Shallow Affect, No Remorse: the Shadow of Trauma in the Inner City

Home , Remorse

Peace and Conﬂict: Journal of Peace Psychology © 2013 American Psychological Association 2013, Vol. 19, No. 3, 000 1078-1919/13/$12.00 DOI: 10.1037/a0032530 Shallow Affect, No Remorse: The Shadow of Trauma in the Inner City

Christopher B. Roach Alliant International University

This article looks at a psychotherapist’s lessons learned at the intersection of trauma and antisocial behavior in 20 years of working in American prisons, forensic hospitals, and trauma centers. Typically, posttraumatic stress disorder (PTSD) presents as an anxiety disorder with the symptom triad of avoidance, reexperiencing, and hyperarousal. Therapy can proceed once some level of safety has been achieved. But many potential patients do not have a safe space for the work to proceed. Instead, they are living in conditions of ongoing exposure to trauma that has been variously described as complex PTSD and continuous traumatic stress. Anxiety would hardly be adaptive for survival in this environment and, in fact, the symptom picture is often dominated by anger, aggression, and callousness. When these potential patients are found in jails, prisons, and hospital emergency rooms, their outward presentation, instead of centering on anxiety, can appear more like conduct disorder or even criminal psychopathy. They may have been victims, but they frequently have also been perpetrators of violence. These patients need and deserve a trauma-centered treatment, but exposure therapy is hardly appropriate for someone who is experiencing ongoing traumatic conditions. Therapy can proceed, however, and be successful, but the techniques that the therapist uses may be quite different from those found in other settings. A theory of how trauma connects to antisocial presentations will be described, and some of the lessons learned in working with this population will be shared.

Keywords: trauma, inner city, anger, PTSD, conduct disorder

That was what I was thinking, about what was in my bers who had returned from an overseas combat heart and what that made me. I’m just not a bad person. zone (Sontag & Alvarez, 2008). The reaction I know that in my heart I am not a bad person. Walter Dean Myers (1999, p. 92) from law enforcement, communities, and fami- lies to these acts by servicemen is often sympa- A soldier leaves Iraq or Afghanistan, arrives thetic. War, they reason, had changed a decent, home, and commits a murder. In 2008, The New moral man and driven him to murder; exposure York Times documented 121 murders that were to violence has changed him. committed in the United States by service mem- A young man leaves prison, arrives home, and murders another young man. In 2008, 124 murders were committed in the city of Oakland, California, alone (Spiker, Garvey, Arnold, & Williams, 2009). Like the soldier in a combat CHRISTOPHER B. ROACH, PsyD, has focused his clinical This document is copyrighted by the American Psychological Association or one of its allied publishers. zone, this young man has been exposed to lethal work on the treatment of the seriously mentally ill and on This article is intended solely for the personal use of the individualtreating user and is not to be disseminated broadly. both the victims and the perpetrators of violence. violence, but the violence he was exposed to He teaches a graduate course in the assessment and treat- was not overseas, it was in his own neighbor- ment of family violence. Prior to his undergraduate and hood (Schwartz, Bradley, Sexton, Sherry, & graduate studies, he spent 12 years as a member of the Ressler, 2005). The reaction from some in the United States Marine Corps. He is currently afﬁliated with Alliant International University, Clinical Psychology PsyD community may be sympathetic, but, from the Program. larger society, law enforcement, and the courts, CORRESPONDENCE CONCERNING THIS ARTICLE should be it is often not. addressed to Christopher B. Roach, Alliant International This article looks at one American therapist’s University, Clinical Psychology PsyD Program, One Beach Street, Suite 100, San Francisco, CA 94133-1221. E-mail: experience with the world of violence and [email protected] trauma in the context of work done in prisons,

