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Review of: The Guide to Interpersonal Psychotherapy: Updated and Expanded Edition (2007/2018), Myrna M. Weissman, John C. Markowitz, Gerald L. Klerman; Oxford, UK: Oxford University Press, 283 pp. ($34.10 (US$)).
Interpersonal therapy (IPT) is a promising, evidence-based, talk therapy. IPT is the innovative brainchild of Gerald L. Klerman, Myrna M. Weissman, John C. Markowitz, and a team of dedicated professionals. IPT has received expanding attention since the mid- and late 2000s.
This book is an IPT manual and it emphasizes: It is important to keep IPT grounded in affect. Therapy feels meaningful to the patient when it comes alive with emotions related to important issues in the patient’s life. The IPT sessions focus each meeting on a recent, affectively charged event in the patient’s life. In short, the therapist encourages the patient to talk about what happened in their life during the past week. Sounds familiar?
The novice practitioner – perhaps a resident in psychiatry who has been concentrating on psychopharmacology, because that is the prevailing paradigm – is given helpful scripts (what to say to the patient): “In interpersonal psychotherapy, we work on the connection between your feelings and your life situation. In the next X weeks, we will work on unfulfilled wishes and problematic relationships that are contributing to your depression. You should begin to become more comfortable with your feelings in problematic close relationships and decide how to use them to change the relationship/situation you’re in” (p. 106).
Originally developed as an intervention for depression, IPT has been progressively extended to other disorders including anxiety, trauma, and personality disorders including borderline personality disorder. Also of note, IPT demonstrably does not work for substance abuse, including alcohol.
IPT draws on the insight of dynamic psychotherapy that events in the patient’s life evoke strong feelings (or not) and that the processing of those feelings (or not) contributes to the patient’s behavior in the community. The “deep history” of the work invokes the tradition of Harry Stack Sullivan (1842 – 1949) and the William Alanson White Institute, acknowledging the interaction of the cultural dynamics between the self and the community.
IPT acknowledges that sadness and depressed mood are part of the human condition. Low mood is a nearly universal response to disruption of close interpersonal relations. John Bowlby argued that attachment bonds [key term: attachment] are necessary to survival: the attachment of the helpless infant to the mother helps to preserve the infant’s life and well-being (p. 10).
However, the resemblance between IPT and the anti-psychiatry sometimes characteristic of the Neo-Freudians such as Sullivan or Bowlby is soon dispelled. IPT embraces the medical model, asserting that (e.g.) depression is an illness such as the flu or even an appendicitis. IPT proudly embraces the common factor – something shared by all [or most] forms of psychotherapy – that the role of doctor and patient are essential to the process.
The IPT doctor is active in educating the patient about what to expect and what to do, along with more subtle forms of inspirational guidance and suggestion. While the patient may usefully learn directly from experience as redescribed in the process of therapy, he or she had better do so promptly – as the process is time-limited to some sixteen sessions.
The time-limit is an essential part of IPT, acting as a “forcing function” to cause both patient and doctor – but mostly the patient – to “cut to the chase,” say what is bothering her, and take action to do something about it. Hence, IPT’s strengths – the cost is relatively predictable and insurance payers love that – it is relatively easy to define a comparative process test (say, against CBT or psychopharm) – and grant writers and approvers like that – and its weaknesses – it is time-limited.
One clarification upfront. When the trainers of interpersonal therapy say that it is “interpersonal,” they do not mean that the therapy targets the relationship between the patient and the therapist. “Interpersonal” means that it is about the interpersonal relationships in the patient’s life.
The powerful insight of IPT is that the way the person feels about what is going on in her or his life results in behavior, including symptomatic behavior such as depression and anxiety, that remits if one connects the dots between the two, i.e., between the feelings as called forth in the therapy and the dysfunctional symptoms. IPT is unconcerned about transference or the deep past of childhood and it tries to identify the focal interpersonal problem area in the patient’s current life. “IPT does not interpret the transference, but rather helps the patient to relate emotions to interpersonal interactions in the here and now” (p. 74) – otherwise known as interpreting the transference.
Basically, with some conditions and qualifications, the patient is allowed one problem area, though each of the area is potentially vast and overlapping: grief (e.g., death, loss), role disputes (interpersonal conflict), role transitions (e.g., divorce), and interpersonal deficits of attachment (aloneness, isolation) (p. 11).
According to Weissman and Markowitz, more than 100 clinical trials of IPT (Barth et al., 2013; Cuijpers et al., 2008, 2011, 2016) are available (p. 12). That is what makes IPT so attractive as “dynamic therapy lite”, especially to psychiatrics who find prescribing insufficient to produce wellbeing in their patients.
The meta analysis by Cuijpers et al. (2016 / see the excellent and extensive bibliography in the book), based on eight randomized trials, suggests efficacy for anxiety disorders: “In anxiety disorders, IPT had large effects compared with control groups, and there is no evidence that IPT was less effective than CBT.” No less effective, but perhaps also no more. [P. 187] However, for those entry level therapists who are not comfortable with the over-intellectualizations of CPT, IPT can have an advantage of validating an approach that empathically gets one in touch with emotions and feelings.
A recurring theme in this approach is that IPT talks to patients about how they feel about what is happening or has happened in their lives and invites patients to make the crucial recognition that their interpersonal encounters evoke strong feelings. Then the IPT mantra (at least in this text): that, rather than being “bad” or “dangerous,” feelings provide interpersonal information (e.g., anger means someone is bothering you) they can reflect upon and use to handle their environment.
The instructions to the IPT psychiatrist in training? “Your aim will be to link the patient’s interpersonal situation (a spouse’s affair, a mother’s death, a move to a different city) to the onset of symptoms in a brief contextualizing narrative that makes sense to both the patient and you. [….] Use the initial sessions to ensure that you have focused on a pivotal, emotionally meaningful area for the patient and that you have ruled out surprises that might otherwise arise later in treatment” (p. 36).
