Review: “No Visible Bruises” refers to strangulation
The title of Rachel Louise Snyder’s eye-opening, powerful, page-turner of a book, No Visible Bruises, refers to strangulation [No Visible Bruises: What We Don’t Know About Domestic Violence Can Kill Us, New York: Bloomsbury Publishing, 2019: 309 pp, $28(US)].
Some sixty percent of domestic violence (DV) victims are strangled at some point during an abusive relationship (p. 65). Turns out that only some 15% of the victims
in one study had injuries visible enough to photograph for the police report (p. 66). Most strangulation injuries are internal – hence, the title.
Since 2012 when I completed the 40-hour training in Understanding Domestic Violence (DV) at the community organization ApnaGhar, several important innovations have occurred. Snyder presents the reader with these, including the distinctions of (1) a Fatality Review Board for Domestic Violence; (2) initiatives to provide treatment for the abusers; (3) the Danger Assessment (which leads back to the role of strangulation).
Lack of oxygen to the brain can cause micro-strokes, vision and hearing problems, seizures, ringing ears, memory loss, headaches, blacking out, traumatic brain injury (TBI) (p. 69). As the victim in near death due to strangulation – but so far there would only be red marks around the neck – the nerves in the brain stem lose control over sphincter muscles. So the urination and defecation were not mere signs of fear. They were evidence that the victim was near death (p. 67).
Such victims may have poor recall of the event. They may not even be aware that they lost consciousness. The victim is not being difficult or drunk in being incoherent. The victim is fighting the consequences of a life-threatening event and may not know it at the moment.
Even medical professionals may overlook the signs of serious injury by strangulation unless they are altered to the circumstance of the visit to the emergency room. Fact: DV victims are not routinely screened for strangulation or brain injury in the emergency room. They are discharged without CT scans or MRIs. The assaults and injuries are not formalized and abusers are prosecuted under lesser charges, say, misdemeanors rather than felonies.
“What researchers have learned from combat soldiers and football players and car accident victims is only now making its way into the domestic violence community: that the poor recall, the recanting, the changing details, along with other markers, like anxiety, hypervigilance, and headaches, can all be signs of TBI” (p. 70).
Now the ultimate confronting fact: Strangulation often is the next to last abuse by a perpetrator before a homicide. The correlation is strong, very strong. Strangulation is a much more significant marker than, say, a punch or kick that the abuser will escalate to lethal violence. Strangulation dramatically increases the chances of domestic violence homicide (p. 66).
This leads directly to an important innovation in the struggle against DV, the Danger Assessment. Jacquelyn Campbell has quantified the Danger Assessment, which is especially effective when combined with a timeline of incident. In addition, to strangulation high risk factors in any combination that portend a potential homicide include: gun ownership, substance abuse, extreme jealousy, threats to kill, forced sex, isolation from friends and family, a child from a different biological parent in the home, an abuser’s threat of suicide or violence during pregnancy, threats to children, destruction of property, and a victim’s attempt to leave anytime within the prior year. Chronic unemployment was the sole economic factor (p. 65). None of these cause DV; but they make a bad situation worse – much worse – and add to the risk of a fatal outcome.
You can see where this is going. First responders, police, medical professionals, family, friends need to ask the tough questions – perform the assessment and have a safety plan ready to implement to get the potential victim out of immediate danger. Hence, the need for Snyder’s important book and its hard-hitting writing and reporting to be better known at all levels of the community.
Snyder reports on a second important innovation in the struggle against DV: the Fatality Review Board (FRB) for DV Homicide. Air travel has become significantly safer thanks to the Federal Aviation Administration commitment to investigate independently every airplane crash. The idea is to find out what sequence of things went wrong without finger pointing. No blame, no shame. The idea is to perform an evidence-based assessment of all aspects of the system – human, administrative, mechanical, procedural.
In a breakdown big enough to cause loss of life, multiple errors, anomalies, and exceptions are likely to have occurred in the system. Rarely is there is single cause of a disaster big enough to cause loss of life. “If systems were more efficient, people less siloed in their offices and tasks, maybe we could reduce the intimate partner homicide rate in the same way the NTSB [National Transportation Safety Board] had made aviation so much safer” (p. 85). The Fatality Review Board is born.
