No Visible Bruises: What We Don’t Know About Domestic Violence Can Kill Us

This chapter opens with Neil Websdale, a criminologist. Websdale once needed eye surgery, and on the day of the procedure, the nurse made a large X over the eye to be operated on. When Websdale inquired about this practice, the nurse recommended he read some stories on airline accidents and surgical errors. Websdale did and realized that in both disciplines, there were simple remedies to common errors, but that finding those remedies meant putting pride aside to review past disasters honestly.

Websdale began to apply the collaborative processes used in other fields to domestic homicide. Looking at a study of Florida’s homicide cases, Websdale realized that, just as with plane crashes, there was very rarely only one causal factor leading to a domestic homicide. Instead, there were several failures along the way, and several missed opportunities where intervention could have saved lives. This led to the establishment of a Fatality Review Team first in Florida and then in other states and countries outside the US. A year after Michelle’s death, a review team was established in Montana, and Michelle’s mother pushed to have Michelle’s case included in the review process.

Despite the widespread adoption of his methods, Websdale admits that some of his views are controversial: “He believes abusers are as stuck as victims. ‘Everyone asks why the victim doesn’t just leave,’ […] ‘But no one asks why an abuser stays’” (85). Websdale also believes that the prevailing wisdom that abuse is all about power is flawed, and that abusers are both powerful and powerless at the same time.

One important aspect of the review team is that they do not blame or shame any individual or agency involved in the case—a carryover from aviation, where collaboration and transparent communication are common. In domestic violence, the two main organizations are police and advocates. These groups have very different cultures, yet studies have shown that when they work together, rates of domestic violence lower significantly.

Snyder introduces a review process she was privy to involving individuals named Timothy and Ruth. The two met online, and within a week Timothy was professing his love. Ruth, long divorced and the mother of grown children, moved in with Timothy three months after they met, selling many of her belongings and relocating from Utah to do so. She found a job cleaning on nights and weekends; Timothy did odd jobs and received disability. He was insecure and quick to anger, and Ruth felt stuck but believed Timothy when he said that his chronic pain was the source of his anger. Timothy owned multiple guns, had delusions of grandeur, lied regularly, and moved Ruth to an isolated house. Timothy also had multiple restraining orders against him in other states, and his first wife had needed the help of her pastor to leave.

Because of the gaps in communication between inter- and intrastate law enforcement agencies and between civil and federal courts, both the Montana police and Ruth were unaware of Timothy’s past. In the review process, however, several red flags become obvious:

Timothy was known to law enforcement; he had unstable employment; he had a history of stalking and stay-away orders; he had significant amounts of pain medication; he had visions of grandiosity, profound narcissism, and a wicked streak of manipulation. He told lies about what he’d done in the military and posted on social media accounts of bravery and heroism that no one could ever find evidence of (local newspaper articles, for example) (94).

The review team looks for places where someone could have intervened and find five: the Veterans Administration (VA) hospital where Timothy received painkillers, the court where Timothy faced charges from his ex-wife, the local police, Timothy’s home health aide who reported him as dangerous and uncomfortable to work with, and Ruth’s minister. Ruth had also spoken with a domestic violence advocate at one point.

The team also comes up with policy recommendations, which include training judges, law enforcement, and advocates about domestic abuse and expanding the use of the Danger Assessment. While those seem like inconsequential steps, they can yield big benefits. Snyder points to Montana’s Hope Card, a wallet-sized laminated card that contains pertinent information about a restraining order and can be ordered in quantity and shared with relevant parties, like teachers and co-workers.

Michelle and her children were the first case the review team took on, and if the same situation happened now, Rocky would not be allowed to bail out of jail so quickly. This would allow a domestic violence counselor to meet with Michelle and make a safety plan. Michelle would also have had advance warning that Rocky was leaving jail, Rocky would have faced charges for breaking into Sally’s house, and Michelle would have received domestic violence resource information when she went to recant her affidavit.