VIOLENT STATES AND CREATIVE STATES (VOLUME 2) : human violence and creative. 9781785925658, 1785925652

Table of contents :
Violent States and Creative States – From the Global to the Individual Volume 2: Human Violence and Creative Humanity. Edited by John Adlam, Tilman Kluttig and Bandy X. Lee
Contents
Part I – Introductorily and Theoretically
1. The Microcosm of Aggression: Early Parent–Child Interaction and the Struggle for Separation – Reinmar du Bois
2. Bad to the Bone or Breaking Bad? A Developmental View of Violent States of Mind – Maggie McAlister
3. The Pathological Third, Violence and Reality – Psychological Pathways to Violence in Psychosis and Narcissism – Clinton van der Walt
Part II – Violent States of Mind
The Language of 4. Is There a Murderer Here?: Agency and Violence in Homicide Perpetrators – Gwen Adshead, Zoe Berko, Sarita Bose, Martha Ferrito and Martina Mindang
5. Forever Hungry for Her Eyes: The Pain of Maternal Absence – Anna Motz
6. Violent States in Feeding Distress: The Antigone Paradigm and the Creative Possibilities of Collective Re-Imagining – John Adlam
Voluntary Self 7. Anorexia Mirabilis: Starvation and the Role of Spirituality as a Legitimate Response to Sexual Violence – Robyn Timoclea
8. Violence, Rage and Creativity – Deborah J. Cohan
Part III – Terror in the Private Sphere
9. Breaking into a Sacred, Bloodier Speech: The Healing Role of Monsters in Child Development, Trauma Play, and the Cultural Imagination – Claude Barbre and Jill Barbre
10. ‘You be the murderer now’ –Tamsin Cottis
11. Into the Labyrinth: Working with Bizarre, Unspeakable and Extreme Violence – Sarita Bose, Martha Ferrito, Alex Maguire, Martina Mindang and Andrew Ware
12. Treat Me Nice: Music Therapy and Extreme Violence – Alex Maguire
Part IV – Creative Approaches – From the Global to the Individual
13. Restorative Justice Applications in Mental Health Settings: Pathways to Recovery and Restitution – Gerard Drennan
14. Violent Acts and Creative Responses: Resilience Building Through Art Psychotherapy – Kate Rothwell and Simon Hackett
15. Spiritual Movements as Creative Forms of Response to Structural Violence – James S. Vrettos
16. Violent states and existential-therapeutic work in Mexican ex voto painting – Wayne Martin
Epilogue – James Gilligan
List of Contributors
Subject Index
Author Index

Citation preview

‘These two multi-authored collections are to be heartily welcomed and recommended… I congratulate all involved in these seminal writings.’ – Christopher Cordess, member, British Psychoanalytical Society and Emeritus Professor of Forensic Psychiatry, University of Sheffield

This is a provocative collection exploring the different types of violence and how they relate to one another, examined through the integration of several disciplines, including forensic psychotherapy, psychiatry, sociology, psychosocial studies, and political science. By examining the ‘violent states’ of mind behind specific forms of violence and the social and societal contexts in which an individual act of human violence takes place, the collection reveals the dynamic forces and processes underpinning the phenomenology of violence. Volume 2: Human Violence and Creative Humanity explores violent states of mind, behavioural or subjective, interpersonal violence (including self-injury), and the fine distinctions between violent and creative states of mind.

John Adlam is Consultant Adult Forensic Psychotherapist at the Bethlem Royal Hospital, London and a founding member of the Association for Psychosocial Studies.

Bandy X. Lee is Assistant Clinical Professor at Yale School of Medicine, co-founder of Yale University’s Violence and Health Group and project group leader for the World Health Organization Violence Prevention Alliance.

Jessica Kingsley Publishers

www.jkp.com Cover design: www.ironicitalics.com

Edited by John Adlam, Tilman Kluttig and Bandy X. Lee

Tilman Kluttig is a Senior Clinical Psychologist, Psychological Psychotherapist, and Forensic Psychotherapist in the Clinic for Forensic Psychiatry and Psychotherapy at the Reichenau Centre for Psychiatry, University of Konstanz, Germany.

Violent States and Creative States Vol 2

‘I thoroughly recommend this book…it is a towering achievement to create a thread of real coherence through such a manifestly complex and fraught field.’ – Dr Dickon Bevington, Medical Director, Anna Freud National Centre for Children and Families

Edited by John Adlam, Tilman Kluttig and Bandy X. Lee

Violent States and Creative States Volume 2: Human Violence and Creative Humanity Epilogue by James Gilligan

VIOLENT STATES AND CREATIVE STATES VOLUME 2

of related interest The Therapeutic Milieu Under Fire

Security and Insecurity in Forensic Mental Health

Edited by John Adlam, Anne Aiyegbusi, Pam Kleinot, Anna Motz and Christopher Scanlon ISBN 978 1 84905 258 0 eISBN 978 0 85700 534 2

Forensic Music Therapy

A Treatment for Men and Women in Secure Hospital Settings

Edited by Stella Compton Dickinson, Helen Odell-Miller and John Adlam ISBN 978 1 84905 252 8 eISBN 978 0 85700 539 7

Psychiatry in Prisons

A Comprehensive Handbook

Edited by Simon Wilson and Ian Cumming ISBN 978 1 84310 223 6 eISBN 978 0 85700 206 8

Forensic Psychotherapy

Crime, Psychodynamics and the Offender Patient

Christopher Cordess and Murray Cox ISBN 978 1 85302 240 1 eISBN 978 1 85302 634 8

VIOLENT STATES AND

CREATIVE STATES From the Global to the Individual

VOLUME 2

Human Violence and Creative Humanity

Edited by JOHN ADLAM, TILMAN KLUTTIG and BANDY X. LEE Epilogue by James Gilligan

Jessica Kingsley Publishers London and Philadelphia

See page 241 for image credits. First published in 2018 by Jessica Kingsley Publishers 73 Collier Street London N1 9BE, UK and 400 Market Street, Suite 400 Philadelphia, PA 19106, USA www.jkp.com Copyright © Jessica Kingsley Publishers 2018 Epilogue copyright © James Gilligan 2018 All rights reserved. No part of this publication may be reproduced in any material form (including photocopying, storing in any medium by electronic means or transmitting) without the written permission of the copyright owner except in accordance with the provisions of the law or under terms of a licence issued in the UK by the Copyright Licensing Agency Ltd. www.cla.co.uk or in overseas territories by the relevant reproduction rights organisation, for details see www.ifrro.org. Applications for the copyright owner’s written permission to reproduce any part of this publication should be addressed to the publisher. Warning: The doing of an unauthorised act in relation to a copyright work may result in both a civil claim for damages and criminal prosecution. Library of Congress Cataloging in Publication Data A CIP catalog record for this book is available from the Library of Congress British Library Cataloguing in Publication Data A CIP catalogue record for this book is available from the British Library ISBN 978 1 78592 565 8 eISBN 978 1 78450 968 2

Contents Part I: Introductorily and Theoretically

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1. The Microcosm of Aggression: Early Parent–Child Interaction and the Struggle for Separation . . . . . . . . . . . . . . 9 REINMAR DU BOIS

2. Bad to the Bone or Breaking Bad? A Developmental View of Violent States of Mind . . . . . . . . . . . 23 MAGGIE MCALISTER

3. The Pathological Third, Violence and Reality: Psychological Pathways to Violence in Psychosis and Narcissism . . . . . . . . . . 37 CLINTON VAN DER WALT

Part II: Violent States of Mind

51

4. Is There a Murderer Here? The Language of Agency and Violence in Homicide Perpetrators . . . . . . . . . . . . . . . . 53 GWEN ADSHEAD, ZOE BERKO, SARITA BOSE, MARTHA FERRITO AND MARTINA MINDANG

5. Forever Hungry for Her Eyes: The Pain of Maternal Absence . . . . 67 ANNA MOTZ

6. Violent States in Feeding Distress: The Antigone Paradigm and the Creative Possibilities of Collective Re-Imagining . . . . . . 81 JOHN ADLAM

7. Anorexia Mirabilis: Voluntary Self Starvation and the Role of Spirituality as a Legitimate Response to Sexual Violence . . . . . . . 95 ROBYN TIMOCLEA

8. Violence, Rage and Creativity . . . . . . . . . . . . . . . . . . . . . . 107 DEBORAH J. COHAN

Part III: Terror in the Private Sphere

121

9. Breaking into a Sacred, Bloodier Speech: The Healing Role of Monsters in Child Development, Trauma Play, and the Cultural Imagination . . . . . . . . . . . . . . . . . . . 123 CLAUDE BARBRE AND JILL BARBRE

10. ‘You Be the Murderer Now’ . . . . . . . . . . . . . . . . . . . . . . . 137 TAMSIN COTTIS

11. Into the Labyrinth: Working with Bizarre, Unspeakable and Extreme Violence . . . . . . . . . . . . . . . . . . 151 SARITA BOSE, MARTHA FERRITO, ALEX MAGUIRE, MARTINA MINDANG AND ANDREW WARE

12. Treat Me Nice: Music Therapy and Extreme Violence . . . . . . . . 165 ALEX MAGUIRE

Part IV: Creative Approaches: From the Global to the Individual

179

13. Restorative Justice Applications in Mental Health Settings: Pathways to Recovery and Restitution . . . . . . . . . . . . . . . . . 181 GERARD DRENNAN

14. Violent Acts and Creative Responses: Resilience Building Through Art Psychotherapy . . . . . . . . . . . . . . . . . . 195 KATE ROTHWELL AND SIMON HACKETT

15. Spiritual Movements as Creative Forms of Response to Structural Violence . . . . . . . . . . . . . . . . . . . . . 209 JAMES S. VRETTOS

16. Violent States and Existential-Therapeutic Work in Mexican Ex Voto Painting . . . . . . . . . . . . . . . . . . . 223 WAYNE MARTIN

Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 JAMES GILLIGAN

List of Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

PART I

INTRODUCTORILY AND THEORETICALLY Little by little I began to realise where I was and to want to make my wishes known to others, who might satisfy them. But this I could not do, because my wishes were inside me, while other people were outside, and they had no faculty which could penetrate my mind… And if my wishes were not carried out…I would get cross with my elders, who were not at my beck and call…and I would take my revenge by bursting into tears. Saint Augustine (on his own infancy), from Confessions (398)

…the criminal himself, at least almost every criminal, is subject at the moment of the crime to a kind of breakdown of his reasoning faculties and of his will-power… According to [Raskolnikov’s] conviction, therefore, it would seem that this eclipse of reason and loss of will-power attacked a man like some disease, developed gradually and reached its climax a short time before the crime was actually committed; it continued the same way at the moment of the crime and for a short time afterwards, according to each individual; then it passed off like any other disease. But the question whether the disease was the cause of the crime, or whether the crime itself, owing to some peculiarity of its nature, was always accompanied by something that is very much like a disease, he did not as yet feel able to answer. Fyodor Dostoevsky, from Crime and Punishment (1866)

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Chapter 1

THE MICROCOSM OF AGGRESSION Early Parent–Child Interaction and the Struggle for Separation REINMAR DU BOIS

INTRODUCTION Articles on aggression, even those restricted to the early years of life (Reebye 2005), all too often fall short of desirable standards – not because they, understandably, choose a very small sector of the overall phenomenon, but because from their respective vantage points they draw too far-reaching conclusions. This chapter will therefore only focus on very few of the many possible implications of aggression: the primary relationship of the child and the caregivers and the consequences in adolescence, if these relationships prove overly traumatic or entangled. Within this framework we shall address feelings of fear and panic, uncertainty, excitement, powerlessness, rage, triumph, struggle for control, love and hate. These sensations go along with strong physical reactions of the sympathetic autonomous system and stress-related hormonal responses (steroids). In sum, we are dealing with many or most of the key components of a violent state of mind. At the same time such psychic and somatic experiences can be more or less contained by mental representations – kept safe in the realms of childhood play and childhood fantasies and endowed with sense and purpose within patterns of attachment. Therefore not all these sensations are pushing toward open aggression. The risk to go down the latter route depends on the load of traumatic memories, for instance if aggressive feelings 9

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were chronically suppressed in a victim situation, but the risk is lessened by empathic caregivers, who will intuitively understand the situation and manage to guide even a vulnerable child with poor affect control through difficult times. With the advent of adolescence and its struggle for autonomy, traumatized children strive to overcome their sense of weakness. Those who have failed to become safely attached during infancy and suffered poor social integration throughout childhood may now reenact aggressive behaviour and fantasies inside and outside their families, as they become adolescents. These same individuals may also be characterized by school-avoidant behaviour, which has become a widespread expression of adolescent turmoil. Aided by our research on youths who batter their own parents, we have been able to trace some aspects of adolescent aggressive behaviour back to early childhood.

