What does it mean to be called a ‘monster’? Inside the UK’s leading psychotherapy clinic
27 November 2018 15:39
On March 29 2016, the archivist Amy Proctor stood in a temperature-controlled strongroom in the London Metropolitan Archive and tried not to feel daunted by the task ahead of her. She was surrounded by shelves and shelves and shelves of acid-free cardboard boxes, stored at a cool 18 degrees, with humidity at 45 to 60 per cent. Inside those boxes were 20,000 patient files – 144 linear metres when laid out end to end. And inside those files were the stories of the men, women and children who received psychotherapy at the Psychopathic Clinic – as it was known when it opened 85 years ago – at the Institute for the Study and Treatment of Delinquency.
Proctor’s job for the next two years was to read and process these files, anonymising the information and uploading it to a huge, searchable database for use by researchers and clinicians. That first day, she says, ‘I just started from the beginning.’ She took a pile back to her slightly warmer office, took out the first file, labelled Patient 1, and read.
Patient 1 was a 47-year-old woman noted as having a violent temper, who had been charged with assault on a female colleague. In September 1933, she became the first patient to be treated in what would become the Portman, part of the Tavistock and Portman NHS Trust. Her treatment marked the opening of both a new clinic and a radical new way of thinking about criminality, based on the ideas of psychoanalysis. At the turn of the century, Freud had uncovered the then revolutionary concept that our behaviour is driven by our unconscious, shaped by our experiences in early life, but 30 years on, these ideas were only just beginning to be applied to crime. These clinicians sought to do something quite extraordinary that had never been seen before. Instead of simply condemning violent and illegal behaviour, they worked to understand what it meant and where it came from, and to help their patients to change.
This was, and remains, controversial work. In the rush of #MeToo and Times Up, the downfall of Harvey Weinstein, Bill Cosby and others, few of us can stomach even thinking about the people behind their monstrous acts. The clinic’s founders knew they would come under attack, so they shored up support from a broad range of influential figures, with vice presidents including Sigmund Freud, H. G. Wells, the Anglican and Catholic Archbishops and the Chief Rabbi. But the original force behind the establishment of the clinic was a psychiatrist and psychoanalyst called Dr. Grace Pailthorpe. Her biography reads like an adventure story, but she is now so forgotten that, until recently, even the English Wikipedia site didn’t remember her.
Born in 1883, into a middle-class family in Essex, Pailthorpe was the only girl in a family of nine brothers. She studied at the Royal College of Music to become a professional pianist, but was also qualified in medicine and, throughout her life, worked as a surgeon on the Western Front in World War One, ran a flying ambulance service in the Balkans, worked with Aborigines in Australia, and studied female prisoners in the UK, publishing her book Studies in the Psychology of Delinquency in 1932. That led her to open the clinic, after which she became a surrealist painter, and, along with her partner Reuben Mednikoff, was hailed ‘the best and most truly surrealist’ British artist by the leader of the French Surrealists, André Breton.
In the intervening 85 years, the spirit of the Portman has not changed much, even since joining the NHS in 1948 – but society has, and therefore so have the patients. Early patients included boys and girls of 14 who refused to work full time; the 30s and 40s saw bicycle thieves; the 50s and 60s, motorcycle and car thieves. Some sought treatment for homosexuality, before it was partially decriminalised in 1967. The clinic’s director Jessica Yakeley – a psychiatrist, psychoanalyst and psychotherapist – says, ‘to emphasise, we were not doing conversion therapy at any point, we were trying to help them to cope with society’s feelings towards it, but we were not trying to change their sexuality.’
The Portman now offers specialist long-term forensic psychotherapy to 140 patients at any one time, including adults, young people and children who present with disturbing sexual behaviours, criminality and violence, referred from across England. As of 2016, the youngest patient referred was four years old, the oldest 80. Their work has never been more vital: figures from the Office for National Statistics show that in England and Wales the number of homicides recorded has risen by 18 per cent over the last year, and the number of recorded sexual offences has increased by 14 per cent. In recent years, Yakeley says that the most striking change has been the huge increase in patients seeking treatment for downloading illegal images of child sexual abuse. ‘Fifteen years ago, we didn’t have any cases at all. Ten years ago, we had only a handful. Today they account for roughly 20 per cent of the patients we take on for treatment,’ she says.
