Toward a Working Definition of Medical Trauma

When we first began researching patient experiences with medical trauma several years ago, we were struck by how little we saw the term “medical trauma” in the research and throughout the Internet. Most of the literature on trauma related to the medical setting has centered on “trauma medicine” and included topics such as specific clinical procedures and best practices for working with patients who have experienced various traumas outside of the medical setting (i.e., serious accidents). From countless conversations about medical trauma with health care professionals, we have realized that the idea that a patient could experience psychological trauma resulting from contact with the medical setting—the very place where people come to be healed—was intriguing to them at best and incredulous to them at worst, especially regarding trauma for adult patients. Despite the numerous research studies that focus on the effects of specific medical traumas (e.g., cardiac arrest) and that use the term “medical trauma,” we have not seen a useful or descriptive definition of the phenomenon; therefore, given the absence of a general working definition of psychological medical trauma, we felt it important to draft one. Note that this definition and the model of medical trauma we discuss in this book refer to the emotional and subjective experience of trauma rather than the complex physiological responses to trauma. For a detailed review of how trauma affects multiple systems within the body, see Desborough (2000).

Definition of Medical Trauma

Medical trauma is a trauma that occurs from direct contact with the medical setting, and develops through a complex interaction between the patient, medical staff, medical environment, and the diagnostic and/or procedural experience that can have powerful psychological impacts due to the patient’s unique interpretation of the event.

Let us break down this definition into its distinct components. First, in using the term direct contact, we attempt to initially define medical trauma for the patient (the phenomenon of vicarious medical trauma, in which family, friends, and medical staff can have a traumatic stress response to a patient’s experience, is another important dimension worthy of attention but not a focus of this book). Second, medical trauma occurs through contact with the medical setting. The term “medical setting” can refer to any aspect of direct experience with the health care system, from spending time in the hospital for treatment of an illness, injury, or procedure; visiting an ambulatory surgery center for an outpatient procedure; visiting an outpatient physician’s office for ongoing treatment of a chronic or life-threatening illness, such as an autoimmune disease or cancer; visiting the dentist’s office for the first time in 15 years; or getting an annual pelvic exam at an OB-GYN’s office. These are but a few examples of the many health care experiences patients face on a daily basis at acute care (hospital) facilities, ambulatory surgery centers, testing centers, and outpatient medical and dental offices. Third, medical trauma develops through a complex interaction of multiple factors, including the patient, medical setting (including interactions with the staff and the environment), and the diagnosis or procedure. It is important to note that, while medical trauma is a subjective experience, the subject (patient) is not the only factor in the equation. In other words, a patient does not experience medical trauma simply because he or she has a predisposition for experiencing a medical event as traumatic: There are many characteristics of the medical environment, staff, and diagnoses/procedures that can influence a patient’s response. Fourth, medical trauma can have powerful psychological impacts, from the development of clinical and subclinical mental health issues to affecting the health of relationships, sense of self, the body, work, leisure, and spiritual life. Lastly, the patient’s unique interpretation of the medical trauma is a key to understanding the overall impacts of the experience. Meaning-making is at the heart of the medical trauma experience.

You might still be wondering how or even if medical trauma might differ from other forms of trauma, especially if we remove the context of the medical environment. Is the experience and maintenance of medical trauma symptoms any different from the traumatic stress response and ensuing psychological sequelae from other kinds of traumatic experiences? Donald Edmondson’s (2014) work examining life-threatening medical events and PTSD has yielded the Enduring Somatic Threat model, a theory which differentiates medical trauma from nonmedical trauma in several compelling ways. First, Edmondson argues that nonmedical traumas and PTSD are in response to a discrete event in one’s past, while medical trauma reactions endure because the threat (of disease, pain, and even death) is located in one’s own body. Second, for many who experience a life-threatening medical event, ongoing medical care and monitoring are required in order to avoid subsequent events (e.g., heart attack and stroke). While many psychophysiological triggers of trauma could potentially be avoided in cases of nonmedical trauma, patients who experience life-threatening medical events can be retraumatized with ongoing medical care that can contribute to symptoms of hyperarousal, reexperiencing, and avoidance. Edmondson (2014) exemplifies this point when describing a patient’s experience of cancer, suggesting that the trauma arises not because of a singular event, but rather from the emotional experience and vulnerability inherent in having this life-threatening disease. Third, Edmondson argues that a real and present danger associated with medical trauma is the influence of the traumatic stress response on subsequent health behaviors and overall health, as the perception of an ongoing threat can impact blood pressure, heart rate, sleep, and inflammation—all of which are risk factors for subsequent life-threatening medical events.

