Abstract
The clinical task in forensic psychotherapy
This book addresses the task of offering out-patient group psychotherapy to violent and sexual offenders, mainly men but including a small number of women in an out-patient NHS setting: the Portman Clinic, London. The Clinic opened in 1931 and group psychotherapy was developed in the 1970s by Estela Welldon. There is no significant reference to cultural or gender background factors influencing the development of a criminal career in the chapters included in this book. The Foreword notes that this patient group tend to have: ‘. . . compulsions to project their internal worlds into all around them, especially into those who might be able to assist them . . . (p.X)’ and this characteristic begins to define how the Portman method needs to differ from other group therapy treatment models.
In the Introduction the authors note that there is a dual nature to forensic work, in that perpetrators of violent and sexual crimes have often also been victims of violent, sexual or neglectful forms of abuse themselves. The importance of working with the forensic team as a whole is stressed throughout the chapters of this book, as the transference pulls and emotional demands on the therapist are considerable, often taking a similar behavioural pattern to the offences that have brought forensic patients into treatment in the first place. Working with both the perverse (chapter 5), the paedophile (chapter 6) and the disability transferences (chapter 9) and particularly with the therapists’ countertransference in response to these emotionally powerful transferences is challenging. However, what lends this book its unique character is the authors’ imaginative and courageous work towards understanding offending behaviour from within the internal world of the offender as well as considering the impact on those affected in the external world.
Principles underlying forensic work are outlined in chapter 1 which describes this work as best conducted in public sector services such as the NHS, not privately, as involvement with statutory Multi Agency Protection Panels is frequently part of the setting as forensic patients’ ‘. . . conflicts will have been with others rather than experienced as internal . . . (p.4)’ and the backing of the clinic, the police and the justice system forms part of the necessary container for the forensic patient group, and for the therapists and their team. The Portman has come to use only one therapist in each group having tried two co-therapists in the past but found the power of splitting and difficulties associated with having two parental figures in the room at the same time was more difficult to work with than advantageous; however, chapter 8 outlines the return of co-therapy work with a new Mentalisation Based Therapy (MBT) group for anti-social personality disorder patients. In chapters one and two the authors clarify that forensic group psychotherapy adopts a strong focus on current behaviour in the external world now and behaviour within the group.
Limit setting, as in the clinical example of Roger in chapter 1, done by group members, as well as by the therapist, stands out as does the group’s involvement in sometimes writing letters to absent group members: These are described as a tangible symbol of empowerment for them by group members. A key component in the Portman approach ‘. . . is the forensic focus. This has to be made explicit, since an emphasis on the presenting problem changes the traditional non-directive stance of the psychoanalytic therapist (p.12)’. It is customary that older group members introduce themselves to newcomers saying what they have come to treatment for and how they are developing. This helps stabilize the group and guard against secrecy about offending behaviour as older group members name their offences.
The Portman clinic experience of group psychotherapy
Chapter 3 begins with Freud’s two principles of mental functioning (1911) in which ‘. . . thinking provides an experimental space in which an action can be imagined without having to carry it out (p.58)’. The shift, the author notes, from action to thinking about action forms a key therapeutic aim but one that takes a long time to become established in therapy. Some patients in this author’s group left treatment but then returned later as the act of giving up their form of acting out presented too much of a challenge, left too great a potential void which was terrifying and could not be faced first time round. Transference develops to the therapist, to fellow group members, to the group-as-a-whole and to the clinic (p.56) and the author describes a culture of constant enquiry and thinking and processing the powerful dynamics emerging in these groups as an important aspect of the therapist’s constant parental watchfulness in which their eye cannot be taken off the clinical ball nor can too much ‘trusting the group’ be guaranteed to work on its own.
