discrimination. 2 3 4 5 6

Quick facts and stats

ACEs are common. About 64% of adults in the United States reported they had experienced at least one type of ACE before age 18. Nearly one in six (17.3%) adults reported they had experienced four or more types of ACEs. 7

Preventing ACEs could potentially reduce many health conditions. Estimates show up to 1.9 million heart disease cases and 21 million depression cases potentially could have been avoided by preventing ACEs. 1

Some people are at greater risk of experiencing one or more ACEs than others. While all children are at risk of ACEs, numerous studies show inequities in such experiences. These inequalities are linked to the historical, social, and economic environments in which some families live. 5 6 ACEs were highest among females, non-Hispanic American Indian or Alaska Native adults, and adults who are unemployed or unable to work. 7

ACEs are costly. ACEs-related health consequences cost an estimated economic burden of $748 billion annually in Bermuda, Canada, and the United States. 8

ACEs can have lasting effects on health and well-being in childhood and life opportunities well into adulthood. 9 Life opportunities include things like education and job potential. These experiences can increase the risks of injury, sexually transmitted infections, and involvement in sex trafficking. They can also increase risks for maternal and child health problems including teen pregnancy, pregnancy complications, and fetal death. Also included are a range of chronic diseases and leading causes of death, such as cancer, diabetes, heart disease, and suicide. 1 10 11 12 13 14 15 16 17

ACEs and associated social determinants of health, such as living in under-resourced or racially segregated neighborhoods, can cause toxic stress. Toxic stress, or extended or prolonged stress, from ACEs can negatively affect children’s brain development, immune systems, and stress-response systems. These changes can affect children’s attention, decision-making, and learning. 18

Children growing up with toxic stress may have difficulty forming healthy and stable relationships. They may also have unstable work histories as adults and struggle with finances, jobs, and depression throughout life. 18 These effects can also be passed on to their own children. 19 20 21 Some children may face further exposure to toxic stress from historical and ongoing traumas. These historical and ongoing traumas refer to experiences of racial discrimination or the impacts of poverty resulting from limited educational and economic opportunities. 1 6

Adverse childhood experiences can be prevented. Certain factors may increase or decrease the risk of experiencing adverse childhood experiences.

Preventing adverse childhood experiences requires understanding and addressing the factors that put people at risk for or protect them from violence.

Creating safe, stable, nurturing relationships and environments for all children can prevent ACEs and help all children reach their full potential. We all have a role to play.

  • Merrick MT, Ford DC, Ports KA, et al. Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015–2017. MMWR Morb Mortal Wkly Rep 2019;68:999-1005. DOI: .
  • Cain KS, Meyer SC, Cummer E, Patel KK, Casacchia NJ, Montez K, Palakshappa D, Brown CL. Association of Food Insecurity with Mental Health Outcomes in Parents and Children. Science Direct. 2022; 22:7; 1105-1114. DOI: .
  • Smith-Grant J, Kilmer G, Brener N, Robin L, Underwood M. Risk Behaviors and Experiences Among Youth Experiencing Homelessness—Youth Risk Behavior Survey, 23 U.S. States and 11 Local School Districts. Journal of Community Health. 2022; 47: 324-333.
  • Experiencing discrimination: Early Childhood Adversity, Toxic Stress, and the Impacts of Racism on the Foundations of Health | Annual Review of Public Health .
  • Sedlak A, Mettenburg J, Basena M, et al. Fourth national incidence study of child abuse and neglect (NIS-4): Report to Congress. Executive Summary. Washington, DC: U.S. Department of Health an Human Services, Administration for Children and Families.; 2010.
  • Font S, Maguire-Jack K. Pathways from childhood abuse and other adversities to adult health risks: The role of adult socioeconomic conditions. Child Abuse Negl. 2016;51:390-399.
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Adverse Childhood Experiences (ACEs)

ACEs can have a tremendous impact on lifelong health and opportunity. CDC works to understand ACEs and prevent them.

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Center for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.)

Cover of Trauma-Informed Care in Behavioral Health Services

Trauma-Informed Care in Behavioral Health Services.

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Chapter 3 Understanding the Impact of Trauma

Trauma-informed care (TIC) involves a broad understanding of traumatic stress reactions and common responses to trauma. Providers need to understand how trauma can affect treatment presentation, engagement, and the outcome of behavioral health services. This chapter examines common experiences survivors may encounter immediately following or long after a traumatic experience.

Trauma, including one-time, multiple, or long-lasting repetitive events, affects everyone differently. Some individuals may clearly display criteria associated with posttraumatic stress disorder (PTSD), but many more individuals will exhibit resilient responses or brief subclinical symptoms or consequences that fall outside of diagnostic criteria. The impact of trauma can be subtle, insidious, or outright destructive. How an event affects an individual depends on many factors, including characteristics of the individual, the type and characteristics of the event(s), developmental processes, the meaning of the trauma, and sociocultural factors.

This chapter begins with an overview of common responses, emphasizing that traumatic stress reactions are normal reactions to abnormal circumstances. It highlights common short- and long-term responses to traumatic experiences in the context of individuals who may seek behavioral health services. This chapter discusses psychological symptoms not represented in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013a ), and responses associated with trauma that either fall below the threshold of mental disorders or reflect resilience. It also addresses common disorders associated with traumatic stress. This chapter explores the role of culture in defining mental illness, particularly PTSD, and ends by addressing co-occurring mental and substance-related disorders.

Graphic: A three-dimensional pyramid divided into ten sections with text inside each section. All but two sections are greyed out. The visible text along the long side of the pyramid reads “Part 1: A Practical Guide for the Provision of Behavioral Health Services”. The visible text in the right section just below the top of the pyramid reads “Chapter 3: Understanding the Impact of Trauma”.

TIC Framework in Behavioral Health Services—The Impact of Trauma

  • Sequence of Trauma Reactions

Survivors’ immediate reactions in the aftermath of trauma are quite complicated and are affected by their own experiences, the accessibility of natural supports and healers, their coping and life skills and those of immediate family, and the responses of the larger community in which they live. Although reactions range in severity, even the most acute responses are natural responses to manage trauma— they are not a sign of psychopathology. Coping styles vary from action oriented to reflective and from emotionally expressive to reticent. Clinically, a response style is less important than the degree to which coping efforts successfully allow one to continue necessary activities, regulate emotions, sustain self-esteem, and maintain and enjoy interpersonal contacts. Indeed, a past error in traumatic stress psychology, particularly regarding group or mass traumas, was the assumption that all survivors need to express emotions associated with trauma and talk about the trauma; more recent research indicates that survivors who choose not to process their trauma are just as psychologically healthy as those who do. The most recent psychological debriefing approaches emphasize respecting the individual’s style of coping and not valuing one type over another.

Foreshortened future: Trauma can affect one’s beliefs about the future via loss of hope, limited expectations about life, fear that life will end abruptly or early, or anticipation that normal life events won’t occur (e.g., access to education, ability to have a significant and committed relationship, good opportunities for work).

Initial reactions to trauma can include exhaustion, confusion, sadness, anxiety, agitation, numbness, dissociation, confusion, physical arousal, and blunted affect. Most responses are normal in that they affect most survivors and are socially acceptable, psychologically effective, and self-limited. Indicators of more severe responses include continuous distress without periods of relative calm or rest, severe dissociation symptoms, and intense intrusive recollections that continue despite a return to safety. Delayed responses to trauma can include persistent fatigue, sleep disorders, nightmares, fear of recurrence, anxiety focused on flashbacks, depression, and avoidance of emotions, sensations, or activities that are associated with the trauma, even remotely. Exhibit 1.3-1 outlines some common reactions.

Exhibit 1.3-1. Immediate and Delayed Reactions to Trauma.

Exhibit 1.3-1

Immediate and Delayed Reactions to Trauma.

  • Common Experiences and Responses to Trauma

A variety of reactions are often reported and/or observed after trauma. Most survivors exhibit immediate reactions, yet these typically resolve without severe long-term consequences. This is because most trauma survivors are highly resilient and develop appropriate coping strategies, including the use of social supports, to deal with the aftermath and effects of trauma. Most recover with time, show minimal distress, and function effectively across major life areas and developmental stages. Even so, clients who show little impairment may still have subclinical symptoms or symptoms that do not fit diagnostic criteria for acute stress disorder (ASD) or PTSD. Only a small percentage of people with a history of trauma show impairment and symptoms that meet criteria for trauma-related stress disorders, including mood and anxiety disorders.

The following sections focus on some common reactions across domains (emotional, physical, cognitive, behavioral, social, and developmental) associated with singular, multiple, and enduring traumatic events. These reactions are often normal responses to trauma but can still be distressing to experience. Such responses are not signs of mental illness, nor do they indicate a mental disorder. Traumatic stress-related disorders comprise a specific constellation of symptoms and criteria.

Emotional reactions to trauma can vary greatly and are significantly influenced by the individual’s sociocultural history. Beyond the initial emotional reactions during the event, those most likely to surface include anger, fear, sadness, and shame. However, individuals may encounter difficulty in identifying any of these feelings for various reasons. They might lack experience with or prior exposure to emotional expression in their family or community. They may associate strong feelings with the past trauma, thus believing that emotional expression is too dangerous or will lead to feeling out of control (e.g., a sense of “losing it” or going crazy). Still others might deny that they have any feelings associated with their traumatic experiences and define their reactions as numbness or lack of emotions.

