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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
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.
Hijazi, A. M., Lumley, M. A., Ziadni, M. S., Haddad, L., Rapport, L. J., & Arnetz, B. B. (2014).Brief narrative exposure therapy for posttraumatic stress in Iraqi refugees: A preliminary randomized clinical trial. Journal of Traumatic Stress, 27(3), 314–322. https://doi.org/10.1002/jts.21922
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.
Morath, J., Gola, H., Sommershof, A., Hamuni, G., Kolassa, S., Catani, C., … Elbert, T. (2014).
The effect of trauma-focused therapy on the altered T cell distribution in individuals with PTSD: Evidence from a randomized controlled trial. Journal of Psychiatric Research, 54, 1–10. https://doi.org/10.1016/j.jpsychires.2014.03.016
Neuner, F., Onyut, P. L., Ertl, V., Odenwald, M., Schauer, E., & Elbert, T. (2008). Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 76(4), 686–694. https://doi.org/10.1037/0022-006X.76.4.686
Neuner, Frank, Elbert, Thomas, Schauer, Maggie. (2011).Narrative Exposure Therapy: A Short-Term Treatment for Traumatic Stress Disorders, 2ndEdition, Göttingen, Germany: Hofgrefe Verlag.
Neuner, Frank, Elbert, Thomas, Schauer, Maggie. (2018).Narrative Exposure Therapy (NET) as a Treatment for Traumatized Refugees and Post-conflict Populations: Theory, Research and Clinical Practice. 10.1007/978-3-319-97046-2_9.
Zang, Y., Hunt, N., & Cox, T. (2013). A randomised controlled pilot study: The effectiveness of narrative exposure therapy with adult survivors of the Sichuan earthquake. BMC Psychiatry, 13(1), 41. https://doi.org/10.1186/1471-244X-13-41
(c) Lou Agosta, PhD and the Chicago Empathy Project
I am catching up on my reading. Christine Ann Lawson’s Understanding the Borderline Mother is a classic in its field, with a whopping 396 Amazon reviews (Q1 2019), enjoying a rating of 4.7 out of 5.0. Impressive. (See the bottom of this review for bibliographic information on the book .)
Numerous readers have remarked that this book opened their eyes to what they had to survive growing up. These survivors were not bad,
crazy, or broken in the way they were led to believe by what was fundamentally an invalidating child-rearing environment. The vignettes and analyses in Lawson’s book provided them with a transformational “Ah ha!” moment. For many survivors this was a tad like Saul becoming Saint Paul on the road to Damascus – a bolt of lightening out of the blue. They then could begin the hard work of incremental change needed to restore the self-soothing, emotional regulation, and distress tolerance capabilities needed to feel like whole persons again – or for the first time ever.
So up front and considering this is not a “soft ball” review, I acknowledge the importance of Lawson’s contribution and recognize that her work made a profound difference for many survivors. It is especially important to keep that in mind, given that I express significant reservations and criticisms.
The technical details? The borderline personality disorder (BPD) gets precisely defined as a psychiatric entity in 1980, entering the third version of the Diagnostic and Statistical Manual (DSM-III). However, long before that signal event “borderline” was understood to be a person whose personality structure (or lack thereof) is characterized by a compensatory but problematic defensive structure that guards against a psychotic breakdown.
Here “psychotic” means “out of touch with everyday reality.” The implication was that such borderline individuals were at risk of completing losing contact with the world of everyday life, decompensating into a full-blown psychotic breakdown. In particular, if the borderline person were treated with psychoanalytic methods, itself encouraging a mild form of regression back to the childhood fixations, whether real or imagined, the risk was of causing the borderline treatment to “go off the rails” into explicit mental illness. In a different, allegedly humorous context, the description “borderline” has come to mean that the patient is hard to work with, difficult, or simply “the therapist doesn’t like the patient.”
A bit more background will be useful. Innovations in treating personality disorders by Heinz Kohut, MD, including new forms of transference such as self-object transference, made narcissistic personality disorders (NPD), arguably on a continuum with borderline personality in a pre-1980 sense, accessible to psychoanalytic methods. (See footnote  below.) However, NPD remains distinct from BPD. The treatment of NPD is relevant here since the children of BPD parents do not necessarily acquire BPD themselves, but sometimes suffer from a pervasive narcissistic vulnerability.
