The majority of the work done in the Portman Clinic is with adult patients, but there is also a small child and adolescent psychotherapy team (three part time psychotherapists plus a trainee) who make a significant contribution to the life of the clinic.
The work undertaken by this team mainly consists of consultations, risk assessments, assessments for psychotherapy, individual on-going psychotherapy and parent work, plus we all teach regular seminars, contribute to CPD events and provide supervision.
The Portman patients are both disturbed and disturbing. Their referral to us can have a ‘last chance saloon’ quality to it. Other interventions have been tried and failed. For the purposes of writing this introduction I did a rough audit of referrals to the child and adolescent psychotherapy team over an 18 month period to give a flavour of who is referred to us, by whom, why and what we do with the referrals.
Eighty-one per cent of our referrals are male and the average age of those referred is 15. We do see younger patients but it is often when a young person reaches adolescence that the behaviours escalate and the level of anxiety rises, triggering a referral to us. Behaviour which can just about be tolerated in a younger child by parents/carers/teachers/social workers or society in general, can become unbearable and unacceptable when the young person’s body becomes mature enough for them to act out sexually in a more harmful way. For a disturbed young person who is already struggling to maintain an emotional equilibrium, the added turbulence of adolescence can increase their drive to act out in harmful ways, in an attempt to avoid feeling something unbearable. We assume that feeling the unbearable thing is worse than the consequences of carrying out a sexual or violent attack.
In 84% of our referrals, the presenting difficulty is of a sexual nature and in 16% it is violence, although the two often go hand in hand.
Sixty-four per cent of our referrals come from CAMHS, other mental health providers or social services. Twenty per cent come from Youth Offending or Looked After Children services and the rest from GPs, schools or disability services. Most of our referrals are therefore involved with other agencies and have been or are still involved with another mental health service.
As we have a national contract, our referrals come from across England. Forty-one per cent of referrals were requests for a consultation, by which I mean that we are often asked to help a YOS (youth offending service) worker, mental health colleague, social worker, teacher or foster carer to think about a young person who is difficult to manage, who raises a lot of concern in the community or who presents in a way that makes it difficult to think clearly or resist the temptation to become reactive. These are often young people who have no interest in engaging therapeutically but who can benefit from our input via our work with the person they are prepared or obliged to engage with. One recent request for a consultation was from a YOS officer who wanted help to understand how to work with a young man who seemed to use violent offending to stave off depression. We consider this work vital, not just in terms of the young person being thought about in a more considered way, but also because it gives us the opportunity to work with the professionals who encounter these young people on a regular basis, who may not have had any specific training in this area. Given the appropriate support, these front-line workers are ideally placed to make a real difference to this type of young person by influencing the way they are thought about in their particular service or network.
Risk
Risk assessment and risk management are a very significant part of what we do at the Portman. Every patient we see comes with an issue regarding risk. Our patients are the perpetrators; they are not in danger of acting out, they have already done so. This means that we deal with risk, the management of risk and the management of the anxiety which the risk can raise in professional networks, with every young person who is referred to us.
Twenty-four per cent of the referrals to the child and adolescent psychotherapy team at the Portman Clinic are requests for risk assessments. This is a paid for service outside our national contract. The young person to be assessed will usually have committed a violent and/or sexual act against a more vulnerable person. What the commissioning body needs from our report is not just an indication of the level of risk, and likelihood of further acting out, but a clinical formulation which provides a deeper, more comprehensive understanding of the young person, and which identifies what needs to be put in place for them to feel safe enough not to repeat the harmful behaviour. As child and adolescent psychotherapists, we have the necessary skills to focus not just on the external behaviours the young person engages in and the impact this has on the environment, but also to consider their internal world and the psychic difficulties which lead to the violent and/or sexual acting out.
In a risk assessment we consider the current situation of the young person, their developmental history and, in particular, any trauma, abuse, neglect or relationship breakdown they may have suffered. This enables us to try to understand what significance the particular nature of the acting out may have for the young person. For example, where and when did the acting out take place? What was the gender and age of the victim? Did the young person act alone? These are all factors in helping us to understand the nature of the disturbance that the acting out behaviour may be defending against and the strength of the young person’s drive to repeat the behaviour.
It is also important to find out what sense the young person makes of what they have done and their understanding of the impact this has had on other people. This systematic gathering of information quite naturally leads to a psychodynamic formulation which we use to help the network to think about risk in the context of the young person’s needs – if the young person’s needs are met the risk goes down, if the young person’s needs are not met the risk goes up. In this way we can think about what is in the best interests of the young person as a way of managing the risk they pose to other people.
