Forensic Psychotherapy

Jessica Yakeley, Gill McGauley, Jessica Yakeley, Gill McGauley

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781351838689
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Forensic psychotherapy explores the roots of violent, sexual and antisocial behaviour. It is a relatively recently created discipline that applies psychoanalytic knowledge to the assessment, management and treatment of mentally disordered offenders, forming a bridge between traditional forensic psychiatry – with its focus on diagnosis and risk – and traditional psychotherapy – with its focus on understanding why things happen. As a discipline, forensic psychotherapy seeks to understand the conscious and unconscious motivations that underpin specific offending behaviours. We need to understand not only the detail of the crime, but also the offender as a whole person within his environment, including the criminal justice environment. It aims to understand the perpetrator, the victim, and the victim within the perpetrator.

In this collection, leading international experts in forensic psychotherapy explore the different aspects and developments within the field. These include first hand experiences of shaping the emerging discipline within the UK, Europe and the United States; working therapeutically with high-risk offenders in prisons and secure hospitals; exploration of female violence and work with incarcerated mothers and babies; and the latest developments in forensic psychotherapy training. This book will be of interest to professionals and academics working within the fields of forensic mental health, criminal justice, psychiatry, psychology, criminology, and sociology. This book was originally published as two special issues of Psychoanalytic Psychotherapy.

Forensic psychotherapy

Estela Welldon

Independent Practitioner, London, UK

Introduction

This edition of the journal looks at the contribution specialist forensic psychotherapy can make to the rigorous disciplines of forensic psychiatry and the law, as well as helping general psychotherapists who encounter forensic issues. As Bluglass (1990, p. 7) put it ‘The role of the forensic psychiatrist in confronting and trying to reconcile the differences between the interests of the law and those of psychiatry is a crucial and important one’.

Forensic psychotherapy can help. It is a bridge between traditional forensic psychiatry with a major focus on diagnosis and risk, and traditional psychotherapy with a focus on understanding why things happen. Williams (1991) described the difficulties encountered in the successful bridging of both disciplines. According to Harding (1992), there is an inevitable, and indeed necessary, conflict of values between the forensic psychiatry and criminal justice systems. Evaluations should ideally be conducted independently, according to criteria that correspond to health-based values (Reed Report, 1992).

Forensic psychotherapy seeks to understand the unconscious motivations that underpin specific offending behaviours. We need to understand not only the detail of the crime, but about the individual as a whole person within his environment (including the criminal justice environment). The criminal action is the central fact. Unfortunately, some psychotherapeutic approaches can seem to be a ‘soft’ option, justifying and rationalizing behaviour to provide ‘false understanding’. Our forensic patients use similar mechanisms to conceal their ‘real selves’ resulting in encapsulation of the offending behaviour and keeping it hidden or minimized. An effective collusion between society and offenders is at work. The criminal action always appears understandable as an action against society, yet at the same time, it is unconsciously a self-destructive act, with harmful effects for the offender also. This aspect of criminality associated with unconscious guilt has been examined by Freud (1915), Glover (1960) and Tuovinen (1973), among others.

Sometimes the criminal behaviour can become explosive, violent and uncontrollable with profound consequences. It can be the equivalent of a neurotic symptom, a sign of personality disorder or of simple criminality (or maybe all three). Pfäfflin (1992) described how the symptom can even be a constructive and healthy reaction. He adds that it is ‘conservative’, meaning that the patient needs it and keeps it until it can be properly understood and then he can give it up. We must remember the axiom of the paediatrician and psychoanalyst Dr. Donald Winnicott: ‘The antisocial tendency (in adolescence) implies hope and it is characterised by an element in it which compels the environment to be important’ (1956).

A psychotherapeutic approach does not seek to condone the crime or to excuse the criminal. On the contrary, the object is to help the offender to acknowledge responsibility for his/her acts and thereby helps to protect the offender and society from the perpetration of further crimes (Welldon, 1988). Taking responsibility and understanding what you did, and why, is more than simply saying you regret it: getting there takes hard work from both patient and therapist(s).

At times, the criminal act is the expression of more severe psychopathology; it is secretive, completely encapsulated and split from the rest of the patient’s personality, which acts as a defence against a psychotic illness (Hopper, 1991). On the other hand, it can be a calculated act associated with professional, careerist criminality. The forensic psychotherapist can help to clarify these difficult diagnostic issues.

The form of psychotherapy involved in forensic work is different from other forms precisely because society is, willy-nilly, involved. Forensic psychotherapy has gone beyond the special relationship between patient and psychotherapist. It is a triangular situation – patient, psychotherapist and society. This is the first of at least three different triangular situations found in working with the forensic patient.

The second is the existence of the triangular process or power dynamics in social roles such as the ‘bully’, the ‘victim’ and the ‘bystander’ (sometimes intervening as ‘rescuer’) well described by Twemlow, Sacco, and Williams (1996). A bully repeatedly uses force, either physical or non-physical to shame, humiliate and dominate a victim. Thus a victim is the target for the bully’s force and can become depressed, hopeless and enraged at the mockery. The bystander is the audience for the bully–victim drama. These are dialectically determined roles, not people, and can switch around very rapidly. The bystander role is an important and often unrecognised part of the problem. Court appearances and psychotherapy assessments can become part of this dynamic.

