Psychological trauma insidiously interferes with the lives of countless millions—children and adults. Traumas are due to various types of violence, as shown in the Trauma Tree. Traumas invisibly inflict immense suffering and undermine health, development, and peace. If not treated, trauma may last a lifetime. And for many it does. But trauma needs no longer be the life sentence it was throughout most of history. Today effective, scalable treatments exist. Morality, enlightened self-interest, and the duty of care all compel us to make them widely available.
Psychological trauma has devastating consequences on individuals, families, and whole communities. It ruins health, inhibits creativity, weakens productivity, harms educability and hampers well-being. It drives violence and that way it limits the space for peace. ‘Hurt people hurt people’, because unresolved trauma may produce anger, fantasies of revenge and lingering resentment that, at any time, could erupt again and be the source of further violence and trauma.
Never in history have so many people been traumatized as today— running into the hundreds of millions of people worldwide. Official statistics of Post-Traumatic Stress Disorders (PTSD) are lacking for most countries, and this has kept trauma’s true extent hidden. But if the world population had the 7% PTSD lifetime prevalence rate of the USA, some 500 million would be living with trauma. I believe the situation in the Global South is worse.
My own indirect estimate comes to 1,000 million people living with trauma symptoms. Look at this Trauma Tree. Its roots represent four types of violence: direct, natural, structural, and cultural, all capable of producing trauma. Multiplying the number of people exposed to these Four Violences with their respective PTSD prevalence rates yields the one billion.
This may not be sophisticated epidemiology, but it reveals a different order of magnitude, a veritable trauma epidemic. And this epidemic may soon become pandemic due to the coming ‘climate trauma’, a meta-trauma that is predicted to trigger all past traumas: personal, cultural, ancestral and intergenerational.
Yet, these trauma realities remain largely unacknowledged.
PTSD is a specific disease entity, a very serious mental disorder with far-reaching emotional, physiological, cognitive, and behavioral manifestations (shown growing out of the Trauma Tree’s branches). Even the traumatic stress that does not rise to the formal level of PTSD exerts a pernicious, pathological force that may lead to impaired brain development. Says Van der Kolk: “Trauma results in a fundamental reorganization of the way mind and brain manage perception. It changes not only how we think and what we think about, but also our very capacity to think… After trauma the world is experienced with a different nervous system.”
Children, vulnerable as they are, are always exposed to many traumatic events and circumstances. Although most children show resilience in the face of almost inevitable adversities, recent research about Adverse Childhood Experiences (ACE) has highlighted their potential severity and long-term consequences.
The two ACE graphs (above) show how adverse childhood experiences in children 0 to 17 may lead to lifelong high-risk behaviors and physical and mental diseases and disorders. ACE underscores the truth that ‘the early years last a lifetime’. The greater the adversity, the higher the risk. Please note that ACE’s annual economic costs to the US and European economies is enormous: US$1.33 trillion due to productivity loss and the cost of health care, special education, child welfare and criminal justice! Similar cost estimates could be made for other countries and for other trauma consequences.
Thus, psychological ill-health is far more damaging than we knew—until recently. In fact, mental health probably influences physical health more than the other way around. It should therefore be much more vigorously pursued, for its own sake and for the sake of better physical health!
Yet, the world’s response has been tepid. True, some preventive efforts are made, but there are no large-scale treatment programs anywhere. Typically, rich countries devote only 5% of their total health budgets to mental health (altogether), but poor countries only one-tenth of that, namely a paltry 0.5%. So, 95 to 100 percent goes to physical health; next to nil remains for all mental health, including trauma.
This imbalance must now be redressed.
Today we have solutions we did not have before. We now have a much better understanding thanks to breakthrough research in neuroscience and psychology. We now have better measuring instruments and effective treatments. WHO recognizes two evidence-based, scientifically validated trauma therapies: Eye Movement Desensitization and Reprocessing (EMDR) and Cognitive Behavioral Therapy (CBT). Each has its operational merits, but the comparative advantages of the more recent EMDR are less well known: rapidly effective; minimal contact time (measured in hours and days, not weeks or months); doable in groups and on consecutive days; no homework; less intrusive, no need to verbalize traumatizing event or circumstance; high acceptability; and early intervention may prevent onset of PTSD.
These therapies must now be widely applied worldwide, with focus on LMICs, to deal with the enormous trauma backlog and to prepare for imminent, overwhelming climate traumas. The urgent need is to take trauma treatment to scale. I suggest focusing on trauma treatment as lead intervention among a whole range of mental health measures—much as GOBI was to PHC.
So, what is holding us back?
In many ways we find ourselves today in a situation like where we were at the start of the (yet unfinished) Child Survival Revolution (CSR). There was a shortage of professional personnel to do the job. Many doubted that the medical simplifications were possible and scalable. Like David Werner’s Where There Is No Doctor, we now have Vikram Patel’s Where There Is No Psychiatrist. And there’s again a need to overcome hesitation (or even opposition) from mental health professionals about simplifying protocols and task-shifting to allied and paraprofessionals.
We need to collect better data and baselines, and to research and evaluate innovations. And to do benefit/cost and benefit/risk studies, for advocacy purposes. Like then, we must counter claims that “we’re already doing it”, because we’re simply not yet on the scale of where we should be. Psychosocial support is more ‘social’ than ‘psycho’, thus leaving the job less than half done; trauma relief should be a sine qua non. Networking with large-scale humanitarian and developmental organizations and donors is needed. Trauma care must be integrated into ‘regular’ service delivery systems: health, education, protection, counseling, NGOs, internet, etc., thus making it ‘everybody’s business’. WHO’s Psychological First Aid should be used much the way we did UNICEF’s Facts for Life.
Strategic priorities must be set. Focus on high-risk populations. First beneficiaries should be staffs of humanitarian organizations themselves, then their traumatized populations, including demobilized child soldiers, school children and refugees/IDPs (especially if captive audiences, for easier reach). Other at-risk populations include war veterans and war journalists, first-responders, peace mediators and negotiators, amputees with phantom limb pain.
Who should be selected as para- and allied professionals to deliver the Psychological Second Aid with its simplified protocols (see Intervention Pyramid)? A careful selection should be made from among the many millions’ frontline workers potentially available: schoolteachers, nurses, community health workers, faith-based counselors, doctors. Already on the ground, they are often the first to offer aid and comfort to potential (trauma) victims. Professional therapists (generally in short supply) would provide critical referral and professional backup.
Like for CSR, we now need a new leadership, for primary mental health. The time has come to unleash a Trauma Relief Revolution, as part of a Mental Health Revolution. It can be done, like then! Recall Margaret Mead’s inspiring insight:
“Never underestimate the power of a few committed people to change the world. Indeed, it’s the only thing that ever has!”
That job would easily keep us busy for the next 75 years. UNICEF would naturally focus on children and adolescents, in the Global South, but also in the Global North. Indeed, children everywhere deserve to be given the highest priority, as it is their right. And investing in them gives very high returns to boot!
More at www.GIST-T.org
This article is part of the XUNICEF News and Views Quarterly Newsletter, December 2021.
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