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victim-support programs, and forensic hospitals who comes home to a space relatively free of for mentally disordered offenders. The violence violence, these victims do not leave the war discussed in this article does not come from the zone; they remain at the scene of the crime, in delusions and hallucinations of major mental the center of their own “war zones,” neither illness (Farrington, 2007). Instead, it comes emotionally nor physically safe. A large per- from men who do not look “sick” and who may centage of these young men are criminals. Un- have never been diagnosed with a mental ill- like the traumatized soldier who receives treat- ness. They have, however, often been exposed ment at the Veteran’s Administration, these to trauma, though they may not appear to be young males receive their treatment, if they traumatized. My question is: How do we under- receive treatment at all, within the prison sys- stand and help them? tem. My investigation, carried out in the spirit of Various authors have expanded on the origi- Bowen Paulle (2007) and Philippe Bourgois nal concept of posttraumatic stress disorder (1995), seeks to integrate aspects of clinical (PTSD) to address the reality that people cannot practice, qualitative and quantitative research, only suffer multiple traumas at different stages sociology, psychology, public health, anthro- of their life, but that their exposure can be pology, criminology, literature, and medicine. ongoing or “continuous.” Judith Herman’s This may be an ambitious goal, but the roots of (1992) concept of complex PTSD (C-PTSD) violence, the care of the traumatized, and the involves repeated traumas, such as sexual treatment of the perpetrator are aspects of the abuse, from which the victim is unable, or per- human condition that exceed the scope of any ceives an inability, to escape. Gillian Straker et single discipline or perspective. In fact, one of al. (Straker & Sanctuaries Counseling Team, the difficulties in the field of treating and un- 1987; Straker & Moosa, 1994) developed the derstanding violence is this multiplicity of per- concept of continuous traumatic stress (CTS) in spectives, each with their own language, meth- the context of work with South African town- ods, and ways of understanding. Integrating ship youth. These youth had endured ongoing multiple disciplines and perspectives is a nec- trauma under apartheid, as well as in postapart- essary task for the therapist who encounters the heid South Africa in the violent aftermath of the wounded in the world of prisons, hospitals, and systemic change the country underwent. For communities, and who seeks to alleviate the these youth, there was no safe haven in which cycle of victimization and violence. the reparative work of therapy could be conducted. CTS brings the political and sociologi- Describing the Population cal elements of institutionalized racism to the discussion of the effects of living in the midst of The average perpetrator of a “simple” violent trauma. Developmental trauma disorder focuses assault in the United States is male, between the attention on the impact of trauma on children ages of 12 and 20 years old, not under the and the diagnostic problems that result when influence of alcohol or drugs, and is dispropor- there is no trauma-specific diagnosis for this age tionately Black. His victim is a male, below the group (van der Kolk, 2005). All of these con- age of 25, also disproportionately Black, with cepts highlight the social, medical, biological, an equal probability of being an acquaintance or and psychological complexity of trauma as a a stranger (Hart & Rennison, 2003; Truman & holistic interactive phenomenon that does not This document is copyrighted by the American Psychological Association or one of its allied publishers. Rand, 2010; U.S. Bureau of Justice Statistics, exist in diagnostic isolation. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 2006). Although overall crime has fallen in the In the United States, there also exist areas United States, the rate of serious, violent vic- where historical racial trauma interacts with on- timizations has remained relatively steady (Tru- going high levels of violent crime. In the areas man, 2011; Truman & Rand, 2010). The group where there is extremely high, ongoing expo- most impacted by serious violent crime in the sure to violence through crime and social dis- United States is comprised of these young males organization, there is a situation analogous to who both assault and are the victims of as- that experienced in some parts of apartheid- sault—a blended perpetratorϪvictim (Roach, era South Africa. These are communities that 2008; Truman & Planty, 2012). Unlike the sol- cannot solve their own problems, and where dier who returns home from the war zone and political, economic, and social forces result in SHALLOW AFFECT AND NO REMORSE 3

sustained disorder and the isolation of these Campbell, 2008; Gomez-Beneyto, Salazar- communities from the economic mainstream Fraile, Marti-Sanjuan, & Gonzalez-Lujan, (Kurbin & Weitzer, 2003). In some of these 2006; Löwe et al., 2011; McQuaid, Pedrelli, communities, there are now multiple genera- McCahill, & Stein, 2001). tions who have grown up in an environment that Outside of the clinical realm, images of post- has many of the characteristics of what might be trauma suffering and PTSD have permeated considered CTS. American culture from Rambo (Feitshans & Although overall crime in America has gone Kotcheff, 1982), to Oprah Winfrey (Morgan, through a steady decrease from its peak in the 1986), to director Tim Burton’s (Guber & Bur- 1990s (U.S. Department of Justice, 2010), in ton, 1989) Batman movie franchise. The patient specific crime “hot spots” there have actually with symptoms of reexperiencing, avoidance been increases in the number of homicides (Po- and numbing, and hyperarousal, the classic triad lice Executive Research Forum, 2008). In 2012, of PTSD (American Psychiatric Association while killings held steady or dropped in Los [APA], 2000), has a presentation that is easily Angeles and New York City, Chicago’s murder recognized in both clinical presentation and rate has climbed 38% from 2011 (Davey, 2012). popular American culture. The patient is What distinguishes these areas from others is haunted, wounded, isolated, and anxious, with a not merely the volume, but the concentration, of psyche scarred by the experiences he or she has crime that occurs in them. In New York City, been through. In media representations, the psy- about 4% of the population lives in public hous- chologically wounded warrior can be angry, but ing, but 20% of all the city’s violent crime in the description of PTSD in the Diagnostic occurs there (Moynihan, 2012). These hot spots and Statistical Manual of Mental Disorders, are predominantly urban, poor, and centered in Fourth Edition, Text Revision (DSM–IV-TR; areas with high concentrations of minority pop- APA, 2000) there is scant mention of “hostil- ulations (Weisburd, Lum, & Yang, 2004). ity”; it is found only once in the Associated Growing up in these areas exposes children, Features and Disorders section (p. 465) and in adolescents, and adults to significantly elevated diagnostic criteria D2 as “irritability or out- lifetime rates of viewing traumatic events, bursts of anger” (p. 468). In trauma-focused knowing someone who has been a victim, and writings and conceptualizations, descriptions of being a victim oneself (Kiser, 2007). Studies anger and hostility are also present, but they are have shown that over three quarters of children largely viewed as secondary to the core diag- in these areas have had direct exposure to com- nostic triad (van der Kolk, McFarlane, & Wei- munity violence (Finkelhor, Turner, Ormrod, saeth, 1996). Hamby, & Kracke, 2009; Thomas et al., 2012). However, for the trauma survivors of crime This is not just an American phenomenon: a “hot spots,” who have spent a good deal of their recent United Nations study showed that 60% of lives in contact with violence, there may be a urban dwellers in developing countries and different diagnostic picture for trauma re- countries undergoing transition have been vic- sponses, one that is frequently far less sympa- tims of crime over a 5-year period, with victim- thetic than the diagnostic picture that gives pri- ization rates reaching 70% in Latin American macy to anxiety. Anger and hostility may be the countries and Africa (United Nations Human most prominent feature of their presentation. Settlements Programme, 2007). These patients might be found not only in clin- This document is copyrighted by the American Psychological Association or one of its allied publishers. It is clear that exposure to traumatic events ics and hospitals, but also in jail holding tanks, This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. causes distress in children and adults. Re- solitary confinement cell blocks, and prison ex- sponses linked to trauma run the gamut of ercise yards. Their experience with mental physical symptoms, including gastric upset, health practitioners, from childhood referrals insomnia and headaches, and psychological for behavioral problems, to adult referrals for symptoms and syndromes such as anxiety dis- crime victim services, are frequently transitory, orders, depression, personality disorders, so- and the interventions they receive frequently do cial isolation, decreased focus and concentra- not change the downward trajectory of their tion, anger and irritability, loss of intimacy, lives. When assessing this population, the ther- distrust, an increase in risk-taking behaviors, apist can find no shortage of childhood, adoles- and substance abuse (Gill, Page, Sharps, & cent, and adult trauma. 4 ROACH