Another aspect of this work is to consider the emotional impact the young person’s harmful behaviour may have on the network of professionals working with them, and whether there is any sign that this has affected the network’s capacity to respond appropriately. Although almost all adult sex offenders start offending in adolescence, only a small percentage of adolescent sex offenders continue to offend into adulthood. Enactments in adolescence can have a variety of meanings rather than the very narrow, encapsulated, ritualised, perverse activity characteristic of adult sex offenders. A psychoanalytic, developmental approach is therefore useful in both understanding enactment in a relational way and in thinking with networks of the best way to address it.
When young people seriously harm others or threaten to do so, networks are faced with the responsibility for preventing further harmful action. Our approach to risk assessments is pragmatic and humble. We explain to professional networks that we are not in the position of being able to predict the future, but we can assess a young person with a view to providing a psychological understanding of their actions and use this understanding to work with the network to inform how they perceive the risk and manage it. Our engagement with the network is vital in demonstrating an ability to tolerate the anxieties provoked by working with young people who are very violent and sexually harmful to others, and to encourage considered thought rather than punitive action.
Psychotherapy
When a referral arrives at the clinic for an assessment for psychotherapy, our first consideration is whether the young person’s presenting difficulties gives them what we refer to as a ‘ticket of entry’. As a service we specialise in working with young people who have acted violently or sexually in relation to another. We do not accept referrals of the victims of sexual and violent abuse. In other words, we work with the perpetrators. We think about whether the young person referred has ‘breached the body boundary’, in other words has the young person crossed the line between phantasy and enactment and was an actual other body involved in the enactment. Some young people might not hurt real others but still enact their disturbing fantasies via the Internet in a variety of ways. Other young people use the Internet to access material involving actual harm of real others, or use social media to exploit or groom vulnerable others. We are unlikely to take referrals of those who do not enact their fantasies but suffer the psychological consequences of acknowledging them. However, because we are dealing with disturbed young people negotiating the ever-increasing enactment opportunities afforded by the Internet, we sometimes have to be flexible and, in exceptional cases, we might decide to take someone on whose ‘ticket of entry’ is not straightforward.
Crucially, we would also look for evidence in the referral that the young person is motivated to seek help. We receive a lot of referrals of young people who either are or have been involved in the criminal justice system. It is imperative that neither the person referring nor the young person referred believe that the therapy is part of their punishment. We often delay accepting a referral in these cases until the judicial proceedings are completed in order to make it clear that the treatment is voluntary and strictly confidential.
Perhaps most importantly, we would need to make sure that the risk that the young person presents in terms of harming others and/or making themselves vulnerable to being harmed is managed by the family or network around them. There is sometimes an assumption by the referrer that psychotherapy will help in risk management. This is not the case. Before we assess a young person for psychotherapy we need to know that the risk is being managed by the system around the young person and feel confident that the young person’s external circumstances, in both a practical and emotional sense, are stable enough to support the emotional volatility which beginning therapy can evoke. Sometimes we work for several months with the network around the young person to help them to strengthen the support the young person is getting before the assessment takes place. Because our patients have usually experienced a great deal of failure, we work hard to give the therapy the best possible chance of succeeding.
If these criteria are met, we would go ahead and assess the young person for psychotherapy. Although we are interested in the whole person who is referred, it is important that the ‘ticket of entry’ behaviour or incident is ‘on the table’ from the beginning. This creates an opportunity to make sure that everyone has the same information and also discourages any attempt to hide or disguise the seriousness of what has led to the referral. We would be interested in the capacity of both the young person and their carers to talk about the ‘ticket of entry’ behaviour and how they make sense of it. It is important to say that we are not looking for a young person who is completely at ease talking about these very difficult matters, but rather trying to find out if the young person has the capacity to make a connection between what they feel and what they do. It is also important to assess the carers’ motivation to be part of the potential treatment as we consider their engagement to be a crucial part of the psychotherapy package.
Common themes in psychotherapy
There are some common themes which emerge during psychotherapy with Portman patients which are either particular to or heightened in this patient group. Very often we take on a perpetrator for psychotherapy and uncover a victim. This is not unusual in that any vulnerable person given a safe and supportive space is well placed to make a disclosure of something they have been hiding. What is different with Portman patients is that we work with the victim and perpetrator at the same time, in the same body. The young person may use one aspect to defend the other, for example one patient when asked about a sexual assault they had made on a younger child replied, “I was raped you know.” Very often the perpetrators who come into our clinic are victims who were not helped to process or recover from their abusive experiences. In order to hold themselves together and keep going they take on the role of the perpetrator, splitting off and projecting their traumatic experience of being a victim into someone else. This solution is temporary and the constant threat of the original trauma re-emerging creates an ongoing drive in the young person to continually evacuate their experience of being a victim into someone else. The investment in strengthening the perpetrator self is equal to the level of fear of being in touch with the victim self and vice versa. Our job is to work with both the perpetrator and the victim parts, to find the links between them and to join them up in an attempt to stop the internal battle which leads to splitting, fragmentation and further enactments.