Emotional dysregulation

Some trauma survivors have difficulty regulating emotions such as anger, anxiety, sadness, and shame—this is more so when the trauma occurred at a young age ( van der Kolk, Roth, Pelcovitz, & Mandel, 1993 ). In individuals who are older and functioning well prior to the trauma, such emotional dysregulation is usually short lived and represents an immediate reaction to the trauma, rather than an ongoing pattern. Self-medication—namely, substance abuse—is one of the methods that traumatized people use in an attempt to regain emotional control, although ultimately it causes even further emotional dysregulation (e.g., substance-induced changes in affect during and after use). Other efforts toward emotional regulation can include engagement in high-risk or self-injurious behaviors, disordered eating, compulsive behaviors such as gambling or overworking, and repression or denial of emotions; however, not all behaviors associated with self-regulation are considered negative. In fact, some individuals find creative, healthy, and industrious ways to manage strong affect generated by trauma, such as through renewed commitment to physical activity or by creating an organization to support survivors of a particular trauma.

Traumatic stress tends to evoke two emotional extremes: feeling either too much (overwhelmed) or too little (numb) emotion. Treatment can help the client find the optimal level of emotion and assist him or her with appropriately experiencing and regulating difficult emotions. In treatment, the goal is to help clients learn to regulate their emotions without the use of substances or other unsafe behavior. This will likely require learning new coping skills and how to tolerate distressing emotions; some clients may benefit from mindfulness practices, cognitive restructuring, and trauma-specific desensitization approaches, such as exposure therapy and eye movement desensitization and reprocessing (EMDR; refer to Part 1, Chapter 6 , for more information on trauma-specific therapies).

Numbing is a biological process whereby emotions are detached from thoughts, behaviors, and memories. In the following case illustration, Sadhanna’s numbing is evidenced by her limited range of emotions associated with interpersonal interactions and her inability to associate any emotion with her history of abuse. She also possesses a belief in a foreshortened future. A prospective longitudinal study ( Malta, Levitt, Martin, Davis, & Cloitre, 2009 ) that followed the development of PTSD in disaster workers highlighted the importance of understanding and appreciating numbing as a traumatic stress reaction. Because numbing symptoms hide what is going on inside emotionally, there can be a tendency for family members, counselors, and other behavioral health staff to assess levels of traumatic stress symptoms and the impact of trauma as less severe than they actually are.

Case Illustration: Sadhanna

Sadhanna is a 22-year-old woman mandated to outpatient mental health and substance abuse treatment as the alternative to incarceration. She was arrested and charged with assault after arguing and fighting with another woman on the street. At intake, Sadhanna reported a 7-year history of alcohol abuse and one depressive episode at age 18. She was surprised that she got into a fight but admitted that she was drinking at the time of the incident. She also reported severe physical abuse at the hands of her mother’s boyfriend between ages 4 and 15. Of particular note to the intake worker was Sadhanna’s matter-of-fact way of presenting the abuse history. During the interview, she clearly indicated that she did not want to attend group therapy and hear other people talk about their feelings, saying, “I learned long ago not to wear emotions on my sleeve.”

Sadhanna reported dropping out of 10th grade, saying she never liked school. She didn’t expect much from life. In Sadhanna’s first weeks in treatment, she reported feeling disconnected from other group members and questioned the purpose of the group. When asked about her own history, she denied that she had any difficulties and did not understand why she was mandated to treatment. She further denied having feelings about her abuse and did not believe that it affected her life now. Group members often commented that she did not show much empathy and maintained a flat affect, even when group discussions were emotionally charged.

Diagnostic criteria for PTSD place considerable emphasis on psychological symptoms, but some people who have experienced traumatic stress may present initially with physical symptoms. Thus, primary care may be the first and only door through which these individuals seek assistance for trauma-related symptoms. Moreover, there is a significant connection between trauma, including adverse childhood experiences (ACEs), and chronic health conditions. Common physical disorders and symptoms include somatic complaints; sleep disturbances; gastrointestinal, cardiovascular, neurological, musculoskeletal, respiratory, and dermatological disorders; urological problems; and substance use disorders.


Somatization indicates a focus on bodily symptoms or dysfunctions to express emotional distress. Somatic symptoms are more likely to occur with individuals who have traumatic stress reactions, including PTSD. People from certain ethnic and cultural backgrounds may initially or solely present emotional distress via physical ailments or concerns. Many individuals who present with somatization are likely unaware of the connection between their emotions and the physical symptoms that they’re experiencing. At times, clients may remain resistant to exploring emotional content and remain focused on bodily complaints as a means of avoidance. Some clients may insist that their primary problems are physical even when medical evaluations and tests fail to confirm ailments. In these situations, somatization may be a sign of a mental illness. However, various cultures approach emotional distress through the physical realm or view emotional and physical symptoms and well-being as one. It is important not to assume that clients with physical complaints are using somatization as a means to express emotional pain; they may have specific conditions or disorders that require medical attention. Foremost, counselors need to refer for medical evaluation.

Advice to Counselors: Using Information About Biology and Trauma

Frame reexperiencing the event(s), hyperarousal, sleep disturbances, and other physical symptoms as physiological reactions to extreme stress.

Communicate that treatment and other wellness activities can improve both psychological and physiological symptoms (e.g., therapy, meditation, exercise, yoga). You may need to refer certain clients to a psychiatrist who can evaluate them and, if warranted, prescribe psycho-tropic medication to address severe symptoms.

Discuss traumatic stress symptoms and their physiological components.

Explain links between traumatic stress symptoms and substance use disorders, if appropriate.

Normalize trauma symptoms. For example, explain to clients that their symptoms are not a sign of weakness, a character flaw, being damaged, or going crazy.

  • Support your clients and provide a message of hope—that they are not alone, they are not at fault, and recovery is possible and anticipated.

Biology of trauma

Trauma biology is an area of burgeoning research, with the promise of more complex and explanatory findings yet to come. Although a thorough presentation on the biological aspects of trauma is beyond the scope of this publication, what is currently known is that exposure to trauma leads to a cascade of biological changes and stress responses. These biological alterations are highly associated with PTSD, other mental illnesses, and substance use disorders. These include:

  • Changes in limbic system functioning.
  • Hypothalamic–pituitary–adrenal axis activity changes with variable cortisol levels.
  • Neurotransmitter-related dysregulation of arousal and endogenous opioid systems.

As a clear example, early ACEs such as abuse, neglect, and other traumas affect brain development and increase a person’s vulnerability to encountering interpersonal violence as an adult and to developing chronic diseases and other physical illnesses, mental illnesses, substance-related disorders, and impairment in other life areas ( Centers for Disease Control and Prevention, 2012 ).

Hyperarousal and sleep disturbances

A common symptom that arises from traumatic experiences is hyperarousal (also called hypervigilance). Hyperarousal is the body’s way of remaining prepared. It is characterized by sleep disturbances, muscle tension, and a lower threshold for startle responses and can persist years after trauma occurs. It is also one of the primary diagnostic criteria for PTSD.

Hyperarousal is a consequence of biological changes initiated by trauma. Although it serves as a means of self-protection after trauma, it can be detrimental. Hyperarousal can interfere with an individual’s ability to take the necessary time to assess and appropriately respond to specific input, such as loud noises or sudden movements. Sometimes, hyperarousal can produce overreactions to situations perceived as dangerous when, in fact, the circumstances are safe.

Case Illustration: Kimi

Kimi is a 35-year-old Native American woman who was group raped at the age of 16 on her walk home from a suburban high school. She recounts how her whole life changed on that day. “I never felt safe being alone after the rape. I used to enjoy walking everywhere. Afterward, I couldn’t tolerate the fear that would arise when I walked in the neighborhood. It didn’t matter whether I was alone or with friends—every sound that I heard would throw me into a state of fear. I felt like the same thing was going to happen again. It’s gotten better with time, but I often feel as if I’m sitting on a tree limb waiting for it to break. I have a hard time relaxing. I can easily get startled if a leaf blows across my path or if my children scream while playing in the yard. The best way I can describe how I experience life is by comparing it to watching a scary, suspenseful movie—anxiously waiting for something to happen, palms sweating, heart pounding, on the edge of your chair.”

Along with hyperarousal, sleep disturbances are very common in individuals who have experienced trauma. They can come in the form of early awakening, restless sleep, difficulty falling asleep, and nightmares. Sleep disturbances are most persistent among individuals who have trauma-related stress; the disturbances sometimes remain resistant to intervention long after other traumatic stress symptoms have been successfully treated. Numerous strategies are available beyond medication, including good sleep hygiene practices, cognitive rehearsals of nightmares, relaxation strategies, and nutrition.

Traumatic experiences can affect and alter cognitions. From the outset, trauma challenges the just-world or core life assumptions that help individuals navigate daily life ( Janoff-Bulman, 1992 ). For example, it would be difficult to leave the house in the morning if you believed that the world was not safe, that all people are dangerous, or that life holds no promise. Belief that one’s efforts and intentions can protect oneself from bad things makes it less likely for an individual to perceive personal vulnerability. However, traumatic events—particularly if they are unexpected—can challenge such beliefs.

Cognitions and Trauma

The following examples reflect some of the types of cognitive or thought-process changes that can occur in response to traumatic stress.

Cognitive errors: Misinterpreting a current situation as dangerous because it resembles, even remotely, a previous trauma (e.g., a client overreacting to an overturned canoe in 8 inches of water, as if she and her paddle companion would drown, due to her previous experience of nearly drowning in a rip current 5 years earlier).

Excessive or inappropriate guilt: Attempting to make sense cognitively and gain control over a traumatic experience by assuming responsibility or possessing survivor’s guilt, because others who experienced the same trauma did not survive.

