Q & A

(917) 710-7578                          hzl@allbluescounseling.com

Howard Z. Lorber, csw

                   Psychotherapist & Anthropologist

Rehabilitation? Treatment?


Recently I heard some practitioners in our field make a distinction between “rehabilitation” and “treatment” for batterers. The drift of their discussion tended to laud “rehabilitation” and condemn “treatment.” Now, this is, from my point of view, a curious distinction and I didn’t know what was meant by it, so I asked. They had a difficult time with their answer, and, ultimately, stated that they would have to ‘think about it’. My sense is that this is an important distinction and, like so many terms in our field, stand in need of clarification.

 Some time ago the philosopher, Wittgenstein, started to change the way we look at language. He compared language to a ‘tool kit’. Like the tools in the kit, though there are important differences among them (as he said “nothing could be more dif­ferent than glue and a chisel”) they “[are] used in a family of ways.” That is, while the glue is used to pull things together and the chisel is used to cut things away, they are both necessary to make a chair. To understand the tool, then, one needs to understand how the tool is used by itself and with others in the kit. That which makes the meaning of a word is the use to which that word it put and the context in which it is used. Nothing new in this really; this is the way we go about under­standing our clients or anybody when we work with them. And, as with our clients, we don’t simply take their words at face value, but evaluate how these mean­ings developed historically. To understand the meaning of “rehabilitation” and “treatment”, then, we need to look at how they are used and what sort of context they have.

 At first glance one would think that “rehabilitation” and “treatment” are equiv­alent tools in our linguistic tool kit much the way two different sorts of hammers, say a maul and a claw, are rough equivalents. Both can drive home a nail, even though, in fact the former is best used to break iron and concrete and the latter is designed to drive and pull nails. In the case of “rehabilitation” and “treatment” it is thought by some that if, like the maul and claw, if they are inserted in the con­text of ‘facilitating change’, they mean, if not exactly the same thing, something very similar. The reasoning goes something like this: if you intend to rehabilitate someone, you are literally trying to re-fit (re-habilitate) them to perform socially; if you involve someone in “treatment” you are attempting to facilitate change so the person can overcome their interpersonal “difficulties in living” (H.S. Sullivan, The Interpersonal Theory of Psychiatry); helping someone resolve interpersonal dif­ficulties is re-fitting someone for social life -- i.e., facilitating change; the terms are, thus, equivalent. Yet nothing could be farther from the case.

 A key interpersonal ‘difficulty’ for batterers, at a behavioral level, is that they are violent in their relationships. Our direct task, then, is to work toward the goal of stopping the inappropriate ‘use of hands’ in relationships. In this sense ‘re-habilitate’ refers back to a slightly different and earlier meaning of the term: to change the way the hands are used socially. Bluntly, we want the hitting to stop. This is, of course, not the only thing wanted or needed: we are trying to effect change so that the conditions that foster such inappropriate social use of then hands in the family no longer exist. How is this to be effected?

 In the history of criminology there have been two standard answers: we can either punish those who are doing wrong so they won’t do it again, or we can try, somehow, to show them, or convince them, that what they are doing is the wrong way to be, so they would want to stop.

The origin of the word ‘penitentiary’ in the 19th century comes from the notion that the wrongdoer should have time and place to reflect on the wrongs committed so they wouldn’t do them again. It was an attempt to move away from strategies of pure punishment: hanging, drawing and quartering, branding, and cutting off ears, noses and lips, were seen as more and more ineffective as deterrents to criminal behavior since the crime rate continued to rise. On the other hand, it was and still is believed that society as opposed to individuals should reserve to itself the right to punish social wrongs, i.e., wrongs against its members as representatives of itself.

 Becoming penitent was intended as a process for accepting guilt for wrongs in or­der to correct one’s wrong behavior. In short, this is punishment internalized in or­der to provide a deterrent to wrongdoing. The penitential process was supposed to rehabilitate re-fit the wrongdoer for society. The origin of ‘rehabilitation’, then, is the use of law as a means of effecting the conversion of social guilt into personal guilt.

 Such a conversion shifts the issue from the external to the internal, from the power of the society to regulate behavior to the self-regulation of behavior. Implicitly, ‘rehabilitation’ requires the acceptance of social guilt as (self) punishment. The fly in the ointment, as those who are quite open in their desire for punishment of wrongdoers are happy to point out, is that ‘rehabilitation’ in this sense does not stop wrongdoing. 

Why should this be so? It is because the attempt to effect a system of (self) punishment, of internalized guilt, leads to internal conflict and resentment. Isn’t this just the sort of thing that Freud spoke of, though from quite a different perspective, in his Totem and Taboo and Civilization and its Discontents? In these works the socialization of the child is bound up in the internalization of the Oedipal struggle and the development of guilt, conflict and resentment from the repression of instinctual aims. Isn’t ‘rehabilitation’ simply this? Isn’t ‘rehabilitation’ equiv­alent to this sort of socialization? This socialization process requires the inter­nalization of guilt; that is, it requires self-punishment and builds in conflict and resentment. 

For the guilty individual to remain within society, that is, to remain within sig­nificant relationships, that individual must build up defenses against self -punishment. That is, they must build up processes of thought and action that relieve themselves from the inner conviction that they are, in some profound sense, “bad.” Isn’t this sense of “badness” what’s meant when we speak of the batterer’s “low self esteem”? 

