Towards Emotional
Health,
Views From
The Front Line.
Proceedings of
the Fifth Annual conference
of the
The James Nayler Foundation
York, March 2003
Published by the James Nayler
Foundation
all proceeds from
sales of this book will go to the James Nayler Foundation
Preface
We were delighted to welcome about 250 participants
to our Fifth Annual Conference, held for the second time in York, in the
beautiful surroundings of the Central Methodist Church.
With this publication, we now have five complete
proceedings of our annual conferences. These form an increasingly useful and vital record of
innovative development in this area.
They add to the our record not only of the thinking of key experts from
the UK, 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.............................................................................. 1
Sue Johnson: Welcome to the
Conference & The Foundation 1
Dr. Elie Godsi: Current and Future
Practice 3
Definitions from Dr Godsi’s
slides – the text 5
Dr Rex Haigh The Role & value of
Therapeutic Communities 8
Personal Perspectives........................................... 12
View
from Broadmoor: Carole Bressington 12
Introduction
to Karl by Bob Johnson 13
Nada Dobre................................................... 13
Bob
Johnson:................................................ 14
Dr
Bob Johnson ‘issues in Personality Disorder 15
Questions for the Panel...................................... 19
Appendix......................................................................... 25
An Inmate speaks about
Personality Disorder. 25
Good morning! It’s good to see so many people here today.
We have a really rich mixture of people here today from probation, from social
services, from psychiatry, psychology, families, friends and from people with
direct personal experience of what Personality Disorder really means. I hope
you will all take the opportunity of sharing experiences with one another and I
look forward to sharing the day with you all.
The James Nayler Foundation exists to promote
understanding of Personality Disorder or what we prefer to call emotional
distress
because that is actually what it is and how it is experienced; and to inject
human values into what too often can be a cruel and terrifying experience for
sufferers for their families, their friends and for the professionals who are
bruised by their attempts to work in a system that provides little in the way
of training.
Having said that, I think that this year I am a little
more optimistic than at previous conferences. There is a bit of a sea change
afoot. The argument about whether Personality disorder is treatable is being
won, despite the scepticism of many clinicians. The National Institute for
Mental Health has just produced this Policy Implementation Guidance for
Trusts to develop
services for people with personality disorder. I would just like to read out
something from it, which encouraged me.
“In a study commissioned for this report, Bateman and
Tyrell conclude that, whilst more research is needed, there are real grounds
for optimism that therapeutic interventions can work for personality disordered
patients.”
They reviewed the available evidence. They don’t prescribe
any particular approach but they conclude that, in general
“a combination of psychological treatments reinforced by
therapy at critical times is a consensus view of treatment in Personality
Disorder…”
I think that is a major step forward in thinking. It
awaits, of course, translation
into practice, but it’s hopeful. I am pleased to say that we have people here
today who have been involved in that translation into practice and who have
some optimism in this whole area. I’d like to introduce Elli Godsi. I have got
his book here and there are display copies outside. It’s going to be published
under a different title later this year (you will be able to find details on
our website).
Over to you Elie.
Dr Elie Godsi is a Consultant Clinical Forensic
Psychologist, Nottingham Forensic
services.
Author of ‘Violence in Society – The
Reality behind Violent Crime’ Constable (1999)
My usual style is to try and get people involved and do
something interactive but because I only have half an hour I‘m going to shoot
through the material. I’m coming from a background of having worked with people
who experience distress, in all forms. I have worked in the community, I have
worked with adults, and I have worked with adolescents.
I am currently working with the Forensic Service, dealing
with people who have offended or who are potential offenders, who have problems
relating with people or problems in relation to people in terms of their
emotional world. I am going to talk about all forms of distress. I don’t have
time for the mainstream terminologies in mental health. I prefer the term
distress. I want to look at the relationship between behaving in destructive
ways in terms of experiencing mental distress and the middle ground with the
so-called Personality Disorders.
The central argument is going to be “made not born” and I
think that has profound implications for how we view and for how we make sense
of people with difficulties; and whether we see them on a continuum of humanity
or whether we want to define them as in some way ‘other’.
Those are going to be quite central arguments and I’m
going to talk my way very rapidly through them. There are a lot of overheads
and I shall provide Bob with a copy of them rather than have you scribbling
them all down as I speak.
How do we make sense of madness and badness? I am
interested, culturally and professionally, in how we make sense of madness and
badness – as a culture, as professionals, as people in this society at
this given period of time. How do we make sense of it? It’s always struck me
that in any particular society, at any particular period in it’s history, the
way it defines madness and badness says much more about that particular society
than it does about the people that are being so defined. It’s very interesting
that we have this whole scientific and medical apparatus around the so called
Personality Disorders because that says so much about how we are making sense
of these things now.
Cultural and professional myths - defining
‘otherness’. I am interested in
how people get there. I am interested in the aetiology, in how people get to be
how they are. I am interested in the relationship between personal distress,
self harm and violence and aggression – that’s my career, that’s what I
have been doing for the last fifteen years in the NHS, those are the areas in
which I am interested. I am interested in the notions of Adaptation rather than the pathologising ab-normalising, technology sort of approach. I
think where people go wrong (for me) is in the types of attitudes. I think a more
environmentalist and social perspective on people’s difficulties would allow
for a more compassionate understanding by making personal experience central.
There is a bigger picture and that is the social, the
economic, the global context in which relationships are formed, in which
children are brought up, which includes much wider social and economic issues
but I don’t have time to go into that. Rather than that, I am going to focus
down on personal experience, but it is important to bear it in mind: that it is
another analysis, it’s another talk, really. Those relationships take place
within a particular context: a cultural, a social and an economic context. I
haven’t time to go into that. Suffice to say, a more social perspective allows
for those things to take centre stage rather than the alternative, which is
looking at a person’s biology or their genetics.
How do we make sense of madness and badness as a culture
generally, not as professionals? I have been going round the country doing a
similar talk, collecting views about madness and badness and of course the
Personality Disorders sit so beautifully between the notions of madness and
badness within this society. We can’t really decide whether they are mad or
bad, or both, or neither, or of whether they are treatable or not and what we
should do. Here are some examples of the terminology we use. I shall do the
official apparatus in a second. There are dozens of these, you know: the usual crazy,
loony, gon’ potty, nutter, barmy, bonkers, barking, loopy, crackpot, doo-lally,
wappy, fruitcake etc. etc. We talk about 3 sheets, sandwich, pudding - this is a favourite of mine
from Lancashire - as bent as a bottle of crisps - the wheel’s turning but
the hamster’s not in - another favourite - a luncheon voucher short of an orgy, a
headcase, basket case, not all there, not at home, screw loose, lost their marbles, blown a fuse, cloud cuckoo
land, freak, weirdo, schizo, psycho, not exactly compassionate, not exactly kind or
understanding terminology but nevertheless the kinds of terminology that are
widespread.
Central to this is the notion that anybody who is
distressed in any way is some way odd. They are deranged, demented, too
emotional, irrational, dangerous, violent, scary, menacing, intimidating,
frightening, they are out of control, they are unpredictable, they are incomprehensible and we don’t really understand as
a culture why it is that someone might wash their hands thirty times a day; why
someone has to check the locks thirty times a day or why someone is too
frightened to go out of their house. It doesn’t make sense to us readily as a
culture how we are to understand things like that. When you look at the heavy
end of things, when we look at child abductors, child killers, sexual offenders,
at these kinds of things, when we really crank it up, then we get some really
interesting notions coming into play.
Of course, historically, as a culture, and globally, many cultures still
hold on to religious and spiritual ways of understanding deviancy. These come
out - the media headlines are typically along the lines of - evil, demonic,
soulless, possessed,
we talk about people being the angel of death and the notion ‘psycho’ which sits nicely between the
evil, deranged and spiritually defunct person and the psychopathic disorder,
modern technology way of understanding things. We talk about people being callous,
frenzied, immoral or amoral, barbaric, animals, irresponsible, we can’t decide whether they
are out of control and it was a frenzied attack or whether they were in
control and they knew exactly what they were doing. We animalise them as reptiles;
we talk about them being cold blooded. All these terms serve to define them as
OTHER, distinguishing an ‘US AND THEM’. There is something fundamentally different
about someone who can do something like that from the us who are over here and
who don’t do things like that. What happens to us as a society? How do we try
and make sense of these things? Well, of course the obvious way to try and make
sense of these things in this society now is to talk about people being sick,
people being ill. The predominant discourse for understanding madness and
badness in society, if you leave aside the surviving religious and spiritual
rules is a medical and a biological one. Now for me, that does the same thing,
it serves the same purpose, of othering people. It makes a distinction,
usually, howsoever softly couched, in the terms of biology and genetics and in
someway implying that people are born different and that’s why they end up
being different rather than a different account which is what I am going to try
and articulate today.
Central to this argument, to the underpinning of the
scientific biological and medical explanation is an argument about Nature or
Nurture? Now typically, if we are going to be grown up people about this, we’re
told, well, it’s a bit of both isn’t it? You know, it’s a bit of this, it’s a
bit of both. It’s still the case that many people within the scientific and
medical community don’t see it like that. Whether they talk about social and
biological factors, at heart is a notion that biology and genetics is absolutely
central. Despite the fact that the genetic argument has not been won and that
if you actually look at the genetics of something like schizophrenia, for
example, there is a huge amount of work done deconstructing and debunking that
particular kind of notion. I haven’t got time to go into that but I am quite
happy to discuss that with anybody at any point. It’s typically seen within mainstream
circles, as far as I can see with my experience of mental health services is
that it’s typically seen as about 85% Nature and about 15% Nurture. I think and
genuinely believe, with my experience as a clinician over the last fifteen
years, that it is completely the opposite way round! It’s about 85% Nurture and
about 15% Nature! Let me articulate this in terms of how the official apparatus
views these things.
This is the schizophrenia as puberty model. It doesn’t really matter
that much what happens to someone, at some point if they are genetically
predisposed, if their genes are wired up in that way, it’s going to come out. I
am simplifying things but, unfortunately, that is how the model is used time
and time again!
This cartoon sums up things for me. This is the horrific
ordeal that psychotic people have to sit through in a lecture theatre in front
of a whole lot of people. Can you imagine being paranoid and terrified and
feeling persecuted and being wheeled out in front of a group of medical
students to talk funny to show people what the symptoms of schizophrenia are
like? Well, actually you have somebody who is actually terrified in the middle
of that. It actually sums things up for me, of the kind of approach that we are
talking about here.
An example of othering:
“They are preoccupied with unjustified doubts about the loyalty or
trustworthiness of friends or associates” (p.637, italics my emphasis).
I’d say that if anyone didn’t have those feelings from
time to time they would be personality disordered. (laughter). I could go on.
The process of ‘othering’ is absolutely crucial. I want to
look at what happens when we don’t take into account the experiences that lead
people to get to where they are. I’ve written a lot about Robert Thompson and
John Venables who are forever etched on the minds of everybody in terms of what
happened to poor James Bulger. Neither the trial nor much of the media debate
had anything to do with what had happened to those two boys in the first ten
years of their life. The trial was just there to say, “Did they do it? Yes. Did
they know the difference between right and wrong in some abstract sense? Yes,
they did” – that was what the court was there to determine. Nothing else
was important. There was very little meaningful discussion of what had actually
happened to those two boys before they did what they did. There was certainly
little or no discussion at any point about the fact that there was an
unmistakeable sexualised element to the killing, for example – not in the
tabloids, not in the media, not in the documentaries. That was simply omitted.
Without that kind of information which gives us vital clues – the fact
that what they did to James Bulger had a sexual element to it – as a
clinician, that tells you something about those children’s’ experience. But
that just wasn’t currency. So what are we left with? We’re left with a
discussion about videos. We’re left with the discussion, as a society, with the
effect of one video, which they didn’t even watch, on the lives of these
children rather than everything else that was going on in their lives. I think that is astonishing.
So what happens to those boys in the process is that they
are ‘othered’, they are defined as in some way different. There were lots of
quotes, lots of explanations of them such as, - “they are freaks, you can’t
compare them to other boys. They are different.” The price you pay when you
don’t actually understand what was going on is that the Judges, the police, are
very quick to define these children as somehow different from other boys. That
they were ‘freakish’, that they were evil in some way. Of course, the inference
is that they were born that way, and not made that way. I’ve written a lot
about what happened to those two boys in the ten years before they did what
they did. There isn’t anything that you can think of that didn’t happen to those two boys.
Time and space doesn’t permit me to go into any great
detail here but you find the usual sort of things that you would expect:
The sexual problems: the killings strongly suggest that at
least one of the boys was sexually and physically abused, there was bullying
and absolute chaos in terms of their boundaries, problems with alcohol in the
families and so on. The bigger picture being that they live in an area of high
unemployment and deprivation.
The counter argument (which I shall attempt to
deconstruct) goes – “OK – so what? There are thousands of seriously
abused little boys who don’t go on to become killers. Up and down the country
social services are involved with lots of children that have those kinds of
backgrounds, yet they don’t end up committing these sorts of offences.”
Lets just keep this simple. Let’s take one hundred boys.
Let us just consider that they have been physically abused only. This is a
gross over simplification since cases are rarely presented in which there is
only one kind of abuse. Lets take a sample of 100 physically abused boys and
let us follow them into adulthood and let us see what happens to them.
How many of them become known adult male violent
offenders?
-
It’s about 10%
The majority doesn’t the argument goes. There isn’t a
strong link. But. If you do it the other way round. If we take a number of
physically violent male adults and we ask them
How many of them had physically abusive childhood
experiences?
-
It’s 95%
Looking back into their experiences, the answer is very
different. I get people coming into my clinic and saying “I was abused and I
think that means I could be an abuser” – well, the good news is that most
of them won’t be! On the other side you get people who are violent saying that
“I had an horrific experience as a child” and people saying to them “Well,
that’s avoiding responsibility, you’re lying, you’re delusional, you’re just
making that up. You’re using that
as an excuse.”
It isn’t an excuse; it’s an explanation. You can
understand something without condoning it. You can understand something by
trying to explain it, without excusing it.
What happens to the others? Lets take these 100 boys and
let us say, for the sake of argument, that 10 of them become violent men. What
happens to the others? Some of them end up as OK – as teachers,
politicians or psychiatrists, mental health professionals or whatever.
(laughter) Some of them end up as violent in acceptable ways like boxers, the
army, something like that. Some of them are not known offenders. They are not
indicated in the statistics. Most violence takes place in secrecy, behind
closed doors and is never reported. Some of them end up on drink and drugs;
some end up homeless, some of them end up with so-called personality disorders.
The very common path of mental health sufferers: a significant proportion of
them will end up dead, suicide. In the Forensic service I commonly see those
who end up with drink and drug problems, as homeless, psychotic, within the
criminal justice system, within the mental health system. The pathways are not
so simple to monitor. They are quite varied.
What happens if these children suffer multiple forms of
abuse, physical, sexual and emotional abuse, being stuck in the care system.
Then repeat the abuse – give them fifteen different homes in ten years.
What happens to those children? The figures for those who end up in the
criminal justice system, in the mental health system, in the high secure
hospitals or committing suicide go up and up. The figures for those OK ones go
down and down. One third of the prison population are care leavers. One third!
If you think of the number of children in care as a proportion of the number of
children in society (an infinitessimally small proportion) that they will then
make up one third of the prison population is astonishing! It is an astonishing
disproportion!