Idealization: Demonstrating inaccurate rationalizations, idealizations, or justifications of the perpetrator’s behavior, particularly if the perpetrator is or was a caregiver. Other similar reactions mirror idealization; traumatic bonding is an emotional attachment that develops (in part to secure survival) between perpetrators who engage in interpersonal trauma and their victims, and Stockholm syndrome involves compassion and loyalty toward hostage takers ( de Fabrique, Van Hasselt, Vecchi, & Romano, 2007 ).

Trauma-induced hallucinations or delusions: Experiencing hallucinations and delusions that, although they are biological in origin, contain cognitions that are congruent with trauma content (e.g., a woman believes that a person stepping onto her bus is her father, who had sexually abused her repeatedly as child, because he wore shoes similar to those her father once wore).

Intrusive thoughts and memories: Experiencing, without warning or desire, thoughts and memories associated with the trauma. These intrusive thoughts and memories can easily trigger strong emotional and behavioral reactions, as if the trauma was recurring in the present. The intrusive thoughts and memories can come rapidly, referred to as flooding, and can be disruptive at the time of their occurrence. If an individual experiences a trigger, he or she may have an increase in intrusive thoughts and memories for a while. For instance, individuals who inadvertently are retraumatized due to program or clinical practices may have a surge of intrusive thoughts of past trauma, thus making it difficult for them to discern what is happening now versus what happened then. Whenever counseling focuses on trauma, it is likely that the client will experience some intrusive thoughts and memories. It is important to develop coping strategies before, as much as possible, and during the delivery of trauma-informed and trauma-specific treatment.

Let’s say you always considered your driving time as “your time”—and your car as a safe place to spend that time. Then someone hits you from behind at a highway entrance. Almost immediately, the accident affects how you perceive the world, and from that moment onward, for months following the crash, you feel unsafe in any car. You become hypervigilant about other drivers and perceive that other cars are drifting into your lane or failing to stop at a safe distance behind you. For a time, your perception of safety is eroded, often leading to compensating behaviors (e.g., excessive glancing into the rearview mirror to see whether the vehicles behind you are stopping) until the belief is restored or reworked. Some individuals never return to their previous belief systems after a trauma, nor do they find a way to rework them—thus leading to a worldview that life is unsafe. Still, many other individuals are able to return to organizing core beliefs that support their perception of safety.

Many factors contribute to cognitive patterns prior to, during, and after a trauma. Adopting Beck and colleagues’ cognitive triad model ( 1979 ), trauma can alter three main cognitive patterns: thoughts about self, the world (others/environment), and the future. To clarify, trauma can lead individuals to see themselves as incompetent or damaged, to see others and the world as unsafe and unpredictable, and to see the future as hopeless—believing that personal suffering will continue, or negative outcomes will preside for the foreseeable future (see Exhibit 1.3-2 ). Subsequently, this set of cognitions can greatly influence clients’ belief in their ability to use internal resources and external support effectively. From a cognitive– behavioral perspective, these cognitions have a bidirectional relationship in sustaining or contributing to the development of depressive and anxiety symptoms after trauma. However, it is possible for cognitive patterns to help protect against debilitating psychological symptoms as well. Many factors contribute to cognitive patterns prior to, during, and after a trauma.

Exhibit 1.3-2

Cognitive Triad of Traumatic Stress.

Feeling different

An integral part of experiencing trauma is feeling different from others, whether or not the trauma was an individual or group experience. Traumatic experiences typically feel surreal and challenge the necessity and value of mundane activities of daily life. Survivors often believe that others will not fully understand their experiences, and they may think that sharing their feelings, thoughts, and reactions related to the trauma will fall short of expectations. However horrid the trauma may be, the experience of the trauma is typically profound.

The type of trauma can dictate how an individual feels different or believes that they are different from others. Traumas that generate shame will often lead survivors to feel more alienated from others—believing that they are “damaged goods.” When individuals believe that their experiences are unique and incomprehensible, they are more likely to seek support, if they seek support at all, only with others who have experienced a similar trauma.

Triggers and flashbacks

A trigger is a stimulus that sets off a memory of a trauma or a specific portion of a traumatic experience. Imagine you were trapped briefly in a car after an accident. Then, several years later, you were unable to unlatch a lock after using a restroom stall; you might have begun to feel a surge of panic reminiscent of the accident, even though there were other avenues of escape from the stall. Some triggers can be identified and anticipated easily, but many are subtle and inconspicuous, often surprising the individual or catching him or her off guard. In treatment, it is important to help clients identify potential triggers, draw a connection between strong emotional reactions and triggers, and develop coping strategies to manage those moments when a trigger occurs. A trigger is any sensory reminder of the traumatic event: a noise, smell, temperature, other physical sensation, or visual scene. Triggers can generalize to any characteristic, no matter how remote, that resembles or represents a previous trauma, such as revisiting the location where the trauma occurred, being alone, having your children reach the same age that you were when you experienced the trauma, seeing the same breed of dog that bit you, or hearing loud voices. Triggers are often associated with the time of day, season, holiday, or anniversary of the event.

A flashback is reexperiencing a previous traumatic experience as if it were actually happening in that moment. It includes reactions that often resemble the client’s reactions during the trauma. Flashback experiences are very brief and typically last only a few seconds, but the emotional aftereffects linger for hours or longer. Flashbacks are commonly initiated by a trigger, but not necessarily. Sometimes, they occur out of the blue. Other times, specific physical states increase a person’s vulnerability to reexperiencing a trauma, (e.g., fatigue, high stress levels). Flashbacks can feel like a brief movie scene that intrudes on the client. For example, hearing a car backfire on a hot, sunny day may be enough to cause a veteran to respond as if he or she were back on military patrol. Other ways people reexperience trauma, besides flashbacks, are via nightmares and intrusive thoughts of the trauma.

Advice to Counselors: Helping Clients Manage Flashbacks and Triggers

If a client is triggered in a session or during some aspect of treatment, help the client focus on what is happening in the here and now; that is, use grounding techniques. Behavioral health service providers should be prepared to help the client get regrounded so that they can distinguish between what is happening now versus what had happened in the past (see Covington, 2008 , and Najavits, 2002b , 2007b , for more grounding techniques). Offer education about the experience of triggers and flashbacks, and then normalize these events as common traumatic stress reactions. Afterward, some clients need to discuss the experience and understand why the flashback or trigger occurred. It often helps for the client to draw a connection between the trigger and the traumatic event(s). This can be a preventive strategy whereby the client can anticipate that a given situation places him or her at higher risk for retraumatization and requires use of coping strategies, including seeking support.

Source: Green Cross Academy of Traumatology, 2010 .

Dissociation, depersonalization, and derealization

Dissociation is a mental process that severs connections among a person’s thoughts, memories, feelings, actions, and/or sense of identity. Most of us have experienced dissociation—losing the ability to recall or track a particular action (e.g., arriving at work but not remembering the last minutes of the drive). Dissociation happens because the person is engaged in an automatic activity and is not paying attention to his or her immediate environment. Dissociation can also occur during severe stress or trauma as a protective element whereby the individual incurs distortion of time, space, or identity. This is a common symptom in traumatic stress reactions.

Dissociation helps distance the experience from the individual. People who have experienced severe or developmental trauma may have learned to separate themselves from distress to survive. At times, dissociation can be very pervasive and symptomatic of a mental disorder, such as dissociative identity disorder (DID; formerly known as multiple personality disorder). According to the DSM-5, “dissociative disorders are characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” ( APA, 2013a , p. 291). Dissociative disorder diagnoses are closely associated with histories of severe childhood trauma or pervasive, human-caused, intentional trauma, such as that experienced by concentration camp survivors or victims of ongoing political imprisonment, torture, or long-term isolation. A mental health professional, preferably with significant training in working with dissociative disorders and with trauma, should be consulted when a dissociative disorder diagnosis is suspected.

Potential Signs of Dissociation

  • Fixed or “glazed” eyes
  • Sudden flattening of affect
  • Long periods of silence
  • Monotonous voice
  • Stereotyped movements
  • Responses not congruent with the present context or situation
  • Excessive intellectualization

( Briere, 1996a )

The characteristics of DID can be commonly accepted experiences in other cultures, rather than being viewed as symptomatic of a traumatic experience. For example, in non-Western cultures, a sense of alternate beings within oneself may be interpreted as being inhabited by spirits or ancestors ( Kirmayer, 1996 ). Other experiences associated with dissociation include depersonalization—psychologically “leaving one’s body,” as if watching oneself from a distance as an observer or through derealization, leading to a sense that what is taking place is unfamiliar or is not real.

If clients exhibit signs of dissociation, behavioral health service providers can use grounding techniques to help them reduce this defense strategy. One major long-term consequence of dissociation is the difficulty it causes in connecting strong emotional or physical reactions with an event. Often, individuals may believe that they are going crazy because they are not in touch with the nature of their reactions. By educating clients on the resilient qualities of dissociation while also emphasizing that it prevents them from addressing or validating the trauma, individuals can begin to understand the role of dissociation. All in all, it is important when working with trauma survivors that the intensity level is not so great that it triggers a dissociative reaction and prevents the person from engaging in the process.

Traumatic stress reactions vary widely; often, people engage in behaviors to manage the aftereffects, the intensity of emotions, or the distressing aspects of the traumatic experience. Some people reduce tension or stress through avoidant, self-medicating (e.g., alcohol abuse), compulsive (e.g., overeating), impulsive (e.g., high-risk behaviors), and/or self-injurious behaviors. Others may try to gain control over their experiences by being aggressive or subconsciously reenacting aspects of the trauma.

