Containment in the Community

Supportive Frameworks for Thinking about Antisocial Behaviour and Mental Health

David Reiss, Alla Rubitel, David Reiss, Alla Rubitel

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429912214
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book is aimed at all practitioners working in healthcare and criminal justice community settings with individuals displaying antisocial, offending, and challenging behaviours, at times complicated by severe mental disorders. Despite risk assessment policies and procedures, we all know how disorientated we can feel when trying to make sense of what is going on in the course of our work. Contributors to this book describe familiar anxiety-provoking situations. Most importantly, they illustrate ideas and perspectives that can help you to rediscover meaning and purpose in your roles and tasks, with the ultimate objective of enabling service-users to manage more effectively the emotional turbulence that invariably lies behind their challenging behaviours.

Chapter One
Working with hard-to-reach patients in difficult places: a democratic therapeutic community approach to consultation

John Adlam and Christopher Scanlon

“An eye for an eye makes the whole world blind.”

(Quote attributed to Gandhi)

Introduction

The difficult relationship between the forensic patient and the system of care is characterized by the giving and taking of offence. The capacity of the individual to act out violently an offended state of mind is what has resulted in his entry into the forensic system, rather than any more conscious motivation for treatment or recovery. In relation to the offender, the wider social systems in turn, for the most part, cannot help but be offended. Those who offend and those who are offended then enter into a reciprocal relationship in which violence and offence of different sorts are transacted in both directions (Scanlon & Adlam, 2009). In this chapter we attempt to examine the quality of hostile dependency that lies at the heart of this relationship, most obviously in the case of recidivist offenders and chronically disturbed and excluded personality disordered individuals.

The very public nature of this relationship is inherent in the very term “forensic”, which derives from the Roman idea of the forum as a public space. There is necessarily something very public about the way that each party to the long and fraught relationship prosecutes and defends the publication of their grievances with each other. The index offence, where there is one (the criminal record), can be understood as both a cryptic and a straightforward expression or publication of the patient’s distress, disturbance, or disaffection (Cordess & Cox, 1996; Morgan & Ruszczynski, 2007; Welldon & Van Velsen, 1997). The sentence meted out is an equivalent public expression of the extent to which the judgement of the courts has taken offence on behalf of the wider community. In cases where the community has taken greatest offence, the offending individual is not only deprived of his liberty or “freedom to act”, but is then often further punished through degrading and inhumane treatment under the cover of correction or rehabilitation (see, e.g., Department of Health, 1992). These are the outward, psychosocial manifestations of the difficulties which follow from the problematic relationship between the offender and the offended. As in any problematic long-term relationship, below the surface there are many less obvious, but no less destructive, behaviours and responses which often make it difficult to distinguish victim and perpetrator or initiator and responder.

In this chapter, we want to examine and explore this complicated relationship. We are thinking about men and women with forensic histories and criminal records who have been caught and sentenced, or who have hurt others but have not been caught, or who have done violence to themselves and to the minds of others but have not been considered to have committed any crime (Motz, 2008; Scanlon & Adlam, 2009b). What we are addressing in all these instances is a reciprocal problem of the antisocial position and the societal response (Norton & Dolan, 1995; Scanlon & Adlam, 2008a). Borrowing a term from Bion (1961), we will consider both the antisocial position and the societal response as expressions of disturbances of “groupishness”, a concept we elaborate upon below. We explore the question of who is or was responding to whom by means of the giving and taking of offence. We suggest that the judgement of the forensic system of care, enforced on behalf of the wider community, might often be itself antisocial and actively offensive to some of the most vulnerable members of our society.

To counter this tendency, we suggest that the primary task is one of engagement between the system of care and the chronically excluded. We go on to describe some of the obstacles to engagement between offenders and the offended. We illustrate our argument by making metaphorical use of what we have called the Diogenes Paradigm, within which we explore the fabled encounter between Diogenes of Sinope and Alexander the Great and its possible implications for the relationship between the offender and the forensic system of care. We illustrate some of the practical difficulties in this relationship using composite clinical material assembled from our own experience. We conclude with an exploration of a model of outreach (to the offender in the wider community) and inreach (to the offender in custody), a model that is derived from our experience in democratic therapeutic communities, and of the ways in which this model can be helpfully applied to other services working with the excluded forensic client.

