It is a genuine pleasure and a privilege to introduce this special forensic issue of the journal which gives a snapshot of some of the child and adolescent work currently being undertaken in the Portman Clinic.
We begin with two shorter introductory pieces. Stan Ruszczynski, who has just stepped down from his role as clinic director after 12 years, provides a very helpful overview of the history of the Portman as a centre of excellence in delivering psychotherapy to patients struggling with violence, perversions, paraphilias, delinquency, serious sexual enactments and, increasingly, worrying and illegal use of screen-based technology such as child pornography. He reminds the reader of the illustrious traditions of the clinic and its sparkling intellectual and therapeutic legacy, all soundly rooted in psychoanalytic thinking. Patricia Allan then takes over the mantle offering an insightful explanation of what the current child psychotherapy team actually does ‘on the ground’ and how the work is approached. She takes the reader steadily and clearly through some of the most notable clinical challenges of this work. Allan emphasises the complications of working with both victim and perpetrator in the same person (a theme illustrated starkly in the paper by John Woods on ‘The making of an abuser’, see below) and the taxing kinds of transference and countertransference issues that inevitably arise in such work. The importance of working closely with professional networks is highlighted, especially with regard to risk, both to the self and to others, an aspect which is always central to our thinking and practice.
Ariel Nathanson’s paper reads as an instant classic. Drawing on many years of experience and a deep understanding of the legacy of the Portman’s distinct brand of psychoanalytic thinking, he theorises about work with young people who act out in perverse and addictive ways. His examples graphically depict how many of our patients seek a particular form of triumphant salvation through enactments perfectly honed to their specific unconscious fantasies. There is here his depiction of one such, the ‘fuck-it’ button, a masterful description of triumphant enactment when coupled with an addiction to self-destructive patterns. More hopefully, Nathanson’s material also illustrates the potential for genuine growth and change which can no longer be completely disavowed by a patient who has become aware of this button; he describes processes of slowing down in which the beginnings of thinking rather than acting take root, so that, in time, we can see a genuine dawning of a belief in a good object that can be relied upon. Nathanson’s account draws on case material from both individual and group work, both of which are central to routine clinical practice at the Portman.
Don Campbell is one of the Portman’s most experienced psychoanalysts, working in this area for many decades with both adults and children, and still the first port of call for many Portman and other psychotherapists who seek help in the form of consultation or supervision. Campbell has written many classic papers on subjects pertinent to Portman patients, but here we are treated to something a bit different: a look at some distinct developmental processes in adolescence that can get hijacked by violent and perverse patients, and how this can, in part, be understood in terms of bodily processes and sublimation. Classic Portman themes are here viewed from a new angle, such as how violence may be used to defend against heterosexuality, or even against castration anxiety and extreme passivity. Campbell makes this detailed theory easy for the reader to follow as he glides seamlessly through classical Freud and related psychoanalytic ideas on processes of identification, sublimation, violence, sexualisation, the body and adolescent states of mind. To cap it all, he links this in his account of the clinical material with a fascinating account of a range of cultural expressions including literature and art, all pertinent to his patient and others. His account of an eight year treatment, alongside the narratives offered within the Woods and Nathanson papers, illustrates a well-held conviction held by most Portman clinicians, based on deep ongoing clinical experience, namely that real change can take place within therapy, but that it is slow and painstaking, and there are no quick fixes – a very counter-cultural idea in our modern, rapid-fire, next-day delivery world.
In my own paper, which appears next in the collection, I investigate the clinical phenomenon of sadism and explore some of the key themes in work with Portman patients, such as core complex anxieties, and the differences between reactive and more callous forms of aggression, as well as addictive states of mind. The paper brings together psychoanalytic and neurobiological ideas and illustrates the key points with clinical examples.
John Woods’ article is another unique piece. Woods has, for many years, been at the forefront of writing and lecturing about psychotherapy with abused and abusing boys. In this paper he asks that fundamental question we are so often asked: what is it that makes someone into an abuser? Although there is plenty of good scientific evidence here and helpful references to other clinicians’ ideas, this paper’s USP is how Woods answers this question through portraying a single case of long-term intensive clinical work. We are treated to a masterclass of clinical understanding in a typically understated way by Woods, who modestly describes extremely complex clinical work with a very challenging boy in a way that sometimes belies his depth of understanding, huge experience and indeed, deep wisdom.
In our final paper we return to the practical outworking of all this ‘in the field’. Janine Sternberg provides an extremely helpful account of doing assessment work for the family courts in which her skills and experience as a teacher and clinician come through vividly. Anyone already involved in or contemplating court work would do well to read this paper and imbibe the careful thinking and lessons that Sternberg brings to these important clinical tasks. Her descriptions of the child psychotherapist’s unique ways of listening, of understanding the countertransference, and of making sense of a child’s symbolic meaning, remind us of the unique gifts of this kind of training, gifts that are too easily taken for granted, especially at times when this kind of work is under threat.
We also include a Clinical Commentary relevant to the kind of forensic work done at the Portman, which focuses on a session with a young man who has both enacted in perverse sexual ways and presented with very worrying psychological functioning. As so often in this section we are treated to not only some detailed and fascinating clinical material from a complex case, but also three thought-provoking and very different responses to it, all deeply rooted in psychoanalytic understanding and a wealth of clinical experience. In addition to Lisa Miller’s absorbing reflections on Edna O’Shaughnessy’s collected papers, we also include two reviews of very different kinds of books, both linked to forensic themes: Marilyn Lawrence’s review of Alessandra Lemma’s recent work on the body, and Maria Papadima’s review of a more personal memoir based around the Columbine killings. This rich forensic issue is rounded off by a Research Digest introducing us to 20 relevant recent papers on the themes of this edition, including findings regarding psychotherapy encompassing aggression, violence and sexual acting out.