Psychiatry and Clinical Neurosciences (1998) 52 (Suppl,), S145 S150

Session 8 Recovery from psychological trauma

JUDITH L, HERMAN, MD Department of Psychiatry. Harvard Medical School. Boston, and Victims of Violence Program. The Cambridge Hospital. Cambridge. Massachusetts. USA

Abstract Trauma destroys the social systems of care, protection, and meaning that support human life. The recovery process requires the reconstruction of these systems. The essential features of psycho- logical trauma are disempowerment and disconnection from others. The recovery process therefore is based upon empowerment of the survivor and restoration of relationships. The recovery process may be conceptualized in three stages: establishing safety, retelling the story of the traumatic event, and reconnecting with others. Treatment of posttraumatic disorders must be appropriate to the survivor's stage of recovery, Caregivers require a strong professional support system to manage the psychological consequences of working with survivors.

Key words posttraumatic stress disorder, principles of treatment, recovery stages, survivor mission, trauma psychology.

The core experiences of psychological trautna are dis- With trauma survivors, the therapeutic alliance can- empowerment and disconnection from others.' Re- not be taken for granted but must be painstakingly covery therefore is based upon etnpowennent of the built,"* Psychotherapy requires a collaborative working survivor and the creation of new connections. Recovery relationship m which both partners act on the basis of ean take place only within the context of relationships; their implicit confidence in the value and efficacy o[' it cannot occur in isolation. In renewed connections persuasion rather than coercion, ideas rather force, with other people, the survivor recreates the psycho- mutual cooperatioti rather than authoritarian control. logical faculties that were damaged or deformed by the These are precisely the beliefs that have been shattered trautnatic experience. These iticlude the basic capacities by the traumatic experience,^ Trauma damages the for trust, autonomy, initiative, competence, identity, patient's ability to enter into a trusting relationship; it and intimacy," Just as these capabilities are originally also has an indirect but very powerful itnpact on the formed, they must be re-formed in relationships with therapist. As a result, both patient and therapist will other people. have predictable difficulties coming to a working alli- Trauma robs the victim of a sense of power and ance. These difficulties must be understood and antic- control over her own life; therefore, the guiding prin- ipated from the outset. ciple of recovery is to restore power and control to the Trauma is contagious. In the role of witness to dis- survivor,'' She must be the author and arbiter of her own aster or atrocity, the therapist at times is emotionally recovery. Others may offer advice, support, assistance, overwhelmed. She experiences, to a lesser degree, the affection, and care, but not cure. Many benevolent and same terror, rage, and despair as the patient. This well-intentioned atternpts to assist the survivor founder phenomenon is known as "vicarious traumatization",'' because this fundamental principle of empowerment is The therapist may begin to experience intrusive, not observed. No intervetition that takes power away numbing, or hyperarousal symptotns. Hearing the pa- from the survivor can possibly foster her recovery, no tient's trauma story is also likely revive strong feelings matter how much it appears to be in her immediate best connected with any personal trautnatic experiences that interest. Caregivers schooled in a medical model of the therapist may have suffered in the past. treatment often have difficulty grasping this funda- The therapist, like the patient, may defend against mental principle and putting it into practice. overwhelming feelings by withdrawal or by impulsive, intrusive action. The most common forms of action are rescue attempts, boundary violations, or attempts to Correspondence address: Judith L, Herman, MD. Department of Psychiatry. The Cambridge Hospital. 1493 Cambridge St, Cam- control the patient. The tnost comtnon constrictive re- bridge, MA 02139, USA, sponses are doubting or denial of the patient's reality. S146 . Herman dissociation or numbing, minimization or avoidance of treated. There is no single, efficacious "magic bullet for the traumatic material, professional distancing, or the traumatic syndromes. frank abandonment of tbe patient.