Newletter Masthead
September 1999 · Vol. 24, No. 3, pp. 14-15

Forensic psychotherapy and the public sphere

8th Annual Meeting of the International Association for Forensic Psychotherapy

[Note: This version contains material written by Dr. Young not included in the published volume.]

John L. Young MD

The 8th annual meeting of the International Association for Forensic Psychotherapy (IAFP) opened in Sheffield, UK, in the comfortable newly-opened Stakis Hotel on the morning of Friday, 9 May, 1999. After being welcomed by IAFP President, Prof. Dr. Friedemann Pfäfflin of Ulm University in Germany, the 175 delegates from 11 countries heard Lord Alderdice, a therapist turned judge and politician, give the opening talk, "From Understanding Individual Violence to the Political Domain." He described how effective it was to open negotiations on Northern Ireland by having both sides acknowledge their shared fear of failure and turn it to something positive: since everyone out there expects us to fail, we can make the most of any small success we manage to achieve, so let’s really try. Otherwise, the very striving of each side for strength to allay its anxiety about the other’s tactics only exacerbates them. This may explain the odd tendency of parties to mimic each other, no matter how patently unhelpful.

Alderdice went on to question the assumption that aggressive urges arise as one of the inner drives, since such drives are cyclical whereas aggressive behaviors like that over Northern Ireland keep spiraling from bad to worse. Also, aggressive wishes can be so strong that parties act in ways that work against their interests. Similarly, aggressive desire is not linear; rather people tend to want something, no matter how worthless, mostly when someone else has it. The Falkland Islands dispute is a perfect illustration. Once they were won, the problem was how to get rid of them. Such chaos is prevented by means of rituals and rules that mark differences among groups. In court, examples are the elaborately polite customs for parties to bow to each other and the reservation of separate places for journalists. It is harder to be aggressive when these markers of difference are firmly in place, keeping order against the entropic chaos that violence entails.

Earl Hopper, a past president of the International Association for Group Psychotherapy, led the discussion, citing several classical sources to emphasize the importance of differentiation as a means of having the benefits of pluralism without fragmentation. Reminding the audience that Freud had understood the beginning of the ego as something bodily expressing itself in action, he suggested that violence can be understood using a matrix of space as either here or there and time as either now or then. The discussion focused on using these ideas to make sense of the current Balkan chaos and on examples of the political role of religion in both justifying and controlling violence. Dr. Estella Welldon speculated on whether gender played a role in the violence associated with the Northern Ireland conflict. The question of how to deal with violence among the relief groups in the Balkans elicited a comment that politicians often resist the involvement of therapists; Lord Alderdice revealed that this phenomenon had moved him, as a therapist, to enter politics!

The next talk, entitled Violence, Torture and Treatment, was by Derek Summerfield of Medical Foundation for the Care of Victims of Torture. He warned of a discourse based on such assumptions as the need for a positivist view of pain in order to measure and treat it, and the emergence of talk therapies as a means of separating trauma from the person bearing it. He expressed concern about a misplaced emphasis on the individual, which facilitates viewing suffering as a technical problem and distracts from the role of the environment. He pointed out that the therapist’s neutrality avoids political and moral concerns and may even incline the patient to adopt the view of the therapist.

The speaker went on to recount 3 vignettes, which illustrated his sense that we should be wary of the reductionist approach. The first was that of a Ruandan woman who saw her mother sliced to death and lost her 4 children. She took the view that it was her place that made her sick. Placed on antidepressant therapy, she broke off treatment after 4 sessions in dissatisfaction. "My whole body is sick; my life is not good," she complained, adding, "Your words are very fine, Doctor, but when are you going to start helping me?" The second was of a man whose town had been destroyed in his absence, and despite all conventional therapeutic efforts kept repeating, "I’ve got to get back there." His bitterness seemed overwhelming, beyond the reach of clinic visits, Prozac, and family therapy. A vacation did not help either, until some relief seemed to come from a scene that could remind him of home. Thirdly, a South African who seemed to give up on life in distraction from hearing the voices of women and children he had slaughtered. His efforts to somehow earn absolution by giving of himself raised the question of whether it could indeed be helpful to allow him some further suffering as part of treatment. We need to craft what we offer patients in a culturally sensitive manner, concluded the speaker.