We revisit the concept of enduring threat and how it can maintain medical trauma symptoms in Chapter 3, but now we continue to build on our definition by addressing some of the characteristics of medical trauma that may exemplify its uniqueness as well as help us understand why it has in some ways been “off the radar” in terms of broader conversations about whole-person care. In order to deepen our understanding of medical trauma, we expand our definition to highlight that medical trauma is subjective for the patient; best understood as being on a continuum; biopsychosocialspiritual in both the experience and in the effects; contextual; and relational.

Medical Trauma Is Subjective

While many trauma researchers study reactions from events universally thought of as traumatic, such as the effects of war, violence, or natural disasters, some contemporary scholars have turned their attention to trauma experienced in everyday life and the importance of subjectivity in the interpretation of the experience. Scaer (2005) and Levine (2010) both speak of their own traumas and how these experiences shape their perspectives and understanding of trauma as subjective. In The Trauma Spectrum, Scaer points to his experiences of medical trauma as a child as being particularly poignant, and argues that trauma exists on “a continuum of variably negative life events occurring over the life span, including events that may be accepted as ‘normal’ in the context of our daily experience because they are endorsed or perpetuated by our own cultural institutions” (p. 2). He continues by asserting that whether or to what degree these negative life events are perceived as traumatic depends upon how they are interpreted by the victim—in other words, if a person experiences an event as traumatic—it is trauma. These points strike at the heart of our understanding of medical trauma, for the subjectivity of this type of trauma is one of its most important characteristics.

In other words, medical trauma is not black or white, nor is it easily detected if we are not partnering with patients in order to understand their experiences. Because the interpretation of medical experiences as traumatic is not something we as clinicians can objectively ascertain without talking with the patient (i.e., we cannot objectively label a patient’s experience as traumatic or not traumatic simply because they received X diagnosis or Y procedure), we should be careful to avoid attempts to characterize the effects of a medical experience without first understanding the patient’s point of view.

Medical Trauma Exists on a Continuum

From the standpoint of assessment, we should approach medical trauma as if it could occur for patients at any point in the care delivery process. While we certainly cannot account for every patient’s moment-by-moment emotional response to medical experiences, we can target specific kinds of medical experiences that are more likely to have psychological effects and intervene appropriately. In terms of building a model of medical trauma, we organize these specific kinds of medical experiences in three levels, moving along a continuum from greater to lesser threat to life: Level 3, or medical emergencies; Level 2, or life-threatening/life-altering diagnoses; and Level 1, or planned/routine medical care. Although we discuss medical trauma in terms of these three levels or categories, we see these categories as being fluid and easily traversed. For example, a patient who has a heart attack (Level 3) and who has a traumatic stress response and ensuing, ongoing psychological effects could continue to struggle through his or her follow-up care (Level 2) to the point that every contact with the medical setting—even a trip to see a family physician for a sinus infection—could ignite acute reexperiencing and hyperarousal of the trauma (Level 1). We examine this model in more detail later in this chapter.

Medical Trauma Is Biopsychosocialspiritual

Through the work of trauma researchers and our increasing understanding of neuroscience and the brain, our body of knowledge about the complex effects of trauma is growing at a remarkable pace. From leading researchers on trauma, we understand what happens in the body and mind when the sympathetic nervous system, or more specifically the hypothalamic–pituitary–adrenal axis (HPA), is activated in response to stress and attempts to regulate the body, as well as what can happen if this activation becomes a patterned response to stressful stimuli. Further, we know the damaging effects of the traumatic stress response and excessive amounts of adrenaline and cortisol flowing through the body, especially in those individuals who develop PTSD.

Like other forms of trauma involving a direct connection to the body, medical trauma happens at multiple levels:

By viewing medical trauma holistically, we can improve our ability to assess how patients are experiencing their compromised health in the context of the medical setting. Given our earlier discussion of the subjectivity of medical trauma, we know that not everyone is going to experience a physical diagnosis or procedure as traumatic; in fact, the majority of people may not. For those who do, it is important to remember that the traumatic stress response can happen not only because of the patient’s unique psychophysiological response, but also due to the qualities of the health care environment—or its context.

