What Trauma Therapists May Get Wrong

It has become fashionable in certain mental health circles to view all mental disorders—indeed, all human suffering—through the lens of trauma. A popular phrase in the anti-psychiatry and anti-diagnosis communities is, "It's not what's wrong with you, it's what happened to you." The Indicative Trauma Impact Manual was published earlier this year as a "non-diagnostic, trauma-informed guide to emotion, thought, and behavior." A "trauma-informed" revolution has been born.

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What is the problem with this? Well, there are many problems. But first, trauma, abuse, neglect, and other adverse life experiences and problems in child-rearing are unquestionably factors at play in a wide range of psychiatric disorders. Nothing to follow is a denial of this basic fact, which has been a well-established finding in the scientific literature for decades. As a psychodynamic psychotherapist, I know all too well the consequences of these experiences on the development of adult psychopathology.

However, when we use trauma as a diagnosis and not as a factor that sets into motion a pathological process, we:

1. misuse the term (trauma is not a psychiatric diagnosis), and, more importantly,
2. fail to recognize that all mental disorders—indeed, all mental and behavioral experiences—result from a complex interplay between interpersonal (what happens between us) and intrapsychic (what happens within one's mind) forces.

To put it another way, no person is a mere passive recipient of experience. We always make our own contributions to and add an element of our creativity to our experiences as we integrate, and transform, them. This has historically been called our integrative activity (Konorski, 1967).

How does this play out in practice? A child is raised by an inconsistent mother. At times, the mother is loving and nurturing. At other times, the mother is cold, hateful, or downright abusive. The child resorts to a defense mechanism known as splitting to preserve the good image of the mother in her mind. She also develops a split sense of self, saying to herself, at times, "I must be a good child to be loved," and at other times, "I must be so bad to be abused."

This child grows to be an adult who is unable to integrate her feelings about self and others. She teeters back and forth between feeling too close and too distant in her relationships. She can be impulsive and engages quite predictably in self-sabotage. She has developed a borderline personality disorder (BPD).

The point is that while the abuse here is quite important in understanding the development of the disorder (virtually all of the experts on BPD spanning the past 50 years—Kernberg, Linehan, Gunderson, Stone—agree that trauma is a significant etiological factor in BPD), it is simply only one part of the equation. The second part—and the part that is much more relevant to psychotherapy—is how the patient internalized those experiences, and how she unconsciously continues to play them out to this day. In good psychotherapy, the aim is to understand how "what happened to you" is transformed into "what you now do to yourself."

The trauma itself is not the disorder. It sets into motion a pathological process that is now ruled by wholly different mechanisms.

There is another problem with the trauma-focused approach. Focusing solely on trauma without considering the patient's contributions to their illness engenders the patient's externalizing defenses. In externalization, an oft-pathological defense mechanism, we see our problems as resulting solely from some external issue or issues. The patient fails to recognize their patterns as having something to do with their problems in life. A trauma-focused approach may only serve to reinforce this defense.

While trauma-focused therapists claim to be breaking new ground when it comes to recognizing the role of trauma in psychiatric illness, the truth is that these ideas have been around for at least the past 100 years. As noted above, most psychiatric scholars today recognize the significant and enduring impact of trauma on mental disorders.

The efforts to redefine psychiatric disorders as natural or normal reactions to trauma fail to account for the complexity of human psychopathology and the patient's internal psychological forces. As a result, they are not to be taken seriously.