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Saint Linehan: Marsha Linehan dishes on what she had to survive to innovate her way to DBT

This is the story, the narrative, of a survivor, Marsha Linehan, an innovator in the treatment of borderline personality disorder (BPD) using a method she and her team

Cover Art: Building a Life Worth Living by Marsha M. Linehan

Cover Art: Building a Life Worth Living by Marsha M. Linehan

invented called Dialectical Behavioral Treatment (DBT). Linehan has written a memoir, not a treatment manual (separately available (see references at bottom)). Her memoir contextualizes the diverse interventions used by DBT such as acceptance, distress tolerance, emotional regulation skills, self soothing skills, communication skills, limit setting skills, assertiveness training, and so on. She attempts and largely succeeds in connecting the dots between DBT and its skills and the key events in her life, many of which had not been publicly available.

While courage is needed for someone who has suffered from invalidation all her life to risk further invalidation in some arbitrary book review, dishing on the details of one’s life is definitely trending. Being vulnerable is trending – see Brena Brown who has virtually branded vulnerability – and Linehan succeeds in spades in opening herself up. Linehan’s narrative is by turns spiritually enriching, educational, funny, discouraging, and inspiring.

For those who require an orientation – and at the risk of over-simplification – DBT combines acceptance and tolerance such as one develops in meditation and mindfulness with the specific cognitive behavioral therapy (CBT) skills designed to interrupt the dysfunctional thinking and negative self-talk of anxious and depressed neurotics. I see it as empathic validation plus homework in CBT skills.

More formally, DBT is an evidence-based, team-abed treatment, requiring individual and group work, that is included in clinical practice guidelines for the treatment of BPD, suicidality, and several other “acting out” types of addictive behavior such as substance dependency that have proved resistant to other forms of treatment.

Linehan’s memoir connects the dots between a specific DBT skill back to her experience in life. Often she calls out the instant in which the DBT skill was born, defined, invented, or got “borrowed” from another theory. For example, and once again at the risk of over-simplification, Linehan does a lot work on mindfulness, meditating in the context of Zen Buddhism; the DBT skill of acceptance is born. Another example, in the case of willingness – like, “I am willing to give it a try” –  Linehan first encounters it at the Shalem Institute. Willingness is borrowed from the existential psychotherapists Gerald and Rollo May, but given its own special spin when combined with the Zen distinction of acceptance (p. 196).

In reading Linehan’s compelling and engaging narrative, she talks a lot about religion and love. The spiritual dimension is front and center.

William James’ The Varieties of Religious Experience (1902) has nothing on Dr Linehan – she sees the golden bright light at the Cenacle Retreat Center over on Fullerton – possibly at about the time I was living around the corner on Belden Avenue.  She has the “blue hydrangea” moment, too. Hence, the title of this review, “Saint Linehan” is not an irreverent joke, in the DBT sense, though it is that, too.

Linehan documents at least two mystical experiences that belong in James’ work. As noted, at the Cenacale Retreat House on Fullerton Avenue, Chicago, she experiences the encompassing, enveloping “bright golden light shimmering all over”  (p. 102, p. 200). Then later she has the “blue hydrangea” pantheism experience of God being everywhere at the Shalem Institute of Christina contemplative prayer with a strong admixture of existential therapy from Gerald and Rollo May (p. 196, 201).

Linehan was in psychoanalysis at the time of her “golden light” experience, and, of course, she told her analyst about it. Now one might expect the analysis had read Freud and he would associate to the “oceanic experience” from childhood that Freud so compelling quotes on the first pages of Civilization and Its Discontents. Instead Linehan reports that the analyst said: “Marsha, I’m an atheist, so I have no idea what happened to you. But I can tell you this: you don’t need therapy anymore.” That was that.

