Trauma and Recovery – the Aftermath of Violence—From Domestic Abuse to Political Terror by Judith Herman, M.D.
PART 1 – Traumatic Disorders
Chapter 1 – A Forgotten History
The study of psychological trauma has a curious history—one of episodic amnesia. Periods of active investigation have alternated with periods of oblivion. Repeatedly in the past century, similar lines of inquiry have been taken up and abruptly abandoned, only to be rediscovered much later. Classic documents of fifty or one hundred years ago often read like contemporary works. Though the field has in fact an abundant and rich tradition, it has been periodically forgotten and must be periodically reclaimed.
This intermittent amnesia is not the result oof the ordinary changes in fashion that affect any intellectual pursuit. The study of psychological trauma does not languish for lack of interest. Rather, the subject provokes such intense controversy that it periodically becomes anathema. The study of psychological trauma has repeatedly led into realms of the unthinkable and foundered on fundamental questions of belief.
To study psychological trauma is to come face to face both with human vulnerability in the natural world and with the capacity for evil in human nature. To study psychological trauma means bearing witness to horrible events. When the events are natural disasters… those who bear witness sympathize readily with the victim. But when the traumatic events are of human design, those who bear witness are caught in the conflict between victim and perpetrator. It is morally impossible to remain neutral in this conflict. The bystander is forced to take sides.
The Heroic Age of Hysteria
This emphatic identification with the patients’ reactions is characteristic of Freud’s early writings on hysteria. His case histories reveal a man possessed of such passionate curiosity that he was willing to overcome his own defensiveness, and willing to listen. What he heard was appalling. Repeatedly his patients told him of sexual assault, abuse, and incest. Following back the thread of memory, Freud and his patients uncovered major traumatic events of childhood concealed beneath the more recent, often relatively trivial experiences that had actually triggered the onset of hyste4rical symptoms. By 1896 Freud believed he had found the source. In a report on eighteen case studies, entitled The Aetiology of Hysteria, he made a dramatic claim: “I therefore put forward the thesis that at the bottom of every case of hysteria there are one or more occurrences of premature sexual experience, occurrences which belong to the earliest years of childhood, but which can be reproduced through the work of psycho-analysis in spite of the intervening decades. I believe that this is an important finding, the discovery of a caput Nili in neuropathology.”
A century later, this paper still rivals contemporary clinical descriptions of the effects of childhood sexual abuse. It is a brilliant, compassionate, eloquently argued, closely reasoned document. Its triumphant title and exultant tone suggest that Freud viewed his contribution as the crowning achievement in the field.
Instead, the publication of The Aetiology of Hysteria marked the end of this line of inquiry. Within a year, Freud had privately repudiated the traumatic theory of the origins of hysteria. His correspondence makes clear that he was increasingly troubled by the radical social implications of his hypothesis. Hysteria was so common among women that if his patients’ stories were true, and if his theory were correct, he would be forced to conclude that what he called “perverted acts against children” were endemic, not only among the proletariat of Paris, where he had first studied hysteria, but also among the respectable bourgeois families of Vienna, where he had established his practice. This idea was simply unacceptable. It was beyond credibility.
Faced with this dilemma, Freud stopped listening to his female patients. The turning point is documented in the famous case of Dora. This, the last of Freud’s case studies on hysteria, reads more like a battle of wits than a cooperative venture. The interaction between Freud and Dora has been described as “emotional combat.” In this case Freud still acknowledged the reality of his patient’s experience: the adolescent Dora was being used as a pawn in her father’s elaborate sex intrigues. Her father had essentially offered her to his friends as a sexual toy. Freud refused, however, to validate Dora’s feelings of outrage and humiliation. Instead he insisted upon exploring her feelings of erotic excitement, as if the exploitative situation were a fulfillment of her desire. In an act viewed as revenge, Dora broke off the treatment.
The breach of [Freud and Dora’s] alliance marked the bitter end of an era of collaboration between ambitious investigators and hysterical patients. For close to a century, these patients would again be scorned and silenced. Freud’s followers held a particular grudge against the rebellious Dora…
Men of science contrasted their benevolent patronage of hysterics with the worst excesses of the Inquisition. Charles Richet, a disciple of Charcot, observed in 1880: “Among the patients locked away in the Salpêtrière are many who would have been burned in former times, whose illness would have been taken for a crime.” William James echoed these sentiments a decade later: “Amongst all the many victims of medical ignorance clad in authority the poor hysteric has hitherto fared the worst; and her gradual rehabilitation and rescue will count among the philanthropic conquests of our generation.”
While these men of science saw themselves as benevolent rescuers, uplifting women from their degraded condition, they never for a moment envisioned a condition of social equality between women and men. Women were to be objects of study and humane care, not subjects in their own right. The same men who advocated an enlightened view of hysteria often strongly opposed the admission of women into higher education or the professions and adamantly opposed female suffrage.
The only one of the early investigators who carried the exploration of hysteria to its logical conclusion was Breuer‘s patient Anna O. After Breuer abandoned her, she apparently remained ill for several years. And then she recovered. The mute hysteric who had invented the “talking cure” found her voice, and her sanity, in the women’s liberation movement.
Traumatic Neuroses of War
The reality of psychological trauma was forced upon public consciousness once again by the catastrophe of the First World War. In the prolonged war of attrition, over eight million men died in four years. When the slaughter was over, four European empires had been destroyed, and many of the cherished beliefs that had sustained Western civilization had been shattered.
One of the many casualties of the war’s devastation was the illusion of manly honor and glory in battle. Under conditions of unremitting exposure to the horrors of trench warfare, men began to break down in shocking numbers. Confined and rendered helpless, subjected to constant threat of annihilation, and forced to witness the mutilation and death of their comrades without any hope of reprieve, many soldiers began to act like hysterical women.
Progressive medical authorities argued… that combat neurosis was a bona fide psychiatric condition that could occur in soldiers of high moral character. They advocated humane treatment based upon psychoanalytic principles. The champion of this more liberal point of view was W. H. R. Rivers, a physician of wide-ranging intellect who was a professor of neurophysiology, psychology, and anthropology. His most famous patient was a young officer, Siegfried Sassoon, who had distinguished himself for conspicuous bravery in combat and for his war poetry. Sassoon gained notoriety when, while still in uniform, he publicly affiliated himself with the pacifist movement and denounced the war.
The Combat Neurosis of the Sex War
The late nineteenth-century studies of hysteria foundered on the question of sexual trauma. At the time of these investigations there was no awareness that violence is a routine part of women’s sexual and domestic lives. Freud glimpsed this truth and retreated in horror. For most of the twentieth century, it was the study of combat veterans that led to the development of a body of knowledge about traumatic disorders. Not until the women’s liberation movement of the 1970s was it recognized that the most common post-traumatic disorders are those not of men in war but of women in civilian life.
The real conditions of women’s lives were hidden in the sphere of the personal, in private life. The cherished value of privacy created a powerful barrier to consciousness and rendered women’s reality practically invisible. To speak about experiences in sexual or domestic life was to invite public humiliation, ridicule, and disbelief. Women were silenced by fear and shame, and the silence of women gave license to every form of sexual and domestic exploitation.
Women did not have a name for the tyranny of private life. It was difficult to recognize that a well-established democracy in the public sphere could coexist with conditions of primitive autocracy or advanced dictatorship in the house. Thus, it was no accident that n the first manifesto of the resurgent American feminist movement, Betty Friedan called the woman question the “problem without a name.” It was also no accident that the initial method of the movement was called “consciousness-raising.”
The results of these investigations confirmed the reality of women’s experiences that Freud had dismissed as fantasies a century before. Sexual assaults against women and children were shown to be pervasive and endemic in our culture. The most sophisticated epidemiological survey was conducted in the early 1980s by Diana Russell, a sociologist and human rights activist. Over 900 women, chosen by random sampling techniques, were interviewed in depth about their experiences of domestic violence and sexual exploitation. The results were horrifying. One woman in four had been raped. One woman in three had been sexually abused in childhood.
In addition to documenting pervasive sexual violence, the feminist movement offered a new language for understanding the impact of sexual assault. Entering the public discussion of rape for the first time, women found it necessary to establish the obvious: that rape is an atrocity. Feminists redefined rape as a crime of violence rather than a sexual act. This simplistic formulation was advanced to counter the view that rape fulfilled women’s deepest desires, a view then prevailing in every form of literature, from popular pornography to academic texts.
Rape was the feminist movement’s initial paradigm for violence against women in the sphere of personal life. As understanding deepened, the investigation of sexual exploitation progressed to encompass relationships of increasing complexity, in which violence and intimacy commingled. The initial focus on street rape, committed by strangers, led step by step to the exploration of acquaintance rape, date rape, and rape in marriage. The initial focus on rape as a form of violence against women led to the exploration of domestic battery and other forms of private coercion. And the initial focus on the rape of adults led inevitably to a rediscovery of the sexual abuse of children.
