Respond & forensic psychotherapy

Richard Curen, Consultant Forensic Psychotherapist, works predominantly with adolescents & adults with learning disabilities, ADHD, autistic spectrum disorders and mental health problems.

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I have worked at Respond in London for almost 11 years and am employed as a consultant forensic psychotherapist. Respond is an organisation that provides assessment and treatment services for children and adults with intellectual disabilities who have experienced abuse and/or who have abused others. Across professions in the United Kingdom there is a growing sense of awareness about the needs of people with intellectual disabilities who are involved in the criminal justice system, or who are at risk of becoming involved in it. My role at Respond is to lead the forensic services for adolescents and adults, as well as providing treatment, assessments and training to other professionals and staff.

I am aware that Ireland often experiences similar problems to those affecting the UK and currently financial constraints affect the allocation of resources in social care and the criminal justice systems. People with intellectual disabilities and their families are often at the sharp end of cuts, with resources being made available only when situations reach crisis point. I know that there are also differences between our cultures borne from, amongst other things, the very close relationship between church and state, the effects of colonialism, and the existing legislation that governs the lives of people with learning disabilities, especially around having sexual relationships outside of marriage (Corbett 2010). I will attempt to describe the situation in the United Kingdom, as I see it, and use some case examples to illustrate some of the challenges we are faced with when working with people with intellectual disabilities and forensic backgrounds.

In May 2009, after ten years of planning, the Irish government published its report Child abuse in institutions in which they examined the extent and effects of abuse on children from 1936 onwards. The Commission’s remit was to investigate all forms of child abuse in Irish institutions for children. Most of the allegations related to 60 residential reformatory and industrial schools operated by religious orders in the Roman Catholic church. There were many allegations of sexual abuse, rape and sadistic torture by brothers. The Guardian (2009) described the abuse as ‘the stuff of nightmares’ the report painted a picture of a system of church and state in Ireland which was horrifically dysfunctional with its combination of sadism and deference.

At the time of publication, I was treating a man with intellectual disabilities who had suffered from the effects of years of rape and sexual abuse he experienced, aged between twelve and sixteen, in an institution run by an order of the Catholic Church. I will call him George. George was referred to Respond when he was 51 for a forensic risk assessment due to a background that included sexually assaulting a number of young boys and raping another man with intellectual disabilities in the home where he lived.

At the end of the risk assessment process we recommended, amongst other things, that he receive longterm psychotherapeutic treatment to help him with his night terrors, insomnia and severe symptoms of stress, symptoms which we felt were linked to his own experiences of victimisation. The treatment would also aim to reduce the likelihood of him reoffending. The funding was sourced and George engaged well in the treatment and was able to benefit from being able to talk about his experiences in childhood. He had never previously spoken of the institutional abuse to anyone and the treatment provided him with an opportunity to make links between his experiences and his offending behaviours. After two years of treatment George had not reoffended and had experienced a very significant decrease in his night-time symptoms of stress.

At Respond we believe that whilst not all sexual offenders are themselves victims of sexual abuse, the field of sex offender treatment would benefit from more research on the relationship between early victimisation and later sexual offending. I have previously stated (Curen 2009) that it is extremely difficult for a perpetrator of abuse to feel empathy for his/her victim, if they feel no empathy for the victim in themselves. How can we expect the perpetrator who dissociated from his own experiences of abuse to be able to understand the feelings of his/her victims? It is my view that psychotherapeutic treatment, informed by psychoanalytic thinking, with perpetrators of abuse that focuses on early trauma experiences is more likely to lead to an understanding of the effects of abuse on the self and on others. This, in turn, will lead to a diminishing of offending behaviours.

Most people referred to Respond’s community-based forensic services have experienced some form of abuse and some have gone on to abuse others or to develop worrying sexualised behaviours. Service users often come with a multitude of diagnoses, a complex mixture of learning disabilities, mental health problems, Autistic Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD). This is almost always coupled with a history of victimisation and often with a history of being violent towards themselves and/or others. Many service users have had a number of placement breakdowns, have been sectioned under the Mental Health Act, or have a history of repeated hospital admissions. They are often considered hard, or even impossible, to treat due to misunderstandings about their ability to engage in psychotherapeutic treatment. It is also the case that some people referred to Respond appear to have no apparent reason for their behaviours.

Alongside forensic service users (almost all of whom are male) who have committed sexual offences are those with paraphilias, also known as sexual perversions. A paraphilia is a condition in which a person’s sexual arousal and gratification depend on fantasising about and engaging in sexual behaviour that is unusual and extreme. A paraphilia can revolve around a particular object (children, animals, underwear) or around a particular act (inflicting pain, exposing oneself). The focus of a paraphilia is usually very specific and unchanging. We often find that professionals and those caring for these individuals struggle to make sense of and to manage/supervise those living in the community.

