Dr. Judith Herman on Complex PTSD and What Survivors Need
Episode 107
Dr. Judith Herman literally wrote the book on complex trauma.
Her 1992 book "Trauma and Recovery" changed everything we understand about PTSD, especially for people who've experienced prolonged, repeated trauma. Her work gave us language for what so many experienced but couldn't name.
In this conversation, we dive into why complex PTSD is fundamentally different from single-incident trauma, what the three stages of recovery actually mean, and what trauma survivors told her they really want when they envision justice.
Why "Trauma is Trauma"
When Dr. Herman wrote "Trauma and Recovery" in the early 1990s, recognition of trauma of any sort was quite new. PTSD didn't become an official diagnosis until 1980 in the DSM-3, and that was largely due to Vietnam veterans organizing and saying, "We're home and we look okay, but in our minds we're still in Vietnam."
By the 1980s, to the extent trauma was recognized at all, it was thought of in terms of combat.
Meanwhile, Dr. Herman and her colleagues at the Victims of Violence Program were seeing mainly women, mainly survivors of child abuse and gender violence. They documented that a majority of people on inpatient psychiatric services and a third to almost half of patients in outpatient clinics had significant trauma histories.
But it was civilian trauma. Trauma in the private domain of family life and sexual life.
The point of "Trauma and Recovery" was to say: Trauma is trauma. It's the same whether you're talking about combat veterans or rape victims. It's the same whether you're talking about political prisoners and hostages or battered women.
What Makes Complex PTSD Different
Complex PTSD comes from prolonged and repeated abuse, which means there's been a relationship of coercive control established.
This creates not only the classic triad of PTSD symptoms (hyperarousal, intrusion, and numbing), but it also creates disturbances in personality and relationships.
Why? Because a relationship of coercive control is a relationship of dominance and subordination. It uses methods that impact personality development or have an impact on a personality that's already formed.
People who've been through that kind of ordeal will say: "I'm not myself anymore."
The Europeans and the World Health Organization have now recognized complex PTSD in the ICD-11, but the American Psychiatric Association still hasn't recognized it in the DSM-5.
And given the prevalence of this problem, Dr. Herman says this should be "trauma 101." This should be in psychology 101. When you have a "subspecialty" that relates to a quarter to a third of the population, or even 10% of women who have PTSD, that's a pretty high prevalence.
The Three Stages of Trauma Recovery
Dr. Herman conceptualizes the stages not as rigid categories you march through from stage one to stage two to stage three, but as a way to consider what the focus of treatment ought to be in early recovery, middle stages, and later stages.
Stage 1: Safety
If you don't feel safe in the present, then you don't have post-traumatic stress disorder. You have ongoing trauma. If you're at risk that this trauma is still going to be repeated, then you don't have any foundation on which to base your recovery.
Creating at least some defensive perimeter in the present within which a person can feel safe is project number one.
And we start with the body. If you don't feel safe in your body, you don't feel safe anywhere.
This means:
Regulating sleep cycles and eating cycles
Addressing self-care basics
Dealing with substance use (alcohol, opioids, benzodiazepines that people use to self-medicate PTSD symptoms)
Concrete things like money, work, housing, having a safe place to sleep
The problem is that alcohol and benzodiazepines are actually quite effective for the hyperarousal and intrusive symptoms of PTSD. People will say, "I have to. I can't sleep otherwise."
While there's no "penicillin for PTSD," we do have fairly good medications to deal with insomnia and hyperarousal symptoms that allow people to sleep without the complications of addiction.
Stage 2: Remembrance and Mourning
At a certain point when people feel stabilized enough, some sort of processing of the trauma memories becomes important.
This involves transforming abnormally stored memories (that make you feel like you're reliving the trauma in the moment with all the smells, sounds, bodily sensations, sights) into one part of a life story. A narrative verbal memory that doesn't completely define who you are, but is part of your story.
This work involves a lot of mourning for all the things that were lost and can't be recovered.
You can't just "vomit out the trauma" and have an exorcism and be the person you used to be. You have to make new meaning out of it. And that gives you a way forward.
Stage 3: Reconnection
Once you've done that mourning work, the focus becomes the way forward. It's much more present and future-oriented.
