written by Michael S. Scheeringa
Read time: 1.9 minutes
 
I wrote The Body Does Not Keep the Score (November 2024) because no one else had published a critical analysis of the claims made by Bessel van der Kolk in The Body Keeps the Score. Given the massive popularity of van der Kolk’s book (reviewed here), and the influence it has on clinical work and social policy, it was amazing that there had been almost no critical analysis of it. It has been one of the most popular books in the world for an amazing eight years and still going strong. My aim was to review the evidence as to whether his claims were true.
 
Book Summary
The majority of the 166 pages of text methodically reviews the evidence for 122 claims made in van der Kolk’s book, including 42 claims about neurobiology, 51 claims about treatments, and 29 claims about miscellaneous topics such as child development and memory. These analyses show that van der Kolk’s claims are wrong because he either misrepresented studies, cherry-picked studies that supported only his claims, or made jargon-filled vague statements with no supporting evidence.

Contrary to van der Kolk’s claims, I showed that the evidence indicates that any brain differences that exist between individuals with PTSD and those without PTSD pre-existed trauma experiences, and probably serve as vulnerability factors for developing PTSD. Also, the evidence does not support the notion that body-based treatments are superior. In fact, the evidence for his claims is thin to nonexistent.

​In addition, I addressed crucial topics that van der Kolk ignored. If his theory that trauma damages the brain is correct, what is the mechanism for causing damage? There is a massive amount of research on cortisol and epigenetics that he barely touched. The research on these topics has been unreplicable and far from convincing, which I addressed in a chapter on mechanisms. Also, if his theory that trauma damages the brain is not true, then what explains the research that shows brain differences in individuals with PTSD? He never considers the diathesis stress theory, which is far better supported than any other theory, which I addressed in a chapter on alternative theory.
The book includes 265 references for those who wish to consult original sources of the evidence.

My 2021 paper reviewed twenty-five pretrauma prospective studies showing that it is highly unlikely that trauma damages brains [1]. I am also the founder of Trauma Dispatch newsletter.

Beyond Neurobiology and Treatment Claims
The popularity of van der Volk’s book seems to be due far more to interest in van der Kolk’s neurobiological theory that “the body keeps the score” than to the claims about bodily-based treatments. My conclusions about this neurobiology theory run counter to the consensus in the field among researchers. How could I arrive at such different conclusions? This wrong consensus cannot be simply an honest mistake among very smart people. I addressed this in a chapter on ideology. The premise of van der Kolk’s theory is an ideology that genetics and heredity play no role in creating fixed behavioral traits in humans. His theory depends on human nature being highly malleable, which is appealing to many other aspects of a leftist progressive agenda that have proven extremely popular with a large portion of the population.

​In this sense, it seems that the popularity of van der Kolk’s book is also about him as a person. The stories of his fighting with psychiatric orthodoxy throughout his career make up a large part of his book. My analyses of this aspect, coupled with his ideological premises, show that The Body Keeps The Score has been popular not because it was about fact-based science, but because it was promoting a certain belief system.
 
 
REFERENCES
1. Scheeringa MS (2021) Reexamination of diathesis stress and neurotoxic stress theories: A qualitative review of pre-trauma neurobiology in relation to posttraumatic stress symptoms. International Journal of Methods in Psychiatric Research 30:e1864. doi: 10.1002/mpr.1864
 
 
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written by Michael S. Scheeringa
Read time: 2.5 minutes
 
Judith Herman says the quiet part out loud in her latest book. One intention of my Trauma Dispatch posts is to demonstrate the pervasiveness of progressive ideology in trauma research, how the purpose of most trauma research has not been to discover slivers of truth in the slow, incremental march of science; the purpose has been to promote a dogma, either to weaponize intellectual ideas for social justice reforms, or, simply for ideology’s sake to make the outer world appear seamless with researchers’ internal worlds. Those who approach trauma as a true science—unbiased, skeptical, empirical—are a small fraction of academia.
 
If any doubt lingers that ideology is the underlying driver of the intellectual leaders of postmodern trauma research, Herman dispelled that in the opening sentences:
“When I first wrote the forgotten history of trauma, in Trauma and Recovery, I argued that the suffering of traumatized people is a matter not only of individual psychology but also, always, of social justice. Because the violence at the source of trauma aims at domination and oppression [emphasis mine], even to recognize trauma, to name it, requires the historical context of broad social movements for human rights...”