Although some therapists may choose to Recent research has shown that the occur- work with violent or underserved populations, rence of major depressive and generalized anx- they seldom come from this world or live in it. iety disorders is significantly reduced in men But in trying to understand violence, I agree who have antisocial personality disorder (Gold- with Paulle (2007) that, “when it comes to stein, Compton, & Grant, 2010). Similarly, the studying violent encounters and the transforma- findings of one study showed that children and tive processes associated with them, being adolescents who had experienced or witnessed there—or getting as close as possible is crucial” significant trauma and met the DSM–IV-TR cri- (p. 761). Direct encounters with violent individ- teria for conduct disorder and oppositional de- uals, however, can be not just instructive but fiant disorder were less likely to develop full also unsettling. I was doing a therapy group in a PTSD (Silva et al., 2000). prison setting when six young men simultane- This research raises more questions about the ously began to show their scars: multiple gun- presentation and treatment of traumatized indi- shot wounds that were described as “the first viduals: Can the experience of trauma have—as time I got shot,” “the second time I got shot,” an endpoint—both a sympathetic suffering pa- and so on. They were engaged and gregarious as tient who comes to therapy seeking relief from they told their stories to one another. I did not acute distress and a callous, narcissistic crimi- see any signs of anxiety, numbing, avoidance, nal who is coerced into treatment and feels that or painful reexperiencing in this lively group. the problem is “the system,” not any internal When I looked at their medical records and saw suffering he is experiencing? Does one have the occasional diagnosis of PTSD, I thought, PTSD and the other a difficult, if not impossible “Where are the symptoms?” I easily saw the to treat, “personality disorder”? trauma, but not the posttraumatic outcome com- Sitting with a patient recently, I felt the issue monly associated with PTSD. was more complex than what is currently en- When these patients arrive at therapy, they compassed under the diagnostic compartments are easy to dismiss as poor prospects for treat- of the DSM–IV. A young, African American ment. The rise of the “nothing works doctrine” male, facing an 11-year sentence for a violent in American criminology, and the departure of offense, spoke with an upbeat affect and a smile psychology from the field of rehabilitation on his face about how his primary therapist did (Ward & Maruna, 2007), has been well docu- not seem to want to spend time with him and mented in the literature, in which predicting told him that he was “adjusting well” to his new violence and the “untreatable” psychopath be- circumstances. There was no anger as he said came the focus (Harris & Rice, 2006). Over the this, but then he began to talk about his one last decade, there appears to have been a rever- prior suicide attempt as an adolescent. His emo- sal, and there is again psychological interest in tions could be construed as superficial or “shal- what works in treating violent offenders (Cul- low,” and he did not evidence obvious emo- len, 2005). However, the fascination with the tional pain. I listened closely as he talked more “psychopath” in forensic psychology continues about the event, while rubbing one hand over (Seabrook, 2008). The traits that characterize the scars on his wrist. He remained smiling and the psychopath, including glibness, superficial upbeat. He had experienced extensive, repeated charm, shallow affect, callousness, and a lack of exposure to trauma as child, as an adolescent, This document is copyrighted by the American Psychological Association or one of its allied publishers. empathy (Hare, 2003), have become a lens and as a young man within the prison system. This article is intended solely for the personal use of the individualthrough user and is not to be disseminated broadly. which young offenders are frequently When we were done, he got up and casually seen and evaluated. Anxiety and psychopathy walked out of the room, his step jaunty and are not commonly placed together. In fact, a low mood apparently unconcerned. He easily joined resting heart rate in a child and adolescent is felt a group of fellow prisoners in the waiting room. to be one of the biological precursors of adult I saw no avoidance, no startle response, no violence (Ortiz & Raine, 2004). This raises the hyperarousal, and yet I felt, as I believe many question: Can someone who is aggressive, cal- therapists would, that I had been in the presence lous, and glib even have PTSD, or is criminality of PTSD. But would it make sense to diagnose a prophylaxis for the development of posttrau- him with PTSD and have the next therapist matic symptoms? wonder, “Where are the symptoms?” SHALLOW AFFECT AND NO REMORSE 5

