Sunday, May 25, 2008

Musings from a Blissed Out Mind

I just want to write. I love life. Sounds cliche. I really mean this. It's not what happens to us so much that determines our outcomes, it is what we choose to make of it. What meaning will we ascribe to our suffering? Existential grief is real. From a woman in the Sudan to men fighting in wars to which no one will ever understand the horrors of, what matters is not what we think our experience should be, but what we make it for. Too often we can get caught in the no man's land of WHY? Why God, why? Many of us have been there, after all, what we have endured is crazy and horrible and nearly unspeakable. We feel we are or have lead a life that can not be listened to, that no one wants to hear it. Well, I have people who do and have and will continue to want to hear "it".
My husband is one. He gets inside my pain. He is there. It is real. He feels it. I believe his tears and his breaths and his eyes when he is in that pain with me. He feels me. I have 2 best girsl who absolutely feel with me, as I do them. I love my family of choice. They know what love really is. It is a blessing we all deserve. I wish this love for all. I do not know why whatever notion of God allows bad things to happen, or why some believe it's karma, or why it happened to me. Or you. I just know I am giving it meaning. I am speaking it. I am living inside of my truth. I am as Rainer Maria Rilke put it, "Living the questions." That is my meaning, to keep learning, to keep asking why it happened to ME.....what am I hear to do, especially with child sexual rape? I will work to continue finding out. I hope to serve others in healing and speaking and creating. I am also here to live a joyful, blissed out life. I am happy, deeply, profoundly happy, and that is my underlying feeling about life, regardless of the stuff that goes on in one's life.....the things we humans go through...and for survivors that includes PTSD, complex emotions, needs and rights. If we are experiencing flashbacks, nightmares, self doubt, self persecution and paranoia, whatever it is, we are here to be bound indelibly to the light that is within us. We are here to en-joy love, life, nature, god, whatever we conceive him or her to be, we are here to manifest our birthright to abundance and clarity, our right to safety and a life lived in harmony. Namaste. S

Saturday, May 17, 2008

Backtalk with Dr. Herman

Backtalk | | March/April 1993 Issue


MA93: Backtalk

For the past twenty years, women have been speaking out about sexual violence, and men have been coming up with denials, evasions, and excuses. We have been told that women lie, exaggerate, and fantasize. Now, with "Doors of Memory" (Jan./Feb.), Mother Jones is telling us that women are brainwashed. According to Ethan Watters, gullible women are misled by fanatical therapists who implant memories of childhood sexual abuse. Forget about the epidemic of rape and incest; what really has Watters worried is the possibility that many complaints may be false. His evidence: one case in which the accusations are sensational and the facts are unclear. This, according to Watters, constitutes a trend.

The only discernible trend here is pack journalism. In the past year, numerous similar stories have appeared, from Playboy to the New York Times, inspired by a well-funded organization called the False Memory Syndrome Foundation. Despite its scientific-sounding title, this is not a research group. In fact, there is no such thing as "False Memory Syndrome." FMSF is an advocacy group for people whose children have accused them of sexual abuse. According to an FMSF newsletter (February 29, 1992), the organization is "not in the business of representing pedophiles." How do they know this? Here's their evidence: "We are a good-looking bunch of people: graying hair, well- dressed, healthy, smiling....Just about every person is someone you would likely find interesting and want to count as a friend." Some members of FMSF even say they are willing to take lie-detector tests. This has been enough to satisfy the media.

Though FMSF has been very successful in capturing public attention, most journalists have tried to preserve at least a semblance of balance in their coverage. Watters, however, seems to have swallowed the entire FMSF press packet. The effect of Watters' piece is to take the spotlight off alleged perpetrators (he does not even acknowledge FMSF as his primary source) and to put it back on victims, for whom all his skepticism is reserved. Once again, those of us who have labored for years to overcome public denial find ourselves debating victims' credibility. How many times do we have to go over the same ground, guys?

Let's review the basic facts, by now exhaustively documented. Sexual abuse of children is common (best estimates: at least one girl in three, one boy in ten). It is not overreported but vastly under- reported (best estimates: under 10 percent of all cases come to the attention of child-protective agencies or police). False complaints do occur, but they are rare (best estimates: under 5 percent of all complaints). Most victims do not disclose their abuse until long after the fact, if ever. Though many suffer long-lasting psychological harm, the great majority never see a therapist.

What do survivors of childhood abuse remember? Many survivors can remember detailed images, feelings, sounds, smells, and tastes as clearly as though the abuse were happening in the moment. In other ways, survivors' memories are often confusing and vague. Important parts of the story may be missing, and survivors may have difficulty putting the pieces together to form a complete narrative with an accurate time sequence. Furthermore, al-though traumatic childhood memories are deeply engraved, they are not stored or retrieved in the same way as ordinary memories. Many survivors have a period of amnesia for the abuse, followed by delayed recall. In a recent careful follow-up study of two hundred women with documented childhood histories of sexual abuse, one in three did not remember the abuse twenty years later.

What triggers delayed recall? Suggestion by a therapist is probably at the bottom of the list. Most commonly, abuse memories start to surface when the survivor is involved in a close relationship. The memories may break through when she starts to have sex, when she gets married, when she has a child, or when her child reaches the age at which she was first abused. Or she may recall her own experience when another victim of the same perpetrator discloses abuse. She may remember the abuse when the aging perpetrator falls ill (and now expects her to care for him), or when the perpetrator dies.

Because the mental-health professions were blind to the reality of abuse for so many years, many therapists are not well trained to treat survivors. The bad old days, when patients were told that they secretly longed for incest, are not far behind us. Most therapists, even if they now believe their patients' reports of childhood abuse, still shy away from exploring the history. Occasionally therapists make the opposite mistake: they try to play detective, leaping to conclusions about their patients' histories without waiting for the memories to emerge. In these cases, however, it is most unusual for patients to accept every suggestion their therapists make. Psychotherapy is a collaborative effort, not a form of totalitarian indoctrination.

No one wants to believe that children are commonly abused by men they love and trust. Survivors want to believe this least of all. They do the best they can to keep their experiences secret, even from themselves. Often they succeed for a long time. They hate getting their memories back, and they cling to doubt long past the point where any impartial witness would be convinced. But once survivors have completed the process of recovering their memories, their stories are both internally consistent and--often--externally verifiable. In my own study of fifty-three survivors in group therapy, three out of four women were actually able to corroborate their memories with evidence from independent sources.

Truth is a funny thing; it seems to have healing powers. Once survivors come to terms with their past, they feel better. They feel even better when they realize they are not alone. Support groups have formed all over the country; in these groups many survivors discover both their personal and political strength. No longer isolated, many lose their shame and their fear. They start to speak out, to expose the men who abused them, and to hold them accountable for their actions. A few perpetrators have even been convicted of crimes on the basis of survivors' testimony. This represents a serious challenge to patriarchal power. Perpetrators are accustomed to silence and impunity. They do not like being confronted, and they have the resources to counterattack with defense attorneys and an effective propaganda machine.

Violence against women and children is deeply imbedded in our society. It is a privilege that men do not relinquish easily. So it's not surprising that we would see serious resistance to change. Historically, every time a subordinate group begins to make serious progress, a backlash occurs. This is what happened one hundred years ago when Freud created the myth that hysterical women fantasize about sexual abuse. It makes perfect sense that we would now see another backlash in the pages of Playboy or even the New York Times. But I have to admit that I'm surprised at Mother Jones.

Judith Herman is an associate clinical professor of psychiatry at Harvard Medical School. She is the author, most recently, of Trauma and Recovery.

Book Allies: A List

Books to help enlighten and recover.

Mothers and Others

It's not so much that you did not know. I get it, you were distracted by your own malignancy, your own past, your own whatever. You, you, you..
It's this:
And that, my dear mother, is the vexing difference. THAT is what separates mothers and others. Those that care to find out, and those that do not.

Recovering After Trauma

This article describes my viewpoint on trauma and whether or not we can ever "get over it", "move on", or be asymptomatic, and really redefines what healing really means. It means not being mean to ourselves for not "being healed enough" or for "living in the past"...those are all symptoms of complex trauma.

