Forensic psychotherapy and tele-psychiatry

The Portman Clinic, part of the Tavistock and Portman NHS Foundation Trust, is a forensic psychotherapy out-patient clinic offering psychoanalytically-informed assessments and treatment to children, adolescent and adults who present with violence, antisocial personality disorder, criminality and/or problematic sexual behaviours. Treatment offered is usually weekly individual therapy or group therapy or, in the case of children and adolescents, child psychotherapy and work with their parents and carers. Therapy is aimed at identifying, exploring and understanding the conscious and unconscious affects, anxieties and conflicts which give rise to their behaviours and which often stem from childhood abuse, neglect or loss, with a view to a reduction in their problematic behaviours and improvement in their relationships with others and themselves. In psychoanalytic psychotherapy the therapist pays particular attention to the therapeutic relationship, or transference, in which the patient’s experiences of the therapist are unconsciously influenced by their early experiences with significant others in childhood and adolescence. Awareness of the therapist’s countertransference – the thoughts and feelings that the therapist has towards the patient which represent the unconscious communications of the patient – can help understand the his ¹ psychopathology and the risk that he poses, and inform therapeutic interventions and interpretations. Exploration and understanding of the transference and countertransference dynamics in the relationship between patient and therapist provides insight into the unconscious fantasies and conflicts which motivate and sustain the patients’ relationships with others.

Since the start of the pandemic, as with other psychological therapy services, therapy for patients ² at the Portman Clinic has shifted from being delivered in person to being delivered remotely, either by the use of the telephone, or by Zoom, from the therapist’s home. This change in the therapeutic frame has had a significant impact on both clinicians and patients, and some of the particular ways in which the patients have experienced and used this remote contact has presented new opportunities in understanding and treating this particular patient population whose emotional and interpersonal difficulties are expressed via destructive bodily actions and behaviours.

Many patients have found the shift to remote therapy difficult. Not having direct contact with the therapist may make some more aware of how much they miss her, ³ but with concomitant fears of dependence and feelings of humiliation and shame, particularly for patients who tend to be dismissive in their attachments and deny the need for meaningful relationships, which is a common feature in people with antisocial personality traits or disorder. One patient, who had been initially difficult to engage in therapy due to ambivalence about whether he could benefit, returned to therapy in person after months of talking on the phone, and on seeing the therapist immediately expressed his fear that the therapy would end at some point, an anxiety that he had never voiced before.

The number of appointments cancelled by the patient has significantly dropped since the start of the pandemic, a measure of how much these patients, who are often hard to engage in therapy due to their difficulties in accepting responsibility for their problems and adopting the patient role which is associated with weakness and vulnerability, are hungry for therapeutic contact. Other patients, particularly those who feel ashamed of their sexual activities, may feel safer in admitting to and exploring such issues with the therapist when there is no face to face contact. In these cases, working remotely may enable the patient to reveal issues that they have not been able to admit to before, but unless this work can be sustained once in vivo therapy resumes, hiding behind the telephone receiver may become an unhelpful defence that prevents the patient from facing his anxieties about negotiating relationships with others in his life. Mindful of the fragility of the mental states of patients, many of whom have become more isolated during lockdown, therapists report being more reluctant to challenge the patient’s defences or interpret unconscious material for fear stirring up difficult emotions which may destabilise them. This raises questions as to whether this more supportive therapy is just ‘holding’ the patient or whether effective therapeutic work is still possible under conditions which are not safe enough to foster the patients’ ability to tolerate such feelings without expressing them in action, and their symptoms and behaviour escalating.

The boundaries of conventional therapy, such as the need to provide a safe, reliable and confidential space in which the patient is expected to refrain from antisocial behaviour, shift with the move to remote working. The patient is now more in control of the setting and has more choice in where to hold his sessions and how he behaves within the sessions. It can be difficult to differentiate between the necessary use of a particular location from which to attend the therapy meeting, and one which is inappropriate. For example, one patient needed to use his car as there was no confidential space in his home due to the presence of other members of his family; whilst another patient, who exhibited narcissistic, grandiose and omnipotent traits, insisted on having his therapy session in the car on the way to work so that he wouldn’t waste time in his busy and successful life.

