Recognizing Medical Trauma

Q: I’ve been hearing about medical trauma in the news and in my professional circles. What is it and how do I address it with my clients?

A: Since the pandemic, there’s been increasing public attention on the mental health impact of illness and hospitalization. Some of these experiences are best understood as medical trauma: a traumatic event related to the experience of pain, injury, illness, or medical intervention. Medical trauma falls under the umbrella of traumatic events, so our current understanding of trauma largely applies to these experiences. However, treating medical trauma requires additional considerations, which aren’t typically included in traditional trauma treatment.

Medical trauma is unique in that it’s both a psychological and physiological response. Although all trauma lives in the body, medical traumas are perceived by the sufferer as ongoing events with somatic origins. They’re triggered whenever attention is directed toward the body. According to the International Society for Traumatic Stress Studies, it might be caused by a sudden or life-threatening illness or injury, treatment for that illness or injury, feelings of shock or loss of control after a diagnosis, life-altering complications or unexpected medical intervention, poor or disruptive hospital conditions, or perceived or actual mistreatment by health­care providers.

Addressing the characteristics of medical trauma and its effects requires broadening our trauma treatment lens. It means thinking about treatment differently, asking new questions, and adapting interventions to support psychological and physical recovery. This might mean, for instance, restructuring a trauma-related belief like It’s my fault that I’m sick while teaching behavioral strategies to reduce the perceived threat of physical symptoms, such as pain or shortness of breath, which, left untreated, can elicit traumatic stress symptoms and alter a patient’s quality of life.

My first professional exposure to medical trauma was as an undergraduate working on a research study examining barriers to accessing preventive colorectal cancer screening. Our team wanted to know why those at high risk for colorectal cancer didn’t get routine preventive screening, which has been shown to improve identification and early treatment drastically. We hypothesized that socioeconomic status, rurality, lack of knowledge, and discomfort with colonoscopies were likely barriers to accessing preventive care.

All those barriers were present, but when I began interviewing people over the phone, I heard more nuanced reasons for not seeking preventive care. I heard stories from patients about how they’d seen loved ones suffer through cancer treatment. They told me they hadn’t gotten screened because “it was just better not to know” if they were at risk. I quickly learned that people’s experiences with the healthcare system—and witnessing their family members’ repeated surgeries, pain, cognitive changes, and disfigurement—had deep emotional effects. Many described experiencing reactions like those of PTSD and said they had difficulty tolerating any type of medical care because of what they’d witnessed. It was a defining moment for me, and it led me to dedicate my career to understanding how better to identify and support patients experiencing medical traumatic stress.

Today, I’m a licensed clinical psychologist with a focus on traumatic stress and integrated healthcare. I’ve worked across the continuum of healthcare settings, including in primary care, emergency departments, palliative and hospice care, acute rehabilitation settings, and general inpatient medical settings. Currently, I work as an embedded clinical psychologist on a trauma surgery service at a level-1 trauma center. In each of these settings, I’ve helped patients and their families understand and process not only the physical impact of their medical experiences, but also the psychosocial implications of medical trauma.

Why a More Expansive Approach Matters

While the conversation around medical trauma is gaining momentum, experiences of medical trauma have existed throughout human history: in traumatic wartime amputations, medical experimentation, forced sterilization, and countless invasive procedures and harrowing hospitalizations. At its core, medical trauma is a disenfranchised trauma, an experience that’s not openly acknowledged or socially validated as traumatic—including by the field of trauma treatment. The DSM, for instance, specifies that life-threatening or debilitating medical events aren’t necessarily traumatic events, and should be considered an eligible stressor for a PTSD diagnosis only if they’re “sudden or catastrophic.” As a result, the psychological effects of many medical experiences—like heart attack, stroke, and inflammatory bowel disease—which can cause significant traumatic stress symptoms, can’t technically be diagnosed as PTSD.

Michelle Flaum Hall and Scott Hall, leading experts in medical trauma and authors of Managing the Psychological Impact of Medical Trauma, describe three levels of medical trauma that cut across the continuum of care, from seemingly routine medical care to life-threatening or life-altering diagnoses to medical emergencies. In this framework, medical traumas can be understood as an interaction of the potential acute threat to life and the amount of emotional distress that someone experiences within the context of their care experience. In other words, it isn’t just the severity of the situation that determines the intensity of the trauma, but also how distressed the patient is about the experience, regardless of its objective severity.

Medical trauma considers the context in which the trauma is happening. It looks at the healthcare system, where patients are exposed to potentially traumatic events, like medical gaslighting or mistreatment, painful or invasive procedures, learning bad news, or a stressful hospital environment. Often, those who experience medical trauma discuss how the event is intertwined with racism, ableism, and sexism—as well as the acute power differential felt in the patient–provider relationship. They describe discrimination based on weight, as well as the moralizing of health—for instance, explicitly or implicitly attributing illness to a patient’s moral failing by labeling them a bad patient when they have difficulty managing a chronic illness. According to the Journal of the American Medical Association, one in five patients report having experienced at least one instance of discrimination while receiving care.

