grounds for
optimism
with
Personality
Disorders
Proceedings of the Third
Annual conference
of the
London March 2001
Published by the James Nayler
Foundation
all proceeds from sales of this book will go to the
James Nayler Foundation
Published by the James Nayler Foundation March 2002. ISBN – 1-904327-01-X
The Foundation takes its name from James Nayler, one of the Early Quakers, who declared as he lay dying from
his many beatings in 1660
– “There is
a spirit which I feel that delights to do no evil, nor to revenge any wrong. .
. Its hope is to outlive all wrath
and contention, and to weary out all exaltation and cruelty. . . . It takes its
kingdom with entreaty and not with contention. . . . ” which succinctly expresses our
aspirations.
The James Nayler Foundation – Admin office P
O Box 235 York YO1 7YW –
Registered Office, 5 The Terrace Niton IoW PO38 2NE. Incorporated in England & Wales Company Reg.
number 3383970 –
Registered Charity number 1072133.
email
– admin@TruthTrustConsent.com
www.TruthTrustConsent.com
Over 300 people crowded into the large meeting room at Friends House on Saturday 31 March 2001 for the Third Annual Conference of the James Nayler Foundation, a Quaker inspired charity, set up to relieve the suffering of those with Personality Disorder and to promote education, training and research into these distressing and disturbing conditions.
The Conference movingly and clearly realised the aspirations of its title "Grounds for Optimism with Personality Disorders". We heard from a barrister, a psychiatrist, a Director of a Sex Offenders Unit, a Mind Advocacy manager, a Grendon Prisoner and accounts from others with direct personal experience of the problems. At the close we were end of the day, able to agree the Conference statement which appears on page 3.
The Foundation is please to print these transcripts of this Third Annual Conference. We are grateful to all who participated, and especially for the help we have received in the process of transcription.
Introduction....................................... 3
Conference
Statement...................... 3
About
the Speakers........................... 4
Nina
Hall Chair Of Trustees.......... 6
Sue
Johnson A Director of the
Foundation 6
Stephen
Field..................................... 7
Untreatability And Human Rights............................................................. 4
Donald
Findlater,............................ 13
Circles of Support and
Accountability: A Community Project.......... 13
A inmate talks about his Grendon
experience........................................... 19
Heather
Castillo.............................. 22
User Experiences Project: Research and Results.................................... 22
Dr.
Bob Johnson and former sufferers 45
Afternoon session: Panel questions 51
Extracts from panel
discussion: questions and answers........................ 51
Sue
Johnson: Closing Conference Statement 58
Appendix......................................... 60
Modern Day Lepers by Bob Johnson............................................................ 60
(1) BORN EVIL – OR CAN WE LEARN ?............................ 61
(2) TREATING UNTREATABILITY & "pulling
yourself together". 61
(3) THE PATTERN BEHIND PERSONALITY
DISORDERS 62
WHAT
SHOULD WE DO ?....................................................... 63
James Nayler Foundation Publications 28
The James Nayler Foundation
Third Annual
Conference 31 March 2001
At the end of the day, conference agreed the following statement.
We have heard from various
speakers, of their grave concerns relating to Personality Disorders. In particular –
¨
That detention for no purpose is "inhuman
and degrading, arbitrary and unlawful"
¨
That the concept of untreatability is "wrong
and damaging"
¨
That in the area of diagnosis, "where
understanding is required, fear has emerged."
¨
Of the damaging effects of all types of childhood
traumas.
But we have also heard
–
¨
Optimistic accounts of the process involved in
change and recovery
¨
and of harnessing humanity through Circles Of
Support in the community, and through support groups
We have vividly experienced
our shared humanity here today.
As a final PostScript, the
prisoner from Grendon, has written the following (extracts taken with his
permission from a letter to the Foundation )
'What I found so amazing was all these people who just wanted to say to me, "thank you", "you have helped me". That meant so much and has given me a lot of strength to face my own fears and anxieties concerning the future.
'It is important for me as a person labelled with Personality Disorder which has arisen as a consequence of traumatic childhood experiences that I am understood, rather than just being contained and controlled. . . .. . .In understanding my own abuse, the trauma and pain associated with the above, I am able to understand the trauma, pain and experiences that I put my own victims through.
'I would like to give back to the outside community – to help heal the wounds, the trauma and pain others have experienced through abuse. This is why I want to help your Foundation.
'After the morning session, this young lady approached me and thanked me for helping understand her own abuse and her hatred towards people like myself. She told me that I had helped her to see that even though I'm a sex offender, I too have suffered and that she could empathise with me and that removed the hatred. This young lady gave me a lot of support and encouragement for which I would like to thank her.'
Stephen
Field
is a practicing barrister at
1, Pump Court, Temple, who, having completed his University of London Law
Degree as a mature part time student, was called to the Bar in 1993. He
specialises in human rights and public law with a particular interest in cases
involving novel or unchallenged factual/legal features. He has had several
published articles and cited cases and is a member of the LAG, Justice and
Liberty. He lectures on an occasional basis and presents legal seminars.
Donald
Findlater,
is Deputy Director of the Lucy Faithfull Foundation ( a child protection charity dealing in all
aspects of child abuse), and Manager of Wolvercote Clinic, this country’s only residential assessment and
treatment centre for adult males with allegation of or convictions for sexual
assaults against children. Prior to his work with the Lucy Faithfull Foundation
he was manager of Surrey Probation Service’s Sex Offender Resource Team. He
sits on the Dangerous Offender Working Group of ACOP (Association of Chief
Officers of Probation) and assists in child protection policy and
practice developments in the mainstream churches, including participation in
the current Nolan Review Committee.
Heather
Castillo
Heather
Castillo is the advocacy service manager for Colchester Mind. For over ten
years she has worked in North Essex to develop advocacy service for children,
adolescents and adults with mental health problems. More recently, she worked
together with fifty local service users, who had attracted the personality
disorder label, to produce a collaborative piece of research which has
subsequently attracted national interest. As far as we are aware this is the
first study of its kind where current users of mental health services have conducted research into a clinical
diagnosis and have been able to effectively define themselves within a system
and have presented a new construct for consideration.
Dr.
Bob Johnson
Bob is the co-founder of the
James Nayler Foundation. He is a consultant psychiatrist specialising in the
treatment of Personality Disorders. He became well known through his work in
the Special Unit at Parkhurst Prison from 1991-1996 which formed the basis of a
BBC TV “Panorama” programme (03.03.97).
Currently,
he runs a clinic in York for Personality Disordered individuals referred to him
by Solicitors, courts, Social Services and others.
His
presentation to the Conference focused on the therapeutic process he developed
for the successful treatment of Personality Disorder – Emotional
Education.
His book, Emotional Health has been printed by the Foundation and is to be published on 16 March 2002, ISBN 1-904327-00-1.
The James Nayler Foundation was set up three and a half years ago as an international charity looking at the issues of personality disorder. Its main focus is to achieve a platform of further education and research into this very difficult area of grave social concern. I’d just like to mention a word about the status of the foundation. It is a charitable organisation, and at the moment we are entirely dependent on volunteer contributions. We have no recognisable funding as yet. So, part of my job this morning, is not only to welcome you, but to thank you all for attending, and for the support of all of you here, attendees and supporters, and helpers, and the speakers, but also to make a small appeal for funding. So there are donation boxes around, and slips with registration for further support for the foundation. So once again, thank you very much for your support, and I look forward to the third conference today
I’ll pass you over now to Sue Johnson who is a director of the foundation.
Right, well I just want to give you a huge welcome and thank you for your support over the years. This is our 3rd conference and I think at this stage it’s really important to just keep going, and we are managing to do that. We’ve got here today a wide variety of people from many types of occupations, interests, and experience. I hope in the lunch hour, you may wish to share some of your experiences and thoughts. What I want to do this morning is to bring you a message from a woman that rang me from Canada last week. And she simply said I want to wish your conference very, very warm wishes, and I want to thank you from all of us sufferers here in Canada. I felt actually quite humbled by that, and especially when I heard some of the lifelong difficulties she’d been experiencing. But then I reflected on it, and I think that probably the message to us is that in a desert, even the smallest drop of water is incredibly valuable, and it’s in that sort of spirit, I think, that we set up the foundation. And that we’re beginning to grow, and create more and more water. Thank you very much for being here.
FOLLOW UP PAPER TO “UNTREATBILITY AND THE LAW”(APRIL
2000) ADDRESSING SPECIFIC HUMAN RIGHTS ISSUES AND PROPOSED AMENDMENTS TO THE
MENTAL HEALTH ACT 1983
1 INTRODUCTION AND SUMMARY
1.1 Since the presentation of last year’s James Naylor Foundation paper on “Untreatability and the Law”, itself a response to the Government’s consultation paper “Managing Dangerous People with Severe Personality Disorder: Proposals for Policy Development”, the Government has published a White Paper entitled “Reforming the Mental Health Act”.
1.2 A copy of the summary version (in various formats) can be obtained free of charge from PO Box 777, London, SE1 6XH (fax: 01623 724524). Both the summary and a full text can be obtained on the internet at the following websites: www.doh.gov.uk/mentalhealth; www.homeoffice.gov.uk; www.hmprisonservice.gov.uk.
1.3 The principle changes to current mental health law, as affecting people with so called “DSPD” are contained in Part 2 of the White Paper under the heading “High Risk Patients” and are summarized below.
1.4 The human rights implications are considered thereafter, with particular reference to “untreatability” issues.
1.5 Whilst this paper does not repeat the contents of last year’s paper, it is submitted that the contents of that paper are still current and the anticipated concerns regarding DSPD voiced last year have all materialized in the White Paper.
1.6 It is submitted that the White Paper is designed to achieve one principal, and populist, purpose, and that purpose is to facilitate, within the restrictions of the European Convention on Human Rights, the detention of an extremely small group of persons who are deemed to have a “Dangerous Severe Personality Disorder”(DSPD).
1.7 The White Paper at paragraph 1.8 of Part 2 recognises that “There is no single answer to the problem of dangerousness. No society can ever be completely free of the risk of serious harm”.
1.8 Yet the paper also suggests that an identifiable group exists, consisting of “between 2,100 and 2,400 men are dangerous and severely personality disordered ... Further work is now underway to refine these estimates and to include women who are DSPD’’.
1.9 The White Paper also envisages that young people should fall within its proposals. At paragraph 6.46 of Part 2 it is asserted that:
Assessment of dangerousness in young people presents an even greater challenge than adults given the developmental factors involved. It is not currently known how to accurately identify those in adolescence who will be assessed as falling into the DSPD group once they reach adulthood.
1.10 This spirit of inexactitude permeates the proposals, and suggests that the underlying concept of the proposed changes to mental health law is motivated by the attraction of populist politics as opposed to the interests of individuals who may be directly affected by the provisions of a new Act.
2 EUROPEAN CONVENTION ON HUMAN RIGHTS
2.1 Since October 2000, the provisions of the European Convention on Human Rights have been directly applicable in domestic law by virtue of the Human Rights Act 1998. Indeed, the Courts can now assert (for the first time) that English statute law is inconsistent with the Convention, forcing Parliament to amend the offending statute.
2.2 The first case of in which the Courts have used this power (R v MHRT N&E London Region and SS Health, ex parte H) is cited in the Times (29 March 2001), and concerns the provisions of the Mental Health Act 1983 in relation to release arrangements for patients. That case has prompted “MIND” to call for an immediate amendment to the 1983 Act in advance of the proposed overhaul. Arguably, the provisions in the new proposals relating to detention of DSPD individuals may expect the same fate in the Courts.
2.3 The key provision of the Convention (Article 5) in terms of current law and the proposed amendments is cited below, and its application to mental health law analysed thereafter.
2.4 It may well be that the White Paper’s proposals inevitably raise Article 8 issues (reproduced below), both in relation to powers to enter private premises and in terms of powers to enforce detention and treatment, though this paper does not address that question separately on account of lack of space and time.
Article
5
The
right to liberty and security of the person
5(1) Everyone has the right to liberty and security of person. No one shall be deprived of his liberty save in the following cases and in accordance with a procedure prescribed by law:
(a) the lawful detention of a person after conviction by a competent court...
(e) the lawful detention of persons for... persons of unsound mind.
Article
8
The
right to respect for private and family life
8(1) Everyone has the right to respect for his private and family life...
3 THE WHITE PAPER- “MENTAL DISORDER”
3.1 The White Paper specifically addresses the implications of the Convention, asserting at paragraph 7 of the introductory summary:
Safeguarding
Human Rights
7 Mental health legislation necessarily includes powers to place significant restrictions on the personal liberty of patients, in particular the freedom to refuse care and treatment. Any new mental health legislation must be fully compatible with the Human Rights Act 1998. This White Paper outlines a new framework for mental health legislation that will include a broad definition of mental disorder covering any disability or disorder of mind or brain, whether permanent or temporary, which results in an impairment or disturbance of mental functioning...
3.2 The notion of “a broad definition of mental disorder” has two significant implications.
3.3 First, the phrase “mental disorder” coincides with Convention case law legitimizing detention under Article 5(1)(e) and Wintwerp v Netherlands (1979-80) 2 EHRR 387 (see paragraph 8.3 of last year’s paper). It is apparent from a reading of Part 2 of the White Paper (and in particular paragraph 3.4 of the full text), that the Government models the purported legitimacy of compulsory detention powers on that authority.
3.4 Secondly, the new proposals do not define particular categories of mental disorder, unlike the 1983 Act, to which compulsory powers can be applied. Lawyers for Liberty (Spring 2001) identify that this places a greater degree of discretion in the hands of clinicians without adequate corresponding safeguards.
4 THE WHITE PAPER - “TREATABILITY” cf “MANAGEMENT”
4.1 The White Paper (Part 2, paragraph 9 of the summary) removes the 1983 Act “treatability” requirement for compulsory detention. This is an alarming concept given the mind set of the psychiatric industry. First, the notion of “treatability” was commented on by Brenda Hoggett (Mental Health Law 1996, Sweet and Maxwell) citing Gunn, 1979:
In effect, then, the new [ 1983] “treatability” test is designed to protect the hospitals from any responsibility towards patients whom they do not want, but it provides no protection at all for the patient who does not want the hospital.
4.2 Secondly, the new criteria for compulsory detention goes beyond treatment (described in the White Paper as “therapeutic benefit to the patient”) to now include “to manage behaviour associated with mental disorder that might lead to serious harm to other people”.
4.3 The upshot of the new regime is simple. Psychiatrists and hospitals who have been willing and able to wash their hands of difficult, objectionable but “untreatable” persons (see paragraph 13 et seq of last year’s paper) are now to be entrusted with their management.
5 THE
WHITE PAPER- THE “RISK” CRITERIA
5.1 Part 2 of the White Paper (“High Risk Patients”) sets out the criteria for compulsory “treatment” (sic), which includes containment without treatment as set out at paragraph 4.2 above.
5.2 Again, clinicians will assume a broad discretion when assessing the risk of future harm to others. This issue is addressed at paragraph 12 et seq of last year’s paper.
6 CONCLUSION
6.1 It is puzzling, if not contradictory or even disingenuous, for a White Paper to introduce criteria for “treatment” and a statutory based “care and treatment plan” when treatment is the last thing on the mind of those authorizing detention.
6.2 This is particularly so when the White Paper asserts that the “Government is committed to ensuring that any new powers [for detention] are fully compatible with the Human Rights Act 1998” Part 2 (paragraph 2.13).
6.3 I suggest that the Government has deliberately adopted (or arguably hijacked) the judgment in Wintwerp as the basis for its proposals, seeking to use the Convention as a weapon of the state rather than a shield for the individual.
6.4 The significance of the distinction between that case and the new proposals (at Part 2, paragraph 3.4) lies in the Government’s departure from a treatment based detention to a potentially indefinite “management” based detention.
6.5 Throughout the White Paper, the notion of a “care and treatment” plan is heralded. Behind this notional “care and treatment” plan, however, lies this notion of “management” of a mental disorder, which has already been deemed to be untreatable. It follows that such “management” must be the opposite of care and treatment, and indeed, can only amount to control and containment of the individual, whilst leaving any mental disorder untreated.
6.6 Enigmatically, the “box” at page 15 of Part 2 suggests that the 1983 requirement of “treatability” is unhelpful. However, it then goes on to suggest that in the case of untreatables, “care and treatment [no mention of management] would be delivered in an “appropriate therapeutic environment” with “interventions that are specifically designed to ameliorate the behaviours that cause them to be a danger to others”. Something of a contradiction, perhaps.
6.7 To illustrate the Government’s additional confusion as to its task and aims I refer to paragraph 2.18 of Part 2:
2.18 It should be stressed that the phrase “dangerous
people with severe personality disorder” is a working definition...
We intend to refine this definition during the pilot
period as we develop a clearer picture of the nature and characteristics of
this group.
Further, at paragraph 6.50, “DSPD is a working definition rather than a single clinical diagnosis”. Pity the person who is wrongly detained while the Government develops a clearer picture.
6.8 It is noted that the text of the White Paper avoids reference to “untreatability” in selling the “care and treatment” aspects of the proposals. However, the two case studies at pages 17 and 25 of Paper 2 appear to reveal the true, and alarming, potential impact of the proposals.
6.9 Both give examples of “untreatable” persons who may be detained under civil powers because they pose proposed risks to others. A DSPD “screening” assessment would lead to containment, euphemistically referred to as “a care and treatment plan would then be drawn up which would be delivered in an appropriate therapeutic environment within the NHS” or “specialist care and treatment.
6.10 It should be noted that the Mute Paper also refers to section 41 of the Health Act 1999 which allows the incorporation of high security psychiatric services into the NHS. Thus plans for the integration into the NHS of Broadmoor, Ashworth and Rampton into the NHS are underway (paragraph 6.3 et seq Part 2).
6.11 These locations may be the “appropriate therapeutic environments within the NHS” envisaged above.
6.12 The area of most concern must lie with the subtle use of the Wintwerp criteria legitimizing detention (see paragraph 8.3 of last year’s paper). The case itself requires review of detention to ascertain whether the mental disorder continues. If the Govenment has abandoned the notion of “treatability” as a prerequisite to detention, how can an untreatable person with DSPD ever change? He can only be managed, and that management will consist of indefinite, and logically, permanent detention.
6.13 Paragraph 2.1 of Part 2 states that “. . . dangerous people with severe personality disorder [will be] kept in detention for as long as they pose a risk to others... “ Logically, that will be permanent (or “indeterminate” as the White Paper puts it at page 10 of Part 2). They are “untreatable”!
