Chapter 20 – Forensic Psychotherapy




Abstract




Forensic psychotherapy is the application of psychological knowledge to the assessment, treatment and management of mentally disordered offenders and patients who commit violent or destructive acts against others or themselves. Forensic psychotherapy creates a bridge between forensic psychiatry with its main focus on mental illness and risk, and psychoanalytical psychotherapy which aims to understand the conscious and unconscious motivations of offender or forensic patient [1]. Forensic psychotherapy emerged from a psychoanalytic theoretical framework, which continues to be its predominant influence, although its remit has widened to encompass other psychodynamic approaches, including group psychotherapy and therapeutic community approaches, and it is also influenced by the related disciplines of psychology, criminology, sociology, ethology, neuroscience, philosophy and ethics.





Chapter 20 Forensic Psychotherapy



Jessica Yakeley



What Is Forensic Psychotherapy?


Forensic psychotherapy is the application of psychological knowledge to the assessment, treatment and management of mentally disordered offenders and patients who commit violent or destructive acts against others or themselves. Forensic psychotherapy creates a bridge between forensic psychiatry with its main focus on mental illness and risk, and psychoanalytical psychotherapy which aims to understand the conscious and unconscious motivations of offender or forensic patient [1]. Forensic psychotherapy emerged from a psychoanalytic theoretical framework, which continues to be its predominant influence, although its remit has widened to encompass other psychodynamic approaches, including group psychotherapy and therapeutic community approaches, and it is also influenced by the related disciplines of psychology, criminology, sociology, ethology, neuroscience, philosophy and ethics.



History of Forensic Psychotherapy


Forensic psychotherapy developed as a specialty in its own right from the pioneering work of psychoanalysts in forensic mental health and prison settings in the 1930s. Although a huge psychoanalytic literature has been established on the nature of aggression since Freud’s initial writings, psychoanalytic treatment was not traditionally thought suitable for violent and antisocial patients. Nevertheless, there were a few early innovative clinicians interested in expanding the boundaries of classical psychoanalysis by attempting to treat violent patients, such as Karl Menninger [2] in the United States. But it was in the UK that forensic psychotherapy was established with inception of the Portman Clinic in London, originally founded in 1931 as the Psychopathic Clinic, the clinical arm of the then Institute for the Scientific Treatment of Delinquency, by Grace Pailthorpe, a gifted psychiatrist and psychoanalyst. The Portman Clinic developed as a centre of expertise in treating patients with violent, antisocial, delinquent and perverse behaviours, and notable psychoanalysts and psychiatrists such as Edward Glover, Mervyn Glasser, Adam Limentani and Estela Welldon who worked there have been influential in advancing psychoanalytic theories on the aetiology and treatment of violence and perversion. Their clinical work inspired other psychoanalytically trained psychiatrists such as Murray Cox, Leslie Sohn and Arthur Hyatt Williams in their treatment of violent individuals in forensic hospitals and prisons in the UK, and laid the foundations for forensic psychotherapy to develop and expand into an international multidisciplinary field of clinicians from different professional backgrounds, including psychiatry, psychology, nursing, art therapies, social work, probation and law. The International Association for Forensic Psychotherapy (IAFP) was formed by Estela Welldon and a small group of European psychiatrists trained in psychoanalytic psychotherapy working within forensic settings in 1991 whose aim is to promote the health of offenders and victims through the use of psychotherapeutic understanding, risk assessment and treatment techniques, and has grown into an international society with members from all disciplines, including service users, in Europe, the United States, South America and New Zealand.


In 1995 the first Consultant Psychiatrist in Forensic Psychotherapy was appointed in the UK at Broadmoor High Secure Hospital, and in 1999, forensic psychotherapy was approved by the General Medical Council and the Royal College of Psychiatrists to become a formal sub-specialty of higher psychiatric training. In 2007, the Forensic Psychotherapy Special Interest Group was established within the Royal College of Psychiatrists, which aims to promote and support practice, training and research in forensic psychotherapy within psychiatry and other disciplines.



Principles of Forensic Psychotherapy



Psychoanalytic Principles


Forensic psychotherapy is based on certain fundamental tenets of psychoanalysis – the existence of a dynamic unconscious of fantasies, feelings, conflicts and motivations; psychic determinism whereby one’s conscious choices are influenced by these unconscious processes; a developmental approach which understands that the adult personality is shaped by significant events in childhood; and the notion that behaviours and symptoms have unconscious symbolic meaning, so that violent and antisocial acts may be understood as a form of ‘acting out’ – a meaningful communication of unconscious wishes, needs and conflicts.



