Successful
work
with
Personality
Disorders
all
proceeds from sales of this book will go to the James Nayler Foundation
Preface
We were delighted to welcome 250 participants
to our Fourth Annual Conference, held for the first time in York, in the
beautiful surroundings of the Central Methodist Church.
With this publication, we now have four
complete proceedings of our annual conferences. These form an increasingly
useful and vital record of innovative development in this area. They uniquely
record the thinking not only of key experts from the UK and the USA, but also
the thoughts and experiences of those who have suffered from Personality
Disorders.
We are grateful to all who participated, thus
helping the positive development of the foundation.
Sue Johnson
Contents.......................................................................................
2
about the
speakers.......................................................................
3
Sue Johnson: Welcome to the Conference
& The Foundation 5
Introduction...............................................................................
5
Dr. Sandy Bloom: “Creating
Sanctuary”................................... 8
Creating Sanctuary: - Assisting the
Process of Healing............. 8
Questions for Dr Bloom from the
floor................................... 25
Dr Bloom’s slides – the
text..................................................... 29
A view from the Prison Service
-............................................. 43
Tim Newell’s slides – the
text – follows next............................ 54
Secure Psychiatric Provision:
Gender Sensitive Services?....... 36
Lin Hankinson Liverpool
Hope University College.................. 36
Lin Hankinson’s slides – the
text............................................. 68
Dr Bob Johnson “Emotional
Health”...................................... 78
introduction.............................................................................
78
Jamie......................................................................................
81
Margaret McCathie speaks of her
experience.......................... 92
An Inmate speaks about Personality
Disorder......................... 99
Nada Dobre speaks of her
experience.................................... 111
Nada.....................................................................................
111
Questions from the
floor......................................................... 118
Dr Sandy Bloom
Psychiatrist,
Past President of the International Society For Traumatic Stress Studies (ISTSS).
Co-founder and former Director of The Sanctuary, an innovative psychiatric
facility in Philadelphia, USA. In September 2001, she began implementing a
“Safe Schools, Safe Communities” grant for Atlantic County (New Jersey
District) using the Sanctuary Model which aims at reducing school violence and
improving the climate in the public school system. Pace School, in Pennsylvania
has also consulted with the Sanctuary team with a view to applying their
concepts to their hospital programme for emotionally disturbed children.
Dr. Bloom is the author of two books, “Creating
Sanctuary: Toward the Evolution of Sane Societies”, published in 1997
(Routledge) and (as co-author) of “Bearing Witness: Violence and Collective
Responsibility” (Haworth Press) and many other articles. She speaks nationally
and internationally about the impact of traumatic experience on individuals,
families, organisations and cultures.
Lin Hankinson
Lin Hankinson is a senior researcher within the
Applied Research Centre at Liverpool Hope. She recently produced a report
'Silent Voices', an evaluation of a forensic psychiatric medium secure unit for
women within the independent sector.
Lin has also been a professional counsellor for 11
years both within statuary sector and voluntary organisations. She worked for
three years within the NHS as a psychological counsellor, working with people
who had suffered severe and enduring mental distress. During this period Lin
was a volunteer with a women's visiting scheme; visiting and befriending
detained women within the Special Hospital system. Lin is currently a Trustee
on the Board of Imagine, Merseyside Community Mental Health Services and is
undertaking a Ph.D. thesis exploring women patient's experiences of seclusion practice
within forensic psychiatric establishments.
Bob Johnson Co-founder of the James Nayler Foundation.
Consultant psychiatrist, and specialist in the treatment of severe Personality
Disorders. He has worked in Parkhurst Prison and Ashworth Maximum Security
Hospital Liverpool. His book, Emotional Health is available direct from JNF,
P.O. Box 235, York, YO1 7YW UK, or through your local bookseller ISBN
1-904327-00-1.
Tim Newell has worked in prisons for
37 years. For the last 10 years he was Governor of Grendon, a prison run on
therapeutic community lines, up until last September. Currently, he is working
for the Prison Service on the application of restorative justice ideas in the
community.
His book “Forgiving
Justice” was published by Quaker Books in May 2000.
It’s just really wonderful to see you all! This is our fourth annual
conference. People have come from all over the country. We have people from
Canterbury, from Edinburgh, from Glasgow, from Wales, Nottingham, Liverpool,
Durham, Leeds and Manchester. It’s tremendous. We have here so much experience,
so much concern and so much expertise. We have people from the Health service,
the education services, from voluntary bodies, faith groups, we’ve got
families, we’ve got friends. We’ve got people with their own unique, personal
experiences of what we’re talking about and what we’re trying to do. So
welcome! We’re an interesting group, I think, and I hope that during the day you’ll
be able to talk to each other get to know each other.
I have two apologies. First of all, from the Chair of
our Trustees, Nina Hall, who has been a dedicated and extremely helpful
supporter of the JNF from the times when it was nothing more than a gleam in
the eye, so to speak. Nina is a high powered Lawyer in the City of London and,
as well as having four children under five, she has steered us through some
very difficult legal issues and has also kept us on track with the statutory
requirements of charitable status.
We have also received apologies from the Barrister,
Stephen Field. Some of you may remember his talk to conference last year when
he talked on “Untreatability”, the proposed mental health legislation and the
Human Rights issues which this would seek to ignore. His paper has been
reproduced in the Conference Proceedings for 2001, which is available at the
back of the hall. I think that he would like us to inform you of a mini triumph
this week. He took a case to appeal which restored Legal Aid to a group of
people who have made a claim for damages following Electro-Convulsive-Therapy
(ECT). That’s quite a breakthrough.
A few years ago we met a very remarkable man, who had
done a number of very remarkable things in his life. He was then very elderly.
We asked him how he’d done it and he said something that has stuck with me. He
said
“Go as far as you can see, then see how far you can
go.”
It’s so true. That’s what we’ve been doing. Each year
when we’ve had our conference, we’ve been able to see more and more.
Following last years conference, we’ve organised five
workshops. We’ve started a development group that meets monthly which is
proving to be a crucible of activities and ideas. We have created quite an
extensive film archive over the last year from which we are actively developing
training films, a promotional video and a documentary. An edited 40 minute
video of last years conference is now available.
Finally, I just want to say that I have been
overwhelmed by the stories that I hear from families, friends, doctors,
probation officers, teachers, carers, chaplains. There is much left to do - but
it is truly wonderful to be able to do something rather than nothing and to be
able to join with others. Last year I said that the important thing was just to
keep going. This year I want to say rather more than that. We do need money.
This year we are going to ask our supporters to give something each month by
standing order. This will allow us to plan with confidence, to go as far as we
can see.
Now, I want to introduce Sandy Bloom, who really has
done something very powerful. Sandy has come all the way from Philadelphia. In
Philadelphia she set up a unique facility for caring for people who have really
suffered traumatic abuse. She is now working in the community. We have got
flyers about her book, “Creating Sanctuary” at the back of the hall. It’s a
very powerful book. It is clear, humanitarian and very readable. Ever since I
saw it, it has been my ambition to meet you. So it’s great to invite Sandy
here. Thank you very much.
I’d like to thank Sue and Bob and the James Naylor Foundation for
inviting me here. It’s a pleasure to be with you. As Susan said, from 1980
until 2001 I had an in-patient unit with some friends of mine and from 1991
until 2001 we specialised in treating adult survivors from childhood abuse,
trauma and neglect. In that time we treated 7000 survivors and they taught us a
lot about what it means to be traumatised.
Understanding the impact of trauma has changed my life and part of what
I have come to understand is how much trauma impacts upon childrens lives and
how much it determines a lot of what happens after that.
Colleagues of mine have observed that prolonged exposure to combat,
torture, captivity, death and destruction can also bring about long-lasting
personality change. As a result of all the science we have now on the impacts
of trauma on people we have a much better idea of how these personality
disorders evolve and we may go as far as to say that childhood maltreatment
increases risk for Personality Disorders during early adulthood (Johnson,
Cohen,Brown, Smailes, Bernstein, 1999).
I want to show you a slide about a community-based longitudinal study we
used to investigate whether childhood abuse and neglect increases risk for
personality disorders during early adulthood. The study showed that people with
documented childhood abuse and neglect were more than four times as likely as
those who had not been abused or neglected to have (to be diagnosed as having)
personality disorders during early adulthood.
I have called this a “Prescription for a Social Disease” or “How to Make
a Personality Disorder” and I think that all you have to do really is abuse,
neglect, or otherwise traumatize a child; make sure the child has no adequate
external resources to deal with overwhelming physical and emotional states that
follow upon being abused or neglected and then prohibit or inhibit their
ability to find healthy outlets and adaptations; then reinforce, reward, ignore
whatever problematic forms of self-regulation they are then compelled to
employ, like cutting themselves, self-mutilation, eating disorders, use of
violence and substance abuse; and then prohibit or inhibit the child from
talking or thinking about what they feel, from talking about their internal
states and the contradictions that they are experiencing; then keep them
isolated with their fears and, as this helps them mould their character, do not
help them to deal with problems of being effective in the world, with shame,
hatred, anger, and self-hatred, as well as the problems of working through
interpersonal conflicts. As all of that is happening encourage excessive
dependence, social isolation, lack of trust, and add the failure to establish
mutually satisfying relationships, and then hold the child entirely and solely
responsible for all this. Punish them if they try to object, protest, or
change. Disbelieve whatever they tell you that does not reinforce pre-existing
notions and predict that they will always be the way they are – and there
you have a clear prescription for how to do it.
“Creating Sanctuary”, for me, refers to the shared
experience of creating and maintaining safety within a social environment and
by that I mean any social environment. What we’ve learned from the people
we’ve worked with is that what they need in order to heal is not that much
different from what we all need to live successfully and feel like we are loved
and cared-for human beings. So what we are trying to do in our work is apply it
across the board in all different kinds of settings.
It’s relies on four basic foundations of knowledge.
There has developed in the last twenty years a more convincing scientific basis
for understanding what happens to people who are exposed to overwhelming
amounts of stress and that comes under the rubric of Trauma Theory.
Now, that’s the content of what we learn and about and
which we teach our clients – but a lot of work goes into creating a
context. We aim at the active creation of non-violent environments, that’s not
anti-violence, not violence prevention, but non-violence,
something that doesn’t get talked about any more, certainly not in my country.
It means that you really have to work from democratic principles. Democracy as
a principle and as a practice is designed to minimise the use of abusive power.
A central issue for traumatised people is exposure to abusive power.
The third main pillar is all that we’ve acquired about
social learning from fifty years of practice in therapeutic communities, most
of which, at least in my country, is being lost! It is no longer being
practiced in the United States.
The fourth pillar is the whole science of Chaos
Theory: Complexity-Emergence, which is really about the science of change. How
living organisms change and of how we come together in any kind of group and
instead of competing for the right answers we find ways to combine our problem
solving and develop a consensus that works better then any individual solution.
Those are the four pillars of knowledge.
What we’ve learned about people who have been abused,
neglected and otherwise maltreated is that they develop a complex of very
complicated, interwoven dilemmas and often they get diagnosed with one or more
peronality disorders as well as acquiring all other kinds of psychiatric
labels. But we have not found those diagnostic labels very helpful in figuring
out how to help the person. We find the concept of post traumatic stress
disorder is much more useful and the situation really looks like this: people
experience problems with managing emotional states, problems in attention and
consciousness. There is a tendency to experience a whole lot of things through
ones body, through all kinds of physical symptoms, the experience of
alterations in the ways people look at themselves, alterations in the way they
look at the people who hurt them, alterations in the way they look at others in
general and profound alterations in systems of meaning, in terms of their
trying to make sense of the world.
I would like to say something here about what we, as
clinicians, have experienced with this material and to mention some of the
implications it presents for treatment and of how it has informed our model.
First of all, this affective arousal – of being
unable to control emotional states as a result of the fight-or-flight response.
This hyperarousal comes, normally, as a result of any kind of danger and from
the tendency of human beings to focus exclusively on any kind of threat; as a
result of prolonged experience, physiologically, with being exposed to danger
and threat over time.
If you repeatedly subject a child to danger and
threat, the child will develop what looks like a hair trigger temper and mood
instability - because they have been prepared by their life experience to
respond to danger in a way that once fitted us (from an evolutionary point of
view) in our original environment but in a way that is not very well suited to
living among other people and, more especially, in situations in which the
people who we are dependent upon are the source of the danger! The child will
develop impulse control problems because if you are in constant danger, you are
not supposed to be able to control your impulses, you are supposed to be able
to respond immediately to any kind of threat, by fighting or by running away.