In 1992, Herman published a paper that would make her a revered figure in the trauma world; she proposed a new disorder, called complex PTSD, which redefined borderline personality disorder as a trauma disorder caused solely by oppressive life experiences [3]. Primarily a community clinician, rigorous research was not one of her skills. Her research methods could be generously described as flawed—always samples of convenience, cross-sectional, mostly small, and predominantly non-standardized qualitative data.

Book Summary
Part One explained that sexual assault trauma is derived from tyranny, inequality, and patriarchy.
Part Two began describing principles of restorative justice--peace circles for apologies instead of incarceration. Chapters stressed the value of acknowledgment of crimes by perpetrators and methods of holding them accountable. Part Three described restorative justice’s healing potential of restitution from and rehabilitation for perpetrators.
​
The totality of her evidence for Parts Two and Three came from her interviews of 30 informants, 26 women and 4 men, spread over twenty years. The interviews were unstructured; most interviews were recorded (she neglects to give a number).
Herman’s prescription to salve the world is a dismantling of perceived oppression to provide the only worthwhile version of justice, which includes repair of relationships.
 
Analysis
Herman’s prescription is, by her own admission, only a vision. She wrote, “At present, the RJ movement is still too new to have amassed a convincing track record on preventing recidivism for violent crimes.”
​
The book omits the history of massive improvements in acknowledging trauma in society, laws to punish it, and efforts to prevent it. In Herman’s telling, you might think human civilization had never addressed sexual assault.
​
The book lacks a serious literature review. Not a single research study was described in any detail. Her evidence, being from a tiny sample and an unsound methodology, is not publishable in a moderately good, peer-reviewed journal.
​
The overall lightness of the book suggests it was a patchwork attempt to publish a treasured idea at the end of her career. Herman, now 82 years old, admitted she started this project twenty years ago, but was interrupted by personal illness and a move to assisted living.

Herman's ideology that she has been pushing for forty years is that human nature is highly malleable and oppression—labelled erroneously as trauma—is the evil that causes all problems. Her prescription for justice, based on this faulty view of human nature, will fail like her recommendations about borderline personality and complex PTSD, and will not truly help any victims, but it does create a simulated reality to appear seamless with her beliefs.
 
 
REFERENCES
[1] Judith Herman and Lisa Hirschman (1977). Father-daughter incest. Journal of Women in Culture and Society 2(4):735-756
[2] Judith Lewis Herman (1986). Histories of violence in an outpatient population: An exploratory study. American Journal of Orthopsychiatry 56(1):137-141
Judith Lewis Herman, J. Christopher Perry, Bessel van der Kolk (1989). Childhood trauma in borderline personality disorder. American Journal of Psychiatry 146(4):490-495
[3] Judith Lewis Herman (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress 5(3):377-391
 
 
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Written by Michael S. Scheeringa
Read time: 2.7 minutes

Book Summary
Abigail Shrier’s 2024 book, Bad Therapy: Why the Kids Aren’t Growing Up, analyzes the so-called youth mental health crisis. Shrier is clear that there isn’t a mental health crisis. Those who believe there is a crisis have conflated two groups of children. One group has “profound mental illness” and are truly impaired in their ability to function; that group has not increased.  
Her aim is to explain the other group—the non-disordered group—those who don’t belong on medications or in therapy, “the worriers; the fearful; the lonely, lost, and sad.” This group has increased and they are miserable. It is not, however, mental illness; "It’s an emotional hypochondriasis and iatrogenesis crisis.” Her book aims to explain how these worriers have been created by the failures of adults. According to Shrier, there is a lot of blame to go around:

• Parents were too soft with therapeutic parenting designed to make children happy, and avoid all risks.
• Schools usurped parental authority with a “therapeutic pedagogy,” taught social-emotional learning, trauma-informed care, and restorative justice.
• Smartphones caused anxiety, depression, and self-harm.
• Academia pushed fake narratives that humans are fragile, i.e., Adverse Childhood Experiences and trauma damage brains and souls. Specifically, Bessel van der Kolk—the “High Priest of the Church of Trauma”—and Gabor Maté were skewered. Van der Kolk, per usual, hid from criticism. Shrier wrote, “I reached out to Dr. van der Kolk for an interview. He responded quickly and affirmatively to the request and then abruptly ceased communication.”
• Government mandated school surveys about suicide, depression, and anxiety, which planted suggestive concepts in children’s minds that maybe they should be worried.
• Therapists framed patients as sick, caused family estrangement, blamed parents, and decreased self-efficacy.