Violence as Communication


In his paper ‘Remembering, repeating and working through’ Freud writes, ‘… the patient does not remember anything of what he has forgotten and repressed, but acts it out. He reproduces it as not as a memory, but as an action: he repeats it, without, of course, knowing that he is repeating it. For instance, the patient does not say that he remembers that he used to be defiant and critical towards his parents’ authority; instead, he behaves that way to the doctor.’ [3, p. 150]. Freud went on to show how acting out represented a resistance to psychoanalytic progress – an unconscious repetition of the patient’s past in action that occurred in the relationship, or transference, with the analyst, that could not be thought about consciously but acted out instead.


The concept of ‘acting out’ has since widened to include a range of impulsive, risky and antisocial behaviours of patients, not solely arising from the clinical context, but as an inherent part of how the person habitually relates to himself and others, where certain thoughts and feelings, stemming from adverse childhood experiences, cannot be represented and processed in the conscious mind, and are therefore expelled in action. One of the tasks of forensic psychotherapy is to help the patient tolerate the disturbing thoughts and feelings, often associated with vulnerability, shame and humiliation, that underlie their violent behaviours, and understand their traumatic origins in the patient’s early childhood. However, forensic psychotherapy is as much aimed at helping the professionals who manage such patients or offenders in understanding that their offences and crimes may not be immoral actions committed by people who are inherently bad, but have arisen within a developmental context as pathological defences against experiences of neglect, trauma and abuse from people responsible for their care.



Understanding Not Condoning


However, professionals, as well as the general public, may be resistant to an approach that pathologises antisocial and illegal behaviours and suggests that the offender may be suffering from a mental disorder, such as antisocial personality disorder, which may be amenable to treatment, particularly when the offender does not appear to suffer, but makes other suffer, and may be reluctant to think of himself as a ‘patient’ or engage in treatment at all. This highlights the historical and ongoing tensions between legal and medical approaches, often played out within the court arena, over whether ‘treatment’ is really a disguise for moral re-education, particularly for people who are not voluntarily seeking help themselves [4]. Confusion arises because the offender attacks the outside world – other people and society – who then understandably focus on that person’s actions which are deemed worthy of punishment. This may indeed be the correct response, as the offender needs to know that his actions damage others and have consequences, but from a psychodynamic viewpoint it is only a partial response. From this perspective, attention is erroneously focussed on the offender’s external actions, rather than his internal world, and any attempt to understand that his offences against others arise from his own self-destructive internal and compulsive needs is equated by the public with condoning them [1]. Forensic psychotherapy does not operate within a condoning–condemning axis but seeks to enable the offender to take responsibility for his actions and choices through a greater understanding of himself. Indeed, treatment and punishment are not diametrically opposed but may be both necessary for rehabilitation where the legal process of proportionate justice – by imposing imprisonment or a community sentence – may establish an essential external boundary without which therapeutic work could not take place.



Three Parties in Forensic Psychotherapy


As with all psychoanalytically oriented psychotherapy, forensic psychotherapy focusses on exploring the internal world of the patient, but the therapist also needs to be aware of what is actually happening in his external life and the potential risks that he poses. In this respect, forensic psychotherapy differs from more traditional psychoanalytic psychotherapy where the relationship between patient and therapist remains private and confidential. In forensic psychotherapy the dyadic relationship between patient and therapist is not sacrosanct as there is always a third party – the criminal justice system – involved in the therapeutic endeavour which brings in the external reality of the patient’s actions, their consequences and management. This third party may be a professional or agency currently involved in the patient’s/offender’s management, such as his probation officer or the court, or may be represented by the patient’s contact with criminal justice or forensic services in the past. However, the therapist needs to have some independent knowledge of the patient’s offending history and risk to others, rather than solely relying on sources of information arising within the therapy from the patient themselves or from the therapist’s countertransference. This triangulation of the therapeutic process alters the nature of confidentiality – on the one hand, confidentiality needs to be protected as much as possible to facilitate engagement in treatment, but on the other hand, where there is a serious risk of harm to others it may be necessary to disclose information to third parties, and not to do so may be unconsciously experienced by the patient as a dangerous collusion on the part of the therapist who is not protecting the patient from his dangerous impulses. Negotiating this triangular situation successfully by managing the competing demands of confidentiality and risk opens up a containing space where a therapeutic process can develop safely. The bringing in of a third perspective or ‘paternal function’ – in contrast to the more ‘maternal function’ of the therapist – parallels the way in which a good ‘parental couple’ will promote the best interests of their child, an experience many offenders never had. When therapy takes place in a forensic setting, the lines of communication and duties of care of different members of the team should be clearly defined [5].