Chronic fear states take hold because it doesn’t take seconds to get over
something like that, it can take days or weeks once you have had a severe
fright, to get over it and feel OK again. You may remember after September eleventh
that it was a little hard to concentrate and to sleep well for days and, for
some people, weeks afterwards, even though it was thousands of miles away.
The problem of hostility directed at the self and
others appears. If you spend a long time in that state of hyperarousal, of that
state of being prepared for danger, then you are going to be geared to respond
with hostility to any kind of a threat. One of the ways of coming to that state
of hyperarousal is you are going to use drugs, you are going to use alcohol and
all kinds of compulsive behaviours to try to manage these overwhelming states.
The attention to threat is supposedly rivetted on any
potential threat within our environment, that’s what we are designed as mammals
to do – but if someone is in that state for prolonged periods of time you
are going to see primitive aggressive behaviour, an increase in territoriality,
a fixation on threat, which is going to lead to attention problems. A
chronically threatened child is going to have a lot of difficulty in the
classroom. The sense of threat or fear does not just evaporate overnight.
There is also going to be an increase in the need to
belong to a group. That can be a real problem for children as they grow up and
have the opportunity to identify with a gang. The chronically threatened child
begins to feel that safety lies in numbers. That is part of the human
experience, its part of what we are designed to do. If you are in that state
you are likely to have trouble taking in new information and to have lots of
problems tolerating uncertainty because in a threatening and uncertain
environment, uncertainty could mean death. So you don’t tolerate situations
that are unclear or ambiguous and yet most situations that require the
sophisticated interactions of social life are pretty ambiguous and can be
interpreted in any one of a number of ways. So you see people who become very
hypersensitive to any kind of threat in the environment and oblivious to
anything positive in the environment. Over time the threatened child will see
threat very rapidly and interperet all kinds of human signals as threatening
even when they are not meant to be! They will not see positive things, they
will not see praise or admiration. That sort of information is unimportant if
you live in a threatening environment.
What are the implications of that for the environments
we create? For the treatment environments or the living environments we create
to help people who have been traumatised? It means that they need physical
safety but it also means that they need safety of all other kinds.
Psychological safety: being able to be safe with yourself, social safety: being
able to be safe with other people and moral safety: to be safe to make the
right choice and to know that if you do make an error that there is going to be
some allowance for the correction of that error, that the environment is not
going to contradict what it says that its highest values are.
It also means that we are going to create environments
that minimise threat if we want to see people heal. We need to minimise
physiological hyperarousal. Post traumatic stress disorder is the way that the
mind and the body gets stuck, stuck in the fight-or-flight response. You can
spend a lifetime stuck, like the hold button on your telephone, with this
prolonged hyperarousal that just doesn’t go away and that you have to react to
in one of a number of ways, one of which may be addiction. We need to treat the
addictions and understand them in the context of what has happened to the person.
A soothing environment is not, in itself, good enough, we have to teach people
how to calm themselves down. We have to use some very deliberate self-soothing
techniques for teaching them to manage these overwhelming emotional states: and
that requires all kinds of cognitive behavioural approaches.
Now the next legacy in trauma is alteration in
attention and consciousness. We have a cognitive need for calm with these very
complex brains and they only work within a certain band-level of arousal. If
you go too high you can’t think, if you’re too under aroused you go to sleep.
We have a pretty narrow band, our central nervous system is vulnerable to
stress. When we’re stressed, “normal” people, we don’t have good decision
making, we become set for yes-no emergency responses, life and death. In that
state we have trouble maintaining attention, we may often dissociate, in order
to protect our CNS from too much stimulation, and under those conditions our
thinking literally goes ‘down the tubes’. You have a child in that state for a
long time, they are going to have learning problems, and that’s going to lead
them down all kinds of problematic pathways. The implication for treatment
being that people need safe environments. Children need safe environments in our
schools. Again, they have to learn how to calm themselves down so that they can
think and work on developing their cognitive, problem solving, decision making
and conflict resolution skills. These skills have to be very deliberately
taught.
It means recognising and treating dissociation:
understanding the way the CNS protects the body from death. You can die of
fright. You can die of a broken heart. We have these very complex brains and we
make many associations to any traumatic event. What we’ve discovered as a
result of trauma is that one of the most devastating aspects of being
overwhelmed by fear is that you lose the capacity for language. At the moment
of fear the verbal centres of our brain shut down. We continue to take in
information, but we take in information in the form of non-verbal images,
sensations and feelings. Our verbal and non-verbal “minds” become separated.
There is a split between verbal and non-verbal communication, verbal and
non-verbal memory, verbal and non-verbal cognition. What that means is that the
most horrible parts of the experience have no words. If there are no words then
you can’t talk to yourself. You can’t know what happened to you. You can’t find
the words to communicate to anybody else. You don’t have the development of
adequate self-talk. You can’t learn actively to control your impulses. You are
going to function in a separated way. There will be one part of you that you
might identify as your Self, that knows and thinks and feels and, autonomously,
this other part of you carries on this separate life that you don’t understand
and you don’t really know and that you don’t really feel. In a very frightening
way, it suddenly re-emerges as flashbacks, the sudden intrusive re-experiencing
of a traumatic event, through the body and through the mind. The inability to
give words to feelings is a devastating experience. One of the principle
aspects of what therapy does is to allow people the space and the relationship
within which to try to put into words those wordless and overwhelming feelings
and that kind of knowing.
It means, for us, that we have to suspend judgment
about what the behaviour means and instead to become curious about it. Why is
this person doing these things that I don’t understand? - rather than judging
them as good or evil from the outset. What we are seeing is verbal and
non-verbal splitting and that means that treatment requires both verbal and
non-verbal interventions. Our traditional forms of therapeutic intervention are
essential but are probably not enough. We need other kinds of modalities. All
the other kinds of creative treatments come in giving voice to that speechless
consciousness. Writing, ‘journaling’, all those kinds of modalities: movement
and psychodrama, all those kinds of therapies that have grown up in the last
thirty years speak to this verbal and non-verbal split, and point to why they
are so critical. That may, indeed, be why the human species evolved the use of
the arts because we need some bridge across the “black hole of trauma”.
Another legacy of this trauma is this tendency to put
the most horrible aspects of experience into the body. What we see from the
outside is we see people remembering things through their body. A rape victim
may have chronic pelvic pain, someone who was hit in the head may have chronic
headaches, someone who was hit in the stomach may have chronic stomach aches.
Those are memories. The body remembers what the mind forgets.
We can also see people with conversion disorders, with
psychosomatic and stress related disorders, with auto-immune disorders, with
basically any kind of other medical problem because as the stress goes on over
time the body reacts. It may start out as a body memory but over time we can be
affected in ways that are not entirely clear or well defined at this point, but
certainly happen. The implication for treatment is that medical personnel have
to understand this. What happens is that body memories often get mis-diagnosed
by medical professionals, they don’t understand what it is, they don’t understand
what they are seeing and they either try to treat something medically that
should be treated psychiatrically or, once they think its something
psychiatric, they call the person a ‘crock’ and send them on their way. We need
to bring back the idea of the mind-body as one unified whole. It means
integrating the somatic component which is what the body memories are and to
find ways to give the body speech. All kinds of body work and other kinds of
non-verbal therapies become critical components of the healing process.
Medication may be entirely necessary, both from the point of view of the
physiological hyper-arousal and in terms of what is happening to the body.
Physical presentation is often one of the ways people express unrelenting
grief.
I am going to focus on two areas concerned with
alterations in self perception: our need to be in control and our tendency to
adapt to any kind of adversity. We hate being helpless. We’ll do anything as
human beings to avoid experiences of helplessness and yet that is the hallmark
of trauma. You probably won’t experience something as traumatic unless you’ve
been helpless in the face of it. By definition, children are helpless. There’s
very little they can do to run away from abusive carers, or to fight and defend
themselves. What you see in children, adolescents and adults who have had these
experiences, is the recurrent experience of helplessness. At this point, when
we see them, they are helpless with regard to their own impulses, over
themselves and over what they experience with reference to other people. You
have a self that does not have a sense of self-control or mastery. A self that
is split and divided. You see a lot of controlling behaviour. Attempts to
control other people, to control therapy, to control the environment, often in
very self destructive or other destructive ways. You see people who could take
more control over their lives but who have learned or come to believe, deep in
their hearts, that it doesn’t matter. There is nothing they can do that can
really make a difference or really bring about change. They experience chronic
shame states and a willingness to give control to substances and behaviours,
but not to other people, who may indeed be reliable. Initially, when people
start to use substances, alcohol or drugs, it provides an illusion of more
control and part of the power of addiction is that you, in actuality, lose
control.
In treatment therefore, we want to increase mastery,
we want to structure environments so that people who have had this happen to
them have repetitive experiences with mastery, in small steps to begin with
because we don’t want to set up environments where they fail. You want to
provide experiences of mastery, you want to avoid the use of any kind of
seclusion or restraint that makes them feel more powerless. You want to help
them develop a realistic appraisal of the self, not as being all-powerful and
not as being powerless. That’s going to require psychodynamic and relational
forms of psychotherapy. You are going to need to confront the controlling
nature of abusive behaviour, of the self and of others. You need to do a lot of
work around Trust. Human beings adapt very rapidly. That’s why we live from the
equator to the Arctic. We can get used to virtually anything. So what you see
are people who survive under incredibly adverse conditions quite admirably.
They have been able to survive horrendous experiences as very young children,
but what that does is, once they have come to adapt to adversity, when they try
to change, when they try to move out of that, it can begin to feel very unsafe.
Paradoxically, they have come to establish a certain degree of safety and
normality under conditions of adversity and then the opportunity to get healthy
can feel very frightening. Frightening at the level of life and death. People
are too terrified to change. They are reluctant to try new things. They are
stuck there in their repetitive patterns of adversity. They take the view of
themself as inadequate to deal with anything except the situations that they
are already in. From the point of view of treatment, the outside world has to
set the expectation of change and movement toward health and to be able to
define what that is. Bob’s new book is called “Emotional Health” and that’s
what we really need to be talking about. There has to be some sort of beacon
that you are moving towards for you to know where to move to! It means helping
people break bad habits and see that what they have are bad habits, not that
they are bad people. At the same time we have to recognise that these habits
for human beings are very hard to break. We tend to err a great deal before we
begin to change the habit. We need lots and lots of practice. Doing the same
thing, making the same mistakes over and over again, before we finally…get it.
For the people who are trying to help it means not settling for pathology, of
recognising that bad habits can be broken. To say, yes, you can do it. Yes,
you’ve made a mistake. But not to give up. That’s one of the problematic aspects
for many people in the mental health community, that we give up on people who
have these bad habits, who we label as having personality disorders. Because we
don’t understand how hard it is for them to change the habits that they have,
that it’s as hard for them to change their habits as it is for us to change the
bad habits that we have!
Alterations in relation to others is about disrupted
attachment. If you have had bad early childhood attachments, attachments that
have hurt you, then you have a disrupted attachment system and what you do is
repeat patterns of early childhood relationships. You are going to form
relationships, as an adolescent or as an adult, in which you re-enact those
early relationships like a drama, over and over again. Although your cognitive
self, your verbal self may say, “I don’t want to get in this relationship, I
don’t want to be with the same person again”, your traumatised self will
re-enact that drama. You will feel like you are a helpless victim of your own
impulses. You will have difficulties with Trust and trouble managing emotions
because that is what the attachment system is supposed to do, help teach us to
manage our feeling states. In treatment we are going to see a constant testing
of relationships. We are going to see a resistance to giving up coping skills
and relational skills that work. We need to understand that this re-enactment
is both unconscious and bilateral. That the person can only re-enact if they
have someone to re-enact with and it is critically important for that helping
person to get out of the re-enactment, to redirect it down a different path.
We are born with an innate sense of fairness and here
I want to come to consider the perceptions of the perpetrator. We consider that
we are born with an innate sense of justice. It’s based on our heritage as a
social species. The basic programme for that is recoprocity. If you hurt
someone, they will have an urge to retaliate, that’s perfectly normal. What you
see with people who have had this sense of justice repeatedly violated is
outrage, anger, fury, rage, an inability to exercise responsible authority over
themselves, over other people or the tendency to submit to abusive authority.