The speaker’s colleague John Schlapobersky led the discussion which followed. Invoking Arthur Koestler’s image of torture victims as futureless men without shadows, he pointed out their low survival rate. Those who do survive and come to treatment can recover, he added, based on the Foundation’s experiences with over two thousand referrals each year from all over the globe, principally from Africa and the Middle East. Listening to the individuals as they tell of families treated violently and often dispersed, prolonging the torture, is paramount. Asked about the place of traditional therapist neutrality, the speaker replied that the goal is more to free these victims than to cure them: to enable them to resolve their utter damage. "The forest was my doctor," he recounted hearing from one victim, while another seemed to survive by teaching his fellow victims to read. One must expand what one counts as therapy in this setting.

Violence research

Following lunch, Dr. Patrick Gallwey chaired a panel on violence research by faculty from the Centre for the Study of Violence and Reconciliation at the University of Sheffield. Dr. Digby Tantam gave an introduction describing the increased risk of suicide among victims of violence, reporting that diverse victims shared biological, social and psychological factors. He reminded the audience that violence becomes integrated into culture, using the example of passion plays which bring out the liminal function of self-harm, also seen in traditions among Old Believers in Russia. Researchers are beginning to identify different mental states and reactions responding to different interventions along with the influences of racism, marginalization, and dissociation. Results are beginning to prove helpful in meeting requests for conflict resolution.

Social worker Emmy Van Deurzen followed with a talk entitled "Addiction to Death," identifying loss of connection as a common experience among victims. Quoting Kierkegaard, she observed that losing oneself, the greatest hazard of all, can occur very quietly, whereas lesser losses are sure to be noticed. She spoke of a case dominated by fear in response to being pressed to the edge of existence and managing to look confident. What proved helpful was allowing the patient to experience himself being understood. Another patient was openly suicidal and repeatedly complaining of unexplained pain. For both individuals it seemed that life was more frightening than death, leading to an addictive morbid preoccupation that Heidegger understood as a daring that frees one from having to act and Nietzsche wrote about in terms of having no purpose.

The third talk of the panel was entitled "Whose Personality Disorder Is It Anyway?" given by Connor Duggan who began by inviting his listeners to take a broad view of the labeling process even though this might lead to eliminating psychopath as a term. Based on a reading of Cleckley’s classic work, he pointed out that some individuals are so lacking in the capacity to form relationships that one must wonder whether the term personality, let alone personality disorder, can be meaningfully applied to them.

Thinking along these lines was the basis of the Impact Message Inventory, an assessment tool under development, of which he then gave a brief preview. He then pointed out that, contrary to some recent thinking, research is beginning to suggest that William James was correct in his 1890 declaration that personality does not change after age 30. He acknowledged the difficulties posed by such results on treatment prospects and the implication of limits on the validity of current approaches to risk assessment. He asserted that these difficulties are increased by current emphasis on patients’ rights as well.

The Arts Therapies, Psychosis and Violence

Following tea, arts therapist Ann Sloboda from Three Bridges Regional Secure Unit, Southall, UK, presented an invited lecture. She defined her subject as including art, music and drama therapies, and possibly dance as well. She indicated satisfaction with recent efforts to standardize the field and certify its training programs, providing protection for patients and professionals alike. In the UK at least, training includes undergoing therapy.

In this work, the art form is used to create content; the patient becomes active, and a therapeutic relationship is developed through sharing creative activity. Through both group and individual work, a bridge connecting thinking and acting can be made, even with very ill patients as they express themselves in sessions as brief as 10 minutes. Also, patients can begin to grasp a sense of boundaries as the therapist sets them through joining in the creative act itself. This is especially suited to patients very limited in verbal skills, the art medium functioning as a third party in a powerful and evolving relationship. Using both a recording and a transcription of its content, the speaker followed with a convincing example of how she worked at the keyboard with a patient referred after failing group therapy due to her aggressiveness. As the patient accompanied on the steel drum over several sessions, the music became more shared and coherent, with corresponding behavioral improvement, enabling a transfer to be arranged.

