Shifting the treatment paradigm for trauma, an allostatic lens asks new questions & includes harm prevention at the highest levels.
After Gina returned home from serving in the Iraq war, she suffered nightmares, intrusive thoughts, and cold sweats – a few of the hallmarks of post-traumatic stress disorder (PTSD).
Walter Cannon’s nearly 100 year old homeostatic model of health asks: What is broken in this individual? What is abnormal? How can balance be restored? Homeostasis seeks to identify the problem to be fixed by returning an individual to their status quo. It may seem reasonable to think of any ailment as something broken (Gina’s nervous system), something missing (a neurotransmitter), or too much of something (like stress hormones); however, health according to allostasis is much more than addition, subtraction, fixing, and even more than about restoring balance. Health is about responsiveness at every level.
Homeostasis, with its attempts to fix the disruption in a feedback loop, fails to account for the interconnection within and between complex biological and social environments. It has also led to a medical culture of “precision medicine” focused on molecular level treatments (like medications) that can distract us from seeing answers right in front of us – missing the forest through the trees. This level of treatment does little for long-term relief and sends the message that Gina is broken, when her nervous system did exactly what it should have done. It was highly responsive to extraordinary events.
Broadening this perspective for trauma, allostasis asks new questions:
What has the individual’s nervous system learned to anticipate? (danger/harm)
What societal systems influence this and how? (lack of support/normalize harm/allow harm to continue)
What will lead to individual and social repair, and growth?
How can trauma be prevented in the first place?
Research investigating predictors of individual resilience still places the emphasis on building up individuals to withstand more trauma. While this may be important and “more research is needed,” what we know already about people and trauma is enough to do better now and this includes preventing known causes of trauma that are directly related to adverse health consequences (violence, poverty, etc). Treatments would then shift from a focus on medicating symptoms to a more inclusive interconnected approach at all biological, psychological, and social levels: cellular, organ, person, community, country, & world society.
Regarding trauma, a paradigm shift from the old molecular and mechanical view (homeostasis) to a context-inclusive and systems view (allostasis) would include these 6 changes. Allostasis:
#1 Views health on a continuum and avoids categorically labeling a person or brain as normal or disordered, sick or well, thus shedding the “D” for disorder of PTSD, leaving it PTS (post traumatic stress) (Lee, 2019).
#2 Views health and illness as a dynamic process that continually oscillates on this continuum – every second of every day. Again, not categorical.
#3 Appreciates that the nervous system is adapting to protect the individual in the most optimal way it can. When trauma is viewed as a rupture in basic safety of an individual in their environment, the dis-order is normalized and treatment is a collaborative process to restore connection, safety, and meaning.
#4 Views the brain as central, but appreciates the impact on all other systems. Allostasis easily predicts that the individual with PTS is at risk for other chronic conditions (comorbidities). All systems within a person, family, community, and society are impacted by the harm caused to the individual. An allostatic view assesses not just the burden of the individual on the community's resources, but society’s burden on the individual.
#5 Informs treatment to include social repair at every level. Since treatment for PTS includes restoration of trust in self and others, socio-political topics cannot be ignored when addressing health in this holistic, non-mechanistic way. With allostasis, cultivating trust among its people becomes a fundamental goal for social and political systems.
#6 Promotes healing and post-traumatic growth for the individual after trauma. Allostasis views adaptive processes as constantly changing, which means growth for the individual after trauma. We heal and grow individually and collectively through appreciating ourselves ("I survived that"), meaning making, creative endeavors, participating in a community (social connection as we determine for ourselves) and spiritual practices (as we see fit).
In this more holistic view, trauma care must also prioritize preventing known causes of harm such as violence and social exclusion. This means preventing war, hate crimes, discrimination, and marginalization, as well as holding accountable the societal structures that serve consumption and capitalism over people. The shared primary goal would be empowerment of all citizens toward collective solutions and shifting resources to support all people to drastically improve health and prosperity for all.
Further reading:
Del Pozo, J. (2022). The Crisis of Despair in the United States, shared with permission of The Los Angeles Psychologist, a publication of the Los Angeles County Psychological Association.
Lee S. (2019). A Copernican Approach to Brain Advancement: The Paradigm of Allostatic Orchestration. Frontiers in human neuroscience, 13, 129.
Sterling, P. (2022). A Neuroscientist Evaluates the Standard Biological Treatment for Depression.