Some forms of trauma are obvious: natural disasters like earthquakes, floods, fires, being physically assaulted, wrongfully terminated, becoming suddenly very ill. Trauma is divided into so called big T and little t experiences, but the distinction is misleading. While physical assault (big T trauma) can lead to serious sequelae such as loss of a sense of safety, chronic hypervigilance, post traumatic stress disorder (PTSD); a dissolved intimate relationship, being bullied, being emotionally or verbally abused or neglected, especially in childhood (all examples of little t) can have equally devastating, far reaching consequences. So called little t can impact an overarching view of the world and the people in it with whom we relate leading to a general sense of distrust. Little t can lead to chronic hypervigilance about which an individual can be completely unaware. Little t leads to cynicism, a loss of faith, an impaired ability to regulate or negotiate emotion effectively. Little t leads to a complex, inescapable internal world from which an individual frequently seeks escape as evidenced by high rates of substance use, suicidality, job loss, and difficulty with relationships. Also known as complex trauma these kinds of experiences can lead to complex post traumatic stress disorder (complex PTSD) impacting individuals in all aspects of life. While social, intimate, and professional life are, to a degree, impaired, individuals are not necessarily aware of negative impact. Think about the frog exposed to increasing water temperature, eventually that water boils but slow change is imperceptible to the frog until it is lethal. Humans are resilient and even in the face of trauma which everyone can expect to experience across the course of a life time, we adapt. We learn, grow, and change. We alter our expectations, we change course, we find meaning in our suffering, we often use it to better the world around us.
Trauma is ever present in the practice of medicine both from the patient and the clinician perspective. Over the course of a lifetime of practice clinicians can be expected to deliver the worst news to parents about the death or terminal illness of a child, to a spouse, friend, colleague. Physicians, nurses, assistants, and technicians, all vital roles, are present and actively involved in saving individuals from catastrophic car crashes; bleeding out, shouting, frenetic events fraught with unrelenting, exhausting urgency for hours at a time. While it is a privilege to deliver good news in a successful outcome, sometimes outcome culminates in the need to deliver overwhelmingly bad news to frightened people waiting to hear if their mom, uncle, child survived. Physicians and nurse midwives are present at what is often the most meaningful event in a couples’ lives- the delivery of an eagerly awaited baby. This can be a most consistently, highly rewarding practice. But present in the back of every clinician’s mind are the other possibilities. Precipitous delivery which can he catastrophic, the many reasons for rapid blood loss compromising mom and baby. Medicine overall has improved potential survival, good survival, in labor and delivery. But sometimes patients die, moms and babies, and this is always devastating. This is clearly big T trauma for the patients involved; life altering, devastating, beyond words. We don’t specifically address the trauma experienced over the course of a professional life to its clinicians who are expected to cope. This is our job, after all.
Therapy helps process trauma, the narrative, the overwhelming feelings, how it fits into our ongoing lives. Therapy addresses trauma from myriad directions, its impact on our nervous system, our unconscious beliefs about what we deserve, our memory networks, emotions, expectations. Therapy provides a container in which there is permission, space, to explore the depths of our darkest experiences. And I wonder, why, in our lifetimes in which we will all experience some trauma, big T, little t, whatever, why the act of choosing to process this is so stigmatized.