A Different Conceptualization stance use and abuse. However, there is another way out, and that is through the emotion of There is no specifier in the DSM–IV–TR anger. (APA, 2000) for PTSD, such as callous type, The 17th-century English churchman and secondary to continuous trauma exposure, but I historian, Thomas Fuller (1864/2012) called an- would contend that PTSD is exactly what the ger “one of the sinews of the soul” (p. 205). therapist is seeing, and that, in criminal popu- Anger strengthens and empowers, it creates lations, PTSD does not manifest primarily as an possibilities. Among the most important of anxiety disorder, but as what is essentially a these is the possibility of eliminating the threat. conduct disorder. This is because survival in Anger can improve conflict resolution, but not situations of continuous danger demands an ac- in a creative way; anger is a blunt instrument tion-oriented adaptation instead of anxious (Geddes & Callister, 2007; Glomb & Hullin, withdrawal. Particular to the diagnostic pic- 1997). Anger narrows the focus but conveys ture I am examining here is witnessing or benefits: the narrowed attentional scope created participating in interpersonal violence as vic- by simply observing another’s anger can illu- tim, perpetrator, or both, within an environ- minate the most important information relevant ment permeated by violence and where to a simple task (De Dreu & Nijstad, 2008). As safety, justice, and social reciprocity are rare closely as anxiety is related to self-preservation, or transitory (Sampson & Bean, 2006; Samp- so is anger. Despite their place far down on son & Wilson, 1995). In this form of PTSD, most lists of the sequelae of trauma, anger, secondary to repeated or continuous trauma, aggression, and violence have a robust relation- there are three dimensions that run counter to ship to both experiencing and witnessing trau- the traditional conceptualization of PTSD as ma. Singer, Anglin, Song, and Lunghofer an anxiety disorder: anger replaces fear, emo- (1995), investigating the relationship between tions are “muted” or “shallow,” and approach adolescents’ exposure to violence, symptoms of to danger replaces avoidance. psychological trauma, violent behavior, and Anxiety is exhausting. For those in contin- coping strategies, found that being a witness or uous danger, there is a preoccupation with victim of violence was reliably associated with threat and an anxious apprehension of the symptoms of psychological trauma, including next danger accompanied by muscle tension, depression, anxiety, PTSD, dissociation, and restlessness, and fatigue (Nitschke, Heller, & anger. Flannery, Singer, van Dulmen, Kret- Miller, 2000). Anxiety is a wide-spectrum schmer, and Belliston (2007) noted: “There is a emotional state promoting hypervigilance, the strong association between violence exposure constant searching of the environment for and increased risk for the perpetration of ag- threats. Anxiety is protective; it is an emotion gression and violence, even after controlling for that is designed to discourage the organism demographic and contextual factors” (p. 315). from engaging in potentially harmful behaviors. The relationship between trauma and anger/ But constant anxiety cannot provide protection aggression extends beyond adolescence into in these areas of continuous danger, and cogni- adulthood. In their study that followed substan- tively, emotionally, and somatically a person tiated cases of childhood abuse and neglect into pays a price for maintaining a forced alertness adulthood, Widom and Maxfield (2001) found (Rosen & Schulkin, 1998). Both police officers that there was a 28% increase in the chances of This document is copyrighted by the American Psychological Association or one of its allied publishers. and civilians in high-crime, high-violence areas the adult with prior abuse having been arrested, This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. can become engaged in a cycle of anxiety, and a 30% increase in the chances that the arrest stress, and fatigue, which results in the individ- was for a violent offense. Residing in areas of ual being even less able to cope with the situa- high social disorganization increases exposure tion in an effective manner. In these “hot spots,” to multiple and ongoing traumatic situations, the end result of this anxiety-driven coping can including witnessing violence both inside and be serious injury or death (Vila & Kenney, outside the home, experiencing physical disci- 2002). At the end of his or her shift, a police pline, being a victim of violence, perpetrating officer can leave these areas and try to decom- violence, and being subject to both educational press, but the resident is stuck there, with the and physical neglect (Drake, Jolley, Lanier, only escape frequently being the relief of sub- Barth, & Jonson-Reid, 2011; Foster, Brooks- 6 ROACH

