This article will briefly explore the history of psychological trauma and why trauma matters within an occupational health specialism. A subsequent article will examine in more detail how to consider psychological trauma in OH work.

The term ‘psychological trauma’ is becoming more common, as are phrases such as ‘trauma-informed’ and ‘trauma-aware’, often in relation to societal circumstances rather than medical arenas. As the OH field crosses the boundaries between medical and societal, it is important to consider both trauma as a diagnosis, and trauma informed as a societal responsibility.

What is psychological trauma?

Psychological trauma, like physical trauma, leaves a wound, perhaps a painful memory, or a significant imprint on the way in which the brain interprets and acts on the messages it receives. This traumatic wound can generate a whole-body response, which, if it is too large, can leave lasting effects. Van der Kolk (2014) simply describes trauma, by definition, as unbearable. He also explores the impact trauma has on a person, from a mental and emotional perspective to the physical symptoms and the development of health conditions. Herman (2022) examines the far-reaching dimensions of trauma, suggesting the different paradigms of trauma include terror, disconnection and illness. They both expand their definitions broader than a painful memory or a purely psychological response.

In the medical world, we associate trauma with Post-Traumatic Stress Disorder (PTSD) or Complex Post-Traumatic Stress Disorder (C-PTSD). But this is where the symptoms and behaviours an individual is experiencing meet a diagnostic threshold, either with the DSM 5 (American Psychiatric Association 2022) or the ICD 11 (World Health Organisation 2019). Regardless of the model, a diagnosis gives a label and justification for someone malfunctioning. However, it does not fully capture the impact of trauma.

Although PTSD is a relatively new concept, there is evidence of trauma throughout history, especially in war veterans. Notably, World War 1 (referred to as ‘shell shock’), World War 2 (referred to as ‘lacking moral fibre’) and, more recently, the Vietnam War. However, the symptoms of trauma have been present for much longer than the wars of the last century. Work from Sigmund Freud in the 1800s identified that many women who were diagnosed with hysteria had survived early-childhood sexual experiences. These were women who were displaying symptoms we would now attribute to trauma (Herman, 2022). Similarly, Burke Harris (2015) identified societal aspects to trauma. noting poorer health outcomes for those who had experienced 4 or more Adverse Childhood Experiences (ACE). In my opinion, neither of these approaches have been fully explored over the last 200 years. This could be due to the implication of wrongdoing by other people. Bearing in mind when PTSD was accepted as a diagnosis to the DSM, it was one of the only medical conditions to explicitly link disorder to environmental events.

The neurobiological model of trauma focuses on the way in which the message of something being traumatic is received by the brain. It is likened to the acute stress response and the fight, flight or freeze responses. The body perceives itself to be under threat and therefore needs to manage itself as best as it is equipped to survive (Steffen et al 2022). The neurological processes change in response to the trauma. This means the brain will respond to survive, which means normal brain processing is not engaged. This can result in a stronger connection to the survival part of the brain, leaving a residual acute stress response, which activates the limbic system and creates chemical changes. This creates an imprint of a memory for future events when protection or survival may be required. The neurobiological model can be seen within the context of classical conditioning theory and recent research on neuroplasticity. Viewed this way, recovery from trauma could be linked to Maguire et al.’s (2000) approach to neuroplasticity through the creation and strengthening of new neural pathways.

Neuroscience is not the only way to understand trauma. Brewin et al. (2002) acknowledge there are various theories and models to understand the psychological processes implicated in psychological trauma, none of which offer an absolute. Therefore, there needs to be recognition of various influencing factors, both of interpersonal and intrapersonal origins, to give a more holistic view of trauma. If we only see trauma through the filter of one model or research theory, we risk simplifying the complexities of both its causes and effects.

Regardless of any differences in the models, they essentially validate that there is something about the response to trauma that overwhelms the brain system. This sense of being ‘stuck’ manifests in various symptoms, including flashbacks; nightmares and intrusions; feeling hypervigilant; avoidance of activities associated with event/trauma and emotional numbing (National Institute for Health and Care Excellence (NICE) guidelines (2024).

Greenberg et al. (2019), Miller (2022) and Herman (1992) agree that, in the aftermath of a traumatic event, most people will recover naturally without the need for professional intervention. According to diagnostic thresholds (ICD-11 and DSM-5), PTSD is identified by persistent distress associated with functional impairment which extends over 4 weeks (WHO, 2019). With trauma theory, Herman (1992) and Van der Kolk (2014)) recognise that trauma may take weeks or months to show, so nuance needs to be applied to the recognised diagnostic thresholds. The importance of social support to reduce isolation and routine with activities of daily living is fundamental to aid the processing during this period.