 
Lastly, Shrier offered common-sense solutions that prescribed essentially the opposite of the problems she uncovered, which I will not detail for brevity.

Analysis
Overall, the book is excellent because Shrier analyzed a lot of things accurately and she's a good writer. My main criticism is that you can’t fully explain a problem if you just describe behaviors; you need to describe the etiology. Shrier correctly identified part of the etiology (e.g., harmful practices of many groups of adults), but omitted that they are a subset with distinctive motivations. She seemed to miss that the worried, non-disordered children are a subset, too. Most children are not suggestible to lunatic teachers and social media rubbish.
For example, Shrier noted in one sentence that liberal females are overrepresented in this unhappy subset of children, but  never explained why and never followed up. It’s not clear if Shrier doesn’t believe there is an underlying ideology, or doesn't understand the ideology of these children and of these zealous parents, teachers, and scholars, or if she opted to ignore it because she (or her publisher) believed, probably wisely, more people would read the book if it wasn’t political.
 
Another criticism is that the book could easily be perceived as anti-medication. She talked to two armchair psychologists who would not recommend medications for ADHD, depression, or anxiety, but never asked a psychiatrist’s opinion, who actually has clinical experience with these medications. The practice of trying medications in humans with heterogenous syndrome profiles is more complicated and less nefarious than Shrier presented it.

Lastly, her description of parents putting their children in therapy when they don’t need it is not my experience during thirty years of practice in child psychiatry. It’s a high bar for parents to bring their kids to therapy or put their children on medication, and it’s usually done only after years of suffering and trying everything else. I don’t recognize the community Shrier lives in. Maybe it’s because I live in a red state and Shrier lives in California. Again, this reinforces my point that when Shrier describes the problems, she absolutely nails them, but they are applicable only to an ideologically-skewed subset of vulnerable humans.

 
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written by Michael S. Scheeringa
Read time: 4.1 minutes
 
Some of the culture war conflicts go by different names but they are about the same thing at the underlying core: What is the cause of human nature?

Environment—or culture or life experiences—is the answer for Marxism, hence Communism, and today’s cultural Marxism movements. According to these theories, human nature is highly malleable. The world is divided into oppressors and oppressed. Environment—in the form of oppression—deforms human character and suffocated the success one can achieve personally and economically. In Marxism, capitalism is the oppressor which destroys workers’ characters and robs them of their full potential as creative, utopian beings. In critical race theory and Black Lives Matter, racism is the oppressor; race is considered a social construct for which there is no biological basis. In queer theory and transgender advocacy, a heterosexual norm is the oppressor; gender is not a biological reality.

​Biology—or genes or heredity—is the answer for much of conservative thinking. Races are real entities wherein the differences driven by biology can extend beyond superficial skin color. Sex is determined by genes at conception. The belief in a fixed conception of human nature is captured in the Declaration of Independence which begins by famously proclaiming that humans have inalienable, i.e., unchanging, rights.
 
Book Summary
Carl Degler’s 1991 book, In Search of Human Nature. The Decline and Revival of Darwinism in American Social Thought, has a simple premise: Trace the history of the debate about the cause of human nature—culture versus biology, nurture versus nature—in terms of how the pendulum of consensus in the social sciences has swung back and forth. The shifts of the consensus revealed that the goal for many social scientists who advocated for environment was never to arrive at true facts. The goal was to arrive at the most useful beliefs.
The first part of the book begins in the mid-nineteenth century when biology was thought to play a strong role in determining human nature. Most people still lived close to the land, were intimately familiar with other species on farms, and witnessed their frequent breeding cycles. Mendel’s discoveries in genetic inheritance were not yet widely known, but the gist of inheritance of characteristics from parent to progeny seemed obvious. The publication of Charles Darwin’s On the Origin of Species in 1859 set a huge piece of the intellectual framework confirming a role for biology.
But a countervailing framework of environment ascended in the late nineteenth and early twentieth centuries as new professions of social science arose. Anthropology, sociology, and psychology provided professional homes for self-selected individuals who, driven by ideological commitments to equality, and passions to better the human race, ejected the role of biology because it didn’t fit with a fast agenda to topple oppressors, lift up the oppressed, and change the world. By 1915, biology had been almost totally discredited by these academics.
 