Wait a minute! Freud was an avowed atheist, too, which is where this analyst got the idea, though Freud highly valued Jewish culture and Hebrew teachings. It may be deeply cynical, but I wonder that this so-called analyst (Victor Zielinski, MD, who spent a lot of years at Hines – another bad fit (?)) had not been wishing for awhile that this difficult individual would just “go away.” Another breakdown of empathy?

Marsha did not see it that way, she was sooo happy as she left the office. Though I accept the happiness, the accuracy of her insight into the cause of this happiness is what I am a tad skeptical about. She had a narrow escape from yet another invalidating, unempathic environment like her mother’s home growing up. I hasten to add this was prior to Heinz Kohut, MD, and his innovations, which powerfully embrace empathic listening and responsiveness in the psychoanalytically inspired (and based) context of self psychology.

The causes of BPD are still being debated, but the person is vulnerable in three areas. The person must have a biological disposition; the group (society, community, family, and so on) to which she is a part leaves the person feeling they do not fit in; and, most importantly, the person is not given a chance to develop the interpersonal skills needed to relate to others, regulate their emotions, and self sooth. In short, the aetiology requires an invalidating environment. Key term: invalidation.

To me the invalidation environment often looks like one that lacks empathy or one in which the caretakers are significantly “out of tune” empathically with the child. Of course, the environment may also include more obvious adverse or traumatic experiences. I hasten to add that while it is fashionable to dump on the parents, that is inadequate. One can get similar results as extroverted children are born to introverted parents (and vice versa) and so on. See Andrew Solomon’s book, Far From the Tree (2012). The apple never falls far from the tree? Oh yes it does! Marsha fell far from the tree. But that is not all.

In Linehan’s life, the mother is the image of the invalidating environment – Marsha was never quite right – she came within a hair’s breath of inventing self psychology but once she ended up on the inpatient psychiatric unit and had been subjected to the rigors of electro shock “therapy” that game was over – to save herself she had to wok from the outside inwards behaviorally and invent DBT.

So what did Linehan actually have to survive? She was the round peg in the square hole of her family. She was smart, got good grades, was out-spoken, and even popular in her own eccentric way. All the women in the Linehan family are wife line – thin; Marsha is “large-boned” and if she is not caution those bones can acquire adipose tissue. The mother is prim and proper and the model of an executive’s wife. The executive was remote, taking solace in his work, and keeping his distance from the “house wife obsessions” of the mother of his children. He emotionally abandons Marsha. Meanwhile, according to Marsha’s mom, she [Marsha] just couldn’t do anything right.

Marsha needed fixing and no one knew better how to do it than mom. Yet no matter how much Marsha improved, no matter how good she got, Mom consistently found something to criticize. One can only get better for so long; then one has to be good enough.

The sister’s example was always there to be thrown at Marsha. And mom apparently even warned the sister to stay away from Marsha, further isolating her emotionally in the family, as Marsha was apparently a bad example. She was getting good grades and popular – a bad example of what? “Girls were supposed to be demure, sweetly charming, quietly spoken, and not given to expressing strong opinions, especially around men. They should defer to men at all times and in all things” (p, 111). Her mom valued a “girly girl,” who knew her place. This was not going to go well.

Marsha starts living into the devaluing judgments of her close relatives. Marsha gets to adolescence and her “apparent competence,” her skill in maintaining a false self [not Linehan’s term], the good girl, even if a tad eccentric, breaks down. She has some dates, but she never succeeds in getting a steady boy friend in high school. She comes unraveled, beset with acting out in the form of cutting – what would come to be called para suicidal behavior thanks to DBT.

There was an noticeable absence of trauma on Linehan’s life, except those traumas which she eventually inflicts on herself in cutting with a razor and related para suicidal acting out. But invalidation was pervasive. If empathy is like oxygen for the soul (psyche), Linehan was suffocating. She starts flailing about like someone who can’t breathe.

A constant drumbeat occurs of “you are not all right,” of “you are not important,” “you are less than.” Highly destructive to the nuclear self.