I want to say something about the OK group who are
typically seen as the “supergenes” (irony). They’ve taken everything we can
throw at them! They’ve come out OK! There must be something really resilient
about this group. They’ve got supergenes. But, no. Environmentalists don’t buy
that. They think that there are better explanations. Now, I’m not saying that
genes don’t play any part but the crucial thing that decides that you can go
through these kinds of experiences and come out OK, in the broad sense, is the
absence or presence of positive, caring and nurturing relationships in that
persons experience. That’s the crucial thing. I’ve worked with professionals - out-patients
- inpatients - prisoners and prisoner patients, with the whole range. The worst
life histories that I’ve heard were when I was working at Rampton. No doubt
about that for me! The irony is that they were the people who were the most
medicalised group of people that I have ever worked with; they were the most
defined in terms of their ‘mental illnesses’ and their ‘personality disorders’.
Leaving that aside. I’ve worked with lots of people who were professional
people, who ended up relatively unscathed despite horrific backgrounds,
precisely because there was one kind grandparent, there was one safe place to
go to, there was one benign professional who stuck with them over a long period
of time. That’s the crucial defining factor as to where people end up. The
crucial and defining factor is not the severity and duration of the abuse it is
rather what positive experience they have had.
It’s a continuum of love and violence, of stability to
chaos. A continuum of emotional to physical abuse, it’s a continuum along
social, cultural and economic lines. I’m running out of time.
Very quickly, what are the implications for therapeutic
practice? We have to find ways of not othering people because it is the attitudes that are most destructive in the
way people are dealt with in the mental health system.
We need moral
and ethical responses not technical solutions, we need a model of healing
rather than ‘treatment’. We should value and hang on to people’s humanity
despite everything. We have to be fair – using respect and compassion
taking account how people got to where they are. Respect not degradation and
punishment. We need to democratise the therapeutic space in some way.
Boundaries not power and control – boundaries are very easily turned into
an issue of power and control but that’s not what I’m talking about if you are
coming from a humane stance. That is not to say you don’t behave
professionally. That is not to say you can’t be very clear and straight with
people. It is precisely about that. Offering choices whenever possible,
affirming people’s experience and allowing the truth to be spoken. “You are not
making it up, you are not delusional. “ There are lots of Offender Programmes
in the Prison system, for example, that explicitly proscribe looking back at
people’s background and experience because they are there as offenders and not
as people who have experiences that may have led them to that, which is seen as
avoiding responsibility in some way.
That’s what it’s all been about for me. If you can
recognise your own experiences within this continuum, then I think that’s a
good starting point.
And I’ll leave it there. (applause).
Dr
Rex Haigh, Consultant Psychiatrist in Psychotherapy, Winterbourne, Reading, and
Chair of the association of Therapeutic Communities. He has a special interest
in involving service users in teaching and research, and in struggling to keep
therapeutic ideals in mind in the bureaucracy of the NHS.
’I’m going to talk about
therapeutic communities, and try and give an idea of what they are about and
what they are up against. I hope I can convey to you how they aren’t some
strange little units that are a bit quirky and old-fashioned (or wild, as there
are sometimes rumours)– but are really about the sort of life-affirming
things that matter to all of us. And I think these things are under threat as
much as ever at the moment – in a pincer movement caught between the
Government’s unchallengeable drive for “modernisation” (which seems to mean
setting therapeutically meaningless and arid bureaucratic targets) and a rampant
tide of individualism and consumerism (that values individuals’ rights well
above the need to establish a culture of meaningful interdependence). To me,
both seem to be inexorable consequences of the terrible times of the 1980s that
haven’t abated much under what we had hoped would be a more sympathetic
Government. But enough rant on matters that I don’t know much about – I
want to start with a story. My first encounter with a therapeutic community.
In
about 1980 I remember being sent to a strange place. I was a medical student,
and we were often sent to strange places - like orthopaedic operating theatres where the surgeons wear space suits and do
operations by remote control to rural GP surgeries where Dr Finlay would have
been at home; from rooms where babies are born to rooms where corpses are
dismembered. This one was even more different, though.
I
had been warned by previous students that this acute psychiatric admission
ward, the Phoenix Unit, in Oxford, in 1980, was not somewhere to wear the
normal jacket and tie. So I kitted myself out in a big red sweater and jeans,
and I arrived there on a bicycle a couple of minutes after the suggested 8.30,
and I was casually pointed in the direction of a large dilapidated room where I
soon had to forget any ideas I had of hospital hygiene. I squeezed into the
room to be confronted with a large circle of chairs - perhaps 40 strangers -
where it wasn't possible to tell the consultant from the cleaner. I had to find my own chair and pull it
up next to a large restless man who just looked at me and laughed. "What's
your diagnosis then, eh? You must be manic like me with a jumper like
that." He trumpeted this at about 120 decibels, everybody laughed, and I
just wanted the ground to swallow me up. Uh oh – life on a TC starts
here. There was an excruciating silence (probably all of twenty seconds) before
everybody introduced themselves.
After
my initial culture shock of joining a therapeutic community, I went on to
thoroughly enjoy it. I found something completely different about the way
people were with each other - I learnt my psychiatry the same as other students
who were on traditional wards, but I also got an inkling of something that is
very hard to define or put in words. It was something about being allowed to be
yourself, about playfulness, and creativity.
Now, nearly twenty five years later, I am the
consultant on a TC (and I don’t think you could tell me from the cleaner on a
bad day), and I am still trying to work out just what "it", this
intangible quality, is. When I
teach medical students and junior
doctors, and all sorts of others, about TCs, the one thing they all know (if
they know anything at all) is what has been called Rapoport's four
"Articles of Faith": permissiveness, reality confrontation, democratisation
and communalism.
The trouble is that I am not happy any longer they really describe what happens
on many TCs. I have been to many different TCs, and tried hard to squeeze their
practice into words like "permissiveness" and
"democratisation", without feeling that those words were doing
justice nowadays to what was happening. So that’s what I’m on the hunt for, and
I hope to give you some sort of answer by the end.
When
some visitors came to Winterboune a couple of weeks ago, they asked me:
"What is a therapeutic community exactly?" - and I found myself
saying something hopelessly woolly like "a place where the whole
experience of being part of it can make a difference to somebody's life
afterwards". And the way I think of these things it is particularly the
relationships in it that make the difference - it is as if they come to realise
that life need not be like they expect it to be, or as it always has been. I
think it is only if we can find a way of really valuing these relationships -
and including a member's relationship with him or her self - that we start to
see what really matters. And funnily enough, I think it ends up quite simple -
and actually very challenging to a lot of contemporary mental health practice.
Before
I begin to look at what happens in these relationships, I just want to spend a
few moments on what might be called a problem of context. In a way, this is
about considering all the relationships which come into play: not just
between members of the community, or between us and the members. It also
includes our relationship with the unit or institution we work in (like us with
the NHS – except that one took a severe turn for the worse last week),
and the sociopolitical system that is a part of.
This
gets horribly complicated if we try to define them all, but they do have a
major impact on the work. Why are so few TCs in existence now, for example? I
would say that the answer has to lie in the institutional environment, and - even more importantly - in
our response to it. In the Northfield experiments during the war, Bion set up a
TC, but blew it in six weeks because what he did was too radical and didn't
take into account the system he was part of - the strict military hierarchy. We
must not repeat his mistake - which is perhaps something that TCs have done in
the past, and we’re struggling with in ATC at the moment: to adapt the helpful
bits of “modernisation” in a generally therapeutic way without “selling out”. I
can give examples of that later, if you want.
But
crucially, a therapeutic community approach, indeed any psychotherapy of any
depth, cannot be considered as a reified and isolated item of treatment taken
apart from its context. It is not like a drug which is administered under the
guidance of some sort of expert, nor is it a box that can be filled in as an
item of "care". In mental health I think it fundamentally challenges
other notions of "care", and exposes a vacuum at their centre, as
something rather insubstantial and empty. In other words, care is ultimately meaningless
unless in the context of a
relationship which really matters.
Since
I have been in medicine - and I first trained as a GP and completed that about
15 years ago - I think there are three sorts of "care" you come
across, and I shall call them medical, administrative and therapeutic.
By
"medical", I mean the whole box of tricks that modern medical science
and technology has brought us: coronary artery grafts, cloning genes and
embryos, prevention of cancer by screening, powerful antibiotics, numerous
other things and - in our own field - potent antidepressants. I'm not including
the art of medicine - bedside manner, listening, allowing healing to
take place naturally - which I would put into the "therapeutic"
category of "care". I just want to say that the medical or technical
approach by itself is rarely enough. And thinking about PD, people whose
lifelong experience - and deeply felt expectation - is of arbitrary use of
power over them, inadequate or perverted care, and life without much meaning,
"medical care" can feel at best useless and at worst like yet more
abuse. It seems hardly surprising that some people "act out", and
often end up running rings round us - I don't blame them. I hope these things
have come through in the user-consultation bit of the new NHS policy for
“personality disorder” – again, something I’d be happy to talk about
later.
But
administrative care seems to be what we are now in the high era of. It may be
more democratic and less authoritarian than a strict medical model, but I think
it gives spurious legitimacy to a rather cold and faceless authority, and I
don’t think we should sign up to it. This works through the stranglehold it has
got with words like "accountability", "transparency" and
"fairness". But it is the consequence of what Kleinian psychoanalysts
would call the paranoid-schizoid mentality of a repressive culture – in
Daily Mail-speak, it is the "something must be done about it"
tendency. Rather than tolerate anxiety and risk through relationship, a defence
is used. The defence is usually called a "policy" or a
"procedure" - some bureaucratic device to put a distance between the
awfulness of some peoples' existence and the limited and meagre resources
available to care. This "administrative care" I am talking about has
names like "case management" or "CPA" or "supervision
register". It fundamentally reduces the person in need of care to the
passive subject of some often unfathomably complex Kafka-esque machine. It
encourages dependency, and strips those who give care and those who need care
of their autonomy. It distorts relationships (never allowing them to be open in a therapeutic way) and
produces quite justifiable opposition and resistance in those upon whom it is
imposed - staff and patients, I think. It ignores most of the
therapeutic principles which I am going to spend the second half of this talk
defining and explaining. Of course it is completely justified for a thousand
reasons (many to do with resources and risk) - but all of those reasons are
there because it is politically based on the paranoid position of
"covering our backs" rather than the more difficult
"depressive" position - that’s the Kleinian opposite of
“paranoid-schizoid - and it basically means a mature, longsuffering and maybe a
bit cynical attitude of accepting the good with the bad and not expecting
squeaky clean technical perfection with all the boxes ticked. It means
tolerating uncertainty, anxiety and risk - and engaging in the hard struggle of
really changing things from the inside out, if you like – hearts and
minds perhaps. I first wrote about this in 1987 amidst high hopes that New
Labour stood for this, rather than a cosmetic managerial approach (particularly
in the public services) but I fear ‘tis not the case, and there isn’t any
understanding or interest in people’s real value or experience. Meritocracy
isn’t good enough for many people.
So,
onto the third paradigm of care, which I'm calling therapeutic. This is more to
do with love than with technology or procedure. Not romantic or sexual
love – but about other people’s minds and feelings mattering to us. This
is what some therapists call agape or koinonia – like the biblical
injunction to love one’s neighbour as oneself, and of affiliation and kinship
in medium sized groups. Of course, it is what we intuitively mean by
"care" - like when we say "take care" or "doctor so-and-so cares about his
patients". It is the ghost we need in the machine, where the machine is
the bureaucracy, or that high-tech medical box of tricks). It might show
through practical things (like a GP making house visits that aren’t strictly
necessary, to a person who’s dying) but it is really about our human, emotional
and invisible
interdependence on each other, and looking at the relationship in which that happens.
It signifies a depth of mutual respect, a tolerance of good-enough-ness (as
Winnicott called it), and a way of being with the other person that transcends
roles or hierarchies or power - although they may also be there. It is what I
think we are in a particularly good position to do when we work with a
therapeutic community framework, although of course it also happens in places
other than TCs.
An
example of therapeutic care. Through our “Community of Communities” lottery-funded project, I
went to visit three TCs in Athens just before Christmas, and have been thinking
about how mental health teams could be run on therapeutic community principles
– rather than the arid administrative way they often are now (and which
was rightly condemned by a recent President of the Royal College of
Psychiatrists, John Cox). I think it is still a long way off - but it did
remind me of the astonishing service that is run on TC lines at the Open
Therapy Centre in Athens. What happens is that if a patient or relative phones
the unit in the midst of some sort of crisis - not unlike any mental health
crisis we would have in this country - the way they respond is like a breath of
fresh air to me: about how things can be done, in way that cares without undue bureaucracy or medicalisation. A
"flying squad" of four assemble themselves from within the main TC at
the Open Therapy Centre - and that will be two community members and two staff.
They go to the house where the crisis is happening, and spend maybe half a day
there doing an assessment. Then they make decisions with the family about who
needs help, and how it can be arranged. And that might mean immediate admission
to appropriate parts of the therapeutic day programme for one or more members
of the family - and, without more ado, it happens. They have no beds, the team
includes psychiatrists who can prescribe medication, and they have shown better
outcome results than the alternative state services who run inpatient
facilities. No surprise there, and it’s probably very relevant that it’s not
part of the state system and patients are charged on a
"pay-what-you-can-afford" basis. Nobody is turned down through
inability to pay.
In
contrast, for most of the people who we deal with, technical medical care and
heavy duty administration is often given in abundance when it is just what they
don't need
– like expensive investigations and physical treatments that aren't
addressing the real problem. Of
course those things are needed in their place, but this is not their place. And I baulk in
horror at the sums of money being invested in high technological solutions to
human and social problems: a great deal is spent wastefully on investigations
and procedures which everybody knows are extremely unlikely to be of lasting
benefit. Recent research work at the TC in Leicester - Francis Dixon Lodge -
has shown how much money can be saved by definitive treatment in a TC. They have showed that psychiatric
bed use is
reduced to about one third of its previous level after admission to their TC -
comparing the three years before and the three years after admission. Yet many
TCs in the country are run on virtually fresh air, and very few are properly
resourced. I heard the other day that our non-residential NHS therapeutic
community in Reading costs about the same as one bed in the sparkly new PFI “Prospect
Hospital” that’s opening half a mile away next month. Prospect is an auspicious
word indeed: perhaps more accurately “NO prospect” - of developing low-tech,
human, grown from the ground upwards, locally meaningful services. And all this
in the face of all Gordon Brown’s NHS billions being spent on meeting these
modernisation targets in bureaucratic and highly managed, but therapeutically
destitute, systems. For example, the funding that goes with the new NHS PD
policy is an outrage: over £128M went immediately to set up the new DSPD units,
which very few people believe in, for less than 2000 patients. For the 5 or 10
MILLION people who suffer with their PD in silent desperation, clinging on as
best they can, (13% it says in the DoH guidance) there will be less than a
tenth of that amount (£18m we heard the other day), spread thinly around the
country. By my reckoning, that will be about 400 therapists with a caseload of
about 35,000 each. If they were pretty efficient, you’d get 3 minutes each per
year. Small wonder we spend all the money on Prozac.
But
many of those who are not much helped by NHS psychiatry currently cost a
fortune in services which don’t help them much, or actually make them worse. If
we look at it as a primary problem of attachment (about which I’ll be saying
more later), who can be surprised that these people try and seek care wherever
they can? Is it unexpected that they frequently attend their GPs, and if they
don't feel cared for there, they cut their arms or take overdoses or numerous
other things - all of which cost the NHS dearly but make little difference to
them? And the response is no less surprising - labels to keep them at a
distance: "attention-seeking", "personality disorder",
"heart sink", "multi-agency family". But to step back, the
"symptom" of unrequited care-seeking, is exactly what we would expect
of somebody who never experienced it properly it in the first place –
again, I’m coming back to this. So the economic measures are exactly what we
are hoping to make a difference to: if somebody feels well cared for, they will
not make unreasonable demands of the services. And we hope that the
relationships in TCs can be "taken inside" people in a way that lasts
for the rest of their lives.
