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German neurologist, Herman Oppenheim (1889)
was the first to use the term traumatic neurosis.
He proposed that functional problems in the
soldiers he examined were produced by subtle
molecular changes in the central nervous system.
The frequent occurrence of cardiovascular
symptoms in soldiers, and others who
experienced accidents or other trauma, started a
long tradition of associating posttraumatic
problems with such diagnoses as cardiac
neurosis and soldiers heart (DaCosta, 1871;
Myers, 1870).
Dr. J. DaCosta described the
‘irritable heart’ in American
Civil War soldiers, which
included physical
symptoms such as
palpitations, chest pain
which greatly increased on
exertion, rapid pulse,
shortness of breath, and
gastrointestinal symptoms,
especially diarrhea.
DaCosta listed nervous
symptoms, which included
headaches dizziness,
disturbed sleep, jerking
movements during sleep
and unpleasant dreams,
although he placed very
little emphasis on
emotional sequelae (Kinzie
& Goetz, 1996).
This link between the effects
of soldiers’ war experience
and circulatory system
deficits continued during
World War I (WWI), when
soldiers were diagnosed
with disorderly action of the
heart or neurocirulatory
asthenia (Merskey, 1991). I
It was reported that 80,000
men were discharged from
the army in WWI due to
soldier’s heart, or effort
syndrome as it became
known (Culpin, 1930).
Charles Samuel Myers (1915), a British
psychiatrist was the first to use the term
shell shock in the medical literature. Shell
shock was believed to be related to factors
such as molecular commotion in the brain,
yet physicians were further challenged by
the fact that even soldiers who had not
experienced direct shell fire also suffered
from the same constellation of symptoms,
including anxiety and sleep disturbance.
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During World War II (WWII),
doctors found it extremely
difficult to distinguish shell
shock from cowardice,
especially since ascribing an
organic origin to traumatic
neuroses was particularly
important in combat soldiers.
Despite this diagnostic
dilemma, more than 200
British soldiers were executed
for cowardice during WWII, and
an astounding 20,000 more
were condemned to death for
cowardice, but were never
executed (van derKolk et al.,
1996).
The tragedy of collective
professional denial of the
suffering of these men and
women remains a crucial
turning point in the history of
trauma in psychiatric
medicine.
One of the most prominent features
throughout the history of the field of trauma
is the debate about whether or not post-war
or post-disaster effects were organic, as
discussed above, or whether there was a
nervous or hysterical component, or even if
there may be some combination of both.
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As early as 1859, the French psychiatrist Briquet
started to make the first connections between
the symptoms of hysteria, including somatization
and childhood histories of trauma. Briquet
reported specific traumatic origins as the cause
of their illnesses in 381 of the 501 patients that
he studied (van derKolk et al., 1996).
Along with the first documentation in the
literature of sexual abuse of children (Briquet,
1859) came the beginning of a long tradition of
disbelieving that continues to this day with the
debate about false memory syndrome, where
childhood memories of abuse are considered
false memories, perhaps induced by the
therapist.
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When Sigmund Freud
visited Charcot at the
Salpetriere at the end of
1885, he adopted many
of Charcot s ideas,
including the notion that
hysterical attacks were
the recurrence of a
traumatic psychical state
which the patient has
experienced earlier (van
derKolk et al., 1996).
Freud (1925/1959) later
recanted this belief and
instead stated….

“I believed these stories [of childhood sexual
trauma] and consequently supposed that I
had discovered the roots of the subsequent
neurosis in these experiences of sexual
seduction in childhood. If the reader feels
inclined to shake his head at my credulity, I
cannot altogether blame him...I was at last
obliged to recognize that these scenes of
seduction had never taken place, and that
they were only fantasies which my patients
had made up. “ (p. 34)
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Pierre Janet (1889) was also inspired by
Charcot s work to continue investigation
of processes involved in the
transformation of traumatic experiences
into psychopathology, and the notion of
dissociation. Janet spent his life making
meticulous clinical observations on
hundreds of patients with a wide variety
of seemingly unrelated symptoms.
Based on his observations, he described
the syndrome of hysteria in which the
primary mode of adaptation is the
dissociation of feelings or memories
related to frightening experiences, which
results in a narrowing of consciousness.
Janet s work on sensory perception,
mental integration, memory storage and
trauma anticipated many of our current
understandings of human response to
overwhelming trauma (van derKolk & van
derHart, 1989).
“In the Vietnam war, the lessons of WWI and WWII
were forgotten yet again, and this time with the
active assistance of the mental health profession.
The unpopularity of the war, the fact that a good
proportion of the soldiers who fought it were
from lower socioeconomic strata while better off
youngsters managed to evade the draft, and the
acknowledged participation of some of the
soldiers in shameful atrocities all rebounded on
the trauma victims. “(Solomon, 1995, p. 272)
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In 1968, just as large numbers of soldiers were beginning
to return from Asia, the American Psychiatric Association
(APA) completely and inexplicably removed stress
reactions from its second edition of the Diagnostic and
Statistical Manual of Mental Disorders, DSM-II (1968).
The first edition of the manual, DSM-I (1952), contained
the diagnostic category ‘gross stress reaction’ and
referred to combat as an example of possible causes
(Solomon, 1995). The removal of stress reactions from the
DSM-II had a profound effect on the attitudes and clinical
judgment of mental health professionals who, as in
current day clinical practice, tend to rely heavily on the
diagnostic categories in the DSM.
One of the most problematic consequences of this reliance
on diagnostic categories is that there is a tendency to
believe that the categories themselves are somehow
conclusive and representative of objective reality, rather
than a historical reflection of ever changing societal beliefs
and attitudes toward what constitutes mental illness.