So, for example, IPT points out that patients with panic disorder experience their paralyzing physical attacks as coming “out of the blue,” yet most talk therapies, including IPT, suggest that panic is a response to interpersonal events: one study found that three-quarters of panic patients had had an interpersonal loss within six weeks of panic onset (p. 191).
So what happens when, for example, a woman who presents saying, “My children are my big problem” later, as she gets to know you, calls out the more pressing area of distress: her spouse’s extramarital affair? Given the time-limited name of the treatment, what to say? Well, IPT tries to address this typical situation, allowing for “maintenance,” typically once a month extensions. Twice a month? However, somehow extended the duration of the sessions by means of maintenance seems not to be the right answer. A new contract and a new engagement is needed.
IPT is quite explicit about giving patients the Sick Role. This does indeed relieve patients of blame. It is not your fault – you are sick. “The sick role excuses patients from what their illness precludes them from doing, but it carries the responsibility to work as a patient to get better” (p. 115). Definitely. A sensible trade-off.
However, the therapist is then left with the difficulty that the illness in question – depression, anxiety, trauma, personality disorder, and so on – is significantly unlike most other diseases in the world of medicine. Yes, there is an underlying molecular process; but it is just that, in most cases, science has not identified the biomarkers.
The IPT role-playing script (p. 39) suggests telling the patient that depression is no different the appendicitis or the flu. Wow. Don’t call Carl Rogers – page the surgeon! We can cure an appendicitis even if the patient is unconscious. Indeed at a certain point in the treatment it is required. However, that is not the case with a significant mental disorder. You cannot cure an unconscious psychiatric patient. More to the point, today the patient’s intentional participation in the process is required.
I can’t resist. The history of the heroic age of psychiatry does present “the sleep cure.” Stay in bed for about three months, highly sedated, with the doctor on call fulltime, waking the person once every twenty four hours for nourishment and bowel movement, and at the end of three months – voila! – something significant has shifted – the individual no longer feels depressed. This is the reduction to absurdity of the medical model – yet, in its day, it worked!
For example, in the case of complicated grief, treatment is not a sign of disrespect for the deceased – but that respect is the way treatment shows up – LIVES– for the patient. Complicated grief is a form of depression (p. 45). The doctor must truly have a magisterial authority in order to overcome the patient’s commitment to her or his suffering. You see the problem? It says right there in the manual: your grief is really depression. But the patient’s experience is that they cannot live without the other person. Yes, it violates the IPT contract that the person seems unwilling or unable to try. That is the therapy – you are in violation of your therapeutic contract?
Whereas in CBT, a therapist might ask a patient to look at the evidence about an anxious thought, an IPT therapist lets the patient sit with the feelings, pointing out at an opportune moment that guilt is a actually a symptom of the depression. What is the evidence that when your friend does not answer your text message, it is because she or he is cheating on you? Are there any facts here? In IPT rather, let’s talk about your feelings about the relationship: have you ever had any feelings of temptation towards cheating? In short, in IPT the therapy is to talk about the temptation (loss, fear, anger, and so on) and bring forth a catharsis – yes, it says it right there in the manual – catharsis makes you better.
IPT acknowledges the need to manage magical thinking, but IPT does not call it that]: The bereaved person fears that if they recover from the grief (i.e., the depressive episode), it means they did not love the deceased as much as they had believed. To their way of thinking, if they really loved the person, the loss would be so great that they could never recover. The treatment? Acknowledge, validate, and work through the loss by talking about it. In that sense, IPT is a talking cure.
The guidance for those practicing IPT (p. 57)? Ask for the details of the interaction. Often, the patient will come in with in interpretation: “He is a jerk.” Okay, got it; but what did he actually say? : “What did you say? What did he say? How did you feel then? Then what did you say?” and so on. Get in touch with facts and feelings. The reconstruction of interpersonal encounters provides a sense of how the patient functions interpersonally, what may be going wrong in the relationship, and where the patient ignores or suppresses emotional responses to the other party
It is a strong point of IPT’s approach to treatment – get the facts. Freud pointed out long ago – the patient comes in and cannot give a coherent account of his or her life. Freud noted the gaps – repression – but equally important are the distorted communications, interpretations, and positions. “The boss is a jerk.” “Okay – I got that – what did he actually say?”
For those curious as to what is a “role transition”: Moving one’s household, taking a new career or job, leaving home after school or divorce, being diagnosed with a serious medical condition, taking on new responsibilities due to the illness of a family member, or a change (decline) in economic status, are other examples of life role transitions. Refugee status has become a transition problems for significant populations in many countries.
Unlike many descriptions of cognitive behavioral therapy (CBT), IPT focuses on discussing feelings, normalizing them as responses to interpersonal interactions and as useful interpersonal information, and using them to take action to change the patient’s interactions in order to resolve the identified problem area (p. 88). That a person feels angry about a perceived or actual interaction contains valuable information for the person, which is usually overlooked due to over-intellectualization or being overwhelmed by emotions (under-intellectualization).
IPT emphasizes, “depression is a medical vulnerability, sort of like having an ulcer. If you should get depressed in the future, the important thing to remember is that it’s a treatable illness, it’s not your fault, and you just need to return for treatment, the way you would for any other medical problem” (p. 113).
IPT is a sensible, practical approach. The take away is that whatever the intervention one should actively try to solve the problem – working on solving the problem = x drives the therapy. The hidden / confounding variable is that the problem seems to be = x but is actually = y or = (x & y). In that case, the openness of psychodynamic therapy will surface an issue of which IPT remains unaware. Of course, the process will require more time.
There are many applications of IPT – to postpartum depression, depression in adolescents, depression in children of tender age (recommendation: treat the parent(s), depression in senior citizen, – here we go into the weed, there are many studies, and the results are generally favorable – the guidance? If one tries, one gets better.