IRRITABILITY AND EXCITATION OF THE INFANT Winnicott (1958) labelled the intensive crying of babies as ‘relentless’: the violent excitement of the baby, even if interpreted as a meaningful signal towards the mother, takes into account neither the limits of the mother’s endurance nor the infant’s own emotional and physical resources. The baby’s excitement is ‘all or nothing’. If a baby is desperately aroused for a prolonged period, this is usually due to an unbalanced state of sympathetic autonomous functioning. The same hyperarousal can be interpreted as an alarm signal indicating an emotional emergency state. The crying of babies is semantically indeterminate and open for interpretation. Classical temperament research suggests that the irritability of infants can be markedly different without having any predictive validity for later aggressive traits (Thomas and Chess 1977). A primary caregiver can be greatly embarrassed at having to decide whether the baby’s crying signifies anxiety, rage, pain, despair or willpower and must make up his or her mind despite considerable uncertainty and ambivalence. At any rate the child will pick up the interpretation offered by the caregiver and will re-assess the situation accordingly. Gradually the child will create a concept of the make-up of his own emotions in accordance with the external reactions it receives. Especially during the first three months of life, prenatal mechanisms of affect regulation still dominate. As the infant grows older, affect

The Microcosm of Aggression

modulation relies on the degree of parent involvement and the ability of the parent to understand and adapt to different temperaments and degrees of arousability. The ability to control states of excitation now depends on the achievement of a good, fast and frequent signal exchange between caregiver and child. Mother–child interactions possessing such intuitive qualities have previously been labelled symbiotic, because the distinction between the source and the target of the signalling remains superficial and the baby probably does not yet experience the mother as a fully separate and independent person. As the mother attempts to navigate the baby through different states of autonomous arousal, she must virtually synchronize her own bodily perceptions with those of the child. Interestingly father–child interaction seems to be particularly suited to encourage the baby to increase his self-comforting strategies (Planalp and Braungart-Rieker 2015). Throughout the phases of cerebral maturation, neuronal growth and biochemical reaction patterns are closely interdependent and rely on the right amount and type of sensory stimulation. Child neglect can therefore seriously interfere with brain functions (Perry and Sullivan 2014). Freud’s late theory that internal stimuli alone could overwhelm an arousable infant and exert a trauma-like effect is hardly imaginable in view of modern empirical evidence. In order to suffer psychic trauma, even an irritable infant must be deprived of all manner of shielding, which he normally receives through interactive nursing procedures. Research on child neglect and abuse has clearly identified what actions may exert traumatic effects on small children and to what extent anger management in adolescence and adulthood will be affected. Caregivers – especially if inflicted with psychiatric disturbances (Narayan et al. 2015) – may have neglected and deserted a child while the child was in a state of excitation, strong tension and neediness. Abusers may have sexually exploited and intimidated a child. Children may have been forced to witness parental violence without understanding its implications or knowing how to react (Cummings et al. 1989). Small children are often initially paralysed and spellbound by such experiences. In essence they react as in Acute Posttraumatic Stress Disorder. We have to assume that even very small children retain fragmented physical and situational memories of these events and may recall them on later occasions. Whatever the underlying cause and whatever the prevailing reaction (numbed and unresponsive or irritable

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and hyperactive), all traumatized young children pose a later risk of becoming involved in aggressive conflicts as they reach adolescence. These adolescent conflicts often turn out to be not simply enactments of earlier identifiable adverse events inside the family, but rather emanations of the same preverbal, poorly understood fragments of memory. The dynamics of child play and in particular rough-and-tumble fights among children and involving the parents illustrate how aggressive impulses can be consciously grasped, mentalized, symbolically transformed and embedded into relationships. In child play, aggression is contained inside small episodes, in which the child expresses and experiences aggressive excitation but at the same time practises good affect control, negotiates suitable limits and stays in good contact with his opponent (Aldice 1975; Dougas, Mouren and Halfon 1985; Smith and Boulton 1990; Boulton 1991, 1994). The playfully fighting child wants to challenge aggressively but then switches to gain assurances of mutual affection from his opponent. Children between two and six usually engage their parents in such play. Their play should be limited in time and seek to reconcile any conflicts by the time the play is finished. In order to play rough-and-tumble confidently without being overwhelmed by rage or fear, the child must be able to understand non-verbal signalling, mimicry and all aspects of body language (Hewes 2014). In order to assist the child in developing his own self-regulation, the caregiver’s mentalizing capacity also comes into play (Taubner et al. 2016).

AGGRESSION AND AUTONOMY – FROM CHILDHOOD TO ADOLESCENCE Successful self-regulation of aggressive impulses is challenged by the child’s desire for autonomy. Temper tantrums are notorious examples of a breakdown of self-regulation. On a cognitive level the attacks indicate that the child is failing to achieve a self-imposed goal. Emotionally the child experiences his failure to control his excitement. The aggression in temper tantrums is partly directed towards the self and partly towards a person to whom the child feels strongly attached. Tantrums are frequently associated with omnipotent fantasies but can leave the child at risk of slipping back into regressive states. Temper tantrums, however, like rough-and-tumble play, contain the desire for reconciliation. At the same time the attacks evoke fears that the targeted person may suffer

The Microcosm of Aggression

permanent damage or turn away from the naughty child. Each attack is equivalent to a painful breakdown of the aspired autonomy. The attacks are suspended between feelings of omnipotence and powerlessness, autonomy and dependency. In the temper tantrums of childhood this type of autonomy conflict is displayed for the first time. The autonomy crises of adolescence are just repetitions of the same. Therefore these early autonomy conflicts have a strong developmental significance. They guide children towards gaining a sense both of their own capabilities and of their limits, as they first decline help, then cry for such help, then have to accept that no easy solution is available. Parents can use such fights to signal understanding, yet at the same time clarify and re-establish realities and boundaries. Some children avoid temper tantrums altogether when they are young, but enact quite similar types of crises for the first time when they have reached adolescence. Other children never stop throwing tantrums. Both the delayed type and the type in which the attacks chronically persist are indicative of a developmental disturbance of autonomy (Wakschlag et al. 2012). Parents and children may become stuck inside their mutually ambivalent relationship in repetition compulsion. They are drawn back into this conflict once they are aggressively aroused. In less troubled development, children use aggressive fantasy play successfully to channel and control their aggression and practise their self-regulatory skills (Flanders et al. 2009). Any playful aggression may also be the precursor of a concrete violent act. Indeed all violent acts are preceded by the corresponding aggressive fantasies of violent states of mind. In turn they are more or less related to real violence previously suffered by the perpetrator, which increases the risk that fantasies are transferred into concrete enactment (Smith, Fischer and Watson 2009). Aggressive fantasies are not easily disclosed by adolescents, except by those with autistic traits, who admit to fantasies with stereotypical content and a persecutory quality, the prognostic validity of which remains uncertain (Palermo and Bogaerts 2015). Two complementary psychodynamic theories are most commonly applied to explain the emergence of aggressive childhood fantasies. Winnicott (1986) argues – quite in accordance with the concept of a primary violent state of mind – that aggressive excitations are the dynamic starting point of all childhood experience. If confronted with a state of emotional indifference and disorientation, the child wilfully

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elicits stress and discomfort in order to be able to resolve this and to recreate a sense of relief and comfort. Paradoxically the child wants to put the world around him at risk to make sure it is still intact. Balint’s (1960) concept of ‘thrill’ implies a similarly ambivalent mechanism. According to Balint, children opt for the thrill of risk taking and quasi‘aggressive’ behaviour in order to reassure themselves that by overcoming such dangers they can regain a feeling of comfort, similar to the early experience of ‘primary love’. At the same time they remain old enough to reach out for more mature object relations, which demand a certain degree of autonomy and detachment from their primary relations. Other aggressive childhood fantasy contents target the body scheme: dolls are subdued to mutilations and ruthless surgical procedures. ‘Bad’ thoughts are dedicated to the dearest loved ones. Because of their magical thinking children cannot be altogether sure if their dangerous imaginations may not become real. Therefore they must continually seek reassurances that their play will end well and leave everyone salvaged. Freud would have argued that children are constantly struggling against their guilt feelings, which arise out of their aggressive propensity. Modern understanding, however, would envisage guilt as a basic human capacity which is parallel, not secondary, to aggression and may be modified by parenting styles (Parisette-Sparks, Bufferd and Klein 2015). The second approach to understanding the individual nature of a violent state of mind takes us back to trauma theory (Terr 1991). It has been empirically shown that aggressive behaviour is strongly enhanced by previous experiences of desertion, helplessness, absence of comfort, pain, paralysis, anticipated or suspended punishments and loss of affective control (Keene and Epps 2016). Duration and repetition patterns are further important factors in all assessments of traumatic effects. Burgess (1987) concludes that children who have for a long time been subjected to such experiences will at some point turn to overt aggressive behaviour directed against others. As they foster a growing sense of being in imminent danger and needing to protect themselves, they undergo the classical role reversal from victim to perpetrator (Burgess 1987). But it must be reiterated that many traumatized children who develop aggressive fantasies and become openly violent have not been subjected to physical harm. They more often have a long history of being engulfed by a weak and depressed mother, who was tormented by male partners, in a generally unstable family background (Narayan et al. 2015).

The Microcosm of Aggression

If a child, as he grows older, becomes increasingly aggressive towards his own parents, they may be often spellbound by such behaviour, probably because what emerges here is but a reflection of their own traumatic history and their plagued relationship with the child. In the past they had been confronted with temper tantrums and lost their temper only to hide their own helplessness. Now mutual desperation builds up once more and eventually erupts into physical attacks, but this time – in role reversal – directed against the parent. In all such situations the underlying aggression may also be held back and conscious reflection may set in just in time. The prevailing affect remains one of fearful anticipation, concealed panic and inner tension. Explicit aggressive fantasies may be suppressed. Any degree of achieved early attachment as well as any degree of mentalizing and insight into the emotional dilemma of the other will assist the child and the caregiver in their attempts to counteract the impulse to burst into open aggression (Taubner et al. 2016).

BATTERED PARENT SYNDROME Steinmetz (1978) and Harbin and Madden (1979) pointed out the existence of a special form of intra-familial violence which was not directed towards the children but towards the parents and was performed by the children. The literature has remained sparse and is entirely based on case studies (Charles 1986; Paulton and Coombes 1990; Chartier and Chartier 2002). Two major surveys conducted by du Bois (1998) and co-workers during the 1990s revealed an incidence of 60–70 such cases in each of the surveys among the 9.5 million inhabitants of BadenWürttemberg, which is situated in the prosperous South of Germany. The age of the perpetrators ranged from 8 to 22 years, with a mean age of 16.5 years and an absolute peak at 14 in both sexes. The number of unreported cases appeared to be considerable. The cases were defined by habitual physical abuse of the mother or father which was triggered by petty arguments. Helplessness and failure to seek effective help and strong feelings of shame and guilt were also included in the definition. The mothers were the victims in 90 per cent of the cases; in the remaining cases both parents were affected. According to the threshold definitions, the abuse had to endure for at least three months, but usually it lasted much longer. Often the Parent Battering

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was accompanied by the generally tyrannical behaviour of the child and refusal to attend school. Most cases were reported to the social services or were presented to child guidance centres; much less frequently a doctor’s surgery was involved.

GENERAL DYNAMIC CONSIDERATIONS All authors who have previously given accounts of this phenomenon have raised doubts about whether it should be labelled a new syndrome (Pears and Trotta 1986). Despite the uniform tyrannical behaviour towards the parents, the prevailing impression was one of enormous variety in most other aspects. In our own survey families with a low social status were over-represented. Inside and outside of this group school failure was four times more frequent as in the general population, even after exclusion of all cases with overt psychopathology which could have interfered with academic success. Thirty-seven per cent of affected families appeared to be socially isolated. This group was correlated with high parental age (over 35 at birth of child) (25%). Twenty-two per cent of the children showed signs of emotional disturbance apart from the battering: eating disorders, compulsive disorder, autistic traits, depressions, phobias. A further 15 per cent showed various degrees of alcohol and substance abuse. Only 9 per cent of all cases had had previous contact with a psychiatric service; no child was considered disturbed to such a degree that inpatient treatment was seen as mandatory. In all other cases mental and emotional function appeared satisfactory outside the abnormal parent–child axis. Thirtysix per cent of patients, however, had already been conspicuous because of antisocial tendencies and petty criminality. About 75 per cent of all cases of Battered Parent Syndrome could be characterized by at least one of three clusters of risk factors: emotional, intellectual or social. More disturbingly, however, about one quarter of all cases remained unaccounted for. While these findings do confirm patterns of the aggressive behaviour of certain children towards their parents, they do not support the notion of a uniform and clearly defined syndrome; rather that of a loose group of considerable heterogeneity. In order to detect a common denomina­tor for Parent Battering, extensive qualitative research was conducted. The aim was to delineate an area of overlap in approaches to understanding

The Microcosm of Aggression

the underlying mechanisms of Parent Battering. Several routes of inquiry turned out to be inconclusive, for example the educational deficiency of parents (lack of rules and value orientation, lack of a positive father figure) or ‘overt psychopathology of a parent or a child’. Instead there appeared to be professional consensus across interviewees of widely differing schools of thought that the study of ‘distorted early parent– child interactions’ could illuminate the dynamics of Parent Battering. This hypothesis was supported by: (a) the observation of parental overprotection and strong ambivalence towards the child; (b) dependent, passive, symbiotic tendencies towards the child; (c) almost masochistic attitudes toward being beaten by one’s own child; and (d) hints that some of the children may have been previously abused. However, the most prominent characterization of battered parents, and children who beat their parents, was that they were socially isolated and lacked social skills.

