Dale Johnson: This week on the podcast, I have with me Dr. Francine Tan. She’s a biblical counselor from Malaysia and has been certified with ACBC since 2021. She has a BA from UCLA, her MABC is from the Master’s University, and she graduated recently—a newly minted graduate, PhD in Applied Theology from Midwestern Baptist Theological Seminary. She also works for ACBC and is a member of Mission Road Bible Church in Kansas City. Francine, it’s good to have you with us today talking about this very difficult subject of trauma.
Francine Tan: Thanks, Dale. Glad to be here.
Dale Johnson: Now listen, complex trauma, a lot of people have heard of the idea of trauma. Complex trauma, or what some people call Complex PTSD or psychological trauma. I want you to introduce us to that concept and even some of the people who gave us this concept. So, talk a little bit about CPTSD, Complex post-traumatic stress disorder. Introduce us to that concept, Francine.
Francine Tan: Sure. So, complex trauma came from Judith Herman. Just a brief history about her: She was a professor of psychiatry at Harvard in 1981, where her research focused on the psychological response of victims of child abuse, rape, and domestic violence. In 1992, Herman published her magnum opus, Trauma and Recover: The Aftermath of Violence, a book that came to redefine the study of post-traumatic stress disorder with a particular focus on women survivors of sexual abuse and domestic violence. And she’s one of the leading figures in modern trauma research, along with Bissell Van de Kolk. You can find their names and their books referenced in almost every literature on trauma.
How Herman would define psychological trauma or complex trauma, she says, “it is an affliction of the powerless.” And then she goes on to say that, “the study of psychological trauma is an inherently political enterprise because it calls attention to the experience of oppressed people.” And her idea of oppressed people here includes the marginalized, women, children, and so on.
As an aside, I want to point out to you that in the APA Handbook of Trauma Psychology, the authors include Herman’s work as a contribution of post-traumatic response from a feminist perspective. And they write, “The construct of Complex traumatic stress or complex trauma emerged from the work done by feminist psychiatrist Judith Lewis Herman and her colleagues at Cambridge in Massachusetts, as they observed the experiences of individuals who had been the targets of repeated trauma exposures, usually during childhood and occasionally as a result of torture or extreme intimate partner violence in adulthood.” So, within the context of trauma, Herman views systems of oppression, such as the patriarchy, racism, classism, anti-immigrant sentiment, and so on. You can add your “isms,” that they are themselves traumatic, as well as rendering people more vulnerable to other specific trauma experiences.
And with that, in 1992, after her book came out, Herman created a new psychological diagnosis. You alluded to it, complex post-traumatic stress disorder, or for short, CPTSD, in 1992 with her proposal paper. What’s different of CPTSD than the normal PTSD, that was coined in the DSM-III in the 80s, is that unlike criterion A of PTSD, where the individual experiences an event, normally outside the range of human experience that is life-threatening, or they would call it a recognisable stressor, now CPTSD applies to people who experience prolonged and repeated trauma during childhood. Repetitive trauma in the context of significant interpersonal relationships, or chronic social stressors, and in this context referring to racism, sexism, and poverty. So here, Herman’s idea is that the diagnostic concepts of the existing psychiatric canon, psychological PTSD, they don’t include prolonged, repeated trauma, and they don’t pertain to interpersonal relationships, which is why she then coins CPTSD.
It includes the core symptoms of PTSD along with three additional groups of symptoms. Now this is important. So, the three additional groups that she added onto it first is problems in affect regulation, so marked irritability, anger, feeling emotionally numb, or also known as emotional dysregulation, that we would hear today. The second symptom is beliefs about oneself as diminished, defeated, worthless, accompanied by feelings of shame, guilt, or failure related to the traumatic event. So, self-identity issues.
And then third, which is key, the third symptom relates to difficulties in sustaining relationships and in feeling close to others. And this is where CPTSD gets applied to attachment styles. Which says that a person has trouble forming, “healthy relationships” in their adulthood due to a lack of secure relationships in their childhood or childhood trauma that’s repeated and prolonged.