Dr. Michael Gunter, whose doctoral work concerned the history of art therapy workshops in Germany, chaired the ensuing discussion. He suggested that art therapies allow a structured projective process with the medium helping patients to organize their disordered thinking. He likened this process to Winnicott’s transitional object theory. The arts media, he suggested, overcome the separateness imposed by verbal language, so that acting out can become a constructive maneuver for dealing with unbearable anxieties.

Forensic Psychotherapy Research

Saturday morning brought a session in two parts updating findings from the forensic psychotherapy process research work at Ulm University in Germany. Prof. Dr. Friedemann Pfäfflin’s report, "Emotion Abstraction Patterns and Insight-Psychotherapy with Sex Offenders in High Security," began with a brief overview of the method and its underlying theory. Based on work by Karasu, Luborsky, Marshall and others, it is assumed that a therapeutic process of change leads to insight, positive self-reflection, autonomy and responsibility. Gains may be sudden or slow and are identified from painstaking transcriptions of the recorded sessions. A computer program quantifies each contribution from therapist and patient according to a well-validated pair of constructs, called emotional and abstract. An average value is determined for each, and compared with that from each portion of dialog. This allows 4 possible patterns, named relaxing (both emotional and abstract below average), reflecting (emotional below average and abstract above), experiencing (emotional above average and abstract below), and connecting (both above average).

Plots made of these measures show a nonrandom cyclic flow, and success across time appears to be associated with increases in the relaxing and connecting patterns at the expense of the other two. Following examples of these plots, the speaker described the case of a convicted child molester in maximum security for 10 years. It appeared that the therapist was regularly connecting ahead of the patient, suggesting some interesting and testable hypotheses. Also, when the investigators checked on the content associated with different patterns, details of the offending were associated with the reflection state, again raising interesting and potentially productive questions on which to base further work.

Graduate student Stephanie Cornehl presented the second report, based on her work with Pfäfflin and Erhard Mergenthaler, entitled "Comparisons of Patient/Therapist Interactions of Sex Offenders and Patients Suffering from Neuroses." Studying 3 sessions from 8 patients in each category, the researchers (contrary to their initial expectations) found no difference in amounts of abstraction and more emotion among the neurotic subjects. As for the 4 patterns, neurotics showed more relaxing and sex offenders more connecting, particularly while talking about their offenses.

Discussion was led by Chris Evans who praised the investigators for their effort and the subjects for their trust. Reflecting on the presentation, he contrasted free association in therapy with restrictions of secure confinement and called on the audience to formulate meaningful questions for the researchers. One member suggested that transference and counter-transference would be hard to operationalize under the presenters’ methods; they agreed. Welldon suggested evaluating for deception by the taking of pulse, blood pressure and galvanic skin response during sessions, but Pfäfflin replied that it was already a struggle to find willing subjects (and therapists). He added that deception was not a concern, especially in view of the possibility that therapists may be self-deceiving all along. It is sometimes possible to hear inconsistencies. An inquiry about goals of therapy led to some discussion of the complexity of this issue, especially with respect to sex offenders, and an emphasis on the focus being brought to finding what brings about connecting between the patient and therapist. Cordess emphasized the power of description when causation is not discernable and in this regard wondered aloud about what may be lost in quantifying and classifying the words two people speak to each other. He referenced this concern to a paper by the late Dr. Murray Cox, "The Great Feast of Languages."