Glasser’s core complex theory is outlined in chapter 1 (p.20). This is based on his earlier experience at the Portman Clinic, in which sadism and sexual perversions are understood to be used to maintain an illusion of power to triumph over and protect against feelings of loss or helplessness and how an understanding of this key dynamic and what it appears to do, defensively, may help therapists surmount their own outrage and well-defended shock that stands in the way of therapeutic work. Reference is also made to Gilligan’s work on male violence being understood as a solution to low self-esteem and shame. Perelberg considers that male violence can play a role in pushing away, repudiating more feminine aspects a man may feel threaten a fragile male identity, seeking certainty in aggression and exaggeratedly ‘male’ behaviour (p.23).
The importance of establishing a strong therapist-patient bond is emphasized in chapter 2 which points out that meeting two or three times for assessment helps achieve this stronger bond (p.36). The authors stress the importance of creating a setting that feels confidential and safe enough to be able to speak about the effect of violent and/or sexual acts and their impact on others (p.37). The Portman group workshop is a space where all staff meet monthly, to share thoughts and experiences, and extends the container-frame for therapists as does the provision of a case manager for all patients, available if difficulties should arise. If need be patients can be referred to a psychiatrist as part of their overall wider network of containment, which is known by all. Another aspect of Glasser’s Core Complex theory holds that patients with sexual perversions tend to feel either overwhelmed or abandoned by those they are intimately involved with (p.33). Aggression felt about this dilemma also raises the fear of abandonment and aggression becomes sexualized in this theory. In this dynamic, a one-to-one therapy setting can be felt to be unmanageable. Group therapy, they argue, can dissipate such intensity in the therapeutic encounter and in so doing offer a wider overall sense of containment and the perspective others’ views can offer.
In chapter 3, an analytically-argued summary outlines the occurrence of the repetition compulsion in forensic work. The author points to Anna Freud’s second form of acting-out from her 1968 paper Acting-out, a more impulsive kind in which ‘. . . action has long been used as a way of avoiding thinking (p.54)’. The task the author describes is that of trying to bring such impulsive acting-out into the transference relationship and into the group so that it can be named and its meaning be better understood. Many patients have come to find their acting-out in offending ways no longer offers relief and the perversion or violent act has ‘broken down (p.54)’. At this point the movement of acting out into the group setting presents an opportunity for understanding and lasting change.
The author notes in the example of Jonathan (pp.57–58) the way in which the sexual act can come to form an envious attack or an act of hatred by the perpetrator when other emotional nourishment is absent, and how (p.59) cognitive distortions by the offender can work to make a risky scenario turn in the perpetrator’s mind into an innocent one. These dynamics can form the main route down which real but hidden, often destructive, feelings emerge into an enactment.
The example of Adrian stands out and in describing his potential move into new relationships while being honest about an offending history, the author sounds more wishful about an accessible future than is likely to be easily achieved. The general public tend not to want to get to know those with known paedophile offence histories readily, and so their opportunities for relationships outside their perverse framework are in reality often limited unless carefully structured in the way that Circles of Support has tried to do in order to help alleviate the issue of contact with non-offending others. This is important, otherwise treatment may offer change in thinking but with few others to engage with in this changed outlook.
As a new therapist taking over a group from an experienced colleague the author of chapter 4 noticed the importance of the clinic as a partner to the patients but also very much to the therapists: ‘Their attitude conjured in my mind the idea of the institution as an internal object upon which I might also be able to rely (p.70)’. After a testing beginning the therapist found the group began to settle and: ‘. . . I would later come to recognize each member’s key themes, which would repeat themselves in a number of variations (p.71) . . .’ over time. Therapy relationships were usually experienced as battles for control and domination (p.74). Anger and guilt at losing previous roles as partners or fathers came into the group at times. In a final passage the author found that: ‘I have been impressed with some of the members’ ability to offer sensitive and accurate interpretations that I would not have thought about (p.75)’. This honest and generous comment gives a good demonstration of how a therapy group can foster members’ agency and ability to show insight and compassion in a genuinely democratic way as therapeutic communities have long known and, I think, as Foulkes wrote of as ego training in action: where the therapist cannot know and so enable the group, when this can realistically be done, to make real personal discovery.