Dale Johnson: One of the things that you said there that I think is really interesting is—and many of you may have heard of Bessel van der Kolk, but you might not know Judith Herman. Judith Herman is one of the primary researchers early on in the 90s that had this idea about trauma, which is so prominent today that van der Kolk has made popular in his 2014 book, The Body Keeps the Score. And what she’s promoting here with CPTSD, you mentioned some of the background, right? Some of the philosophy that’s involved in her feministic approach and all the “isms” that go along with it.
I think those things are important to contemplate for a lot of reasons. It’s important for us to know ideologically where these topics come from and how we’re seeing the trauma that somebody experiences. Notice what we’re not saying. Okay, Francine, I want to just make this clear:
What we’re not saying is that traumatic experiences, we’re not saying that those don’t happen, right? What CPTSD is, is it’s an explanation of how and why these things are happening, why people are experiencing certain things. And that’s really our biggest question, is raising those concepts. Now, we’re not the only ones to question those. I want you to keep giving some basic information that really sets the context for how we’ll talk about Herman’s contribution in just a minute.
And one of those is even among secularists, there has been a hesitancy to recognize the way in which Herman and then later Van der Kolk describe this. There is a hesitancy to adopt or accept this into a criterion like the DSM. So, talk a little bit about why complex PTSD—you mentioned that PTSD was adopted in 1980. Then moving forward, the next two, the DSM-IV, which was in 1994, and then the DSM-V, which was in 2013, and its subsequent revision, which we now have, CPTSD was actually excluded.
And so, talk a little bit about why that concept is excluded. And that sounds so wild to me because of how popular that is today. Even the underlying concepts of complex trauma that we describe today, or psychological trauma as we describe today, is so prominent in the popular level, but yet it was excluded in the DSM-IV and-V. And so, I want you to talk about some of the reasons that that happened.
Francine Tan: Yeah. So, it was excluded because it lacked empirical support to be a distinct diagnosis. And secondly, that it overlapped with other existing diagnosis like PTSD, major depressive disorder, borderline personality disorder. And Herman’s 1992 proposal paper failed to provide any standardized data and not even one description of a real patient. So, PTSD researcher Patricia Rissig, which is huge in this field, she said, along with other trauma theorists, that the reason why they have questioned the validity of CPTSD is that there are no studies that have examined neurobiological mechanisms in individuals diagnosed with CPTSD.
So therefore, to say that CPTSD provides a coherent formulation of the consequences of prolonged and repeated exposure to trauma is unfounded. Even the US Department of VA pointed out that complex PTSD was excluded on both editions because there was too little empirical evidence supporting Herman’s original proposal.
Now, not just hearing from them. In Herman’s own admission, she said, “the APA chose not to designate it as a distinct entity in its most recent diagnostic manual, the fifth edition, because the description of the condition includes symptoms that overlap with several other diagnostic categories like depression, anxiety, borderline personality disorder, and other dissociative disorders.” So it’s been long debated. There’s no research. It’s really just a proposal paper. Yet clinicians and counseling practitioners still adopt the construct of CPTSD or the idea behind it of complex or psychological trauma.
Dale Johnson: Now, that’s really helpful to give a little bit about where we are currently with her ideas and how these ideas have actually been excluded from the DSM-IV and V, the current edition that we are under. Now, let’s do a little bit of a history lesson, because I think it’s important for us to understand even further how we got to Judith Herman. Just so that I can set this up, as we talk about the DSM, the Diagnostic and Statistical Manual of Mental Disorders. What you see in the first two, the DSM I (1952 edition), and then the DSM II (1968 version) is that they are very laden with Freudian terminology.
Psychoses, neuroses was the basis of how we understood, from a secular disposition, diagnoses. And it basically formulated the criteria. Basically, what was happening is people started to dismiss the scientific nature of Freud’s concepts. And psychiatry started to find itself as a discipline that did not fit either in the counseling discipline or within the medical field.