This is when people can:
Try something new
Use more initiative
Deepen their relationships
Expand their relationships
Have confrontations with abusers (if they choose)
For people who seem to make particularly good recoveries, they develop what Dr. Herman's colleague Robert J. Lifton called a "survivor mission."
He interviewed survivors of the Hiroshima atomic bomb who had lost everything. They asked, "Why am I alive?" Some of them made meaning by saying, "I must be alive to tell the world so that this will never happen again."
People who develop a survivor mission and join with others to try to make a better world seem to make particularly good recoveries.
Stage 4: Social Healing
Dr. Herman's argument in "Trauma and Recovery" was that trauma is not just an individual psychological problem. It's a social problem. It's a political problem. It's about abuses of power and oppression.
So if that's true, then maybe recovery also isn't just an individual psychological process, but involves some sort of accountability, some sort of effort to seek social justice.
This realization led to her new book, "Truth and Repair."
What Survivors Really Want
Dr. Herman interviewed 30 survivors (26 women and 4 men) who had suffered some form of gender violence: sexual assault, sexual harassment, sexual trafficking, child abuse, intimate partner violence.
She asked them what justice would look like if they could write the script. It seems like an obvious question, but nobody had ever bothered to ask it.
What all 30 out of 30 agreed on unanimously:
Acknowledgment and vindication. They wanted that as much or more from bystanders as from the abuser. They wanted the community to recognize the facts and recognize the harm.
They wanted the shame lifted from their shoulders and put on the shoulders of the offender where it belonged.
What they were mixed on:
Apology. Some really wanted one. More people wanted apologies from bystanders than from offenders. They wanted people who failed to protect them or didn't believe them to apologize.
Many were skeptical about whether the offender could ever be sincere. One survivor who'd been sexually abused by her older brother said, "I think he'd enjoy talking about what he did. He'd get his kicks that way. And I would feel slimed all over again."
What they also wanted:
Restitution and prevention of future harm. They were ambivalent about financial damages, particularly taking money directly from the perpetrator, which would feel like dirty money or being bought.
Dr. Herman recommends the Victims of Crime Act (VOCA) model, which creates trust funds based on fines from convicted offenders. The money goes to victim compensation, victim advocates in courts, and crisis services like rape crisis centers and battered women's shelters. Survivor representatives sit on advisory boards that allocate the funds.
What they were NOT big on:
Punishment. They mostly said, "What good is punishing him going to do me?"
What they did want was the offender exposed and contained. They wanted whatever level of constraint would be necessary to prevent this from happening again.
They weren't invested in punishment as much as they were in public safety and prevention.
They also weren't big on forgiveness. As one Protestant minister who runs an interfaith partnership on domestic violence said, "I have yet to hear anyone say I'm holding people accountable because I'm setting limits because I am a Christian."
The Antidote to Isolation
Isolation is a very powerful predictor of poor recovery. And abusers do everything they can to isolate and silence victims.
Dr. Herman sees a lot of people who come in saying, "I've never told anyone." Often these are people who were abused as kids and weren't allowed to have friends over or visit other kids' houses because perpetrators didn't want them to make friends who they might tell.
If someone doesn't have friends, one of the first projects is to make a friend. They do a scan of the person's social environment: Is there anyone who seems possibly trustworthy? Is there anybody you like?
Dr. Herman recommends trauma survivor groups because they're an underutilized treatment modality and a wonderful antidote to shame and isolation. Survivors really get one another and tend to have more compassion for each other than they do for themselves.
In survivor groups, people often pick a personal goal of disclosure. "I want to tell my husband." "I want to tell my sister." They carefully plan it out with contingency planning so people can expand their social support networks.
Dr. Herman's Message to Survivors:
Don't try to do it alone. Find your buddies. Find your posse.
Ready for trauma-focused therapy? If you're in Pennsylvania and looking for therapists who understand complex PTSD and the stages of recovery, connect with our team.
Read Dr. Herman's work:
Trauma and Recovery (1992)
Truth and Repair: How Trauma Survivors Envision Justice (2023)
Father-Daughter Incest (1981)
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