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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

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
• https://doi.org/10.1371/journal.pone.0252747
• Reader Comments

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).

Conclusions

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. https://doi.org/10.1371/journal.pone.0252747

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).

Eligibility

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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https://doi.org/10.1371/journal.pone.0252747.g001

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 ].

https://doi.org/10.1371/journal.pone.0252747.t001

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.

https://doi.org/10.1371/journal.pone.0252747.t002

https://doi.org/10.1371/journal.pone.0252747.t003

https://doi.org/10.1371/journal.pone.0252747.t004

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 ].

https://doi.org/10.1371/journal.pone.0252747.t005

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..

https://doi.org/10.1371/journal.pone.0252747.s001

S1 Appendix. Search strategies.

https://doi.org/10.1371/journal.pone.0252747.s002

Acknowledgments

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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Introduction

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

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.

Medications

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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Acknowledgments

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). https://doi.org/10.1007/s10615-014-0496-z

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Neuroepigenetics researcher Isabelle Mansuy describes how the effects of trauma can pass from generation to generation.

Isabelle Mansuy’s neuroepigenetics lab researches the impact of life experiences and environmental factors on mental health, exploring if these impacts can be passed on to descendants.

Epigenetic inheritance, she says, is not confined to diets and exposure of factors such as like endocrine disruptors or environmental pollutants. All of these can modify our body and have effects in our offspring. But Mansuy, who is based at the University of Zurich and Swiss Federal Institute of Technology in Zurich, Switzerland, also asks if trauma modifies not only our brains, but also our reproductive systems.

There is still a lot of work needed, she adds, but the possibility that depression or borderline personality disorder might be something inherited from parents would be important for patients and clinicians to understand.

Mansuy’s lab seeks to expose animals prenatally or after birth to conditions which mimic human stress. Her collaborators also provide access to blood and saliva samples from people exposed to childhood trauma, and medical students who are undergoing work placements in emergency rooms.

This is the penultimate episode in Tales from the Synapse , a 12-part podcast series produced in partnership with Nature Neuroscience and introduced by Jean Mary Zarate, a senior editor at the journal. The series features brain scientists from all over the world who talk about their career journeys, collaborations and the societal impact of their research.

doi: https://doi.org/10.1038/d41586-023-01433-y

Jean Mary Zarate: 00:04

Hello, and welcome to Tales From the Synapse , a podcast brought to you by Nature Careers in partnership with Nature Neuroscience . I'm Jean Mary Zarate, a senior editor at the journal Nature Neuroscience.

And in this series, we speak to brain scientists all over the world about their life, their research, their collaborations, and the impact of their work. In episode 11, we meet a researcher who was set on understanding trauma and to what extent it passes from generation to generation.

Isabelle Mansuy: 00:40

I’m Isabelle Mansuy. And I'm professor in neuroepigenetics at the University of Zurich, and the Swiss Federal Institute of Technology in Zurich, Switzerland.

Neuroepigenetics is a new discipline in biology and neuroscience, which combines neuroscience and epigenetics.

So it’s a discipline which studies the intimate mechanisms which regulate brain function, so the functions of the nervous system.

So classically, we know that the genome, and genes that it contains, or it carries, regulate complex functions. Now, with epigenetics, we are looking at factors and mechanics which are beyond the genetic sequence itself, beyond the DNA sequence, beyond the genome, which regulate the function of the genome.

So neuroepigenetics, it’s really looking at the heart of brain cells or nervous, cells of the nervous system, looking in the nucleus at the level of the genome, to understand how the genome is regulated, and what are the consequences for behaviour and for brain functions.

Not only it’s how the brain develops, how the brain functions, how the brain can drive our thoughts, how the brain can drive our movements, how all of this is regulated, and how diseases can affect the nervous system, mental health and physical health because you have, if you have a neurodegenerative disease, your body is going to be affected, and your internal organs.

So it’s really the general science of understanding how brain cells, or cells of the nervous system, function.

Isabelle Mansuy: 02:42

My work is in a discipline which is even different, or which complements neuroepigenetics, which is epigenetic inheritance.

The overall question is how indeed life experiences or environmental factors can shape, augment our brain and our body and our mental health. Not just ours, but also the one from our children, our descendants.

So there are multiple questions here. First is how our life experiences can modify our brain, but also our reproductive system, our germ cells. So in men, sperm cells, and in women, all sides.

And if these reproductive cells are modified by the life experience, or traumatic experiences, for instance, at the same time as the rest of the body, this could be responsible for the transfer, the transmission, of some of the effects of the exposure to the children.

This derives from observation, epidemiological studies in human that for many psychiatric disorders, borderline personality disorder, anxiety, depression, very severe and complex diseases.

In many cases, people have been exposed to traumatic experiences in childhood. Not necessarily them, but sometimes the parents or grandparents.

So the idea emerged that such type of adverse extreme experiences in childhood can modify the body so much that it can have imprints or traces even in reproductive cells.

And these traces may be responsible for the expression, the manifestation of symptoms of exposure in the children, or perhaps even the grandchildren.

So what we are interested in is identifying these molecular traces in germ cells. And for this, we are using animal models.

Isabelle Mansuy: 05:00

Animal models are used really to dissect out the mechanism, but all of this initially was observed in human.

There have been many cohorts linked to war trauma, linked to different experiences that populations, oppressed populations, for instance, have been, have gone through.

In animal research, we are trying to mimic human conditions by exposing the animals, either prenatally or after birth, during development or in adulthood, to various conditions which mimic, which try to mimic the best human stress.

