What Is Trauma? Understanding PTSD, Complex PTSD, and the Long-Term Effects of Trauma

Trauma is a highly complex subject, both for patients and clinicians. While people often associate trauma with catastrophic events, trauma may also emerge from repeated experiences that may not even seem traumatic to many people.

The way trauma presents can vary considerably. For some individuals, trauma presents through obvious symptoms such as flashbacks, nightmares, or hypervigilance. For others, the effects are far more subtle, appearing through chronic anxiety, numbness, shame, difficulties in relationships, or persistent patterns that are not always immediately recognized as trauma.

Treatment can also take very different forms. For some individuals, treatment primarily involves reducing intrusive symptoms and suffering. For others, processing trauma becomes a way of understanding themselves — understanding how certain ways of feeling, reacting, relating to others, and experiencing the world may have been shaped by earlier experiences.

What Is Trauma?

There is not a single universal definition of trauma, but most people would agree that experiences such as natural disasters, sexual assault, severe accidents, physical violence, sudden loss, war, or combat exposure can be traumatic.

However, other forms of trauma may be more easily overlooked. Experiences such as neglect, chronic criticism or humiliation, interpersonal abuse, unstable or unsafe environments, and attachment disruptions can all be deeply traumatic for many individuals, even if others may not immediately recognize them as such.

The subjective nature of trauma is therefore very important. The psychological impact of the experience — including how the individual processes it — is often what defines trauma. Some people appear more resilient than others even when their experiences were similar.

Equally important is recognizing that direct exposure is not always necessary for trauma to occur. Indirect experiences, such as witnessing another person’s trauma or suffering, can themselves become traumatic.

What Is the Difference Between PTSD and Complex PTSD?

As a psychiatrist who works extensively with trauma, I can say without hesitation that trauma may present in extraordinarily complex ways.

In some individuals, particularly those exposed to repeated trauma over long periods of time, trauma affects far more than isolated intrusive symptoms such as flashbacks, nightmares, or intrusive memories. It can appear as though the entirety of the person’s inner world has been shaped by traumatic experiences.

Clinicians and researchers have long attempted to capture this broader and more pervasive reality through the concept of complex PTSD (C-PTSD).

Why Is Trauma Often Missed in Mental Health Treatment?

Trauma is frequently overlooked in psychiatric and psychological settings. There are several reasons for this.

In many cases, trauma may remain unspoken during appointments because of hesitations coming from both clinicians and patients.

Some clinicians may hesitate to explore trauma because they fear overwhelming reactions that cannot easily be managed within limited appointments. Others may feel uncertain about how to approach trauma safely or effectively.

Patients themselves may also hesitate to discuss trauma because of shame, fear, difficulty trusting others, or lack of awareness regarding the relevance of certain experiences.

In other cases, trauma may be acknowledged but not adequately connected to the origins of one’s symptoms. For example, symptoms may instead be attributed primarily to other conditions such as ADHD, depression, bipolar disorder, anxiety, obsessive-compulsive disorder, or psychosis.

Why Is It Important to Explore Trauma in Psychiatry or Psychotherapy?

For many individuals, this is not really a question. Trauma is so present at the forefront of their minds that it becomes difficult to ignore, and the reason they seek psychiatric treatment is specifically to address it.

Others may seek treatment for reasons that they do not initially recognize as related to trauma, such as depression, anxiety, irritability, substance use, or relationship and work instability. For these individuals, recognizing that some experiences in their life were traumatic can be the beginning of a deeper understanding of themselves.

Even individuals seeking treatment for a particular trauma may sometimes overlook earlier experiences that are also worth exploring.

How Is Trauma Properly Assessed in Psychiatry and Psychotherapy?

Effective trauma treatment begins with careful and comprehensive assessment.

Assessing trauma requires understanding the experiences that were perceived as traumatic with openness, curiosity, and an effort to understand how the individual experienced those events from their own internal reality rather than through our own expectations.

This requires being capable of holding the complexity of one’s internal reality and being willing to work through feelings and thoughts that may be complicated and at times conflicting.

The assessment also requires understanding how those experiences affected the individual psychologically, relationally, and biologically over time.

It is important that we look not only into the past, but also into the present — into the dynamics that emerge during our days, our relationships, our reactions, and even during our nights when we fall asleep.

The assessment often involves understanding different parts of ourselves and different “selves” existing in different states of mind. At times, the adult part of ourselves may consciously long to “let go” of the trauma, while our inner child may continue holding on to it.

