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When Stress Constitutes Trauma and Trauma Constitutes Crisis: The Stress-
Trauma-Crisis Continuum

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 When Stress Constitutes Trauma and Trauma
Constitutes Crisis: The Stress-Trauma-Crisis
Continuum

Catherine N. Dulmus, PhD, ACSW

Carolyn Hilarski, PhD, CSW, ACSW

The literature indicates researchers and practitioners often confuse the terms stress,
trauma, and crisis. Commonly these terms describe both the event and the response,
which is circular reasoning. This article attempts to address the confusion through
definition of terms, explanation of the stress-trauma-crisis continuum, and a case study
to illustrate points. The correct use of terms is essential for appropriate assessment,
intervention, and outcome measurement. [Brief Treatment and Crisis Intervention 3:27–35
(2003)]

KEY WORDS: stress, crisis, trauma events, perceptions, appraisal, perceived coping,
trauma exposure.

The stress, trauma, and crisis literatures attempt
to understand and differentiate the mediators
and moderators that influence the human ex-
perience of each in order to determine appro-
priate assessment, prevention, and intervention
methods. Yet the reader is often left confused
with the use of terminology in this process,
as frequently terms are used interchangeably
(Lewis & Roberts, 2002). To illustrate, past at-
tempts to conceptualize trauma focused on pro-
viding a sequence of the trauma experience that
encompassed three phases: environmental in-
From the College of Social Work at the University of Ten-
nessee (Dulmus) and the Social Work Department at
Rochester Institute of Technology (Hilarski).
Contact author: Catherine N. Dulmus, PhD, ACSW, Assis-
tant Professor, The University of Tennessee, College of So-
cial Work, 301 Henson Hall, Knoxville, TN 37996. E-mail:
cdulmus@utk.edu.
© 2003 Oxford University Press
put, perception and immediate appraisal of the
event, and psychological reaction (Green, 1990).
However, the means used to label these phases
is perplexing, as the terminology is circular in
its reasoning. For example, an event is a trauma,
because its consequences are traumatic. More-
over, the multiple usage of the term trauma is
unclear and hampers integration of research
outcomes. For instance, frequently the word
trauma refers to the trauma exposure, the per-
ception, and the process linking the two (Kasl,
1990).
It is imperative for researchers and profession-
als to understand that an event or circumstance is
not a stress, trauma, and/or crisis. The level of
personal distress regarding an event or circum-
stance relates to the individual’s perception of
the event, depending upon personal character-
istics and context (Roberts & Corcoran, 2000;
Valentine, Roberts, & Burgess, 1998). This per-

