September 24, 2013
Trauma was once thought to be unusual. In fact, DSM-III defined traumatic events as those “occurring outside the range of usual human experience.” Epidemiology taught us that even some of the most severe traumatic events were not rare, but common, even in high income, politically stable countries. One-in-five US women report having been sexually assaulted. One in ten British children suffer child maltreatment. Whether in South Africa, Northern Ireland or the United States, the majority of the population reports having a least one and usually multiple traumas.
I have been considering whether the danger for the field is not amnesia, that trauma will somehow again be forgotten, but acceptance. Has our knowledge that trauma is common made us complacent? I recently posed this question to a colleague who replied, “Like Jesus and the poor – trauma will always be with us.” Many of us (including me) focus on identifying persons at high and low risk of PTSD, conditional on trauma exposure. The trauma is a given – what matters is who develops the disorder.
Looking across populations over time it is evident that while trauma may be common, very little about trauma is a given. First, the prevalence of specific types of trauma changes over time (e.g. decline of violence globally has been observed if much debated). Second, the importance of specific event types for the population burden of PTSD varies widely cross-nationally. In South Africa, witnessing events account for the largest proportion of the PTSD burden. In contrast, the PTSD burden in Northern Ireland is explained more by conflict events linked to ‘The Troubles.’ Trauma exposure is not fixed, but clearly changes in time and space and is perhaps modifiable. Emerging evidence also suggests that trauma, even in the absence of PTSD or other disorders, may have pernicious effects on physical health. These data suggest that traumatic stress should not remain in the domain of mental health professional, but represents a broader public health problem.
Prevention is a key aspect of the public health approach. The definition of ‘prevention’ is the act or practice of stopping something bad from happening. Trauma exposure seems, by this definition, a natural target for prevention. However, prevention in the context of traumatic stress is usually focused on PTSD. Early interventions (primary prevention) have been shown to reduce incidence of PTSD and we have effective treatments for those who develop the disorder (secondary prevention).
Our current approaches continue to leave us with a substantial minority of persons with treatment resistant chronic PTSD. A recent paper in PLOS ONE revealed that our typical trajectory of recovery from trauma actually hides three trajectories: rapid remitting, slow remitting and non-remitting or chronic. A subgroup of those followed were part of a clinical trial; the treatment was shown to be effective. However, the trajectory analysis revealed the treatment only impacted the slow-remitting trajectory; the non-remitting trajectory was unaffected. These data suggest that simple dissemination of effective treatments will continue to leave us with a minority of persons suffering with chronic PTSD. Of course, we continue to need to develop treatments that will be effective for those with chronic, treatment resistant PTSD. However, prevention of trauma exposure also has the potential to reduce the public health burden of PTSD.
Statements about trauma prevention can appear naive if not backed up by specifics. I encourage skeptical readers to follow recent developments in the movement to reduce sexual assault on university campuses, or bystander intervention training in the Navy for concrete examples of trauma prevention efforts. What seems to be lacking from these efforts is data on their effectiveness. Traumatic stress professionals have a larger role to play in both designing and testing trauma prevention programs.
Preventing trauma exposure, focused on the events that account for the greatest burden of PTSD in the population, is a strategy that should also be placed more firmly within the scope of ISTSS’ mission. This point and others will be among those considered by the new Trauma and Public Health Task Force led by Dr. Kathryn Magruder. The mandate of the Trauma and Public Health Task Force is to collaborate with other organizations with interests related to trauma and public health and to develop three concrete proposals that will move ISTSS toward the goal of establishing traumatic stress as a public health issue for the general public and policy makers. The ISTSS Board of Directors established this task force to meet objectives set out in the Strategic Plan. Specifically Goal #3: Societal Impact, whereby ISTSS contributes to the health and resilience of people and communities in the face of traumatic events.