What Are the Goals of Trauma Treatment?

Treatment of PTSD and other forms of trauma may take various forms, ranging from different forms of therapy to medication management.

The goals of treatment are individualized and dynamic. Oftentimes, it is important to establish which symptoms are most debilitating and provide some degree of relief, whether that pertains to intrusive symptoms, mood, anxiety, irritability, or even psychosis in broader trauma presentations.

With time, other goals may emerge. Oftentimes, the goals go beyond symptom reduction and extend toward understanding oneself and finding new ways of relating to oneself and the world around us.

Why Are Antidepressants, Mood Stabilizers, and Antipsychotics Used for PTSD or Complex PTSD?

Patients are sometimes confused when medications such as antidepressants, mood stabilizers, or antipsychotics are prescribed for PTSD or complex PTSD.

However, psychiatric medications are generally selected based on the symptoms and neurobiological systems involved — not simply based on the traditional name of the medication category.

In many cases, medications are selected because trauma may affect mood, sleep, anxiety, perception, and the way individuals respond to stress in highly complex ways.

Medication treatment is therefore often approached through a broader and more individualized understanding of psychological functioning, neurobiology, and symptom patterns.

Trauma Requires Patience, Safety, and Compassion

Working through trauma can be deeply demanding. Even subtle exploration of trauma may trigger feelings of vulnerability, helplessness, fear, grief, shame, overwhelm, or numbness, and may even temporarily increase intrusive symptoms. The process is not linear, and at times it may feel as though things are getting worse when they should be getting better.

Because of this, trauma work often requires patience, consistency, safety, and compassion — both from clinicians and from patients themselves.

In Summary

None of us is entirely immune to traumatic experiences. At the same time, trauma affects different individuals in profoundly different ways.

Providers should not place themselves as evaluators of whether someone’s experiences were “bad enough” or whether someone should simply “let go” of their trauma.

Instead, providers are asked to approach trauma with careful assessment — past and present — from the perspective of the patient’s inner reality.

Once trauma is adequately understood, meaningful treatment can occur, and patients may gradually move toward lives that are less organized around trauma.

- Helder Araujo MD PhD

Understanding Bipolar Disorder: Psychological and Biological Perspectives in Treatment

Bipolar disorder is a complex condition. It encompasses a wide array of mood changes that are collected under a single diagnostic umbrella. The heterogeneity of bipolar disorder often makes it difficult for providers, patients, and their families to feel fully contained by any single explanatory model or treatment approach.

Interpretations of bipolar disorder often fall somewhere between two broad perspectives. On one end lies a psychological model, in which depression and mania are understood as responses of an individual’s mind to internal and external events. On the other end lies a biological model, which regards these mood extremes primarily as the result of neurobiological imbalance.

Similar distinctions emerge in treatment approaches for bipolar disorder. Someone who works primarily within a psychological framework will tend to understand mood changes in relation to events and dynamics in a person’s psychological life. In contrast, someone who operates within a biomedical framework may focus primarily on neurotransmitters and neurobiological mechanisms that can be modulated in order to stabilize mood.

These perspectives do not only influence the relationship between providers and patients. They often appear within families and friends as well. Patients who feel more comfortable within a psychological framework may struggle with others who believe their difficulties should be addressed primarily through medication.

On the other hand, patients who feel more comfortable within a biomedical framework may struggle with providers who emphasize psychological work and may instead request medication adjustments in the hope of restoring their sense of normality.

There Is Nothing Intrinsically Wrong With Viewing Bipolar Disorder From One Perspective or the Other

In the past, there was considerable debate about whether excessive reliance on psychological explanations deprived patients of effective medical treatment for bipolar disorder. This concern is not unreasonable. At the same time, it is also possible to argue that providers who rely exclusively on biological explanations may deprive patients of a deeper psychological understanding of mood changes.

Fortunately, these perspectives do not have to be mutually exclusive. In many cases, combining psychological and biological approaches provides a more comprehensive understanding and a more effective form of bipolar disorder treatment.

Treatment should be individualized and evolve over time, drawing on the best available evidence. This includes not only evidence from clinical research conducted at the group level, but also the practical evidence that emerges from observing what actually works for a particular individual.

The Goals of Bipolar Disorder Treatment

Bipolar disorder treatment presents particular challenges because acute mood episodes are often what bring individuals into treatment.