6.14 It is difficult to contemplate a more extreme (or arbitrary) abandonment of the dignity, liberty and integrity of a person. (who would previously have been rejected by clinicians deeming them untreatable, and who may well have done nothing wrong to attract the compulsory powers to detain), to be placed in the hands and custody of those professionals who did not want them in the past, in locations formerly reserved for convicted offenders.
6.15 I suggest that the Government has attempted to utilize the Convention (and the Wintwerp criteria as a prop for its proposed measures, whilst ignoring the underlying principle of Article 5, namely, to prevent arbitrary detention.
6.16 The lack of evidential basis for defining DSPD, for assessing dangerousness, and the notion that a person may be permanently detained even though that person has committed no offence must arguably fall foul of Article 5 of the Convention, as suggested at paragraph 9.2 of last year’s paper.
STEPHEN
FIELD
1 Pump Court Temple 29 March 2001
Summary
‘Circles of Support and
Accountability’ is an innovative concept, tried and tested in Ontario, Canada,
providing intensive support to high profile and/or high risk sex offenders upon
their return to the community. The purpose of a circle is to
·
reduce the risk of re-offence by the offender
·
ease his transition into the community on release
from prison
·
speak to the fears of victims and the community
These purposes are achieved
by the creation of a support group: a ‘Circle of Support and Accountability’
around the offender, at the request of the offender, who commits to relate to
the Circle and accept its help and support. This is alongside any ongoing
intervention by the statutory agencies and with the commitment of the offender
to act responsibly in the community. The Circle will provide intensive support
and help to the offender, ideally daily, for a minimum of one year and assist
in his safe and orderly adjustment to everyday life.
Circle members act in an
entirely voluntary capacity and are typically recruited from within faith
communities. They receive training to equip them for their task.
In reality ‘Circles of
Support and Accountability’ formalises and strengthens the occasional ad hoc
arrangements that encircle a number of sex offenders at any one time. Circles
are to be piloted in one or two counties
before more general roll-call can be expected.
At this very early stage and
with only one formal Circle in operation in the UK, the response of the faith
communities to these ideas has been very positive. The selection, recruitment,
training and operation of volunteers will be the next real test.
It is to the credit of the Society of Friends and the Home Office that they took the initiative to bring this concept across the Atlantic from Canada and present it to statutory and voluntary bodies and individuals to consider.
I happen to work with a lot of people that have been labelled with personality disorders but I’m not sure that’s a helpful label to work with. I will explain a little bit more about that in a moment.
I’d like to move on to a different subject, but just as a silent commitment to the title, can I show you this? Yes, these are my holiday photos from Toronto! Top left hand Evan and David, then we have Niagara Falls, then we have Evan and his sister Elizabeth and then myself and Evan at the bottom. I was in Niagara Falls in Canada last October, I guess what’s remarkable for me and was remarkable to my visit was I asked if I could make a visit to several supporters of ‘Circles of Accountability’ in Canada and the organiser and co-ordinator at that time was Evan, who we saw in the photos. I said could we take him down to the falls? -and on the drive out we picked up Evan’s sister, and then we stopped off further on the way and picked up David.
David just happens to be a sex offender, three years out of prison and he’s also in ‘Circles of Support and Accountability’, and Evan is one of his supporters. So, as Evan was having a day out at Niagara Falls with a visitor from England, we take David. We popped in on a family party later on that evening, had pizza and coke and then went home again.
The challenge I’d like to take to people is to try and imagine the situation with someone who has done some very dangerous, irresponsible, wicked things. What kind of life do we want for them in the future and how do we think we can help them to manage their risk and behave responsibly in the community? If we can provide a community for them then we will be helping them to manage their own risk. I personally don’t think we are at the present time.
Anyway, I shall head somewhere else for the moment. The work at Wolvercote clinic is a part of the Lucy Faithfull foundation. This is a child protection charity. We work in all aspects of child sexual abuse. Wolvercote, itself, is this country’s only community based residential assessment treatment centre for adult males with convictions for sexual offences against children. I’ve left 25 men there this morning who have been there since 1995. It is the successor to what you may have heard of earlier: Gracewell in Birmingham, which closed in 1992. We’ve been in Epsom since 1995, with 25 residents, all of them come for four weeks assessment and, for some of them, they will stay all 12 months. Staying on is a tough deal though, because it involves accepting the limitations of the community and so, whilst they are in an environment of friendship and support, I provide an extremely intensive treatment and assessment programme. I provide staff who work and have worked with sex offenders over the years, and understand the behaviour of people that offend. None of my staff are psychiatrists, I employ a couple of psychologists to make assessments in terms of some psychometric work that I need to do to demonstrate the effectiveness of what we do to the public and the Home office, because I need proof of what we do. Then you work with people that are going through assessments or treatment programmes and I hope what we do is to offer them a structure of assessment, treatment, support and care that is genuine but has boundaries. I guess we have an ethos within the clinic, we say the boundaries are staying in my garden and my building and when you leave the premises during your stay, you will leave accompanied, you won’t go out on your own.
Okay that’s a tough call, people have to accept that or decide not to stay but I do that for a reason; I’m trying to move the clinic. We saw what happened in South London when there was a misunderstanding in a hostel. The local public were not too happy with that, and it has since been closed down. I’m not a very popular neighbour, despite the fact that five years later and 290 sex offenders later, no local person has been harmed at all directly by any of our residents. They might have been harmed by the knowledge that they are there, but not by any action of those men because they have chosen to act responsibly. We’ve selected people who we believe can do that, and we work with them within certain constraints to make sure the public are not put at risk by them, but they are still sex offenders and we’ve got to work within the law here.
There’s a woman from the states that has been an inspiration over the last couple of years and she has heralded a movement that we are trying to make at the clinic and along with the foundation to look at the problem of child abuse seriously, and with wise eyes. “The way we see the problem is the problem”. If we perceive the problem of sexual abuse and the problem of personality disorders in a very limited ways, then I think that we narrow the field too much, and we don’t do things too well.
Fran Henry is a survivor of child sexual abuse herself, and she’s very clear about that, she has started a campaign in Vermont in the States called; “Stop it Now. Stop It Now! means this, she talks of a time when she was a child being sexually assaulted by her father, and she talks about the time now in the UK and the States and she says:
“Right now our entire system stands behind the child. Waiting for the child to report sexual abuse and to report reliably. We simply cannot expect this kind of self protective behaviour by children that are being neglected or physically or emotionally abused. I find the current prevention efforts pathetic, and a glaring spotlight of this burden being placed on children”.
Suppose right now I ask those of you who are survivors of sexual abuse to stand up and then I ask those of you who knew a family member or friend who survived to stand up. And to ask those of who have offended at some point in your life to stand up. Can you feel how hard it would be to stand up? And yet that’s what they expect of a child. It’s therefore not a surprise that less than 10% of children who are sexually abused tell about their experience. Even if they told, frankly, it’s not going to be, generally speaking, the most considered or effective account. But 90% don’t tell for very good reasons, and therefore the help that they need is not provided. And then the non provision of the help that they need means they grow up through childhood and adolescence and into adulthood (entitled to it but not receiving it) with major unresolved problems from childhood. And it’s no surprise therefore that at Wolvercote 70%-80% of sex offenders, themselves, were sexually abused as children. This is not an excuse. I’m not bringing that to you as an excuse for what they go on to do, but they have unresolved issues that have affected them because of the secrecy that they have been left to live with and because of a host of other factors. They grew into adulthood, causing harm to others and, certainly, still suffering harm that was caused to them. We need a big response to that.
In the treatment programme at Wolvercote we provide that response. Alongside of, not instead of, a treatment programme for offenders that is about their behaviour, their actions, their responsibility, their thinking processes, their sexual fantasies, their lack of victim empathy, their relationships. Parallel to all that we ask them; “How were you as a child, and what was childhood like for you? What were the lessons you learned? How did this help you? How can we help you ?”
Within this context of the community at Wolvercote, 25 men, plus staff, in a therapeutic community where people are cared for, well grounded and valued and respected in this, and to help them to learn to grow towards responsibility and to take their place in society.
Before I go on can I just want to mention something that starts next week and I guess it would give grounds for hope, the ‘Stop It Now’ Campaign in America in Vermont and in Philadelphia, United States. It tells us as adults, that child sexual abuse is our problem. It shouldn’t be left to the children, but to individuals, now.
How can we do that? I was on the train this morning, on the tube, coming in and opposite me was a list of things telling me what insurance I could buy and one of them said
‘imagine the person opposite you was sitting there naked, if that doesn’t turn you on then how about our insurance offers?’
It didn’t turn me on, neither did the insurance company.
This is in Philadelphia right now (refers to OHP showing on ad on Philadelphia Public Transport):
“Mummy
told us to save our virginity for someone special. Daddy told us he was”
Is
your child sexually abused by someone you both love?
90%
of children who are sexually abused, are abused by someone they know.
Look
around you, talk about it. It may be closer to your home than you realise.
For more information call Salisbury 188. Prevent! Stop it Now!’ will help you uncover the truth.
Well, imagine this on London transport!
Another message for a Saturday morning on the tube (another OHP): These are the posters designed in Philadelphia and launched last October
“Sexual abusers are often the
child’s father, step parents grandparents, even brother or sister”. “If you suspect someone you know is
touching a child in a sexual way, call Salisbury 188 Prevent
’Stop it Now’. Because you can prevent child sexual
abuse.”
I guess that’s the message from me this morning, and that’s a message for you this morning. Because we can prevent child sexual abuse. But only if we can see it and talk about it. There are the posters in Philadelphia, there are public broadcasts about it on radio and TV that talk about child sexual abuse. I think we need to be aware of the society context which we’re talking about, or I’m talking about, sex offenders and child sexual abuse in particular, it’s a massive problem.
The problem affects a large percentage– in Wolvercote 70-80% of the offenders have been sexually abused. A large percentage of females have been sexually abused, typically not going on to abuse, but who probably will be acting in self destructive ways or ways that harm. But the world tends not to see that. We will tend to see sex offending as this, sex offenders as the predator. The sex offender as the distinctly odd looking individual, typically with bulging eyes (if you get the right photo), clearly obvious to spot in the street. Those are the people who do this kind of stuff. So it’s not dads and step-dads and social workers and neighbours, grandads and vicars, youth workers, it’s distinctive odd looking people that prey on children.
We do know from research that those children are sexually assaulted by people they know, sexually assaulted as children by those they care for or love. Those children are sexually assaulted by people who have responsibility for them. They are not sexually assaulted typically by a predator. But this predator is a person too and there is a danger, in the use of labels, that we can dehumanise people, and say this person doesn’t deserve anything. Ideally this person has a future, and that’s a challenge for all of us in society, for those who are working in the area of child sexual abuse, working with offenders, are saying “what place do we have in the life of this person?”. The challenge of Circles of Support and Accountability, which I’ll come to in a second, is about how can we support this person to be responsible and safe within the community. I talked about the process of assessment and I just want to fit Circles of Support and Accountability into that. Circles of Support and Accountability for me are about the end of the need for treatment and of moving on into the community. But while they are at Wolvercote they are in the Community at Wolvercote and, yes, in supported trips out. But basically, that’s not real life in the community. That’s a great restraint for them.
So I’ll talk briefly about personality disorder. Then I’ll let you listen to a man talking about his sense of life after Wolvercote. This is from a court report prepared for him by professionals:
“This risk assessment indicates a high level of future
risk of re-offending”.
It is difficult to assess people with a psychopathic disorder. For this man, the report recommends that there be a mutlidisciplinary assessment over a long period of time. So we are looking for a section 38 of the Mental Health Act for a 6 months assessment, the inter hospital order, and he will be sectionable under the category of psychopathic disorder. There are no alternative resources available for the safe containment and treatment of this man.
These are fairly powerful recommendations for a man who had been appearing in court for a series of sexual assaults against children within the family. During interviews, this man was non verbal, he was soiling himself and behaving in a strange way. It was difficult to be convinced that he was behaving in a way that felt like he was being cared for. We were responding to all the issues that brought him to us, me and my staff are not psychiatrists or psychologists or probation officers by training. We were protective and we got to chatting to him and he talked to us and we asked him if he’d like to come to Wolvercote. When he came we had to go to court. We had our own report alongside this report. We had to explain why we didn’t believe it to be necessary for him to be 6 months assessed in a secure unit nor in a local hospital and how Wolvercote would be effective and secure enough to treat this man’s problems. Let me play you a tape twelve months on. He is talking to my boss Hilary Eldridge (she comes down every 4 months to take stock, to catch up on residents – and he was about to leave). He had met her only twice in his life and she asked him what he’d learned at Wolvercote:
“ I’ve learned how to control myself, to cope in situations, respecting other people, thinking about other people’s feelings and how I affect them by my behaviour, self awareness. Questioning myself: how do I deal with situations? How to speak to people, how to be happy.
I mean because its hard to live in a place where you are unhappy really. How to be myself, how to hold conversations, how to be positive, how to control negative moods, how to deal with past things and put them into context. How it hurts people. How to solve problems, not to let things happen…saying how I feel. I never done that before until I came here, which is actually saying how I feel. That’s the reason, because I had to lie so much, that’s what led to offending, just so to say how I feel, what I want, what my needs are….”
So this man has been out of Wolvercote for just over 18 months now. We keep in touch. He’s found a life out there and he has been restored to some kind of community, family, who weren’t able to help him in the past…but they had contact with him while he was at Wolvercote and went through the process alongside him, to better understand his needs, where he is coming from. He has got a job and a place and he’s got a girlfriend. He’s getting on with life. I’m not going to say that’s all and that he won’t face further difficulties but I think that he has got much more hope in his life and I think that he’s learned how to care for himself. He has changed his sense of himself and that’s something that he is not going to lose, the people around him are going to see to that – just as he is able to reinforce good things about them too. That’s one person, who left successfully.
Last October, X was leaving Wolvercote. X was a different kettle of fish. He’d spent the last 20 years in and out of night shelters, abusing himself with drink and drugs, and on a relatively daily pattern, indecently exposing himself to adolescent and adult females, indecently assaulting some of them. He was in and out of prison. Any attempts by probation to support him, frankly, he dismissed readily, he just used to get out of his head. So 14 court appearances later, he’d say, everyday of his life, exposing himself, for the last 20 years and he’d talk about how many victims he’d had. He’d count them on his hands, so many victims, in his head. That was his life, his future. He’s not the kind of guy we take at Wolvercote. But he was a local man. We might not typically take him because we don’t want the local public to be at risk. But he came. He fouled up first time round and was sent back to prison. The local police asked could we take him back after prison? I told them no, but he had a ‘bracelet’ on him and came to us, courtesy of the Home Office. We could see when he was there and when he wasn’t there. His licence was for three months and he stayed. He stayed 12 months in all. He left last November. He asked if he could have a “Circle of Support” and we set one up at Guildford, where I live. We approached the local church with a challenge: here’s a man who wants community, who has a need for support and a need to become accountable on a daily basis. Four people came forward to say that they were prepared to have a go. We met together, as a group with X, once a week for an hour and a half. Typically we’d discuss work things, like visiting the job centre. The alternative remained what X had before, where there was no real future, with street people who he’d drink with and get into trouble with. He found a place in a hostel but one of the others recognised him and told the others what he’d done. He wasn’t trusted by the other people. They saw him as a predator. We don’t keep predators: they need a good kicking. They didn’t see the person X is, so he left. He sent me a text message saying “I’m off!” which was very distressing for the Circle and me. Three days later I got another text saying that he’d moved. The next step is to talk to the local police where he now lives. X wants that too and the police are happy to support and manage him. We’ll try to sort that one out.
It just so happens that another resident, Y, from Wolvercote has left, he’s got a job. Y is different again. He was sent to Feltham at seventeen for abducting a seventeen year old girl at gunpoint and assaulting and abusing her with intent to rape. Fortunately, he didn’t get that far. He came to us at Wolvercote and now, nine months on he’s got in touch, saying that he’s got nobody in his life, probation was there for the next three weeks and he was about to finish his licence. He’d be a registered sex offender. He’d got a job and said that he could do with some kind of support so the Circle of Support has been reactivated and they now meet up with Y every week to be a part of his life, to represent community and, hopefully, to help him develop his own, to welcome other people into his life. Y has done some dangerous things, he remains at risk but, by supporting him, I think that we can help him to manage that risk and help restore him to community and not be unnecessarily fearful about his being there.
So thanks. It’s a great scheme. Two people will be moving from Wolvercote in the next three months and we’ll be setting up Circles of Support for them. There are other possibilities in Scotland. The challenge is to churches and to you people, whether it is a role that you might wish to fulfil. We require people just to be alongside (not therapising), but sharing a life and sharing some degree of humanity, to have wise eyes, to help support these people with realism and to respect their humanity.
Thank you very much for your support.
Grendon Prison provides a therapeutic community environment
for dangerous, long sentenced offenders who are willing to work at the issues
of their behaviour and its roots within a living, learning setting of openness,
honesty and trust.
The idea behind the
therapeutic community is that all of us can be therapists and can be helped to
function better within a setting of community.
The main hope for men coming
to us is that they learn the implications of becoming responsible for their
actions and accept the challenge of remaining within socially acceptable
boundaries when they leave prison.
To those who haven’t heard about Grendon, it’s in Aylesbury, it’s a big location. The one thing I’d say about it is that you have to volunteer to go there. It’s not the kind of prison you get sent to against your will: you have to volunteer to go there. It’s hard, it’s strenuous, it’s a unit where you are made to face your responsibilities, especially about the crimes you have committed.
For me, Grendon has been a lifeline, it has given me a chance to experience and to feel the pain, not only what I have caused my own victims, but also the pain of my own abuse that I, too, suffered, from an early age. Throughout my life, from age six, I have endured some of the most horrific kinds of abuse: both emotional and sexual abuse at home, mental and physical abuse at school and been ritually and sexually abused by various men. I was taught that abuse itself was part everyday nature. Child pornography was a part of my life. It was their way of grooming my mind to accept what was happening to me as being real. Unfortunately, my parents were people who had their own lives to live, they had careers, they thought that the person looking after me could be trusted, but he couldn’t.
Grendon has helped me to understand who I am and also what I became: a person – not just a sex offender. I am one of the people that Donald spoke about who abuses against children: not because I wanted to, but it’s because it’s all I knew how to. That has been part of my life. I’ve had many adult relationships. Sadly, through no fault of my own, each one of them broke down. See, to me, if an adult didn’t give me sex, they didn’t want me.. Grendon helped me to understand that sex isn’t the end all and be all, it was what I was programmed with, from an early age. Grendon, for me, has been a lifeline, it has given me the strength, the support and the ability to talk about my past, the abuse experienced and the difficulties that I have faced throughout my life.
Excuse me, I have never done this before.