Recovering after trauma

Print Me

Judith Herman says you do better if you’re not facing it alone.

Judith Herman helps survivors of trauma work toward recovery. She’s a pioneer in the study of Post–Traumatic Stress Disorder and the sexual abuse of women and children. Herman is Professor of Clinical Psychiatry at Harvard University Medical School and Director of Training at the Victims of Violence Program in the Department of Psychiatry at the Cambridge Hospital, Cambridge, Massachusetts. She spoke with Earth & Sky’s Eleanor Imster in October, 2005, in the aftermath of hurricanes Katrina and Rita, and the earthquake in Kashmir.

Imster: Is a trauma that’s personal and specific, such as rape or torture or child abuse, more damaging than an “impersonal” trauma – such as a hurricane or an earthquake?

Herman: Yes. There’s a big difference. The operative thing seems to be that you’re getting an up close experience of human hatred and malice. Whereas with a hurricane or a flood or a fire, it’s not intentional. No one is intentionally trying to harm you.

The other difference is that with a natural disaster, an earthquake, flood, that sort of thing, there’s no stigma attached to victims. What’s mobilized usually in the aftermath is other people trying to help. Hurricane Katrina is actually an exception to that rule, in the sense that the helpful response was so bungled, and there was a certain amount of victim blaming going on. But usually victims immediately get the sense that other people are trying to help, and that there’s no stigma attached to their plight.

But with rape, for example, the opposite is true. The victim is often blamed or scorned. With child abuse, the trauma is often repeated over and over again. There’s no safe place. With a single–impact kind of trauma, once it’s over, you can get to safety and you can get to people who are going to help you and take care of you and be sympathetic. With something like child abuse, that doesn’t happen, and similarly with rape. So, it’s not surprising that you see much higher levels of distress and post–traumatic stress disorder with the kinds of traumas that are interpersonal.

Imster: How do you know what’s a natural reaction to trauma and what’s PTSD?

Herman: Well, the question is, does it go away? A lot of people have acute stress reactions in the immediate aftermath of the trauma. They have nightmares and sleep disturbances and are very agitated and upset. But over time, it diminishes and goes away. And by six weeks later or two months later, it’s gone. That’s why we call it post traumatic stress disorder. You can think of it as almost a failure of the normal recovery adaptation to any stressor. It’s a question of whether the symptoms diminish over time, or whether the person seems stuck in the past.

Imster: So, if you’re a child who’s getting molested, your feelings of terror and helplessness are what you should feel. But then if it’s stopped, and ten years later, you still have those feelings…

Herman: That’s post traumatic stress.

Imster: PTSD seems to be suddenly appearing in news reports in the newspapers and on TV.

Herman: Right. Because we have all these soldiers in Iraq who are coming back with terrible PTSD.

Imster: And also in the aftermath of hurricanes and earthquakes. But you’re saying that compared to soldiers, and to rape and torture victims, the people who have endured these natural disasters at lesser threat of ending up with PTSD.

Herman: Their chance of recovery from the trauma is greater. And what seems to be a big protective factor in disasters is if there’s another close person that stays with you. If you able to take action together. So, that kids who are separated from their parents are at much higher risk, for example, than are kids who, whatever happened, the family stuck together and they were able to cope, together. Just keeping up your relationships seems to be very protective.

Imster: And that ability to handle it varies between individuals and depends on what kind of situation you’re in?

Herman: And how much social support you have. If you’re not facing it alone, you do much better.

Imster: So, for the survivors of, say, hurricane Katrina, a helpful thing to do would be to look to other people.

Herman: Yes, to find people, buddies, friends, family, to stick together and cope with your losses together.

Imster: When people are about to enter a situation in which they are likely to experience terror and helplessness – such soldiers going off to war – are there ways to help prevent PTSD?

Herman: What they’ve found, as far back as World War II, was that, again, the human connection seemed to be so important. In that war, the emphasis was on getting the soldier back to be with his buddies as quickly as possible. Unfortunately, that often meant going back into the war zone, so that isn’t really ideal. But it’s keeping up those relationships. In Vietnam, the PTSD was much worse, because people had one–year rotations. They were rotated in and out of the war zone individually, rather than as a unit. And that, again, broke up supportive relationships that might have been protective.

Imster: Why are some people more resilient, able to recover more easily from trauma?

Herman: I don’t know that we know the answers to that. We do know that people who are able to stay active in connection with others seem to do better. People who are more naturally sociable and have what we call an “internal locus control”, who aren’t fatalistic, who can see themselves as in charge of the situation and who work closely with others to try to get to safety or stay safe. These people do better. But in terms of what actual characteristics are protective, that’s still something that’s being researched. Because usually we don’t get to see people before the disaster. We’re only seeing them afterwards.

Imster: From what you are telling me, I would guess that child molestation would be the worst, as far as PTSD goes.

Herman: Yes, you do see very severe long–term consequences with child abuse. Because there’s no safe place to go. It’s done in secrecy, and there’s often a tremendous amount of blame and stigma. Kids are often not believed, if they do try to disclose. They’re really trapped. They’re like prisoners. And the abuse usually goes on not just once, but repeatedly, over and over.

Imster: I have read that there’s evidence that there are biological differences in people who suffer form PTSD. For example, research using PET scans, indicates that parts of the brain, the hippocampus, are smaller in people who have PTSD.

Herman: Yes, you’re seeing actual differences in brain functioning with people who have PTSD.

Imster: But, so far, there’s no cure for PTSD.

Herman: That’s right.

Imster: What does that mean? That your hippocampus will never be a normal size again? That your hyper–arousal will never go away?

Herman: We see it as a chronic problem, but that doesn’t mean that people can’t get a lot better. Often times in treatment, we find that people improve to the point where the symptoms really aren’t bothering them. They’re not interfering with their lives. They can get on with their lives and function quite well. Where I think you see some lasting vulnerabilities if there’s another stressor. The damage can be cumulative, so that combat veterans who, say, get sent to another war would be more vulnerable.

Imster: But people can get better and learn to live with PTSD.

Herman: Absolutely. And really, there are very effective treatments, both psychological and pharmacological that really diminish the symptoms to the point that they don’t interfere at all and people can live normal lives.

Imster: When we look to the future, to an increasingly crowded human world, do you think we’ll see more PTSD?

Herman: I don’t know the answer to that. I think the question is really about exposure to violence, not just crowding. I could imagine a very crowded world where people lived together more peacefully, and then you wouldn’t see so much PTSD.

More Dr. Herman Brilliantia

Post-Traumatic Stress Disorder

So you focused on trauma, especially in women and children. Help us understand what Post-Traumatic Stress Disorder is.

Okay. Well, I can tell you about what it says in the DSM-IV.

Which is the official Bible of the Psychiatric Association.

Right. The Diagnostic and Statistical Manual of the American Psychiatric Association, Fourth Edition. I was on the committee that helped write this definition, so I have to take some responsibility. And the committee, I have to say, brought together people who'd worked with traumatized people on many different social settings -- combat veterans, accident victims, less from the sphere of sexual and domestic violence, but we were represented to some degree, and political violence. And what the consensus came out to be was that traumatic events were those that instilled a feeling of terror and helplessness. We used to say, by the way, that these had to be events outside the realm of ordinary human experience. We had to get rid of that, because if you're living in a war zone or you're living in a country emerging from dictator or that's experienced dictatorship, these are not out-of-the-ordinary experiences, unfortunately, but experiences that instill helplessness and terror. And terror turns out to be different from fear.

Fear is something that we're all biologically wired to experience when we're in danger. We share this with other animals. When we perceive danger, we alert, we startle, we look around and figure out, do a quick appraisal of the situation, and we either fight or flee. That's being revised now by some researchers looking more at women who say that "fight or flight" is a little bit more the male response. "Tend and befriend" -- there's a tendency to kind of huddle with one's kind that you observe more in females. But, okay, fight or flight: there's a whole biology of fear that's involved.