The defensive process that provide this sort of relief is something that R.W.D. Fairbairn (Psychoanalytic Studies of the Personality) called “the moral defense”. In this process the individual, having internalized and repressed a sense of self as “unconditionally bad,” continually fears its re-emergence. The means of muting and mitigating this hopeless feeling state is the attempt to recognize the self as merely “conditionally bad ... leaving] room for hope owing to the possibilities of repen­tance and forgiveness.” (Op. Cit.: 165) Repentance and forgiveness, in their turn, ‘prove’ the individual “conditionally bad” to themselves as well as to others. This ‘proof’ leaves open the possibility of the re-emergence of the sense of self as “unconditionally bad,” and so on, ‘round and ‘round in a cyclical manner. In other words, an individual’s acceptance and internalization of guilt is, at one in the same time, an internalized self-punishment and an attempt to mitigate the hopeless state of “unconditional badness”. As only mitigated, however, the sense of hopelessness un­derlies and continually tries to ‘break through’, so the individual is left with con­flict and resentment, internally and toward those empowered to forgive. If this process sounds familiar to us it is because it parallels, actually it underlies, the “batterers’ cycle” as developed by Leonore Walker (The Battered Woman).

 Since this cycle is so familiar to us I won’t do any extensive presentation of it here. To refresh our memories though, the batterers cycle has three phases, the acute battering phase, the “contrite, loving phase,” and the phase of anxiety and build—up to the next acute battering phase. As a cycle, one can break in at any point since each phase is equally significant in the process. The usual pattern is to start with e either the build—up or the acute battering phases. I’m going to start, however, with the contrite loving phase because of its particular defensive qualities. 

In Walker’s “contrite, loving phase” the aggressor comes to the victim asking for forgiveness and undertakes the process of ‘courting’ the battered mate. In the after­math of the outbreak of violence the aggressor senses the emergence of the repressed feeling of being “unconditionally bad” because of those very acts of violence. In or­der that the self not be regarded as “unconditionally bad,” the mate is sought for forgiveness so that the batterer can be proved to be merely “conditionally bad.” The mate then can act as the external conscience (super ego), on the one hand, and as the object of desire, on the other. The mate, in turn, for a variety of dynamic reason, is enabled to fulfill their own internal need to sense themselves as good. That is, the one battered can find, in the batterer’s desire for forgiveness, the external realization of themselves as “conditionally good” and thus (internally) forgiven for the aggression they bear toward their own sense of badness. This process in turn sets off, on both parts, fantasies of merger and a sense of dependency. This, in turn, leads to a growing fear of the loss of self and a need to guard their “self-esteem.” Once again they will then be lead right back into the build—up to the acute bat­tering phase, continuing the cyclical process. The batterer’s contrition and acts of penitence remain indesolulably contradictory so long as they do not lead out of the morass of internalized self-punishment. 

And so it is with the ‘rehabilitation’ process. so long as the ‘re-fitting’ of an individual requires the penitential process of accepting social guilt as self punishment, the individual remains locked into conflict and resentment. 

What can be done to help extricate the people with whom we work, and our programs, from this bind? 

Helping people break out of the cycle of their defenses against their feelings of “unconditional badness,” that is their struggle with self-punishment, is the work of psychotherapeutic treatment. This treatment will work to show the individual how they protect themselves against the sense that they have lost themselves in their mate, and that their feelings of rejection because they cannot, in fact, merge and be ‘one’ with that mate. The treatment process will, further, facilitate the development of an independent, differentiated, sense of having a self, in order that the individual’s dependency needs become expressible without the guilty feeling that these needs will gobble up either themselves or their mate. In the development of a differentiated self both the rageful, destructive impulses arising from thwarted dependency needs and the need to be ‘forgiven’ for having these needs will be reduced. The violent acting out of these defenses against the neurotic sense of loss of self and attendant self/other punishment will then be extinguished.

At the beginning of this piece I introduced Wittgenstein’s notion that we under­stand words by how they are used. Now we are in a better position to understand the meaning of “rehabilitation” and clearly distinguish it from “treatment.” Making this distinction clear will help us better develop programs and clinical approaches that steer clear of the contradiction noted above.

As it has been developed and as it has been used, the ‘rehabilitation’ process, whatever its proponents assert it to be, is an essentially punitive process. Thus it should come as no surprise that those who seek to develop rehabilitative schemes see them belonging to the criminal justice system. Moreover, it is a particularly perni­cious process in that it demands the internalization of self-punishment while being radically blind to the damaging internal processes it engenders. The substitution of external punishment for internal not only changes its venue, it places the guilty at the moral boundaries of society — it alienates rather than integrates. The treatment process, on the other hand, addresses the operation of the internalized self-punitive processes, the defenses against this internalization, and the violent acting out of these defenses. Treatment looks not to the “control” of impulses by making an al­liance with an individual’s self-punishment; rather it looks to change the way feel­ings are generated, received and acted upon so the desire for punishment and penitence are no longer needed. By helping the individual move from his isolation and fear, the treatment process facilitates his sense of integration, both internally as a self and socially as an individual.

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