In contrast with Kohut’s deficit model of the narcissistic self, Otto Kernberg, MD, developed a formulation that posited actual defects in the structure of the borderline personality – aspects that were not merely missing but broken. The resulting borderline behaviors need to be confronted and rooted out by a kind of “tough love” on the part of the therapist.
Meanwhile, Marsha Linehan, PhD, a self-styled radical behaviorist, is the innovator who created a treatment approach called “Dialectical Behavioral Therapy” (DBT) that often is effective in treating BPD while other approaches have been [are] less successful. No short description of Linehan’s program is available, but a suitable over-simplification may be useful: DBT combines cognitive behavioral therapy (CBT) within a framework that emphasizes mindfulness, empathic listening, and validation of the grain of truth in even the BPD person’s most perplexing distortions to restore the BPD individual’s capabilities for emotional regulation, distress tolerance, self-soothing, interpersonal skills, and self-esteem. DBT is not for the faint of heart and requires an entire team, including both one-on-one counseling and extensive work in groups. It is different than boot camp, but sometimes not by much. Substantial evidence-based, peer-reviewed publications support the effectiveness and validity of the approach.
Lawson, gets matters right with her use of Marsha Linehan, Heinz Kohut, Otto Kernberg, and Ernest Wolf, even when these innovators are not specifically addressing borderline personality disorder (DPB). As noted, Kohut and Wolf have done a deep dive on narcissistic personality disorders. In comparison to BPD, though related, neither the symptoms nor the treatments options are the same. This points to the hazards of broad-brush stroke labeling segments of suffering humanity, albeit with the worthy end of expanding our empathy and understanding for the survivors.
Lawson gets the Diagnostic and Statistical Manual(DSM) criteria right in terms of the BPD person’s fear of abandonment [“I hate you – don’t leave me!”], volatility of relationships, volatility of emotions, volatility of self-image, self-injurious (para suicidal) behavior, impulsivity and acting out, and physiological symptoms. People have different ways of expressing their suffering and the suffering of the BPD person can be intense, so engaging with them is not for the faint of heart.
One strong point. Lawson’s is perceptive in the use of Christina Crawford’s searing memoire, Mommy Dearest, about Christina’s Academy Award winning movie star mother, Joan Crawford (1905 – 1977). This paints a convincing picture of growing up with and surviving the BPD mother (in this case, Joan Crawford). Once again, such material is not for the faint of heart. It turns out that many Hollywood movie starts are good actors both in front of the camera on stage and off of it. “Acting” is different than “faking,” but to a child of tender age the distinction is not always clear. “All the world is a stage,” but when one is a child of tender age, one cannot simply walk out of the show if one does not like it or is being traumatized by it. The lives of the rich and famous are as susceptible to mental and emotional disorders as anyone.
The criticism? To generalize from the example of the tortured genius of Joan Crawford to the run-of-the-mill perpetrations, self-deceptions and manipulations of the standard, working class BPD mother is to go from the sublime to the ridiculous or at least to tear a passion to tatters. It makes for bad theatre, but then again so does real life. I would have liked to hear more about how Christina and her brother dealt with the worst of the perpetrations and escaped the disorder themselves, even if it did leave them with a pervasive narcissistic vulnerability.
Christina describes an invalidating environment, one of the principle causes of BPD. Yet she retained powers of self-expression and freedom that allowed her to overcome [some of] the worst consequences of her environment. This is not to say she did not suffer. She did. What made a difference? What enabled her to compensate – acquiring the distress tolerance, emotional regulation, and self-soothing skills in which mother was so dramatically lacking? Strange to say, maybe Christina got these life saving skills from the nuns at the religious boarding school where she was sent. No doubt the matter is more complex.
Thus, the help promised in the subtitle “Helping her children transcend the intense, unpredictable, and volatile relationship” is mostly targeted at the grown ups who have survived childhood with a BPD mother. It is not clear what such help would look like for a child of tender age other than to turn to the other parent, relative, or mentor-like friend of the family for the mirroring and recognition needed to acquire skills in emotional regulation, distress tolerance, and self-soothing. In some cases cited by Lawson, the abuses rises to a level at which intervention by the state (Children and Family Services) would be appropriate, though such is sometimes like going from the frying pan into the fire.