Medical Trauma Is Contextual

Studies of the effects of medical trauma often focus on specific factors of the patient: Preexisting mental health problems, past history of trauma, and personality factors are but a few topics addressed in the literature about medical trauma. It is important to remember that medical trauma, while subjective, does not happen in a vacuum. A medical experience is not traumatic simply because a patient has a vulnerability or predisposition to being traumatized; in other words, having been traumatized by a medical event does not denote weakness on the part of the patient. There are a number of other factors that can influence a patient’s experience of a medical event as traumatic, one being the context of the medical environment. Qualities of the setting, such as lighting, unfamiliar or frightening objects, sounds, and scents, as well as uncomfortable furniture are but a few examples of how environmental factors can influence a patient’s psychological response. Further, protocols within the medical environment that can increase a patient’s feeling vulnerable—such as waiting for a procedure alone in a hospital gown without one’s clothing—can heighten stress and leave someone susceptible to intense emotional reactions. How medical staff members communicate with patients and their overall sensitivity to the unique situation of the patient constitute other important factors in a patient’s overall experience of a procedure or ongoing care with a chronic diagnosis. In sum, the environment and staff create a context for each episode of care that can either subtly or greatly impact patients’ experiences.

Throughout this book, we explore the many factors that make up the context of medical trauma, and how characteristics within the medical setting can contribute to the experience of medical trauma. Beyond the medical environment, another contextual factor that is highly influential in a patient’s experience is the context of the relationship between patients and providers.

Medical Trauma Is Relational

While some traumas occur outside of human relationships (for instance, a man sustaining injuries from a car accident caused by black ice or a woman who sustains serious injuries by slipping on rubble while hiking, causing her to fall several feet), medical trauma is often a relational trauma in that it occurs within the context of the patient–provider relationship. This is an important distinction and one that adds to the complexity of trauma experienced in the medical setting. The quality of the patient–provider relationship is foundational to the patient experience and rests upon the ability of a provider to build rapport, inspire and earn trust, and communicate care and respect. When a medical trauma occurs, the patient–provider relationship can become fractured; if a medical trauma remains undetected and goes unaddressed, the patient–provider relationship can suffer as a result.

The patient–provider relationship is a unique one. While much attention is paid to achieving a patient-centered health care experience, there is some debate about what that means and how to achieve it. Although we have made strides to move away from paternalistic care in favor of collaboration, regardless of our efforts a power differential always exists in a helping relationship. Despite the empowerment that can come from knowledge gained in this age of online information gathering, the fact remains that a patient submits himself or herself to the skill and expertise of a provider, especially in disempowering situations such as surgery or an invasive procedure. The fact also remains that in a helping relationship, there is vulnerability for the person seeking help and great responsibility for the person giving it.

Disenfranchised Trauma

As a result of the silent suffering experienced by some patients, medical trauma can be thought of as a disenfranchised trauma. For our purposes, we are using the term “disenfranchised” to simply mean unacknowledged. You might already be familiar with the term “disenfranchised grief,” which is sometimes used to describe grief that a woman may experience after having a miscarriage or an abortion, or the grief following the death of a pet. When grief is disenfranchised, it is not discussed or acknowledged sometimes because the person grieving fears that people may not understand or that they may minimize the pain or suffering he or she is experiencing. For example, a few weeks ago I had dinner with a friend who shared with me the sad news that her cat had died. She told me the story of how she had to make the heart-wrenching decision to end her pet’s life and then shared details of the experience. At the end of her story, she said that she had not told many people because she knew that most people “wouldn’t understand” (and she knows how much I love my pets, and it probably did not hurt that I am a counselor, so she could at least expect an empathic response). It really struck me in that moment how vulnerable she was in her grief, and how disenfranchised some forms of grief can be. I thought back to the countless times clients would tell me—often with much trepidation—about abortions, miscarriages, divorces, and other experiences that are sometimes invalidated or minimized by others. Just as some grief can be disenfranchised, so too can trauma be invalidated or remain unacknowledged. Medical trauma can be one such trauma.