For example, the authorities knew the perpetrator. They had visited the home multiple times. The abuser was released from detention without notifying the potential victim. An order of protection was denied due to a paperwork error, or, if granted, the police could not read the raggedy document that the woman was required to have on her person at all times. The prosecutor was unaware of a parallel complaint by the victim’s mother because it was filed in the same docket and dismissed when the victim recanted in the hope of placating the abuser and saving her own life.
For example, multiple touch points occur at which victims and perpetrators interact with social services, healthcare facilities, community organizations, the veteran’s administration, law enforcement, and the clergy. The FRB is tasked with determining how the fatal outcome could have been avoided.
Chase down all the accidental judgments, missed cues, and blind spots. Talk to everyone able to talk. Gather all the data. Someone knew something, had actionable information that was not acted upon. Formulate recommendations to avoid repeating the mistakes.
That means building formal lines of permissioned communication between administrative siloes. For example, there as a restraining order against the abuser but it was in another state and the local authorities did not know about it.
In the age of the Internet there needs to be a central clearing database that preserves such data. Or, for instance, the shooter had no criminal record, but the victim had expressed fear for her life to the local pastor at church based on his statements. Who can he (or she) call? Who can intervene with a safety plan?
No one single factor can be singled out as causing the fatality; instead a series of relatively small mistakes, missed opportunities, and failed communications. The FRB looks for points where system actors could have intervened and didn’t or could have intervened differently (p. 86). Today more than forty states now have fatality review teams. Though the violence continues, this is progress.
Snyder makes an important contribution in clarifying why the victim does not run leave the abuser and the abusive relationship. Why does she return to the abuser, or recant her testimony in the police report, frustrating the attempt of the prosecution to get a conviction?
Though every situation is unique, Snyder builds a compelling narrative that often the victim is trying to save her own life. The system works much slower than a determined abuser, and the victim knows it. In short, the abuser knows how to work the system; and all-too-often the victim cannot rely on the system to protect her when she most needs protection. In addition, her judgment may be impaired due to being called every name in the book and slapped, punched, or strangled.
As the abuser senses he is losing power and the victim is getting ready to leave, the risk of violence to regain control escalates. The abuser is strangling her, escalating to deadly violence, and yet he is charged with a misdemeanor. He will be out on $500 bail in 24 hours – buying a gun and gasoline to burn down the house after killing her and the children. In fear for her life, the victim is makes up a story about love to try to placate the abuser – she is recanting to try to buy time – while she accumulates enough cash or school credits to escape and have a life. The victim recants her narrative in the police report and says she loves him because she wants to live.
A third major strong point of Snyder’s work is her report on interventions available for abusers. Incarcerating an abuser to protect the community is necessary. But that does not mean the abuser does not need treatment. He does. Absent treatment, jail just makes the abuser worse. The entire middle section of the book is devoted to the dynamics of perpetrator treatment.
At another level I found Snyder’s deep insight to be an extension of Simone de Beauvoir’s assertion circa 1959 that woman is not a mere womb. The enlightened man adds to de Beauvoir’s statement (which is notquoted by Snyder): man is not mere testosterone. In both cases, biology is important, but biology is not destiny. I repeat: biology is not destiny. Some men have not been properly socialized and need to get in touch with and transform their inner uncivilized cave man.
The recovery programs in jails on which Snyder reports sound rather like “boot camp” to me. The emphasis is on “tough love.” This is a function of the close association, if not identification, of masculinity with violence.
In some communities, violence is how masculinity gets expressed. This extends from “big boys don’t cry” and if he hits you, hit him back all the way to a misogynistic gangster mentality that uses devaluing language to describe woman as basically existing for the sadistic sexual satisfaction of men. It may also be common (and justified!?) in a military context. As near as I can figure – and this is an oversimplification – the treatment groups are given lessons in cognitive or dialectical behavioral therapy: skills in emotional regulation, distress tolerance, self-soothing, and interpersonal negotiations.
For those perpetrators, not incarcerated or suffering from post traumatic stress disorder (along with their victims), but rather brought up in relative privilege or affluence, Snyder has less to say. While the poverty, crime, and substance abuse of the inner city can intensify DV, DV is an equal opportunity plague, occurring in affluent neighborhoods too. Only here we are dealing with “snakes in suits” – think: Harvey Weinstein or Bill Crosby (“date rape” drugs) [granted, these individuals were sexual predators, not necessarily DV perpetrators]; perpetrators who are quite sophisticated in using the system to isolate and disempower their victims financially, legally, emotionally as well as physically (violently). This is an incompleteness rather than a flaw in an otherwise compressive study. Another chapter – or book – may usefully be written about DV scenarios among the rich and famous – or at least affluent. DV lives there too.