The Unconscious in the Courtroom

The session after lunch, "The Unconscious in the Courtroom: Mental Responsibility, Culpability and Unconscious Intent - A Case," provided an opportunity to hear from major participants in the aftermath of a particularly notorious double murder in Wales. Dr. Tegwyn Williams recounted in detail the highly bizarre psycho-social history he had gathered in performing one of the psychiatric assessments on the accused. An isolated upbringing was followed quickly by enlistment in the military, which ended early. A public humiliation led to 10 years of extreme isolation marked by aversion towards the mother. The first hospitalization occurred only when a girlfriend’s rejection produced massive chaos, which ended quickly and was followed by the murders.

Defense lawyer Rob Hale took up the sorting out required by legal definitions and rules of evidence, supporting his own view of how unhelpful these can be. This included, for him, the jury’s freedom to consider medical evidence and reject it "if something before them in their good judgment contradicts and outweighs it." The defense chose a strategy based on psychodynamics, and he characterized the other side as using a "tabloid approach." The third presenter, John Basson, provided salient details of the course of the trial, illustrating how difficult it was to present the defense that was used. This he attributed in some part to what it seemed to stir up in hearers. In the end, he felt, the jury convicted the defendant of his unconscious guilt. The case was revived, however, on the basis of new evidence, and this time the defense had the opposite outcome (amidst considerable controversy), largely because they had discovered a diagnostic label to apply to their client, Asberger’s Syndrome. Before breaking for tea, a brief discussion period touched on shortcomings of the National Health Service, the value of addressing the ultimate legal question, and the importance of better public support for victims.

Shame and guilt

Dr. James Gilligan from Harvard gave the final lecture on Sunday morning, "Shame, Guilt and the Pursuit of Justice: a Psychoanalytic Theory of Violence." He began with an assertion that ours, the most violent of centuries, marks the culmination in failure of a moral-legalistic approach to violent behavior. Worse than not dealing effectively with violence, this approach only adds more violence as it treats prisoners as if they were amoral despite the observable fact that they readily develop and follow a system of values among themselves.

Nor is most violence a result of mental illness, the speaker added, pointing out that only some 1% of murderers are found NGRI. Far more often, violence occurs as a response to disrespect, evidenced by the common use of the slang expression, "He dissed me," as an explanation for aggression. There is considerable theoretical support for this, beginning possibly with the primordial story of Cain and Abel and including Aristotle and Aquinas. It also fits Kohut’s concept of the narcissistic wound.

From this point, citing numerous additional authorities, Gilligan developed a theory explaining how an immature and ultimately inadequate ethical system based on shame is prone to producing violent responses to life’s inevitable slights and humiliations. He contrasted this with a more mature construct based on guilt and leading to constructive behavior. Having emphasized differences for the sake of clarity, he concluded with a reminder of Freud’s observation that neurosis is the inhibition of the capacity to love, and that none of us can be ideally loving all the time, raising the need for rules and customs of morality. Questions brought out a need for filling in the scheme in order to correct its oversimplifications, including the need to recognize that shame and its progeny can be a normal and inevitable response to racism and similar evils.

The meeting also included 2 pairs of parallel sessions, encompassing a total of 26 presentations on a broad range of topics including a scholarly account by Dr. Abe Halpern of the James Hadfield trial with several pointed lessons for expert witnesses and my discussion of managing incompetent refusal of medication. Fortunately, there were printed abstracts to facilitate selecting session to attend and gathering information on sessions missed. An interesting innovation for this meeting was the option to attend two Large Group sessions, skillfully led by Sheffield University’s Graeme Farquarson, to exchange reactions and suggestions, one after the first day and the other at the meeting’s end. Based on the ample attendance at the second session, the experiment was a success. There was also a pre-meeting public evening session on violence and film, attracting some 130 local people for a lively discussion and stimulating reception afterwards.

The meeting included a hearty lunch and two refreshment breaks each day. Two evening socials at well-chosen venues were also featured as part of the registration, beginning with drinks, including live music and fine dining, followed by dancing. The 9th meeting is planned for Boston April 28-30, 2000, under the theme "Learning from Violence." The IAFP leadership is eager to see AAPL well represented that weekend. More about that meeting and about joining IAFP is available at its Website: