The Therapeutic Milieu Under Fire

Security and Insecurity in Forensic Mental Health

John Adlam, Anne Aiyegbusi, Pam Kleinot, Anna Motz, Anne, Aiyegbusi, Christopher Scanlon, Christopher, Scanlon, Anna, Motz, Pam, Kleinot, John, Adlam

• Publisher: Jessica Kingsley Publishers
• Year: 2012
• Print ISBN: 9781849052580
• eBook ISBN: 9780857005342
• Topic: Psychology
• Subtopic: Forensic Psychology
• Index: Psychology

This groundbreaking book explores the psychodynamics and socio-politics of the forensic therapeutic milieu, addressing some of the most difficult and complex issues facing practitioners. It sets out a psycho-social framework for understanding the predicament and the needs of those who live in and those who work in forensic mental health settings. It brings to life the thinking of those working on the frontline in an increasingly difficult and hostile environment, and draws together fresh and stimulating approaches to engagement with highly complex individuals who present challenges to traditional models of psychiatric assessment and treatment.

Contributors with considerable clinical experience and expertise from a range of disciplines consider the ethical, emotional and intellectual challenges of their work, and describe ways in which genuine containment and change can be achieved despite numerous perceived assaults on therapeutic relationships, and on the therapeutic milieu itself. Combining clinical case studies with organisational perspectives and clear descriptions of theoretical processes, they explore key issues including the challenges of maintaining role-appropriate, 'boundaried' relationships; the tensions between public protection and individual confidentiality; questions of risk and responsibility; duty of care and respect for individual liberty; the challenges posed by inter-professional tensions and rivalries; as well as specific clinical dilemmas. The difficulties they experience in fulfilling specific therapeutic roles in the face of uncertainties about the funding and commissioning of their services are addressed, and the final part of the book outlines some of the ways in which individuals, particular services and whole organisations may protect themselves when under attack.

This unique and highly original book is essential reading for all those working, or training to work, in both forensic and non-forensic inpatient therapeutic milieux and for academics and lay readers interested in the societal dynamics of inclusion and exclusion that are replicated andmagnified in these settings.

Part I

The Interpersonal Minefield

The Psycho-Social dynamics of Engagement

Infernal world, and thou profoundest Hell

Receive thy new Possessor: One who brings

A mind not to be chang’d by Place or Time.

The mind is its own place, and in it self

Can make a Heav’n of Hell, a Hell of Heav’n.

What matter where, if I be still the same…

Better to reign in Hell, than serve in Heav’n.

From Paradise Lost, John Milton (1667)

Chapter 1

Nursing at the Scene of the Crime^[1]

Rebecca Neeld and Tom Clarke

In this chapter Rebecca Neeld and Tom Clarke discuss experiences of what they describe as nursing ‘at the scene of the crime’ at the Families Unit at the Cassel Hospital, now sadly closed down. They describe how traumatised parents managed the difficulties of caring for their children, in what seemed to them like a harsh environment, and the inherent tensions for nursing staff in balancing the therapeutic needs of parents and the health and welfare of their children. They examine the interpersonal minefield between Claire, a young mother of twins, her family and the therapeutic milieu. They focus on the relationship between this family and Margaret, their nurse, to show how the setting of the therapeutic community enabled these dynamics to be thought about (and not thought about) by Claire and Margaret as they grappled with the difficulties they each faced. Neeld and Clarke movingly describe both Margaret’s struggle to relate to Claire’s experience of being mistreated in her early life (and the ways in which she risked mistreating her own ‘at risk’ children) and Margaret and Claire’s struggle to reach out to the victim and the perpetrator within each of them.

Introduction

If you were to withhold food, apply restraints so that a person was confined in a chair, left in soiled wet underwear and shouted at repeatedly, you could, if caught in the act, be charged with ‘actual bodily harm’. If the person you did this to is your child, the local authority may apply to have your child taken into their care. If you were to contest this decision, one possible outcome used to be that the court could refer you and your child to the Families Unit at the Cassel Hospital for assessment and treatment.