So what is Grendon? Grendon is a no holds barred place, you are held totally accountable for your actions, of what you say and of how you behave. Only recently, we’ve had somebody who has been voted out of Grendon and is now wanting to leave, because his behaviour was not acceptable. He was showing to the community that he was not willing to change. So the community said OK then, if you are not willing to change, there is no place here for you. Grendon is a therapeutic establishment where inmates, as I say, the inmates volunteer to go in there. Its your choice to come and its your choice to leave. But, to that choice, you still have to make yourself accountable. If you decide to leave, you have to explain to all 40 members of the community why you want to leave, what your reasons are and what you are running away from – because that’s what some people do do, they run away because the therapy is too hard.
At Grendon we have three small group sessions a week: Mondays, Wednesdays and Fridays. Each group: there’s five groups and each has eight people in it, plus three facilitators. There are two big meetings a week, that’s when the whole community of 40 people get together and discuss everything from business issues and social issues. And if anybody steps out of line on the wing they are held accountable, it doesn’t matter what they say or what they do, they have to explain to the community, their behaviour. This is not a punishment, but it is for them to explore the issues that are affecting them at that point and for them to explore any linking past elements in their individual past that are affecting them in this way. Both as a group and in other therapies, it is accompanied by other therapies as well, they are the sex offenders treatment programme (SOTP), art therapy, psychodrama, and shortly we’ll start the extended programme. All these programmes have their own way of approaching therapy, they have their own goals in helping the inmate to rehabilitate themselves against the crimes they have committed and their past as well. But it is equally important to say that all these programmes, they all complement each other and help each other, because what they don’t learn from one they will learn from the other.
Grendon has helped me to identify my faults, how I offended in the way that I did and how I justified my behaviour. Looking at these issues has helped me develop self awareness and by looking at my past and its effects I have been able to develop victim empathy and awareness, taking full responsibility for my actions and the torment that I have caused my victims. This in turn has helped me to change the beliefs and values with which I have been programmed from an early age. Programmed, deceived, whatever you call it. Its hard to look back and see that your whole life has been one lie. To see just what victims I’ve hurt. Its my own family, my own relatives, and when you look at it, the endless victims carry on from generation to generation. Grendon has helped me to recognise how my feelings and my emotions affect the way I behave and Grendon has helped me to develop new coping strategies where I don’t fall back in to my old ways, behaviours, attitudes, thoughts and feelings.
Grendon also has a system where every six months you are assessed. Your group does an assessment on you, each member of the group writes a report of how they see you and the therapy you are doing. Also the key elements of the staff at Grendon, the probation, your personal officer, the wing therapist and other committed staff who are there to help you, all write reports. These reports also set objectives for you to look at. It could be looking at your anger, it could be looking at your fantasies, it could be anything for you to deal with in the groups that you attend. Also, this gives you the chance to talk about what’s going on for you at the time, how you are feeling, what’s getting you down or any other issues that might be important. In being able to understand why I offended, I am now able to identify my risk factors, what could trigger them in the future and how I can avoid making the same mistakes which led me to offend.
Donald mentioned that many children don’t speak about their abuse. I’ll give you some insight into why. People go through many feelings when they are being abused. The abuser deliberately sets out to make their feelings one of pleasure, one of secrecy and one of comfort. The abuser deliberately sets out to make the child feel that they are the only person that can be depended upon. My parents were never around, but my abuser was. He gave me the love, the comfort, the feeling wanted that I wanted from my parents but didn’t get. Grendon has helped me to recognise that all that was fake, it wasn’t real, it was a grooming process to enable me to feel comfortable with what he was doing to me. Sadly, I went through the same things with my victims, I programmed them in the same way that I was, too, programmed. In being able to recognise this, it has caused me a great deal of anguish and pain, because, when I look back now – it’s now twenty odd years since when the abuse on me now started, and I think, well if my abuse is affecting me now, twenty years later, then, no doubt, in twenty years time my victims will be going through the same thing. It’s not a nice thought for me because I can recognise the horrific torment I put them and their family through. But what Grendon is doing is helping me to understand that, it’s helping me to work out a way where I don’t fall back into this life of crime that is so devastating.
I chose to go to Grendon because I have had enough of the way I was feeling. The pain I was experiencing wasn’t being met at all by the SOTP (Sex Offenders Treatment Programme) in Wandsworth, it wasn’t being met by the relation skills I was doing in other prisons. They only concentrate on certain areas. In Grendon they pulled together all the areas of expertise available. They help you to look at who you are and what you are and why you’ve become that person. Yes, I’m a sex offender, I’m also a person who has been classed as having a personality disorder. I’ve heard today that a lot of people think that a personality disorder is untreatable. That is wrong. For me, Grendon proves that. I have been given the chance to look at my personality disorder, to look at my fears, to look at my anxieties, to look at my compulsive disorders, to look at why I’m afraid to be with people. Six months ago I wouldn’t have dreamed of doing this – it’s only because of people like Jenny there in the front row, and Mark, one of my prison officers, who have given up their time to help me to understand myself and the crimes I have committed.
All that I am asking of this Conference today is, that out there are many, many people who have been abused, who have grown up into adults who do not know how to cope. Some of them have gone out, themselves, to abuse and have ended up in prison like I have. This personality disorder business is one that really needs looking at very, very much. As far as someone being untreatable, that is completely wrong. Grendon does give the person the option to change, if they want to change. It’s up to that person. I chose to change. I chose to talk about things that I have never, never, in my whole life, discussed with anybody. Not even my own parents. But because of the way Grendon was set up, because of the way they gently coach you to look at your life and help you to make the links with the crimes you, yourself have committed. I know, myself, that I am on my way to recovery. It’s long, I still have a lot of problems, my fears are still great. I am now five years into a twelve year sentence and in three years time I could be released. I have a lot of fears because, with the papers producing so much hatred towards people like myself, I may not have a chance. Fortunately, there have been people who have been released from Grendon and who have got jobs, who have got stable home lives and I just hope that I will be given that chance.
I thank the Conference for giving me the opportunity to talk about Grendon and what Grendon is about because that is very important. Grendon is the only one of its kind, at the moment, in this country. We need people to support Grendon, both financially and through commitment to sustain the working environment because, without Grendon, there will be no prison location that will be able to treat people as they should, effectively, as they should be treated and I thank you for listening.
The
account of this emancipatory research study begins with a description of why
service users came to carry it out. It represents a journey of the ‘uninformed’
and tells of the discovery while analysing the historical psychiatric origins
of this diagnosis and the psychological theories regarding its causes and
treatment.
Service users
tell of how they
worked, and struggled to carry out this study. Descriptions of the efforts of
the research group, the perils of gaining ethical permission, and the battle against
current illness, are recounted.
Findings
question the validity of the diagnosis and the sub-categories within it. Their
construct about the disorder incorporates precipitants, contexts,
symptomatology, coping strategies, insight into the effectiveness of
interventions and treatments, and outlines a link between the two most commonly
diagnosed categories of the disorder, which has implications for treatment.
This study
questions how psychiatry has come to learn about personality. What is its paradigm?
Findings show that, for a significant
percentage, life events regarding early trauma offer a theory regarding the origins of the disorder. The label of personality disorder is very
stigmatising, and can compound the effects of trauma.
Fundamentally,
it fails to capture the experience of the sufferer. Have we arrived at
containment and control, rather than understanding and effective caring,
interventions? It is hoped that this research is beginning to help bring the
focus back from surface manifestations to living human beings, their
contextualised personal histories, experiences and interpretations.
PERSONALITY DISORDER TEMPERAMENT OR TRAUMA?
A Co-operative Inquiry, by Service Users, into the Nature and Treatment of Personality Disorder. Heather Castillo
‘Personality Disorders are
characterised by behaviour patterns that are not socially acceptable and
emotions that are uncontrolled and strong’.
(Linehan, Oldman and Silk, 1995:75)
‘People with personality disorder
fall on a continuum from near normal behaviour to extreme disruption in
personal and social functioning. The overwhelming majority do not pose any risk
to the public.’
(DoH 1999a:5)
A Historical Perspective
Almost two hundred years ago in, 1801, the French psychiatrist, Pinel, spoke of ‘manie sans delire’, mania without delirium. Pinel defined what might now be called Dissocial Personality Disorder, and believed it was characterised by unexplained outbursts of rage and violence, in the absence of impaired intellectual function or delusion. At that time delusions were regarded a the central factor of mental illness and Gelder, Gath and Mayou (1989) presume that this group also included those mentally ill patients who were not deluded, for example, those suffering from mania or mood disorder.
In 1835(:126) a doctor at Bristol Infirmary, Pritchard, formulated a new term called Moral Insanity. Defined as ‘A morbid perversion of the natural feelings, affections, inclination, temper, habits, moral dispositions and natural impulses’. Pritchard considered that instances of moral insanity also included the melancholy and unnaturally excited. The new classification again appeared to refer to both Personality Disorder and mood disorder.
Further classifications were suggested throughout the Nineteenth Century, including, Monel’s Degenerative Deviation in 1857, followed by Moral Imbecility, Congenital Delinquency, Constitutional Inferiority and Moral Defeciency. Later in the century a recognition of mental illness without delusion occurred and distinctions were drawn between schizophrenia and affective or mood disorders. The concept of moral insanity was consequently modified. In 1872 Lambroso spoke of the ‘unborn criminal’ and in 1885(:127), Henry Maudsley described one patient as having ‘No capacity for true moral feeling.’ Maudsley also commented that the term moral insanity was ‘A form of mental alienation which has so much the look of vice or crime that many people regard it as an unfounded medical intervention’ However, the concept was here to stay and remained a forerunner to Koch and Kraepelin’s investigations into ‘Psychopathic states’. By 1891, the German doctor, Koch, introduced the term Psychopathic Inferiority. Kraepelin (1905) was to replace ‘inferiority’ with ‘personality’. He defined Psychopathic Personality as falling into seven types:- excitable, unstable, eccentric, liars, swindlers, anti-social and quarrelsome.
The existing Lunacy Act, at the turn of the Century, did not certify ‘socially dangerous’ people because ‘Insanity is necessarily a disorder of the intelligence, that it means delusion or it means intellectual disorder, or intellectual defect’. Therefore, the 1904 Royal Commission on the Care and Control of the Feeble Minded proposed that the ‘moral imbecile’ should become an additional category of patient to whom care and control should be extended. This category was defined as ‘Persons who from an early age display some mental defect, coupled with strong vicious or criminal propensities on which punishment has little or no different effect’. The Moral defective then became a category incorporated into the Mental Deficiency Act 1913.
Schneider, another German psychiatrist, was to extend the classification of Psychopathy, in 1923, to include ten sub-classifications incorporating not only those who caused suffering to others but also causing suffering to themselves and not necessarily others. He included among them markedly depressive and insecure characters. If there already existed confusion concerning the barriers between behaviour, mood and illness, Schneider’s theory was to now introduce two clearly different meanings for the term. It included not only Dissocial Personality Disorder but a much wider meaning regarding personality abnormalities of all types. (Gelder, Gath and Mayou 1989).
In 1941, Cleckley coined the phrase ‘The Mask of Sanity’ and confusion regarding nomenclature continued with Sir David Henderson’s book ‘Psychopathic States’ (1939:128) Henderson began by defining Psychopaths as people who, ‘Throughout their lives, or from a comparatively early age, have exhibited disorders of conduct of an anti-social or asocial nature, usually of a recurrent or episodic type which in many instances have proved difficult to influence by methods of social, penal or medical care or for who we have no adequate provision of a preventative or curative nature’. However, Henderson went on to broaden his definition to include three groups of Psychopaths: aggressive; inadequate and creative. Examples of the latter, suggested by Henderson were Joan of Arc and T.E.Lawrence. His classifications also included those prone to suicide, drug and alcohol abuse, pathological lying, hypochondria, instability and sensitivity.
Shorter (1997) examined the fact that World War II presented psychiatric challenges which were different from insanity, but that only terms such as Psychopathic Personality were available for understanding them. He suggests that this demand for new systems in classification multiplied psychiatric nosologies, which became included in DSM 1 (1952), thus lowering the threshold and increasing the patient base.
Borderline Personality Disorder was a concept devised around the 1950’s to describe patients who were considered to be on the borderline between neurosis and psychosis. Many clinicians disputed this borderline and the concept evolved into Personality Disorder. It is defined in DSM IV (1994:459), the American Diagnostic and Statistical Manual of Mental Disorders as follows: ‘These impulsive people make recurrent suicide threats or attempts. Affectively unstable, they often show intense inappropriate anger. They feel empty and bored and they frantically try to avoid abandonment. They feel uncertain about who they are and lack the ability to maintain interpersonal relationships’. ICD 10 (1992:205), the British Classification of Mental and Behavioural Disorders defines Emotionally Unstable Borderline Type as ‘Disturbed self image, aims and preferences. Chronic emptiness, intense unstable relationships and self-destructive behaviour’.
By the 1950’s it was considered that the 1913 Mental Deficiency Act legislated for an insufficiently homogeneous group. Concern was expressed about how to deal with ‘moral defectives of higher intelligence’ (Percy 1957). This saw the first legal definition of Psychopathy within legislation, in the 1959 Mental Health Act. It is this definition which is largely retained in the current Act. Anti-social or Dissocial Personality Disorder is a clinical diagnosis used interchangeably with Psychopathic Disorder which is defined in The Mental Health Act 1983 as ‘A persistent disorder or disability of the mind (whether or not including significant impairment of intelligence) which result in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned’. Response to treatment is required before an individual can be detained under the Act. Many problems have arisen regarding this fact. Finding an instrument in law which gives reasoned consideration to the question of treatability is difficult (Clift 1999). In Scotland this has been very widely interpreted in recent case law where the definition of treatability was defined as an alleviation of the deterioration of symptoms, rather than treating the disorder itself (Reid v Secretary of State 1999). A major concern within government remains one of public safety and containment. This is reflected in the Home Office Consultation Document (1999a:5) and its proposal to detain people in this category without limit of time. ‘Some have a criminal history but are not convicted of any current offence. Most are not admitted to hospital because they are assessed as unlikely to benefit from the sorts of treatments that are available’. Here merges the newest sub-categorisation of Personality Disorder. Appearing initially as an imprecise but ‘useful clinical term called Severe Personality Disorder (Kernberg 1984)(Tyrer 1988)(Norton & Smith 1994), it is now described in government documents as Dangerous Severe Personality Disorder.
Therefore, the modern concept of Personality Disorder is represented by two connected notions. Either that the personality abnormality causes problems to self or/and others. Or that behaviour is so anti-social as to be dangerous to society. The concern of the medical profession is a history of definition and classification and, theoretically, ten subclassifications of Personality Disorder exist today. They are defined in ICD 10 and a definition table of these classifications, together with their transatlantic comparisons from DSM IV, are included in this study as Appendix I.
Gelder, Gath and Mayou (1989:129) ask us to consider that ‘Human beings resist precise measurement and, unlike the phenomena of disease, abnormal individuals cannot be classified neatly into the manner of clinical diagnosis’. Dr. David Fainman of the Henderson Hospital suggests that ‘Behind the label of Personality Disorder there is a personality, behind which is a person. We have struggled with what these labels mean for years. All of us have personalities and ten percent of us in the general population are considered to have a Personality Disorder’ (Tyrer and Stein 1993 ).
The classification of Personality Disorder continues to generate a kind of moral panic in society, although its clinical definitions range from the most timid to the most dangerous among us. The diagnosis is characterised by confusion and lack of agreement. Where understanding is required, fear has emerged.
The
Disliked Patient
‘The refractory nature of personality problems creates immense service load and nihilistic responses.’ Dolan, Evans and Wilson (1992:745)
In his analysis of secure provision Larry Gostin recognised the tendency for people diagnosed with Personality Disorder to be excluded from services or to receive inappropriate care in Special Hospitals, or prison (1985). Bell and McCann (1996:206) indicate attitudes still prevail that those diagnosed with Personality Disorder ‘Need to try harder because their behaviour is under control’ or ‘are not to be trusted and may attempt to kill themselves with medication’ and ‘have enduring patterns which may even worsen in therapy’. Groves describes the challenge of trying to treat ‘hateful patients’ ‘independent clingers; ‘entitled dreamers, ‘manipulative help rejecters’ and ‘self-destructive deniers’ (Oldman 1994:1774). Lewis and Appleby (1988:44) report that untreatability is a widely held belief. In their study ‘The Patients Psychiatrists Dislike’ a random sample of 240 psychiatrists were assigned one of six case histories. Patients who had a previous history of Personality Disorder were seen as difficult, annoying, manipulative, attention seeking, in control of their suicidal urges and less deserving of care. This caused Lewis and Appleby to conclude that ‘Personality Disorder appears to be an enduring pejorative judgement, rather than a clinical diagnosis’.
Dunn and Parry (1997:19) describe Borderline patients who repeatedly cut themselves, try to hang themselves or overdose. ‘The staff are often stressed and de-skilled, the psychiatrist is frustrated and irritated, and other clients are both traumatised and neglected as a result of obvious management problems which affect the units’. They were struck by ‘The number of clients who generated a lot of chaos and stress in the mental health service: the person who keeps their appointments erratically in spite of repeatedly asking for crisis responses; the young woman who repeatedly presents at A & E with deliberate self-harm or suicide attempts’. These sorts of behaviours were characterised as
‘Arousing negative feelings’ .... .......... ‘This is not mental illness, it is attention seeking, or acting out, or behavioural, or badness’... ... ... ... ‘Often the psychiatrist feels torn between those who think this client should be in hospital and those staff who know that they do not have a coherent plan for treatment’. A secure setting, with a regime bounded by the Mental Health Act and Home Office Orders, may activate all an individual’s despair and rage regarding authority. This can result in rebellion, self-harm, absconsions, and threatened or actual violence against patients and staff. Add substance misuse to any of the above situations and a truly compounded problem may result.
Bob Hinshelwood (1998:187), Professor of Psychoanalysis at Essex University, hypothesises that difficult patients create reactions in those who try to care for and treat them. He suggests this results in an emotional retreat on the part of staff into what he calls the ‘scientific attitude’. This retreat causes ‘scientific justification’ which can blind staff to some aspects of the subjective experience of the patient. ‘That blind-spot crucially feeds back directly into the patients’ difficulties’. Hinshelwood believes this professional defence causes staff to lose sight of rich information, about the complexity of relating, which is right there in front of them.
Hinshelwood describes Freud’s ‘difficult feelings’ in relation to a patient suffering from paranoid schizophrenia. Here was ‘a man for whom meaning itself has gone’ suggesting a quality ‘so distant from myself and from all that is human’. In this situation ‘meaning’ may disappear for both parties, and with it the humanitarian and subjective interest of the professional. Families in this situation may feel they must remove the family member with psychosis from a ‘human’ to a ‘treatment’ setting and the person may be seen as a troublesome object that only professionals can restore (Laing and Esterson 1964).
