Family work with victims and offenders in a secure unit

Journal of Family Therafiy (1991) 13: 105-1 16 0163-4445 $3.00

Family work with victims and offenders in a secure unit

Sue Robinson, Sue Vivian-Byrne, Rick Driscoll and Chris Cordess*

Two examples of family therapy in a secure unit for violent mentally ill offenders are described. The model used incorporated ideas from reparation schemes for victims and offenders in addition to an emphasis on the circumstances of the offence.

In Britain serious violence frequently occurs within the family; nearly 50% of homicides involve family members. A study of prisoners awaiting trial in Brixton prison, South London, by Robertson (1988) found that 39% of victims of violent schizophrenic offenders were family members or close friends. Mentally ill offenders may be committed by the courts to one of the few Special Hospitals, such as Broadmoor and Rampton, which take patients from all over the country, or to a local Regional Secure Unit (RSU).

There are very few accounts of psychotherapeutic intervention and treatment within Special Hospitals: notable exceptions are Cox (1979 and 1988) and Pilgrim (1987). RSUs can offer, if only by their location and proximity to family members, the chance to enable regular family meetings.

The inherent dificulties of providing any form of psychotherapy in a secure and coercive setting have been reviewed and discussed by Berman and Segal (1982). They consider that the more authoritarian and powerful the medical model within the hospital the ‘more it sabotages the psychotherapy’. Pilgrim (1987) has elaborated their views with regard to Special Hospitals.

In our work in an RSU with offenders and victims within the family, we have tried to:

- use family therapy models in a secure setting; - use reparation and restitution methods between victims and

offenders in the therapeutic work;

* Regional Secure Unit, St Bernards’ Wing, Ealing Hospital, Middlesex, UBI 3EU, U.K.

106 Sue Robinson et al.

- find methods which encompass both the statutory and the psychotherapeutic role, rather than being constrained by one or the other.

Victim restitution and reparation schemes

The notion of working jointly with offenders and victims has begun recently to re-emerge (Schafer, 1975; Cohen, 1975; Marshall and Walpole, 1985; Davis et al., 1987). Eglash ( 197.5) considered such joint work to be a particularly effective way of rehabilitating the offender; he believed that reparative work relieved feelings of guilt which might otherwise precipitate re-offending. Davis et al., in a Home Office study, recorded upwards of forty ‘victim/offender mediation schemes’. The relevant principles here are those which try to bring together offenders and victims. In cases where the victim is a family member reparation can be crucial.

Focusing on the offence

The premise underpinning this family work is that stressful events or circumstances can precipitate relapse. Our approach differs from others in its emphasis on the relationships between the significant systems of the offender’s family, and the offence.

We have found that the offence behaviour can be central to the functioning of the family unit, and therefore needs to be addressed directly. We hoped that by examining the offence and its circumstances and by bringing about a change in the understanding of it, the family relationships could change for the better and the risk of further offending be reduced. I t also afforded the opportunity for the offender to make reparation and the victim, or victims, to increase their understanding of events in their family.

Clinical method

Our clinical method was influenced by four main strategies, which are summarized below.

(l) Acquiring information To obtain information and assess fully the situation, emphasizing

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especially dangerousness. The family sessions revealed much that was previously unknown: for example, details of the offence; undisclosed aggression and violence; the style of family interaction; and a related understanding of the motivations behind the offence and the part played by the victim. The expansion of knowledge meant an increased ability and confidence to monitor and predict dangerousness.

(2) Aiding communication

The family work helped to increase and stengthen communication between family members and professionals. I t also required regular dialogue within the family about the offence. In the cases we consider later, this sort of discussion had not hitherto occurred.

(3) Facilitating reparation and giving victims the chance to come to terms with their trauma

Reparation plays an important part in our treatment, in terms both of internal psychological process and of behavioural events. Reparation includes both the internal process and the behaviour. In families with ingrained patterns of unusual communication, the ability to deal with a catastrophe such as the violent offence is limited.