And I could go into great detail about this, but just suffice it to say that psychiatry was sort of finding themselves without a particular home. And basically, what you discover is that Robert Spitzer, in the early 70s, began this proposal to change from a distinctly Freudian framework in how to understand the diagnostic criteria to move into more of a, what we call a biological explanation, an explanation that tries to explain these diagnoses from a biological perspective.
And this is well-documented. It has several books that document this. Hannah Decker actually wrote a book called The Making of the DSM-III that I think there are many that document this. But as well as any, she documents this transition that happened. And what you see is Judith Herman comes along a decade after the DSM-III comes out.
And so, what you see is really some Freudian influence in her perspective. I want you to go into detail about that because I think that’s going to be helpful for people to understand: how did we get to where we are today? Like how do we get to the place where Judith Herman and Bessel van der Kolk are saying, now there’s repression in the body? That didn’t just come out of thin air. It has an ideological heritage. Help us to understand the influence of Sigmund Freud through that process and that history on someone like Judith Herman and her thinking.
Francine Tan: Yeah, I’m so glad you mentioned Freudian influence in her because she is explicit that she’s influenced by Freud, especially his concept of repression and seduction theory. So, Freud believed that repression is a defense mechanism protecting individuals from painful memories. And his hypothesis of seduction theory is basically the idea that neurosis or hysterical symptoms stem from memories of childhood sexual abuse. And that is where Herman’s research pertains.
And this is precisely what Herman’s view of CPTSD is. As she says, “The ordinary response to atrocities is to banish them from one’s consciousness.” And atrocities here refer to violence done by other people, especially in the context of sexual abuse. So, Freud’s idea is that at the bottom of every case of hysteria, neurosis, which you alluded to, there are occurrences of premature sexual experience and that they can be reproduced through the work of psychoanalysis, and then recall it many decades later.
And so, Herman comments on the influence of Freud’s early writings on hysteria, on her understanding of complex trauma in this way. So, she says, “a century later, Freud’s paper still rivals contemporary clinical descriptions of the effects of childhood sexual abuse. It is a brilliant, compassionate, eloquently argued, closely reasoned document.”
So, Herman drew inspiration from Freud’s theories of transference. She talked about traumatic countertransference in her book, Trauma and Recovery, where it’s the idea that hearing about a patient’s trauma might trigger repressed memories in the therapist’s unconscious, leading to the onset of CPTSD symptoms in a therapist. This is also known today as vicarious traumatization. So repression, which is a key concept of Freud’s psychoanalytic theory, is understood as a defense mechanism to block unwanted thoughts and memories as they pertain to sexual abuse. Now it’s interesting that Freud later disavowed his own seduction theory and claimed that symptoms came not from repressed memories but repressed sexual fantasies. So, fantasies, not actual memories. Yet Herman still insists that Freud was right the first time.
Dale Johnson: My mind is going a thousand directions, because this is something that we see today. And what we’ve seen essentially is Freud updated where it’s no longer repression in the psyche or the unconscious, but now repression in the body, right? This concept.
But let’s pause for a second, because I think how you may be commenting on Elizabeth Loftus is really important. One of the ways that Freud was debunked was you had lots of court cases where this idea of repression was being raised. And what was being found out is that these were not actual memories. And so, Elizabeth Loftus and her views of memory was really important on this.
I want you to sort of give some background as to what really halted this movement forward in trying to raise question on this concept of repression and the idea of recovered memories and so on. Because I think this plays into the modern day in quite a big deal, because we’re circulating back to some of these concepts. It’s just reframed biologically. So, talk a little bit about, you know, the 80s and the 90s with the work of Elizabeth Loftus and how she can be helpful to us.