Hinshelwood’s thesis is that those with severe Personality Disorder pose an opposite situation. Rather than the distancing effect of incomprehensible meaning, they offer ‘a relationship too intensely suffused with human feelings - usually very unpleasant ones. These patients operate predominantly in a world of feelings’ and they ‘directly and deliberately, although unconsciously, interfere with our feelings. We feel intruded upon and manipulated - and indeed, we feel’.
Experienced as a kind of abuse of time, help and care, the professional may fail and is in danger of being overwhelmed. Rather than the depersonalisation of the schizophrenic into an object, someone with a Personality Disorder diagnosis may find the condemnatory label extended to ‘bad’ not ‘mad’, and the perception of them becomes a compounding of strong moral judgement. Professional debates regarding Personality Disorder have extended beyond the clinical arena. The role of the media in shaping opinion inflamed the public response to events in the early nineties, surrounding psychiatric patients such as Ben Silcot and Ytopher Clunis. The latter part of the decade has seen a shift of media focus, and public fears, to such cases as Robin Lane, Tony Gamble and Michael Stone (Gillan & Campbell 1998). Brutal murder and Personality Disorder are now featured synonymously in the press. A Conference was recently held in London called ‘Severe Personality Disorder, Who is Responsible?’ (Gateway 1999). The programme included eminent speakers from the Home Office, psychiatric, secure and prison services, the legal and civil rights field. The last entry on the programme for the day read ‘The Views of People Using the Services’. Two service users outlined their views. Neither had a diagnosis of Personality Disorder. The Home Office has subsequently proposed a discriminatory regime which, rather than providing a criminal justice response on grounds of public safety, singles out one particular category of psychiatric diagnosis for preventative detention (Pedler 1999).
A hundred years ago schizophrenia was not considered treatable and was often categorised together with some of the most degenerative of physical conditions, such as severe syphilis. The Aids epidemic has moved beyond vilification. Advances in knowledge not only improve the treatment of human conditions, they can also change the emotional response to them.
Personality Development
‘My mother loves me.
I feel good
I feel good because she loves me.
I am good because I feel good.
I feel good because I am good.
My mother loves me because I am good.
My mother does not love me.
I feel bad
I feel bad because she does not love me.
I am bad because I feel bad
I feel bad because I am bad
I am bad because she does not love me.
She does not love me because I am bad
R.D. Laing (1971:9)
The Freudian concept of personality development acknowledges the role of the unconscious and presumes that early experience is the cause of later emotion and behaviour. Melanie Klein (1946) suggested that the mother’s breast was a primal object in early external relations. An object which could manifest not only nurture, love, life and safety for the infant, but also greed, hate and persecutory feelings if withdrawn. Klein’s premise, that object relations exist from early life, the mother’s breast being the first object which for the child becomes split into good (gratifying) and bad (frustrating), proposes that this splitting results in a severance of love and hate. An interplay occurs between introjection and projection and, to escape persecutory feelings and depressive pain, an individual may blame or idealise, demonise or fantasise about external ‘objects’, people, things or situations.
During the 1030’s and 40’s, studies occurred, in both the US and the UK, which began to highlight the impact of early childhood experiences on personality development. These experiences included prolonged institutional care, war, homelessness and loss or frequent change of the mother figure during early life (Bender and Yarnell 1941) (Burlingham and Freud [Anna] 1942) (Hargreaves 1949). In 1950, English Psychoanalyst, John Bowlby began to develop his Attachment Theory. The studies of the previous decade left him in no doubt that inadequate maternal care in childhood and separation of children from those they know and love, had an adverse effect on personality development. But Bowlby began to question what features of experience are responsible for distress. If the child forms ties to the mother primarily because it is the mother who feeds the child, the personal relationship, or ‘dependency’, of child on mother might be viewed as secondary. Bowlby challenged this theory. He considered that the Kleinian emphasis on food and orality did not match his experience of children. Instead of starting with the adult, expressing thoughts and feelings years later, and attempting to trace origins retrospectively, Bowlby began by observing children who had experienced early trauma and attempted to build a theory of personality development from this information.
An individual tries to maintain proximity to another clearly identified person who is perceived as being able to cope better with the world and is expected to give care, comfort and security. This encourages us to value and continue relationships. Bowlby recognised that this attachment behaviour is emphasised in childhood but also continues throughout life. A child or adult who has attachment to someone is strongly disposed to stay near and seek contact with that individual, especially in times of threat and emergency. He expanded the theory of separation anxiety by pointing out that both psychoanalysts and psychiatrists had made an unexamined assumption that fear is aroused in mentally healthy individuals only by obviously dangerous or painful situations. He observed that increased risk also carries a signal, for example, threats to abandon a child as a means of control, or parental threat of suicide. He suggested that this might also result in increased arousal, not just in terms of fear, but also intense anger, especially in older children or adolescents (Bowlby 1988).
Verrier (1993) proposes that attachment theory and separation anxiety have huge significance in terms of the biological mother and suggests we neglect the fact that the unborn child has already accumulated experience and achieved bonding during the forty weeks prior to birth. She sees this as a continuum of physiological, psychological and spiritual events which, for those children who are adopted, can result in a loss which is indelibly imprinted on the unconscious mind as a ‘primal wound’. Bowlby also challenged traditional psychoanalytic theory in terms of the model of developmental stages a child is expected to pass through. Rather, he proposed that the child has an array of potential pathways for personality development, some mentally healthy, some not. Bowlby considered that these pathways might be determined by the environment the child meets along the way.
The dialectical theory of self-development assumes that a sense of self develops through the perception of oneself in another person’s mind. An infant builds up a viable sense of self from the repeated internalisation of the mother’s processed image of the child’s thoughts and feelings. This provides containment. Not only does the mother, or close caregiver, interpret the baby’s physical expressions, she also gives back to the child a manageable interpretation of what is being communicated. Peter Fonagy (1997), Freud Memorial Professor of the Anna Freud Centre in London, suggests that an absence, or distortion, of this early mirroring experience can lead to a desperate search on the part of the child to find alternative ways of containing psychological experience. This may develop into destructive physical expression, either towards self or others. A child who has not received recognised, but modified, images of behaviour and emotional states may have trouble in differentiating reality from fantasy, and physical from psychic reality. This suggests a tendency, in later life, to cope with thoughts and feelings through physical action. DO IT EITHER TO MY BODY OR THEIR BODY. Not being able to feel oneself from within, that individual is forced to find a sense of self from outside by treating themselves as an object, or by getting others to react to them. This results in experience of self in a more authentic, if very limited, way and the need for re-enactment to augment the incomplete representation of self which has been achieved.
At puberty this factor may become critical because the body changes in shape and function in a way which signifies a far greater change in identity for those whose sense of self has been impaired. This has relevance for the development of existential anxieties and anorexia in adolescents, where the body shape may literally be felt to represent aspects of the personality. A feeling of well-being and relative integrity can sometimes be achieved by cutting or self-starvation. Fonagy suggests this is because the mind is left feeling more contained or bounded, and belonging more to the self, as the body is sacrificed.
In his paper on Transgenerational Transmission of Holocaust Trauma (1999) Fonagy outlines an attachment-theory based model of transgenerational trauma where the transmission of specific trauma ideas is shown to cross generations. Holocaust trauma may undermine parenting capacity in a survivor who may suffer depression and poor control of emotions, guilt and aggression. This can impact on the infant-parent relationship when the frightened or frightening care-giver cannot adequately mourn the ‘murdered objects’ of past experience. The objects are then re-created in the mind of the second generation survivor at the cost of extinguishing an authentic sense of self. This telescoping of holocaust trauma through generations has caused Fonagy to conclude that much more needs to be learned about second generation victims of unresolved trauma. Main, Kaplan and Cassidy (1985) also ask us to consider that an infant’s behaviour may trigger flashbacks in a parent who has suffered from trauma.
Tenable psychodynamic theories exist, yet there appears to be little interchange between those who try to conceptualise personality development and clinicians who aim to understand and treat Personality Disorder. Even less interest has been manifest regarding what service users may have to say about themselves, beyond sensationalist writing such as ‘Sybil’ (Schreiber 1973).
‘The
Black Hole of Trauma’
‘I have been told I was a
perfect baby and a very bubbly child ........From 7 or 8 years old I suddenly
changed ........ I was always alone ........ I did not go to school I was disruptive....
...I began to have fits and blackouts and memory loss. No one could understand
why my personality had changed so suddenly ........no one but myself and my
older brother’.
Case Study - Ainscough and Toon (1996:19)
In his
practice manual for treating Post Traumatic Stress Disorder Meinchenbaum (1994)
discovered that seventy percent of those diagnosed with Borderline Personality
Disorder are survivors of childhood sexual abuse. Joseph et al (1997) observes
that there is accumulating evidence for an additional form of more Complex
Post Traumatic Stress Disorder. Felicity de Zueleta (1999:238), examining the disorder
from an attachment perspective, is claiming to be attempting ‘to
provide mental health care workers with a way of making sense of some of the
individual’s terrifying, soul destroying experiences and their destructive,
even though often defensive behaviours’.
Zueleta suggests a reframing of the category into Complex
Attachment Disorder.
Herman
(1992:24) also reviewed evidence for this and concluded that ‘Unsystemised
but extensive empirical support exists for the concept of a post-traumatic
syndrome in survivors of prolonged, repeated victimisation’. Herman (1992:123) considered that this may
sometimes co-exist with Post Traumatic Stress Disorder but, whether it did or
not, it extended beyond it. ‘The syndrome is characterised by
enduring personality change and high risk for
repeated harm, either self-inflicted, or at the hands of others’. Herman also
observed that ‘Traumatised people are frequently misdiagnosed and
mistreated in the mental health system. Because of the number and complexity of
their symptoms, their treatment is often fragmented and incomplete. Because of
their characteristic difficulties with close relationships, they are vulnerable
to become re-victimised by caregivers. They may become engaged in ongoing,
destructive interactions, in which the medical system replicates the behaviour
of the abusive family’.
Dunn and Parry (1997) also recognise that those with this diagnosis tend to relate to mental health services as they would to parents, enacting early abusive developmental roles. This has caused mental health services in Hull and Holderness to adopt a formulation which attempts to listen to the client’s earlier abusive experiences within the system and aims to achieve collective ownership of the problem before treatment options are discussed. An innovative formulation has also been created by one therapist in Colchester which aims, as a primary action, to focus on the diagnosis in terms of damaged personality, thereby shifting attention to what happened to that person in earlier life, rather than compounding the guilt and suffering of feeling inherently bad (Acland 1999). Such interventions, where they have arisen, seem to have been grasped intuitively by experienced front-line workers, in a hectic climate where sufficient training and knowledge do not exist. Such formulations are not always consistent with the wider service area.
The
acknowledgement of the profound effects of trauma were set in motion during the
First World War when men experienced shellshock. Many common soldiers were shot
for desertion, but when officers of proven character began to be afflicted this
provoked a crisis in Victorian psychiatric theory (Stone 1985). Psychiatry
rediscovered the impact of trauma in the early 70’s and the diagnosis of Post
Traumatic Stress Disorder was included in DSM III. Today DSM IV includes,
within the criteria for possible diagnosis, combat victims, survivors of
disaster, rape, kidnap or hostage victims, and children who have been
victims of sexual and other abuse. ICD 10 includes survivors of combat,
disaster, accident, torture victims, terrorism, rape and witnessing violent
death. Abuse in childhood is not
included within the possible criteria.
In 1994 the American Psychiatric Association, aware of research into Post Traumatic Stress Disorder, included an additional category in DSM IV, under Table 9.2 for Disorders of Extreme Stress Not Otherwise Specified, ‘DESNOS’. This acknowledged that trauma affected a whole range of core psychological functions, including arousal, consciousness, somatisation, character changes, and meaning. In ICD 10 this is included as F.62 (P. 208–210) - ‘Enduring Personality Change, not Attributable to Brain Damage and Disease’. Emphasising personality change after severe psychiatric illness, it also encompasses catastrophic experience. Examples include concentration camp experiences, torture, disasters and prolonged exposure to life-threatening circumstances e.g. hostage situations - prolonged captivity with an immanent possibility of being killed. Again, childhood trauma is not explicitly stated.
Nemiah (1995:4) in his study of early trauma, considers ‘since psychiatry has started to organise psychological problems in a diagnostic system that is based purely on their surface manifestations, it has, as a profession, increasingly lost interest in the workings of the mind and the mystery of medicine’. The inclusion of post-traumatic stress as a category of psychiatric disorder is judged by the American psychiatrist, Bessel Van der Kolk (1996), to open the way to scientific investigation into the nature of human suffering. He believes that this begins to correct the emphasis on disorders as ‘things’ and focuses attention within the context of personal histories and environments and brings us back to living people, their experiences and the meaning they give to those experiences.
Herman and Van der Kolk (1987), in their work with incest victims and Vietnam Veterans, discovered that trauma, especially prolonged trauma from caregivers, had a profound effect on personality development and the development of Borderline Personality Disorder. They concur with Fonagy (1997) that behaviour manifestations of self-mutilisation, re-victimisation, victimising others, dissociative disorders, substance abuse and eating disorders, are an effort to try to regain internal equilibrium. Van der Kolk (1996:3) has characterised this subject as ‘the back hole of trauma’ and has described post traumatic stress as a failure of time to heal all wounds. For some, there is an inability to integrate the traumatic experience. He points out that there is a very complex interrelationship between traumas, neglect, environmental chaos and attachment patterns, and that clinicians fail to pay attention to the effects of early trauma, or to perceive the patterns of reliving, warding-off reminders, or repetitive re-exposure to situations reminiscent of trauma.
Kingsley Norton and Bridget Dolan (1995:319) examine ‘acting-out’ and the institutional response in terms of an unconscious emotional conflict which causes a sense of impulse and immediacy. This impulse, often performed as a scenario of great fidelity, involves a rehearsed and carefully scripted, but unconscious, activity and is performed in an effort to replace, with action, the inability to recall trauma. ‘A typical example is the Personality Disordered inpatient who self-mutilates rather than seeking support and speaking about distress’. Eliciting strong emotional reactions from those around, this fixed behaviour may result in expressions which are professionally questionable and a therapeutic stalemate. Norton and Dolan consider custodial psychiatric institutions, involving a limited repertoire of surveillance, sedation and seclusion, provide the kind of immediate response from the environment that an ‘acting-out’ patient is requiring. Restoration of control may reassure staff and provide short-term relief from pain and insecurity for the patient, but does not explore motive and consequences or help someone to achieve psychological maturity by remembering the emotional conflict. Van der Kolk (1996:204) suggests that clinicians often become rescuers, victims or victimisers because ‘these are patients who are force-fed, thrown into seclusion, medicated against their will, and/or transferred without warning’. Sometimes they are simply discharged with optimistic careplans which are a paper-exercise masking a truer therapeutic pessimism.
Van der Kolk (1996) has also measured the physiological effects of trauma by examining responses to specific stimuli. He discovered significant increases in heart-rate, skin conductance and blood flow, increased hormone release, decreased serotonin activity, and increased opiate release often associated with dissociative states. He suggested that problems with arousal and stimulus response may account for the high incidence of the diagnosis of attention deficit hyperactivity disorder in traumatised children. His discoveries also have implications for research claims in relation to symptomatic improvements for pharmacological treatments of Personality Disorders including low-dose neuroleptics for perceptual distortions, tricyclic and serotonin uptake anti-depressants for depressive symptomatology, mood stabilisers for impulse control, and benzodiazepines for anxiety (Oldman 1994).
Simply uncovering memories of trauma is considered by Van der Kolk to have little therapeutic benefit. These memories need to be reconstructed in a way that is meaningful to the person. He also advocates helping that person to become attached to other experiences of feeling safe, understood, strong and capable. Being able to empathise with and help fellow sufferers was cited as potentially healing. A sense of safety from therapeutic massage was also found to help many women whose bodies had been violated. One illustrative example described a lady suffering from nightmares and all treatments, including pharmacological, proving ineffective, until she moved to a house which reminded her of the apartment of her loving aunt from childhood. She felt safe.
Implications
for Treatment
‘When
the issue of causation becomes a legitimate area of investigation, one is
inevitably confronted with issues of man’s inhumanity to man, with carelessness
and callousness, with abrogation of responsibility, with manipulation, and with
failures to protect. In short, the study of trauma confronts one with the best
and worst in human nature, and is bound to provoke intense personal reactions
in the people involved’.
Bessel van der Kolk (1996:6)
In the early 80’s a presenter at a Conference about cognitive behavioural approaches did not explicitly state the topic of his paper within the title because he feared being criticised as too radical or even heretical, because ‘Personality Disorder was not a legitimate topic for behavioural research’ (Pretzer 1994:257). Studies carried out during the 80’s about the effects of Personality Disorder on the cognitive treatment of other disorders, such as severe bulimia and social phobia, produced discouraging results (Giles 1985), (Turner 1987). Roth and Fonagy (1997) note that most clinical trials for major depressive disorders have tended to exclude those with Personality Disorder. Those who have included such patients suggest poorer outcomes when there is a diagnosis of Personality Disorder.
However, in the late 50’s an uncontrolled study was carried out where forty two patients were treated with psychodynamic psychotherapy. Predating the development of current diagnostic categories, clinical descriptions suggest the majority met the criteria for Borderline Personality Disorder. The approach was a blend of psychoanalysis, expressive and supportive psychotherapy. Adopting a practical approach, analysis was rarely carried out in a pure form and included a significant degree of ego-building. Follow-up data available for twenty seven of the sample showed a good long-term result for eleven and partial resolution for seven. The higher the ego-strength the better the quality of interpersonal relationship and the more positive the outcome. Low ego-strength was augmented with hospitalisation where necessary (Roth and Fonagy 1997).
Pretzer (1994) outlines a number of inconclusive and contradictory studies, in the use of cognitive behavioural therapy, which have included Personality Disordered patients. Some showed that those who persisted through a full course of treatment responded well. Those studies which produced encouraging results tended to use a more flexible approach, tailored to the needs and characteristics of the individual.
During the 90’s Anthony Ryle (1997) began to pioneer the development of Cognitive Analytic Therapy for Borderline Personality Disorder. This is an integrative approach using cognitive behaviour and psychodynamic therapy. Here the therapist also acts as a teacher or an enabler. Ryle recognised the value of the psychoanalytic concepts of transference and _ countertransference, not just as a way of identifying shifting patterns encountered in treatment but, as a method of recognition and classification which could be used as a treatment tool. Ryle considered the diagnosis to be an ‘unsatisfactory’ one but felt it was currently ‘irreplaceable’. He has attempted to go some way to address the discontinuity and variability of DSM IV and ICD 10 diagnoses by developing a model which overcomes some of these defects and tries to measure the degree of integration of the self. This gives the client the beginnings of a self-reflective way of integrating unavailable dissociative parts of the self.