There are two aspects to reparation. The first is that involving financial andlor physical acts (one patient ensured that his wife received money from the compensation scheme for the assault); the second, which is sometimes overlooked, pertains to the feelings and emotions which the family could not previously articulate. We focused our work on facilitating communication about the offence between family members. This enabled the participants to articulate their feelings about, and reactions to, the events of the past.

Feelings of guilt from all parties within the family, as well as the offender, were expressed in different ways, as were the fears about the recurrence of offending. In the case studies further features were prominent:

(i) a denial of the offence, in which - until the family sessions - the incident and its circumstances had not been discussed to any significant degree in the years since it occurred;

(ii) a morbid fascination with the crime, where the details dominated the sessions, but in a ruminatory and repetitive way.


(4) Dealing with the speczjk factors within the fa rn ib system which contributed to the offence

The factors addressed primarily in the family work were social, such as alcohol abuse and family conflict. Our formulations were derived from psychodynamic, cognitive and systems theories. This variety caused tensions between us which were resolved through careful discussion within the team.

This system of family work seems to reduce the risk of relapse and further offending. I t offers the chance for the offender and victim to become involved in the reparation which is often necessary in families where there has been internal violence. This opportunity enhances the understanding of events within the family, on the part of both the offender and the victim, and can therefore change and improve relationships within the family. This increased knowledge (for all parties including the professionals) helps the assessment of dangerousness and the making of informed decisions about subsequent discharge into the community.

Two illustrative accounts are presented of patients who offended against family members. The first case was particularly difficult because of the patient’s wish to continue his relationship with his common-law wife, whom he had attempted to murder prior to admission to the Secure Unit. This wish made further life-threatening violence a real possibility. With the second family the patient’s delusional symptom had precipitated his unsuccessful murderous attack on his parents. The delusion remained fixed and his resistance to contact with his family suggested that their safety could not be assured because he still wished them dead.

Example One Background

A thirty-year-old white man was transferred to the Secure Unit under a compulsory order (Section 37 with a 41 restriction order without limit of time, Mental Health Act 1983). He had spent quite some time in a Special Hospital; his placement there when he was twenty-eight had been the result of his causing Grievous Bodily Harm by multiple stabbings of his common-law wife. At the time of the attack he believed he was God and she was a prostitute, and as he stabbed her he alleged he heard the voice of God saying ‘thou shalt not kill’. It was


for this reason that he averted the blows from her heart. His wife had been unfaithful to him earlier in the relationship and this had long been the subject of acrimony between them. She had brought up the subject provocatively on the night of the stabbing. She was talking of returning home to the West Indies and used this as a way implicitly to reject him. The full significance of these factors was only realized fully during the joint sessions.

During the offender’s childhood his parents had argued continually, and after a number of separations his mother had left home suddenly when he was nine, leaving only a note. Thereafter he was a loner. He joined the army when he was sixteen, but had to leave at the age of nineteen because he suffered his first breakdown. He subsequently found employment as an engineer for one year, but was unable to sustain this. Since then he had only worked sporadically, at a lower level of attainment.

Since adolescence he had committed a number of offences, mostly of a minor nature, although one was more serious: an indecent assault on a women when he was fifteen. Between the ages of nineteen and twenty-eight he had thirty-two admissions to psychiatric hospital, mostly of short duration.

At twenty-two he married a fellow patient. Their relationship was poor and on occasion minor violence occurred between them. This marriage ended and at the age of twenty-five he met his second wife, the victim, whilst she was also in psychiatric hospital. They began cohabiting. He had spent virtually all the previous two and half years in hospital, so this marked an improvement for him in that he was not admitted to hospital for eighteen months. After he went to Special Hospital she visited him regularly every month, and three times a week when he came to a unit.

Therapy

Six sessions were initially planned for the couple. Before these began the common-law wife agreed to attend only on the condition that the subject of her previous extra-marital affair would not be mentioned. This demand was respected at first, and the first session concentrated on the couple’s more practical needs with both parties sharing a reluctance to discuss more personal details. Nevertheless, the staff team decided that this forbidden issue could not continue to be ignored.

