Summary of the
Presentation by Judith Lewis Herman, M.D. to the NESTTD on
by Patricia
Papernow
Introduction: Dr. Herman began by noting that, despite the “never the twain shall meet” gulf between the worlds of research and clinical work, clinicians need to know what works and what doesn’t. Toward this end, Dr. Herman and her colleagues have developed a packet of testing which they ask patients to complete in the waiting room (“Otherwise we never get them back.”). Testing takes about 45 minutes and patients are debriefed afterwards to process any issues which emerged. Testing is repeated at 18 months and 24 months.
Population: In terms of population, the VOV program now treats primarily folks with chronic complex trauma histories, and three categories of “people who come to VOV wanting a trauma diagnosis but should not have one”: (1) those with bipolar disease who are fighting the diagnosis and would prefer a trauma diagnosis. (2) patients whose appropriate diagnosis is NPD (“We don’t do any better with narcissistic personality disorder than anyone else.”). (3) perpetrators who suddenly discover their trauma history when a court date nears. She also warned that people seeking asylum cannot do the necessary grief work with a case hanging over their heads. In addition, for many, once asylum is granted, PTSD symptoms recede.
Measures
in the VOV packet include: PTSD
Distress Scale (17 items), Beck Depression Inventory (21 items), Brief Symptom
Inventory (53 items), Dissociative Experience Scale (28 items),
Research
results:
Looking more closely at the results for dissociation, Dr. Herman noted that one half of DID patients are getting reliably better, but a quarter were getting worse. Although there is no clear explanation for this yet, at least one of these was a patient whose active prostitution remained hidden from the team for two years. Another case illustrated an interesting pattern at the 24 month point: A patient who had reached stabilization showed significantly lower symptoms at 18 months. At 24 months as she was starting exploratory work, measures of global psychological symptoms and PTSD went up. However, suicidality, drinking, and DID measures remained low and stable.
Prostitution: Building on the article she e-mailed to us, Dr. Herman stressed the reality of prostitution and its role in creating trauma. She reminded us that, “The need for slavery is not gone,” a point she made chillingly obvious with a quote about the pleasure of having someone to dominate. “We are with prostitution where we were 30 years ago with incest—we are just starting to deal with it,” she stated. “The escort section of the Yellow Pages is as thick as the pizza section.” “We see it all around without seeing it,” including the accepted ritual visits of sports teams to the whorehouse and the stripper at bachelor parties. Methods used by pimps to control prostitutes are similar to those used by torturers to force submission, and they are the same the world over: Isolation, degradation, humiliation, verbal attack, “and, if you really want to break the spirit,” forcing a person to sit by helplessly while loved ones are hurt. “Then coercion is no longer needed; self-hatred will hold her captive.”
Treatment: VOV does both group and individual treatment. Individual treatment is primarily psychodynamic. Dr Herman’s list of Stage One stabilization items provided some reminders to deal with the real basics first: Drugs and alcohol “right away.” Daily cycles of sleeping, eating, exercise, basic health car, work, securing a safe living situation and money. She reminded us that it is critical to ask, where is this person getting her/his money? What sacrifices of income are involved in giving up prostitution? Treatment includes behavioral strategies (meditation, relaxation, hard exercise) and cognitive strategies (symptom logs, what helps and doesn’t, lists of goals beginning with one behavioral goals to re-establish capacity for autonomy and mastery). For many patients, especially those who were prostituted, recovery is “like moving from another country.” “It’s like trying to completely gut and re-model your house while living in it.”
Groups: Much of the early stabilization work is done in groups. Groups include: a 10-12 week Trauma Info Group, Stress Management; Safety and Self Care (16-20 weeks), Male Survivors (16-20 weeks). Groups, which are time-limited and repeating, focus on psychoeducation, not exploration. “Spilling” is contained and discouraged. Most important to me, group leaders actively intervene to teach feedback and attunement skills like: “When I hear that I feel…” “You must have been so scared.” “I see that you are sad.”
Dr. Herman shared the most compelling results of this research last: The most dramatic changes in the VOV results came after group treatment. DES scores come down significantly and self-esteem scores come up in group treatment (which was not true for individual therapy alone). Furthermore, those with the highest DES scores improved the most! Over 80 percent are better on 3 out of 4 measures, many on 4 out of 4. Dr. Herman reminded us, with several quotes from her mother, Helen Block Lewis, that shame is an intrinsic part of abuse and trauma. Paradoxically, most people expect a group experience to increase shame. However, Dr. Herman believes that exactly what groups do best is to “de-shame the shame.” (I would add, especially groups like those at VOV, where leaders actively teach the skills of resonance and mirroring.) Herman notes that the transference is so complex for trauma survivors, that individual therapy just can’t do the same job with shame. Quoting Shelly Taylor’s “Tend and Befriend” research, Herman pointed out that there is a whole other biological system that can be mobilized in connection, and that may be critical for trauma recovery.