3 Stages of Trauma Recovery
it starts with Dr. Judith Herman
Dr. Judith Herman is a US-based psychiatrist who has been conducting research and seeing patients who had gone through significant sexual abuse for over forty years. She was one of the first people to describe the difference between PTSD and complex trauma. She distinguished event trauma as Type I and relational or developmental trauma as Type II.
If only she had more pull on the creation of the latest DSM, because this was one of the early formulations of what we now understand as complex trauma. This is what tends to occur in childhood when caregivers abuse or neglect their kids. It is not a singular event, but multiple events over multiple timelines. And it affects people quite differently.
The other important contribution that Judith Herman made to psychiatry and psychological theory is a three stage sequence of trauma treatment. This was seminal to my understanding of the process, and I have developed my own formulation based on her work.
Dr. Herman‘s book Trauma and Recovery was first released in 1992. It’s surprising to me that in the last thirty years, there isn’t a greater understanding of this within all mental health training. Interestingly, in 2023 she re-entered the public eye after, many years being quiet, due to her own physical health. The most recent book, Truth and Repair, outlines a fourth step focused on justice.
Here are her 3 steps:
Establishing Safety
First and foremost is the establishment of safety, which can be difficult when trauma is ongoing. Imagine a person who is caught in domestic violence, whose family remains in danger in a refugee camp, or their child is ill. It’s quite difficult to fully establish safety in those kinds of circumstances.
The way that I describe it is NOTICING, becoming more familiar with interoception our internal signals. How do we get to know our own nervous system and the way that it behaves under stress? How can we learn what our nervous system does when it’s overactivated, or has an abundance of sympathetic nervous system tone? What are the early warning signs that we are becoming flooded? Some people might notice tension in their muscles, racing mind, or a general sense of restlessness.
Likewise, how do we recognize when we have too much underactivation, or parasympathetic tone? What are the early warning signs of freezing? For many people, it’s difficulty getting off the bed or off the couch, doom-scrolling social media or shows, or just not getting anything done off here to-do list.
Central to this stage is learning how to shift the nervous system. This brings us back into the window of tolerance, a phrase coined by another psychiatrist Dr. Daniel Siegel. I always describe the early warning signs as sitting on the windowsills. And when we’ve flown right out the window is when we either freeze or flood.
Remembrance and Mourning
The second stage, Dr. Herman called remembrance and morning. The name suggests that we are accessing the traumatic content and then going through a grief process. This is the stage where we actually rewire the brain through neuroplasticity. I call it SHIFTING.
What we are looking for is a permanent change in the way that we experience the past. Leaving the pain in our history instead of having it sneak into the present.
Understanding this stage requires some awareness of neuroanatomy. When we have been exposed to danger, our amygdala stores the associated sensations, emotions, and context that we were experiencing at the time. This is because our amygdala has a protective strategy. The more that it can remember about the threat, the better chance we can flag it in the future and keep us safe. But what happens is we end up having intrusive symptoms (flashbacks and nightmares) related to the content. We also end up triggered when either an emotion or contextual sign sneaks into the present.
If the amygdala believes that there is an imminent danger, it will send us down the pathway towards fight and flight (or enhanced sympathetic tone), or freeze-collapse (or enhanced parasympathetic tone). This mechanism is a reflex rather than a conscious desire. This is why I’m such a huge fan of somatic and metaphorical tools for the first two stages, because these reflexes are not always in conscious control.
The goal here is to recognize which of the scenarios stored in the amygdala represent active threats, and which ones can remain in the past. If they are something unlikely to recur, or we could lower the intensity of the threat-level, we can clear those associations by creating new ones. So this stage of processing means that we are accessing the traumatic content and shifting the associations to more neutral ones.
Reconnection
The last stage is called reconnection, which is truly the evolution of post traumatic growth. Who do you want to be - outside of those trauma reflexes? What are your values and priorities and how can you move towards them. At this stage, our cognitive capacity is more available to us because we aren’t driven so much by the reflexes created by the amygdala. This is when talking (cognitive) therapies are more efficacious. I sometimes refer to this step as RESOURCING.
Therapeutic modalities are often called the alphabet soup. There are so many different ways that we can do psychotherapy with any given person. It has to be tailored - not just to their preferences, their culture, and their nervous system, but also to the stage of recovery. This is why I subtitled The Modern Trauma Toolkit “nurture your path to post-traumatic growth with personalized solutions.”