But history teaches us that this knowledge could also disappear. Without the context of a political movement, it has never been possible to advance the study of psychological trauma. The fate of this field of knowledge depends upon the fate of the same political movement that has inspired and sustained it over the last century. In the late nineteenth century the goal of that movement was the establishment of secular democracy. In the early twentieth century its goal was the abolition of war. In the late twentieth century its goal was the liberation of women. All of these goals remain. All are, in the end, inseparably connected.
Chapter 2 – Terror
Psychological trauma is an affliction of the powerless. At the moment of trauma, the victim is rendered helpless by overwhelming force. When the force is that of nature, we speak of disasters. When the force is that of other human beings, we speak of atrocities. Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning.
It was once believed that such events were uncommon. In 1980, when post-traumatic stress disorder was first included in the diagnostic manual, the American Psychiatric Association described traumatic events as “outside the range of usual human experience.” Sadly, this definition has proved to be inaccurate. Rape, battery, and other forms of sexual and domestic violence are so common a part of women’s lives that they can hardly be described as outside the range of ordinary experience. And in view of the number of people killed in war over the past century, military trauma, too, must be considered a common part of human experience; only the fortunate find it unusual.
The many symptoms of post-traumatic stress disorder fall into three main categories. These are called “hyperarousal,” “intrusion,” and “constriction.” Hyperarousal reflects the indelible imprint of the traumatic moment; constriction reflects the numbing response of surrender.
Traumatic memories have a number of unusual qualities. They are not encoded like the ordinary memories of adults in a verbal, linear narrative that is assimilated into an ongoing life story. Janet explained the difference:
[Normal memory,] like all psychological phenomena, is an action; essentially it is the action of telling a story. … A situation has not been satisfactorily liquidated … until we have achieved, not merely an outward reaction through our movements, but also an inward reaction through the words we address to ourselves, through the organization of the recital of the event to others and to ourselves, and through the putting of this recital in its place as one of the chapters in our personal history. … Strictly speaking, then, one who retains a fixed idea of a happening cannot be said to have a “memory” … it is only for convenience that we speak of it as a “traumatic memory.”
In their predominance of imagery and bodily sensation, and in their absence of verbal narrative, traumatic memories resemble the memories absence of verbal narrative, traumatic memories resemble the memories of young children. Studies of children, in fact, offer some of the clearest examples of traumatic memory. Among 20 children with documented histories of early trauma, the psychiatrist Lenore Terr found that none of the children could give a verbal description of the events that had occurred before they were two and one-half years old. Nonetheless, these experiences were indelibly encoded in memory. Eighteen of the 20 children showed evidence of traumatic memory in their behavior and their play. They had specific fears related to the traumatic events, and they were able to reenact these events in their play with extraordinary accuracy. For example, a child who had been sexually molested by a babysitter in the first two years of life could not, at age five, remember or name the first two years of lief could not, at age five, remember or name the babysitter. Furthermore, he denied any knowledge or memory of being abused. But in his play he enacted scenes that exactly replicated a pornographic movie made by the babysitter. This highly visual and enactive form of memory, appropriate to young children, seems to be mobilized in adults as well in circumstances of overwhelming terror.
Traumatized people relive the moment of trauma not only in their thoughts and dreams but also in their actions. The reenactment of traumatic scenes is most apparent in the repetitive play of children. Terr differentiates between normal play and the “forbidden games” of children who have been traumatized: “The everyday play of childhood … is free and easy. It is bubbly and light-spirited, whereas the play that follows from trauma is grim and monotonous. … Play does not stop easily when it is traumatically inspired. And it may not change much over time. As opposed to ordinary child’s play, post-traumatic play is obsessively repeated. …Post-traumatic play is so literal that if you spot it, you may be able to guess the trauma with few other clues.
More recent theorists also conceptualize intrusion phenomena, including reenactments, as spontaneous attempts to integrate the traumatic event. The psychiatrist Mardi Horowitz postulates a “completion principle” which “summarizes the human mind’s intrinsic ability to process new information in order to bring up to date the inner schemata of the self and the world.” Trauma, by definition, shatters these “inner schemata.” Horowitz suggests that unassimilated traumatic experiences are store in a special kind of “active memory,” which has an “intrinsic tendency to repeat the representation of contents.” The trauma is resolved only when the survivor develops a new mental “schema” for understanding what has happened.
Reliving a trauma may offer an opportunity for mastery, but most survivors do not consciously seek or welcome the opportunity. Rather, survivors do not consciously seek or welcome the opportunity. Rather they dread and fear it. Reliving a traumatic experience, whether in the form of intrusive memories, dreams, or actions, carries with it the emotional intensity of the original events. The survivor is continually buffered by terror and rage. These emotions are qualitatively different from ordinary fear and anger. They are outside the range of ordinary emotional experience, and they overwhelm the ordinary capacity to bear feelings.
When a person is completely powerless, and any form of resistance is futile, she may go into a state of surrender. The system of self-defense shuts down entirely. The helpless person escapes from her situation not by action in the real world but rather by altering her state of consciousness. Analogous states are observed in animals, who sometimes “freeze” when they are attacked. These are the responses of captured prey to predator or of a defeated contestant in battle.
These detached states of consciousness are similar to hypnotic trance states. They share the same features of surrender of voluntary action, suspension of initiative and critical judgment, subjective detachment or calm, enhanced perception of imagery, altered sensation, including numbness and analgesia, and distortion of reality, including depersonalization, derealization, and change in the sense of time.
Janet thought that his hysterical patients’ capacity for trance states was evidence of psychopathology. More recent studies have demonstrated that although people vary in their ability to enter hypnotic states, trance is a normal property of human consciousness. Traumatic events serve as powerful activators of the capacity for trance. As the psychiatrist David Spiegel points out, “it would be surprising indeed if people did not spontaneously use this capacity to reduce their perception of pain during acute trauma.
Constrictive symptoms also interfere with anticipation and planning for the future. Grinker and Spiegel observed that soldiers in wartime responded to the losses and injuries within their group with diminished confidence in their own ability to make plans and take initiative, with increased superstitious and magical thinking, and with greater reliance on lucky charms and omens.
The Dialectic of Trauma
In the aftermath of an experience of overwhelming danger, the two contradictory responses of intrusion and constriction establish an oscillating rhythm. This dialectic of opposing psychological states is perhaps the most characteristic feature of the post-traumatic syndromes. Since neither the intrusive nor the numbing symptoms allow for integration of the traumatic event, the alternation between these two extreme states might be understood as an attempt to find a satisfactory balance between the two. But balance is precisely what the traumatized person lacks. She finds herself caught between the extremes of amnesia or of reliving the trauma, between floods of intense, overwhelming feeling and arid states of no feeling at all, between irritable, impulsive action and complete inhibition of action. The instability produced by these periodic alternations further exacerbates the traumatized person’s sense of unpredictability and helplessness. The dialectic of trauma is therefore potentially self-perpetuating.
while general anxiety symptoms tended to diminish over time, psychosomatic symptoms actually got worse.
Chapter 3 – Disconnection
Traumatic events call into question basic human relationships. They breach the attachment 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 systems that give 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.
The damage to relational life is not a secondary effect of trauma, as originally thought. Traumatic events have primary effects not only on the psychological structures of the self but also on the systems of attachments and meaning that link individual and community. Mardi Horowitz defines traumatic life events as those that cannot be assimilated with the victim’s “inner schemata” of self in relation to the world. Traumatic events destroy the victim’s fundamental assumptions about the safety of the world, the positive value of the self, and the meaningful order of creation. The rape survivor Alice Sebold testifies to this loss of security: “When I was raped I lost my virginity and almost lost my life. I also discarded certain assumptions I had held about how the world worked and about how safe I was.
The Damaged Self
A secure sense of connection with caring people is the foundation of personality development. When this connection is shattered, the trauma-tired person loses her basic sense of self. Developmental conflicts of childhood and adolescence, long since resolved, are suddenly reopened. Trauma forces the survivor to relive all her 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. When a parent, who is so much more powerful than a child, nevertheless shows some regard for the child’s individuality and dignity, the child feels valued and respected; she develops self-esteem. She also develops autonomy, that is, a sense of her own separateness within the relationship. She learns to control and regulate her own bodily functions and to form and express her own point of view.
Traumatic events violate the autonomy of the person at the level of basic bodily integrity.
In the aftermath of traumatic events, as survivors review and judge their own conduct, feelings of guilt and inferiority are practically universal. Robert Jay Lifton found “survivor guilt” to be a common experience in people who had lived through war, natural disaster, or nuclear holocaust. Rape produces essentially the same effect: it is the victims, not the perpetrators, who feel guilty. Guilt may be understood as an attempt to draw some useful lesson from disaster and to regain some sense of power. To imagine that one could have done better may be more tolerable than to face the reality of utter helplessness.