On a personal note, when I started reading this book, I knew it was not for the faint of heart. I said to myself: “Ouch! This is like the ‘ketchup scene’ in Shakespeare’s Hamlet.” At the end of Hamlet, the entire family gets killed. To deal with something as disturbing (and hope inspiring) as Snyder’s book, I had to go to Shakespeare.
Indeed Hamlet begins with domestic violence. Hamlet’s uncle kills his own brother, Hamlet’s father, to seize the throne by marrying Hamlet’s mother. The latter is not technically DV, but a boundary violation. (This is the original Game of Thrones if there ever was one.) In turn, Hamlet perpetuates verbal and emotional abuse, whether fake insanity or genuine narcissistic rage, against his fiancé, Ophelia. Hurt people, hurt people. Sensitive soul that Ophelia is, she commits suicide. Ophelia’s brother then seeks revenge. Hamlet kills her brother as the brother simultaneously kills Hamlet with a rapier tipped with a deadly poison. The mother drinks the poisoned goblet, intended for Hamlet, and the uncle is run through by Hamlet – also with the poisoned rapier. The point?
Horatio’s provides a summary at the backend of Hamletwhich also forms a review of Snyder’s work: “So shall you hear – Of carnal, bloody, and unnatural acts – Of accidental judgments, casual slaughters, – Of deaths put on by cunning and forced cause, – And, in this upshot, purposes mistook, – Fall’n on the inventor’s heads. All this can I truly deliver.” Just so.
All too often the events seemed to me to unfold like a Greek tragedy – or in this case a Shakespearian one. You already know the outcome. The suspense is enormous. You want to jump up on the stage and shout, “Don’t open the door – therein lies perdition!” But everything the actors do to try to avoid the tragic outcome seems to advance the action step-by-step in the direction of its fulfillment.
Snyder provides a compelling narrative – and actionable interventions – of how to interrupt the seeming inevitability and create the possibility of survival and even, dare one hope, flourishing.
Wilson, K. J. (1996 ). When Violence Begins at Home: A Comprehensive Guide to Understanding and Ending Domestic Abuse, 2ndEdition. Alameda, CA: Hunter House (Publishers Group West).
Websdale, Neil. (1999). Understanding Domestic Homicide. Northeastern University Press.
Campbell, Jacquelyn et al. (2003). “Risk Factors for Femicide in Abusive Relationships: Results from a Multisite Case Control Study. American Journal of Public Health93, no. 7 (July 2003).
Agosta, Lou. (2012). A Rumor of Empathy at Apna Ghar, the Video: https://tinyurl.com/y4yolree [on camera interview with Serena Low, former executive director of Apna Ghar about the struggle against DV]
Agosta, Lou. (2015). Chapter Four: Treatment of Domestic Violence inA Rumor of Empathy: Resistance, Narrative and Recovery in Psychoanalysis and Psychotherapy. London: Routledge.
(c) Lou Agosta, PhD and the Chicago Empathy Project
Review: Mind Fixers by Anne Harrington
In spite of the many patients who have been helped to lead emotionally stable, more productive lives thanks to two generations of psychopharmacological medicines, psychiatry is facing an ongoing challenge of its foundation and legitimacy. That is the take-away in Anne Harrington’s Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness (W.W. Norton, 2019, 366 pp., $27.95).
So what is the “trouble” with the “troubled search”? Thereby hangs the tale. The optimistic biological psychiatry of the 1980s and 1990s is beginning to unravel in the new millennium. Harrington’s is an equal opportunity debunking.
All the new drugs that eventually displaced the Freudians, whose pride in the 1950s through 1980s preceded their fall, were developed during that period of time. “All
the major categories of drugs still used today in psychiatry were discovered then [….] no minds were changed that did not want to be changed” (p. xvi).
Meanwhile, in 2013 some thirty years after the biological psychiatrists declared victory, Thomas Insel, Director of the National Institute of Mental Health (NIMH), reported with concern that all of psychiatry’s diagnostic categories were still based, not on biological markers of disease, but “on a consensus about clusters of clinical symptoms.” This was, according to Insel, “equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever” (p. xv).
With a characteristic dry wit, Insel concludes that biology never read the DSM. If this was supposed to be the biological underpinning of psychiatry, the firm foundation was more shifting sand than any might wish.
