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Complex Post-Traumatic Stress Disorder
Herman (1992) divides recovery from CPTSD into three stages:
establishing safety, remembrance and mourning for what was lost, and
reconnecting to society. Before this work can begin, a healing
relationship must be established; Herman believes recovery can come
only within a relationship and only if the survivor is empowered.
Establishing safety
This stage is further subdivided into a series of tasks that must be
accomplished in order for the client to feel safe in therapy. First,
the therapist and client must name the problem. This involves not so
much making a formal diagnosis as acknowledging the trauma and its
past and present effects, both mental and physical. Next, one must
restore a sense of control to the client. This begins with control of
the body: controlling physical symptoms by balancing diet, exercise,
and sleep and by getting the client appropriate medical care,
including medication where it is indicated. Finally, control moves
outward to establishing a safe environment: setting up support
networks of caring people, helping the client to protect him/herself
from any physical danger they may face (particularly from an abuser),
and developing a plan for dealing with for future protection, one that
takes into account any self-destructive behaviors the client engages
in. This includes such things as setting up no-harm contracts (or
procedures in case of harm), establishing sobriety, etc.
Herman cautions that there's not easy way to tell when this (or any)
stage of recovery is complete. The first stage in particular is
demanding; therapists and clients must be careful not to push on until
safety is well established. Herman states that when the client has
regained some trust in herself and her environment, when the
therapeutic alliance is good, and when the most disturbing symptoms
are controlled and the client knows which people can be relied on in
times of crisis, it is reasonably safe to proceed.
Remembrance and mourning
The second stage is also divided into sub-stages. First, the client
must reconstruct the story of the trauma. Many times, traumatized
person have never been able to put it all together and make it into a
narrative. During this stage, a sense of continuity with the past is
reestablished. Herman stresses the importance of, in this stage,
retrieving both the memories and the emotions attached to them; this
corresponds to the view of some practitioners that free-floating
anxiety can be "emotional memories" that have somehow gotten unstuck
from the memories of the events during which they were experienced.
When the narrative reconstruction is complete, Herman says, the
traumatic memories must be transformed using flooding/exposure (as in
cognitive therapy) or testimony techniques. Finally, the losses that
resulted from the trauma must be mourned fully. Only when all of this
is accomplished is the second stage complete.
Reconnection
The final task for a trauma survivor in Herman's model is to "reclaim
her world." The client must create a future by re-learning how to
live. The first step is learning to defend him/herself, learning to
fight for what is important and to protect her/himself. Reconciliation
with the self, identifying and appreciating what is positive about
oneself while recognizing and accepting the negatives, follows. Then
comes reconnecting with others -- becoming part of a community. Herman
also recommends finding a survivor mission -- some work to add meaning
to life.
Herman notes that even after these steps are complete, the trauma may
never be fully resolved; she considers recovery to be a lifelong
process. However, at this point, it becomes on of many factors in a
client's life and not the dominant one.
Complex Post-Traumatic Stress Disorder
Recommended DSM diagnostic criteria, per Trauma and Recovery by Judith
Herman, c1992 by Basic Books.
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:
+ persistent dysphoria
+ chronic suicidal preoccupation
+ self-injury
+ explosive or extremely inhibited anger (may alternate)
+ compulsive or extremely inhibited sexuality (may alternate)
3. Alterations in consciousness, including:
+ amnesia or hypermnesia for traumatic events
+ transient dissociative episodes
+ depersonalization/derealization
+ reliving experiences, either in the form of intrusive
post-traumatic stress disorder symptoms or in the form of
ruminative preoccupation
4. Alterations in self-perception, including:
+ sense of helplessness or paralysis of initiative
+ shame, guilt, and self-blame
+ sense of defilement or stigma
+ sense of complete difference from others (may include sense
of specialness, utter aloneness, belief no other person can
understand, or nonhuman identity)
5. Alterations in perception of perpetrator, including:
+ preoccupation with relationship with perpetrator (includes
preoccupation with revenge)
+ unrealistic attribution of total power to perpetrator
(caution: victim's assessment of power realities may be more
realistic than clinician's)
+ idealization or paradoxical gratitude
+ sense of special or supernatural relationship
+ acceptance of belief system or rationalizations of
perpetrator
6. Alterations in relations with others, including:
+ isolation and withdrawal
+ disruption in intimate relationships
+ repeated search for rescuer (may alternate with isolation and
withdrawal)
+ persistent distrust
+ repeated failures of self-protection
7. Alterations in systems of meaning:
+ loss of sustaining faith
+ sense of hopelessness and despair
http://www.heart7.net/herman.html
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