The damage to the survivor’s faith and sense of community is particularly severe when the traumatic events themselves involve the betrayal of important relationships. The imagery of these events often crystallizes around a moment of betrayal, and it is this breach of trust which gives the intrusive images their intense emotional power. For example, in Abram Kardiner‘s psychotherapy of the navy veteran who had been rescued at sea after his ship was sunk, the veteran became more upset when revealing how he felt let down by his own side: “The patient became rather excited and began to swear profusely; his anger was aroused clearly by incidents connected with his rescue. They had been in the water for a period of about twelve hours when a torpedo-boat destroyer picked them up. Of course the officers in the lifeboats were taken off first. The eight or nine men clinging to the raft the patient was on had to wait in the water for six or seven hours longer until help came.
Vulnerability and Resilience
The most powerful determinant of psychological harm is the character of the traumatic event itself. Individual personality characteristics count for little in the face of overwhelming events. There is a simple, direct relationship between the severity of the trauma and its psychological impact, whether that impact is measured in terms of the number of people affected or the intensity and duration of harm. Studies of war and natural disasters have documented a “dose-response curve,” whereby the grater the exposure to traumatic events, the greater the percentage of the population with symptoms of post-traumatic stress disorder.
Follow-up studies find that rape survivors have high levels of persistent post-traumatic stress disorder, compared to victims of other crimes. These malignant effects of rape are not surprising given the particular nature of the trauma. The essential element of rape is the physical, psychological, and moral violation of the person. Violation is, in fact, a synonym for rape. The purpose of the rapist is to terrorize, dominate, and humiliate the victim, to render her utterly helpless. Thus rape, but its nature, is intentionally designed to produce psychological trauma.
Though the likelihood that a person will develop post-traumatic stress disorder depends primarily on the nature of the traumatic event, individual differences play an important part in determining the form that the disorder will take.
Only a small minority of exceptional people appear to be relatively invulnerable in extreme situations. Studies of diverse populations have reached similar conclusions: stress-resistant individuals appear to be those with high sociability, a thoughtful and active coping style, and a strong perception of their ability to control their destiny.
Half of all victims are aged twenty or younger at the time they are raped; three-quarters are between the ages of thirteen and twenty-six. The period of greatest psychological vulnerability is also in reality the period of greatest traumatic exposure, for both young men and young women. Rape and combat might thus be considered complementary social rites of initiation into the coercive violence at the foundation of adult society. They are the paradigmatic forms of trauma for women and men respectively.
The Effect of Social Support
The psychiatrist Herbert Spiegel describes his strategy for preserving attachment and restoring the sense of basic safety among soldiers at the front: “We knew once a soldier was separated from his unit he was lost. So if someone was getting tremulous, I would give him the chance to spend the night in the kitchen area, because I would give him the chance to spend the night in the kitchen area, because it was a little bit behind, a little bit protected, but it was still our unit. The cooks were there, and I would tell them to rest, even give them some medication for sleep, and that was like my rehab unit. Because the traumatic neurosis doesn’t occur right away. In the initial stage it’s just confusion and despair. In that immediate period afterwards, if the environment encourages and supports the person, you can avoid the worry of it.”
This is the survivor’s feelings of fear, distrust, and isolation may be compounded by the incomprehension or frank hostility of those to whom she turns for help. When the rapist is a husband or lover, the traumatized person is the most vulnerable of all, for the person to whom she might ordinarily turn for safety and protection is precisely the source of danger.
Because the entrenched norms of male entitlement, many women are accustomed to accommodating their partners’ desires and subordinating their own, even in consensual sex. In the aftermath of rape, however, many survivors find they can no longer tolerate this arrangement. In order to reclaim her own sexuality, a raper survivor needs to establish a sense of autonomy and control. If she is ever to trust again, she needs a cooperative and sensitive partner who does not expect sex on demand.
Returning veterans may be frustrated by their families’ naive and unrealistic views of combat, but at least they enjoy the recognition that they have been to war. Rape victims, by and large, do not. Many acts that women experience as terrorizing violations may not be regarded as such, even by those closest to them. Survivors are thus placed in the situation where they must choose between expressing their own point of view and remaining in connection with others. Under these circumstances, many women may have difficulty even naming their experience. The first task of consciousness-raising is simply calling rape by its true name.
In their study of combat veterans with post-traumatic stress disorder; Herbert Hendin and Ann Haas found that resolving guilt required a detailed understanding of each man’s particular reason for self-blame rather than simply a blanket absolution.
Finally, the survivor needs help from others to mourn her losses. All of the classic writings ultimately recognize the necessity of mourning and reconstruction in the resolution of traumatic life events. Failure to complete the normal process of grieving perpetuates the traumatic reaction. Lifton observes that “unresolved or incomplete mourning results in stasis and entrapment in the traumatic process.”
The Role of the Community
When veterans’ groups organize, their first efforts are to ensure that their ordeals will not disappear from public memory. Hence the insistence on medals, monuments, parades, holidays, and public ceremonies of memorial, as well as individual compensation for injuries. Even congratulatory public ceremonies, however, rarely satisfy the combat veteran’s longing for recognition, because of the sentimental disorientation of the truth of combat. A Vietnam veteran addresses this universal tendency to deny the horror of war: “If at the end of a war story you feel uplifted, or if you feel that some small bit of rectitude has been salvaged from the larger waste, then you have been made the victim of a very old and terrible lie.”
Probably the most significant public contribution to the healing of these veterans was the construction of the Vietnam War Memorial in Washington, D.C. This monument, which records simply by name and date the number of the dead, becomes by means of this acknowledgment a site of common mourning.
Women quickly learn that rape is a crime only in theory; in practice the standard for what constitutes rape is set not at the level of women’s experience of violation but just above the level of coercion acceptable to men. That level turns out to be high indeed. In the words of the legal scholar Catherine MacKinnon, “rape, from women’s point of view, is not prohibited; it is regulated.”
The legal system is designed to protect men from the superior power of the state but not to protect women or children from the superior power of men. It therefore provides strong guarantees for the rights of the accused but essentially no guarantees for the rights of the victim. If one set out by design to devise a system for provoking intrusive post-traumatic symptoms, one could not do better than a court of law.
Chapter 4 – Captivity
A single traumatic event can occur almost anywhere. Prolonged, repeated trauma, by contrast, occurs only in circumstances of captivity. When the victim is free to escape, she will not be abused a second time; repeated trauma occurs only when the victim is a prisoner, unable to flee, and under the control of the perpetrator. Such conditions obviously exist in prisons, concentration camps, and slave labor camps. These conditions may also exist in religious cults, in brothels and other institutions of organized sexual exploitation, and families.
Since [a perpetrator] is contemptuous of those who seek to understand him, he does not volunteer to be studied. Since he does not perceive that anything is wrong with him, he does not seek help—unless he is in trouble with the law. His most consistent feature, in both the testimony of victims and the observations of psychologists, in his apparent normality. Ordinary concepts of psychopathology fail to define or comprehend him.
The desire for total control over another person is the common denominator of all forms of tyranny. Totatliatarian governments demand confession and political conversion of their victims. Slaveholders demand gratitude of their slaves. Religious cults demand ritualized sacrifices as a sign of submission to the divine will of the leader. Perpetrators of domestic battery demand that their victims prove complete obedience and loyalty by sacrificing all other relationships. Sex offenders demand that their victims find sexual fulfillment in submission. Total control over another person is the power dynamic at the heart of pornography. The erotic appeal of this fantasy to millions of terrifyingly normal men fosters an immense industry in which women and children are abused, not in fantasy but in reality.
Walker observes that the “reconciliation” phase is a crucial step in breaking down the psychological resistance of the battered woman. A woman who eventually escaped a battering relationship describes how these intermittent rewards bound her to her abuser: “It was really cyclical actually .. and the odd thing was that in the good periods I could hardly remember the bad times. It was almost as if I was leading two different lives.”
Terror, intermittent reward, isolation, and enforced dependency may succeed in creating a submissive and compliant prisoner. But the final step in the psychological control of the victim is not completed until she has been forced to violate her won moral principles and to betray her basic human attachments. Psychologically, this I the most destructive of all coercive techniques, for the victim who has succumbed loathes herself. It is at this point, when the victim under duress participates in the sacrifice of others, that she is truly “broken.”
Prisoners, even those who have successfully resisted, understand that under extreme duress anyone can be “broken.” They generally distinguish two stages in the process. The first is reached when the victim relinquishes her inner autonomy, world view, moral principles, or connection with others for the sake of survival. There is a shutting down of feelings, thoughts, initiative, and judgment. The psychiatrist Henry Krystal, who works with survivors of the Nazi Holocaust, describes this state as “robotization.” Prisoners who have lived through this psychological state often describe themselves as having been reduced to a nonhuman life form.
