Trauma, Loss and Chronic Discord cause emotional pain and psychological injury that result in depression and anxiety, fueled by Guilt, Shame and Anger.

1. Emotional Pain and Psychological Injury
Much is written on the effects of trauma in its various forms and circumstances. Unresolved, we believe it
to be cumulative and corrosive. What’s more, we can measure the physical consequences of the
associated stress and the psychological toll on emotional health. Several models exist for describing it
with many finely differentiating one form from another; each having its corresponding descriptors and its
consequent expressions in behavioral and emotional terms. All can lead to complications in mood, such as
anxiety, depression, rage, shame, and guilt or in one’s sense of self, security and beingness in the world:
Accidents, Natural Disaster, Illness, Injury
 Accidental Physical Injury
 Fire
 Industrial Accident
 Work Accident
 Invasive Medical Procedures
 Injury or Illness
 Motor Vehicle Accident
 Natural Disaster
 Property Loss
Threat or Harm to Others
 Death of a Loved One
 Injury or Illness of a Loved One
 Threat to a Loved One
 Witness to Violence
 Suicide of a loved one
Threat or Harm to Self
 Adult Sexual Assault
 Captivity
 Childhood Sexual Abuse
 Combat & Military Sexual Trauma
 Communal Rejection (Scapegoating, Shunning)
 Cults and Entrapment
 Domestic Violence
 Physical Assault
 Rape
 Robbery
 Sexual Harassment
 Threat of Physical Violence
 Torture
 Victim of Crime
 Victim of Violence
 Witnessing Traumatic Event
For the purpose of psychotherapy, I prefer to regard such injury as “emotional or psychological pain” and
speak of three different categories based on their prevailing characteristics: Trauma, Loss and Chronic
Discord. It assists me in thinking about the way that pain is experienced and of the best possible way of

2. approaching it for treatment. Since the extent of harm is ultimately unique to the individual, segregating
injury in such a manner is for conceptual and instructive purpose.
The table below highlights the most salient features of each.
Psychological injury typically is associated with strong feelings of Guilt, Shame and Anger. Injury results
in one believing that they have been targeted or that they have somehow failed to adequately protect
themselves. The sense is that I incurred the injury because I am somewhat less able or capable, with the
resulting belief being that one is less worthy; either because they have done something wrong, did not do
something right, or are more vulnerable in some manner or way.
In Foundations of Adlerian Psychology, Rudolph Dreikurs posited that one’s sense of worth, their self-
esteem, was inextricably tied to one’s valuation by others and that when that estimation was found
wanting symptoms developed to protect one’s belief about their self: “The purpose of a symptom is to
safeguard against the danger of discovering one’s own lack of value.” The premise that we gauge our
worth, and thereby our place within the social milieu, by the opinion of significant others is of great
consequence to the development of one’s personality and sense of well-being. When one is less-than, they
invariably experience rejection and shame. Their actions and behaviors are then wanting, resulting in
feelings of guilt. As the source of this pain is identified in the opinion or actions of others, it gives rise to
anger and resentment. As these feelings and thoughts are typically reconciled on an ongoing basis, it is
those of greater consequence, that when unresolved, are of particular interest to the therapist. It should
also be noted that the Shame and Guilt, then Anger, triad is an inter-dynamic pattern that results in beliefs
of helplessness and feelings of worthlessness; a repeating pattern of continual rumination of one’s failure
Emotional Pain - Demetrios Peratsakis, LPC, ACS © 2017
Type Feeling/Tone Distinguishing Feature Preoccupation Injury Symptoms
___________________________________________________________________________________________________________________
Trauma Vulnerability Fear; Need for Safety Avoidance Trust; Intimacy Anxiety/Depression
Loss Emptiness Grief Replacement Trust; Intimacy Anxiety/Depression
Chronic Discord Power Struggle Rage; Betrayal Revenge Trust; Intimacy Anxiety/Depression
 Emotional pain is fueled by Guilt, Anger, and Shame (GAS). Tapping the underlying Anger lifts the Depression and Anxiety.
 It diminishes our sense of Worth, which is inextricably tied to others.
 Unresolved, we seek remedies that circumvent the pain but that may not reconcile the injury.
 Perhaps the greatest injury is borne by betrayal.

