I want to talk about something that is missed quite often, while it may well be the most important thing we have learned about trauma in recent years. Namely this: what happened is not the same as what it did to you. And it is in the second that most of the misery lies, and where we as professionals can do something.
Two ways of measuring, two groups of people
You can establish maltreatment in childhood in two ways. Prospectively: you follow children, you have files, child protection reports, observations by researchers. Or retrospectively: you ask adults what happened in the past.
Everyone always assumed that this gave you the same people. It turns out not to. The agreement between the two measurements is a kappa of 0.19. For those who do not work with kappas: that is not much more than chance. More than half of the children for whom it was recorded prospectively do not report it themselves later. And more than half of the adults who do report it are not in any file.
That is not even the interesting part. The interesting part comes now.
If you look at which measurement is associated with mental distress later in life, the retrospective measurement wins by a wide margin. A relative risk of 2.14 against 1.27. In other words: the fact that you remember it and put it into words is much more strongly related to how you are doing than the fact that it was in a file.
So there is something in that self-report on top of the event. Something the file does not see.
What is in that difference
If you unpack it, you find four things. None of the four is about the event itself:
- How you experienced it at the moment itself. Did you think you were going to die. Did you feel there was nowhere left to go. Did you leave, did you dissociate, did you look down on yourself from above. That experience predicts the outcome better than the objective severity of what happened.
- Who you blamed. Self-blame is one of the strongest predictors of how things turn out. Children are ‘masters’ at this: they would rather love their parents and think of themselves as bad than the other way round.
- Who did it. The same act by someone you depend on does something very different from the same act by a stranger. Betrayal has an anatomy of its own.
- And then the fourth, which in my view weighs heaviest: what happened afterwards. Were you believed. Was there someone. Was something done. A recent study found that people whose maltreatment was in the file but who did not report it themselves reported more social support throughout their lives and had fewer complaints. You cannot draw a big conclusion from that, but it does point somewhere.
This is emphatically not “it is all in your head”
I know exactly how this can be misused, so let me say it straight away. If someone concludes from this that trauma is a matter of interpretation and that you have to learn to look at it differently, that person has understood it completely wrongly.
The event does matter. Prospectively recorded maltreatment does predict, only more weakly. And neglect, sexual abuse, physical violence: those things should not have happened and the responsibility lies with the person who did it. Full stop.
What the research shows is something else. Namely that the damage is not only done at the moment itself, but also in everything that came afterwards, or did not come. And that is exactly the part we can do something about. We cannot change the past. We can change how we respond today to someone who tells us something.
And then the figures
A word about those numbers, because I want to be honest about what they can and cannot do.
At population level, trauma is the largest modifiable factor we know for mental distress. Somewhere between 21 and 41 per cent of common mental health problems can be attributed to it, and that is after correction for genetic confounding. No other factor comes close. That is a rock-solid public health argument.
But at the level of the individual person it does not work. The famous ACE score, that list of ten questions you tick, predicts almost nothing for you personally. There is no evidence-based cut-off point, there is no treatment linked to it, and there is no evidence that the benefits outweigh the burdens.
That is exactly how it works with blood pressure. At population level we know very well what salt does. At your table we do not. Cardiologists have solved this by doing both: taking the salt out of the bread for everyone, and looking at the whole person in the consulting room. In mental health care we have taken over only the checklist from those two.
What this means for the consulting room
The first diagnostic question remains: what happened. But we need to add three more.
What did it do to you, at the time. Who was there, and who was not. And: have you ever been able to tell it to someone who could bear it.
That third question is the most important and the cheapest. No specialist is needed for it. Being believed by your GP, at the reception desk, in the emergency department, by an expert by experience in a recovery group: that is itself an active ingredient. The technical term is social holding. We all need another person who holds us.
And for the people who read this and recognise themselves: you are not tied to your score. That list of ten questions says something about the population you happen to be in, and almost nothing about you. What happened to you is not your fault, and what you can do with it is not fixed. We call that recontextualising: putting the experience back into the story where it belongs. Not polishing it away, not medicalising it. Giving it a place.
Work to be done
In mental health care we thought for years that a trauma approach means: asking, scoring, referring. That is the fix-it logic, and it runs aground on waiting lists, because the capacity will never be there.
The alternative is less spectacular and much more effective. Make sure that someone who tells something gets a good response. Everywhere, from everyone, also without a protocol. This is more than a soft precondition for treatment: it is the treatment, or at least the part of it that we can deliver on a large scale.
The question is when we are going to do this, no longer whether.
Jim van Os
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Prof. dr. Jim van Os, Chair Division Neuroscience, Utrecht University Medical Centre. Jim works at the interface of ‘hard’ brain science, health services research, art and subjective experiences of people with ‘lived experience’ in mental healthcare.
Jim has been appearing on the Thomson-Reuter Web of Science list of ‘most influential scientific minds of our time’ since 2014. In 2014 he published his book ‘Beyond DSM-5‘, and in 2016 the book ‘Good Mental Health Care’. In 2026 he published 'Wat psychisch lijden is'.
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Blogs by Jim van Os can be read here
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