REGRESSIVE AROUSAL STATES If one considers the locked-up and sometimes helpless character of parent–child interactions within which small children have to gain control of their own excitation and, later, of their aggressive fantasies – and if one further considers how easily children can be caught in the wake of the undigested aggressiveness or despair of their parents – then it is easy to understand why children and even older adolescents may find themselves still entangled in the same interaction type with their parents; only that after the typical role reversal from victim to perpetrator, it is now the parents who have become the victims. Regressive acting-out patterns as they typically occur in Parent Battering are most easily reminiscent of early childhood. The beatings appear as an involuntary abreaction of inner tensions under repetition compulsion. Perpetrators and victims are united by a strong sense of helplessness and neediness. As both sides realize their situation, more discomfort and further aggressive acts ensue. Objects are demolished under the eyes of the caregiver. The parent may be shoved around as if he or she was a transitional object. These acts are often tinged with desperation on both sides. The youths have been observed wailing loudly as they beat their parents. A 20-year-old youth who appeared quite normal outside his family was reported charging at his mother and ‘punishing’ her, when he had contracted nasal bleeding. Another 14-year-old used to

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leave the house despite the pleas of his parents not to do so, get himself drunk and then return to his parents. They received him on the sofa, expecting to be beaten. They would lie on the couch, their faces down, as if saying ‘beat us, we deserve nothing better’. The boy would sometimes fall asleep in the midst of the beating, and resume the beating later. The mother would cover him with a blanket and caress him. The majority of Parent Battering youths foster a strong hatred towards their mothers. Mother remains the all-important trigger for their aggressive arousal. Children threaten their mothers by using the same intonations and silly remarks as when they were small. Despite the strong aggressive impact of the attacks, the accompanying language often suggests the opposite: an apology or even the wish to surrender. This explains why many caregivers who are habitually beaten by their children dismiss the real danger they are faced with. They forget to protect themselves. Their child’s behaviour reminds them of previous temper tantrums. Even if a caregiver has already suffered severe injuries, he or she may still enjoy a secret sense of superiority which is only briefly interrupted by moments of horror.

SOCIAL AWKWARDNESS Parent Battering is a discomfiting phenomenon in families at a time when most adolescents seek to detach themselves from their parents. Normally parents of adolescents are spared the recurrence of an autonomy conflict that is reminiscent of early childhood. Stable developmental progress is normally assured by nature. Additional support is given by the social systems of schools, peer groups, clubs and neighbourhoods. New experiences and interactions draw them away from their families and inspire them to re-orient themselves; intellectual growth enables them to afford greater critical distance. Feelings of discomfort and aggressive tensions are carefully held back. Adolescents shun their parents in order to avoid situations in which childish behaviour may re-emerge. They are duly embarrassed and ashamed at discovering that aggressive and sexual sensations are dangerously mingled and confused. This is another reason why they are anxious to hide any temperamental behaviour while at home. How can this normal course of adolescent maturation go wrong? Unresolved emotional dependence plays a key role. Distorted attachment patterns including outbursts of rage and helplessness can only prevail

The Microcosm of Aggression

if the above-mentioned mechanisms of personal maturation, social integration and external support have never been built up. Attachment research has contributed greatly to the understanding of such disruptive patterns. Parents with attachment deficits (Gleason et al. 2011) and lack of social competence (Waters and Sroufe 1983) may feel unable to navigate their personal conflicts away from their primary relationships. Socially clumsy people tend to cling to their objects of primary love (Balint 1960), whereas the external world retains an aura of danger, strangeness and inaccessibility. Parents who are entangled with their children in unresolved and disruptive attachment patterns may disregard that their offspring need breathing space. If parents insinuate that any separation is causing them pain, this may provoke a further shock. The child – deeply conscious of his own inability to separate – is not used to seeing the parent equally weak and dependent. The parent may be tempted to surrender to the child and accept maltreatment, hoping that the child will be caught in the same trap of guilt and shame together with the parent. The resulting relationship pattern amounts to a sado-masochistic collusion (Welldon 1988; van der Kolk 1989).

THERAPEUTIC INTERVENTIONS Treatment of Parent Battering cannot be psychotherapy in a conventional sense. No participant in the drama would be prepared to accept such help. The affected juveniles oppose vehemently any intervention from outside. They forbid their parents to address official agencies or to make events inside the family public. They consider this as treason. By taking the courage to commit such treason, parents have made an important step towards resolving and reshaping their abnormal and virtually sadomasochistic relationship to the child. The first step always consists of a decision taken by the parents to confess their plight to someone possessing external authority. Often the social services are the first place to call. But even the police or the judiciary can respond creatively and introduce new rules to the game which is being played in the family. The parents must be encouraged to come out of their hiding, move forward and seek new allies. In some outcomes parents eventually manage to tear themselves away from their child or even expel him from home, but their move is

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answered by the child becoming delinquent. This appears like another turn of the screw and ensures that the parent–child entanglement will continue, as the delinquency serves to embarrass and humiliate the parents further. The crimes may even be interpreted as retaliatory acts directed against the parents. Some youths who have finally arrived in custody give a strangely cheerful impression. Psychological examination reveals that they foster strong fantasies of punishing their parents. Any positive outcome depends on the parents taking the first step to liberating themselves. Then the adolescent has no choice but to follow. So any therapeutic concept must involve an element of social manipulation. The complementary element consists of in-depth understanding of the calamity in which both sides are stuck together. The parents should be professionally guided through a process of separation and then through a phase of personal maturation. The first target, however, is physical separation. To begin with, the parents will feel deeply disoriented and guilty. They now realize that they might need therapeutic assistance. The children, even though confronted with totally new circumstances, adapt unexpectedly quickly. The persistence of a quasi sado-masochistic collusion, a shared and co-produced violent state, must not be underestimated. In one example a 17-year-old girl had received extensive inpatient psychotherapy because of aggressiveness toward her mother and had finally agreed to move to another town to go to university. Three years later she returned home temporarily to look for a job. Mother and daughter suffered a severe relapse, as a row between them culminated in a perverse scene, where the mother was locked up in the cellar and her daughter flogged her with a garden hose. This may be shrugged off as a singular overstated example, but it may serve as a useful mental stumbling block to remind us that violent states cast a lifelong shadow on the human condition. They require continuous internal and societal efforts to be controlled and contained.

REFERENCES Aldice, O. (1975) Play Fighting. New York: Academic Press. Balint, M. (1960) ‘Primary narcissism and primary love.’ Psychoanalytical Quarterly 29, 6–43.

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Boulton, M.J. (1991) ‘A comparison of structural and contextual features of middle school children’s playful and aggressive fighting.’ Evolution and Human Behavior 12, 119–145. Boulton, M.J. (1994) ‘The Relationship between Playful and Aggressive Fighting in Children, Adolescents and Adults.’ In J. Archer (ed.) Male Violence. London: Routledge. Burgess, A. (1987) ‘Abused to abuser: antecedents of socially deviant behaviour.’ American Journal of Psychiatry 144, 1431–1436. Charles, A.V. (1986) ‘Physically abused parents.’ Journal of Family Violence 1, 343–355. Chartier, J.-P. and Chartier, L. (2002) Les Parents Martyrs. Lausanne: Payot & Rivages. Cummings, E.M., Vogel, D., Cummings, J.S. and El Sheikh, M. (1989) ‘Children’s responses to different forms of expression of anger towards adults.’ Child Development 60, 1392–1404. Dougas, M., Mouren, M. and Halfon, O. (1985) ‘Les parents battus et leurs enfants.’ Psychiatrie de l’Enfant 28, 185–219. du Bois, R. (1998) ‘Battered Parents – Psychiatric Syndrome or Social Phenomenon?’ In A.Z. Shwartzberg (ed.) The Adolescent in Turmoil. Westport, CT, and London: Praeger. Flanders, J.L., Leo, V., Paquette, D., Pihl, R.O. and Séguin, J.R. (2009) ‘Rough-andtumble play and the regulation of aggression: an observational study of father– child play dyads.’ Aggressive Behaviour 35, 285–295. Gleason, M.M., Fox, N.A., Drury, S., Smyke, A. et al. (2011) ‘Validity of evidence-derived criteria for reactive attachment disorder: indiscriminately social/disinhibited and emotionally withdrawn/inhibited types.’ Journal of the American Academy for Child and Adolescent Psychiatry 50, 216–231. Harbin, H. and Madden, D. (1979) ‘Battered parents – a new syndrome.’ American Journal of Psychiatry 136, 1288–1291. Hewes, J. (2014) ‘Seeking balance in motion: the role of spontaneous free play in promoting social and emotional health in early childhood care and education.’ Children (Basel) 1, 280–301. Keene, A.C. and Epps, J. (2016) ‘Childhood physical abuse and aggression: shame and narcissistic vulnerability.’ Child Abuse and Neglect 51, 276–283. Narayan, A.J., Chen, M., Martinez, P.P., Gold, P.W. and Klimes-Dougan, B. (2015) ‘Interparental violence and maternal mood disorders as predictors of adolescent physical aggression within the family.’ Aggressive Behaviour 41, 253–266. Palermo, M.T. and Bogaerts, S. (2015) ‘Violent fantasies in young men with autism spectrum disorders: dangerous or miserable misfits? Duty to protect whom?’ International Journal of Offender Therapy and Comparative Criminology 61, 9, 1–16. Parisette-Sparks, A., Bufferd, S.J. and Klein, D.N. (2015) ‘Parental predictors of children’s shame and guilt at age 6 in a multimethod longitudinal study.’ Journal of Clinical Child and Adolescent Psychology 4, 1–11. Paulton, M.F. and Coombes, R.H. (1990) ‘Youths who physically assault their parents.’ Journal of Family Violence 5, 121–123. Pears, R.L. and Trotta, R. (1986) ‘Youths who physically assault their parents.’ Journal of Family Violence 1, 99–110.

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Perry, R. and Sullivan, R.M. (2014) ‘Neurobiology of attachment to an abusive caregiver: short-term benefits and long-term costs.’ Developmental Psychobiology 56, 1626–1634. Planalp, E.M. and Braungart-Rieker, J.M. (2015) ‘Trajectories of regulatory behaviors in early infancy: determinants of infant self-distraction and self-comforting.’ Infancy 20, 129–159. Reebye, P. (2005) ‘Aggression during early years – infancy and preschool.’ Canadian Child and Adolescent Psychiatry Review 14, 16–20. Smith, C.E., Fischer, K.W. and Watson, M.W. (2009) ‘Toward a refined view of aggressive fantasy as a risk factor for aggression: interaction effects involving cognitive and situational variables.’ Aggressive Behaviour 35, 313–323. Smith, P.K. and Boulton, M. (1990) ‘Rough-and-tumble play, aggression, and dominance: perceptions and behavior in children’s encounters.’ Human Development 33, 271– 282. Steinmetz, S.K. (1978) ‘Battered parents.’ Society 15, 54–55. Taubner, S., Zimmermann, L., Ramberg, A. and Schröder, P. (2016) ‘Mentalization mediates the relationship between early maltreatment and potential for violence in adolescence.’ Psychopathology 49, 236–246. Terr, L. (1991) ‘Childhood traumas: an outline and overview.’ American Journal of Psychiatry 148, 10–20. Thomas, A. and Chess, S. (1977) Temperament and Development. New York: Brunner and Mazel. van der Kolk, B. (1989) ‘The compulsion to repeat the trauma: reenactment, revictimization and masochism.’ Psychiatric Clinics of North America 12, 389–411. Wakschlag, L.S., Choi, S.W., Carter, A.S., Hullsiek, H. et al. (2012) ‘Defining the developmental parameters of temper loss in early childhood: implications for developmental psychopathology.’ Journal of Child Psychology and Psychiatry 53, 11, 1099–1108. Waters, E. and Sroufe, A. (1983) ‘Social competence as a developmental construct.’ State University of New York. Reprinted from: Developmental Review 3, 79–97. Welldon, E. (1988) Mother, Madonna, Whore: The Idealization and Denigration of Motherhood. London: Free Association Books. Winnicott, D.W. (1958) Maturational Processes and the Facilitating Environment. London: Norton. Winnicott, D.W. (1986) Home is Where We Start From. London and New York: Norton.

Chapter 2

BAD TO THE BONE OR BREAKING BAD? A Developmental View of Violent States of Mind MAGGIE MCALISTER

INTRODUCTION Within the discipline of forensic psychotherapy, it is axiomatic that forensic patients have a tendency to ‘act out’: to ‘talk with their fists’ as one patient put it. Symbolisation and reflective function have broken down (Cordess and Cox 1996), leading to the dominance of very concrete states of mind. This is ultimately expressed in the ‘index offence’ itself, psychodynamically understood as an attempt to evacuate, through action, overwhelmingly intolerable states of mind (Morgan and Ruszczynski 2007). This violent state of mind therefore links strongly to the propensity to act out physically and is particularly relevant to violent offences. Glasser (1998) defines violence as ‘a bodily response with an intended infliction of bodily harm on another person’ (p.887). Therefore the primary place of the body, with the consequent loss of ‘mind’, is central to an understanding of violence as a symptomatic phenomenon. This chapter will explore a particular strand of recent psychoanalytic theory and research which views violence as a deficit or a failure in the capacity for mentalisation, defined as the ability to reflect on your own and  others’ mental states (see Chapter 4, Volume 2). In essence, mentalisation allows mental states to be experienced as representa­ tional and intentional, allowing one to draw upon a range of possible explanations and motivations in a way we could define as our ‘social intelligence’. Mentalisation is the legacy of secure attachment from 23

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infancy and our early formative years; so much so that there is evidence for conceptualising anti-social personality disorder (ASPD) as a ‘disorder of attachment’ (Yakeley and Williams 2014). Although originally conceived as a treatment for those with borderline personality disorder (Bateman and Fonagy 2004), mentalisation-based treatment (MBT) has become increasingly piloted in other clinical areas, including work with violent and mentally disordered offenders (see e.g. Adshead et al. 2013). In order to contextualise mentalisation, I will first give a psychoanalytic overview of the aetiology of violence, before focusing specifically on the relationship between mentalisation and violence. I will then present a clinical vignette from my own work setting (a medium secure unit) to explore MBT in working with violent, mentally disordered offenders.

