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

Session 8Recovery from psychological trauma

JUDITH L, HERMAN, MDDepartment of Psychiatry. Harvard Medical School. Boston, and Victims of Violence Program. The CambridgeHospital. Cambridge. Massachusetts. USA

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

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

The core experiences of psychological trautna are dis-empowerment and disconnection from others.' Re-covery therefore is based upon etnpowennent of thesurvivor and the creation of new connections. Recoveryean take place only within the context of relationships;it cannot occur in isolation. In renewed connectionswith other people, the survivor recreates the psycho-logical faculties that were damaged or deformed by thetrautnatic experience. These iticlude the basic capacitiesfor trust, autonomy, initiative, competence, identity,and intimacy," Just as these capabilities are originallyformed, they must be re-formed in relationships withother people.

Trauma robs the victim of a sense of power andcontrol over her own life; therefore, the guiding prin-ciple of recovery is to restore power and control to thesurvivor,'' She must be the author and arbiter of her ownrecovery. Others may offer advice, support, assistance,affection, and care, but not cure. Many benevolent andwell-intentioned atternpts to assist the survivor founderbecause this fundamental principle of empowerment isnot observed. No intervetition that takes power awayfrom the survivor can possibly foster her recovery, nomatter how much it appears to be in her immediate bestinterest. Caregivers schooled in a medical model oftreatment often have difficulty grasping this funda-mental principle and putting it into practice.

Correspondence address: Judith L, Herman, MD. Department ofPsychiatry. The Cambridge Hospital. 1493 Cambridge St, Cam-bridge, MA 02139, USA,

With trauma survivors, the therapeutic alliance can-not be taken for granted but must be painstakinglybuilt,"* Psychotherapy requires a collaborative workingrelationship m which both partners act on the basis oftheir implicit confidence in the value and efficacy o['persuasion rather than coercion, ideas rather force,mutual cooperatioti rather than authoritarian control.These are precisely the beliefs that have been shatteredby the traumatic experience,^ Trauma damages thepatient's ability to enter into a trusting relationship; italso has an indirect but very powerful itnpact on thetherapist. As a result, both patient and therapist willhave predictable difficulties coming to a working alli-ance. These difficulties must be understood and antic-ipated from the outset.

Trauma is contagious. In the role of witness to dis-aster or atrocity, the therapist at times is emotionallyoverwhelmed. She experiences, to a lesser degree, thesame terror, rage, and despair as the patient. Thisphenomenon is known as "vicarious traumatization",''The therapist may begin to experience intrusive,numbing, or hyperarousal symptotns. Hearing the pa-tient's trauma story is also likely revive strong feelingsconnected with any personal trautnatic experiences thatthe therapist may have suffered in the past.

The therapist, like the patient, may defend againstoverwhelming feelings by withdrawal or by impulsive,intrusive action. The most common forms of action arerescue attempts, boundary violations, or attempts tocontrol the patient. The tnost comtnon constrictive re-sponses are doubting or denial of the patient's reality.

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dissociation or numbing, minimization or avoidance ofthe traumatic material, professional distancing, orfrank abandonment of tbe patient.^ The therapistshould expeet to lose balance from time to time. She isnot infallible. The guarantee of her integrity is not heromnipotence but ber capacity to trust others. Thera-pists who work with traumatized people require anongoing support system. Just as no survivor can re-cover alone, no therapist can work with trauma alone.

Ideally, the therapist's support system should includea safe, structured, and regular forum for reviewing herclinical work. This might be a supervisory relationshipor a peer support group, preferably both. The settingmust offer permission to express emotional reactions aswell as technical or intellectual concerns related to thetreatment of patients with histories of trauma. In ad-dition to professional support, the therapist mustattend to the balance in her own professional andpersonal life, paying respectful attention to her ownneeds. Confronted with the daily reality of patients inneed of care, the therapist is in constant danger ofprofessional overcommitment. The role of professionalsupport is not simply to focus on the tasks of treatmentbut also to remind the therapist of her own realisticlimits and to insist that she take as good care of herselfas she does of others.