The second, irreversible stage in the breaking of a person is reached when the victim loses the will to live. This is not the same thing as becoming suicidal: people in captivity live constantly with the fantasy of suicide, and occasional suicide attempts are not inconsistent with a general determination to survive. Timerman, in fact, describes the wish for suicide in these extreme circumstances as a sign of resistance and pride.
The Syndrome of Chronic Trauma
People subjected to prolonged, repeated trauma develop an insidious progressive form of post-traumatic stress disorder that invades and erodes the personality. While the victim of a single acute trauma may feel after the event that she is “not herself,” the victim of chronic trauma may feel herself to be changed irrevocably, or she may lose the sense that she has any self at all.
The worst fear of any traumatized person is that the moment of horror will recur, and this fear is realized in victims of chronic abuse. Not surprisingly, the repetition of trauma amplifies all the hyperarousal symptoms of post-traumatic stress disorder. Chronically traumatized people are continually hypervigilant, anxious, and agitated. The psychiatrist Elaine Hilberman describes the state of constant dread experienced by battered women: “Events even remotely connected with violence—sirens, thunder, a door slamming—elicited intense fear. There was chronic apprehension of imminent doom, of something terrible always about to happen. Any symbolic or actual sign of potential danger resulted in increased activity, agitation, pacing, screaming and crying. The women remained vigilant, unable to relax or to sleep. Nightmares were universal with undisguised themes of violence and danger.
When the victim has been reduced to a goal of simple survival, psychological constriction becomes an essential form of adaptation. This narrowing applies to every aspect of life—to relationships, activities, thoughts, memories, emotions, and even sensations. And while this constriction is adaptive in captivity, it also leads to a kind of atrophy in the psychological capacities that have been suppressed and to the overdevelopment of a solitary inner life.
The ability to hold contradictory beliefs simultaneously is one characteristic of trance states. The ability to alter perception is another. Prisoners frequently instruct one another in the induction of these states through chanting, prayer, and simple hypnotic techniques. These methods are consciously applied to withstand hunger, cold, and pain.
Later, after learning meditation techniques from other prisoners, [Alicia Partnoy] was able to limit her physical perception of pain and emotional reactions of terror and humiliation by altering her sense of reality.
In addition to the use of trance states, prisoners develop the capacity voluntarily to restrict and suppress their thoughts. This practice applies especially to any thoughts of the future. Thinking of the future stirs up such intense yearning and hope that prisoners find it unbearable; they quickly learn that these emotions make them vulnerable to disappointment and that disappointment will make them desperate. They therefore consciously narrow their attention, focusing on extremely limited goals. The future is reduced to a matter of hours or days.
The more the period of captivity is disavowed, however, the more this disconnected fragment of the past remains fully alive, with the immediate and present characteristics of traumatic memory.
This narrowing in the range of initiative becomes habitual with prolonged capacity, and it must be unlearned after the prisoner is liberated. A political dissident, Mauricio Rosencof, describes the difficulties of returning to a life of freedom after many years of imprisonment:
Once we got out, we were suddenly confronted with all these problems. … Ridiculous problems—doorknobs, for instance. I had no reflex any longer to reach for the knobs of doors. I hadn’t had to—hadn’t been allowed to—for over thirteen years. I’d come to a closed door and find myself momentarily stymied—I couldn’t remember what to do next. Or how to make a dark room light. How to work, pay bills, shop, visit friends, answer questions. My daughter tells me to do this or that, and one problem I can handle, two I can handle, but when the third request comes I can hear her voice but my head is lost in the clouds.
A study of prisoner relationships in these camps found that the overwhelming majority of survivors became part of a “stable pair,” a loyal buddy relationship of mutual sharing and protection, leading to the conclusion that the pair, rather than the individual, was the “basic unit of survival.”
In the words of the Holocaust survivor Levi: “We have learnt that our personality is fragile, that it is in much more danger than our life; and the old wise ones, instead of warning us ‘remember that you must die,’ would have done much better to remind us of this greater danger that threatens us. If from inside the Lager, a message could have seeped out to free men, it would have been this: take care not to suffer in your own homes what is inflicted on us here.”
Chapter 5 – Child Abuse
Repeated trauma in adult life erodes the structure of the personality already formed, but repeated trauma in childhood forms and deforms the personality. The child trapped in an abusive environment is faced with formidable tasks and adaptation. She must find a way to preserve a sense of trust in people who are untrustworthy, safety in a situation that is unsafe, control in a situation that is terrifyingly unpredictable, power in a situation of helplessness. Unable to care for or protect herself, she must compensate for the failures of adult care and protection with the only means at her disposal, an immature system of psychological defenses.
The pathological environment of childhood abuse forces the development of extraordinary capacities, both creative and destructive. It fosters the development of abnormal states of consciousness in which the ordinary relations of body and mind, reality and imagination, knowledge and memory, no longer hold. These altered states of consciousness permit the elaboration of a prodigious array of symptoms, both somatic and psychological. And these symptoms simultaneously conceal and reveal their origins; they speak in disguised language of secrets too terrible for words.
The Abusive Environment
In addition to the fear of violence, survivors consistently report an overwhelming sense of helplessness. In the abusive family environment, the exercise of parental power is arbitrary, capricious, and absolute. Rules are erratic, inconsistent, or patently unfair. Survivors frequently recall that what frightened them most was the unpredictable nature of the violence. Unable to find any way to avert the abuse, they learn to adopt a position of complete surrender.
Adaptation to a climate of constant danger requires a state of constant alertness. Children in an abusive environment develop extraordinary abilities to scan for warning signs of attack. They become minutely attuned to their abusers’ inner states. They learn to recognize subtle changes in facial expression, voice, and body language as signals of anger, sexual arousal, intoxication, or dissociation. This nonverbal communication becomes highly automatic and occurs for the most part outside of conscious awareness. Child victims learn to respond without being able to name or identify the danger signals that evoked their alarm. In one extreme example, the psychiatrist Richard Kluft observed three children who had learned to dissociate on cue when their mother became violent.
When abused children note signs of danger, they attempt to protect themselves either by avoiding or by placating the abuser. Runaway attempts are common, often beginning by age seven or eight. Many survivors remember literally hiding for long periods of time, and they associate their only feelings of safety with particular hiding places rather than with people.
A Double Self
In the abusive environment, moderation and tolerance are unknown. Rather, the victim’s self-respresentations remain rigid, exaggerated, and split. In the most extreme situations, these disparate, self-representations from the nidus of dissociated alter personalities.
In the course of normal development, a child achieves a secure sense of autonomy by forming inner representations of trustworthy and dependable caretakers, representations that can be evoked mentally in moments of distress. Adult prisoners rely heavily on these internalized images to preserve their sense of independence.
Self-injury is also frequently mistaken for a suicidal gesture. Many survivors of childhood abuse do indeed attempt suicide. There is a clear distinction, however, between repetitive self-injury and suicide attempts. Self-injury is intended not to kill but rather to relieve unbearable emotional pain, and many survivors regard it, paradoxically, as a form of self-preservation.
These three major forms of adaptation—the elaboration of dissociative defenses, the development of a fragmented identity, and the pathological regulation of emotional states—permit the child to survive in an environment of chronic abuse. Further, they generally allow the child victim to preserve the appearance of normality which is of such importance to the abusive family. The child’s distress symptoms are generally well hidden. Altered states of consciousness, memory lapses, and other dissociative symptoms are not generally recognized. The formation of a malignant negative identity is generally disguised by the socially conforming “false self.” Psychosomatic symptoms are rarely traced to their source. And self-destructive behavior carried out in secret generally goes unnoticed. Though some child or adolescent victims may call attention to themselves through aggressive or delinquent behavior, most are able successfully to conceal the extent of their psychological difficulties. Most abused children reach adulthood with their secrets intact.
The Child Grown Up
Almost inevitably, the survivor has great difficulty protecting herself in the context of intimate relationships. Her desperate longing for nurturance and care makes it difficult to establish safe and appropriate boundaries with others. Her tendency to denigrate herself and to idealize those to whom she becomes attached further clouds her judgment. Her empathic attunement to the wishes of others and her automatic, often unconscious habits of obedience also make her vulnerable to anyone in a position of power or authority. Her dissociative defensive style makes it difficult for her to form conscious and accurate assessments of danger. And her wish to relive the dangerous situation and make it come out right may lead her into reenactments of the abuse.
For all of these reasons, the adult survivor is at great risk of repeated victimization in adult life. The data on this point are compelling, at least with respect to women> The risk of rape, sexual harassment, or battering, though high for all women, is approximately doubled for survivors of childhood sexual abuse.