The internalisation of depriving and abusive caregivers results in a narrow or distorted range of what Ryle calls reciprocal roles. Pairs of reciprocal roles involve variations on the ‘parent derived role’ - the way we experience parenting and may later parent ourselves, and ‘child derived roles’ - the way we receive and respond to parenting. Examples of pair sets might include Abuser/Abused Neglecting/Deprived, Controlling/Rebellious or Rejected/Rejecting. CAT therapists establish which aspect of the personality is maintaining dissociation and which particular contrasting self-state, or reciprocal role, the client uses to respond. Initial mapping of self-states is carried out collaboratively between therapist and client. This is a dialogic, active, problem-solving process which attempts to change destructive behaviour. Session numbers may extend from sixteen to twenty four and a good outcome would include internalisation of the therapeutic relationship, enabling the client to thereafter become their own therapist.
Parallel transatlantic studies by Marsha Linehan (1999) have resulted in Dialectical Behaviour Therapy which has been developed specifically to treat Borderline Personality Disorder. Linehan considers that the disorder is the result of an emotionally vulnerable individual growing up in what she terms the ‘Invalidating Environment’. Such an individual has an autonomic nervous system which reacts excessively to low levels of stress and takes longer to return to normal when stress is removed. The role of the DBT therapist is that of a teacher. Validation is a primary tool. The therapist will include frequent and sympathetic acknowledgement of an individual’s suffering and sense of desperation, will believe that patients are doing the best they can and want to improve, will adopt a matter-of-fact attitude towards dysfunctional behaviour, will encourage an equal partnership with mutual commitment and goal-setting and will work to teach emotionregulation skills and increased interpersonal effectiveness. Linehan, Oldman and Silk (1995) claim that the best treatment you can provide for someone with Borderline Personality Disorder is a consistent and caring professional relationship. Linehan’s research provides the most widely known controlled outcome studies for the treatment of Personality Disorder. In the National Service Framework for Mental Health, issued in October 1999, the Government has included Dialectical Behaviour Therapy and acknowledges its particular effectiveness in treating those who self-harm.
Co-existence of Personality Disorders with Axis I disorders is reportedly very high. Comorbidity within Personality Disorders has also been identified. Anti-social Personality Disorder is frequently diagnosed in people with Borderline Personality Disorder (Roth and Fonagy 1996). Patients diagnosed with Dissocial Personality Disorder are considered by some psychoanalytic writers to have a basically Borderline Personality structure (Ryle 1990). The sub-categories of Personality Disorder are not mutually exclusive. With the investigation of causation, links are implied. Yet the development of psychological treatments has tended to be almost exclusively for Borderline Personality Disorder.
The case that breakthroughs in integrative approaches may have implications for the treatment of Dissocial Personality Disorder is possibly an unpopular one. Confronted with the worst in human nature, the current emphasis appears to be, not on engagement, but on detention without limit of time (DoH 1999a). How difficult is it for us to accept the membership of all within the human race? In her memoirs of Auschwitz, the French opera singer Fania Fenelon (1997) recognised that her fellows had changed, they had discovered a little something about the human race which they had not known before, and it was not good news. But she persisted in her refusal to call the perpetrators inhuman. The tragedy was that they were human. In February 1993 a two and a half year old little boy, called Jamie Bulger, was murdered. He was injured in a way that was difficult to accept or understand. This caused national grief and bitterness. Since that time Jamie’s killers, two ten years old boys, have remained in detention. Lesser known facts are that Robert Thompson was one of seven children, in a single parent family, who habitually roamed the streets with little or no parental control. Jon Venable’s family had been monitored by social workers for three years and he was a victim of violence (Britton 1998). Recent debate about whether they should be released on reaching adulthood is more truly a debate in democracy about the right to rehabilitation, the need for punishment as a deterrent, and perpetration as a moral agent. Is the individual a perpetrator of crime, or a victim of severe Personality Disorder and a projection of society’s ills?
Russian
psychiatrist, Professor Alexander Bukanovsky (1999), has taken extraordinary
steps to investigate the causes and treatment of dissocial disorders. In the
Russian city of Rostov there have been thirty serial killers in the last eight
years. Bukanovsky’s involvement began when a policeman from Rostov pointed out
to him that his daughter might be the next victim. He began to work
therapeutically with Andre Chicitilo, before his execution, and he continues to
work with other serial killers on death row in Moscow in his conviction that it
is possible to chart the development of a serial killer from childhood. ‘There
is no such thing as a born serial killer. One can’t just go to bed a decent
person and get up a serial killer. This
is a long process’. His blueprint involves
three stages. The first stage is fantasy, including violence, terrorism or
destruction. The second stage is compulsive sadism such as kicking animals around.
The individual discovers that there is something whose lord and master he can
be because these animals are small and defenceless. Soon animals no longer
satisfy. The third stage is physical attack - rape - murder - ‘ I
have suffered so much I want to kill everyone’.
With his conviction that there is currently a socio-economic decline in Russia causing psychological crisis in its people and enormous mental pressure for the individual, Bukanovsky has extended his work to some young men who have not yet reached stage three, ‘a child version of the serial killer’ and, in the name of science, is treating a young man who has gone beyond fantasy and has actually begun to commit crimes. In his belief that he can stop them, he has refused to identify these patients to the police. His methods appear to involve close recounting of crime, examination of motives, self-states, and early childhood trauma, often involving sadistic victimisation.
Serial killer Vladamir Kristopha wrote to Bukanovsky ‘In truth I did not plan these murders because the women were alive when I left the scene of the crime. So what was happening in my mind?’ Although on death row, with no possible chance of reprieve, Vladamir was obsessed with the question of why he killed and why he could not remember the crimes. Bukanovsky worked with this man during the six weeks prior to his execution. Vladamir believed ‘He could have cured me’. At some point Chicitilo came to see a psychiatrist because he realised that something was terribly wrong with him and he couldn’t stop. The psychiatrist laughed at him and he never returned. He went on to kill many more times. ‘Who can guarantee that a killer won’t kill again. I can’t. One thing I do know is that we do reduce the risk. Without help the risk is much greater’.
David Glasgow (1998), the former psychologist at Ashworth Special Hospital, has stated ‘At the heart of the hospital has always been a therapeutic vacuum’. More recently, Special Hospitals have begun to address questions of treatment versus security needs for those with Personality Disorder and are beginning to introduce psychotherapeutic, cognitive and creative therapies (Storey and Dale 1998), (Guy and Hume 1999). It has been suggested that the prison service looks after some 30,000 people with severe Personality Disorder (Morris 1999). The Royal College of Psychiatrists (1999:34) is now proposing that more research is needed ‘that may ultimately suggest new interventions for both primary prevention in childhood and adult offenders with Personality Disorder’. Grendon Underwood Therapeutic Prison attempts to move away from the pure containment stereotype of prison. Grendon is highly selective about which prisoners they will accept and consider they must be very motivated because the clinical impression is that you can work with people if they are willing. Grendon employs behavioural boundaries and cognitive elements which are evidence based and have produced a ten to fifteen percent reduction in re-offending. Dr. Mark Morris, the clinical director, believes that Nigel Eastman (1999) is wrong to say the prison service can hold all of this category because some people so severely self-harm that it is inhumane to try to treat them in prison. Therapeutic Communities have achieved acknowledged successes in the treatment of Personality Disorder. One consideration is that the attributes of Personality Disorder are evidence that an individual is vulnerable because of being unable to maintain control over their actions. When cared for in forensic settings this is compounded as the individual is being held under the Mental Health Act.
Encouraging results have been achieved by the Henderson Hospital, a Therapeutic Community in Surrey. Espousing the theory that the individual needs to regain control, the Henderson has a flattened hierarchy and considers the ‘community as doctor’. The traditional medical model, which puts the patient in a passive role, is avoided. Peer selection and peer treatment strategies allow residents major responsibility in the running of the community (Dolan, Evans and Wilson 1992). VVhiteley (1980) recognises the Henderson as a treatment option for patients who do not respond well to orthodox psychiatric services but are able to deal with exposure to therapeutic confrontation, with their peers, as a learning situation. Although the Henderson is not an option which is open to current forensic patients, Whiteley also indicates that the strongest lobby of support has come from forensic psychiatrists who have conceived of the Henderson as an alternative to the secure unit for mentally disordered offenders. Menzies, Dolan and Norton (1993) argue that it is a false economy to deny specialist treatment as this may result in the consumption of considerable amounts of psychiatric, social, probation and prison services in an unproductive way. Follow-up studies for twenty four Henderson patients showed a saving of £12,700 per person, per year, meaning the cost of specialist treatment could be recouped in under two years. The Department of Health have now taken measures to ensure that the Henderson is centrally funded and plan two additional communities based on the Henderson model (Salford and South Birmingham NHS Trusts 1999).
Faced with treating the effects of human trauma, acknowledgement of suffering, flexibility and engagement appear to be precursors to any form of education and work with reintegration of the personality. Dysfunctional behaviour towards self, or others, is not always considered legitimate territory, worthy of support, per se. Issues concerning entitlement may be coloured by assumptions that perpetration is always under the individual’s control. Even if help is mobilised, there exists an unspoken contract that sufferer and helper will work together. There is an expectation of co-operation and response to treatment. In reciprocation, support may continue to be made available. However, if initial engagement is flawed, by lack of understanding or moral judgements regarding entitlement, this may replicate earlier trauma and result in re-victimisation, and sometimes obscure willingness and the wish to co-operate with treatment.
Is
Suffering an illness?
‘Psychiatry
and neurology are not sister sciences, both belonging to the super-ordinate
class called medicine. Psychiatry stands in meta relation to neurology and to
other branches of medicine. Neurology is concerned with certain parts of the
human body and its functions ... objects in their own right ... Psychiatry is
expressly concerned with signs as things pointing to objects.’
(Thomas Szasz 1961:64)
‘If mental illnesses are diseases, they are diseases of the brain, not the mind If mental illnesses are names of behaviour, they are forms of behaviour, not diseases.’ (Szasz 1991:1574 - Diagnoses Are Not Diseases)
Are neuroses disorders or diseases? Formerly described as a disease of the nervous system, the post-Freudian concept presents as a personality, or mental, disturbance not due to any known neurological or organic dysfunction (Reber 1985). Indicating a causal role played by unconscious conflicts evoking anxiety, the social context surrounding and preceding the disorder also has relevance. It has been argued that deviance results from the culture and structure of society (Merton 1968). It is suggested that society needs deviancy, as a projection of its own ‘shadow’, in order to safeguard the well-being of the majority (Durkeim 1970). Szasz (1961) continues a compelling argument that an ‘illness model’ pathologises human behaviour, fails to assign personal responsibility for condition and action, and promotes stigma, helplessness and dependency.
Whether a diagnosis, disease or disorder, epidemiological studies of the indirect costs of neurosis are likely to be very high. But in considering the need for psychiatric services, establishing a diagnosis is only the first step. A crucial stage concerns treatment and resource implications. Psychiatrists Bracken and Thomas (1998) also question whether issues of distress and alienation are the sole concern of psychiatry or whether they are social and political issues, which demand cultural change. They suggest that this should not be turned into a clinical issue requiring treatment and management and that psychiatry should accept its limitations. With the acceptance, that Aneurin Bevan’s vision of comprehensive healthcare for all is not likely to be a future reality, comes the concept of rationing. Already experienced in this area (Ooi 1997), (North Essex Health Authority 1998), no further in-patient treatment for Personality Disorder was amongst the proposals. With acute services claiming that ninety five out of two hundred and thirty three inpatients in a six month period, approximately forty percent, are likely to have some element of personality problem, this did not become a reality (Acland 1997). However, rationing is at risk of continuing subtly. Claims of untreatabilty and diagnostic confusions are unlikely to help. The impulse to challenge the biological, reductionist model of psychiatry has enormous, positive implications for exploration, and creativity, in terms of understanding and healing. However, it also has overtones of exclusion and of reasons to offload challenging, intractable and ‘undeserving’ cases. Pathologising and stigmatising suffering may compound the situation, but great suffering requires a response, and resources are currently concentrated within the psychiatric area. The questions are...... who requires a response? ...... and what that response should be?
Coid (1989) considers that an alternative is to view Personality Disorder as a single category. Norton and McGauley (1998) suggest that clients could simply be given a diagnosis of Personality Disorder if they fitted the basic definition, whether or not criteria required in sub-categories are achieved. It is argued that personality psychopathology should be conceptualised by dimension rather than category because the complexity of one individual cannot be adequately defined by diagnostic label (Oldman 1994). According to DSM IV and ICD 10, a number of criteria must be present in order to diagnose a disorder. A dimensional system might rather look at the degree of anxiety, depression, sociability and trust. Whether or not someone with this diagnosis has committed a crime is also a dimensional consideration. Government Guidance for the care and protection of severely mentally ill people, Building Bridges (1995), emphasises dimensional criteria which focus not just on diagnosis, but also on disability, duration, safety, and the need for informal or formal care. A dimensional system implies clinical and economic answers to questions of service eligibility and demarcation.
A dimensional concept does not, however, fully address the basic categorisation of such human difficulties into a definition consistent with their aetiology.
Conclusion
‘There is nothing as practical as a good theory and, of course, nothing so handicapping as a poor one Without a reasonably valid theory, therapeutic techniques tend to be blunt and of uncertain benefit ...... and systematic and agreed measures of prevention will never be supported’
John Bowlby (1988:37)
What is in a name? Stigma is in a name. Fear is in a name. Strong moral judgement is in a name, explicitly so in the nineteenth century. Pseudo insight through terminology is in a name. Erroneous insight through terminology is in a name.
The literature suggests newer approaches to understanding and working with trauma, and ways in which the personality may become more integrated. Is this diagnosis really irreplaceable? Complex Attachment Disorder has been suggested as a name. Why, instead of ‘manipulative’ or ‘acting-out’ behaviour, do we not acknowledge ‘attachment seeking behaviour’? Complex Post Traumatic Stress Disorder has been suggested as a name. ‘DESNOS’ or Disorder of Extreme Stress has been suggested as a name. These re-definitions more clearly encompass cause, are more compatible with effective treatment models, and free the mind to estimate dimension and so establish treatment eligibility.
Yet knowledge, which has begun to crystallise during the last fifty years, appears to be impeded by a sense of futility and fear. The gulf between sufferer and healer remains largely unbridged. Our premise is that part of the answer lies with service users themselves and their ability to bring the focus back to living people, by describing personal histories and feelings in their own words, and by evaluating those experiences in their own terms. Little attention has been paid to the service users with this diagnosis, and the meaning they give to their inner world. This study invites you within.
The Aims
of the Research
‘Sometimes
it is hard to believe that the real stakeholders...... those who provide it
with its raison d’étre...... are its users.’
Geoffrey Hunt (1998:9)
The public and professional debate regarding Personality Disorder is largely uninformed by the user perspective. Among the extensive literature written on this subject, one article emerged, ‘Borderline Personality Disorder from the Patient’s Perspective’. Glick-Miller (1994:1215) discovered that ‘narratives revealed strong similarities in the patients’ experiences ... ... reports of their experiences differed markedly from the clinical descriptions of the disorder’. This caused her to conclude that ‘little attention has been paid to experiences of patients with this disorder’.
When service
users are devalued it is difficult for them to question the assumptions of the
majority alone. The support of other people, who share experiences and
perceptions, helps to set in motion collective action which may challenge
conventional wisdom (Brandon 1995). American service user, Judi Chamberlain
(1988:xi) considers that ‘our ideas about our care and treatment at the
hands of psychiatry, about the nature of mental illness, and about new and
better ways to deal with, and truly help, people undergoing emotional crisis
differ drastically from those of mental health professionals’.
Service users with this diagnosis were, individually, seeking change. Concerns ranged from inappropriate treatment, attitudes concerning untreatability, to being viewed as intrinsically bad. Sixteen people with the diagnosis had begun to participate in professional consultations. Their views had been valued sufficiently to inform local policy guidelines. They were keen to continue to explore questions connected to the diagnosis and to express ideas about the kind of services they wanted. They wished to increase the generalisability of their discoveries by exploring the experiences of a wider number of people who had attracted this diagnosis. Canlan (1987:164) suggests that ‘where there is considerable clinical uncertainty... there is also perhaps the greatest potential for tension between doctor and patient... ... Questions about the value of medical care and medical procedures, as well as questions about clinical expertise of the practitioner, are rarely seen as appropriate for investigation’, suggesting a ‘managerial bias’. Evaluation of professional practice by service users is not usually considered appropriate, yet ‘clients can become “expert”... (and) have clear criteria for judging the ability of their professionals and for evaluating the care provided’ (Carr-Hill 1995:30).
Audit
Commission Report ‘Finding a Place’ (1994) highlighted the need to listen to
service users because professional assumptions often differed widely from those
of users. The Sainsbury Centre and Rowntree Foundation had initiated studies ‘which
would also have wider import as an innovative way of measuring the impact and
quality of a service from the user perspective’ (Beeforth, Conlan and Grayley 1994:3). This introduced service users
as thinking, reflecting people who could become partners in the care process.
Beeforth, Conlan and Grayley (1994:22) consider that ‘user
researchers bring a new and different perspective, which generates new ideas
and constructs and enhances the quality of the whole research process’.
Lindow and
Morris (1995:90:25) suggest that ‘the involvement of service users in
setting the research agenda, developing the methodology, carrying out analysis
and dissemination is crucial’. Rose et al
(1998:5:25) began with a perspective that service user involvement in research ‘can
give rise to fruitful and valid findings which have implications for policy’
and discovered that ‘even very psychologically distressed people responded to
questions about services and satisfaction with professionals coherently’ .
The group’s identified themes included common emerging patterns involving early life events. This suggested a complex relationship between life events, response and disorder (Brown and Harris 1989). Additional psychiatric diagnoses also had significance for the group. Morrison (1995:479) suggests that a long list of Axis I disorders can be confused with Borderline Personality Disorder and that this diagnosis is probably applied to a far greater proportion of patients than is necessary. He considers it may be the most overdiagnosed condition in DSM IV and that many may have more easily treated disorders, including major depressive disorder. He attributes its remarkable popularity as a diagnosis to the fact that ‘So many patients can be shoehorned into its capacious definition’. Crichton (1995) also outlines the danger of patients with psychotic disorders, who are perceived as difficult or challenging, being given revised diagnoses of Personality Disorder. On the subject of labelling, it was Goffman (1963) who suggested that psychiatric diagnosis swamps the person, coming to define them as an individual. Pilgrim (1991) has described Personality Disorder as a diagnosis with maximum stigma effect. In terms of both life events, and experience within the ‘system’, we wished to know:
·
What it means to have attracted a diagnosis of
Personality Disorder?
