Trauma May Explain The Suffering of CEOs, Leaders, & Startup Founders

Leadership Trauma may be a new category of chronic trauma - a fear disorder. Silicon Valley titans like Ben Horowitz have been talking about it for years, just in different terms.

Executive Summary:

When Ben Horowitz, tech legend and co-founder of VC firm Andreessen Horowitz, wrote about hundreds of CEOs dealing with "The Struggle" - the psychological difficulties faced by founders and entrepreneurs - he may not have realized how closely his portrayal mirrored descriptions of chronic trauma as defined by world leading experts such as Bessel Van der Kolk.

This article explores the link between Horowitz and Van der Kolk's concepts and suggests a new category of chronic trauma called Leadership Trauma. One of Leadership Trauma's main differences from other forms of chronic trauma may be in time orientation - in chronic trauma, the individual is haunted by events of the past, whereas in Leadership Trauma, the individual is traumatized by intolerable fear about their future. Instead of flashbacks, leaders have flash-forwards of panic, which neuroscientists have shown can affect the same parts of the brain as real-life experiences. To make an analogy, there is a reason that mock executions are a form of torture. Leadership Trauma is envisioning the death of the social self because of a catastrophic failure in a life devoted to work.

Chronic trauma generally occurs when an individual absorbs significant stressors from a human ecosystem. During extreme crises, startup founders, CEOs, and anyone serving as "Corporate Heroes" may be at risk of undergoing some form of chronic trauma, especially in situations of extreme fear, financial duress, unethical behavior, or any situation in which dehumanization exists. Whereas chronic trauma leads to revisiting the past, Leadership Trauma requires addressing the traumatic future.

This trauma may be exacerbated by the ego-involvement of the leader who may spend an inordinate amount of their time future-gazing towards scenarios in which they cast themselves as the Hero, bathed in glory, or as the Villain, bathed in shame. Significant ego attachment to these outcomes, especially prevalent in startup founders, can make this situation worse. Constantly living in a duality between being savior or a disgrace plunges the leader into prolonged exposure to Fear of the Future or Fear of Shame (making Leadership Trauma also a relational trauma). This can be exacerbated by C-Suite politics. While tolerable in small doses without meaningful consequence, too much exposure to the psychic stressors of Leadership Trauma, especially in the case of startups, may lead to symptoms similar to chronic trauma exposure. In particular, some startup founders find that they need 2-3 years between companies to recover from the psychological stress of their roles. Corporate bureaucracy, as in Fortune 500 companies, exists to shield executives from these pressures, but is typically absent in startups. Nonetheless, leaders in any organization can experience Leadership Trauma.

Interestingly, individuals with Post-Traumatic Growth (a form of trauma resilience) from childhood may gravitate to these extreme leadership environments or find them motivating. While they may shine in these situations using their trauma-resiliency superpowers, they may also see such situations as normal and stay in them far too long, whereas less resilient leaders, out of self-preservation, may bow out earlier or force healthy organizational change sooner. Their prior chronic trauma can also be triggered and amplified by these environments. Leadership Trauma is exacerbated when leaders begin to ignore their own suffering and dehumanize themselves in order to "get through it." Numb to the damage that is happening, they can then stay in unhealthy or dysfunctional situations far longer than they should, layering damage on damage and risking dehumanizing those around them in turn. Leaders in the midst of Leadership Trauma often need problem solving help compatible with their state of "CrisisMind." Most importantly, they need to connect with other individuals who can help them understand what they are feeling and help them crisis-solve under extreme duress. This typically involves: (1) Connection, naming, and de-shaming of their feelings; (2) Prioritization of the problems to solve; and (3) Values based solutions for the most complex situations. On the positive side, CrisisMind in lower doses can be accompanied by a willingness to try new solutions and increased mental flexibility. Many times, this allows for transformationally positive change, even in the midst of an extremely difficult situation. Above all, Leadership Trauma should not be overly pathologized, as one natural outcome is leader resilience.

(1) INTRODUCTION

"Honestly, it was traumatizing."

It's a statement I hear more and more frequently from founders, CEOs, executives and other corporate leaders who play the role of "Corporate Hero" during an organizational crisis.

Ben Horowitz, the Silicon Valley legend and serial entrepreneur, describes it this way (The Hard Thing About Hard Things):

By far the most difficult skill for me to learn as CEO was the ability to manage my own psychology.... Over the years, I’ve spoken to hundreds of CEOs all with the same experience. Nonetheless, very few people talk about it and I have never read anything on the topic. It’s like the fight club of management: The first rule of the CEO psychological meltdown is don’t talk about the psychological meltdown.

Compare this exact sentiment to what Bessel Van der Kolk, one the world's leading researchers on trauma, has said (Psychology Networker):

For people with trauma, talking about what bothers you is not acceptable.... Trauma stories cannot be told.

Could these be related?

That’s the question this article explores. This article: (a) compares first person accounts such as in The Hard Thing About Hard Things to descriptions of complex trauma by researchers such as van der Kolk, and (b) based on their descriptive similarity, explores a hypothesis that such leadership experiences may in some cases be a form of complex trauma - what we call Leadership Trauma.

(2) THE HIGH LEVEL VIEW

"Great CEOs face the pain. They deal with the sleepless nights, the cold sweats, and what my friend the great Alfred Chuang (legendary cofounder and CEO of BEA Systems) calls 'the torture.'" ~ Horowitz

Most simply, what does Leadership Trauma feel like?

It feels like a failure.  A failure that is shameful and humiliating.  A failure that is against your values and stated objectives.  A failure that is against your predictions.  A failure that is against your business projections.  A failure that is against your entrepreneur persona.  And a failure that is extremely, extremely public.  And it's a failure that you have dragged others into. Everyone who followed you, invested in you, and sacrificed for you has failed also - because they believed in you. 

Except it hasn't happened yet.  It only could happen - depending on what you do.  So you need to fight that failure, constantly, because otherwise it will become reality.

How is Leadership Trauma different from other kinds of trauma?  In normal trauma, you are haunted by things that happened in your past.  This is what I call the "time displacement" of trauma.  Van der Kolk is explicit about this (Psychology Networker):

Trauma is a disease of not being able to pay attention to the present.

Leadership Trauma, however, has a completely different orientation to time. In Leadership Trauma, you are haunted by things that could happen in your future.

Instead of flashbacks, you have flash-forwards of disaster, either explicitly in thoughts, or implicitly, in your body, as you twist in anxiety.