Like mouse, we can use restraint, for instance, Or during development, we can use maternal separation unpredictable maternal separation.

And by using these paradigms, which can vary in severity and duration in chronicity, we can induce stress, signs of stress in the animals, and then benefit from that, or explore these animals to study the makeup, the underlying mechanism across tissues.

We had a cohort of traumatized children at some point in Pakistan. But it was, it’s a small cohort that we put together to collect blood as a pilot or proof of principle of some of the results we have collected in mice. Other than this, we are not directly involved with patients.

We have collaborations with the psychologist, psychiatrist through different consortia. I belong to four different consortia, three European and one Swiss, where I have access to blood or saliva if I want, with different people, people exposed to childhood trauma or to, we have a cohort of medical students who are in the emergency room and who go through several weeks of very stressful life.

So these type of of studies, and we can have access to the biological fluids from these people and do analysis if we want. But ourselves, we are not directly involved in these patients.

Isabelle Mansuy: 07:28

And indeed, there are two levels, I think. First of all is the knowledge, the gaining knowledge because epigenetic inheritance itself, it's a form of heredity, which is linked not only to life experiences, but also to diets, to exposure of various factors like endocrine disruptors, or pollutants in the environment. It is known that all these factors, elements, the things that we encounter during our life, can modify our body and have effects in our offspring.

So the general concept of epigenetic, of inheritance, this form of transmission of acquired traits. There are features that an organism starts developing after being exposed to some factor, and that these features are passed to the following generations. And that is not by culture, by behaviour or by anything else, but embedded into reproductive cells.

So when this relates to traumatic experiences, or childhood adverse experiences, our finding, or the results of our research, could help people who are affected by this in their mental health, in their physical health.

There is still a lot of work needed to be able to help these people directly. But if we could already confirm the possibility, that indeed, complex diseases like depression or borderline personality disorder, may not necessarily be caused by something the person has done wrong, but could be something that is inherited from mum or dad.

That would already be something very important for people to know and for psychiatrists and for medicine in general.

Isabelle Mansuy: 09:35

Traumatic experiences can affect many people in the population. We naturally think of war conflict, but in the daily life in families, there are many different types of trauma.

Trauma can be physical violence, sexual violence, abuse, neglect, humiliation, verbal violence. Many things which can happen not only in low socioeconomic milieu but also in, in wealthy families, when you have abusive parents, abusive father, very often, or at work or at school.

I mean, the past couple of years around the globe, I mean, there have been a number of examples of abuse in children, whether in church, whether, you know, abusing in young women, in young girls.

So, we are concerned, I mean, this is a type of trauma, which is in the society everywhere, and can affect everyone. Of course, there is also people who are experiencing or exposed to very violent events, like war conflicts. If there are soldiers or even in countries which are going through, through major, major conflicts. It could be an accident, it could be a natural disaster.

You know, if, if there is a tsunami, for instance, in, in various countries, in the past two decades, I mean, that can be extremely traumatic for many people, and for a very long time.

Isabelle Mansuy: 11:24

Traumatic experiences can have multiple effects on the brain. It really depends on the severity of the trauma and on the age during which the trauma was experienced, and the duration of trauma.

If it’s a chronic trauma in childhood, you know, when the child brain is developing, it can have massive effects, not just effects in the cells, but also structural effects, and prevents the brain from developing normally from establishing proper connections.

If it’s a traumatic, one single traumatic event in an adult, it may have shorter lasting effects, which may be alteration of functions of some cells, and consequences of the the release of stress hormone in the body.

And there are different ways to measure the internal effects of trauma in the body. But it’s a bit complicated, because you imagine an engine, which is working more or less well, and starts to not work very well.

What is your readout, you cannot, you don’t really understand necessarily how the engine works. But you may look at the exhaust pipe and the gas, analyze the gas, and then realize that something is wrong.

So with the body, it’s a little bit the same. I mean, we don’t understand exactly how the body functions, but we have blood as a readout. We can take blood to analysis, like, look at the composition of blood and maybe guess that something is going wrong in the body and perhaps in the brain. But today, we don’t know exactly, we have only a very rough idea of what can be altered in the body due to traumatic experiences.

A child may have lots of difficulties in developing normally and being self confident, having self esteem and having a balanced behaviour. In adult it can modify behaviour, and people who have been, who have gone through an extreme stress, they may (or trauma), they may then be very fearful. They may have PTSD, which is an overreaction, or obsessive fear, which are not related to the environment. Someone can become suddenly very stressed and have the heartbeat, which raises, and starting to sweat and feel bad when there is no threat around.

Obsessive memories and traumatic memories can also happen in someone who has been experiencing traumatic experiences in traumatic events in childhood. So there can be multiple effects affecting the brain and the body.

Isabelle Mansuy: 14:44

It’s very important to understand biology, to understand how the brain functions, how the brain reacts to various environments, and to understand disease aetiology.

Why are people exposed to traumatic experiences, suffering all their life and why sometimes even the children suffer? We need to understand what are the origins of such disease and why someone gets a neuro, Alzheimer’s Disease, or a neurodegenerative disorder, or mood disorder. So this fundamental research is absolutely essential, to hope to obtain answers to these questions.

Isabelle Mansuy: 15:35

Yes, well, being a scientist is a very tough profession.

It’s very difficult to be to become a researcher and have the freedom to do the research you want.

But once you reach this level, it’s an extremely exciting, very interesting, very stimulating profession. Each day is different. And we have the freedom to work on things that we like. And you know, to discover how nature functions, how new things which have, which are not well understood, is extremely exciting.