27
DULMUS AND HILARSKI
ception defines the event for that individual.
Understanding this is critical as it influences
the development of assessment, prevention ap-
proaches, and intervention methods for those
at risk of, or who are currently suffering with
such distress. Moreover, it is essential that re-
searchers adhere to such understanding con-
cerning their findings. It is not the event that is
causal, but the individual’s unique perception
of the event.
Just as stress, trauma, and crisis are percep-
tions of an event, so are sadness, happiness, and
anger. For example, the concept of anger in-
cludes a continuum of perception outcomes that
range from no anger to murderous rage. Along
this continuum fall such related perception out-
comes as frustration, miffed, irritated, annoyed,
perturbed, and so on, depending on the indi-
vidual’s view. Each perceived outcome looks,
feels, and behaves differently. Moreover, each
outcome may be additive to pathology or stand
alone as an issue depending upon the context,
developmental stage, and psychological and
physiological make up of the individual. The
stress-trauma-crisis continuum is a similar ex-
ample as perception outcomes may look, feel,
and behave differently; add to each other, or
stand alone as an issue, depending on the indi-
vidual’s perception of the event (Valentine et al.,
1998).
This article attempts to define, differentiate,
and offer case examples of specific human life
events or circumstances and explore why some
individuals may perceive such events as stress,
trauma, and/or crisis. Through examining how
perceptions look, feel, and behave the article
will explore how a perceived stress develops
into a perceived trauma and crisis.
Stress as a Perception
Every person perceives stress. Yet research ac-
knowledges that the individual’s perceptions of
28 Brief Treatment and Crisis Intervention / 3:1 Spring 2003
stress are not homogenous (Aldwin, Levenson,
& Spiro, 1994). Stress is defined as a “force: pres-
sure: urgency: strain” (Webster’s Dictionary,
1990, p. 830). The study of stress includes a
number of perspectives and descriptions. For
example, stress is a response to an environmen-
tal situation (Selye, 1973), an environmental
challenge (Dohrenwend, 2000), or the relation-
ship between environmental demands and the
ability to meet those demands (Taylor & Rob-
erts, 1995). Lazarus (1984) asserts that stress
is a “particular relationship between the person
and the environment that is appraised by the
person as taxing or exceeding his or her re-
sources and endangering well-being” (p. 376).
Crucial to this definition is the appraisal and
coping resources of the individual, as stress rep-
resents the individual’s subjective perceptions
and interpretations more than an objective exis-
tence of a negative event or situation. Thus, the
cognitive, behavioral, and/or emotional out-
come of perceived stress may run along a con-
tinuum of its own ranging from not at all to
somewhat or mild to extremely severe.
Perceived Stress
Perceived stress is the individual’s response to
an event (Roberts & Corcoran, 2000). Such an
event may be acute, meaning an isolated event
in one’s life experience (e.g., a broken leg) or
chronic, meaning an ongoing cumulative effect
situation (e.g., substance abuse). Examples of
life events that could be perceived as stress in-
clude divorce, poverty, homelessness, violent
communities, and limited educational opportu-
nities (Garbarino, 1995; Masten & Coatsworth,
1998).
An essential concern in the stress literature is
the lack of consensus on how to define stress
(Rutter, 1999). The controversy centers on
whether stress is as an objective or subjective
circumstance and how to measure subjectivity
(Gruen, Folkman, & Lazarus, 1988; Lazarus,