Francine Tan: Yeah, before that, I would also like to add that it’s not just Herman, but Van der Kolk’s idea of dissociation is the same idea that traumatic memory is not like ordinary memory. The mind can, “protect itself” by banishing the most painful experiences from awareness or consciousness. So really, then the body now takes the place of the unconscious.
So, all of this, you know, in the heyday of the recovered memory movement in the 80s and 90s. What happened was that you have therapists saying that they can help clients unearth supposedly repressed memories of childhood sexual abuse through hypnosis, through dream interpretation and so on. And then clients would now say they have unearthed all kinds of unimaginable horror done against them or even satanic child abuse and all these things that they would claim. And so, accusations that follow shattered families across the country with lawsuits because clients would then sue their family member of supposed rape, supposed abuse.
So, therapists of that time, they reanimated an early Freudian theory that repressed early experiences of sexual abuse were the root cause of all hysterical symptoms. Or we would say psychological symptoms, negative emotions, erratic behavior, and all of that. And the therapist during the recovered memory movement, then they would interpret body memories, flashbacks, fragments, sudden intense feelings, avoidant behaviors, images, sensory processes, and even dreams, all of which they would say they’re implicit memories of dissociated or repressed trauma.
So, the body remembers even if the mind cannot, which is the same idea that continues to be paddled by Judith Herman and Van der Kolk today. And with Elizabeth Lotus, in fact, other memory experts like Richard McNally, Harrison Pope, and Henry Otgaar, they have long said that memory gets intensified when something is emotional and a difficult event. Not repressed. Not forgotten.
Dale Johnson: Yeah, that’s quite the opposite, right? I think that’s a really important and key factor is that the memory itself, most of the time when a traumatic event happens is actually highlighted or emphasized, not actually repressed in a person’s mind. And that makes sense to us, right?
Because you go on, you’re beeping up and through your day, normal experience, and you have a tendency to forget the mundane. But when something intense happens, it does grip us in such a way to where we start to sort of describe our life around those events, because there’s such a major and distinct moment in history of our lives. But yet this concept of repression—I want you to continue on here. What I’m trying to get you to understand through some of what Francine is saying, for the listeners, is that the concept of repression in Freud has now been updated and moved forward. And what has brought about this update is not scientific research. What’s brought about this update is philosophical shift.
And the philosophical shift has been now from Freud to a more biological perspective. So, we move from repressed memories in the unconscious and the psyche, now to repression of traumatic events that now are stored in the body. And that’s where Judith Herman, which we’ll talk about in another podcast, and Bessel van der Kolk come in. And the way Herman gets there is through her view of people and what she describes as her view of recovery.
So, I want you to give her perspective from C-PTSD, her view of a recovery model. And I think that’ll help us to understand even something you mentioned earlier about attachment theory and how attachment theory is very underladen in some of the concepts promoted by Judith Herman that ought to be a concern for us. So, unpack for us, if you can, Francine, Herman’s recovery model.
Francine Tan: Sure. She calls it a tripartite recovery model, which means that the treatment of trauma comes in three stages. The first stage is to establish safety. The second is to remember and reconstruct a verbal narrative of the traumatic event. And third, to empower and reconnect the individual to the community. So, for Herman, the goal of recovery is to give the survivor a sense of power and control over his or her own life as a way to overcome this kind of systematic, repetitive infliction of psychological trauma. And so, she would say that autonomy and empowerment, they’re the watchwords of recovery for her.
I just also want to note that her three stages are actually also reflected in the principles of trauma-informed care. According to SAMHSA, the Substance Abuse and Mental Health Services Administration, their trauma-informed care in behavioral health services protocol, they say, “beyond identifying trauma and trauma-related symptoms, the initial objective of trauma-informed care is establishing safety. And another key objective is to prevent re-traumatization. Borrowing from Herman’s 1992 conceptualization of trauma recovery, safety is the first goal of treatment.” So, the idea of complex trauma as they pertain to interpersonal relationships, childhood trauma gets picked up. And her idea of safety is not just physical safety. It’s feeling safe with regards to interpersonal relationships.
