Beyond Psychiatry: A Trauma-Centric View of Mental Health

As regular readers of Mad in America are well aware, the field of psychiatry’s level of success at treating (or even understanding) mental health is lackluster, to put it mildly. Since embracing a biomedical model of mental health over 40 years ago, an “It’s all about the Drugs” mentality has redefined how we think of mental pathology and treatment. Seeing a psychiatrist nowadays has essentially become synonymous with having medications prescribed, the significance of which is perhaps only eclipsed by how ineffective these drugs often are—as shown over and over again by independent research—along with the litany of side effects that accompany them.

There is perhaps no greater indicator of the failings of psychiatry than the ever-growing mental health crisis amongst youth and young adults. Just within the last few weeks, a CDC report was released on youth trauma and mental health. Amongst its sobering findings are that “Nearly all indicators of poor mental health and suicidal thoughts and behaviors increased from 2011 to 2021”, and “The percentage of students across every racial and ethnic group who felt persistently sad or hopeless increased.” Several decades into psychiatry’s embracing of a biomedical mindset, it’s clear that fundamental change is needed.

In my view, the shortcomings of psychiatry roughly fall into three categories:

• A Hyper-focus on the Physical. An obsession with biology, neurotransmitters, and hormones dominates the field. The fundamental problem with this is that even if certain mental disorders are clearly associated with biological changes (something that may be less common than many people think), this tells us nothing about causality. Did the biological changes cause the disorder, or did the disorder cause the biological changes? And even if, hypothetically, we establish that a given set of biological abnormalities results in mental/emotional/behavioral difficulties, this knowledge does nothing in of itself to address the Why; i.e., what caused the biological changes in the first place?

• Irrational Geneticism. When pressed for a root cause of mental disorders, psychiatry invariably falls back on an old faithful: Genetics. Despite the lack of evidence for this view as shown by study after study, the myth nonetheless persists. This may be because, most fundamentally, genes are the only possible way to explain the etiology of mental disorders if one believes that biology and biochemical imbalances explain everything. In this way, a mutually-reinforcing relationship has developed between these two ideologies (geneticism and biomedicalism), the result of which has been disastrous for mental health treatment in our society.

• Symptom-based Diagnoses & Treatment: What psychiatry calls diagnoses are nothing more than constellations of symptoms. Each entry in the DSM is the name of a “disorder”, to which a set of symptoms is mapped. As these symptoms are mental/emotional rather than physical, they are necessarily abstract and subjective. Worse still, symptoms are effects, not causes. As such, a diagnosis doesn’t explain anything—it’s merely a name given to a set of symptoms, and says nothing about causality.

As a result, psychiatry’s treatment approaches (i.e., drugs) necessarily focus on symptoms rather than causes. When you don’t know what causes something, the best you can do is try to manage the symptoms. Unfortunately, this approach isn’t at all unique to psychiatry—Western medicine as a whole, along with many popular forms of psychotherapy, simply attempt to manage symptoms and call it a day. Mental disorders and chronic physical diseases are therefore fundamentally treated the same way – and our society’s declining health is the result.

My aim in this article is to look past the dominant paradigm and describe how trauma leads to mental dysfunction, including both “diagnosable” conditions such as depression, as well as other mental, emotional, and behavioral patterns which, while perhaps being more subtle, are nonetheless quite problematic (e.g. a bad temper, self-shaming, emotional numbness). I’ll go beyond trauma-informed and take a trauma-centric approach to understanding the causality of these patterns, and I’ll also highlight what this means for effective treatment.

We’ll start with an overview of what trauma is from my perspective, using a much broader lens than is typical.

Trauma Overview

The word trauma comes from the Greek word for wound. As author and trauma expert Gabor Maté points out, the two words are perfectly analogous in a number of ways. Wounds create a sensitive area that is painful to the touch; trauma makes us sensitive to emotional triggers. Wounds are covered with scar tissue that is inflexible, numb, and doesn’t grow; trauma’s impacts on a person can be described with precisely the same words. Trauma, therefore, can perhaps best be understood as a psychological wound.

With trauma, however, we have the opportunity to actively heal rather than passively wait for scar tissue to form. But first, a deeper look at trauma and its impacts.