Perhaps because of their deeply inculcated self-loathing, survivors seem more disposed to direct their aggression as themselves. While suicide attempts and self-mutilation are strongly correlated with childhood abuse, the link between childhood abuse and adult antisocial behavior is relatively weak. A study of over 900 psychiatric patients found that while suicidality was strongly related to a history of childhood abuse, homicidality was not.
Chapter 6 – A New Diagonsis
Most people have no knowledge or understanding of the psychological changes of captivity. Social judgment of chronically traumatized people therefore tends to be extremely harsh. The chronically abused person’s apparent helplessness and passivity, her entrapment in the past, her intractable depression and somatic complaints, and her smoldering anger often frustrate the people closest to her. Moreover, if she has been coerced into betrayal of relationships, community loyalties, or moral values, she is frequently subjected to furious condemnation.
Observers who have never experienced prolonged terror and who have no understanding of coercive methods of control presume that they would show greater courage and resistance than the victim in similar circumstances. Hence the common tendency to account for the victim’s behavior by seeking flaws in her personality or moral character. Prisoners of war who succumb to “brainwashing” are often treated as traitors. Hostages who submit to their captors are often publicly excoriated. Sometimes survivors are treated more harshly than those who abused them. In the notorious case of Patricia Hearst, for instance, the hostage was tried for crimes committed under duress and received a longer prison sentence than her captors.
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.”
Need for a new Concept
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.
Complex Post-Traumatic Stress Disorders
1. A history of subjection to totalitarian control over a prolonged period (months 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.
2. Alterations in affect regulation, including
3. Alterations in consciousness, including
4. Alterations in self-perception, including
5. Alternations in perception of perpetrator, including
6. Alterations in relations with others, including
7. Alterations in systems of meaningful
Survivors as Psychiatric Patients
The mental health system is filled with survivors of prolonged, repeated childhood trauma. This is true even though most people who have been abused in childhood never come to psychiatric attention. To the extent that these people recover, they do so on their own. While only a small minority of survivors, usually those with the most sever abuse histories, eventually become psychiatric patients, many or event most psychiatric patients are survivors of childhood abuse. The data on this point are beyond contention. On careful questioning, 50-60 percent of psychiatric inpatients and 40-60 percent of outpatients report childhood histories of physical or sexual abuse or both. In one study of psychiatric emergency room patients, 70 percent had abuse histories. Thus abuse in childhood appears to be one of the main factors that lead a person to seek psychiatric treatment as an adult.
Patients with all three disorders also share characteristic difficulties in close relationships. Interpersonal difficulties have been described most extensively in patients with borderline personality disorder. Indeed, a pattern of intense, unstable relationships is one of the major criteria for making this diagnosis. Borderline patients find it very hard to tolerate being alone but tare also exceedingly wary of others. Terrified of abandonment on the one hand and of domination, on the other, they oscillate between extremes of clinging and withdrawal, between abject submissiveness and furious rebellion. They tend to form “special” relations with idealized caretakers in which ordinary boundaries are not observed. Psychoanalytic authors attribute this instability to failure of psychological development in the formative years of early childhood. One authority describes the primary defect in borderline personality disorder as a “failure to achieve object constancy,” that is, a failure to form reliable and well-integrated inner representations of trusted people. Another speaks of the “relative developmental failure in formation of introjects that provide to the self a function of holding-soothing security; that is, people with borderline personality disorder cannot calm or comfort themselves by calling up a mental image of a secure relationship with a caretaker.”
The common denominator of these three disorders is their origin in a history of childhood trauma. The evidence for this link ranges from definitive to suggestive. In the case of multiple personality disorder the etiological role of severe childhood trauma is at this point firmly established. In a study by the psychiatrist Frank Putnam of 100 patients with the disorder, 97 had histories of major childhood trauma, most commonly sexual abuse, physical abuse, or both. Extreme sadism and murderous violence were the rule rather than the exception in these dreadful histories. Almost half the patients had actually witnessed the violent death of someone close to them.
These three disorders might perhaps be best understood as variants of complex post-traumatic stress disorder, each deriving its characteristic features from one form of adaptation to the traumatic environment. The physioneurosis of post-traumatic stress disorder is the most prominent feature in somatization disorder, the deformation of consciousness is most prominent in multiple personality disorder, and the disturbance in identity and relationship is most prominent in borderline personlaity disorder. The overarching concept of a complex post-traumatic syndrome accounts for both the particularity of the three disorders and their interconnection. The formulation also reunites the descriptive fragments of the condition that was once called hysteria and reaffirms their common source in a history of psychological trauma.
Understanding the role of childhood trauma in the development of these severe disorders also informs every aspect of treatment. This understanding provides the basis for a cooperative therapeutic alliance that normalizes and validates the survivor’s emotional reactions to past events, while recognizing that these reactions may be maladaptive in the present. Moreover, a shared understanding of the survivor’s characteristic disturbances of relationship and the consequent risk of repeated victimization offers the best insurance against unwitting reenactments of the original trauma in the therapeutic relationship.
STAGES OF RECOVERY
Chapter 7 – A Healing Relationship
The core experiences of psychological trauma are disempowerment and disconnection from others. Recovery, therefore, is based upon the empowerment of the survivor and the creation of new connections. Recovery can take place only within the context of relationships; it cannot occur in isolation. In her renewed connections with other people, the survivor re-creates the psychological faculties that were damaged or deformed by the traumatic experience. These faculties include the basic capacities for trust, autonomy, initiative, competence, identity, and intimacy. Just as these capabilities are originally formed in relationships with other people, they must be reformed in such relationships.
The first principle of recovery is the empowerment of the survivor. She must be the author and arbiter of her own recovery. Others may offer advice, support, assistance, affection, and care, but not cure. Many benevolent and well-intentioned attempts to assist the survivor founder because this fundamental principle of empowerment is not observed. No intervention that takes power away from the survivor can possibly foster her recovery, no matter how much it appears to be in her immediate best interest. In the words of an incest survivor, “Good therapists were those who really validated my experience and helped me to control my behavior rather than trying to control me.”
The technical neutrality of the therapist is not the same as moral neutrality. Working with victimized people requires a committed moral stance. The therapist is called upon to bear witness to a crime. She must affirm a position of solidarity with the victim. This does not mean a simplistic notion that the victim can do no wrong; rather, it involves an understanding of the fundamental injustice of the traumatic experience and the need for a resolution that restores some sense of justice. This affirmation expresses itself in the therapist’s daily practice, in her language, and above all in her moral commitment to truth-telling without evasion or disguise.
The therapist’s role is both intellectual and relational, fostering both insight and empathic connection. Kardiner notes that “the central part of the therapy should always be to enlighten the patient” as to the nature and meaning of his symptoms, but at the same time “the attitude of the physician in treating these cases is that of the protecting parent. He must help the patient reclaim his grip on the outer world, which can never be done by a perfunctory, pill-dispensing attitude.”
Patients who suffer from a traumatic syndrome form a characteristic type of transference in the therapy relationship. Their emotional responses to any person in a position of authority have been deformed by the experience of terror. For this reason, traumatic transference reactions have an intense, life-or-death quality unparalleled in ordinary therapeutic experience. In Kernberg’s words, “It is as if the patient’s life depends on keeping the therapist under control.” Some of the most astute observations on the vicissitudes of traumatic transference appear in the classic accounts of the treatment of borderline personality disorder, written when the traumatic origin of the disorder was not yet known. In these accounts, a destructive force appears to intrude repeatedly into the relationship between therapist and patient. This force, which was traditionally attributed to the patient’s innate aggression, can now be recognized as the violence of the perpetrator. The psychiatrist Eric Lister remarks that the transference in traumatized patients does not reflect a simple dyadic relationship, but rather a triad: “The terror is as though the patient and therapist convene in the presence of yet another person. The third image is the victimizer, who…demanded silence and whose command is now being broken.”
Trauma is contagious. In the role of witness to disaster or atrocity, the therapist at times is emotionally overwhelmed. She experiences, to a lesser degree, the same terror, rage, and despair as the patient. This phenomenon is known as “traumatic countertransference” or “vicarious traumatization.” The therapist may begin to experience symptoms of post-traumatic stress disorder. Hearing the patient’s trauma story is bound to revive any personal traumatic experiences that the thearpist may have suffered in the past. She may also notice imagery associated with the patient’s story intruding into her own waking fantasies or dreams. In one case a therapist began to have the same grotesque nightmares as her patient, Arthur, a 35-year-old man who had been sadistically abused in childhood by his father:
Arthur told his therapist that he still feared his father, even though he had been dead for ten years. He felt that his father was watching him and could control him from beyond the grave. He believed that the only way to overcome his father’s demonic power was to unearth his body and drive a stake through his heart. The therapist began to have vivid nightmares of Arthur’s father entering her room in the form of a rotting disinterred body.
