DEE WILSON CONSULTING
Book Review:
Extraordinary Look at Trauma Victims
Trauma and Recovery
by Judith Herman, Basic Books (1992, 1997)
Judith Herman has authored one of the few truly extraordinary books in child welfare or a child welfare related subject. What makes this book extraordinary is the combination of Herman's theoretical brilliance and passionate evocation of the experiences and inner worlds of trauma victims. Herman's language and her "voice" has exceptional clarity and penetration; the book has x ray depth along with exceptional moral eloquence.
Herman maintains that "The ordinary human response to danger is a complex, integrated system of reactions, encompassing both body and mind." "Threat initially arouses the sympathetic nervous system," causing an adrenaline rush and "concentrates a person's attention on the immediate situation." "In addition, threat may alter perceptions: people in danger are often able to disregard hunger, fatigue or pain." "Finally, threat evokes intense feelings of fear and anger." "These changes in arousal, attention, perception and emotion are normal, adaptive reactions." "They mobilize the threatened person for strenuous action, either in battle or in flight."
However, "Traumatic reactions occur when action is of no avail." "When neither resistance or escape is possible, the human system of self defense becomes overwhelmed and disorganized." "Each component of the ordinary response to danger, having lost its utility, tends to persist in altered and exaggerated state long after the actual danger is over." "Traumatic events produce profound and lasting changes in physiological arousal, emotion, cognition and memory." "Moreover, traumatic events may sever these normally integrated functions from one another." (underlining is mine)."The traumatized person may experience intense emotion but without clear memory of the event, or may remember everything in detail but without emotion." "She may find herself in a constant state of vigilance and irritability without knowing why." "Traumatic symptoms have a tendency to become disconnected from the source and to take on a life of their own."
"This kind of fragmentation, whereby trauma tears apart a complex system of self protection that normally functions in an integrated fashion, is central to the historic observations on post - traumatic stress disorder." "Traumatized people feel and act as if their nervous systems have been disconnected from the present." They are subject to symptoms which fall into the three main categories of PTSD, hyper-arousal, intrusive memories and constriction, i.e., numbing. Trauma victims are also frequently plagued by a dazzling variety of physical health problems, including headaches, gastro- intestinal disturbances, pelvic pain, sleep disturbances, fatigue. The Kaiser Permanente retrospective studies of the relationship between childhood trauma and adult health have found strong associations between child abuse and neglect, early exposure to domestic violence, substance abuse and mental illness and a variety of serious illnesses, risky health conditions and emotional problems in adults 50 -65 years of age, including heart disease, diabetes, obesity, substance abuse, depression and suicide attempts.
Trauma and Recovery has chapters on child abuse (from the perspective of chronically and severely abused children), captivity and torture, diagnosis, therapy with trauma victims and stages of recovery. Herman comments that "The chronically abused person's apparent helplessness and passivity, her entrapment in the past, her intractable depression and somatic complaints, and her smoldering anger often frustrate the people closest to her." "Moreover, if she has been coerced into a betrayal of relationships, community loyalties, or moral values, she is frequently subjected to furious condemnation." Herman strongly advocates for a separate diagnostic classification of "complex post- traumatic stress disorder" for persons who have been subjected to prolonged trauma, as opposed to a single traumatic event. Herman has acid comments regarding some diagnoses, e.g., borderline personality, which she regards as "little more than a sophisticated insult" within the mental health field.
Herman's book has deepened my understanding of how so many parents involved in chronic neglect become hopeless/ helpless, i.e., demoralized. Prior to reading Trauma and Recovery, my notion was that demoralization is the extreme end of a depressive spectrum, with long term, severe poverty having a major causal influence. Rates of depression are highly elevated among low income populations (40% of women in welfare to work programs are severely depressed), but depression is also the most common outcome of trauma.
PTSD and depression can combine to intensify hopeless/ helpless reactions. Herman comments: "Every aspect of the experience of prolonged trauma works to aggravate depressive symptoms." "The chronic hyper-arousal and intrusive symptoms of post traumatic stress disorder fuse with the vegetative symptoms of depression, producing what Niederland calls the "survivor triad" of insomnia, nightmares, and psychosomatic complaints." "The paralysis of initiative of chronic trauma combines with the apathy and helplessness of depression." "The debased self image of chronic trauma fuels the guilty ruminations of depression." "And the loss of faith suffered in chronic trauma merges with the hopelessness of depression." Long term severe poverty plus trauma is a powerful demoralizing set of adversities which work through both depression and PTSD, and subsequently through substance abuse, to sometimes produce a demoralized emotional condition which is hard to impact.
However, the most inspiring part of Trauma and Recovery is Herman's account of the recovery process. If anyone in social work needs more reasons to embrace empowerment practices, he/she should carefully attend to Herman on this issue. "Trauma robs the victim of a sense of power and control; the guiding principle of recovery is to restore power and control to the survivor." Regarding therapeutic decisions of whom to involve in establishing safety for survivors and attending to self care issues, "In this, as in all other matters, the survivor must be in control of the decision making process."
Herman pulls no punches regarding the pain involved in recovery or about the therapeutic challenges involved in working with trauma victims. There are many references in this book to conflicts with colleagues, supervisors, institutions, and the psychiatric establishment. To work with trauma is to place oneself in the middle of severe tests of judgment and emotional balance and in the middle of heated professional conflicts. The work is not for the faint hearted, as Herman makes clear, but the astonishing thing is that facilitating recovery from horrific events can be done at all. Trauma and Recovery is a powerful affirmation of what can be achieved when in depth understanding is combined with moral engagement. There is no detachment in this book, but neither is there any compromise of intellectual integrity.