Forensic psychotherapy – history and theoretical schools of thought
Forensic psychotherapy “is a bridge between traditional forensic psychiatry with a major focus on diagnosis and risk, and traditional psychotherapy with a focus on understanding why things happen.” (Welldon, 2015b) Williams (1991) examines the difficulties in bridging these disciplines. Eastman (1993: 28) noted that “in a specialty where there is an extraordinary level of psychopathology, as well as of childhood deprivation and abuse, it seems extraordinary that the (forensic) establishment has paid so little attention to the psychopathological understanding and psychotherapy”.
Forensic Psychotherapy seeks to understand the unconscious motivations of the offender’s antisocial behaviours, with the objective of preventing their repetition, which might lead to further crimes against society. The better the criminal mind can be understood, the more effectively positive action can be taken to prevent criminal acts, and the better counter-transferential responses can be understood and managed. The expectation is that in time, this should lead to more effective and economically viable treatments. (Welldon, 1994)
Typically, criminal behaviour is responded to with punishment, so a compassionate response that attempts to understand the offender and his delinquent actions in the context of self-destructive and compulsive behaviours is equated with condonement. (Welldon, 2015) As such the Forensic Psychotherapist has the invidious task of both trying to help his/her patient, whilst also trying to work through some of the painful problems that society contends with.
Unlike the dyadic relationship between therapist and patient in traditional psychotherapy, forensic psychotherapy involves a triadic relationship between therapist, patient, and society. (de Smit, 1992) Welldon (2015b) draws other triadic relationships into this work: between the social roles of ‘bully’, ‘victim’ and ‘bystander’ (Twemlow, Sacco and Williams, 1996), and; between the cultures of concern, learning and blaming. (Welldon, 2011)
The modifications of traditional psychoanalytic practice that have led to forensic psychotherapy as a model in its own right have received support from eminent psychoanalysts such as Kernberg (2014) and Twemlow (2013).
Over the years this approach has made progress, and behaviours traditionally treated as transgressions deserving punishment have been steadily recognised as being understandable, with a basis in the patients life experiences. This is evidenced by the inclusion of such behaviours in the Diagnostic Statistical Manuals, e.g. DSM – III-R ((American Psychiatric Association (APA), 1987).
Fishman and Ruscynski (2004) note that it is due to the work of the International Association of Forensic Psychotherapy and Dr Estela Welldon, that the title of forensic psychotherapist came into existence.
The UK has been at the vanguard of the development of forensic psychotherapy, since, in 1931, the Institute for the Scientific Treatment of Delinquency and Crime was established. This later became known as the Institute for the Study and Treatment of Delinquency (ISTD) (Cordess, 1992; Glover, 1960). The Institute identified its goal as to promote alternative and better ways of dealing with criminals than imprisoning them. It also sought to advance understanding of the causes and prevention of crime through scientific research, as well as consolidating the literature already extant, promoting cooperation between the relevant statutory and professional bodies involved in forensic work, and to advise and educate colleagues and the public. Its first chair was the eminent and influential psychoanalyst Dr Edward Glover.
The ISTD was strongly influenced by the work of the psychiatrist and psychotherapist, Dr Grace Pailthorpe, who worked in Birmingham and Holloway prisons following time as a doctor in the trenches in the First World War. Dr Pailthorpe eventually wrote Studies in the Psychology of Delinquency (1932) in which she explored her interest in the personalities of female prisoners, which attracted other like minded psychoanalysts, including Dr Glover, who had himself been expanding the literature around sexuality, criminality, and addictions.
Glover wrote in his own history of the ISTD that, as the work dealt with social phenomena, it required the involvement of a variety of disciplines, including social workers and social psychologists, but that the most vital approach to making sense of crime, was psychoanalytic. (Fishman & Ruszcynski, 2004) Welldon (2015) notes that forensic psychotherapy is typically a multi-disciplinary team approach, in recognition of the complex interconnected set of systems through which the forensic patient moves.
Due to the stigma attached to its work, the clinicians of the ISTD were prevented from working under one roof until May 1937. In 1948, with the establishment of the National Health Service, one part of the ISTD joined the NHS as the Portman Clinic, offering treatment primarily, and a part that remained the ISTD (now located at Kings College London) focused on research and training. (Welldon, 1992) In the United States during the early 20th century, Dr Karl Menninger was establishing the Menninger School of Psychiatry in Topeka, Kansas. He believed that punishment protected neither society not the criminal, and went considerably further with a psychodynamic perspective.
Dr Menninger famously critiqued the popular interpretation of Lee Harvey Oswald’s case, as an example of the alienated, little man, gaining attention and notoriety through a transgressive act directed at society (1967).