The second part of the book explained how a revival of biological explanations began in the late 1940s and continued to a point in 1975 when a book like Sociobiology, by E.O. Wilson could be published. This happened due in parts to renewed recognition of Darwinism, new discoveries in genes, new knowledge about animal behavior (e.g., Jane Goodall and chimpanzees; Konrad Lorenz and imprinting), and tests of intelligence in massive samples.
 
I’ve left out huge chunks of the book on fascinating topics, such as social Darwinism, the eugenics movement, and the roles of many famous scientists such as Franz Boas, Margaret Mead, John Watson, and B.F. Skinner, and the contributions of dozens of lesser knowns.
 
Degler didn’t take a clear stand on which cause he believed. He did, however, prominently note the ideological motivations of those who advocated for environment. They came in with ideology predetermined and then created the facts for it. He also noted how environmentalists were successful in creating a hostile atmosphere to the truth and made it taboo to consider certain hypotheses and facts.
 
Who Wrote This?
Carl N. Degler taught history at Vassar College from 1962 to 1968 and at Stanford University from 1968 to 1990. His legacy has been described as illuminating the experiences of oppressed and marginalized groups, including African Americans and women [1]. Degler was known as a founding feminist and was one of the first male historians to write a history of women with his 1981 book, At Odds: Women and the Family in America from the Revolution to the Present. He won the Pulitzer Prize for his book Neither Black Nor White about slavery and race relations. Following the publication of In Search of Human Nature, he unsurprisingly encountered some resistance from social scientists who favored environment. Degler died in 2015 at the age of 93. 

Analysis
Degler’s book was published before the dominant resurgence in the past twenty years of the modern cultural Marxism movements. This includes the trauma field, where the pendulum has swung back far to the environmentalists’ side. If a more sensible discourse is to be achieved, this underlying misconception of human nature needs to be acknowledged and attacked.
 
Degler’s book never touched on trauma. The book was published in 1991, and the trauma advocacy movements did not hit a stride until around 2000. Degler’s narrative, however, is appropriate. The various trauma advocacy movements—ACEs, toxic stress, complex PTSD, and trauma-informed care—and all the pseudoscientific fabricated traumas—developmental, complex, historical, racial, intergenerational, and climate—are based on the same premise as Marxism that human nature is highly malleable.
 
The pushback against the trauma advocacy movements has been slow, as it must be. Whereas it is easy to publish commentaries, books, and convenience research of unverified assertions that elevate trauma to the role of causing all that is wrong with society, it takes a long time to design, fund, conduct, and publish good research that answers complex questions. There are now substantial amounts of good research showing that the assertions of the trauma advocacy movements are just that—unverified and discredited assertions.
 
Overall, Degler’s book is worthy for documenting the history of one of the important paths that has led to the current eruptions of ideology in Western societies. The legitimacy of these movements is contingent on the denial of the biological basis of human nature. Degler’s contribution was to show how the tides in belief have shifted over time, how the social sciences can be easily corrupted, and the constant battle that seems will always be between ideology and truth.
 
Degler nudged up to a deeper question but never answered it. He asked several times why beliefs in environment found such friendly lodging in the minds of many social scientists when evidence of biology was before them. Yes, they acted on humanitarian impulses to make the world better, but why were those impulses so strong in certain individuals and not in others? Degler was a historian whose skill set was more to explain what happened, not the psychology of why. In my book, The Trouble With Trauma: The Search to Discover How Beliefs Become Facts, I offered an explanation based on fundamentally different moral foundations of liberals versus conservatives.
 