For example, Lawson’s examples of the mother who drowned her two children, strapped into their car seats in her SUV (Susan Smith (1994)), and the mother who shot her three children at close range (Diane Downs (1983)). These examples result in the reader feeling vicariously traumatized. I am not saying these are not horrific examples of criminality, insanity, or both. They are. I am saying these examples in the book are symptomatic of Lawson’s rhetorically “over the top” approach.
DBP is properly distinguished from manic depression (Bipolar I), post partum depression that reaches psychotic proportions, psychopathy, or paranoid schizophrenia. My concern is that Lawson gathers wide-ranging and provocative examples of trauma, deceptions, perpetrations, manipulations, lies, dangerous half-truths, and total nonsense – and attributes them to BPD. BPD is characterized by boundary issues – and violations – and so are the distinctions in this book.
In short, BPD mother is straight out of Grimm’s fairy tales – now the waif, now the hermit, now the queen, now the wicked witch. Well and good. This is not a treatise on fairy tales; yet Lawson misses the point about the uses of enchantment. To the child who is being weaned, the loving (not BPD!) mother who is temporarily withholding the breast in favor of a Sippy-cup, this standard mother suddenly seems like the devouring witch. She is now and will be the loving caretaker again once the crisis of weaning has passed, but with an enriched personality that includes both positive and negative aspects instead of the splitting and extremes of early childhood. In short, there is nothing wrong – but something is missing – empathy.
For example, Lawson does a nice job marshaling a nightmare and candidate BPD mother from the ancient Greeks, Euripides’ Medea. When Medea’s faithless husband, Jason, proposes to leave Medea for another woman, the gates of chaos are opened. In revenge, Media kills her children and the other woman. This is perhaps the literary origin of the expression “hell hath no fury like a woman scorned.” From another perspective, a common place exists that when people do not get the empathy or dignity that they feel they deserved, they become enraged. But this takes rage to new, heretofore unprecedented levels. Medea “acts out” her revenge with chilling effectiveness. Medea’s pending loss gets transformed into psychopathic, psychotic, criminally insane rage. Does anyone besides me think that to attribute such perpetrations to BPD would be overstating the case?
One of Lawson’s commitments is to expand the reader’s empathy for the child of a BPD mother. Of course, to the child it is not BPD. It is just behavior that leaves the child bewildered, confused, in semi-shock, or even traumatized. By definition, the diagnosis of BPD cannot be applied to anyone younger than adolescence. Personality disorders usually show up in puberty or adolescence.
The BPD person’s behavior is a study in invalidation, misuse, abuse, emotional disregulation, boundary issues, boundary violations, lack of empathy, lack of recognition, lack of mirroring, lack of response to the child as a whole person, and inconsistent, intermittent, low quality parenting. When the environment is sufficiently invalidating and the child lacks resilience or another sane adult model to help compensate, then the result can indeed be a perpetration of generational BPD.
Ultimately Lawson shocks, shifts, and shakes our complacency about BPD. She may even leave some vicariously traumatized by her narratives of child abuse and boundary issues. However, she fails to enhance our empathy with the BPD person by sensationalizing and “demonizing” the worst excesses of BPD.
I hasten to add that BPD can be described as lying a spectrum with demonic behavior. This is especially so if one is describing BPD from the perspective of the child of tender age. But, once again, that is the issue. The devouring witch of Hansel and Gretel is a representation of the standard mother who is withholding the breast from the child as the latter is being weaned. But the standard mother is usually not suffering from BPD.
The fairy tale narrative informs our empathy with the child. Within the story, the story teller inspires empathy with the children (Hansel and Gretel) such that it seems to them alternatively like a death sentence by starvation, leaving a hunger big enough to eat a house (which is how the children first encounter the gingerbread house). It is of course neither of these, but the narrative enables the grown up empathically to get inside the child’s experience.
The issue with Lawson’s book is that it does not distinguish between BPD, child abuse, and criminality. Yes, BPD mothers’ relationships with their children sometimes cross the boundary between “mere” BPD and even more severe forms of loss of reality testing, psychosis, and sheer insanity. However, BPD is distinct from narcissistic exploitation, manipulation, and criminality. It takes more than BPD to produce the kinds of horrific results that occur when a parent murders her child, but we only hear about BPD as if it were the only “cause.”
No one is endorsing using a child as a narcissistic extension of the parent’s defective grandiosity. The mental health consequences of the latter are severe, especially when occurring habitually. No one is endorsing everyday, run-of-the-mill bad parenting. There is not a lot of good news here. However, all these failings are different than child abuse and criminality.