Since this is not a softball review, the most critical thing I can think to say is that it is not really treating what the DSM describes as depression – it is treating stress – and there is nothing wrong with that – the cytokine theory of depression makes the case that “depression” is “sickness behavior” – this aligns well with the repetition (nearly ad nauseam) to the patient that “depression” is a sickness like the flu or [incredibly] enough an appendicitis. Okay, let’s take this seriously. This is supposed to be a common factor – but you would not hear Carl Rogers say it. You would not hear CBT practitioners say it – rather they would say, “you have a skills deficit – and while that is not your fault, no one ever taught you the skill, we are not “blaming” biology, we are blaming the parent or the early environment
At times and at risk of over-simplification, CBT is committed to how thinking causes, brings forth, determines one’s feelings. IPT emphasizes how one’s emotional experiences cause, bring forth, and determine one’s thinking. “Therapists work hard with […] patients to identify emotions— and particularly negative affect and feelings of competitiveness, anger, and sadness— that arise in everyday situations. The therapist and patient discuss whether such feelings are understandable and warranted. The idea of a transgression— that there are some behaviors that break expected social conduct, warrant anger, and deserve at the least an apology— may be helpful in normalizing such feelings for patients” (see p. 164).
I call out some statements that, strictly speaking, make no sense: “Klerman advocated for research standards in psychotherapy that were comparable to those in pharmacotherapy research” (p. 12). Okay, but: The authors cannot be referring to double blind testing where neither the patient nor the doctor knows what treatment he is delivering. I am giving you CBT versus IPT versus psychopharm, but neither of us knows what it is. Notwithstanding the many useful results provided by IPT practitioners, this points to a significant blind spot.
A silly statement by the authors, in which the authors get carried away with their own greatness: “No other psychotherapies explicitly focus on the IPT problem areas” (p. 106). Really? Counter-examples? Freud’s “Mourning and melancholia”? Life transitions in DBT? Lack of skills in CBT? Role disputes and discrepancies (all of the above)?
Another thing that seems just plain crazy to this author is the approach to trauma, though, once again, trauma survivors have benefited from IPT in evidence-based studies. IPT acknowledges accurately: The trauma explains why the patient is struggling interpersonally, but receives no further direct discussion (p. 195). However, a time occurs in most conversations with trauma survivors (with or without a bit of nudging) when the trauma seems to erupt – spontaneously comes up – and IPT ties the therapist’s hands because she or he cannot engage with it. Why not? It is not part of the definition of IPT? The researchers are doing an evidence-based study and to do so would “confuse” the modality with exposure focused treatments? So much the worse for the evidence ( am inclined to say). If the patient brings up the trauma and is willing – indeed wants and give every evidence of wanting to talk about it – then it would be unethical not to do so. Did anyone think of that?
The ultimate true but trivial statement, apparently now required to be fully buzzword compliant: “Neuroimaging studies have shown that psychotherapy changes your brain chemistry [Brody et al., 2001; Martin et al., 2001 9see the excellent bibliography in the book itself for details)]: it’s a biological treatment” (p. 110). Hey, studying French will change your brain and brain chemistry. Studying French is now a biological treatment?
Time-limits are essential to IPT and are a kind of “good news,” “bad news” sort of practice. Freud himself made use of setting a time limit in the case of Sergei Pankejeff (“the Wolf Man”) when Freud felt, after months and months of work, the treatment was stalled, the patient was living in genteel poverty, burring through his modest fortune, couldn’t pay, and it was time to fish or cut bait (my expression, not Freud’s). It seemed to have worked, or at least worked well enough, as a “forcing function.” However, this parameter on Freud’s part was used on an exception basis. IPT takes the “forcing function” and makes it the rule. In fact, traditional Freudians may see IPT as a case collection of parameters (exceptional practices that are employed in the face of contingencies in treatment) that try to add up to “psychoanalysis lite.”
The risk is that while a medical molecular process may not aware of the clock, the blind spots, self-deceptions, and self-serving behaviors by which people afflict themselves unwittingly are acutely aware of the passage time. Therefore, the “disorder” goes under ground until the time is up. In a telling analogy, the process is like announcing to the local armed insurgency, freedom fighters, or your opponent of choice that the UN expeditionary force is going to pull out in sixteen weeks. The opponent’s strategy strategy going forward is clear. Lay low until the powers-that-be pull out. Then it is back to business as usual.
Meanwhile, once feelings are identified and normalized, role playing is needed to help patients become comfortable with self-assertion or confrontation. “They may never have expressed a wish and almost never have said “no” to anyone. Yet if a patient has a successful experience in one of these situations (e.g., asking for and receiving a raise, confronting a spouse), the patient will have learned a new skill, discover some sense of control over the local environment, and likely feel better” (p. 164).
The IPT text and training repeatedly emphasize that “feelings are powerful, but not dangerous—and in fact, you need them [feelings] to decide whom you can trust. Expressing your feelings to another person may seem risky, but it provides a test of whether the other person is trustworthy or not. If you feel angry and voice it to another person, the other person has the chance either to apologize and change behavior, or to confirm that he or she is uncaring or untrustworthy” (pp. 194 – 195).
Agree – but there is a big “but.” The thing is that for some people feelings ARE dangerous if the feelings threaten to fragment the coherence and integrity of the sense of self. This is especially the case with survivors of trauma. There is it not just an over-feeling, but a feeling “I am gonna die!” One can dismiss this as a “personality disorder,” but I do not believe such dismissal would be fair or accurate. If subjected to strong enough feelings, just about anyone is capable of being shaken to their core. Therefore, methods are for strengthening the person’s self’s sense of stability and equilibrium in the face of strong feelings. Expanded distress tolerance? Expanded emotional regulation? Self-soothing? Working through? Exposure? Transmuting internalization? Suggestion? Encouragement? All of the above?
Having gotten in touch with emotions, patients can proceed to more usual IPT maneuvers, such as solving a role transition. As patients gain comfort with their feelings, they engage interpersonal situations with expanded competence, life feels safer, and they begin spontaneously—without IPT therapist encouragement—to face the situations and traumatic reminders they have been avoiding. In the vast majority of instances, the authors assume the patient is out of touch with his or her feelings. The therapy consists in invoking the feeling so that the patient can get in touch with it. But what about being over-whelmed by one’s feelings? Yes, one can also lose touch with one’s feelings if one is overwhelmed, but it is significantly different mode of losing touch. What about that?
