Forensic Psychotherapy: Pathologies and Treatment Strategies for Working With Violence

This presentation describes some concepts underpinning forensic psychotherapy, including a theory of a triangular dynamic between patient, psychotherapist and society that was developed by Dr Estela Welldon. The talk explores the countertransference in relation to personality disorder, and how challenging this can be for the clinician, arousing such responses as collusion, disbelief and condemnation and also stirring our own sadism via projective identification. He considers how even the most apparently insane violence has meaning inside the mind of the person who commits it. This is explored in relation to two cases in which the violence erupted through a fragile narcissistic structure that had been attempting to hold the self together. This concept of a narcissistic organisation of the mind, which arises when there is a failure of containment in infancy, is discussed as a means of understanding this fracturing of psychic defenses.

Video lecture – 28 mins

The History of Murder – and the Murder of History

In this detailed theoretical and case-based presentation, Dr Ronald Doctor considers the many-faceted but mostly concealed psychological states and experiences underlying the act of murder. In most cases, killing occurs concretely only after it has been committed many times previously in dreams, nightmares and unconscious fantasies that have never become conscious. Before the deed, conscious efforts – sometimes unconscious too – are designed and devoted to keeping the impulse to murder encapsulated to prevent action. Commonly a sudden reversal takes place internally that breaks the murderousness loose from its cordoned-off status. Ronald Doctor proposes that there is always an underlying psychically traumatic and indigestible experience of loss and death. Using clinical material from two patients who suffered severe loss he explains how they sought refuge: the first in psychosis, and the second in a sado-masochistic retreat.

Video presentation – 52 mins

Mary Haley is the lead psychotherapist on a Category B prison wing of 35 prisoners. In this video she describes the task of rehabilitating these men, who have invariably suffered extreme neglect or abuse in childhood. The therapeutic approach consists of living within a democratic therapeutic community, in which the residents learn how to tolerate themselves and each other in close quarters by sharing responsibilities for the community. They have small group, in-depth psychotherapy 3 times each week in which they challenge and support each other in facing both their crimes and the childhood experiences that predisposed them to acts of violence. Bearing what is often extreme past shame and humiliation, facing their demons and accepting personal responsibility takes great courage and Mary Daley movingly illustrates how the longer term residents often show great tenderness and compassion towards new prisoners. She illustrates the combination of attachment theory, object relations that forms the integrative therapeutic approach underlying the work. She also explores the value or otherwise of such terminology as Borderline Personality Disorder, and the therapeutic use of the International Personal Disorder Examination (IPDE).

Video talk to camera – 42 mins

Offering a prison governor’s perspective, Dr Jamie Bennett talks about the principles by which HMP Grendon is run as Democratic Therapeutic Community. This prison provides group therapy within a social climate which promotes positive relationships, personal responsibility and social participation for men who have elected to be transferred there from mainstream prisons in order to gain insight into their violent behaviour. Therapeutic Communities address interpersonal relationships, emotional regulation, self-management and psychological wellbeing. To foster these skills, the residents at Grendon participate in group therapy and structured community living in which they are encouraged to have shared responsibility for day to day decision-making and problem solving on their wing. Dr Jamie Bennett discusses the effectiveness of their work, which is measured in part in terms of improved behaviour in the prison community and reoffending statistics.

Presentation to camera – 28 mins

The International Association for Forensic Psychotherapy has at its core a focus on the psychodynamic understanding and treatment of offenders. This knowledge is also applied to explore the meaning of such behaviours in a societal and cultural context. All cultures have taboos on killing other human beings, with different sanctions, yet all have exceptions to this rule. The exceptions are not merely legitimised, but often strongly held ethical beliefs. Thus the meaning of killing differs widely in different contexts and cannot be reduced simply to individual psychopathology. Dr Sandra M Grant here considers the significance and impact of killing for all of us. While defences such as splitting and projective identification are prominent in the discussion there will also be consideration of catharsis, sublimation and displacement with specific reference to film and literature.

Video lecture with slides – 44 mins

In this talk Anna Motz describes the unique manifestations of female perversion and violence, with illustrative clinical material. She draws on Welldon’s (1988) model of female personality and consider in particular whether the concept of psychopathy has any relevance to women, or if it is a misappropriation of a construction related to men. She will also describe societal responses to crimes perpetrated by women, and how details of the potential for female violence and perversion only serves to perpetuate unhelpful stereotypes and vilify those women. Finally, she will outline therapeutic approaches for working with violent and sadistic women.