Behavioral reactions are also the consequences of, or learned from, traumatic experiences. For example, some people act like they can’t control their current environment, thus failing to take action or make decisions long after the trauma (learned helplessness). Other associate elements of the trauma with current activities, such as by reacting to an intimate moment in a significant relationship as dangerous or unsafe years after a date rape. The following sections discuss behavioral consequences of trauma and traumatic stress reactions.


A hallmark symptom of trauma is reexperiencing the trauma in various ways. Reexperiencing can occur through reenactments (literally, to “redo”), by which trauma survivors repetitively relive and recreate a past trauma in their present lives. This is very apparent in children, who play by mimicking what occurred during the trauma, such as by pretending to crash a toy airplane into a toy building after seeing televised images of the terrorist attacks on the World Trade Center on September 11, 2001. Attempts to understand reenactments are very complicated, as reenactments occur for a variety of reasons. Sometimes, individuals reenact past traumas to master them. Examples of reenactments include a variety of behaviors: self-injurious behaviors, hypersexuality, walking alone in unsafe areas or other high-risk behaviors, driving recklessly, or involvement in repetitive destructive relationships (e.g., repeatedly getting into romantic relationships with people who are abusive or violent), to name a few.

Self-harm and self-destructive behaviors

Self-harm is any type of intentionally self-inflicted harm, regardless of the severity of injury or whether suicide is intended. Often, self-harm is an attempt to cope with emotional or physical distress that seems overwhelming or to cope with a profound sense of dissociation or being trapped, helpless, and “damaged” ( Herman, 1997 ; Santa Mina & Gallop, 1998 ). Self-harm is associated with past childhood sexual abuse and other forms of trauma as well as substance abuse. Thus, addressing self-harm requires attention to the client’s reasons for self-harm. More than likely, the client needs help recognizing and coping with emotional or physical distress in manageable amounts and ways.

Resilient Responses to Trauma

Many people find healthy ways to cope with, respond to, and heal from trauma. Often, people automatically reevaluate their values and redefine what is important after a trauma. Such resilient responses include:

  • Increased bonding with family and community.
  • Redefined or increased sense of purpose and meaning.
  • Increased commitment to a personal mission.
  • Revised priorities.
  • Increased charitable giving and volunteerism.

Case Illustration: Marco

Marco, a 30-year-old man, sought treatment at a local mental health center after a 2-year bout of anxiety symptoms. He was an active member of his church for 12 years, but although he sought help from his pastor about a year ago, he reports that he has had no contact with his pastor or his church since that time. Approximately 3 years ago, his wife took her own life. He describes her as his soul-mate and has had a difficult time understanding her actions or how he could have prevented them.

In the initial intake, he mentioned that he was the first person to find his wife after the suicide and reported feelings of betrayal, hurt, anger, and devastation since her death. He claimed that everyone leaves him or dies. He also talked about his difficulty sleeping, having repetitive dreams of his wife, and avoiding relationships. In his first session with the counselor, he initially rejected the counselor before the counselor had an opportunity to begin reviewing and talking about the events and discomfort that led him to treatment.

In this scenario, Marco is likely reenacting his feelings of abandonment by attempting to reject others before he experiences another rejection or abandonment. In this situation, the counselor will need to recognize the reenactment, explore the behavior, and examine how reenactments appear in other situations in Marco’s life.

Among the self-harm behaviors reported in the literature are cutting, burning skin by heat (e.g., cigarettes) or caustic liquids, punching hard enough to self-bruise, head banging, hair pulling, self-poisoning, inserting foreign objects into bodily orifices, excessive nail biting, excessive scratching, bone breaking, gnawing at flesh, interfering with wound healing, tying off body parts to stop breathing or blood flow, swallowing sharp objects, and suicide. Cutting and burning are among the most common forms of self-harm.

Self-harm tends to occur most in people who have experienced repeated and/or early trauma (e.g., childhood sexual abuse) rather than in those who have undergone a single adult trauma (e.g., a community-wide disaster or a serious car accident). There are strong associations between eating disorders, self-harm, and substance abuse ( Claes & Vandereycken, 2007 ; for discussion, see Harned, Najavits, & Weiss, 2006 ). Self-mutilation is also associated with (and part of the diagnostic criteria for) a number of personality disorders, including borderline and histrionic, as well as DID, depression, and some forms of schizophrenia; these disorders can co-occur with traumatic stress reactions and disorders.

It is important to distinguish self-harm that is suicidal from self-harm that is not suicidal and to assess and manage both of these very serious dangers carefully. Most people who engage in self-harm are not doing so with the intent to kill themselves ( Noll, Horowitz, Bonanno, Trickett, & Putnam, 2003 )—although self-harm can be life threatening and can escalate into suicidality if not managed therapeutically. Self-harm can be a way of getting attention or manipulating others, but most often it is not. Self-destructive behaviors such as substance abuse, restrictive or binge eating, reckless automobile driving, or high-risk impulsive behavior are different from self-harming behaviors but are also seen in clients with a history of trauma. Self-destructive behaviors differ from self-harming behaviors in that there may be no immediate negative impact of the behavior on the individual; they differ from suicidal behavior in that there is no intent to cause death in the short term.

Advice to Counselors: Working With Clients Who Are Self-Injurious

Counselors who are unqualified or uncomfortable working with clients who demonstrate self-harming, self-destructive, or suicidal or homicidal ideation, intent, or behavior should work with their agencies and supervisors to refer such clients to other counselors. They should consider seeking specialized supervision on how to manage such clients effectively and safely and how to manage their feelings about these issues. The following suggestions assume that the counselor has had sufficient training and experience to work with clients who are self-injurious. To respond appropriately to a client who engages in self-harm, counselors should:

  • Screen the client for self-harm and suicide risk at the initial evaluation and throughout treatment.
  • Learn the client’s perspective on self-harm and how it “helps.”
  • Understand that self-harm is often a coping strategy to manage the intensity of emotional and/or physical distress.
  • Teach the client coping skills that improve his or her management of emotions without self-harm.
  • Help the client obtain the level of care needed to manage genuine risk of suicide or severe self-injury. This might include hospitalization, more intensive programming (e.g., intensive outpatient, partial hospitalization, residential treatment), or more frequent treatment sessions. The goal is to stabilize the client as quickly as possible, and then, if possible, begin to focus treatment on developing coping strategies to manage self-injurious and other harmful impulses.
  • Consult with other team members, supervisors, and, if necessary, legal experts to determine whether one’s efforts with and conceptualization of the self-harming client fit best practice guidelines. See, for example, Treatment Improvement Protocol (TIP) 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders ( Center for Substance Abuse Treatment [CSAT], 2005c ). Document such consultations and the decisions made as a result of them thoroughly and frequently.
  • Help the client identify how substance use affects self-harm. In some cases, it can increase the behavior (e.g., alcohol disinhibits the client, who is then more likely to self-harm). In other cases, it can decrease the behavior (e.g., heroin evokes relaxation and, thus, can lessen the urge to self-harm). In either case, continue to help the client understand how abstinence from substances is necessary so that he or she can learn more adaptive coping.
  • Work collaboratively with the client to develop a plan to create a sense of safety. Individuals are affected by trauma in different ways; therefore, safety or a safe environment may mean something entirely different from one person to the next. Allow the client to define what safety means to him or her.

Counselors can also help the client prepare a safety card that the client can carry at all times. The card might include the counselor’s contact information, a 24-hour crisis number to call in emergencies, contact information for supportive individuals who can be contacted when needed, and, if appropriate, telephone numbers for emergency medical services. The counselor can discuss with the client the types of signs or crises that might warrant using the numbers on the card. Additionally, the counselor might check with the client from time to time to confirm that the information on the card is current.

TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment ( CSAT, 2009a ), has examples of safety agreements specifically for suicidal clients and discusses their uses in more detail. There is no credible evidence that a safety agreement is effective in preventing a suicide attempt or death. Safety agreements for clients with suicidal thoughts and behaviors should only be used as an adjunct support accompanying professional screening, assessment, and treatment for people with suicidal thoughts and behaviors. Keep in mind that safety plans or agreements may be perceived by the trauma survivor as a means of controlling behavior, subsequently replicating or triggering previous traumatic experiences.

All professionals—and in some States, anyone—could have ethical and legal responsibilities to those clients who pose an imminent danger to themselves or others. Clinicians should be aware of the pertinent State laws where they practice and the relevant Federal and professional regulations.

However, as with self-harming behavior, self-destructive behavior needs to be recognized and addressed and may persist—or worsen—without intervention.

Consumption of substances

Substance use often is initiated or increased after trauma. Clients in early recovery— especially those who develop PTSD or have it reactivated—have a higher relapse risk if they experience a trauma. In the first 2 months after September 11, 2001, more than a quarter of New Yorker residents who smoked cigarettes, drank alcohol, or used marijuana (about 265,000 people) increased their consumption. The increases continued 6 months after the attacks ( Vlahov, Galea, Ahern, Resnick, & Kilpatrick, 2004 ). A study by the Substance Abuse and Mental Health Services Administration ( SAMHSA, Office of Applied Studies, 2002 ) used National Survey on Drug Use and Health data to compare the first three quarters of 2001 with the last quarter and reported an increase in the prevalence rate for alcohol use among people 18 or older in the New York metropolitan area during the fourth quarter.