Of course, most people worry about their future.  But many CEOs and leaders stake their entire happiness on a very particular, very public, future outcome.  One single outcome.  An outcome which they promised everyone in order to gain followership.  A promise to employees.  A promise to customers.   A promise to investors.  A promise to co-founders.  A promise to the Board.  A promise to their families.  A promise to themselves. 

When you invest this deeply on a single outcome, at some point, you are no longer just staking your money, your time, your effort, your relationships, or your reputation on it. At some point, you start to stake your sanity on it. There is no other outcome that seems acceptable to you. In cases like these, the leader's identity seems to fuse with their corporate outcomes, making their mental state mirror the company's commercial state, blow for blow.

Why is it difficult for us to watch an action film where the hero has to cross a narrow bridge, walk along a ledge, or walk across a tightrope? Because one misstep means the loss of everything that we hold dear. When you watch the hero in these scenes, there is always a moment when the hero slips and almost falls - and in those moments they are terrified.

Imagine living with that kind of pressure, day in and day out, for years. Imagine that every once in a while there is a gust of wind that risks blowing you off that tightrope. Imagine that wind could be in the form of business partners, or friends, or competitors, or any force that competes with your full attention to that tightrope. Get distracted by them and you will fall. But ignore them at your peril, for they may need your focus.

Imagine bathing your mind in that kind of stress, 24/7, for years. And then imagine slipping.

That's Leadership Trauma. To make an analogy, like Ebenezer Scrooge from Dickens’s A Christmas Carol, people with Leadership Trauma are haunted by the Ghost of Christmas (Business) Future. 

Here is how Marc Andreessen, another one of the world's most famous entrepreneurs, describes it to Horowitz (The Hard Thing About Hard Things):

Marc: “Do you know the best thing about startups?”

Ben: "What?”

Marc: “You only ever experience two emotions: euphoria and terror."

Leadership Trauma is being forced to perform at a high level - to walk the tightrope - while in terror of the future.

I call this state "CrisisMind." Stay in it too long or too intensely, and it starts to take a toll - and can become traumatizing.

But, some may ask, is it possible for these imagined futures to really affect the brain? Neuroscientists from the University of Colorado at Boulder certainly seem to think so. Here is a summary of one of their recent findings:

New brain imaging research shows that imagining a threat lights up similar regions as experiencing it does. Imagine a barking dog, a furry spider or another perceived threat and your brain and body respond much like they would if you experienced the real thing.

It seems that in your mind, at least, such time travel is possible: fears from the future can haunt the present.

How bad can Leadership Trauma get? I regularly see people who cannot return to the workforce for 2-3 years because of the Leadership Trauma of their companies. Their entire worlds can crumble.

To further understand the stakes, consider the following: if we estimate US corporate spending at over $10 Trillion per year, and if 1% of CEOs have Leadership Trauma, that would mean that over $100 Billion of financial decisions each year could be under the control of people who are in traumatic situations. This doesn't mean that their decisions are worse or better - but that the frame of mind behind this performance needs to be understood.

Welcome to chronic trauma.

(3) CHRONIC TRAUMA

"The moment you are still, you go crazy." ~ Van der Kolk

According to the APA, trauma is "an emotional response to a terrible event like an accident, rape, or natural disaster."

Unbelievably, gaining broad acceptance of chronic trauma had been a struggle for researchers for over twenty years. For decades prior, trauma work had been focused on acute, physical trauma - wars, violence, accidents, and occasions of bodily harm. When chronic trauma - originating from human relationships - was considered, it was in the context of familial physical or sexual abuse. That lens is now broadening.

Consider this quote from the World Health Organization:

Complex post traumatic stress disorder is a disorder that may develop following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible…. Complex PTSD is characterised by severe and persistent 1) problems in affect regulation; 2) beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event; and 3) difficulties in sustaining relationships and in feeling close to others.

The good news is that we, as a society, are finally taking chronic trauma more seriously. If you want proof of this, consider the graph below, which shows the Google search results for C-PTSD ("Complex Post-Traumatic Stress Disorder") versus searches for "therapy" from 2004 to 2020.

We can also make a few points of clarification.  First, we can ask:  (a) are we saying that Leadership Trauma is the only trauma with a “fear of the future” - or (b) that other forms of complex trauma don’t have such forward-facing fears?  Not at all.  What we are pointing out is that Leadership Trauma may be unique in that a significant portion if not the majority of the suffering is caused from anticipation of the future.  In other words, the main mechanism of the injury is future-oriented fear - and this seems distinct from (even if coincident with) other forms of complex trauma. 

Why is this "future time orientation" worth emphasizing in Leadership Trauma?  The answer is that it may change how we deal with it and what interventions clients demand.  

With Leadership Trauma, clients often show up in the midst of the crisis.  It is an ongoing live event for them.  The psychological relief they seek does not come from resolving their past issues (although that is an extremely useful thing to do later on), but addressing the traumatic future unfolding in front of them.  Although past events may increase vulnerability, until that fearful future is addressed, the damage keeps getting done.  

To put it differently, when you are in a war, your priorities are not historical issues.  Your priority is not getting shot.  An immediate trauma is always a priority over a distant one, even if they may be related.  The good news with Leadership Trauma is that effective interventions may be able to reduce or even prevent it, as compared with complex traumas that are already baked-in historical facts.

This future orientation may also be one reason why clients in this situation may want the help of problem-solving coaches to help solutionize their issues (in addition to the help of therapists who excel at resolving the past).  Said differently, these leaders may seek coaches and advisors precisely because timely problem solving may help them avoid a worsening of the traumatic crisis they are in.  

Additional points of distinction should also be made.  As we discuss later, it’s possible that leaders who suffer from Leadership Trauma may, in fact, have a history of complex trauma which affects how they navigate through crisis.  In other words, the traumas may stack, compound, or interact in some meaningful way.    

A second point is that we also do not want to overly focus on negativity and treat people as “broken toys” or “flawed objects” (as Tim Ferriss put it) simply because they have suffered something traumatic.

On the contrary, I heard a lecture by psychologist Sue Erikson Bloland, the daughter of world renowned psychologist Erik Erikson, who spent her entire life studying success and trauma.  She concluded that many great leaders have achieved their greatness, not despite their trauma, but because of it.  As we discuss further in the section on Post-Traumatic Growth, recovery from developmental trauma can be associated with important leadership skills. 