We end on a positive note. IPT is demonstrably effective with borderline personality disorder, though the time-limited aspect is “finessed” by [apparently] doubling the number of sessions to distinguish between establishing trust with the therapist and actually doing the work.
We give the last word to the authors of this engaging, practical text: “The therapist presents BPD to the patient as a poorly named syndrome that has a significant depressive component. A major difference between MDD [major depressive disorder] and BPD [borderline personality disorder] is that while depressed patients often have difficulty expressing any anger, patients with BPD often do the same much of the time but then periodically explode with excessive anger, which reinforces their tendency to avoid expressing anger whenever possible. The goals of treatment are, as is usually the case in IPT, to link mood (including anger) to interpersonal situations, to find better ways of handling such situations, and to build better social supports and skills.” (p. 201).
(c) Lou Agosta, PhD and the Chicago Empathy Project
Real Hallucinations by Matthew Ratcliffe [book review] – Okay, so what would FAKE hallucinations be?
“Reality testing” is a distinction that is in the background of Matthew Ratcliffe’s penetrating and incisive book Real Hallucinations: Psychiatric Illness,
Intentionality, and the Interpersonal World(Cambridge, MA: MIT Press, 2017, 290 pp.). Disturbances of the sense of reality are among the key phenomena that cause people who suffer from hallucinations or delusions to be referred to psychiatrist professionals.
Ratcliffe takes pains to work through the various senses of reality that confront one as soon as one wishes to assert that something = x is not real. For example: “Illness or jet lag can involve an all-enveloping and lingering sense of one’s perceptual experience as somehow lack, not quite right” (p. 44). But that is just the beginning.
The memoires of psychiatric patients, who have survived psychosis – as well as thought experiments invented by philosophers and Ratcliffe’s own survey research – are full of examples where the distinctions between perceiving, imagining, remembering, anticipating, and experiencing, begin to break down and actually do break down. All these are engaged in the narratives of those who have survived psychosis such as Elyn Saks, M. Sechehaye, or reports from a survey collected by Ratcliffe.
Ratcliffe collects extensive evidence of the intermittent flexibility of the boundary between imagining that something happened and remembering that something happened; between intending to fill up the gas tank of the car and remembering that I did so (but did not); between perceiving the bear at the window of the cabin and imagining the bear at the window, and so on. I look into the mirror and see a face that does not look anything like my own (my example, not Ratcliffe’s). The face is so different that I realize I must be dreaming, and wake up. If I do not wake up, and the face still looks frighteningly different, then modes perception and imagination have gotten mixed up, I am having a psychotic breakdown and need help.
These considerations result in Ratcliffe’s innovative account of hallucinations and delusions. Ratcliffe’s nuances, conditions, and qualifications are many, but they boil down to: in hallucinating, content is framed using an intentional mode at variance with what it might be anticipated to be. Thus, a voice that is remembered or imagined is misconstrued as being actually perceived in the here and now; in delusions such as thought insertion, a thought that is imaginary or remembered or otherwise fictional is misframed as an occurring belief. The misframing, slippage, or “going off the rails,” occurs because of an anxious anticipation of something = x, including the possibility that what the individual is fearing is fear itself.
This account finds strong support in the works of R. Bentall, L. Sass, and the reports of survivors of psychosis, distinguishing between hallucinations as having an experience versus having a sense of an experience. (The reader may usefully consult the book itself for the excellent bibliography.) In hallucinating, one is having a “sense of an experience.” And, notwithstanding the insistence of the psychotically disturbed that they are really experiencing what they are experiencing – which is what makes it so frightening – a moment often comes in which the [psychotic] individual acknowledges he or she can distinguish the voices or anomalous beliefs from everyday, standard situations, places, and practices.
This leads to what is sometimes described as “double bookkeeping” – the psychotic person seems to inhabit two worlds – the standard, shared world and his own special, different one. Or the psychotic person may feel that the standard world has been completely annihilated and he is the only survivor or feel that he is already dead. In either case, the individuals looks carefully both ways before crossing the street. Curious. Yet this is the disorder itself.
Ratcliffe also finds support in the work of Marius Romme and Sandra Escher, who are credited with giving rise to the Hearing Voices Movement (p. 30 – 33). This is not just a theory or collection of data, but a normative position about how those who have anomalous experiences such as hearing voices should engage with their voices and engage with the medical community. In so far as I understand it, Ratcliffe is a fellow traveler with the view that voices with distressing content are socially embedded and events such as trauma, neglect, abuse, adult social isolation, and so on, are important determinants of the anomalous experience.
Often the disordered individual’s sense of reality is demonstrably in breakdown, but differences and variations in the degree of disorder are of the essence in description, diagnosis, and treatment.
You and I – as average ordinary everyday citizens – have trouble communicating with psychotic individuals because we no longer share the same methods or procedures for reality testing. The psychotic’s reality testing is producing a different result than yours and mine. The result may be so vastly different that we say the psychotic has no sense of reality at all. None. The individual is banging his head against the wall. However, fortunately, that is rarely the case. Most often a form of “double bookkeeping” is occurring, and sense can be made out of the seemingly senseless.
This is where Ratcliffe’s powerful contribution comes into its own and makes a difference. Inquiring minds want to know: what the heck is going on with hallucinations and delusions such as thought insertion?
Ratcliffe’s contribution is an important, even outstanding one; but this reviewer is at pains to create a context for a review that will connect with the prospective readers.
Yet another digression must be bracketed before one can engage the book in context and on its own merits.
