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Trauma and Recovery
The Aftermath of Violence--From Domestic Abuse to Political Terror
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Trauma and Recovery is revered as the seminal text on understanding trauma survivors. By placing individual experience in a broader political frame, Harvard psychiatrist Judith Herman argues that psychological trauma is inseparable from its social and political context. Drawing on her own research on incest, as well as a vast literature on combat veterans and victims of political terror, she shows surprising parallels between private horrors like child abuse and public horrors like war.
Hailed by the New York Times as “one of the most important psychiatry works to be published since Freud,” Trauma and Recovery is essential reading for anyone who seeks to understand how we heal and are healed.
THE ORDINARY RESPONSE TO ATROCITIES is to banish them from consciousness. Certain violations of the social compact are too terrible to utter aloud: this is the meaning of the word unspeakable.
Atrocities, however, refuse to be buried. Equally as powerful as the desire to deny atrocities is the conviction that denial does not work. Folk wisdom is filled with ghosts who refuse to rest in their graves until their stories are told. Murder will out. Remembering and telling the truth about terrible events are prerequisites both for the restoration of the social order and for the healing of individual victims.
The conflict between the will to deny horrible events and the will to proclaim them aloud is the central dialectic of psychological trauma. People who have survived atrocities often tell their stories in a highly emotional, contradictory, and fragmented manner which undermines their credibility and thereby serves the twin imperatives of truth-telling and secrecy. When the truth is finally recognized, survivors can begin their recovery. But far too often secrecy prevails, and the story of the traumatic event surfaces not as a verbal narrative but as a symptom.
The psychological distress symptoms of traumatized people simultaneously call attention to the existence of an unspeakable secret and deflect attention from it. This is most apparent in the way traumatized people alternate between feeling numb and reliving the event. The dialectic of trauma gives rise to complicated, sometimes uncanny alterations of consciousness, which George Orwell, one of the committed truth-tellers of our century, called “doublethink,” and which mental health professionals, searching for a calm, precise language, call “dissociation.” It results in the protean, dramatic, and often bizarre symptoms of hysteria which Freud recognized a century ago as disguised communications about sexual abuse in childhood.
Witnesses as well as victims are subject to the dialectic of trauma. It is difficult for an observer to remain clearheaded and calm, to see more than a few fragments of the picture at one time, to retain all the pieces, and to fit them together. It is even more difficult to find a language that conveys fully and persuasively what one has seen. Those who attempt to describe the atrocities that they have witnessed also risk their own credibility. To speak publicly about one’s knowledge of atrocities is to invite the stigma that attaches to victims.
The knowledge of horrible events periodically intrudes into public awareness but is rarely retained for long. Denial, repression, and dissociation operate on a social as well as an individual level. The study of psychological trauma has an “underground” history. Like traumatized people, we have been cut off from the knowledge of our past. Like traumatized people, we need to understand the past in order to reclaim the present and the future. Therefore, an understanding of psychological trauma begins with rediscovering history.
Clinicians know the privileged moment of insight when repressed ideas, feelings, and memories surface into consciousness. These moments occur in the history of societies as well as in the history of individuals. In the 1970s, the speakouts of the women’s liberation movement brought to public awareness the widespread crimes of violence against women. Victims who had been silenced began to reveal their secrets. As a psychiatric resident, I heard numerous stories of sexual and domestic violence from my patients. Because of my involvement in the women’s movement, I was able to speak out against the denial of women’s real experiences in my own profession and testify to what I had witnessed. My first paper on incest, written with Lisa Hirschman in 1976, circulated “underground,” in manuscript, for a year before it was published. We began to receive letters from all over the country from women who had never before told their stories. Through them, we realized the power of speaking the unspeakable and witnessed firsthand the creative energy that is released when the barriers of denial and repression are lifted.