They retain fantasies about their perpetrators, who are able to continue to
exercise an influence over them even though they may be long dead. There is
often a tendency for the victim to re-enact those abusive relationships. You
see a preoccupation with justice paired with the exercise of abusive authority;
the failure to recognise injustice, both on the part of the perpetrator and the
self; you see twisted, delayed, self-directed forms of revenge that are not
understood in that context but can be; and a fierce defence of the helpless.
The implications for treatment are that we have to find ways to help people
seek justice, its going to be there and its going to be critical to help them
find ways to do it. It means giving very clear and concrete guidance in using
authority fairly and effectively. Its about learning to play democratically.
If you have grown up in an abusive home then what is
going to happen to you in the sequence of environments that you find yourself
in over and over again is that you are going to end up demoralised, alienated,
feeling hopeless, helpless, despairing, with a loss of faith, a loss of hope
and, of course, engaging in all kinds of destructive behaviours. What we need
to do is establish communities of meaning. We have to educate people about what
has happened to them, put it into a social and political context and help them
to restore their hope. Ultimately, in the hope of creating some kind of
transformative possibility and experience.
I want to tell you a little bit
about what we are doing now, because we had to close our programme last July
(the Health care programme in the States now is quite appalling). We want to
show other people how to do it. We have created this model (only part of which
I have been able to tell you about) and we are now putting it into residential
treatment centres for adolescents, into in-patient hospitals in settings to
reduce restraint, into domestic violences shelters and rehab settings for women
who have been incarcerated, for substance abusers and in the public and private
schools as a form of violence prevention. We are about to start training a
whole social service system in a city north of Philadelphia because they have
come to recognise that in order to provide adequate service they have to be
speaking the same language and that training is will rest on the same basic assumptions
of the Sanctuary model. I will finish with that and answer some of your
questions.
Sue: Its lovely to hear a Psychiatrist
say “Don’t give up!” It’s lovely to hear such an intelligent, informed
approach. It’s great to hear that you are moving out into the community and
setting up preventative centres.
I’m sure that there are people with questions.
Question: My ex-husband suffers from a
personality disorder, a borderline personality disorder, but my difficulty, all
the time, has been to get him to admit that there was a problem, so eventually
I divorced him. I’d do anything to help him get treatment.
Sue: Thank you Gwen, but I think that
this is more a question about what provision there is in this country. Perhaps
if you were in Philadelphia…
Sandy: It’s also the question of the barriers we put up
before people. If to begin with you have to recognise that the price you have
to pay is that you have to be diagnosed and put into a box, then you start out
from a position of shame and that’s what the mental health system does. Before
you can get help you have to surrender your pride. People have already
experienced overwhelming helplessness. That’s an insurmountable barrier. It’s a
problem of ours. What we found is that if we shared our framework with people
from the very beginning: that you are an injured person, not sick, not a bad
person, that you are injured, it’s not your fault, but you have to take responsibility
for your injuries, that changes the framework entirely for the person. The
whole system is designed not to have that happen, then we wonder why people
don’t get into treatment who really need it. It’s asking too much.
Question: Psychiatrists and the mental health services give out
drugs. It’s unusual to hear a psychiatrist giving a talk and not mentioning the
use of drugs. What psychiatrists say, and I respect them when they say it, is
that they “can treat with drugs but the rest is very, very difficult indeed and
it’s too expensive to do”. Now, are they being despairing? These are people who
care. I hear about others who don’t care, they are doing dreadful things with
drugs, but these are people who genuinely feel that they can treat a small section
of illness and the rest is very difficult indeed. Are you in that difficult
area?
Sandy: We use a lot of drugs. I don’t want to convey
otherwise, because of the material I was talking about, about the chronic
hyperarousal. Sometimes the only thing you can do is calm the body down is to
use some kinds of medications. That can really help. We are not averse to
medications. We are averse to using medications as a substitute for the much
more complicated kinds of treatment that people need. Now, if you don’t
understand the impact of trauma, if you don’t understand the material I was
just talking about, as a psychiatrist, then you will not be effective in the
treatment of people with personality disorders and a lot of other people. The
things that you do won’t work very well. The things that we used to do didn’t
work very well. I’m talking from the point of view of before and after.
Our methods were effective not because there was a
change in our patients but because there was a change in us! This is very new
information – it’s not even twenty years old so it has not yet filtered
out into the wider community, into training programmes, it is only now
beginning to impact on the field in very inchoate ways. The longer you’ve been
a clinician, the longer you’ve had to get entrenched in your ways. It’s going
to take time for this information to percolate outwards. I think that as
psychiatrists and therapists begin to understand the psycho-biology of this
material, not just the psychology, but what’s going on in the person’s body and
how it affects what’s going on in their mind, we can find better ways of
marrying the biological place of using medication with other forms of
treatment. There is in fact lots of hope. There is no reason to despair any
more.
Question: What about those others outside your profession? Do
they just sit on their hands and wait?
Sandy: I think what people are doing is that they are
learning. the people here, they are reading, they are finding out, they are
making judgments about which therapists and which psychiatrists they should
see.
Question: I’m a social worker and I have been working with the
children of parents who have experienced considerable trauma. What role do you
think the parents can play?
Sandy: It depends a lot on the family. If the family is
willing. The problems that we see are multi-generational. They start many
generations before. If you get the family into treatment and you work
simultaneously with the children, of course it will increase the odds that
something is going to change. The parents of course, will come in feeling
terribly guilty and will try to defend against the guilt they have, to deny the
problems because they put themselves in the position of perpetrators by so
doing. There’s a knee jerk barrier for clinicians too, to let this material in,
because they have then to account for the mistakes that they made in the past.
Parents have to allow for having made mistakes. If you can get to them that is
ideal! Realistically though, it’s going to be hard work, that’s all. Parents
here in the UK are held to be totally accountable, but in the US, over the last
25 years, it has become really very difficult because nobody is there!
Everybody has to work and there is no adequate day care. It’s a serious social
dilemma that society is not prepared to take responsibility for.
Sue: I think that we’ll stop the questions there. There
will be another opportunity for questions this afternoon, to ask Sandy more
questions. Of course, there is her book: “Creating Sanctuary” and you can find
details at the back.
Continuing staff development and education
materials for staff
Establishing the Context: - Components of a Sanctuary® Environment
·
On-going milieu management
·
Regular individual/group
consultation and supervision
·
Evaluation of outcome
Introduction
The definition we are
working with in the Prison Service is related to our concept of Severe Personality
Disorder. It is news and a pleasant surprise to many prison staff that the
disruptive difficult behaviour exhibited by many prisoners over the years can
be defined. There is also some surprise that the treatment of difficult
prisoners is under such scrutiny today and that new models for treatment are
being considered for the future.
The definition of
personality disorder we work with is -‘Patterns of behaviour or experience
resulting from a person’s particular personality characteristics which differ
from those expected by society and lead to distress or suffering to that person
or others.’
The size of the
population in prisons
The Home Office and the NHS have been reviewing the
management of those offenders who can be described as having a severe
personality disorder. The definition of such people used in the report is:
‘those people who (using validated assessment / diagnostic procedures)would be recognisable
as having a personality disorder which is manifested in seriously irresponsible
and damaging behaviour, and who on account of the disorder are considered to
represent a serious risk to the public.’
This gives a broader
definition of ‘psychopathic disorder’ than that used in the Mental Health Act
and is potentially more useful.
The recent survey of
psychiatric morbidity in the prison population carried out by the Office for
National Statistics ‘Psychiatric morbidity among prisoners’ (1998) has shown
high levels of disorder in the population. When several factors were combined
it was possible to extract that about 1400 in the male sentenced population
would meet the definition of severe personality disorder. There are 400 people
in the secure psychiatric hospitals with a primary diagnosis of psychopathic
disorder. There are thought to be between 300 and 600 people in the community
who would qualify for the new description. The evidence is that 63% of male
remand prisoners, 49% of male sentenced prisoners and 31% of female prisoners
were assessed as having antisocial personality disorder. These results are
broadly in line with findings from the prison population in the United States
and contrast with the prevalence of such disorders in the general community
which are estimated to be about 4.5% for men.
Prisoners with personality
disorders were more likely than other prisoners to be young, unmarried, from a
White ethnic group and charged with acquisitive offences (burglary, robbery or
theft) rather than drug offences and less likely to be held in open prison. A
large proportion of all prisoners had several mental disorders. Those with
anti-social personality disorder were more likely to report hazardous drinking
in the year before coming to prison than others and were more than six times
more likely to report drug dependence.
The ONS Report describes
the population of prisons as having only fewer than one in ten with no evidence
of any of the five disorders considered in the survey (personality disorder,
psychosis, neurosis, alcohol misuse and drug dependence). There is thus a most
disturbed group in custody in prisons exhibiting all the elements of high risks
of reoffending. The focus in prison often is on the management of risk and the
skills developed over the years by prison staff is to assess and manage risk to
ensure that the environment of a prison is sustained at an equilibrium.
Although the emphasis in prisons is focused upon reducing the likelihood of
major risks such as riot and escape there are systems for considering other
risks such as suicide and self harm, health issues, family breakdown and
increasingly now the issue of reducing rates of reoffending.
Assessment
Routine assessment of
prisoners for personality disorder is not carried out by the Service because
this information has not been central to our priority work. The measurement of
a feature may also bring with it certain obligations and responsibilities to
treat the diagnosis. With the very high rates of psychiatric morbidity described
in the recent report and in previous ones (Gunn 1996 - which tended to
underestimate the level of disturbance) there might be an expectation that we
should be able to provide some management of the findings of disorder. Some
individuals of course receive treatment for their personality disorder, when it
is diagnosed, through the Prison Healthcare system or the problem may be
addressed through programmes or therapeutic regimes - such as that at Grendon.
However there is currently no strategic treatment approach to dealing with this
group and sometimes there appears to be an underlying assumption that the
traits represented by the population are normal for those in custody and that
it is our business to handle and care for the people as best we can.
Assessment for personality
disorder and for psychopathic traits as measured by the PCLR is increasingly
being introduced as Offending Behaviour Programmes are available for serious
offenders. These programmes, arising from the ‘What Works’ movement of evidence-based
effective courses, require those participating to be screened as one of the
criteria for acceptance on a cognitive behavioural course is determined by the
absence of high psychopathic characteristics as measured by the PCLR. The
Dispersal Prisons are also routinely assessing new receptions using the PCLR.
Treatment in Prison
There has been grave concern that the treatment of
such people in special hospitals is now recognised as unlikely to prove
effective for many of those diagnosed as having a psychopathic disorder. There
is thus a move to transfer them out of that expensive setting where they have
been bringing the whole ethos of the hospitals into disrepute, particularly
following the Ashworth Inquiry. They are known to be amongst the most intractable
of the prison population and with the development of offending behaviour
programmes in prison regimes much consideration is being given to the
disruptive nature of the presence of such prisoners on courses. The hard
evidence is that many may not benefit from cognitive-behavioural courses and
indeed participation in such courses can be harmful and so some are now being
screened out at the selection process. The discharge of some high profile sex
offenders last year led to a renewed impetus from health services, the police,
the probation service and from politicians to resolve the dilemma of offenders
who are still considered to be dangerous being discharged into the community,
sometimes with no formal supervision responsibilities. The procedures to provide
safe settings for such offenders are cumbersome and costly and are sometimes
dependent upon the co-operation of the ex-prisoner. Thus there are many
motivators to provide alternative, safer, more workable and less costly
solutions to the issue of risk represented by such a group.
I.
Within prison the management and treatment of prisoners is dependent on the
establishment of clear boundaries within which staff and prisoners understand
their relationships. The emphasis on security and the concern about the risk of
riot and disturbance has led prisons to develop a closely controlled setting.
II.
Within this setting there is a system of clear incentives and earned
privileges which are understood and generally accepted by prisoners as being
legitimate and fair in their application. Thus good behaviour is rewarded by
key privileges such as extra money and more visits, whilst poor behaviour is
reflected in a lower standard of daily access to activities such as leisure
time association.
III.
All prisons have a system of sentence planning through which the prisoner
and the staff concerned with him decide on priorities for the sentence
activities over time.
IV.
Within the sentence planning process is the expectation that there will be a personal
officer system
in training prisons, so that role modelling is a possibility as well as the
establishment of a sound working relationship through which personal problems
and issues can be resolved.
V.
There are opportunities for long-term prisoners to be admitted to the Maxwell
Jones type of therapeutic community settings, such as Grendon, Gartree and the
Max Glatt Centre in Wormwood Scrubs. These seek to improve the level of personal
functioning within a caring, supportive community and there are good
indications of their effectiveness in short term and long term behavioural
changes. There is also evidence of a reduced risk of re-offending over a long
period at risk (7 years).