To
come back to "administrative care", I am sure many areas of practice
have been made more efficient by the managerial approach I've just been so rude
about. But now that it is seen as the main approach for mental health
problems, we have thrown the baby out with the bathwater. Because these
bureaucratically-run services don't seek a way to value and use their
relationships with those they try to help, they risk becoming machines and
losing their humanity, and making their professionalism like a pompous show of
authority, through things like CPA and use of the Mental Health Act.
I
have mentioned a couple of political points, and I do think this is
political, and it’s not my field so I can’t go into it very far. It is the
politics of how we are with each other - I can't remember who it was who said
something like "the personal is the political", but that is exactly
what it is about. Do we all want to live in an anxious, brittle, sort-of
borderline state where nothing feels safe - or do we want to aim for real
change in the way we look at the world? That is a personal question as well as
a political one - and I think we create an artificial outer or inner world if
we try to separate the two. We live in the inner world we create - and we
deserve the outer world we get. To be extremely contentious, I don’t think
anybody can humanly think that America deserves to have people randomly killed,
but what they are doing at the moment seems likely to make it more probable in
the future, not less. And perhaps this is all because they see themselves in an
anxious, brittle, dangerous world, which they have to defend to the limit in a
paranoid-schizoid way - rather than talk about why some people might hate them,
and where they might have got it wrong.
Enough imponderable problems, I want to turn to solutions
– at least at the level of thee and me. This is fundamentally about
recreating an environment in which these human things can happen, and the
experience of that can change people’s expectations, and maybe their lives.
So
I want to propose a simple theory that is a framework to the importance of the experience
of being a member
of a TC. I believe that the internal experience is what changes people - in the
same way as our experience of life as we grow up makes us much of what we
are. It uses some of Rapoport's
ideas (like I mentioned earlier – TCs being defined as permissive,
reality confrontation etc), take some of the concepts of object relations
theory, and borrow from the ideas of group analytic psychotherapy – so
it’s peppered with the names of great psychoanalysts and it’s their ideas that
I have thrown together.
It
is a journey through five linked ideas - five concepts which describe essential
qualities of a therapeutic environment. The way I have put them together is
also a progression, a developmental progression - from the vulnerability and
nakedness of attachment, through both maternal and paternal aspects of containment to the social intercourse of communication. Then onto the adolescent
struggle of involvement and the adult and empowered position of agency - finding the self which is the seat of action, and
for members of our TCs to deploy their own power and effectiveness.
In
this theory, emotional development is something that happens to all of us. It
is the sequence of necessary experience to end up with a normal personality. Of
course, nobody's personality is perfect - but for most of us, our development
has been "good enough" - so we survive in a reasonable way most of
the time. But some people end up with personalities that mean they have
considerable difficulty. They have trouble in much of their dealings with what
we call reality: the inner world, relationships and the way they get on in the
world - like education, employment and general functioning. In object relations
language, they lack object constancy, relate in a part-object way and live
continually through intense transferences. In psychiatric terms, they have
personality disorder and an increased risk of episodes of mental illness.
Is
it genetic or environmental? Nature or nurture? I want to argue that the
question is irrelevant, because it is all of both. A child is born with a certain
genetic makeup, and history of nourishment, space, oxygenation and chemical
milieu in utero. Before birth, these have an almost total effect on what sort
of brain and body he or she has. Some children are born with much more
difficult constitutions than others: more needy, we could say. For example, a
child with certain random genes, severe anoxia at birth or exposed to much
alcohol in utero will have a different brain to a luckier child. And some of
those children will be "more difficult" - it will be harder to meet
their emotional developmental needs. I wonder if this is what Melanie Klein
called "death instinct": some children are born with more of it than
others.
After
birth, what happens to every child is development. For the lucky ones, as long
as they have a "good enough" parenting, they will emerge
well-adjusted. The constitutionally disadvantaged ones may come out OK if they
have extra input for their emotional development - and maybe that includes
professional help. But any child who has a bad experience of emotional
development will end up at a higher risk of having an unhelpful view of
themselves, other people, and the world - in other words, a personality
disorder. By bad experience, I mean something that disrupts their emotional
safety, for example:
• neglect
• deprivation
• abuse
• trauma
• loss
Some
people in the field, for example Sandra Bloom from New York and Felicity
Zulueta from Charing Cross in London, see all these as varieties of trauma: but
I think the difference between us is only semantic. For example, deprivation is
trauma – like the consequences of loss of something you never had.
Some
with a fortunate or strong constitution may be protected, and able to cope
fairly well as adults, because they have some good relationships to help
develop a less distorted view of themselves, others and the world. Those who
start life with a congenital disadvantage are very much likelier to suffer a
severe impact from inadequate emotional development.
And
to make it more complicated still - and even more impossible to separate out
the nature and nurture effects - both aspects (what we are born with, and
environmental conditions) are continuously variable, and not simply
"good" or "bad". Environmental conditions (including how
much a child feels loved) also change over time. And I think modern
neuro-imaging and neuroscientific techniques (with all that hi-tech gear I’ve
been so rude about) support this idea by showing us that environmental events
can have an impact on brain structure itself. And of course, it works the other
way too. The way a child behaves - because of its brain maybe - will have an
effect on, for example, whether it is punished or comforted. So I think it is
far too complex to ever say reductionist things like "personality disorder
is 65% genetic" - it is never possible to separate them like that - it is
all of both.
So
emotional development is something that needs to be considered for everybody -
not just for those who end up with severe and incapacitating difficulties. And
what I have described could be called “PRIMARY EMOTIONAL DEVELOPMENT”. By that, I mean what happens -
or should happen - as a normal part of growing up. So constitutional make-up +
primary emotional development = personality.
Psychotherapy,
and therapeutic communities in particular, offer the opportunity to
re-experience emotional development
which I call "SECONDARY EMOTIONAL DEVELOPMENT". Hopefully, from this,
people can gain experience that leads to better adjustment, and less likelihood
of breakdown with mental illness.
So,
back to the developmental sequence. I am saying that the five necessary
experiences for a satisfactory emotional development are
• attachment
(feeling connected, and belonging)
• containment
(feeling safe)
• communication
(feeling heard, in a culture of openness)
• inclusion
(feeling involved, as part of the whole)
• agency
(feeling empowered with a solid sense of self)
Now
I will just spend a minute on each to explain its roots, and how we recreate it
in a TC.
Attachment
All individuals start their lives
attached: umbilically, within the mother and with the blood of one flowing
right next to the blood of the other.
At birth, this attachment is suddenly and irreversibly severed: it is
the first separation and loss, with many others to come later. How well the emotional and nurturant
bond replaces the physical one was classically described by Bowlby. He
describes problems resulting in anxious attachment or avoidant attachment; it’s
very similar to Balint's "Basic Fault", which is about a lack of fit
between mother and baby -the bond is not secure, and nor is the infant.
When
disturbance is this fundamental, the first task of treatment is to reconstruct
a secure attachment, and then use that to bring about changes in deeply
ingrained expectations of relationships and patterns of behaviour.
What
we so often find in working in TCs is that attachment is powerfully sought, but
strongly feared. This is the struggle between Fairbairn's libidinal and
antilibidinal egos: the one desperate and needy, and the other angry and
rejecting. Not enough stable ground has developed between them, and the demands
of reality almost always meet the emotional responses of anger, shame,
humiliation and pain.
Containment
This
one is about the experience of safety, and the capacity to trust oneself, other
people and the world in general. A balanced internal representation of
containment is both maternal and paternal. The maternal element is safety and survival in
the face of infantile pain, rage and despair. All those are certainly permitted, and this in itself may be
a mutative new experience for community members, whose usual expectation will
be to face hostility, rejection and isolation when they feel and act like this.
Now they have the new experience of not having these powerful primitive
feelings denied and invalidated.
The
paternal element
is about limits, discipline and rules. I know this is stereotyping – it’s
just to make the point simpler to say. Again it is safety - but safety through
knowing what is and
is not possible
and permitted. The same as knowing the limits, or enforcing the boundaries.
Bion
described this process best: he talked about the turbulent and primitive
internal experience, and its link to thinking and the earliest mental states
imaginable. Winnicott described the sensuous and nurturant qualities of the
environment in which it needed to happen: the mother who actively gives the
baby a sense of its own existence. It is the difference between
"containing" and "holding" - one is mostly inside, and one
is mostly outside – but these are the key features of what we need to do
to provide containment.
Communication
Tom
Main wrote that the culture of a unit is more decisive in bringing about change in
human relationships, than is the structure. He wrote of the "culture of enquiry"
. I want to try calling it “a culture
of openness”
to make it less inquisitorial. Of course, openness is what a lot of therapy is
all about: "talking treatments", "putting it into words",
and "being heard". It is very important, it is at the heart of
therapy - but I think we must not forget what comes before it, and what needs
to be done with it afterwards. A demand on people for open communication is simply not
enough: they must want it, and feel safe about doing it. This requires an
intangible quality that must be present in the atmosphere. It mostly depends on
establishing the first two conditions: attachment and containment - for it is
only when a member belongs and feels safe that they can start to look at and
think about potentially difficult and painful experience.
I
think this is what Foulkes – the founder of group analysis - implied when
he wrote "Working towards an ever-more articulate form of
communication is identical to the therapeutic process itself" - so the therapeutic process is
not just one of communication, but the work and struggle to get into a position
to be able to communicate. This means establishing the network of relationship
in which that can happen. The term
that group analysis uses for this is the matrix. And it is in the matrix that a
depth of connectedness can exist where hidden, split-off and dark experience
can be examined and integrated.
Inclusion
For
24 hours a day, all interaction and interpersonal business conducted by members
of the community "belongs" to everybody – even in a day unit,
everybody is held in mind twenty four hours a day, seven days a week, and what
they do in any of that time matters to the community. The expectation will be to use it and understand it as part
of the material of therapy. Not in isolation, but in the real and
"live" context of the interpersonal relationships all around.
In
this way in a therapeutic community, individuals can find a very deep
understanding of their place amongst others: this will be examined the whole
time. People are responsible for themselves, for the others, and for the
relation between the two. There is "no place to hide" as one of our
members recently put it.
When
the group is considered together, this is basic group analytic theory. Each has
a different but vital contribution to make to the health of the whole. "The
group constitutes the very norm from which each member may individually
deviate":
the aggregate of all the individual elements produces a thing with its own
qualities and a whole that amounts to more than the sum of its parts.
Margaret
Thatcher said that there was no such thing as society, Winnicott said there is
no such thing as a baby, and Foulkes tells us there is no such thing as an
individual: "each individual is an abstraction: determined by the
world of which he forms a part". This is the opposite of an individualistic view - and
the richness and variety of the web of relationships between the members, with
all the rights and responsibilities that implies, is itself a creative and
reparative force - in other words, the matrix again.
Agency
In
1941 at Mill Hill Hospital, Maxwell Jones noticed that soldiers suffering from
"effort syndrome" were better than the staff at helping each other.
At Northfield, Bion's wartime experiment which I have already mentioned was
stopped after six weeks, when he refused to own total responsibility for the
disorder of others, and he was replaced by Main, Foulkes and Harold Bridger,
who led a different sort of TC. These two locations are the start of
therapeutic communities as we know them, and the point I want to make is that
both made fundamental challenges to the nature of authority. Now they seem less
strange, for in a funny bureaucratic way, some of these ideas have become
mainstream – like the very welcome development of service users becoming involved
in planning services. But I would urge caution about needing to acknowledge the
depth of feelings that must go behind this process. I and others do believe it
will slowly bring about an unthinkably significant change in the relationship
between helped and helpers – but woe betide us if we treat it as a piece
of tokenism, or if we forget that even helpers need help sometimes. We have to
be really in it together.
But
for therapeutic communities, this challenge was there at the beginning. It like
Jung's idea that the patient's unconscious knows better where to guide the
therapy than does the analyst's expertise. It also has a strong tradition in the teachings of Harry
Stack Sullivan and the interpersonal theorists, as well as Kohut, where any
power imbalance is seen as authoritarian, distancing and against the
establishment of a satisfactory therapeutic space.
This
is what I’m calling the principle of agency, where authority needs to be
fluid and questionable within the frame of therapy. It is not fixed but it is
negotiated - and the resulting culture is one of empowerment. This goes much
further than the original "flattened hierarchy" of what Rapoport
called democratisation. Rather than being a fashionable idea, or a policy which
is imposed on a unit, it demands a deep recognition of the potential intrinsic
worth of each individual. It is not a "harmony theory" that says we
simply have to find this within people - for it includes powerfully
destructive, envious and hateful dynamics which exist in all of us, and are
sometimes beyond reach. However, working this way does presuppose the
possibility of a considerable degree of intimacy, which is an intimacy which is
safe, open and healing rather than frightening, dark and abusive.
Having
a second try at emotional development
So
Secondary Emotional Development is what we try to do by recreating these conditions in a
therapeutic community. We are trying to provide a psychic space in which the
things that went wrong or got stuck in primary emotional development can be
re-experienced and re-worked in this artificially created place for
"secondary emotional development". It can never be quite the same as
first time round, or quite as good and nurturant, but we try to make it as good
as we can get.
It
can also work the other way and produce an environment which is unhealthy, or
anti-therapeutic. With a culture that discourages attachment, that does not
feel safe or containing, with perverse and distorted communication, unspoken
rules about what is and is not admissible, and power based on arbitrary
criteria. Where human needs for
secondary emotional development are being ignored or obstructed. I’m sure we
can all think of places like that, for this can be as much true of a school,
office, company or a hospital ward as of a family or therapeutic community: any
setting where a group of people are emotionally engaged in some sort of
developmental task. But these are the tings that matter.
So
what I am talking about is not only about specialist hospital, or prison units
for treating personality disorders - it is about everyday life, and struggling
to try and meet needs that we all have. Which goes to prove the old therapeutic
community joke: Q: “How do you tell the patients from the staff in a
therapeutic community? A: The patients are the ones who get better and leave”.
Rex Haigh: rex.haigh@virgin.net
Thank you so much for inviting me to offer the personal
perspective from Broadmoor, and I feel very privileged to represent a fantastic
group of women survivors inside and out.
Getting what’s good for them? Some certainly think so but before unwrapping this package I
would like to refer you back to last year’s conference, when my friend Lin
Hankinson presented a brilliant paper explaining in depth Secure Service
Provision highlighting the need for Gender Sensitive Services and describing
the route into secure care for the women currently in the system. I am not
going to repeat her presentation but I completely endorse and I recommend
it. And if you missed it you can I
believe obtain and read a copy for yourself in last year’s conference report.
We are collectively at a time in our history when our
lives are to some extent governed by external events, listening out for the
ever-changing news. We are all
waiting for the next impending crisis, and all of our futures and our lives
depend on those in whom we have no choice but to trust. It feels as if the whole of humanity is
holding its breath while the few who hold the power, the power literally of
life and death are even as we sit here, making ready to let loose the dogs of
war.
Soon, another generation of traumatized young men and
women will be coming home to their families, changed forever by their
experiences. And yet again, we
will have to count the cost of war for future generations. Meanwhile, it seems that the ordinary
and mundane areas of life seem to be in suspension; other issues are passing by
almost without note.
One newspaper last week described the current situation
thus “Every day this week has been a Jo Moore day, when bits of bad news are
being buried the moment they surface, and politicians are quietly hopeful that
they’ll stay buried”. Here are a
few examples from national and local sources:
Thursday 6th March BBC Local radio: “Cases of sexual abuse,
including rape, are reportedly widespread in Broadmoor.”
Friday 7th March BBC
Radio 4, The Today Programme: “A management Whistleblower claims that rape and sexual
abuse in a wide variety of forms is taking place inside Broadmoor. Coincidentally, suicide rates among
young women are on the increase.”