The really troubling thing that I learned from Harrington is not that drug companies have become less an “engine of innovation” than a “vast marketing machine.” That is already widely appreciated by anyone who has not been living in a cave – including most psychotherapists, psychiatrists, and front line medical doctors.
Harrington’s reasoned, documented, and compelling narrative contains the ultimate smack down: “many psychiatrists, having tethered so much of their identity to drugs and prescribing rights, sold their services to the drug companies” (p. xviii). This remains the blind spot of the profession, even among those who acknowledge the dilemma. If you make a deal with the devil, be sure to read the find print.
The blind spot becomes a black hole as the gravitational pull, in this case of revenue, prevents practitioners from escaping, even though they really want to talk with their patients at the length needed to figure out what is actually troubling them.
The breaking news? What is less well known is that Big Parma is now nearly flat out stopped in its quest. The quest to find the biological foundations of mental illness is on a slope of diminishing return; and Big Pharma seems to be abandoning the search. This does not mean that there will not be copycat drugs of medicines coming off patent or new variations on old themes. To my mind, this development needs to be better known and debated.
Another former NIMH director, Steven Hyman, comments on the abandonment of the field by the pharmaceutical industry: “the underlying science remains immature and . . . therapeutic development in psychiatry is simply too difficult and too risky” (p. xv).
In a separate email communication with Harrington, Hyman writes: “When [pharmaceutical] companies were told they had to compare new drugs not only to placebo but to an existing drug known to be efficacious, or have a predictive biomarker to gain approval in Europe – their response was ‘we don’t know how to do that.’ . . . In essence the EMA [European Medicines Agency] called their bluff” (p. 266).
Full disclosure: in my own training as part of the Committee on Research and Special Topics (CORST) at Rush Medical University in the 2010-2012 time frame, all my teachers, the psychiatrists, without exception, made us memorize the generic name for the medications so as not unwittingly to give publicity to the brand name of the drug companies.
While acknowledging that the medicines often helped, the teachers sensed – indeed knew – something was off the rails. Thus, they expressed their disdain for the monopoly rents of Big Pharma (though not using these exact words). Yet, for so many reasons, they continued to turn the crank as rapidly as possible in prescribing the pharmacological interventions that were the prevailing paradigm. No alternative paradigm was visible.
How could this happen? The irony is that, at a high level, the biological psychiatrists made the same mistake as the Freudians. It is a “pride that goeth before the fall” moment, and notwithstanding selected voices of moderation, both sides came to embrace a position that no one else but us (really) knows anything about anything.
Harrington’s ultimate analysis of the unraveling of the optimistic biological psychiatry paradigm of the 1980s: “I argue that this happened, not just become the gap between hype and the state of scientific understanding was too great to bridge (though it was), but also because of a critical error that the original revolutionaries had made. Instead of reflecting on the extent to which the Freudians had lost credibility by insisting that they could be experts on everything, the new generation of biological revolutionaries repeated their mistake: they declared themselves thenewexperts on everything. No one suggested that it might be prudent to decide which forms of mental suffering were best served by a medical model, and which might be better served in some other way. Revolutionaries don’t cede ground” (p. xvii).
Harrington’s narrative is a page turner, even for those who already know the details and the usual suspects, extending from Charcot’s ground breaking work and monumental self-deception, Emil Kraeplin’s distinction between thought disorder and mood disorder, Karl Jasper’s “brain mythology,” the psychoanalysts domination of psychiatry, through the fever cure of Julius Wagner-Jauregg, John Cade’s lithium salt discoveries, the dancing tuberculosis patients responding to iproniazid (complete with a photo from Life Magazine, 1952), the human rights violations, “operation icepick” of Walter Freeman (and James Watts), Ugo Cerletti’s electroshock machine, the breakthrough to the chemical lobotomy of chlorpromazine, the emptying of the asylums, the broken promises, the litigation faced by Chestnut Lodge, the appalling case of Rose Kennedy, listening to Prozac, anti-psychiatry, the accidental judgments, the good intentions gone bad, and, in the upshot, purposes mistook and fallen on the inventors’ head. All this does Harrington truly deliver.
The narrative left me wondering whether we are not living through another period of brain mythology. Granted the account of neurotransmitters, of serotonin and/or dopamine imbalance, can be traced down to neural synapses, science is at the effect of a massive correlation versus causation fallacy. The voodoo correlations in fMRI research support the colonization of vast areas of the social sciences and humanities by neurophilosophy, neuromarketing, neurolaw, neurohistory, neuroaesthetics, and so on. But enough of my cynicism and resignation.