To be sure, the biological explanation of hallucinations and delusions looms large. But Ratcliffe does not go there, and the reader will find none in this text, though their appropriate applicability is acknowledged. The conventional wisdom is: dopamine up, hallucinations up. Take a bunch of cocaine. Do this enough (or sometimes only once) and the brain is flooded with dopamine (and related, activating neurotransmitters). The person is hearing and seeing all sorts of stuff that is not really there. We call this stuff = x “hallucinations and delusions.”
This neurotransmitter imbalance explanation is evidence-based and pharmacological interventions that reduce the ratio of available dopamine to dopamine-receptors really do seem to restore equilibrium to the brain.
However, something seems to be missing from the neurological discussion – an account that puts the suffering, struggling human being in a personal world that is able to support and sustain his recovery and return to humanity. Hence the need for Ratcliffe’s contribution, which lays the foundations for such a conversation (without, however, actually completing the journey).
Ratcliffe’s account begins by taking issue, cautiously, with Dan Zahavi’s (and other’s) approach to the minimal self. Key term: minimal self. At the risk of oversimplification, psychosis is then hypothesized to be a disorder of the integrating and synthesizing capabilities of the minimal self. Ratcliffe generally endorses what Zahavi has to say but is at pains to include the requirement that the minimal self emerges out of a social matrix: “Our most basic sense of self is developmentally dependent on interactions with other people” (p. 16). Thus, when the social milieu is disrupted – through trauma, adverse childhood experiences, metabolic disorders, or addiction – the minimal self and its meaning making and integration capabilities also break down. Viola! Psychosis.
How minimal is the minimal self, asks Ratcliffe? He answers that it includes the sense that the individual is having a pre-reflective sense of “mineness” in perceiving, imagining, engaging in inner speech, moving around in the space, and remembering.
These immediate prereflexive, unproblematic acts of seeing, imagining, verbal thinking, moving, and remembering are called “modalities of intentionality” in the phenomenology of Edmund Husserl. These acts of intentionality have a temporal form. Anticipation is one of the fundamental forms of intentionality along with retention (recollection) and being present. (Note this material is technical and not for the faint of heart, but will be of interest to many readers.)
This analysis of intentionality opens up deep philosophical issues at this point, and Ratcliffe engages with them. The bottom line for Ratcliffe is that an intentional analysis of consciousness is on the critical path to providing an account of hallucinations and delusions.
For example, is the intentional act of seeing distinct from the content of consciousness? Can an individual disentangle the sense of seeing a tree from the shape, color, location in space, and so on, of the experience, leaving us with access to an act of perceiving in itself? Is the form separable from the content? It seems that it is, though their togetherness is such that one can only get access to the form through and by means of the content.
Since this is not a softball review, one may ask: So what? Hard working, dedicated, committed psychiatrists are taking arms against a seeming epidemic of psychotic disorders using the tools with which they have been trained – second generation anti-psychotic drugs. If a person comes in claiming to hear things that are not there and the person does not have a metabolic disorder, then the doctor is probably going to err on the side of caution and start him on a low does of one of those anti-psychotic medications. So why do we need a phenomenological analysis of real hallucinations – and “real hallucinations” as opposed to what? Fake hallucinations?
It turns out that, for the most part (and absent a study such as Ratcliffe’s and a few others like it), we do NOT know what hallucinations are. Even more problematically, we think we know, but we do not. We may usefully take a step back here to put the matter in context.
The average person, for example, thinks of hallucinations the way they occur in the Hollywood movie A Beautiful Mind (my example, not Ratcliffe’s). In the movie, the Nobel Prize winning mathematician and economist John Nash is having a conversation with his roommate. The audience sees the roommate, hears him and Nash talking together, and the scene is portrayed as if Nash sees and relates to the roommate the way we, the audience, see and relate to him.
Ratcliffe does not mention the Nash movie, and I bring it up to relate Ratcliffe’s contribution to the average, everyday misunderstanding of hallucinations. This academy award-winning movie about Nash contains many compelling performances, much engaging narrative, a good example of an elaborate, delusional system, but what it does NOT contain is an example of a real hallucination. (By the way as regards Hollywood fictions, The Black Swan (2010) with Natalie Portman does a much better job of capturing what psychotic hallucination are like as the lace of a ballet costume seems to grow like a malevolent fungus.)
Nash’s roommate does not exist – the audience eventually learns (to their astonishment) that the roommate is a hallucination. The roommate is part of Nash’s elaborate delusional network, resulting in Nash’s being given a diagnosis of paranoid schizophrenia – along with electroshock therapy and first generation antipsychotics (but that is another story). Meanwhile, if one gets inside the experience of the person who is having conversation with someone who is not really there, the experience is nothing like an ordinary experience. Okay, so what is it like? Hollywood gives us examples of fake hallucinations. Hence, the need for Ratcliffe’s Real Hallucinations.
(c) Lou Agosta, PhD and the Chicago Empathy Project
When I say, reading Arthur Kleinman’s books changes one’s listening, I do not mean changes one’s listening the way reading Lacan or being hit on the head with a rolled up newspaper changes one’s listening. What I mean is, reading Kleinman expands one’s humanity, empathy, and capacity for engaged caring.
This is likewise the case with The Soul of Care: The Moral Education of a Husband and a Doctor (due out September 17, 2019 from Viking), the most important memoire by a psychiatrist since Carl Gustav Jung’s Memories, Dreams and Reflections (1962) [though with a different source and trajectory], an unsolicited prepublication copy of which showed up in my snail mail. It is a real page-turner.
Arthur Kleinman, MD, trained as a psychiatrist, is an innovator in medical anthropology, a discipline of which he is the virtual founder. He and his late wife Joan, also an academic, spent considerable time and effort doing cross cultural (anthropological) research in China on traditional medicine, modern medicine, and the connecting points (and divergences) thereof. Of particular interest were survivor of Mao’s Cultural Revolution, who suffered from the symptoms of “neurasthenia,” a disorder whose explicit diagnosis has declined in the west – including fatigue, dizziness, anxiety, demoralization, and hard to diagnose pain(s).