Cause & Effect

It’s important to differentiate between trauma and traumatic event; the latter being the cause of the former. We often think of trauma as being what happened, but it’s actually the internal consequences of what happened—how the traumatic event impacts us today, and what we make it mean about ourselves. As author and healer Thomas Hübl points out: “Many people think that trauma is the terrible event that happened to us. But trauma is the response that happens within the body’s nervous system.”

Overt vs. Covert

Traumatic events are often divided into two categories. The first of these is the more obvious one: specific, overt events such as physical/sexual abuse, or a car accident. Such events can inflict an immediate trauma on an individual, which if not addressed will manifest in various ways for the rest of their lives.​

The second type of traumatic event is more subtle (covert), and is often called developmental trauma. Here, the traumatic “event” is a prolonged misattunement between a child and his/her parents, resulting in pain for the child. When the fundamental developmental needs of children aren’t met—as is quite often the case in modern societies—trauma results. Developmental trauma, therefore, is most often what didn’t happen rather than what did happen.​

The resultant traumas from these two types of events are often distinguished as Big-T and Little-T trauma. While I understand the intent behind this language, it’s not phrasing that I use. There is nothing “little” about Little-T trauma. Not only is developmental trauma more common, but its insidious nature make its impacts on a person’s life harder to recognize. Many pathological behaviors, thought patterns, and tendencies—both at the individual and societal levels—are the result of pervasive developmental trauma, and are so common today that they’re considered normal. Recognition is an important first step.​

Note that this is by no means an intent to minimize overt trauma. The point is simply that both types of trauma, in my view, warrant equal attention.

The Effects of Trauma

Whether overt or developmental, trauma is a spectrum—and we’re all on it somewhere. The extent to which it affects us in our day-to-day lives is often shocking to discover, but the key to keep in mind is that all of these impacts are coping strategies which, when they originally formed, were very intelligent responses to the environment. These adaptations came along to protect us, typically as a result of trauma during childhood, and at first were quite effective at doing so. Over time, however, they become maladaptive.​

Below is a summary of some ways in which trauma adaptations impact us:

Disconnection from the Self: Trauma disconnects us from who we are, in the sense that coping strategies and adaptations aren’t fundamentally the real “us”. We tend to identify with these behaviors, not realizing that our real selves are hidden underneath. Someone may say, for example, “I’m a very anxious person”. But their true self isn’t anxious—the anxiety is a trauma response.

Disconnection from the Present Moment: Trauma disconnects us from the present moment in a number of ways. In day-to-day life we tend to think that we’re reacting to the present, but often we’re reacting to the past. When someone triggers us, we can be sure that what is being triggered is a past trauma. But even more subtly, the adaptations and coping strategies that we use are all based on the past—so we’re essentially living in the past whenever we employ them.

Turning against the Self: Just as we can identify with trauma adaptations such that they seem like they are truly “us”, so too can we turn against them and make them the enemy. This can take shape in the form of resisting emotions/behaviors that we consider bad, criticizing ourselves, or blaming ourselves for our past (or its resultant coping mechanisms). This creates what might be considered a psychological autoimmune condition. In medicine, the term autoimmune condition refers to the immune system attacking the body’s own tissues; over time, this causes immense damage and can lead to death. The mind’s version of this is no less severe: negative self-talk is a chronic condition for many of us, however “normal” it may seem.​

Trauma and Mental Health

Despite how apparent it is to every one of us that our environment—physical, social, relational, ecological – can and does impact our thoughts, emotions, and overall functioning, the amount of attention that environmental factors get with respect to mental health is astoundingly small. Even more remarkable is the fact that this lack of consideration is in no way due to lack of evidence. Quite the contrary, in fact: Locked into a paradigm of neurotransmitters and genetics, psychiatry misses what is right in front of its face, and turns a blind eye to mountains of evidence supporting the role of environmental distress—i.e., trauma—in mental health.

Adverse Childhood Experiences

The Adverse Childhood Experiences (ACE) study was conducted by the CDC and Kaiser Permanente in the late 1990s. Over 9,000 adults (in the first iteration) responded to a questionnaire regarding their experiences in childhood, as well as their current physical and mental health. The survey assessed mostly overt forms of childhood trauma, including emotional, physical, and sexual abuse, domestic violence, and substance abuse in the household. For each participant, an ACE Score—the number of ACEs experienced in their childhood—was tallied. These scores were then correlated against a variety of both physical and mental health diagnoses in adulthood, including depression, addiction, suicidal ideation, heart disease, and so on.