Serena Williams is just one prominent figure who has come forward with a personal experience of medical trauma. After giving birth, she experienced life-threatening blood clots, but doctors dismissed her discomfort as medication-related confusion. Only after she repeatedly insisted upon a CT scan were several clots revealed that required immediate care and an extensive recovery period. She’s not alone: today, Black women are three times as likely to die from pregnancy-related causes than white women and are therefore likelier to experience negative pregnancy-related outcomes and medical trauma. Understanding the contextual factors that create, and sustain, health-related inequities and disparities for marginalized people matters when we’re treating medical trauma.

Treating Medical Trauma

It’s likely that many of your clients with significant mental health concerns also come to your practice with one or more chronic health conditions. Rather than noting medical diagnoses and moving on, be curious about the emotional and social impacts of their diabetes, stroke, chronic pain, cancer, seizures, complicated labor and delivery, or any other current or past medical conditions or procedures. You may even consider integrating health-related quality-of-life measures like the SF-36 into your intake procedures, or assessing for traumatic stress symptoms associated with diagnosis, treatment, or management of a chronic health condition or medical event using a disease-specific measure like the Diabetes Distress Scale or the City Birth Trauma Scale. Of course, not all clients will experience medical trauma, but for those who do, identifying it early can drastically improve treatment and outcomes.

Even when it’s influencing a person’s life, medical trauma isn’t always immediately obvious to the client, or to you as a professional. When there isn’t language or awareness around the potential impact of a medical trauma, it’s harder for our clients to identify or talk about. Consider, for example, a client who needs to be cared for by others or relies on their partner to meet their emotional and physical needs. They report panic attacks when they’re left alone, lack self-confidence, have trouble making decisions, and avoid personal responsibility. Based on this information alone, your clinical hypothesis may be that the client is experiencing a diagnosis of dependent personality disorder.

Without additional knowledge about medical trauma, consider how you might treat this client or conceptualize their behaviors. How would your treatment differ if you learned this client was diagnosed with a congenital heart condition as a child and was told by a doctor that overexertion or too much excitement could result in death? What if you learned they were never allowed to leave home without an escort and their parents repeatedly told them they were fragile? Or that they grew up being hypersensitive to bodily cues like shortness of breath or rib aches, meaning they never experienced a laugh-until-you-can’t-breathe moment without it being swiftly followed by a crushing, impending fear of dying? How might the way you think about your client change? How might your interventions change?

Assessing for medical trauma should sound familiar to clinicians with experience treating trauma. You’d ask about medical experiences that may have resulted in trauma, like a client’s poor experience during a hospital stay, and the impact of the event on their physical and psychological health, as well as their bidirectional interaction—for example, gastrointestinal distress leading to anxiety and vice versa. In addition, you might consider assessing for the effects on quality of life and the presence of trauma-related sensory impressions, like trauma memories triggered by smells, sounds, or strong physical sensations. Medical trauma can also present as a lack of medication or treatment adherence, avoidance of appointments or lack of follow-through, or difficult interactions in a care environment.

Medical trauma is best addressed when we break down the silos between mind and body, as well as those between trauma psychology and the fields of health and rehabilitation psychology. I explicitly talk to clients about how paced breathing can manage emotional distress and reduce physical pain. I facilitate interventions and therapeutic exposures that minimize their avoidance of physical sensations that remind them of their medical trauma. I might ask, “What thoughts and feelings come up when you look at your scars?” Doing this ultimately helps clients process difficult emotions, like grief, fear, disgust, and anger, which can get in the way of recovery.

Leveraging social support can also be used to promote healing after medical trauma. Helping clients connect with others who’ve been through similar experiences, who look like them, or who must navigate a world that doesn’t always consider what they’re struggling with, physically or emotionally, can have a profound impact on their recovery.

Clients benefit when we apply an ecological-systems lens to their experiences of medical trauma, addressing what’s happening not only in their body and mind, but also in their interactions with family, work, and the healthcare system—as well as societal values and pressures that influence how they make meaning of their medical trauma and health.

Just as we might talk to a survivor of sexual assault about cultural practices that normalize sexual violence, we can talk to survivors of medical trauma about cultural practices that contribute to thoughts of “not being good enough” or “being a burden” when they don’t meet societal standards of good health. Too many people internalize negative messages about being a bad or difficult patient or blame themselves for not getting over traumatic medical events or diagnoses. By addressing these factors, we can help clients create a new avenue for fuller physical and emotional healing