You might be wondering why we view medical trauma as being disenfranchised. The fact that we are well into the 21st century and, despite the abundance of books written about trauma, this is the first book dedicated solely to the topic of managing the psychological and emotional impacts of this unique trauma, is the first reason. Second, it has only been in the past few years that we have even seen the term “medical trauma” used; just a few years ago when Googling the term, I (Michelle) would consistently see resources related to trauma medicine, not medical trauma. The only exception to this was the National Child Traumatic Stress Network, which uses the term medical trauma, but only as it relates to children and their families. This was curious to me, and it would have given me pause to wonder if adult medical trauma actually existed, except for the fact that I experienced an extreme medical trauma and am still managing its effects over 10 years later. It is through this experience that my intense interest in researching medical trauma has grown, and it is from this experience and through countless conversations with others that I have learned that medical trauma is disenfranchised.

How does medical trauma go unacknowledged? There are many factors that can contribute to this, with patients, families, and providers playing roles in the issue. First, despite some efforts to provide more integrated services at primary care, specialty care, and hospital settings, the focus of care is overwhelmingly on the physical body: We see this in the information given at discharge, which often addresses only the physical implications of an episode of care; we hear it in conversations with providers and family members, who inquire about level of pain and physical discomfort; and we see how patients’ emotional discomfort can become eclipsed by physical distress and pain. The result of this lack of acknowledgment of the psychological implications of medical treatment is that it remains off the radars of providers, family, and perhaps most seriously, the patients themselves. Furthermore, because the stigma for seeking mental health treatment is very much a reality in the lives of many patients, psychological distress and emotional consequences of medical trauma can remain unacknowledged, perhaps permanently.

What Is the EP?

When you see the word ecology, what comes to mind? For most of you, ecology has to do with the natural world, and more specifically, the environment. In basic terms, ecology is the study of relationships between living things and their environments. It seems logical that this would apply just as aptly to people as to animals, plants, and the like, and in the 1930s, psychologists borrowed the tools of ecology and began applying them to human behavior. Lewin (1935) did just that and created a formula, conceptualizing human behavior (B) as an interaction (f) between a person (P) and his or her environment (E), whereby indicating the complexity of interplay between the factors within a person (e.g., thoughts, emotions, traits, values, attitudes, personal history) and his or her context (i.e., the physical environment and sociocultural forces within the environment). The following is Lewin’s now well-known formula or heuristic to represent the relationship:

$$B=f(P,E)$$

While the EP is an incredibly detailed and complex theory, we present it briefly here in order to illustrate a simple point: Behavior is contextual, and there are often multiple factors—both from a person and from his or her environment—that influence his or her thoughts, feelings, and actions.

Beyond Lewin’s formula, there are other aspects of the EP relevant to our exploration of medical trauma. An example would be the conceptualization that our environment is composed of multiple systems (or contexts) of varying degrees of direct and indirect influence on our everyday lives. Bronfenbrenner (1979) first presented the concept of nested systems or environmental contexts using concentric circles, wherein the innermost circles represent environments more proximal, and therefore influential to an individual (such as school, workplace, or church) and the outermost circle represents more distal influences, such as mass media, the global environment, and other sociocultural forces. In this model, multiple systems make up the entirety of our environment (Figure 1.1).

FIGURE 1.1:

Bronfenbrenner’s ecological model.

At the center we see the individual, whose personal characteristics, including personality, physical features and health, development, history, thoughts, feelings, and behaviors interact to create each unique person. Moving beyond the person, we see the most proximate system of influence in his or her life, or the microsystem. The microsystem includes family and friends, place of work, school, the local community, and places of worship—and represents the context in which individuals play multiple roles and engage in dyadic interactions (e.g., spouse, coworker, parent, and friend). Beyond the microsystem is the mesosystem, which represents the connections between elements in the microsystem. In the context of the medical setting, the mesosystem can be the interactions between family and health care providers. The exosystem represents a larger social system in which the individual does not directly participate but from which an individual can benefit or by which an individual can be affected. For example, the community and its resources, neighbors, local industry, and media are elements in the exosystem. Finally, the macrosystem includes the cultural context that is removed from the individual but still affects him or her, such as cultural attitudes or beliefs. The EP purports that people exist not in a single context but in multiple, nested systems much akin to the Russian stacked dolls where the smallest doll in the very center represents each person within his or her multiple, nested contexts of varying proximity and influence.

The EP provides a nice platform on which to build a model for understanding medical trauma due to the complex interactions between patients, staff, the medical environment, and medical experiences. The salient factors that exist within an individual patient, such as risk and protective factors, tolerance for the medical environment, and issues of identity (Chapter 2), as well as the many environmental forces at play, such as the physical environment of the medical setting (Chapter 3) and the medical staff (Chapter 4), create a complex interaction that influences how patients respond to a medical diagnosis, procedure, or event (Chapter 5). The EP reminds us that behavior is complicated, and that people exist in unique contexts that affect them and that are affected by them.