In the course of their time in China, Kleinman (Arthur) gets a combination of exhaustion and dysentery, which reaches life disabling and even life threatening, stages. Joan is the very soul of caring – nursing him back to health.
This provides one of the paradigms for Arthur when Joan eventually gets early onset Alzheimer’s and he decides to take care of her at home.
The Soul of Care is the memoir of Kleinman’s life’s work (to date) and what happens when he decides to practice what he preaches and takes on the task of carrying for his increasingly ill wife, Joan.
Kleinman does not use the word “empathy” much, but it lives in his work, and in this case, the man is living in an empathy desert and that includes the health care system that is relating to him as pain instead of a whole person. Kleinman’s listening, which creates a context for human relatedness, succeeds in moving the dial back a few notches, though no way exists of undoing the now fused spine.
I have frequently had my mind blown by the power and precision of Kleinman’s writings. For example (and now we are in The Soul of Care), another patient has intractable pain relating to her diabetes, yet the diabetes is under control. The numbers from the blood work and related tests show that the diabetes should not be producing such results. Something is not adding up. Is the patient faking? Is there some disorder that has been overlooked?
This fellow, Kleinman, sits down and has a conversation with someone with intractable pain. He is genuinely curious about the patient. He is interested. He nails it. He brings along a medical student on a home healthcare visit. The above-cited patient is a diabetic, and is eligible for Meals on Wheels, transportation to the hospital, alternative housing (p. 206). The medical team (notice: there is a team!) had no idea, because no one asked.
Time-after-time, Kleinman shows up and asks a few questions – it all comes tumbling out – in many cases out-and-out trauma; in other cases, subclinical post traumatic stress disorder; in most cases, life circumstances, stress, inaccurate or incomplete diagnoses being transformed into bodily symptoms.
Continuing the above example, the patient is a single working mother; poor; working the grave yard shift while simultaneously cooking, cleaning, getting her kid (who is doing quite well, thanks) to school, and managing everything else well enough – everything except her pain. The patient is not faking – the pain is authentic, but diabetic neuropathy is not the cause. The cause is a work life imbalance of virtually unimaginable proportions (once again, “work-life balance” is my summary description, not Kleinman’s). The patient is running flat out, and is eligible for food stamps and other support available within the system. But no one on the team even bothered to have the conversation, even bothered to ask.
What is happening is that a medical issue does indeed exist. But the human being is more than an insulin pump. If medicine wants to be a caring profession not a bureaucratic profit center, then the doctor may useful make inquiry as to what the patient thinks is going wrong (and right) in her life. What is happening is that the emotions, affects, cognition, personal spirit, are elaborating what is in effect the anatomical or organic lesion and defect.
One can appreciate that individual practitioners may well feel they are like the “Lone Ranger,” single-handedly arrayed against human suffering. One will do what one can, writing the prescription at the end of the session for something, anything, to at least get the placebo affect as a positive expectation itself sets off a cascade of neurotransmitters. Kleinman appreciates how devilishly tricky it is both to address the biological system and the suffering human being present in the space
Yet Kleinman is uncompromising – and with good reason. Time-after-time, simple inquiries as to what are the facts of the person’s life circumstances point powerfully in the direction of human interventions that shift the person out of suffering and stuckness and into action. Putting the pain in context enables the person(s) to improve their own health through life style adjustments.
After all, is this not the age of the informed, engaged, proactive health care consumer? Many medical doctors pay lip service to such engagement, yet are not prepared to answer questions or, just as importantly, help the patient formulate the half-formed questions they are struggling to express. Do the job, do it completely, and do it the way it was meant to be done on behalf of the patient and suffering humanity.
Pain is one of those things that sometimes one can’t live with, but one certainly can’t live without. The reflex that causes one’s hand to jerk off of a hot casserole dish is not yet pain. The reflex precedes the experience of pain by a couple of seconds.
The reflex does not go through the brain; the experience of pain does. To become pain, the sensory information in the nerves has to go through the brain. In short, pain is important to tell the person about damage to his or her body that requires attention. Pain powerfully focuses one’s attention on getting actionable results in addressing the problem. But pain can cause a member or organ to become hyper-cathected – a tight loop that creates pain in anticipating pain to avoid pain. By focusing on the pain, attention can expand pain, grow pain, and become a habitual pattern of pain stimulation to the organism. Focus one’s attention elsewhere? Easier said than done, though alternative interventions such as meditation, hypnosis, and self-soothing stress reduction activities (which Kleinman does not much discuss) aim to do just that.
Kleinman is himself something of a survivor: a son who never met his biological father, a grade school student who bore two utterly separate family names once his mother remarried, from two opposed sub-ethnic factions, one in public school, the other in religious school; a scion of a mysterious past about which his Victorian family was silent or whispered inarticulately, so that he had the extra developmental task of figuring out by himself, yet not announcing to others, lest they be hurt what identified me, which therefore could not be authorized (or denied). (See Writing at the Margin (p. 2).
I learned a lot about empathy from Kleinman, though he rarely uses the word. Nor would I consider Kleinman an advocate of empathy understood in the narrow sense of a psychological mechanism. Rather in a medical world (Kleinman is a psychiatric), in which diagnostic categories are mapped to psychopharm interventions, Kleinman is an articulate advocate for sitting down and talking to the individual about what is going on in the person’s life. What is working and what is not working? While it takes extra time upfront, such a conversation for possibility makes a profound difference in actually getting an accurate diagnosis as opposed to a good enough, makeshift band-aide.
Kleinman several times quotes the celebrated founder of sociology Max Weber in his studies on bureaucracy. As institutions become larger and more complex, rules and roles independent of individual charisma and personal genius are needed to scale up to deliver services to more people. Nothing wrong with that as such – serving more people with high quality medical care is everyone’s aspiration. Yet when I have a disorder whose cause or course are unclear, like most people, I want the brilliant diagnostician, the TV doctor from central casting whether Ben Casey or House or whoever is trending, not a functionary.
For those interested in additional diagnostic pyrotechnics or just plain background, The Illness Narratives, the essentials of which are recapitulated in The Soul of Care, is the place to look for expanded and amazing narratives. It too is a real page turner.
Kleinman’s The Illness Narratives: Suffering, Healing, and the Human Condition (Basic Books 1989) distinguishes incisively between the person’s experience of illness and the doctor’s concept of the disease as part of a biological system. To be sure, substantial overlap often exists between these two, but not always. What then opens up and becomes possible is an entire method and approach to healing that puts biological reduction in its proper place.
For example: When chest pain can be reduced to a treatable acute lobar pneumonia, the biological reduction[ism] is a success. When chest pain is reduced to chronic coronary artery disease for which calcium blockers and nitroglycerine are prescribed, while the patient’s fear, the family’s frustration, the job conflict, the sexual impotence, and the financial crisis go undiagnosed and unaddressed, it is much less of a success (The Illness Narratives, p. 6).
The Illness Narratives expanded my appreciation of how a physical injury can take on a life of its own. The injury is real enough and it becomes a grain of sand around which a misshaped black pearl is elaborated (my metaphor, not Kleinman’s). The physical issue is elaborated by the emotions, as unresolved personal issues in a person’s life seem to be magnetically drawn towards making meaning out of pain and suffering.
Another example, in The Illness Narrativesa self made assistant police captain, performing good work, helping a neighbor, throws out his back. The pain gets habituated. He just can’t shake it off – month after month. It is affecting his job performance. He needs even more down time, sick time. He starts to feel that people do not believe him – he is really suffering.
To demonstrate to others and to himself how serious the matter is – and in the hope of finding relief for his pain – he agrees to surgery. However, if one is in pain, surgery can be a deal with the devil (so be sure to read the fine print), because, at least in the short term, surgery is a cause of acute pain.
Several years – and surgeries – later, the person – now a picture of pain – walks into Dr Kleinman’s office. The patient is the walking embodiment of pain. His every more seems painful. A conversation reveals a life narrative not for the faint of heart. He was not quite abandoned as a child, but basically he had to raise himself. He would have starved as a kid of tender age if he had not learned how to scramble some eggs; his head barely reaching high enough to assess the progress of the food in the frying pain.
Culminating in his latest contribution, The Soul of Care, Kleinman’s career has spanned the Corporation Transformation of American Medicineas identified by Paul Starr (1984) during which the medical doctor has gone from being a sovereign authority, whose word was virtually the law, to being a functionary in a corporation optimized for capitation and revenue generation, all the while paying marketing firms to communicate how caring everyone really is.
In order to preserve the integrity of his commitment amidst the corporate transformation of American medicine, Kleinman innovates, inventing his own field of study, medical anthropology. It has legs. It works. A journal is founder. High quality articles are published. Institutions, funders, and financial support are forthcoming. He teaches it at Mass General – we pause to honor the storied name – and at Harvard – another pause. With all this pausing, we are never going to get through this review. Yet the broader lessons for healthcare as a whole of medical anthropology do not break out of its own resonant, transformational niche.
Kleinman is definitely not living in a cave. He spends seven continuous years doing cross cultural research in China with his wife Joan, who becomes fluent in Chinese and provides important auxiliary functions in team building, networking, and having a life. (I shall follow the convention of calling “Arthur” by “Kleinman” and “Joan Kleinman” by “Joan” for simplicity.)
Therefore when Kleinman’s own world is brought low as the love of his life and his professional partner, his wife of thirty years, Joan, is stricken with early onset Alzheimer’s, he find himself wrestling not only with the disease but with the medical bureaucracy and the fact that his innovations in medical education have definitely notbeen widely adopted.
First he learns how to perform household chores. He learns how to pay the bills. He takes over bathing Joan and preparing meals. He marshals support from his gown up children, who have kids of tender age of their own and are running flat out – all the while continuing teaching and research (albeit with a certain amount of flex time provided by his long-term employers – pause again to honor them – for whom Kleinman is a celebrity academic).
He gets a home helper, who is indeed an essential part of the support system. With 20-20 hindsight, he second guesses his own agreement, requested by Joan, that she be allowed to decline (and die) at home. He has an important late insight, realizing that Joan is no longer the person who entered into that agreement, the dementia having robbed her of [essential aspects of] her identity. Nor is he the same person, who he was after the ongoing ten year long struggle. Between Joan’s agitation, loss of identity, intermittent fear or psychosis, and incontinence (wandering was less of an issue, because the patient became blind), all bets – and prior agreements – are problematic.
The couple consult many specialists. The neurological resident Kleinman and his wife visit is interested in talking with them again – in six months – and in following the irreversible course of the disease, not in engaging with the human impact and cost for the wife and husband.
Confidentiality is important; but it becomes yet another obstacle as the well-intentioned neurology resident insists on addressing Joan, even though her expressed wishes are that Arthur be included in all the decisions. Queue up the living will and health care power of attorney. All well and good. But the problem is that the patient does not want to have a legal conversation, she wants to have one about caring. Noticeably absent is guidance as to caring. Key term: caring.
Kleinman matriculates in the college of hard knocks. As caring – and empathic – has he already is, it is all used up by the progressive dementia. He gets a home helper since, though relatively well off, he must keep working to pay the mounting bills – and for his own sanity. Towards the end of the middle stage of the disease, he actually takes her with him to Shanghai, China, in order to fulfill academic obligations and complete a stalled project in cross cultural health care.
The reader cannot help but wonder, “What is this guy thinking?” as he takes Joan, by then an easily agitated person developing Capgras (“imposter”) syndrome, through airport security to Shanghai. Somehow he pulls it off. The quality of care in China and the support for the family is truly inspiring, especially given how eager his Chinese colleagues are to be supportive with both traditional and modern medicine (and given that no one really has the answer regarding Alzheimer’s).
Without using the word “empathy,” Kleinman was already operating at an advanced level in relating to others in a caring way. He is the Other whose listening brought relatedness to suffering individual in one case after another. Now he faces new, life-defining challenge.