Interviews with New York City residents who were current or former cocaine or heroin users indicated that many who had been clean for 6 months or less relapsed after September 11, 2001. Others, who lost their income and could no longer support their habit, enrolled in methadone programs ( Weiss et al., 2002 ). After the Oklahoma City bombing in 1995, Oklahomans reported double the normal rate of alcohol use, smoking more cigarettes, and a higher incidence of initiating smoking months and even years after the bombing ( Smith, Christiansen, Vincent, & Hann, 1999 ).


Khantzian’s self-medication theory ( 1985 ) suggests that drugs of abuse are selected for their specific effects. However, no definitive pattern has yet emerged of the use of particular substances in relation to PTSD or trauma symptoms. Use of substances can vary based on a variety of factors, including which trauma symptoms are most prominent for an individual and the individual’s access to particular substances. Unresolved traumas sometimes lurk behind the emotions that clients cannot allow themselves to experience. Substance use and abuse in trauma survivors can be a way to self-medicate and thereby avoid or displace difficult emotions associated with traumatic experiences. When the substances are withdrawn, the survivor may use other behaviors to self-soothe, self-medicate, or avoid emotions. As likely, emotions can appear after abstinence in the form of anxiety and depression.

Avoidance often coincides with anxiety and the promotion of anxiety symptoms. Individuals begin to avoid people, places, or situations to alleviate unpleasant emotions, memories, or circumstances. Initially, the avoidance works, but over time, anxiety increases and the perception that the situation is unbearable or dangerous increases as well, leading to a greater need to avoid. Avoidance can be adaptive, but it is also a behavioral pattern that reinforces perceived danger without testing its validity, and it typically leads to greater problems across major life areas (e.g., avoiding emotionally oriented conversations in an intimate relationship). For many individuals who have traumatic stress reactions, avoidance is commonplace. A person may drive 5 miles longer to avoid the road where he or she had an accident. Another individual may avoid crowded places in fear of an assault or to circumvent strong emotional memories about an earlier assault that took place in a crowded area. Avoidance can come in many forms. When people can’t tolerate strong affects associated with traumatic memories, they avoid, project, deny, or distort their trauma-related emotional and cognitive experiences. A key ingredient in trauma recovery is learning to manage triggers, memories, and emotions without avoidance—in essence, becoming desensitized to traumatic memories and associated symptoms.


A key ingredient in the early stage of TIC is to establish, confirm, or reestablish a support system, including culturally appropriate activities, as soon as possible. Social supports and relationships can be protective factors against traumatic stress. However, trauma typically affects relationships significantly, regardless of whether the trauma is interpersonal or is of some other type. Relationships require emotional exchanges, which means that others who have close relationships or friendships with the individual who survived the trauma(s) are often affected as well—either through secondary traumatization or by directly experiencing the survivor’s traumatic stress reactions. In natural disasters, social and community supports can be abruptly eroded and difficult to rebuild after the initial disaster relief efforts have waned.

Survivors may readily rely on family members, friends, or other social supports—or they may avoid support, either because they believe that no one will be understanding or trustworthy or because they perceive their own needs as a burden to others. Survivors who have strong emotional or physical reactions, including outbursts during nightmares, may pull away further in fear of being unable to predict their own reactions or to protect their own safety and that of others. Often, trauma survivors feel ashamed of their stress reactions, which further hampers their ability to use their support systems and resources adequately.

Many survivors of childhood abuse and interpersonal violence have experienced a significant sense of betrayal. They have often encountered trauma at the hands of trusted caregivers and family members or through significant relationships. This history of betrayal can disrupt forming or relying on supportive relationships in recovery, such as peer supports and counseling. Although this fear of trusting others is protective, it can lead to difficulty in connecting with others and greater vigilance in observing the behaviors of others, including behavioral health service providers. It is exceptionally difficult to override the feeling that someone is going to hurt you, take advantage of you, or, minimally, disappoint you. Early betrayal can affect one’s ability to develop attachments, yet the formation of supportive relationships is an important antidote in the recovery from traumatic stress.


Each age group is vulnerable in unique ways to the stresses of a disaster, with children and the elderly at greatest risk. Young children may display generalized fear, nightmares, heightened arousal and confusion, and physical symptoms, (e.g., stomachaches, headaches). School-age children may exhibit symptoms such as aggressive behavior and anger, regression to behavior seen at younger ages, repetitious traumatic play, loss of ability to concentrate, and worse school performance. Adolescents may display depression and social withdrawal, rebellion, increased risky activities such as sexual acting out, wish for revenge and action-oriented responses to trauma, and sleep and eating disturbances ( Hamblen, 2001 ). Adults may display sleep problems, increased agitation, hypervigilance, isolation or withdrawal, and increased use of alcohol or drugs. Older adults may exhibit increased withdrawal and isolation, reluctance to leave home, worsening of chronic illnesses, confusion, depression, and fear (DeWolfe & Nordboe, 2000b).

Neurobiological Development: Consequences of Early Childhood Trauma

Findings in developmental psychobiology suggest that the consequences of early maltreatment produce enduring negative effects on brain development ( De Bellis, 2002 ; Liu, Diorio, Day, Francis, & Meaney, 2000 ; Teicher, 2002 ). Research suggests that the first stage in a cascade of events produced by early trauma and/or maltreatment involves the disruption of chemicals that function as neurotransmitters (e.g., cortisol, norepinephrine, dopamine), causing escalation of the stress response ( Heim, Mletzko, Purselle, Musselman, & Nemeroff, 2008 ; Heim, Newport, Mletzko, Miller, & Nemeroff, 2008 ; Teicher, 2002 ). These chemical responses can then negatively affect critical neural growth during specific sensitive periods of childhood development and can even lead to cell death.

Adverse brain development can also result from elevated levels of cortisol and catecholamines by contributing to maturational failures in other brain regions, such as the prefrontal cortex ( Meaney, Brake, & Gratton, 2002 ). Heim, Mletzko et al. (2008) found that the neuropeptide oxytocin— important for social affiliation and support, attachment, trust, and management of stress and anxiety—was markedly decreased in the cerebrospinal fluid of women who had been exposed to childhood maltreatment, particularly those who had experienced emotional abuse. The more childhood traumas a person had experienced, and the longer their duration, the lower that person’s current level of oxytocin was likely to be and the higher her rating of current anxiety was likely to be.

Using data from the Adverse Childhood Experiences Study, an analysis by Anda, Felitti, Brown et al. (2006) confirmed that the risk of negative outcomes in affective, somatic, substance abuse, memory, sexual, and aggression-related domains increased as scores on a measure of eight ACEs increased. The researchers concluded that the association of study scores with these outcomes can serve as a theoretical parallel for the effects of cumulative exposure to stress on the developing brain and for the resulting impairment seen in multiple brain structures and functions.

The National Child Traumatic Stress Network ( ) offers information about childhood abuse, stress, and physiological responses of children who are traumatized. Materials are available for counselors, educators, parents, and caregivers. There are special sections on the needs of children in military families and on the impact of natural disasters on children’s mental health.

  • Subthreshold Trauma-Related Symptoms

Many trauma survivors experience symptoms that, although they do not meet the diagnostic criteria for ASD or PTSD, nonetheless limit their ability to function normally (e.g., regulate emotional states, maintain steady and rewarding social and family relationships, function competently at a job, maintain a steady pattern of abstinence in recovery). These symptoms can be transient, only arising in a specific context; intermittent, appearing for several weeks or months and then receding; or a part of the individual’s regular pattern of functioning (but not to the level of DSM-5 diagnostic criteria). Often, these patterns are termed “subthreshold” trauma symptoms. Like PTSD, the symptoms can be misdiagnosed as depression, anxiety, oran other mental illness. Likewise, clients who have experienced trauma may link some of their symptoms to their trauma and diagnose themselves as having PTSD, even though they do not meet all criteria for that disorder.

Combat Stress Reaction

A phenomenon unique to war, and one that counselors need to understand well, is combat stress reaction (CSR). CSR is an acute anxiety reaction occurring during or shortly after participating in military conflicts and wars as well as other operations within the war zone, known as the theater. CSR is not a formal diagnosis, nor is it included in the DSM-5 ( APA, 2013a ). It is similar to acute stress reaction, except that the precipitating event or events affect military personnel (and civilians exposed to the events) in an armed conflict situation. The terms “combat stress reaction” and “posttraumatic stress injury” are relatively new, and the intent of using these new terms is to call attention to the unique experiences of combat-related stress as well as to decrease the shame that can be associated with seeking behavioral health services for PTSD (for more information on veterans and combat stress reactions, see the planned TIP, Reintegration-Related Behavioral Health Issues for Veterans and Military Families ; SAMHSA, planned f).

Case Illustration: Frank

Frank is a 36-year-old man who was severely beaten in a fight outside a bar. He had multiple injuries, including broken bones, a concussion, and a stab wound in his lower abdomen. He was hospitalized for 3.5 weeks and was unable to return to work, thus losing his job as a warehouse forklift operator. For several years, when faced with situations in which he perceived himself as helpless and overwhelmed, Frank reacted with violent anger that, to others, appeared grossly out of proportion to the situation. He has not had a drink in almost 3 years, but the bouts of anger persist and occur three to five times a year. They leave Frank feeling even more isolated from others and alienated from those who love him. He reports that he cannot watch certain television shows that depict violent anger; he has to stop watching when such scenes occur. He sometimes daydreams about getting revenge on the people who assaulted him.