Trauma and Recovery represents the fruits of two decades of research and clinical work with victims of sexual and domestic violence. It also reflects a growing body of experience with many other traumatized people, particularly combat veterans and the victims of political terror. This is a book about restoring connections: between the public and private worlds, between the individual and community, between men and women. It is a book about commonalities: between rape survivors and combat veterans, between battered women and political prisoners, between the survivors of vast concentration camps created by tyrants who rule nations and the survivors of small, hidden concentration camps created by tyrants who rule their homes.
People who have endured horrible events suffer predictable psychological harm. There is a spectrum of traumatic disorders, ranging from the effects of a single overwhelming event to the more complicated effects of prolonged and repeated abuse. Established diagnostic concepts, especially the severe personality disorders commonly diagnosed in women, have generally failed to recognize the impact of victimization. The first part of this book delineates the spectrum of human adaptation to traumatic events and gives a new diagnostic name to the psychological disorder found in survivors of prolonged, repeated abuse.
Because the traumatic syndromes have basic features in common, the recovery process also follows a common pathway. The fundamental stages of recovery are establishing safety, reconstructing the trauma story, and restoring the connection between survivors and their community. The second part of the book develops an overview of the healing process and offers a new conceptual framework for psychotherapy with traumatized people. Both the characteristics of the traumatic disorders and the principles of treatment are illustrated with the testimony of survivors and with case examples drawn from a diverse literature.
The research sources for this book include my own earlier studies of incest survivors and my more recent study of the role of childhood trauma in the condition known as borderline personality disorder. The clinical sources of this book are my twenty years of practice at a feminist mental health clinic and ten years as a teacher and supervisor in a university teaching hospital.
The testimony of trauma survivors is at the heart of the book. To preserve confidentiality, I have identified all of my informants by pseudonyms, with two exceptions. First, I have identified therapists and clinicians who were interviewed about their work, and second, I have identified survivors who have already made themselves known publicly. The case vignettes that appear here are fictitious; each one is a composite, based on the experiences of many different patients, not of an individual.
Survivors challenge us to reconnect fragments, to reconstruct history, to make meaning of their present symptoms in the light of past events. I have attempted to integrate clinical and social perspectives on trauma without sacrificing either the complexity of individual experience or the breadth of political context. I have tried to unify an apparently divergent body of knowledge and to develop concepts that apply equally to the experiences of domestic and sexual life, the traditional sphere of women, and to the experiences of war and political life, the traditional sphere of men.
This book appears at a time when public discussion of the common atrocities of sexual and domestic life has been made possible by the women’s movement, and when public discussion of the common atrocities of political life has been made possible by the movement for human rights. I expect the book to be controversial—first, because it is written from a feminist perspective; second, because it challenges established diagnostic concepts; but third and perhaps most importantly, because it speaks about horrible things, things that no one really wants to hear about. I have tried to communicate my ideas in a language that preserves connections, a language that is faithful both to the dispassionate, reasoned traditions of my profession and to the passionate claims of people who have been violated and outraged. I have tried to find a language that can withstand the imperatives of doublethink and allows all of us to come a little closer to facing the unspeakable.
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 of 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 or “acts of God,” 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.
It is very tempting to take the side of the perpetrator. All the perpetrator asks is that the bystander do nothing. He appeals to the universal desire to see, hear, and speak no evil. The victim, on the contrary, asks the bystander to share the burden of pain. The victim demands action, engagement, and remembering. Leo Eitinger, a psychiatrist who has studied survivors of the Nazi concentration camps, describes the cruel conflict of interest between victim and bystander: “War and victims are something the community wants to forget; a veil of oblivion is drawn over everything painful and unpleasant. We find the two sides face to face; on one side the victims who perhaps wish to forget but cannot, and on the other all those with strong, often unconscious motives who very intensely both wish to forget and succeed in doing so. The contrast . . . is frequently very painful for both sides. The weakest one . . . remains the losing party in this silent and unequal dialogue.”1
In order to escape accountability for his crimes, the perpetrator does everything in his power to promote forgetting. Secrecy and silence are the perpetrator’s first line of defense. If secrecy fails, the perpetrator attacks the credibility of his victim. If he cannot silence her absolutely, he tries to make sure that no one listens. To this end, he marshals an impressive array of arguments, from the most blatant denial to the most sophisticated and elegant rationalization. After every atrocity one can expect to hear the same predictable apologies: it never happened; the victim lies; the victim exaggerates; the victim brought it upon herself; and in any case it is time to forget the past and move on. The more powerful the perpetrator, the greater is his prerogative to name and define reality, and the more completely his arguments prevail.