CONFLICT VS DEFICIT: THE PSYCHOANALYTICAL DEBATE The question whether destructiveness is inherent or acquired has given rise to different schools of thought within psychoanalysis. The eternal (and perhaps inherently circular) nature/nurture debate is contentious not only in psychiatry, psychology and psychotherapy but also in the areas of public policy, sentencing practice and forensic mental health service provision. A violent offender is provided with ‘treatment’ if they are also diagnosed as having a mental illness. If they are not, they are sentenced to prison; where, despite the recommendations of the Bradley Report (2009), they often remain untreated for mental health issues, even though 80 per cent of violent offenders in prison are likely to have a personality disorder (McGauley 2017). Whether somebody is deemed as mentally ill after committing a violent offence or just plain ‘bad’ is a distinction that will affect how they are later sentenced and rehabilitated into society. Even within forensic mental health services, one may often hear a patient’s violent acting out described either as ‘illness-driven’ or as ‘behavioural’ (by which latter term is usually meant: ‘bad behaviour’). What causes people to act violently? Glasser (1998) has defined two types of violence: self-preservative violence, arising from the fight/flight instinct, aimed at eliminating the threat to the physical or psychic self; and sado-masochistic violence, which can begin as self-preservative violence, but is essentially sadistic and more considered in character.

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The aim of sadistic violence is not to eliminate the threat, but to make the object suffer. Meloy (1992) has similarly distinguished ‘affective violence’ and ‘predatory violence’. The argument as to whether we view ourselves as purely biologically, genetically predisposed, or as shaped entirely from our environmental influences, can seem oversimplified, but this is central to how psychoanalysts have sought to understand the capacity for violence. Freud’s original premise (1915) was of aggression as acting in the service of self-preservative instincts, from the ego’s struggle to preserve and maintain itself, but in Beyond the Pleasure Principle (1920) he expounded his theory of aggression as an innate manifestation of the death instinct. His ideas about the death instinct arose from a need to understand how the apparent compulsion to repeat unpleasant experience did not abide by the pleasure principle (the instinctual seeking of pleasure and avoidance of pain). He also observed from biological sciences that all living organisms hold within them the seeds of their own destruction. The theory of the death instinct was developed by Klein (1932) into a concept fundamental to an understanding of human development and of the primitive forms of anxieties within infant mental states which later manifest in psychosis and severe mental illness. The Kleinian model of the mind sees the death instinct as the prime instigator of the infant’s unconscious phantasies, ushering in the ‘paranoid-schizoid position’ (a primitive mental state, whereby the infant splits good and bad experiences as a way to preserve and protect internal good objects) due to the infant’s anxieties about its innate destructiveness. As the death instinct is predominantly an internal, intrapsychic event, this line of theory is defined as ‘the conflict model’. Individuals with a greater capacity for destructiveness are seen, constitutionally, as having an excess of death instinct – excessive aggression, destructiveness and envy are in their genetic make-up, hence in their ‘nature’. Such characters may be described as ‘bad to the bone’: as powerfully represented by the mass murderer protagonist in Lionel Shriver’s novel We Need to Talk about Kevin (2003). From the moment he is born, right from the start a raging, furious baby, his mother struggles with the sense that Kevin is malevolent, becoming ever more sadistic, hateful and contemptuous as he develops into a child and young adult. The rejection of the argument for the existence of the death instinct (and innate destructiveness) led to an opposing view developed by

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psychoanalysts such as Bowlby (1969) and Winnicott (1971) among many others. Rather than seeing aggression as innate, they would broadly categorise aggression (and violence as the external sign of aggression) as a reaction to experiences of a deficit in the individual’s environment: frustration, threat or maternal deprivation. This is defined as ‘the deficit model’, representing the ‘nurture’ pole of the debate. An example of this secondary process type of violence is depicted in Gilligan’s television series Breaking Bad (2015). Following a diagnosis of lung cancer at the age of 50, Walter White abandons his previous life as a mild-mannered chemistry schoolteacher to manufacture crystal meth as a way to provide for his family. By incremental degrees he becomes increasingly violent as he attempts to neutralise each new threat to his survival, and in the process of ‘breaking bad’ transforms utterly into a violent, psychopathic mastermind. As his wife struggles to adjust to his new identity, he tells her, ‘I am not in danger…I am the danger. A guy opens his store and gets shot and you think that of me? No. I am the one who knocks!’ In both models, psychoanalytical approaches largely view the impulse towards violence as a defence against an unbearable alternative: thoughts, representations and psychic processes that are felt to be intolerable. In this state of mind, any perceived threat to a fragile sense of self become catastrophic to the survival of the physical or psychological self, resulting in the primitive anxieties and defences that lead to violence. Therefore, although it is non-symbolised, an act of violence has an unconscious psychological meaning: it is an attempt to eliminate a perceived threat to physical or psychological survival and also a reversal of experience in which loss, terror and vulnerability are evacuated and forced into the victim. This is the case whether the violence is self-preservative or sadomasochistic. Although both Kevin and Walt could be seen to be at opposite poles, in truth it is difficult to argue where the line for each can be drawn in the nature/nurture debate. Kevin is certainly exposed to a subsequent deficit in maternal care, and in Walt, there may have been a murderous psychopath lurking in the shadows all along. Therefore a third position in this debate would be offered by a combined conflict and deficit model – one in which an inborn potential for destructiveness meets catastrophic failure in the environment. It is this area which Bion (1970) foreshadows with his concept of container-contained, in which internal world fragments of experience (‘beta elements’) are helped towards

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coherence of self-experience by mindful maternal care (‘alpha function’). It is also the position of mentalisation theory, in which violence is viewed as having its roots in both nature and nurture.

MENTALISATION, ATTACHMENT AND VIOLENCE Mentalisation theory (Bateman and Fonagy 2004) draws heavily on attachment theory (Bowlby 1969, 1973, 1980), which builds upon the recognition that we are solely dependent on others in our early life for survival, through our caregiver’s protection, nurturance and love. However, in addition to physical survival, mentalisation theory stresses the role the caregiver provides in the development of the infant’s mind – the emotional and social intelligence that results from the development and connectivity of different parts of the brain (Fonagy and Adshead 2012). When an infant and caregiver form a secure attachment, the infant thrives in two important ways, developing a positive and coherent sense of self and the capacity for emotional regulation. The caregiver’s emotionally attuned responses to the infant (the mental and emotional space in her mind) become a source of information to the infant about his internal states. This is achieved via two important emotionally responsive regulators: contingency, where the caregiver’s response appropriately matches the infant’s internal state; and markedness, the ability to demonstrate the caregiver is reflecting and empathising with the infant’s state and not with their own. These two regulators allow an infant to feel psychologically contained, both emotionally (understood and emotionally validated) and existentially (‘my destructive feelings are survivable’). This attunement gradually facilitates the development of mental and emotional space in the growing child and the capacity for reflection on the mental states of self and others. In neuroscience terms, these emotional processes lay down neuronal structures in the brain that regulate experiences of the self and the development of emotional and social intelligence. These pathways equip us to regulate and manage stress and to hold ‘mind in mind’: to imagine the state of mind of others (Adshead et al. 2013). Even when the infant expresses destructive or aggressive states, the caregiver needs to be able to remain receptive and emotionally attuned and to contain and modify the emotional state without becoming overwhelmed herself (which would amount to a failure of

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both contingency and marking). Of course this is not possible all of the time (and there is an argument for it not to be), but if the infant has an accumulated experience of an emotionally attuned caregiver, this process unfolds into one where the infant becomes a child and then an adult who can mentalise well, or who can readily recover the capacity to mentalise when it is temporarily lost. This developmental trajectory is located in secure attachment. When a child is insecurely attached, the attachment behaviour they display falls into categories such as dismissive/avoidant (where the infant turns away from the caregiver); preoccupied (overly clingly, anxious behaviour); or disorganised (a combination of the two). The Adult Attachment Interview (developed by George, Kaplan and Main 1985), administered in studies of high-risk violent offenders, indicated high incidence of dismissive and/ or preoccupied attachment styles (McGauley 2017). In a further study measuring the reflective function of prisoners (Levinson and Fonagy 2003 cited in Fonagy 2003a, p.33), violent offenders with dismissive attachment styles showed the greatest deficits in reflective function: …prisoners’ developmental path of psychopathology is characterised by a disavowal of attachment-related experiences and of the capacity to think about them, in partial response to severe childhood trauma… making individuals who have suffered this impairment more liable to act, especially in violent ways. (Fonagy 2003a, p.33)

It is within this very early area of primitive experience that trauma creates damage to the infant’s mental states and emotional well-being – at a time when the infant is utterly helpless and dependent on caregivers. Attachment difficulty at this level (due to neglect, abuse or loss) can be catastrophic to the development of the personality. Insecure attachment can then provide context and ground for vulnerability to certain forms of arousal, violent states of mind, in which an experience of object relationship can only be managed by evacuation; in which certain triggers, such as feeling ‘dissed’ (Gilligan 1997), can generate a violent act. Fonagy (2003b) argues that violence is not learned, but in fact is unlearned, due to the development of mentalisation which serves to inhibit violence. Fonagy bases this evidence on epidemiological data following children from school entry to the end of adolescence where violence decreases with age.

A Developmental View of Violent States of Mind

Historically, models of aggression have tended to focus on how human aggression is acquired. Yet aggression appears to be there from early childhood, arguably from toddlerhood and perhaps from birth. Violence ultimately signals the failure of normal developmental processes to deal with something that occurs naturally. (2003, p.1)

The conclusion to draw from this is that we become more able to manage our (innate) violent impulses when we are provided with the right, early environment to socialise our inherent destructiveness.

THE THREE PRE-MENTALISTIC MODES AND THE RISK OF VIOLENCE Fonagy and Target (1996, 2000; Target and Fonagy 1996) have identified three ‘pre-mentalistic’ modes that we revert to when we are unable to mentalise. The first mode, ‘psychic equivalence’, is when our beliefs become reality. There is no separation between inside and outside: what we believe to be the case is how things really are. A person operating in this mode is unable to ‘reality test’ and is filled with omnipotent certainty that how they feel is the way it is. Fonagy argues that ‘[v]ulnerability to a regression to the state of psychic equivalence, where internal is equated with external, is an essential precondition for violence’ (2003a, p.27): thoughts become real and the minds of others become a threat; the ‘certainty’ holds sway, that only a physical act can eradicate a mental state. The second mode, the pretend mode, is when the individual is dissociated in thought and feeling. There is a dis-connect between the internal and external, resulting in inner emptiness and lack of reality. This state of mind lends itself to deception, disavowal and difficulties in linking affective experience with cognitions – ‘talking the talk but not walking the walk’. In terms of violent acts, the pretend mode may best describe those individuals whose violence remains ‘out of character’, encapsulated in a dissociated, cut-off state. Such individuals frequently speak about ‘a moment of madness’, or feel that the experience of perpetrating the violent act ‘happened’ to someone else. These are the rage-type murderers (Cartwright 2002), who present a particular challenge, as they regain a sense of psychic equilibrium following the offence. After the violent attack they remain cocooned in a state of supreme calmness and serenity, often presenting as ‘model patients’.

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The third mode is the ‘teleological mode’, in which the individual can only accept concrete, physical signs as evidence of reality. This is in the realm of: ‘show me, don’t tell me’; ‘if you really loved me, you would do this for me’; and ‘I know he hates me because he ignored me’. Physical, demonstrable acts are all that count, excluding any other possible explanation or narrative of ‘mind’ or ‘intent’. In themselves, these states do not lead to violence, but in individuals who have a fragile sense of self, and a tendency to act out in a highaffect, hyper-aroused way with impaired reality testing and low reflective function, the risk of violence is high. Fonagy writes that ‘the common path to violence is the momentary inhibition of the capacity for communication or for interpretation’ (2003b, p.6). In mental disorder, paranoia with a disinhibiting factor, for example command auditory hallucinations in the second person (hearing voices commanding acts of violence), is possibly the most dangerous risk factor in psychosis. Despite being driven by psychosis, it could be argued that this type of violence has much in common with Glasser’s self-preservative or Meloy’s affective violence. The broadening out of MBT to patients with ASPD (Bateman and Fonagy 2008) has led to it being increasingly piloted in forensic services (see e.g. Yakeley and Williams 2014). The Portman Clinic in the UK has piloted MBT for outpatient community treatment of violent offenders diagnosed with ASPD, as part of a wider research project. In my own work setting, which is a medium secure unit for mentally disordered offenders, we have also piloted the use of MBT in group work for patients whose psychosis is in remission, where anti-social personality problems have come to the fore. The therapy groups are ‘unstructured’, in that any topics may be brought up, but the facilitators aim to steer the group towards areas that are central to the reasons for detention. It is this work which I shall now describe in the following clinical material.

CLINICAL VIGNETTE: ‘A MOMENT OF MADNESS’ This vignette from an MBT group is heavily disguised in order to protect confidentiality. The six patients (whom I have named Tom, Mike, Nigel, Dave, Jack and Kevin) have a high incidence of assaulting staff members, and their index offences involve violent offences, including homicide. All received a psychiatric disposal at the time of sentencing, on account of diminished responsibility.