In the UK, during the mid 1960s, Dr Maxwell Jones founded a “therapeutic community” (Jones, 1953) at the Henderson Hospital for the treatment of severe personality disorders, at the time known in a pejorative sense as psychopaths. This clinic was run in such a way as to achieve greater parity and equality between staff and patients, with patients having a much greater say in the running of the institution, and even the discharge of their peers. In this way Dr Jones further eroded the stigma engrained in the treatment of such individuals.
During the 1960s the Portman Clinic continued to play a central part in the development of the field, holding conferences (in 1961), and publishing volumes (the same year, and a second edition in 1979) on pathology and the treatment of sexual deviation, such as “Sexual Deviation” (Eds Ismond Rosen, 1964)
Fishman & Ruszcynski (2004) note that a number of seminal works emanated from clinicians working within the Portman Clinic. For example “From the analysis of a transvestite” (1979a), and “On violence: a preliminary communication” (1998) by Dr Mervin Glasser, “Clinical types of homosexuality” (1989c) and “A re-evaluation of acting out in relation to working through” (1966) by Adam Limentani and Estela Welldon’s work on female perversion “Mother, Madonna, Whore” (1988). Another key publication is the twin volume edition “Forensic Psychotherapy” edited by Christopher Cordess and Murray Cox.
Having been embedded within the fabric of the NHS for some years, and established a theoretical basis, the place of forensic psychotherapy within statutory services in the UK was at risk during the mid 1980s, due to a serious review of the role of psychotherapeutic work offered through the NHS. However, the Seymour review (1985) ultimately concluded that psychotherapy did have a part to play in the NHS.
A pivotal moment in the recognition of forensic psychotherapy as a discipline in it’s own right, was the initiation of the International Association of Forensic Psychotherapy (IAFP). As an idea, the IAFP emerged from a conference on Law & Psychotherapy in Leuven, Belgium, in 1991.
At this time, the gap between the psychodynamic and judicial understandings of criminal behaviour was being bridged through residential weekends for judges, co-led by staff from the Portman Clinic, to enable them to become familiar with a psychodynamic understanding of unconscious motivations of offenders. (Welldon, 2015b)
The IAFP emerged, driven by Dr Welldon, from the European symposia, originating in the 1980s with annual meetings at the Portman Clinic that brought together practitioners from Holland, Belgium, Austria and Germany, along with staff from the Portman Clinic, to explore work with patients involved with the criminal justice system due to their psychopathology.
The IAFP is a robust enterprise, which marked its 25th anniversary in 2016, with its 25th annual conference in Ghent, Belgium.
The most important contribution to the field emerged from the Portman’s array of workshops and conferences was the 2 year Diploma in Forensic Psychotherapeutic Studies, sponsored first by the British Post Graduate Medical Federation, and later by UCL. The course was pioneered by Dr Estela Welldon, who was appointed as clinical tutor at the Portman Clinic in 1988. Dr Welldon and Professor Michael Peckham structured the course, with a faculty of Portman Clinic staff, and other consultants delivering the teaching. The course was the first of its kind, and ran for 4 years and was the embodiment of the challenges of bridging the disciplines of forensic psychiatry, and of psychodynamic psychotherapy. In this respect, it played a crucial role in furthering understanding of the field, and creating a cohort of newly equipped clinicians, in this “evolving species”. (Adshead, 1991).
Many of the alumni have become influential figures in the sector and held leading offices within the IAFP, and since the course was multidisciplinary, books from a broad range of different professions continue to emerge, illuminating and widening the scope of this field.
These books include Toxic Couples: The Psychology of Domestic Violence (2014) and The Psychology of Female Violence: Crimes Against the Body (2008) by Anna Motz, and Dangerous Patients: A Psychodynamic Approach to Risk Assessment and Management (2003) and Murder: A Psychotherapeutic Investigation (2008) by Ronald Doctor.
The first consultant psychiatry post in forensic psychotherapy was created in 1994 by Professor Eastman and Margaret Orr, then medical director at Broadmoor Prison, which was held by Dr Gill McGauley. (McGauley, 2016)
Forensic psychotherapy is being adapted for a variety of purposes, for example, working with offenders with learning difficulties (Corbett, 2014; Sinason, 2010; Curen & Sinason, 2010), music therapy and art therapy have been shown to be effective for patients in prisons and other secure settings (Compton Dickinson, Odell-Miller, & Adlam, 2012). Group analysis has also been utilised effectively with forensic patients. (Welldon, 1993)
Despite a growing body of evidence for both the effectiveness of these treatments, and the cost-effectiveness of such an approach in comparison to penitentiary and other traditional responses to crime, there are still those who question it’s efficacy. (Altshul, 2013)