And if on top of this, you’re working on something that can help medicine, to crack a problem, to work on a problem, which affects people in the society is makes the job even more interesting, more challenging. But really everyday, it fuels our everyday work. Curiosity and excitement by things which look mysterious, and also with the drive of changing, Doing something that can improve people that can be helpful for the society, for medicine. And for, yeah, for people in general. Being useful, being useful to research by bringing new knowledge and by discovering how the brain functions.

Jean Mary Zarate: 17:30

Now that’s it for this episode of Tales From the Synapse . I’m Jean Mary Zarate, a senior editor at Nature Neuroscience . The producer was Don Byrne. Thanks again to Professor Isabelle Mansuy, and thank you for listening

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Researchers reveal how trauma changes the brain

Exposure to trauma can be life-changing – and researchers are learning more about how traumatic events may physically change our brains. But these changes are not happening because of physical injury, rather our brain appears to rewire itself after these experiences. Understanding the mechanisms involved in these changes and how the brain learns about an environment and predicts threats and safety is a focus of the  ZVR Lab  at the  Del Monte Institute for Neuroscience at the University of Rochester , which is led by assistant professor  Benjamin Suarez- Jimenez, Ph.D.

“We are learning more about how people exposed to trauma learn to distinguish between what is safe and what is not. Their brain is giving us insight into what might be going awry in specific mechanisms that are impacted by trauma exposure, especially when emotion is involved,” said Suarez-Jimenez, who began this work as a post-doctoral fellow in the lab of Yuval Neria, Ph.D., professor at Columbia University Irving Medical Center.

Their research, recently published in  Communications Biology , identified changes in the salience network – a mechanism in the brain used for learning and survival – in people exposed to trauma (with and without psychopathologies, including PTSD, depression, and anxiety). Using fMRI, the researchers recorded activity in the brains of participants as they looked at different-sized circles – only one size was associated with a small shock (or threat). Along with the changes in the salience network, researchers found another difference – this one within the trauma-exposed resilient group. They found the brains of people exposed to trauma without psychopathologies were compensating for changes in their brain processes by engaging the executive control network – one of the dominate networks of the brain.

“Knowing what to look for in the brain when someone is exposed to trauma could significantly advance treatments,” said Suarez-Jimenez, a co-first author with Xi Zhu, PhD, Assistant Professor of Clinical Neurobiology at Columbia, of this paper. “In this case, we know where a change is happening in the brain and how some people can work around that change. It is a marker of resilience.”

Adding the element of emotion

The possibility of threat can change how someone exposed to trauma reacts – researchers found this is the case in people with  post-traumatic stress disorder (PTSD) , as described in a recent study in  Depression & Anxiety . Suarez-Jimenez, his fellow co-authors, and senior author Neria found patients with PTSD can complete the same task as someone without exposure to trauma when no emotion is involved. However, when emotion invoked by a threat was added to a similar task, those with PTSD had more difficulty distinguishing between the differences.

The team used the same methods as the other experiment – different circle sizes with one size linked to a threat in the form of a shock. Using fMRI, researchers observed people with PTSD had less signaling between the hippocampus – an area of the brain responsible for emotion and memory – and the salience network – a mechanism used for learning and survival. They also detected less signaling between the amygdala (another area linked to emotion) and the default mode network (an area of the brain that activates when someone is not focused on the outside world). These findings reflect a person with PTSD’s inability to effectively distinguish differences between the circles.  

“This tells us that patients with PTSD have issues discriminating only when there is an emotional component. In this case, aversive; we still need to confirm if this is true for other emotions like sadness, disgust, happiness, etc.,” said Suarez-Jimenez. “So, it might be that in the real-world emotions overload their cognitive ability to discriminate between safety, danger, or reward. It overgeneralizes towards danger.”

“Taken together, findings from both papers, coming out of a NIMH funded study aiming to uncover neural and behavioral mechanisms of trauma, PTSD and resilience, help to extend our knowledge about the effect of trauma on the brain,” said Neria, lead PI on this study. “PTSD is driven by remarkable dysfunction in brain areas vital to fear processing and response. My lab at Columbia and the Dr. Suarez-Jimenez lab at Rochester are committed to advance neurobiological research that will serve the purpose of development new and better treatments that can effectively target aberrant fear circuits.”

Suarez-Jimenez will continue exploring the brain mechanisms and the different emotions associated with them by using more real-life situations with the help of virtual reality in his lab. He wants to understand if these mechanisms and changes are specific to a threat and if they expand to context-related processes.

Additional authors include co-first authors John Keefe, Ph.D., of Albert Einstein College of Medicine and Xi Zhu, Ph.D., of Columbia University Irving Medical Center, Amit Lazarov, Ph.D., of Columbia University Irving Medical Center, Ariel Durosky of the University of Tulsa, Oklahoma, Sara Such of the University of Pennsylvania, Caroline Marohasy of the University of Washington, Seattle, and Shmuel Lissek of the University of Minnesota, Minneapolis. The research was supported by the National Institute of Mental Health.

Additional authors on the  Communications Biology  paper include co-first author Xi Zhu, Ph.D., Amit Lazarov, Ph.D., Scott Small, M.D., of Columbia University Irving Medical Center, Ariel Durosky of the University of Tulsa, Oklahoma, Sara Such of the University of Pennsylvania, Caroline Marohasy of the University of Washington, Seattle, Tor Wager, Ph.D., of Dartmouth College, Martin Lindquist, Ph.D. of Johns Hopkins, and Shmuel Lissek, Ph.D., of the University of Minnesota. The research was supported by the National Institute of Mental Health.