Krystal observes that the encounter with the traumatized patient forces therapists to come to terms with their own capacity for evil: “What we cannot own up to, we may have to reject in others. Thus, the friendly, compassionate attitude which one regards as most helpful may be replaced by anger, disgust, scorn, pity, or shame. The examiner who acts out his anger…is displaying a symptom of his own difficulty, as is the one who suffers from depression, or who has the need to overindulge or seduce the patient. What I have said is of course well known, but we must be especially alert to this problem in dealing with massively traumatized individuals…because of the extraordinary impact of their life stories.”
Finally, the therapist’s emotional reactions include not only those identified with victim and perpetrator but also those exclusive to the role of the unharmed bystander. The most profoudn and universal of these reactions is a form of “witness guilt,” similar to the patient’s “survivor guilt.” In therapists who treat survivors of the Nazi Holocaust, for example, guilt is the most common countertransference reaction.
Traumatic transference and countertransference reactions are inevitable. Inevitably, too, these reactions interfere with the development of a good working relationship. Certain protections are required for the safety of both participants. 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
The alliance between patient and therapist develops through shared work. The work of therapy is both a labor of love and a collaborative commitment. Though the therapeutic alliance partakes of the customs of everyday contractual negotiations, it is not a simple business arrangement. And though it evokes all the passions of human attachment, it is not a love affair or a parent-child relationship. It is a relationship of existential engagement, in which both partners commit themselves to the task of recovery.
From the outset, the therapist should place great emphasis on the importance of truth-telling and full disclosure, since the patient is likely to have many secrets, including secrets from herself. The therapist should make clear that the truth is a goal constantly to be striven for, and that while difficult to achieve at first, it will be attained more fully in the course of time. Patients are often very clear about the fundamental importance of a commitment to telling the truth. To facilitate therapy, one survivor advises therapists: “Make the truth known. Don’t participate in the cover-up. When they get that clear don’t let them sit down. It’s like being a good coach. Push them to run and then run their best time. It’s OK to relax at appropriate times, but it’s always good to let people see what their potential is.”
Decisions on limits are made based upon whether they empower the patient and foster a good working relationship, not on whether the patient ought to be indulged or frustrated. The therapist does not insist upon clear boundaries in order to control, ration, or deprive the patient. Rather, the therapist acknowledges from the outset that she is a limited, fallible human being, who requires certain conditions in order to remain engaged in an emotionally demanding relationship. As Patricia Ziegler, a therapist with long experience working with traumatized patients, puts it: “Patients have to agree not to drive me crazy. I tell them I’m sensitive to abandonment too—it’s the human condition. I say I’m invested in this treatment and I won’t leave you and I don’t want you to leave me. I tell them they owe me the respect not to scare the daylights out of me.”
The Therapist’s Support System
The dialectic of trauma constantly challenges the therapist’s emotional balance. The therapist, like the patient, may defend against overwhelming feelings by withdrawal or by impulsive, intrusive action. The most common forms of action are rescue attempts, boundary violations, or attempts to control the patient. The most common constrictive responses are doubting or denial of the patient’s reality, dissociation or numbing, minimization or avoidance of the traumatic material, professional distancing, or frank abandonment of the patient. Some degree of intrusion or numbing is probably inevitable. The therapist should expect to lose her balance from time to time with such patients. She is not infallible. The guarantee of her integrity is not her omnipotence but her capacity to trust others. The work of recovery requires a secure and reliable support system for the therapist.
By constantly fostering the capacity for integration, in themselves and their patients, engaged therapists deepen their own integrity. Just as basic trust is the developmental achievement of earliest life, integrity is the developmental achievement of maturity. The psychoanalyst Erik Erikson turns to Webster’s dictionary to illuminate the interconnection of integrity and basic trust: “Trust…is here defined as ‘the assured reliance on another’s integrity.’”
Integrity is the capacity to affirm the value of life in the face of death, to be reconciled with the finite limits of one’s own life and the tragic limitations of the human condition, and to accept these realities without despair. Integrity is the foundation upon which trust in relationships is originally formed, and upon which shattered trust may be restored. The interlocking of integrity and trust in caretaking relationships completes the cycle of generations and regenerates the sense of human community which trauma destroys.
Chapter 8 – Safety
Recovery unfolds in three stages. The central task of the first stage is the establishment of safety. The central task of the second stage is remembrance and mourning. The central task of the third stage is reconnection with ordinary life. Like any abstract concept, these stages of recovery are a convenient fiction, not to be taken too literally. They are an attempt to impose simplicity and order upon a process that is inherently turbulent and complex. But the same basic concept of recovery stages has emerged repeatedly, from Janet’s classic work on hysteria to recent descriptions of work with combat trauma, dissociative disorders, and multiple personality disorder. Not all observers divide their stages into three; some discern five, others as many as eight stages in the recovery process. Nevertheless, there is a rough congruence in these formulations. A similar progression of recovery can be found across the spectrum of the traumatic syndromes. No single course of recovery follows these stages through a straightforward linear sequence. Oscillating and dialectical in nature, the traumatic syndromes defy any attempt to impose such simpleminded order. In fact, patients and therapists alike frequently become discouraged when issues that have supposedly been put to rest stubbornly reappear. One therapist describes the progression through the stages of recovery as a spiral, in which earlier issues are continually revisited on a higher level of integration. However, in the course of a successful recovery, it should be possible to recognize a gradual shift from unpredictable danger to reliable safety, from dissociated trauma to acknowledged memory, and from stigmatized isolation to restored social connection.
Stages of Recovery
Stabilization, symptom-oriented treatment
Exploration of traumatic memories
Personality reintegration, rehabilitation
Trust, stress-management, education
Integration of trauma
Complicated post-traumatic stress disorder
(Brown & Fromm 1986)
Integration of memories
Development of self, drive integration
Multiple personality disorders
Diagnosis, stabilization, communication, cooperation
Metabolism of trauma
Resolution, integration, development of postresolution coping skills
Remembrance and mourning
Naming the Problem
With patients who have suffered prolonged, repeated trauma, the matter of diagnosis is not nearly so straightforward. Disguised presentations are common in complex post-traumatic stress disorder. Initially the patient may complain only of physical symptoms, or of chronic insomnia or anxiety, or of intractable depression, or of problematic relationships. Explicit questioning is often required to determine whether the patient is presently living in fear of someone’s violence or has lived in fear at some time in the past. Traditionally these questions have not been asked. They should be a routine part of every diagnostic evaluation.
The traumatized person is often relieved simply to learn the true name of her condition. By ascertaining her diagnosis, she begins to process the mastery. No longer imprisoned in the wordlessness of the trauma, she discovers that there is a language for her experience. She discovers that she is not alone; others have suffered in similar ways. She discovers further that she is not crazy; the traumatic syndromes are normal human responses to extreme circumstances. And she discovers, finally, that she is not doomed to suffer this condition indefinitely; she can expect to recover as others have recovered.
Often it is necessary for the therapist to reframe accepting help as an act of courage. Acknowledging the reality of one’s condition and taking steps to change it become signs of strength, not weakness; initiative, not passivity. Taking action to foster recovery, far from granting victory to the abuser, empowers the survivor. The therapist may need to state this view explicitly and in detail, in order to address the feelings of shame and defeat that prevent the survivor from accepting the diagnosis and seeking treatment.
Trauma robs the victim of a sense of power and control; the guiding principle of recovery is to restore power and control to the survivor. The first task of recovery is to establish the survivor’s safety. This task takes precedence over all others, for no other therapeutic work can possibly succeed if safety has not been adequately secured. No other therapeutic work should even be attempted until a reasonable degree of safety has been achieved. This initial stage may last days to weeks with acutely traumatized people or months to years with survivors of chronic abuse. The work of the first stage of recovery becomes increasingly complicated in proportion to the severity, duration, and early onset of abuse.
Establishing a Safe Environment
From control of the body, the focus on safety progresses to control of the environment. The acutely Trust, stress-management, educationtraumatized person needs a safe refuge. Finding and securing that refuge is the immediate task of crisis intervention. In the first days or weeks following an acute trauma, the survivor may want to seclude herself in her home, or she may not be able to go home at all. If the perpetrator of the trauma is a family member, home may be the most unsafe place she can choose. Crisis intervention may require a literal flight to shelter. Once the traumatized person has established a refuge, she can gradually progress toward a widening sphere of engagement in the world. It may take weeks to feel safe in resuming such ordinary activities as driving, shopping, visiting friends, or going to work. Each new environment must be scanned and assessed with regard to its potential for security or danger.
Though the survivor may make a rapid and dramatic return to the appearance of normal functioning, this symptomatic stabilization should not be mistaken for full recovery, for the integration of the trauma has not been accomplished.