Saturday 8th March
Meridian local news: “Suicide and attempted suicide rates
among women are on the rise, in line with sexual abuse and rape in Broadmoor”
Sunday 9th March:
Independent on Sunday: Headlines: “ Macho culture blamed for plight of
female patients” and “Women in Broadmoor should not be there.” Ian Johnstone,
director of the British Association of Social Workers said, “…the treatment of
women at Broadmoor is an outrage.
It’s almost like these people are not worth protecting.”
The ‘Whistleblower’, a former
Director of Women’s Services in Broadmoor has exposed these practices after
having worked to improve conditions for women inside Broadmoor over several
years. During her time there she
abolished mixed gender activities and campaigned for women only space in
educational and social settings.
She organized the very first women
only rock concert and brought in women only bands and entertainers. The women patients said at the time
that they felt liberated. So what
happened? What went wrong?
Again I’m going to refer you back
to Lyn’s presentation which identifies very accurately the women in question,
but essentially they represent a body of women currently in secure containment
who between them have histories of the very worst examples of physical,
psychological, emotional and sexual abuse ever documented. With just a very few exceptions they
have all experienced horrendous diabolical treatment at the hands of
others.
Moira Poitier, a psychologist who
for many years worked with women in Ashworth said:
“There
is a common existential experience shared by women of not being heard, and
rarely believed, chronically frightened and overwhelmingly powerless except in
outbursts of rage against property, self or others.”
How they came to be in maximum
security can be explained briefly using a composite history including all of
the abuses already mentioned, from infancy in some cases, and adding on
torture, social isolation and exclusion, procurement for pornography and
prostitution of every variety, all of which of course we know is still taking
place in our society as we speak.
These women have been the victims of terrible unspeakable crimes
perpetrated against children and women of every age.
They come into contact with
services at the point where sooner or later their behaviour becomes
problematic. They are bounced in
and out of the remit of education authorities, social services, care orders and
their the failure to care.
Sometimes there might be issues around addiction, difficulties with
relationships and sexuality, employment and for some the involvement of the
criminal justice system and/or mental health service providers and
inappropriate treatments such as ECT, and flawed medication regimes.
Inevitably there comes the moment
when we have insult added to injury by the pathologising of our experiences. We
are told we are born liars, pathologically compulsive liars. That is closely followed by the
attachment of the label of Personality Disorder or Borderline Personality
Disorder. Abandon hope all ye who
get this piece of stigmata because mud sticks! Many of us who suffer the stigma and of course I
include myself, completely reject it, and leave it to the people for whom it
has proved most useful –politicians, psychiatrists and the media in
general. It has become a term of
abuse within and without mental health and social services and says absolutely
nothing positive or helpful about the person behind the label.
The women reach Broadmoor for a
wide variety of reasons to do with systemic and legislative abuse, often having
survived community psychiatric services and the rigours of secure containment
in regional unit. For some, and
these are the minority, their inner distress becomes manifest by the commission
of crime, most commonly Arson. For
others it is their challenging behaviour that proves most taxing for society
and services to cope with.
They are in short a bloody
nuisance and a huge drain on resources.
They fail to engage with services, and so they are labelled BPD and PD
and dustbinned off to Broadmoor, Rampton or Ashworth. They are tidied away behind high walls and razor wire where
nobody need concern themselves with the few, who’s joint history represents
tales of horror and wickedness of a kind that not even the worst tabloid editor
could imagine. It is highly judgmental
and punitive. Take the word of one
who has been there, it is a punishment for having survived thus far.
They are not sentenced. For many there has been no crime, but
they will have no idea of their likely length of stay. Sound familiar?
The new unit currently under
construction in Broadmoor will house up to 70 men classified as Dangerous
Borderline Personality Disorder.
There has been a huge outcry in the grown up press, in the House of
Commons, among professionals and human rights campaigners all of whom quite
rightly condemning the legislation passed to permit this. Detention without crime and without
trial is a serious abuse of the power of the state. Pardon my cynicism, but our society has been doing this to
women since before Broadmoor was built in 1863, so what’s so special about now.
I know this is difficult, perhaps
even hard to believe but I am going to ask you to trust me to deliver the
truth. It is unpalatable.
Over the years, and throughout the
entire history of Broadmoor, the women patients have had a vital and important
role to play in the treatment of men.
I want to tell you about the clinical disco. Groups of up to fifteen or twenty men were brought under
close escort to the women’s ward and in one of the day rooms they would be
paired off with a woman patient and observed closely while they chatted over a
cup of tea and a snack, and enjoyed a dance or a quick fumble.
For the men involved this
represented both therapy and reward.
They were only allowed to attend if their good behaviour that week had
earned them sufficient points on the ward score, and if their previous
offending behaviour had demonstrated an inability to relate safely to
women. Large and expensive
programmes of research have been conducted on the nature of Broadmoor men,
their offending profiles and background, their sexuality and how that impacts
on their violence to women.
For the women, we were just part
of that programme. Forensic and
psychiatric researchers could hardly believe their good fortune. Well just imagine the outcry had they
tried to access the data any other way.
Any volunteers?
Attendance for us was of course
compulsory. We all had to take our
turn on the rota regardless of age or sexual orientation. This came under the heading of normalisation,
and how normal does it sound to you?
The same situation applied across the board to include educational
facilities, sports both indoor and out, integration in all areas except actual
living quarters was commonplace.
What does that tell you of the
role of women in maximum secure hospitals then and now. The Broadmoor Rampton and Ashworth
women have been as victimized by the system as they were before they joined
it. For more than thirty years,
evidence has been presented to politicians and responsible ministries, demonstrating
very clearly that women were not receiving any form of treatment in
Broadmoor. Not anything. The actual victims of male aggression
were locked in with the perpetrators as an aid to risk assessment and treatment
of the men. Meanwhile, the women
were cutting themselves to the bone, tying their necks with their own underwear
and swallowing anything they could get their hands on from furniture polish to
toilet cleaner in an attempt to escape.
Take the example of the clinical
disco and replicate it into sporting and social pursuits, concerts and film
shows. Include with that the
educational facilities, unsupervised classrooms, the library, the chapel, the
gardens and workshops and the role of women in Broadmoor should become
apparent.
Sadly this is not just an
historical perspective. It isn’t
even just my personal perspective, it is happening now. Or was, until just last Thursday, when
Julia Wassell sounded the alarm and Broadmoor responded in a flash by
immediately cancelling their entire programme of mixed events and
functions.
During my time in Broadmoor we
were told that for women with PD there was no treatment, no hope, and no
explanation. We would quite
probably grow out of it and when that happened we would be transferred
out. Their judgment of our
readiness was entirely behaviour based and when we understood what they
expected of us, in terms of behaviour, we simply colluded, it wasn’t that
difficult most of the time and we understood the principles of milieu
therapy. Prolonged and aggravated
abuse depends upon the collusion of the victim.
Good personal management and
emotional control, allied to observed acceptable behaviour permitted slow
progress through the system.
Occasionally and for some it became too difficult. We all of us experience stress and
develop ways of dealing with it but many of us lacked the skills or vocabulary,
or opportunity to explain or describe the worst of our internal pain and
grief. Add to that the fact that
nobody wanted to hear it. I am both heartened and depressed by recent advances
in neuropsychiatry. Brain scans
confirm what we have always known, the difference is that now we might be
believed, because doctors just love something with a bit of science
attached.
Life for women in Broadmoor has
changed since my time there. One
of the changes is that a small number of women are now being offered therapy,
until quite recently the only treatment was containment. It is only available to a very few and
it isn’t always appropriate, and the women have no choice of therapist or the
therapist gender, and in some cases it is almost entirely cosmetic. In recent years one woman was made to
attend family therapy with the father who had been her abuser. I think he found it helpful. Another could only communicate with her
therapist by writing notes to him, because she was too humiliated to speak the
language of abuse to a man. I’m
sorry to tell you that both of those women ended their lives in Broadmoor
What this tells us about the
Broadmoor women is that they are still highly vulnerable in a system entirely
designed to meet the needs of men, many of whom are violent and potentially
very dangerous, and not just for the women, some of whom are mothers.
Some men are carefully building
relationships with women who have children to return to. The men are protected by rules of
confidentiality, and the women have no way of knowing why the men are in
Broadmoor. Their interests are
protected. Nobody is suggesting
that children visiting their mothers are at risk, because Broadmoor took
immediate steps after the second Ashworth enquiry, but the dangers are still
very real.
We are getting to the beginning of
the end of this terrible state sanctioned systemic and systematic abuse of
women, and the courage of Julia Wassell will have an important part to play
because for the first time one of their own side, and in a senior post, has
spoken out. They did everything
possible to prevent it in the same way they tried everything to prevent the
reforms she introduced while she worked there.
I can’t jeopardize her current
situation by including too much detail, but she was driven out of her job by
the same bullies who have a great deal invested in maintaining the status
quo. Not only their jobs, and
research grants, but subsidized housing, fantastic sports and social provision
and very good pay in a beautiful corner of England in which to raise their
children in order that they too can follow the family tradition of going up the
hill to work with the loonies.
A history and culture stretching
back for a hundred and forty years is finally coming to an end, for the women
at least.
The strategy is written. The recommendations are going to be
followed and the women are moving out but don’t get too excited, it may well be
another three to four years before provision is available for all of them. There are still bridges to cross and
units to build, and we still have people with a vested interest in keeping
abused women behind the razor wire for a bit longer, and we are still looking
for clarity in the areas of Rampton and Ashworth.
So did we get what was good for
us? I would like to leave
you with a few thoughts about some very precious and special women. There have
been women in Broadmoor for 140 years and many will never leave. We have lost so many wonderful
lovely gifted and creative women of all ages, and far too many have dropped
exhausted, too filled with grief, too tortured by their dreams and nightmares
to carry on without hope of rescue.
Young for the most part and altogether magnificent, for having managed
to go so far along the road without support. They might become the subject of public debate only now that
the suicide rates are being talked about. Funerals and inquests are held in
private inside Broadmoor. The patient’s cemetery is behind bars. They deserved
better. Thank
you.
introduction
Bob: I
had intended to introduce a prisoner at this point. He came to the conference last
year and he is due to be released in about three weeks time. He is, at the
moment, on unescorted leave to his home in the south of England from the prison
in Scotland. We asked the prison governor about six months ago for permission
for him to attend. He said “No”.
What I want to do instead is to show you an eight
minute video we took of Karl last year. He speaks of his experience and it
covers some of the issues that we have heard recounted here today, very
clearly.
He has a very positive and optimistic message. I
shall play a short extract and then I shall stop it for discussion.
Video of Karl from 2002 Conference.
Bob:
I think I’ll interrupt it
there because we are rather pressed for time, but you can see there: he
describes it very clearly. He had this terror as a consequence of the abuse
that he could not discuss or deal with in any way. He was given the opportunity
almost, as it were, by mistake. At least it wasn’t in the ordinary way and he
started looking at his childhood, that he had forgotten - not forgotten in the
ordinary sense, but that he had repressed. It was just too frightening for him.
I became involved because I was asked to write a
medical report on him for the tribunal system in Scotland. This is actually a
consequence of the European legislation which is having a very benign effect.
I’m sorry that Karl couldn’t come but, hopefully, we shall have him with us
next year because he is such a dynamic, positive and optimistic speaker as you
can see.
Nada, would you like to come up and say a few words
for us?
Nada: I need some lessons to learn how to
speak in front of so many people – so forgive me if I am not a very good
speaker. I don’t know if you know my history: it is very similar to the last
speaker. I was terrified, I was traumatised by my childhood. My dad didn’t want
me and he hit me, he bullied me. He bullied my mum because she produced a
daughter instead of a son. He beat my mother and he beat all of us. It’s a long
story. He was an army officer. He
put a gun in front of my face. On a couple of occasions I couldn’t hear for
three months. He pointed this gun at me. He had this fixation. He didn’t want
me.
I grew up and I was traumatised, I didn’t
understand – “Why was I angry? – Why was I violent?” I couldn’t work, couldn’t relate to
men. I had a lot of problems, I had a lot of fears, a lot of suicide thoughts.
Nobody in the family had any kind of mental illness so I couldn’t understand my
fear – where it was coming from – I knew it but I didn’t want to
deal with the childhood problems,
of the victimisation my dad gave me.
I had a lot of treatment over the years. It didn’t
help. It dealt with the stuff – what happened to me? - Why was I violent?
– Why was I trying to hurt myself? – Why was I trying to kill myself?
– all of this. We didn’t try to understand. I’ll tell you what I mean. On
a couple of occasions the psychiatrist accused me of lying and pretending about
everything that had happened! On a second occasion I was asked to punch a bag.
That produced a lot of violence. I wanted to punch his face! (laughter). I knew
that this didn’t happen. I knew that I would be in hospital. I would have been
sectioned. I knew that so I didn’t do that.
I never felt that I was mentally ill. I felt in my
heart and my soul that something was wrong. I didn’t know that there was this
box and I ended up with lots of problems.
Finally, in 1995, I met this gentleman, Dr Bob
Johnson. To me he is a gentleman (turning and smiling to Bob). He showed his
humanity, his understanding of my past and I told him what had happened to me.
On our second meeting, I spoke about my past and he sort of led me to an
understanding of my past, of where my anger, my violence and my suicide
thoughts were coming from. He connected me with my father, with the violence
and the abuse of me, the blood and the violence and everything else. I learned
that I should separate myself from the past. In effect, what he was doing was
giving me the tools with which I could have a relationship with my past, with
myself. The relationship with my past was one thing but the relationship with
myself was quite another. I learned this from Dr Johnson. I had buried the
past.
I was able to deal with it, to understand where my
violence was coming from: I cut the umbilical cord that still held me in my
past. When I realised this, when I understood where my behaviour was coming
from, I realised that I am a human being, that I am not violent! Since then I
have opened a business. I am a personal trainer. I have studied some more.
Last year I broke my arm. I closed the business. I
didn’t panic. I didn’t traumatise myself! I was cool and calm and collected. I
picked myself up. I am now qualified Pilates teacher. I have found a profession
I like. My emotional health is improving all the time. I feel that I can do
anything and everything with the knowledge that I have now. That today, I am a
person in my own right, that I can be anything I want to be, that I shall be
what I want to be.
Applause.
Thank you very much Nada. Wonderful! What I think
is so important about these meetings that we have: the input in the morning
sessions from experts, discussion of the history and the background and then
the input from people who have experienced these feelings and have found a way
through. Nada speaking of the tools I gave her– I gave her a pair of
scissors and she would cut through the umbilical cord. The model I work with
contains so many echoes of what we have heard this morning. I can summarise it
with the phrase:
“Parenting
keeps infants alive and adults insane”
What
that means is that, as an in infant, you need sound attachment. Your parents
are your life support system. Both parents have two jobs:
To bring the child up and to bring the child up to
be independent.
If, in adulthood, you are still surviving on
childhood infantile strategies (as you are always bound to do if you have had
an unsound attachment – a traumatic childhood as Nada described) then you
are going to have childhood
tantrums, childhood frustrations and childhood violence. It’s a question of
transferring your life support systems from those childhood patterns (where you
are looking to others to look after you) to yourself, which is as Nada said,
‘to have a relationship with herself’, that is, being an adult and
solving your own problems. Not
in isolation of course, but with mutual emotional support, rather than looking
around to find someone who can solve your problems for you.