Fight or flight doesn't work in conditions of terror and helplessness. Under those conditions, it appears that some kind of biological rewiring seems to happen in people and in animals as well. So that even after the danger is over, the person continues to respond to reminders, to both specific reminders and to generally threatening situations as though this terrifying event were still occurring in the present. So you have the activation of the fear system, hyper-arousal. You have a kind of re-experiencing of the trauma that takes the form of flashbacks, nightmares, and so forth. And then you have this other more poorly understood part of the traumatic syndrome that has to do with a shutting down of responsiveness. Numbing, a sense that things aren't real. There may be amnesia for some, more, or all of the event. A sense in the aftermath that one is just not really oneself. One is going through the motions. There's a loss of connection of things that are or previously of interest. And these are called the numbing or withdrawal or symptoms of PTSD. So hyper-arousal, re-experiencing, numbing is the triad. It's a descriptive formulation. We understand a little bit about the psycho-biology, not a whole lot. And I think we're coming to understand more and more that that's the simple form. That is what happens to some people after a single impact trauma. If you repeat it, over and over, and especially if it begins early on and one's development is formed in this environment, it gets a lot more complicated.

This is often the case of women and children who are in domestic situations where the cycle goes on and on.

I think it's true of people in any situation of coercive control, whether you're talking about a hostage situation that goes on for a long time, whether you're talking about domestic violence or sexual child abuse ... some religious cults have this same captivity kind of situation. And then, of course, the political situations of concentration camps or political prisoners.

In summarizing or introducing your discussion, you say, "The dialectic of trauma gives rise to complicated, sometimes uncanny alterations of consciousness." And then you go on to compare the political doublethink in an Orwell novel with what the psychologists and the psychiatrists call disassociation. So, you're suggesting that this kind of repression, inability to confront both the individual reality and the larger reality, is something that happens to the individual and in some ways to the society.

Yes. It's fascinating. If you talk to survivors of, especially the prolonged and repeated trauma, where the perpetrator, the captor, the torturer isn't content to just have external compliance, but wants the captive to adopt and endorse his worldview, even after liberation you'll get people saying, "I'm living in a double reality. I have the present and the past co-existing in my mind. It's not clear which is more real to me. I have what's left of my old value system, and my old way of seeing the world, and the perpetrator's way of seeing the world co-existing in my mind. I can go back and forth between the two, and I'm not sure which I belong to or which belongs to me any longer." So people have the experience of living in a double reality. And they describe ... even the amnesia, people will describe simultaneously knowing and not knowing what happened. Remembering and not remembering what happened. When people get their memories back, they will often describe it as simultaneously re-living the experience and being outside of it as though it happened to somebody else. So, people learn to divide their consciousness under captivity, under conditions of coercive control. And since we don't even understand unitary consciousness very well, when people have double consciousness, double reality, I'm in awe. I think it's a fascinating window into how the mind works.

This experience that you're describing in your book; you quote extensively from the memoirs of everyone from a forced participant in pornographic films to a political prisoner. And there are common elements that run through their sense of this experience which you have just summarized.

That's not surprising, given that the methods of the torturer and the methods of the pimp or the pornographer are often similar. I think when we understand more about criminal gangs as an intermediary form of organization between, say, state-sponsored terrorism and one-family cells of domestic violence, we'll understand more about the transmission of methods of torture, methods of coercive control. But if you use the same methods on people, whether you're doing it in the name of the state, in the name of a criminal gang that's marketing your body, or whether you're doing it in the name of the authority of a father, or the name of some religious cult, the methods are the same and so the mental processes that they produce are likely to be the same.

In your work, you enter this realm of such apparent hopelessness and despair, but the other side of your work is identifying the features of hope and recovery and the road back. I want you to discuss with us the elements of survival. book cover That is, survival and recovery, which is the other part of the title of your book [Trauma and Recovery]. So what are the common elements that we see in people who experience this but make it back?

First of all, I guess I should say, that that's the other reason I stick with this work: I'm constantly in awe of the resilience of the people we work with. They really do get better; they really do make new lives for themselves. They find incredibly creative ways to put the pieces of their lives back together, and a lot of times, since a lot of the work I do now is supervising students, teaching them how to be therapists, I get to observe the way the patients re-instill hope, constantly, not only in my students, but in those who are privileged to watch and observe this process. The students will come in and say, "I just met with the woman from Rwanda. She lost her whole family. She managed finally to get out to Uganda with two of her brother's kids, staying with a minister in Uganda. And she came here. They only could get papers to bring her. She's working under the table, cleaning houses or cleaning offices at night. She has no money. She's living in an apartment with ten people. She has the worst PTSD I ever saw, and she's here for a political asylum evaluation. What do I possibly have to offer this person?" In the first interview, the woman speaks in monosyllables. Her eyes are down, her head is bowed, her shoulders are like this, she's hunched over. If you drop something on the floor or a car backfires outside, she jumps out of her seat. Otherwise, she's immobile like this. You think, "This is the worst depression, this is the worst PTSD I've ever seen ... "

PTSD means Post-Traumatic ...

Post-Traumatic Stress Disorder. "What am I going to do?" So you work on documenting her case for her political asylum here. And you also work with her on trying to understand if she's safe now. What's her environment like now? What does she need now to begin to rebuild her life? And within a few months, this same person comes back into our office and she's lively. She's smiling, she's talking. She's gotten her asylum, so she's safe now. She's starting to work on bringing those kids over. She's joined a church, or she's started an English class (a lot of work we do is through interpreters). She's found, on her own, some kind of community, with our encouragement. And she will come back and say, "You listened to me. You seemed to care. You helped me out. You gave me what I needed to get what I needed. That restored my faith in people." And we feel like all we did was ... we did so little! But it was enough. There's a way in which survivors, many survivors, make do with the least little bit of human caring, human concern, to put back the pieces of their lives. And so, from my point of view, if we can provide that, it's a gift that comes back to us many times over.

So, as you just said, there are three elements. It's providing them a zone of safety. Then they remember and tell their story. And then, very importantly, they have to reconnect. I'm curious as to how you would characterize what you do beyond what you just said. Obviously, you do some interviewing. And is an important element of that interviewing to be a witness and to provide the essential elements of this safety, this support for telling the story?

I think bearing witness is important. I don't want to minimize the skill or the sophistication of the treatment that we do, because a lot of people who come to us do have complicated medical and psychiatric conditions. And they don't just necessarily have Post-Traumatic Stress Disorder. They need all of their needs attended to and they're often quite complex. I'm thinking of a woman, for example, who, it turned out ... here's an example of how complicated it becomes. This is someone who had been repeatedly raped -- it's another political asylum case -- and was having persistent vaginal bleeding, and had never had a medical exam. But because of the vaginal bleeding, was considered unclean, she couldn't have intercourse. Also couldn't enter a mosque. This was an Arab woman, a Muslim woman from Algeria. So getting her proper GYN attention, on the one hand, the medical part of it, needed to be attended to, and on the other hand, we needed to find sort of a friendly mosque. We needed to find someone in the clergy who could actually begin to reconnect her with a spiritual community. And we needed to do some family work in order to start helping her repair her relationship with her husband. And this is someone for whom the meaning of the trauma, in terms of a sense of stigma, contamination, ostracism, and so on, was not metaphorical. It was carried on in the physical symptom of bleeding. And until the bleeding was addressed, there really wasn't any hope of making new meaning out of what happened to her. So we pay a lot of attention to the meaning of specific symptoms in individual cases, and we take an approach that ranges from the biological to the social.

In your work, this emphasis on community, and broader issues such as power, recur again and again. In a specific case of your careful examination of the problem of incest, you end up, if I can summarize, and I hope I'm not being unfair, by looking at the broader society and asking the question, "Will this kind of problem ever go away in a patriarchal society?" And your answer is "No." But that leads you to propose the need for political action. What you have to then look at is the family in which the partners are equal, the male is not the dominant one. And it's only in such an environment that one can find a kind of equality where men, for example, are involved in the rearing of children. More than involved -- are equal partners. And that's how you get at the root of the problem. So, in a way, this analysis goes back to what you learned at the dinner table.

That's right.

That psychological insight cannot be separated from political insight. And action.


So would you add anything to that? I hope it wasn't an unfair summary. But the individual can't deal with this alone, is what I'm trying to get at.