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Tom: I’ve had lots of time to reflect while I’ve been here and I won’t make the same mistakes again. Therapist 1: What have you reflected on? Tom: Impulsivity. My offence was a moment of madness. I was stressed and working too hard. Therapist 1: I imagine I’d be frightened to think I’d had a moment of madness – it must be very frightening to lose one’s temper, lose the plot in that way. Mike: I never learn from my mistakes. I keep coming back in, keep taking drugs. I don’t know why I can’t learn – the boredom. Then the control and the restrictions. Nigel: I’ve lost my leave. I got into a fight – I couldn’t walk away. (Goes on to talk about fellow patient disrespecting him.) I’ve always found it hard to put my feelings into words. Therapist 1: Just now you mentioned feeling disrespected? You think it was that feeling that caused the fight? Nigel: You can’t be weak, you can’t allow other people to walk all over you. Jack goes on to talk very calmly and reasonably about an altercation on the ward with Sam, another patient, indicating it was all Sam’s fault. Dave: That doesn’t sound like Sam! Kevin: The quiet guy? Jack: Well yes…yes…but he just came at me out of nowhere… (Goes on to describe it all very calmly and reasonably.) Therapist 2: You know I’m having this odd feeling. Here you are all talking so nicely – so civilised, and yet you’re all here in a secure unit. If people from outside saw you now they would wonder what you were all doing here. So quiet…but like Sam there is this sudden eruption…and where does it all go when you’re here? They seem to think about this. Jack: Like I say, we leave our baggage on the wards.

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Therapist 2: But is that really helpful to us, I wonder? Because that is the reason you are here and it needs to come into the group somehow. Kevin: People used to say I was really quiet. When I committed my index offence my doctor said it was probably a one off. It was very out of character for me. Therapist 2: So I wonder how that feels? Kevin: Well, they say it’s the quiet ones you need to watch. I wasn’t very well, I was so stressed. I had a cold and I felt ill and I just blew my fuse. I’m normally such a calm person. Dave: The same thing happened to me. It was very out of character – my index offence. I was a very relaxed person. Therapist 2: I imagine that’s hard to come to terms with – this thing happening out of the blue. Mike: That’s right. I realised as you were talking that my index offence was the same. I thought I’d never pick up a weapon but then I realised my index offence did involve a weapon. Therapist 1: That’s a big connection to make. How does it feel to make that connection? Mike: Just a moment of madness. When I went to court, my unconscious was signed up to being in prison. I wanted to be locked away. They talk about prison. Therapist 2 makes a link to Tom about how he was impulsive and aggressive when he first arrived. Tom agrees – they all talk about how they had to be aggressive in prison. Mike: I felt really pissed off through the week. And the one thing that stopped me from having a go was thinking about this group. Knowing that for one hour a week I can sit in a circle and talk in a civilised way keeps me sane for the rest of the week.

DISCUSSION This vignette conveys the painstaking task of helping individuals reflect on their own minds, and the minds of others, where there is an impairment in the ability to do this. Rather than an interpretative analytic stance

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based on transference interpretations (which have the potential to be emotionally arousing, hence triggering the loss of mentalising), we work according to the MBT model of a direct, active stance of ‘not knowing’, challenging assumptions and generalisations and helping patients make links between thoughts and feelings, feelings and actions. The greatest challenge we have found in the work is that patients tend to operate in pretend mode due to the reality that they are detained under forensic sections of the Mental Health Act and therefore there are issues regarding non-compliance, lack of insight and being detained against their will; they have learned to co-operate and comply in a superficial way. The fact that they have a diagnosis of psychotic illness can also lead them to ‘blame’ their offence on their illness at the time, rather than look at any other underlying issues. This can be a way of externalising and distancing themselves, using ‘diminished responsibility’ as a psychological defence. A further difficulty with pretend mode is the staff temptation to collude, as this closely fits the organisational social defence of the institution (Menzies Lyth 1992; Hinshelwood 2012). This is a collective unconscious defence used by an organisation to protect staff from undue anxiety and distress in the workplace, which then creates more difficulty as a result. In forensic mental health, one is not only facing anxiety arising from severe mental disturbance, but also the risk of close proximity to dangerous offenders who have been violent to others in the past. Social defences can then manifest as difficulties in the staff ‘holding things in mind’ – the tendency towards avoidance, minimisation, denial and ‘turning a blind eye’. This serves not only to keep true disturbance out of mind but also obscures feelings of disgust, hatred and loathing towards those who have committed such horrific acts. In short, these social defences serve to conceal or cover up violent states of mind of our own. Therefore it is important to recognise the importance of restoring mentalisation first in our own minds, when the capacity for this gets lost, before attending to the mentalisation in another.

CONCLUSION In this chapter, I have explored violence from a developmental perspective – namely as the consequence of early difficulties in attachment which result in deficits in the ability to mentalise. Although this may include constitutional factors, environmental deprivation in the form of neglect

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and abuse is shown to have a direct impairment on the infant’s developing mind. This leads to lasting personality disturbance due to difficulties in emotional regulation, communication, reflective function and impaired reality testing. Deficits in these areas are directly linked to violent states of mind. I have explored the nature/nurture debate from the psychoanalytic perspective of a conflict versus deficit model and argued for an understanding of a third model that combines constitutional aggression with environmental factors. In fact, it is neither a case of ‘bad to the bone’ nor ‘breaking bad’. The stories of both Kevin and Walt suggest a circular process, in which it is difficult to say which comes first, innate destructiveness or environmental threat. The implication for this combined approach is for a more ‘relational’ model of treatment where the focus is on mentalisation, the aim being to develop new connections between thoughts and feelings, feelings and actions, instilling reflection and greater symbolic space where this has previously broken down. In individuals with a greater propensity to act out, this is difficult to achieve by a purely interpretative stance, as this may only offer a kind of ‘pretend mode’ short-cut (talking the talk) as opposed to beating a new pathway (walking the walk) that one needs to develop in the circuitry. This needs painstaking care to the task of mentally joining up the dots, or joining up the neurones, to override the force of habit, pattern and reflex, which is one of the reasons why offender patients are notoriously difficult to treat. Although we cannot replace old neuronal pathways, we can perhaps create new ones over time, leading to more meaningful choices becoming available due to richer inner resources. These inner resources (particularly the greater capacity for alternative perspectives of self and others) may be the best protective and preventative measure against violence.

REFERENCES Adshead, G., Moore, E., Humphrey, M., Wilson, C. and Tapp, J. (2013) ‘The role of mentalising in the management of violence.’ Advances in Psychiatric Treatment 19, 67–76. Bateman, A. and Fonagy, P. (2004) Mentalisation Based Treatment for Borderline Personality Disorder. Oxford: Oxford University Press.

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Bateman, A. and Fonagy, P. (2008) ‘Co-morbid antisocial and borderline personality disorders: mentalization-based treatment.’ Journal of Clinical Psychology 64, 2, 181–194. Bion, W.R. (1970) Attention and Interpretation. London: Karnac. Bowlby, J. (1969) Attachment and Loss Vol 1. Attachment. London: Hogarth Press and The Institute of Psychoanalysis. Bowlby, J. (1973) Attachment and Loss Vol 2. Separation: Anxiety and Anger. London: Hogarth Press and The Institute of Psychoanalysis. Bowlby, J. (1980) Attachment and Loss Vol 3. Loss, Sadness and Depression. London: Hogarth Press and The Institute of Psychoanalysis. Bradley (2009) Lord Bradley’s Review of People with Mental Health Problems or Learning Disabilities in the Criminal Justice System. London: House of Lords. Breaking Bad: The Complete Series (2015) Created by Vince Gilligan (DVD). Sony Pictures. Cartwright, D. (2002) Psychoanalysis, Violence and Rage Type Murder. Hove and New York: Brunner-Routledge. Cordess, C. and Cox, M. (eds) (1996) Forensic Psychotherapy Vol 1. Mainly Theory. London: Jessica Kingsley Publishers. Fonagy, P. (2003a) ‘The Developmental Roots of Violence in the Failure of Mentalisation.’ In F. Pfafflin and G. Adshead (eds) A Matter of Security: The Application of Attachment Theory to Forensic Psychiatry and Psychotherapy. London: Jessica Kingsley Publishers. Fonagy, P. (2003b) ‘Towards a developmental understanding of violence.’ British Journal of Psychiatry 183, 190–192. Fonagy, P. and Adshead, G. (2012) ‘How mentalisation changes the mind.’ Advances in Psychiatric Treatment 18, 353–362. Fonagy, P. and Target, M. (1996) ‘Playing with reality I. Theory of mind and the normal development of psychic reality.’ International Journal of Psychoanalysis 77, 217–233. Fonagy, P. and Target, M. (2000) ‘Playing with reality III. The persistence of dual psychic reality in borderline patients.’ International Journal of Psychoanalysis 81, 5, 853–874. Freud, S. (1915) Instincts and their Vicissitudes. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol 14. London: Hogarth Press and The Institute of Psychoanalysis. Freud, S. (1920) Beyond the Pleasure Principle. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol 18. London: Hogarth Press and The Institute of Psychoanalysis. George, C., Kaplan, N. and Main, M. (1985) The Adult Attachment Interview. Unpublished manuscript, University of California at Berkeley. Accessed on 27/3/17 at www.psychology.sunysb.edu/attachment/measures/content/aai_interview.pdf Gilligan, J. (1997) Violence: Reflections on a National Epidemic. New York: Vintage Books. Glasser, M. (1998) ‘On violence: a preliminary communication.’ International Journal of Psychoanalysis 79, 887–902. Hinshelwood, R.D. (2012) ‘Personal Stress and Collective Disorder.’ In E. Hopper (ed.) Trauma and Organisations. London: Karnac.

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Klein, M. (1932) The Psychoanalysis of Children. New York: Grove Press. McGauley, G. (2017) ‘Attachment, Mentalisation and the ID Consultation.’ In J. Gordon, G. Kirtchuk, M. McAlister and D. Reiss (eds) Consulting to Chaos: A Patient Centred Approach to Reflective Practice. London: Karnac. Meloy, R. (1992) Violent Attachments. London: Jason Aronson. Menzies Lyth, I. (1992) ‘The Functioning of Social Systems as a Defence Against Anxiety: A Report on a Study of Nursing.’ In Containing Anxiety in Institutions. Selected Essays Vol 1 (Second Edition). London: Free Association Books. Morgan, D. and Ruszczynski, S. (2007) Lectures on Violence, Perversion and Delinquency. London: Karnac. Shriver, L. (2003) We Need to Talk about Kevin. Berkeley, CA: Counterpoint (and London: Serpent’s Tail, 2005). Target, M. and Fonagy, P. (1996) ‘Playing with reality II. The development of psychic reality from a developmental perspective.’ International Journal of Psychoanalysis 77, 459–479. Winnicott, D. (1971) Playing and Reality. New York: Basic Books. Yakeley, J. and Williams, A. (2014) ‘Antisocial personality disorder: new directions.’ Advances in Psychiatric Treatment 20, 132–143.

Chapter 3

THE PATHOLOGICAL THIRD, VIOLENCE AND REALITY Psychological Pathways to Violence in Psychosis and Narcissism CLINTON VAN DER WALT

INTRODUCTION Violence is deeply relational and yet simultaneously attacking of relationality to the point of destruction. This paradox is the jagged rhythm to which violence moves. This chapter explores the question of the paradoxical relationality of violence from the perspective of thirdness. In all my work with violent subjective states, I experience a deepseated desire to go to another place in my mind to escape the difficult dyad: to rest, to think, and ultimately attain an elusive understanding and creativity. This desire represents the need for the ‘third position’ in my own mind. It was consistently difficult to achieve this kind of thirdness with violent patients. When I was able to think creatively in the face of violent states of mind, this seemed to be associated with an ability to contain the dynamic. Violent states of mind are frequently associated with repetitive, thoughtless and unimaginative responses to overwhelming emotions. This may also be true of clinicians’ responses to such states of mind. Thirdness is a theoretical construct (Green 2004; Hanly 2004) that has enabled me to draw from diverse bodies of literature without getting hamstrung by the theoretical and conceptual silos so prevalent in some psychoanalytic and psychiatric thinking. I have worked mainly in student counselling centres and private practice settings. This has 37

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necessitated finding my own path, in the absence of a dominant clinical and theoretical discourse: finding and creating metaphorical language to forge understanding and connection. My work with violent patients has been to imagine and to dream with them their own minds. The metaphors I will discuss here have emerged primarily from reveries and dream material in clinical sessions. The relationship between violence and thirdness has been underexplored in the psychoanalytic literature. Building upon previous work (van der Walt 2011; van der Walt and Long 2013), I use case material to argue that different kinds of pathological thirds are created by psychotic and narcissistic patients who present with violence. These pathological thirds serve to manage overwhelming feelings associated with making relational contact with the self and the other. For psychotic and narcissistic patients, it is suggested, the disruption of the pathological third evokes a different relationship to reality, and violent states of mind ensue. The chapter also aims to bring together understandings of thirdness with mentalization theory. Sontag (2003, p.118) observes that ‘nobody can think and hit someone at the same time’. Violence coincides with a failure to mentalize. This link has been most fruitfully explored in relation to borderline states (Bateman 1995; Fonagy and Target 1995; Fonagy et al. 2004); here it is extended to other kinds of pathology. I argue that a pathological relation to thirdness, linked to violence, goes hand in hand with a pathological relationship to reality. The aim of the chapter is to propose a possible relationship between thirdness, violence, relationship and mental reality. The focus is on the formulation of this relationship; some implications for therapeutic engagement are also proposed.