The therapist who commits herself to working withsurvivors commits herself to an ongoing contentionwith herself, in which she must rely on the help ofothers and call upon her most mature coping abilities.Sublimation, altruism, and humor are the therapist'ssaving graces. In the words of one disaster reliefworker, 'To tell the truth, the only way me and myfriends found to keep sane was to joke around and keeplaughing. The grosser the joke the better'.^ The rewardof engagement is the sense of an enriched life. Thera-pists who work with survivors report appreciatmg lifemore fully, taking life more seriously, having a greaterscope of understanding of others and themselves,foraiing new friendships and deeper intimate relation-ships, and feeling inspired by the daily examples oftheir patients' courage, determination, and hope.*^

The traumatic syndromes are complex disorders,requiring complex treatment. Because trauma affectsevery aspect of human functioning, treatment must becomprehensive. At each stage of recovery, treatmentmust address the characteristic biological, psychologi-cal, and social components of the disorder. Well-designed biological treatments, for example, may beunsuccessful if the social dimensions of the patient'straumatic experience are not addressed. Conversely,even excellent social support may be ineffective if thepatient's psychophysiologic disturbance remains un-

treated. There is no single, efficacious "magic bullet forthe traumatic syndromes.

The therapist's first task is to conduct a thoroughand informed diagnostic evaluation, with full aware-ness of the many disguises in which a traumatic disor-der may appear. With patients who have suffered arecent acute trauma, the diagnosis is usually fairlystraightforward. In these situations clear, detailed in-formation regarding posttraumatic reactions is ofteninvaluable to the patient and her family or friends. Ifthe patient is prepared for the symptoms, she will be farless frightened when they occur. If she and those closestto her are prepared for the disruptions in relationshipthat follow upon trautnatic experience, they will be farmore able to take them in their stride. Furthermore, ifthe patient is offered advice on adaptive coping strat-egies and warned against common mistakes, her senseof competence and efficacy will be immediately en-hanced. Working with survivors of a recent acutetrauma offers therapists an excellent opportunity forpreventive education.

With patients who have suffered prolonged, repeatedtrauma, the matter of diagnosis is not nearly sostraightforward. Disguised presentations are commonin complex posttraumatic stress disorder (PTSD).'"Initially the patient may complain only of physicalsymptoms, or of chronic insomnia or anxiety, or ofintractable depression, or of problematic relationships.Fxplicit questioning is often required to determinewhether the patient is presently living in fear of some-one's violence or has lived in fear in the past. Tradi-tionally these questions have rarely been asked. Theyshould be a routine part of every diagnostic evaluation.

If the therapist believes the patient is suffering from atraumatic syndrome, she should share this informatiotifully with the patient. Knowledge is power. The trau-matized person is often relieved simply to learn the truename of her condition. By ascertaining her diagnosis,she begins the process of mastery. No longer impris-oned in the wordlessness of the trauma, she discoversthat there is a language for her experience. She dis-covers that she is not alone; others have suffered insimilar ways. She discovers further that she is not crazy;the traumatic syndromes are normal human responsesto extreme circumstances. And she discovers, finally,that she is not doomed to suffer this condition indefi-nitely; she can expect to recover, as others have re-covered.

Recovery unfolds in three stages. The central task ofthe first stage is the establishment of safety. The centraltask of the second stage is remembrance and mourning.The central task of the the third stage is reconnectionwith ordinary life. Treatment must be appropriate to

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the patient's stage of recovery, A form of therapy thatmay be useful at one stage may be of little use or evenharmful to the same patient at another stage.

The first task of recovery is to establish the survivor'ssafety. This task takes precedetice over all others, forno other therapeutic work can possibly succeed if safetyhas not been adequately secured. No other therapeuticwork should even be attempted until a reasonable de-gree of safety has been achieved. This initial stage tnaylast days to weeks with acutely traumatized people ormonths to years with survivors of chronic abuse. Thework of the first stage of recovery becomes increasinglycotnplicated in proportion to the severity, duration,and early onset of abuse.