The author of chapter 5 writes of the implications of therapist gender and begins by pointing to the very wide range of social, familial and societal influences that permeate the forensic therapy group and this wide range of influences is not neatly encapsulated in the group-as-family model (p.79). This chapter’s focus is on issues arising from the role of female therapists working with all male patient therapy groups at the Portman and the transference scenarios this activates. The author notes that the psychic level of these groups’ functioning is predominantly pre-oedipal (p.92). Experiences of being a pregnant therapist in wider clinical practice, reported in a 1994 special issue of Group Analysis, found a general tendency for the group to show more pre-oedipal functioning in response to their therapist’s pregnancy. This is found more acutely in the Portman experience, the author notes, where men’s experience of early adversity and/or perverse mothering make pregnancy a greater psychic threat (pp.95–96). A valuable and lengthy example of the impact of the therapist’s pregnancy is given and, after some absences from the group, real mental illness emerging in one member and anger at being abandoned when the therapist left to have her baby. The group, over time, became able to hold a more benign maternal transference after the therapist’s return, and after the painful emotional storms had abated, some positive change took place, exemplified in one group member recounting beginning to repair his relationship with his real mother outside the group (pp.96–102). The author considers Foulkes’ (p.92) idea of the group holding maternal qualities as presenting an idealizing image of the group which contrasts with the Portman experience of more primitive, anxious, aggressive pre-oedipal anxieties that emerge with those struggling with destructive and violent impulses, sexual identity and perverse sexual enactments. However, what appears more tolerated, the author notes, is the wider clinic, the secretarial staff, the building itself as holding a containing and widely dispersed symbolic maternal function. A paternal function as punitive, abusive, and violent can also be projected into the therapist, regardless of gender. However, the perverse mother transference tends to form around the figure of the female therapist and to symbolically crystallize the most abusive and potent qualities of past perverse mothering in reality; these can be held and re-formed in the transference generated in the group. This presents the female therapist with particular challenges and sounds taxing. This is a strongly analytic chapter showing how powerful the dynamics are facing therapists working at the Portman and what they have to face and attempt to help translate (a very Foulkesian term) into thinking and meaning through dialogue in the group over some time. One example given is of John (p.90), who goes from angrily considering seducing (a phantasy) his wife’s sister when she refused to have sex with him after the birth of their child, went through several interactions to more thoughtfully consider whether his female cousin who had abused him and later committed suicide had in her own past been abused herself. More damaged patients have a knack of intuitively sensing much that is going on with the therapist and this chapter can feel strong on the use of theoretical language which evokes its own defensive quality, though hardly surprising in view of the emotional storms recounted.
The wide range of social, family and community influences in the genesis of paedophilia are considered in chapter 6 where the author points to the absence of these formative influences in press reports amid the shock of the impact of offending on victims. However, it is clear from the East Hubert Report from Wormwood Scrubbs (HMSO, 1939) onwards, that sexual offenders have regularly been subject to disproportionately high rates of sexual abuses themselves. My own brief research review (Parker, 2006) found 40 to 60% of the male sexual offender group had been sexually abused themselves and suffered other co-existing forms of violent, verbal, neglectful or abandoning abuses that have been categorized in some treatment programmes as ‘justifications’ or as ‘cognitive distortions’, thereby invalidating an offender’s own real subjective experience in a fashion that has felt destructive and painful to them and in some cases resulted in rage and a tightening of their defensive structure. Farrington and colleagues in the longitudinal Cambridge Study on Delinquent Development found that exposure to verbal aggression without accompanying physical violence was criminogenic in itself. This finding is replicated more recently in Spillane-Grieco (2000). The author of chapter 6 finds that many of those who experience sexual abuse as children do not go on to sexually abuse others themselves but may use their ‘. . .sexuality to turn away from human contact, using the child in a power relationship that denies reality rather than engages with it (p.109)’. Given the difficulty in relating with other adults ‘. . . the therapy group . . . becomes a containing experience for the entire person, not just the problem he presents to society (p.110)’. The author notes that Glasser proposed that for the paedophile, the actual child carries the projection of the idealized child, (in which he phantasizes he should have been admired and loved) on whom the individual lavishes “parental”-type love (p.110)’. The strength of this identification overrides age-appropriate difference and ego-strength is lacking. The author refers to