Stepping out of diagnostic thresholds, Herman (2022) suggests there are two types of trauma: type 1 relates to those reacting to single exposure, and type 2 is a response to recurrent or endured exposure to trauma. However, if we think about the neurobiological model in relation to ACEs, we can understand that changes to the brain that occur at an early age will lead to the brain developing differently as the individual matures. This will surely create different symptoms of trauma compared to a mature brain whose previous positive neural connections should be more manageable or treatable than someone exposed to trauma immaturely. There is a crossover of symptoms/behaviours present in adults who experienced early life trauma and conditions, such as Attention Deficit Hyperactivity Disorder (ADHD), due to the similar behaviours seen in both (Maté 2019). Work from both Herman (2022) and Van der Kolk (2014) suggests that trauma can also be felt in the body with physical symptoms. This was further recognised by Levine (2008), who suggested that trauma is physiological before it becomes psychological.

Van der Kolk (2014) makes a link between recurrent exposure to trauma or complex trauma and physical symptoms such as chronic unexplained pain, headaches, migraines, and dizziness. Gupta (2012) describes these as somatic symptoms associated with trauma exposure. Levine’s (2024) concept of the somatic experience approach to therapy advances this theme, recognising the trauma experience does not only sit within the brain. Kang et.al. (2002) suggest that another commonly linked condition is chronic fatigue syndrome (CFS), drawing correlations of high instances of CFS in war veterans. Nelson et al. (2020) suggest toxic stress is held in the body and can develop into chronic and inflammatory diseases such as asthma, metabolic diseases including diabetes and cardiovascular conditions. Gupta (2012) refers to toxic stress as the constant arousal caused by trauma and limbic instability as a cause of somatic symptoms. These were all noted in the work by Burke-Hariss, who presents a thought-provoking TED talk on this issue, recognising the societal issues and potential intergenerational impact.

Psychological trauma is a subjective experience. Individuals will have different reactions to the potentially traumatic stimulus; the impact various social aspects of life have on this response cannot be ignored, nor can how safe the individuals feel in their world. Everyone’s individual life experience affects whether they perceive an event as traumatic or not and how resilient they are. Trauma can therefore be viewed on a macro or individualistic level. As an example, an undercover police officer exposes himself to dangerous and volatile situations daily. He has the knowledge that he is protected by his status as a police officer and feels assured that if something goes wrong, he can start the process of extraction. But, if this assumption is challenged and, in a specific situation, he is criticised, he may develop an acute stress response. His beliefs of his place, status and safety in his policing world have been shattered. Janoff- Bulman (1989) links this type of experience to a shattered assumptions theory. Their work is focused on the wider view of society, but it can be reflected to a macro level of workplaces, especially when someone identifies themselves with that workplace, such as ‘I am a police officer’ not ‘I work as a police officer’. This can be linked to many professions where individuals will assume they are safe when they are at work or believe ‘if I work hard, I will be rewarded.’ Often bullying, professional humiliation, or an instance that forces someone’s values or assumptions to be questioned can fall into this paradigm of trauma. There may be a different stimulus, with one triggered by moral injury, rather than fear-based trauma, but the effect on the individual is equally as profound.

How does all this link to Occupational health?

When we think of trauma in the workplace, we often picture frontline responders or those serving in the forces, but it is relevant to us all. British workplaces are incredibly diverse, full of individuals who have had many experiences, both in and out of the workplace, and who have potentially experienced trauma before they even entered the workforce. The Society of Occupational Medicine (SOM) defines OH as a function that “maintains the wellbeing of employees, preventing and removing ill-health and developing solutions to keep staff with health issues at work” (SOM n.d.). In doing this, the OH professional will assess individuals who are referred to their service and provide advice or support in line with the SOM statement above. O’Neill (2021) describes how OH assessments follow a biopsychosocial model, meaning that the OH specialist will gather relevant information to inform a holistic assessment and provide appropriate advice back to the workplace based on their assessment. In contrast, the UK’s primary care sector predominantly follows a medical model (Lacobucci 2018) often at the expense of a full understanding of the social aspect of health. Because OH assessments are about an individual’s ability to work and function in professional situations, it is necessary to understand more than just symptoms when offering advice on functionality.

The next article in this series will examine in more detail how to apply this knowledge about psychological trauma to the OH setting. 

References

O’Neill, J. (2021). Triage in occupational health. Occupational Health at Work, 17(6), 29–34.​