Someone experiencing depression may reach out for help because they are suffering and wish to feel better again. For individuals experiencing hypomania or early mania, however, the situation is often different. These states may feel subjectively positive, which can make it difficult to recognize the need for treatment. Nevertheless, elevated mood states often produce dysfunction in a person’s environment, and eventually the individual—or those around them—may seek help.

It can be tempting to disengage from treatment once mood returns to baseline. However, treatment in bipolar disorder is not only about managing acute mood episodes. A central aspect of treatment is prophylaxis — the prevention of future mood switches.

Avoiding Depriving Oneself of Helpful Treatments

Providers should not deprive patients of treatment approaches that may complement care or prove beneficial. At the same time, a patient cannot simply demand that a provider work outside the domains in which they feel professionally competent.

For this reason, it is entirely reasonable for a person to work with both a psychiatrist and a psychotherapist, particularly when the psychiatrist does not provide psychotherapy as part of their practice.

At the same time, patients should also be mindful not to deprive themselves of helpful treatments.

Many people have understandable concerns about psychiatric medication for bipolar disorder. Taking a medication every day may feel burdensome. Some worry that medication will change who they are, impair their functioning, or create a permanent dependency. Others feel uneasy with the idea that their subjective experiences might be reduced to something that can be addressed with a pill. They may want to feel understood and therefore reject medication treatment altogether.

Psychological treatment can raise its own concerns. Engaging in psychological work often requires examining oneself closely, reflecting on one’s experiences, and confronting difficult emotions. For some, this may create the impression that all responsibility for change falls entirely on their shoulders. Some may reject psychological treatment altogether and ignore that, despite having bipolar disorder, they are still people and are not immune to life stressors and challenges. They may instead insist on medication changes at every encounter, in pursuit of a hypothetical “perfect pill.”

Both concerns are understandable, and it is important to work through them with time and patience, clarifying what needs clarification and gradually working toward a treatment approach that adds to one’s life rather than allowing bipolar disorder to interfere with the pursuit of personal goals.

In Summary

Bipolar disorder treatment requires individualized psychiatric care.

An individualized treatment involves finding a balance that respects both the biological and psychological dimensions of human experience. It also requires time—time for careful assessment, time to observe how a person evolves over the course of treatment, and time to develop strategies that support long-term mood stability and well-being.

The goal of treatment is not to force an individual into a predetermined framework, but to gradually construct—together with the patient—an understanding of their bipolar disorder and a treatment approach that is both clinically useful and personally meaningful.

— Helder Araujo, MD, PhD

Is There a Right Way?

On decision-making, uncertainty, and learning to live without guarantees

When we scroll through social media, we encounter an endless stream of videos, reels, and advice from people whose credentials are often unclear—yet who confidently tell us that we are doing something wrong and that they have the answer to the right way to do it.

There is a right way to paint our walls, a right way to grow plants, a right way to purchase items, a right way to organize our homes, a right way to eat, a right way to sleep, a right way to live.

There is even a right way and a wrong way to approach things we may never have previously thought required instruction. There is a right way to be environmentally friendly and a wrong way to be environmentally friendly. There are companies we should support and companies we should not. There are products that are “toxic” and others that are “less toxic.” The list goes on and on.

Three questions arise from this increasingly prevalent phenomenon:

• Are all decisions equally important?


• Who has the answers?


• Is there really a right way?

Not All Decisions Are Equally Important

When every decision must be optimized to achieve the best possible outcome, every decision begins to feel equally consequential. Choosing a cereal brand may carry a strange psychological intensity similar to choosing a career path. When everything feels equally important, we risk allocating our time and our mental and emotional resources indiscriminately.

Part of knowing ourselves is knowing what matters most to us. This evolves over time as we grow and our circumstances change. Still, establishing priorities helps us decide where to invest our effort and where to conserve it.

What matters most to us varies depending on many factors. Some decisions may be trivial in the grand scheme of things but touch on topics that are dear to us, where we want to exercise our subjectivity. In some cases, for example, it may not even be essential that a decision be the best possible one; it may simply need to be ours.

Once we establish priorities, we can decide how much effort to allocate. Some problems may not be ours after all, because they do not truly matter to us.

When decisions feel less important or less consequential, a coin toss—or even delegating the choice to something like a ChatGPT algorithm—may suffice.

When they feel more important and consequential, we may need to deliberate more than we initially wanted. At the same time, let us not forget the power of the unconscious. Sometimes, sleeping on it may truly help.

Prioritizing based on personal importance is only one method. We can also prioritize decisions based on time and consequences. What must be decided now? What can wait? What is truly at stake? Sometimes asking, “What is the worst that can happen?” helps us move forward—whether that means finding the right word, the right timing, or deciding whether to send that message.