Robert Stoller’s ideas on the sexualization of aggression that accompanies paedophile behaviour, and the use of the child as a part-object and the negation of the needs of the other: the child. This behaviour has an out of control, psychotic shape, the author continues, in which symbolization and thinking have become abandoned to the urgency of immediate gratification. The author distinguishes between internet (now the largest group in treatment) and contact offenders and there is current unresolved debate about how similar or different these different offender groups are (p.112). Robert Hale, the author writes, considers there may be a paedophile transference which features a sexualized and secretive power relationship showing in a special and more intimate relationship with the therapist (p.115). From experience at the Portman, paedophilia is unlikely to change and so has to be worked with in the hope of reducing future damage to those who are at risk of becoming victims. In Portman groups there is pressure to keep the external world in mind and to offer a moral compass that forms a shared assumption that children should not be abused (p.116).
Chapter 7 is based on a detailed clinical example from the life of a group the author took over from an experienced male therapist. Of five group members at the start two were women who experienced incest in their own lives and had gone on to commit acts of cruelty (unspecified) towards their children and three men who were both victims and perpetrators of sexual abuse (pp.131–132). After a testing beginning featuring some sado-masochistic interactions within the group, the author noticed that: ‘. . .tenderness is often viewed suspiciously by abused / traumatized patients, as if it is bound to be followed by cruelty and sadistic treatment (p.133)’. This is suggestive of the repetition compulsion at work resonating at a group level. Foulkes focused little specifically on this psychoanalytic concept but it comes to life in this chapter. Within the group, some had committed sexual offences against children and some had been victims of sexual abuse against others, a rapid oscillation was seen live in the same patients between being an abuser and appearing abused (p.137).
The author notes that downloaders, those convicted of downloading images of child abuse from the internet but who had not physically abused children, seem to have difficulties with feelings, alexithymia, in common. The author notes that Joyce McDougall considers alexithymia more radical than denial and that this appears to function to deaden the self and defend against more psychotic anxieties and fears of fragmentation and this may help offer understanding of the compulsive nature of this offending style (p.141).
The author offers a construction based in the narratives emerging in the group: that non-contact (online only) abusers present an early life pattern of neglectful abuse in which the patients’ parental gratification and the absence of a father figure co-existed with a phantasy of finding tenderness that has been missed but has become enacted through the act of masturbatory gratification via images online of child sexual abuse. In these phantasies the child survived this encounter, the author posits, as the perpetrator would like to have done, but did not, in their own earlier life (p.143). The downloaders had been subject, the author found, to continuous cumulative traumas of emotional abuse and neglect and the screen functioned as an object onto which to project their unbearable internal reality, where it was located outside them, away from their own internal world, and so rendered them freer, in phantasy, from it (p.145). Through hard emotional work the author found that this group became more able to trust each other and their therapist and discover aspects of empathy previously distant and to encounter different aspects of themselves and others.
A new venture from 2009 is described in chapter 8. This is an MBT group therapy for male patients with a history of violent antisocial personality disorder and which the author notes is, among other things, a ‘. . . developmental disorder rooted in attachment . . .’. The ability to mentalize, to hold mind in mind, to be able to reflect on one’s own behaviour and its effect on others: ‘. . . develops within the context of a secure attachment relationship (p.157)’. This important developmental understanding holds that through treatment different, more pro-social attachment patterns may emerge, be modelled and, in theory, be identified with and internalized and then practised within the group and eventually outside it. This MBT group was conducted by two psychiatrists. Weekly group and monthly individual sessions are offered to this patient group who meet as a slow-open group (a group analytic concept). The author notes that individual meetings are more often missed than the therapy groups (p.164). The chapter has a clear medical model flavour to it, including reference to it being likely that such individuals are psychopathic or perverse and ‘. . . a considerable genetic and biological basis . . .’ underlies their condition (p.155). While likely true this contrasts with the stress on the attachment origins of behaviour made earlier. Only one of their early group cohort scored as severely psychopathic using the Hare Psychopathy Checklist-Revised checklist all were given prior to beginning treatment and this chapter lacks an empathic feel to it at times and can sound bleak, perhaps a countertransferential resonance to the material projected into the therapists from this particular group.
