Traumatology: An Overview
The study of human reactions to traumatic events is not new (e.g., Birmes, Hatton, Brunet, &
Schmitt, 2003; Weisaeth, 2002). Reports of human reactions to traumatic events, “…can be
traced to the earliest medical writings in 1900B.C. in Egypt” (Figley, 1989a, p. 574). Weisaeth
(2002) provided a European history of traumatology and wrote, “The recognition of psychic
trauma as a perceived causal factor in psychiatry and psychosomatic medicine and even general
medicine has a long pedigree. Homer’s Iliad, the oldest text in Western literature, is an
impressive account of psychological trauma” (p. 443). Specific to posttraumatic stress disorder,
Ben-Ezra (2002) suggested evidence of PTSD symptoms extended over the period from 350
years ago to over 4,000 years ago. The historical evolution of PTSD from Freud to the creation
of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, (DSM-IV,
American Psychiatric Association, 1994) has been discussed by Wilson (1994a).
For decades, there has been interest in how people are affected by events outside the normal
range of human experiences. Perhaps more than any other area, curiosity surrounding the effect
of military and peacekeeping on soldiers has propelled a continued onslaught of research and
clinical interest. Weisaeth (2002) wrote,
A perusal of the scientific history of traumatic stress shows that the Great War, 1914–18, was a
watershed. The study of combat stress in that war led to new understanding of traumatic stress
disorders, of their etiological and prognostic factors, and of how they could be prevented and
It appears that interest in the response of soldiers to traumatic and shocking events prompted
researchers and helping professionals to eventually consider the effect on others who are exposed
to similar experiences. The response to traumatic experiences has received enormous attention
and different labels have been created for what is perceived as similar symptomatology.
The following section provides a historical overview and briefly describes how and when
various psychological syndromes evolved. More important, such a timeline demonstrates how
clinical attention gradually moved from an organic focus to one where individual psychology
was recognized. For example, there is a stark contrast between how human responses to trauma
were perceived during the U.S. Civil War as compared to the horrific events of September 11.
During the Civil War, soldiers who exhibited emotional despair after witnessing human suffering
and death were perceived as psychologically defective. The heightened emotional response (e.g.,
distress, grief, disbelief) of rescue and public service personnel during the horrific events of
September 11, however, was viewed as a normal and expected reaction to human devastation. A
negative response to caregiver distraught was absent and emotionally wounded caregivers were
embraced, comforted, and honored worldwide. Over time, a better understanding regarding the
human reaction to trauma has developed and a greater compassion toward the emotional
experiences of caregivers has emerged.
An important distinction was drawn between acute combat stress reaction and PTSD during
the Vietnam War. It is worth mentioning that PTSD was initially referred to as post-Vietnam
syndrome. A distinction between acute combat stress reaction and PTSD pertains to the
emergence of symptomatology.
In terms of acute combat stress reaction, there are immediate consequences associated with
traumatic events. The consequences of PTSD, on the other hand, are long-term. For example,
Vietnam nurse veterans with a diagnosis of PTSD who were exposed to imagery of militaryrelated nursing events showed much higher physiologic responses when compared to non-PTSD
nurses (Carson et al., 2000). Based on this study, it appears that witnessing death and injury can
result in enduring psychophysiologic arousal.
CONTEMPORARY TRAUMATIC EVENTS
The events of September 11 clearly illustrated the devastating effect of trauma. Eidelson,
D’Alessio, and Eidelson (2003) vividly recounted this event and wrote,
An entire nation was stunned by the destruction of life and property brought on by the crashing
of four passenger airliners into the World Trade Center in New York City, the Pentagon in
Washington, D.C., and a field outside Shanksville, Pennsylvania. Ultimately, over 3,000 lives
were lost and countless others were forever changed in both obvious and immeasurable ways.