The results? To say that ACE scores are predictive of mental health would be an understatement. A 2004 analysis by Chapman et al focused on depression, concluding that “Adverse childhood experiences have a strong, graded relationship to the risk of lifetime and current depressive disorders that extends into adulthood.” Another study by Park et al focused on patients with Bipolar Disorder, and found that “ACEs had a robust negative effect on clinical outcomes, including earlier age at onset, presence of psychotic episodes, suicide attempts, mixed symptoms or episodes, substance misuse comorbidity, and worse life functioning.”

These types of findings have been replicated again and again, using other datasets. One meta-analysis of 41 studies found that “childhood adversity and trauma substantially increases the risk of psychosis.” Books could be written on the available literature on this subject. For our purposes here, however, two things stand out. The first is that the practice of modern day psychiatry doesn’t account at all for such findings on childhood trauma and subsequent mental health, despite the fact this data is prevalent throughout the literature, and has been so for many decades. There is nothing new under the sun here—upwards of a century ago, psychoanalysts such as Heinz Hartmann were keying in on the connections between childhood experiences, emotional development, and subsequent mental health. The breadth of data on this subject is overshadowed only by the number of mental health practitioners who aren’t aware of it.

The second major point is that these studies, as noted, focus on overt trauma. As the earlier section on trauma noted, developmental trauma—some or all of a child’s emotional needs not being met over a prolonged period of time—is pervasive in our society. If overt trauma can have such massive effects on future mental health, how does developmental trauma impact us?

While observational research involving more subtle types of parent/child misattunement is relatively thin—due in no small part to the difficulty of assessing more covert indicators—the available data supports a link. For example, Lyons-Ruth et al. found that “maternal withdrawal in infancy predicts both borderline symptoms in general, and suicidality/self-injury in particular, almost 20 years later.” And perhaps not coincidentally, the aforementioned 2004 Chapman et al study on ACEs found that “Of all the individual ACEs, emotional abuse exhibited the strongest relationship to both measures of depressive symptoms among both men and women.” It’s when looking at the science of brain development, however, that things become even clearer.

Brain Development

The process of brain development is the key to understanding the impact of trauma—both overt and developmental—on future mental health. The Center on the Developing Child at Harvard University has been at the forefront of research within this field, and the findings are clear: Brain development is shaped substantially by the environment. Amongst a treasure trove of data on their site, they conclude that “The exceptionally strong influence of early experience on brain architecture makes the early years of life a period of both great opportunity and great vulnerability for brain development,” and that “What happens during [the first few years after birth] can have substantial effects on both short- and longterm outcomes in learning, behavior, and mental health.”

The Road Ahead

The degree to which all of the above findings are rock-solid scientifically (not to mention how intuitive they often are) makes it all the more remarkable how little of an effect they continue to have on mental health treatment in our society. Our task, therefore, should be to incorporate this massive dataset into better treatment approaches.

Cause-focused Treatment

Becoming Whole

The word heal evolved from an Old English word that meant to make whole. While today we typically think of healing as curing or eliminating what ails us, its older definition was broader in scope, and recognized that humans strive for wholeness. While the specific meaning of wholeness could be debated, what’s clear is that trauma takes us away from it. Trauma disconnects us from ourselves by splitting off, shutting down, and hyper-activating various parts of our minds (and bodies).​ This results in various thought, emotional, and behavioral patterns which, if severe enough, get labeled as “mental illness”. And even when these patterns don’t rise to a clinically diagnosable level, they still tend to significantly impact our lives on a daily basis.

The healing journey is therefore one of returning to wholeness by reconnecting with ourselves. How precisely this is achieved will vary for each person: from psychotherapy to yoga to psychedelics, the list of available modalities is a long one. Here I’ll focus on a form of therapy called Internal Family Systems (IFS) which, rather than subscribing to a pathologizing model of “disorders” and diagnoses, instead takes a compassionate approach to understanding and working with emotional/behavioral symptoms.

Treating Trauma with IFS

IFS is perfectly-suited to work with traumatic adaptations (aka mental health dysfunction) for a number of reasons: Its recognition of the multiplicity of the mind, its trauma-centered nature, its non-pathologizing mindset, and its bottom-up treatment approach.