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The Debate Over Trauma in the New DSM Revision

Why definitions matter for clinical care..

Posted May 30, 2024 | Reviewed by Abigail Fagan

• What Is Trauma?
• Find a therapist to heal from trauma
• The DSM shapes how we define trauma in psychology and psychiatry within the U.S.
• Posttraumatic stress disorder requires exposure to a "Criterion A" traumatic event as part of the diagnosis.
• People can develop PTSD-like symptoms from non-Criterion A events, like racial discrimination or cancer.

When I use the word "trauma," something different may come to mind for each of you, highlighting its subjective nature and how a traumatic event may impact each of us differently. However, in the world of traumatic stress research and clinical practice, defining trauma and finding the line of what counts (or doesn’t count) as a traumatic event becomes critical to correct diagnosis and resulting treatment.

Post-traumatic stress disorder ( PTSD ) is a unique mental health condition in that it requires the existence of an event to precipitate the onset of PTSD symptoms. Specifically, as outlined in the Diagnostic and Statistical Manual , 5th edition text revision (DSM-5-TR 1 ), in order to be diagnosed with PTSD, an individual first has to be exposed to a traumatic event (i.e., Criterion A). That event must fall outside the realm of normal human experience and include things like exposure to actual or threatened death, serious injury, or sexual violence through the direct experience or witnessing of the event, learning about it happening to a loved one, or through repeated exposure as part of one’s job. The DSM-5 made efforts to restrict the definition of trauma to ensure the definition distinguished the extreme nature of Criterion A events from lower magnitude stressors.

Importantly, the rules and stipulations of what counts as a trauma based on the DSM-5-TR can mean that very difficult life experiences that may lead to trauma responses are left out, such as being confronted with the death of a loved one to cancer or being witness to a debilitating chronic illness of one’s child. The current definition of Criterion A trauma also does not account for experiences of racial discrimination , leaving out highly impactful and distressing life events that have been shown to lead to the same symptom profile as PTSD.

The debate on Criterion A within the trauma field is well laid-out in a recent review article by Marx and colleagues 2 in which they describe four potential paths that the PTSD trauma definition could take moving forward:

• Expanding Criterion A
• Narrowing Criterion A
• Eliminating Criterion A
• Keeping Criterion A unchanged

A recent meta-analysis by Georgescu et al. 3 highlights a main argument behind the expansion of Criterion A by finding that across 124 studies, the pooled average of potential PTSD symptoms following non-Criterion A events (such as racial discrimination or cancer) was comparable to those observed in studies of PTSD from Criterion A events. These results suggest that by maintaining a narrow definition of trauma, we may be missing people with PTSD symptom profiles that are clinically significant. Is defining trauma actually necessary or can the focus be on who displays PTSD symptoms? This is a primary question raised among those who also consider the full elimination of Criterion A from the PTSD diagnosis. Alternatively, experts advocating for narrowing Criterion A suggest that the exclusion of any indirect exposures from qualifying for Criterion A can clarify the difference between traumatic and nontraumatic stressors and limit misclassification of PTSD or diagnosis drift. However, as Marx et al. 2 point out, there is still a great deal we need to discover about how changes to the DSM-5 definition of trauma may affect our understanding of PTSD as a disease, its underlying mechanisms, and who is most likely to develop or recover from PTSD.

As a trauma researcher, it is easy for me to get in the weeds about these paths and their implications because while strict adherence to diagnostic criteria ensures rigor and reproducibility across studies, narrow definitions can result in missed opportunities to capture clinically relevant symptom presentations. Each option has its drawbacks.

This debate necessarily translates to the clinical space as well. The diagnosis we determine for a client should lead to an evidence-based treatment that aligns with that condition. If PTSD is present, but missed, the focus of the treatment may be misaligned with the primary symptoms and could lead to delayed recovery for the client. In the current diagnostic landscape, adjustment disorder and other trauma and stressor-related disorders are viable options for diagnosis when Criterion A is not present. Ultimately, as a clinician, the key should be thorough assessment of both traumatic experiences and difficult life events not captured in trauma inventories, like racial discrimination, childbirth, or non-traumatic loss, and how those may influence psychological symptom presentation. Understanding common experiences of the population you serve is key. If you do not ask, you will not know. Instead of getting caught in the debate, we can learn from it, and still make choices about how we conceptualize and treat clients based on their symptoms while keeping the whole person – and all the experiences that have come with them – in mind.

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Marx, B. P., Hall‐Clark, B., Friedman, M. J., Holtzheimer, P., & Schnurr, P. P. (2024). The PTSD Criterion A debate: A brief history, current status, and recommendations for moving forward. Journal of Traumatic Stress , 37 (1), 5-15. https://doi.org/10.1002/jts.23007

Georgescu, T., Nedelcea, C., Letzner, R. D., Macarenco, M. M., & Cosmoiu, A. (2024). Criterion a issue: What other events lead to the onset of posttraumatic stress disorder symptoms? A meta-analysis. The Humanistic Psychologist .

Abigail Powers Lott, Ph.D., ABPP, is a board certified psychologist and Assistant Professor in the Department of Psychiatry and Behavioral Sciences at Emory University School of Medicine. She serves as Co-Director of the Grady Trauma Project and Clinical Director of the Grady Trauma Recovery Center.

