The Externalization of Trauma: A View of PTSD Symptoms as Healthy

Woman sitting looking sad

Individuals who are “symptomatic” of post-traumatic stress disorder (PTSD) may seem sick, crazy, or irrational. They might appear dissociative, clinically depressed, anxious, highly reactive, or rageful (or all of the above). In addition, it’s common for an individual to cultivate a sense of self-loathing for displaying these characteristics. During treatment, both therapist and survivor may agree that these symptoms are a mark of disease, making it their goal to alleviate the symptoms. Alternatively, both may choose to believe that these symptoms are an expression of health versus illness. This could enable more directed treatment, internal compassion, decreasing fear of symptoms, and a relationship between survivor, therapist, and trauma.

According to the DSM IV (American Psychiatric Association, 1994) criteria for diagnosing PTSD includes intrusive memories, thoughts, or dreams of an event, a sense of reliving the event, and intense distress in response to both internal and external cues that resemble an event(s).  Individuals may thus avoid triggers or cues, increase isolation or have a sense of ‘waiting for the other shoe to drop’ (a foreshortened future), and detachment.  Sleep difficulties are common; mood liabiality, and hyper vigilance are also common (American Psychiatric Association[DSM-IV], 1994). When a survivor feels hopeless, confused, and self-loathing because of the manifestations of their trauma, the initial layer of treatment is frequently the unraveling of self-loathing for the expression of symptoms themselves.

To begin to evaluate trauma and develop a relationship with its influence on survivors, we can draw from the practice of narrative therapy and the concept of externalizing a problem, which recognizes that the person is not the problem; the problem is the problem (Playful approaches to serious problems: Narrative therapy with children and their families. Freeman, Jennifer C.; Epston, David; Lobovits, Dean New York, NY, US: W W Norton & Co. (1997). xvii, 321 pp.). PTSD, as a character in a survivor’s life, uses symptoms as tools to protect us, remind us of our core values, and ensure that what happened before won’t happen again. The trauma response could even correspond to the level of violation on self and values; from this perspective, a profoundly disturbing event calls for a profoundly disturbing response. Flashbacks, dreams, invasive thoughts, and triggers provide specific information about the violation the client’s event(s) infringed upon them. These also exemplify the concept of “stuck points” in Trauma-Focused Cognitive Behavior Therapy (Akin-Little, Angeleque (Ed); Little, Steven G. (Ed); Bray, Melissa A. (Ed); Kehle, Thomas J. (Ed), (2009). Behavioral interventions in schools: Evidence-based positive strategies, School Psychology (pp. 325-333). Washington, DC, US: American Psychological Association, xi, 350 pp.)

The aspect of a survivor’s past that is troublesome can be quite specific and idiosyncratic. Groups of people exposed to the same event often are disturbed by different parts of it. Interpersonal trauma such as child abuse, domestic violence, or sexual assault may render someone feeling responsible for what happened to them, feeling dirty or shameful, betrayed, foolish, unimportant, or completely exposed.  Trauma might be conveying to someone that they are at fault for an assault because it wants the individual to have a sense of mastery or agency.  Helplessness is too passive, so self-blame is an acceptable tone to assume. An individual might also begin to associate a traumatic feeling of betrayal with a feeling of foolishness, ensuring s/he does not trust people too easily and maintaining inner safety.

The way in which a survivor expresses their PTSD can vary widely and presentations can be very complex and oppressive.  It is common for survivors to blame themselves for their past experiences, and they often enter into treatment with a great deal of shame because they feel they should have “gotten over it” without help. A therapist can offer some relief from shame by viewing survivors’ symptoms as useful, even critical to their treatment.

Through the process of healing, a survivor can learn to establish trust in self to clearly identify his/her core values, to reflect his/her significance in the world, and to maintain personal safety. The character of trauma will refrain from presenting images (flashbacks and dreams) when the stuck point has been identified, and will cease making statements that the individual is culpable for what happened once there is a demonstration of mastery over the event. It will hold back on invasive, persistent thoughts once the survivor is able to look at the event rather than avoiding it.  PTSD symptoms reflect individual values and provide explicit guidance for healing; if therapist and client are willing to work with trauma, and absorb the information it has to offer, it will not invade with such rigor.


© Copyright 2011 by Athena H. Phillips, MSW, LCSW. All Rights Reserved. Permission to publish granted to

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

  • Leave a Comment
  • Kyle

    December 7th, 2011 at 5:31 PM

    Personally I have always thought it would be a whole lot healthier to wear those fears and anxieties instead of always trying to hide them. That is the problem with so many people. Instead fo confronting their fears they shove them further and further down. That is not anything that is ever going to offer anything positive to one’s mental health.

  • Lisa Burns, PhD

    December 12th, 2011 at 8:19 AM

    Well done, Athena! Thank you for this fine article. I will be sharing this. I agree wholeheartedly. Lisa

  • Abigail

    February 12th, 2012 at 11:24 AM

    Dear Athena –
    I am an LCSW in New York City. I just came across your article and wanted to tell you that I really enjoyed it and agree with your “thesis.” I prefer to see my clients’ strengths and adaptive behaviors as opposed to pathologizing their difficulties or symptoms.
    Thank you for this article.
    Abigail List, LCSW

  • Kristina

    March 27th, 2012 at 1:48 PM

    I want to get better with treatment in cognitive behavior therapy (trauma focused)

  • Michelle

    July 26th, 2012 at 10:55 AM

    I think this approach can greatly enhance trauma work, especially when dealing with long-term, complex trauma issues. It creates an atmosphere in which individual trauma reactions, including long-term manifestations to the trauma response, can perhaps more easily begin to be understood by the survivor and re-framed to illicit a more positive reaction to triggering events.

  • Rick Belden

    December 9th, 2012 at 10:01 AM

    This is one of the better articles I’ve read about philosophy and treatment of PTSD. I’ve found the approach described to be very effective in my own experience. I hope it comes into wider acceptance and use so that others can benefit.

Leave a Comment

By commenting you acknowledge acceptance of's Terms and Conditions of Use.


* Indicates required field.

GoodTherapy uses cookies to personalize content and ads to provide better services for our users and to analyze our traffic. By continuing to use this site you consent to our cookies.