This pattern of infantile emotional strategies in
adult life is one that took me a long time to uncover because the individual,
as you saw with Karl, as Karl confirmed, does not want to discuss, does not
want to look at the painful items. If you traumatise the child, the child says
“This is not happening to me” They put the lid on the box. They don’t want to
look. It’s dangerous to look. The child has learned that the abuse will recur
if you look, so the child comes into adult life and doesn’t look. They need the sort of care and support
that we have heard about and they need a proactive discussion. I will now show
a couple of clips of a video I
made which show a man called Tony who is 41. He has spent his life burgling
because the system ‘owes him a living’. He starts off by saying that he was put
into care at three months. He took half an hour to tell me the story –
half an hour recounting the most horrendous abuse in the care system, that he
was moved from care home to care home. There was sexual abuse all sorts of
physical abuse.
However, this is an optimistic story. I shall show
you the clips where I suggest to him that he no longer needs to bind himself to
his maternal yearning, that he needs to abandon this infantile yearning for his
mother, that he needs to be more self reliant. I want to show you how I suggest
that to him and how the process works.
(End of morning session).
Afternoon
Session.
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.
Author of
“Emotional Health” published by JNF,
Bob: I
had intended to introduce a prisoner at this point. He came to the conference
last year and he is due to be released in about three weeks time. He is, at the
moment, on unescorted leave to his home in the south of England from the prison
in Scotland. We asked the prison governor about six months ago for permission
for him to attend. He said “No”.
What I want to do instead is
to show you an eight minute video we took of Karl last year. He speaks of his
experience and it covers some of the issues
(See
Appendix for a full transcript of Karl’s experience)
Bob introduces the afternoon session
Bob: Good afternoon everyone just let me say
that we shall begin this session with some video clips for the first half hour
then we are going to have the panelists up here and take questions from the
floor.
Speaking of Truth, Trust and Consent. Consent is
the cement that holds the other parts of the triad together. We are not pieces
of wood, we operate by consent.
Truth is your understanding of reality, today’s
reality.
What is the truth today?
Today’s truth, as I was saying at the close of the morning session, is that we
are adults. We need to operate with adult strategies. In order to do that we
have to be educated. We have
to learn to leave behind the trauma that freezes us
so often at a particular age.
Trust. Trust is the ability to rely on someone
else. It’s a very elemental emotion. You can’t buy it, you have to both earn
and learn it. If you haven’t earned and learned it, if you haven’t got trust,
then you are vulnerable. We belong to a species where our very life depends on
trust. Truth, Trust and Consent. Consent was taught to me by the murderers that
I treated in Parkhurst. The prison service says that you must coerce these
people so that they don’t hit each other. That’s quite wrong! We work with them,
we work with them by
consent. If we don’t work with them by consent
then we are building on sand. We live in a coercive society. Lip service is
paid to consent. In a democracy, we give consent to those who rule. The consent
is absolutely critical.
Now I am going to show you some clips of Tony. The
intention behind consent, the notion of intent is something that contemporary
psychiatry omits. They try to live in a mechanical world. To live in a
mechanical world is very boring. Nobody wants to be irrational. Now I have my
definition of irrationality: it is that it comes from infancy. The logic is
sound, but the emotions are relevant to a different context, to a different
time. Now there is a twenty four year old in Parkhurst whose aim is to become a
serial killer. He says “If I have my tantrums as a four year old, I smash my
foot on the floor. If I have my tantrums as a twenty four year old, somebody
dies”. It’s the same tantrum! As an adult he could have learned to achieve what
he needed to achieve without a tantrum. The irrationality is the hidden part.
Now this is the crucial bit. We all start very small and very young. All
infants are helplessly dependent but they are startlingly aware. This is where
the whole body of psychiatry has gone wrong.
A picture of a new born infant appears on the
screen.
Here we have Ethan, he was born as you see in December 1999. There he is
(referring to the screen), he is twenty seconds old. There’s the evidence: he’s
smiling. Here he is again: he is seventeen minutes old. The man on the left is
looking at Ethan and he is sticking his tongue out. Ethan is looking at this
face and he sticks his tongue out too! He’s seventeen minutes old! Ethan’s mind
is already absorbing. He can’t discuss, he can’t verbalise, but he is already
observing and learning. He is learning social rules. This curious face nearby
has stuck out his tongue so he responds.
Because all human infants are paraplegic and are
totally helpless – if they are left, they are dead. So all infants
require sound parental attachment. If the attachment is robust, reliable,
trustworthy, consensual, truthful and realistic: then if you escape something
traumatic - even if you break a leg, or if someone dies, if you have sound,
good, reliable attachment then the effects are ephemeral. If, on the other hand, the attachment is not
sound, the consequences are not so much catastrophic, as infantile.
I want to look at some instances of this in my
psychiatric practise. This is a tale of two cases.
Case A: a leg disease, your leg won’t do what you
want. A woman goes to the doctor and she says “My leg won’t work”. As a doctor
confronted with such a case, you can expect moderate to mild satisfaction. The
doctor enjoys the challenge, works out why the leg won’t work and off you go.
No problem at all. Case B, a mind disease. Your mind doesn’t do what you want.
You go to the doctor and the doctor says: “It’s in your genes. I’m sorry, it’s
a clockwork universe, there’s nothing I can do”. You feel trapped. There’s nothing you can do. The doctor’s
satisfaction is nil. There are vacancies for 388 consultant psychiatric posts
because there is, for the reasons outlined with case B, no interaction.
Psychiatry is the most fascinating occupation that I can possibly imagine. I
love it! I enjoy it! I am a contradiction in terms – a happy
psychiatrist! (laughter). I believe this because I engage with another human
being. The sort of engaging that I do (as you heard with Nada) is that I
challenge them. I ask them, “Do you need your mother? How old are you?” This is
something that I have already covered in my book, “Emotional Health” .
The psychiatric text called DSM IV the “Diagnostic
and Statistical Manual Issue IV” i.e. edition four issued in 1994, and prior to
that the DSM III from 1980, specifically says “ We are not interested in
causative factors.” They are not interested in engaging with human beings. The
DSM IV is a very thick book (Bob holds up a copy to illustrate) In October, I
was invited to speak at a conference in New Jersey and a friend of mine
obtained a copy for me, she knew what I was going to do, I was going to hold
the book up and say that it was crap!
What it actually is, is it’s descriptive. You go through DSM IV and you
find symptoms. Thousands of symptoms! I am interested in why.
Really, the breakthrough that I made was to do with
the difference between an adult and an infant. An infant clings and tries to
attach. The parent has two jobs: one is to allow the clinging and the
attachment whilst, simultaneously, encouraging the individual to learn to stand
on their own two feet.
I’m going to show you some clips of Tony which
illustrate what can go wrong if this doesn’t happen.
He describes to begin with, what the problem is:
Tony: When I was in Durham prison I asked to see a listener.
Bob: Oh yes I remember that.
Tony: I said to the listener, I told him the basic problem.
I said, “Why do I keep coming back inside? What I want is a normal life”. He
said that it was me that was, he said it was my fault. I thought, “No! - it’s
not my fault, it’s their fault, they did it!” and I had a chat with the
minister and he said “You are pressing the self destruct button all the time”.
Bob: I wonder why, eh? I wonder why?
Tony: But I wonder why! How do you deal
with it?
(End
of first clip)
Bob: He was abandoned at the age of three months
and then his mother “materialised” when he was 12 with disastrous consequences.
He had problems with the stepfather, ran away and was living on the streets.
Here he is at the age of 41. Quite a long and horrendous history. He repeatedly
talked to people about it. But I had a different take on all of this. I am
proactive. I regard myself as an emotional educator. I hear of this welter of
abuse and torture that he has
experienced coming from him. He wants compensation, his life is ruined, he
doesn’t trust anybody. I made my intervention, a bit later than usual, about
thirty five minutes in. What I suggested to him was that he did not need his
mother. Now this had never occurred to him, he had never been introduced to
this idea.
Bob: Well, that’s the key! This is my trade! This is what I do all
the time! We start with your parents. How do you feel about them?
Tony: Resentful.
Bob: Who were you first angry with?
Tony; My mum.
Bob: You are, aren’t you?
Tony: Yeah.
Bob: What do you think about that? Should you be?
Tony: (Pause) Because of things like say my dad
used to hit my mum and things like that. Saying you couldn’t look after me. But
one of my uncles said that she tried to help me when I was little.
Bob: Let’s just go back. You are
angry with your mother for not looking after you. Are you sure?
Tony: Yeah.
Bob: The thing is, you are very small. You are
looking for your parents, to look after you. They are your life support system.
She leaves you at three months, is that right?
Tony: Yeah.
Bob: And that fills you with rage.
When you get to eighteen, twenty one, you should be on an even footing, but
what’s happening is: she’s still looking after you at the age of eighteen. Does
that make sense? Describe it, if it makes sense.
Tony: Yeah. In the normal family situation, I
would imagine, you are with the parents and you get love, you have your
arguments, but that’s just family life. By the time they are eighteen they are
walking away from it. They say, “I still love you and I still know you are
there for me when I am in trouble and when I need you, but no thank you, I am
making my own way in life now.”
Bob: The tragedy is you haven’t had a
steady infancy to get independence in adult life! In a situation like yours,
where infancy was rocky, you are still clinging on! But you don’t need to at the age of twenty one. You have to
cut the link between yourself and your mother. Can you do that?
Tony: Yeah.
Bob: Can you? Are you sure?
Tony: Yeah.
Bob: “Ta-ra mother. I don’t want to see you
again.” Can you say that?
Tony: Pauses. Raises hands to shoulder height.
(Thinking how to say it)
Bob: Do you see what I am saying? What am I
saying first? - before you answer the question.
Tony: To completely go. This is how I felt because of
this, because of that. It’s all my mum’s fault. Cut the link and say “Right
mum, this was in the past. This is what’s gonna happen now.”
Bob: That’s right. You need to say “I
don’t need you mum!” Can you say that? Off you go! Sit her over there and say
“Hello mum, I don’t need you!”
Tony: Hello mum, I don’t need you.
Bob: Do you believe that?
Tony:
Yeah.
Bob: Are you sure?
Tony: Positive!
Bob: Is that a new idea for you, or not?
Tony: Yeah.
Bob: What are you going to do about it? What am I
suggesting to you?
Tony: To free myself.
Bob: Can you do it?
Tony: Yeah.
Bob:
Can you tell me
why you didn’t do it before?
Tony: I didn’t want to let go of it.
Bob: Didn’t want to let go of mum! Say it!
Tony: I didn’t want to let go of my mum.
Bob: It’s true isn’t it? Now, I’ve suggested it to
you. Do you think it’s a good idea? It hasn’t occurred to you before has it?
Nobody has said.
Tony: Yeah. (Starting to smile).
Bob: So what’s the disadvantage of not letting
go of mum?
Tony: All the bad moments are staying with me.
Bob: And there’s no way out! You need someone
outside, to talk with you, which you’re doing today, and they say something to
you that is quite outrageous, in one sense, “Say goodbye to mum”. “But I’ve been looking for her all my
life!” you say. That’s wrong!
You’ll do better without your mum. Do you agree with that?
Tony: Yeah.
Bob: Why is that?
Tony: Because when you are small, you need parenting.
You need people to look after you and make decisions for you. When you are
older, er, you get your own ideas. You can’t live somebody else’s life. How
they want you to live is different to how you want to live. It’s different to
how they think you should live.
Bob: Are you are still going back to your mother in
your mind?
Tony: Yeah, everything I do stems from my mother.
Bob: Absolutely right! What’s changing about
that? How can you change that?
Tony: The reason I want, personally to change it, and this
is the reason why I told my solicitor what I told her, and because of what that
listener said in Durham, is because I am sick of pressing the self destruct
button.
Bob: Why do you self destruct?
Tony: I think it’s because I’ve never ever known any other
way out but to self destruct.
Bob: Wait. Self destruct is anger turned to you. It
should be turned to somebody else. Who should it be turned at?
Tony: My parents.
Bob: Especially your mum. What’s the
remedy?
Tony: Not to bother at all! (Begins to smile and
relax) I like it!
Bob: You do, don’t you? (they laugh
together) So what have you learned this afternoon?
Tony: (Smiling) I don’t have to live with my
past.
Bob: Listen to you!
Tony: I don’t have to live my future by my past. I can
live with it instead of living against it or whatever it is I’ve been doing.
I shall stop it there. He is smiling for the first
time. He’s happy. There he says it, he’s glad. It’s just astonishing! In spite
of that, Tony has now got in his mind a blue print for sorting out his
emotions. He can in fact free himself. There’s a bit in this next clip that I
want to show you where we actually discuss how much he needs or rather doesn’t
need his mother.
Bob:
Self destruct, you see, it’s so important to understand where it comes
from and what to do. When it comes to your mind, say no! – I am angry
with my mother and the anger is out of date. Say that.
Tony: The anger is out of date and I’m not
with my mother.
Bob: You’re not, are you?
Tony: No.
Bob: What do you think about that?
Tony: I’m glad.
Bob: You are, aren’t you?
Tony:
Yeah.
Bob: You’re cheerful! You didn’t expect
that, did you?
Tony:
No.
Bob: So how would you describe what we
have been talking about this afternoon?
Tony: Er.
Relieving. Understanding. Able to understand it. To explain the reason why I
tell my solicitor and the reason why I want to get it out of my system is
because I know I’ve come to it in my head through what that listener said is
that I’m not gonna get any compensation. I’m not gonna get a sorry off the
social services…
Bob:
Or off you’re mum!
Tony:
Or off my mum.
Bob:
That’s it, isn’t it?
Tony:
They’re never gonna love me the way I’ve been wanting to be loved and to
have the family and the care that I pine for. The only person that can do that
is myself.
Bob:
And I’ll tell you something! All this love you pine for, you don’t need!
Tony:
All this love I pine for I don’t need.
Bob:
Why not?
Tony:
Because I’ve got myself.
Bob:
How old are you?
Tony:
41.
Bob:
Don’t forget that! That’s the most important question I ask anybody
– How old are you?
Tony:
Yeah.
Bob:
I don’t need it because I’m 41. You needed it when you were small and
that’s a fact! That’s the reality! The point is that you were programmed to
need it.
Tony:
All the time people have been like, I’ve been given a probation officer
and I expected them to make everything better and say, look, we have destroyed
your life, Tony now we’ll make it better. But it doesn’t happen, it’s never
gonna happen.
Bob:
And does that matter?
Tony:
Yeah! It does matter!
Bob:
What’s the answer then?
Tony:
Really, I don’t need a probation officer. I’ve had 41 years of probation
officers! I need my own love. I need to get it into my head that I don’t need
anybody else. I don’t need a wife, I don’t need a mum, I don’t need children. I
used to think I need another child to replace and to love and then I talked to
a bereavement counsellor and they told me that I didn’t need another child. I
was yearning for another child because I wanted a replacement, I wanted
something to love.
Bob:
You wanted a replacement?
Tony: I wanted a replacement for my mother. I don’t need my
mother.
Bob:
Are you sure?
Tony:
Yeah.
Bob:
Why don’t you need her?
Tony:
I’m happy without her.
Bob:
You really don’t need her, do you? How do you feel?
Tony:
(Smiling broadly by now) Good.
Bob:
You do, don’t you? You didn’t expect that, did you?
Tony:
No.
Bob:
What did you expect?
Tony:
I expected someone just to say “Yeah, you’ve had a bad life, but that’s
just life!” Because, probation officers in the past, I’ve told them things but
not like what I’ve told you. They just say “Well, it wouldn’t happen these
days. It happened then and that’s it”. That’s been their cure! I’ve gone along
with it so long and it’s been in my head and I’ve been trying to push it out
and it doesn’t matter what I do and where I go, at the end of the day or the
beginning of the day (gesturing with his hands around his head and then pushing
them into his head as if it is imploding) this problem has been in my head and
it’s just sent me off the rails again.
Bob:
So what is the problem?
Tony:
The problem’s gone!
Bob:
What’s the problem that has gone?
Tony:
My mum.