A recurring theme becomes how his ten years of care giving becomes a descent to the hell of irreversible dementia without the prospect of rebirth. As near as I can figure, his is a journey of the hero, with ample commitment and tragic struggle, but without heroism.
Even given his training as a psychiatrist and anthropologist, a well-connected professorial network with high quality, [relatively] responsive support, he is brought low, isolated, at the brink of emotional despair. But how could it be otherwise? He is losing his wife to a disease that robs a person of her identity (i.e., dignity), but she is still physically present and intermittently coherent. Even so he struggles to get straight answers from the medical professionals about the course of the disease, about the trade-offs between home care and assisted living.
The back story is that at some point early on in their relationship Joan decided that her life project was to take care of him (Arthur), the family, the kids, even supporting his research – they published academic papers together – while also mastering the Chinese language and immersing herself in that culture. She got good at it – very good indeed.
Kleinman decides that he wants to return the favor. Of course, it is not as simple as that. Kleinman talks about his own guilt and what he had to survive coming up. The point is that this man Arthur Kleinman is already the soul of caring; but he takes his caring to a new level through the refiner’s fire of caring for Joan.
It is a heart-warming and inspiring narrative – the ultimate illness narrative (also the title of Kleinman’s most impactful work prior to this one) – but also a harrowing one. Not for the faint of heart. Apparently at some point, [many] advanced Alzheimer’s patients stop eating. A morphine drip and lip moistening are the palliative measures recommended.
If you need a good cry, you will get one by the time Kleinman realizes there is no way to take care of Joan at home even with a full time assistant. The end is not
quick, but given the morphine drip, neither is it painful. What it is is impossible to put into word. The image of suffering of Shakespeare’s Lear, blind and wandering in a storm of agitated emotions towards the edge of the cliff, looms large. It’s her; it’s him; it’s both, though he ends up being a survivor. What is painful is the loss – the loss of humanity of the Alzheimer’s patient.
When Kleinman uses the word “moral” – it occurs in the subtitle of The Soul of Care as well as in the subtitle of his What Really Matters(Oxford 2007) – of course, he is referring to value judgments, candidate categorical imperatives, and assessment of ethically right and wrong behavior and character. At times, I doubt that the word “moral” adds to the discussion, since it is mainly about preserving one’s sanity in the face of the disintegration of the skills needed for the activities of daily living.
“Humanity” and “morality” overlap extensively and I doubt it makes sense to ask which came first. Yet they are not identical. There is a conflictual aspect to our humanity that morality attempts in vain to capture and make right by judging. Lear, blind and stumbling towards the edge of the precipice, is also wandering at the edge of morality, though arguably he never stops being a struggling human being. Neither does Kleinman.
Nor at any time does Kleinman become a moral relativist, though he is keenly in touch with the fuzzy, grey areas. The problem is that the space of human action and engagement becomes so thick with judgments and evaluations that one can hardly think, much less take action in the face of urgent emergencies.
Most of the tough (and narratively engaging) cases involve fraught decisions where fundamentally good people actually perform bad actions. In some cases the consequences of the action escape from the agent – as when the soldier follows the sergeant’s orders and blows up the car supposedly containing the suicide bomber, but it is actually a family of five on the way to deliver a baby. That is moral trauma. But in other cases individuals actually, intentionally commit war crimes (e.g., Winthrop Cohen in Kleinman’s What Really Matters) and spend the remainder of their lives twisted in knots over what happened, what does it mean, and how to go on.
Taking matters up a level, one such looming moral trauma is the ongoing corporate transformation of American medicine.
Kleinman channels some of his well-founded anger into targeting the systematic breakdowns of the American Healthcare system in the face of revenue incentives, corporate metrics, and devaluing caring. His jeremiad – I mean, argument – may usefully be made required reading – not only for doctors but especially for administrations and managers – in medical schools and systems. It is often the administrators who are taking advantage of the medical professional’s empathy in demanding more patients per period with no compromise of quality or attention to the demands of addressing human suffering in its physical as well as emotional and spiritual aspects.
Kleinman throws down the gauntlet, demonstrating just how far main stream, neoliberal, bio-political health care has diverged from his humanistic vision: “The problem, as some suggest, is not that we fail to quantify these experiences [of caring], but that they cannot be quantified, because they are essential human interaction, the soul of what health care is” (p. 238).
Many long term advantages exist in reducing spending upfront by life style changes in nutrition, exercise, stress management – and avoiding expensive medical technologies and interventions once the damage is done. A compelling quantitative case can be made that an ounce of prevention is worth a pound of cure.
Nevertheless the fact remains: quality health care is expensive. Though I am just a citizen, the Siemens Magnetic Resonance Imagining (MRI) device that took a picture of the torn cartilage in my knee looks to be almost as large and as complex, though in totally different ways, as the lunar excursion module (LEM) that landed two men on the moon in 1969. It turns out to be Rocket Science, so why should it be less expensive? Imaging, genomics, proteomics, personal medicine, personalized treatment using the most advanced technologies are quite simply expensive.
What is a lot less expensive – though by no means totally without cost – is sitting down and having a conversation for possibility with another human being – about her pain, disorder, and her life. And this conversation is one of the sources of quality healthcare and human flourishing, or at least pain management. This provides a powerful picture, too.
Read an excerpt from the book, quoted in Time Magazine: https://time.com/5680723/doctor-wifes-alzheimers/
A rumor of empathy is no rumor in The Soul of Care and Kleinman’s works. Empathy LIVES in Kleinman’s contribution. Kleinman does not emphasize this point about the power of ordinary language, though it is near enough to the surface of his text, but rather calls out the moral imperative: we must think deeply and with integrity about the kind of society and community we want to be. The extreme wealth being generated by innovations in technology make possible maximizing acts of humanity that advance community well-being. Whether that happens to the USA, as a healthcare nation is an existential choice of the highest order on the part of the individual and the community.
Lou Agosta, PhD and the Chicago Empathy Project
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