In other words, many people who survive chronic trauma early in life may become excellent organizational leaders due to the tremendous compassion, sensitivity, and resilience their trauma recovery taught them.

So, what do experts say Leadership Trauma feels like?

(4) THE FEELING OF LEADERSHIP TRAUMA

"Self-blame is almost universal in chronic trauma... It’s always about blaming yourself for what you did or did not do..." ~ Van der Kolk

I remember a CEO to whom I mentioned the idea of "CEO Trauma" at a coaching conference years ago (I had a different name for it then). She laughed at the idea and said it couldn't possibly be real. Later over dinner she un-ironically pulled me aside to talk about suicide rates of CEOs.

Based on years of working with leaders in various crises, there is no doubt in my mind that Leadership Trauma - at least for some - is real and that we need to discuss it. 

First, let's look at how some psychologists describe the feeling of chronic trauma:

It’s always about blaming yourself for what you did or did not do...

(Bessel Van der Kolk, How to Work with Shame, NIBACM)

It’s the self-loathing and shame that becomes the central issue in chronic trauma.

(Bessel Van der Kolk, How to Work with Shame, NIBACM)

Symptoms of intrusive thoughts, mood instability, nightmares, rage,

perseveration, or obsession.

(Stan Tatkin, How to Work with Shame, NIBACM)

How does chronic trauma compare to what I am calling Leadership Trauma? Horowitz refers to Leadership Trauma as "The Struggle." His book is considered one of the best books ever written on CEO psychology. He has spoken to hundreds of CEOs on this topic and is an expert on the issue.

Horowitz doesn't use the word "traumatic," but judge for yourself based on his description of CEO psychology from The Hard Thing About Hard Things:

The Struggle is when you wonder why you started the company in the first place.

The Struggle is when people ask you why you don’t quit and you don’t know the answer.

The Struggle is when your employees think you are lying and you think they may be right.

The Struggle is when food loses its taste.

The Struggle is when you don’t believe you should be CEO of your company. The Struggle is when you know that you are in over your head and you know that you cannot be replaced. The Struggle is when everybody thinks you are an idiot, but nobody will fire you. The Struggle is where self-doubt becomes self-hatred.

The Struggle is when you are having a conversation with someone and you can’t hear a word that they are saying because all you can hear is The Struggle.

The Struggle is when you want the pain to stop. The Struggle is unhappiness.

The Struggle is when you go on vacation to feel better and you feel worse.

The Struggle is when you are surrounded by people and you are all alone. The Struggle has no mercy.

The Struggle is the land of broken promises and crushed dreams. The Struggle is a cold sweat. The Struggle is where your guts boil so much that you feel like you are going to spit blood.

This is an account from someone who took his company public with only 6 weeks of cash left in the bank.  Horowitz has a tremendous amount of mental resilience, nerves of steel, and can handle psychological pressure that would crush most people.   When someone like that tells you it feels like your guts are boiling, you could spit blood, and you can't hear anything but your own pain, please believe that it is really bad.

Here are 6 examples of parallels between Horowitz's Struggle and descriptions of chronic trauma.  See if you notice any similarities.

(1) For instance, is there any relationship between what Horowitz and van der Kolk are discussing below?

....you wonder why you started the company in the first place... people ask you why you don’t quit and you don’t know the answer.... your employees think you are lying and you think they may be right. (Horowitz)

Self-blame is almost universal in chronic trauma...It’s always about blaming yourself for what you did or did not do... (van der Kolk)

(2) What about here?

The Struggle is where self-doubt becomes self-hatred. (Horowitz)

It’s the self-loathing and shame that becomes the central issue in chronic trauma. (van der Kolk)

(3) Are there parallels here?

...the land of broken promises and crushed dreams... a cold sweat... where your guts boil so much that you feel like you are going to spit blood. (Horowitz)

... symptoms of intrusive thoughts, mood instability, nightmares, rage, perseveration, or obsession. (Stan Tatkin)

(4) Or consider these statements:

The Struggle is when you go on vacation to feel better and you feel worse. (Horowitz)

The moment you are still, you go crazy. (van der Kolk)

(5) What about these two statements?

....when food loses its taste... when you are having a conversation with someone and you can’t hear a word that they are saying because all you can hear is The Struggle. (Horowitz)

Trauma is a disease of not being able to pay attention to the present. (van der Kolk)

(6) How about these statements?

The hard thing is waking up in the middle of the night in a cold sweat when the dream turns into a nightmare. (Horowitz)

People who have PTSD wake themselves up as soon as they get into a dream state. (van der Kolk)

As the President of a fintech company that handled $3 Trillion in annual transactions, I have experienced this myself, as have many entrepreneurs I know.  During the worst stretch of running my company, I was waking up ten to twelve times a night for months, consumed with thoughts, including the risk of going bust, lawsuits, laying off employees, deserting customers, and major management conflicts.  The worry was constant and overwhelming.  When you cannot anticipate where the pain will come from next, you are only left with fear.  There was no escape.  It was torturous and absolutely nothing like the depression or burnout that people talk about in startup founders.  It wasn't a dull, lethargic feeling.  It wasn't learned helplessness.  I wasn't able to stop caring or to stop being mentally vulnerable to the company, even when I desperately needed it to stop.  It was relentless. 

Did I recover?  Yes, resoundingly.  And I’m likely better for the wear, when experience is included in the calculus.  That experience is part of what enables me to coach people through similar situations with a degree of calm, detachment, and perspective.  But was it hard?  Absolutely. 

Most executives, in fact, have no idea the world of pain they could be getting themselves into when they take on the pinnacle of leadership, especially in startups.  I describe the employee aspects of the problem as the Human Ant Hill problem.  You think that you will sit atop of the Ant Hill as the king or queen and all the problems will roll downhill for your employees to solve.  Little do you realize how much of the suffering rolls uphill.  Little do you realize how much anger, politics, and resentment can be directed at you from below.  The pressure is almost impossible to ignore.  It's not theoretical.  It's relational - from living, breathing human beings.  Perhaps you can ignore it if you are sociopathic, but otherwise - and especially if you are highly empathic - it hits you squarely in the chest with a force that's hard for outsiders to appreciate, even including the people working most closely with you every day. 