VI.
There are also concept based therapeutic communities within prison which address
the drug treatment needs of prisoners.
VII.
The provision of close supervision centres in dispersal prisons for the
most disruptive of prisoners provide an incentive based regime for the most
difficult of men to improve their behaviour over time and be rewarded by a
progressively improved quality of activity and access to privileges. The CSC
system is for a very small hardcore of prisoners who do not respond to existing
control mechanisms. The aim is to strike a balance between fairness to the
prisoner and the security of the establishment, the safety of staff and other
prisoners. For prisoners with severe personality disorders at the top level of
the CSC system at Woodhill individual behaviour problems are addressed through
structured activities, one to one psychological intervention and locally
developed group therapy. Prisoners at Hull receive counselling and undertake
cognitive behaviour programmes. The Durham Unit manages prisoners who have a
history of highly disturbed behaviour in a therapeutic small centre environment
with specialist psychological and psychiatric support.
VIII.
The management of life sentenced prisoners provides a model for the
risk assessment process over a number of years. A Lifer Sentence Plan
identifies with the lifer the areas of concern which are those the prisoner
should work upon in order to demonstrate that the factors which contributed to
the offence have been dealt with. This happens within a setting of reducing
security and control settings as the lifer is moved towards release through an
open prison and eventually through working in the community.
IX.
A series of accredited offending behaviour programmes have been developed to
ensure that the results of research are applied to focus work on reducing
reoffending. These are primarily cognitive behavioural in their approach. There
is increasing evidence from the results of such courses that they can affect
the long-term behaviour of offenders for the good. Some of those on courses
have been those with severe personality disorders, but generally those with
psychopathic traits as measured by the PCLR are excluded.
X.
As prisoners come towards release from a long sentence there is an opportunity
for many to prepare for their eventual return to their community by going to an
open or resettlement prison. During this period of focused time which is
concerned with developing working skills and activity routines which will
enable the person to support themselves or their family on their release there
is much attention given to restoring and maintaining relationships within the
family. Probation staff who will be supervising the person on release maintain
contact with the family throughout the sentence and as home leaves and
community visits become more available there are more opportunities to support
the family working together for the future.
Many of the above factors
are dependent upon the level of motivation from the prisoner and
particularly those which involve the intense activity of the therapeutic
community experience or the offending behaviour programme. There is evidence
that as prisoners get older they are likely to respond more fully and effectively
to treatment programmes or to change their behaviour as a result of the
maturation process. There is also in our experience the likelihood of an event
or a crisis which may trigger a prisoner seeking to engage in
treatment, such as a bereavement, an anniversary, a birthday or a visit. There
is a need for staff to be sensitive to these opportunities and make appropriate
assessments at the time.
Management of release
There are closer
partnerships being developed between the police, probation and prison services
in the management of the release of potentially dangerous offenders. The probation
service
are working closely in prisons throughout the prisoner’s time in custody and
increasingly there are many prisons which have liaison police staff working within them to
co-ordinate intelligence and improve communications. Particularly important for
good contact are those times when there is a likelihood of a home leave or
release when there will have to be risk assessments carried out of the likely
eventualities. The probation service has a duty to consult the victim of offenders when a leave
or as release is imminent.
The release of medium and
long term prisoners nearly always involves a period of supervision by the probation service
during which the concerns of resettlement can be worked through. This is
subject to a period of recall to prison should there be breakdown or failure to
comply with the requirements of supervision.
Release can be earlier than
the sentence would normally expect through parole. This is determined by the
Parole Board after careful consideration of the risks involved in such a
discharge, through reports from within the prison, from without through the
probation service and an actuarial risk assessment outline on the individual.
The prisoner if so released is subject to supervision by a probation officer
and to recall to prison should the conditions of supervision be breached.
Dealing with risks from
offending individuals
Prisons are dominated by
managing risks. The episodes of escapes five years ago and the disturbances of the past decade
have made us very alert to the risks to the safety of the public and to the integrity
of the establishment represented by those major possibilities. Systems are well
developed to enable these likelihoods to be kept to a minimum and it has been
the case that as we focus on those high risk areas for us other areas of
concern may have been ignored or may not be given the priority they deserve.
Thus minor risks may well be tolerated. There are systems for addressing the risks
of self harm and suicide, health concerns receive much attention, family
breakdown is a matter for consideration, the provision of an equal opportunity
environment has much focus in our work and increasingly in the past three years
the risk of reoffending is being addressed in systematic and effective ways.
The prisoner may face other
risks however from custody ;
life and health
·
the risk of
victimisation within the prison and the experience of living in fear
of disease, especially HIV
and Hepatitis B
·
exacerbated
risk of suicide and self harm
oppressive and
arbitrary treatment
·
decisions made
from the courts and the right of appeal
·
decisions made
by staff locally who exercise discretion at all levels
social being
·
employment and
earning capacity is reduced
·
family
relations can be strained, social ties disrupted and housing lost
·
probability of
returning to prison is increased.
Conclusion
The evidence that severe
personality disordered offenders can be managed in prison is largely sustained
by the fact that many are held in normal location in our top security prisons and
are controlled through the systems described above. There are a few - about 10%
of the total held in custody - who are in some form of treatment or therapy.
Prisons should remain places of last resort for society for the holding of
those who represent such a risk to the public that they must be detained.
Within that detention it should be our purpose to seek to address that
dangerousness in any way we can in order to ensure that the person is not
exposed to other and great risks to their person. Thus although the evidence
from the Prison Service is predominantly of managing the high numbers of
severe personality disordered people in prison there are some signs that with a
common understanding of the disorders we can become clearer about their
responsitivity to treatment. There is a need as we engage in the debate
between services to develop a common language, commonly used methods of valid
and reliable assessments, clearer understanding and respect for each others
skills and capabilities in managing and treating dangerousness and a consensus
about the values which will enable us to establish working relationships with
due accountability to the public, to the people in our care as well as to those
who determine the boundaries within which we can work.–
It’s great to have the
opportunity at this years JNF conference to talk about an area I feel
passionately. Slide X 1
I’ll start with a very
brief overview of the structural framework of secure psychiatric services, then
attempt to present the case for gender sensitive services within this area and
finally give an example of an organisation that set out to provide such a service
– using the words of the staff and the women themselves.
As I’m sure many of you
here today are aware - Secure psychiatric services are arranged broadly in
three bands; the three special or high security hospitals (Ashworth, Rampton
& Broadmoor), the medium or regional secure units and the low secure units
which are often wards within general hospitals but with a higher level of
security than open wards.
Women make up approximately
15% of the population in these secure settings in Britain and there have been
long–standing concerns about the appropriateness and the quality of
services for women in this sector. So women are very much a minority –a
minority in a male dominated culture - because it’s a service developed with
the majority in mind – men.
And it’s the case that many
women remain in high security settings just because the alternative is a mixed
sex medium secure unit – a unit where she could be the only woman. We need to understand the psychological
impulses of severely traumatised women [for that’s what they are] who often
actively seek & repeat the pattern of damaging & abusive relationships
with men. Many women therefore need a women only environment, - a safe haven in
which they can heal at their own pace.
And although they are not
an homogenous group, women are from different ethnic groups, have different
cultural experiences, have a wide range of ages, personal, psychiatric and
forensic histories, as a group women patients are different to male patients in
significant ways.
A study in 1999 by Penny
Stafford carried out on behalf of WISH identified major differences between men
and women patients in respect of their life experiences, their offending
behaviour and their mental health needs.
She analysed the case
register data of the 3 Special Hospitals [where at the time there were 3000 men
to 300 women] and demonstrated that women were more likely than men to have
experienced the following during their lives prior to admission:. Slide X 2
[women] X2 [Men]
These very different
profiles reflect the different way women & men deal with their chaotic
histories and the different socialisation processes involved.
The profile of women using
secure psychiatric services also suggests that if support and early
intervention had been available for them and their families, this may have
averted their journey into secure care and or the criminal justice system. We
need to avoid other headlines like this: Slide X 1
What is surprising about
statutory secure provision is that, despite a body of research on gender issues
going back 30 years, this provision has not developed with an awareness of the
different life experiences and therefore different needs of women & men.
The need to respond within a context of women’s socio-economic, political and
gendered realities.
Instead women become
labelled as ‘difficult to manage or challenging behaviour’ – it is the
system of care rather than the woman herself which is challenged to provide
more appropriate needs-led provision for women at all levels of security.
So it was within this
framework, with the future of women’s secure services at a critical stage and
with enormous potential therefore for radical development, that a provider in
the independent sector sought to design a service that addressed some of these
issues.
The philosophy was grounded
within a social inequalities framework with an awareness that mental distress
needed to be understood within the social, economic and political context in
which it developed and underpinned by a positive expectation of recovery.
They also understood that
women who have experienced sexual and violent abuse in their childhood face
re-victimization within the psychiatric system as many of the standard
practices can echo and reinforce their childhood trauma. And it was for that
reason that they went against the norm and made the decision not to use
seclusion in their units. A decision viewed with some scepticism by other
providers.
They aimed to offer women a
safe, therapeutic environment in which to heal and importantly the opportunity
to access the wider community with a view to eventual full social inclusion.
People with mental health problems generally, have relatively few opportunities
to take responsibility for their lives – being widely excluded from work,
parenting and other possibilities to contribute to society, and this is
multiplied manifold when considering detained psychiatric patients within the
secure system.
Ok my involvement –
in 2000 Liverpool Hope were commissioned to evaluate this new service
provision. In order to do this, the research was designed to take time to
listen to the women’s experience of the provision and give them the opportunity
to hopefully influence any future service development and policy.
I spent 9 months at the
unit, getting to know the women and the staff and attempting to gain an insight
into what was different, if anything about this service. I was in a privileged
position. I was given unlimited access to the units, I was able to spend long
periods of time with the women, days, evenings, weekends gradually gaining
their trust and confidence. I joined in the life of the unit as much as
possible, going for walks, going shopping with the women, painting with them,
eating with them, experiencing their strength, their courage, their tenacity,
their pain.
In the time left I’ll just
try to give a flavour of what they were trying to achieve.
Firstly I think it’s
important to explore with you the key elements of the philosophy underpinning
the model of care envisaged and this came across very strongly when talking to
staff – the importance of sharing a vision, a shared philosophy. Slide X
2
An important aspect of this
gender sensitive vision as far as many of the women themselves were concerned
was that there were no male patients, no ill men to deal with. Slide X 1
Another tenet on which this
model of care rested was the intention to provide a flexible service that could
be tailored to the individual needs of the women resident at the time. Slide X
1
One way for a small
organisation to achieve this individual care was to access resources in the
community. Thus rather than continuing to segregate the women within their care
with isolating practice, they envisaged a service that tapped into the wider,
natural community and utilised existing mainstream community activities and
organisations
If social inclusion is to
be truly attained then women must become valued and active members of society
and not just placed out in the community to sit on the sidelines and watch.
Slide X 2
Many of the women talked
about the informality, flexibility and freedom of the environment [not usually
words you would hear to describe a secure unit] and they commented on being
treated as an individual rather than in an impersonal and generalised way
Another crucial aspect of
the philosophy of this service involved empowerment. Empowerment is a much-used
word, often paid scant lip service to.
However facilitating and
realising true empowerment takes not just the will but considerable time,
effort & resources. The practical implications can be far reaching. Members
of staff however were keen to emphasis the empowerment component Slide X 1
The mechanism used to
empower was the human relationship.
The women within secure
forensic services have collected an enormous variety of medical and legal
labels over time, the staff here however felt it imperative to see, understand
and relate to the person behind the label. To see them as a person first, a
patient second. Slide X 2
Not surprisingly, when
talking with the women this aspect of their care was also considered of crucial
importance to them and for many women this was the first time they had been
treated as a person, as another human being and they talked of how this was a
very empowering and healing experience Slide X 1
This statement so simply
yet so eloquently sums up what the residents felt had made the crucial
difference here in comparison with previous detainments. The staff here related
to the women as fellow human beings
So simple - yet seemingly
difficult to achieve at other units – WHY?
If staff own &
operationalise this ethos then what they are offering is relational security.