In this case, creating a safe environment required the patient to make major changes in her life. It entailed difficult choices and sacrifices. This patient discovered, as many others have done, that she could not recover until she took charge of the material circumstances of her life. Without freedom, there can be no safety and no recovery, but freedom is often achieved at great cost. In order to gain their freedom, survivors may have to give up almost everythingTrust, stress-management, education else. Battered women may lose their homes, their friends, and their livelihood. Survivors of childhood abuse may lose their families. Political refugees may lose their homes and their homeland. Rarely are the dimensions of this sacrifice fully recognized.
Completing the First Stage
Because the tasks of the first stage of recovery are arduous and demanding, patient and therapist alike frequently try to bypass them. It is often tempting to overlook the requirements of safety and to rush headlong into the later stages of therapeutic work. Though the single most common therapeutic error is avoidance of the traumatic material, probably the second most common error is premature or precipitate engagement in exploratory work, without sufficient attention to the tasks of establishing safety and securing a therapeutic alliance.
At this point, especially after a single acute trauma, the survivor may wish to put the experience out of mind for a while and get on with her life. And she may succeed in doing so for a time. Nowhere is it written that the recovery process must follow a linear, uninterrupted sequence. But traumatic events ultimately refuse to be put away. At some point the memory of the trauma is bound to return, demanding attention. Often the precipitant is a significant reminder of the trauma—an anniversary, for instance—or a change in the survivor’s life circumstances that brings her back to the unfinished work of integrating the traumatic experience. She is then ready to embark upon the second stage of recovery.
Chapter 9 – Remembrance and Mourning
In the second stage of recovery, the survivor tells the story of trauma. She tells it completely, in depth, and in detail. This work of reconstruction actually transforms the traumatic memory, so that it can be integrated into the survivor’s life story. Janet described normal memory as “the action of telling a story.” Traumatic memory, by contras, is wordless and static. The survivor’s initial account of the event may be repetitious, stereotyped, and emotionless. One observer describes the trauma story in its untransformed state as a “prenarrative.” It does not develop or progress in time, and it does not reveal the storyteller’s feelings or interpretation of events. Another therapist describes traumatic memory as a series of still snapshots or a silent movie; the role of therapy is to provide the music and words.
The basic principle of empowerment continues to apply during the second stage of recovery. The choice to confront the horrors of the past rests with the survivor. The therapist plays the role of a witness and ally, in whose presence the survivor can speak of the unspeakable.
Reconstructing the Story
Reconstructing of the trauma story begins with a review of the patient’s life before the trauma and the circumstances that led up to the event. Yael Danieli speaks of the importance of reclaiming the patient’s earlier history in order to “re-create the flow” of the patient’s life and restore a sense of continuity with the past. The patient should be encouraged to talk about her important relationships, her ideals and dreams, and her struggles and conflicts prior to the traumatic event. This exploration provides a context within which the particular meaning of the trauma can be understood.
The next step is to reconstruct the traumatic event as a recitation of fact. Out of the fragmented components of frozen imagery and sensation, patient and therapist slowly reassemble an organized, detailed, verbal account, oriented in time and historical context. The narrative includes not onlyh the event itself but also the survivor’s response to it and the responses of the important people in her life. As the narrative closes in on the most unbearable moments, the patient finds it more and more difficult to use words. At times the patient may spontaneously switch to nonverbal methods of communication, such as drawing or painting. Given the “iconic,” visual nature of traumatic memories, creating pictures may represent the most effective initial approach to these “indelible images.” The completed narrative must include a full and vivid description of the traumatic imagery.
Both patient and therapist must develop tolerance for some degree of uncertainty, even regarding the basic facts of the story. In the course of reconstruction, the story may change as missing pieces are recovered. This is particularly true in situations where the patient has experienced significant gaps in memory. Thus, both patient and therapist must accept the fact that they do not have complete knowledtge, and they must learn to live with ambiguity while exploring at a tolerable pace.
It is understandable for both patient and therapist to wish for a magic transformation, a purging of the evil of the trauma. Psychotherapy, however, does not get rid of the trauma. The goal of recounting the trauma story is integration, not exorcism. In the process of reconstruction, the trauma story does undergo a transformation, but only in the sens3e of becoming more present and more real. The fundamental premise of the psychotherapeutic work is a belief in the restorative power of truth-telling.
Transforming Traumatic Memory
Therapeutic techniques for transforming the trauma story have developed independently for many different populations of traumatized people. Two highly evolved techniques are the use of “direct exposure” or “flooding” in the treatment of combat veterans and use of formalized “testimony” in the treatment of survivors of torture.
The flooding technique is part of an intensive program, developed within the Veterans’ Administration, for treating post-traumatic stress disorder. It is a behavioral therapy designed to overcome the terror of the traumatic event by exposing the patient to a controlled reliving experience. In preparation for the flooding session, the patient is taught how to manage anxiety by using relaxation techniques and by visualizing soothing imagery.
In addition to hypnosis, many other techniques can be used to produce an altered state of consciousness in which dissociated traumatic memories are more readily accessible. These range from social methods, such as intensive group therapy or psychodrama, to biological methods, such as the use of sodium amytal. In skilled hands, any of these methods can be effective. Whatever the technique, the same basic rules apply: the lotus of control remains with the patient, and the timing, pacing and design of the sessions must be carefully planned so that the uncovering technique is integrated into the architecture of the psychotherapy.
Mourning Traumatic Loss
Trauma inevitably brings loss. Even those who are lucky enough to escape physically unscathed still lose the internal psychological structures of a self securely attached to others. Those who are physically harmed lose in addition their sense of bodily integrity. And those who lose important people in their lives face a new void in their relationships with friends, family, or community. Traumatic losses rupture the ordinary sequence of generations and defy the ordinary social conventions fo bereavement. The telling of the trauma story thus inevitably plunges the survivor into profound grief. Since so many of the losses are invisible or unrecognized, the customary rituals of mourning provide little consolation.
Like revenge, the fantasy of forgiveness often becomes a cruel torture, because it remains out of reach for most ordinary human beings. Folk wisdom recognizes that to forgive is divine. And even divine forgiveness, in most religious systems, is not unconditional. True forgiveness cannot be granted until the perpetrator has sought and earned it through confession, repentance, and restitution.
The best way the therapist can fulfill her responsibility to the patient is by faithfully bearing witness to her story, not by infantilizing her or granting her special favors. Though the survivor is not responsible for the injury that was done to her, she is responsible for her recovery. Paradoxically, acceptance of this apparent injustice is the beginning of empowerment. The only way that 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.
Leonard Shengold poses the central question at this stage of mourning: “Without the inner picture of caring parents, how can one survive? … Every soul-murder victim will be wracked by the question ‘Is there life without father and mother?’”
The reconstruction of the trauma is never entirely completed; new conflicts and challenges at each new stage of the lifecycle will inevitably reawaken the trauma and bring some new aspect of the experience to light. The major work of the second stage is accomplished, however, when the patient reclaims her own history and feels renewed hope and energy for engagement with life. Time starts to move again. When the “action of telling a story” has come to its conclusion, the traumatic experience truly belongs to the past. At this point, the survivor faces the tasks of rebuilding her life in the present and pursuing her aspirations for the future.
Chapter 10 – Reconnection
Having come to terms with the traumatic past, the survivor faces the task of creating a future. She has mourned the old self that the trauma destroyed; now she must develop a new self. Her relationships have been tested and forever changed by the trauma; now she must develop new relationships. The old beliefs that gave meaning to her life have been challenged; now she must find anew a sustaining faith. These are the tasks of the third stage of recovery. In accomplishing this work, the survivor reclaims her world.
Survivors whose personality has been shaped in the traumatic environment often feel at this stage of recovery as though they are refugees entering a new country. For political exiles, this may be literally true; but for many others, such as battered women or survivors of childhood abuse, the psychological experience can only be compared to immigration. They must build a new life within a radically different culture from the one they have left behind. Emerging from an environment of total control, they feel simultaneously the wonder and uncertainty of freedom. They speak of losing and regaining the world. The psychiatrist Michael Stone, drawing on his work with incest survivors, describes the immensity of his adaptive task: “All victims of incest have, by definition, been taught that the strong can do as they please, without regard for conversation. … Re-education is often indicated, pertaining to what is typical, average, wholesome, and ‘normal’ in the intimate life of ordinary people. Victims of incest tend to be woefully ignorant of these matters, owing to their skewed and secretive early environments. Although victims in their original homes, they are like strangers in a foreign country, once ‘safely’ outside.
Learning to Fight
Reconciling with Oneself
This simple statement—“I know I have myself”—could stand as the emblem of the third and final stage of recovery. The survivor no longer feels possessed by her traumatic past; she is in possession of herself. She has some understanding of the person she used to be and of the damage done to that person by the traumatic event. Her task now is to become the person she wants to be. In the process she draws upon those aspects of herself that she most wants to be. In the process she draws upon those aspects of herself that she most values from the time before the trauma, from the experience of the trauma itself, and from the period of recovery. Integrating all of these elements, she creates a new self, both ideally and in actuality.