At its worst, Leadership Trauma can make you question your sanity, especially if those closest to you are in the midst of it also.  Remember - this is relational trauma.  It consumes the entire human ecosystem you are part of.  Even if you don't believe their fears, your partners' stress is contagious.  Have you ever tried to calm a group of terrified people?  How calm did you feel after a long period of exposure to them?  In a prison, both guards and prisoners get traumatized, despite the enormous differential in power and authority.  This relational contagion is why chronic trauma can be so overwhelming.  You cannot escape your human ecosystem, even as - or especially as - the CEO.  The worst of such experiences resonate with van der Kolk's account (The Body Keeps the Score):

Trauma by nature drives us to the edge of comprehension....

The pain is often worst for a leader when the organization is in financial trouble.  In my experience, one of the most terrible feelings was the fear of not making payroll.  A former C-Suite executive from a top 3 energy company once told me that nothing he encountered while working for the oil giant was more painful than the suffering he went through at his own startup, years later, when they almost ran out of money to pay employees.  Employees fund their families' food, rent, and mortgages with your payrolls.  Missing payrolls is a family tragedy on top of a corporate crisis.

Because of this, Leadership Trauma is more likely to hit leaders in startups than in giant corporations.  Not only is this because startups are much more likely to fail, but also because giant corporations are structurally developed to take pressure off of their key executives.  HR departments, legal departments, and an entire hierarchy of policies, procedures, and managers exist to distance top leaders from suffering, by distributing away direct human or relational accountability.  Big corporations can offer buffer after buffer after buffer.

At worst, Leadership Trauma can become a mentally addictive cycle.  Have you heard of a CEO or founder who is obsessed with their company?  Who can't turn it off thinking about it?  Who is literally consumed with it 24/7? Consider this quote from van der Kolk (The Body Keeps the Score):

Somehow the very event that caused them so much pain had also become their sole source of meaning. They felt fully alive only when they were revisiting their traumatic past.

This is yet another part of the tragedy.

(5) CAUSES OF LEADERSHIP TRAUMA

There is an acronym for it, WFIO, which stands for “We’re F*cked, It’s Over” ~ Horowitz

What are the most common causes of Leadership Trauma?  I will focus on 3 of them (Fear of the Future, Fear of Shame / Humiliation, and Human Shield / Moral Injury) in addition to 1 major risk factor (Dehumanization of the Self).  There are many more, including poor financial performance, employee layoffs, missing payroll, and the other usual suspects.  And as a relational trauma, C-Suite and Board politics can exacerbate all of these feelings.

(A) Fear of the Future / the Unknown

"What will happen to the company? Our employees? Our customers? Our investors?"

There is a reason that mock executions are a form of torture (this is when a prisoner is led up to the point of being executed, but then is not - the fear is the goal).  Fear itself can be a form of trauma.  Here is what Horowitz has to say about it (The Hard Thing About Hard Things):

My partner at Andreessen Horowitz, Scott Weiss, relayed that it’s so common that there is an acronym for it, WFIO, which stands for “We’re F*cked, It’s Over”. As he describes it, every company goes through at least two and up to five of these episodes.

Leaders who are not familiar with Leadership Trauma may reason that, since the worst has not yet happened, that nothing bad has happened to them.  They may not realize that their constant replaying of future fears can itself be a source of trauma.  "No harm, no foul," as they say.  Not true.

What they don't consider is how living in a future of imagined disasters, reinforced by supporting subordinates who act on and have the same fears, unrelentingly, day in and day out, with no one to discuss it with and no rest, for months, can lead to mental exhaustion or traumatization.  

(B) Fear of Shame / Humiliation / Exposure

This is where the ego of the leader can work against them.  The Fear of the Future outlined above is a fear for the company.  But the Fear of Shame / Humiliation / Exposure is a fear of what will happen to the leader personally. 

Typically, founders launch their company with a dream of changing their industry or their world.  They may imagine generating fabulous wealth for themselves, their investors, and their employees.  They hope to transform the lives of their customers.  And they have to sell this vision to other people, repeatedly, in order to gain any traction.  Leadership requires followership.  A startup founder, for instance, is constantly convincing people to "Follow me!" That includes investors, employees, and customers.  They go on the record promising success.  Then they must become the heroes they have promised the world they would be (and which they have raised money for). 

The flip side of this heroism, however, is the terrible shame of failing to deliver on all these public promises.  This is the Fear of Shame, Humiliation, and Exposure. 

The whipsaw vacillation between these two imagined extremes of Hero and Villain - sometimes multiple times a week - can drive a leader to the brink of their sanity.   In other words, the leader may spend an inordinate amount of their time ruminating upon scenarios in which they cast themselves as the Hero, bathed in glory, or as the Villain, bathed in shame, guilt, remorse, and self-doubt. 

If they feel they have no control over these outcomes, they can go into learned helplessness and depression.  If they feel that the outcomes are entirely reliant on them (a side effect of ego), then the whipsaws can give them extreme anxiety.  Both can contribute to Leadership Trauma.  Now imagine how much worse it can get if the leader's family finances are fully reliant on the company's fortunes?

It may be hard for outsiders to see this fear because leaders typically hide it extremely well, including from those closest to them.  They may even actively lie in order to cover up this fear (for instance, many leaders of family businesses hide the company's financial troubles from their spouses).  And, for many of them, they may not even be aware they labor under this fear until they are in recovery from Leadership Trauma.  To them, it's just the water they swim in - i.e., the natural course of being a founder or a CEO.

Remember how Marc Andreessen describes it (The Hard Thing About Hard Things):

Do you know the best thing about startups? You only ever experience two emotions: euphoria and terror.

The euphoria is when they think they will walk across the tightrope and become the Hero. The terror is when they think they will fall off the tightrope, become the Villain, and plunge themselves into shame and humiliation. 

In that light, it's not surprising to hear this from van der Kolk on chronic trauma (The Body Keeps the Score):

In trauma, the self-system breaks down.... Self-loathing coexists and fights with grandiosity...

Interestingly, one pattern I’ve noticed is that some leaders who have Leadership Trauma were the ones who had the most grandiose ambitions or hopes in the first place - in other words, the higher they aspire and the more necessary they make this achievement, the harder they can crash.  This is noteworthy as grandiose hopes, no matter how well intentioned, can be an early risk signal. 

In sum, we can say that between a Fear of Shame and a Fear of the Future, the leader fears the death of the social self because of a catastrophic failure in an overly narrow life devoted to work.

