THE ‘OTHER 23 HOURS’: SPECIAL PROBLEMS OF PSYCHOTHERAPY IN A ‘SPECIAL’ HOSPITAL

Abstract

In this paper, I describe and discuss the complexities of being a therapist in a maximum security forensic psychiatric hospital, working with patients who have committed acts of serious violence, and who also suffer from severe mental illness and personality disorders. I suggest that profound disturbances in the patient's inner world get played out in triangular disputes between the patient, the therapist and other professionals working in the hospital. I also describe how real events in the life of the institution impact on the therapeutic process, and the importance for the therapist of reflection on the ‘other 23 hours’ that the patient lives outside of therapy. Finally, I raise some ethical dilemmas that arise for therapists working in such settings, where the stated therapeutic aim is not only treatment but also the containment and prevention of future violence.

ACKNOWLEDGEMENTS

I am grateful to Dr Cleo van Velsen, Consultant Forensic Psychotherapist and Psychoanalyst at John Howard Center for her invaluable comments on an earlier draft. I am much indebted to Dr Leslie Sohn, Supervising Analyst and Dr Gwen Adshead, Forensic Psychotherapist, both of Broadmoor Hospital, for discussions I had with them over the years in supervision. I am also grateful to one anonymous reviewer who made invaluable suggestions to improve the readability of this paper.

Notes

Apologies to Trieschman, Whittaker and Brendtro (1969).