Lawson rides the slippery slope from perpetrations and emotionally traumatizing behavior all the way down to dehumanization and homicide. Granted it may seem to the survivor of a BPD mother as if she or he were a Holocaust survivor – nor should anyone devalue the suffering of what anyone else had to survive, including the Holocaust – but a significant difference between the two still exists.
Lawson’s best guidance for surviving the BPD mother, whether as a child of tender age or a grown up survivor, may be summarized: set limits, deploy different ways of setting limits to inbound aggression, insist on respect for boundaries, drain the emotion out of emotionally fraught situations, deconstruct upsets, do not personalize accusations, call out “crazy making” behavior. These are all ways of managing manipulation, bullying, emotional perpetration, and so on. All are easier said than done.
The most critical remark I can think of? Lawson deploys the main psychological mechanism underlying BPD, splitting, resulting in a black and white representation of the BPD mother – only there is no white. In short, the BPD mother is literally described as a “witch” (as well as a queen, waif, and hermit). This satisfies the definition of “demonization,” both literally and metaphorically.
I am just getting warmed up here. Granted Lawson does not aspire to evidence-based peer-reviewed research. Her argument is narratively and rhetorically strong. However, how is Lawson’s argument that the BPD mother is the cause of the child’s suffering any different than that the “ice box” mother (usually attributed to Bruno Bettelheim (but the matter is debatable)) is the cause of childhood autism?
In both cases, as the mother enters the narrative – or the room – the audience expresses its negative opinion of the mother by breaking out in hisses and boos. Well and good. You have got to blame someone. Blame the mother?! Still, as usual, correlation is not causation; and the correlation is indeed compelling in the case of BPD in the ways that escape the “ice box” mother description.
Lawson documents that the BPD mother enacts a long list of behaviors that are manipulative, perpetrating, and out-and-out boundary violations. This is not disputed. Unacceptable. From the perspective of the child of tender age, the behaviors are particularly appalling.
What Lawson may usefully have acknowledged is people have different way of expressing their suffering. The BPD person’s dramatic, para suicidal behavior – cutting, substance abuse, acting out – inevitably gets our attention. That is the effect of the behavior – it gets our attention. But that is not the reason why the person misbehaves in this way.
The BPD person is trying to regulate her emotions, deal with the distress she is experiencing, or sooth herself. The person is trying to survive her life – survive the distress of the moment. That one can attain emotional equilibrium in an emotional emergency by carving up one’s upper arm with an Exacto knife is hard for the non mental health professional to get one’s head around. Indeed it is hard for anyone to get their head around it; but that is what needs to happen to understand the BPD person.
Lawson properly directs such empathy as is available in the conversation at what the children have to survive. I am not proposing at this late point that Lawson needs to have expanded her empathy for the BPD mother. Rhetorically and narratively that is not in the cards. However, this may be a moment to hate the sin and “love” – or at least provide treatment for – the sinner. That someone ends up in jail for child abuse does not mean that the perpetrator does not need treatment. She does – as does the child.
By the time the survivor of the BPD mother shows up at the door of Lawson’s clinic, it is too late for early intervention. It is too late for empathy lessons in child development. It is too late to teach parenting skills. It is too late. Period.
Still, I came away persuaded, identifying and devaluing the BPD mother as the cause of the survivor’s suffering, too – fully enrolled in Lawson’s project and interpretation. However, what did not happen was creating a space of validation, toleration and acceptance in order to engage the tough issues of recovery, transformation, change, and mourning one’s losses.
Borderline personality disorder remains stigmatized even today. Lawson’s account does nothing to remove the stigma, and, in several ways, reinforces it with devaluing labels such as “witch.” Once again, I hasten to add there is no excuse for bad behavior on the part of anyone, including BPD persons or those committed to treating them.
Truth and reconciliation commissions are in short supply in the political world; and, likewise, such is the case in the milieu of psychotherapeutic treatment. Rare is the instance in which a BPD mother says, “I did it – I was the perpetrator – no excuses – I was a shit. This is what happened [….]” And the survivor then gets to say whether or not she accepts that as the truth and can go forward on that basis. However, I would have appreciated Lawson’s at least calling out the value of such interventions in the context of community mental health – prior to referring the subjects and survivors to Dialectical Behavioral Therapy.
 Christine Ann Lawson, (2004), Understanding the Borderline Mother: Helping Her Children Transcend the Intense, Unpredictable, and Volatile Relationship. New York: Rowan and Littlefield. 330 pp. $46.92 [“free” Audiobook with (Amazon) Audible Subscription].
© Lou Agosta, PhD and the Chicago Empathy Project
Here is my short, half day course on Empathy, Stress (Reduction) and Neural Science delivered at the Joe Palombo Center for Neuroscience at the Institute for Clinical Social Work on December 03, 2016. The image depicted below is the punchline to a Richard Feynman joke about the cosmos – “It’s turtles all the way down” – in the case of neuroscience “It is neurons all the way down!” Granted that the joke is not funny if one has to explain it, the video provides all the background you need to laugh (one way or the other!) –
A famous person once said: “Empathy is oxygen for the soul.” So if one is feeling shortness of breath, maybe one needs expanded empathy! This course will connect the dots between empathy and neuroscience (“brain science”). For example, empathic responsiveness releases the compassion hormone oxytocin, which blocks the stress hormone cortisol. [This is an over-simplification, but a compelling one.] Reduced stress correlates to reduced risk of such life style disorders as cardiovascular disease, diabetes, weak immune system, depression, and the common cold.
The session engages each of the following modules in the discussion segment, including suggested readings. Except for the first two topics, we can take them in any order and the participants will get to select:
- This is your mind on neuroscience – mirror neurons: do they exist, and if not, so what?
- Sperry on the split brain: the information is in the system: how to get at it
- The neuroscience of trauma – and how empathy gives us access to it
- MRI research: as when Galileo looked through the telescope, a whole new world opens
Presenter: Lou Agosta, PhD, is the author of three scholarly, academic books on empathy, including A Rumor of Empathy: Resistance, Narrative, Recovery (Routledge 2015). He has taught empathy in history and systems of psychology at the Illinois School of Professional Psychology at Argosy University and offered a course in the Secret Underground Story of Empathy at the University of Chicago Graham School of Continuing Education. He is an empathy consultant in private practice in “on the forward edge in the Edgewater Community” in Chicago.
(c) Lou Agosta, PhD and the Chicago Empathy Project
The image depicts a mirror neuron – the neurological basis for empathy – admiring itself in the mirror. But do mirror neurons even exist? If not, what is the underlying neural implementation mechanism for empathy? At another level of analysis, how is empathy like oxygen for the soul, reducing stress and enabling possibility? Find out more here …
To register or for more info call Elizabeth Oller: 1-312-935-4245 or email: JosephPalomboCenter@icws.edu
Empathy, Stress Reduction, and Brain Science
A famous person once said: “Empathy is oxygen for the soul.” So if one is feeling shortness of breath, maybe one needs expanded empathy! This course will connect the dots between empathy and neuroscience (“brain science”). For example, empathic responsiveness releases the compassion hormone oxytocin, which blocks the stress hormone cortisol. Reduced stress correlates to reduced risk of such life style disorders as cardiovascular disease, diabetes, weak immune system, depression, and the common cold.
We will engage each of the following modules in the discussion segment, including suggested readings. Except for the first two topics, we can take them in any order and the participants will get to select:
- This is your mind on neuroscience – mirror neurons: do they exist, and if not, so what?
- Sperry on the split brain: the information is in the system: how to get at it
- The neuroscience of trauma – and how empathy gives us access to it
- MRI research: as when Galileo looked through the telescope, a whole new world opens
Presenter: Lou Agosta, PhD, is the author of three scholarly, academic books on empathy, including A Rumor of Empathy: Resistance, Narrative, Recovery (Routledge 2015). He has taught empathy in history and systems of psychology at the Illinois School of Professional Psychology at Argosy University and offered a course in the Secret Underground Story of Empathy at the University of Chicago Graham School of Continuing Education. He is a psychotherapist (and empathy consultant) in private practice in “on the forward edge in the Edgewater Community” in Chicago.