 
References
[1] Emily  Langer (January 9, 2015), Carl N. Degler, Pulitzer Prize-winning historian of marginalized groups, dies at 93, The Washington Post. Accessed 5/20/2024)
 
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written by Michael S. Scheeringa
Read time: 3.5 minutes
 
For some years now, progressives dominated the ranks of academia and media and have largely controlled many of the ideas and language we are exposed to. One of the primary ideas upon which many leftist agendas rise or fall is the conviction that human material is highly plastic. This is evident in the old claim by Marx that capitalism oppresses the soul of the proletariat to the new claim of modern neuroscience that trauma alters the self by changing the brain. As Daniel Patrick Moynihan wrote, “The central liberal truth is that politics can change a culture and save it from itself,” i.e., the central progressive belief is that politics ought to be a tool to change individuals, hence, unrestrained government is justified to expand, regulate, and intervene in society.
 
Book Summary
The title of the book What Happened to You? has long been the catchphrase of the trauma-informed approach movement, and it concisely sums up the belief that humans are highly plastic. Perry and Winfrey claimed that if you received love and affection during the first two months of life, your neural development protects you from trauma with resilience. If you didn’t, your brain was permanently altered in many maladaptive ways. These alterations affect everything in your life. Literally. Everything. When you experience trauma without that resilience installed, trauma causes you to have “a different sort of world view,” shapes the very core of ourselves, determines the dosage of medications one can take, creates individuals who commit crimes, and determines personality development. It also causes drug addiction, heart disease, asthma, gastrointestinal problems, stroke, diabetes, and auto immune disease. Trauma is apparently transmissible to children just by watching parents be afraid, and can also be passed to children through birth in their genes by the mysterious and unproven mechanisms of epigenetics. They say trauma impacts “education, mental health, health, law enforcement, juvenile and criminal justice, family courts. It is impossible to find any part of society where this is not an issue.”
 
The book is formatted as a back-and-forth conversation, with Perry in black font and Winfrey in blue font. But it’s obviously not an actual conversation. It’s largely a tag-team swapping of anecdotes to make readers’ heads swivel toward assertions about how trauma is the cause of nearly every bad thing in life. Perry “conversated” nineteen anecdotes to Winfrey’s thirteen.

Analysis
Winfrey provided some of her childhood trauma story involving her demented grandfather trying to choke her grandmother. But if you’re looking for insight into how Winfrey overcame her childhood, you won’t find it here. If trauma shaped Winfrey, as the book claims trauma does to everyone to some degree, how did she become so successful? She must have had other resilience factors in her nature that other people didn’t have.

Perry did not critically examine the research on any claims about trauma. He never described a single research study. Instead, Perry made broad generalizations from skewed interpretations of the science. From their book you would think experts totally agree with Perry and there are no controversies. His claims about the impact of trauma are, however, nearly all wrong. If you’re looking for the science on how trauma is associated with neurobiology, you won’t find it here.

But if you’re looking for an ideology to explain your problems, this book is for you. Perry and Winfrey wield their beliefs to prove again that progressive leftists are not willing to allow empiricism to get in the way of a good theory.

What is the real science? I’ve been a researcher on childhood trauma and PTSD for over thirty years, and I published some of the research that Perry and Winfrey should have read, so I think I can confidently grade Perry an F on his understanding of the science. The truth is that there are indeed many studies that show associations between PTSD with size differences in brain centers, different activations of neural networks, and different autonomic nervous system states. But it was never mentioned that those come almost entirely from cross-sectional studies, which means subjects were studied at only one point in time. Cross-sectional studies have absolutely no power to make causal conclusions. When better studies have been conducted, which are pre-trauma prospective longitudinal studies, the evidence does not support Perry and Winfrey’s extraordinary narrative that trauma can literally change your brain.
​
Perry does have a few good things to say about treatment, but those were not based on science and they’re not new.
 
Why Did This Happen?
The book is another parcel in the trauma-informed campaign that has been spreading these beliefs across the U.S. since approximately 2000. Toxic stress, adverse childhood experiences, and complex PTSD are the main pillars of the beliefs. With Winfrey’s celebrity wattage landing the book on the best-seller list, this is the media-star version of Bessel van der Kolk’s equally wrong book The Body Keeps the Score. As I’ve described in my book, The Trouble With Trauma, I think a motivation for trauma-informed supporters to hold these beliefs comes from a skewed moral foundation that leads them to believe that nurture, not nature, causes many of the problems of most victims in our society, and fighting for victims makes supporters feel worthy. Their intent is to leverage trauma as a tool to achieve culture change, acquire funding for social programs, and alter society to make reality appear seamless with their vision of liberal truth.
 
This is a shortened and revised version of my one-star review posted on Amazon.com in 2021.