Dale Johnson: Now before you move on to the next stage, I think it’s important, I want to highlight what you just said. Even though Herman’s perspective has been excluded from the DSM-IV and V, what you’re seeing now in this, “trauma-informed approach” from the secular entities is they’re bringing in these concepts from Herman, particularly safety. Which I think is rooted in some concepts of Bowlby’s attachment theory from the 60s, is that right?
I want to make sure that we’re understanding clearly that Herman’s concepts, while they’ve been excluded in the DSM, they’re still being promoted in this trauma-informed approach from US entities, of the US government. So, it’s still very impactful, and we’re seeing it at the popular level today. So, I want you to continue talking about the recovery model.
Francine Tan: So actually, again, because Herman is Freudian in her thinking, the way she viewed recovery is the patient’s relationship with the therapist and how the therapist is now helping the client to “recover.” In fact, she later then says in her book that the three stages of recovery are abstract. How they apply to each client-therapist relationship differs and should not be taken too literally and calling them “a convenient fiction.”
But again, you know, I think one of the primary reasons why CPTSD has a lot of traction with children and women—you know, gets picked up by SAMHSA is because of its emphasis on interpersonal relationships. Where trauma-informed proponents, they would now say that psychological trauma occurs during the period of developmental growth, like childhood or adolescence. Then an individual is alleged to have lasting traces of trauma into adulthood.
This is also why the Adverse Childhood Experiences, the ACE study, now eventually became the seminal research that established the legitimacy of CPTSD construct, even though when Herman proposed it in 1992, it lacked any empirical support. So going back to Herman’s model, her tripartite model for trauma: first safety, second remembrance, and we construct a verbal narrative of the traumatic event. So this pertains to, again, we talked about repressed memory where you don’t remember. And so it’s important for the therapist to help you recall and remember and to be able to verbalise this event, whether or not it has happened.
And then thirdly, to empower and reconnect the individual to the community. The idea of empowering, she would view it as oppressed, marginalized people in a system of power differential. And so, again, because her view of psychological trauma pertains to systems of oppression, then for her, in her later book, Trauma and Justice, she talks about how empowerment is key to help the clients.
Dale Johnson: That’s really important because what you’re saying is the undergirding of the feminist philosophy that’s certainly at play in how she proposes the things that she proposes. And again, I want to reiterate the fact that we’re not saying that trauma doesn’t happen.
We’re not even saying in this case, if you’re talking about oppression or abuse, that that doesn’t happen. The Bible makes clear that those types of things happen when people misuse another person and that there are certainly effects of that. We’ve talked about that in our abuse documents, our committed to care statement. So we’re not saying that those things don’t exist. This explanation, however, is disconnected from that which is empirical and it’s becoming sort of the philosophical, you know, philosophically popular model.
You mentioned one thing and maybe we’ll finish with this because there’s a lot more questions that people have. And I just want people to see the influence that’s undergirding, you know, all that’s happening right now in the whole trauma movement. You mentioned ACEs. What an important construct, right? And you’re showing that this was rooted in some of the research done by Herman, adverse childhood experiences.
And there’s an inventory or a test that’s associated here. And this has really become a primary measuring stick for many people on how have they been affected in the past. And so I want you to talk about the application of ACEs, adverse childhood experiences, in the way we’re seeing it utilized today. You can talk about the development of it, but specifically on how it’s being used today, I think it would be helpful.
Francine Tan: So, the ACEs relation to Herman is that in 1992, because her proposal paper lacked empirical research and data, she then eventually says that the ACEs—which was developed by Robert Anda and Vincent Filati in 1994. That the long-term health consequences of child abuse were brought to light by the ACEs and that the results were “stunning.”
And the ACE scores were by far the most powerful predictors of clinical depression and suicidal behavior. And basically, the ACEs now is popularized as a diagnostic tool to uncover hidden trauma, to evaluate the extent of traumatic experiences an individual may experience during their childhood. And how that is supposed to predict if a person is at a higher risk for physical or psychological issues.
