Have you ever been hit by something that fundamentally challenges the thoughts and beliefs you have about who you are? I started writing this blog in 2007 after I sustained a concussion and had quite a lengthy rehabilitation period (nearly two years). Over that time I struggled with a profound sense of loss: the things I thought made up ‘me’ were gone, like word finding, reading and decision-making.
Self-identity/concept is a big topic in psychology and social sciences. Who we are, or who we think we are, is a characteristic of humans, so there are many theories about how we develop this sense. It’s important because we see ourselves as having this unitary ‘me’ that has existed throughout our lives, and when something happens to threaten that sense of self we can find it so difficult to know how to regain it. We also find it hard to be a person without that sense of ‘self’. I know I felt sad for the loss of things I was used to finding effortless and afraid that the person I was being in those moments (and didn’t like very much) would be me for the rest of my life.
There’s a lot of talk about people who’ve experienced traumatic events and the impact trauma has on sense of self. The research from a recent meta-analysis looking at the relationship between exposure to traumatic events and maltreatment and its association with self-concept in children and adolescents found a small negative relationship between trauma exposure and self-concept (r = − 0.20, 95% CI − 0.22, − 0.18) (Melamed et al., 2024). This relationship was significantly moderated by some variables (type and nature of trauma exposure) but not others (participant gender, type of self-concept measure, quality of studies, country economic status). Now this study defined trauma as the DSM-5 PTSD definition: “actual or threatened death, serious injury, or sexual violence” – and considered maltreatment to be any form of sexual abuse, physical abuse, emotional abuse, or neglect.
This study’s findings surprised me a little because the relationship was so small and the definition of trauma both very clear – a PTSD diagnosis means participants will have been diagnosed and meet the criteria for this disorder. This in turn means that people who have temporary or minimal impacts from experiencing traumatic events aren’t included. It also likely means the traumatic events are quite significant.
In another recent systematic review looking at interpersonal trauma and self-identity (so slightly more restrictive inclusion criteria), found 10 studies looking only at the effects of adult experiences of trauma on self-concept (‘mixed’ trauma), and one looking at exposure to terrorism, while the rest included either paediatric or combined paediatric and adult participants (Kouvelis & Kangas, 2021). Their results concluded that traumatic events disrupt a sense of self, particularly if these events occur as children, but that much of the research is cross-sectional, and the measures of self-concept/self-identity were pretty mixed. It did find that interpersonal trauma (things like exploiting one’s bodily autonomy, physical violence, and intimate partner violence) has a negative effect particularly if it’s on top of pre-existing childhood adversity.
From a chronic pain perspective, we already know that adverse childhood experiences pose a risk factor for developing chronic pain (Karimov-Zweinenberg et al., 2024), and we also know that developing chronic pain has a profound effect on identity (Vorhees, 2023) while negative evaluations of ‘self’ are associated with problems in daily life functioning (Yu et al., 2015). The question that remains is whether a negative sense of self from exposure to traumatic events in adulthood has similar impacts, and whether there’s a cumulative effect.
Some points to note: In all these studies, traumatic events and the impact on individuals has been carefully defined. Social media conversations about these topics are not as careful in their use of the term ‘trauma’ and could be over-inclusive. This is not intended to diminish their experiences – but it does mean that the conversations about what clinicians ‘should’ do coming from social media might not reflect either the kind of trauma that’s been researched, or the kind of psychological disorders that arise. And trauma concerns are emotive, creating quite a demand for information and clear-cut ‘remedies.’
Having delved into the research a bit now, the attention paid to trauma and how we should work as clinicians remains murky to me. On the one hand there is an association between trauma, pain, and negative psychosocial consequences including an impact on sense of self. On the other hand, the social media discourse (and especially adverts for courses on ‘trauma-informed’ care) probably includes experiences and effects that wouldn’t meet criteria in the research we need to draw on for clinical practice.
A pragmatic question might be: is it harmful to draw on what we do know (probably on the severe end of trauma impact) and apply it to people with lower levels of trauma? And the answer is vexed – and for me, turns me back to my thoughts about how we conceptualise ‘self.’
This is a two-part post – next part is coming right up!
Karimov-Zwienenberg, M., Symphor, W., Peraud, W., & Decamps, G. (2024). Childhood trauma, PTSD/CPTSD and chronic pain: A systematic review. PLoS ONE, 19(8), e0309332. https://doi.org/10.1371/journal.pone.0309332
Kouvelis, G., & Kangas, M. (2021). Evaluating the association between interpersonal trauma and self-identity: A systematic review. Traumatology, 27(2), 118-148. https://doi.org/10.1037/trm0000325
Melamed, D. M., Botting, J., Lofthouse, K., Pass, L., & Meiser-Stedman, R. (2024). The Relationship Between Negative Self-Concept, Trauma, and Maltreatment in Children and Adolescents: A Meta-Analysis. Clin Child Fam Psychol Rev, 27(1), 220-234. https://doi.org/10.1007/s10567-024-00472-9
Voorhees, H. L. (2023). “I Was Literally Just Not Myself”: How Chronic Pain Changes Multiple Frames of Identity. Health Commun, 38(8), 1641-1653. https://doi.org/10.1080/10410236.2022.2025702
Yu, L., Norton, S., Harrison, A., & McCracken, L. M. (2015). In search of the person in pain: A systematic review of conceptualization, assessment methods, and evidence for self and identity in chronic pain. Journal of Contextual Behavioral Science, 4(4), 246-262.