A particular distortion of sexual life is described by the late author of chapter 9 referring to Valerie Sinason’s development of Wolfensberger’s concept of sex as perceived as ‘death-making’. The chapter explores how people with disabilities’ unconscious sense of sex as something that can result in the creation of something damaged or abnormal is a useful insight into how the creative core of sex may come to be unconsciously distorted in offences against other people in concrete reality. Rather linked with this is a longing for but fear of intimacy found in this patient group. ‘At the heart of this was a deep ambivalence about attachment coming from these men who so often thought of themselves as unloved and unloving, men whom someone would only wish to be close to if they were being paid (p.195)’. The chapter conveys a deep compassion for the predicament of this particular offender group.
Foulkesian group analytic factors in forensic group psychotherapy
Group therapy is a democratic and egalitarian form of treatment (p.9) in the Portman version as well as the Foulkesian version and chapters 1, 5 and 9 evoke most of the spirit of Foulkes’ democratic wariness of therapist over-dominance. Group members in chapter 1 report a sense of real empowerment coming from this particular group style and that they no longer feel that they are in such a passive position as they have been in other programmes or criminal justice settings. This seems to provide potential space for mind where an often-traumatized patient group can feel some limited agency and a real sense of an ability to gather together and express their own thoughts from their own experiences. This is often quite new. In my own experience at HMP Grendon with men and HMP Send therapeutic community with women these small differences both offered personal meaning but also tended to lessen acting out and so improve dynamic security within the prison and group setting and help hold the violent and sexual eruptions more analytically, non-judgmentally.
Robert Hinshelwood, a Kleinian psychoanalyst, notes that the Foulksian approach tends to give more space to the individual within the group and is less stressful to those who need to reorientate their relationship life in what Foulkes called the ‘matrix’ of their social world (p.6). Arguably a Foulksian approach offers more flexibility with which those with severely damaged attachment histories feel heard in their own experiences, provided the authoritative conducting style and the structure of the group are containing enough. Here, this book makes the point that a move away from Foulkes’ sometimes vague description of how to structure group life is required. The MBT therapy experience indicates that more damaged individuals do need more mentalizing structure and therapist verbal containment to guard against the kind of fragmentation and collapse that has been and is far more present in their lives.
The author of chapter 9 points to a Foulksian area of dynamic administration in a wider than usual sense, in citing Ronald Doctor’s advice to assess not only the internal world of the potential patient, but also their external world to ensure it has the potential to contain and hold the patient through the lifetime of the group. (p.185). This is not often highlighted. The author found that work was needed with patients’ carers because forms of splitting and rage had occurred when their care staff team were found to oscillate, at times, between objectifying their clients or feeling objectified by them and reacted to these dynamics (p.187). This author’s concept of the Disability Transference: how the therapist’s countertransference could hold intensely powerful projections of disability making them unable to find words, think clearly or hold their usual sense of time and space is an important contribution to forensic psychotherapy (p.194).
Theoretical and technical principles stand out clearly in this book which offers a clear clinical framework to consider group therapy for forensic patients. This clarity in proposing a clear structure, the place of the wider team as container, authoritative conducting, clarity of communication and scrupulous honesty and fairness helps avoid risk to patients, to therapists and to society. I would recommend this book as a guide to forensic group therapists and other professionals working with offenders as offering wide-ranging insights.