(C) Playing Human Shield / Cover Ups / Moral Injury / Injustice

The third cause I will mention is acting as the "Human Shield" - someone who hides or downplays a major risk or moral issue to keep it from disturbing the productivity or success of the company.  This could be a COO who looks the other way at the poor behavior of a star performer.  Or it can be a CEO who is overly optimistic about the probability of investors to fund the company in order to keep employee morale up when the company is already in financial distress.  Or it can be a sales manager who hides the questionable behavior of a major client in order to preserve revenues and keep the company going. 

In every case, the Human Shield becomes a morally ambiguous figure, even if they are acting for the survival of the company and even if their own personal ethics are otherwise sound.  This comes from simply covering up or defending against the issue while promising an aura of benevolence that they cannot guarantee. 

Because of this, they bear the fear of moral or business failure.  They store this fear and tension in their body.  This may be one of the worst forms of Leadership Trauma since the Human Shield is absorbing a toxicity that they sometimes had no role in creating, yet which they fully ingest. 

If the hidden risk does, in fact, happen, then having played Human Shield can make it all the more painful.  For instance, a CEO who hides the company's financial performance from employees (to prevent a death spiral) will get hit doubly hard when they run out of money and are forced into surprise layoffs.  On top of shame and panic over their financial failings, they will receive employee blame for not giving any warnings whatsoever of the layoffs, likely plunging them into a guilt and shame vortex.  This trauma can also build up over time.  An executive I know from a Fortune 500 had to be institutionalized after being forced to quietly deal with abusive work conditions for years without getting sufficient support.  What was worse was that this employee did not cause these work conditions and tried to have them remedied - to no avail.

Playing the Human Shield can be related to the concept of Moral Injury:

Moral injury is a trauma related syndrome caused by the physical, psychological, social and spiritual impact of grievous moral transgressions, or violations, of an individual's deeply-held moral beliefs and/or ethical standards due to: (i) an individual perpetrating, failing to prevent, bearing witness to, or learning about inhumane acts which result in the pain, suffering or death of others, and which fundamentally challenges the moral integrity of an individual, organization or community, and/or (ii) the subsequent experience and feelings of utter betrayal of what is right caused by trusted individuals who hold legitimate authority.

The violation of deeply-held moral beliefs and ethical standards—irrespective of the actual context of trauma—can lead to considerable moral dissonance, which if unresolved, leads to the development of core and secondary symptoms that often occur concurrently. The core symptoms commonly identifiable are: (a) shame, (b) guilt, (c) a loss of trust in self, others, and/or transcendental/ultimate beings, and (d) spiritual/existential conflict including an ontological loss of meaning in life. These core symptomatic features, influence the development of secondary indicators such as (a) depression, (b) anxiety, (c) anger, (d) re-experiencing the moral conflict, (e) social problems (e.g., social alienation) and (f) relationship issues (e.g., collegial, spousal, family), and ultimately (g) self-harm (i.e., self-sabotage, substance abuse, suicidal ideation and death).

In many cases, brief or isolated encounters with these 3 causes do not trigger any kind of trauma.  The outcome completely relies on how severe and how sustained the exposure is and if there was a prior history of such events in the life of the leader.

One risk factor that can make things much worse is a leader's self-neglect, which I call "Dehumanization of the Self." In other words, Leadership Trauma is exacerbated when leaders begin to ignore their own suffering and dehumanize themselves in order to "get through it." 

For instance, in order to pull their company through a crisis, leaders may work 80-100 hour weeks (I had many of those), not get enough sleep, not eat well, not exercise, drink too much, or use excessive medications or drugs.  This is not to shame any of these behaviors.  In the moment, the leader may feel they need to do this in order to survive (and they may be right).  This is very common with trauma. 

It can, however, feed into a cycle during a company crisis.  The closer the leader thinks they are to failure, the closer they are to shame or negative self-regard, and therefore, the more willing they are to not treat themselves well.  At an extreme, they start to go numb from these behaviors.

Once the leader starts to become numb to their own pain, they have dehumanized themselves.  This is when the long-term damage to them can skyrocket since the normal pain feedback loop has been turned off.  They are dissociated. They can risk dehumanizing themselves at an accelerating pace and traumatizing themselves in ways they would normally object to.  To the extent that they had suffered trauma in the past, this could worsen these effects.

There is also a secondary risk here.  Once the leader starts to dehumanize themselves, it becomes easier to dehumanize everyone around them through abusive work conditions (which, in turn, can lead to Moral Injury in the ecosystem, as per above).  This is how relational trauma spreads.

(6) WHY LEADERSHIP TRAUMA IS NOT DISCUSSED

"Very few people talk about it and I have never read anything on the topic." ~ Horowitz

If all these situations are so common, what should we make of Horowitz when he says,"very few people talk about it and I have never read anything on the topic"?   Why is Leadership Trauma an under-discussed problem?  [Please note, this has materially changed since the original publication of this paper. Leadership mental health awareness has improved dramatically, and part of the reduction in Leadership Trauma that I've witnessed may be attributable to this.]

When fear is suffered in an abusive relationship, we have a word for it - being terrorized by a partner.  We are not, however, used to seeing "self-generated fear" as equally traumatic. 

But when it comes to fear, it does not matter how rational it is.  It matters how deeply we live in the terror and what we believe to be real.

As a society, we certainly don't expect this kind of self-generated terror in the minds of aspirational figures, such as people at the top of a power or wealth hierarchy, like a CEO.  Before I became an entrepreneur, I couldn't imagine how bad it could be at the top. 

Few people in our society want to believe that such a desirable position of power could possibly bring such pain with it.  After all, being a CEO is meant to be an aspirational goal of capitalism.  

There is also a societal bias that says many founders and CEOs don't feel this kind of pressure because they are unfeeling jerks who are ego-driven and narcissistic.  Many absolutely are.  But those people are no more immune to being traumatized by fear than any other person. 

And this is not to mention all the empathic leaders, who deeply care about the stewardship of their responsibilities and feel leadership pain acutely (yes, there are many).  

Either way, Horowitz is correct.  We do not broadly discuss it.  Until I wrote this article, I never even came across a concept like Leadership Trauma.  Only leader depression and burnout - which I mentioned above, is not my experience of what it feels like, at all.

All of this is ironic, given our popular culture.  Consider how many films, stories, and books are written about the terrible existential drama of fictional superheroes.  There is almost always a crisis of mental health in every superhero story - a point where the hero's mental resilience is pushed to its absolute end.  That becomes the spiritual core of every single superhero movie. 