Date: Saturday December 03, 2016
Time: 9 AM – noon
Registration Fee: $35
Location: to be provided upon registration: at or near ICSW at 401 S. State St Chicago, IL
Registration: Call Elizabeth Oller: 312 935 4245 or email: JosephPalomboCenter@icsw.edu
Virtual reality (VR) is coming to psychotherapy. Based on a briefing on July 08, 2016, a company named “Psious” provides VR technology. Psious’ collaboration agreement, available temporarily to Chicago-area mental health professionals, includes training forthe therapist on how to use the VR technology. Online manuals integrating the simulated scenarios provide step-by-step guidance from psychologists on how to help patients shift out of fear, expanding positive responses to a variety of stress-laden situations that people find confronting such as fear of heights, flying in airplanes, insects, and more (to be detailed momentarily).
The one thing that immediately occurred to me: Psychotherapy invokes a virtual reality all its own – even without goggles. This is especially the case with dynamic psychotherapy that activates forms of transference in which one relates to the therapist “as if” in conversations with a past or future person or reality. Indeed, with the exception of being careful not to step in front of a bus while crossing the street on the way to therapy, we are usually over-confident that we know the reality of how our relationship work or what people mean by their communications. This is less the case with certain forms of narrowly focused behavioral therapies, which are nevertheless still more ambiguous than is commonly recognized. Never was it truer that meaning – and fear – are generated in the mind of the beholder.
Positioning an intervention that exploits VR in any psychotherapy clinical practice raises numerous issues that must be engaged, and the economics of virtual reality mean the time is now. Flight simulators in which airplane pilots train still cost millions of dollars. The initial “one off” VR goggles used to cost hundreds of thousands of dollars. Psious brings the goggles, plus the necessary software subscription for a compelling price of $1299 a year not including the hardware (Samsung Gear VR goggles and Samsung Galaxy smartphone), the platform on which the software operates). Hardware bought on Amazon for about $700 is discounted to $259 with an annual subscription. The total cost is about $1558 a year for access and ownership of the hardware. At current rates for psychotherapy that is about ten session to break even.
The therapist has a display on his computer of what is being presented in the Goggles to the client. For example, in the scenario in which the patient is dealing with fear of public speaking, one is presented with a “speaker’s eye view” of an audience. Controls allow the therapist to incorporate the patient’s expectations and feedback on what he is ready to confront. The therapist controls different scenarios – a member of the audience gets up and walks out, members of the audience are audibly talking with one another and not listening to the speaker, applause, booing, questions are shouted out (e.g.) “What is the weakness in your proposal?” The list goes on. Close coordination is required between the therapist operating the controls and the subject of the therapy in order for this simulated speaking experience not to become re-traumatizing. Of course, even the latter could become a therapeutic opportunity if the patient is flooded but is enabled to recover his equilibrium thanks to an empowering conversation with the therapist at the moment of the upset.
Modules are currently available for fear of flying, needles, heights, public speaking, animals/insects, driving, claustrophobia, agoraphobia, social anxiety, and generalized anxiety. Given that as soon as one is confronted with fear the intervention also involves imagining or activating a “safe place” from which to function in the face of fear, positive modules are available that provide coaching in breathing exercise, mindfulness, and Jacobsen Relaxation (progressive muscle relaxation).
While the VR technology is innovative and disruptive in many ways, a moment’s reflection suggestion continuity between VR technology and the “virtual reality” of the transference in classic psychodynamic therapy. There is a strong sense in which the conversation between a client and a psychodynamic therapist already engages a virtual reality, even when the only “technology” being used in a conversation is English or other natural language. For example, when Sigmund Freud’s celebrated client, Little Hans, developed a phobia of horses, Freud’s interpretation to Hans’ father was that this symbolized Hans’ fear of his father’s dangerous masculinity in the face of Hans’ unacknowledged competitive hostility towards his much loved father. The open expression of hostility was unacceptable for so many reasons – Hans was dependent on his father to take care of him, Hans loved his father (though he “hated” him, too, in a way as a competitive for his mother’s affection), Hans was afraid of being punished by his father for being naughty – so the hostility was displaced onto a symbolic object. Hans’ symptoms (themselves a kind of indirect, virtual expression of suffering) actually gave Hans power, since the whole family was now literally running around trying to help and consulting The Professor (Freud) about what was going on. In short, the virtual reality made present in the case is that the horse is not only the horse but is a virtual stand-in for the father and aspects of the latter’s powerful masculinity. So add one virtual reality of an imagined symbolic relatedness onto another virtual reality of a simulated visual reality (VR) scenario, the latter contained in a headset and a smart phone.
