When Judith Herman published Trauma and Recovery in 1992, the concept of trauma in mental illness was held very differently from today. Post-traumatic stress disorder (PTSD) had entered psychiatric classificatory systems in 1980 (DSM-III) and mainly focused on men with combat experiences. Herman, a feminist psychotherapist, widened the scope of trauma to include adult survivors of child sexual abuse and survivors of domestic violence. She had already begun this work in Father–Daughter Incest (Herman Reference Herman1981). It is Herman’s contention that the systematic study of trauma requires a political movement for support. She contends that there is always a wish to turn away from and deny the reality of traumatic experiences, particularly those within the domestic arena. In 1980, the leading American textbook of psychiatry still claimed that incest occurred in less than one in a million women and that its impact was not particularly damaging (Saddock Reference Saddock, Kaplan, Freedman and Saddock1980: pp. 1806–1808). With women’s groups evolving and growing as a part of the feminist movement, the evidence for sexual and domestic violence became increasingly difficult to ignore.
Complex trauma: coining a term
Herman was responsible for coining the term complex trauma or complex PTSD (CPTSD). She emphasised that the central feature involved captivity: being unable to escape from unbearable repeated experiences of helplessness, terror and dread that overwhelmed existing defences. For many the result was characterised by a constellation of symptoms, the PTSD presentation and:
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affect dysregulation
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revictimisation
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dissociation
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somatisation
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identity disturbance.
Clinicians recognised this description and found it a helpful way of understanding their patients. Many had received multiple other psychiatric diagnoses leading to various therapeutic interventions, often failing to link their current difficulties with their trauma.
Attempts to have CPTSD recognised by the DSM have proved unfruitful and it took 30 years from Herman’s original description before ICD-11 included the diagnosis. The ICD-11 diagnosis draws considerably on Herman’s original descriptions and provides an alternative conceptual understanding of these presentations, which were often labelled as borderline (or emotionally unstable) personality disorder (BPD/EUPD). Herman highlighted the pejorative nature of the BPD diagnosis and emphasised her belief that this diagnostic category should be subsumed under the CPTSD syndrome. This links with later work by Lomani (Reference Lomani2022), who highlights the potential for re-traumatisation within the BPD/EUPD diagnosis. Herman suggests:
‘Survivors of childhood abuse, like other traumatized people, are frequently misdiagnosed and mistreated in the mental health system. Because of the number and complexity of their symptoms, their treatment is often fragmented and incomplete. Because of their characteristic difficulties in close relationships, they are particularly vulnerable to revictimization by caregivers. They may become engaged in ongoing, destructive interactions, in which the mental health system replicates the behaviour of the abusive family’ (Herman Reference Herman1992: p. 123).
Trauma-informed care: empowerment in recovery
One can recognise the seeds of the trauma-informed care (TIC) movement, which arose in the late 1990s and now influences health, education and other settings:
‘Trauma-Informed Care is a strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment’ (Hopper Reference Hopper, Bassuk and Olivet2010).
The principles of TIC parallel many of the recommendations made by Herman, not least the call to prevent re-traumatisation. Herman stresses the importance of empowerment in recovery – an essential tenet of TIC that suggests recovery is only possible in a therapeutic setting that empowers the survivor, whether that be through the use of trauma psychoeducation, choice and voice in treatment decisions, mutuality and cooperation in the therapeutic stance, or peer support and survivor engagement and activism. This is a political and social position that challenges the traditional medical model of hierarchy and returns power to the survivor. It also highlights the issue of reconnection in recovery, the need for traumatised individuals to reconnect with their community, which might be through peer support groups, linking to Herman’s feminist roots.
Herman highlighted the centrality of shame in the experience of trauma: recognising this strengthens the argument for empowerment within the therapeutic encounter, to minimise shame-based re-traumatisation. Linking with other survivors, including through group therapy, may serve to lessen the shame with shared experience and validation through connection with other survivors.
The phases of recovery
Trauma and Recovery outlines a recovery process that is phase-based. For Herman, these fundamental phases are establishing safety, remembrance and mourning, and reconnection with ordinary life. Herman says:
‘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. […] 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. […] 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’ (Herman Reference Herman1992: p. 155).
These phases are an essential part of work in CPTSD today, with best practice guidelines (McFetridge et al., Reference McFetridge, Hauenstein Swan and Heke2017) suggesting:
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phase 1: stabilisation – establishing safety, symptom management, improving emotion regulation and addressing current stressors;
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phase 2: trauma processing – focused processing of traumatic memories;
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phase 3: reintegration – re-establishing social and cultural connection and addressing personal quality of life.
Herman’s emphasis is on relationships, especially the therapeutic one, as essential to recovery. She highlights that this is an inherent aspect of trauma therapy and that it takes time – this is long-term work – and that it will inevitably have an impact on the clinician, which recognises the potential for vicarious traumatisation and the need to attend to this with appropriate support, reflective spaces and self-care.
‘Trauma’: a concept diminished by familiarity?
The recognition of trauma as an important aetiological factor in mental illness exploded in subsequent decades. The Adverse Childhood Experiences Study demonstrated the dose-related response of physical and mental illness in adults linked to childhood trauma (Felitti, Reference Felitti2002), challenging the body–brain dichotomy in physical and mental health. The publication of the The Body Keeps the Score in Reference van der Kolk2014 by Bessel van der Kolk brought trauma more profoundly into public discourse, while a growing societal recognition of the ubiquity of child sexual abuse through Independent Inquiries (UK) and Royal Commissions (Australia and Canada) has occurred.
This continues to influence the provision and delivery of mental healthcare, although some might say not sufficiently so. However, trauma as a word has become so overused and ubiquitous that it may serve to diminish the reality of the unbearable experiences and their ongoing impact into adult life that Herman was attempting to capture. The danger here is one Herman has already described when she speaks of the study of psychological trauma demonstrating the quality of episodic amnesia: ‘Periods of active investigation have alternated with periods of oblivion’ (Herman Reference Herman1992: p. 7).
This danger is perhaps to be offset by her latest book, Truth and Repair (Herman Reference Herman2023), where she elaborates on a fourth phase of recovery – justice – moving the responsibility of recovery from the survivor to the community:
‘These wounds are part of the social ecology of violence, in which crimes against subordinated and marginalized people are rationalized, tolerated, or rendered invisible. If trauma originates in a fundamental injustice, then full healing must require repair through some measure of justice from the larger community’ (Herman Reference Herman2023: p. 3).
Herman’s political stance in relation to trauma emphasises community responsibility through the radical act of listening to survivors, acknowledging the reality of their experiences, with justice including the question of prevention – how does the larger community create safety and correct the wider historical wrongs? There is little doubt that the publication of Trauma and Recovery in 1992 was a seminal moment in this process and holds more relevance than ever in today’s world.
Funding
This work received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
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