Bob:
(Laughing) You didn’t think that did you?
Tony:
No.
Bob: How did you get rid of her?
Tony:
I just realised that I don’t need my mum! And I’ve realised (beginning
to laugh out loud) that I’ve never really had a mum anyway! So I don’t know how
I’ve missed her really. Laughing (together with Bob). It’s weird!
Bob:
You never had a mum?
Tony:
No.
Bob:
And now you don’t need one? It’s weird that isn’t it?
Tony:
Yeah!
Bob:
Don’t forget that will you?
Tony:
No. Never.
(End
of clip.)
There we go. The mum that he has got rid of, and we
must be quite clear about this, is a figment in his head. (In other words he
wasn’t allowed, he wasn’t encouraged, he didn’t have permission, he didn’t have
his own consent to change it). You can see the sort of personality change
taking place in thirty minutes. He doesn’t need mum. When he feels secure, as
he was there with me, he felt he could trust me, the truth was that he never
really had a mum! His first mum gives him away at three months. He had a series
of part satisfactory or unsatisfactory, temporary mums. To the infant the
solution to these problems comes from mum. He had a deep yearning for a mum,
which was what he needed. That was true – when he was small. Nobody sat
down and said “Well, let’s have a
look at this yearning that you have got in there, this craving for maternal or
parental security and let’s look at it.” You can see why I enjoy my work!
Because when you get it right, there is a tremendous glow, a tremendous beam of
joy. He’s not a particularly articulate man. You can see that I was probing him
to see how secure this idea was in his head. I asked him to repeat it, to tell
me what this idea was, what it was we were talking about. I wanted to show, in
the first few clips, that it takes time. What I asked him to do, and I hope you
can see that, was, I asked him to make a leap, a leap of security, a leap of
life support systems. These are not trivial matters, these are very deep
matters. To take a leap from the old pattern, which is looking backwards to an
unsatisfactory, parental model to a more secure, adult model: where he could
relate, for the first time in his life!
Because prior to this exploration, he thought of himself as small, as
impotent, as infantile, as helpless; and he makes a transition. That’s the
transition I’m looking for all the time. It’s called emotional maturation, it’s
growing up emotionally. It is so close to this secondary emotional development
that we heard about this morning. You get infantile emotional development and
then the priority of the infant is a sound attachment, for survival purposes.
That’s the purpose of the infant’s emotional strategies and the infant’s
emotional strategies are extremely powerful because it is a matter of life and
death! To get left “on a mountainside” as an infant and that’s it! Then there
is the transition through to adult life where your emotional survival, your
survival in general, reverts to you. You are now the adult, you are in charge
of yourself. You are a social animal so you learn how to relate to other human
beings. You learn how to work, you learn how to be sociable, you learn how to
trust. That leads to Truth and
to Consent. One is working as a
mutual, equal and consenting partner. This is the ideal of democracy. It’s the
only stable situation. They are not fathers or parental figures, they are not
emperors or kings. They are just human beings. We consent to work together.
That is the objective.
Thank you for listening. I shall now ask the
speakers to come on to the platform and we shall take questions from the floor.
Question: Where do you start with prevention?
Bob: Excellent question! I would start in
infancy. I would take the infant and, as
soon as they can talk, I would seek their consent, you hear such
terrible things being said in what passes for child rearing. “You wait till I
get you home! I’ll murder you when you get home!”. There’s a coercive pattern
there. As we saw with Ethan, even at seventeen minutes old, he sticks his
tongue out, he is responding to the world around him. The old pattern was the
Paterfamilias, “I’m your father!
Shut up!”, or whatever it’s going to be … little children are “seen and
not heard” that’s the most dire prescription for mental illness that I‘ve ever
heard! The dialogue starts in infancy, in infant schools. They are much better
now than they were. The independence and the self reliance starts as soon as
the child develops locomotive abilities, when the child begins to walk. It’s an
attitude of mind. Children – infants can be very noisy, smelly and very
tiring. But they are actually mini human beings! They have a mind (they have an
adult mind in many ways) and they
need talking to, they need to be related to and encouraged.
I’ll
hand over to the rest of the panel.
Rex:
Let me mention here something to be found in the Personality Disorder document.
There’s a paragraph there that says that “Facilities should be set up for 15
– 25 year olds”, because
that is a very important age range, it’s before people really get stuck into
the adult mental health system when there’s still time to do something flexible
enough to make a difference. There are two or three Therapeutic Communities
that have been set up. There is one in Cambridge and there will be another one
in Luton dealing with just that age group, because it is generally perceived as
good to intervene during just that period, before they can become, as it were,
set in their ways. I think that’s a really exciting prospect. The principles
are much the same. I think that we have to be even clearer on the boundaries.
Question:
I don’t think it’s so much a question but I am a bit confused, people do need
parents, so do you think you could explain a bit more about.
Bob: We have to put a caveat in there! I’m
not against parents (smiling). They are in fact quite important people! But, as
I say, they have two important jobs: one is to bring you up and the other is to
bring you up to be independent. You’ll have noticed, and I’ll emphasise it if
you didn’t, that when I started to press Tony on this question, saying,
“Please, I’m inviting you to cut your link with your mother” I was very soft on
him, I said, “take your time, I don’t want to rush you!” because it’s very
critical. Everyone needs emotional support. That’s absolutely correct. You need
people who can love you. You need people who can look out for you. This is most
important. It requires clarification. Parents have an almost impossible job.
It’s a very important and difficult job. There’s a lot of anxiety about what is
happening to the child. The parent wants to do what’s best for the child, just
as the child wants what’s best for the parent. The difficulty is if the parent
is over protective or if, as in Tony’s case, the parent is non existent, then
the parent child bond is distorted. When people come to me for help, generally,
they are well in to adult life and, as you saw with Tony, he was looking for
somebody to mother him. Somebody to look after him. Now the skill, and it
sometimes requires a high level of expertise to find a fault line between the
emotional demands that are perfectly legitimate for any human being and that of
wanting somebody to mother you, of somebody parenting you, who is going to
(say) brush your teeth for you! You have to be so careful! The dilemma is very
easily described for a toddler. If you have a toddler and you are teaching the
toddler to walk, you hold the toddlers hand and you walk along. Everybody is
happy because you are holding the child’s hand and he can’t fall down. There
comes a time when you have to let go of that hand. If you don’t then the child
will never walk. As soon as you do let go of the hand all the anxieties arise.
Is he going to fall over? Is she going to crash her head against a stone? You
are responsible. That is a constant parental dilemma. It’s not an easy
situation, but it can be resolved – with dialogue and support. The object
at the other end is that we are all adults. The parents are adults, I am an
adult.
Elie:
I think it’s very difficult to generalise about these things. For a lot of the
people I have seen over the years, their model of mothering or parenting has
been so different and so extreme in many ways. It’s not that they don’t need
it. I think the hardest thing for all of us as human beings at any stage, is to
let go of things that we have never had. The hope. The yearning. One day I will
get that approval. One day I will have that relationship. If I do this they are
going to love me. People spend years, they spend decades: into their sixties,
all the way through their lives trying to behave in ways to achieve something
that isn’t going to happen. Sometimes it is just a matter of recognising that
it isn’t going to happen.
Rex:
I almost agree with Bob, but not completely. I think that it comes and goes for
all of us. I don’t think that anyone is never completely adult or ever not in
someway a child. We all have that neediness that comes and goes. Sometimes we
need infantile securities. Sometimes we are stressed or we have lost something
important. We need the infantile securities so that for the rest of the time we
can feel the adult independence. It’s not a simple yes or no, black or white
sort of thing. It’s part of that to-ing and fro-ing of development as I see it. I like the point about the
things that you have never had. I think that is terribly important.
Nada:
I believe respect and communication should always be there for you whether as a
child or an adult.
Floor: One of the hardest things I ever did
was to give up the yearning for the love from my mother and to recognise that I
never would have it. I achieved that and it gave me my freedom to be myself. I
invented people who would be my aunts and my grandmothers and people like that
– and it worked.
Bob:
Yes, I think that’s what we saw there in the clip. Tony had this deep yearning
for his mum and she was never there for him. The look of joy that he had on his
face when he realised this indicates that something in the way that he looks at
things has undergone a serious change. Everybody needs a point of attachment.
In infancy that is a powerful parent. As an adult it is a wide social network
of attachment. Everybody needs attachment.
Question:
How do you deal with a situation of the damaged child still in need of a
parent? How does your model operate in those circumstances? I work with
children between the ages of 8 and 12 who are coming from such circumstances,
they still need a parent to take care of them, what would be the best approach?
Bob:
This is one of the most difficult questions that keeps coming up, it’s one of
the issues we hear very much, in calls received by the JNF. For example, one
caller told us that he adopted his son when he was five years old. The child
was very damaged by that time and was giving his adoptive parents a great deal
of trouble. He is now twelve years old. The difficulty is communicating, as
Nada said, respect and stability. These children have no stability. They have learned, very deeply, that all human
beings are powerful human beings, dangerous human beings and you have to
‘weary’ them through that and it’s very challenging, it’s very debilitating.
One of the people on the platform a couple of years ago was adopted. I remember
a conversation that I had with him. He used to get very angry with his adoptive
mother because he felt safe to do so. He felt safe to express the very real
anger that he felt toward his real mother for not being there for him. It can
get very tangled. Like all human beings we need stability, security,
reliability and trust in the people around us. That’s often the last thing,
when we are disturbed, that we are going to produce. When we are disturbed we
produce more and more destruction, more and more unpleasantness and aggression.
It wears people out. What one actually needs is comfort. Everyone needs
comfort.
Elie: I don’t really know that we know, on
one level. I think the basic tenets are the same regardless of who you are
working with, in terms of compassion, in terms of patience, in terms of
stability, all of those things. I think that we have today, generations of
children who have had interventions, and for whom we don’t yet know what the
outcomes are going to be. We have a whole generation of children now who have
had interventions when they have been abused. That never used to happen before.
We know the outcomes for those people who suffered in silence, but we don’t
really know what intervention does in these cases. The outcomes don’t look very
good at the moment but then I don’t think the interventions that take place are
typically that good anyway. But at least they are not suffering in silence! At
least there is some progress!
Rex:
There is one therapeutic community that tries to do something here. Does
anybody here know the Cotswold community? They take in boys between the ages of
5 and 9. They re-parent these children, to the level of giving them a glass of
milk and a biscuit before they go to bed and going through basic routines like
cleaning their teeth with the new arrivals. They thoroughly re-parent them.
They attempt to provide the important kinds of experience that the children never
had, the love and care that they didn’t receive from their parents. In my view,
the earlier this intervention occurs the better. One may feel more hopeful for
the children when intervention is early, since it can occur before they can get
set in their ways.
Questioner:
What I have actually tried to tell them is that the big people who have been
unkind to them are very damaged people. The children are OK and that what has
happened to them isn’t their fault. The children think that they are
responsible and they blame themselves.
Question:
I think I may possibly be straying from the subject but I wonder if the panel
have any comments about emotional senility rather than emotional maturity and
about the sort of role reversal that comes about in the elderly when their
deprivation would seem to increase.
Bob: If I can tell a little personal story
(because it’s the one I know best) as it were. My parents were Edwardian. They
were very, very anxious. My father was shelled by Kaiser Wilhelm II when he was
four years old. The shells flew over his house, he was living in Scarborough.
He had this underlying anxiety all his life. My mother came from a very large
and powerful family, she is one of seven daughters. I had occasional glimpses
of what her family life must have been like among these daughters. To my
parents, children were regarded as a bit of a problem. They didn’t trust us. We
moved to York, permanently. Eventually, my parents became more and more infirm
mentally and physically. Over the years established a new relationship in
which, for the first time, they were trusting us. It was a blessing really, for
us, because there was a change. Their children had been a pain, you didn’t
discuss the important things. I watched them both as their horizons diminished.
But they realised that we were reliable, that we actually could look after them
and that they could begin to lean on us, which I don’t think they had ever
done. That’s my personal story, but it shows that if you can provide stability
and reliability you can sometimes bring about an improvement.
Carole:
That’s a really interesting and thought provoking question. I have recently
been blessed to go back to my home town to take care of two ageing aunts. I
haven’t much experience of being around old people. In the last two years, they
had both become widowed. They’ve seen their children grow up and move away.
They had to face the prospect of living the rest of their lives alone. Last
year one of them died and there was only one left. We have been talking a lot
about how she feels as an older person, how it’s almost as though she has no
right, as an older person, to an emotional life. Because she is older, she
should expect bereavement, she should expect to be widowed. I keep telling her
that she is going to live longer than anybody else. You have to prepare
yourself to be alone. She doesn’t know how to go about it and how to find some
sense of who she is now in the face of all the changes that have happened in
her life. Added to this, she has to deal with the ageing process itself. We are
dealing here with issues of failing eyesight, deafness, decreased mobility.
But, in the face of the loneliness that she is experiencing, nobody seems to
allow her to experience that. I don’t know if this connects to your question
but there seems to be a denial of the fact that older people have the right to
life experience at an appreciable level of intensity of emotions, as, say
younger people do.
Rex:
I have one example that perhaps I can add. One of our students, who was a
middle aged woman, for her research project, ran a group for elderly people
with severe dementia. What she found was that, although they were unable to
conduct a normal conversation, they were able to connect, emotionally with one
another. They found much value in company and conversation with one another.
Even if it sounded incoherent, there was still something very human going on.
There was something that hadn’t been lost, something that couldn’t be denied in
the fact that they could still interact and do something meaningful together.
Question: I don’t have an enormous amount of
knowledge about therapeutic communities but from what I understand you to have
said today, the therapeutic community is kind of opposite to the hospital, is
that correct? If this is so, then how does it work that you have a therapeutic
community that is actually called a hospital? For example the Henderson Hospital. I don’t understand this.
Rex:
Therapeutic Communities actually started up in hospitals. As they grew, it was
Maxwell-Jones who was responsible for much of the early work, whole hospitals
were actually transformed into therapeutic communities. All the wards and all
the systems adhered to therapeutic principles. Unfortunately, that has all been
phased out now. Bob was talking of his early experience in hospital psychiatry.
The whole system was geared to being therapeutic. That’s something which has,
sadly, disappeared in the last twenty or thirty years. Now the therapeutic
communities exist as stand alone units, that are set up in particular places.
The Henderson is an example of this. It isn’t a hospital and it isn’t a
psychiatric hospital. They have 29 places and its linked to the hospital, but
it works on different principles, they have a different way of working. For
example, the people don’t have any medication in there. Everything is done in
groups, there is no individual therapy. People stay for up to a year. Does that
answer your question? They are not opposite to hospitals, they are very
specialised hospitals. Formerly, we were much more optimistic! Whole hospitals
would be therapeutic! Everything now has to be defined, one has to say why and
what you are doing.
Bob:
I’d like to reminisce a little here. When I went to Claybury, we used to have
ward meetings and all the staff, everyone, including the cleaners would be
sitting in the ward, the doctors and people would be sitting around, and this
was the way it was meant to operate right throughout the ward structure in
Claybury, which was a large Victorian “bin” into which people were
“dumped” In those days, unlike
today, the established view was that there should be a community in which the
ethos was therapeutic. Efforts were made to implement that ethos. There were regular
ward meetings. There were groups all over the place. The idea was that any
contact that the “customer” had would be part of the therapeutic contract. I’d just completed my orthodox training
and it was mind blowing because we were discussing emotions,. Something we had
never discussed before during my
medical training. It was a positive educative process which I can now bolster
with a set of philosophical statements: it’s actually a very democratic
situation. Nowadays, you go into a hospital set up and you get the “bosses”,
the people in the white coats, the hierarchy and, above them, the “big chief”:
a situation which is actually anti democratic.
One
thing I have learned is that human rights are therapeutic.