No, and I think that's the take-home message that I try to give whenever I teach, and whenever I do my therapeutic work. I don't think patients, survivors, victimized people can recover in isolation. They need other people and they need to take action in affiliation with others. I don't think therapists can do therapeutic work alone. When we're isolated with this, we do give in to despair. We do burn out. Or we lose our perspective. Ultimately if you're talking about horrible abuses of power, you're talking about the atrocious things that one person does to another person. And just when you think you've heard everything, and there's simply nothing else that you could imagine that one person would intentionally do to another, somebody comes along with a story that just blows you away all over again. So, you're dealing with very profound questions of human evil, human cruelty, human sadism. The abuse of power and authority. And the antidote to that is the solidarity of resistance. Nobody can do that alone.

You say at one point, "But we do know that the women who recover most successfully are those who discover some meaning in their experience that transcends the limits of personal tragedy. Most commonly women find this meaning by joining with others in social action." And this means concrete things. It means hearing other people's stories, it means mentoring in the context of a tragedy, but also joining organizations that change the laws about what the criminal justice system says is a violation of human rights.

Right. It means going down and testifying before the legislature. Or taking part in some kind of public education campaign, or going to court, or accompanying someone else to court, or demonstrating in favor of the assertion of victim's rights, human rights.

Next page: Lessons Learned

© Copyright 2000, Regents of the University of California

See also: Interview with Alice Karekezi on Justice in Rwanda: The Rights of Women

Judith Herman is my HERO

Judith Lewis Herman (born 1942) is a psychiatrist, researcher, teacher, and author, whose ground-breaking work on the understanding and treatment of incest and traumatic stress has been widely influential.

Herman is Professor of Clinical Psychiatry at Harvard University Medical School and Director of Training at the Victims of Violence Program in the Department of Psychiatry at the Cambridge Health Alliance in Cambridge, Massachusetts, and a founding member of the Women’s Mental Health Collective, now in Somerville, Massachusetts.

She was the recipient of the 1996 Lifetime Achievement Award from the International Society for Traumatic Stress Studies and the 2000 Woman in Science Award from the American Medical Women's Association. In 2003 she was named a Distinguished Fellow of the American Psychiatric Association.

She is the author of two books, Father-Daughter Incest, first published in 1981, and Trauma and Recovery: The aftermath of violence from domestic abuse to political terror, first published in 1992

Perhaps her most distinctive contribution to the understanding of trauma and its victims is the concept of complex post-traumatic stress disorder (CPTSD), which extends the diagnostic category post-traumatic stress disorder (PTSD) — a diagnosis that, according to the United States Veterans Administration's Center for Post Traumatic Stress Disorder, "accurately describes the symptoms that result when a person experiences a short-lived trauma" [1] — to include "the syndrome that follows upon prolonged, repeated trauma."[2]

It was in Herman's second book Trauma and Recovery, considered a classic and ground-breaking work[3][4] that she coined the term complex post-traumatic stress disorder[5]." In it she defines this concept not only in terms of prolonged trauma, but in terms of what she calls "subjection to totalitarian control." Examples of this concept include:

...hostages, prisoners of war, concentration-camp survivors, and survivors of some religious cults. Examples also include those subjected to totalitarian systems in sexual and domestic life, including survivors of domestic battering, childhood physical or sexual abuse, and organized sexual exploitation.[6]

Trauma and Recovery was praised as a landmark book by Gloria Steinem, the New York Times Book Review, the Boston Globe, the Women's Review of Books; Bessel van der Kolk, M.D. of Harvard Medical School; Lenore Walker, Ed.D., Director of the Domestic Violence Institute; Laura Davis, coauthor of The Courage to Heal, and more.[7][4] Herman was interviewed by Harry Kreisler, Executive Director of the Institute of International Studies at the University of California at Berkeley, for his ongoing series Conversations with History at the Institute of International Studies, UC Berkeley.[8]


  • Herman, Judith Lewis (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror, (Previous ed.: 1992), Basic Books. ISBN 0465087302.
  • Herman, Judith Lewis (2000). Father-Daughter Incest, (Previous ed.: 1981), Harvard University Press. ISBN 0674002709.

This interview is part of the Institute's "Conversations with History" series, and uses Internet technology to share with the public Berkeley's distinction as a global forum for ideas.

Welcome to a Conversation with History. I'm Harry Kreisler of the Institute of International Studies. Our guest today is Dr. Judith Lewis Herman, M.D., Professor of Clinical Psychiatry at Harvard University Medical School and Director of Training at the Victims of Violence Program in the Department of Psychiatry at the Cambridge Hospital, Cambridge, Massachusetts. Her fields of research are the psychology of women, child abuse and domestic violence, and post-traumatic disorders. A pioneer in the study of Post-Traumatic Stress Disorder and the sexual abuse of women and children, her numerous publications include Trauma and Recovery and Father-Daughter Incest.

  1. Background ... influence of parents ... the moral example of her mother ... mentored by Laurence Wylie ... cooperative, observation-based learning ... the women's movement ... consciousness raising ... the civil rights movement
  2. Seeing Face to Face ... the case of incest ... psychological insight and political understanding ... women's new consciousness ... from the particular to the universal ... the simplicity of radical ideas
  3. Post-Traumatic Stress Disorder ... diagnosis ... despair and helplessness ... dissociation and the double reality ... hope and recovery ... complex solutions to complex cases ... incest and its relationship to patriarchy ... connecting to others ... transcending trauma
  4. Lessons Learned ... the importance of history and politics ... the really interesting questions

© Copyright 2000, Regents of the University of California

Need for a New Concept

Trauma and Recovery

By Judith Lewis Herman, M.D.

Chapter 6 - A New Diagnosis (see chart at end)

Diagnostic Mislabeling

The tendency to blame the victim has strongly influenced the direction of psychological inquiry. It has led researchers and clinicians to seek an explanation for the perpetrator’s crimes in the character of the victim. In the case of hostages and prisoners of war, numerous attempts to find supposed personality defects that predisposed captives to "brainwashing" have yielded few consistent results. The conclusion is inescapable that ordinary, psychologically healthy men can indeed be coerced in unmanly ways. In domestic battering situations, where victims are entrapped by persuasion rather than by capture, research has also focused on the personality traits that might predispose a woman to get involved in an abusive relationship. Here again no consistent profile of the susceptible woman has emerged. While some battered women clearly have major psychological difficulties that render them vulnerable, the majority show no evidence of serious psychopathology before entering into the exploitative relationship. Most become involved with their abusers at a time of temporary life crisis or recent loss, when they are feeling unhappy, alienated, or lonely. A survey of the studies on wife-beating concludes: "The search for characteristics of women that contribute to their own victimization is futile . . . It is sometimes forgotten that men’s violence is men’s behavior. As such, it is not surprising that the more fruitful efforts to explain this behavior have focused on male characteristics. What is surprising is the enormous effort to explain male behavior by examining characteristics of women."

While it is clear that ordinary, healthy people may become entrapped in prolonged abusive situations, it is equally clear that after their escape they are no longer ordinary or healthy. Chronic abuse causes serious psychological harm. The tendency to blame the victim, however, has interfered with the psychological understanding and diagnosis of a post-traumatic syndrome. Instead of conceptualizing the psychopathology of the victim as a response to an abusive situation, mental health professionals have frequently attributed the abusive situation to the victim’s presumed underlying psychopathology.

An egregious example of this sort of thinking is the 1964 study of battered women entitled "The Wife-Beater’s Wife." The researchers, who had originally sought to study batterers, found that the men would not talk to them. They thereupon redirected their attention to the more cooperative battered women, whom they found to be "castrating," "frigid," "aggressive," "indecisive," and "passive." They concluded that marital violence fulfilled these women’s "masochistic needs." Having identified the women’s personality disorders as the source of the problem, these clinicians set out to "treat" them. In one case they managed to persuade the wife that she was provoking the violence, and they showed her how to mend her ways. When she no longer sought help from her teenage son to protect herself from beatings and no longer refused to submit to sex on demand, even when her husband was drunk and aggressive, her treatment was judged a success.