Psious was founded in 2013 in Barcelona, Spain. It has operations in Barcelona, and is opening a branch in Chicago, which is where I met with Scott Lowe. Psious has about 50 employees worldwide and some 400 clients using the technology in a clinical or closely related setting.
Psious’ claim is that virtual reality based therapy (VRBT) is superior to CBT alone, when the latter uses merely the patient’s imagination [see references to peer-reviewed articles at the end]. For example, if one is so afraid of flying that one is unable to do one’s job because it requires travelling on an airplane for business, one is sitting there in the therapist’s office imagining boarding an airplane and taxiing towards the runway for takeoff. Instead of closing one’s eyes and imaging a trip to the airport, put on the VRBT goggles and find oneself sitting in a seat in coach. For someone seriously stressed by such a situation, the person’s pulse is accelerating, sweat is breaking out, fear is escalating faster than the airplane, and comfort is in free fall until one wants to jump up and run screaming down the aisle and try to open the emergency exit. Not good.
Presumably one would work with the therapist to adjust, adapt, and accommodate to the environment in small steps during which the client’s comfort level is monitored in an on-going conversation with the therapist (and the available biofeedback tool, a galvanic skin sensor). First, are you willing to put on the headset and sit in the airplane seat? Close the cabin door? Taxi towards the runway. Rev up the engines? Start rolling down the runway? Picking up speed? Nose wheel off the ground? Wheels up? Vibration in the cabin as the plane gains altitude? Shaking from side-to-side as the plane ascends through turbulence? Big bump as the plane picks up and enters the jet stream? While the headset provides compelling visual and sound clues, the seat does not vibrate. Still, up until now, if one wanted to confront one’s fear of flying (in an airplane), one had to charter an airplane, time in a flight simulator, or use one’s imagination. It’s a whole new world with Psious.
Let me say up front that I have gone to the demo for the fear of heights, heard the presentation, put on the headset, and I am inclined to say that this technology has legs. At the risk of paradox, virtual reality therapy is the real deal. However, as the Psious people make clear, it is not a replacement for a therapist, it is a tool that can augment the process of confronting and engaging one’s fears under the guidance of a therapist. Why? Because the virtual reality goggles put the client back in a simulated situation that is most calculated to arouse the anxiety that requires treatment. The conventional wisdom is that one cannot overcome one’s fear without engaging with it. However, the engagement must find a stretch to the client’s comfort zone, no matter how narrow, that does not result in retraumatization. In short, the kid gloves are on. The head set should not cause the patient to run screaming from the room as he or she did from the spider or public bathroom. This scenario motivates the need for fine-grained controls as well as training the therapist in how to use them and how to talk the client through an empowering – or at least survivable – experience with the fearful.
The knock against individual dynamic psychotherapy has been that it does not scale. It is highly individual, one size definitely does not fit all, and a third of the population would have to be therapists in order to treat all the members of the armed forces who are suffering from some significant measure of PTSD. If one could define a process that enabled the wounded warrior to bring CBT tips and techniques such as interrupting the pathogenic thought and going to his or her “safe place” while confronting the trauma, perhaps initially in a diminished presentation, then it just might make a scalable difference in treating significant numbers of clients using a method that really works (presumably as opposed to medications with substances that may be addictive).
The fear of horses that manifest itself in Little Hans’ fear of going out onto the street (due, in turn, to fear of encountering a horse) was actual fear. Hans was not faking. He was really terrified. However, his fear was inauthentic in that it masked his unexpressed hostility and ambivalence toward his father and his new baby sister. He was not afraid of horses; he was afraid of being punished for wishing to do away with his new sister. “The stork should take it back.” “Throw it down the drain (that is, the sister).” Remember has was only four years old. However, it is in the nature of an emotion such as fear to glom (“adhere”) onto an available object. This binds the fear to a specific target that may be able to be avoided or otherwise managed in a survival drill rather than have free-floating fear paralyze the entire organism, endangering the survival of the whole. There may even some objects such as spiders, snakes, and thorns that we humans are biologically and evolutionarily predisposed to experience as automatically and inevitably arouse fear. What then of the technology?