The third triangular situation is that of three different ‘cultures’: of blaming, of concern and of learning. These terms came to mind when I was invited to give the Oxford Brookes University Fellows Lecture in 2004, From the Court to the Couch, and I used them later in my book, Playing with Dynamite (Welldon, 2011, p. 142). The culture of blaming is left to the lay public and society at large. The titillating front pages of tabloid newspapers make it very difficult, if not impossible, to understand the inner world of those who offend or the motivations for their crimes. The common blaming and retaliatory responses to violence or sexual abuse are characterised by splitting and projective identification mechanisms (Klein, 1946) that see people as ‘good’ or ‘bad’ in a black or white way. ‘Good’ people need to safeguard their own goodness by locating badness in others. It is essential that we educate the public about these unconscious attitudes that people display, such as in Knox’s (2014) recent article, ‘The blame and shame society’, but perhaps more importantly and topically, it is heartening to see that these concepts are being used more widely in journalism and in popular non-fiction literature, such as Ronson (2015) So You’ve Been Publically Shamed.

Unfortunately, the culture of concern is almost always left to clinicians, social workers and the judiciary. There is a prejudice among some clinicians that judges are not ready to listen about unconscious motivations and what they would perceive as manoeuvring legal processes to diminish the guilt of the accused. On the contrary I have found that many are open and ready to learn and feel better prepared to face their own role. I always felt that they would be only too willing to listen to clinicians and learn from their own experience. This was confirmed in 1991 when, at an annual meeting of the Advisory Group to the Diploma Course, I put forward a proposal for a ‘Judges’ residential weekend’ that would provide judges with a unique opportunity to learn and understand about unconscious motivations of offenders. To my delight, this was taken seriously and action was immediately taken by Tony Lloyd, now Baron Lloyd of Berwick, and a residential weekend was made possible in Windsor in 1991. Later on Matthew Thorpe, now The Rt. Hon Lord Justice Matthew Thorpe, another member of the Advisory Group, followed suit as a family judge and began to convene a series of weekends for the family justice system with the same format, involving Portman Clinic staff. Forensic psychotherapists have to work to influence this broader system.

Altshul (2013, p. 48), in reviewing a paper on forensic psychotherapy by Yakeley and Adshead (2013), described his reservations about the applicability of psychodynamic principles to judicial and legal processes, but goes on to say ‘They describe a humane, sophisticated, and civilised position, and they describe it in a thoughtful and scholarly manner. A large part of me hopes they can prove me wrong’. According to Kapoor and Williams (2012, p. 460) ‘We simply believe that thinking through the possible unconscious forces at play in a forensic case adds a layer of richness that would otherwise be lost’.

Thinking and listening and learning are needed to acknowledge and understand these perspectives. We need to promote discussion about such issues in a broad arena, the general public, the politicians, the media and other academic disciplines. Perhaps especially, we need to work better with non-governmental organisations (NGOs) who work with offenders and victims – and with these individuals themselves, in a broader context than the clearly defined clinical setting. We should support relevant academic work. This is the learning culture.

Society instinctively views sexual offenders and their victims in distinct and reflex ways. Whereas the treatment of victims is encouraged and everyone is concerned about their welfare, the same does not apply to perpetrators, and lip service may be paid to the fact that victims could easily become perpetrators. ‘Splitting’ is in full operation. Linked to this I have challenged the stereotype that women tend to be seen as victims and men as perpetrators, especially in instances of sexual abuse. The difficulties in acknowledging a woman’s abusing power in motherhood (‘they don’t do those awful things’) may be the result of massive denial, as a way of dealing with this unpalatable truth (Welldon, 1988). Until recently a lack of legislation on female perversion reflected society’s total denial of it. The woman is thereby seen as a part-object, or just a receptacle of men’s perverse designs. The apparent idealisation of mothers prevalent in society contains a denigrating counterpart. Following on from my work, this theme has been further reviewed and researched by Motz (2009, 2014, 2014) in her psychoanalytic explorations of the nature of female violence, and by Minne (2011) in her clinical work with psychotic women who have killed their children. Many others have described their psychotherapeutic work with both men and women within the prison and maximum-security units (see Aiyegbusi & Kelly, 2012).

Forensic psychotherapy may appear to be a narrow field yet has been able to push boundaries in order to work with offender patients (sometimes in secure settings). Boundaries have been further extended to offer treatment to groups of people not previously seen as suitable for psychotherapy, such as people who were previously referred to as mentally handicapped, later as having learning disabilities and presently as having intellectual disabilities. In the UK, Sinason has pioneered the application of psychodynamic psychotherapy in the treatment of patients affected with intellectual disabilities (Sinason, 2010) and Curen has also written extensively about their psychodynamic work with children and adults with intellectual disabilities (Curen & Sinason, 2010). More recently Corbett (2014) has described a carefully designed specific treatment along psychodynamic lines for children and adults who show offending behaviour, including inappropriate sexual activity. Others, such as Tilman, have described therapeutic work with other marginalised groups within society, such as migrants.