The perpetrator’s arguments prove irresistible when the bystander faces them in isolation. Without a supportive social environment, the bystander usually succumbs to the temptation to look the other way.2 This is true even when the victim is an idealized and valued member of society. Soldiers in every war, even those who have been regarded as heroes, complain bitterly that no one wants to know the real truth about war. When the victim is already devalued (a woman, a child), she may find that the most traumatic events of her life take place outside the realm of socially validated reality. Her experience becomes unspeakable.
The study of psychological trauma must constantly contend with this tendency to discredit the victim or to render her invisible. Throughout the history of the field, dispute has raged over whether patients with posttraumatic conditions are entitled to care and respect or deserving of contempt, whether they are genuinely suffering or malingering, whether their histories are true or false and, if false, whether imagined or maliciously fabricated. In spite of a vast literature documenting the phenomena of psychological trauma, debate still centers on the basic question of whether these phenomena are credible and real.
It is not only the patients but also the investigators of post-traumatic conditions whose credibility is repeatedly challenged. Clinicians who listen too long and too carefully to traumatized patients often become suspect among their colleagues, as though contaminated by contact. Investigators who pursue the field too far beyond the bounds of conventional belief are often subjected to a kind of professional isolation.
To hold traumatic reality in consciousness requires a social context that affirms and protects the victim and that joins victim and witness in a common alliance. For the individual victim, this social context is created by relationships with friends, lovers, and family. For the larger society, the social context is created by political movements that give voice to the disempowered.
The systematic study of psychological trauma therefore depends on the support of a political movement. Indeed, whether such study can be pursued or discussed in public is itself a political question. The study of war trauma becomes legitimate only in a context that challenges the sacrifice of young men in war. The study of trauma in sexual and domestic life becomes legitimate only in a context that challenges the subordination of women and children. Advances in the field occur only when they are supported by a political movement powerful enough to legitimate an alliance between investigators and patients and to counteract the ordinary social processes of silencing and denial. In the absence of strong political movements for human rights, the active process of bearing witness inevitably gives way to the active process of forgetting. Repression, dissociation, and denial are phenomena of social as well as individual consciousness.
Three times over the past century, a particular form of psychological trauma has surfaced into public consciousness. Each time, the investigation of that trauma has flourished in affiliation with a political movement. The first to emerge was hysteria, the archetypal psychological disorder of women. Its study grew out of the republican, anticlerical political movement of the late nineteenth century in France. The second was shell shock or combat neurosis. Its study began in England and the United States after the First World War and reached a peak after the Vietnam War. Its political context was the collapse of a cult of war and the growth of an antiwar movement. The last and most recent trauma to come into public awareness is sexual and domestic violence. Its political context is the feminist movement in Western Europe and North America. Our contemporary understanding of psychological trauma is built upon a synthesis of these three separate lines of investigation.