1984). Certainly, defining stress objectively re-
lieves the research of contaminated subjective
bias. However, relying on a purely objective
definition or measure is simplistic and ignores
the heterogeneity of the individuals with the
perceived stress. Lazarus (1990) states that
“there is no way to separate person and envi-
ronment in the appraised person-environment
relationship without destroying what is meant
by psychological stress as conceived in a cogni-
tive-relational theory” (p. 10). For this reason
we support the definition of stress to be one’s
perception to an event.
Perceived Stress Outcomes
Perceived stress threatens the homeostasis of an
organism (Roberts, 2000). The stress perception
depends on the individual’s stage of develop-
ment, life experience, personality, context, and
coping strategies as well as the intensity and
duration of the life experience (Honig, 1986).
Associated issues are behavioral and health
concerns and social and internal disturbances
(e.g., depression, anxiety, and low self-esteem;
Shalev, 2002). A chronic perceived stress can
compromise the immune system response and
impair cognitive function (Glaser, Calhoun, &
Horne, 1999).
To illustrate the above points, the following
case study provides an example of a preadoles-
cent’s perception of an event as stress:
Tom, age 12, is suddenly taken to boarding
school by his parents who have decided that
this is best for him. Tom feels extremely lonely
and homesick since arriving at the new school
2 weeks ago. He wonders what he did to be
sent away. He has not participated in any
after-school activities, choosing instead to
spend time alone in his room. Today when
his dorm parent encouraged him to attend a
sporting event he became angry and shouted
at her to leave him alone.
Brief Treatment and Crisis Intervention / 3:1 Spring 2003
Stress, Crisis, and Trauma
Trauma as a Perception
Some individuals will move along the contin-
uum where an event they perceive as stress will
develop into a perception of trauma. Stedman’s
Medical Dictionary defines trauma as a psycho-
logical or physical injury and elaborates that it is
a Greek word for wound (Dirckx, 1997). Camp-
bell (1989) explains, “As originally described,
psychic trauma referred to a sudden intense
surge of anxiety, secondary to some external
event, that exceeds the subject’s ability to cope
and to defend” (p. 775). Hence, the perceived
trauma develops when the individual under-
stands, through thoughts and/or feelings, that a
physical and/or psychological injury is present
in his or her worldview.
Perceived Trauma Events
Intuitively, it would seem that a trauma-produc-
ing experience would be easy to recognize.
However, there is no generally accepted defini-
tion of what constitutes a trauma-producing
event (Mueser, Rosenberg, Goodman, & Trum-
betta, 2001). This may be due to trauma actually
being one’s perception of an event that when
combined with their attributional response
clearly individualizes when an event will be a
trauma-producing occurrence. To illustrate, the
bomb dropped on Hiroshima may be a trauma-
producing event, a military victory, or a divine
retribution depending on the individual’s
“meaning making” (Crystal & Folkman, 1997) or
attribution and perception of the occurrence.
The perceived trauma does not begin with the
life event but with the psychic structure that at-
taches specific attributions to the event (per-
ceived stress), which includes the individual’s
history and culture. For example, in the previ-
ous century beating a child or sending him or
her to work was normal and even healthy. Today
this treatment towards children is termed child
abuse and deemed a trauma-producing experi-
29
DULMUS AND HILARSKI
ence, although not always perceived as a trauma
by every child.
Perceived Trauma Outcomes
Fundamental to a perceived trauma is a shatter-
ing of the worldview (Herman, 1992; Roberts,
2000). In this outcome of a new worldview,
there is no meaning, control, connection, safe
place, or dependable individual (Herman, 1992;
Ochberg, 1993). This new belief or scheme vio-
lates the basic needs of safety and thwarts hu-
man growth and healthy functioning (Maslow,
1968). Other perceived trauma outcomes in-
clude disruptions in the psychic equilibrium,
which alters the optimal levels of arousal (Knox
& Roberts, 2001; Roberts & Corcoran, 2000;
Wilson, 1995). The psychological experience
includes helplessness and disconnection (Her-
man; Valentine et al., 1998), powerlessness and
loss of control (McFarlane, 2000), difficulty in
communicating (Wright, Master, & Hummard,
1997), and chronic or disrupted feelings of fear
and vulnerability (Wilson, 1995). The physio-
logical indicators include hypertension, heart
murmurs, coronary heart disease, migraine head-
aches, ulcers, and irritable bowel syndrome (Ev-
erly, 1995) as illustrated by Tom’s situation in the
following:
It has been 6 weeks since Tom arrived at
boarding school. His grades have begun to de-
cline to the point that he is failing two sub-
jects. When his math teacher approaches him
about his grades he reports that he is having
a hard time concentrating, is experiencing
frequent headaches, and finds he is worry-
ing about several things recently. When the
teacher tells Tom that he will need to call his
parents to inform them of his failing grades
Tom replies that they won’t care as he knows
they don’t love him anymore.
Some individuals will never move beyond
perceiving the event as a trauma, others will
30 Brief Treatment and Crisis Intervention / 3:1 Spring 2003
find healing at this point in the continuum,
while still others will progress to perceiving the
trauma as a crisis and move to another level of
thinking, feeling, and behaving (Roberts & Cor-
coran, 2000; Valentine et al., 1998). What will it
be for Tom?
Crisis as a Perception
Webster’s Dictionary (1990) defines the word cri-
sis as “a decisive or crucial time, stage, or event”
(p. 171). Roberts (2000) relates that a crisis in-
cludes an upset in the individual’s steady state.
Roberts and Corcoran (2000) further elaborate:
A person in a crisis state has experienced a . . .
threatening . . . or traumatic event, is in a vul-
nerable state, has failed to cope and lessen the
stress or trauma through customary coping
strategies, and thus enters into a state of dis-
equilibrium (p. 327).
Hence, for crisis to present, the individual’s
trauma perception must progress to a place of
understood instability and disorganization due
to an unresolved acute or chronic perceived
stress.
Perceived Crisis Events
An event or circumstance precipitates a crisis if
the individual perceives the event or circum-
stance as a danger or threat and decides to make
personal changes or “protect” the self against
the perceived peril with pathological defense
mechanisms (e.g., overcontrol, lethargy) (La-
zarus, 1984; Roberts, 2000). Further, it is the
individual’s perception of an event as stress,
within a specific context, that defines the life
event or circumstance as a crisis (Knox &
Roberts, 2001; Roberts & Corcoran, 2000). For
example, children will evaluate an environmen-
tal circumstance according to caregiver reaction
(Cicchetti, Rogosch, & Toth, 1998). If the care-