What are the possibilities going forward? Is an alternative paradigm coming into view? Though Harrington’s recommendations are combined in a section on Afterthoughts that left me wishing for more, what she does offer are powerful and on target. Still, after having spent so much time and effort telling the tortured tale of psychiatry’s rise and looming fall, will the profession be willing to listen to her call for “an act of great professional and ethical courage” (p. 273)?
Her recommendation is to cut scope. Given the lack of underlying science, this also implies expanded modesty about psychiatry’s entitlement to power, authority, and market boundaries. Positively expressed, renew the commitment to engaging with the most severe forms of mental illness and leave the routine care of the “worried well” and support for the mentally ill to other professionals. “
Harrington: “The new psychiatry I am envisioning could also aim to overcome its persistent reductionist habits and commit to an ongoing dialogue with the scholarly world of the social sciences and even the humanities [….] [E]ven as it [psychiatry] retains its focus on biological processes and disease, it seeks to understand ways that human being functioning, disordered or not, is sensitive to culture and context (as the recent crisis over the placebo effect in psychopharmacology […] has likely shown)” (pp. 275 – 276).
Harrington calls for interdisciplinary collaboration on a “pluralistic, powering-sharing approach” (p. 274). Make it a priority to overcome the position that “the knowledge and practices of all the nonmedically trained workers are by definition subordinate to those of the medically trained ones” (p. 274). This would help to close the credibility gap suffered by the psychiatric establishment as a result of the shameful ways of deinstitutionalization in the 1960s and ‘70s led to homelessness, incarceration, and premature death (pp. 274 – 275).
I can hear psychiatrists saying, off camera, we too were blindsided, we too did not know. That may indeed be the case, but professional psychiatry has been left holding the smoking chlorpromazine gun. A major tranquilizer and a highly useful one; but nothing like insulin that a diabetic would contemplate taking for lifetime due to a specific disease that leaves the patient deficient in insulin. Begin the process of rehabilitation by acknowledging the solid social science research that shows many people with serious mental disorders benefit far more from being given their own apartment and access to support communities than a script for new or stronger antipsychotic (p. 275).
Harrington makes a powerful case that general practitioners and psychiatrists are perpetuating a fiction that the drugs they are prescribing are correcting biochemical deficiencies caused by disease, much as (say) a prescription of insulin corrects a biochemical deficiency caused by diabetes (p. 273). Such rhetoric is badly oversold. Harrington does not say that the medicines do not help the person tolerate distress, regulate emotions, or self-sooth. Often they do. If one is going to step in front of a bus, far better to take the medicine. Live to fight another day.
Given the complexity of the scientific challenges, psychiatry need not feel embarrassed. However, neither should it be zealously promoting imminent breakthroughs and revolutions as if it were an adjunct to the popular press or a corporate press release.
Harrington makes the case that the underlying science is not anywhere near the level the neurohype would have us believe. “You have a chemical imbalance” is a marketing position, not a scientifically established truth. “Schizophrenia is like diabetes and you have to take this antipsychotic drug for the rest of your life” is a rhetorical position, not a scientific fact. This is scientism, not science. This is psychiatry’s troubled search for the biological basis of mental illness.
(c) Lou Agosta, PhD and the Chicago Empathy Project
Review: Narrative Exposure Therapy – and empathy
Narrative Exposure Therapy (NET) was originally designed as a treatment for victims of war, persecution, and torture. Civil wars (e.g., Rwanda, Burundi, DR Congo, Iraq) often target civilians and include widespread atrocities and human
rights violations. For example, the widespread use of rape as a weapon of war and the recruitment of child soldiers in the civil wars of east Africa have left entire populations traumatized even after the cessation of hostilities.
Engaging with these survivors is not for the faint of heart. Therapists are at risk of compassion fatigue and burn out. Many survivors have had to run the gauntlet of multiple, complex traumas, requiring a raid on the inarticulate even to bring their suffering to language. NET is such a raid on the inarticulate.
The colleagues at the Universities of Konstanz and Bielefeld have innovated in the matter of an intervention that aims at restoring the survivor’s humanity, does not leave the therapist overwhelmed, is scalable, is relatively brief, indirectly gathers data to pursue justice against the perpetrations, and is evidence-based in reducing the symptoms of post traumatic stress disorder (PTSD) even in populations with limited resources.