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Choi J , Karr S , Jain A , Harris TC , Chavez JC , Spain DA. Access to American College of Surgeons Committee on Trauma–Verified Trauma Centers in the US, 2013-2019. JAMA. 2022;328(4):391–393. doi:10.1001/jama.2022.8097

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Access to American College of Surgeons Committee on Trauma–Verified Trauma Centers in the US, 2013-2019

• 1 Department of Surgery, Stanford University, Stanford, California
• 2 Department of Computer Science, Stanford University, Stanford, California
• 3 School of Medicine, Stanford University, Stanford, California

A 2016 National Academies of Sciences, Engineering, and Medicine report highlighted timely trauma center access as a critical component of national health care infrastructure and essential to avoid preventable deaths after injury. 1 Nationwide access to trauma centers by both ground and air transport has not been evaluated since 2010. 2

We evaluated trends in nationwide access to American College of Surgeons Committee on Trauma (ACS-COT)–verified trauma centers between 2013 and 2019, hypothesizing that trauma center access has improved but geographic differences would be present.

The ACS-COT verifies trauma center levels based on the presence of resources to provide optimal care for injured persons. Level I trauma centers are tertiary centers with 24-hour capability for definitive trauma care, while level IV trauma centers can provide initial evaluation and resuscitation before providing appropriate transfers. We found ACS-COT verification levels and addresses of US trauma centers using the Trauma Information Exchange Program database (2013-2019) and encoded their geographic coordinates using Google Geocoding, ArcGIS, and MapQuest application programming interfaces. Three states (Washington, Pennsylvania, and Mississippi) did not have ACS-COT–verified trauma centers in the study period. We obtained the proportion of residents within each census block group (the smallest geographic census unit, typically comprising 600-3000 individuals) using American Community Survey data (2013-2019).

We calculated fastest travel time (ground or air) from each census block group’s population centroid to the nearest trauma center. Ground transport time included call-to-ambulance arrival time (national median, 7 minutes 3 ), on-scene time (10 minutes; National Association of State Emergency Medical Services benchmark), and time from census block group population centroid to the nearest trauma center (accounting for road-specific speed limits and historic traffic data). For air transport time, we found geographic coordinates for air bases with 1 or more trauma transport rotor-wing aircraft using the Atlas & Database of Air Medical Services (2013-2019). 4 Air transport time included call-to-takeoff time (national average, 3.5 minutes 5 ), flight time from nearest air base to census block group population centroid, on-scene time (national average, 21.6 minutes 5 ), and flight time to the nearest trauma center.

Primary outcome was the proportion of US residents with 60-minute access to a trauma center. Access trends throughout 2013-2019 were evaluated using the Mann-Kandall test. Secondary analysis delineated trauma center access by ground vs air medical transport, state, and trauma center levels (I-II vs I-IV) using descriptive statistics. We used R version 4.1.2 (R Foundation for Statistical Computing) for statistical analyses. A 2-sided P  < .05 defined statistical significance. This study did not meet Stanford University institutional review board review criteria. The Supplement details methodology.

A total of 457 trauma centers were ACS-COT verified in 2019 (increased from 315 centers in 2013).

Compared with 78% in 2013, 91% of US residents had 60-minute access to a trauma center in 2019 ( Figure ), a statistically significant trend ( P  = .002). In 2019, 89% of US residents had 60-minute access to a level I/II center; level III/IV centers provided 60-minute trauma center access to an additional 1% of residents ( Figure , A and B; Table ). Compared with 68% of US residents with 60-minute trauma center access by ground ambulance transport alone, air ambulance transport expanded 60-minute trauma center access to an additional 23% in 2019 (total, 91%) ( Figure , C).

Over the study period, trauma center access improved within 38 states and decreased in 4 states ( Table ). The greatest absolute improvements were in Georgia (+80%), Florida (+58%), and Iowa (+55%).

In this study, trauma center access improved from 2013 to 2019, but there were geographic differences. A limitation of the study was restricting analysis to ACS-COT–verified trauma centers, underestimating access but facilitating standardized comparison nationwide. State-level access estimates should be interpreted with the understanding that residents could access out-of-state trauma centers.

The US maintains a geographically fragmented trauma network model (injury response coordinated at state or local levels), which challenges efforts to ensure all US residents access to timely, quality management of traumatic injuries. A nationalized trauma network that can monitor and expand equitable trauma center access for all US residents should be considered.

Accepted for Publication: April 26, 2022.

Corresponding Author: Jeff Choi, MD, MSc, 300 Pasteur Dr, H3591, Stanford, CA 94305 ( [email protected] ).

Author Contributions: Dr Choi had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Dr Choi and Ms Karr were co–first authors.

Concept and design: Choi, Spain.

Acquisition, analysis, or interpretation of data: Choi, Karr, Jain, Harris, Chavez.

Drafting of the manuscript: Choi, Jain, Harris, Chavez.

Critical revision of the manuscript for important intellectual content: Karr, Chavez, Spain.

Statistical analysis: Choi, Jain.

Administrative, technical, or material support: Karr, Chavez, Spain.

Supervision: Karr, Spain.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the American Trauma Society and Calspan–University of Buffalo Research Center for granting access to the TIEP and ADAMS databases, respectively. Additionally, we thank David Medeiros, MA, and Stace Maples, MSc (Stanford Geospatial Center), for their assistance with the ArcGIS and Open Streetmap Premium data set; these individuals received no compensation for their contributions. Dr Choi thanks the Neil and Claudia Doerhoff fund for support of his scholarly activities.

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Resilience after trauma: from surviving to thriving

Nicole r. nugent.