3. or lacking in status or character. Naturally, much can occur to break this sequence and mitigate its
corrosive effect: the support and caring of others, resiliency factors in one’s life, one’s own recuperative
efforts to right one’s perspective and beliefs about the event, spiritual and religious belief, and counseling
and psychotherapy. Often the therapist encounters the reverse: the results of painful circumstances in
early life, chronic distress, and harm from overwhelming events too devastating to fully reconcile or
arrest in their impact. The underlying Guilt, Shame and Anger reverberate until some resolution is found.
Trauma
Trauma, while an all-inclusive term in much of the literature, it connotes a sudden happening for a
defined period of time and affirms the prevailing sentiment that “something terrible has happened”.
Natural and made-made disasters fall into this category, as does victimization, accidents and sudden
medical and physical injuries. There is a shock element as the root cause is often unforeseen or occurs
with such immediacy as to provide little or no prior preparation. This is an important distinguisher; while
one may feel they could or should have been better prepared, the clear lack of foresight to self-protection
reduces the likelihood, and probable extent, of any feelings of shame or guilt. There is, typically, less
blame from others. Severe trauma can in a pervasive sense of worry or angst about one’s one
vulnerability. Where the source is clear or generally recognizable the over-riding sensation is fear; where
the source is unidentified, the generalized sense of threat is called anxiety.
Loss
Loss is a very complex mix of sadness feelings and thoughts. It has many forms, including loss of a loved
one; loss of a valued possession; loss of prestige, job, status or lifestyle; loss of a familiar way of being;
loss of a body part, function or ability; and, loss of a directing goal.. Different kind of losses can affect
each individual differently, depending on the role the individual or status, or object played in the
individual’s sense of self and their own sense of prestige. Pain is typically in proportion to the level of
intimacy or the degree of interdependence that existed prior to the loss. It also matters if the loss allows
for some sense of closure and whether the loss is shared; ambiguous loss is particularly demoralizing for
its lack of closure and finality. All loss increases one’s own sense of vulnerability and possibly even sense
of mortality. Because loss tends to leave one feeling empty and hallow, the tendency is to replace,
substitute or fill the void as readily as possible. This can result in problems, as the new attachment may be
premature, hurried or not appraised with the same degree of scrutiny or balance. Attempts to fill the
absence may be the result of one’s effort to negate their lack of control over others or circumstances, or
may be a form of denial of the inevitability of one’s own non-beingness and death. When the loss of a
loved one causes recurring distress, guilt and remorse fuel a long string of “I should have” and “I should
have not” preoccupation; the ensuing guilt transforms to shame for not having done a better job.
Chronic Discord
In many ways chronic discord, perpetual battle or enduring conflict with others is the most insidious form
of emotional pain and injury. It involves a breach of the basic trust agreement between intimates and,
typically, involves acts of retaliation and purposeful injury of another. It results in a continuous power-
struggle that erodes the trust and intimacy in the relationship, reduces cooperation and can make for
bitterness and suspicion, often generalized to others. Where the power-struggle degrades into a stalemate,
hurtful action may be taken to breach the impasse; this can include overt acts of violence and abuse,
bullying and denigration, or covert forms of punishment such as infidelity, incest, addiction, self-harm
and suicide. It may also result in extreme distancing such as emotional cut-off, eating disorders, criminal
acts or delinquency. One’s own conduct results in shame and guilt, while the behavior of the other, in

4. anger, resentment and rage. Where hurt is extreme and the ability to express anger thwarted, more passive
aggressive forms of retaliations may be taken such as depression, illness, inadequacy and abject failure.
Treatment Considerations
While there are countless safety, security and healing measures that can be taken, exploring the
individual and the family’s feelings of guilt and shaming are paramount. The distortions that arise must
be challenged and put to rest.To alleviate the accompanying anxiety and depression, the therapist must
tap into the underlying anger and resentment by first giving it recognition and then giving it voice. Often,
these feelingsare targeted at a specific individual or group; bring them to the forefront and expose or
exorcise their ghosts.
When anxiety or depression is so severe as to preclude sufficient opportunity for clinical change,
medication to help stabilize mood should be considered. In all instances, the therapist should assess the
potential risk (acuity) of suicide and develop a safety plan or contract; true despondency is of particular
concern, especially when alcohol or drug use may be factors as they greatly increase impulsivity.
As a general rule, activity and future planning are critical to offsetting the effects of depression and
instilling hope; there is no greater healing than meaningful involvement with others. No matter how
depleted an individual feels,caring forothers and contributing in a socially meaningful way is immensely
restorative and a direct path to enduring mental health.
Below are sample tactics, most of which are interchangeable:
Trauma
1. As fear is the central tone, examine avoidance behaviors and address injury to trust and intimacy.
While feelings of guilt may be present, shame tends to be the more dominant feature. Anger,
especially due to victimization, is a critical to anticipate, explore and give voice to.
2. Self-protection and self-care measures are critical: any practical activity that increases the sense
of safety and security or reduces exposure and vulnerability should be employed. Turn rumination
or pacing into structured rituals, security check-lists and behavioral safety rehearsals.
3. Thoroughly and dispassionately review the incident; is it an isolated or indicative of a trend of
toward similar experiences? Clarify “fact” from “fiction” (guilt vs guilt feelings; pity vs pity-pot),
explore possible culpability and self-blame/remorse, scale appropriately and plan for moving
forward.
4. Confront distortions or changes in self-image and social competency; use Image Enrichment (Ego
Building) techniques and increase actual competencies.
5. Postpone major decisions and attend to proper health (exercise, rest, nutrition, stress, etc)
6. Explore the need and benefit of retribution, joining social causes, and working with other victims.
Loss
1. Grief and possibly remorse are the dominant tones.
2. “Fill the hole” that loss has left: letters; foundation; new relationships; meaningful activity;
eulogies. Conduct future planning
3. Balance one’s recollection of the deceased or lost item: the “Good, the Bad and the Ugly”.
4. Predict relapses, obsessive rumination and triggering of sadness and feelings of futility

5. 5. Reconnect to others, activities and daily chores; address long-standing cut-offs. Again,
meaningful activity and purposeful involvement with others is critical. Caring for others helps the
individual feel more in control, valued and more whole.
Chronic Discord
1. Safety and preserving the physicality of the individuals is paramount. Legal and protective
services may need to be implemented. Power-struggles and power-plays fuel the hurt and
justification for retaliation.
2. Anger and the desire for revenge or vengeance are dominant themes. As an effective act of
revenge, suicidality can be reduced by tapping into the underlying anger. Rage can be expressed
in many ways, including covertly through sabotage, illness and failure. Depression can be an
effective form of punishment, often providing self-protection while thwarting the energy and
efforts of others.
3. Disengage and redirect power-plays toward cooperation and shared interests.
4. Plan for safe methods of retribution. Negotiate “amends”, an enormously powerful remedy for
wrongful acts and thoughts.
5. Individuation and individual development is critical to reducing reactivity.
6. Use imagery for residual pain, implement truce arrangements and examine possibilities for
structured separations.
7. Where chronic abuse, neglect or discord is present, serious devaluation exists; individuals feel
trapped, have exceedingly low self-esteem, often experiencing themselves as powerless, helpless
and worthless.
8. Anger, may be necessary for empowerment and motivation.