While this unabashed, open sexism is rarely found in psychiatric literature today, the same conceptual errors, with their implicit bias and contempt, still predominate. The clinical picture of a person who has been reduced to elemental concerns of survival is still frequently mistaken for a portrait of the victim’s underlying character. Concepts of personality organization developed under ordinary circumstances are applied to victims, without any understanding of the corrosion of personality that occurs under conditions of prolonged terror. Thus, patients who suffer from the complex aftereffects of chronic trauma still commonly risk being misdiagnosed as having personality disorders. They may be described as inherently "dependent," "masochistic," or "self-defeating." In a recent study of emergency room practice in a large urban hospital, clinicians routinely described battered women as "hysterics," "masochistic females," "hypochondriacs," or, more simply, "crocks."

This tendency to misdiagnose victims was at the heart of a controversy that arose in the mid-1980s when the diagnostic manual of the American Psychiatric Association came up for revision. A group of male psychoanalysts proposed that "masochistic personality disorder" be added to the canon. This hypothetical diagnosis applied to any person who "remains in relationships in which others exploit, abuse, or take advantage of him or her, despite opportunities to alter the situation." A number of women’s groups were outraged, and a heated public debate ensued. Women insisted on opening up the process of writing the diagnostic canon, which had been the preserve of a small group of men, and for the first time took part in the naming of psychological reality.

I was one of the participants in this process. What struck me most at the time was how little rational argument seemed to matter. The women’s representatives came to the discussion prepared with carefully reasoned, extensively documented position papers, which argued that the proposed diagnostic concept had little scientific foundation, ignored recent advances in understanding the psychology of victimization, and was socially regressive and discriminatory in impact, since it would be used to stigmatize disempowered people. The men of the psychiatric establishment persisted in their bland denial. They admitted freely that they were ignorant of the extensive literature of the past decade on psychological trauma, but they did not see why it should concern them. One member of the Board of Trustees of the American Psychiatric Association felt the discussion of battered women was "irrelevant." Another stated simply, "I never see victims."

In the end, because of the outcry from organized women’s groups and the widespread publicity engendered by the controversy, some sort of compromise became expedient. The name of the proposed entity was changed to "self-defeating personality disorder." The criteria for diagnosis were changed, so that the label could not be applied to people who were known to be physically, sexually, or psychologically abuse. Most important, the disorder was included not in the main body of the text but in an appendix. It was relegated to apocryphal status within the canon, where it languishes to this day.

Need for a New Concept

Misapplication of the concept of masochistic personality disorder may be one of the most stigmatizing diagnostic mistakes, but it is by no means the only one. In general, the diagnostic categories of the existing psychiatric canon are simply not designed for survivors of extreme situations and do not fit them well. The persistent anxiety, phobias, and panic of survivors are not the same as ordinary anxiety disorders. The somatic symptoms of survivors are not the same as ordinary psychosomatic disorders. Their depression is not the same as ordinary depression. And the degradation of their identity and relational life is not the same as ordinary personality disorder.

The lack of an accurate and comprehensive diagnostic concept has serious consequences for treatment, because the connection between the patient’s present symptoms and the traumatic experience is frequently lost. Attempts to fit the patient into the mold of existing diagnostic constructs generally result, at best, in a partial understanding of the problem and a fragmented approach to treatment. All too commonly, chronically traumatized people suffer in silence; but if they complain at all, their complaints are not well understood. They may collect a virtual pharmacopoeia of remedies: one for headaches, another for insomnia, another for anxiety, another for depression. None of these tends to work very well, since the underlying issues of trauma are not addressed. As caregivers tire of these chronically unhappy people who do not seem to improve, the temptation to apply pejorative diagnostic labels becomes overwhelming.

Even the diagnosis of "post-traumatic stress disorder," as it is presently defined, does not fit accurately enough. The existing diagnostic criteria for this disorder are derived mainly from survivors of circumscribed traumatic events. They are based on the prototypes of combat, disaster, and rape. In survivors of prolonged, repeated trauma, the symptom picture is often far more complex. Survivors of prolonged abuse develop characteristic personality changes, including deformations of relatedness and identity. Survivors of abuse in childhood develop similar problems with relationships and identity; in addition, they are particularly vulnerable to repeated harm, both self-inflicted and at the hands of others. The current formulation of post-traumatic stress disorder fails to capture either the protean symptomatic manifestations of prolonged, repeated trauma or the profound deformations of personality that occur in captivity.

The syndrome that follows upon prolonged, repeated trauma needs its own name. I propose to call it "complex post-traumatic stress disorder." The responses to trauma are best understood as a spectrum of conditions rather than as a single disorder. They range from a brief stress reaction that gets better by itself and never qualifies for a diagnosis, to classic or simple post-traumatic stress disorder, to the complex syndrome of prolonged, repeated trauma.

Although the complex traumatic syndrome has never before been outlined systematically, the concept of a spectrum of post-traumatic disorders has been noted, almost in passing, by many experts. Lawrence Kolb remarks on the "heterogeneity" of post-traumatic stress disorder, which "is to psychiatry as syphilis was to medicine. At one time or another [this disorder] may appear to mimic every personality disorder. . . . It is those threatened over long periods of time who suffer the long-standing severe personality disorganization." Others have also called attention to the personality changes that follow prolonged, repeated trauma. The psychiatrist Emmanuel Tanay, who works with survivors of the Nazi Holocaust, observes: "The psychopathology may be hidden in characterological changes that are manifest only in disturbed object relationships and attitudes towards work, the world, man and God."

Many experienced clinicians have invoked the need for a diagnostic formulation that goes beyond simple post-traumatic stress disorder. William Niederland finds that "the concept of traumatic neurosis does not appear sufficient to cover the multitude and severity of clinical manifestations" of the syndrome observed in survivors of the Nazi Holocaust. Psychiatrists who have treated Southeast Asian refugees also recognize the need for a "expanded concept" of post-traumatic stress disorder that takes into account severe, prolonged, and massive psychological trauma. Others speak of "complicated" post-traumatic stress disorder.

Clinicians who work with survivors of childhood abuse have also seen the need for an expanded diagnostic concept. Lenore Terr distinguishes the effect of a single traumatic blow, which she calls "Type I" trauma, from the effects of prolonged, repeated trauma, which she calls "Type II." Her description of the Type II syndrome includes denial and psychic numbing, self-hypnosis and dissociation, and alternations between extreme passivity and outbursts of rage. The psychiatrist Jean Goodwin has invented the acronyms FEARS for simple post-traumatic stress disorder and BAD FEARS for the severe post-traumatic stress disorder observed in survivors of childhood abuse.

Thus, observers have often glimpsed the underlying unity of the complex traumatic syndrome and have given it many different names. It is time for the disorder to have an official, recognized name. Currently, the complex post-traumatic stress disorder is under consideration for inclusion in the fourth edition of the diagnostic manual of the American Psychiatric Association, based on sever diagnostic criteria (see chart). Empirical field trials are underway to determine whether such a syndrome can be diagnosed reliably in chronically traumatized people. The degree of scientific and intellectual rigor in this process is considerably higher than that which occurred in the pitiable debates over "masochistic personality disorder."

As the concept of a complex traumatic syndrome ahs gained wider recognition, it has been given several additional names. The working groups for the diagnostic manual of the American Psychiatric Association has chosen the designation "disorder of extreme stress not otherwise specified." The International Classification of Diseases is considering a similar entity under the name "personality change from catastrophic experience." These names may be awkward and unwieldy, but practically any name that gives recognition to the syndrome is better than no name at all.

Naming the syndrome of complex post-traumatic stress disorder represents an essential step toward granting those who have endured prolonged exploitation a measure of the recognition they deserve. It is an attempt to find a language that is at once faithful to the traditions of accurate psychological observations and to the moral demands of traumatized people. It is an attempt to learn from survivors, who understand, more profoundly than any investigator, the effects of captivity.