When we began to work with the concept of forensic psychotherapy, we were accused of diluting psychoanalysis and ‘losing its preciousness’. But now the modifications from psychoanalysis necessary for forensic psychotherapy to apply to larger sectors of the community are supported by internationally well-known psychoanalysts such as Kernberg (2014) and Twemlow (2013). Forensic psychotherapy may also contribute to understanding the widespread sexual abuse perpetrated by idealised professionals such as the clergy (priests and nuns), teachers (male and female) or high-profile figures in the entertainment industry, which has been recently exposed but had been hidden from public consciousness for so long. It is not just ‘them’ of course – therapists can also be abusers.

A personal perspective

Looking at forensic psychotherapy from my own personal professional experience over a 40-year period, it is clear that the understanding of human behaviour has deepened beyond recognition in the last half century. I want to acknowledge the seminal work of two pioneers in the field of forensic psychotherapy, whom I was fortunate to work with and who influenced my future career.

After completing medical school in Argentina, I studied at the Menninger School of Psychiatry in Topeka, KS, USA. Dr Karl Menninger believed that punishment neither helps the criminal nor protects society.

Regardless of its futility and expense, punishing criminals gratifies, comforts, and even delights the general public: sadistic attacks in the name of righteousness deal with the public’s unconscious guilt about their projective identifications, having conveniently located their aggressive impulses in the criminal, the ‘other’. (Menninger, 1967, p. 333)

At the time of the assassination of President Kennedy, Menninger had been devoting his attention to the neglected ‘weaker fellowman’. In this instance it was Oswald, the man responsible for President Kennedy’s assassination. Menninger stated:

Thwarted in repeated efforts to have someone pay attention to his puffed up insignificance, this nonentity had concealed himself in a warehouse whence he could overlook thousands of his despised fellow citizens. Far below him they were singing hosannas to their radiant, beloved young leader … The little man in the warehouse was no longer anonymous. (Menninger, 1967, p. 333)

Akhtar’s concept of the ‘mental pain of the minorities’ describes this process aptly as ‘In terms of being perceived by the majority, the minority feels both the anguish of invisibility and the torment of hyper-visibility … If one is not wanted but does exist, then what is one to do with one’s existence?’ (Akhtar, 2014, p. 144)

Menninger’s understanding of the single, insignificant man and his position in a society where he was despised and ignored resonates with many current issues that give rise to great concern, even perhaps the terrorist. In this regard, I find it extremely helpful to refer back to the assertion by Gilligan (1996) that a subjective feeling of being humiliated invariably precedes any acts of violence, especially those considered to be ‘irrational’. Doctor further elucidates,

… Even the most apparently insane violence has a meaning in the mind of the person who commits it. There is a need to be aware of this meaning and to learn from it in an attempt to prevent further violence. (Doctor, 2008, p. 2)

From De Zulueta (2006) we have learnt the almost inevitable process that takes place in between mental and physical pain and its development into physical violence. Where De Zulueta makes reference to individual situations, Meloy and Yakeley (2014) apply a similar approach within the context of group and social violence, including acts of genocide and terrorism, which are of topical importance now.

When I left Topeka in 1964 and went to the UK, I worked in one of the most exciting and revolutionary clinical institutions: the Henderson Hospital in London. Dr Maxwell Jones, the second person whom had a major influence on my professional development, had founded this residential unit, or ‘therapeutic community’ (Jones, 1953), with the aim of treating people with severe personality disorders. I had already met Jones at the Menninger when he came in 1963 to lecture us on his creation of the therapeutic community and we were all deeply impressed by his searching for dignity and social justice for those who, at that point, were called psychopaths and sociopaths.

The enormous challenge of their treatment was met by a sound structure of democracy and the division of labour, in which everyone, patients and staff...

Table of contents

• Cover
• Half Title
• Dedication
• Title
• Copyright
• Contents
• Citation Information
• Notes on Contributors
• Dedication – Making minds more secure: Remembering Gill McGauley
• Foreword
• 1. Forensic psychotherapy
• 2. Female violence and toxic couples
• 3. 3 Man unlock: out of sight, out of mind – Art psychotherapy with a woman with severe and dangerous personality disorder in prison
• 4. The place of psychoanalytic psychotherapy in the treatment of high-risk personality-disordered offenders
• 5. ‘This is the pain I feel!’ Projection and emotional pain in the nurse–patient relationship with people diagnosed with personality disorders in forensic and specialist personality disorder services: findings from a mixed methods study
• 6. Safety in numbers: group therapy-based index offence work in secure psychiatric care
• 7. Can psychoanalysis help us to understand the causes and prevention of violence?
• 8. Forensic follow-up care for outpatients in Germany
• 9. Creating mother and baby therapy groups in prison: emotional valuation
• 10. A child’s loss becomes a young man’s violence
• 11. In praise of Dr Leslie Sohn 1919–2013
• 12. A fertile matrix: the birth of the Forensic Psychotherapy Society
• Index