At the beginning of the second session the topic was broached. This led to the exploration of factors and feelings leading up to the offence,

110 Sue Robinson et al .

such as jealousy and the unexpressed fear that the patient’s wife, like his mother, might leave him. This fear was something that constantly cropped up during the sessions and was an implicit part of their relationship. The fears relating to this were constantly concealed by the couple in an eagerness for the husband to be discharged from hospital. It became clear that the patient believed his wife would not wait for him if he were not discharged from hospital, whilst the wife had quite an investment in keeping him in hospital, not only on account of her safety but also for her own family reasons.

The husband’s preoccupation with abandonment could be linked with his mother’s departure in early childhood, and certainly he likened the letter his mother left to the one he received from his wife during the course of therapy. These particular worries had increased since the offence, and to some extent they were more realistically based, because his mother-in-law was in fact trying to persuade his wife to leave him and return to the West Indies.

A vicious circle had emerged. The sessions helped to reveal how this had characterized the couple’s interaction for some time ‘and how this had probably comprised part of the circumstances of the offence. The man in his vulnerability became anxious and bad- tempered. His response was to shout at his wife, who in turn became resentful and helpless, wanting nothing more then to escape from the situation. He sensed this desire and became more anxious, angry, and frightened, and the denouement was a violent explosion.

During therapy she told him she would not leave him, but neither party was completely convinced. He claimed she talked about leaving only when she became ill, so he constructed a formulation that her sanity meant staying with him. She remained uncertain that a similar attack would not occur, and so was unable to be convincing about her wish to stay with him.

The violence was rationalized by the man as his ‘illness’, which he saw as being totally independent of these other simultaneous patterns which had not been articulated prior to the family work. Continued elaboration of these themes enabled some shifts in later sessions which altered the defensive nature of his beliefs. The beginnings of a broader understanding of the connections between events seemed possible, and related to this the question of responsibility for the offence became central. Both offender and victim placed this firmly on the ‘illness’, as they perceived it, to the exclusion of all else. It was possible in the therapeutic work to challenge this, and to introduce the idea that the wife’s contribution to the offence was her provocation,

Family work in a secure unit 1 1 1

and that the husband’s jealousy and fear of abandonment were important precipitating factors. In this way the couple began to consider that the offence was the embodiment of more than ‘illness’. The husband found this extremely painful and met all these suggestions with denial. He claimed that such an idea would mean he was ‘just a jealous boyfriend’. He interpreted this as meaning he had responsibility for the act, and therefore should be in prison not hospital.

Both individuals had histories of mental illness and their response to these could be contrasted during the family work. Illness does not in itself lead to murderous attacks; our work enabled other factors to be considered in order to comprehend and confront the offence behaviour. The wife summarized this aptly when she asked; ‘How come when you’re mentally ill you want to kill me and when I’m mentally ill I want to kill myself?’

Example Two A 36-year-old Afro-Caribbean man was admitted to the Secure Unit on a Restriction Order with a three-year limit of time. The index offence was malicious wounding. He had on two occasions, separated by three days, attacked both his parents with a knife.

Three years prior to the offence he had withdrawn from family life and moved away. A year before the offence a delusional memory came to him of a conversation between his parents describing their marriage as ‘an arranged marriage’. He also had auditory hallucina- tions: voices telling him that his parents were not his parents; his sisters were not his sisters; and that his parents should have arranged a marriage for him. This was not the practice in his family, or in his culture of origin. He also expressed a belief that he should have been present at his parents’ wedding in order ‘to object to the banns being declared’. This belief system made him want to put the situation right by killing his parents. Accordingly, after a long absence, he arrived at their house and on entry threatened to attack them both with a carving knife. A scume followed, and he made off, but two days later broke into the flat and stabbed each parent brutally and multiply, endangering both their lives. Subsequently, for most of the ten-month period he was on remand, he deteriorated and was mute.

He came from an apparently stable, close and religious family. He had three older sisters who were all married with children. There was no history of mental health problems or criminality among the other


family members. His early history was not untypical of other Caribbean familes of his generation who came to England. His father was the first of the family to emigrate, when the patient was four. Gradually the family joined the father and finally the patient came to Britain at the age of nine. On arrival in England, according to his sister, he did not recognize his parents, and would repeatedly ask for confirmation that they were his parents.

