The Many Masks of Trauma

By Russ Harris, author of Trauma-Focused ACT

“Trauma” is the Greek word for “wound,” and “psyche” is the Latin word for “soul.” From these ancient words, we get both the clinical term, “psychological trauma,” and the poetic term, “soul wound.” The latter term seems to convey much better the deep anguish and suffering so commonly involved in trauma. The pain from these wounds—physical, emotional, psychological, or spiritual—can impact every area of human life, and the fallout is often devastating: shattered world views; a fractured sense of self; loss of trust, security, or meaning; and the list goes on.

Soul wounds may occur at any age. For some, the trauma starts in childhood, at the hands of abusive caregivers. For others, it’s not until adulthood that something tears their world apart. And when these life-shattering events happen, they can affect anything and everything: relationships, work, leisure, finances, physical health, mental health—even the very structure of the brain.

In acceptance and commitment therapy (ACT), we work intensively with every aspect of these soul wounds: cognitions, emotions, memories, sensations, urges, physiological reactions, and the physical body itself. And at times we will find this work intensely challenging. Inevitably, it triggers our own painful thoughts and feelings: perhaps anxiety, sadness, or guilt; perhaps frustration or disappointment; perhaps worry, self-doubt, or self-judgment. But when we make room for our own discomfort, dig deep into our compassion, and create a sacred therapeutic space—a place where we stand side by side with our clients, to help them heal their pasts, reclaim their lives, and build new futures—then our work, though often stressful, is deeply rewarding.

What Is Trauma?

Somewhat surprisingly, while it’s easy to find a definition of post-traumatic stress disorder (PTSD), it’s hard to find a clear definition of trauma. So, to ensure we’re on the same page, I’m going to share my own. (This isn’t the “right” or “best” definition; it’s just one that I trust works for our purposes.)

A “traumatic event” is one that involves a significant degree of actual or threatened physical or psychological harm—to oneself or others. This can include everything from miscarriage to murder; from divorce, death, and disaster to violence, rape, and torture; from accidents, injuries, and illnesses to the medical or surgical treatments for those things. It may also include incidents where people instigate, perpetrate, fail to prevent, or witness actions that violate or contradict their own moral code.

A “trauma-related disorder” involves:

1. Direct or indirect experience of traumatic events

2. Distressing emotional, cognitive, and physiological reactions to that experience

3. The inability to cope effectively with one’s own distressing reactions

In this book, whenever I use the word “trauma,” it’s short for “trauma-related disorder,” an umbrella term for a vast number of problems resulting from trauma, including PTSD, drug and alcohol problems, relationship issues, depression, anxiety disorders, personality disorders, sleep disorders, moral injury, chronic pain syndrome, sexual problems, aggression, violence, self-harming, suicidality, complicated grief, attachment disorders, impulsivity, and more. (Indeed, a clear diagnosis of PTSD is rare in comparison to the many other presentations of trauma.)

Many of these problems mask the trauma history that underpins them, leaving it deeply buried and long forgotten. And although we talk of “simple” trauma (a reaction to one major traumatic event) or “complex” trauma (relating to many traumatic events over a long period, often starting in childhood), there are many shades of gray between these extremes. However, no matter how simple or complex trauma may be, it always involves three streams of symptoms which continually flow in and out of each other:

• Reexperiencing traumatic events: People reexperience traumatic events in a variety of ways, including nightmares, flashbacks, rumination, and intrusive cognitions and emotions.

• Extremes of hyperarousal and hypoarousal: Later, we’ll explore these terms in depth; for now, let’s keep it simple. With clients, rather than “hyperarousal,” we talk about “fight-or-flight mode,” which gives rise to anger, irritability, fear, anxiety, hypervigilance, difficulty sleeping, and poor concentration. Likewise, rather than “hypoarousal,” we talk about “freeze-or-flop mode”: the immobilization and shutting down of the body, which fosters apathy, lethargy, disengagement, emotional numbing, and dissociative states.

• Psychological inflexibility: The overarching aim of ACT is to develop psychological flexibility: the ability to be present, focused on, and engaged in what we’re doing; to open fully to our experience, allowing our cognitions and emotions to be as they are in this moment; and to act effectively, guided by our values. More simply: “Be present, open up, and do what matters.”

The flipside of this is psychological inflexibility, which boils down to:

• Cognitive fusion (our cognitions—including thoughts, images, memories, schemas, and core beliefs—dominate our awareness and our actions)

• Experiential avoidance (the ongoing attempt to avoid or get rid of unwanted cognitions, emotions, sensations, and memories—even when doing so is problematic)

• Remoteness from values (lack of clarity about or disconnection from our core values)

• Unworkable action (ineffective patterns of behavior that tend to make life worse in the long term, such as social withdrawal, self-harm, and excessive use of drugs)

• Loss of contact with the present moment (distractibility, disengagement, and disconnection from thoughts and feelings)

These three streams of symptoms—reexperiencing trauma, extremes of arousal, and psychological inflexibility—overlap and reinforce each other in a myriad of complex ways, giving rise to a truly vast range of clinical issues.

What Is Trauma-Focused ACT?

Trauma-focused ACT (TFACT) is neither a protocol nor a treatment for one specific disorder, such as PTSD. It is a compassion-based, exposure-centered approach to doing ACT, which is (a) trauma-informed: drawing upon relevant fields, such as evolutionary science (ES), polyvagal theory, attachment theory, and inhibitory learning theory; (b) trauma-aware: attuned to the possible role of trauma in a wide range of clinical issues; and (c) trauma-sensitive: alert to the risks of experiential work, especially mindfulness meditation.

TFACT has three interweaving strands that apply to all trauma-related issues: living in the present, healing the past, and building the future.

Living in the present. This is the lion’s share of our work in TFACT. It includes helping clients learn how to ground and center themselves; catch themselves disengaging or dissociating and bring their attention back to the here and now; connect with and be “at home” in their body; overcome debilitating hyperarousal and paralyzing hypoarousal; unhook from difficult cognitions and emotions; practice self-compassion in response to their pain; focus on and engage in what they’re doing; interrupt dwelling on the past and worrying about the future; access a flexible, integrated sense of self; narrow, broaden, sustain, or shift attention as required; practice ACT-congruent emotion regulation; savor and appreciate pleasurable experiences; and connect with, live by, and act on their values. And it also includes skills training as required (e.g., assertiveness and communication skills) to enable values-based living.

Healing the past. Here we explore with clients how their past has shaped their present thoughts, feelings, and behaviors, and actively work with past-oriented cognitions and the emotions that go with them. This includes “inner child” work, exposure to traumatic memories, forgiveness, and grieving.

Building the future. Here we use values-based goal setting, including relapse-prevention plans, to help clients plan and prepare for the future. Ideally, we’re aiming for “post-traumatic growth”: growing and changing in positive ways through the ordeals of the past, and applying the strengths, insights, and wisdom gained along the way to build a better future.

Russ Harris is an internationally acclaimed acceptance and commitment therapy (ACT) trainer and author of the best-selling ACT-based self-help book The Happiness Trap, which has sold over 600,000 copies and been published in thirty languages. He is widely renowned for his ability to teach ACT in a way that is simple, clear, and fun—yet extremely practical.