Who Has the Answers?

One premise behind the overload of advice is that someone out there has the answers—not only to questions we already have, but to questions we did not even know to ask. Should we trust these people? Should we trust algorithms such as ChatGPT?

There is nothing wrong with outsourcing decisions. In fact, we have been doing it since the beginning of life. As infants, we rely entirely on others to interpret our needs. We cry, and someone else must decide what that cry means and how to respond. Our distress becomes their task to regulate. Psychoanalysts describe this process as projective identification.

As we grow, caregivers introduce rules and guidelines that help structure the world and provide safety. Over time, we notice inconsistencies. We see adults breaking the very rules they teach. We realize that rules are contextual and imperfect. We cannot wait to grow up and decide everything by ourselves.

Yet even as adults, we never fully stop relying on others. Most of us oscillate between dependence and independence depending on context and circumstance.

There is nothing inherently wrong with having someone else hold an answer for us. Some problems, for instance, may be too paralyzing and can make us feel like a helpless child. In those moments, it can be comforting to let someone else carry the decision.

At the same time, relying too heavily on others may bring problems. It may, for example, challenge our sense of agency. Excessive dependence can strain relationships by placing the burden of decision-making onto others.

On the other hand, excessive independence is not necessarily good either. Being too independent may limit our ability to ask for help or collaborate. In relationships, it may be experienced as emotional distance or rigidity.

And Let Us Not Forget Self-Discovery

Millions of people lived before us. They faced similar challenges, failures, and successes. Why should we deprive ourselves of accumulated wisdom? Few of us want to learn everything through painful trial and error.

Yet some lessons must be learned personally.

Learning about ourselves is not only about discovering what we choose; it is also about discovering how we choose. How do we tolerate loss? How do we face ambiguity? How do we respond when certainty is unavailable?

Self-discovery extends beyond the “hows” into the “whys”—why we are the way we are, why certain decisions matter to us, and why others do not.

As we discover ourselves, we clarify what truly matters to us. That clarity may evolve over time, but it helps us determine which decisions deserve our energy and which do not.

Is There Really a Right Way?

Since the emergence of life, organisms have had to distinguish effective from ineffective strategies. At a basic biological level, right and wrong can mean survival or death. As complexity extends into psychological and social life, the idea of a single right way becomes more elusive.

It is true that science and accumulated knowledge have illuminated many domains of life. In some areas, there truly are better ways of doing things. Yet, there are domains where variability and subjectivity are so great that we may never have definitive answers.

Many decisions resist absolute evaluation because they unfold over time, across relationships, and within changing circumstances.

No matter how long we deliberate, or whether we choose on our own or with the help of others, choices are entangled with loss, uncertainty, and limited control.

Choosing one path often means leaving others behind. We gain, but we also lose. We celebrate successes, yet we may grieve losses. What is more, we grieve not only concrete losses, but also imagined futures and unrealized possibilities.

With each decision, we momentarily embrace a sense of certainty. Yet no matter how carefully we deliberate, uncertainty cannot be eliminated.

Our decisions can only go so far. With each decision, we take matters into our hands and control some factors, but we cannot control everything. Outcomes depend on factors beyond us—other people, timing, circumstance, chance, or, for some, destiny.

Living Without a Single Right Way

Trusting that there is a perfect solution for every problem—or that someone else has it—is not always possible, particularly when decisions involve complex aspects of one’s life.

Eventually, there will always be areas where we are left with ourselves—along with uncertainty, losses, and perhaps regrets.

One way or another, we must learn to live with ambiguity, imperfection, and loss. Where there is life, there is death. Where there is gain, there is loss. Where there is certainty, there is also doubt.

And sometimes, all a decision gives us is that lesson.

— Helder Araujo MD PhD

What Is the Best Treatment for Me?

The search for the best treatment for mental health issues can be exhausting. It may drive you down a path of seeking multiple psychiatric opinions, reading endlessly online, and trying to reconcile conflicting advice. This process alone can become overwhelming.

The truth is that the best mental health treatment for you is what ultimately works best for you in the long run. That answer may feel unsatisfying at first, but it reflects the reality that effective mental health care depends on multiple individual variables, ranging from your biology to the kind of relationship you have with your psychiatrist or provider.