Establishing safety begins by focusing on control ofthe body and gradually moves outward toward controlof the environment. Survivors ofteti feel unsafe in theirbodies. Their emotions and their thinking feel out ofcontrol. Issues of bodily integrity include attention tobasic health needs, regulation of bodily futictions suchas sleep, eating, and exercise, management of post-traumatic symptoms, and abstinence from substanceabuse,

Environtnental issues include the establishtnent of asafe living situation, financial security, mobility, and aplan for self-protection that encompasses the full rangeof the patient's daily life. Securing a safe environmentrequires strategic attention to the patient's economicand social ecosystem. The patient must become awareof her own resources for practical and etnotional sup-port as well as the realistic dangers and vulnerabilitiesin her social situation. Many patients are unable tomove forward in their recovery because of their presentinvolvement in unsafe or oppressive relationships. Inorder to gain their autonomy and their peace of mind,survivors tnay have to make difficult and painful lifechoices. Battered women may lose their homes, theirfriends, and their hvelihood. Survivors of childhoodabuse may lose their fatnilies. Political refugees maylose their homes and their homeland. The social ob-stacles to recovery are not generally recognized, butthey must be identified and adequately addressed inorder for recovery to proceed.

With survivors of prolonged, repeated trauma, theinitial stage of recovery may be protracted and difficultbecause of the degree to which the traumatized personhas become a danger to herself. The sources of dangermay include active self-harm, passive failures of self-protection, and pathological dependency on the abuser.Self-care is altnost always severely disrupted. Self-harming behavior may take numerous forms, includingchronic suicidality, self-mutilation, eating disorders,substance abuse, impulsive risk-taking, and repetitive

involvetnent in exploitative or dangerous relationships.Many self-destructive behaviors can be understood assymbolic or literal re-enactments of the initial abuse.They serve the function of regulating intolerable feelingstates, in the absence of more adaptive self-soothingstrategies. The patient's capacities for self-care and self-soothing must be painstakingly reconstructed in thecourse of long-tenn individual and/or group treatment.Biologic, behavioral, cognitive, interpersonal, and so-cial therapeutic tnodalities have all shown promise withsome patients; each patient should be encouraged todevelop a personal repertoire of coping strategies.

When safety and a secure therapeutic alliance areestablished, the second stage of recovery has beenreached. The survivor is now ready to tell the story ofthe trautna, in depth and in detail. This work ofreconstruction actually transfonns the traumaticmemory, so that it can be integrated into the survivor'slife story," The basic principle of empowerment con-tinues to apply during the second stage of recovery. Thechoice to confront the horrors of the past rests with thesurvivor. The therapist plays the role of a witness andally, in whose presence the survivor can speak of theutispeakable. Out of the fragmented components offrozen imagery and sensation, patient and therapistslowly reassemble an organized, detailed, verbal ac-count, oriented in time and in its historical context. Thenarrative includes not only the event itself but also thesurvivor's emotional response to it and the responses ofthe important people in her life.

As the survivor summons her tnemories. the need topreserve safety tnust be balaticed constantly against theneed to face the past. The patient and therapist togethermust learn to negotiate a safe passage between the twindatigers of constriction and intrusion. Avoiding thetrautnatic memories leads to stagnation in the recoveryprocess, while approaching thetn too precipitouslyleads to a fruitless and datnaging reliving of the trautna.Decisions regarding pacing and timing need tneticulousattention and frequent review by patient and therapistin concert. The patient's intrusive symptoms shouldbe monitored carefully so that the uticovering workremains bearable.

Because the truth is so difficult to face, survivorsoften vacillate in reconstructing their stories. Denial ofreality tnakes thetn feel crazy, but acceptance of the fullreality seems beyond what any hutnan being can bear.Both patient and therapist must develop tolerance forsome degree of uncertainty, even regarding the basicfacts of the story. In the course of reconstruction, thestory may change as missing pieces are recovered. Thisis particularly true in situations where the patient hashad significant gaps in tnemory. Thus both patient and

S148 J. L. Herman

therapist must accept the fact that they do not havecomplete knowledge, and they must learn to live withambiguity while exploring at a tolerable pace.