We
did a study of therapeutic communities on our way back from the US in 1965 and
we visited one in Sydney, Australia where they had patient admission committees
and patient discharge committees. This was undoing the noxious effects of
institutionalisation, trying to devolve power down to the “customers” of the
institution! The ideals are correct and it’s therapeutic!
Elie:
There are some therapeutic communities in prison settings as well. It’s not
just one thing or the other. There’s Grendon, which is for sex offenders. It’s
a therapeutic community set up within the prison service to look at sex
offending.
Bob:
The problem is that people like bureaucracies. They like structure and they
then move to regulation, rigidity and so on. The human mind is fluid. What is
needed is something that is supportive and, at the same time flexible.
Question:
Two questions. The first, something that has always puzzled me about the
special hospitals. Why are they called hospitals and the staff called nurses?
The second question concerns the prisons and why is there such a very high
incidence of mental ill health in the prison population? I was at a student
presentation recently where a student group had estimated that 90% of prisoners
suffer from some mental health problem. The Chief Inspector of Prisons
estimates it to be about a third of all prisoners but, clearly, whatever the
exact figure is, it is very high. One of our students who had been in prison
reported to us that if you do get ill in hospital, you do your utmost to keep
yourself out of the hands of the doctors. The Prison health service has a very
bad reputation. My question is about the contradictions in the language that we
use and, more particularly, the absence of adequate treatment.
Carole:
As far as the three secure hospitals in England are concerned, (we won’t
include Carstairs because it is in Scotland and it has a different register
attached to it): in England we have Broadmoor, Rampton and
Ashworth, which were all, historically, (and it’s all an accident of
history) spin-offs from the asylums of the 19th century. The staff
working in the larger asylums
tended to come from the prison service because the people there were
seen to require a custodial as opposed to a caring regime. For instance, when
Bedlam became overcrowded, Broadmoor was built in Berkshire to relieve the
situation and, when the patients were transferred, they came along with their
warders and wardresses who were prison, custodial staff. This is what I mean by
the historical accident of the nursing staff at Broadmoor Hospital being made
up largely of members of the Prison Staff Association, the trade union of
prison staff. That situation is actually changing now. It has been a long
standing problem. In addition to this, the nursing staff have a sort of ‘split
personality’ because some of them wear prison officers uniforms and some of
them wear nurses uniforms. Only about 60% of them have had any nursing
training. There is something of a dilemma about their role and about society’s
expectations of them. One day last week, one of the broadsheet newspapers
carried a report about the prisoners in Broadmoor. That kind of remark is the one thing
that is guaranteed to get me on the ‘phone to them; it’s commonplace, but it’s
based on ignorance. Broadmoor is a hospital and the people in Broadmoor are patients. They are quite separate from the people in the
prison system. The prison service is quite different. I would just like to say, going on from the last question,
that Broadmoor and Harbury have both attempted to set up therapeutic communities.
In both cases, they have failed because the care staff were also the
custodians. We found that patients were unable to establish therapeutic
relationships with the people holding the keys. It broke down on both cases.
Bob:
The harder and the harsher the traumas and sufferings of the individual, the
harder and the harsher the traumatic treatment that they then receive! It’s
something I learned afresh at Parkhurst. The more dangerous, the more damaging,
the more horrendous the crimes and threats of crimes that I hear, to how
damaged, distorted and tortured the childhood experience of the people
perpetrating or making them were.
Children
are impressionable. It’s axiomatic. You can’t sexually abuse someone if you
don’t know how to do it. You have to be taught to be a sexual abuser. Freud
said that in 1896. It’s one of the few things he said that I agree with: he
documented it and he actually coined a phrase, he called it pseudo
hereditary: it’s passed on in the
family. The boys are sexually abused and they abuse their younger sisters. If
you want to know why something has happened, you look at the antecedents. Where
does this violence come from? Well, actually my father did this. Every one of
the hundred individuals, sixty murderers and six serial killers, that I treated
and got to know in Parkhurst, invariably, had a dire childhood! It doesn’t come out of the blue! What I
learned there is that human beings are born loveable, sociable and non-violent!
Something dreadful has to happen to prevent that. So when I approached them and
said, “I expect you to be loveable, sociable and non-violent, where has it
gone?” - they looked at me dazed. When I continued to say it, every week, over
a long period, over months and years, they began to change. Well if Bob expects
it, maybe it’s in there…It’s education. You need to have this expectation.
That’s why this sort of meeting is so important!
Elie:
With this question you are hitting on the quirkiness of psychiatric diagnosis,
the Mental Health Act, where people end up. Dangerous personality disordered
patients in Scotland don’t end up in hospitals, they end up in prisons because
it’s not part of the Mental Health Act legislation. In England and Wales they
do. Or some of them do. The whole thing is quite messy to be frank, depending
upon who is diagnosing what, the whole thing about whether Personality
Disorders, so called, are diagnosable at all and, if so, who’s going to treat
them? There’s a battle going on at the moment between the prison service and
the special hospitals about who is going to corner all the new funding for all
this. The whole thing is a mess in terms of where people end up and the
services they get.
Carole:
Allow me to clarify this word ‘special’. It means special in terms of special
security measures, not in terms of the quality of the service delivered.
Question:
I also believe, and my experience seems to bear it out the fact that, if
somebody wants to change, they can. Would you agree that unless somebody wants
to make a change in their life, then the change won’t come! What happens to the
person who doesn’t want to change? Does one reach the point where one decides
to stop trying to make a difference?
Elie:
I have come across people who were intransigent and weren’t ready to change at
that point. I have known people who have been in security systems for a long,
long time before they were ready to admit that they had committed the serious
crime they had been sentenced for having committed. To some extent, that’s
attributable to the legal process, because they are getting advice not to admit
it. There's no point in admitting it. Timing is important. Sometimes I get
people who are there coercively, because of reasons of child protection, for
example. That’s not always a bad thing - motivation doesn’t always have to come
from inside. Some people can be persuaded. I have certainly worked with people
who could not be persuaded over the time available – maybe it was the
wrong time, maybe I was the wrong person. I have come across people who were so
damaged that I wasn’t going to be able to help them at that point. Whether they
were ever going to be able to change, I can’t answer that really.
Carole:
When the potential for change is there, it needs to be nourished, given the
right kind of environment and the right type of routines and people. That’s the
overriding concern with the needs of the women in the secure and maximum
special secure units. The majority of the women don’t require physical security of any kind. We are
looking for small, women only units because, generally, that’s the kind of
environment in which they are going to be enabled to effect change in their own
lives; something that is just not going to happen in the places where they are
currently incarcerated. One very sad feature of the current situation, the
difficulty of moving the women out of the ‘‘specials’’, arises because there is
a shortage of appropriate places to send them to outside. They do reach a peak
of ‘wildness’ (like anybody subjected to those kinds of stresses) and you need
to do a great deal of work usually among their friends, or on their own, in the
special hospitals. Then they are ready to be released, they are ready to start
leading some kind of life in the community. But there’s nowhere for them to go!
Understandably, if you imprison anyone for no reason, they experience a
decline, they lose the advantage of the progress that they have made and you
are back to the situation you had to begin with! I think it’s a question of
timing, conditions and absolutely the right support. The women know what they
need! They know what they need to recover! When they are listened to, then we
shall see some change.
Nada: I remember when I was five years old, I
ran away from home. My mum couldn’t find me. I don’t remember how I was found
but, in fact, my mum told me. I would have killed myself, I was so scared of my dad, so scared of
facing him. If I had had somebody
to help me then, a support system, then I would not be sitting here today. If I
had had the right people. It’s like today, people suffer within their own skin. We need to be
given the opportunity to be helped.
Bob: This is a very critical question. Are
there some people who can’t change or who won’t change? The word won’t is critical. My position is very clear: Everybody
wishes to be loveable, sociable and non-violent. Whether they can be reached or not can be, as
Elie said, problematic. Mostly, in my view, it’s my fault because I am not
selling it properly. I require their consent. They are entitled to withdraw
their consent. If they withdraw their consent then it must be that the product
on display is not sufficient for them to buy. I am asking them, as with Tony on
the clip, I am asking them to swap a life support system that they have used
for forty, for sixty years, for howsoever many years, to swap that life support
system, or to drop it, throw it away and to swim. Now, it has to be under
circumstances in which that proposition makes sense to them. It makes sense to
me, but if it doesn’t make sense to them they are not going to jump. I ask them
to jump, but if they refuse, there’s no problem. By way of illustration, let me
tell you a lovely story. When I was working in Parkhurst, there was one
particularly notorious man, who used to cut people up with scissors, in prison.
I would be sitting at my table each morning, taking appointments and he would
walk around me. I’d say “Good Morning” and he’d say, “Good Morning” and he did
that for months, “Are you coming to see me?” I’d ask. – “Fat chance, fat
chance”, he would reply. He was watching, he was watching people make
appointments to see me and not turn up. He was finding out. It was critically
important. There was no push on him at all! He wanted to make absolutely sure
that he was coming by consent. His consent. So, if you find somebody who says
that he doesn’t want to change, it may be the case. One chap took two years, to
change. It’s clear from the start. It’s the old story. If
you are brought up in a concentration camp the only people with any power are
the guards. It’s the same in any prison setting, or in the hospital setting,
medical setting. You are not going to trust the people with power unless you
have the absolute assurance that it’s not going to do you more damage when you
allow yourself to be persuaded to expose your innermost secrets to them; to
people who are powerful and who will then destroy you! That is precisely the
challenge to any therapist, particularly to psychiatrists in prison.
Psychiatrists can be very dangerous people! They also have lots of power. You
cannot avail yourself of that power unless the person trusts the individual
concerned. This is where the trust comes in.
We’ve
heard Karl say that he knew when they were coming (the therapists) and he
couldn’t stop himself and he put the concrete walls in place and they would get
nowhere with him. Yet, he gives them the clue! Now why does he do that? He
gives them the secret passage. He gives them the code to break through the high
security fences built around the terror. Why does he do that? Because he trusts
them, he wants help!
Despite
the best endeavours of the prison service he has decided that this help is
going to be useful! So he tells
them what to do! The magic word is that they should come on to the wing when he
least expects it. Did you hear what he said? “They came in unexpectedly”, they sit him down and he breaks down he
falls to the floor, literally! Nose bleeds, everything falls to pieces. He has
actually given them permission to get in to where the real hurt was. Astonishing!
Question:
What do you think of the notion that history repeats itself?
Carole:
Psychiatrists love it! According to them, abuse is cyclical and inevitable. The
abused go on to become the abusers. It’s absolutely not the case! Except in
only the minority of situations, as Elie said this morning. Who and why and how
it happens he doesn’t know and I don’t know. By and large, the majority, and
I’m thinking in terms of the women that we work with in Broadmoor, have
excellent parenting skills and are excellent mothers. It is a problem for them
because they tend to be approached by social services whilst they are pregnant
and their unborn children are put on the “at risk” register, but they do
extremely well.
Question:
I was pleased to see Tony (in the video) laughing because I believe that one of
the good things about helping people is getting them to laugh. It does help.
It’s a good point and I wanted particularly to bring that out. I spend a lot of
time on the internet, talking to people cutting themselves. Quite a number of
them are young people who are frightened of letting their parents know that
there is something wrong with them. They know that they need help but they
won’t ask for help. They need to go and speak to someone, their GP, the
Samaritans, somebody like that. I have no training but I find that people allow
me to listen to them. I wonder if there is any advice the panel could give to
me to help me be more effective.
Elie: I think, as we have said already, if
you are someone they feel safe with, they will take it up. There are lots of interesting
developments, things like “Child Line” and third party agencies that people
feel safe with because they are anonymous. These agencies just didn’t exist 15
or 20 years ago. It’s important to recognise that there is just as much
potential for abuse within them because they are anonymous. I think that there
is a whole new world of possibilities with the developing technologies, in
terms of offering people a “first port of call” but that is no substitute for face
to face trust. It’s an
illusion on one level, but it’s a good starting point. All you can do is
recognise that if that experience is good, if that experience is healing, if
that experience has encouraged them to come forward and to feel safe then you
would hope that they would be able to move forward from that, to seek the help
they need.
Rex: Our community has something for this
sort of thing where (we are there for six hours a day) people are there in
their homes for the other eighteen hours of the day and they phone each other
up if they need to and they are very supportive of one another. They are
thinking about each other, they matter to each other and they know that they
will be listened to if they phone for support. In fact, one of the things that
comes from this document, which comes from an organisation called Borderline
UK, which I think has a chat forum on the web about this sort of thing, is that
these official self help groups should be established because they really know
how to help each other. I don’t know what the role of these other voices are,
but certainly a network of people who know and can help is really important, I
think. The new technology offers us these opportunities.
Questioner: May I say that I actually help out at a
Yahoo group called “Depression and Self Injury”. These are genuine members of
this group and they are already talking to each other. The problem is that they
know they need face to face help and that’s precisely what they are scared of
initiating because they are scared that their parents will get to know. They
don’t want their parents to “flip”.
Bob: I think, as Elie says, “they need a
good hard listening to”, they do! As regards guidelines, about therapy, people
will only go as far as they are ready to go. That has to be understood.
Sometimes, in my therapy, I offer people only one option, one way out, but we
have already agreed before hand that the option is growing up and taking
responsibility. It is possible to raise things, but in a gentle fashion, as I
did with Tony, about saying goodbye to his mother. It wasn’t forceful. It’s a consensual matter. You can raise
things, like taking more responsibility, more autonomy, like in five years time
or in ten years time, where you are looking forward to taking more
responsibility in the world. I would, however, strongly advise, in these
situations, against “parenting”
because then you are taking on their problems as if you were a parent,
which you are not.
Question:
You have talked about cognitive behavioural programmes in the community and I
have seen some very good work done on a programme with certain individuals. My
question concerns the therapeutic intervention, it’s about the relationship
between the therapist and the person seeking help. I’m interested in the fact that two of you, I think, are trained
psychotherapists. My understanding of the psychotherapeutic approach is that
you provide a safe environment within which you explore childhood issues.
Presumably, you would hope that they would reach their own conclusions about
this mystical “parent figure” that
they have been seeking. I’m wondering about that because trying to match the
persons needs with what you have to offer, the model or framework they would
use to understand themselves, I wonder whether a lot of people would be put off
by that, because it is what they should know, it’s about consent, but given the
sensitive nature I wonder if that could put people off. The consensual approach
may be more effective with some people.
Bob: I think that you are right. I am
proactive. I am actually an educationalist. If you are teaching somebody to
swim, some people say that you have to get into the water. I can swim. That’s
not the issue. The question is, can they swim? It’s like all education, you
have to get down to the individual. The reason I showed the clip of Tony is
because the changeover was rapid. The probation officer had his doubts, but
Tony was quite clear. He knew what had happened. It’s a pattern, it’s a
blueprint, it’s something that I work to and I do it on a take-it-or-leave-it basis. Some people, as you say, leave it and
that’s their choice. I know and I can accept when they do that because the
feedback comes, as it did with Tony, with the smile that crosses their face! He
was clearly delighted to see that there is a way through. What I am aiming to do is to offer them
a clarity that they have never had, an option that they have never had before.
Nobody has gone in there before and said, “Look, you are 41 years old, you
don’t need mothering anymore!” Nobody said that. It’s not in the culture. It’s
countercultural. You get into all sorts of difficulties with, you know, she’s
always been your mother, you’ve always done so and so, you get a lot of
emotional difficulties like that. Now, I don’t go into that side of things,
what I go into is “Can you survive if your mother disapproves?” His mother
disapproves so much that (as far as he was concerned) she gave him away at the
age of three months! He has lived with that burden ever since.