1 Department of Psychiatry and Human Behavior, Warren Alpert Medical School at Brown University and Bradley Hasbro Research Center, Rhode Island Hospital, Providence, Rhode Island

Jennifer A. Sumner

2 Department of Epidemiology, Columbia University Mailman School of Public Health New York, NY, USA

Ananda B. Amstadter

3 Virginia Institute for Psychiatric and Behavioral Genetics in the Departments of Psychiatry, Psychology, & Human and Molecular Genetics at Virginia Commonwealth University, Richmond, VA, USA

Resilience after trauma is one of the most compelling phenomena in contemporary traumatic stress research. To increase the understanding of resilience and its applications to policy, research, assessment, prevention, and intervention in the field of traumatic stress, professionals from across the globe gathered for the 29th annual meeting of the International Society for Traumatic Stress Studies (ISTSS) themed “Resilience after Trauma: From Surviving to Thriving.” In this thematic cluster, we highlight contributions from the plenaries from the 2013 meeting. We hope to find answers to: What is resilience? Who is resilient and what makes them so? How can resilience be fostered in the wake of trauma? What can we learn from highly resilient individuals that will help inform our work with survivors?

The first paper is based on a panel discussion chaired by Dr. Steven Southwick (Southwick et al., 2014 ). The esteemed panelists, Drs. George Bonanno, Catherine Panter-Brick, Ann Masten, and Rachel Yehuda, had a lively and spirited discussion about how best to approach the definition and scientific study of this important concept. Here, the panelists expand on the discussion points posed by Dr. Southwick. The second paper, written by Dr. Dennis Charney and his colleague Dr. Brian Iacoviello (Iacoviello & Charney, 2014 ), was inspired by Dr. Charney's moving plenary session that integrated his research on the neurobiology of resilience with real-world examples from his personal interviews with resilient individuals. The third paper is a dialog between Amanda Lindhout, a humanitarian and social activist, and Dr. Katherine Porterfield, a psychologist who has been an important part of Ms. Lindhout's treatment experiences (Lindhout & Porterfield, 2014 ). At the conference, Ms. Lindhout delivered a poignant personal account of her resilience in the aftermath of her kidnapping, and the related submission is inspired by questions from attendees of her talk. Amanda was a journalist in Somalia when she was kidnapped and held hostage for 460 days. After her release, she enacted the promise she'd made to herself during her captivity by founding the non-profit Global Enrichment Foundation, which provides educational and community-based empowerment programs, as well as humanitarian interventions during crisis. These plenary presentations, and the manuscripts yielded from them, will aid the field's understanding of the many potential trajectories of health following traumatic exposure, ranging from the development of persistent stress-related disorders to posttraumatic growth.

In the perceptive piece contributed by Southwick et al. ( 2014 ), Southwick and his co-authors—experts in resilience from different disciplines—tackle the challenging task of answering key questions regarding the nature of resilience. These questions do not have simple answers, and this article offers a thought-provoking discussion about the current state of the field and presents ideas about next steps to further our knowledge about fostering resilience in individuals, families, and communities affected by traumatic stressors. Each of the experts provides a commentary on their work on resilience and how it has evolved over time. These authors have employed different definitions of resilience in their own work, and many noted that the definitions they themselves use in their research have evolved over time. Nonetheless, there were a number of points of consensus among the experts. First, it was noted that a large focus of energy has been placed on understanding the underpinnings of responses to traumatic stressors that are on the negative end of the spectrum (e.g., chronic psychopathology and impairment), and by doing so, the field has neglected to also focus on the factors that give rise to resilient outcomes. Second, the complexity of this concept was uniformly agreed upon; the authors note that resilience is not monolithic, but rather is more of a continuum. They note that resilience may be domain specific, as well as culture and context specific. Third, the authors concurred that given that individuals are embedded in systems (e.g., families, religions, organizations, communities, societies), a multilevel and multidisciplinary approach must be implemented in order to fully elucidate determinates of resilience and effectively foster resilience. In addition, the authors agreed that the inclusion of novel technologies into resilience studies, such as biomarkers, has scope both for basic and intervention science.

Although not presented by the panelists, an additional perspective described in other talks and in the dialog of ISTSS attendees is that resilience and psychological symptoms are not necessarily a single continuum. During Amanda Lindhout's talk, for example, Ms. Lindhout described her daily (and sometimes moment-to-moment) decision to be present in her life and to move forward in resilience at the same time that she continues to face symptoms commonly experienced by those with posttraumatic stress disorder (PTSD). Others have argued that resilience and symptoms can coexist as independent orthogonal constructs (Luthar, Cicchetti, & Becker, 2000 ; Shalev & Errera, 2008 ; Shalev, Tuval-Mashiach, & Hadar, 2004 ). Indeed, one study of Jews exposed to repeated terrorism found that higher levels of posttraumatic growth were associated with probable PTSD (Hobfoll et al., 2008 ). Amanda Lindhout's discussion with Dr. Porterfield illustrates the idea that extreme trauma can take a real toll while the survivor may remain resilient in critically important ways.