The Technical Aspects of Psychiatric Treatment

From a technical standpoint, good treatment depends on accurate psychiatric diagnosis and an appropriate choice of treatment. It is reasonable to expect that a psychiatrist, as a mental health specialist, is better equipped to diagnose mental illness and choose appropriate treatment than a health professional who is not specialized in mental health.

Choosing a psychiatric specialist is therefore essential, but that does not eliminate all the complexity and variabilityinvolved in treatment.

Not All Psychiatrists Are Alike

Unlike some medical specialties that rely on strict and highly standardized protocols, psychiatry offers a wide range of treatment approaches within what is considered standard of care. Some psychiatrists rely heavily on structured interviews and standardized questionnaires, while others make use of broader techniques that draw from psychoanalysis, relational psychiatry, and other psychological frameworks.

Both approaches can be valid. What matters most is how well a given approach fits your needs, personality, and treatment expectations.

Not All Mental Illnesses Are Alike

While diagnostic standardization is essential, over-standardization may risk losing the richness of individual experience.

The fact that two individuals are diagnosed with the same condition—such as major depressive disorder—does not mean that their illness is alike. Each depression may be uniquely shaped by an individual’s biology, developmental history, existential concerns, and current life stressors.

Depression symptoms can express themselves in many ways: in thoughts and internal experiences, and in behaviors such as sleep, appetite, motivation, and social engagement.

Not All Bodies Are Alike

If our psychology differs, the same is true of our biology. While humans are alike to a certain extent, we also harbor meaningful biological differences. These differences may seem small or subtle, but they can influence a variety of processes, such as how we think, behave, and respond to psychiatric medications. This helps explain why a treatment that works well for one person may be ineffective or poorly tolerated by another.

Not All Families and Cultures Are Alike

Family dynamics and cultural backgrounds shape how we think, feel, behave, and relate with others. Failing to attend to this cultural variability can turn a benign and culturally normative expression into something that is mistakenly labeled as a mental illness.

Understanding a person’s cultural and familial context is therefore essential to accurate diagnosis and meaningful psychiatric treatment.

Not All Treatments Are Alike

It is true that psychiatry and neuroscience still have a long way to go, and much remains unknown. At the same time, it is important to pay attention to evidence-based treatment, supported by scientific research, including higher levels of analysis such as meta-analyses.

However, no single scientific study accounts for 100% of human variability. Evidence-based practice must therefore be balanced with clinical judgment and flexibility, always aiming toward an individualized treatment plan rather than a one-size-fits-all approach.

Not All Relationships With Providers Are Alike

Therapeutic relationships vary widely, and what feels like a good fit differs from person to person. Some individuals prefer providers who are warm, inquisitive, and exploratory. Others feel more comfortable with a structured, symptom-focused approach centered on medication management.

There is no universally correct therapeutic style. What matters is whether the patient-provider relationship feels sufficiently safe, respectful, and effective to allow meaningful work to take place.

How to Make Sure You Are Receiving the Best Treatment

Setting realistic expectations is essential. Life is complex, and the mind’s processing of life can be equally challenging. Expecting “magic” solutions that eliminate all negative thoughts or feelings, or that lead to perfect thinking and behavior, is often unrealistic. Likewise, expecting that a psychiatrist is as attuned to your needs as an AI algorithm is unrealistic, as psychiatrists, like all people, are “imperfect”.

Having said that, trusting that a therapeutic relationship feels right is essential and may require some degree of comparison shopping. At the same time, flexibility is important, as the therapeutic relationship itself can become part of the treatment—even if you were convinced that all you receive from your psychiatrist are prescriptions.

For example, a person who struggles to assert their needs may avoid expressing concerns to their provider. Practicing assertion within treatment can be therapeutic.

Similarly, someone who tends to walk away from relationships at the first sign of frustration may benefit from attempting repair rather than immediate disengagement.

In fact, many providers informed by relational psychiatry and psychological theory are intentional in how they relate to patients and may base a significant portion of treatment on the therapeutic relationship itself.

Along these lines, it can be important to trust that a provider may challenge you thoughtfully and for a reason. While comfort and familiarity have value, treatment that never evolves can become stagnant. Psychological growth often requires tolerating some degree of purposeful and well-contained discomfort.

In Summary

The best psychiatric treatment is not a single diagnosis, medication, technique, or provider. It is an ongoing process informed by multiple variables—biological, psychological, social, and cultural individuality, therapeutic approach, and—most importantly—the relationship between you and your provider. Finding that fit takes time and patience, but it is often the most meaningful part of the work.

Helder Araujo, MD PhD