Nurses caring for these mothers accompanied by children in the Families Unit not only had to observe these mothers but also had to intersect these abusive and neglectful behaviours of mothers towards their children and intervene. Nurses in these roles therefore had a vicarious experience of the traumas that impacted upon the child. Nurses, like children, prefer to hold on to what is good with the mother (Blum 1981) which is why in order to maintain hope, and possibly to avoid separation, there are occasions when they may turn a blind eye to abuse (see also Chapter 5 and Chapter 10). It is this re-enactment of the trans-generational transmission of trauma, either of what the mother experienced as a child or of what the mother was attempting to repeat with her own child, that the nurse tries to process and resolve within the nurse-patient relationship, in order that this relationship can develop along a different route. Nursing these mothers and their little victims is forensic nursing at the scene of the crime.

Background

The individual, group or institution’s ‘personality’ comes about through a combination of experience and the sense that can be made of that experience. The Families Unit’s experience was of coming into being after the Second World War. Tom Main, the then medical director, brought his experience and learning gained at Northfield Military Hospital (Harrison 2000) to inform the development of individual psychotherapy and group work to assist individuals to recover from their severely disabling neurotic symptoms. The treatment regime with its emphasis of developing a culture of enquiry and a therapeutic community was extended and broadened to include the treatment of whole families, and the first family was admitted in 1949. From then until the closure of the Families Unit in 2011 there were always babies and children in the building. In the early years it was more usual for these families to consist of a mother who stayed in the Unit and looked after the child and a father who went out to work. Latterly it was more usual to encounter a single mother with a new baby; a mother who often had an older child, or children, already in care.

Rohner (1986) defines abuse as a specialised form of rejection, expressed as the absence or significant withdrawal of warmth and affection of parents towards their children. Such rejection can take the form of hostility and aggression or indifference and neglect. Many of the mothers who came to the Families Unit were extremely vulnerable and yet they had often escaped the attention of adult mental health services. Many had been abused themselves as children (at previous ‘crime scenes’); many had self-harmed or used street drugs. Approximately 50 per cent of the women had also spent a period of their childhoods in the care system but it was only when they become mothers that ‘the system’ started to take notice.

The majority of families, 90 per cent, were referred by the family courts rather than through mental health routes. The mother was usually single (in 80% of cases) and had agreed to come into treatment because she was contesting the social services application to have her child permanently put into foster care, as well as asking for help to stay with and look after her child. The mother may also have neglected her children; a child may have died in suspicious circumstances; older children may have been harmed or malnourished, taken into care or may already be going through the process of being adopted.

The Cassel’s particular brand of therapeutic community features individual psychotherapy as a hallmark of its treatment and, prior to the closure of the Families Unit, families and single adults were housed in separate units that came together for community meetings, meals and activities where the full range of society was represented: from babies to grandparents (Kennedy 1987). This coming together of these different strata of society often diluted the intensity that might otherwise develop between individuals when similar sub-groups of people with similar difficulties are in close proximity. The presence of young children running around at teatime or toddlers climbing onto your knee for a cuddle, holding your hand, taking you to see a dead ant, can infuse one with pleasure as well as representing hope for the future: a hope that it might be possible to break the cycle of abuse and rejection. For the hospital itself, the presence of children also signified financial security and perhaps that we were potent and fecund. There was an obvious tension between this sense of growth and potential and the reality of the suffering that preceded and accompanied the presence of children who were ‘at risk’ in this particular community (as well as the looming socio-economic and political pressures that were increasingly placing the hospital itself ‘at risk’).

In the wider therapeutic community, the single adult patients often resented the care that the children got, because they didn’t have it when they were children. Similarly, a single adult might see a new mother receiving more nursing time than they were getting themselves and feel neglected. Sometimes they refused to participate in helping the new mother to find her feet in the hospital. In these ways, single mothers, and their children, were often the subject of powerful projections from other patients, and from staff, even before they had a name or a history in the therapeutic community. This was often because the compulsory, or coercive, nature of the admission of these mothers also brought the thought (and a reality) of child-abusers in a community where 80 per cent of the single adults had experienced abuse and where the abusive nature of patients was often denied and ignored and victimhood claimed or bestowed (Van Velsen 1997; see also Chapter 10). The presence of these mothers with their children who had been harmed brought into stark relief the unavoidable truth that victim-perpetrator roles are often embodied in the same person (Adshead 1997).