The length and depth of the work will depend on the entrenchment of the defences, but it is vital to proceed with caution and allow the young person to disarm at a bearable rate otherwise the risk of re-traumatisation and breakdown is high. Giving voice to both the victim and the perpetrator means acknowledging ‘what has been done to me’, but also ‘what I have done to others’. The shame and loss involved is painful and complicated. Defences come and go. The therapeutic trajectory is unlikely to be straightforward. This is why it is so important to ensure that the young person is held in a stable and thoughtful network before the therapy begins. It is also important that the Portman is able to offer these young people long-term therapy.
Another common theme with our patients is how they manage intimacy. Mervyn Glasser, psychiatrist, psychoanalyst and former chairman of the Portman Clinic created the concept of ‘the core complex’ (Glasser, Citation1979) to help to understand the pathologies of the patients referred to the Portman, which he went on to regard as a universal phenomenon. Glasser described how we all have a fundamental need to feel connected to another person, but for those who have not had the experience of successfully attaching and then separating from the primary carer as an infant, the quest for intimacy is fraught with danger. The attempt to connect with and feel close to another can quickly be experienced as too intrusive, triggering a fear of engulfment. This activates a fight or flight response – either attack the smothering other or beat a hasty retreat into separation and denial of the original need to connect. The retreat leads to feelings of abandonment and a loss of a sense of self. This activates the drive to be in relation to another and so the whole harmful cycle is perpetuated.
One way of staying in contact with the object without destroying it is to sexualise the aggressive urge to retaliate which the fear of engulfment activates. This can lead to relationships which are controlling and sadistic, but give the impression of engagement with another. A young person with these difficulties starting psychotherapy is bound to bring them into the therapeutic relationship.
I would like to finish by briefly highlighting what it can feel like to have close contact with a young person who, in order to survive, projects their disturbance into whoever they are with. I think most people will be familiar with the good feeling we get when we look into the eyes of a baby and they smile. We feel valued, as though the baby has detected something good in us. By the same token if we look into the eyes of a young person and see mockery, threat, fear or seduction, all manner of responses can be activated in us. We can feel competitive, afraid, cruel, ashamed or repulsed. The young person might come just a little bit too close and fill us with a desire to step back. They might feel cut off and hard to reach, rendering us useless, or they may be openly hostile, filling us up with feelings of fear or retribution. As clinicians, opening ourselves up to such complex projections can lead, almost inevitably, to enactments in the therapy room. For this reason, the robust system which the Portman operates of individual supervision for clinicians and the provision of forums where staff meet for support and to think about the clinical work is considered vital.
Most of the young people referred arrive at the Portman having exhausted many other options. They have usually been to many schools, had many foster placements, different social workers and have been referred to a variety of mental health providers. They are emotionally bent out of shape and hard to be with. They use up a lot of resources and are pre-disposed to sabotaging any input which is thoughtful or understanding. We might be seduced into thinking that we can ‘save’ these young people and then go through crashing disillusionment when they go on with their harmful behaviour despite our best efforts.
Winnicott (Citation1964) when describing his work with juvenile delinquents wrote about how, when you encounter a disturbed young person, you are meeting a life that has gone wrong, usually very early on. Working with the types of young people referred to the Portman takes a lot of thought and a lot of carefully joined up work with multi-disciplinary colleagues. Lots of resources are required. Networks and individual workers have to be courageous and resilient. All of this, plus a willingness in society to invest in the future, is needed to create the circumstances conducive to positive change in young people whose defence against breakdown is to sexually harm others. What’s also needed is hope; these young people are referred to the Portman because they are doing something that someone has noticed. They may still harbour the hope that, rather than condemn them, someone will work with them to bear, understand and help alleviate the truly dreadful psychic pain which they suffer.
Portman Clinic
Tavistock & Portman NHS Foundation Trust
8 Fitzjohn’s Avenue
London NW3 5NA
UK
Email: [email protected]
© 2016 Association of Child Psychotherapists
http://dx.doi.org/10.1080/0075417X.2016.1238138
References
- Glasser, M. (1979) ‘Some aspects of the role of aggression in the perversions’. In Rosen, I. (ed.) Sexual Deviation. 2nd ed. Oxford: Oxford University Press.
- Winnicott, D.W. (1964) ‘Aspects of juvenile delinquency’. In The Child, The Family and The Outside World. London: Penguin.