THE HEROIC AGE OF HYSTERIA
For two decades in the late nineteenth century, the disorder called hysteria became a major focus of serious inquiry. The term hysteria was so commonly understood at the time that no one had actually taken the trouble to define it systematically. In the words of one historian, “for twenty-five centuries, hysteria had been considered a strange disease with incoherent and incomprehensible symptoms. Most physicians believed it to be a disease proper to women and originating in the uterus.”3 Hence the name, hysteria. As another historian explained, hysteria was “a dramatic medical metaphor for everything that men found mysterious or unmanageable in the opposite sex.”4
The patriarch of the study of hysteria was the great French neurologist Jean-Martin Charcot. His kingdom was the Salpêtrière, an ancient, expansive hospital complex which had long been an asylum for the most wretched of the Parisian proletariat: beggars, prostitutes, and the insane. Charcot transformed this neglected facility into a temple of modern science, and the most gifted and ambitious men in the new disciplines of neurology and psychiatry journeyed to Paris to study with the master. Among the many distinguished physicians who made the pilgrimage to the Salpêtrière were Pierre Janet, William James, and Sigmund Freud.5
The study of hysteria captured the public imagination as a great venture into the unknown. Charcot’s investigations were renowned not only in the world of medicine but also in the larger worlds of literature and politics. His Tuesday Lectures were theatrical events, attended by “a multi-colored audience, drawn from all of Paris: authors, doctors, leading actors and actresses, fashionable demimondaines, all full of morbid curiosity.”6 In these lectures, Charcot illustrated his findings on hysteria by live demonstrations. The patients he put on display were young women who had found refuge in the Salpêtrière from lives of unremitting violence, exploitation, and rape. The asylum provided them greater safety and protection than they had ever known; for a selected group of women who became Charcot’s star performers, the asylum also offered something close to fame.
Charcot was credited for great courage in venturing to study hysteria at all; his prestige gave credibility to a field that had been considered beyond the pale of serious scientific investigation. Prior to Charcot’s time, hysterical women had been thought of as malingerers, and their treatment had been relegated to the domain of hypnotists and popular healers. On Charcot’s death, Freud eulogized him as a liberating patron of the afflicted: “No credence was given to a hysteric about anything. The first thing that Charcot’s work did was to restore its dignity to the topic. Little by little, people gave up the scornful smile with which the patient could at that time feel certain of being met. She was no longer necessarily a malingerer, for Charcot had thrown the whole weight of his authority on the side of the genuineness and objectivity of hysterical phenomena.”7
Charcot’s approach to hysteria, which he called “the Great Neurosis,” was that of the taxonomist. He emphasized careful observation, description, and classification. He documented the characteristic symptoms of hysteria exhaustively, not only in writing but also with drawings and photographs. Charcot focused on the symptoms of hysteria that resembled neurological damage: motor paralyses, sensory losses, convulsions, and amnesias. By 1880 he had demonstrated that these symptoms were psychological, since they could be artificially induced and relieved through the use of hypnosis.
Though Charcot paid minute attention to the symptoms of his hysterical patients, he had no interest whatsoever in their inner lives. He viewed their emotions as symptoms to be cataloged. He described their speech as “vocalization.” His stance regarding his patients is apparent in a verbatim account of one of his Tuesday Lectures, where a young woman in hypnotic trance was being used to demonstrate a convulsive hysterical attack:
CHARCOT: Let us press again on the hysterogenic point. (A male intern touches the patient in the ovarian region.) Here we go again. Occasionally subjects even bite their tongues, but this would be rare. Look at the arched back, which is so well described in textbooks.
PATIENT: Mother, I am frightened.
CHARCOT: Note the emotional outburst. If we let things go unabated we will soon return to the epileptoid behavior. . . . (The patient cries again: “Oh! Mother.”)
CHARCOT: Again, note these screams. You could say it is a lot of noise over nothing.8
The ambition of Charcot’s followers was to surpass his work by demonstrating the cause of hysteria. Rivalry was particularly intense between Janet and Freud. Each wanted to be the first to make the great discovery.9 In pursuit of their goal, these investigators found that it was not sufficient to observe and classify hysterics. It was necessary to talk with them. For a brief decade men of science listened to women with a devotion and a respect unparalleled before or since. Daily meetings with hysterical patients, often lasting for hours, were not uncommon. The case studies of this period read almost like collaborations between doctor and patient.