Psychiatric and neurological evaluations do not reveal a cause for Frank’s anger attacks. Other than these symptoms, Frank has progressed well in his abstinence from alcohol. He attends a support group regularly, has acquired friends who are also abstinent, and has reconciled with his family of origin. His marriage is more stable, although the episodes of rage limit his wife’s willingness to commit fully to the relationship. In recounting the traumatic event in counseling, Frank acknowledges that he thought he was going to die as a result of the fight, especially when he realized he had been stabbed. As he described his experience, he began to become very anxious, and the counselor observed the rage beginning to appear.

After his initial evaluation, Frank was referred to an outpatient program that provided trauma-specific interventions to address his subthreshold trauma symptoms. With a combination of cognitive– behavioral counseling, EMDR, and anger management techniques, he saw a gradual decrease in symptoms when he recalled the assault. He started having more control of his anger when memories of the trauma emerged. Today, when feeling trapped, helpless, or overwhelmed, Frank has resources for coping and does not allow his anger to interfere with his marriage or other relationships.

Although stress mobilizes an individual’s physical and psychological resources to perform more effectively in combat, reactions to the stress may persist long after the actual danger has ended. As with other traumas, the nature of the event(s), the reactions of others, and the survivor’s psychological history and resources affect the likelihood and severity of CSR. With combat veterans, this translates to the number, intensity, and duration of threat factors; the social support of peers in the veterans’ unit; the emotional and cognitive resilience of the service members; and the quality of military leadership. CSR can vary from manageable and mild to debilitating and severe. Common, less severe symptoms of CSR include tension, hypervigilance, sleep problems, anger, and difficulty concentrating. If left untreated, CSR can lead to PTSD.

Common causes of CSR are events such as a direct attack from insurgent small arms fire or a military convoy being hit by an improvised explosive device, but combat stressors encompass a diverse array of traumatizing events, such as seeing grave injuries, watching others die, and making on-the-spot decisions in ambiguous conditions (e.g., having to determine whether a vehicle speeding toward a military checkpoint contains insurgents with explosives or a family traveling to another area). Such circumstances can lead to combat stress. Military personnel also serve in noncombat positions (e.g., healthcare and administrative roles), and personnel filling these supportive roles can be exposed to combat situations by proximity or by witnessing their results.

Advice to Counselors: Understanding the Nature of Combat Stress

Several sources of information are available to help counselors deepen their understanding of combat stress and postdeployment adjustment. Friedman (2006) explains how a prolonged combat-ready stance, which is adaptive in a war zone, becomes hypervigilance and overprotectiveness at home. He makes the point that the “mutual interdependence, trust, and affection” (p. 587) that are so necessarily a part of a combat unit are different from relationships with family members and colleagues in a civilian workplace. This complicates the transition to civilian life. Wheels Down: Adjusting to Life After Deployment ( Moore & Kennedy, 2011 ) provides practical advice for military service members, including inactive or active duty personnel and veterans, in transitioning from the theater to home.

The following are just a few of the many resources and reports focused on combat-related psychological and stress issues:

  • Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery ( Tanielian & Jaycox, 2008 )
  • On Killing ( Grossman, 1995 ), an indepth analysis of the psychological dynamics of combat
  • Haunted by Combat ( Paulson & Krippner, 2007 ), which contains specific chapters on Reserve and National Guard troops and female veterans
  • Treating Young Veterans: Promoting Resilience Through Practice and Advocacy ( Kelly, Howe-Barksdale, & Gitelson, 2011 )
  • Specific Trauma-Related Psychological Disorders

Part of the definition of trauma is that the individual responds with intense fear, helplessness, or horror. Beyond that, in both the short term and the long term, trauma comprises a range of reactions from normal (e.g., being unable to concentrate, feeling sad, having trouble sleeping) to warranting a diagnosis of a trauma-related mental disorder. Most people who experience trauma have no long-lasting disabling effects; their coping skills and the support of those around them are sufficient to help them overcome their difficulties, and their ability to function on a daily basis over time is unimpaired. For others, though, the symptoms of trauma are more severe and last longer. The most common diagnoses associated with trauma are PTSD and ASD, but trauma is also associated with the onset of other mental disorders—particularly substance use disorders, mood disorders, various anxiety disorders, and personality disorders. Trauma also typically exacerbates symptoms of preexisting disorders, and, for people who are predisposed to a mental disorder, trauma can precipitate its onset. Mental disorders can occur almost simultaneously with trauma exposure or manifest sometime thereafter.

Acute Stress Disorder

ASD represents a normal response to stress. Symptoms develop within 4 weeks of the trauma and can cause significant levels of distress. Most individuals who have acute stress reactions never develop further impairment or PTSD. Acute stress disorder is highly associated with the experience of one specific trauma rather than the experience of long-term exposure to chronic traumatic stress. Diagnostic criteria are presented in Exhibit 1.3-3 .

Exhibit 1.3-3

DSM-5 Diagnostic Criteria for ASD. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways: Directly experiencing the traumatic event(s).

The primary presentation of an individual with an acute stress reaction is often that of someone who appears overwhelmed by the traumatic experience. The need to talk about the experience can lead the client to seem self-centered and unconcerned about the needs of others. He or she may need to describe, in repetitive detail, what happened, or may seem obsessed with trying to understand what happened in an effort to make sense of the experience. The client is often hypervigilant and avoids circumstances that are reminders of the trauma. For instance, someone who was in a serious car crash in heavy traffic can become anxious and avoid riding in a car or driving in traffic for a finite time afterward. Partial amnesia for the trauma often accompanies ASD, and the individual may repetitively question others to fill in details. People with ASD symptoms sometimes seek assurance from others that the event happened in the way they remember, that they are not “going crazy” or “losing it,” and that they could not have prevented the event. The next case illustration demonstrates the time-limited nature of ASD.

Differences between ASD and PTSD

It is important to consider the differences between ASD and PTSD when forming a diagnostic impression. The primary difference is the amount of time the symptoms have been present. ASD resolves 2 days to 4 weeks after an event, whereas PTSD continues beyond the 4-week period. The diagnosis of ASD can change to a diagnosis of PTSD if the condition is noted within the first 4 weeks after the event, but the symptoms persist past 4 weeks.

ASD also differs from PTSD in that the ASD diagnosis requires 9 out of 14 symptoms from five categories, including intrusion, negative mood, dissociation, avoidance, and arousal. These symptoms can occur at the time of the trauma or in the following month. Studies indicate that dissociation at the time of trauma is a good predictor of subsequent PTSD, so the inclusion of dissociative symptoms makes it more likely that those who develop ASD will later be diagnosed with PTSD ( Bryant & Harvey, 2000 ). Additionally, ASD is a transient disorder, meaning that it is present in a person’s life for a relatively short time and then passes. In contrast, PTSD typically becomes a primary feature of an individual’s life. Over a lengthy period, PTSD can have profound effects on clients’ perceptions of safety, their sense of hope for the future, their relationships with others, their physical health, the appearance of psychiatric symptoms, and their patterns of substance use and abuse.

There are common symptoms between PTSD and ASD, and untreated ASD is a possible predisposing factor to PTSD, but it is unknown whether most people with ASD are likely to develop PTSD. There is some suggestion that, as with PTSD, ASD is more prevalent in women than in men ( Bryant & Harvey, 2003 ). However, many people with PTSD do not have a diagnosis or recall a history of acute stress symptoms before seeking treatment for or receiving a diagnosis of PTSD.

Case Illustration: Sheila

Two months ago, Sheila, a 55-year-old married woman, experienced a tornado in her home town. In the previous year, she had addressed a long-time marijuana use problem with the help of a treatment program and had been abstinent for about 6 months. Sheila was proud of her abstinence; it was something she wanted to continue. She regarded it as a mark of personal maturity; it improved her relationship with her husband, and their business had flourished as a result of her abstinence.

During the tornado, an employee reported that Sheila had become very agitated and had grabbed her assistant to drag him under a large table for cover. Sheila repeatedly yelled to her assistant that they were going to die. Following the storm, Sheila could not remember certain details of her behavior during the event. Furthermore, Sheila said that after the storm, she felt numb, as if she was floating out of her body and could watch herself from the outside. She stated that nothing felt real and it was all like a dream.

Following the tornado, Sheila experienced emotional numbness and detachment, even from people close to her, for about 2 weeks. The symptoms slowly decreased in intensity but still disrupted her life. Sheila reported experiencing disjointed or unconnected images and dreams of the storm that made no real sense to her. She was unwilling to return to the building where she had been during the storm, despite having maintained a business at this location for 15 years. In addition, she began smoking marijuana again because it helped her sleep. She had been very irritable and had uncharacteristic angry outbursts toward her husband, children, and other family members.

As a result of her earlier contact with a treatment program, Sheila returned to that program and engaged in psychoeducational, supportive counseling focused on her acute stress reaction. She regained abstinence from marijuana and returned shortly to a normal level of functioning. Her symptoms slowly diminished over a period of 3 weeks. With the help of her counselor, she came to understand the link between the trauma and her relapse, regained support from her spouse, and again felt in control of her life.

Effective interventions for ASD can significantly reduce the possibility of the subsequent development of PTSD. Effective treatment of ASD can also reduce the incidence of other co-occurring problems, such as depression, anxiety, dissociative disorders, and compulsive behaviors ( Bryant & Harvey, 2000 ). Intervention for ASD also helps the individual develop coping skills that can effectively prevent the recurrence of ASD after later traumas.