Patients’ antisocial or transgressive behaviour may be more evident when working remotely. At a more benign level, a patient may smoke during a session, which would be forbidden in the therapist’s office. The therapist is faced with a more difficult dilemma when the patient brazenly contravenes the law in full view of the therapist, such as smoking cannabis. Again, it may be difficult to ascertain whether such actions are being used to alleviate the patient’s anxiety, or whether they are being deliberately provocative to test the therapist’s responses. The technical issue for the therapist is how to best address this behaviour without, on the one hand, appearing as a persecutory and prohibitive authority figure, but on the other hand, colluding with the patient by not mentioning his conduct and miss the underlying anxiety or aggression which is fuelling his behaviour. For patients, such as those with a diagnosis of antisocial personality disorder who are difficult to engage in treatment in general, a degree of flexibility in tolerating the testing of boundaries by the patient may be necessary at the start of remote therapy until they feel more contained.

Working via the virtual medium of the Internet raises particular issues in patients who misuse the internet in destructive ways. Patients who are addicted to the two-dimensional fantasy world of internet pornography may feel a sense of power and excitement which temporarily compensates for their anxieties about achieving intimate relationships with others. In on-line therapy the picture on screen of the therapist may be experienced consciously or unconsciously as another pornographic image to be controlled and used for erotic purposes. Patients who use chatrooms or webcams for sexual interactions with others may cast the therapist in the role of on-line prostitute, or voyeur to the patient’s exhibitionistic behaviour. For example, one patient, who had been referred for his obsessive use of on-line sex workers with whom he enacted sado-masochistic scenarios involving bondage and humiliation, attended his first therapy session via Zoom with no shirt on, revealing his bare torso and attributing his state of undress to it being a very hot day. The therapist decided at this early stage of treatment not to interpret this behaviour to the patient as an enactment of his sexual fantasies, as this might have been experienced by him as either humiliating or seductive; nor did she tell him to get dressed, which may have come across as punitive or create a sado-masochistic dynamic which might unconsciously sexually gratify the patient further. Instead, she made a simple comment about how perhaps the boundaries between a therapy session at the Portman Clinic, and one where the patient was in his own home, were unclear.

Another patient, who had been brought up in foster care where he had been sexually abused and then worked as a prostitute himself in late adolescence, had sought treatment to explore his difficulties in his relationship with his wife. When she wanted to be physically and emotionally close to him, he described feeling suffocated and withdrew into looking at pornography. This inevitably led to arguments in which his wife would threaten to leave him, whereupon he would feel abandoned and would then try to seduce her into sexual intercourse, which temporarily allayed his fears of rejection but quickly progressed to him feeling overwhelmed again by her attention and a longing to escape. This pattern of inter-related feelings and behaviour repeated itself in the transference with his female therapist. Following sessions, delivered by Zoom, in which the therapist thought the patient had made good emotional contact and felt understood by her when describing some of the anger he felt towards his mother for abandoning him, he would inevitably miss the following session or dial in late and be sullen and uncommunicative, causing the therapist to feel irritated, denigrated and ineffectual. This would be followed by a session in which he would join from his bedroom, lying on his bed in a suggestive pose, and would talk in a rushed and animated manner which the therapist found impossible to interrupt, and left her feeling rather confused and overwhelmed. The therapist eventually drew parallels between what was happening in the relationship with his wife and what emerged in the sessions with her. She interpreted his distrust of care – that when he starts to become emotionally involved with someone, he feels trapped in a situation in which he fears the other person might abuse him, as happened in childhood, reactivating anger at not being loved or protected by his mother, and therefore has to escape, by not talking to his wife, or by missing sessions. But this then leaves him feeling increasingly isolated, and so he seeks to regain contact with the other but believes this will only be successful if it is erotised, as if he will only be valued for his sexual prowess, which conceals his underlying lack of confidence and identity confusion. The therapist’s countertransference feelings of anger and degraded by the patient were replaced by those of being seduced then engulfed by his continuous chatter, which blocked any meaningful communications between them. These emotional responses evoked in the therapist mirrored those of the patient and provided a live demonstration of how he experiences and treats others, dynamics which could be discovered and explored in the here-and-now of his interactions with the therapist.