What we so often dramatize in film and television, we drastically under-diagnose in real life.

(7) POST-TRAUMATIC GROWTH

"The normal response to trauma is not PTSD.  The normal response to trauma is resilience."

There is an interesting twist to all of this, however.  And that comes from an area of psychology called Post-Traumatic Growth (PTG) - which is the flip side of PTSD.  PTG is the resilience and growth that comes from people who have suffered trauma, recovered, and built up the resources to help lead others through it.  Here is how some describe PTG:

Post-traumatic growth was introduced by Richard Tedeschi and Lawrence Calhoun in

1995, referring to positive changes that some trauma survivors report as a result of the struggle to cope with traumatic events. People report five areas of growth: [1] improvements in interpersonal relationships, [2] a greater appreciation for life, [3] new opportunities or pathways in life, [4] a greater sense of personal strength in ability to cope with crises, and [5] spiritual changes or development.

During the coronavirus crisis, I noticed that many of the most engaged leaders I saw were ones who, in fact, had some form of PTG.  I wrote about this in my article "Unleashing Human Adaptability During Crisis." Afterwards, I heard from many people who thanked me for pointing out how their prior traumas had in fact made them much stronger and had given them superpowers to deal with the crisis which their peers simply did not have.  Here is some of what I wrote there with regard to early 2020 coronavirus planning:

Additionally, and anecdotally, some of the most capable leadership I'm seeing right now is from people who have survived and made a superpower out of relational trauma (traumas with a relationship component vs. physical trauma). In other words, people who are survivors. These folks are powerful because they can process enormous amounts of uncertainty while still anticipating problems and mobilizing solutions. They know how to function in the face of fear.

They have a tell-tale "Early Adopter" pattern:

1. They see the problem before anyone else does, get a surge of productive anxiety, and start planning. They often can't stop themselves from this planning.

2. Once they start to implement plans, their anxiety drops about 30-40%.

3. Once everyone else sees the danger and their plans are implemented, their anxiety drops 80-90%.

After Step 3, they will likely be calmer than anyone else.

Despite their stress, and through all of it, they remain highly functional. They are simply highly intense / emotional, especially at the first step.

These are the people who need to have a seat at the table in your organizational response. I'm finding them to have more mental resilience than even ex-military types.

As mentioned above, the psychologist Sue Erikson Bloland found that many great achievers had trauma in their past and used it as a form of motivation. In fact, one VC I recently spoke to is convinced that, for many successful people, escaping trauma becomes a deep motivational mindset, pervading all their greatest accomplishments.

Although Post-Traumatic Growth is a brilliant thing to observe it has its limits.  While leaders with trauma-resiliency may shine in these situations by using their superpowers, they may also see traumatic situations as familiar, normal, and nothing out of the ordinary.  To the extent that these situations mirror their past traumas, they may allow bad conditions to endure far too long without an intervention, whereas less resilient leaders, out of self-preservation, may bow out earlier or force healthy organizational change sooner, because they simply have lower tolerance for this and no prior such survivorship conditioning.  

Nonetheless, if the work trauma strikes too closely to their developmental trauma, even people with PTG can become overwhelmed quickly.  A trauma history from earlier in their lives can therefore cut both ways - it can both strengthen resilience, but also create a vulnerability for bringing back suffering.

(8) WINNING WITH CRISIS-MIND

"CrisisMind is the problem-solving & special skills capacity of a person who has absorbed the properties of an extremely challenging or potentially traumatic situation."

This brings us to the final point - how do you coach or work with leaders who have been traumatized or are in trauma-inducing situations (assuming you have a trauma-informed practice)?  Please note that this section is not meant to address coaching as a replacement for therapy (it can't be, as they are not the same thing), but for helping leaders with the work problems for which they are seeking coaching.  Some may argue that even trauma-informed coaches should never work with leaders who they suspect are in traumatic situations (even after they have referred a therapist).  Each situation has to be evaluated individually. But we have to consider that everyone in the leader's company is already working with the leader in this state.  Such leaders are not sitting on “Therapy Island” immune from making decisions - every organizational function, external parties, customers, vendors, stakeholders, and investors interact with them daily.  Therefore, the question is how to be helpful to them with the problems they are bringing. 

Leaders in this state are very likely in what I call CrisisMind: the problem-solving and special skills of a functioning, responsive person in a very extreme or potentially traumatic situation. 

First, we can consider whether or not trauma actually has an effect on how people can think.  This is what van der Kolk had to say about it:

Trauma results in a fundamental reorganization of the way mind and brain manage perceptions. It changes not only how we think and what we think about, but also our very capacity to think.

The reason we call this CrisisMind (versus our prior designation, TraumaMind) is because the level of difficulty here is on a continuum - not every crisis becomes traumatic, but they share many similarities in terms of what they do to leadership thinking.

CrisisMind is a complex psychological state to work with.   When the intensity or trigger is too much, CrisisMind looks very much like a “fight, flight, freeze, or fawn” stress response or a trauma response.  However, at lower levels of intensity, or for those who have built up trauma resiliency, CrisisMind can be extremely productive, even if it is only intermittently functional. 

What’s it look like? CrisisMind is characterized by high levels of vigilance, urgency, and hyper-focus.  Stress may be extremely high.  Obsessive patterns or recurring thoughts are likely.  Worry and anxiety will be very high. 

But, there are two strengths of CrisisMind, however.  The first is that psychic pain tolerance goes up, potentially dramatically.  Things that were psychologically unbearable in the past can be borne with a courage born of necessity.  The mind can rise to the occasion.

The second, however, is perhaps more important.  And this strength is CrisisMind's mental flexibility (when CrisisMind is at manageable levels!). 

Since crisis challenges and breaks prior expectations, restrictive assumptions and constraints of the past may also go out the window - which means new options and solutions may be considered.   After all, when any bad thing becomes possible (which CrisisMind's hyper-vigilance will notice), then any good solution can also be possible.  Creativity can go into new, unexplored territories. 

As Sun-Tzu states, in the trauma of war, flexibility and adaptability are what matter:

As water varies it flows according to (yin) the fall of the land, so an army varies its method of gaining victory according to (yin) the enemy.  Thus an army does not have fixed strategic advantages (shih) or an invariable position (hsing).