In view of the complexities of risk, security, confidentiality and disclosure inherent to forensic work, forensic psychotherapy should take place in the public sector in an institutional setting that can provide the appropriate governance structures and multidisciplinary team support to ensure the necessary containment for individuals who pose a significant risk to themselves and others. Forensic psychotherapy is ideally located at the juncture of two institutional systems in the UK: the National Health Service (NHS) and the criminal justice system. This ensures that the work between therapist and patient/offender is not carried out in isolation, but is subject to the regulatory frameworks and institutional boundaries needed to protect both parties in the therapy dyad. While the forensic psychotherapist must be constantly mindful of the tensions arising from the different ethos and agendas – therapeutics versus public protection – of the respective institutions, being able to work within the rules of the institutional settings is a vital part of facilitating the offender’s eventual transition back into the wider society from which he has been excluded.



Theoretical Contributions to Forensic Psychotherapy



Unconscious Sense of Guilt, the Superego and Primitive States of Mind


Freud described in his paper ‘Some character-types met with in psycho-analytic work’ [6] individuals whom he referred to as ‘criminals from a sense of guilt’ who were drawn to committing forbidden antisocial deeds to relieve an unconscious sense of guilt, which preceded the crime, and which Freud linked to unresolved forbidden Oedipal wishes and led to the need for punishment. Freud later attributed the unconscious sense of guilt to the existence of the death instinct [7].


Although Freud believed that the superego was absent in psychopaths, Klein furthered these ideas in proposing that by contrast, their superego was present but overly harsh and punitive, which led to an internal sense of persecution between the superego and ego and unconscious sense of guilt that could only be alleviated via violent or antisocial actions [8]. Klein believed that violence was the result of innate envy and destructiveness that were manifestations of the death instinct and predominated in early life, giving rise to the primitive anxieties, defences, unconscious phantasies and archaic superego which characterised the ‘paranoid-schizoid’ position [9]. Klein’s ideas are helpful in conceptualising violent and antisocial states of mind as being governed by primitive defence mechanisms such as splitting, denial, omnipotence and projection, with a lack of more mature defence mechanisms such as repression and sublimation. Similarly, primitive emotions such as envy, shame, boredom, rage and excitement predominate, whereas more mature affects such as guilt, fear, depression, remorse and sympathy which involve an appreciation of whole objects and are characteristic of the ‘depressive position’ [10] are missing.



Violence as a Defence against Trauma and Disorders of Attachment


Klein’s belief that aggression and violence were primarily instinctual were opposed by Winnicott, who viewed aggression as a creative force necessary for healthy development, facilitated by a ‘good enough mother’ by enabling individuation and separation [11]. He proposed that pathological aggression and antisocial behaviour arose as a defensive reaction to early deprivation and trauma [12, 13]. Bowlby coined the term ‘affectionless psychopaths’ for children whose apparent indifference to others hid their anxiety of ‘the risk of their hearts being broken again’ [14].


Influenced by these ideas of Winnicott and Bowlby, more contemporary authors (e.g. De Zulueta [15], Gilligan [16], McGauley [17], Meloy [18]) highlight the high frequency of early abuse and loss in the histories of antisocial and forensic patients, and view adult antisocial behaviour as a defence against early trauma which interferes with the normal development of attachment between the infant and mother or primary caregivers. Such pathological attachment relationships in early childhood may lead to later difficulties in affect regulation, impulse control and a deficient capacity for representation and mentalisation. Gilligan [16] proposes that all violence is a defence against experiences of shame and humiliation, which has its roots in the person’s early abusive experiences of being shamed and humiliated. Such painful affects are associated with anxieties of vulnerability and dependence, which cannot be tolerated or mentalised within the fragile defensive structure of the person’s mind and instead are converted into the excitement of violence or projected into others.


These ideas are illustrated in the case of Mr B, who was physically abused by his mother and stepfather, his own father having disappeared when he was a baby. Mr B was initially a very anxious child with persistent bedwetting, which further enraged his mother and made him feel terribly ashamed. As a teenager he became aggressive and delinquent, getting into fights, stealing cars and drinking heavily. In early adulthood Mr B became closer to his mother after she divorced from his stepfather, but had a series of relationships in which he was domestically violent to female partners, culminating in a conviction for grievous bodily harm and a custodial sentence. In prison he commenced a group treatment programme for intimate partner violence, but was soon excluded due to his argumentative behaviour resulting from his sensitivity to feeling slighted and humiliated by the female group facilitators.