Gunn, & Martin, 2007; Kiser, 2007). Exposure lack of appreciation for the pain of others that to violence in children, adolescents, adults, and comes when violence is a routine event. In this combat veterans (Chemtob, Novaco, Gross, & environment, deep feeling is not adaptive. In Smith, 1997) has been found to result in prob- fact, a lessening of the capacity to experience lems with anger regulation, including the be- painful emotions becomes a successful coping havioral expressions of aggression and anger. In strategy in both the combat soldier and the inner communities subject to CTS, it is almost as city adolescent (Huesmann & Kirwil, 2007; though anger and aggression have become “in- Vitzthum, Mache, Joachim, Quarcoo, & digenous coping strategies” that replace the dis- Groneberg, 2009). empowerment of fear with the much more adap- Another quality that distinguishes these pa- tive empowerment of anger (Hamber & Lewis, tients is a history of aggressive violence; these 1997). patients have not just been a repeated victim, Anger replaces fear in this model of posttrau- they have also been a repeated perpetrator. On matic stress, and the other emotions have a the face of it, seeking out traumatic situations particular quality in that they are muted or does not seem to be congruent with the diag- “shallow.” The criminal psychopath is “callous” nostic criteria of PTSD; the obvious reaction (Hare, 2003), lacks the capacity for empathy, would be to avoid these situations. Freud (1920/ and has “emotional poverty or a limited range or 1955) himself saw this failure to avoid or learn depth of feeling” (Widiger & Lynam, 1998, p. from trauma, and coined the phrase “repetition 174). The survivor of trauma shares this quality, compulsion,” in part to describe those who act but with trauma it becomes “psychic numbing” out their trauma instead of remembering it. Otto and a “markedly reduced ability to feel emo- Fenichel (1946) saw “repetitions of traumatic tions (especially those associated with intimacy, events for the purpose of achieving a belated tenderness and sexuality)” (APA, 2000, p. 464). mastery” (p. 542), and the idea of the need to However, the psychopath is a “callous mon- achieve “mastery” of the trauma is frequently ster,” while the trauma survivor is a “numb seen in contemporary accounts of PTSD (van victim.” In therapy groups with violent inmates, der Kolk, 1987). However, there may be an- many awaiting transfer to prisons where they other explanation for those who live in the pres- would face long sentences, for some life with- ence of CTS. For a soldier out on patrol, the out parole, the therapist sees the visible scars quickest way out of danger may be to go over from their prior battles. Despite limps and the top of it. In an ambush, a soldier strives to lingering pain, the mood is often light and get out of the “kill zone” as quickly as possible. conversational; it is as though the wounds had Running away can keep the soldier in the ene- been physically painful but emotionally pain- my’s field of fire, whereas going through the less. I have sometimes wondered at the lack enemy gets one out of the kill zone and helps of emotional suffering in some of these men the soldier to regain the initiative in the fight. who so easily resort to anger and aggression, For someone in continuous danger, a similar sometimes at the slightest provocation. The response of closing the gap and going through difference between “numbness” and “callous- an imminent or possible danger may be an adap- ness” may, however, rest more with the coun- tive conditioned response. However, whereas tertransference of the observer than with any the soldier can (one hopes) return from patrol to objective measure. the relative safety of his base, for these victims/ This document is copyrighted by the American Psychological Association or one of its allied publishers. With repeated exposure to violence, there can perpetrators going home to a cell block or a This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. come an “emotional desensitization,” a gradual troubled community does not provide safety. A and increasing lack of response to the fear and readiness for quick aggression is a valued qual- shock of seeing human victimization occur ity in both of these places. again and again (Aizer, 2009; Huesmann, & Kirwil, 2007). Across their life span, residents Thinking About Treatment of high-crime, poverty-stricken areas witness and experience a high occurrence of violence Now we have our patient: angry, with shal- (Agnew, 2007; Margolin & Gordis, 2000). low affect, and a history of violence. He has There are both short-term and long-lasting ef- endured repeated traumas, and he has been the fects following violence exposure, including a perpetrator of potentially traumatic acts as well. SHALLOW AFFECT AND NO REMORSE 7