This brings us to our three-step progression in coaching an executive in CrisisMind for help with their work problems:

(A) CONNECTION, NAMING, & DE-SHAMING

Leaders in CrisisMind desperately need connection. To quote psychologist Karen Treisman, "Relational trauma requires relational repair." A deeply stressed-out or traumatized person does not want to be alone with their thoughts.  When their entire reality has been shaken, the most important first step in problem solving is to ground the leader with someone who can contain what they are feeling, put names to it, and help them lay out their "items of focus" (see also Susan David's outstanding work on naming, in Emotional Agility).

As a practical matter, the minimum output of this stage is often a form of a problem statement, even if that problem statement is a form of feelings, e.g., “I’m very anxious that…” or “I’m terrified that…”  These are both trailheads for problem solving in addition to potential stress-relief admissions to share with an advisor or coach. 

As trauma therapist Dr. Frank Anderson puts it, when it comes to working with hyper-aroused clients who need regulation (Treating Complex Trauma with Internal Family Systems, PESI):

"You can borrow my pre-frontal cortex."

This is the importance of connection.  As Van der Kolk states:

Our words are not meant to tell the truth...

[But] Without words, you cannot connect to the rest of the human race. And so words are essential to reconnect.

Remember, the leader's main challenge at this point will be understanding what their own reality is - not what yours is, as an outside observer.  Said differently, the connection needs care to preserve the client’s frame and sense of reality.  Consider this illustrative dialogue in which traumatized folks can find themselves from van der Kolk:

Look around. 

There's nothing to be afraid of. 

And my frontal lobe knows that, but my limbic system doesn't know that, and I actually feel deeply ashamed about the way I feel. 

And if you tell me I shouldn't feel that way, I feel even more ashamed because I cannot control my limbic system.

The point is not whether or not the leader is being rational.  That analysis can come in step two.  The traumatized leader needs to communicate their reality to someone who is willing to help them identify it proactively, name it, and put it into words - without rejection and with compassion. 

As a practical matter, we also need to consider that emotions not only have information about the person, but they may also have information about the business situation.  One CEO I have worked with knows that her anxiety is often the canary in the coal mine for a problem that may not be fully recognized yet, but which may be brewing.  In other words, emotions can be actual business information.

At this stage, leaders also need to be de-shamed in order to regain their effectiveness, especially if they have deeply dehumanized themselves.  This again is why a warm connection as a collaborator makes the difference.  Here is what that sounds like (you should only say this if it is true!):

"I understand what you feel, I would probably feel the same exact way..."

"Of course, you would feel that way, that makes total sense to me..."

"I had the same experience myself, and I felt just like you did..."

(B) PRIORITIZATION

The next point of difficulty in solving their work problems will be establishing an order of operations and prioritization.  In other words, "finding what must be done and in what order."  Leaders in traumatic crises cannot afford to stop problem solving.  Of course, they need to take breaks (which can be revelatory), but the source of their traumatization is the ongoing problem, so it must be solved.  And prioritizing the issues is essential to action.  Here is how van der Kolk says it can lead to recovery (The Body Keeps the Score):

Only after you identify the source of these responses can you start using your feelings as signals of problems that require your urgent attention.

This stage is when the rationality of fears can be examined, if necessary. After this second step, there is usually significantly more calmness in the leader.

In a problem solving process, this is a different step than solutionizing.  It is more akin to prioritizing the problem statements identified in the first stage.

(C) VALUES

Once the problems are prioritized, you can turn to defining exactly where the leader is stuck in each problem - and then explore solutions. Given that the leaders may be extremely afraid of potential failure, there is a risk of exasperation or flailing at this point. 

In some cases, the solutionizing is a business-only proposition.  However, in other cases, the crisis may be so advanced that there is no obvious solution.  This would be analogous to a “chaotic” situation in the Cynefin framework, where there is no clear relationship between cause and effect, making predictive action very difficult.

This is where a focus on values is paramount to keeping the leader focused, ethical, and creative.  It's important to keep a strong grounding in wisdom and moral, ethical, or spiritual values to help guide the way through excessive ambiguity.  If there has been any dehumanization of others (employees, customers, vendors, investors, etc.), this is also the time to address it.

Often, this stage becomes the key inflection moment where leaders find what matters most to them.  When properly supported, many leaders brainstorm some of the best transformations of their careers at this stage, with unrestricted creativity and new courage.  These are the moments that we dramatize in superhero movies.  It's the Abyss in the Hero's Journey.  This is pulling victory from the jaws of defeat (although, at this stage, the definitions of victory and defeat may have changed to match the leader's deepest values).

Sometimes, coaches will try to snap the leader out of CrisisMind thinking - because the coach themselves is uncomfortable with the intensity.  For example, they may try to discount the emotions as irrelevant or label them irrational.  As a practical matter, as mentioned above, this can be a bad idea as CEO emotions often are compressed, early warning signals for business conditions - in other words, doing so would be losing information. 

But there is also another issue with avoiding this emotional processing.  As van der Kolk’s earlier dialogue suggests, telling a leader they shouldn’t feel afraid only deepens their shame, since they cannot control their limbic system.  This can break rapport with the client to the level of impeding the practical crisis work.  Depending on the complexity of the problem, a coach stuck in this tension should consider referring out the client, especially if they do not have a crisis-informed or trauma-informed practice.  

Despite all these difficulties, please do not underestimate the power of the CrisisMind and traumatic situations to be positively transformative to the long-run health of the organization.

As Horowitz has pointed out, these WFIO ("We're F*cked, It's Over") moments occur in all companies.  These are the defining moments of change.  Re-imagining the organizational system at these junctures, based on deep values, can help reset the culture and success of the organization for years to come.  

Even in the midst of traumatic situations, problems that have been avoided for a long time can be solved and imbalances finally put into balance.

(9) FINAL WORDS

"Life is full of trauma. None of us is immune."

A final key point with regards to Leadership Trauma is not to overly pathologize Leadership Trauma. Life is full of trauma. None of us are immune from encountering it.

How we recover can set the tone for a brighter future - for us and for those people whose futures we are entrusted to defend.

It is not always obvious, but every trauma is potentially an opportunity to do something constructive - even if that future has to be put together stitch by painful stitch.

As Horowitz says:

This is not checkers; this is motherfuckin’ chess – Technology businesses tend to be extremely complex. The underlying technology moves, the competition moves, the market moves, the people move. As a result, like playing three-dimensional chess on Star Trek, there is always a move. You think you have no moves? How about taking your company public with $2M in trailing revenue and 340 employees, with a plan to do $75M in revenue the next year? I made that move. I made it in 2001, widely regarded as the worst time ever for a technology company to go public. I made it with six weeks of cash left. There is always a move.