Complex Post-Traumatic Stress Disorder

  1. A history of subjection to totalitarian control over a prolonged period (moths to years). Examples include hostages, prisoners of war, concentration-camp survivors and survivors of some religious cults. Examples also include those subjected to totalitarian systems in sexual and domestic life, including survivors of domestic battering, childhood physical or sexual abuse, and organized sexual exploitation.
  1. Alterations in affect regulation, including
  • persistent dysphoria (a state of anxiety, dissatisfaction, restlessness or fidgeting)
  • chronic suicidal preoccupation
  • self-injury
  • explosive or extremely inhibited anger (may alternate)
  • compulsive or extremely inhibited sexuality (may alternate)
  1. Alterations in consciousness, including
  • amnesia or hyperamnesia for traumatic events
  • transient dissociative episodes
  • depersonalization/derealization (depersonalization - an alteration in the perception or experience of the self so that the usual sense of one's own reality is temporarily lost or changed; derealization - an alteration in the perception of one's surroundings so that a sense of the reality of the external world is lost)
  • reliving experiences, either in the form of intrusive post-traumatic stress disorder symptoms or in the form of ruminative preoccupation
  1. Alterations in self-perception, including
  • sense of helplessness or paralysis of initiative
  • shame, guilt, and self-blame
  • sense of defilement or stigma
  • sense of complete difference from others (may include sense of specialness, utter aloneness, belief no other person can understand, or nonhuman identity)
  1. Alterations in perception of perpetrator, including
  • preoccupations with relationship with perpetrator (includes preoccupation with revenge)
  • unrealistic attribution of total power to perpetrator (caution: victim’s assessment of power realities may be more realistic than clinician’s)
  • idealization or paradoxical gratitude
  • sense of special or supernatural relationship
  • acceptance of belief system or rationalizations of perpetrator
  1. Alterations in relations with others, including
  • isolation and withdrawal
  • disruption in intimate relationships
  • repeated search for rescuer (may alternate with isolation and withdrawal)
  • persistent distrust
  • repeated failures of self-protection
  1. Alterations in systems of mean
  • loss of sustaining faith
  • sense of hopelessness and despair

Understanding Just What Trauma Really Is and What It Does

Trauma and Recovery

Judith Lewis Herman, M.D.

Basic Books, 1992

To return to Psych 270's home page, click here.

The conflict between the will to deny horrible events and the will to proclaim them aloud is the central dialectic of psychological trauma

When the truth is fully recognized, survivors can begin their recovery. But far too often, secrecy prevails and the story of the traumatic event surfaces not as a verbal narrative but as a symptom.

Denial exists on a social as well as an individual level... We need to understand the past in order to reclaim the present and the future. An understanding of psychological trauma begins with rediscovery the past.

The fundamental stages of recovery are:

1. Establishing safety

2. Reconstructing the traumatic story

3. Restoring the connection between the survivor and his/her community.

It is very tempting to take the side of the perpetrator. All the perpetrator asks is that the bystander do nothing. He appeals to the universal desire to see, hear, and speak no evil. The victim ask the bystander to share the burden of the pain. The victim demands action, engagement, and remembering. (A tendency to render the victim invisible; to look the other way.)

Freud's investigations led the furthest of all into the unrecognized reality of women's lives. His discovery of childhood sexual exploitation at the roots of hysteria crossed the outer limits of social credibility and brought him to a position of total ostracism within his profession. (He eventfully repudiated his own findings.)

Traumatic Neurosis of War

The soldier who developed a traumatic neurosis was at best a constitutionally inferior human being, at worst, a malingerer and a coward. They were described as moral invalids. Hysterical symptoms such as mutism, sensory loss, or motor paralysis were treated with electric shock; threatened with court martial. The goal of treatment was to return the soldier to combat.

In WWII, it was recognized that any man could break down under fire and that psychiatric casualties could be predicted in direct proportion to the severity of combat exposure.

There is no such thing as "getting used to combat." Each moment of combat imposes a strain so great that men will break down in direct relation to the intensity and duration of their exposure. Thus, psychiatric casualties are be inevitable as gunshot and shrapnel wounds in warfare.

In their quest for a quick and effective method of treatment, military psychiatrists once again found the mediating role of altered states of consciousness in psychological trauma. They found that artificially induced altered states could be used to access traumatic memories.

As in earlier work on hysteria, the focus of the "talking cure" for combat neuroses was on the recovery and cathartic reliving of the traumatic memories with all their attendant emotions of terror, rage, and grief.

Combat leaves a lasting impression on men's minds, changing them as radically as any crucial experience through which they live. It points to the need for integration.

After Vietnam, the diagnosis "post traumatic stress disorder" included in the APA's DSM, giving it legitimacy.

Not until the women's liberation movement of the 1970s was it recognized that the most common PTSDs are those not of men in war, but of women in civilian life. The cherished value of privacy created a barrier to consciousness and rendered women's reality practically invisible.

Research of the '70s confirmed the reality of women's experience that Freud had dismissed as fantasies a century before. Sexual assaults against women and children were shown to be endemic and pervasive in our culture. The results: On women in four had been raped. One women in 3 had been sexually abused as a child.

Rape was the feminist movements's initial paradigm for violence against women in the sphere of personal life.

Women experienced rape as a life threatening event having feared mutilation and death during the assault. Rape victims complained of insomnia, nausea, startle responses, and nightmares as well as dissociative or numbing symptoms. The symptoms resemble that of combat neurosis.

Necessity for a political movement to support the continued exploration of trauma or its survival as a legitimate are of study is in jeopardy.

Psychological trauma is an affliction of the powerless. At the moment of trauma, the victim is rendered helpless by overwhelming force. Traumatic events overwhelm the ordinary symptoms of care that give people a sense of control, connection, and meaning.

Certain experiences increase the likelihood of harm.

1. Being taken by surprise

2. Being trapped

3. Being at the point of exhaustion

4. Being physically violated or injured

5. Being exposed to physical violence

6. Witnessing grotesque deaths

Trauma occurs when action is of no avail--when neither resistance nor escape is possible.

The traumatized individual may experience intense emotion but without clear memory of the event--or may remember everything in detail but without emotion. Traumatic symptoms have a tendency to become disconnected from their source and to take on a life of their own. (Dissociation)

The Main Categories of Post Traumatic Stress Disorder

1. Hyperarousal: Persistent expectation of danger

2. Intrusion: The indelible imprint of the traumatic even returning unbidden.

3. Constriction: The numbing response of surrender

In Hyperarousal
The system of self preservation goes into permanent alert as if the danger could return at any moment. (Symptoms: Startle easily, reacts irritably to small provocations, sleeps poorly). It is the constant arousal of the autonomic nervous system.

In Intrusion
Long after the danger is past, traumatized people relive the event as though it were continually recurring in the present. The trauma interrupts daily life. (Symptoms: Flashbacks during waking; nightmares during sleeping)

Traumatic memories lack verbal narrative and context; rather they are encoded in the form of vivid sensations and images. They resemble the memories of young children.

Traumatized people find themselves reenacting some aspect of the trauma scene in disguised form without realizing what they're doing (e.g., putting themselves in dangerous situations this time to make the end come out differently (a version of the repetition compulsion).

Seen as a possible attempt at integration--to relive and master the overwhelming feelings of the traumatic moment(s).

Attempts to avoid reliving the trauma too often result in a narrowing of consciousness or withdrawal from engagement with others and an impoverished life.

In Constriction (numbing)
The system of self esteem shuts down completely (a state of surrender). The helpless person escapes not by action, but by altering her/his state of consciousness.

Events continue to register in awareness but its as though these events have been disconnected from their ordinary meaning (similar to trance states).

Those who cannot dissociate may turn to drugs or alcohol for their numbing effects.

Adaptive during the trauma, numbing becomes maladaptive once the danger is past.

In an attempt to crease some sense of safety, traumatized people restrict their lives.

In avoiding any situation reminiscent of the past trauma or any initiative that might involve future planning and risk, traumatized people deprive themselves of those new opportunities for successful coping that might mitigate the effect of the traumatic experience.

Because post traumatic symptoms are so persistent and widespread, they may be mistaken for enduring characteristics of the victim's personality.
Traumatic events breach the attachments of family, friendship, love, and community. They shatter the construction of the self that is formed and sustained in relation to others. They undermine the belief system that gives meaning to human experience. They violate the victim's faith in a natural or divine order and cast the victim into a state of existential crisis. It is a shattering of "basic trust." A sense of alienation, disconnection pervades every relationship.