Assessment and engagement

At the point of contact with a given service, the antisocial individual generally expects to be surveyed, judged, and found wanting. This is so partly because the familial, educational, and social systems he grew up in usually generated this expectation by means of their own punishment structures and the intrusion into the child of their own disappointments and disillusionments. It is also so because it is often precisely his experience of desperate wanting that has driven him to act in the first place, and because, in this state of mind, he cannot easily or reasonably expect to be a reasoned judge himself. Once inside the forensic arena, this judgemental surveillance becomes formalized in terms of the assessment: most particularly in relation to the perception of his risk to self and others (Blumenthal & Lavender, 2000; Doctor, 2003). This assessment often becomes particularly contested because his supposed riskiness is not so much a part of his own experience as it is a function of other people’s experiences of him. This is problematic because, in the judgemental relationship, within which others may perceive him as dangerous, he simultaneously experiences himself as having become endangered and, thus, really dangerous. He may also be aware that he is being asked to give up, or give away, the very dangerousness which he may feel has helped to hold him together. He also feels that he may need to preserve his secret access to his dangerousness in order to survive this examination.

At the same time as feeling endangered, he may also be aware of a painfully contrasting longing for acceptance and inclusion: to be brought inside. The oscillation between these internal states of mind finds its echo in a duality inherent in the nature of the assessment, which presents him with both carrot and stick. The carrot is an implicit invitation that, if he engages with the assessor on the assessor’s own terms, he can “come in from the cold”. The stick is an implicit threat that if he cannot or will not do this, he must stay out in the cold and remain dangerous and endangered. Of course, he also knows that the invitation is heavily conditional and that there will be certain parts of his experience of himself that may not be allowed through the door, such as the sense of himself and of the offence as having been justified and justifiable, reasoned and reasonable.

The antisocial patient is all the more vulnerable to becoming alienated in this kind of assessment because, as is well documented (Tyrer & Stein, 1993), the prevalent normative model of personality disorder is one that collects groupings of “symptoms” without necessarily prioritizing an understanding of the distress, disturbance, or disaffection in relation to which the symptoms are produced. Both diagnosis and treatment can become infused with hostility, both individually and systemically (Adshead & Jacob, 2009; Declerk, 2006; Department of Health, 2003; Hinshelwood, 1999; Johnson & Webb, 1995; Kelly & May, 1982; Lewis & Appleby, 1988; Stockwell, 1974). There can be little room to consider the ways in which these symptoms may display an offended reaction to offence, or a sane reaction to an insane world (Foucault, 1961; Laing, 1960). The filling in of the diagnostic interview and the administering and application of risk assessment tools tend to fuel the illusion that there is the possibility of a conversation. In reality the two parties to the transaction inevitably become interrogator and interrogated: ‘us and them’. There is little scope for the interpersonal encounter, for conversation and interaction, or for any shared questioning of the meaning of the process.

The patient, perhaps in particular the “revolving doors” patient or recidivist offender, who may be the veteran of many such assessments, will do extremely well to allow himself to be emotionally available during the encounter, even if to withdraw is to relinquish a longed-for experience of engagement and inclusion. Many such patients tend to launch into their “history”, scripted and sculpted in the studio of so many previous encounters. Clinicians can show a parallel tendency to go through the (risk) assessment almost as if the patient was not there, ticking boxes in order defensively and safely to conclude that he is indeed a threat to self or others— whether or not this is probably the case (Blumenthal & Lavender, 2000). There is often a palpable sense of shared relief as both patient and clinician veer away from the stormy seas of the possibility of making and sustaining contact with each other into the familiar backwaters of, for example, a pro forma family history or a conventional substance misuse assessment. The potential for a more empathic understanding of the wanting that emerges from this potentially dangerous liaison does not survive the assaults upon it inherent in such an encounter. Instead, the potential for a real meeting is replaced with reciprocal disinterest, detachment, and disaffection.

The Diogenes paradigm

In previous papers (Adlam & Scanlon, 2005; Scanlon & Adlam, 2008b), we have explored encounters between systems of care and “offensive” persons using the legendary encounter between Diogenes, the Cynic philosopher, and Alexander the Great. We have suggested a framework for imagining this encounter as a kind of paradigm for the problematic relationship as it is played out between the antisocial individual and the system of care in our own times. Diogenes’ index offence was that of debasing the currency of Sinope, the city where he lived. If this offence was “merely” a white-collar crime, it certainly caused sufficient offence that he had to flee his home to escape retribution. He made his way to Athens, where he established himself in a barrel in the main square or forum. Diogenes’ ongoing offensiveness, his Cynicism, was to refuse accommodation from societal systems that he regarded as fundamentally untruthful. He would also express something perhaps of the shamefulness inherent in the poverty of his unhoused state by masturbating in his barrel. When challenged, he is supposed to have said that “he wished it were as easy to relieve hunger by rubbing an empty stomach”.

Diogenes seemed to understand, if people were offended by him, that this was not his problem: but that, if he was offended by what he saw in the world around him, this then was his problem, one that he needed to manage as best he could. He took up the only position in relation to the world that was open to him, a position that was both criminal and liminal. His was a threshold, borderline existence that was neither in nor out. His Cynical position was necessarily an antisocial one, but he also maintained a questioning and challenging stance. His protest took the form of a kind of running commentary, through both words and deeds, on the corruption inherent in the power relationships between people and how they were played out in the world around him.