THIRDNESS, REALITY AND VIOLENCE Thirdness is a difficult concept in the literature because it is an abstraction, denoting not only the sequence of one, two and three but also the qualities of whatever constitutes these designations. In psychoanalysis, each school of thought accounts for the one, two and three differently, and this muddies the water, although there have been notable attempts to address this theoretical quagmire (see Gerson 2004; Green 2004; Hanly 2004). Freudian notions of the third engage the triangular by speaking of Oedipus and the socializing function of paternal prohibition (Freud 1924) involving the father, the mother and the phallic-stage child. States

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of autoeroticism (one) (Freud 1914) give way to dyadic relating (two), which in turn emerge into Oedipal thirdness. The sequence of three for Freud is ‘me’, ‘mother’ and ‘father’. Object relational accounts of thirdness bring the triangular relations of thirdness into the internal emotional world of the infant. For Klein (1946), the infant is always in a state of dyadic relations with its primitive internal objects. Thirdness involves a capacity to apprehend an external reality (and the whole objects therein), whilst at the same time maintaining a link to the internal objects. Three, here, is ‘me’, ‘my internal objects’ and ‘you’. Britton (2004) casts the players of Oedipus as internal objects. The reality of two external others that can come together in exclusion of the self is internalized as a cognitive capacity to adopt two different and essential subjective relations to the self. Britton describes thirdness as an internal triangular space that allows both observing and participatory relations with the self. These positions are correlations of external object relations in which the child can relate to the Oedipal couple by observing them interact with each other, and participate with each member of the couple in a dyadic relation. Winnicott’s (1971) notions of thirdness involve a progressive subjective journey out of monadism into an awareness of external others. For Winnicott there is an intermediary subjective position, between the self and an awareness of an other, called transitional space. The transitional third space is an intersubjective realm in which there is a blur between what is self and what is other. Three for Winnicott is ‘me’, ‘part-you and part-me’, and ‘you’. This theoretical advance lays fertile ground for intersubjective notions of thirdness developed by Ogden (2004) and Benjamin (2004), as well as relational psychoanalysts such as Mitchell and Greenberg (1983). This idea of intersubjective thirdness is also adopted by attachmentbased schools of psychoanalytic thought (Stern 1985; Fonagy et al. 2004). These theoretical schools develop a close-grained examination of processes between mother and infant that progressively introduce the reality of others and the self. Fonagy et al. (2004) link attachment, developmental intersubjectivity and affects to the development of a self that can emotionally engage with reality. Three, in these systems of thought, is ‘me’, ‘you’ and an ‘emotionally valenced reality’. Relational thirdness and developmental thirdness are frequently dis­ cussed synonymously in the literature. Intersubjective developmentalists

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such as Benjamin (2004) describe how the human subject comes into being in relation to another mind. These developmental processes hinge on a relationship to a third entity or mental position outside of the immediate experience of the caretaker–child dyad. In post-structural psychoanalytic schools (see e.g. Lacan (1977)), thirdness is language and meaning itself. Thirdness, or relational contact that involves a contact between two minds, is therefore particularly important for patients in violent states of mind for whom establishing a shared relational contact (what Benjamin (2004) calls a state of mutual recognition) is a considerable challenge. Psychotic and narcissistic patients who are violent, by definition, contort and attempt to negate a third shared space. Their own developmental deficits are primary agents of the contorted or pathological third space. To put this the other way round, a violent state of mind could be described as one in which a creative sense of thirdness is undermined or collapsing. It is also the case that the therapist is brought in to participate in a foreclosure of a healthy thirdness. Healthy thirdness can be understood as the capacity to relate to self and other without becoming emotionally overwhelmed: a mental vantage point from which reality can be organized. Fundamentally, it describes how the human subject gets from the internal world to the external world of the other, and back again, without dissolving in terror or violently destroying the threat of reality. Thirdness here links specifically to the mental work of affect regulation, which plays such a central role in violence. Fonagy et al. (2004) link the capacity to regulate affects to what they call mentalization: the capacity to be aware of and represent mental states in the self and subsequently be aware of these states in others (see e.g. Chapter 2, Volume 2). Inability to mentalize has been centrally linked to violence and self-harming behaviour. Similarly, thirdness can be understood as an awareness of an other, or an awareness of a third something produced by two people. Ultimately, the third position is internalized as a reflective function (Fonagy et al. 2004), a thinking triangular space (Britton 2004), an observing ego function (Aron 2000) or the internal analytic working model (Zwiebel 2004). Reality can be engaged with from subjective and objective perspectives, based on a stable reflective ego mechanism that contains an organized conception of the self. The mind can be imagined and thought about, as can the minds of others. Affects can be regulated and contained.

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Clarkin, Fonagy and Gabbard (2010) link the structural integrity of the mind to developmental notions of mentalization. The less differentiated the ego constellations are, the more pathological the individual is likely to be. This has implications for the patient’s likelihood of having recourse to more primitive defences, including resorting to violence. In more pathological ego constellations, the subjective experience of affects is persecutory and ego threatening. Feelings are experienced as though they are concretely real: there is an inability to distinguish between internal subjectivity and external reality. In the mentalization literature this state is described as ‘psychic equivalence’ (Fonagy et al. 2004). This subjective state is contrasted to ‘pretend mode’ (Fonagy et al. 2004) in which reality has little or no emotional consequence. In a developed capacity for mentalization, psychic equivalence and pretend modes are integrated and function together so that a person can know about internal and external reality in an emotionally responsive way without becoming overwhelmed. This relies on the ability to move dynamically between these two subjective states in response to various realities.

PATHOLOGICAL THIRDS Physically destructive behaviour is associated with states of mind in which either psychic equivalence or pretend mode dominate, to the exclusion of the other. In the clinical material to follow I wish to demonstrate how violence is associated with non-mentalizing subjective states linked to two types of pathological third. These pathological thirds have been introduced more thoroughly elsewhere (van der Walt 2011; van der Walt and Long 2013); they are specifically described in this chapter in relation to the eruption of violence. The prosthetic third is a semiotic object (discourse, music or complex games, for example) that coheres and regulates the fragmented ego of the psychotic patient. Psychotic functioning is concrete; so too is the pathological third. The prosthetic third is used much like a prosthetic limb, to concretely regulate affect and to create an illusory sense of thirdness in order to shore up coherence. The case of Mr K below shows that when his prosthetic third is ruptured – when the concrete object is challenged by thoughtfulness – violence ensues. The autogenic third is linked to narcissism, which turns on the belief that the self is centrally special. The narcissistic patient may believe

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himself to have been a participant in his own conception. Narcissistic patients, such as Mr A in the second case, may create a pathological third around this intrusive, autogenic phantasy, which allows them to deny the reality of a procreative couple that precedes them. Affect is regulated by remaining relationally aloof and unconsciously ignorant of the separateness and significance of others. When the phantasy is challenged or shattered, violence may erupt.

CASE 1: MR K – PSYCHOSIS AND THE PROSTHETIC THIRD Mr K was prone to regular episodes of physical violence directed against his family members. In my first meeting with Mr K I was struck by how scared he was. In order to create a sense of emotional safety, Mr K had constructed strict routines and created certain special objects in order to keep his overwhelming terror at bay. He was obsessionally attached to these routines and objects and would experience psychotic breakdowns and episodes of violence if his obsessional order was disrupted. Mr K worked obsessively on one such special object: an auto­-biographical manuscript in which he would organize his experience and consolidate his identity. He used his autobiography as an external mind or prosthetic third to manage reality. He used his sessions to read his manuscript to me: I was the mental editor to his emotional life. When narrating himself he was mostly calm and emotionally detached. Sometimes this calm would be disrupted; in these moments the catalysts of his violent states of mind could be more clearly seen. In one session, whilst reading the ‘relationships’ section of his manuscript, I became stressed and confused about his understanding of homosexuality. He described himself as having homosexual feelings for a woman. When I wondered if he identified himself as a woman, he became very frightened and consequently menacing and threatening towards me. It seemed that I had invited myself into his prosthetic third and asked him to think, and that this was intolerable for him. This had come about in response to my own stress and confusion regarding his narration. My affectively aroused state as well as my ‘pseudomentalizing’ could be seen as signals that we were entering into violent subjective states. He was convinced that I had sexual feelings for him, and that if he did not give in to me, I would rape him. Mr K had moved

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from a state of pretend mode into a state of psychic equivalence. In this subjective state Mr K experienced my question and his transferential reaction as a dangerous and penetrating reality. In response to this perceived threat, Mr K threatened to report me to the authorities and demanded that I hand him his file. He was very menacing and said that he would destroy my career. I felt frightened, enraged and intruded upon: a mirror, perhaps, of Mr K’s own feelings. All my attempts at exploring these feelings as a reaction to what had transpired in the session failed and only served to escalate the emotional temperature. Eventually in desperation I asked Mr K to explain to me how he would write up his experience of the session in his autobiography. He did so, possibly responding to a more congruent therapist stance and in the process calmed down to the point of saying that what had happened was a misunderstanding.

THE PROSTHETIC THIRD AND VIOLENCE Mr K was a man whose ego was in tatters. His primary affective relation to the world and to others was terror, as he lived under the constant threat of annihilation. His experience of perhaps any therapeutic reflexivity that did not immediately match his own was persecutory: something ego-destructive, a malicious foreign body whose destabilizing presence required urgent life-preserving aggression to be mobilized. A question about sexuality and gender had produced a terrifying internal experience which threatened the integrity of Mr K’s understanding of himself. In order to restore a sense of safety, Mr K had to get me to back down and stop thinking. At this point both Mr K and I had entered into a violent state. This highly aroused intersubjective state was calmed when Mr K was able to cohere his self-experience in the organizing narrative of his autobiography. The prosthetic third is a complex semiotic system or organized structure of symbols that the psychotic patient uses as an alternative ego formation. For Mr K, his autobiography was a concrete object serving as an external mind with the power to reduce terrifying affect. When his prosthetic object was disrupted, so too was his reflective and affect regulation capacity and he responded in a threatening and aggressive manner. This aggression was mobilized in order to preserve the integrity of the prosthetic third. In other areas of Mr K’s life, those around him were

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not able to respond to the warning to back away that was communicated by his aggression. In these instances, it seemed that his prosthetic third collapsed and violence was enacted.

CASE 2: MR A – NARCISSISM AND THE AUTOGENIC THIRD Mr A was a man in his early twenties referred for ‘anger issues’. He had a history of violent encounters with others, and his romantic relationships were characterized by rageful fights followed by intense reconciliation. Mr A presented as a highly strung, agitated individual, unstable and volatile, whose psycho-somatic presence crackled with manic energy. His legs bounced, his fingers tapped, his shifting never ceased for more than a few minutes. I always felt nervous and imposed upon in sessions: a bodily resonance with his violent state of mind. After our first session he saw me take up my notebook to write down my impressions of our meeting. He immediately challenged me about this and demanded that I not take any notes on his sessions. Startled, I suggested we take this up in our next session. He refused to leave and insisted that he would like to check my notebook the following week to see if I had kept my word. He was aggressive and intrusive and I felt rattled. My own defensive need to write and gain some reflective distance from his violent emotional state resonates with the case of Mr K. As with the initial telling of Mr K’s autobiography, note-taking and narrating was not playfully or creatively shared, leading to violent intersubjective states. The following session I braced myself for further onslaught. To my surprise, he did not raise it until I did so; he was disinterested and disconnected, signalling a pretend mode state. He dismissed it, saying he did not care to think about it and that I should do what I wish. Throughout the therapy, I constantly felt uncertain as to whom I should expect in the room: the remote and unconnected patient, or the intrusive and controlling one. The primary content of Mr A’s sessions concerned his relationship with his mother and his girlfriend. He was extremely possessive and jealous of both women. He had had violently conflictual relationships with the various men his mother had been sexually involved with. When it came to his girlfriend he could not tolerate any other man in her life or her mind. He would regularly rage at her for some or other

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misdemeanour she had perpetrated with other men, real or imagined. They would fight vociferously and then come together in a sensual cocoon of eating, sleeping, stroking and having sex for prolonged periods. These were blissful but precarious times, poised for imminent collapse with the intrusion of another hated man. These sensual cocoons were supplemented by drug and alcohol binges. In Mr A’s first session he told me about two incidents of violence. In the first incident, Mr A described being beaten up outside a nightclub by two men. He described how they had used knuckle-dusters and chains, and how sadistic they had been in their protracted assault. The violence he described was graphic – a spectacle of pain and suffering. His narration felt staged, inauthentic and incomplete. I later learned that his account had omitted the crucial detail that Mr A had precipitated the altercation a month beforehand when the perpetrator had threatened Mr A, after witnessing him in a jealous fight with his girlfriend. Although there had been no physical violence at this point, Mr A was so incensed that he had sought out the man’s address and had begun vandalizing his property. The second incident was reported in fuller detail and in a manner that felt sincere. The incident had begun at a restaurant. Mr A and his girlfriend were having another fight. A man sitting at the adjacent table had asked Mr A to stop swearing. Mr A had then threatened this man with physical violence. The situation rapidly escalated and Mr A assaulted the security officer attending to the incident. As Mr A was telling me about this, he became agitated and manic. I noticed that his mouth was dry in response to his adrenaline surge. Mr A described how he had become like a ‘machine’: he felt no pain and he experienced himself as invincible. In the session his memory and his sensual descriptions were heightened. He ran through and broke the restaurant window, and jumped down a storey in the shopping centre in an attempt to evade the security officers. Eventually he was wrestled to the ground by a number of police officers, assaulted and then arrested.