Even though Marsha eventually overcomes many of her demons, mom’s behavior never changes in spite of an honest effort. For example, years later, Marsha is getting her doctorate in social psychology, a significant accomplishment under any circumstances. Congratulations? “Mother had made a dress for me for Aline’s [her sister’s] wedding, and on the morning of graduation she was more focused on fitting my dress than she was on my getting a doctorate” (p. 118).

The word “empathy” occurs once in Linehan’s text (p. 94); and, of course, the word itself as a mere word is dispensable in principle. The text and Linehan’s life work is steeped in empathy. Empathy LIVEs in Linehan’s work. But not empathy as emotional contagion or “touchy feely” fragilization. Key word: fragilizing (p. 223). Not you are very fragile and have to be spoken to softly and treated with kid gloves.

There may indeed be moments for a quiet heart-to-heart talk, and such conversations are highly significant, but if a person is carving up their arm with a razor, this person may be a lot of things, but fragile is not exactly one of them. How shall I put it delicately? They are in a lot of pain and suffering and are employing emergency merges to try and survive the moment.

Paradoxically pain and suffering can become a highly uncomfortable “comfort zone” for the client. Personal suffering is ruining the person’s life, but the person is attached to the suffering. This is the case not only with BPD but with most kinds of mental and emotional disorders. This is different than moral masochism, but sometimes not different by that much. The patient has to be motivated to engage the tough work of moving beyond stuckness to have new experiences, which are by no means guaranteed to be immediately rewarding or satisfying. That is where validation comes in.

We have conceptualized invalidation as a cause of the suffering, so Linehan and DBT deliver validation as part of the treatment. But what is validation? A lot of work is done to meet the client where she is. The client says, “My life sucks.” And that is usually the most accurate available description. The person really is miserable and there are good reasons for it. What’s so about life needs to be validated before the individual can consider the possibility of moving forward out of stuckness. The therapist’s validation provides access to the client’s acceptance of their situation. Acceptance of the situation provides an opening for moving beyond the limits of the situation.

The challenge to the treatment is that acceptance and validation provide access to change, but it does not seem that way to the person who is in pain. The challenge is that pain and suffering can be sticky.

“Validation” means you experience your experience. Invalidation is being told – sometimes quire persuasively – you did not experience your experience. How is that even possible? Believe me, it happens a lot. Blaming the victim. Redescribing the experience as caused by the survivor’s own shortcomings. “Don’t you ever talk that way about Uncle John again! He did not pull down your pants” [not an example in Linehan]. Pretty soon the child does not know what he is experiencing.

The client usually likes to be validated. Validation is different than agreement or disagreement. It means the other person “gets who you are.” It means one is responded to as a whole person, not a diagnosis, label, body part, or partial entity. It means one is responded to as the possibility of flourishing and accomplishment, even if, at the moment, one is stuck in emotional misery. For my money, that is an alternative redescription of empathic understanding. For many, validation is itself a new experience and some can’t believe it or be open to it. It takes time, but most people promptly, though not instantaneously, perceive it as authentic, especially when it is authentic.

Then the client can be motivated, leveraged, incented, to practice new skills, take risks interpersonally, and just try stuff out instead of wallowing in a funk of anxiety and depression. The validation is the empathic moment. To get it right requires expanded empathy. Though the word is not much used, as noted, empathy LIVEs in the work Linehan and DBT treatment programs are doing. But then you also have to do the exercises.

 

Before I read Linehan’s memoir, I knew that she was a survivor. I knew she was a survivor of some of the things for which DBT is a successful treatment. I knew about the “physician, health thyself” aspect of her work and the work at Zen Buddhist retreats – as indeed is often the case with innovators who have to overcome personal demons in order to thrive – Kay Redfield Jameson and Elyn Saks, for example. Indeed Freud and Jung belong on this list – especially Jung.