This powerful combination of social challenging and Cynical enquiry comes into focus in Diogenes’ encounter with Alexander the Great. Alexander is supposed to have sought out Diogenes in his barrel when Diogenes (dangerously) refused an invitation to join Alexander at a public function. According to legend Alexander greeted him saying, “I am Alexander the great king”, and Diogenes answered, “And I am Diogenes the Dog”, explaining that “I brownnose those who give me alms, I yelp at those who refuse, and I set my teeth on those who are rascals” (Navia, 2005). Alexander found himself so impressed, both by Diogenes’ insights and also by the parlous state of his living conditions, that he asked if there was anything he could do for Diogenes. The latter replied from his barrel, in terms familiar to any clinician seeking to offer “help” to the difficult-to-reach patient, that, yes, there was something he could do: Alexander was blocking Diogenes’ light, and would he please step out of the way?

Part of Alexander’s own response to Diogenes is supposed to have been to declare that if he were not Alexander, he would be Diogenes, thereby recognizing how much they were a part of each other, how close they were as well as how far apart. Each expresses something of his disturbance of groupishness: each is, in Bion’s words, “a group animal at war, not simply with the group, but with himself for being a group animal and with those aspects of his personality that constitute his groupishness” (Bion, 1961). In the same way, a forensic worker may work in a secure unit by way of managing something of his own antisocial tendency or aggression (Bray, 1999; Scanlon & Adlam, 2009a), or a support worker in a housing project may identify herself with the outsider culture of the clients she serves in order to manage something of her own unhousedness (Adlam & Scanlon, 2005; Scanlon & Adlam, 2006).

The difficulty here is that this position is, in itself, as dangerous as it is humane. It is humane in recognizing a truth, that “there but for the grace of God go I”. It is dangerous because, in so doing, it runs the risk of ignoring or minimizing another reality: that the most dangerous difference between “us” and “them” may lie in the vexed and vexatious concept of “role” and the potentially humiliating power differential that goes with it (Gilligan, 1996; žižek, 2008). Foucault (1975) makes the point that the brutality of punishment in the Middle Ages reflected the conception of a crime as an offence against the person of the King and of the punishment inflicted upon the offender’s body as a very public reassertion of royal omnipotence; he argues that all that has changed is the method and object of punishment (now directed against the mind of the offender rather than his body), not the power differentials. From this perspective, it is not clear who is the more dangerous, except that Alexander’s expression of his dangerousness is socially sanctioned (perhaps especially by those populations that he conquered) whereas the antisocial position of our latter day Diogenes rarely is.

This, then, is our paradigm for the problem of refusal that is both clinical and societal. Diogenes stands for the socially excluded: the homeless, the truant, the antisocial, the borderline, and all others who, in their “unhoused” states of mind, literally and metaphorically, cannot be accommodated either in the formal structures of the social world or in the minds of its members. Standing in relation to these latter-day Diogenes, Alexander comes to represent both the might and the impotence of the system of care and of those who choose or otherwise find themselves working within it. What, then, becomes of us as clinicians, or, for that matter, as citizens, when our authority is disregarded? If we stand in Alexander’s sh...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• ACKNOWLEDGEMENTS
• ABOUT THE EDITORS AND CONTRIBUTORS
• PREFACE
• FOREWORD
• INTRODUCTION
• CHAPTER ONE Working with hard-to-reach patients in difficult places: a democratic therapeutic community approach to consultation
• CHAPTER TWO The lived experience of rehabilitation work with forensic patients in the community
• CHAPTER THREE Sustainable organizations in health and social care: developing a "team mind"
• CHAPTER FOUR Bearing and not bearing unbearable realities: the limits of understanding
• CHAPTER FIVE Thinking about antisocial behaviour and mental health in Youth Offending Services
• CHAPTER SIX An alternative to "slapping": multi-agency working with excluded young people exhibiting antisocial behaviour
• CHAPTER SEVEN Managing difficulty: a journey with a murderous adolescent by a CAMHS psychiatrist and team
• CHAPTER EIGHT The interface between forensic psychiatry and general adult psychiatry
• CHAPTER NINE Multi-agency public protection arrangements (MAPPA): can we work with them?
• CHAPTER TEN Gut feelings
• CHAPTER ELEVEN Work discussion group for trainees working in forensic settings
• CHAPTER TWELVE Valuing the splits and preventing violence
• CHAPTER THIRTEEN The healthy and the unhealthy organization: how can we help teams to remain effective?
• INDEX