Damaged Self
Trauma forces the survivor to relive all earlier struggles over autonomy, initiative, competence, identity, and intimacy.

The developing child's positive sense of self depends upon a caretaker's benign use of power.

Traumatic events violate the autonomy of the person at the level of basic bodily integrity (Body ego -> first sense of "I")

The belief in a meaningful world is formed in relation to others and begins earliest life. Basic trust, acquired in the primary intimate relationship is the foundation of faith. Trauma creates a crisis of faith.

Damage to the survivor's faith and sense of community is particularly severe when the event themselves involve the betrayal of important relationships.

Survivors oscillate between:

Uncontrollable outbursts of anger and intolerance of rage in any form.

Seeking intimacy desperately and totally withdrawing from it.

Self esteem is assaulted by experiences of humiliation, guilt, and helplessness.

Vulnerability and Resilience

Individual personality characteristics count for little in the face of overwhelming events. With severe enough experience, no person is immune.

Individual differences play a part in determining the form PTSD will take. It is related to individual history, emotional conflicts, and adaptive style.

Highly resilient people are able to make use of any opportunity for purposeful action in concert with others, while ordinary people are more easily paralyzed or isolated by them.

Some features of highly resilient people:

1. Alert, active temperament

2. Unusual sociability

3. Good communicating skills

4. Strong internal locus of control



Increased vulnerability is enhanced by:

1. Disempowerment (children, adolescents)

2. Disconnection from others

3. Lack of social supports

4. Poor or absent communication avenues

The Effect of Social Support

The survivor's social world can influence the eventual outcome of trauma.

The emotional support that is sought takes many forms and changes during the course of resolution.

In the immediate aftermath, rebuilding of some minimal form of trust is the primary task. Assurances of safety and protection are of the greatest importance.

Then, the survivor needs assistance of others in rebuilding a positive sense of self. Others must show tolerance for the oscillating behaviors of the survivor. It is not blanket acceptance but the kind of respect for autonomy that fostered the original development of self esteem in the first year of life. (Movement toward self-regulation).

The survivor needs the assistance of others in her/his struggle to arrive at a fair assessment of her/his conduct. Harsh criticism or ignorance or blind acceptance greatly compounds the survivor's self blame and isolation. Realistic judgments include a recognition of the dire circumstances of the traumatic event and the normal range of the victim's reactions. They include the recognition of moral dilemmas in the face of severely limited choices. This, hopefully, leads to a fair attribution of responsibility.

Finally, the survivor needs help from others to mourn her/his losses. Failure to complete the normal process of grieving perpetuates the traumatic reaction.

The Role of Community

Sharing the traumatic experience with others is a precondition for the restitution of a meaningful world.

Once it is publicly recognized that person has been harmed, the community must take action to assign responsibility for the harm and to repair the injury. Recognition and restitution are necessary to rebuild the survivor's sense of order and justice.

Repeated trauma in adult erodes the structure of personality already formed, but repeated trauma in childhood forms and deforms the personality.

Under conditions of chronic childhood abuse, fragmentation becomes the central principle of personality organization. Fragmentation in consciousness prevents the ordinary integration of knowledge, memory, emotional states, and bodily experiences. Fragmentation in the inner representations of the self prevent the integration of identity. Fragmentation of the inner representation of others prevents the development of a reliable sense of independence within connection.

On Idealizing
By idealizing the person to whom she becomes attached, she attempts to keep at bay the constant fear of being either dominated or betrayed. Inevitably, however, the chosen person fails to live up to her fantastic expectations. When disappointed, she may ferociously denigrate the same person whom she so recently adored. Ordinary interpersonal conflicts may provoke intense anxiety, depression, or rage. In the mind of the survivor, even minor slights evoke past experiences of deliberate cruelty. These distortions are not easily corrected by experience since the survivor tends to lack the verbal and social skills for resolving conflict. Thus, the survivor develops a pattern of intense, unstable relationships repeatedly enacting the drama of rescue, injustice, and betrayal.

Relationship problems
1. Desperate longing for nurturance make it difficult to establish safe and appropriate boundaries.

2. Denigration of self and idealization of others.

3. Empathic attunement to the wishes of others and unconscious habits of obedience make her vulnerable to people in positions of authority.

4. Dissociative tendencies make it difficult to form conscious, accurate assessments of danger.

5. The wish to relive dangerous situations to make them come out differently leads to reenactments of abuse.

A New Diagnosis -- Complex Post Traumatic Stress Disorder

A history of subjection to totalitarian control over a prolonged period (months or years). Examples include hostages, prisoners of war, concentration camp survivors, and survivors of some religious cults. Examples also include those subjected to totalitarian systems in sexual and domestic life, including survivors of domestic battering, childhood physical or sexual abuse, and organized sexual exploitation.

Alterations in affect regulation, including

Persistent dysphoria
Chronic suicidal preoccupation
Self injury
Explosive or extremely inhibited anger (may alternate)
Compulsive or extremely inhibited sexuality (may alternate)

Alterations in consciousness, including

Amnesia or hypermnesia for traumatic events
Transient dissociative states
Reliving experiences either in the form of intrusive post traumatic stress disorder
symptoms or in the form of ruminative preoccupations.

Alterations in self-perceptions, including

Sense of helplessness or paralysis of initiative
Shame, guilt, and self blame
Sense of defilement or stigma
Sense of complete difference from others (may include sense of specialness, utter
aloneness, belief no other person can understand, or nonhuman identity)

Alterations in perception of perpetrator, including

Preoccupation with relationship with perpetrator (includes preoccupation with revenge)
Unrealistic attribution of total power to perpetrator (caution: victim's assessment of
power realities may be more realistic than clinician's)
Idealization or paradoxical gratitude
Sense of special or supernatural relationship
Acceptance of belief system or rationalizations of perpetrator

Alteration in relations to others, including

Isolation or withdrawal
Disruption of intimate relationships
Repeated search for rescuer (may alternate with isolation and withdrawal)
Persistent distrust
Repeated failures of self protection

Alterations in systems of meaning

Loss of sustaining faith
Sense of hopelessness and despair

Survivors as Patients

They present a bewildering array of symptoms. They come for help because of their many symptoms or because of difficulty with relationships, ,problems in intimacy, excessive responsiveness to the needs of others, and repeated victimizations.

Often receive the diagnosis of (1) Somatization Disorder; (2) Borderline Personality Disorder; or (3) Multiple Personality

Communalities in the above three diagnoses

1. High levels of dissociation
2. Unstable relationships (oscillating between clinging and withdrawal; submissiveness and ferocious rebellion.
3. Disturbances in identity formation (fragmentation leading to good self/bad self identities)
4. Origins in chronic abuse

Stages of Recovery

Recovery is based upon the empowerment of the survivor and the creation of new connections. It can take place only in the context of a relationship.

The survivor must be the author and arbiter of her own recovery.

The therapist abstains from using her/his power over the patient to gratify his/her needs and does not take sides in the patient's inner conflict or try to direct the patient's life decisions. The therapist is called upon to bear witness to a crime.

Traumatic Transference
"It is as if the patient's life depends on keeping the therapist under control." -- Kernberg

Because the patient feels as though her life depends on the therapist, she cannot afford to be tolerant; there is no room for human error. There is likely to be a displacement of the rage from perpetrator to caregiver.

The patient feels a desperate need to rely on the integrity and competence of the therapist but cannot because her capacity to trust has been damaged by the traumatic experience.

The survivor also mistrusts the therapist who does not move away. She attributes the same motives as those of the perpetrator. The dynamics of dominance are reenacted in the therapy.

The patient scrutinizes the therapist's every word and gesture in an attempt to protect herself rom the hostile reactions she expects. Because she has no confidence in the therapist's benign intentions, she persistently misinterprets the therapist's motives and intentions.

Traumatic Countertransference

No therapist can work with trauma alone.
As a defense against the unbearable feelings of helplessness, the therapist may try to assume the role of rescuer.

There is also the danger of identifying with the perpetrator.

Witness guilt is also a danger. Guilt over having been spared the same plight.

The two most important guarantees of safety are the goals, rules, and boundaries of the therapy contract and the support system of the therapist.

