Recovery from Psychological Trauma

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 psychological 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

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