The disaster was experienced not only directly by thousands of individuals but repeatedly by
millions of television viewers from around the world. For many, the repetitive viewing of the
attacks, eyewitness accounts, and stories of survivors and rescue workers had its own
traumatizing and retraumatizing effects. (p. 144)
To better understand the psychological impact on caregivers, Eidelson, D’Alessio, and
Eidelson (2003) focused specifically on the experience of psychologists. Survey data suggested
that psychologists were not immune from the fallout of this traumatic event and reported both
positive and negative reactions. Respondents felt good about providing assistance and support to
clients and making a genuine contribution to others. They also, however, experienced “…the
sense of inadequacy and/or helplessness in the face of such enormity of suffering” (p. 147).
Psychologists struggled with similar issues, feelings of unpreparedness for such magnitude,
increased referrals, and increased demands on their time. These professionals had two different
responses regarding their personal lives.
For example, some felt closer to their families while others experienced feelings of increased
anxiety, fatigue, and sorrow over personal loss.
PROGRESSION OF TRAUMATOLOGICAL INQUIRY
Despite its long history, it appears that a closer examination of psychological trauma
developed during the past century and has been marked by two distinct phases. The first phase
involved challenging the generalization that individuals who demonstrated psychological distress
following a traumatic event (e.g., battlefield combat, tragic accidents) were emotionally unstable
and susceptible prior to the occurrence of the traumatic event. In reference to rescue workers, for
example, Dunning and Silva (1980) stated,
The prevailing sentiment, both in and out of the profession, is that if you can’t take the heat, get
out of the kitchen. Such a stance precludes the opportunity for the research and development of
screening, training, and support programs to forestall the negative consequences of disaster in
those persons who can least afford to be so affected. (p. 289)
It became clear that becoming traumatized after experiencing, witnessing, or learning about a
horrific event was a normal human reaction (Waters, 2002) and that the prevalent theory
suggesting a predisposition of personal weakness and psychological defect had to be
reconsidered and eventually discarded. Until the psychological defect theory was challenged,
traumatized individuals manifesting psychological symptomatology would sometimes be
perceived as emotionally unstable and vulnerable to mental disorders. Their response to a
traumatizing event was evidence of a preexisting emotional fragility. Steed and Bicknell (2001,
para. 1) commented: “Initially, psychological theories, research and development of effective
intervention techniques, methods and processes were client focused.” Adherence to these
theories disregarded the influence of an individual’s environment and factors that contributed to
an individual’s distress were ignored. It appears that due to the absence of a theory of anxiety,
the physical signs of anxiety were misperceived as symptoms of organic illness (Weisaeth,
2002). Everstine and Everstine (1993) elaborated,
The fact is that one’s ego must contend with any environmental stimulus that comes along.
Sudden stimuli must be dealt with swiftly and painful stimuli must be met by a healing force. This
is true no matter what the person’s condition before the event and whether or not the person was
emotionally vulnerable in advance. In short, anyone can be traumatized, from the most welladjusted to the most troubled. (p. 7)
Over time, these theories were given less importance and a greater connection was made
between the experience of trauma and normal human response. On a cautionary note, however,
subscribing to a single theory or broad-brush perspective is discouraged. One should not leap to
conclusions and discount the possibility that some individuals who appeared psychologically
injured following a traumatic event may have had a preexisting psychological disorder that was
aggravated by the traumatic experience (Regehr, Goldberg, Glancy, & Knott, 2002). As with
most issues, a balanced perspective is encouraged in order to invite varying perspectives and to
stimulate debate and discussion.
The second phase, which appeared to take hold during the past decade, involved an
appreciation of how family members and significant others of helping professionals (e.g., mental
health workers, emergency medical, fire, and safety personnel, disaster workers) and caregivers
could be vicariously traumatized. The ripple effect inherent of trauma has been noted and it has
been suggested that damage spreads in waves out from victims to significant others with whom
the victim has intimate contact (Remer & Ferguson, 1998, 1995). Remer and Ferguson (1998)
remarked, “For each primary victim, there are numerous secondary victims—partners, children,
parents, family, friends. When one considers the number of people touched directly or indirectly
by the traumatic events, the magnitude of the problem becomes apparent” (p. 140).