^ The therapist The therapist's first task is to conduct a thorough should expeet to lose balance from time to time. She is and informed diagnostic evaluation, with full aware- not infallible. The guarantee of her integrity is not her ness of the many disguises in which a traumatic disor- omnipotence but ber capacity to trust others. Thera- der may appear. With patients who have suffered a pists who work with traumatized people require an recent acute trauma, the diagnosis is usually fairly ongoing support system. Just as no survivor can re- straightforward. In these situations clear, detailed in- cover alone, no therapist can work with trauma alone. formation regarding posttraumatic reactions is often Ideally, the therapist's support system should include invaluable to the patient and her family or friends. If a safe, structured, and regular forum for reviewing her the patient is prepared for the symptoms, she will be far clinical work. This might be a supervisory relationship less frightened when they occur. If she and those closest or a peer support group, preferably both. The setting to her are prepared for the disruptions in relationship must offer permission to express emotional reactions as that follow upon trautnatic experience, they will be far well as technical or intellectual concerns related to the more able to take them in their stride. Furthermore, if treatment of patients with histories of trauma. In ad- the patient is offered advice on adaptive coping strat- dition to professional support, the therapist must egies and warned against common mistakes, her sense attend to the balance in her own professional and of competence and efficacy will be immediately en- personal life, paying respectful attention to her own needs. Confronted with the daily reality of patients in hanced. Working with survivors of a recent acute need of care, the therapist is in constant danger of trauma offers therapists an excellent opportunity for professional overcommitment. The role of professional preventive education. support is not simply to focus on the tasks of treatment With patients who have suffered prolonged, repeated but also to remind the therapist of her own realistic trauma, the matter of diagnosis is not nearly so limits and to insist that she take as good care of herself straightforward. Disguised presentations are common as she does of others. in complex posttraumatic stress disorder (PTSD).'" Initially the patient may complain only of physical The therapist who commits herself to working with symptoms, or of chronic insomnia or anxiety, or of survivors commits herself to an ongoing contention intractable depression, or of problematic relationships. with herself, in which she must rely on the help of Fxplicit questioning is often required to determine others and call upon her most mature coping abilities. whether the patient is presently living in fear of some- Sublimation, altruism, and humor are the therapist's one's violence or has lived in fear in the past. Tradi- saving graces. In the words of one disaster relief tionally these questions have rarely been asked. They worker, 'To tell the truth, the only way me and my should be a routine part of every diagnostic evaluation. friends found to keep sane was to joke around and keep If the therapist believes the patient is suffering from a laughing. The grosser the joke the better'.^ The reward traumatic syndrome, she should share this informatioti of engagement is the sense of an enriched life. Thera- fully with the patient. Knowledge is power. The trau- pists who work with survivors report appreciatmg life matized person is often relieved simply to learn the true more fully, taking life more seriously, having a greater name of her condition. By ascertaining her diagnosis, scope of understanding of others and themselves, she begins the process of mastery. No longer impris- foraiing new friendships and deeper intimate relation- oned in the wordlessness of the trauma, she discovers ships, and feeling inspired by the daily examples of that there is a language for her experience. She dis- their patients' courage, determination, and hope.*^ covers that she is not alone; others have suffered in The traumatic syndromes are complex disorders, similar ways. She discovers further that she is not crazy; requiring complex treatment. Because trauma affects the traumatic syndromes are normal human responses every aspect of human functioning, treatment must be to extreme circumstances. And she discovers, finally, comprehensive. At each stage of recovery, treatment that she is not doomed to suffer this condition indefi- must address the characteristic biological, psychologi- nitely; she can expect to recover, as others have re- cal, and social components of the disorder. Well- covered. designed biological treatments, for example, may be Recovery unfolds in three stages. The central task of unsuccessful if the social dimensions of the patient's the first stage is the establishment of safety. The central traumatic experience are not addressed. Conversely, task of the second stage is remembrance and mourning. even excellent social support may be ineffective if the The central task of the the third stage is reconnection patient's psychophysiologic disturbance remains un- with ordinary life. Treatment must be appropriate to Recovery from psychological trauma S147 the patient's stage of recovery, A form of therapy that involvetnent in exploitative or dangerous relationships. may be useful at one stage may be of little use or even Many self-destructive behaviors can be understood as harmful to the same patient at another stage. symbolic or