Parts-Centric: Fundamental to IFS is the notion that our minds consist of parts, rather than being a singular entity. While this may sound strange at first, it’s typically a fairly easy concept to grasp because it aligns with how we typically experience our minds. We often say things like “A part of me wants to do this, but a part of me doesn’t”, or more generically, “I feel conflicted about this issue”. These types of thoughts are reflections of our parts at work. In addition, behavioral tendencies such as an uncontrollable temper are the work of parts; for example, someone may have a part that is prone to angry outbursts and essentially takes over the person’s system (generally for a short period of time) when triggered. Yet at other times this part is invisible, operating in the background.​

Despite the ease and frequency at which most people experience their parts, the field of psychology has largely spent its 150+ year history denying parts-based views of the mind. In fact, it has pathologized this perspective by viewing Dissociative Identity Disorder (DID), formally known as Multiple Personality Disorder, as a condition where a person’s mind is fragmented into parts as a result of severe trauma. The unstated assumption here is that the rest of us have unitary minds. In reality, DID is simply a more extreme situation whereby one’s parts tend to be unaware of each other, causing the person to have a number of independent personalities.

The IFS position is that we are born with parts—they are inherent to our minds from the beginning, much like our bodies have parts. These parts, collectively, are a family that forms the inner system that we colloquially refer to as the mind—hence the name Internal Family Systems.

Trauma-Centric: IFS aims to heal our parts from the traumas they have sustained, restoring harmony to the inner system. When a part behaves in a maladaptive way (e.g., addictive behaviors, an incessant inner critic, or even depression), this is seen as the result of trauma—the part’s behavior is a coping strategy intended to protect the system against further trauma. Contrary to the majority of psychotherapy approaches, working with this part as its own entity tends to be much more effective than simply treating it as an undesirable behavior to be eliminated.

Non-Pathologizing: The recognition that the mind consists of parts, and that their undesirable behavioral patterns are due to trauma, results in a much less pathologizing perspective on dysfunctional thoughts and behaviors. A parts-aware perspective allows us to separate from the thoughts, behaviors, and reactivity of our parts—providing a pathway to understanding and self-compassion rather than blame and shame. Self-compassion is a critical component of true healing. As the spiritual teacher A.H. Almaas says, “It is only when compassion is present that people allow themselves to see the truth.” Healing requires seeing the truth about ourselves, and seeing the truth requires self-compassion. Without a parts-aware mindset, however, we essentially have no choice but to identify with our behaviors (“I have an anger issue“) and blame ourselves (“I should be ashamed of myself“).

Bottom-Up: IFS is a bottom-up approach in that it largely works with the unconscious to effect change. This is in contrast to common approaches such as Cognitive Behavioral Therapy (CBT), which focus on changing behaviors. Such approaches are top-down in that they work with conscious processes to attempt to change the system. As IFS founder Dr. Richard Schwartz often notes, CBT and the like are often based on a principle of addition: adding new insights and skills on top of maladaptive thoughts/behaviors that are already in place, and trying to get the new to “push out” the old.​

The aim of IFS, on the other hand, is to release constraints which hamper the inner system, at which point more adaptive behaviors and relational skills come along as a natural outcome.​ When it comes to trauma and our parts, there’s every reason to believe that the subconscious is usually in the driver’s seat; hence, a bottom-up approach to therapy tends to be more conducive to healing.

The Self: Crucial to IFS is the notion of the Self. Also found in nearly every spiritual and religious tradition, the Self is our true essence, the true “us”—the aspect of us that isn’t a part. When our parts are traumatized at a young age, and Self is too young to protect the system. As discussed above, parts therefore step in to do the job via adaptations and coping strategies. This has the effect of essentially covering up the Self, and parts end up running most of the show in our day-to-day lives. The Self, however, can never be damaged. It is curious, compassionate, open, and patient. Along with healing our parts, the goal of IFS is therefore to reconnect with the Self, and have it become the leader of the internal system.

IFS Summary: The beauty of IFS is that it’s fundamentally interwoven with every aspect of trauma: how trauma impacts us so dramatically, why our parts adapt to traumatic events in the ways that they do, and how they can be healed. While there’s no one-size-fits-all approach for trauma healing, my hope is that this quick look at IFS provides some context for how mental health can be approached in a very different way than is typical.

Conclusion

I believe a revolution is brewing with respect to mental health treatment in our culture. While large-scale changes are always frustratingly slow, the writing is on the wall—due in no small part to efforts like Mad in America.