Now when Felitti and Anda studied this in 1994, they conducted their research from 1995 to 1997, where they surveyed over 17,000 members from Southern California who received standard medical examinations. They completed confidential surveys regarding their childhood and they were basically asked about their health status and behaviors. And ACE scores were divided into seven categories of childhood exposures to abuse.
So again, the key to childhood abuse and household dysfunction, they broke it down to psychological, physical, sexual abuse, violence against mother, living with household members who were substance abusers, mentally ill or suicidal, or in prison. And what they would do is that they would give one point for each category of adverse experience that a person has been exposed to and then now correlate that with their current life in terms of physical illness or any kind of psychological diagnosis. And what they found was that the ACE scores were correlated with greater incidence of leading causes of death in the U.S., such as heart disease, lung disease, and other things. Now, correlation is key, even for them to recognize that what they’re doing is correlation, not causation. However, the study now has been used as a community-wide screening tool or a diagnostic tool that you mentioned in recent years.
In fact, one of the co-authors, Robert Anda, is now cautioning against its over-application. He says that the study was initially designed as a relatively crude measure for populations, that the ACE questionnaire was designed to research, not screen the relationship between childhood adversities and health and social outcomes.
They were very clear that the ACE score is not a diagnostic tool. It is not an appropriate screening tool. It is not a predictor of risk at the individual level because they were doing a population study of over 17,000 people. So, popularizing the ACE scores or the ACE assessment tests as a screening tool, they said, can actually compromise client and provider safety. It also creates a false standard that is leading to policy and legislation that assumes the ACE screening is appropriate when it’s not.
Dale Johnson: I think this is so significant because even what the creators of the ACEs were trying to accomplish was not to create some sort of screening assessment, which is the way it’s often used today. It’s trying to help us to understand some sort of correlation, but how does some level of trauma early on in childhood affect a population? And that’s quite a different use, where we’ve altered the use of it. But it has become popular, so we have to deal with it.
Francine, we’re going to close out today, but I want to make sure that you come back because I want to make the connection, if I can, between the influence of Judith Herman and then Bessel van der Kolk. And it’s important that you, as listeners, not just understand who these people are, but some of the ideas that they promote. You’ll see some of these ideas promoted in things like EMDR, eye movement desensitization reprocessing therapy. You can hear some of that language that Judith Herman established, even some of the things Francine has talked about today.
It’s important that you understand those concepts and where they come from because those are misunderstandings and now become explanations of trauma that happens or explanations of effects that a person may experience later. It becomes the believable reality or believable truth that people now live their life by, as opposed to assessing it from what the Word says, about trauma and how trauma, calamity, affliction or suffering impacts us.
And it certainly does. But the Bible has a better framing, I would argue, in calling us toward things like perseverance and so on. So, I want us to revisit this, and this is why we raise this issue, because we’re seeing in the whole trauma-informed world that’s happening now in the biblical counseling movement, what’s at base here are some of the ideas that are rooted from many years ago in people like Judith Herman. She’s not the only person.
She’s not the only concept that’s being moved forward. But we’re seeing some of this. You can see the lack of empirical data when you study her ideas long-term. You’ve just written a dissertation on this, one that I think will be very helpful for people. And so, we just wanted to raise your attention about these things and continue to do so, so that you can assess even better and not allow a secular framework to subsume the way that we understand the Scriptures. Or to think that it veils what the Scripture has to say about these events as they happen in our life. I think that the Bible explains those experiences better than any other system, including what Judith Herman proposed in her perspective of complex PTSD.
Thank you for your work. I’ll say, you and I have been working on this for quite some time. Thank you for working on this. Thank you for your articulation of it and helping us to understand Judith Herman and how she plays into this modern concept of trauma-informed. I think we’ll be better served and better helped by knowing some of these ideas and being discerning moving forward.
Thanks, Francine.