I digress at this point to point out that Henri Ellenberger (Discovery of the Unconscious (1970)) has the distinction of a “creative illness” – which often has major psychosomatic aspects as the body is the best picture of the human soul/psyche – from which the individual emerges with renewed energies to produce his or her magnum opus or masterpiece. Arguably Linehan’s two years on the inpatient unit were her “creative illness,” though I cannot believe it seemed to her that way at the time.

What I did not know prior to reading the memoir was about the electro convulsive therapy (ECT). Linehan reports she once knew how to play the piano. The ability never returned after the ECT. She got into a pre med program at Loyola in college and found that she had forgotten all her biology and much of her science, once again probably as a result of it having it blasted out of her by ECT and significant does of anti-psychotics – you forget what is bothering you and a whole bunch of other stuff too). So Marsha Linehan is also a survivor of ECT, and not in the best sense of the words.

Need I add that Linehan, with some conditions and qualifications, does not endorse the inpatient treatment of psychiatric disorders? One of her many videos on Youtube makes the distinction between a “life worth living program” and a “suicide prevention program.” I paraphrase Linehan in redescribing suicide to a suicidal client: “It’s good that you see feeling suicidal is a problem; but really suicide is a solution to escape from a messy and painful life; and our job in DBT is to give you a better solution through skills such as self-soothing, distress tolerance, mindfulness, emotional equilibrium training,” By the way, “redescribing” is a DBT skill that has many origins, but most properly credited to the modern philosopher Elizabeth Anscombe.

Linehan’s makes a strength out of a weakness in the memoir as she enrolls important people in her life of giving her an account of publication of what was going on at the time, which she then quotes in the memoir. Still, the number of times is significant that she reports, “I just can’t remember” or “I don’t know why I did this” [or words to that effect].Such statements become an important part of the rhetorical stance of this work. They are also, in their own way, examples of a DBT skill. One does not always need to understand in order to get the result. Understanding has its uses, but also its limitations. If one sits around waiting to understand, it could be a long wait. Get in action. Try something. If it does not work, stop doing that, and try something different.

 

What I did not know was about the extent and depth of the self-harm. She gets put in isolation, and she launches herself head first off the chair in a frenzy of disequilibrated self-harm. Yes, people were supposed to be watching her, but somehow this kept happening. Traumatic brain injury?

What I did not know is that Linehan, finally on the road to recovery, considered becoming a monk or nun. She took vows of poverty, chastity, and obedience as a Lay Religious person instead. In the irreverent spirit of DBT, I note that her career total was zero for three, though here I am making an educated guess, I believe she honored the spirit of her vows.

Since this is not a softball review, I have critical observations. Linehan learned more from that unempathic psychoanalysis than she realized – she was working on an early version of self psychology. Thus, I have some “tough love” for one of the inventor’s of tough love in the context of treatment. However, the one thing I am not going to do is invalidate Linehan’s experience. Her report of her own experience is whole and complete and perfect in every way. She gets to say.

This business of “wise mind” – a DBT koan – needs work. My intuition is that human beings cannot intentionally “be wise.” Some people may end up being wise as a result of processing their experiences in profound ways. Wisdom comes forth “out of the mouth of babes” in that some individuals get in touch with a “beginner’s mind” and are able to express hard-to-capture distinctions hidden in plain view, about life, relationships, and everything. In that sense, yes, “wisdom happens.” Kant said, “Only God is wise.” Kohut said that a certain wisdom – along with humor and expanded empathy – can be brought forth as the result of a successful analysis of the self; but that wisdom was mostly acceptance of our limitations, suffering, and finitude. So I have NEVER been comfortable or “on board” with the over-simplifications in DBT about “wise mind.”

Linehan is often on a tear – standard behavioral therapy doesn’t work with the most seriously distressed (suicidal) patients and cognitive behavioral therapy has serious issues, too. You have to get a person whose life and all-available-evidence “prove” that “all the good one’s are taken” or “life sucks” to be reasonable and admit that “some of the good ones are not taken” or “life does not have to suck at all times.”