In a Grand Rounds session on NET at Rush Medical Center, Chicago, in March (2019), I raised the issue of empathy and the risk of burn out with Dani Meyer-Parlapanis Doctor of Psychology, University of Konstanz). Dr Dani is notone of the authors of the text under review here. However, she trains NET practitioners and is providing leadership in extending NET to other applications, including girls and women who embrace violence. I said to her: “If this is not empathy, I would not know it: Empathy LIVEs in NET and in the work you-all are doing. You are engaging with child soldiers and really tough cases. What about it?”
Dr Dani of course acknowledged that compassion fatigue (“burn out”) was a significant risk in engaging with large numbers of survivors of complex trauma, so the NET trainers, are, in effect, counseling the lay counselors notto go into unnecessary detail at first (or words to that effect). Just get the time-line and a label for what happened. But then acknowledging full well that the work was precisely to go into the details she said: “The idea is to be like an investigative reporter.” Though acknowledging the matter may be controversial, I took that to mean empathy in the sense of data gathering and sampling the survivor’s experience, not immersing oneself in it. The investigative reporter is not hard-hearted, but in tune with what the survivor is experiencing. That indeed is the heart of the investigation.
Thus, “empathy” is distinct from compassion. Empathy targets a form of data gathering about what the other person experienced, a sampling of the other’s experience. Such empathy is in tune with the boundaries between self and other and leaves each individual whole and complete in a context of acceptance and toleration. I believe the definition of empathy of Heinz Kohut (1959) as vicarious introspection aligns remarkably well with that employed in NET.
In the face of compassion fatigue, dial empathy up or down by simulating the role of an investigative reporter. If one can say exactly what happens, the trauma begins to shift, lose power, and shrink, typically by being reintegrated in the context of everyday life and experience. In this case, the investigative reporter also uses vicarious introspection. Easier said than done; but necessarily both said and done.
The reader in Chicago may say that’s fine, but what has it got to do with the situation here in the USA? We do not have child soldiers or wide spread traumatized populations.
Think again. Gangs are recruiting children of tender age not only as messengers but also as triggermen, because they know youngsters will face a different criminal justice system and process, generally more lenient, than adults.
After two wars, stretching back to the consequences of the 2001 terrorists attacks, the population is peppered with wounded warriors, both men and women, with a diversity of untreated symptoms from subclinical substance abuse to PTSD, thought disorders, and depression. Violence against (and abuse of) women is no longer an issue in the inner city, but is acknowledged to be a challenge from Hollywood to corporations and the US Supreme Court.
So, while NET has not received much application in the USA (or the first world), the unmet need is great and it deserves consideration. Hence, the value of this overview.
In some four to fourteen sessions of 90–120 minutes each, the therapist and client create an autobiographical time-line that names the events that have stimulated the most affective arousal in the person’s life. These include traumatic events such as aggression, sexual boundary violations, deaths of loved ones, becoming a refugee, and so on. Positive events are also included on the time-line such as births, marriages, graduations, and life successes. Fast forwarding through the process, the client is handed a copy documenting the narrative at the end of the sessions and a copy is retained just in case the client wishes/agrees to submit the report to the authorities for judicial, prosecutorial follow up.
One of the innovations and most challenging aspects of the narrative in working with former child soldiers (who have grown up in the interim) is to create a context of acceptance and tolerations. Naturally the therapist must employ empathy, but he or she does so as an investigative reporter gathering data about what happened. To become a child solider the survivor is generally required to commit an atrocity such as kill a member of his or her family. Issues of shame and guilt along with the deadening loss of one’s own humanity are powerfully present and evoked.
The first session begins. Diagnosis and psycho-education occur up front. The client may not even know what is PTSD. The client may be living a basically resigned and hopeless existence, and she or he must be enrolled in the possibility of recovery. The education includes information on symptoms, what is involved in the therapy, as well as a statement about the universality of human rights.
An initial pass through the client’s autobiography occurs. A time-line, the life span history, is completed during the second session. The task is to name or label the event in the course of one 90–120 minute session without calling forth the details and hot emotional impact of the traumatic incident. A rope line is used with a variety of stones for traumas, flowers for positive events, and sticks for when the client perpetrated a dignity violation against another. The subsequent work of sessions three through fourteen is to engage sequentially with the events. The work at hand is to find words to express what has previously been unexpressible.