When describing her response to serving as a journalist reporting on extreme trauma, Amanda Lindhout describes how her experiences at that time had compelled her to want to understand what “enables human survival when so much has been destroyed.” Her article provides a remarkable window into the qualities and experiences that would permit Ms. Lindhout's own survival and even resilience during, and in the years that followed, her abduction and captivity. While facing trauma, Ms. Lindhout describes using mindfulness, relaxation techniques, exercise, cognitive strategies ranging from distraction to reframing and cognitive flexibility, and social support. Ms. Lindhout also describes forgiveness as critically important to facilitating her coping and resilience both during and after her traumatic experiences. An emerging scientific literature points to the benefits of forgiveness—of others and of oneself—for survivors of a range of traumatic experiences (Hamama-Raz, Solomon, Cohen, & Laufer, 2008 ; Snyder & Heinze, 2005 ; Van Loey, van Son, van der Heijden, & Ellis, 2008 ; Weinberg, Gil, & Gilbar, 2013 ; Witvliet, Phipps, Feldman, & Beckham, 2004 ). Indeed, there is initial evidence supporting an intervention focused on forgiveness (Reed & Enright, 2006 ), and one recent intervention study framed forgiveness as a key part of “affective resolution” (Ford, Chang, Levine, & Zhang, 2013 ). Ms. Lindhout also provides important information for the trauma community regarding being pushed to spend 10 days detailing her experiences to a psychologist in a “debriefing.” Ms. Lindhout described having been in a vulnerable place following her release and feeling unable to refuse the interview, which she experienced as distressing both during the interview and upon later reflection. Importantly, imposed acute posttrauma “debriefing” is not supported by research or practice parameters from relevant professional organizations (Bisson et al., 2010 ; Forneris et al., 2013 ; Nash & Watson, 2012 ; Tol, Barbui, & van Ommeren, 2013 ). Of particular relevance to clinicians and researchers alike, Ms. Lindhout describes her own experiences with symptoms of PTSD as well as components of her experiences with psychotherapy. Finally, Dr. Porterfield comments on Ms. Lindhout's responses, placing them in the context of extant scientific research related to resilience and treatment for PTSD.

This cluster also includes a thoughtful contribution written by Dr. Karestan Koenen (Koenen et al., 2014 ) on Amanda Lindhout and Sara Corbett's book, A House in the Sky . In this paper, Dr. Koenen reflects on her personal reactions to A House in the Sky . She notes how the authors struck a delicate balance between describing the details surrounding the traumatic experiences Amanda was exposed to, while simultaneously focusing on Amanda's reactions to the events and her active and purposeful efforts to cope with the atrocities she experienced. Dr. Koenen comments on how Amanda's recovery process in the areas of both physical and mental health can inform traumatic stress professionals.

In their contribution to this special section, Drs. Iacoviello and Charney provide a nuanced and encompassing perspective on what characterizes resilience and how we can foster these adaptive characteristics in order to promote well-being after adversity. Based on an integration of findings from both empirical studies and interviews with individuals who exhibited resilience in the aftermath of severe trauma, Charney and colleagues have identified six psychosocial factors that promote resilience in individuals: 1) optimism, 2) cognitive flexibility, 3) active coping skills, 4) maintaining a supportive social network, 5) attending to one's physical well-being, and 6) embracing a personal moral compass. These factors comprise cognitive, behavioral, and existential elements, a conceptualization that has been supported by other research on the nature of resilience (e.g., Bradley et al., 2013 ; Connor & Davidson, 2003 ), and they interact with one another to encourage resilient functioning after adversity. Not only do these psychosocial factors help to identify those individuals who are most likely to exhibit resilience after trauma (e.g., Ahmad et al., 2010 ; Bonanno, Papa, LaLande, Westphal, & Coifman, 2004 ; Pietrzak & Southwick, 2011 ), but they also represent targets for intervention. These psychosocial factors are malleable, and Charney provides recommendations for how individuals can foster the different cognitive, behavioral, and existential components that promote resilience.

Moreover, Drs. Iacoviello and Charney describe how two empirically supported treatments for PTSD—prolonged exposure therapy and cognitive processing therapy—cultivate some of these characteristics in trauma-exposed patients (e.g., by fostering active coping). Nevertheless, existing interventions do not address all six psychosocial factors that promote resilience, and the authors highlight ways to augment current treatment protocols by specifically targeting additional factors shown to foster resilience, such as interpersonal effectiveness. Although efficacious treatments for PTSD exist (e.g., Bisson et al., 2007 ; Cloitre, 2009 ), not all individuals respond to current approaches. Expanding treatments by incorporating resilience-focused elements could be one way to increase the positive impact of psychosocial therapeutic interventions. Furthermore, specific resilience-focused training programs (e.g., Lester et al., 2011 ; Rose et al., 2013 ) may represent another promising future direction, particularly with respect to prevention. Iacoviello and Charney acutely note how resilience is not just relevant to posttrauma functioning but that it is also pertinent before individuals experience trauma. Promoting resilience with these training programs prior to trauma exposure, as well as in the immediate aftermath of trauma prior to the development of posttraumatic psychopathology, may hold potential as primary and secondary prevention measures.

In addition to describing the psychosocial characteristics that promote resilience in individuals, Iacoviello and Charney describe four qualities (i.e., social capital, community competencies, economic development, and information and communication) that characterize resilient communities (e.g., Norris et al., 2008 ). In doing so, they make connections between research on resilient individuals and resilient communities, and they draw parallels between the cognitive, behavioral, and existential factors that promote resilience at both the individual and the community level. In sum, resilience does not apply to just one population or context. Charney's collaborative work emphasizes how the psychosocial factors that promote resilience operate at multiple levels and are relevant both prior to and after trauma. The contributions of this work offer guidance and inspiration for both researchers and clinicians who strive to help trauma-exposed populations.

