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 in A Rumor of Empathy: Resistance, Narrative and Recovery in Psychoanalysis and Psychotherapy. London: Routledge.
(c) Lou Agosta, PhD and the Chicago Empathy Project
Categories: Apna Ghar Our Home, Danger Assessment (Domestic Violence), Dialectical Behavioral Therapy (DBT), domestic violence (DV), Fatality Review Board (Domestic Violence), fMRI, narcissistic rage, Neurology, social justice, TBI Traumatic Brain Injury