The narrative work consists of going through the events of the time-line. When? Where? And what? The five senses are invoked. Hot memory, sensation, cognition, and emotion are called forth. What did the background look like? What were the people wearing. Small, cold details call forth powerful hot emotions.
The idea is to put into words and capture verbally the hot affect and experience. The session is not over until the client (often with the support of the therapist) is able to describe what happened in words – that is the narrative.
Now “what a person made it mean” also starts to emerge at this time, and those meanings will naturally be compared with reasonable (or unreasonable) assessments of what to expect of children or people literally with a gun or machete to their necks.
Talking about what happened in the course of the traumatic events calls forth the hot experiences. Talking about what happened following the traumatic events put the hot events back into the context of cold experience. Talking about what happened following the trauma enables the client to reintegrate the trauma into the all-encompassing, greater life narrative. The client is reoriented in time and space to the present, the trauma is contextually situated as to emotional meaning. Before the session ends, the therapist verifies and validates that the client’s arousal has subsided to standard levels and is oriented to the present.
Cognitive restructuring occurs automatically in the days after the story telling. The client may return to the next session with new insights, meanings, and understanding of her or his own behavior in the trauma. Formerly inaccessible details (memories) may emerge and should be included in the narrative.
For example, one child soldier reported that he killed his sister by cutting her neck with a machete as part of the initiation, for which he bore a great emotional and moral burden; but he subsequently remembered that one of the paramilitaries hit his sister in the head with his rifle butt, a fatal blow, prior to his own action. Therefore, though he did in fact cut his sister, he did not kill her. Small comfort; and not a choice anyone should have to make; yet a significant step in recovering this individual’s dignity and humanity.
In the final session, the client is given a document of her or his narrative lifeline with the details filled in. Where appropriate, the client is asked if he wants to forward the data to the authorities for prosecution of the high level authorities and perpetrators who organized the war crimes. Follow up occurs at six months and a year, often documenting further improvement in symptom reduction, acquisition of life skills, and accomplishments.
NET is trauma focused but unlike many trauma focused therapies that require the survivor to identify thetrauma or select the worst trauma (“good luck with that”), NET acknowledges that survivors of war, torture, and persecution have encountered a sequence of traumas. This is call a “life span” approach.
Granted NET evokes a grim calculus, the number of traumatic event types – beating, rape, killing, torture, branding, amputation, witnessing these, destruction of home by paramilitaries, domestic violence and/or substance abuse by family member, perpetrating or participating in these, and so on – predicts the symptoms of PTSD over and above the actual number of traumatic events.
The results? Studies showing the effectiveness of NET have been independently conducted (Hijazi et al 2014, Zang et al 2013). Centrum 45 in the Netherlands and the Center for Victims of Torture in Minnesota use NET in treating survivors and refugees. NET manuals are now available in English, Dutch, French, Italian, Slovakian, Korean, and Japanese and are also available from the authors in Spanish and Farsi.
Further detailed evidence of the effectiveness of NET is at hand. Reorganizing traumatic memories seems to be inherently stress reducing. Chronic stress causes a weakening of the body’s resilience and defenses against disease and emotional disorder. Reducing stress improves one’s health and well-being. “Morath, Gola et al. (2014) showed that symptom improvements caused by NET were mirrored in an increase in the originally reduced proportion of regulatory T cells in the NET group at a one-year follow-up.” “These cells are critical for maintaining balance in the immune system and regulating the immune response to infection without autoimmune problems. This finding fits with the observation that NET reduces the frequencies of cough, diarrhea, and fever for refugees living in a refugee settlement (Neuner et al. 2008, Neuner et al 2018).”
NET works. NET produces positive results for those suffering from PTSD. This brings us to the question: Why does it work? Thereby hangs a tale – and a theory.
NET conceptualizes PTSD and related disorders as disorders of memory.
For example, hot memories include the sounds of people screaming for help, the sight of dead or wounded persons, the smell of the perpetrator pressing his body against the victim, the taste of one’s own vomit, the experience of being unable to move and helplessness, and so on. These are “hot memories.” These occur or occurred in a context of coldmemories of place, time, and standard activities.
For example: “We were working in the garden behind the house when the paramilitaries drove up in a truck.” In the case of an individual trauma or series of traumas of the same type, as a defensive measure to preserve the integrity of one’s personal experience, the individual may take himself out of the situation in thought automatically, watching and experiencing the situation as if he was an observing third party. How this occurs is not well understood, but it seems to support survival of the organism in extreme situations.