He remains in a dangerous situation in which a Because sustained traumas contain stories that readiness to be violent is to his apparent advan- span very different developmental periods tage. He is social, he can be quite gregarious, within the adult’s telling, the therapist may find and much of his behavior is the opposite of the structures of narrative from the perspectives avoidant. He thinks and talks about his trau- of the child, the adolescent, and the adult (Hunt, matic experiences and carries their scars, but he 1994). It is the therapist’s job to help the patient does not appear to have PTSD. Instead, his find a way to weave these narratives together presentation is more in line with a diagnosis of and to find the common coherent themes and antisocial personality or conduct disorder. In meanings: “By giving a theme to the wounded contending that PTSD in criminal populations person’s life, trauma changes the meaning of sometimes does not manifest primarily as an that life, becoming a means of struggle and not anxiety disorder, but rather as closer to a con- a weakening” (Cyrulnik, 2005, p. 160). duct disorder, it is necessary to separate muted When one considers the history of forensic affects and lack of emotional expression as an treatment in America, working with narratives artifact of PTSD from the “cool pose” of the becomes even more compelling. Concluding inner city male (Anderson, 2000; Major & Bil- their article on the therapeutic treatment of vi- son, 1993). Violence is traditionally a male- olent aggression, Heyman and Selp’s (2007) dominated phenomenon, but lately, in the recommended the following to treatment pro- United States, violence perpetrated by adoles- viders: “First do no harm” (p. 612). They cite cent and adult women has been increasing (Sub- findings that group cognitive–behavioral treat- stance Abuse and Mental Health Services Ad- ments for high-risk adolescents actually in- ministration, 2009; Zahn et al., 2008). The crease rather than decrease delinquent behavior greatest increases in women’s violence are (Poulin, Dishion, & Burraston, 2001). Simi- again among minority, low-income, inner-city larly, so-called boot camps for young offenders, populations and, again, similar factors of expo- once a popular alternative to incarceration, have sure to violence, victimization, and poverty been found to have no significant effect on seem to be correlated with the actions of women recidivism (Wilson, MacKenzie, & Mitchell, perpetrators (Rosich, 2007; Bottos, 2007). Al- 2003), and common juvenile justice therapeutic though this article is primarily concerned with interventions are not just inefficient but also male victims and perpetrators, an implication is exert iatrogenic effects on their recipients that angry, violent expression of traumatic (Gatti, Tremblay, & Vitaro, 2009). There is stress is not an exclusively gender-specific phe- even the concern that therapy can weaken the nomenon, or a cultural expression, but a human survival skills necessary to navigate and survive reaction to certain conditions, and that it is a in a dangerous environment (Brown, Shear, posttraumatic stress response. Schulberg, & Madonia, 1999; Meeks, 2011). I am arguing that PTSD has both an internal- Glancy and Saini (2005) note that “There re- izing and an externalizing expression, and both mains no clear consensus among therapists and are legitimate targets of treatment. We know researchers on the best way to treat angry clients that exposure is the evidence-based treatment and little information exists to guide therapists for PTSD, but what about when PTSD mani- in their work with specific angry populations” fests as an externalizing disorder? How is treat- (p. 229). Given the cautions and lack of con- ment conducted in situations in which safety is sensus on how to best proceed, narrative can be This document is copyrighted by the American Psychological Association or one of its allied publishers. elusive and the expression of affect or vulnera- chosen as a therapeutic medium, because it is This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. bility can result in even more victimization? less invasive and more flexible than more struc- One basic medium in working with cases of tured interventions, and thus potentially less repeated traumatization is the story or narrative. harmful. This is not a call for therapeutic nihil- Cyrulnik (2005), in his study of resilience, has a ism, but an acknowledgment that the therapist chapter entitled, “Storytelling Enables Us to needs to proceed with a judicious sense of hu- Sew Up the Pieces of a Torn Self” (p. 37), and mility and respect when undertaking to treat this he delves into the way the stories of the trau- population. matized—spoken, written, autobiographical, The metaphor for working with patients who and fictional—contain the “images, actions and remain in danger is as old as humanity. It is the words” (p. 39) that are the key to resilience. story told at campfire’s light. Although outside 8 ROACH