The Importance of Meaning-Making

In our earlier examination of the characteristics of medical trauma, we asserted that medical trauma is a highly subjective experience; in other words, a person’s unique interpretation of his or her medical experience plays a central role in how that person thinks, feels, and acts in response to the physical sensations of an illness or intervention, behavior of staff, and aspects of the treatment environment. In terms of the EP, this subjective interpretation is understood to be a person’s meaning-making. Each patient experiences the medical environment, diagnoses, procedures, interactions with providers, and adjustment following health care treatment in varied and unique ways, and it is really a person’s meaning-making that drives his or her emotions, decisions, ability to cope, and behaviors throughout life.

In order to assess how a medical experience has impacted a patient, we must work to understand its meaning to them and for them. Later in this book, we present tools to help providers ascertain patients’ meaning-making, or their unique interpretations of their diagnoses, treatment experience, and implications for their future health and well-being.

Four Factors of Medical Trauma

While we recognize the complexity of medical trauma and acknowledge the difficulty in simplifying the interactions among numerous contributing factors, we can at least begin by exploring the major categories within the formula that seem to account for the variables. While we explore each of these factors in detail in the next four chapters (Chapter 2, Patient Factors; Chapter 3, Diagnoses/Procedures; Chapter 4, Medical Staff; and Chapter 5, Medical Environment), we provide a brief introduction to each of the factors in the following.

Medical Trauma Factor: The Patient

We have already discussed the subjective nature of medical trauma, and how little we should assume about the unique experiences and interpretations of the patient. We learned about the importance of meaning-making within context, but what factors contribute to patients’ interpretations of medical events as being traumatic? There are numerous variables we can explore regarding the uniqueness of each patient, but some factors seem to significantly influence a person’s reactions to medical diagnoses/procedures, staff, and environment. From personality traits such as the Big Five (i.e., openness, agreeableness, conscientiousness, extraversion, and neuroticism), past history of trauma, and preexisting mental health conditions, patients’ predispositions and histories can increase the likelihood of their experiencing a significant medical event as traumatic; conversely, patients bring protective factors to the equation, be it their resilience, hopefulness, strength, and/or optimism.

FIGURE 1.2:

Ecological model of medical trauma.

Medical Trauma Factor: Diagnoses/Procedures

While it is true that a patient could experience any diagnosis, procedure, or medical event as traumatic, some circumstances could be considered more likely to trigger a traumatic stress response. For the purposes of this book, we focus on diagnoses that can have chronic, life-altering effects or that can be life-threatening, as well as emergency procedures and events that can present a threat to life and well-being. Recognizing that some patients can be predisposed to having a traumatic stress response to even routine medical care, we suggest providers view medical trauma as being on a continuum with various levels according to the specific medical experience and the unique interpretation of the patient. Along that continuum we can plot three distinct levels of medical trauma, recognizing the interrelationship between all levels.

Level 1: Planned or Routine Medical Procedures

In a Level 1 Medical Trauma, patients can experience psychological distress as a result of medical procedures or office visits that are planned (e.g., a scheduled outpatient surgery or in-office procedure such as a pelvic exam). While the actual threat to life or well-being may be extremely low to absent in these circumstances, patients can interpret such experiences as threatening or stressful, especially with prior history of traumatic medical experiences. Whether they are triggered by some aspect of the setting, the actual procedure, fear of pain or discomfort, prior history of trauma, or by any number of other risk factors, patients’ unique interpretations are important for providers to understand because they can impact overall health in many areas of life. Furthermore, in many cases the real effects of a Level 1 Medical Trauma do not manifest until after patients leave the medical setting, making follow-up care that much more critical. In Chapter 6, we present the case of Keith who experienced a Level 1 Medical Trauma.