The nurse, the baby and the mother

These mothers, as has already been noted, had also been victims (Corby 1993) and were sometimes little more than children themselves and most had not previously had the opportunity of getting help with their capacity to be mothers. The effect that nursing these families had on the nurses was phenomenal. There was the ordinary awfulness of being assaulted with projections that is part and parcel of working with people who have personality disorders who have been subjected to various degrees of childhood trauma. The women could treat the nurses with such contempt, complaining that they were never available, were useless. Perhaps the contempt they manifested was so intense because the mothers felt trapped by their wish to keep the child, as well as their more secret and shameful thoughts that they did not so desire: they were in conflict with competing wishes to be a mother, to be childless and free and without responsibilities and their own ‘child-ish’ wishes to be looked after. The nurse reaped the consequence of this internal conflict as they tried to respond to these different needs. In order to get to know these young women the nurses had to hear about the children’s homes they had been in, the bullying they were subjected to, the total lack of care that they had experienced in ways that generated a great deal of sympathy and warmth as well as the more harrowing tales of their patients’ deprivation, neglect and abuse of their own children. The shared task between nurse and patient was perhaps to hold a sense of hope that this time it might be different.

The getting to know each other – nurse and patient, patient and patient – happened within the context of a therapeutic community where nurses and patients managed together the programme of therapeutic ‘opportunities’, that is, talking, listening, cleaning, cooking, playing and relaxing. For the nurses this often meant being identified with any number of significant others from the mother’s past, for example parent, teacher, social worker, police, prison warder and others who may have previously denied them freedom, or removed their children. The internal working model in relation to authority figures of the mothers who contested the removal of their children was naturally one of suspicion and distrust – not helped by the reality that they were in fact being observed and assessed. The mothers may have been abused as children and felt that ‘the authorities’ had not helped them, or at least not to the extent that made any difference. Establishing a relationship with a woman who hoped to impress upon you her ability to be a good mother, whilst resenting the fact that she experienced your presence as a reminder that she was not a good mother, was of course very difficult and the nurse was often experienced as a kind of critical jailer (see also Chapter 6).

The behaviour of a woman without her children has very little bearing on how she will be when she is with them. Many women who have some degree of personality disorder are able to manage their lives. They have multiple relationships, fall out with people on a regular basis, self-harm, take drugs, drink too much and have difficulty holding down a job for any length of time. But many of these women do not become involved with mental health services until they have children. The longed-for love of another, focused in the baby, does not compensate for the restrictions a baby places upon the mother’s tried and tested coping strategies. The mother who at times of stress goes out seeking attention from a man or seeks solace from alcohol will feel impinged upon by their crying babies.

Even when the Families Unit was seen in a good light and as a source of help by the mother, the admission nonetheless did not feel optional or voluntary. It often felt like it was her only way to hold on to her child, or to assert some power over authority figures: an attempt to transform powerlessness into possession and control (Welldon 1988). The nurse usually greeted a new mother whilst awaiting the arrival of her child or children and was often lulled into thinking that the relationship was off to a good start. This time with the nurse and her patient was vital as it was here that the relational bonds were established that helped pull the mother through the times ahead when she came to feel unable to cope with the demands of treatment and motherhood. The patient hopefully felt sufficiently mothered by her nurse to have some mothering to give her baby.

It was not the aim of nursing these mothers to produce a corrective emotional experience. The aim was to help the mothers recognise what they hadn’t had and didn’t have, so as to help them bear their own deprivation, as well as to manage their envy of their children getting what they did not. The work of nursing the mothers was about being alongside during the trials and tribulations of coping with the restrictions of motherhood and the subjugation of their own needs to their children’s needs. In many ways the nurse became the voice of the baby, and so was experienced as a whining, whinging, complaining child. The nurse, when prioritising the baby’s needs, could be experienced as if she was disregarding the mother’s needs. The care they gave to the baby was felt as the exposure of both a deprived aspect of the mother’s past and of her ...

Table of contents

• Cover
• Title
• Contents
• Foreword
• Acknowledgements
• Editorial Commentary
• Part I The Interpersonal Minefield
• Part II Shot By Both Sides
• Part III Courage Under Fire