giver reacts negatively to a given situation, the
child will likely react and cortically store the
perception accordingly (Cicchetti et al., 1998).
When a crisis is perceived it may facilitate life
change positively or negatively. In Tom’s case
study an example of a negative life change is elu-
cidated.
Again last night, for the third night in a row,
Tom’s parents did not call him. He has become
extremely combative and is refusing to get out
of bed this morning for school. He tells his
roommate that he can no longer stand know-
ing his parents do not love him or want him
home. In a panicked manner, he tells his room-
mate that he plans to steal a car today and
drive across the county. When his roommate
confronts him as to the consequences of steal-
ing a car and running away, Tom responds that
it doesn’t matter as he won’t be missed by any-
one, including his parents.
Perceived Crisis Outcomes
A perceived crisis may or may not result in
pathology (Roberts & Corcoran, 2000; Valentine
et al., 1998). For instance, an event such as being
passed over for a promotion might be inter-
preted as a disappointing incident that will ulti-
mately be overcome, or it could be seen as proof
of intense personal inadequacy. The difference
between the two interpretations is due to inter-
nal beliefs about the self and world (Kelly, 1955)
formed by secure or insecure attachment (Lynch
& Cicchetti, 1998). For example, if an individ-
ual’s internal working model is concrete (e.g.,
success-failure: formed by insecure attach-
ment), then being denied a promotion might
lead to thoughts of failure and further pes-
simistic and depressive feelings. These feelings
might then lead to nonproductive maladjusted
thoughts and behaviors that describe the per-
ceived trauma outcomes.
The case study of Tom provides an example of
outcomes related to a stress perceived event in
Brief Treatment and Crisis Intervention / 3:1 Spring 2003
Stress, Crisis, and Trauma
regards to thoughts, feelings, and behavior at
each stage in the stress-trauma-crisis contin-
uum. The case study is illustrated visually in
Figure 1.
Influence of Personal
Characteristics
Personal characteristics certainly influence the
interpretation of stress as a trauma and a crisis.
Several theoretical frameworks include the in-
fluences of personal characteristics on percep-
tion of stress and outcomes (Folkman, 1984). For
example, transactional theories propose an in-
teraction between environment and personal
characteristics in the initial stage of perceived
stress that influences stress circumstance ap-
praisal and future coping responses. Individuals
who perceive that they are capable view the
stress event as a challenge. Those who view
themselves as incapable focus on perceived
ineptness, view the world as dangerous, and
overreact to the life event. This can lead the indi-
vidual to perceiving the stress as trauma and
subsequently crisis. Some characteristics that in-
fluence the stress-trauma-crisis continuum are
personality and resiliency (Wilson, 1995; Wright
et al., 1997). Social support, or lack of it, is also
influential.
Personality
Personality is “dimensions of individual differ-
ences in tendencies to show consistent patterns
of thoughts, feelings, and actions” (McCrae &
Costa, 1989, p. 587). Personality traits have
been consistently linked to individual’s percep-
tions of self and others, evaluation of situations,
and assessments of well-being (Diener, 1984;
Hooker, 1992). Understanding personality is
critical since personality traits influence indi-
viduals to interpret their worlds and the cir-
cumstances in it as benign or threatening (Diener,
1984; Hooker, 1992). As an example, neurotic
31
DULMUS AND HILARSKI
FIGURE 1
An illustration of the stress-trauma-crisis continuum using the case study of Tom.
personalities have a tendency to understand
their world in pessimistic terms (Costa, McCrae,
& Zonderman, 1987). Moreover, these individu-
als tend to comprehend and react negatively and
are more vulnerable to the negative conse-
quences of life events (Mahoney, 1995). As a re-
sult, individuals with neurotic personalities are
more likely to appraise situations negatively and
perceive an event as stress, trauma, and subse-
quently crisis (Wofford, Daly, & Juban, 1999).
Resilience
Resilience refers to individuals who effectively
use internal (e.g., temperament) and external
(family and community) resources to overcome
life circumstances and accomplish developmen-
tally appropriate tasks (Garmezy, 1991; Masten,
2001; Rutter, 1987; Shalev, 2002). Resiliency is
not a static trait but developmentally and con-
textually influenced, as individuals often be-
come more resilient over time (Egeland, Carlson,
& Sroufe, 1993; Rutter, 1987; Werner, 1986). Re-
32 Brief Treatment and Crisis Intervention / 3:1 Spring 2003
siliency does not imply that perceived stress is
without pain, but the response is effective cop-
ing in spite of the distress (Haggerty, Sherrod,
Garmezy, & Rutter, 1994).
The internal characteristic mastery is an ex-
ample of a significant protector against per-
ceived stress (Skaff, Pearlin, & Mullan, 1996).
Mastery refers to the extent to which a person
feels that he or she has control over life circum-
stances (Skaff et al., 1996) and plays a moderator
role regarding stress (Gorman-Smith & Tolan,
1998).
Social Support
Social resources play a constructive role in re-
sponding to stress (Gorman-Smith & Tolan,
1998). Social support is a predictor of increased
life satisfaction and decreased depressive symp-
tomatology (Reading & Reynolds, 2001). A defi-
cit in social support is associated with greater
event exposures and higher levels of perceived
stress (Redinbaugh, MacCallum, & Kiecolt-