Emotional mind does not acknowledge cognitive penetrability or cognitive impenetrability. Cognitive mind does not acknowledge the emotions display a “logic” of their own, disclosing important aspects of a situation while also concealing other aspects. Cognitive mind can tell you “what’s so,” but cognition lacks the power to motivate you to do anything about it. Abstractions do not move people, emotions do. There is a dialectical encounter between the two – and that is commitment, which tries to find a emotional motivation for what cognition shows to be an authentically valid path forward.

The thing about the iceberg is that it’s the iceberg “all the way down.” The visible part of the iceberg is not a different iceberg than the less visible part submerged beneath the water. The behavior is visible, but the biology is not visible, what the individual had to survive is not visible, how the community reacts to the individual of is not visible.  But unlike – or perhaps just like – the iceberg, research treats these all as different siloes. It is true that we all – including Linehan – now speak of the bio-psycho-social individual and express authentic commitment to integration. But the effort required to integrate just shows how dis-integrated the entire phenomenon is.

The tip of the iceberg does not regard itself as distinct from the iceberg. The “tip” is our abstraction. Likewise, with behavior. Linehan demonstrates this compelling as she takes the psychoanalytic distinction of “introject,” operationalizes it, and shows collects evidence that DBT improves measures of introject over against a stricter behavioral intervention. Amazing.

How shall I put it delicately? Like every other individual, Linehan has a privileged access to her own first person experience – the golden light moment, the blue hydrangea moment. She also has many advantages in interpreting what that experience means, since, like every other individual, she knows a lot about her own history that others might or might not know. But as to what the experience “really means,” one individual has as good a chance of getting it right as another once the experience has been captured and reported. At first she says “The golden light means God loves me”; but then, since that experience was like [felt like] her love for Ed [a person who she actually loved deeply], she reinterprets the golden light to mean “I love God.” So she has to continue searching for God’s love for her, which brings us to the blue hydrangea by which time the meaning of God and of love have shifted.

But wait. Her Zen experience will eventually have taught her this is just another Zen koan – it is like the ambiguous Gestalt image the duck-rabbit where the rabbit’s ears and the duck’s bill and the figure spontaneously reverses – perhaps she got it right the first time – “God is God” and “love is love.” In short, Linehan is really slinging it here, and there is nothing wrong with that. It works. Her rhetoric is that of the beginner’s mind after long struggle. She is irreverent, assertive, disruptive within limits (and without), and contrary within  limits (and without), innovative, all DBT skills, and we thank you, Marsha, for being Marsha.

References

Marsha M. Linehan. (2020). Building a Life Worth Living: A Memoir. New York: Random House, 384 pp.

Marsha M. Linehan. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.

Marsha Linehan Interviews Kelly: https://www.youtube.com/watch?v=tgzw50SbokM

© Lou Agosta, PhD and the Chicago Empathy Project

Review: “No Visible Bruises” refers to strangulation

The title of Rachel Louise Snyder’s eye-opening, powerful, page-turner of a book, No Visible Bruises, refers to strangulation [No Visible Bruises: What We Don’t Know About Domestic Violence Can Kill Us, New York: Bloomsbury Publishing, 2019: 309 pp, $28(US)].

Some sixty percent of domestic violence (DV) victims are strangled at some point during an abusive relationship (p. 65).  Turns out that only some 15% of the victims

Cover Art: No Visible Bruises by Rachel Louise Snyder - a picture of cracked plaster - not only of an enraged fist but of a damaged, fragmented self (?)

Cover Art: No Visible Bruises by Rachel Louise Snyder – a picture of cracked plaster – not only of an enraged fist but of a damaged, fragmented self 

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.

 

Further Reading

Wilson, K. J. (1996 [2006]). 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 Videohttps://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