Of the remaining 80 per cent of patients, some present with behaviours that are perfectly legal, such as consensual sadomasochistic practices, fetishism and compulsive use of online adult pornography – in these cases, treatment is only provided to those who find their experiences distressing or problematic. Other patients have committed offences, including burglary and theft, fraud, exhibitionism, voyeurism, violence, murder, sexual violence, rape, incest and paedophilia.
Because of its incredibly sensitive work, the clinic rarely appears in the press. Its more famous sibling, the Tavistock Clinic, a few minutes’ walk away, is all grey concrete and sixties Brutalism; there is something surprising about the Portman’s charming red brick house, with its white timber-framed bay windows. It is almost indistinguishable from the surrounding homes on the residential tree-lined Hampstead street, save for the discreet sign. There is a cliché about the difference between the two; that victims of crime and abuse go to the Tavistock, while perpetrators go to the Portman. But it is not as simple as that, the clinicians say.
Yakeley, who has worked at the clinic for 15 years and as director for 18 months, says, ‘many of these individuals, particularly the more violent ones, tend to come from deprived backgrounds in which they have very poor access to health services. But when you get them into psychotherapy and they use it, it’s very, very moving.’ She speaks with a composure and reserve that makes her words more poignant.
For one of the clinic’s longest-standing employees, Carine Minne, another psychiatrist, psychoanalyst and psychotherapist, the answer is more personal. She works between the Portman and Broadmoor, the high-security hospital, seeing patients in both locations and in medium-secure units in between, and has done so for the last 20 years. She speaks with calm, warmth, humour, and the kind of verbal precision and insight that says, ‘do not mess with me’. Growing up in the north of Ireland during the Troubles, she reflects, left her with questions that would shape her career. ‘I found it frightening and perplexing, and I think that might have contributed to my need to try and understand how can people turn against each other in such horrendous ways?’
The Portman patients, at the more extreme end of the scale, have committed crimes that are so disturbing, they test the faith even of those who consider themselves committed to the idea of rehabilitation, let alone those who would attack a paediatrician, mistaking her for a paedophile. Multiple rape, child abuse, parricide. Some feel these crimes make people monsters, that to view them as human beings who require treatment is an insult to their victims.
That is why, child and adolescent psychotherapist Ariel Nathanson explains, it is so important to interrogate this overly simplistic division between perpetrator and victim, Portman patient and Tavistock patient. He sits relaxed in his chair, laid-back but still scrupulous in his explanations, his voice a languid, low-pitched thrum. ‘Before you do this work, this is how you think about it: how can I work with someone who is not a victim, with someone who is not suffering? But it’s not true that people are only victims or only perpetrators – life doesn’t work like this.’
These therapists are accustomed to having to defend their work, and their arguments are unemotional and compelling. With energy and bonhomie that fizz out of his big gestures and his bright red tie, patterned with white horses, psychotherapist, psychoanalyst and past director of the clinic Stanley Ruszczynski says, ‘one isn’t going to convince everybody. But part of our responsibility for social care in our community is to try and understand why some people do behave in that way.’ As a clinician he does not condemn or condone the behaviour of his patients – he tries to unpick it to read the meaning behind it. ‘My experience is that every single patient here comes from anything from a neglectful abusive background to a horrendous background. It’s very rare that you don’t get a depressingly horribly sad history. That does not excuse anything. But if you recognise the victim in the patient, as well as the perpetrator, if you recognise the perpetrator as well as the victim, then maybe you can actually help some of these people cut down on their behaviour. And that benefits them and, most importantly, it benefits others in society.’ These therapists do the opposite of excuse; they take a magnifying glass to examine the true nature of these acts, in all their horror, without turning away. That means understanding why and how they came about in the first place.
In a healthy family situation, parents help their child to grow up, providing the food and love that nurtures them physically and psychologically. Just as the body cannot develop without nutrients, the feeling, thinking parts of a child cannot develop without love and thought – this is food for the mind, and it could help explain why some brain scans have shown the brains of neglected toddlers to be smaller than those from loving families.
A child who is starved of these psychological nutrients can, sometimes, grow into an adult who perpetuates the cruelty that they suffered. Ruszczynski explains, ‘if you as a child were a victim, for whatever reasons, of neglect and violence, whether that violence is emotional, physical or psychological, your world as that child is a world of victim and perpetrator.’ As the child grows up, that world-view does not change, nor does the fear, or the need to escape those horrors, says Minne. ‘There can be a desperate attempt to reverse early traumas. From feeling at the mercy of a big frightening person, there is a wish to become the big frightening person who is in control, in order not to experience the terrible helplessness of being the victim.’