The Psious technology is still relevant to address the delta between one’s ordinary uneasiness towards a spider that allows one to take a napkin and remove it from the kitchen and someone else extreme distress that causes them to hyperventilate and, as noted, run screaming from the room. True, they may just have an intensified biological disposition, but they may also be adding expanded meaning based on their individual experience. As far as I can tell, the scenarios are useful in evoking the feared object regardless of the cause, but the therapy still has to intervene with a narrative to shift the fear in the direction of a manageable de-escalation of the fear. Whether the narrative is a CBT one that send the individual to his “safe place by the calming waters” or one that deconstructs the fear as a transference displacement from one’s reaction to one’s father’s scary masculinity, is independent of the technology. It remains a function of the therapeutic intervention.
I am excited by these developments for three reasons. First, the scenarios presented in the goggles are compelling. I have climbed mountains and I regularly fly on airplanes, but I still have a lurking fear of heights. When I put on the goggles and found myself near the glass bottomed sky deck, I was literally unable to step forward over the visual cliff. Amazingly enough, it did not even help when I closed my eyes – since I still vividly imagined being in the scenario. However, taking off the goggles worked just fine in interrupting the process. I do not know if the other scenarios are as compelling. However, I do not have a fear of any of the other things quite as visceral as my fear of heights, or more properly speaking, the visual cliff.
Second and more importantly, this technology may enable individuals who are unable to be helped any other way (“treatment resistant”) to get the treatment they require. We can debate whether or not it is the best treatment; but I am persuaded that if someone is suffering, then a treatment that works is one worth engaging. If a person is so confronted that they are unwilling or unable to imagine a scenario in which they encounter their fear, this technology gives the client an opportunity, with his permission, to puts himself in the fear arousing situation – which, if I am any judge, can be “tuned down” to a significant degree such that a gradual “on ramp” is available to client with the encounter.
Third, some individuals who need help but do not value a conversation for possibility with another person (such as a therapist) may be persuaded to engage by using the goggles as a kind of lever to open up access to their upset. The same people who are fascinated by the technology of the functional magnetic imaging (fMRI) apparatus that shows what area of the brain lights up as they are empathizing with the pain of another will be able to engage in a conversation with the therapist while in the process of using the goggles. Some may say it is a “gimmick”; but I say if this be gimmickry, make the most of it. The provisioning of a virtual reality platform provides an “on ramp” to the virtual reality of a transference conversation in which displacement, symbolization, and interpretation can be marshaled above and beyond the VR scenarios.
Frankly, the most engaging scenario is one that Psious does not have available. As the result of the wars in Afghanistan and Iraq, the US and its allies has many soldiers suffering from diverse forms of post traumatic stress disorder. Worse yet, the diagnosis of PTSD does not even encompass the forms of moral trauma (see further the work of John Mundt, Ph.D., Jesse Brown, VA Center, Chicago) from which many service men and women are suffering. For example, In Iraq a car with four occupants is speeding towards a check point containing multiple passage, ignoring warnings to stop, zig sagging around the barriers. A suicide bomber? The sergeant orders the gunner to fire. The family was rushing to the hospital with a pregnant woman giving birth. One of the now orphaned children survives. The gunner cannot forgive himself, but this does not qualify as PTSD under current rules unless all the criteria are satisfied. The VR technology offers rich possibilities for reenacting the scenario with diverse outcomes, enabling an empowering conversation about what the soldier experienced, what it meant to him, and how to work through his suffering and guilt. Note at this point this is all “brain storming” and “blue sky,” but the possibilities are significant and deserve the urgent attention of software innovators, Veteran Affairs decision makers, politicians, psychotherapists, and survivors alike.
Issues include whether in what sense the hardware is a medical device. What sense, if any, does it make to certify it as health insurance compliant? There are so many rules and regulations around health care that I am not even clear that I know how to ask the right questions. Does a therapist using this device as an adjunct or augmenter to CBT or dynamic psychotherapy need to call it out in her or his coding of the insurance claim, and what sense would it make to try to do so? Presumably Psious will be engaging with these issues over the next year.
References: A selection of publications:
Chapman, L. K., & DeLapp, R. C. (2013). Nine session treatment of a blood–injection–injury phobia with manualized cognitive behavioural therapy: An adult case example. Clinical Case Studies. Retrieved October 26, 2014, from http://ccs.sagepub.com/content/early/2013/10/28/1534650113509304
Wiederhold, B.K., Mendoza, M., Nakatani, T. Bulinger, A.H. & Wiederhold, M.D. (2005). VR for blood-injection-injury phobia. Annual Review of CyberTherapy and Telemedicine, 3, 109-116.
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(c) Lou Agosta, PhD