~ Arzhang Kamarei is the founder of Kamarei Advisory, LLC.

He can be reached via the contact link above.

[Author note:  I have noticed a material change in Leadership Trauma since I first wrote this article in 2020.  The first difference is that the popular usage of the term trauma has ballooned to cases that likely outstrip its clinical definition.  In other words, this paper originally tethered itself to a concept of complex trauma that was primarily psychological.  But now that trauma has a ubiquitous pop psychology meaning, it’s possible that Leadership Trauma may get extended to situations which are merely quite difficult, but not traumatic.  To that end, we changed the term “TraumaMind” to “CrisisMind” to allow the framework to extend to a wider range of situations.  Secondly, I’ve encountered significantly less of this phenomena over the years since the paper was written.  I ascribe this to potentially three causes:  (a) this paper was written in the midst of the covid pandemic, when the world itself felt collectively distressed, amplifying all forms of crisis and making Leadership Trauma ubiquitous; (b) awareness of leadership mental health has improved materially allowing more of these issues to be pre-empted; and (c) it’s also possible that the incidence of Leadership Trauma has not changed, and what I’m noticing is more of an artifact of a difference in the client populations that I’m working with now compared to then.  My bet is that it is mostly (a) and (b).]

References:

American Psychological Association. "Trauma." Accessed May 6, 2026. https://www.apa.org/topics/trauma.

Anderson, Frank. Treating Complex Trauma with Internal Family Systems: A Comprehensive Certificate Training Course. Online course. Eau Claire, WI: PESI, 2018.

Bloland, Sue Erikson. "Childhood Trauma and the Drive to Attain Greatness." Lecture, Psychoanalytic Psychotherapy Study Center Annex, New York, NY, September 20, 2019.

Bloland, Sue Erikson. In the Shadow of Fame: A Memoir by the Daughter of Erik H. Erikson. New York: Viking Penguin, 2005.

Bonanno, George A. Advances in Trauma Treatment Today. Video lecture. In Trauma Treatment Mastery: Effective Healing Interventions for Mind and Body. Eau Claire, WI: PESI / CMI Education Institute, 2014.

Bonanno, George A. "Loss, Trauma, and Human Resilience: Have We Underestimated the Human Capacity to Thrive after Extremely Aversive Events?" American Psychologist 59, no. 1 (2004): 20–28. https://doi.org/10.1037/0003-066X.59.1.20.

Carey, Lindsay B., and Timothy J. Hodgson. "Chaplaincy, Spiritual Care and Moral Injury: Considerations Regarding Screening and Treatment." Frontiers in Psychiatry 9 (2018): 619. https://doi.org/10.3389/fpsyt.2018.00619.

David, Susan. Emotional Agility: Get Unstuck, Embrace Change, and Thrive in Work and Life. New York: Avery / Penguin Random House, 2016.

Ferriss, Tim. "Tim Ferriss — My Healing Journey After Childhood Abuse." Transcript of The Tim Ferriss Show, episode #464, with Debbie Millman, September 16, 2020. https://tim.blog/2020/09/16/how-to-heal-trauma-transcript/.

Figley Institute. Compassion Fatigue Educator: Course Participant Guide. Revised August 2013. Tallahassee, FL: Figley Institute.  Accessed May 6, 2026. http://www.figleyinstitute.com/documents/Workbook_AMEDD_SanAntonio_2012July20_RevAugust2013.pdf

Horowitz, Ben. The Hard Thing About Hard Things: Building a Business When There Are No Easy Answers. New York: HarperBusiness, 2014.

Reddan, Marianne Cumella, Tor D. Wager, and Daniela Schiller. "Attenuating Neural Threat Expression with Imagination." Neuron 100, no. 4 (2018): 994–1005.e4. https://doi.org/10.1016/j.neuron.2018.10.047.

Snowden, David J., and Mary E. Boone. "A Leader’s Framework for Decision Making." Harvard Business Review 85, no. 11 (November 2007): 68–76.

Sun Tzu. Sun-Tzu: The Art of Warfare; The First English Translation Incorporating the Recently Discovered Yin-ch'üeh-shan Texts. Translated by Roger T. Ames. New York: Ballantine Books, 1993.

Tatkin, Stan. "How to Unravel the Shame in Relationships, Part 2: How Shame in a Relationship Can Trigger PTSD." Video 9, part 2. In How to Work with Shame. Online course. Storrs, CT: National Institute for the Clinical Application of Behavioral Medicine, 2017.

Tedeschi, Richard G., and Lawrence G. Calhoun. "The Posttraumatic Growth Inventory: Measuring the Positive Legacy of Trauma." Journal of Traumatic Stress 9, no. 3 (1996): 455–471. https://doi.org/10.1002/jts.2490090305.

Tedeschi, Richard G., and Kanako N. Triplett. "Spiritual Intelligence and Posttraumatic Growth." In Encyclopedia of Trauma: An Interdisciplinary Guide, edited by Charles R. Figley. Thousand Oaks, CA: SAGE Publications, 2012.

Treisman, Karen. A Therapeutic Treasure Box for Working with Children and Adolescents with Developmental Trauma: Creative Techniques and Activities. London: Jessica Kingsley Publishers, 2017.

University of Colorado Boulder. "Your Brain on Imagination: It's a Lot Like Reality, Study Shows." ScienceDaily, December 10, 2018. https://www.sciencedaily.com/releases/2018/12/181210144943.htm.

van der Kolk, Bessel A. "How to Work With Shame When It's Connected to Trauma, Part 1: A Way to Heal Trauma-Based Shame Using a 3-Dimensional Space." Video 7, part 1. In How to Work with Shame. Online course. Storrs, CT: National Institute for the Clinical Application of Behavioral Medicine, 2017.

van der Kolk, Bessel A. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York: Viking, 2014.

van der Kolk, Bessel A. When Talk Isn't Enough: Embodied Awareness in the Consulting Room. Video lecture. In Trauma Treatment Mastery: Effective Healing Interventions for Mind and Body. Eau Claire, WI: PESI / CMI Education Institute, 2014.

World Health Organization. International Classification of Diseases, Eleventh Revision (ICD-11). Code 6B41, "Complex post traumatic stress disorder." Geneva: WHO, 2019. Accessed May 6, 2026. https://icd.who.int.