The results of the removal of ‘stress
reactions’ from the DSM in the late 1960s
echoed in the experiences of trauma
survivors for over a century: the seemingly
relentless tendency of mental health
professionals to disbelieve trauma stories
and/or discount the possibility of
traumatization, and thus attribute suffering
to inherent personality weakness or preexisting psychiatric illness.

Finally, after over a century of controversy, the
third edition of the DSM (1980) included a
detailed diagnostic guide for posttraumatic
stress disorder (PTSD). In the DSM-III diagnosis,
we finally begin to see the historical antecedents
(Briquet, 1850; Charcot, 1887; Janet, 1889;
Stierlin, 1911) of contemporary trauma literature.
DSM-III criteria for PTSD included:
◦ (1) exposure to a trauma; (2) re-experiencing the trauma
in the form of dreams, flashbacks, intrusive memories,
or unrest at being in situations that are reminiscent of
the trauma; (3) avoidance behavior or a numbing of
emotions and reduced interest in others and the outside
world; and (4) physiological hyperarousal, as evidenced
by insomnia, agitation, irritability or outbursts of rage.
 The
women’s movement, the civil
rights movement…. Opening up
discussion about the political and
social context of trauma…
From 2000 to the end of 2006, the
total of all U.S. military and law
enforcement deaths—including
accidents and suicides—was 4,588.
The combined total of all Canadian
military and law enforcement
deaths in that period was 101. In
that same seven years more than
8,000 women in the U.S. were
shot, stabbed, strangled, burned,
or beaten to death by the intimate
males in their lives. ..
While in Canada, over 500 women—
five times more than Canadian
soldiers and police officers—were
killed by their current or former
male partners. Even adding in all
the victims of 9/11 to the U.S. law
enforcement and military total, it’s
still less than the number of
women killed. (Vallee, 2007,
Abstract)
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Event(s) is
persistently reexperienced…
There is persistent
avoidance of stimuli
associated with the
trauma…
There are persistent
experiences of
increased arousal…
(also see DSM
definition in text, p.
238)

Therapeutic boundaries in the context of
trauma work:
◦ Containment
◦ Believing
◦ The wounded healer

The road to healing
◦ Beginning with the fundamentals
◦ Consciousness raising
◦ Working with trauma material (maybe…)
Refers to the clinician’s therapeutic work in helping the client
maintain their own boundaries regarding emotional and
spiritual safety, especially in terms of processing trauma
material, stories, memories. Does not mean silencing the
client.

First: Therapeutic communication skills: listening (being there,
mindfulness…), empathy…

Assessing the context of your interaction:
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Is it relatively short term? (e.g. hours, days: the emergency department).
Is it medium term? (e.g. days, weeks: prenatal care
Is it long term (e.g weeks, years: long term cardiac care follow-up)
Knowing when to refer and having a thorough knowledge of
referral options in your geographic area
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Acknowledging societal silencing of trauma
stories (e.g. historical denial of PTSD related to
soldiers’ experiences in war; current lack of court
and media attention to trauma perpetrators)
‘Stopping the bus’: trauma survivors may feel
safe to tell you their story in many different
contexts (e.g. childbirth, addictions treatment,
nursing home care). This is a time when
clinicians take the time to acknowledge the story,
yet help client maintain boundaries…
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The wounded healer is a clinician who has not
had the opportunity ,or is not yet ready, to
process their own trauma histories
The wounded healer may inadvertently cause
further spiritual or emotional damage for the
trauma survivor
As nurses and healers, it is important for us to
do our own internal work…a tough sell in the
context of biomedical dominance in the health
fields

First: Healing is possible

Taking stock

The healing process
◦ Effects: Recognizing the damage
◦ Honoring what you did to survive
◦
◦
◦
◦
◦
◦
The decision to heal
The emergency stage
Remembering
Believing it happened
Breaking the silence
Understanding that it was not your fault
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The healing process (cont’d)
◦
◦
◦
◦
◦
Grieving and mourning
Anger
Forgiveness?
Spirituality
Resolution and moving on
The road to healing: More implications for nursing care (in
addition to containment, believing, the wounded healer,
beginning with fundamentals of self care)
◦ Consciousness raising with the client and ourselves(e.g
societal context of violence in working with women who
have been, or are, in abusive relationships; societal
context of war, as in Viet Nam war or war in Iraq; e.g.
societal context in child abuse)