The Therapy Contract
A relationship of existential engagement in which both parties commit themselves to the task of recovery.

  • Emphasis on truth telling and full disclosure

  • Cooperative nature of the work

  • Preparation for repeated testing, disruption, and the rebuilding of trust

  • Careful attention to the boundaries

  • Decision on limits based on whether they empower the patient and foster a good working relationship--not whether they patient should be frustrated or indulged. Negotiation

Because of the conflicting requirements for flexibility and boundaries, the therapist can expect repeatedly to feel put on the spot.

Recovery unfolds in three stages: (1) The establishment of safety; (2) Remembrance and mourning; and (3) Reconnection with ordinary life.

Therapist who believes that the patient is suffering from a traumatic syndrome should share the information fully. There is a name for what is going on.

Patients with Complex PTSD feel as if they have lost themselves. Patients with PTSD feel as if they have lost their minds.

A guiding principle of recovery is to restore power and control to the survivor. The first task is to establish the survivor's safety. Nothing can happen until this is accomplished.

Establishing safety begins by focusing on control of the body and gradually moves outward toward control of the environment.

With the survivor of chronic abuse, establishing safety can be an extremely complex and time consuming task. Self care is disrupted and self harm may take various forms (symbolic reenactments of the initial abuse) serving the function of regulating intolerable feeling states. Self soothing must be painstakingly constructed in later life. As she begins to exercise these capacities (e.g., initiating action, using her best judgment) she enhances her sense of competence, self esteem, and freedom.

To counter the compelling fantasy of a fast cathartic cure, the therapist may compare the recovery process to running a marathon. Recovery is a test of endurance, requiring long preparation and repetitive practice.

Completing the First Stage

  • The survivor no longer feels completely vulnerable although still less trusting

  • Development of some confidence in the ability to protect her/himself

  • Patient know how to control her most disturbing symptoms

  • Patient knows t who to rely on for support

Remembrance and Mourning

Reconstruction: (Telling the story in depth.) Transforms the traumatic memory so that it can be integrated into the survivor's life story. The choice to confront the horrors of the past rests with the survivor. The therapist is witness and ally.

As the survivor summons her memories, the need to preserve safety must be balanced against the need to face pain. (Negotiating a safe passage)

The patient's intrusive symptoms should be monitored carefully so that the recovering work remains within the realm of what is bearable.

A narrative that does not include the traumatic imagery and bodily sensations is barren and incomplete. The ultimate goal, however, is to put the story, including the imagery, into words. The patient must construct not only what happened but also what she/he felt.

The therapist must help the patient move back and forth in time, from the protected anchorage in the present to immersion in the past, so that she can simultaneously reexperience the feelings in all their intensity while holding on to the sense of safe connection that was destroyed in the traumatic moment.

Why me? The arbitrary random quality of her fate defies the basic human faith in a just or even predictable world order. She is faced with the double task of rebuilding her own "shattered assumptions" about meaning, order, and justice in the world and also find a way to resolve her differences with those who beliefs she can no longer share.

The therapist's role is to affirm a position of moral solidarity with the survivor.

As the therapist listens, she/he must constantly remind him/herself to make no assumptions about either the facts or the meaning of the trauma to the patient.

The goal of recounting the trauma story is integration, not exorcism.

Transforming Traumatic Memory

Flooding: A controlled reliving experience in which the patient learns how to manage anxiety. A script is prepared including (1) context; (2) fact; (3) emotion; (40 meaning. The patient chooses the sequence for presentation from easiest to most difficult memories and events.

Testimony: Similar to Flooding, it is used with survivors of political torture. The central point is to create a detailed, extensive record of the traumatic experience.

It appears that the action of telling the story in the safety of a protected relationship can actually produce a change in the abnormal processing of the traumatic memory.

The patient may be reluctant to give up symptoms such as nightmares and flashback because they have acquired important meanings. The symptom may be symbolic means for keeping faith with the lost person, a substitute for mourning, or an expression of unresolved guilt.

Mourning Traumatic Loss
Trauma inevitably brings loss. The descent into mourning is at once the most necessary and the most dreaded task of this stage of recovery. It is an act of courage not humiliation.

Resistance to mourning:

The Revenge Fantasy: where victim and perpetrator roles are reversed. Based on the fantasy of getting even which is not possible. A goal is to transform anger into righteous indignation.

The Forgiveness Fantasy: transcending the rage through a willful, defiant act of love.

Healing depends on the discovery of restorative love in her own life--not on the contrition of the perpetrator.

The Compensation Fantasy: is a formidable impediment to mourning. Prolonged, fruitless struggle to wrest compensation from the perpetrator or from others, may represent a defense against facing the full reality of what was lost. Mourning is the only way to give due honor to loss; there is no fair compensation. The wish for compensation ties the survivor's fate to the perpetrator's and she is then held hostage.

In the course of therapy, the patient may focus her demands for compensation on the therapist. She may resent the limits; insist on some form of special dispensation. Underlying these demands is the fantasy that only the boundless love of the therapist can undo the damage of the trauma. Unfortunately, therapists sometimes collude with their patients fantasy of restitution. Boundary violations ultimately lead to exploitation of the patient even when they are initially undertaken in good faith.

The only way the survivor can take full control of her recovery is to take responsibility for it. The only way she can discover her undestroyed strengths is to use them to their fullest.

Survivors of chronic childhood abuse face the task of grieving not only what they lost but also for what was never theirs to lose. The childhood that was stolen from them is irreplaceable.

The reward of mourning is realized as the survivor sheds her evil, stigmatized identity and dares to hope for new relationships in which she no longer has anything to hide.

The second stage of recovery has a timeless quality that is frightening.

The survivor may wonder how she can possible give her due respect to the horror she has endured if she no longer devotes her life to remembrance and mourning. She will never forget. But the time comes when the trauma no longer commands the central place in her life.

The reconstruction of the trauma is never completed; new events at each stage of the life cycle will inevitably reawaken the trauma and bring some new aspects of the experience to light. The second stage is completed when the patient reclaims her own history and feels renewed hope and energy for engagement with life.


The survivor faces the task of creating a future:

Developing a new self

Developing new relationships

Developing a sustaining faith

Empowerment and reconnection are the core experiences of recovery.

Taking power in life involves the conscious choice to face danger. Survivors have come to understand their symptoms are a pathological response to danger. It is not the same as reenactment because the task (facing danger) is taken consciously, in a planned, methodical manner.

As survivors recognize their own socialized assumptions that rendered them vulnerable of exploitation in the past, they may also identify sources of continued, social pressure that kept them confined in a victim role in the present

Reconciling with Oneself
"I know I have myself." Her task is to become the person she wants to be. She draws upon the aspects of herself she most values from the time before the trauma, from the experience of the trauma itself, and from the period of recovery. Integrating all these aspects, she creates a new self both ideally and in actuality.

Here, the work of therapy focuses on the development of desire and initiative.

As the survivor recognizes and "lets go" of those aspects of her/himself that were formed by the traumatic experiences, she/he also becomes more forgiving of him/herself.

Reconciling with Others
The survivor has regained some capacity for appropriate trust. The therapeutic alliance feels less intense but more relaxed and secure.

As trauma receded, it no longer represents a barrier to intimacy.

Finding a Survivor Mission
This may take the form of social action and a willingness to speak the unspeakable. It is also a form of pursuing justice.

The survivor who elects to engage in public battle cannot afford to delude herself about the inevitability of victor.
Resolving the Trauma

The resolution is never complete, it is often sufficient for the survivor to turn her attention from the task of recovery to the tasks of ordinary life.

Dr. Mary Harvey's (colleague of Judith Herman) criteria for the resolution of trauma:
1. Symptoms are brought within manageable limits.

2. Survivor is able to bear the feelings associated with traumatic memories.

3. Survivor has authority over the memories.

4. Memory is a coherent narrative.

5. Self esteem has been restored.

6. Important relationships have been reestablished.

7. There has been a reconstruction of a coherent system of meaning and belief that encompasses the story of the trauma.

The restoration of social bonds begins with the discovery that one is not alone and that others have experienced similar events and can understand them. Participation in a group may provide a sense of "universality."