THE AUTOGENIC THIRD AND VIOLENCE The narcissist feels himself to be at the pivotal centre of all reality and action. His mental arithmetic calculates accordingly. Others are treated as though they are inconsequential and they are used expediently and

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selfishly. Cognition, affect regulation and relationship all assume this dyadic logic in which a triangular reality (Britton 2004) is negated. In previous work, following Perelberg (1999), I have called this dynamic the autogenic third (van der Walt and Long 2013) because the patient, in phantasy, produces a pathological third which maintains his centrality and self-production, thereby allowing him to avoid relational thirdness. When the autogenic third is compromised by reality, affects become dysregulated and envy, hatred and aggression arise to threaten the ego. Violence ensues when these affects are mobilized to restore the autogenic third and the precarious safety it offers. Affects are managed through the defensive maintenance of pretend mode in what Rosenfeld (1964) termed ‘thick-skinned’ aloofness. In ‘thin-skinned’ positions, in contrast, affects are dispelled and enacted through a violent imposition on external reality in an attempt to restore the dyadic phantasy. There is a clear sequence in the two incidents described by Mr A: a passionate and jealous fight with his girlfriend (involving the threat of a sexual rival); a patriarchal other who intervenes to oppose Mr A’s aggression against his girlfriend; and finally, a violent act against the third who dares to intervene. There is also a highly selective retelling of the events, which hides Mr A’s culpability and disguises the role of his rage as a catalyst. In this sequence, Mr A’s sense of being the only man in relation to a woman seems to be destabilized. The woman is a source of idlinked pleasure and sensual idealization. He is the only beneficiary of this pleasure. This includes the pleasure of bullying his girlfriend into acquiescence and forcefully demanding that she declare her absolute allegiance. He responds angrily and violently to the threat posed by any entity that interrupts his pleasure. The aim of his violent response is to obliterate the actual third that challenges his autogenic cocoon. An important feature of the sequence is the intense pleasure linked to the violence. I observed this when Mr A was telling me about the violent action – an ecstatic agitation, a prelude to thanatic orgasm, perhaps as addictive as any of the substances Mr A misused. When Mr A negated triangular reality, he was able to disconnect from others and use them as objects to pleasure himself. The sensual cocoons with his girlfriend and his aloof disconnection in the sessions attest to this thick-skinned state. In both cases the rival third had been banished through aggression and violence. In our first session Mr A intimidated

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me by demanding that I cease my note-taking: a concrete indication of me communicating with myself and my thoughts defensively. Once this was achieved in the mind of Mr A, he no longer had the need to engage with me, and so he felt no need for confrontation in the second session. The incomplete retelling of his episodes of violence evidenced the same manipulation of reality. His subjugation, culpability, fear, pain and injury were muted. He was a ‘machine’. However, in the second narration of violence, the perturbing impact of the patriarchal other is closer to consciousness. His dry mouth and psycho-motor agitation betray the emotional impact of the retelling. Two subjectivities play out in the material described. The first of these states is a thick-skinned subjectivity associated with aloofness and the selfish use of his objects: the pleasuring subservient girlfriend/ therapist. Affect is excised of all vulnerability. He is deadened, scary, omnipotently controlling and/or sadistically rageful. The second state, identifiable through his psycho-motor agitation and the corresponding paranoid, intrusive dynamics in the transference, is thin-skinned. It is characterized by psychic equivalence and is associated with vulnerability, fear and threat. A panic reaction ensues in which Mr A uses aggression and menace to gain the upper hand at any cost. In a violent state of mind, he must destroy triangular reality and the consequent ability to think, in order to re-establish his all-powerful thick-skinned position.

CONCLUSION For some narcissistic patients prone to violence, authentic engagement with a third is threatening. Instead, such patients (and their therapists, at times) construct a pathological third in service of evading reality: they conjure a ‘pseudothird’. The ‘pseudothird’ is precarious, and its disruption ushers in violent mental states which may lead to violence. This pathological third takes on a concrete quality so distinctive of psychotic functioning. For Mr K, his manuscript soothed his jagged affects and gave him an organized structure and meaning. Mr A’s pathological third supports his narcissistic centrality in his own universe by warding off awareness of competition and by negating triangular reality. In both of these cases, the pathological third holds a fragile coherence in place and regulates affect; disruption of the pathological third leads to violence in order to recreate psychic safety.

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In my work with violent patients there has very rarely been a situation where violence has been enacted in the session. This no doubt has something to do with the basic containment functions offered by the psychotherapeutic setting, as well as sensitivity to registering certain cues that have signalled the risk of an onset of violence. As I have become more attuned to these cues, they have started to take on a technical significance of their own. These cues have ranged from subtle shifts in the affective-relational minutiae of the exchange between a patient and myself, to more overt signals of aggression and distress. What all of these cues has in common is an attempt to ameliorate or negate an aspect of the interaction that poses a threat to the patient’s sense of safety and integrity. This precarious sense of safety is brought about by the pathological third. It is in these moments that the patient’s pathological third comes most clearly into focus. When creative, collaborative and playful states of relational thirdness can be created, a safer, less violent state of intersubjectivity can emerge. Narratives of violence have an emptiness that is tricky to hear amidst all the highly charged affect and destructive excitement. Like death, violence is a radically unsymbolizable other. When violent patients narrate their violence, I am listening to an event reconstructed by the pathological third. Often these narratives serve as threats themselves, warning the therapist to back off and be frightened, perhaps in identification with the damaged fragile ego. In this sense, narrations of violence need to be treated in the same way that a competent psychotherapist would approach a dream – a creative reconstruction from the unconscious, to be associated to in the hope that something of its meaning will be reclaimed. The value of this approach lies in the respect it has for the patient’s defensive manoeuvres which lend a primary process veneer to material that would otherwise be too threatening. It is possible to conclude that violence can be held creatively within the therapeutic relationship, but that, precisely because pathological thirdness prevents full engagement with reality, the underlying dynamics are difficult to change. For the therapist, this goes some way to addressing the issue of how difficult it is to prompt psychic change for violent pathological patients. Nonetheless, the emergence of the pathological third in the therapeutic relationship reproduces the patient’s destructiveness in a different form. This destructiveness, if given the

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chance to emerge, can be listened to, articulated, elaborated and, perhaps, creatively transformed.

REFERENCES Aron, L. (2000) ‘Self-reflexivity and the therapeutic action of psychoanalysis.’ Psychoanalytic Psychology 17, 667–689. Bateman, A. (1995) ‘The treatment of borderline patients in a day hospital setting.’ Psychoanalytic Psychotherapy 9, 1, 3–16. Benjamin, J. (2004) ‘Beyond doer and done to: an intersubjective view of thirdness.’ Psychoanalytic Quarterly 73, 5–46. Britton, R. (2004) ‘Subjectivity, objectivity, and triangular space.’ Psychoanalytic Quarterly 73, 47–61. Clarkin, J.F., Fonagy, P. and Gabbard, G.O. (2010) Psychodynamic Psychotherapy for Personality Disorders: A Clinical Handbook (1st edn). Washington, DC: American Psychiatric Pub. Fonagy, P. and Target, M. (1995) ‘Understanding the violent patient: the use of the body and the role of the father.’ International Journal of Psychoanalysis 76, 487–501. Fonagy, P., Gergely, G., Jurist, E. and Target, M. (2004) Affect Regulation, Mentalization, and the Development of the Self. London and New York: Karnac. Freud, S. (1914) ‘On Narcissism: An Introduction.’ In J. Strachey (ed. and trans.) The Standard Edition of the Complete Psychological Works of Sigmund Freud (Vol. 14). London: Hogarth Press. Freud, S. (1924) ‘The Dissolution of the Oedipus Complex.’ In J. Strachey (ed. and trans.) The Standard Edition of the Complete Psychological Works of Sigmund Freud (Vol. 19). London: Hogarth Press. Gerson, S. (2004) ‘The relational unconscious: a core element of intersubjectivity, thirdness, and clinical process.’ Psychoanalytic Quarterly 73, 63–98. Green, A. (2004) ‘Thirdness and psychoanalytic concepts.’ Psychoanalytic Quarterly 73, 99–135. Hanly, C. (2004) ‘The third: a brief historical analysis of an idea.’ Psychoanalytic Quarterly 73, 1, 267–290. Klein, M. (1946) ‘Notes on some schizoid mechanisms.’ International Journal of Psychoanalysis 27, 99–110. Lacan, J. (1977) Ecrits, a Selection (A. Sheridan, trans.). New York: Norton. Mitchell, S. and Greenberg, J. (1983) Object Relations in Psychoanalytic Theory. Cambridge, MA: Harvard University Press. Ogden, T. (2004) ‘The analytic third: implications for psychoanalytic theory and technique.’ Psychoanalytic Quarterly 73, 167–195. Perelberg, R.J. (1999) ‘Psychoanalytic Understanding of Violence and Suicide: A Review of the Literature and Some Formulations.’ In R.J. Perelberg (ed.) Psychoanalytic Understanding of Violence and Suicide (Vol. 33). London: Routledge. Rosenfeld, H. (1964) ‘On the psychopathology of narcissism: a clinical approach.’ International Journal of Psychoanalysis 45, 332–337. Sontag, S. (2003) Regarding the Pain of Others. New York: Farrar, Straus and Giroux.

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Stern, D. (1985) The Interpersonal World of the Infant. New York: Basic Books. van der Walt, C. (2011) ‘The prosthetic third in violent, psychotic, male patients.’ Psycho-analytic Psychotherapy in South Africa 19, 1, 6–23. van der Walt, C.M. and Long, C. (2013) ‘Tri-bar mental structure in masochistic perversion.’ Psycho-analytic Psychotherapy in South Africa 21, 2, 39–73. Winnicott, D. (1971) Playing and Reality. London: Tavistock Publications. Zwiebel, R. (2004) ‘The third position: reflections about the internal analytic working process.’ Psychoanalytic Quarterly 73, 215–265.

PART II

VIOLENT STATES OF MIND A great terror burst in upon his sleep, and the sweat broke out all over his body and soaked him to the bone. In a frenzy of rage he roared for his armour. ‘My armour!’ he shouted, ransacking his bed and the whole palace for it. The lust for battle raged within him, the criminal madness of war and, above all, anger. It was as though a heap of brushwood were crackling and burning under the sides of a bronze vessel, making the water seethe and leap up, a great river of it raging in the pot, with boiling foam spilling over and dense steam flying into the air. Virgil, The Aeneid, Book 7 (29–19 BC)

…as soon as Alyosha had gone, Lise unbolted the door, opened it a little, put her finger in the crack, and slamming the door, pinched her finger with all the force at her command. Ten seconds later, releasing her finger, she went back to her chair slowly and quietly, sat up erect in it, and began examining intently her blackened finger and the blood that oozed from under the nail. Her lips quivered, and she whispered rapidly to herself: ‘Mean, mean, mean, mean!’ Fyodor Dostoyevsky, The Brothers Karamazov (1880)

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Chapter 4

IS THERE A MURDERER HERE? The Language of Agency and Violence in Homicide Perpetrators GWEN ADSHEAD, ZOE BERKO, SARITA BOSE, MARTHA FERRITO AND MARTINA MINDANG

Richard loves Richard, that is I am I. Is there a murderer here? Yes. No. I am. Then fly! What? from myself? Shakespeare, Richard III: Act V, Scene 3, lines 195–197

INTRODUCTION This quote is a poignant exploration of the experience of a violent identity and of how language contains and expresses the violent state of mind. In what follows, we explore how violence perpetrators talk about their identities and how language can fail in the face of overwhelming affects, such as shame, fear and anger. Like Bateman, Bolton and Fonagy (2013), we argue that violent states of mind indicate a collapse of mentalising and an inability to experience ownership of action. We explore how these ‘lapses’ are expressed in language and narrative, perhaps as a defensive attempt to keep some kind of identity alive. We then suggest that the therapeutic process is needed to help make verbally explicit something about agency and responsibility that has been literally ‘unspeakable’. 53

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We present linguistic material from two different types of work with violence perpetrators from two very different contexts. The first study involves the language of agency in young male offenders from socioeconomically deprived urban communities in New York City. The other material comes from transcripts of therapeutic conversations that took place in a therapy group for homicide perpetrators detained in a secure psychiatric hospital in the UK.