literal re-enactments of the initial abuse. The first task of recovery is to establish the survivor's They serve the function of regulating intolerable feeling safety. This task takes precedetice over all others, for states, in the absence of more adaptive self-soothing no other therapeutic work can possibly succeed if safety strategies. The patient's capacities for self-care and self- has not been adequately secured. No other therapeutic soothing must be painstakingly reconstructed in the work should even be attempted until a reasonable de- course of long-tenn individual and/or group treatment. gree of safety has been achieved. This initial stage tnay Biologic, behavioral, cognitive, interpersonal, and so- last days to weeks with acutely traumatized people or cial therapeutic tnodalities have all shown promise with months to years with survivors of chronic abuse. The some patients; each patient should be encouraged to work of the first stage of recovery becomes increasingly develop a personal repertoire of coping strategies. cotnplicated in proportion to the severity, duration, When safety and a secure therapeutic alliance are and early onset of abuse. established, the second stage of recovery has been Establishing safety begins by focusing on control of reached. The survivor is now ready to tell the story of the body and gradually moves outward toward control the trautna, in depth and in detail. This work of of the environment. Survivors ofteti feel unsafe in their reconstruction actually transfonns the traumatic bodies. Their emotions and their thinking feel out of memory, so that it can be integrated into the survivor's control. Issues of bodily integrity include attention to life story," The basic principle of empowerment con- basic health needs, regulation of bodily futictions such tinues to apply during the second stage of recovery. The as sleep, eating, and exercise, management of post- choice to confront the horrors of the past rests with the traumatic symptoms, and abstinence from substance survivor. The therapist plays the role of a witness and abuse, ally, in whose presence the survivor can speak of the Environtnental issues include the establishtnent of a utispeakable. Out of the fragmented components of safe living situation, financial security, mobility, and a frozen imagery and sensation, patient and therapist plan for self-protection that encompasses the full range slowly reassemble an organized, detailed, verbal ac- of the patient's daily life. Securing a safe environment count, oriented in time and in its historical context. The requires strategic attention to the patient's economic narrative includes not only the event itself but also the and social ecosystem. The patient must become aware survivor's emotional response to it and the responses of of her own resources for practical and etnotional sup- the important people in her life. port as well as the realistic dangers and vulnerabilities As the survivor summons her tnemories. the need to in her social situation. Many patients are unable to preserve safety tnust be balaticed constantly against the move forward in their recovery because of their present need to face the past. The patient and therapist together involvement in unsafe or oppressive relationships. In must learn to negotiate a safe passage between the twin order to gain their autonomy and their peace of mind, datigers of constriction and intrusion. Avoiding the survivors tnay have to make difficult and painful life trautnatic memories leads to stagnation in the recovery choices. Battered women may lose their homes, their process, while approaching thetn too precipitously friends, and their hvelihood. Survivors of childhood leads to a fruitless and datnaging reliving of the trautna. abuse may lose their fatnilies. Political refugees may Decisions regarding pacing and timing need tneticulous lose their homes and their homeland. The social ob- attention and frequent review by patient and therapist stacles to recovery are not generally recognized, but in concert. The patient's intrusive symptoms should they must be identified and adequately addressed in be monitored carefully so that the uticovering work order for recovery to proceed. remains bearable. With survivors of prolonged, repeated trauma, the Because the truth is so difficult to face, survivors initial stage of recovery may be protracted and difficult often vacillate in reconstructing their stories. Denial of because of the degree to which the traumatized person reality tnakes thetn feel crazy, but acceptance of the full has become a danger to herself. The sources of danger reality seems beyond what any hutnan being can bear. may include active self-harm, passive failures of self- Both patient and therapist must develop tolerance for protection, and pathological dependency on the abuser. some degree of uncertainty, even regarding the basic Self-care is altnost always severely disrupted. Self- facts of the story. In the course of reconstruction, the harming behavior may take numerous forms, including story may change as missing pieces are recovered. This chronic suicidality, self-mutilation, eating disorders, is particularly true in situations where the patient has substance abuse, impulsive risk-taking, and repetitive had significant gaps in tnemory. Thus both patient and S148 J. L. Herman