Glaser, 1995). Perception of support is essential
in safeguarding against stress (George & Tucker,
1996; Regehr, Hemsworth, & Hill, 2001).
Implications for Practice
Throughout the stress-trauma-crisis continuum
it is critical for the practitioner to understand
that such are one’s perceptions of events. Recog-
nizing this, practitioners must conduct ongoing
assessment in order to measure how the client’s
perceptions are proceeding along the contin-
uum and to provide appropriate intervention as
indicated. Roberts (2002) provides his newly
developed ACT Intervention Model for Acute
Crisis and Trauma Treatment, a conceptual
three-stage framework and intervention model
that integrates assessment, crisis intervention,
and trauma treatment. Adoption of Roberts’
model can assist practitioners throughout the
assessment and intervention phases with clients
who struggle with perceptions of events that
they equate as stress, trauma, and/or crisis.
Conclusion
As indicated throughout this article, multiple
variables influence the stress-trauma-crisis con-
tinuum resulting in a wide range of perceptions
and outcomes. In addition to personality, re-
silience, and social support, research indicates
that gender, cultural factors, previous life ex-
periences, secure attachments, and coping skills
contribute to how one perceives an event
(Chambers et al., 1998; Kessler, Kendler, Heath,
Neale, & Eaves, 1992; Rutter, 1985; Scheier, Bot-
vin, & Miller, 1999). This complex process re-
quires further investigation and conceptual de-
velopment to fully understand the continuum.
Such understanding will lend itself to further
development of appropriate assessment tech-
niques (Lewis & Roberts, 2002) and improved
Brief Treatment and Crisis Intervention / 3:1 Spring 2003
Stress, Crisis, and Trauma
intervention approaches for treatment, as well
as prevention. The first step in this important
process, though, is to utilize a consistent set of
terms and definitions when speaking and re-
searching the stress-trauma-crisis continuum.
Such will lend itself to consistency in outcome
measurement as we build this important knowl-
edge base.
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