An environment where women can learn to trust, with mutual respect &
dignity, often for the first times in their lives, and begin to value
themselves. They are able to learn slowly about healthy and empowering
relationships. Slide X 2
One resident who, in her
previous detainment, had been on two to one observations for a number of years,
had progressed within 6 months at this unit to the stage that she had been
granted unescorted leave. When interviewed for this study she explained how for
the first time in her life she had developed a trusting relationship with some
of the staff. She really believed that they cared about her well being and was
now able to seek help and verbalise her pain rather than self injure, the
coping strategy she had previously resorted to. This woman felt respected as a
person for the first time in her life and was subsequently learning to respect
and value herself
Another important aspect of the care in this
unit was the ethos of a non-punitive approach – in relation in particular
to observation, C&R, and as I mentioned before seclusion. Slide X 1
The women explained how seclusion had been used
in other institutions, and in the recent past, as an element of the induction
procedure when entering a Special hospital. Slide X 1
Not surprisingly none of the women spoke
positively about the practice of seclusion as they described how the experience
had impacted on their mental well being. Slide X 1
Another widely used clinical tool within the
psychiatric system is the practice of observation. Patients thought to be at
risk for one reason or another are put on a one or two to one observation
schedule. Slide X 1
The strategy appeared to be
effective both in terms of risk management and staff job satisfaction. It was
felt that it was more acceptable and clinically effective for staff to interact
and talk to women when distressed rather than just monitoring the situation
In fact there was also the feeling that the
women needed the facility and support to express emotions rather than
repressing them as they had been encouraged to do previously -- Slide
Well this all sounds very
positive doesn’t it and it was in many ways - however
As is the predatory nature
of capitalism - since this research was completed the service I have described
has been bought out by another but larger independent organization - thankfully
not before innovative possibilities for the care of women had been
demonstrated.
And it now looks as though
the national climate is slowly changing, [mainly because of the commitment,
dedication and sheer hard work of activists in this area]. We now understand
when designing, delivering and commissioning these services, that we have to
acknowledge women’s marginalisation, and disadvantage and the part played by
socio-economic factors, patriarchal traditions and early life experiences that
predispose individuals towards distress behaviours currently diagnosed as
mental illness or personality disorder.
Finally there appears, we
hope, the political will to address these injustices with the much awaited and
eagerly anticipated National Services Framework for Women due later this year.
However the major challenge
ahead is still ensuring that embedded in the development of new services is a
different philosophy of care designed to meet the different needs of women. We
cannot view mental health services in isolation from the oppressive
circumstances in which the damage developed. We need a more holistic approach
to care, treatment and ongoing support, a truly integrated model of care. A
holistic service, taking account of her past, her present, the hopes &
fears for her future, addressing the whole person.
Empowerment should be at
the heart of any service for women or indeed men, active listening, engaging
with them as people, validating their experiences & facilitating their
authentic participation in their care & treatment.
Recognising the strengths,
abilities & potential of the women begins with a validation of their
courage & resilience to survive their often-traumatic pasts.
Thank you – I’ll
finish there.
follows overleaf
Women patients in high security hospitals are significantly more likely
(than male patients) to:
·
have experienced disruptions and
changes in their care as children, and to have experienced institutional care in
a children's home or hospital before the age of 16
·
have experienced sexual and /or
physical abuse during childhood
·
be parents (usually single parent)
·
have never experienced employment
·
have been solely dependent on
social security benefits
·
experience problems with alcohol
misuse/dependency
·
be detained under part 11 of the Mental
Health Act as civil patients rather than in connection with a prosecuted
offence
·
be classified as having a
personality disorder and to meet the diagnostic criteria for BPD
·
have an index offense of fire
setting (arson)
·
be admitted because of damage to
property, suicidal or self-harming behaviour or as a result of aggressive
behaviour towards staff in psychiatric hospitals of lesser security
·
be admitted at a younger age and
to stay longer
·
to have at least one previous
inpatient admission to a psychiatric hospital or numerous prior psychiatric
inpatient admissions
·
to self-harm
·
If we analyse the data for men
however a very different profile emerges.
Men patients in high security hospitals are significantly more likely
(than women patients) to:
·
have been young offenders
·
have been employed during the
three years prior to admission
·
have been earning their own living
at the time of their admission offence
·
be transferred from prison
·
be detained under a Restricted
Mental Health Order
·
be classified as mentally ill
·
have an index offence relating to
serious physical or sexual violence against a person/s
·
be admitted because of their
sexual behaviour or symptoms of mental illness
·
have a prior offending record for
physical and/or sexual violence
·
have experienced previous
custodial penalties
·
have victims who were strangers
·
be admitted to high security
provision a second time
Sue: Thank you Lin. Humanity is seen as an
innovation. We see it as a necessity.
Now then introducing Bob. we’re launching his book
today: “Emotional Health” today…
Bob: I’d like very much to welcome you. First of all this
is not my organisation-it is our organisation. I want to let you into a little
secret-if you weren’t here, I wouldn’t be here either. Thank you for coming. It
has been very difficult over the last number of years. I’ve given up tackling
the psychiatrists head on. I was having a chat with Sandy yesterday and I asked
her “How do you tackle psychiatrists?” and she said, “I don’t!” (Laughter).
I’m going to talk about my book. I’m not going to sell
my book – you can decide if you want to buy it or not. What I am going to
do is to sell you the ideas. The ideas are critical. They cover a number of the
points that have been raised. There’s a chapter that asks: “Is Psychiatry
bankrupt?” You have to look at the evidence and decide for yourselves. The
difference between selling the book and selling the ideas is what I call the
mental loaf. In twenty five minutes I’m going to have a sandwich. I can cut the
sandwich in half and share it with you. We’ll each have half a sandwich. If I
have ideas (I have several!) and I share them with you – then we’ll have
double! That’s critical, and that’s what is so important.
We are now moving forward. We have a regular annual
conference, in 2003 our next conference will take place here (on March 15th),
in 2004 0n March 13th and so on. It’s an on going process. This
organisation is alive. It’s a conviction organisation and it’s working. At last
conference, I said that I wanted to begin some workshops. We have done just
that and the workshops were stunningly successful. We had a series of five
workshops and from the about one hundred people who attended these workshops we
now have a development group. These are people who are prepared to commit to
one meeting a month. We’re filming the sessions and we are going to produce
training packs. The notes from one of the workshops can be found on the white
sheet in your folder. It contains some of the questions that came up in the
workshops: it’s a developmental process, we’re moving forward. We are finding
out what works. We’re finding out what is puzzling. A lot of the concepts on
this sheet are expanded in here [holding up the book].
I want to repeat my definition of personality disorder
from last year because there was some confusion in the questions this morning.
A personality disorder is when your mind won’t let you do what you want: what you want. If you have leg
disorder you can’t walk from A to B. Everybody recognises that and they say
well, here’s a remedy, here’s a crutch, here’s a wheel chair, let’s try and
cure your leg. Nobody doubts that your leg can be cured. You break a leg, it
may take a long time, you may require an operation but nobody doubts that
you’ll walk again. You break your personality and……nothing. Well that’s not
good enough. There should be exactly the same confidence that if you have a
personality disorder – your mind won’t let you do what you want –
you can get help so that it can. Emotional education.
At the bottom of the white sheet you’ll find a
dialogue with Jamie, he’s sitting over there. He’s very brave. What I want to
do is to read you his first sentence. It’s only a two minute clip and I want
you to pay particular attention to his first sentence:
“If I‘ve let somebody down in any way I immediately
think that they are going to be angry with me and that anger is going to leave
me in pain.”
So he avoids making people angry at the cost of great
distress to himself.
“I’ve built my life around the
fact that if you upset people they’ll leave you”…
and that needs to change. It’s very difficult to
change.
“They will leave you and you will hurt for it. Even
if they did say something awful to me, it’s the same thing. The thought of
anybody saying anything negative, either in front of my face or behind my back,
was life threatening.”
Now these are his words. My picture of mental
development, of healthy emotional development, emotional health is that every
infant is 100% dependent. They can’t even roll over. They can scream, they can
squeal. That’s it. So you have an attachment. If it’s a sound attachment, fine.
When you’re 18 or 21, you can blossom. If it’s an unsound attachment you slip.
You grow up and you’re still slipping, still trying to re-attach, saying
“where’s my life support system? I still need to attach.” Problems are going on
over there [points to the right]. You’ve got the mortgage to pay. You’ve got
troubles in your relationships, you’ve got trouble at work and you’re still
trying to attach. What’s the most important thing? [points to the left].
Attach. So you are changing over the fundamental foundation stones and if you
get into a block, you bury it. You don’t come in to the doctor and say, “I’m
having trouble with attachment here”. No. You don’t do that. It’s deep. You
have to Trust first. You have to give your Consent. You have to accept the
Truth of the matter, that the emotional survival strategies that you are
adopting today are out of date.
I’ll ask Jamie to come up now. What I want to do now
is to show you this clip, it lasts about a minute and a half. [video played
– with the following dialogue].
Jamie: If I have to
let somebody down in any way, I immediately think that they are going to be
angry with me, and that anger is going to leave me in pain. I’ve built my life
around the fact that if you upset people, they’ll leave you. And you’ll hurt
for it. Even if they did say something awful to me, that’s the thing. The
thought of anybody saying anything negative towards me, either in front of my
face or behind my back, was life threatening.
Bob:
That’s better! That’s better!
Jamie: That’s why I got
confused, because I couldn’t understand why, afterwards, how I could panic
about something
Bob:
that was so small
Jamie:
either so small, or had to be done anyway.
Bob:
Right! Life threatening, OK? Explain that!
Jamie: I actually seriously
must’ve believed that without these peoples’ positive remarks or attitude, that
I was going to get dumped again, which brought me back to my mother, brought me
back to pain.
Bob: And death! Life threatening is death!
Jamie: Yes. It
does ring so many bells with things I’ve done. . . . .
The point at issue is: this is not cups of tea, this
isn’t “Oh, let’s have a chat”. Jamie is facing a life-threatening situation. It
happens to have been a life-threatening situation when he was eight months old.
It isn’t today. He’s 28 and his life surviving strategies are radically
different.
Bob: So, what was it like when I started ‘squeezing’
you?
Jamie: It was very painful.
It was taking me to places I never wanted to go, to feelings that I have always
wanted to hide rather than show anyway. It was very hard.
Bob: I think that the breakthrough that I made is
that every individual has a unique personality disorder. When the personality
is disordered, when it won’t let you do what you want, then that is going to be
unique to that individual. I have no time at all for psychiatric labels. None.
I think it’s wrong. I stretch myself to search for metaphors for the psychiatry
of today and when I was writing it, it was quite clumsy. I said that when you
visit a petrol station because you want more petrol, you say to the petrol
attendant, ”Can I have some petrol, please”, and he says “I’m sorry, we only
supply steam engines. Here’s some coal!” (Laughter). We are looking here at a
chap who is very articulate. He is very intelligent. He’s very strong, a very
strong character…and we had some fun didn’t we?
Jamie: You did!
Bob: The point is that Jamie was working as hard as he
could to stay in his nightmare because there wasn’t another one. Was there?
Jamie: No, in some way I
thought I had comfort and found that I had somewhere to turn to. Yet what I
turned to was a problem in itself, but it was motherly and it was comforting.
Bob: Briefly, Jamie was adopted at the age of eight
months. What astonished me was that he would get himself into situations in
which “his mother would appear and rescue him” - didn’t you?
Jamie: Yes. Everything I
did in life, every problem I had in my life, I would associate the person who
was the problem to me as being my mother and I’d treat them in such a way that
I didn’t want them to leave and I would keep them sweet. I’d do everything I
could for them. I’d lie to them. I’d tell them things that they’d want to hear
about the things that were actually going on in my life just for the fact that
I didn’t want my mum to leave again. I saw my mother in everybody and in
everything in my life.
Bob: The difficulty is that Jamie didn’t tell me this.
Jamie said, look I’m having to go to court again. I’m having to do this, I’m
having to do that, and it’s by scraping away at the most painful areas in
Jamie’s mind that we uncovered it. That was the difficulty.
Jamie: I was seeing it
all from my point of view. I just didn’t see it at all. It took…from the very
first time. it was quite abrupt when you (Bob) told me and, at least, from that
point onwards I knew that I had some kind of problem.
Bob: What was it I was telling you to begin with?
Jamie: That I was a
baby, if I remember rightly. (Laughter). Not as such. Not like that but you
explained that I was reacting, I was emotionally reacting to situations as a
two year old, as I felt when I was adopted, how I felt then. I thought that by
hurting people they’d leave me or by doing things they didn’t want, they’d
leave me and that was from being adopted. I’d carried that through my life. I’d
never spoken about it or thought about it in any other way, that everything I
did, was via thinking of my mother and being adopted.