As a result of new insights, the notion of an emotional membrane believed to shield and
protect helping professionals and significant others from the emotional effect of a traumatic
event was challenged. Appreciating the contagion effect of trauma opened up the new and
exciting field of traumatology. As discussed below, the vulnerability and impact of trauma on
helping professionals and significant others began to gain increased attention (e.g., Wee &
ABSORBING THE PAIN OF OTHERS
Historically, psychological trauma described the emotional experiences of individuals who
found themselves in harm’s way and minimal concern was devoted to caregivers (Dunning &
Silva, 1980; Figley, 1995b; Haley, 1974; Raphael, Singh, Bradbury, & Lambert, 1983).
Attempts, however, have been made to classify types of victims associated with disasters
(Shepherd & Hodgkinson, 1990). In 1981, Taylor and Frazer proposed the following victim
classification: primary (maximum exposure to a catastrophic event), secondary (grieving
relatives and friends), third-level (rescue and recover personnel), fourth-level (community
members), fifth-level (individuals affected although directly uninvolved), and sixth-level
(survivors who are vicariously affected) (Shepherd & Hodgkinson, 1990).
The importance of secondary trauma has been underscored, “It is highly unlikely that an
individual will avoid the direct experience of a traumatic event or events during his or her
lifetime. However, if that person is fortunate enough to avoid direct contact with trauma,
secondary exposure to the trauma of others is unavoidable” (Williams & Sommer, 1994, p. xiii).
Stamm (1997) also presented a literature review that tracked the progressive interest in helpinginduced trauma.
A metaphor for people who found themselves psychologically traumatized as a result of their
work and service to others was presented by Janik (1995, para. 8). The metaphor is entitled the
sin-eater. Janik noted that the sin-eater, “… is a social scapegoat role played by members of the
superstitious society of Wales during the Dark Ages” and provided the following description,
In Welsh villages, sin-eaters would eat meals offered by the families of deceased villagers. The
food consumed was believed to have absorbed the sins committed by the villager during his or
her life on earth, and consumption of the food by the sin-eater released the deceased from
obligatory punishment in the next life and freed him or her for heavenly rewards. Sin-eaters
ordinarily would consume only a small portion of the food and take the rest home for their
families. Thus, sin-eaters and their families were able to survive through their social service to
the community. (para. 9)
Janik pointed out that earning their sustenance by assuming the role of sineater was not
inconsequential. For example, realizing that sin-eaters were accumulating the sins of others,
villagers would worry about contamination and, thus, view sin-eaters with suspicion. Sin-eaters
experienced, “…the honor and degradation of fulfilling a formal social role of scapegoat and
detoxifier” (para. 11).
Just as sin-eaters would metaphorically swallow the transgressions and faults of villagers,
correction officers harbor toxic and corrosive ideas, images, and memories associated with their
work (Janik, 1995). This scenario presents challenges for the individual, significant others, and
clients and reminds us that, “There is a cost to caring” (Figley, 1995b, p. 1).
EXPANDING THE PARAMETERS OF TRAUMA
Familiar terms such as combat fatigue and shell shock characterized the experiences of war
veterans. These terms were very useful in helping people better understand the emotional
experiences of some veterans. A broader picture eventually emerged and the emotional
experiences of other professionals who experienced trauma gained increased attention. Attention
was directed to the spillover of traumatic events outside of combat (e.g., emergency personnel).
This natural evolution was accompanied by an interest in the vicarious impact of trauma on
significant others and caregivers (e.g., offspring, colleagues).
Realizing that personal trauma could extend beyond the actual victim and profoundly effect
the lives of significant others, particularly spouses and offspring (Shakespeare-Finch, Smith, &
Obst, 2002) exemplified trauma’s permeating force. In reference to significant others, “…little, if
any direct attention has been paid to identifying them, validating their experiences, or assisting
them in either their support of the victims, or even more important, their personal struggles to
cope with their own victimization” (Remer & Ferguson, 1995, p. 407). The effect on families
was addressed by Nelson and Schwerdtfeger (2002, para. 1) who wrote, “Partners, parents, and
siblings often must endure the effects when a family member is traumatized. The family may
serve as a resource for support or an obstacle that blocks a traumatized member’s recovery.”