Now
there is a different life that he can have, without that burden! I believe that
identifying that burden in him, in that amount of time (because I know people
can take years to work through a similar thing) the key fact is that we have
not even begun until we are looking at the irrational structures, at the
irrational emotions affecting that particular individual! The opening period,
whether it’s one session, three sessions or nine months, is needed to establish
the boundaries. That is to say, “I am offering you these things and you can
take them or you can leave them” and it’s the leaving them that has to be
established. Once you’ve got that, then you can suggest things. Not - “It’s
time you grew up!” or - “It’s time you grew up emotionally!”, (pointing his
finger) - “Grow up!”, which is the parental thing, no, rather, it’s an
authoritative thing. I call myself an emotional “plumber”. You want your
central heating fixing? - Get a new boiler! You don’t want to get a new boiler?
Well, don’t get a new boiler! I
have to have that detachment, which a parent doesn’t have. You don’t want the
new boiler? Well, that’s your decision!
You
have to devolve down, at that level as well. It probably comes across as more
directive than it actually is. The skill that I have developed is how far to
push. If you push too far they will explode. They will get angry. That shows
that I have pushed them into opening the box before they have got the
confidence. I am confident that I have to be proactive in suggesting that they
open up the box, suggesting that there is a box there, suggesting that there is
a parental figment. This is something that I have set up in contradistinction
to the training I had! The training I had that taught me to sit there and to
wait. In fact, in one dreadful presentation, the therapist said “Well, he’s
been coming for six months! It’s about time he said something!” and I thought
to myself, just a minute!
Rex: The whole point of therapy is ‘mucking
in’ getting on with life, looking at it all and seeing how you get on with it.
One of the things that you said was talking about past experiences, that is
only a very small part of it really. Most of what I was saying in that ‘five
stage model’ was to do with getting people into a position where they feel
safe. That’s more than half the task! They feel they belong and it is a safe
space to do that. That’s the job of therapy. That’s the preverbal stuff, that’s
children before they have learned to put things into words, that’s the
primitive, raw emotional stuff from really early on. I think this comes back to
consent actually, asking people for their consent is where the whole thing
starts. We don’t ask people, “Do you want to come into the programme?” We give
them a drop-in, introductory programme for up to a year, where they can come in
and they can talk to people who are already in it, they can see if it is for
them, think about it, discuss it with us and so on. It is only when they have
been through it, have dipped their toes, when they decide if they want to
attach in that way. I think that is a good way of obtaining real, informed
consent rather than making them sign a form and tick a box. Consent is so
important.
Matthew: ……in the end for me it was fantastic having Bob turn
the switches on which is how I saw it at the time, and that’s one of the main things
– it’s daring
– and I think a lot of the
psychiatric profession, from the patient’s point of view, I think they have got
to be a bit more daring just to say things that touch on a “raw nerve”, so to
speak. It’s very common with certain so called criminals who say “You talk
about my mother and I’ll and I’ll ****** do you!” and we talk about everything
except his mother and that becomes a sensitive area and it’s very daring to
say, ”Look, your mother is part of the problem”. It’s a very difficult thing to
go into and I think a lot of therapists are cowardly in that way. Now this is
not a criticism it’s just that one of the things about meeting Bob was that he
dared to touch those sensitive areas, which is fantastic.
Carole:
Let me emphasise again how important it is for you, the survivor, to
become part of the programme planning. I am speaking personally. Unless I agree
to engage with the therapeutic
facilities that are on offer there is nothing else. There is no
alternative! I am not a “user”
because there is no “service” for me to use! I am a survivor of the existing “services”. I think it would be
– I know there isn’t time today – useful to look at other forms of
therapy – more holistic approaches to care - working with survival
groups, working with music, working with dance, working in all kinds of other
creative areas that we haven’t had time to talk about today. It’s important to
recognise that there are approaches that don’t necessarily require
psychotherapeutic input.
Elie:
I’d like to say something here since cognitive behavioural approaches
have been mentioned. Firstly, There are shelves full of literature saying that
the most important thing in any therapeutic intervention is the quality of the
relationship. Regardless of what people think they are doing, I think that it
is the relationship that is the most important thing. Secondly, I think, in
it’s pure simplistic form, cognitive behaviourism doesn’t actually have much to
say about people’s emotions. Just consider the title: it’s about how people
think and how people behave. It doesn’t have much to say about people’s
emotions. Whether people practise it in that pure way or not is another matter.
Thirdly, I’d like to say that most people who do cognitive behavioural therapy
are not cognitive behavioural therapists! It’s a form of therapy that has been
disseminated and handed down willy nilly to every single mental
health care professional under the sun. They are practising a sort of
bastardised version of cognitive behavioural therapy that is very simplistic
and can be very damaging! That’s my reason for having reservations about that.
I am proactive. I am probably not as proactive as
Bob. I do believe in telling it as-it-is and laying it on the line quickly. I
usually work over three or four sessions and arrive quite quickly at my
assessment of what’s going on and whether the person wants to opt in, then and
there and, if not, for them to come back at another time. I think timing is
really very important. When it’s right for people, when the timing is right,
something is possible. I’ve had the experience where I have been trying to work
with a person for months and months and
got nowhere. I’ve said, “Look, let’s leave it now, but you come back when
you are ready, when you think you are ready or when things in your life are
sorted” and I have had people come back two, three, four years later and the
work gets done in such a short period of time because it’s the right time for
them and because they are opting in! Consent is absolutely crucial. The skills
we can bring are about making it safe. Creating the space that is safe. If it’s
safe, people will opt in. If it isn’t safe for them then they won’t. That’s as
simple as I can put it.
Rex:
Just one thing that you mentioned, Carole, about “service users” being
involved in planning, one of the things we have set up since the meeting of the
focus groups at the Department of Health is, for anyone interested in
continuing that kind of work with
us, we have set up a pool of people. I have the forms with me and if any ‘service users’ are
interested in joining that pool of people, please take one. We’ll contact you
as and when an event comes up, you can come along and be part of the teaching
pool. There are one or two a month at the moment. There is an explanation and
an address to write to us. You’ll be very welcome, we’ll keep your details safe
and we’ll contact you from time to time and you will have a choice about which,
if any of the things you would like to be involved in.
Question:
Is it ever too late to do this kind of work?
Bob:
It’s actually soul to soul contact, that’s what we are talking about. I
don’t want to be too theological in the matter but it’s actually to do with
that. Where is your heart in the matter? Where is your soul in the matter? If
you are actually concerned that the person in front of you is someone who you
are trying to relate to and you ar trying to draw out – the sufferings
are writ large, the burdens and the yearning and the dragging down are clear to
see! As I have already said, the most exciting thing for me was to discover
that the destructive emotions were always coming from a long time ago.
(Questioner interrupts): One of the things I do want to know is, I’ve noticed that
other words than the word “patient” have been used. The use of the word
“patient” could imply an imbalance of power. You have used the word yourself
once or twice today. (Laughter)
Bob: I
try not to use the word “patient” and if I have today it has been unintentional
(more laughter).
Nada:
I was a “patient” in the Charing Cross Hospital and I was referred to Dr
Johnson by my own doctor and I am glad that he did.
Bob:
It can vary quite a lot and it depends how efficient and how confident I
am, the more confident the quicker. I met Tony for the first time. He’d
actually done a little bit of work with what he called a “Listener” at Durham
Prison. Tony blamed the system. He said that he had a self destruct button. It
can be very brief or it can be very long. It depends. The cleverer the people
are, the brighter, the quicker, they run rings round me. I say “Just a minute!
I’m trying to catch up, to help you, this is actually an infantile emotion”.
The other thing that I should add is the group
situation, if you get a good group context going. In my first six months of
psychiatric training, it was totally group orientated and we sat in on a group.
I learned a lot by watching other doctors, the superintendent was a very
charismatic man, by watching how other doctors reacted to what was going on and
then how I reacted! That was very interesting.
Question:
There have been a number of times today when I have found that what you
were saying reflected my thought but it seemed as if my reflections couldn’t be
voiced. I want to offer, first of all, simply, some words in the context of
what you have just been talking about, that is, group participation. I want to
look at the words, Truth, Insight, Recognition, Change, because we have talked
about change but we haven’t looked really at how we bring about change. What I
want to address today is how do you bring about change in a conference? What do
you take away from the conference which changes your emotional understanding?
Now, I will talk about three conferences that I
attended. The first was a conference on “Shame”. I was a new therapist much in
awe of the London Psychoanalysts that were talking. There was one question
which got through to me in that entire conference! That question was “Where is
the place of pain in what we have been talking about?” The psychoanalysts were talking about
Nazi Germany, that was where shame could be located. I came out of that
conference and found people sleeping on the streets of London and begging.
Somebody asks me for money and I refused it. There was my shame and there was
their shame and there was my deep pain, the feeling that I had to refuse. That
was the first lesson.
The second conference which I went to two weeks ago
was a conference on Trauma and I am now a Trauma specialist perhaps because I
care about pain. I heard four people, four people, talking about eight clinical
cases of Trauma. In the morning I could listen and in the afternoon these two
people talking had dead voices. The Trauma in the delivery was unbearable. I
now think, as a therapist, the trauma in the room was unbearable. The people in
the morning had touched so much that the people in the afternoon couldn’t bear
to listen and those talking couldn’t bear to speak. My colleague and I said to
each other as we came away from this conference that they didn’t reach the
trauma we work with, we couldn’t talk about our experience of trauma: severe
trauma that can scarcely be voiced, the torture of refugees.
Today I hear a repetition of two weeks ago. I hear
a number of people talking cogently about their work and I have given them a
lot of “good listening to” but I haven’t sensed that we have truly participated
because, although it has been acknowledge that we are all in this together,
there hasn’t been the opportunity for people to get together in a reflective
space to say “This is my pain, this is me. These people are another one of
myself”
Bob:
Thank you very much.
Question: That was a good point. I really enjoyed
what that lady said. I come from a
background of a lot of physical, mental and sexual abuse and I’ve been very
hard on myself to get to this point. My question is what is the difference
between conventional and normal therapy? I’ve done a lot of work on myself and
I’ve found a lot of help in touching on the core of trauma, going right to the
depths of these feelings and I felt great relief going though that - in the
more conventional psychotherapy, leading on into the past. The position I am
facing at the moment is the realisation that there is a frozen being (I read it
on the cover of your book) where you come to the point of realising that you
have been a frozen being to enable you to get through this trauma – the
emotions arise, your feelings come back –it’s the therapeutic side that I
am interested in – and I am wondering if your kind of therapy can help me
– the emotions and feelings, everything that has been frozen in time and
is thawed out and the emotions are arising – if your mode of therapy can
help me.
Bob: The model is very simple. The
child is growing up, something dreadful happens, they get frozen, they put it
in the box at that particular age, they get frozen at that particular age. Now,
I am not claiming that the only way to do it is the way I do it. Manifestly,
people can derive benefit from a whole series of therapies. The trouble with my
experience of other people doing therapy and trauma work is that the risk of
re-traumatisation is very high. I shall give you an example. The Behaviour
Therapists, they go in and they say, “What happened? Let’s have all the details”
… but they haven’t got a plan, they haven’t got a blueprint for getting rid of
it. The reason I showed the clip of Tony is that, clearly, he has got this
yearning in his head and so forth and he was able to begin to cut the links and
let that slide into the past where it should be because it wasn’t in the past
as far as he was concerned when I first saw him and that’s the deal. The
problem with trauma and the human mind is that trauma is extremely
destabilising. It actually stops the mind thinking clearly about a particular
item.
You
may have seen what was happening with Tony I said “What happened? What did I
say?” and this happens all the time throughout the therapy. I do that all the
time. You come back next week and you say, “I’m feeling better now” and I ask
you “Really? Why? - What happened?
- What was the difference?” You are working all the time. Even if you have a
rigid structure like with the cognitive behavioural therapy and you have got
some support from the staff and from the customer then you can start to let
your own personality come out, you can begin treatment, you can begin to move
in a different way. Any two individuals are going to be unique: the therapist
and the customer. It’s a dipole. It’s a dyad. It’s always going to be unique
because you have two unique personalities. You have to be flexible, you have to
move in that way. Until you can actually get enough support to look at the
terror and say “I can see the terror, I am walking through it and it is over”
it remains frozen, you say “I’m not going back there again!” and you back off.
That’s why it’s frozen, that’s why it never moves, in general terms. You come
up to it and you say you can’t do that again. The mind backs off from it. As a
child that’s all you can do. But
if the customer is backing off you can’t say that the abuse has stopped. You
haven’t actually worked it through. The contexts of working it through are
legion. I have no monopoly on that at all. What I would say is that you wait
until you get enough support to confront the terror. You say “Yes! That was
appalling! What you did to me!” I often did this with women who had been
sexually abused. I say “Sit your abuser over there and tell him what he did was
wrong and that you are not going to let him do it to you again!” “O no, I
couldn’t do that!” they reply. I say “I beg your pardon, it’s an empty room,
it’s an empty chair! Why couldn’t you do it?” We discuss it. As the customer’s
confidence develops, “I was very angry with you for doing it!” These words are
blocked, they can’t say it, they can’t articulate the words! They say the words
to me, we discuss what they should say, they turn to the empty chair and they
can’t say the words. We work on that. It’s a learning process. It’s like
learning to talk, it’s like learning to think. Where they have taught
themselves not to think. It’s a complex process on one level. It’s also a very
simple process on another if they have the support.
Claire: I was brought to see Bob for about
eighteen months. I saw the difference working with Bob. I had been in the
mental health services for about twenty seven years off and on since I first
went in. It was an awful long time and I found that it was a retraumatising
experience talking about the abuse. All it did was centre in on the abuse. It didn’t
give me any view of a life different from that. Working with Bob, as Nada said,
goes back to giving you the responsibility. Working with Bob gave me that. He
encouraged me to take responsibility for myself. That’s all I want to say really.
Elie: May I ask. You feel stuck. Is that what
you are saying?
Questioner: I feel that the block is frozen and I
feel my emotions are coming up. I am realising that I have got so little trust.
I have had so much abuse that I can’t do anything right. That I’m actually
stuck.
Elie: I do spend a lot of time talking to
people. The preparation may take a long time. For me, the healing takes place
in actually speaking about what happened. Going through. Speaking about it in
detail. You have got to feel safe before this is possible. Before you can open
up this box. You cannot force that! You just cannot force that. It will happen
at it’s right time. Some things can happen in terms of negotiation with the
therapist, you can discuss how to make it safe enough for it to happen. There
is an element in which you cannot rush that, it will happen in it’s own time.
The best way to encourage that to happen is to talk about what it is you are
there to talk about, if you know what I mean. You have to just let that happen
in it’s own time. But I am also very proactive. I don’t believe in just sitting there. I think it’s a myth
about counsellors just sitting there and listening. It’s not about that. It’s
about proactive, interactive listening. The counsellor is there to have an
opinion. You are there to make comments. Having that opinion and making those
comments are not the same as imposing that opinion, those comments. People appreciate it most when you are
straight with them, when you are honest with them and when you are genuine with
them. Just stick with it is what I say.
Bob: I think we are running out of time.
Nice conference. What do you think?
Conference: Agreement.
Bob:
I know people have trains to catch.
Elie: It would have been better had we had a
little time after each speaker for questions and answers. I like that kind of
interaction when I am speaking.
Bob: Noted. Any other comments?
Questioner: Whilst we are discussing a wish list:
we haven’t discussed the child today. That’s another subject and another
conference.
Questioner: A conference for the families of people
diagnosed with PD.
Bob:
The JNF was set up to educate the public and the profession on this issue of
Personality Disorder and in particular to give out a message of optimism. The
sort of comments and the sort of support we have got here today indicates that
this is not a dead issue. It is a live issue! Thank you again for all your
support.
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.