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written by Michael S. Scheeringa
Read time: 3.9 minutes
 
Bessel van der Kolk’s The Body Keeps the Score was the strike of lightning every science popularizer wishes for. Since publication in 2013, it has parked on the non-fiction best-seller lists, often at #1. At the time I am writing this, it is ranked number ten among all books sold on Amazon.  Due to its popularity, it became the bible of a new social movement for trauma-informed care.
 
The Premise
In the first half of the book, van der Kolk explained that psychological stress and trauma lodges in the body and damages the operation of many brain functions. The dysfunctions include thoughts, memory, relationships, personality, and the most basic capacities to live, work, and enjoy life. These dysfunctions are vast, ergo, the only logical conclusion is that trauma is the supreme public health crisis.
In the second half of the book, van der Kolk then promotes “body treatments” that follow from that conclusion, including sensorimotor psychotherapy, somatic experiencing therapy, psychomotor therapy, EMDR, neurofeedback, theater, yoga, singing, and dance. According to van der Kolk, these treatments are superior to standard treatments, namely cognitive behavioral therapy and medication, because they treat the soul, the whole self, by connecting at the visceral level.
Consequently, the book became for the nascent trauma-informed approaches movement what Al Gore’s An Inconvenient Truth was to climate change activists. Whenever progressive bills and projects have been proposed for saving children from violence, preventing crime, or transforming the culture of public schools, this book is almost always cited as the fountainhead of evidence that trauma is the root cause of every group’s problems.

Analysis
Does trauma really damage the brain? Van der Kolk is provably wrong on every neuroscience claim he makes about trauma damaging the brain. I published a booklet in 2023 that debunked every one of the 42 different claims he made (Analysis of The Body Keeps the Score. Update 11/14/24: This booklet was superceded in 2024 by The Body Does Not Keep the Score).
 
Are the “body treatments” really that great? There is no solid evidence that these treatments are better than conventional treatments, mainly because few controlled studies have been conducted with them. The evidence is so sparse that it’s arguable whether they are even treating PTSD; they could simply be helping with distress from related or separate problems, which get conflated with trauma symptoms. The treatments undoubtedly help some types of people with some issues, but they are not the potent answers to healing trauma, the self, or the soul as van der Kolk suggests.
 
The stunning lack of evidence begs the question of what was the real purpose of this book? If so much effort was put into making dozens of wrong science claims, and alternative treatments were promoted so strongly on nearly non-existent evidence, why was the book written? In my booklet, I concluded that the point was to create a fabricated reality. The aim was to construct a view of human nature that brains are fragile; experience, not genetics, molds nearly all human behavior; and only those who believe this message are the best type of people who have the right morals to truly care about disadvantaged people.
The moral high-handedness in this narrative leaks out everywhere in the  book. Van der Kolk tries to shame nearly every constituency for treating patients wrong because they are ignorant or greedy: psychiatrists, “mainstream medicine,” therapists, medical journals, and drug companies. He even blames patients for wanting medications as a shortcut instead of dealing with their problems the right way. The disdain seems like a feature, not a bug, of his writing style. Shaming is the point when we realize that this is really about creating an ideology. It seems inconceivable that his aim was to get the facts right; the point was to have the right beliefs.
 
Why Did This Happen?
Thus, the most illuminating issue may be to ask why the book resonated so strongly with so many people. It clearly seems to have filled a gap that many people were waiting to have filled.
Viewing the popularity of the book as an index of public appetite, the book is a thick, satisfying sandwich that pretends to address the entire self and soul and experience of being human. It is a revolt against the reductionist, evidence-based thin sandwiches of science that can address only what is actually true and known. It feels better to attach oneself to a belief that promises more, even if it’s not true. The message in this book is that nurture, particularly the negative experiences of nurture, not nature, determines almost completely how we turn out.  This narrative is part of a radical leftist ideology that runs from Locke’s blank slate, through Rousseau’s noble savage and Marx’s proletariat, that there is no such thing as human behavior due largely to genetics; all personality traits are developed mostly by life experiences. We all start with the same potential for success, and it is only the forces of oppression that mold some people to be disadvantaged, ipso facto, we need to revolt against the establishment, which, in van der Kolk’s expert manipulation of language and ideas, is the handmaiden of trauma.


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