Taken together, these articles highlight the challenges in defining and measuring resilience, as well as the importance of increased scientific and clinical focus on resilience. Illustrated by the debate among the panelists, perhaps the greatest challenge ahead for the trauma community is to continue to work toward refining and even redefining our definitions of “resilience.” Researchers may wish to distinguish the dynamic process of resilience, which may change both across and within individuals over time, from a trait-like construct, although traits such as optimism or hardiness may indeed contribute to resilience during and following trauma (Luthar et al., 2000 ). As others have described (Luthar et al., 2000 ), researchers and clinicians would be well served to distinguish among domains of functioning when considering resilience; for example, a police officer might perform at a high level at work while also experiencing symptoms of PTSD that may impact other areas of life, such as social functioning. Illustrated nicely by all of the articles, the study of resilience, including understanding factors that promote resilience over the course of trauma and life after trauma, must be the central goal for researchers and clinicians in the field of traumatic stress studies.

This paper is part of the Special Issue: Resilience and Trauma . More papers from this issue can be found at http://www.eurojnlofpsychotraumatol.net

Conflict of interest and funding

Dr. Amstadter is supported by grants R01AA020179, K02 AA023239, BBRF 20066, R01MH101518, and P60MD002256. Dr. Nugent is supported by grants K01 MH087240, R01 MH095786, and R01 HD071982.

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PTSD Has Surged Among College Students

The prevalence of post-traumatic stress disorder among college students rose to 7.5 percent in 2022, more than double the rate five years earlier, researchers found.

By Ellen Barry

Post-traumatic stress disorder diagnoses among college students more than doubled between 2017 and 2022, climbing most sharply as the coronavirus pandemic shut down campuses and upended young adults’ lives, according to new research published on Thursday.

The prevalence of PTSD rose to 7.5 percent from 3.4 percent during that period, according to the findings . Researchers analyzed responses from more than 390,000 participants in the Healthy Minds Study, an annual web-based survey.

“The magnitude of this rise is indeed shocking,” said Yusen Zhai, the paper’s lead author, who heads the community counseling clinic at the University of Alabama at Birmingham. His clinic had seen more young people struggling in the aftermath of traumatic events. So he expected an increase, but not such a large one.

Dr. Zhai, an assistant professor in the Department of Human Studies, attributed the rise to “broader societal stressors” on college students, such as campus shootings, social unrest and the sudden loss of loved ones from the coronavirus.

PTSD is a mental health disorder characterized by intrusive thoughts, flashbacks and heightened sensitivity to reminders of an event, continuing more than a month after it occurs.

It is a relatively common disorder , with an estimated 5 percent of adults in the United States experiencing it in any given year, according to the most recent epidemiological survey conducted by the Department of Health and Human Services. Lifetime prevalence is 8 percent in women and 4 percent in men, the survey found.

The new research also found a sharp rise in the prevalence of a similar condition, acute stress disorder, which is diagnosed less than a month after a trauma. Diagnoses rose to 0.7 percent among college students in 2022, up from 0.2 percent five years earlier.

Use of mental health care increased nationally during the pandemic, as teletherapy made it far easier to see clinicians. Treatment for anxiety disorders increased most steeply, followed by PTSD, bipolar disorder and depression, according to economists who analyzed more than 1.5 million insurance claims for clinician visits between 2020 and 2022.

PTSD was introduced as an official diagnosis in 1980, as it became clear that combat experiences had imprinted on many Vietnam veterans, making it difficult for them to work or participate in family life. Over the decades that followed, the definition was revised to encompass a larger range of injury, violence and abuse, as well as indirect exposure to traumatic events.

However, the diagnosis still requires exposure to a Criterion A trauma, defined in the Diagnostic and Statistical Manual of Mental Disorders as “death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence.”

It is not uncommon for young adults to experience traumatic events. A 1996 study of Detroit residents found that exposure to traumatic events — such as violent assaults, injuries or unexpected death — peaked sharply between the ages of 16 and 20. It then declined precipitously after age 20.

Research suggests that less than one-third of people exposed to traumatic events go on to develop PTSD.

Shannon E. Cusack, an academic researcher who has studied PTSD in college students, said there was division within the field about whether the profound disruptions that young adults experienced during the pandemic — abrupt loss of housing and income, social isolation and fear about infections — amount to triggering events.

“They’re causing symptoms that are consistent with the PTSD diagnosis,” said Dr. Cusack, a clinical psychologist and an assistant professor of psychiatry at Virginia Commonwealth University. “Am I not going to treat them because their stressor doesn’t count as a trauma?”

The prevalence data, she said, points to a pressing need for PTSD treatment on college campuses. Short-term treatments developed for veterans, such as prolonged exposure therapy and cognitive processing therapy, have proved effective in managing PTSD symptoms.

Stephen P. Hinshaw, a professor of psychology at the University of California, Berkeley, said that the disruptions of the pandemic might have left college students emotionally depleted and less resilient when faced with traumatic events.

“Midway through this study, there may have been legitimately more trauma and death,” he said, adding that the lockdowns may have caused more general despair among young people. “With the general mental health deterioration, is it harder to cope with traumatic stressors if you do get exposed to them?”

Some changes to the diagnostic manual may have blurred the line between PTSD and disorders like depression or anxiety, Dr. Hinshaw said. In 2013, the committee overseeing revisions to the manual expanded the list of potential PTSD symptoms to include dysphoria, or a deep sense of unease, and a negative worldview, which could also be caused by depression, he said. But the changes, he added, do not account for the sharp increase in diagnoses.

Ellen Barry is a reporter covering mental health for The Times. More about Ellen Barry