Meaning here might also reveal possible precipitating cause, resulting self-states or condition, and behavioural consequence. It seemed that these were three different, but related, aspects of the problem which were often confused by professionals, the symptom becoming the disorder. If we could examine these aspects more closely perhaps we would more clearly see and effectively ask:
·
Which interventions have been helpful or useful,
and which have not?
......and so contribute some insight into the usefulness of responses, support and services offered, and add to suggestions for a framework that might better meet needs and vulnerabilities. These two research questions would become the impetus for our study.
‘Locked Up’
‘I asked for counselling and I was told it’s not available in prison. I felt I needed it to ace life in prison. I started cutting my arms. 1 never saw a doctor, only a prison screw put dressing on. I am one of the lucky ones. I came out alive. I saw three people take their own life. All had mental health problems. If you have a mental health problem you don’t get any help at all. Prison is not for people with mental health problems of any kind.’
‘In prison I received quite a lot of support after I had been beaten up by the screws. So they put me on section in hospital and I get treated okay.’
‘I’ve had experiences with quite a few services, from being brought up in care all my child life and then in youth custody centres, also child lock up centres, mental health hospitals and prison. I found hospital more demeaning than prison, even though it was more relaxing in some ways.’
‘Special Hospital was one of the worst experiences of my entire life. I will never forget it. 1 was mixed with rapists, murderers, arsonists and paedophiles, and we were expected to get better. The average stay for a woman was eight years. However, I only stayed for one and a quarter years.’
‘I love violent films - Krays - Scum - Texas Chainsaw Massacre. I thought it would be fun to go in prison. You don’t know what it’s like to be ill treated in prison- to drink water out of the toilet.
Learning Disabilities Secure Unit - ‘I was locked away for four years. They said I had contact with a girl, but nothing happened and now my name is clear. I was locked in a padded cell. If you did something wrong you would be physically beaten. I didn’t think 1 would come out alive. I thought I’d come out in a box.’
‘In prison there was no support at all. Absolutely appalling - hell - horrendous - a lot o the people I met had serious mental health problems or they were drug addicts or alcoholics.’
‘I was in hospital for a bipolar condition. My diagnosis was changed by a locum psychiatrist. Within a few days I was discharged without moneylbenefits, medication or proper aftercare, into inadequate accommodation - with so-called “untreatable Personality Disorder”. I fell into the hands of the police, as I was wandering around Colchester aimlessly and for two consecutive nights I was held in a police cell because I was so ill. The consultant would not readmit me, either informally or under section. I was taken to court on a harassment charge, in a prison van, in handcuffs, held in the cells beneath the magistrates court. I would have been sent to the remand centre at Holloway Prison, if I had not been collected by my parents and sent back on bail to Wales. We made a difficult and dangerous journey in my parents’ car. During a break in the journey I was described by a doctor as practically “psychotic” and “very manic”. He advised my parents to get me into hospital as soon as possible. When we arrived home I was sectioned and treated as bipolar, NOT Personality Disordered. Once again, with the right medication and adequate therapeutic support, I gradually became very well again. I find it hard to accept that someone was diagnosed as having a Personality Disorder who was a head girl at school, with good relationships with both parents, obtained the highest qualifications at her school, studied law, history and politics, obtained a good degree with honours and made loyal friends.’
‘I want to kill - think about killing all the time. If I was to kill it would make Hungerford look like a teddy bears’ picnic. I make my home my prison.’
Reflections
and Suggestions
‘Something is seriously wrong with a system that treats anyone, whatever their education or background, like a “sinner” or a “criminal”.’
‘Self-harm is not a diagnosis, it is a symptom of something deeper happening to you. Self-harm is not a suicide attempt but may result in accidental suicide. There are many reasons why people self-harm. What I can say for me, and I believe many other selfharmers, is that self-harming activities are used as a coping mechanism. Some professionals see it as “acting out” or attention seeking behaviour. These attitudes are not helpful to self-harmers. Most self-harmers keep their wounds and behaviour secret and they feel too ashamed or embarrassed to tell anybody about it. They are scared o the reaction that they will get from family, friends and professionals.’
‘Isn’t it about time professionals started to find out more about the realities o Personality Disorder and the self-destructive torment, frustration and utmost loneliness sufferers go through. Loneliness? Yes, loneliness because we are so misunderstood, humiliated, desperate, cut-off - the list is endless. Why oh why don’t and won’t these professionals and health authorities accept that there is such a condition and illness. Basically 1 am beginning to realise that they are all possibly too much in denial to acknowledge and accept it. It is said that Personality Disorder cannot be treated. I think it can, with the help of different medications, but most of all by just sitting with us and recognising and trying to understand this condition by listening.’
‘It is no wonder that those of us with a Personality Disorder diagnosis feel like second, or more like third class citizens (life’s rejects). You only have to look at the definitions given in ICD 10 and DSM IV and read comments such as “limited capacity to express feelings - disregard for social obligations - callous unconcern for others - deviant social behaviour - inconsiderate of others - incompetence - threatening or untrustworthy”. The list is endless, but one thing that these comments have in common is that they are not helpful in any way.’
‘How can the experts really treat us seriously and with any degree of compassion or understanding when they define us as “attention seeking” or as “acting out”. These types of comments do not help and only serve to deepen the distrust we feel and add to our feelings of persecution. As a group we already feel sub-human, threatened, misunderstood and vulnerable, and now we are tarred with the brush of being bad as well as mad. I do believe that sub-consciously we pose such a threat that, to some extent, professionals have lost their way. There is no doubt that Personality Disorders are complex and cover many types of behaviours but, together with losing their way, many professionals seem to have lost interest and patience too.’
‘Those of us with Personality Disorder can elicit a negative response and a kind o aloofness from professionals and carers, probably because we are a mass of churning emotions and, unintentionally, this is threatening to others, or stirs up their deep seated emotions. I think as a nation we British are still too fond of the “stiff upper lip” and that certain subjects are still very much taboo in this country. Personality Disorder seems to create a similar response to that of bereavement. When a person is bereaved others are slow to get involved, not because they do not care, but because grief stirs up a whole host of feel ings and deep emotions in ourselves. Perhaps the severe trauma of someone with a Personality Disorder is able to tap into similar, albeit less intense, but nevertheless overwhelming or threatening emotions.’
‘I have been thinking about how the staff in general react to the needs of their clients and I firmly believe that in some cases it would be helpful if clients could speak to someone who truly understands how they feel, someone with first hand experience. I anticipate that this will not go down well with all of the professionals involved in a client’s care and I can envisage quite strong opposition. But surely the person who understands best how a suicidal or abuse victim feels is someone who has experienced these feelings and has been in the same situation. I don’t mean any service user advocate or a professional, but someone who has had the same or very similar problems.’
‘What’s needed on the wards are abuse counsellors. There is one on one of the wards that I found helpful to talk to. But I found it more difficult to talk to him at first because he is a male nurse. I’m a man, so women might find that even more difficult. This should be available on all wards.’
‘I do believe that a small specialist unit would be helpful. A sort of crisis intervention unit, perhaps run from a non-hospital setting i. e. from a house. This unit would only take a small number of victims of childhood abuse, say five, and they would all be female, as would the staff. Obviously a similar unit may need to be set up for male victims, but you would need to discuss that with the people who have more of an insight into male childhood abuse, because it is quite possible that a male unit would need to be staffed by both sexes. As for my suggestions on the female unit, many victims of childhood abuse eel quite threatened by the presence of male staff and clients. Personally, despite having been abused by males and females, whenever I entered hospital it was because 1 was at crisis level and a risk to myself, but whenever I left it was because I could no longer stand being around so many men, most of whom did not understand how scared and threatened I felt. Somehow to me women pose less of a threat than men, although they are capable of doing just as much damage. It is possible that this type of unit would be even more beneficial to its clients because everyone would have very similar problems and there would be a feeling of solidarity and mutual support.’
‘A human failing, and one particularly of the medical profession, is that of the need to “distance/diagnose%ategorise/separate “. Perhaps if more people could “accept/ understand/sympathise/not judge “, then this world would be a better place. I heard some comment on a children’s programme a few weeks ago in which someone said that a man should respect and understand the ‘four B’s” of a woman, but this is applicable to all individuals. The ‘four B’s” were: - respect for a person’s background, respect for a person’s body, respect and understanding for a person’s behaviour and, above all, balance. All I know is that we cannot call ourselves a civilised society when so many people are outcasts and are simply not understood.’
CONCLUSION
‘For too long a time, for half a century in fact, psychiatry tried to interpret the mind merely as a mechanism, and consequently the therapy of mental disease merely in terms of technique. I believe this dream has been dreamt out. What now begins to loom on the horizon are not the sketches of a psychologised medicine but rather those of a humanised psychiatry’.
Viktor Frankl (1962:136)
Temperament or Trauma is a co-operative inquiry by service users which, nationally, is one of the first full-scale research studies aimed beyond user-focused monitoring. It may be the first to involve service users directly in clinical issues, where current users of psychiatric services have investigated, analysed and redefined their conferred diagnosis, and have presented a new construct for consideration by mental health professionals and legislators. This study represents the views of the major stakeholder which, until now, have not informed the professional and public debate regarding Personality Disorder.
Service users who have attracted this diagnosis may help others to look, not so much at how they are, but how they came to be that way. In so doing, they also offer abundant knowledge about symptomatology. They may not always know what is helpful, but they frequently know what is unhelpful, what is upsetting, and what provides a trigger for the worsening of their difficulties. They seem to be saying that acceptance and understanding will get professionals halfway there. Those who have begun to receive effective treatment are clearly defining the types of therapy and support which prove helpful.
Findings suggest that many respondents in this study have a diagnosis of depression and/or anxiety. Where Axis I diagnoses of, for example, depression, anxiety and bipolar disorder exist, there may be no justification in conferring a diagnosis of Personality Disorder to clients who clearly suffer from such depressive or mood disorders. It might be challenged that a category such as Personality Disorder has no place in a diagnostic manual for the classification of mental health problems. However, where an individual’s symptoms include features such as the kind of complex stress disorder described by the many of our sample, there is no adequate diagnostic category to give validity to such difficulties. Post traumatic stress disorder is a category included in DSM IV and ICD 10, as is DESNOS - disorders of extreme stress not otherwise specified (DSM IV), and enduring personality change not attributable to brain disorder or disease (ICD 10). However, neither category in ICD 10 acknowledges early childhood trauma as valid criteria for inclusion.
This questions how psychiatry comes to learn about personality. What is its paradigm? The disciplines of psychology and psychiatry may see Personality Disorder differently. The interpretation of the mind merely as a mechanism, and the categorisation of psychological problems based on surface manifestations, has resulted in a series of psychiatric classifications which see disorders as things. Our study is an attempt to bring attention back to living human beings, their personal histories and interpretations of experience.
The archetype of co-operation is a partnership between equals for the purpose of growth. Such a partnership, in a new millennium, would necessarily include psychologists, should be informed by service users, may include specialist services for those with a sufficient dimension of need, all encompassed within the remit of psychiatry which, after all, does have a literal meaning defined as re-animating the psyche, and healing problems of the mind.
The service users involved in our study have expressed their primary wish regarding this research. They have not asked, firstly, that the name of the diagnosis be changed and that it be differently defined, although this is something many wish for. They are not asking, initially, for a better service response or for a local Crisis or Safe House, this year. They simply ask that this research be read.
The full research report, full references and findings are available from Heather Costillo at Colchester Mind.
Good afternoon. And welcome. I do appreciate your support by coming here today. The James Nayler Foundation is a conviction organisation. It is a conviction that people are believable, they are reachable, they are changeable.
My definition for personality disorder is brutally simple. If you broke your leg you’d have a leg disorder, because your leg can’t take you from A to B. If it’s a mental disorder, your mind stops you doing what you want. Your mind stops you doing what you want. With talk, support and Truth, Trust and Consent, this can be restored.
I’m now going to ask Matthew if he’ll join me on the platform here, and I want to show you a video that I took of Matthew a couple of months ago. Matthew wanted to speak about his experience, having heard Nada speak at the last Conference. So thank you very much Matthew.
I want to show you a clip lasting a minute and a quarter, in which I am discussing with Matthew his anger. But the part I want you to listen for, is when he talks about upsetting his mother. And he eventually comes to the phrase; ‘If I upset my mother I cease to exist’. I’m not sure what existence means in the philosophical sense – but it doesn’t sound pleasant. Matthew has been trained not to upset his mother. So he bottles up a lot of anger. I would say on behalf of his mother, that that’s the last thing she would want to have been the outcome of her upbringing of Matthew. But that’s not the point. The point is that Matthew has this (had this) blockage. You can see he exists: I can reach out and touch him. I want you to watch his thinking on this. Because this is actually the nub. The title of this is experiencing the reality of personality disorder. This is how Matthew’s mind lets him down.
(The video shows Matthew blocking when Bob asks him about his mother. Matthew fears that if he upsets his mother he will cease to exist.)
|
Matt |
I think I'm still
appallingly angry. |
|
Bob |
Very very angry ? |
|
Matt |
Yes |
|
Bob |
Say that then. |
|
Matt |
I'm very very angry. |
|
Bob |
Sit her over
there. And tell her. |
|
Matt |
I'm . . . Oh God – get out of my fucking life. I feel
very . . Why are you so
aggressive towards me. Because
she . . is . . . |
|
Bob |
Are you entitled to be
angry with her ? |
|
Matt |
Well it's . . . |
|
Bob |
I want to know what
stops you ? |
|
Matt |
Her being upset, stops
me. |
|
Bob |
And then what happens
to you when she's upset ? |
|
Matt |
I feel like I've let
her down |
|
Bob |
And then what happens
if you let her down ? |
|
Matt |
I feel like I don't
exist. |
|
Bob |
That's better, that's
better. See what you're
telling me ? See what
you've just told me ?
I'm going to write that down. If I don't write it down I'll lose it. I don’t exit if . .
. If what . . ? |
|
Matt |
I don't exist, if my
mother is upset |
|
Bob |
If I upset my mother,
I cease to exist – say that |
|
Matt |
If I upset my mother,
I cease to exist |
|
Bob |
That's true isn’t
it. You can believe that
can’t you ? You do believe
it. It's crap – but
it . . . |
|
Matt |
Well yes it is crap, but it's a drag. |
|
Bob |
No. It's crap. |
|
Matt |
Yes, it is crap. |
|
Bob |
But you just have to
see it long enough. You're a floater, you
. . |
|
Matt |
a floating voter . . .
. . . |
|
|
––––– |
What I wanted you to see there, is that this is a total bind. What Matthew prefers to do is to exist rather than upset his mother. Nothing is worth that risk. So you get what’s called a blockage. And in the next clip a little bit later in the same interview, Matthew actually does block. I call it block-ed. He blocks. We’re going along, and we appear to be discussing the same topic, and then he says ‘what’s going on?’. And that’s not because he’s fallen asleep, or he’s got bored with the interview, or he’s lost the thread. His mind says “just a minute!” I can have this so it switches off).
What happens if there’s not enough support, (Truth, Trust, Consent and expertise) is that this block remains in place. At this stage of the process my interventions are sometimes misinterpreted as ‘bullying’: but this is not a normal conversation, this is not discussing cups of tea, this is rooting out a problem (with Truth, Trust and Consent) where Matthew’s mind, sometimes, does not let him do what he wants. So this is the problem.
(In the second video clip,
Bob steers Matthew through the blockage to the expression of the fact that if
he upsets his mother he is, in fact, free!)
|
Bob |
What do I want the converse of? |
|
Matt |
If I upset my mother, I don't exist |
|
Bob |
Great. So what's the opposite of that – ‘If I upset my mother, I don't exist’ ? |
|
Matt |
If I make her happy . . . |
|
Bob |
Whoops. Whoops. Whoops. You're slippery – you are. 'I don't care upsetting her, I'll still exist.' |
|
Matt |
Oh that sort of opposite |
|
Bob |
Yes, that sort of opposite |
|
Matt |
If I upset my mother I don't exist. |
|
Bob |
That's fundamental to you – and it's crap. What is the opposite to that ? |
|
Matt |
What did you just say ? |
|
Bob |
[roars with laughter] This is why I video tape it -- You have not fallen asleep. You are an articulate man. You have block-ed. So that is exactly where we need to be. I tell you what fascinates me -- I learn something new every time. 'If I upset my mother I don't exist.' I want the opposite of that. So first of all you give me – keep her sweet. That's standard stuff. That's crap. So I want the opposite of that. What were we talking about – was it the weather ? I want the opposite to that – If I upset my mother, I don't exist – what's the answer ? |
|
Matt |
I don't know – that's a hard one for me |
|
Bob |
I know [it is]. I'll tell you the answer -- and you'll kick yourself. If I upset my mother – I'm free. If I upset my mother, I'm free of all this crap, |
|
Matt |
I don't need this . . . . [continues] |
Thank you very much, first of all, it’s very important that we don’t go down a victim road, which is very easy to do in this particular situation. Obviously, if you start feeling: “why me?”. Well, first of all, it’s absolutely right that my life reached a certain climax two years ago, where it felt hard. And I had, if you like, a kind of a breakdown. It’s always very, very difficult to talk about your own stuff. So it becomes something to sweep under the carpet, I’m not important…but what Bob has made me realise over the last two years is that we are all important - no matter who we are… and that we have destructive and positive elements in us as much as anyone else. And two years ago I think I reached a point where I felt, “I can’t go on like this…”,
What Bob has helped me to do, a fantastic amount, is to recognise my legacy that’s powered from my parents. That legacy has been brought and passed down to them, so it’s not a question of fault, it’s not a question of blame.
Two years ago I found myself in a situation having, before that, having always pointed the finger, blaming institutions, blaming other people, and I still feel myself, sometimes, getting into that habit of blaming my mother or blaming my father. It is only through the help that Bob has given me that I’ve been able to start to free myself of these chains, if you like, and they are chains.
What happens when you live with your mind, day in day out, and the circle becomes ever increasing, like the hamster going round and round, is that you think there is no way off this, this is a treadmill that I’m born with and it’s part of my parentage. It’s so cunning if you like, and cunning is a word that comes up a lot between us. It’s cunning. I manipulate myself into my own negativity very, very easily. But there is a way of breaking out of this negativity, there is a positive step that you can take. We can get off the treadmill, make a decision and face the facts. Otherwise we just go on screwing ourselves into the floor and giving ourselves short change.