These failures in mentalisation and poor impulse control may be seen to be the result of Mr B’s early childhood history of trauma and neglect, in which his mother was unable to foster the development of a secure attachment, but instead violently intruded upon his mind and body. His experiences of being abandoned by his biological father, and violently abused by his stepfather offered him no opportunities for developing a healthy male identification, nor any respite from the pathological relationship with his mother. However, Mr B was not consciously aware of his anger towards his mother, but unconsciously projected this in the violence towards his girlfriends, making them feel humiliated and powerless, as he himself did as a child.



Perversions


Forensic psychotherapy has also been concerned, since its inception at the Portman Clinic, with the origins and psychotherapeutic treatment of perverse sexual fantasies and behaviours. Although the term perversion has assumed pejorative connotations, and has been replaced by the diagnostic category of paraphilias and paraphilic disorders in the DSM-5, certain psychoanalytic concepts of perversion retain utility in how we might think about and help individuals whose sexual desires and practices cause distress to themselves and/or others, particularly in the realm of intimate relationships [19].


Freud originally proposed that perversions were due to infantile sexual instincts that had escaped repression, and later as a defence against castration anxiety [20]; later psychoanalysts shifted the aetiological roots of perversion, as with those of violence, to earlier in the person’s development, locating them in the primary relationship between the mother and baby, where perverse fantasies and behaviours arise as a sexualised defence against primitive anxieties and aggression towards a narcissistic, abusive or neglectful mother. Sexualisation, however, is a more mature defence than the primitive defences of projection, splitting, idealisation and denigration which characterise the mental states of individuals who are more overtly violent, whose aggression may be understood as a more primitive defence against disturbances and related anxieties in the early mother–infant relationship. As described above, when these anxieties become overwhelming, they are no longer kept in check within the mind but are projected into others in overt violence. By contrast, in people with perversions, violence is inhibited by the sexualisation of their aggressive impulses towards the mother in early development into fantasies and behaviours that provide gratification and preserve the relationship with the mother, but in which sadomasochism takes the place of care and love.


Stoller described perversion as ‘the erotic form of hatred’ [21], where hostility, hidden behind overt sexualisation, was the primary motivation in perversion and represented a fantasy of revengeful triumph over childhood trauma and a pathological relationship with the mother. Extending Stoller’s ideas, Glasser proposed, in his theory of the core complex, that sexual perversion in adulthood arose from a constellation of primitive anxieties, sadistic sexual fantasies and denigratory defences [22], which he called the core complex, originating in infancy as a defence against fears of aggression, separation, abandonment and helplessness in relation to the mother. For both Stoller and Glasser, the father is absent or ineffectual, and thus unable to protect the child from an engulfing relationship with the mother. In adulthood, true emotional intimacy is avoided by keeping the other person at a distance within a paradigm of sexual dominance and control, where the aggression may be openly manifest, as in sadomasochistic sexual practices, or more hidden, as in the secret triumph of voyeurism or the omnipotence of exhibitionism, where hostility towards the other person is concealed within an envelope of sexual excitement [19].


These interpersonal dynamics may be seen in a patient, Mr M, who was referred for therapy for his ‘addiction’ to sadomasochistic sexual practices such as bondage, which left him feeling increasingly isolated and depressed. He was the only child of a single mother and remembered feeling suffocated by his mother’s attention and control. He exhibited aggressive and disruptive behaviour in primary school, but as an adolescent withdrew into a fantasy world of violent video games, which were gradually replaced by internet pornography of an increasingly sadistic nature. As an adult he could only become sexually excited in aggressive encounters with his partners, and although these sexual relationships were initially consensual, he became increasingly aroused the more his partners resisted his violent behaviours, and finally sought treatment when he feared that his aggressive and sadistic impulses could no longer be contained.


Although Stoller and Glasser focussed on the early relationship with the mother, patients with perversions and paraphilic disorders often have pervasive histories of childhood traumas, abuse or rejection in later childhood or adolescence and may have been prematurely sexualised via experiences of overt childhood sexual abuse, or more covertly sexualised such as being prematurely exposed to pornography. Normal psychosexual developmental is hijacked and sexual impulses may become confused with aggressive impulses arising from prior experiences of maltreatment or neglect. Such individuals frequently describe a very disturbed sense of self in which feelings of self-disgust, shame and humiliation predominate.

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Jun 6, 2021 | Posted by in PSYCHOLOGY | Comments Off on Chapter 20 – Forensic Psychotherapy
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