
              Treatment of 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.
   
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References

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