In order to develop a full understanding of the traumastory, the survivor must examine the moral questions ofguilt and responsibility and reconstruct a system ofbelief that makes sense of her undeserved suffering. Themoral stance of the therapist is therefore of enormousimportance. It is not enough for the therapist to be'neutral' or 'non-judgmental'. The patient challengesthe therapist to share her own struggles with these im-mense philosophical questions. The therapist's role isnot to provide ready-made answers, which would beimpossible in any case, but rather to affirm a position ofmoral solidarity with the survivor.'"

The telling of the trauma story inevitably plunges thesurvivor into profound grief. The descent into mourn-ing is a necessary but dreaded part of the recoveryprocess. Patients often fear that the task is insur-mountable, that once they allow themselves to startgrieving, they will never stop. Survivors of prolongedchildhood trauma face the task of grieving not only forwhat was lost but also for what was tiever theirs to lose.The childhood that was stolen from them is irreplace-able. They must mourn the loss of the foundation ofbasic trust, the belief in a good parent. As they come torecognize that they were not responsible for their fate,they confront the existential despair that they could notface in childhood.'"^

Grieving has an additional meaning for survivorswho have themselves harmed or abandoned others. Thecombat veteran who has committed atrocities may feelhe no longer belongs in a civilized community. Thepolitical prisoner who has betrayed others under duressor the battered woman who has failed to protect herchildren may feel she has committed a worse crime thanthe perpetrator. Although the survivor may come tounderstand that these violations of relationship werecommitted under extreme circumstances, this under-standing by itself does not fully resolve her profoundfeelings of guilt and shame. The survivor needs tomourn for the loss of her moral integrity and to find herown way to atone for what cannot be undone. Thisrestitution in no way exonerates the perpetrator of hiscrimes; rather, it reaffirms the survivor's claim to moralchoice in the present.''*

The confrontation with despair brings with it, at leasttransiently, an increased risk of suicide. In contrast tothe impulsive self-destructiveness of the first stage ofrecovery, the patient's suicidality during this secondstage may evolve from a calm, flat, apparently rationaldecision to reject a world where such horrors are pos-sible. Patients may engage in sterile philosophical dis-cussions about their riaht to choose suicide. It is

imperative to get beyond this intellectual defense andengage the feelings and fantasies that fuel the patient'sdespair. Commonly, the patient has the fantasy that sheis already among the dead, because her capacity forlove has been destroyed. What sustains the patientthrough this descent into despair is the smallest evi-dence of an ability to form loving connections.

The second stage of recovery has a timeless qualitythat is very frightening. The reconstruction of thetrauma requires immersion in a past experience offrozen time; the descent into mourning feels like asurrender to endless tears. Patients often ask how longthis painful process will last. There is no fixed answer tothe question, only the assurance that the process cannotbe bypassed or hurried. It will almost surely take longerthan the patient wishes, but that it will not go on for-ever. After many repetitions, the moment comes whenthe telling of the trauma story no longer arouses quitesuch intense feeling. It has become a part of the sur-vivor's experience, but only one part of it. It is amemory like other memories, and it begins to fade asother memories do. Her grief, too, begins to lose itsvividness. It occurs to the survivor that perhaps thetrauma is only one part, and perhaps not even the mostimportant part, of her life story.

The reconstruction of the trauma is never entirelycompleted; new confiicts and challenges at each newstage of the lifecycle will inevitably reawaken thetrauma and bring some new aspect of the experience tolight. The major work of the second stage is accom-plished, however, when the patient reclaims her ownhistory and feels renewed hope and energy for en-gagement with life. Time starts to move again. Whenthe second stage has come to its conclusion, the trau-matic experience belongs to the past.

At this point, the survivor faces the tasks of re-building her life in the present and pursuing her aspi-rations for the future. She has mourned the old selfwhich the trauma destroyed; now she must develop anew self. Her relationships have been tested and foreverchanged by the trauma; now she must develop newrelationships. The old beliefs that gave meaning to herlife have been challenged; now she must find anew asustaining faith. These are the tasks of the third stage ofrecovery.