therapist must accept the fact that they do not have imperative to get beyond this intellectual defense and complete knowledge, and they must learn to live with engage the feelings and fantasies that fuel the patient's ambiguity while exploring at a tolerable pace. despair. Commonly, the patient has the fantasy that she In order to develop a full understanding of the trauma is already among the dead, because her capacity for story, the survivor must examine the moral questions of love has been destroyed. What sustains the patient guilt and responsibility and reconstruct a system of through this descent into despair is the smallest evi- belief that makes sense of her undeserved suffering. The dence of an ability to form loving connections. moral stance of the therapist is therefore of enormous The second stage of recovery has a timeless quality importance. It is not enough for the therapist to be that is very frightening. The reconstruction of the 'neutral' or 'non-judgmental'. The patient challenges trauma requires immersion in a past experience of the therapist to share her own struggles with these im- frozen time; the descent into mourning feels like a mense philosophical questions. The therapist's role is surrender to endless tears. Patients often ask how long not to provide ready-made answers, which would be this painful process will last. There is no fixed answer to impossible in any case, but rather to affirm a position of the question, only the assurance that the process cannot moral solidarity with the survivor.'" be bypassed or hurried. It will almost surely take longer The telling of the trauma story inevitably plunges the than the patient wishes, but that it will not go on for- survivor into profound grief. The descent into mourn- ever. After many repetitions, the moment comes when ing is a necessary but dreaded part of the recovery the telling of the trauma story no longer arouses quite process. Patients often fear that the task is insur- such intense feeling. It has become a part of the sur- mountable, that once they allow themselves to start vivor's experience, but only one part of it. It is a grieving, they will never stop. Survivors of prolonged memory like other memories, and it begins to fade as childhood trauma face the task of grieving not only for other memories do. Her grief, too, begins to lose its what was lost but also for what was tiever theirs to lose. vividness. It occurs to the survivor that perhaps the The childhood that was stolen from them is irreplace- trauma is only one part, and perhaps not even the most able. They must mourn the loss of the foundation of important part, of her life story. basic trust, the belief in a good parent. As they come to The reconstruction of the trauma is never entirely recognize that they were not responsible for their fate, completed; new confiicts and challenges at each new they confront the existential despair that they could not stage of the lifecycle will inevitably reawaken the face in childhood.'"^ trauma and bring some new aspect of the experience to Grieving has an additional meaning for survivors light. The major work of the second stage is accom- who have themselves harmed or abandoned others. The plished, however, when the patient reclaims her own combat veteran who has committed atrocities may feel history and feels renewed hope and energy for en- he no longer belongs in a civilized community. The gagement with life. Time starts to move again. When political prisoner who has betrayed others under duress the second stage has come to its conclusion, the trau- or the battered woman who has failed to protect her matic experience belongs to the past. children may feel she has committed a worse crime than At this point, the survivor faces the tasks of re- the perpetrator. Although the survivor may come to building her life in the present and pursuing her aspi- understand that these violations of relationship were rations for the future. She has mourned the old self committed under extreme circumstances, this under- which the trauma destroyed; now she must develop a standing by itself does not fully resolve her profound new self. Her relationships have been tested and forever feelings of guilt and shame. The survivor needs to changed by the trauma; now she must develop new mourn for the loss of her moral integrity and to find her relationships. The old beliefs that gave meaning to her own way to atone for what cannot be undone. This life have been challenged; now she must find anew a restitution in no way exonerates the perpetrator of his sustaining faith. These are the tasks of the third stage of crimes; rather, it reaffirms the survivor's claim to moral recovery. choice in the present.''