Where the labels come from
The phrase originated in the Eye Movement Desensitization and Reprocessing therapy literature in the 1990s, as a teaching device for distinguishing single-incident catastrophic events (the "Big T" examples: assault, serious accident, sudden bereavement) from accumulated smaller adversities (the "small T" examples: low-level humiliation, ongoing instability, repeated minor losses). The distinction made the point that smaller events can accumulate into something significant. As a teaching device, it had its uses.
What the framing gets wrong
The framing has become, in popular use, a hierarchy of which events count as "real" trauma. That hierarchy is not what the research supports. Two findings are worth noting.
The first is that the formal diagnostic threshold for posttraumatic stress disorder, set out in DSM-5 Criterion A as exposure to actual or threatened death, serious injury, or sexual violence, is itself the subject of sustained academic debate. The narrowness of Criterion A excludes many experiences that produce trauma-like presentations, including prolonged neglect, betrayal, coercion, and chronic discrimination (Marx et al., 2024).
The second is that even when the formal criterion is applied, it does very little gate-keeping work. A peer-reviewed study by Hyland and colleagues in 2021, using a nationally representative Irish sample of 1,020 adults, found that removing the formal exposure requirement changed the qualifying rate for PTSD or Complex PTSD only marginally, from 13.7% to 13.2%. Events that would not meet Criterion A were as strongly associated with PTSD and Complex PTSD as the events that did (Hyland et al., 2021).
What the research suggests instead
The clinical literature increasingly frames the question as impact, capacity, and accumulation rather than event magnitude. The Australian Guidelines for the Prevention and Treatment of Posttraumatic Stress Disorder (Phelps et al., 2021) formally recognise Complex PTSD alongside PTSD and Acute Stress Disorder, signalling that the response pattern and functional impairment are what anchor clinical understanding, not the size of the precipitating event.
The size question can be set aside. The clinical question is whether the response pattern is present, whether the impairment is present, and whether the person's capacity at the time was overwhelmed in a way the body and mind are still working to integrate.
For how we work with trauma, what sessions cost, and how to begin, see Working with trauma in adults.
