‘Forensic Disabilities’, a morning seminar led by Tamsin Cottis and Richard Curen of Respond, London, brought us into the world of intellectual disability, trauma and sexual harmful behaviour. Respond has pioneered the use of psychotherapy as a treatment choice for those who have experienced abuse and trauma, and for those who have abused others. Besides psychotherapy, Respond also has a range of other supportive services which they provide for those most vulnerable.
The Respond model is based on attachment theory, neuroscience, object relations and using a relational psychotherapeutic relationship to attribute meaning to thoughts, behaviours and expressions. The notion of thinking, reflective functioning and developing and increasing the ability to mentalise as a means of understanding trauma was explored during the seminar. We considered how early trauma—in particular, domestic and sexual violence—can affect the developing brain.
Richard, a forensic psychotherapist, briefly introduced the services of Respond. Tamsin, an integrative child psychotherapist, then spoke about her work with adolescents and young adults. She offered the thought that ‘what goes around comes around’, in that the past is always present in one’s experience. This is a chilling thought, as we considered the effects of trauma and violence on the developing mind. She promoted psychotherapy for this group to be chiefly concerned with providing a high quality thoughtful relationship with very damaged people. She stressed that a child needs assistance to make sense of the experience of sexual abuse. Play and expression are helpful therapeutic techniques, as they put outside the child what is inside him in a contained way. The therapist needs to be aware of the child’s attachment styles as it affects the child’s attachment behaviour. She highlighted that children from age 5-8 years have harsh superegos and that we should never underestimate the child’s desire to stay out of trouble. Children learn to shut down and the provision of therapy allows for a safe expression of feelings.
We learnt that a frightened child’s brain floods with cortisol and this affects brain development at the expense of thinking and developing. Therapy can become a place to experience regulation. Children who cannot regulate their feelings need an opportunity to do so, and this can happen through play. In play, a child can do violent things, which allow them to get the violent images out of their head for someone else to see and make sense of. She spoke about the impact of witnessing domestic abuse on young minds and its links between sexual abuses between children as a way of making sense of the experience. She also highlighted the early experience of being loved for who you are and how negative attachment experiences impact on a young mind. Again and again she returned to the idea of creating a thinking space in the relationary experience between child and therapist.
Richard spoke about his work with young adults and adults who display sexually harmful behaviour.
With forensic clients, a thorough risk assessment phase is part of any Respond treatment. The risk assessment is therapeutic and focuses on the behaviour and what it feels like to be that person. Adults were once children and their early experiences are considered. He outlined factors affecting sexual development that include poor attachment and being victims of sexual abuse and violence, lack of ‘normal’ sexual development such as experimenting with peers, and parental denial of sexual development, or their anxiety towards it. This is then linked with limited sexual knowledge, supervision, lack of privacy, being impulsive with fewer inhibitions, lack of opportunity to purchase items with an erotic charge and difficulties making peer relations. Intellectual disability and paraphilia were considered and he suggested that for some, intellectual disability could be a paraphilia.
Richard introduced the idea that paraphilia could be a defense—against unstable sexual identity, loneliness, anxiety, shame, anger or the demands of life. He also suggested, based on Stanley Ruszczynski’s work, that paraphilia could be a result of loss. Loss can be the result of the experience of not being contained or not having learnt to mentalise. The core clinical issues with this population include guilt, rage, shame, ‘damage goods syndrome’, fear, sexualisation of anxiety, disability, dissociation and denial and confusion.
Sheila Hollin’s ‘Three Secrets of Disability’ are considered in treatment. These secrets are Sex, Death and the Disability itself- Treatment hopes to increase the capacity for reflection, in order to support difficulties in managing compulsions. Treatment also focuses on the positive in people’s lives and the therapist retains hope that things can be made better. For the therapist this can seem, at times, unfeasible. Supervision and team meetings are seen as invaluable as they involve in their inherent nature a thinking space with another.
There was a short question and answer period at the end of the seminar. Participants were interested in the ideas of infantile containment as advocated by W.B Bion and D.W Winnicott, the capacity for reflection, play, the systemic approach to delivering psychotherapeutic treatment utilising a case manager who acts as a bridge between the therapist and outside supporters, and who provides consultation with staff and services to assist them to think psychodynamically so that treatment is not sabotaged by those who do not understand why it is so important and more than just sexually harmful behaviours. The seminar presenters then answered individual questions and distributed literature about Respond and Books beyond Words.
The seminar proved to be a thoughtful and thought provoking experience. It highlighted how thinking about one’s early experience and behaviour and the ability to think and be thought about play a significant developmental role. Most importantly, the seminar provided an opportunity for participants to come and think together, so that those most vulnerable are thought about and understood. Without thinking and understanding together, the experience and perpetration of trauma continues in isolation.