When Does Trauma Ever Become “Post”? Rethinking Trauma in Frontline Work.
For many frontline workers, trauma is not something that happens once and is then left behind. It builds gradually, shift by shift, year by year, shaped not only by what is seen or experienced, but by the context in which that work takes place. A new paper by clinical psychologist Dr Nicola Cogan offers a more realistic and humane way of understanding this reality.
The paper introduces the concept of Persistent Traumatic Stress Exposure (PTSE). Rather than viewing trauma as a single event that leads to post-traumatic stress disorder (PTSD), PTSE recognises trauma as an ongoing occupational exposure. For people working in health, emergency services and social care, distress often arises from repeated exposure to suffering, responsibility for others, moral dilemmas, organisational pressure and chronic uncertainty.
Crucially, PTSE recognises that trauma is contextual and nuanced. It is not only about what happens, but how it is experienced and supported. Two people can be exposed to the same situation and be affected very differently depending on leadership response, team support, workload, values, psychological safety and whether they feel believed and supported. Trauma is therefore relational and systemic, not simply event-based.
The idea for PTSE emerged from frontline voices themselves. During research interviews, one paramedic asked a simple but powerful question: “When does trauma ever become post?” For many workers, there is no clear “after”. The work continues, the exposure continues, and its impact accumulates alongside everyday pressures such as staffing shortages, fear of error, public scrutiny and ethical tension.
Traditional PTSD frameworks have been vital in recognising trauma and legitimising psychological injury. PTSE does not replace PTSD. Instead, it highlights an important gap. Many frontline workers experience significant distress that does not fit neatly into diagnostic thresholds, particularly when harm arises from chronic strain, moral distress or organisational conditions rather than a single incident. This can delay support and reinforce stigma.
By framing trauma as exposure rather than weakness, PTSE shifts responsibility away from individual vulnerability and towards shared organisational and system-level responsibility. It recognises that psychological harm becomes more likely when exposure is repeated without adequate protection, recovery time or support. This reframing helps normalise emotional responses to demanding work and reduces the shame that often prevents people from seeking help.
The paper also argues for moving beyond reactive approaches that only respond once someone is already unwell. Instead, it calls for prevention, early support and embedded protection, sometimes described as “PPE for the mind”. This includes psychologically informed leadership, clear and compassionate responses to distress, accessible support pathways and workplace cultures where people feel safe to speak openly.
A key contribution of the paper is the distinction between organisational readiness and organisational preparedness. Readiness refers to having the right values, policies and leadership commitment in place. Preparedness is about whether those principles are actually enacted in everyday practice, especially under pressure. Trauma is more likely to become harmful when organisations appear supportive in principle but fail to respond consistently in reality.
The consequences of ignoring persistent and contextual exposure are wide-ranging. Burnout, emotional withdrawal, compassion fatigue and mental health difficulties affect not only individuals, but families, teams and entire systems. Rising sickness absence and quiet quitting increasingly reflect environments under strain rather than individual weakness.
Ultimately, PTSE offers a more nuanced way of understanding trauma in frontline work. It recognises that harm arises at the intersection of exposure, meaning, context and support. By acknowledging trauma as an occupational and systemic issue, organisations and societies can create conditions that reduce harm, protect wellbeing and support long-term resilience and growth.
“Trauma is not just about what happens, but about the context in which it happens. The same experience can be protective or harmful depending on support, leadership, safety and meaning.”
The full preprint of this paper is available at the link below for those who would like to explore the framework and evidence in more detail.
https://osf.io/tm4cj_v1