the circle the danger remains, inside that light is patient examining his life for different forms of safety and a place to find strength. Knowing that meaning and constructing a new narrative. danger awaits the patient, the therapist treats the patient’s narrative like a gift, one that is un- Use of Humor folded and shared and then packed away in a hard protective case until it is again revealed. The importance of humor in working with What follows are some ideas and reflections on trauma cannot be underplayed. In Freud’s view, how to listen to these stories. We know that humor or jokes happen when the conscious al- trauma has its effect on both the survivor and lows the expression of thoughts that society the person who listens to the survivor’s tale usually suppresses or forbids. The superego al- (Straker & Moosa, 1994), and that how one lows the ego to generate humor as a compen- listens, and what one listens for, makes all the sation for life’s pain (Freud, 1920/1955). The difference. particular form of humor that underlies repeated trauma is irony. This is the “battlefield humor” Locate the Affect of the soldier, the cop, and the emergency room nurse. For Freud, and for the person who re- The therapist listens for parts of the narrative mains in danger, humor and, in particular, irony in which affect connects to human interactions is a gift. It allows the truth of a situation to be and works to form a scene from what the patient acknowledged, but protects the person voicing is saying, complete with characters, light, and it from being overwhelmed by fear or despair. color (Cyrulnik, 2005). “Flashbacks” derive The lives of those who live with the constant some of their power by involving the whole possibility of death or injury are tragedies in the spectrum of senses: touch, smell, hearing, and fullest sense. Irony stands here at the juxtapo- sition of humor and tragedy, and it is a gift to vision (Nemeroff et al., 2006). The more sense those who live in the face of CTS. The enemy of modalities the therapist and patient bring to irony is cynicism, the loss of belief that good- these voluntarily elucidated scenes, the more ness is possible in human nature and in human potential potency they will have when con- interactions. Accompanying cynicism the ther- trasted to distressing involuntary memories. apist may find sadism: the pleasure taken in the Compared to the drama of flashbacks, this work suffering of others. The therapist needs to be can be quite pedestrian (Lion, 2008). These new prepared to find sadism in these violent patients scenes will become touch points in constructing (Lion, 2008), and the task as one listens to these a narrative that contains a past, a present, and a narratives becomes finding and nurturing irony, future. Of necessity, some scenes will evoke to see with the patient that there is a way to live depression and pain, and because the scenes are with tragedy that allows for the humanity of all linked and explicated, depression may become the players caught up in the drama, both the more prominent for the patient. The affects of victims and the perpetrators. the blended victimϪperpetrator, however, in- volve more than the pain of victimization. Slowly Deconstruct the Myth of When the patient relates scenes in which he has Self-Creation been violent, he may be filled with the power and excitement of acting out and retaliating Often, patients who come from a background This document is copyrighted by the American Psychological Association or one of its allied publishers. against his enemies and his environment, even of repeated traumatic exposure have survived This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. at the cost of pain and imprisonment (Katz, by being members of male-dominated street and 1988). These emotion-filled scenes may come prison gangs. These gangs, which create a struc- easily into the narrative. Competing with these ture with their own hierarchy, laws, punish- actively powerful but violence-sustaining ments, and rewards, bring order and, some- scenes are the more subtle emotions of the si- times, safety into dangerous environments. lent, passive scenes formerly associated with These groups frequently embrace a mythology loneliness and victimization. Made salient by of self-creation, the myth of “I grew up alone on the therapist, these scenes form the basis for the street.” This is essentially a fascist world in thought and reflection in contrast to the formally which women are either idealized or demeaned. dominant value of action. This is the start of the In this creation story, men make themselves; SHALLOW AFFECT AND NO REMORSE 9

they are born into the gang. Women become crime, “begin by establishing the goodness and either a Madonna or a whore in this world in conventionality of the narrator” (p. 87). The which feelings are dangerous, womanly, and child begins in innocence and falls into evil associated with victimization (Theweleit, ways. The child represents the “true” or “core” 1987). In listening to the narratives that accom- self, who the violent young man really is. For pany C-PTSD and CTS, the therapist can find those violent young men who find and sustain figures—men and woman—who provided nur- within their narratives this “original” good self, turance. But frequently the nurturance is mixed leaving off from violence is not a change, but a with abuse, or it exists as a seemingly futile return to the good person that they always were. gesture in a world of trauma. These figures may even appear as persecutors. But if the therapist Make a Classroom listens carefully to the narrative, he or she will Describing his work with French street chil- see which of these persons gave more than dren, Boris Cyrulnik (2005) wrote: “It’s surpris- abuse. It is important to make these figures ing to see an adult organizing a philosophy club salient, and to preserve them in the developing with street children . . .[but] we’re inviting them story, because, however flawed, they are the to transcendence, suggesting that they can con- connections to humanity (Cyrulnik, 2005). quer a world other than the one they have to deal with” (p. 33). In revealing another world, Find the Child in the Narrative and Pair the therapist invites the patient to transcend Him With the Adolescent or Adult their past traumas and their world of ongoing trauma. To do this, therapists can reveal and Steve Harmon, the 16-year-old hero of My- share their own areas of interest and curiosity, ers’s (1999) novel Monster, sits in his jail cell and use them as the way to structure a relation- and struggles to reconcile the “monster” the ship that involves elements of pedagogy. Struc- prosecutor has portrayed him as in court with turing the therapeutic space or a portion of the the person he conceives himself to be. “I know treatment endeavor as a classroom can often be that in my heart I am not a bad person” (p. 92), very effective. Areas of social disorganization he thinks to himself. There is often this nascent are also areas of educational neglect and tru- “good self” in violent patients, but it exists in ancy. Parents are often too stressed to focus on rotation with the “bad man” the patient has the needs of their children. The combined ef- become. It seems untenable that these two ver- fects of the caregivers’ losing the struggle to sions of the self can occupy the same space in provide focused, interactive attention to their the narrative. Violence tends to obviate com- children, and subsequent educational depriva- plexity and subtlety, and a self-narrative that tion, are as significant and devastating to a involves blended perspectives is an act of cre- child’s future as exposure to violence (Bigelow, ative complexity. 2006; Kelly, Barr, & Weatherby, 2005). In these One therapeutic technique to promote com- areas, schooling often essentially stops at the plexity is to look for the child to appear in the age of 14 or 15, or sometimes earlier. As Cyrul- narrative and then to pair him with the strengths nik (2005) wrote, under conditions of loss and of the adolescent or man. The task is for the trauma, “all learning becomes a source of anx- adult perpetrator to assume responsibility for iety. Insecure . . . he does not take pleasure in protecting the child in their own narrative. In This document is copyrighted by the American Psychological Association or one of its allied publishers. discovery” (p. 19). Leaving off from the cycle this way, there is both vulnerability and strength This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. of violence entails a willingness to discover the within the same scene, a way to go through the new. Treatment that opens doors to the world, trauma narrative in a protected and more com- while also opening doors within the patient’s plex manner. The story of trauma and violence narrative, is an example of how interventions can potentially become an act of self-rescue. informed by multiple perspectives are required This allows for an inner pride to grow that for success with these patients. gradually eclipses the outer show of strength necessary to ward off danger. In his study of Conclusion how ex-convicts reformed and rebuilt their lives, Shadd Maruna (2001) noted that the nar- How difficult-to-treat patients are conceptu- ratives of “desisters,” those who desist from alized can make all the difference in treatment. 10 ROACH