Although predictive science for ASD and PTSD will continue to evolve, both disorders are associated with increased substance use and mental disorders and increased risk of relapse; therefore, effective screening for ASD and PTSD is important for all clients with these disorders. Individuals in early recovery—lacking well-practiced coping skills, lacking environmental supports, and already operating at high levels of anxiety—are particularly susceptible to ASD. Events that would not normally be disabling can produce symptoms of intense helplessness and fear, numbing and depersonalization, disabling anxiety, and an inability to handle normal life events. Counselors should be able to recognize ASD and treat it rather than attributing the symptoms to a client’s lack of motivation to change, being “dry drunk” (for those in substance abuse recovery), or being manipulative.

Posttraumatic Stress Disorder

The trauma-related disorder that receives the greatest attention is PTSD; it is the most commonly diagnosed trauma-related disorder, and its symptoms can be quite debilitating over time. Nonetheless, it is important to remember that PTSD symptoms are represented in a number of other mental illnesses, including major depressive disorder (MDD), anxiety disorders, and psychotic disorders ( Foa et al., 2006 ). The DSM-5 ( APA, 2013a ) identifies four symptom clusters for PTSD: presence of intrusion symptoms, persistent avoidance of stimuli, negative alterations in cognitions and mood, and marked alterations in arousal and reactivity. Individuals must have been exposed to actual or threatened death, serious injury, or sexual violence, and the symptoms must produce significant distress and impairment for more than 4 weeks ( Exhibit 1.3-4 ).

Exhibit 1.3-4

DSM-5 Diagnostic Criteria for PTSD. Note: The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see the DSM-5 section titled “Posttraumatic Stress Disorder for Children 6 Years (more...)

Case Illustration: Michael

Michael is a 62-year-old Vietnam veteran. He is a divorced father of two children and has four grandchildren. Both of his parents were dependent on alcohol. He describes his childhood as isolated. His father physically and psychologically abused him (e.g., he was beaten with a switch until he had welts on his legs, back, and buttocks). By age 10, his parents regarded him as incorrigible and sent him to a reformatory school for 6 months. By age 15, he was using marijuana, hallucinogens, and alcohol and was frequently truant from school.

At age 19, Michael was drafted and sent to Vietnam, where he witnessed the deaths of six American military personnel. In one incident, the soldier he was next to in a bunker was shot. Michael felt helpless as he talked to this soldier, who was still conscious. In Vietnam, Michael increased his use of both alcohol and marijuana. On his return to the United States, Michael continued to drink and use marijuana. He reenlisted in the military for another tour of duty.

His life stabilized in his early 30s, as he had a steady job, supportive friends, and a relatively stable family life. However, he divorced in his late 30s. Shortly thereafter, he married a second time, but that marriage ended in divorce as well. He was chronically anxious and depressed and had insomnia and frequent nightmares. He periodically binged on alcohol. He complained of feeling empty, had suicidal ideation, and frequently stated that he lacked purpose in his life.

In the 1980s, Michael received several years of mental health treatment for dysthymia. He was hospitalized twice and received 1 year of outpatient psychotherapy. In the mid-1990s, he returned to outpatient treatment for similar symptoms and was diagnosed with PTSD and dysthymia. He no longer used marijuana and rarely drank. He reported that he didn’t like how alcohol or other substances made him feel anymore—he felt out of control with his emotions when he used them. Michael reported symptoms of hyperarousal, intrusion (intrusive memories, nightmares, and preoccupying thoughts about Vietnam), and avoidance (isolating himself from others and feeling “numb”). He reported that these symptoms seemed to relate to his childhood abuse and his experiences in Vietnam. In treatment, he expressed relief that he now understood the connection between his symptoms and his history.

Certain characteristics make people more susceptible to PTSD, including one’s unique personal vulnerabilities at the time of the traumatic exposure, the support (or lack of support) received from others at the time of the trauma and at the onset of trauma-related symptoms, and the way others in the person’s environment gauge the nature of the traumatic event ( Brewin, Andrews, & Valentine, 2000 ).

People with PTSD often present varying clinical profiles and histories. They can experience symptoms that are activated by environmental triggers and then recede for a period of time. Some people with PTSD who show mostly psychiatric symptoms (particularly depression and anxiety) are misdiagnosed and go untreated for their primary condition. For many people, the trauma experience and diagnosis are obscured by co-occurring substance use disorder symptoms. The important feature of PTSD is that the disorder becomes an orienting feature of the individual’s life. How well the person can work, with whom he or she associates, the nature of close and intimate relationships, the ability to have fun and rejuvenate, and the way in which an individual goes about confronting and solving problems in life are all affected by the client’s trauma experiences and his or her struggle to recover.

Posttraumatic stress disorder: Timing of symptoms

Although symptoms of PTSD usually begin within 3 months of a trauma in adulthood, there can be a delay of months or even years before symptoms appear for some people. Some people may have minimal symptoms after a trauma but then experience a crisis later in life. Trauma symptoms can appear suddenly, even without conscious memory of the original trauma or without any overt provocation. Survivors of abuse in childhood can have a delayed response triggered by something that happens to them as adults. For example, seeing a movie about child abuse can trigger symptoms related to the trauma. Other triggers include returning to the scene of the trauma, being reminded of it in some other way, or noting the anniversary of an event. Likewise, combat veterans and survivors of community-wide disasters may seem to be coping well shortly after a trauma, only to have symptoms emerge later when their life situations seem to have stabilized. Some clients in substance abuse recovery only begin to experience trauma symptoms when they maintain abstinence for some time. As individuals decrease tension-reducing or self-medicating behaviors, trauma memories and symptoms can emerge.

Advice to Counselors: Helping Clients With Delayed Trauma Responses

Clients who are experiencing a delayed trauma response can benefit if you help them to:

  • Create an environment that allows acknowledgment of the traumatic event(s).
  • Discuss their initial recall or first suspicion that they were having a traumatic response.
  • Become educated on delayed trauma responses.
  • Draw a connection between the trauma and presenting trauma-related symptoms.
  • Create a safe environment.
  • Explore their support systems and fortify them as needed.
  • Understand that triggers can precede traumatic stress reactions, including delayed responses to trauma.
  • Identify their triggers.
  • Develop coping strategies to navigate and manage symptoms.

Culture and posttraumatic stress

Although research is limited across cultures, PTSD has been observed in Southeast Asian, South American, Middle Eastern, and Native American survivors ( Osterman & de Jong, 2007 ; Wilson & Tang, 2007 ). As Stamm and Friedman (2000) point out, however, simply observing PTSD does not mean that it is the “best conceptual tool for characterizing post-traumatic distress among non-Western individuals” (p. 73). In fact, many trauma-related symptoms from other cultures do not fit the DSM-5 criteria. These include somatic and psychological symptoms and beliefs about the origins and nature of traumatic events. Moreover, religious and spiritual beliefs can affect how a survivor experiences a traumatic event and whether he or she reports the distress. For example, in societies where attitudes toward karma and the glorification of war veterans are predominant, it is harder for war veterans to come forward and disclose that they are emotionally overwhelmed or struggling. It would be perceived as inappropriate and possibly demoralizing to focus on the emotional distress that he or she still bears. (For a review of cultural competence in treating trauma, refer to Brown, 2008 .)

Methods for measuring PTSD are also culturally specific. As part of a project begun in 1972, the World Health Organization (WHO) and the National Institutes of Health (NIH) embarked on a joint study to test the cross-cultural applicability of classification systems for various diagnoses. WHO and NIH identified apparently universal factors of psychological disorders and developed specific instruments to measure them. These instruments, the Composite International Diagnostic Interview and the Schedules for Clinical Assessment in Neuropsychiatry, include certain criteria from the DSM (Fourth Edition, Text Revision; APA, 2000a ) as well as criteria from the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10; Exhibit 1.3-5 ).

Exhibit 1.3-5

ICD-10 Diagnostic Criteria for PTSD. The patient must have been exposed to a stressful event or situation (either brief or long-lasting) of exceptionally threatening or catastrophic nature, which would be likely to cause pervasive distress in almost anyone. (more...)

Complex trauma and complex traumatic stress

When individuals experience multiple traumas, prolonged and repeated trauma during childhood, or repetitive trauma in the context of significant interpersonal relationships, their reactions to trauma have unique characteristics ( Herman, 1992 ). This unique constellation of reactions, called complex traumatic stress, is not recognized diagnostically in the DSM-5, but theoretical discussions and research have begun to highlight the similarities and differences in symptoms of posttraumatic stress versus complex traumatic stress ( Courtois & Ford, 2009 ). Often, the symptoms generated from complex trauma do not fully match PTSD criteria and exceed the severity of PTSD. Overall, literature reflects that PTSD criteria or subthreshold symptoms do not fully account for the persistent and more impairing clinical presentation of complex trauma. Even though current research in the study of traumatology is prolific, it is still in the early stages of development. The idea that there may be more diagnostic variations or subtypes is forthcoming, and this will likely pave the way for more client-matching interventions to better serve those individuals who have been repeatedly exposed to multiple, early childhood, and/or interpersonal traumas.

  • Other Trauma-Related and Co-Occurring Disorders

The symptoms of PTSD and other mental disorders overlap considerably; these disorders often coexist and in clude mood, anxiety, substance use, and personality disorders. Thus, it’s common for trauma survivors to be underdiagnosed or misdiagnosed. If they have not been identified as trauma survivors, their psychological distress is often not associated with previous trauma, and/or they are diagnosed with a disorder that marginally matches their presenting symptoms and psychological sequelae of trauma. The following sections present a brief overview of some mental disorders that can result from (or be worsened by) traumatic stress. PTSD is not the only diagnosis related to trauma nor its only psychological consequence; trauma can broadly influence mental and physical health in clients who already have behavioral health disorders.