I would like to thank Matthew so much for this. It’s so important because Matthew is a human being, I’m a human being, and we’re all human beings, and what we see here is one form that the problem can take. I would emphasise again that this is a very, very difficult box to undo. And one of the reasons is that Matthew did not want to open the box. Matthew’s training was: upset your mother and that’s the end of everything. There’s nothing after that. That’s what he has learned. I had to say to him, “Look! See! You’re still alive!- and that’s all that happened”. And you never get there unless you get a deep, supportive bond, truth, trust, consent, whichever way you want to call it, that is between two human beings who are saying, look we’ll do it together.
It’s very moving.
I’m very glad you came up, Matthew. Thank You.
Nada wants to give a progress report. Those of you who were here last year will remember Nada, how electrifying her account was then, and we want to find out what’s happened since, what her progress has been.
Nada what’s been happening since last year?
Nada Dobre, one of Bob’s customers.
Since last time I spoke to you I have opened my own business, a new clinic in Chiswick, anybody who wants a card, let me know. (Laughter)
The progress has been tremendous from last time. I know now that my past is no longer valid, and that my present is what matters. I feel I have achieved freedom from my father, total freedom from my father. So my father is certainly out of the picture. That was something I could not face most of my life. Dr Johnson helped me to see my past and now I am able to run my own life today, as a professional person, as a friend or socially. In every which way I am totally free from the past. If I didn’t speak to Dr. Johnson when I did, I would have most certainly ended up in prison. I had so many problems, I was mentally ill, I thought I was going mad or that I would end up dead!
Dr Johnson’s theory was clear, it guided me and it gave me the tools to become the balanced and happy human being that I always thought I was. I haven’t got fear like before and I’m not running away like before. I can connect my past with my present. Every time I feel that fear I take the scissors: Dr Johnson told me to, when I couldn’t breath, when I couldn’t rationalise, to get the scissors and quickly cut the umbilical cord between me and my dad. That was a miracle for me to cut the cord between the two of us. Now I am my own person, able to run my own life and getting respect from Nada!
If we had more Dr Johnsons we wouldn’t have so many locked up people, we wouldn’t have so many misunderstood people. When I remember the last time I came to this country, when I ran away from my dad, he was trying to keep me and my mum, wanting to kill us, smashing mums face in, pointing a gun at me, especially when he was drunk. I was absolutely terrified. I ran away. I ran to the airport. I wanted to go anywhere so I couldn’t feel. I’ll never forget that. My sister was crying and she said, “Where are you going?”. I didn’t know. I couldn’t tell anybody about my dad, about the terrible things he done to us.
So, I’m in touch now, I’m battling now. The fact is I have my own life. I can look at my past. I am able to function normally, I like to think I’m good enough. People like Dr Johnson give us the tools to run our own life, run our own emotions. I had terrible problems myself. That’s the last thing I want to say. I just realise that life is about people like Dr Johnson helping people like me, who are traumatised. Life is about managing all this crying in the past. I lost everything. I haven’t got my family, that’s the way it is, that’s what has happened to me. You can imagine how it is, I am Serbian. How it is all so terrible to deal with, the grief, everything. Dr Johnson helped me to realise and to understand, that I can separate out the anger, understand everything and calm down. I just say, “Dad, that’s the past”, I think rationally, deep breathing, then I feel I am free. I am finally free. I can deal with it.
Most of my life I have had therapy, they always said “How terrible for you!” Nobody asked me the question, asked me why I was crying. But Dr Johnson came up and opened the Pandora’s Box, of the terrible things that had happened in the past. He told me, he said, “Lets open that box, lets talk about the past and then maybe tomorrow we can channel that anger and we can help you.” I realise now that I have a problem and I talk about it and analyse it. Thank you Dr Johnson, thank you very much.
I think what Nada says is just wonderful. When I first met her in those first few months it was very worrying, almost frightening for the clinic where we worked, because the violence which she describes so clearly, was so near the surface. I believe absolutely that if she hadn’t taken that decision to leave her native country, her father was definitely in danger, I would say that. She’s very complimentary to me, and what I have to say to you is that the James Nayler Foundation is promoting and sowing seeds of the ethos in which this sort of work can continue. These are the tools. Now these tools come from support, these tools come from people saying, this isn’t good enough. We’re human beings, we need to work this out. We can’t say to people with personality disorder “Go away! Go fall off the edge!” That’s not good enough. And that’s what this Foundation is about.
This is a Foundation to look for the tools, to find the tools. The tools I found for Nada worked for Nada, that’s the way to go. The JNF says that what’s happening is not satisfactory. Do not write off these people! Learn what these impulses are, where they come from. We must empower the individual, as Nada so clearly said. We must empower the individual to enable them to throw these dangerous feelings away. To do that Nada needed support. She needed to continue to do the work. I needed support. That’s what I’m getting.
‘Why
can’t personality disorder be defined by the law as a treatable condition, and
why has there been so much legal rhetoric from Stephen Field about personality
disorder being unmanageable, what about potential victims? Government Policy is
not merely populist, there are possibilities for management’.
Can I deal with the question the way the question was put? Before I do so can I just clear up one other potential misconception? The talk earlier this morning focussed on Part Two of the act, this notion that there is a group of people called DSPD (Dangerous Severe Personality Disorder) individuals who warrant compulsory detention in circumstances where they have been deemed to be untreatable. I’m not tackling the rest of the paper, I’ve not analysed that, there doesn’t appear to be anything as sinister in part one of the paper as I suggest there is in part two. Part one doesn’t seem to be designed to genuinely assist, modify, and improve conditions in the mental health regime as a whole. There’s just this one aspect of detaining people in what I’d submit as in an arbitrary way that I’d challenged this morning.
The question: “Why can’t personality disorder be defined by law as a treatable condition”. The answer to that is that because the psychiatrists who told the lawyers how to draft the act, told the lawyers that it’s untreatable. Dr Johnson doesn’t agree with that, he thinks that everybody is treatable. In my first paper, I endorsed that and endorsed the fact that, on the committee that’s behind this white paper there isn’t one doctor who said, “there’s no such thing as untreatable, if a patient comes to me I have to treat him, that’s why I’m a doctor”. So it’s not the lawyers, it’s not the law who defines whether it’s treatable or not, it’s the psychiatrists. Psychiatrists are leading the lawyers to invent or create a condition that is untreatable. Untreatable is a matter of law because that’s what the psychiatrists have told them. So the law, if the law was enlightened, perhaps by people like Dr Johnson, they would define personality disorder as a treatable condition.
However, the current psychiatric industry doesn’t define it as treatable, it actually says that there will be some untreatable people. Those untreatable people, what they call untreatable, will then be put in a place of detention. Not for treatment because, the system, the psychiatric system, has decided they are untreatable. If the psychiatric industry would redefine them, and say, actually, they are treatable, we’ve just had the help of Dr Johnson, who’s enlightened all of us, we are now in a position to treat these people. There would be no need to remove the word treatability as a condition of detention which is what the white paper has done. In other words, the system is telling us there are some untreatable people. That system is a system that will be putting them into detention. That system therefore, is washing its hands of them. So the system is creating a group of people who have no hope. It’s an artificial creation, because they do have hope, but the system won’t give it to them because the system has already judged and decided they’re untreatable (sic). So it’s psychiatrists who are telling you all, that there is in existence this group of people who are untreatable.
Then the rest of the question: ‘Why so much legal rhetoric from Stephen Field about personality disorder being unmanageable?’. Well, again, that’s not legal rhetoric from me about being unmanageable, if the person who wrote this question means about untreatable, I’ve just dealt with that, answering the first part. The new act doesn’t say that personality disorder is unmanageable, it says that it is untreatable, it goes beyond care and treatment and the new act invents or introduces for the first time to mental health legislation this question of management. So far from saying that personality disorder is unmanageable, the new white paper says it is manageable. By manageable though, it doesn’t mean treatable, it means managed. And it’s interpretation of management is to put people in a place of detention. That manages them. Of course it manages the person, because while they are in a place of detention without sharp things or matches, they can’t be dangerous or putting a risk to society. Psychiatrists think that they are dangerous if they are allowed access to matches and sharp things. So that management has no notion of clinical management, I would suggest, because they would have been, for example given medicine. It must mean, effectively, putting them in a strait jacket, if people are in strait jackets or as it happens to be, in a cell. Now that is the insidious thing about the proposals. All it will create is a system that will compulsorily detain them. And that’s what I’ve been challenging.
Then this is where it comes down to a question of opinion, and this is where everyone is entitled to be divided, I would suggest. What about…potential victims? Government policy was not really a populist response, there are possibilities for management”. Now then, if the person who wrote this means there are possibilities for treatment, that’s why I’m speaking on behalf of the James Nayler Foundation. If the person who wrote this means management, there are possibilities for management, but one must accept that that management will be actually compulsory detainment, then this is where it comes down to opinion. Some people may think that it is possible to determine risk with some degree of accuracy of people who aren’t doing anything wrong, such as the girl I mentioned in case study A, living in a bed and breakfast, who in the past has killed somebody, set light to things. So if you take that person as an example what “about potential victims, Government policy has not been a populist response”.. unless psychiatrists can convince society that it can assess risk, to such a degree of accuracy, to be able to single that person out, to become something more than arbitrary, then I would agree with the person who has written this question.
Other than that, all we’re doing is protecting victims that need protecting, because any of us here could be a potential victim. We could walk out and be stabbed with a knife by someone, who (it would have been nice if) the psychiatrists could have anticipated they were about to do that. I think that’s wholly unrealistic that in society we have to live with the imperfect situation. There will always be people who will do this. If we took it to its logical limit, all of us here is capable of being violent towards another person, and I would suggest that that is typical of everybody, everybody is capable of producing a violent response, it just depends on a trigger situation or criteria or circumstances. You'd ultimately need to lock us all up because then certainly we wouldn’t be a risk because none of us could hurt anybody if we were all safely locked away. I think that that is a line we wouldn’t cross: lock everybody up. I think that no person should be locked up simply on the basis of an unquantifiable, perceived risk in, circumstances where they’ve not committed criminal offences that would legitimise their detention. There is no suggestion that they could be treated in a sense of being made better, cured, whatever the term people want to use. I would suggest if you pose a risk and we’ve got to think of potential victims, the list is so large that we could be locking up hundreds and hundreds of people who, if they were left to their own devices, wouldn’t cause any danger.
Risk is, itself an industry in terms of bookmakers and I suggest that’s where it should remain. Bookmakers take risks. You can’t assess it. This isn’t about gambling, you can’t gamble with individual liberty. Unless there’s some justification for locking them up, I suggest that whether it’s a populist response, and it certainly is a populist response, because I would imagine the average person will lock up dangerous people without going any deeper. So it is populist. Whether it’s more than that, whether it can be justified as a legitimate legal process, I would suggest that it can’t. I for one, it may be a personal prejudice, but I, for one, will never be persuaded that we are going on to arbitrary detention, which would single out this 2000 or so potential harmers. If people think that locking these people up will stop people burning things, and putting sharp things into each other, I think it’s wholly unrealistic. So, in the circumstances, it is seeking out a very, very small group of people for special attention in circumstances where it has never been appropriate in the past and in fact, I would suggest, we are going backwards in civil liberties and human rights, rather than forward.
I think one of the problems that’s been revealed by the apalling psychiatric advice which has been given to the legislators, if you want to put it that way, is this question of assessment. I do psychiatric reports for the courts and they want risk assessments. I never do an assessment without starting emotional therapy. My assessment of risk is involves finding out if the customer still feels murderous rage. I need to find that out. People are violent because they have violent emotions from the past. Now if you are going to assess risk, if I’m going to assess risk, I just start addressing those issues, bringing them closer to the surface and allowing the individual to address them. Once you can say this individual is violent because they’ve experienced violence when they were very small, you can start treatment. You assess how close that violence is still to the surface, and you’ve the assessment of risk from that, or practically.
So it’s actually two aspects of current psychiatric practice looped together. The lack of causation for these various self destructive, and other destructive actions and symptoms, on the one hand and untreatability on the other. They link together and, when linked together, they make an accurate and humane risk assessment impossible..
I think there are a couple of questions that lead into each other, there’s one saying that:
“There have
been almost limitless labels this morning which only goes to further alienate
customers from society.”
And going on
from that (I think I have to link these together) -“Is it not a little naïve
to say that people are not born violent?”
Yes I agree. I would label everybody as a human being just start with that. A human being. If their mind isn’t working then they’ve got a mental disorder, and if their mind is working they are a human being with a mind that is working. I reject all of the labels. It may sound extremely naïve but we’re born non-violent. I worked for five years, as some of you will know, in the most violent context in the British Isles. A special unit in Parkhurst prison, which at that time was a maximum security prison. People selected to go there were unnecessarily violent, and unnecessarily unstable and so forth. Now, they taught me that they didn’t want to be violent. Now, there’s only one place that can come from, and that’s the way they were born. Every one of them who had enough confidence and trust in me, and in the situation to tell me that, to tell me these grievous violent things that they’ve been suffering as a child.
There’s no question in my mind that violence is a learned disease, it’s a learned disease and therefore it can be unlearned. And I will concede to no one that particular fact. People get very violent, some of the prisoners assured me to begin with that they’d been born violent. Since that particular man was a serial killer, I disagreed very gently. (Laughter). I could not agree with him, but he’d been “taught”, and other psychiatrists had agreed with him, other psychologists had agreed with him. I don’t agree with that. I see an individual, and I expect them to want to be non-violent. That’s my expectation, and some of them remain violent, but that’s because they haven’t, as I would think, understood where the violence comes from. Violence is a learned disease, and it needs to be unlearned.
Now, this is the question of conviction, and I base my conviction on my clinical experience. Let me give you an example, I worked with a man during my 5 years at Parkhurst, who wouldn’t have an argument, but who would use his fists. He would get by with his fists, and the person with the strongest fists won. He was fearless and taught himself to ignore the pain, he would beat everybody up and then he’d win the argument. He started to talk to me, and he developed these feelings that he hadn’t had, he developed an interest, he developed a conscience. And he relished not being violent. It was a real change, and that’s what convinces me.
Bob didn’t know me before today. But I think there’s one or two areas where we might part company. We developed the work with sex offenders at Wolvercote, that’s the description of the behaviour they’ve got, I wouldn’t particularly call them paedophiles, because they use that word without really understanding what it means. And if there’s any labelling around personality disorder I don’t use that label to anybody at Wolvercote. We don’t send them out with that label on those terms. What we do talk about, and discuss with them, is the fact that they’ve learned their behaviour. That they didn’t come into the world with that behaviour innate within them. They learned how to do it, they learned how to sexually offend. And that we can help people to learn how to excercise future self control. I guess the reason we don’t talk at Wolvercote certainly, about disease, is that we are now getting into the realms of cure. I guess that’s the terminology I would use. I believe that people can exercise future self control. And that they can learn to be supported in exercising that self control. That’s what we’re talking about at Wolvercote about working with sex offenders.
But I think that we are in dangerous territory if we don’t acknowledge the fact that a good predictor of future behaviour is past behaviour. I think that if one lines up ten people who have been historically excessively violent, 5 of them historically evidently have not. We need to be clear that some of these people are deemed to be a greater future risk than others. There is no precision that’s good enough to say how big is that risk and when it will happen. But I think that we can know that some people are distinctly more risky than other people. And I say that because I think we know people who are at Grendon, Underwood, and in other prison sectors and treatment programmes at Wolvercote re-offend, and that they themselves have to recognise their capacity to be at future risk. And out of that, to recognise their wish not to be, to accept the responsibility of choosing that future act or behaviour.
Bob.
Very good.
‘Please
give a brief idea of what personality is, so that I might have some idea of what disorder is.
‘What are
the current ideas of the genetics
of personality disorder, is it related to the presence or absence of a firm relationship being made in
very early infancy. Do genetics
play a part in personality disorders, or purely parenting and/or tragic
experiences. Can drugs particularly Librium in pregnancy bring about
personality disorder when the new born baby becomes adult.’
Somebody here is thinking that ‘Personality disorders are caused by materialism’ And ‘ Please give a definition of personality’.
So there’s a whole raft of questions around defining what we’re talking about.
It’s not a strictly legal definition, given the mental health law. Because of the approximation of the International Classification of Diseases ICD 10, dissocial personality disorder, personality disorder usually comes to the attention because of the gross disparity between behaviour and the prevailing of social norms, characterised by;
a) the apparent unconcern for the feelings of others.
b) a gross persistent attitude and irresponsibility and a disregard for social norms, rules and obligations.
c) incapacity to maintain & enjoy relationships even though having no difficulty in establishing them.
d) Low tolerance to frustration and & a low threshold to the discharge of aggression including violence.
e) Incapacity to experience guilt or profit from experience, particularly punishment.
f) Marked proneness to blame others, plausible rationalisation for behaviour has brought the patient in conflict with society.
Bob.
Those six points very clearly describe an infant. (Laughter). They get very frustrated and they have tantrums, and they have a wonderful time. I’ve puzzled over these definitions myself, from what you might call the lexicon point of view.
Personality, in my view, is the sort of person you are. I wouldn’t go further than that. I would make the point that if you are reading a novel and the characters in that novel show no character development, so it’s rather a poor novel. The personality, in my view, is very similar, and can change. Personality disorder, as far as I’m concerned, stops you being sociable. We’re born loveable/sociable, we’re a social species. The fact that we’re bipeds and not quadrupeds, means that we can’t run as fast as quadrupeds, so we can’t escape lions and tigers so we have to co-operate, be sociable. And in fact I rather enjoy being sociable. Because we’re sociable we have to have a personality which says hello, a personality that says hello in a sociable way. The difference with a personality disorder is that our human relations are disordered. You expect people to be as unkind and as anti-social to you, as you’ve learned to be when you were smaller. It’s so obvious to me. Personality disorder, as far as I’m concerned, means that you are not interacting in a social way for you.
Human beings can’t exist in isolation, our minds and our cerebral activity need others out there to confirm what we think, our beliefs, and our structures, to assure and reassure us. I don’t find any problem with that. I think a healthy human being is a sociable individual. This list, from DSM 4, the latest Diagnostic and Statistical Manual says something very similar with descriptions such as:
‘callous
unconcern’
‘irresponsible social concern for social norms’
and so on. This division, is paranoid, its stupid.
I would say, just to put these diagnostic categories into a context, that DSM 4 was published in 1994/95, and DSM 1 was published in 1952. DSM 1 in 1952, said mental disease is caused by and they give 3 points –
Environmental
contribution
Social
contribution
Psychological
contribution
The current DSM 4 says we throw away all we believed in 1952, we throw that away and it’s all biogenetics i.e. it’s all to do with brain chemistry. Now that is so sad, stupid and regressive, in my view.