The particular success of Marsha Linehan’s di- young former combatants as moral outlaws on alectical behavior therapy has been its ability to the margins of society may be based more in the change not merely patients’ attitudes toward moral panics of adults than the lived realities” their problems, but also therapists’ attitudes to- (pp. 359–360). As it is with Africa’s child sol- ward their problematic patients (Becker & Zay- diers, so it is with our own Western urban fert, 2001; Hazelton, Rossiter, & Milner, 2006). combatants; if they are seen as fully human, A diagnostic conceptualization of the “antiso- complex, and worthy of care, a new world can cial” or “psychopathic” patient as a legitimate unfold for them and for the therapist privileged endpoint for a life of ongoing, continuing to work with them. trauma and violence moves the therapist’s focus from reforming conduct to treating trauma. References These patients can be scary, and they are ripe for countertransference fantasies that paint them Agnew, R. S. (2007). Strain theory and violent be- as “monsters” both morally depraved and behavior. In D. J. Flannery, A. T. Vazsonyi, & I. D. yond help. But there can often be no develop- Waldman (Eds.), The Cambridge handbook of vi- ment of vulnerability in these well-armored pa- olent behavior and aggression (pp. 519–529). tients without it being modeled in the treatment. New York, NY: Cambridge University Press. The therapist’s willingness to expose his or her Aizer, A. (2009). Neighborhood violence and urban youth. In J. Gruber (Ed.), The problems of disad- own internal process in front of those from vantaged youth: An economic perspective (pp. cultures of violence, in which information about 275–307). Chicago, IL: University of Chicago another’s inside world is a way to gain advan- Press. tage, to find chinks in the armor, requires a American Psychiatric Association. (2000). Diagnos- thoughtful courage and intelligence. tic and statistical manual of mental disorders (4th This is not a call for self-sacrifice or unrea- ed., text revision). Washington, DC: Author. sonable optimism. Work with these patients is Anderson, E. (2000). Code of the street: Decency, hard, and an informed view acknowledges that violence and the moral life of the inner city. New the odds are frequently against the patient’s York, NY: Norton. recovery and, sometimes, even his survival. Becker, C. B., & Zayfert, C. (2001). Integrating dialectical behavior therapy into exposure therapy Thought delays action, and encouraging thought for complex posttraumatic stress disorder. Eating in a world in which action equates with survival Disorders Review, 12, 1–3. is itself a paradox. Finding and developing an Bigelow, B. J. (2006). There’s an elephant in the emotional narrative that encompasses complex- room: The impact of early poverty and neglect on ity and ambiguity in the patient who leaves the intelligence and common learning disorders in office to go out into a dangerous world requires children, adolescents and their parents. Develop- that the therapist work with reason, science, art, mental Disabilities Bulletin, 34, 177–215. and even faith. Bottos, S. (2007). Women and violence: Theory, risk, For the therapist, these patients seldom fail to and treatment implications. Research Branch: Cor- evoke a reaction. Their acts and their personal- rectional Service Canada. Retrieved from http:// www.csc-scc.gc.ca/text/rsrch/reports/r198/r198- ities may be repellant. Working with these pa- eng.shtml tients requires the therapist to examine his or Bourgois, P. (1995). In search of respect: Selling her own reaction to the patient’s past as both a crack in El Barrio. Cambridge, England: Cam- victim and a perpetrator, and to the patient’s bridge University Press. This document is copyrighted by the American Psychological Association or one of its allied publishers. current environment of danger to both himself Boyden, J. (2003). The moral development of child This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. and others. America may not have had South soldiers: What do adults have to fear? Peace and Africa’s formal apartheid, but for the therapist Conflict: Journal of Peace Psychology, 9, 342– in the United States this work involves an un- 362. doi:10.1207/s15327949pac0904_6 derstanding of political and economic oppres- Brown, C., Shear, M. K., Schulberg, H. C., & Ma- sion similar to that found in CTS. The therapist donia, M. J. (1999). Anxiety disorders among Af- rican-American and white primary medical care needs to understand his or her own and society’s patients. 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