Group therapy presents particular challenges for remote working. Groups have been held via Zoom which means that instead of all being physically together in a room, patients and therapists see their own and the other group members’ disembodied faces in boxes on the screens of their tablet. Some patients do not like looking at themselves on screen or feel uncomfortable in allowing others to do so, and therefore choose keep their cameras off, which may be experienced by the other group members as ejecting or aggressive. More paranoid patients may be reluctant to use Zoom due to fears that the sessions are being recorded and used for malevolent purposes; interestingly such patients are frequently proponents of conspiracy theories regarding Covid, for example that the virus doesn’t exist and or was deliberately manufactured by China. Such beliefs tend to take on an exciting fantasy life of their own in the collective mind of the group, impeding therapeutic work and emotional contact with their shared anxieties and vulnerabilities which have been exacerbated by living in the pandemic.

The need to find a confidential space in their home in which to join the remote group without intrusion from others is an important consideration, not just for themselves, but also to protect the privacy of other members of the group and ensure that group sessions are not seen or overhead by anyone else. The patients have shown differing responses to allowing each other to see their living circumstances. One patient wanted to show the group the reality of his poor living conditions, taking them on a virtual tour of his cramped room and the rest of the hostel in which he currently resided. Another patient appeared in his dressing gown in his living room, told the group that he was just going to the bathroom, disappeared for a few minutes leaving the camera on and whilst the other patients in the group couldn’t see what he was doing, the therapist was left feeling as if he had invited them into a part of his life that should have remained private.

Other patients feel more self-conscious or that the privacy of their home is being violated by allowing other patients a view inside. Glimpses into the external circumstances of patients can be illuminating and allow access to information about the patient that may not otherwise become evident in therapy. For example, the Zoom camera for one particularly chaotic, antisocial and paranoid man revealed that his home was immaculately clean and tidy, demonstrating an unexpected capacity for organisation and order which compensated and contained, at least in part, the fragmentation of his inner world.

Some patients, due to their convictions for accessing paedophilic chatrooms or downloading illegal images of children, or for cultural or religious reasons, are not allowed access to the Internet and therefore have to telephone in to group sessions. This partial exclusion from the group in being prevented from seeing the therapist or other group members may lead to feelings of rejection, anxiety or anger, tapping into their earlier experiences of abandonment in their lives, which may then lead to an exacerbation of the patients’ unhelpful behaviours which have developed as a defence against these feelings. For example, one man whose religion forbade him from having his own device which allowed access to the Internet, became suicidal and started visiting prostitutes again to temporarily allay such feelings. Another, who had been convicted of downloading illegal images of children and engaging in illegal chat rooms, was banned from accessing any on-line groups, and had to seek special dispensation from the police to join the on-line group, which he greatly resented. Prior to this being granted he telephoned into the group but admitted later that he would look at on-line pornography, albeit legal, during the sessions. The feelings of power, omnipotence and excitement generated by this behaviour reversed the situation in which he felt helpless and controlled by others, as well as representing an attack on the group and negation of anything positive that he might gain from his therapy.

Finally, risk issues must be taken into consideration when working remotely. Therapy will inevitably make patients feel more disturbed as difficult issues are spoken about and their habitual defences are challenged, and for some this may increase suicidal ideation or their impulses to harm others. If they are being seen in person, they may stay in the building following their session until they feel calmer, or is cases of acute risk of harm to self or others, the clinician may ask the patient to remain whilst appropriate help is sought, such as phoning the crisis team. With remote therapy, the therapist has less control in ensuring the safe management of the patient following sessions. It is also more difficult to pick up subtle cues of distress, such as the patient being tearful. This is particularly important for patients who tend to externalise their distress by being aggressive to others, and for whom being suicidal is weak and shameful, and are therefore less likely to acknowledge how depressed they may be feeling. For patients at high risk of harm to self or others, remote therapy may not be possible, or if it is carried out, it should be primarily supportive and there should be active on-going active monitoring of the patient’s mental state.