When he first came to Britain his mother alleged he had bad dreams, and she kept taking him to a child guidance clinic. Professional notes at the time asserted that the mother was ‘demanding and difficult’. The patient had a long history of petty offending, but had not committed any offences in the four years before he attacked his parents. He left school at the age of fifteen with no qualifications, and then worked for three years as a panel beater. As a young man he had a group of friends from whom he gradually withdrew. He had a girlfriend, whom at one time he intended to marry, but this did not happen. He used cannabis regularly, and drank heavily, until one year before the offence.

O n admission to hospital, he remained mute for some months but suddenly for no apparent reason he began to communicate tentatively. His delusional ideas remained fixed, and he maintained, in addition, that he was justified in his attempts to kill his parents. He showed no remorse. Slowly he began to talk over his feelings, and his hallucinatory ideas and delusional notions ceased.

Therapy After some six months of in-patient treatment he still refused to associate with his family, although his family very much wanted to get in touch with him. After much discussion a decision was made to involve his family in the work, largely because they were so keen to re- establish contact after so many years. To ease the shock and prepare the patient, the sister to whom he had always been closest wrote to him. He read the letters but quickly destroyed them.

After an initial refusal by the patient, and reluctance on the part of his sisters, an interview was arranged between the patient and his sisters. This was felt to be potentially dangerous, confronting as it did the margins of his delusional system. The patient became acutely anxious in some respects at the prospect of this long-postponed meeting, but informed some professionals, some not directly involved in the family work, that he liked the idea.


At his request the first interview took place with his sisters and one therapist in one room and the patient and the other therapist behind a one-way screen. This enabled him to see his sisters without having to communicate with them. He became very anxious and after fifteen minutes, at his wish, the interview was terminated. Later sessions involved the patient together with his sisters, with two therapists in the room and one behind the screen. A number of similar sessions followed at three-weekly intervals, and he seemed to become genuinely re-attached to his sisters. Since that time they have visited him regularly on the ward, and it has not been felt necessary to be present at the meetings. Throughout this period he still refused resolutely to see his parents. At an affective level they seemed to be ‘dead’ for him; yet intellectually he slowly began to recognize the reality of their still being alive. He still denied they had any relevance for him or that he might have any wish to see them. Letters they sent to him were aggressively torn up, unread.

With some reservations, the team maintained a consistent attitude of encouragement and expectation that he should one day meet his parents again. Eventually he professed himself willing: this change of heart was viewed with caution, since the proposal confronted his delusional beliefs so directly. Consequently, the first family session took place in conditions of security and restriction. The fear evoked in the workers was exceedingly powerful, such that one therapist interrupted the mother’s embrace of her son as if to prevent a further attack. The intention in the first session was to avoid direct reference to the attack, but the parents appeared compelled to supply full details of the offences. I t seemed essential for them to do this, as if they had been holding on to the memories too long. The mother described it as lifting an ‘intolerable burden . . . to get this off my chest’, which was indeed the site of the worst knife wounds. These recountings were met with silent interest, and we supposed from his smirking also some pleasure from the patient.

During the next six months there were eight family meetings. He gave up his delusion about his parents; this was rather forced upon him by his seeing them again in person, if nothing else. He also surrendered his ideas about his parents’ and his sisters’ marriages and his ideas about his parents either needing to be, or actually being, dead.

The family work has continued regularly and further information has been uncovered which has been helpful in diagnosing potential dangerousness when the family is together. For example, the sessions


showed that the mother found it hard to voice her trepidation about his becoming violent again; thus the work permitted articulation of her fears and demonstrated the mother’s need to have a professional escort on the patient’s first return home visit.

The sessions made the workers realize that marriage had a special meaning in this family. I t did not seem accidental that an early request came for the patient to attend his parents’ golden wedding anniversary. Explorations about the significance of this to individual family members were fascinating. For instance, the father said there are ‘only two important days in your life, when you marry and when you die’; he was asked about being born but responded that ‘it did not count’. The sessions also allowed for creative scrutiny of the parents’ life before marriage. This was surprising to all because the mother gaily revealed that she had had previous offers of marriage, and the couple ebulliently described the festivities on their wedding day. The patient, enthralled, listened closely.