Video lecture with captions – 23 mins

Dissociative Identity Disorder (DID) (American Psychiatric Association 2013) is examined in this presentation from the perspective of its relevance to the criminologist. As this psychiatric condition is linked to severe and prolonged childhood abuse, accounts of DID patients inevitably involve reports of serious crimes, in which the person was the victim, perpetrator or witness. These reports can thus contain crucial information for criminal investigations by the police or for court proceedings. However, due to the person’s dissociative states, such reports are often very confusing, hard to follow or believe and difficult to obtain. Through the analysis of clinical examples, Dr Adah Sachs explores how decisions are made by a person with DID, the notions of choice and’competent reasoning’, and the practical and ethical ways for interviewing a person with DID who has witnessed or participated in a crime.
(A version of this presentation was published (2015) at the International Journal for Crime, Justice and Social Democracy)

Audio presentation with slides – 30 mins

Grendon – a Category B, medium secure prison, is the first prison to operate as a dedicated therapeutic community (TC). In this third video filmed with staff at Grendon Prison, which specialises in the therapeutic treatment of violent prisoners, Richard Shuker explains how democractic TCs offer a “consciously designed, social environment and programme of treatment intended to help their members understand and less or overcome their social, psychological and emotional problems”. Their offender behaviour is understood to be the result of early experiences of trauma or abuse in childhood. In TC prisons, the residents and prison staff work together to separate these childhood experiences from the offender behaviour and thus prepare prisoners for a non-offending future. Dr Shuker describes the principles of a democratic therapeutic community (safety, interpersonal relationships, emotional regulation, self-management and psychological wellbeing).

Presentation to camera – 25 mins

Working with people with antisocial or psychopathic personality disturbance can have a profound impact on clinicians. Many of the offences committed by these individuals are of a highly sadistic kind and therefore traumatic to hear about and process, leading to angry and punitive responses. On the other side of the coin, some staff identify strongly with the victim within the offender, since childhood histories of appalling abuse and disrupted attachments are common. Team splitting and conflict frequently ensue, thus undermining the best efforts at treatment. This talk will consider the dynamics impacting on teams’ ability to function together in this work, and what measures can be taken to mitigate these effects.

Video lecture with slides – 47 mins

Dr Estela Welldon suggests the principle cause of violent crime is the need to express rage, helplessness and humiliation rooted in unconscious childhood memories of abusive experiences and domestic violence. When these experiences have been extreme, and there has been a lack of loving containment by an attachment figure, something powerful is held inside the psyche until it is released in adulthood through loss of control, often triggered by a repeated trauma. Although the violent act may appear irrational, in the context of the patient’s past experiences it may be very meaningful. The violent act, furthermore, provides a sense of agency, of being seen and experienced by others. The key to forensic psychotherapy is for the patient and therapist to uncover the unconscious meanings of the act, through language. Hopefully this will be aired before the ‘splash’ – the moment when the crime is committed – if that person has access to therapeutic help. By gaining an understanding of their own past experiences of rage, impotence and humiliation the patient may resolve the unconscious impulses underlying the crime. We see that in effective psychotherapy, talking and thinking replace the acting-out.

Video talk to camera – 26 mins

Individuals diagnosed with Antisocial Personality Disorder (ASPD) or psychopathy continue to be viewed by many as untreatable. However, psychopathy and ASPD are not synonymous and there is convincing evidence that a subgroup of individuals with medium to low psychopathy scores have suffered early trauma and attachment difficulties which have contributed to their personality pathology as adults. Mentalization-based therapy is based on attachment theory and offers a credible treatment for people with ASPD. Dr Jessica Yakeley here presents findings from an ongoing project developing and researching a new Mindfulness Based Therapy community services for ASPD nationally, which has been commissioned by the Ministry of Justice and Department of Health as part of the Personality Disorder Offender Pathway Strategy.

Video lecture with slides – 50 mins

This presentations suggests that a key assumption, central to forensic psychotherapy, is that the offence has a meaning to the offender and can be understood in the context of their internal world, developmental history and relationships. The offence is considered as a symptom. Once it has been committed a line has been crossed where psychic reality has been acted out in external reality. Just as with physical diseases, the offence often has a prodromal period – a time when the disease process has begun but is not yet clinically manifested. If the underlying symptoms and mechanisms are not recognised and understood by the patient then the risk of similar offending remains. In this presentation Professor Gill McGauley theoretically explores how forensic psychotherapy can help us recognise and understand more about this prodrome to murderous attacks. She presents qualitative and quantitative data to illustrate how the patient’s representation of their index offence, their offence narratives and capacity to mentalise can help us predict and treat the unfolding of both aggressive and prosocial behaviour.

Video lecture with slides – 30 mins

Fortunately, most people who attend for psychotherapy have never perpetrated acts of criminality and do not suffer from an overtly diagnosable mental illness. A small cohort of non-forensic patients will, however, commit a variety of offences, none of which constitute a breach of the law of the land but which, nevertheless, cause significant suffering to themselves and to others. In this presentation, we shall explore the psychodynamics of the sub-clinical “non-forensic” patient, concentrating on how and why such individuals function in this quasi-forensic fashion and what impact their unconscious “criminality” might have. We will question whether the definition of forensic psychotherapy might need to be expanded in recognition of the broader range of unconscious sadism that we often encounter in our work.

Video lecture with slides – 35 mins