Bob: You see, it’s not easy – it’s simple,
but it’s not easy. All that has happened is that Jamie has woken to the
realisation that he is 28 and not eight months old – and that was long
and painful and very hard work. But the objective was never in doubt. I’m
looking at a 28 year old now. I’m looking at him and I’m saying, “You’re an
adult, you are in charge of yourself! If somebody leaves you, you say you are
lost. But you’re not.”
He couldn’t do that. Somebody leaves him, appears to
leave him, he’s straight back in to an eight month old situation, where he is
helpless and the powerful people in his life are unreliable.
The reason I asked Jamie here today, is that, in the
clip he gets down to the nub, he gets to the bottom of it. He is now describing
it, that’s what he’s doing. This is taken from practically the final session.
Sometimes he’s been up, sometimes down, sometimes he didn’t turn up. Very
difficult. But what he is now describing is what I was looking for from the
beginning and he couldn’t see. (Turning to Jamie) You couldn’t see it could
you?
Jamie: Not at all. Out
of all the things that I thought might have been wrong with me, I never even
came close. I thought I was a criminal for life. I thought I was a bad person.
I’ve done bad things and I wasn’t going to change. I could see no way out of
it. It was a vicious circle that I’d go continually around. Within every
eighteen months to two years of my life I’d
build something and then systematically destroy it, until I’d end up back in
prison. Until eventually, I understood what my problem was and what I had to do
about it.
Bob: What I’m trying to say is that a lot of people
have come up to Jamie, have had a relationship with Jamie through his life
because he is a lovely lad, he’s charming and he is all there. But. Until he
and I had agreed to go into the most painful area and give him a blueprint
– ‘I’ve built my life around being eight months old’. Now why should he
do that? Why has he got to do that? He’s got to do that because, I keep
nattering him, I get his consent, I keep saying to him, “OK, so you didn’t show
up last time, I’m still here, I’m waiting for you”. It was touch and go. I said
”What are you doing this for?” He made great strides and then one time, I
remember, you said (turning to Jamie)- and he’ll confirm this - “I feel alright
today, I won’t bother to go.” or “I feel lousy today, he won’t like me, he’ll
leave me, so I won’t go!”
Jamie: I’d say the worse one
was when I’d be running late by two minutes and I’d think- ‘he’s going to be
angry with me. I can’t go!’ and I’d disappear for months on end. Then again I
would think I really needed his help, I’d really want to talk to him but the
thought of what he might say to me when I got there was enough for me never to
get in touch with him.
Bob: Don’t ever get angry with your customers!
Alright. But that’s it. Look at him. He’s a lovely lad. He’s working, he’s keen
and there are all these hurdles and the hurdles are as big as he is
strong.
And you have to have an objective, a shared objective.
Here we have a 28 year old adult who’s perfectly capable of managing his own
life support system. Let me emphasise that – Life support. Here’s this phrase:
‘Life-threatening’ and as soon as he says that I jump on him – because
life threatening to an adult is different to life threatening to an infant
– and that’s all there is!
The whole of psychiatric morbidity relates to the
misapplication in adult life of infantile strategies. Why are you going to change
these survival strategies? Someone said that “you’re evil, you’re naughty,
you’re wrong! Look at what a dreadful person you are!” You know that! That’s
already built in! You have to say “Just a minute! There’s a different way of
doing this. How old are you?”
Jamie: For me it was
very good because I needed reminding of the situation that I was in. Whenever
we talked about situations in my life we returned to the question “How old am
I?” It was quite straightforward then to understand that the way I was acting
was immature. The choices I made were also very immature. After a crime or
after any decision I made I was always able to tell where I’d gone wrong and
that it was the wrong decision, it was a spur of the moment thing. It was a
desperation feeling, of “What am I going to do now?”. Of “What’s my mum going
to think?” at the end of it all.
Bob: And what you’re mum thought goes inwards…
Jamie: Exactly, yes.
Bob: What we need to emphasise is that the
psychiatric treatment, as far as I am concerned, comes down to two words, “Grow
up”. It’s very difficult. If you have a sound attachment its OK. If you have an
unsound attachment, you spend all your time trying to get this attachment to
work. You’re wondering, “What’s the matter with it?” You are fully preoccupied
with making the system work because it’s built wrongly. You’ve built your life
around the wrong facts.
The next point I want to make is “Is he going to do it
again?” Is he going to commit further crimes? Is he going to fall off the
rails?”
Jamie: No.
Bob: Why not?
Jamie: Well, firstly,
one of my offences was driving, and I also felt that I got a lot of comfort
from driving. I don’t need it now. It doesn’t form part of my life. The other fact
is that I can face up to responsibilities and decisions that I have to make in
my life, that might lead me to trouble. I won’t fall into that trap I know what
my responsibilities are and how to control myself.
Bob: The point is that as a twenty eight year old,
it pays Jamie to be responsible. Sociable human beings relate. They find values
in networking, they find values in taking responsibility. Before, Jamie was
operating on the wrong programme. He didn’t know what that programme was. I
reflected, “Umm, adoption eh?” I didn’t know. I kept telling him to throw
things out. To see where it went…and then we had enough evidence on the table,
I just kept insisting (to Jamie:) Didn’t I? Tell us what you were doing when
you first came to see me.
Jamie: Before I came to
see you, I’d start by getting myself a job. I’d get into trouble one way or
another. Usually by running away from things rather than facing up to them. It
led me back to prison time and time again. I went to see Dr Bob through Dr
Carr, and I must admit, I was using it at first as a way of keeping out of
prison, without having something that could help me. For the first couple of
appointments what I was saying wasn’t hurting me, I was using it to stay out of
prison, but there came a point where, once he’d persuaded me that I did have
this problem, that there were ways of getting round it. I must have used him as
a mother on several occasions, I think (Bob groans, provoking laughter), as my
mother, as someone to go to. Eventually, painfully, usually when he set me
homework, what we’d been saying, I could see them in the things that I had done
in my life.
The more it made sense, the more I trusted him and the
more I believed in what he was telling me. In time, things that he was telling
me, I was putting into practice and it was making a difference in my life. So,
obviously, I could see the results and I did feel better. I could walk down the
street and look at people’s faces rather than my shoes, which was new for me.
Bob: That’s really why I asked Jamie to do this and
I am grateful because I argue and I try to persuade, using the consent from
individuals, but they are the judge, they are the customer. They buy the
product or they don’t buy the product. If they buy the product, as Jamie did,
they then see, that as mature adults, that they are, in fact, Loveable Sociable
and Non Violent and that other people are the same.
We are a sociable species, being sociable is our one
evolutionary advantage. It gets “clogged” because we have a mammalian problem
that, at birth, we are 100% dependent. We can be frightened, we can be very
frightened and, if something very frightening happens, then it leaves a scar
for eighty or ninety years. I need to emphasise this again, Jamie didn’t want
to go in there any more, the reason being, and let me emphasise this again, is
that it’s too painful. Now, if I hadn’t played it the right way, as I didn’t
from time to time, the pain was more than the benefit. I wasn’t selling it
right. I wasn’t persuading him right, but the answer was never in doubt. What
do you see? You see an adult. You don’t see a two year old. You see an adult
who is perfectly competent if you give him the tools, if you give him the
correct emotional education.
Morning Session ends.
Circles of Support and Accountability. Dick Foot spoke about
Circles of Support and Accountability. He told the conference that the Home
Office has agreed to fund four pilot projects in the Thames Valley area to
develop Circles
of Support and Accountability. A display has been set up and Dick offered to
provide further information.
Afternoon Session.
I am a member of the development group and I thought
that I would like to share my story of my journey through mental problems
myself. I feel that Bob is a great pioneer and I love pioneers because if
somebody doesn’t go out on a limb nothing happens, nothing changes. My story
took me into mental hospitals four years ago.
I had tried to commit suicide and was taken into
hospital for four weeks and my psychiatrist at that time saw me for ten minutes
a week. I was given medication and no other therapy. What I don’t want to do
here is to rubbish the psychiatric services. They don’t know any different. I
don’t want to rubbish what happened to me but it was not a model that helped
me. I was sent home still feeling suicidal, although I had managed to convince
them that I wasn’t. I made a very serious attempt and nearly succeeded at
trying to kill myself. They sectioned me under the Mental Health Act and I was
kept in hospital for two months. During that time, I saw my psychiatrist for
just ten minutes a week. No other therapy was given. My family asked for other
things. The psychiatrist said that there was no time, that there was nothing
they could give me. Again, after two months, I was still suicidal so I decided,
“I’ll really do it right this time! I’ll throw myself over a waterfall!” and,
believe it or not, I didn’t succeed because my big fat back side got stuck in
the rocks! (Laughter). It’s true! So, there’s a lot to be said for having a bit
extra. So they decided to take me back into the mental health ward, sectioned
me again and, very, very much against my wishes, gave me electric shock
treatment.
“This is going to do the trick!” says the
psychiatrist.
Again, it did nothing for me. I was very upset that
they were doing this to me. I had a dreadful fear of electric shock treatment.
I then started to get into the car and drive off. I had this idea that I was
going to drive to the end of Britain and drive off. That was in my head, it was
crazy. Any way, my husband stopped me taking the car so I pinched a car. The
police set up a nation-wide search for me and they found me in Wales and I was
brought back. I was put into hospital again and I decided that I needed
healing.
I decided that I was going to go to Brazil. I had read
a book the previous year about a healer in Brazil. The next day, I hopped on to
a plane not knowing where I was going and a picture that I saw on the front
cover of the book was of Matchaputcho with the author beside it. I thought I
was going to a mountainous area. I eventually arrived in Brazilia and got a
taxi and they kept going on and on into this desert. I was looking for the
mountains and there were no mountains and then, two hours later, on this
deserted road, I got dumped, out of the taxi! This was where the healer was
meant to be! I thought that I needed a miracle and that I was going to get this
miracle. All I got told to do was meditate for three hours, which I couldn’t do
for even five seconds! My trip to Brazil turned out to be an absolute disaster.
I came back and was put back into hospital. Then I
decided on Homeopathy. That I would treat the body, the mind and the spirit. I
was going to get well using Homeopathy. I managed to get accepted to the
Homeopathic Clinic in Glasgow. Again, nobody connected with me, nobody came
near me. My husband decided to have a meeting with the consultant. He said
“Nobody’s talking to Margaret, they are just giving her the remedies” and the
main nurse, who is meant to spend half an hour a day with you, my husband said
to her, “You haven’t spoken to Margaret and she’s been in for two weeks”. She
said, and my husband will verify this, “We don’t like her energy and we’ve all
decided to stay away from her in case we all get sucked into it!” (Laughter)
Actually, I hated my energy, I was this big, black cloud. I hated myself. I was
desperately trying to get rid of ‘this person’ that was on the planet that was
a waste of space. That was what I felt. The doctor in the Homeopathic hospital said
“We can do no more for her,” turfed me out and wouldn’t take me back again. My
husband, by this time, was at his wits end and was ready to run away.
Again we got the psychiatrist and again they said
“We’re sectioning you”. Again just drugs and when I got discharged I found a
very good therapist who worked with me. He was a Jungian analyst and he took me
into my depression rather try to get me out of it. He took me in to where all
my stuff was. I was very much somebody who needed to be liked. If you didn’t
like me I would do anything I could to get you to like me. I was brought up a
very strict catholic. I’m 57 years old and I’ve only just got rid of the wee
man with a beard in the sky who is going to punish me and I mean that was what
was in my head. Part of my illness was around the devil and feeling “bad”, that
I was “of the devil”. I had to get rid of all this early indoctrination. I had
a very strict father who used to hit me a lot. My mother was illegitimate and
had had no parenting whatsoever, she never knew how to love me and I knew, I
was desperate to be loved. I think that is the basis of us all. I understand my
parents now, they’re both dead. I wish they were both here today so that I
could show them the compassion and the understanding that I have now because of
my own journey.
My therapist was of
tremendous help to me. The Serenity Prayer also helped me. (“God grant me the
serenity to accept the things I cannot change, the courage to change the things
I can and the wisdom to know the difference”). When I let go and surrendered,
when I went into the darkness, I started to see the light. Within four weeks of
therapy, of seeing this therapist, I was off all my medication! I was beginning
to heal. What I felt, the psychiatrist said to my husband, (he gave the
impression that they were the professionals), was that they knew best. He said
to my husband that,
“Margaret will be on
medication for the rest of her life! She’ll be in and out of hospital for the
rest of her life.”