The re-creation of an ideal self involves the active exercise of imagination and fantasy, capacities that have now been liberated. In earlier stages, the survivor’s fantasy life was dominated by repetitions of the trauma, and her imagination was limited by a sense of helplessness and futility. Now she has the capacity to revisit old hopes and dreams. The survivor may initially resist doing so, fearing the pain of disappointment. It takes courage to move out of the constricted stance of the victim. But just as the survivor must dare to confront her fears, she must also dare to define her wishes.
Reconnecting with Others
Finding a Survivor Mission
Most survivors seek the resolution of their traumatic experience within the confines of their personal lives. But a significant minority, as a result of the trauma, feel called upon to engage in a wider world. These survivors recognize a political or religious dimension in their misfortune and discover that they can transform the meaning of their personal tragedy by making it the basis for social action. While there is no way to compensate for an atrocity, there is a way to transcend it, by making it a gift to others. The trauma is redeemed only when it becomes the source of a survivor mission.
Social action offers the survivor a source of power that draws upon her own initiative, energy, and resourcefulness but that magnifies these qualities far beyond her own capacities. It offers her an alliance with others based on cooperation and shared purpose. Participation in organized demanding social efforts calls upon the survivor’s most mature and adaptive coping strategies of patience, anticipation, altruism, and humor. It brings out the best in her; in return, the survivor gains the sense of connection with the best in other people. In the sense of reciprocal connection, the survivor can transcend the boundaries of her particular times and place. At times the survivor may even attain a feeling of participation in an order of creation that transcends ordinary reality.
When a crime has been committed, in the words of Hannah Arendt, “The wrongdoer is brought to justice because his act has disturbed and gravely endangered the community as a whole. … It is the body politic itself that stand in need of being repaired, and it is the general public order that has been thrown out of gear and must be restored. … It is, in other words, the law, not the plaintiff, that must prevail.”
Resolving the Trauma
Resolution of the trauma is never final; recovery is never complete. The impact of a traumatic event continues to reverberate throughout the survivor’s lifecycle. Issues that were sufficiently resolved at one stage of recovery may be reawakened as the survivor reaches new milestones in her development. Marriage or divorce, a birth or death in the family, illness or retirement, are frequent occasions for a resurgence of traumatic memories. For example, as the fighters and refugees of the Second World War encounter the losses of old age, they experience a revival of post-traumatic symptoms.
The psychologist Mary Harvey defines seven criteria for the resolution of trauma. First, the physiological symptoms of post-traumatic stress disorder have been brought within manageable limits. Second, the person is able to bear the feelings associated with traumatic memories. Third, the person has authority over her memories: she can elect both to remember the trauma and to put memory aside. Fourth, the memory of the traumatic event is a coherent narrative, linked with feeling. Fifth, the person’s damaged self-esteem has been restored. Sixth, the person’s important relationships have been reestablished. Seventh and finally, the person has reconstructed a coherent system of meaning and belief that encompasses the story of the trauma. In practice, all of these issues are interconnected, and all are addressed at every stage of recovery.
Chapter 11 – Commonality
Traumatic events destroy the sustaining bonds between individual and community. Those who have survived learn that their sense of self, of worth, of humanity, depends upon a feeling of connection to others. The solidarity of a group provides the strongest protection against terror and despair, and the strongest antidote to traumatic experience. Trauma isolates; the group re-creates a sense of belonging. Trauma shames and stigmatizes; the group bears witness and affirms. Trauma degrades the victim; the group exalts her. Trauma dehumanizes the victim; the group restores her humanity.
Groups for Safety
Groups are rarely the first resource to consider in the immediate aftermath of a traumatic event. The survivor of a recent acute trauma is usually extremely frightened and flooded with intrusive symptoms, such as nightmares and flashbacks. Crisis intervention focuses on mobilizing the supportive people in the survivor’s environment, for she usually prefers to be with familiar people than with strangers. This is not the time for a group. Though in theory the survivor may feel comforted by the notion that she is not alone in her experience, in practice she may feel overwhelmed by a group. Hearing the details of others’ experiences may trigger her own intrusive symptoms to such a degree that she is able neither to listen empathically nor to accept emotional support. Accordingly, for survivors of an acute trauma, a waiting period of weeks or months is generally recommended from the time of the trauma until time of entry into a group.
Groups for Remembering and Mourning
One model of a trauma-focused group is found in the incest survivors’ groups developed by myself and Emily Schatzow. This model has an inner logic and consistency that lends itself to broad replication. It has two essential structural features: a time limit and a focus on personal goals. The time limit serves several purposes. It establishes the boundaries for carrying out a carefully defined piece of work. It fosters a climate of high emotional intensity while assuring participants that the intensity will not last forever. And it promotes rapid bonding with other survivors while discouraging the development of a limited, exclusive survivor identity. The exact length of the time limit is less important than the fact of its existence.
A trauma-focused group requires active, engaged leadership. Leaders are responsible for defining the group task, creating a climate of safety, and ensuring that all group members are protected. The role of the group leader is emotionally demanding, because the leader must set an example of bearing witness. She must demonstrate to the group members that she can hear their stories without becoming overwhelmed. Most group leaders discover that they are no more capable than anyone else of doing this alone. For this reason, shared leadership is advisable.
This dialogue illustrates how group members help each other to bear the terror and confusion of recovering traumatic memories. Similarly, group members can help one another to bear the pain of mourning. The presence of other group members as witnesses makes it possible for each member to express grief that would be too overwhelming for a lone individual. As the group shares mourning, ti simultaneously fosters the hope for new relationships. Groups lend a kind of formality and ritual solemnity to individual grief; they help the survivor at once to pay homage to her losses in the past and to repopulate her life in the present.
Groups for Reconnection
Whereas trauma-focused groups are usually time-limited, interpersonal groups are typically open-ended, with a stable, slowly evolving membership. Whereas trauma-focused groups are highly structured, with an active leadership, interpersonal groups are relatively unstructured, with a more permissive leadership style. Matters such as time-sharing, which are structured by a leader in the trauma-focused group, are settled by negotiation among group members in an ongoing psychotherapy group. Finally, while trauma-focused groups discourage conflict among members, interpersonal groups allow an encourage such conflict to develop, within safe limits. This conflict is in fact essential to the therapeutic task, for it is through understanding and resolution of conflict that insight and change occur. The feedback, both supportive and critical, that each member receives from others is a powerful therapeutic agent.
Afterword – the Dialectic of Trauma Continues
Some of the most exciting recent advances in the field derive from highly technical laboratory studies of the biologic aspects of PTSD. It has become clear that traumatic exposure can produce lasting alterations in the endocrine, autonomic, and central nervous systems. New lines of investigation are delineating complex changes n the regulation of stress hormones, and in the function and even the structure of specific areas of the brain. Abnormalities have been found particularly in the amygdala and the hippocampus, brain structures that create a link between fear and memory.
Preliminary results of brain scanning studies of patients with PTSD, using the sophisticated technique of positron emission tomography, suggest that during flashbacks, specific areas of the brain involved with language and communication may indeed be inactivated.
Insight into the recovery process may also be gained by drawing upon the wisdom of the majority of trauma survivors worldwide, who never get formal treatment of any kind. To the extend that they recover, most survivors must invent their own methods, drawing on their individual strengths and the supportive relationships naturally available to them in their own communities. Systematic studies of resilience in untreated survivors hold great promise for developing more effective and widely adaptable methods of therapeutic intervention. The search for simple and reproducible models of intervention has now become an international, cross-cultural project, as part of a growing effort to mount an international response to outbreaks of war and mass violence.
In addition, establishing any lasting peace requires an organized effort to hold individual perpetrators accountable for their crimes. At the very least, those responsible for the worst atrocities must be brought before the law. If there is no hope of justice, the helpless rage of victimized groups can fester, impervious to the passage of time. Demagogic political leaders well understand the power of this rage, and are only too willing to exploit it by offering to an aggrieved people the promise of collective revenge. Like traumatized individuals, traumatized countries need to remember, grieve, and atone for their wrongs in order to avoid reliving them.
Some attacks have been downright silly; many have been quite ugly. Though frightening, these attacks are an implicit tribute to the power of healing relationships. They remind us that creating a protected space where survivors can speak their truth is an act of liberation. They remind us that bearing witness, even within the confines of that sanctuary, is an act of solidarity. They remind us also that moral neutrality in the conflict between victim and perpetrator is not an option. Like all other bystanders, therapists are sometimes forced to take sides. Those who stand with the victim will inevitably have to face the perpetrator’s unmasked fury. For many of us, there can be no greater honor.