Level 2: Life-Threatening/-Altering Diagnoses

Level 2 Medical Traumas, which include life-threatening diseases and/or chronic, life-altering diagnoses, can have a profound effect on patients’ lives and psychological well-being. The Agency for Healthcare Quality and Research has labeled 15 of these conditions as a “top priority” because they “affect many people and account for a sizable portion of the national health burden and associated expenditures” (Institute of Medicine [IOM], 2001, p. 10). The 15 top priority conditions that make up Level 2 Medical Traumas are:

Cancer

Diabetes

Emphysema

High cholesterol

HIV/AIDS

Hypertension

Ischemic heart disease

Stroke

Arthritis

Asthma

Gallbladder disease

Stomach ulcers

Back problems

Alzheimer’s disease and other dementias

Depression and anxiety

Of these 15 top priority conditions, we would venture to guess that only the last disorders in the list—depression and anxiety—are consistently treated using an approach that integrates mental health professionals into the health care treatment team and vice versa. There are great opportunities to improve how we care for the whole person with respect to these chronic and potentially life-threatening diseases, which we explore later in this book. We present an example of a Level 2 Medical Trauma in the case of Sharon in Chapter 6.

Level 3: Medical Emergencies

Level 3 Medical Traumas are perhaps the most obvious medical events that could trigger a traumatic response, given their critical nature. Most objective observers would readily understand how and why a patient may have a traumatic stress response to a medical crisis, especially one that is life-threatening. Events such as heart attacks, strokes, accidents, emergencies requiring surgery, and childbirth traumas (e.g., postpartum hemorrhage), during which a patient is cognizant of the potentiality of his or her death and conscious while experiencing life-saving procedures that may be painful, can be traumatic for patients, their families, and even providers. Regardless of how obvious the traumatic nature of an event may be to patients, families, and providers, this awareness does not always translate to ensuring that patients are assessed for psychological distress and that they receive mental health intervention. We explore a Level 3 Medical Trauma in Chapter 6 through the case of Ann.

While the levels of medical trauma include many kinds of health care experiences, it does not necessarily mean that patients who have these conditions or who experience these events will necessarily have a traumatic stress response or even that they will struggle to adjust following the experience. Figure 1.3 illustrates the continuum of medical trauma, plotting each level of trauma according to the actual threat to life and well-being and the patient’s subjective interpretation of the experience. Notice the diagonal line of intervention, which suggests mental health intervention for medical trauma, and prevention and wellness for patients who experience less psychological distress.

FIGURE 1.3:

Three levels of medical trauma.

It should be noted that patients can experience trauma at each point on the care continuum, depending on his or her unique medical history. Consider a patient (John), who suffers his first heart attack (Level 3 Medical Trauma) and who has a traumatic stress response to the event. Following a brief hospital stay, John is discharged from the hospital with the knowledge of his diagnosis: coronary artery disease. As a result of his life-threatening medical diagnosis (Level 2 Medical Trauma), John is now living with the possibility of having additional heart complications and feels a looming threat with regard to his physical health and safety. John will have to continually monitor his health, which will require regular visits to his physician and cardiologist. Given his acute experience and the ongoing challenges of living with a life-threatening disease, even visits to his primary care physician (Level 1 Medical Trauma) trigger an intense psychological response.

Most research on medical trauma has explored the effects of specific medical events and diagnoses on various psychological domains and on the development of PTSD, sometimes isolating certain risk factors and qualities of the patient. Although fewer studies have examined characteristics of medical staff and how providers can influence the psychological state of patients, we feel it is important to examine such characteristics and how they contribute to the patient experience of medical trauma.

Trauma and Clinical Disorders

Consequences of Medical Trauma: Primary and Secondary Crises

In addition to the subclinical and clinical mental and emotional responses to medical trauma, patients can also experience crises as a result of medical conditions and procedures. We organize these crises in two levels: primary crises, which are immediate physical and emotional effects of a medical trauma; and secondary crises (Hall & Hall, 2013), which result from primary crises and develop through patients’ meaning-making and unique context. In our personal and professional experience, many primary and secondary crises of medical trauma can often be overlooked—by medical providers, patients, families, and even mental health professionals who will likely recognize the crisis but may or may not make the connection to the patient’s medical experience.

The following section introduces these crises and provides brief examples of how they might manifest in different levels of medical trauma. We have conceptualized these primary and secondary crises according to categories of wellness, recognizing that medical traumas can compromise wellness in all areas of life: A life-threatening or chronic diagnosis can have dramatic impacts on our bodies, emotions, spiritual well-being, relationships, development, identity, work, leisure and lifestyle, finances, and sense of self. We explore each of these in this section, as well as in Chapter 6 through case studies. We begin with the physical crisis, which can become the first domino in a cascade of crises in a patient’s life following the experience of a medical trauma.