His first visit home was perhaps symbolic because it was to this wedding anniversary celebration. The last visit had been to attack them. The event was enjoyed by all so much that further and regular visits occurred. Sadly these included, six months later, the father’s funeral following his death from leukaemia. The patient behaved appropriately.

Discussion

Aside from the familiar problems of working with families, our interventions suffered from what could be thought of as the inevitable entanglements encountered in secure settings (Menzies-Lynth, 1988). Some are also mentioned generally in the work of Kennedy et al. (1987) but some are specifically different. In both the families mentioned, these include an unavoidable conflict of roles by professionals. Therapists found themselves acting in a custodial d e , for example, in relation to the provision of accommodation or the prescription of medication. This raised the issue of the patient’s capacity to accomplish genuine change, rather than promoting his own progress through the system.

Professionals became involved in debates about the extent to which the patient in the second case was acquiescing to the sessions as a manipulative charade so as to increase his chances of being discharged. Quantitative evaluation was needed to establish how much he was seeking to please, and the degree to which he was


actually modifying his behaviour. These dynamics impinged most powerfully on the consultant, who invariably had to contain conflicting views in a way which produced a consistent line. This was especially pertinent in relation to the statutory responsibilities with the Home Office when decisions were required about leaving hospital. There was much discusson and re-working with the patient.

A further hazard specific to in-patient work meant that there could be almost no developments outside the therapeutic process. In an out- patient setting much of what is important to family therapy happens outside the sessions in the form of both general day-to-day inter- actions and formal home work. Obviously in a secure setting this opportunity is restricted to visiting times and periods of leave, all of which tend to be planned and measured cautiously and prudently. Therefore progress may be slower, and the effect of the sessions has to be observed in the effect on relationships and behaviour within the Secure Unit rather than within the context of the family.

In both the cases reported it has been possible to broach topics within the family meetings which were previously considered ‘taboo’; thereby the workers were able to challe?ge issues which were central to the offence and to the breakdown of mental health. Full and open communication was encouraged throughout, between the offender and the victim(s), about the offence(s) and the nature of their relationships in the past, present, and future.

This approach has become an important ingredient in assessing the safe development of offenders’ family relationships with their erst- while victims in future. It was considered necessary for the sessions to be sustained while the patients remained at the Secure Unit, but more importantly when the individuals returned to live in the community again. This was an endeavour to move beyond retributive models of rehabilitation to an atmosphere of greater forgiveness and understanding between victims and offenders, in the hope of averting that cycle in which, in the phrase memorably quoted by Gandhi, ‘an eye for an eye makes the whole world blind’.

References

Berman, E. and Segal, R. (1982) The captive client. Psychotherapy Research and Practice,

Bruce, T. (1982) Family work in a secure unit. In: A. Bentovim, G. Gorrell-Barnes

Cohen, I . (1975) The integration of restitution in the probation service. In: J. Hudson

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and B. Galaway (Eds), Considering the Victim: Readings in Restitution and Victim Compensation. Springfield, Illinois, Charles C. Thomas.

Cox, M. (1979) Group psychotherapy in a secure setting. Proceedings of the Royal Society of Medicine, 69: 215-220.

Cox, M. (1988) The holding function of dynamic psychotherapy in a custodial setting: a review. Journal o f the Royal Society of Medicine, 79: 162-164.

Davis, G., Boucherat, J. and Watson, D. (1987) A Preliminary Study of Victim Offender Mediation and Reparation Schemes in England and Wales. London. Research and Planning Unit. Home Office Paper No. 42.

Earp, J. D. (1988) The role of the regional secure unit. In: R. Mackay and K. Russell (Eds), Psychiatric Disorder and the Criminal Process. Leicester. Leicester Polytechnic Law School Monograph.

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Family work with victims and offenders in a secure unit

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