The issues of the first stage of recovery are oftenrevisited at this time. Once again the survivor devotesattention to the care of her body, her immediate envi-ronment, her material needs, and her relationships withothers. But while in the first stage the goal was simplyto secure a defensive position of basic safety, by thethird stage the survivor is ready to engage more activelyin the world. She can establish an agenda. She can re-cover some of her aspirations from the time before the

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trauma, or perhaps for the first time she can discoverher own ambitions.

By the third stage of recovery, the survivor has re-gained some capacity for appropriate trust. She canonce again feel trust in others wheti that trust is war-ranted, she can withhold her trust when it is not war-ranted, and she knows how to distinguish between thetwo situations. She has also regained the abihty to feelautonomous while retnaining connected to others; shecan maintain her own poitit of view and her ownboundaries while respecting those of others. She hasbegun to take tnore initiative in her life and is in theprocess of creating a new identity. With others, she isnow ready to risk deepening her relationships. Withpeers, she can now seek mutual friendships that are notbased on performance, image, or tnaintenance of a falseself.'^ With lovers and fatnily, she is now ready forgreater intimacy.

At this point, the survivor may be ready to devoteher energy more fully to a relationship with a partner.If she has not been involved in an intimate relationship,she may begin to consider the possibility without feel-ing either dread or desperate need. If she has been in-volved with a partner during the recovery process, sheoften becomes much more aware of the ways in whichher partner suffered from her preoccupation with thetrauma. At this point she can express her gratitudemore freely and tnake atnends when necessary. Thesurvivor may also become more open to new forms ofengagement with children. If the survivor is a parent,she tnay come to recognize the ways in which thetrauma experience has indirectly affected her children,and she may take steps to rectify the situation. If shedoes not have children, she tnay begin to take a newand broader interest in young people.

Most survivors seek the resolution of their traumaticexperietice within the confines of their personal lives.But a significatit minority, as a result of the trauma, feelcalled upon to engage in a wider world. These survivorsrecognize a political or religious ditnension in theirmisfortune, and discover that they can transform themeaning of their personal tragedy by tnaking it the basisfor social action. While there is no way to cotnpensatefor an atrocity, there is a way to transcend it, by makingit a gift to others. The trautna is redeemed only when itbecotnes the source of a survivor mission.'^

Social action offers the survivor a source of powerthat draws upon her own initiative, energy, and re-sourcefulness, but which magnifies these qualities farbeyond her own capacities. It offers her an alhance withothers based on cooperation and shared purpose.Participation in organized, detnanding social effortscalls upon the survivor's most tnature and adaptivecoping strategies of patience, anticipation, altruism.

and hutnor. It brings out the best in her; in return, thesurvivor gains the sense of connection with the best inother people. In this sense of reciprocal connection, thesurvivor can transcend the boundaries of her particulartime and place,'^

Social actioti can take many fonns, from concreteengagement with particular individuals, to the abstractintellectual pursuits. Survivors tnay focus their energieson helping others who have been sitnilarly victitnized,on educational, legal, or political efforts to preventothers from being victimized in the future, Comtnon toall these efforts is a dedication to raising publicawareness. Survivors understand that the natural hu-tnan response to horrible events is to put them out oftnind. They also understand that those who forget thepast are often condetnned to repeat it. It is for thisreason that public truth-telling is the cotntnon de-notninator of all social action."^

The survivor tnission may also take the form ofpursuing justice. In the third stage of recovery, thesurvivor recognizes that the trauma cannot be undone,and that personal wishes for cotnpensation or revengecannot be fulfillled. She also recognizes, however, thatholding the perpetrator accountable for his critnes isitnportant not only for her personal well-being but alsofor the health of the larger society.

The survivor who undertakes public action alsoneeds to come to terms with the fact that not everybattle will be won. Her particular battle becomes partof a larger, ongoing struggle to uphold the rule of lawand the principles of non-violence against the rule offorce. She tnust be secure in the knowledge that sitnplyit! her willingness to tell the truth in public, she hastaken the action that perpetrators fear the most. Herrecovery is not based on the illusion that evil has beenovercome, but rather on the knowledge that it has notprevailed, atid on the hope that restorative love maystill be found in the world,

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