The term “ co-occurring disorders ” refers to cases when a person has one or more mental disorders as well as one or more substance use disorders (including substance abuse). Co-occurring disorders are common among individuals who have a history of trauma and are seeking help.

Advice to Counselors: Universal Screening and Assessment

Only people specifically trained and licensed in mental health assessment should make diagnoses; trauma can result in complicated cases, and many symptoms can be present, whether or not they meet full diagnostic criteria for a specific disorder. Only a trained assessor can distinguish accurately among various symptoms and in the presence of co-occurring disorders. However, behavioral health professionals without specific assessment training can still serve an important role in screening for possible mental disorders using established screening tools ( CSAT, 2005c ; see also Chapter 4 of this TIP). In agencies and clinics, it is critical to provide such screenings systematically—for each client—as PTSD and other co-occurring disorders are typically under diagnosed or misdiagnosed.

People With Mental Disorders

MDD is the most common co-occurring disorder in people who have experienced trauma and are diagnosed with PTSD. A well-established causal relationship exists between stressful events and depression, and a prior history of MDD is predictive of PTSD after exposure to major trauma ( Foa et al., 2006 ).

Many survivors with severe mental disorders function fairly well following trauma, including disasters, as long as essential services aren’t interrupted. For others, additional mental health supports may be necessary. For more information, see Responding to the Needs of People With Serious and Persistent Mental Illness in Times of Major Disaster ( Center for Mental Health Services, 1996 ).

Co-occurrence is also linked with greater impairment and more severe symptoms of both disorders, and the person is less likely to experience remission of symptoms within 6 months.

Generalized anxiety, obsessive–compulsive, and other anxiety disorders are also associated with PTSD. PTSD may exacerbate anxiety disorder symptoms, but it is also likely that preexisting anxiety symptoms and anxiety disorders increase vulnerability to PTSD. Preexisting anxiety primes survivors for greater hyperarousal and distress. Other disorders, such as personality and somatization disorders, are also associated with trauma, but the history of trauma is often overlooked as a significant factor or necessary target in treatment.

The relationship between PTSD and other disorders is complex. More research is now examining the multiple potential pathways among PTSD and other disorders and how various sequences affect clinical presentation. TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders ( CSAT, 2005c ), is valuable in understanding the relationship of substance use to other mental disorders.

People With Substance Use Disorders

There is clearly a correlation between trauma (including individual, group, or mass trauma) and substance use as well as the presence of posttraumatic stress (and other trauma-related disorders) and substance use disorders. Alcohol and drug use can be, for some, an effort to manage traumatic stress and specific PTSD symptoms. Likewise, people with substance use disorders are at higher risk of developing PTSD than people who do not abuse substances. Counselors working with trauma survivors or clients who have substance use disorders have to be particularly aware of the possibility of the other disorder arising.

Co-Occurring PTSD and Other Mental Disorders

  • Individuals with PTSD often have at least one additional diagnosis of a mental disorder.
  • The presence of other disorders typically worsens and prolongs the course of PTSD and complicates clinical assessment, diagnosis, and treatment.
  • The most common co-occurring disorders, in addition to substance use disorders, include mood disorders, various anxiety disorders, eating disorders, and personality disorders.
  • Exposure to early, severe, and chronic trauma is linked to more complex symptoms, including impulse control deficits, greater difficulty in emotional regulation and establishing stable relationships, and disruptions in consciousness, memory, identity, and/or perception of the environment ( Dom, De, Hulstijn, & Sabbe, 2007 ; Waldrop, Back, Verduin, & Brady, 2007 ).
  • Certain diagnostic groups and at-risk populations (e.g., people with developmental disabilities, people who are homeless or incarcerated) are more susceptible to trauma exposure and to developing PTSD if exposed but less likely to receive appropriate diagnosis and treatment.
  • Given the prevalence of traumatic events in clients who present for substance abuse treatment, counselors should assess all clients for possible trauma-related disorders.

Timeframe: PTSD and the onset of substance use disorders

Knowing whether substance abuse or PTSD came first informs whether a causal relationship exists, but learning this requires thorough assessment of clients and access to complete data on PTSD; substance use, abuse, and dependence; and the onset of each. Much current research focuses solely on the age of onset of substance use (not abuse), so determining causal relationships can be difficult. The relationship between PTSD and substance use disorders is thought to be bidirectional and cyclical: substance use increases trauma risk, and exposure to trauma escalates substance use to manage trauma-related symptoms. Three other causal pathways described by Chilcoat and Breslau’s seminal work ( 1998 ) further explain the relationship between PTSD and substance use disorders:

  • The “self-medication” hypothesis suggests that clients with PTSD use substances to manage PTSD symptoms (e.g., intrusive memories, physical arousal). Substances such as alcohol, cocaine, barbiturates, opioids, and amphetamines are frequently abused in attempts to relieve or numb emotional pain or to forget the event.
  • The “high-risk” hypothesis states that drug and alcohol use places people who use substances in high-risk situations that increase their chances of being exposed to events that lead to PTSD.
  • The “susceptibility” hypothesis suggests that people who use substances are more susceptible to developing PTSD after exposure to trauma than people who do not. Increased vulnerability may result from failure to develop effective stress management strategies, changes in brain chemistry, or damage to neurophysiological systems due to extensive substance use.

PTSD and substance abuse treatment

PTSD can limit progress in substance abuse recovery, increase the potential for relapse, and complicate a client’s ability to achieve success in various life areas. Each disorder can mask or hide the symptoms of the other, and both need to be assessed and treated if the individual is to have a full recovery. There is a risk of misinterpreting trauma-related symptoms in substance abuse treatment settings. For example, avoidance symptoms in an individual with PTSD can be misinterpreted as lack of motivation or unwillingness to engage in substance abuse treatment; a counselor’s efforts to address substance abuse–related behaviors in early recovery can likewise provoke an exaggerated response from a trauma survivor who has profound traumatic experiences of being trapped and controlled. Exhibit 1.3-6 lists important facts about PTSD and substance use disorders for counselors.

Exhibit 1.3-6

PTSD and Substance Use Disorders: Important Treatment Facts. PTSD is one of the most common co-occurring mental disorders found in clients in substance abuse treatment (CSAT, 2005c). People in treatment for PTSD tend to abuse a wide range of substances, (more...)

Case Illustration: Maria

Maria is a 31-year-old woman diagnosed with PTSD and alcohol dependence. From ages 8 to 12, she was sexually abused by an uncle. Maria never told anyone about the abuse for fear that she would not be believed. Her uncle remains close to the family, and Maria still sees him on certain holidays. When she came in for treatment, she described her emotions and thoughts as out of control. Maria often experiences intrusive memories of the abuse, which at times can be vivid and unrelenting. She cannot predict when the thoughts will come; efforts to distract herself from them do not always work. She often drinks in response to these thoughts or his presence, as she has found that alcohol can dull her level of distress. Maria also has difficulty falling asleep and is often awakened by nightmares. She does not usually remember the dreams, but she wakes up feeling frightened and alert and cannot go back to sleep.

Maria tries to avoid family gatherings but often feels pressured to go. Whenever she sees her uncle, she feels intense panic and anger but says she can usually “hold it together” if she avoids him. Afterward, however, she describes being overtaken by these feelings and unable to calm down. She also describes feeling physically ill and shaky. At these times, she often isolates herself, stays in her apartment, and drinks steadily for several days. Maria also reports distress pertaining to her relationship with her boyfriend. In the beginning of their relationship, she found him comforting and enjoyed his affection, but more recently, she has begun to feel anxious and unsettled around him. Maria tries to avoid sex with him, but she sometimes gives in for fear of losing the relationship. She finds it easier to have sex with him when she is drunk, but she often experiences strong feelings of dread and disgust reminiscent of her abuse. Maria feels guilty and confused about these feelings.

Sleep, PTSD, and substance use

Many people have trouble getting to sleep and/or staying asleep after a traumatic event; consequently, some have a drink or two to help them fall asleep. Unfortunately, any initially helpful effects are likely not only to wane quickly, but also to incur a negative rebound effect. When someone uses a substance before going to bed, “sleep becomes lighter and more easily disrupted,” and rapid eye movement sleep (REM) “increases, with an associated increase in dreams and nightmares,” as the effects wear off ( Auerbach, 2003 , p. 1185).

People with alcohol dependence report multiple types of sleep disturbances over time, and it is not unusual for clients to report that they cannot fall asleep without first having a drink. Both REM and slow wave sleep are reduced in clients with alcohol dependence, which is also associated with an increase in the amount of time it takes before sleep occurs, decreased overall sleep time, more nightmares, and reduced sleep efficiency. Sleep during withdrawal is “frequently marked by severe insomnia and sleep fragmentation…a loss of restful sleep and feelings of daytime fatigue. Nightmares and vivid dreams are not uncommon” ( Auerbach, 2003 , pp. 1185–1186).

Confounding changes in the biology of sleep that occur in clients with PTSD and substance use disorders often add to the problems of recovery. Sleep can fail to return to normal for months or even years after abstinence, and the persistence of sleep disruptions appears related to the likelihood of relapse. Of particular clinical importance is the vicious cycle that can also begin during “slips”; relapse initially improves sleep, but continued drinking leads to sleep disruption. This cycle of initial reduction of an unpleasant symptom, which only ends up exacerbating the process as a whole, can take place for clients with PTSD as well as for clients with substance use disorders. There are effective cognitive–behavioral therapies and nonaddictive pharmacological interventions for sleep difficulties.

  • Cite this Page Center for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.) Chapter 3, Understanding the Impact of Trauma.
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