I wasn’t born a sex offender, I was taught this, that was how I became very obsessive. I became obsessive with work. And I couldn’t learn to be different, to unlearn what I’d learned. I’ve heard people say that people are born with this and they’re born with that. We all grow up with a stable mind if we are born with a stable mind, it’s the environment we’re brought up in that changes that mind. The important thing is that its happening all around us. Children are being taught to live above their age, adults are being taught to conform with what society wants. All leads to these disorders, whether it’s like eating disorders or alcoholism, people are fighting to live with what they would see as a normal society. I would question what is normal society, could we define normal society. That would be the question.
‘Can you get help for somebody that
you care about if they don’t agree to be helped’.
‘Can you
get help when a person refuses to accept that he or she has a problem’.
The critical thing that I learnt in Parkhurst was this word consent. For six months one man walked round me, he didn’t even say good morning. I said, “Good morning, are you coming to see me?”, and he said “No chance!” Six months, right. And he watched what I did. He watched people make appointments and break them. He was a customer. He was either going to buy my product or he wasn’t, it was entirely his decision. So I had to give him that six months so that he could find out what I was like, find out if and how I was being parental, how I was being coercive. It’s a question of persuasion in that context. When he decided, he sat down. And he disclosed yards, cubic yards, of dreadful stuff that had happened to him that he had not expressed before. So in the first six months nothing, he couldn’t get help because he didn’t want to get help. This is part of the disorder, part of the disease, the lack of sociability. They don’t trust you. It’s like being brought up as a small child in a concentration camp. He was in the power of the guards, he wasn’t allowed an opinion. So you get into adult life believing that the people in power are actually dangerous. And I believe that my task was to be 100% benign, 100% consensual, coercive to the least possible degree, so that eventually he would open the door. If they don’t open the door there’s no way of getting in.
Treatable – yes, it’s the fault of the treaters. If I’d failed to persuade this man as I’ve failed in other contexts, it’s because I haven’t sold the product. In the context that that man or that woman could accept. That’s all. There’s a person that’s suffering. Listen to the stories of suffering, they are hurting themselves, they are hurting others, it’s dreadful. They are suffering and you say basically you’d prefer them not to suffer. Certainly. They don’t believe, the people who have the problem, they don’t believe there’s any point talking to me. There’s no point talking about the pain, because I can’t help. That’s why they’re refusing treatment, because I haven’t convinced them. I haven’t managed to get their trust, that is the primary task.
I feel that this will be woefully inadequate, but I’m feeling a bit light headed at this stage. I think it’s been a wonderful day, there’s been such a tremendous variety of people here. I think that all the team felt greatly encouraged by everyone’s attendance here. I just want to read out a statement that we’ll put at the forefront of the proceedings. We’ll be publishing the proceedings of this conference as we have the other ones. This is my attempt at a very brief summary of what has happened today. Then I’ll invite any comments. And then just a brief word of what we’re doing next. Here goes.
We have heard from our many and varied speakers of their concerns. In particular that:
§ detention for no purpose is inhuman and degrading, arbitrary and unlawful.
§ that concept of untreatability is wrong and damaging
§ that in the area of diagnosis where understanding is required, fear has emerged instead
§ we have heard personal accounts of the damaging effects of all types of childhood traumas.
§ we’ve heard optimistic accounts of the processes involved in change and recovery and
§ of the harnessing of humanity through Circles of Support in the community and through support groups.
§
collectively the experience of our shared
humanity here today.
Does that sum up what’s happened today do you think? (Assent)
Thank you
What of the future? I’ve been reading what I said about the James Nayler Foundation, of our vision last year. In a way, I don’t think I can improve on it. Especially after such a conference as today. Our vision is to try and move this country of ours. Working for a cultural change from despair, coercion and fear as motivating factors behind our social policy and legislation, which is what Stephen so eloquently described. The thinking behind that, the fear behind that, which we said last year was just ridiculous, and I still think it is just ridiculous. We should be looking for solutions, not coercive sin bins. We want to move to a world where there is recognition for what is needed and a willingness to search and persist along with a generosity of spirit and humanity which benefits us all. I think we’ve had a lot of that generosity of spirit shown today, and it’s really incredibly heartening.
Our next annual conference is on the 16th of March 2002, and we will be holding that in York this time. The first of our workshops, start in York on Saturday the 25th of May. We hope to be moving more into training, because this something we’re really being asked for. There are two main strands that are emerging, one is in the whole area of treatment, and the other is the whole area of social policy and legislation. We’ve got a lot of sound advice and expertise within the organisation that we can draw on to push forward those two strands. So those are our two immediate areas that we’ll be working with.
I think that’s all I’ve got to say so thank you.
Paper
written for inclusion in ‘Personality Disorder and human worth’ a conference
organised by the Church of England Board for Social Responsibility.
"It's a
horror story", said my wife the other day, handing me a letter from the morning post. "A medical report
horror story". What I read shocked me, though perhaps it
shouldn't have, since I had met its like, too many times before. A bereft father, still grieving
from his son's suicide, had sent us a medical report he had found in his dead
son's wallet.
The report rang like a death warrant. The psychiatrist had diagnosed his son as suffering
from a 'severe psychopathic and borderline personality disorder'. Great concern was expressed in
the report for the safety of the staff. The report then continued by reviewing all
future avenues - each was punctiliously but effectively closed. Further hospital admission
the doctor advised, was best avoided, though psychotherapy should only be
contemplated as an in-patient – a real Catch-22. There was little
expectation that drug treatment could help; supportive counselling might benefit him, but could make him
worse. Admission to
the Henderson Hospital had been considered, but he was judged likely to fail
the admission procedures.
His prognosis was declared to be 'poor', and the risk of suicide
high. If you received
an authoritative assessment of your condition like this – what would you
do ? The report was dated
a few months before the son killed himself.
The chilling feature of this report is its
orthodoxy. The consultant
psychiatrist was playing by the rules. Every feature was correctly noted, every point solemnly
covered – there must be many, many thousand reports with exactly the same
tenor, the same bleak outlook, being written all the time. And that's the
problem. Psychiatry is
now facing the wrong way – and needs all the help it can get from its
many friends in the community to nudge it into more humane, and necessarily
more effective paths.
You may have no qualifications in psychiatry – you may feel
entirely unqualified to pronounce on the merits of obscure psychiatric
formulations. But you know
what human nature is fundamentally like – and sadly, this is something
that academic psychiatry seems essentially to have forgotten.
There are four questions –
1.
Are we really born
evil, or can we learn ? In other
words are we redeemable ?
2.
Is 'untreatability'
a reasonable concept, or is it something we shouldn't even give house room to
?
3.
Is there a simple
pattern behind every Personality Disorder ? And
4.
if so, what should
we, and especially the churches, be doing about it ?
I need to put my cards on the table. I have four psychiatric qualifications
and have treated mental health problems for 40 years. My research, especially my five years in
Parkhurst Prison, convinces me that childhood traumas distort adults'
personalities. Sadly,
despite my enthusiasm, several major psychiatric establishments elected to
discourage this approach.
The label 'Personality Disorder' is coming to resemble that of 'leper'
in the Middle Ages. How
would you react if the equivalent of a leper colony was proposed today ? And if this were happening in our
society, even if surreptitiously, what would you do ?
I sometimes think that there is a link between
the aftermath of the First World War and the bleak view too many psychiatrists
now take of what we humans are really like. The 'Vienna Circle' of the early 1920's
which so influenced Logical Positivism, Wittgenstein and Linguistic Analysis
was born in the cinders of the Austro-Hungarian Empire. Struggling for some stability,
something solid after all the earlier certitudes had crashed, these pioneering
philosophers decided that every word used had a simple meaning which could be
scientifically verified.
Without 'verification', the word was judged meaningless.
As Freddie Ayer later confessed, this basic tenet
was fundamentally false.
But the damage had been done. Words such as 'love', 'soul', 'spirit' were thrown
into the bin. The notions
that we have a choice, and a responsibility for how we behave were given short
shrift - after all, none of these 'values' could possibly be defined
'scientifically'.
My psychology degree at Cambridge University in 1957 taught me that I
was a cog in a cosmic clock – like a rat in a maze, I was destined to
scurry from one stimulus to another, without choice, free will or any sensible
alternative. Now of
course there are some religions who agree with this notion – they see the
wheel of life as immutable, whatever we do, or wish to do. But there are other faiths which
claim that we have moral choices, we have obligations and responsibilities, and
that we are blessed with the ability to choose. We may not always make a go of it, indeed too
often we make a hash of it –
but there is a chance we can improve matters, at least in some small way.
I have tried to argue this point with several of
my psychiatric colleagues.
At times it was like trying to decide the number of angels dancing on
the head of a pin. What do
you say to someone who is adamant that the individual under consideration has
no autonomy, no means of changing their situation, indeed no will power at
all ? This may sound something of an academic
theological question – but believe me, it has direct practical
consequences.
If doctors are dealing with a machine, a subset
of the clock work universe, then why bother to ask that person what they would
really want to do. If
the individual concerned has no ability to have any impact on anything, which
in a fully deterministic universe they cannot have – then why waste your
breath asking them.
Here the fundamental view of what human beings are really like, impinges
on how we should treat them, in all senses. You may not claim any deep or esoteric psychiatric
expertise – but if you believe we are not just mere bits of the cosmic
clockwork – then you are in fundamental disagreement with one of the
basic tenets of too many psychiatrists.
And of course, how you see human beings,
determines how you treat them. I find the notion of 'untreatability' quite
repugnant – what are doctors for, if not to treat people who are
suffering ? And as the
medical report mentioned above indicates, there is very real suffering in this
branch of medical practice.
Untreatability does not leap unannounced into the
medical vocabulary. It has
deep and unhappy roots.
I have found it gruelling trying to expose these roots, and as an
individual consultant psychiatrist have largely failed to expunge them, which
is why it is so vital that others see the problem for what it is, and lend
their shoulders to the wheel to remedy it. In a significant sense Personality Disorders are
too important to be left to the psychiatrists. I know there are many psychiatrists
who agree with my point of view – sadly none were in positions of power
to support my clinical work at the relevant time. There is also a social dimension to this problem even
a political one – which is why your personal 'take' on it is so
important. If you
agree with the psychiatric establishment that it is entirely justifiable to
label Personality Disorders as 'untreatable' then you should be aware of the
parallels with leprosy from an earlier era.
The simplest way to talk about treating
Personality Disorders is to start with the phrase "pull yourself
together". We all know
that when things get on top of us, we wilt. No one is a superman or superwomen – when
we get to our limit, then we tend to sag.
Some may have higher thresholds than others – but all will succumb
once the going gets too rough for their individual resources. So when you come across your
friend slumped in their kitchen bemoaning their circumstances – you put a
kindly arm around their shoulder, give them a cup of tea, and gently encourage
them to pull themselves together.
You can help most by explaining matters in a new light, pointing out
pathways through which the victim can improve their lot, paths they had not
seen, indeed perhaps could not have seen for themselves. But 'pulling themselves
together' provided it is done in a positive, friendly supportive manner is by
far the best assistance you can supply.
What you apply as a matter of course in the
kitchen, is ruled out of court in the psychiatric clinic. Were I to suggest to a
psychiatric seminar that my chief work is finding ways to assist my clients to
pull themselves together, I would be laughed out of court, or worse (as I have
been). And yet that is
precisely what I do, and the reasons I do it, are exactly similar to those you
would employ without thinking twice, to any of your friends in distress. It's just that people
with Personality Disorders have already 'sagged' catastrophically, while at the
same time arrive fully equipped with negative social skills – they insist
on asking for what they don't want, and have not the least idea how to ask for
what they do. In a word they
are socially dysfunctional.
Of course there is simply no way you can advise
others to pull themselves together if your view of human beings is that they
are automatons, who could no more initiate anything than add a cubit to their
stature. This is a fundamental issue. Can we influence ourselves and
our circumstances ? Do we
have choices ? If your entire psychiatric
training has taught you that we do not, then insisting on helping others to
pull themselves together can lead only to excommunication – hardly the
best route to promotion.
Untreatability has gained a sickening hold on
academic psychiatry, thence onto the statute book. It is deplorable in both settings. It is unlikely to shift soon -
the reason being that established psychiatry, at least as expressed in the
current psychiatric 'bible' (the DSM-IV), has not the least idea where
Personality Disorders come from. If you don’t know what causes a disease,
then you are likely to have trouble treating it, and you can certainly kiss any
cures goodbye.
So this is one of the roots of 'untreatability'
– a deep therapeutic nihilism pervades the psychiatric view of
Personality Disorders – nothing works. The medical report quoted above is typical. But let us suppose that the
reason why sufferers from Personality Disorder are so anti-social is that they
don't know any better. Their
experience in childhood has not been happy. They have learnt that human beings, especially those
with power, are unreliable, untrustworthy and destructive – somewhat
reminiscent of concentration camp guards.
Individuals traumatised in childhood will not be able to access normal social patterns of support – in a sense they have become immunised against any possible help at 'pulling themselves together'. Of course, those who can, will already have done so, and will therefore never appear in clinics or courts. It is only the ones who fail to remedy their deep seated traumas who find themselves in trouble. And this is precisely what I found during my five years working in Parkhurst Prison. There I was treating the most Dangerous Severe Personality Disorders (the notorious DSPDs), too violent for Broadmoor. And in every one of the 60 murderers and the six serial killers there was a grievous wound, or perceived wound from long ago. None of my work condoned the crime – but pursuing this approach in the teeth of some opposition we successfully explained that crime (generally murder), and as important, ensured it did not recur.
The data is encouraging – though the Home Office prefers not to publish it. During my five years in Parkhurst Special Unit the number of violent assaults recorded, dropped from one every two months to one every two years. Tranquilliser usage fell from 3.6kgs a year to 150 gms. No alarm bells were rung for 2½ years – a unique record world-wide for any Maximum Security Prison Wing. Were this an orthodox medical condition, such data would be tightly scrutinised. The fact that it languishes unpublished might indicate that it crosses unspoken ideological lines – which is another reason for enlisting wider involvement.
Some idea of the ideological barriers which this sort of approach transgresses can be seen from the media representation of DSPDs. Donald Duck is more like a drake, than Hannibal Lecter is a real serial killer – you can't have both social skills and killing skills, they don't mix. All real people are human beings underneath – if you can ever contact their deeply buried humanity – then, and only then, can you begin to assist them in pulling themselves together. One informal aim of the James Nayler Foundation Charity is debunking the Hannibal Lecter Myth.
Suppose, as I
do, that Personality Disorders arise from faulty childhood experiences –
then you would expect deficits in social skills on a scale commensurate with
the trauma suffered. Every
definition of DSPDs includes anti-social behaviour among its symptoms. What better remedy for unsociability than teaching them to be
sociable. Obviously this is
not as easy as it sounds – they come with built-in anti-social
mechanisms. But incarcerating
them in solitary confinement explicitly worsens the disease – it's like
overcrowding infectious lepers as a matter of public policy.
Being sociable to anti-social individuals carries
a potential risk – just as befriending lepers did in the Middle
Ages. But if no one
approaches them ever, if they are shut away in windowless concrete cupboards as
happens in California, or for 23½ hours a day as happens in Britain –
does this make any sense in a sociable species ? Does this really reflect what we think human
beings are, or should be ?
Are we really justified in doing this to them ?
I cannot get over the fact that our Prime
Minister, Tony Blair, stated loud and clear – "Our spiritual
values . . . matter more than either material wealth or political
ideology."
He said this during the recent Holocaust Memorial service. He also made clear that "A society without spiritual values is a society at risk". I wonder if he realised quite how true this is for how we treat our most dangerous prisoners, and indeed everyone else with a Personality Disorder. In the absence of robust spiritual values, anti-social diseases remain untreatable,
Spiritual values are difficult to define – though this troubles me not a jot. The 'Vienna Circle' was wrong – just because something is indefinable is no bar to it being the most important thing in human life. My minimum basic set of spiritual values starts with Truth, Trust and Consent. Every encounter I embarked on in the prison (and elsewhere) was characterised, as near as possible, by these three values. Furthermore, I took it as axiomatic that every human being is born Lovable, Sociable and Non-violent. This is what I found to be the case there. People from different faiths may express the same ideas in different idioms. You may chose to express these indefinables in ways you are more comfortable with, but so long as they overlap sufficiently, I shall not baulk. (I discuss these points more fully in my book 'Emotional Fitness' whose publication is currently delayed by cashflow problems at the publisher's.)
And so we come
to the lepers. 600 years ago lepers were exiled, cut off from
normal social intercourse in case they infected everyone else. A few dedicated souls
worked with them, improved their standard of living, and long before
anti-leprous drugs were available, enabled them to live longer. The optimum treatment for
this dread disease, then as now, was human comfort. How can we do less to our own mentally ill, merely
because the currently dominant section of the psychiatric profession has
determined that Personality Disorders are as 'untreatable' as leprosy ever was
? Isn’t it time to
apply other criteria ?
Nothing I have written ever condones what
dangerous individuals do.
Three murderers in Parkhurst threatened to kill me. Nor do I shrink from locking 'mad
axe men' up – temporarily and explicitly for treatment – to protect
society. But we need to ask
and ask promptly – what are the roots of this socially destructive
behaviour ? The obvious
answer is that they know no better.
So who amongst us, will help them learn ?
Ø Ø Ø Ø
Dr Bob Johnson
Monday, 26 February 2001
Consultant Psychiatrist, P O Box 235 York YO1 7YW
GMC speciality register for psychiatry reg. num. 0400150
formerly Head
of Therapy, Ashworth Maximum Security Hospital, Liverpool
Consultant Psychiatrist, Special Unit,
C-Wing, Parkhurst Prison, Isle of Wight.
MRCPsych (Member of Royal College of
Psychiatrists),
MRCGP (Member of Royal College of
General Practitioners).
Diploma in Psychotherapy Neurology
& Psychiatry (Psychiatric Inst New York),
MA
(Psychol), PhD(med computing), MBCS, DPM,
MRCS.
Approved under Section 12(2) of the Mental
Health Act 1983.
1999 “Building a Violence Free Society £5
2000 “Healing Emotional Conflicts” £5
2001 “Grounds for Optimism with Personality
Disorders” £5
2002 “Successful Work with Personality Disorders” £5
Video and Training Materials
“Extracts from Conference 2001” (45 minutes approx) TBA
“Emotional Education” (Video and Handbook)
(in preparation) ( Price to be decided)
Books
“Emotional Health” by Bob Johnson....... £12
(ISBN: 1-904327-00-1 )
All Proceeds from the sale of these publications go to the James Nayler Foundation.