This is not a conscious wish, but that makes it even more powerful, she says. ‘I’ve come across hundreds and hundreds of patients in various criminal justice settings, and I have never yet met one who, when he was a little boy, wanted to be a paedophile when he grew up. This ain’t no choice.’ The Portman does not accept patients who are mandated to have treatment by the courts or social services; they come because they want more than anything to change. Minne distinguishes the paedophiles treated at the Portman from those who defend their actions, who say the problem is society’s, not theirs. Those who come to the clinic, she says, ‘suffer from paedophilia. And they suffer because they are aware of how much suffering they have caused to others.’
Minne says she has never met a paedophile who was not physically, emotionally or sexually abused or neglected in childhood, usually within the family home. The age at which that trauma happens, she says, can be around the time at which one part of their mind stops developing. A part of the patient remains at that age, and that can often be the age-range of their victims. She explains that, unconsciously, ‘they try to get rid of what is intolerable by giving it to somebody else – which of course never works, because they stay traumatised, and now they’ve traumatised another person, and their friends and family.’
Though it sounds hopeless, if these people can find their way to the Portman, they could have the chance to change. As Nathanson explains, ‘the goal is to look at the action and understand where it’s coming from, and then go to that place, as this is where trauma lies. Then you can understand it, have feelings and thoughts about it, and then, at some point, the action is no longer needed. The mind can tolerate what is in there, so you don’t need to enact it anymore.’ When it works – it does not always – the therapists, over months and years, help their patients to develop a new space in their minds, where they can feel pain and think about it, but without acting on it. This space between feeling something and doing something, between impulse and action, means reflection can bloom, and violence diminishes.
This happens when the patients’ problems come alive in the consulting room; the famous transference. Yakeley gives an example of patients who present with indecent exposure or exhibitionism, who come to the Portman for group therapy. ‘They may attend a couple of times, be very vocal, get all the group’s attention, and then disappear – you could say they have come, flashed in the group, and then vanished. Or, someone who is very controlling in their behaviours might come along and want to control the therapist, though it isn’t necessarily conscious.’ The therapist’s job, then, is to bring this to the patient’s awareness, so that the unconscious becomes conscious. ‘If they can see it actually happening in the relationship, it’s more real to them, they have to own it more, and be able to tolerate the feelings that come up within the sessions – it’s a live way of putting them in touch with themselves,’ she says.
The work is done in tiny, repeated happenings, observations, interpretations and realisations, and progress is slow – but when it works, it can be transformative. Minne says she has seen suffering from slavery, the Holocaust and other intra-family traumas passed down from parent to child, and then watched that trans-generational inheritance be interrupted, through therapy. When this kind of therapy works, the frequency of problematic behaviour can drop fairly quickly, in the first six months to year of treatment, but re-shaping the underlying personality traits is more difficult, and takes much longer. The Portman’s research lead Felicitas Rost says that the data they have been collecting for the last 10 years shows a distinct trend among the patients who do well: ‘Between the third and fourth year of treatment, you can see real significant changes in personality structure. A huge chunk of change.’
Other changes, however, are more difficult to explain, such as the surge in people presenting with an addiction to illegal images of children. This change in the population of the Portman reflects a change in society at large: the Chief Constable of West Midlands Police Dave Thompson told the Commons Home Affairs Select Committee in October 2017 that ‘the amount of men in this country who appear to show an active interest in this area is horrifying and the scale of it, I think, takes my breath away.”
For Stephen Blumenthal, psychotherapist, psychoanalyst and head of research at the Portman, this problem is complex. His manner is precise and interested, as he explains that many patients have become addicted to adult pornography, and then followed links to more and more disturbing material. He says, ‘in a group of users, you’ll have a minority who are contact offenders as well, but there are also many people in that group who have stumbled into it accidentally, and who have been upping the ante. There is a weak link between illegal images and actual contact offences.’ The point he is making is nuanced – he is clear that looking at these images perpetuates the abuse of children, but careful to emphasise that it does not always mean the viewer will go on to commit a contact offence.
