Judith Lewis Herman

A Developmental Approach to Complex PTSD: Childhood and Adult Cumulative Trauma as Predictors of Symptom Complexity

Exposure to multiple traumas, particularly in childhood, has been proposed to result in a complex of symptoms that includes posttraumatic stress disorder (PTSD) as well as a constrained, but variable group of symptoms that highlight self-regulatory disturbances. The relationship between accumulated exposure to different types of traumatic events and total number of different types of symptoms (symptom complexity) was assessed in an adult clinical sample (N = 582) and a child clinical sample (N = 152). Childhood cumulative trauma but not adulthood trauma predicted increasing symptom complexity in adults. Cumulative trauma predicted increasing symptom complexity in the child sample. Results suggest that Complex PTSD symptoms occur in both adult and child samples in a principled, rule-governed way and that childhood experiences significantly influenced adult symptoms.

Justice From the Victim’s Perspective:

What are the meanings of justice, as seen from the perspective of victims of violent crime? Are victims’ visions of justice represented by the conventional legal system? Are they represented by restorative justice? The author engages these questions, drawing on in-depth interviews with 22 victims of violent crime. It is argued that survivors’ views of justice do not fit well into either retributive or restorative models. This has implications for current efforts to use restorative models in cases of violence against women.

HISTORIES OF VIOLENCE IN AN OUTPATIENT POPULATION: An Exploratory Study

Diagnostic summaries of 190 consecutive psychiatric outpatients were reviewed for experiences of physical and sexual violence. Close to one third of female patients had been victimized, and 29% of male patients had been abusive to others. The majority of the violence was intrafamilial. The findings suggest that systematic questioning of all patients regarding their experiences of violence is warranted.

A Stage-by-Dimension Model of Recovery From Sexual Trauma

This article articulates a model of treatment-facilitated recovery from sexual trauma. The model integrates (a) an ecological view of psychological trauma, (b) the idea that recovery from interpersonal trauma generally unfolds in progressive stages, and (c) a multifaceted definition of what constitutes recovery from psychological trauma. Examples of the models application are presented, and the implications for treatment and research are discussed.

REPORTING PRACTICES OF PSYCHIATRISTS WHO KNEW OF SEXUAL MISCONDUCT BY COLLEAGUES

Of 1423 psychiatrists responding to a national survey, 65% reported treating patients who had been sexually involved with previous therapists. Respondents saw these prior involvements as harmful in 87% of cases but reported the sexual abuse in only 8% of cases. The majority, however, favored mandatory reporting of such incidents. The problem of underreporting and the need for effective management of sexual abuse cases are discussed.

Amnesia, Partial Amnesia, and Delayed Recall among Adult Survivors of Childhood Trauma

Abstract Clinical experience suggests that adult survivors of childhood trauma arrive at their memories in a number of ways, with varying degrees of associated distress and uncertainty and, in some cases, after memory lapses of varying duration and extent. Among those patients who enter psychotherapy as a result of early abuse, three general patterns of traumatic recall are identified: (1) relatively continuous and complete recall of childhood abuse experiences coupled with changing interpretations (delayed understanding) of these experiences, (2) partial amnesia for abuse events, accompanied by a mixture of delayed recall and delayed understanding, and (3) delayed recall following a period of profound and pervasive amnesia. These patterns are represented by three composite clinical vignettes. Variations among them suggest that the phenomena underlying traumatic recall are continuous not dichotomous. Future research into the nature of traumatic memory should be informed by clinical observation.

Core Schemas and Suicidality in a Chronically Traumatized Population

The Young Schema Questionnaire (YSQ) has been demonstrated to tap into core beliefs, or maladaptive schemas, of clinical populations. This study used the YSQ to investigate maladaptive schemas of 137 chronically traumatized patients seeking outpatient psychiatric treatment and to assess whether specific schemas might be associated with suicide risk in this population. Participants completed a modified version of the YSQ-S (short form), post-traumatic diagnostic scale, dissociative experiences scale and self-harm and risk behaviors questionnaire-revised at treatment intake. Significant correlations were found between most YSQ scales and the post-traumatic diagnostic scale, and between all YSQ scales and the dissociative experiences scale. Suicide risk variables were most highly correlated with the social isolation/alienation, defectiveness/shame and failure YSQ scales, suggesting that these schemas may mark individuals at particularly high risk for suicidal ideation and suicide attempts. These results offer important implications for the assessment and treatment of high-risk traumatized patients.

Adult memories of childhood trauma: A naturalistic clinical study

The clinical evaluations of 77 adult psychiatric outpatients reporting memories of childhood trauma were reviewed. A majority of patients reported some degree of continuous recall. Roughly half (53%) said they had never forgotten the traumatic events. Two smaller groups described a mixture of continuous and delayed recall (17%) or a period of complete amnesia followed by delayed recall (16%). Patients with and without delayed recall did not differ significantly in the proportions reporting corroboration of their memories from other sources. Idiosyncratic, trauma-specific reminders and recent life crises were most commonly cited as precipitants to delayed recall. A previous psychotherapy was cited as a factor in a minority (28%) of cases. By contrast, intrusion of new memories after a period of amnesia was frequently cited as a factor leading to the decision to seek psychotherapy. The implications of these findings are discussed with respect to the role of psychotherapy in the process of recovering traumatic memories.

Recognition and treatment of incestuous families

Incest is a major mental health problem, in terms of both prevalence and morbidity. Father-daughter incest constitutes the majority of reported cases. The possibility of incest should be considered in a family which includes a violent father, a disabled mother, a child in an adult maternal role, or an “acting out” adolescent girl. Intervention requires recognition of the criminal and addictive aspects of the fathers behavior. Active cooperation between mental health professionals and mandated child protective and law enforcement agencies is necessary for effective treatment. Group therapy and affiliated self-help programs appear to be the treatment modality of choice. Rehabilitation of the family is based upon restoration of the mother-daughter bond as a guarantee of safety for the child.

Attending to dissociation: assessing change in dissociation and predicting treatment outcome.

ABSTRACT High dissociation has been linked to severe psychopathology. However, relatively little is known about the impact of dissociation on treatment outcome. We sought to examine (a) whether initial levels of dissociation predicted treatment outcome, (b) whether changes in dissociation were associated with changes in other forms of psychopathology, and (c) to what extent individuals with high initial dissociation reported meaningful symptom improvement. Participants (N = 174) were patients at an outpatient trauma clinic. Initial dissociation was significantly associated with general symptom severity. Change in dissociation was significantly and positively associated with change in posttraumatic stress disorder, depression, suicidal ideation, and self-harm. Approximately 40% of high dissociators demonstrated reliable decreases in dissociation during treatment.