No hope was given to my
family. It’s now three years since I recovered and they are still waiting.
They’re asking, “Is she going to go back in?”, it’s a bit loopy, it’s like,
“What’s she up to now?”, it’s true! I felt that what was said gave me no hope. One
of the psychiatrists said, and I challenged them on it, he said,
“Mrs McCathie, if you
succeed in committing suicide, you’re husband will sue me!”
I said, “So what you’re
saying to me is that you’re only interested in yourself, you’re not interested
in me”. That really hit home to me.
I said to him that “I
didn’t want to be looked at as a ‘clinical depression’, as a ‘manic
depressive’, I want to be seen as a soul. It isn’t my head that’s wrong, it’s
my soul!”
He would listen and he
would say, “What do you mean? Where’s you’re soul? At the bottom of your
shoes?” I mean, that was the answer that I got!
I bumped into my
psychiatrist last year and I said to him, “Oh, hiya Michael!” and I gave him a
big cuddle ( as I do!), he freaked out by the way (Laughter), totally freaked
out! He had been jogging. He stays in the same town as I do, he must have been
thinking “Oh my god! I go jogging and I meet this woman!”.
I said to him, “You know
Michael, you certainly got it wrong with me didn’t you?”
He said, “Well Margaret, we
only speak in probabilities.”
I said, “Well you should
use that when you’re speaking to your patients family, because you did not say
‘it’s a probability’, you said, ’Margaret will be in and out of hospital for
the rest of her life.”
He said that “as a
professional” and “in his opinion”, that “that was what would happen to me”.
I was really delighted when I heard what Sandy said
because I certainly felt ashamed that I was mentally ill. I was treated like
somebody who folk were ashamed of. But now I feel that I have actually been
given a great blessing in life. I have had, the journey that I have had, into
the depths, and the fact that I’ve survived, if I can use what’s happened to me
to give other people hope and to say “You can recover. You can go forward to
have a wonderful life”, I feel so blessed that I can be here today to be able
to say to people that “its OK and we are souls and we are people, treat us with
kindness and love, see us as human beings because this could be any of you,
anybody can be hit by this”.
I was one of the happiest-go-lucky people in the
world. I never thought that I’d end up in the “loony bin”. I want to help to
change our view of mental illness. To get away from the fact that it might be
better if we had cancer rather than a mental illness.
Bob: Thank you Margaret. It’s so important on
occasions like this for people to speak from the heart and I think that’s what
we’ve heard. It gives support to people working in the mental health field.
That’s very important. I’d like to introduce Karl now. Karl.
Karl: I’ve been in prison for twelve years now and I’m still
in prison. I came down from Edinburgh prison this morning with a few particular
things that I’d like to share with you about personality disorder and how it
was cured.
As I grew up, as a child, I
lived with fear. I lived with fear all my life. Mindless fear and terror. I
didn’t know why. When I was 21, I started to get into serious trouble, a lot of
violence, I ended up in prison. While I was in prison, I started to get
nightmares that I’d never had before and I started going back into my childhood.
I could always remember my childhood up to the ages of about eight and then
about ten. Then there was a two year gap. I never thought anything of it. As
these nightmares started, I was going back into that two years.
I found out that as I was going
home from school one day, as I was crossing this waste ground, a guy grabbed me
and pulled me into some bushes. He had a large knife, a large steak knife, and
he wanted to sexually abuse me. He had this knife and he threatened to kill me.
All these memories came back. Right in the middle of what was going on, I
thought I was going to die. I had this huge weight on top of me, this knife at
my throat, and my mind shut off, just cut out. I can remember everything up to
that point, the smells, the sounds, but I didn’t want to deal with it while I
was lying in this cell. It frightened me too much. I pushed it away.
I got out of prison, went back
to the same lifestyle: violence, control, terror, living with this terror, and
my mind pushed it so far away that I didn’t remember it anymore. This went on
for many years, a lifestyle of dysfunctional behaviour, addictions, extreme
violence of all different kinds. The trigger for the violence would be when I
would lose control, the emotional control. The terror would come in. I created
the violence as a tool to kill the terror. Violence and anger for me were tools
that I used, they were the best friends that I had. They kept me safe from the
terror.
So I ended up in prison in 1990,
for another violent offence and I was given counselling. It didn’t work. Nobody
could get near. I’d lived with this terror for so long that if anybody got near
I was violent. I couldn’t stop it. I didn’t know how to stop it. My natural
reaction was violent, because I felt comfortable, I felt safe. I was put into a
therapy group and that was the catalyst that caused me to lose control. I could
cope with what I had done because I had anaesthetised myself to it and pushed
it away but I could not cope with what other people had done and listening to
what they had done. I found that in listening to what other people had done I
would feel vulnerable and get back into being a child and identify with the
victim they were talking about and identify with the woman they were talking
about or the man they were talking about. The terror started to come out in the
group. The violence started. I hated the anger and the violence and I was
frightening everybody in the group! I didn’t see any of this! It was such a
part of my life! However, the group leaders saw this and they realised that it
was a problem in my childhood. I still, at this time, I didn’t realise what was
going on, it so controlled my mind. My terror would not let me see what was
wrong.
So they took me for one to one
counselling in conjunction with the group therapy. But it still wasn’t working.
They said to me, “Well, why
isn’t this working?”
I said, “Well I know that you’re
coming. You make an appointment with me and tell me when you’re coming and I
can’t stop my mind preparing for you coming. I can’t stop it. It’s impossible.
So when you come for your appointment, I’m frozen and you’re not getting near!”
So I said, “Don’t tell me when you’re coming. Just come into the Hall and
immediately go into the session.”
So that’s what they did and the
first session I just collapsed. I ended up on the floor, just sobbing on the
floor, I went immediately back in to that period in my childhood where the
abuse was happening. That was the start of a progressive understanding because
I had to let the terror go. I realised that, when my mind had shut down in the
middle of my abuse, I thought I was going to die. The terror was caused by that
trauma. When I was losing control, I was waking up in the middle of that abuse
and all my emotions were telling me that I was going to die and that this
person was on top of me. Now that wasn’t the case but the trauma was telling me
that! So, I had to release that trauma and it took two years and a lot of hard
work and most of that was done behind a steel door because I could not work with
anyone in dealing with that trauma at the beginning. It was so severe. I would
just get violent.
I found that the more I tried to
deal with it, the more physically ill I would become. I would get severe pains
in my head that would literally drop me to the floor. I would vomit all over
the floor, blood would come out of my nose. I ended up in hospital and this
would go on for a long time. It was only when I slowly released the terror that
I learned to interact emotionally with other people. I found that the one to
one counselling dealt with the damaged child, which allowed me to go into the
group therapy and emotionally educate the adult. It had to be that way. I could
not go and deal with the adult and work back the way because the child was
creating the aggression and the terror that was keeping everyone away.
I went right through the prison system and I was being
assessed for release and that was when my problems really started. I’d been
working with people for ten years. I had an excellent record of work and
therapy. My security review said: this man is now little risk to the public.
However I came up against psychiatrists and psychologists who depended on the
Hare Psychopathy Checklist. Despite the fact that I had an excellent record,
and was assessed positively for release – they contradicted my whole
record using the Psychopathy Checklist. They said “This man is in the top 5%
most dangerous prisoners in Scotland and he should never be released.”
But I had reports from everyone else, including psychologists
and psychiatrists, that did not have any dependence on Hare or other absolute
tools. It just didn’t add up. So I’d heard of Bob and I asked Bob to come and
assess me and he came. The Parole Board read his report and said they accepted
it.
One thought that I’d like to leave you with is this:
it took me forty years to come home from school. The people who brought me home
were not highly trained professionals, psychologists, psychiatrists,
psychosexual counsellors or whatever, they were just two ordinary people: a
basic grade prison officer and a middle aged social worker, who saw what was
being triggered off in me and decided to do something about it. That was not
normal practice in the type of therapy that was offered at that time. It didn’t
deal with childhood issues that surfaced. The normal practice just dealt with a
set programme. It’s now becoming more a part of the programme that, if
something surfaces, it needs to come out: you need one to one counselling in
addition to group therapy.
It’s completely gone now, totally gone!
That’s the part that I wanted to
impress upon you today, that nothing in the prison system worked. You could
have locked me up, you could have done anything you wanted to, it wouldn’t have
worked. The more you’d have tried to use force and coercive control methods the
more I would fight you because I didn’t know how to do anything else. All I
knew was how to get angry because that made me safe and it kept me comfortable.
I will leave you with that one thought, that it wasn’t highly skilled people
that helped me, it was just two ordinary people who saw a wounded kid. Thank
you.
Bob Johnson: Well if this isn’t, as the
title says: “Successful work with Personality Disorders”, I don’t know what is.
Wonderful! I want to revisit two parts of that story which are absolutely
typical. I’ll take the last one first. I’m afraid a lot of the training tends
to dehumanise. I think it’s a fundamental flaw in the training.
What we’re presenting here, what we’re finding, is an
analysis of what happened. Karl was saying that “my mind shut down, I turned to
the violence”. He said that violence made him feel comfortable. I would say
that it shut the mind down – make a lot of noise, make a lot of anger
– cover up the fear. Is that right?
Karl:
That’s correct.
Bob:
When I saw Karl, I looked for these factors. When I started working at
Parkhurst with very violent prisoners, I worked on the basis that they didn’t
want to be violent, there was something underneath. That there was something
that was preventing them from being non violent, some fear and some terror. I
would develop an approach where I would focus, ask people. When I got a
referral from a solicitor to come and see Karl, I looked for some terror that
had driven the violence because my model is that human beings are basically
born non-violent. If they’re being violent, they have to find out why.
I can see that Karl has obviously read my book before I
wrote it! (Laughter). It’s so clear. If Karl can think straight then he’s not
going to terrify people. If he can’t think straight, then he will use anything
to stop him from thinking things through.
Karl: I was
dysfunctional in relationships, especially with men. If men stepped within
certain barriers, I had to get them out. It wasn't them that bothered me, it
was what was being triggered off inside me, that was bothering me. So I would
just show violence. I wouldn’t even know why I was doing it. I had to get away.
I was also dysfunctional with women because there comes the point in a
relationship when you need to interact emotionally, you have to give and take.
I could only take. If I started to give, I started to become emotionally
vulnerable. The terror was triggered off. It was an endless cycle of
dysfunctionally failed relationships.
Bob:
And again, there were
one or two of your colleagues, if I could refer to them that way, that I’ve
seen in a similar context, one of whom, particularly, comes to mind. He went on
this sex offender treatment programme [(SOTP) I don’t hold a very high opinion
of it, generally] after which nothing happened. So he went on it again!
(laughter). I thought to myself oh gee! But the second time round … like you
said, you go into the group, you can’t stand the group, gradually, you reasoned
it out.
Karl:
Yes, I’d reasoned it out because the more the terror was provoked, the more I
was forced to deal with it, when I realised what was happening.
All my life I couldn’t read a newspaper story or watch
a television story if someone, a woman or a child was killed in an accident or
a house fire or anything like that because it was triggering off what was in
me. If I picked a paper up and that was the story, I would immediately turn the
page. If it came on the news, I would get up and walk away.
These things were subconscious. I didn’t realise that
I was doing it. I couldn’t cope with any of these things and it was only when I
went into the group and I heard other people talking about these things, I had
no defence! It got through and I wanted to attack them and to hurt them! I
mean, they threw me out a few times. The understanding was progressive, as I
began to clear the terror. Before I couldn’t think properly, there was a vice
on my mind. I couldn’t function properly. I couldn’t talk, I was uneducated, I
couldn’t stand being in the company of groups of people, of adults. I just
didn’t know what to do. But I found that when the vice was released in my mind,
I found that I had a brain that I could use. I found that it was easy to study.
I could do a lot of other things that I’d never been able to do, that came
quite easily.
Bob:
“Vice on his mind” …. that’s it! I talk about “frozen terror” and there you
have it! I didn’t tell Karl it was frozen terror. But I picked it up when I
talked to him, he described it so clearly. And what is it? It’s trauma during
childhood! Guess what! Children are impressionable! They’re vulnerable! And how
do they deal with trauma? They say, “It didn’t happen!”, they block it out.