He has watched his patients’ addictions to pornography intensify with internet speed, he says: ‘In the days of the dial-up modem, when it made that clanging noise, you had to work hard to get your images. Nowadays, it’s so readily available, it’s so easy. It is terrifying. I think there’s a potential public health issue here, and we just don’t
know it yet. It could be like thalidomide, and we won’t know the consequences of what we’re doing now for 10 or 20 years.’
While most of us would rather turn our backs on this disturbing part of humanity, the Portman’s attitude of less denial and more open-eyed honesty has found traction in the #MeToo and Times Up movements. Ruszczynski emphasises that the harassment and assaults that have been uncovered are not, at heart, about sex: ‘It’s violence, it’s control, it’s domination, it’s power. It’s, “I need you to be weak, so I can feel strong, because inside I feel very weak.”’ For Blumenthal, ‘what sexual abuse requires is a perpetrator, a vulnerable victim, and a setting in which people turn a blind eye. For society to respond by picking up on how blind we’ve been for so long is absolutely vitally important.’
But, he says, there is a danger: ‘We tend to simply want to punish the perpetrators, and perhaps men in general, and particular aspects of maleness, rather than looking at ourselves, and the fact that we’ve known but chosen to ignore these things for so long.’ Of course, he says, the perpetrators must be condemned and punished. But in the rush to condemn others, we miss the crucial step of owning the problem; ‘#MeToo could also be interpreted as “not me”’.
Reflecting on one’s own responses is central to the work of the Portman. Crucial to managing and understanding these feelings is supervision, weekly meetings where clinicians present cases and talk about their patients. ‘Working here for many years, you do get more experienced and more resilient, but nevertheless, obviously I’m affected – I can feel angry, shocked, and very sad,’ Yakely says. ‘Left alone with your feelings, it could be very difficult. You could come across as punitive or persecutory with a patient, or you might feel depressed, burnt out, inadequate. It’s absolutely essential to be able to talk about those feelings, to reflect on them.’ And that is why all clinicians only work at the clinic part-time, Ruszczynski says: ‘To work full-time with this client group messes with your mind’.
These feelings are not only evoked in therapists, but in anyone who works with people who act impulsively on their feelings. This group of patients do things, emotionally, to the people they encounter, and professionals have to be able to manage that. That is why this approach is not just a form of treatment; it is also a way of understanding problematic behaviour. A significant proportion of the work that these clinicians do does not happen inside the Portman, but outside it in the form of consultancy in prisons, probation services, secure hospitals and social services. As Ruszczynski puts it, anyone who works with these people, ‘will also be the theatre onto which the patients will display their internal states, and our responsibility is to have ways and means of thinking about it. Why does this person make me feel angry? Why does this person make me think he’s a pussycat when he’s killed two people?’
Violence in prisons hit a record high in the year to March, with assaults up 16 per cent on the previous year, almost double what it was 10 years ago, according to the Ministry of Justice. Some 59 per cent of adults serving sentences of under 12 months are reconvicted within a year of their release; for children serving sentences of under six months, the figure is 78 per cent. A quote Minne remembers from a lecture by a mentor of hers, Dr Patrick Gallwey, remains as relevant and haunting today as when she first heard it 30 years ago: ‘Our patients grow up in hell, and then they carry out hellish acts, and we respond as a society by putting them into hell, with the expectation that they’ll come out and become un-hellish.’ Minne speaks of how important prison is in protecting the public, letting justice be done and grounding the perpetrator in reality. But the punishment, she says, should be the loss of freedom. ‘To further brutalise these people won’t help. What happens behind those walls should address their problems. I believe society isn’t civilised enough yet to want to provide what works – even though society itself would benefit from it.’
The Portman clinicians force us to question the images we have in our minds of what it means to be a rapist, a killer, a paedophile. The people who come to the Portman, they say, do not look like the baddies of our fairytales, cackling with glee and rubbing their evil hands together at the thought of what they’ve done. They look like patients.
Over the course of two years, the archivist Amy Proctor read through thousands of these files to create a database that, if printed out, would be over 4000 pages. Because of her work, the suffering of anonymous patients from the past 85 years will be used by clinicians of the present and future to learn about the mind, helping to trace an answer to a question that is older than the Ten Commandments: Why do people do evil things? As the project comes to an end, she says, ‘there wasn’t anything that made me think, this group of people are radically different to the rest of society. There were things that tied them together – they quite often had a disturbed upbringing and background – but the overwhelming thing I noticed about the patient group is that, essentially, it’s anybody.’