Frank was referred to Respond due to his sexual interest in wearing nappies. He would often become sexually aroused when he saw a young child wearing a nappy and would sometimes attempt to remove nappies from children. This was initially viewed as being a sexual interest in children, however upon further investigation it became clear that Frank wanted to get nappies for his own sexual gratification. As psychotherapists we often think about the meaning behind certain paraphilias and in cases where nappies are involved there is often a complex history of early abandonment or of having been kept in nappies much longer than necessary, even up until puberty. This can lead to the person fusing their desired feelings for containment and comfort, with emerging sexual feelings that may be being suppressed or denied by family or carers or the individual. Frank had been arrested by the police and was some way through the criminal justice process before it became clear that his ‘attacks’ on very young children were not as serious as first thought.

There are many reasons why a person with an intellectual disability may sexually offend. These include: having limited sexual knowledge; being more often supervised and therefore more likely to be discovered; being more impulsive or having less inhibition; difficulties in making peer relationships; and often being unable to have access to pornography or other opportunities to purchase items with a sexual charge. In Frank’s case it was possible to facilitate him to buy nappies for himself and for him to then take control of and manage his own sex life without putting himself or anyone else at risk. However, what emerged in treatment was that he had experienced sexual abuse from his mother who had kept him in nappies until he was eleven and had shared a bed with him until he was sixteen.

Valerie Sinason (1996) highlights research that states that although a large proportion of people who abuse were themselves abused, a large proportion of people who were abused (13 out of 14) do not go on to repeat their abuse (Browne 1993). Sinason describes how sexual abuse goes directly through the body and into the mind of the victim, creating what she describes as a ‘double tragedy’. The victim has to contain the despair, perversion and sadism of the abuser and, in addition, the internal fantasies and bodily responses that the trauma aroused. The original hurt can then harden into a pattern that is repeated either through abusing or through perversion.

According to the most recent research in the UK, approximately 7% of adult prisoners have intellectual disabilities (i.e. they have an IQ score under 70). The same study found that 25% had an IQ under 80 (Loukes 2007). It is generally accepted that the figure is between 5-10%. In a study of people with intellectual disabilities under 18 in prison, it was found that 23% had a learning disability and a further 36% had scores between 70-79 (Harrington and Bailey, 2005). What kind of crimes are we talking about here? Well, for most people with intellectual disabilities the crimes are petty (such as theft), but of course they are also responsible for much more serious crimes too. At Respond we are most familiar with those who commit sexual crimes, crimes of violence and arson. Accurate statistics are hard to come by, but there is general acceptance that people with intellectual disabilities commit fewer crimes than non-disabled people. This begs the question then as to why the number of prisoners with intellectual disabilities is disproportionately higher in forensic and prison settings.

In the United Kingdom if the fact of a person’s intellectual disability is not recognised before a suspect is questioned, and there is therefore no appropriate adult present, then this will affect the ability to use their statement in court. An ‘appropriate adult’ needs to be present when a person with learning disabilities is being searched or questioned by the police. Recognising that someone has an intellectual disability is often very difficult and police are often very poor at it. There is a strong case for training police officers in order to recognise people with intellectual disabilities and those with other developmental disorders. Also, police officers often try to dissuade suspects from getting a lawyer, saying that it will take many hours, so why not be interviewed now and then you’ll be home before teatime. Many people with intellectual disabilities will want to get home as quickly as possible and thereby waive their right to have a lawyer present or to make a no-comment interview. There is also the issue of people with intellectual disabilities making false confessions in order to end an interview and to get home as soon as possible.

At Respond we believe that lots of work needs to be done in order to improve access to justice for all people with intellectual disabilities. In a recent publication published by the Advocacy Training Council (2011) (for which Respond provided expert opinion), two excellent points are made: ‘the manner in which the vulnerable are treated in our court system is a mark of how civilized a society we are.’ And ‘the effective handling by advocates of vulnerable witnesses, victims and defendants is crucial for the good and fair administration of justice and requires skill, experience, education and understanding.’ The report helps to describe how to improve the experience of vulnerable defendants in court who are, of course, innocent until proven guilty, and who should therefore have the same access to support that is available to victims and witnesses.

As a psychotherapist I am very interested in the processes at work in people’s minds. I think that having a ‘forensic’ label, i.e., having been through the criminal justice system, will lead to most people with intellectual disabilities feeling quite traumatised. The psychological impact of appearing in court should not be underestimated; both witness and defendant can be re-traumatised in the process. For defendants who are victim/perpetrators, like George and Frank above, this might be exacerbated if they have never addressed their own experiences of abuse. At Respond we are not just concerned about deteriorating mental health, but also the impact of shame and the vulnerability to abuse in prison and the lack of support upon being released back into the community.

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