Karl had no recollection. Had I seen him in what we
may call his infant phase, I’d have said, “what happening?” and he’d have said
“I don’t want to talk to you!”. Fine, and I would just persist, as with Jamie.
With Jamie, I kept saying “Jamie, what’s going on? Lets get to the bottom of
it!”
Now the other thing that I want to emphasise is,
you’re through! You’re out the other end! You don’t need any violence, or this
reputation you had, it’s gone. It’s evaporated! What do you need it for?
Karl: You
don’t need it. Over the years I’ve known some very violent men in prison, who
are well known by the media, who think they’re really hard men. And they’re
not. They’re just frightened individuals inside, because so many of them have
been traumatised and that’s the way they function, through that violence. There
other men being set free through the same procedure, men who had been diagnosed
as psychopathic killers, never to be released from prison. The transformation
in them is unbelievable. But Hare would have kept them in using these absolute
assessment tools that admit to no possibility of change. They’d spend the rest
of their lives in jail, but they’ve gone free!
Bob:
I have to say something about Professor Robert Hare! He’s a professor of
psychiatry, in British Columbia. His position is that once you are a psychopath
- that’s it! Forever! So this checklist, the PCL-R, is used to decide whether
you are in the bucket marked ‘psychopath’ or not, and if you are, well you can
forget it!
If you are trained this way, then you give the tests
– there are twenty items, you tick them, “is he glib? - A pathological
liar? - Callous? - grandiose?” And so on! Tick the boxes, enter the scores 0, 1
or 2, add them up. If they are over thirty, then throw away the key! I’ve sat
in a Sheriff’s Court in Scotland, much as Karl did, and the psychologist reads
his report that he’s one of “the most dangerous men, the top 5%”. Where are the
twenty prison officers holding him down so he doesn’t attack them? Similar to
yourselves, we were just sitting there normally, because he was no longer a
threat! But the Hare Psychopathy scale said mark the word Psychopath across his
forehead!
This is an ethos that needs changing. This is the
wrong view of human beings! If human beings can choose, if human beings have
intent, then human beings can change! They may be difficult to change, they may
take a while to change, that doesn’t matter! The expectation should be, “Here you
are Karl. You are being violent. A better situation is a non-violent Karl. What
do you think?” You engage Karl in a rational discussion, you listen to what he
says, he thinks it through, he gets it. He goes back to his cell and he finds
that he’s been getting angry in the group, he feels his anger and his tension,
but there’s nothing happening in the group. What’s going on? He’s thinking it
through, rationally. He’s digging it out. Something is there that is wrong and
he’s sorting it out. Fantastic!
Karl: I’d like to say a few words about this terror because
it’s so important. This terror is literally mind numbing. Literally. It can
drop you to the ground. It can drive you into all kinds of illnesses in trying
to release it. When I ended up in the prison hospital, I was so ill. My body
was swelling up, I had various problems and they said to me, “You’re allergic
to something” and I went through this process every time I tried to deal with
the problem. They kept telling me that I was allergic and I needed an anti-histamine!
I said to them that the only thing that I was allergic to was Professor Hare!
(laughter).
Once that terror is released, for those men in prison,
believe me, you wouldn’t know them, they’re so gentle, so kind. The thing they
always wanted to be. Yet, before they were treated and set free, you could not
talk to these men, they were so dangerous to everyone round about them and they
could take your life without batting an eyelid! They were so damaged.
Bob: Well, thank you so much Karl. That was wonderful!
Thanks very much!
Bob: I’d like to ask Nada to come up on stage. I
don’t know whether you recall that two years ago I dreamed up the scheme of
asking the people who had gone through the process of Emotional Education to
sit on the platform before a large group of people. I was strongly advised that
this would be a dreadful thing to do, that it was awful, that they would suffer
and didn’t want me to attempt it. Nada did just that. It was two years ago.
It’s a significant fact. She came and she talked. She did it again last year to
update. Here we are again. How are you getting on Nada? Making progress?
Nada: I’ve made
progress, yes. A lot of calm. Apart from on this platform (laughter). I feel
very much myself, in my own right. Completely separate from my dad. I’ve
completely buried him. I’m no longer angry at my dad. When I go back to
Yugoslavia, I always put flowers on his grave. I still have a problem forgiving
him, but I have more understanding now. Dr Johnson taught me to take a step
back, to separate from my past, from my dad. I now have the tools to separate
from my unfortunate childhood. Until I did separate from my dad, I wasn’t able
to heal completely. I do have problems here and there, emotional problems, but
I recognise them. I used to hurt people, but deep down inside I knew that I wasn’t a violent person.
That I was a good woman, I come
from a good family. My dad terrorised me and did horrible things when he was
drunk. When he was sober, he was completely different. I grew up with the
violence.
For most of my life, I did not understand my violence,
my frustration, why I couldn’t relate to men. I wanted so much love and I was
celibate for 13 years. I had a lot of conflict within myself. I have been “treated
and treated and treated” and nothing changed until, finally, I met Dr Bob
Johnson. I was diagnosed with PTSD (Post Traumatic Stress Disorder) through my
childhood. The war happened in my country and I relived the childhood terror. I
tried to commit suicide. Dr Johnson reunited me with my past, with my frozen
terror. He told me that his treatment was called Emotional Education. I finally
realised that I wasn’t mad. Very slowly he crept inside me and brought out the
child. It took a while. Now, it’s three years later, now I’m happy and I’m free
in my own right.
Bob: What I wanted to do was to take you the next
step forward. When you described your father, he was violent. When you turned
to him for affection, he kicked you. This sort of thing. But what we worked on,
most recently, for you, was that you were hanging on to him. You couldn't let
him go. This is the attachment thing again. If you get a sound attachment, you
get a good response from the people you are attached to, the people say “yes,
you’re alright”, then you can leave, you can be independent. If you get bad
attachment, then you are slipping all the time. Even when they kick you,
they’re violent, they get drunk and they threaten you, you still go back. But
it’s hidden, as Karl said, it’s not available to you until you can unpack it.
Would you say something about that?
Nada: Yes, I
realise, myself, that I still have this attachment, but as long as I understand
where this attachment comes from, that I can identify it, then I can help myself,
then the attachment doesn’t bother me anymore. It is no longer sick. It is not
so intense. Now, it gets to the point that it lasts just a few seconds, the
intensity of the emotion. It lasted over a couple of months in the past. Then
it was for hours and minutes. Now it’s just seconds. I recognise it. I say,
”This is the anger and the frustration!”. The great big traumas that I have
with myself because I cannot solve the problem. It is the attachment to my dad.
I quickly take the scissors, cut the umbilical cord to my dad. I am, in my own
right, a person. I can make my own decisions. The last meeting I had with Dr
Johnson he said he would separate me from my mum as well. (laughter).
Bob:
(coughing nervously) Which is a very good thing, I think.
Nada: I had
problems with my sister and my brother. There was a huge area where I felt
guilty. He has managed to separate me from everybody. Bit by bit, I feel free.
I can see a lot of goodness in me and I am proud of myself, of what I have
achieved in breaking away from a lifetime of fear, of tears and blood and guns
and what have you. Today, I feel strong and I want the love. I want to receive
the love, I understand, now, what love is. I am looking forward to have that. I
have open arms. Before when they were coming, I would run away. I would faint
so much, if I felt somebody wanted me. Now, I invite everybody! (laughter).
It’s kind of healed and I feel happy that I am getting strong, getting
balanced.
Bob: It’s absolutely wonderful. What the words Emotional
Education
mean is to peel off the layers. Not so that I can improve, but so that the
person can improve. It’s an educative model. The teacher can do the algebra.
Fine. That’s not the issue. The issue is: can the pupil? Can the person who is
learning, is being educated, can they do the algebra? Only by encouraging them
to control their emotions, to get hold of this terror. Karl was so graphic,
this terror, this vice, this lump, this total paralysis. When you can lift the
vice, when you can lift the terror, to talk to the real person, the real person
inside, then the person comes alive. Listen to Nada! It’s beautiful!
Nada: I remember,
three years ago, when you wanted to talk about my dad. I just couldn’t talk
about it. I was sick. I was just like Karl. I couldn’t breath. I was asking,
“Where is this coming from?” I felt guilty, I felt crazy. I erupted in huge
shingles that almost killed me. For a while they treated the shingles. Then I
met Dr Johnson and I felt from his mannerisms that he is human, he is not a
psychiatrist. He didn’t put labels on me. He talked to me, related to me. I
thought, “My god! He’s a real person!” He wanted to help me and I felt that
every time I told my story that he looked into my soul rather than just like
everybody else. “That must be very difficult for you Nada!” he said and at the
same time yawning (laughter). I really felt that I could totally trust him,
really, feeling total confidence. It suddenly struck me that the theory was
very simple. All I had to do was to think a little bit deeper about it, to get
the tools and to apply them in my life. That’s what I’m doing right now. I know
that I’ll never go back to where I was before because I have equipped Nada
Dobre with dignity, with self respect, with everything that I need as a human
being, as a woman. It’s up to me and I make the choices.
Bob: Fantastic! Two comments I want to make here.
Vast violence. As with Karl and with Jamie. These are not small emotions, these
are not trivial. They’re vast, and the person who is keeping them “behind iron
bars” is working extremely hard to keep them in there. Like Karl said, the
other violent people that he knows in prison are violent children. That’s
precisely it! These are very powerful forces. The people who are carrying these
very powerful forces, like Karl, like Nada, are very powerful. When you are
dealing with these powerful forces you have to move very delicately, very
carefully. You have to be clear what the objective is: there is never any doubt
that you are stable. The Lovable, Sociable Non-Violent adult is there and we are
digging them out!
The second comment I want to make is that, as you said
Nada, “it suddenly struck you”. You need to do the homework. “I can manage
without you!” You find, at first, that you can’t say it, whatever it is that
you need to say in order to educate the emotions. That’s the homework. Say
it. Do you agree with it? Yes. Then say it! Write it down. Repeat it. You’re
actually conditioned to believe, as Jamie said, that “that was the way the
world was built”. Well, that’s quite wrong! As an infant, there are vast
emotions with no possibility for doing anything about the situation. You can
wail, but there’s not much else you can do as an infant. In adult life, if I
see violent or powerful emotions, I say “that’s childhood, that’s from infancy,
what’s that doing there?”. You tell me. What’s going on? I have the expectation
that the person will take charge of this, will look at it. Will take hold of
it, because the assumption is, there is an adult who is Loveable, Sociable and
Non-Violent. That’s where they want to be! Everything else is symptoms.
They can be very dangerous symptoms. When I was in
Parkhurst, my life was threatened on three occasions! There’s an explosion of
violence and you’re dead! Well, I don’t want and I’m not going to risk that.
This isn’t trivial. The violence is real and people can die! They can kill
themselves, they can cut themselves. The violence is there. The origin of the
violence is not there. The origin of the violence comes from many years before,
when they were very small.
Margaret: I was very touched by what you had to say Karl.
I saw a very beautiful human being. What came to mind was what I read once:
“Often we come to see the
rough, practical exterior of a man or a woman. If we could cut away the thorns
we would find a gentle and beautiful nature sleeping within.
Try always to find the
princess hidden behind all the prickly growths. We all possess the light
within, so deal with each other lovingly, always seeking the best in every
possible way.”
That’s what I think you do in your work, Bob. You see
that beautiful centre, which everybody has. I really believe that. To hear
somebody like Bob, putting his “money where his mouth is”, “walking the talk”,
is absolutely wonderful. I feel blessed that I have encountered him.
Talking of terror. My terror, and I can remember
feeling it, was when somebody told me, when I was at a psychotic stage of my
illness, that the devil was in me. I felt the terror in the root of my body,
and this is what I said to the doctor. Listen to what I said, this is a cracker
– I felt this jangly feeling and it was in my vagina! This was very scary
stuff for me. When we were talking of terror that really brought it back for
me.
Question: There is very much the sense that we here
today are the converted and that we are preaching to the converted. How do we
get the message out?
Lin: Basically, by spreading the word. It
sounds very evangelical. It’s great, there are 230 people here today. People
who are working in the field. It can feel like you’re beating your head against
a brick wall, but you need to keep at it, really. Don’t lose faith and get
support from other people who feel the same as you do. What we are doing is
right. It’s on the right path.
Margaret: I would like Bob to come to Scotland and do some work there. The bigger the voice you have, the more that people start to listen. The more data that you get behind you, that this is working, the more likely it is to change. If we go in with guns blazing they are likely to feel attacked, they become protective. Just go in and say, “Here we have an