These investigations bore fruit. By the mid 1890s Janet in France and Freud, with his collaborator Joseph Breuer, in Vienna had arrived independently at strikingly similar formulations: hysteria was a condition caused by psychological trauma. Unbearable emotional reactions to traumatic events produced an altered state of consciousness, which in turn induced the hysterial symptoms. Janet called this alteration in consciousness “dissociation.”10 Breuer and Freud called it “double consciousness.”11
Both Janet and Freud recognized the essential similarity of altered states of consciousness induced by psychological trauma and those induced by hypnosis. Janet believed that the capacity for dissociation or hypnotic trance was a sign of psychological weakness and suggestibility. Breuer and Freud argued, on the contrary, that hysteria, with its associated alterations of consciousness, could be found among “people of the clearest intellect, strongest will, greatest character, and highest critical power.”12
Both Janet and Freud recognized that the somatic symptoms of hysteria represented disguised representations of intensely distressing events which had been banished from memory. Janet described his hysterical patients as governed by “subconscious fixed ideas,” the memories of traumatic events.13 Breuer and Freud, in an immortal summation, wrote that “hysterics suffer mainly from reminiscences.”14
By the mid 1890s these investigators had also discovered that hysterical symptoms could be alleviated when the traumatic memories, as well as the intense feelings that accompanied them, were recovered and put into words. This method of treatment became the basis of modern psychotherapy. Janet called the technique “psychological analysis,” Breuer and Freud called it “abreaction” or “catharsis,” and Freud later called it “psycho-analysis.” But the simplest and perhaps best name was invented by one of Breuer’s patients, a gifted, intelligent, and severely disturbed young woman to whom he gave the pseudonym Anna O. She called her intimate dialogue with Breuer the “talking cure.”15
The collaborations between doctor and patient took on the quality of a quest, in which the solution to the mystery of hysteria could be found in the painstaking reconstruction of the patient’s past. Janet, describing his work with one patient, noted that as treatment proceeded, the uncovering of recent traumas gave way to the exploration of earlier events. “By removing the superficial layer of the delusions, I favored the appearance of old and tenacious fixed ideas which dwelt still at the bottom of her mind. The latter disappeared in turn, thus bringing forth a great improvement.”16 Breuer, describing his work with Anna O, spoke of “following back the thread of memory.”17
It was Freud who followed the threat the furthest, and invariably this led him into an exploration of the sexual lives of women. In spite of an ancient clinical tradition that recognized the association of hysterical symptoms with female sexuality, Freud’s mentors, Charcot and Breuer, had been highly skeptical about the role of sexuality in the origins of hysteria. Freud himself was initially resistant to the idea: “When I began to analyse the second patient . . . the expectation of a sexual neurosis being the basis of hysteria was fairly remote from my mind. I had come fresh from the school of Charcot, and I regarded the linking of hysteria with the topic of sexuality as a sort of insult—just as the women patients themselves do.”18
This empathic identification with his 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 hysterical 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.”19
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
- "One of the most important psychiatric works to be published since Freud."—New York Times
- "A landmark."—Gloria Steinem
- "A stunning achievement ... a classic for our generation."—Bessel van der Kolk, M.D., author of The Body Keeps the Score
- "A book of luminous intelligence. You must read it as soon as possible."—Sophie Freud
- "Astute, accessible, and beautifully documented. Bridging the worlds of war veterans, prisoners of war, battered women, and incest victims, Herman presents a compelling analysis of trauma and the process of healing. A triumph."—Laura Davis, coauthor of The Courage to Heal
- "Brilliant."—Boston Globe
- "This book will surely become a landmark work on the social impact of psychological trauma and on its treatments.... A magnificent gift to survivors."—Women's Review of Books
- "Herman's brilliant insights into the nature of trauma and the process of healing shine through in every page of this rich and compassionate book."—Lenore Walker, ED.D., Director, Domestic Violence Institute, and author of Terrifying Love
- "Herman links the public traumas of society to those of domestic life in this provocative work of psychiatric theory."—Publishers Weekly
- On Sale
- Jul 7, 2015
- Page Count
- 336 pages
- Basic Books