This disconnects the “hot” and “cold” contexts. In the case of an individual surviving multiple trauma types, beating, rape, loss of home, the cumulative traumatic load causes the traumas to be grouped into a network disconnected from the standard, cold context of everyday life. Fear generalizes forming a fear network. Emotional, sensory, cognitive and physiological representations interconnection with the excitatory force of hot memories. Ordinary, random events become triggers of this network.
The trauma LIVEs. It takes on a life of its own as the fear network. PTSD survivors learn to avoid triggers that act as activators of hot memories. The client isolates. He or she has difficulties with the cold context of autobiographical memory. A negative cascade of experiences is mobilized as symptoms suck the life out of the individual, leaving him or her as an emotional zombie. “Shut down” replaces intrusive thoughts and hyper-arousal with passive avoidance and disassociation.
The effectiveness of NET consists in reestablishing the connections between hot and cold memories, the hot traumatic events and the cold, everyday occurrences that situate them in place and time. In a context of acceptance and toleration (i.e., non-judgment and empathy), the client is supported in reliving the details of what happened by putting them into words without losing the connection to the here and now. If one can say what happened, the emotion is called forth and reintegrated into the context of the person’s life. The trauma starts to shrink.
The imagined exposure to the traumatic event is maintained long enough for the affect, especially the fear, to be called forth and allowed to begin to fade in intensity. The narrative is essential. Absent words, retraumatization – invoking the trauma in an uncontrolled way – is the risk to the client. Even if time is running short, the session must not end until the client (with the help of the therapist (as appropriate)) has found some words to describe what happened. (If the trauma involves organized or domestic violence, the testimony may be recorded or documented for forensic purposes.)
Two of the strengths of NET are the low drop out rate and the scalability due to building a network of lay therapists. Lay therapists?
The World Health Organization endorses this approach for those communities with limited resources (Jordans, Tol 2012). Given the limited resources of third world countries or even many communities in the USA due to the monopoly-like rents being collected by healthcare insurance providers, NET embraces “task shifting.” “Task shifting” consists in training lay therapists to perform the intervention.
Regarding the training and use of lay therapists to deliver NET, it is scalable, affordable, and workable. It is also controversial. In the State of Illinois (USA) one needs a license to cut hair. However, so far as I know, one does not need a license to have a structured conversation for possibility with another human being about what they had to survive. No doubt the graduates of PsyD programs may have an opinion about that; but personally having taught in two PsyD programs, I know the dedication, commitment, and hard work of the students and teachers; and I also know that one cannot take a course entitled (or with the content of) “empathy lessons” or with “empathy training” in any of these programs. I know because I proposed to do so, but it simply did not get approval due to other priorities.
NET offers significant potential not only to treat PTSD survivors of violence and trauma. Anxiety and panic disorders, depression, eating and substance abuse disorders, borderline personality disorder (BPD), all report intrusive memories filled with upsetting content but lacking cold memory context.
One final thought. Those suffering from PTSD are suffering from reminiscences – disorganized, toxic memories. The astute reader may recall this is what Freud said, in slogan-like sound byte, about hysteria (Breuer, Freud 1893). Each memory has to be transformed into words, into a narrative. Each memory has to be expressed in speech so that the body no longer has to function as the corporeal narrator in flashbacks, startle response, panic attacks, intrusive ideas, emotional numbing and overstimulation. Narrative exposure therapy gives new meaning to the phrase “the talking cure,” and it is one. How shall I put it delicately? My “French” fails me: The more things change, the more they stay the same.
Breuer, Josef and Freud, Sigmund. (1893). Studies on Hysteria. Translated from the German and edited by James Strachey. (The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. II.) Hogarth Press, London 1955.
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Jordans, M. J., & Tol, W. A. (2012). Mental health in humanitarian settings: Shifting focus to care systems. International Health, 5(1), 9–10.
Kohut, Heinz. (1959). Introspection, empathy, and psychoanalysis. Journal of the American Psychoanalytic Association7. (July 1959): 459–407.
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Neuner, Frank, Elbert, Thomas, Schauer, Maggie. (2011).Narrative Exposure Therapy: A Short-Term Treatment for Traumatic Stress Disorders, 2ndEdition, Göttingen, Germany: Hofgrefe Verlag.
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(c) Lou Agosta, PhD and the Chicago Empathy Project