These authors remarked that traumatized parents may be overwhelmed by a personal traumatic
experience and can sometimes underestimate their own trauma and how their children are
There could be a negative impact associated with prolonged service on caregivers and patients
(Chen & Hu, 2002). Research conducted by Sisk (2000) supported the notion that “…both
caregiving activities and the feelings associated with caregiving may negatively affect the
caregiver’s ability to participate in various health-promoting behaviors” (p. 41). It has been
proposed that caregivers store away their emotional pain—a pain which can later devastate
individuals, their families, or both (Harbert & Hunsinger, 1991). Realizing that caregivers may
hide, underestimate, or otherwise obfuscate their psychological distress is a disconcerting
scenario that warrants ongoing attention.
Helpers and Family Traumatization
A more complete consideration regarding the systemic costs of caring within families was
offered by Figley (1998); the researcher asserted that the field of traumatology has overlooked
families and other supporters of psychologically injured people. As described below, families
could be traumatized via simultaneous effects, vicarious effects, chiasmal effects, and
intrafamilial trauma (Figley, 1989a).
The simultaneous effect refers to when an entire family experiences a traumatic event. In
general families who are traumatized, “…are relatively free of disasterrelated emotional
difficulties” (Figley, 1989a, p. 19). According to Figley this response could be attributed to the
fact that the event is shared by a group whose members can provide mutual support.
It was Figley’s (1989a) contention that individuals could be vicariously traumatized when
learning about events experienced by significant others. For example, a father can experience
emotional trauma when learning about a catastrophe involving his son or daughter. Figley
suggested that a significant other may experience more stress than an actual victim.
Originally termed secondary catastrophic stress response, chiasmal effect refers to a process
whereby significant others are emotionally touched when attending to the victimization of a
close friend, relative, or family member. Significant others are affected through their efforts to
help. Referring to an earlier study regarding crime victims and their supporters, Figley (1989a)
…as expected, the major predictor of supporter distress was victim distress [and] it is clear that
a pattern of effects emerged in both the victim and supporter. The crime victims as well as their
supporters suffered from the crime episode long after the initial crisis had passed. (p. 20)
Figley (1989a) stated: “Families certainly have the capacity to be extremely helpful in
enabling family members in recovering from traumatic stressors. They may become traumatized
through their assistance” (p. 21). It is only logical that the close bond between family members
would increase a likelihood of shared trauma.
In an attempt to better understand how families can be affected by trauma, for example, Figley
(cited in Peeples, 2000) described burnout in families. Based on earlier interviews regarding
combat-related stress disorder, Figley discovered that family members “…were living the war
indirectly through the emotional responses of their veteran family member” (Peeples, 2000, para.
As the construct of secondary trauma was emerging, caution was recommended regarding
global and unsubstantiated statements (Jenkins & Baird, 2002; Waysman, Mikulincer, Solomon,
& Weisenberg, 1993). It was noted:
There is a growing body of literature on secondary traumatization, but it is almost entirely
anecdotal. There have been virtually no systematic empirical studies aimed at documenting and
understanding these phenomena. Very little is thus known about factors that may influence
the process of secondary traumatization, such as the degree of empathy and responsibility family
members feel for one another, the quality of the marital relationship, the social climate, and so
forth. (Waysman et al.,
1993, p. 104)
As discussed below, the void regarding secondary trauma research was acknowledged and is
gradually being addressed.
HELPING PROFESSIONAL TRAUMA RESEARCH:
ANSWERING THE CALL
Over the years, researchers have begun to answer the call for more investigation regarding
caregiver burden and strain (Sisk, 2000; Chen & Hu, 2002) and secondary traumatization (e.g.,
Baird & Jenkins, 2003; Bride, Robinson, Yegidis, & Figley, 2003; Dunning & Silva, 1980;
Raphael, Singh, Bradbury, & Lambert, 1983). Preliminary research also demonstrates a
relationship between the degree of exposure to trauma-associated material and the experience of
secondary traumatic stress disorder (Arvay & Uhlemann, 1996; Collins & Long, 2003; Follette,
Poluusny, & Milbeck, 1994; Kassam-Adams, 1995; Motta, Kefer, Hertz, & Hafeez, 1999;
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