* The issues of the first stage of recovery are often The confrontation with despair brings with it, at least revisited at this time. Once again the survivor devotes transiently, an increased risk of suicide. In contrast to attention to the care of her body, her immediate envi- the impulsive self-destructiveness of the first stage of ronment, her material needs, and her relationships with recovery, the patient's suicidality during this second others. But while in the first stage the goal was simply stage may evolve from a calm, flat, apparently rational to secure a defensive position of basic safety, by the decision to reject a world where such horrors are pos- third stage the survivor is ready to engage more actively sible. Patients may engage in sterile philosophical dis- in the world. She can establish an agenda. She can re- cussions about their riaht to choose suicide. It is cover some of her aspirations from the time before the Recovery from psychological trauma S149

trauma, or perhaps for the first time she can discover and hutnor. It brings out the best in her; in return, the her own ambitions. survivor gains the sense of connection with the best in By the third stage of recovery, the survivor has re- other people. In this sense of reciprocal connection, the gained some capacity for appropriate trust. She can survivor can transcend the boundaries of her particular once again feel trust in others wheti that trust is war- time and place,'^ ranted, she can withhold her trust when it is not war- Social actioti can take many fonns, from concrete ranted, and she knows how to distinguish between the engagement with particular individuals, to the abstract two situations. She has also regained the abihty to feel intellectual pursuits. Survivors tnay focus their energies autonomous while retnaining connected to others; she on helping others who have been sitnilarly victitnized, can maintain her own poitit of view and her own on educational, legal, or political efforts to prevent boundaries while respecting those of others. She has others from being victimized in the future, Comtnon to begun to take tnore initiative in her life and is in the all these efforts is a dedication to raising public process of creating a new identity. With others, she is awareness. Survivors understand that the natural hu- now ready to risk deepening her relationships. With tnan response to horrible events is to put them out of peers, she can now seek mutual friendships that are not tnind. They also understand that those who forget the based on performance, image, or tnaintenance of a false past are often condetnned to repeat it. It is for this self.'^ With lovers and fatnily, she is now ready for reason that public truth-telling is the cotntnon de- greater intimacy. notninator of all social action."^ At this point, the survivor may be ready to devote The survivor tnission may also take the form of her energy more fully to a relationship with a partner. pursuing justice. In the third stage of recovery, the If she has not been involved in an intimate relationship, survivor recognizes that the trauma cannot be undone, she may begin to consider the possibility without feel- and that personal wishes for cotnpensation or revenge ing either dread or desperate need. If she has been in- cannot be fulfillled. She also recognizes, however, that volved with a partner during the recovery process, she holding the perpetrator accountable for his critnes is often becomes much more aware of the ways in which itnportant not only for her personal well-being but also her partner suffered from her preoccupation with the for the health of the larger society. trauma. At this point she can express her gratitude The survivor who undertakes public action also more freely and tnake atnends when necessary. The needs to come to terms with the fact that not every survivor may also become more open to new forms of battle will be won. Her particular battle becomes part engagement with children. If the survivor is a parent, of a larger, ongoing struggle to uphold the rule of law she tnay come to recognize the ways in which the and the principles of non-violence against the rule of trauma experience has indirectly affected her children, force. She tnust be secure in the knowledge that sitnply and she may take steps to rectify the situation. If she it! her willingness to tell the truth in public, she has does not have children, she tnay begin to take a new taken the action that perpetrators fear the most. Her and broader interest in young people. recovery is not based on the illusion that evil has been Most survivors seek the resolution of their traumatic overcome, but rather on the knowledge that it has not experietice within the confines of their personal lives. prevailed, atid on the hope that restorative love may But a significatit minority, as a result of the trauma, feel still be found in the world, called upon to engage in a wider world. These survivors recognize a political or religious ditnension in their REFERENCES misfortune, and discover that they can transform the meaning of their personal tragedy by tnaking it the basis 1, Herman JL, Trauma and Recovery. Basic, New York, for social action. 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