The therapeutic milieu under fire: Security and insecurity in forensic mental health edited by John Adlam, et al.

Published by Jessica Kingsley Publishers. Reviewed by Sandra Rosieur, Counsellor, London

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This book explores the personal and interpersonal complexities taking place within the therapeutic community, together with destructive processes that have external origins (such as governmental and health-care commissioning). These ‘attacks’ take place under the guise of policy changes, uncertainties around funding and commissioning, service cuts and, in some cases, they result in the closure of iconic services, such as the Henderson Hospital.

The book started out as a series of seminars held to promote psychosocial enquiry around forensic systems of care, and it encourages discussions between service users, the general public and multidisciplinary professionals (such as nurses, project workers, probation officers, psychiatrists, psychotherapists, managers, researchers). It comprises fifteen chapters, each written by an author working within the forensic, and forensic-related, field. Many of the concepts discussed throughout are generalisable into other healthcare settings; as such, I think this book will have a wide reaching audience. Three chapters (Corbett, Sinason and Hopper) focus specifically on learning disabilities, an often neglected and marginalised group.

Alan Corbett (Life on the borders of thought) writes of the history of forensic disability psychotherapy, and the prevalence of forensic patients with intellectual disabilities. He provides a wonderful case example of individual psychotherapy sessions with a learning disabled patient, highlighting common difficulties faced by those working in this field, such as the challenges staff teams face in not colluding with the patient’s splitting process, instead holding a more integrated view of narratives of victimhood and aggression. He discusses how in this work, the most important tool is the therapist’s use of self- He refers to Disability Transference, where the patient projects into the therapist disavowed feelings which are too unbearable to hold, at times leaving the therapist feeling as if their intelligence is under attack.

Valerie Sinason (Infanticide and paedophilia as a defence against incest ) also provides rich clinical material based on her individual psychotherapy with a learning disabled patient, who exhibits violent sexual acts. The patient, in dealing with trauma, abandonment and loss of biological history, finds a creative (though illegal) solution of paedophilia and infanticide as a defence against his fear of committing incest. The article highlights the societal death-wish towards people with learning disabilities, where foetuses identified as disabled are aborted; the patient internalised these death wishes, which were then projected onto small boys and babies.

Earl Hopper (Some challenges to the capacity to think, link and hope in the provision of psychotherapy for the learning disabled) echoes Corbett and Sinason, identifying various ways in which society devalues both the learning disabled, and their support workers. He cautions against burnout, and advocates for reflective spaces such as group/supervision to explore transferential and countertransferential processes, together with the need for openness and honesty within team meetings.

Celia Taylor (Complaints as a tool for bullying) eloquently explores the complaints system at a unit for personality disordered patients residing in a therapeutic community, highlighting the possibility that complaint/s may be of a vexatious or malicious nature, often leaving staff feeling unsafe. She demonstrates how the milieu can be held and sustained under these attacks, with complainants being supported to see the links to earlier trauma. This chapter left me wondering how this could be translated into different types of settings; I think that any organisation on the receiving end of complaints will find this useful material!

In regard to theory, the authors often use a mixture of the therapeutic community model, systems-psychodynamic thinking and attachment theory. Whilst physical security is provided within secure units, the authors highlight the need for psychological, relational security. The instituting of processes such as regular supervision, reflective practice, team meetings and sympathetic management styles are frequently advocated.

Overall, I found this book fresh and engaging, rich with clinical illustrations, presenting conscious and unconscious processes in a thought provoking and accessible format.

Sandra Rosieur is an integrative BACP accredited counsellor working in private practice in South London, and within the voluntary sector as a Rape Crisis Counsellor. She has worked within a number of different counselling settings, supporting clients affected by violence, trauma, abuse and addictions. She has a growing interest in learning disabilities and sexual perversions.’

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