THE LANGUAGE OF VIOLENCE: PREVIOUS RESEARCH Sykes and Matza (1957) carried out an early study of how juvenile offenders talk about their violence. They describe how these young men used the language of justification and excuse to rationalise their deviant behaviours and minimise their agency, using statements such as ‘it wasn’t me’ or ‘it’s not my fault’. Such statements are ‘neutralisation techniques’ that allow offenders to deflect feelings of guilt and shame, and align themselves with dominant social norms, thus reducing a sense of alienation from others. Later authors have commented that non-criminals use such techniques and that it is all too human to deny painful ownership of antisocial behaviour (Maruna and Copes 2005; Ugelvik 2012). Tony Parker (1969, 1990) was one of the first researchers to study the authentic ‘voice’ of offenders using taped and transcribed interviews with convicted murderers and paedophiles. These verbatim accounts do not explicitly address agency, although many interviewees reveal ambivalence and confusion about their responsibility and alienation. Lois Presser’s (2004, 2009) work with young violence perpetrators in prison did explore linguistic constructions of agency; like Sykes and Matza, she found that these offenders often generated narratives of their offences that diffused their responsibility; and they also used language to create a more positive and heroic image of themselves as offenders. O’Connor (1995, 2000) studied agency and responsibility in convicted violence perpetrators using a socio-linguistic approach. She describes how offenders appeared to place themselves on a ‘continuum of agency’, using language to position themselves as agentic or not. They used intentional pauses in speech that seemed to indicate moments of self-reflexivity (‘reflexive frame breaks’ (p.119)), which could then allow for a new

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engagement with their offence. O’Connor argues that the act of speaking and reflecting on crime can act as an opening of a process towards developing moral agency, through a generative process of self-reflection. Her work is echoed by that of McAdams (1993), who has also suggested that ‘telling the story’ of bad experiences allows for change at the narrative level of the personality; and the potential for generating a new identity, which ‘makes good’ out of negative experiences. These ‘redemption narratives’ (McAdams et al. 2001) are creative vehicles for a different and changed identity, and a different way of relating to others. Maruna (2001) applied McAdams’ work to persistent offenders, comparing the narratives of those offenders who ‘make good’ by desisting from crime with those who persist, and found significant differences. The desisters’ narratives highlighted a sense of agency in terms of ability to change from a criminal identity towards a restoration of a prosocial identity. In contrast, those persistent offenders talked about themselves in passive ways, and expressed beliefs that suggested that they were waiting to be changed by external events. In previous work, we drew on McAdams and Maruna’s work to study ‘redemption narratives’ in homicide perpetrators who were patients in a secure psychiatric hospital (Ferrito et al. 2012). Using interpretive phenomenological analysis (IPA), we found that the patients did express a wish to make good of themselves but feared it might not be possible because of the stigma of their identities as mentally ill offenders. More recently, we (Adshead, Ferrito and Bose 2015) used verbatim material from therapy groups with similar patients to explore the concept of ‘recovery’ in this group; specifically the concept of recovery as ‘coming to terms with their offence’ (Drennan and Alred 2013). We found that group members struggled with their identities as homicide perpetrators, and found it hard to ‘come to terms’ with the idea that their identities were now permanently changed in a highly stigmatised way. We wanted to develop these ideas about agency and language using a mentalising perspective with two different groups of violence perpetrators. A key aspect of mentalising is its self-reflective quality: what Allen (2003) calls the ability to keep ‘mind-in-mind’, which is linked in turn to the reality of one’s mental experience and that of others. In this chapter we explore linguistic evidence of lapses in mentalising and how they may relate to offenders’ lack of a sense of agency and responsibility in relation to violence.

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STUDY 1: MENTALISING, IDENTITY AND AGENCY IN VIOLENT YOUNG MEN In a previous study, Berko (2015) examined mentalising processes, identity and agency in the narratives of violent juvenile offenders from low-income urban neighbourhoods. The study invited violent offenders and non-offending controls to watch movie clips in which perceived disrespect gives rise to fatal gun violence; and it used participants’ responses to generate narratives that could be compared between groups. Participants were minority (African American; Latino or Bi‑racial) male adolescents aged from 15 to 19 who resided in low-income, high-crime city neighbourhoods, who had all been exposed to urban street culture. Violent offenders (n=10) had a self-reported history of arrest for a violent offence (assault, robbery and/or weapons possession), and nonoffending controls (n=8) had no arrest history. A key focus of the study was the concept of street code adherence as a measure of personal identity. Street code adherence refers to the view that it is advantageous and/or justifiable to project a violent social identity and use violence to maintain one’s respect on the streets (Anderson 1999). The psychoanalytical and sociological literature emphasises identity vulnerability as a critical determinant of code adherence and the violence it prescribes in response to perceived disrespect (Goffman 1955; Bracher 2000). In communities characterised by a concentration of social-structural inequalities with few legitimate forms of social capital, code adherence provides ‘both functional (i.e., status and identity), material, and symbolic meaning (i.e., power and control) as well as strategic importance in everyday social dangers’ (Fagan and Wilkinson 1998, p.84), where the threat of violence is omnipresent. Street code adherence becomes a way for young men with vulnerable social and psychological identities to maintain a sense of self and ‘face’, where your ‘face’ is the self that others see.

Assessing mentalising Mentalising processes were assessed via an experience-near, interviewbased measure featuring three movie clips of murders perpetrated by adolescents in response to perceived disrespect. For each clip, participants were first called upon to provide an initial narrative in response to an open-ended question that permitted demonstration of mentalisation

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(How would you describe to a friend what happens between the characters in this scene?). Next, participants were called upon to provide narratives of the offence from the perspectives of perpetrator and victim through a series of questions explicitly prompting and probing for mentalisation at pivotal moments in the scene. These questions included: What thoughts and feelings does the shooter have as he shoots the guy? What was the victim thinking and feeling as he sees the gun pointed at him? Interview transcripts were coded using the Reflective Function (RF) scale (Fonagy et al. 1998).

Mentalising differences As predicted, violent offenders exhibited significantly reduced mentalising processes in the context of disrespect murder. Qualitatively, their narrative processes were characterised by different types of breakdown in mentalisation. These ranged from an overall reduced engagement with the affective states of both perpetrator and victim to the complete collapse of mentalisation, epitomised by descriptions of the perpetrator’s mind ‘going blank’ and the claim that the victim was feeling ‘nothing’. In contrast, controls could maintain a reflective stance and provide descriptions of what both perpetrator and victim might experience in terms of affects, beliefs and motivations. The narratives of the violent offenders differed in terms of their language of agency and identity. In the absence of explicit prompts, they tended to omit any reference to the offence. The initial narratives of the violent offenders were also characterised by brevity, as evidenced by their significantly lower mean word count compared to non-offending controls. These initial offence narratives were more characterised by descriptions of behaviour, with little or no reference to the perpetrators’ and victims’ underlying mental states; they used vague internal and interpersonal contextual language. Murders were described as ‘ending up happening’ rather than being the product of intentional agency. This passivity and sense of identity as someone to whom things ‘just happen’ recalled the narratives of the repeat offenders in Maruna’s (2001) study. When explicitly prompted to mentalise the perpetrators’ and victims’ experiences, code-adhering violent offenders generated narratives that emphasised the perpetrator’s focus on the task of threat neutralisation to preserve his life and social identity, often expressed as ‘doing what

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I got to do’. As one violent offender participant explained: ‘…you gotta stop it right there. At any means necessary…it’s called protecting your manhood.’ This threat neutralisation focus seemed to result in affectively restrictive narratives in the violent offenders. Compared to controls, their narratives were characterised by the frequent omission of affective terms; muted, incongruent affective terms; and/or highlighting the absence of affect: ‘At that moment he’s like, oh, he’s disrespecting me. I’m a kill him. I’m a kill him. No type of feelings. No type of emotions.’ Mentalising processes further collapse under the experience of intense rage and/or fear, and result in an absence of thought and choice: ‘I don’t actually think he’s thinking right there… It’s just blank and it’s like just action.’ This is consistent with Twemlow, Fonagy and Sacco  (2005) description of ‘reactive non-mentalized violence’ and Fonagy’s (2003)  observation that physical actions are experienced as ‘agentless’ when decoupled from their underlying mental states.

Street code adherence and agentic self As expected, violent offenders were significantly more invested in street code adherence than controls. Street code rules cited by participants were seen to operate as a ‘procedural script…for handling interpersonal conflicts and identity formation’ (Anderson 1999, p.80). Personal agency is thus abdicated through adherence to street code rules that prescribe reflexive violence in defence of one’s disrespected manhood. Empathic responsiveness towards one’s victims is inhibited as they are rational­ ised to have brought about their own death through violating street code rules. For youth adhering to street code rules, disrespect-driven violence can be seen as the enactment of a narrative (Toch 1993; Presser 2009), with the narrative operating as a vehicle for identity rather than a ‘post hoc, interpretative device’ (Youngs and Canter 2012, p.234). Disrespectdriven murder, while perceived by law enforcement as ‘mindless’ and ‘about nothing’ (Pearson and Peltz 2014), was seen by code-adhering participants as motivated by the imperative to protect against the death of one’s physical and psychological selves (the latter corresponding to what Gilligan (2000) terms the death of the self). Maintaining one’s respect ‘by any means necessary’ was viewed as ‘the only way to survive’

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on the streets. Respect was considered to enhance the social capital of both the perpetrator and his ‘whole block’. Disrespect-driven murder thus functions to preserve the perpetrator’s self and social identity within his subcultural context.

STUDY 2: LAPSES IN MENTALISING IN THERAPY WITH HOMICIDE PERPETRATORS We used material obtained from two therapy groups to look for lapses of mentalisation in relation to agency and identity. Group members were men who had killed when mentally ill and were detained in a secure psychiatric hospital. They had killed family members, friends or strangers; most had been detained for some time in hospital. These groups were set up in recognition that some homicide offenders experience both posttraumatic stress disorder and complex grief reactions to killing someone (if known to them). In previous work, we have described how killing an attachment figure like a parent or partner can result in loss of identity as well as the stigma of a new and unwelcome identity (Adshead 2011; Adshead et al. 2015). The group therapists used techniques from mentalisation-based treatment (MBT: Bateman and Fonagy 2006) and general traumabased  therapy (Allen 2012) to help group members articulate their experience and explore the narratives that they used at the time of the offence to explain what they had done. Members were encouraged to explore new perspectives on their experience and the possibility of new narratives of their past and future. We work on the assumption that the homicidal act requires a unique combination of unconscious motivations, conscious cognitions and psychotic thoughts that facilitate the killing of another human being. The men are invited to just be themselves and talk with each other in the here-and-now as part of an ordinary psychodynamic group process. They are expressly invited to be the authorities and owners of the stories of their homicide offence; and also to be curious about each other’s stories. They are also encouraged to speak at their own pace, and contribute only when they feel ready, which in some cases may take years. The men learn agency development through repeated opportunities to grapple with their own and other members’ accounts of themselves and the offence.

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Violent states of mind: failures of mentalising in the engagement process A significant clinical issue for these groups was the level of anxiety for all concerned in these therapeutic processes, both therapists and offenders. Anxiety reduces mentalising, so the start of any social process is especially difficult. This anxiety is greatly raised when people are expected to talk about events and experiences that are shaming, terrifying and have led to permanent social exclusion. For some, delusional beliefs and the experience of psychosis provides a defensive rationale for the homicide; for example, Member F describes his mental state thus: I didn’t give a fuck at that time…at the time I didn’t kill for bad reasons but for good – I believe that bad people are raping me in my sleep and good people were saved when I killed this person. The action is bad but the cause is right.

Coming to terms with having killed another person seemed, at times, an overwhelmingly complicated task. Their initial narratives consistently featured language of justification, confusion, incoherence, distress and acute anxiety. Often men described the homicide as arising from feelings of total alienation, desperation and suicidal hopelessness. It seemed that language sometimes failed them in response to such overwhelming affects; for example, at the beginning of the groups, the group members’ intense anxiety was manifested in their use of phrases such as ‘it’ or ‘my index’ when referring to their offence. The therapists found it equally difficult to articulate the offences for fear of evoking unknown, distressing and possibly dangerous affects in the room. All the participants (both members and therapists) had to learn how to regulate their anxiety, and take responsibility for thinking about their choice of words and language when describing emotional states. Repeated experiences of mentalising collapse that were tolerated by the group led to improved emotional tolerance and increased confidence that the group could listen and make sense of what had previously been ‘unspeakable’. Given opportunities to repeat a narrative process and review others’ responses, most members became better able to mentalise their agency for the offence by naming their victims and thinking of the impact of their violence on others. An obvious linguistic shift was

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when the men began to name their victims, especially in the group where victims were known and previously loved. Where they had been speechless about what they had done in terms of agency, they became more able to say ‘When I killed X.’ Behavioural (teleological) examples of lapses in the task of mentalising continued at different points in the therapeutic process, and included sleeping or the closing of eyes for long periods; leaving the room to go to the toilet; and getting up and going for a drink. Verbal examples include describing the homicide in grotesque detail without apparent thought for the people listening.

Identity, agency and mentalising about the time of the killing Statements that suggest a breakdown in mentalising at the time of the offence include references to an identity in which the offender perceives themselves as having no agency; insofar as they described the physical act of homicide as one in which they had ‘no other choice’. Consider this quote from C: I knew I had to kill someone and then I would finally get the help I wanted. So I picked a man out from the crowd, locked my eyes on him, stood behind him and waited for the bus to approach, then I just pushed him in front of the bus, then walked away.

In the group, C portrayed himself as someone to whom things ‘just happen’, but his action expresses a desperate agency that will validate his need. Significantly this man’s offence was preceded by a row with his father in which he felt invalidated. Compare D’s account of his homicide: I was set to kill someone else that day and ended up killing someone I didn’t know… I had murder in my heart that day and this guy crossed my path at the wrong time.

There is a type of agency here, and D shows some self-reflective skills and ownership of his experience. In his narrative, he both owns his intention to kill and also implies that it took place by chance (‘the wrong time’).

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His intention to kill was a solution of sorts and he both did and did not achieve his aim because the actual victim was not the ‘intended’ victim. D’s language indicates ambivalence about agency; he owns his intention, but he also implies that the victim did something by ‘crossing my path’. D refers to himself as ‘set to kill’, which is ambiguous in terms of intention; it might suggest D was determined, but it also implies that D was set, as if he were a machine with a homicide setting. In the group (perhaps like the moment of the homicide), D’s early attempts to mentalise his state of mind at the time emphasised the need to preserve his life and identity, saying of his victim, ‘It was him or me!’ In this homicide narrative, he is a victim who had to neutralise a perceived threat to his identity. Failure of mentalisation is evidenced by D’s persistent perception of his victim (a complete stranger) as a personal enemy. Although he can attempt to mentalise about what was in his own mind at the time, he does not attempt to consider what might have been in the victim’s mind. He both accepts and rejects the identity of a violent perpetrator, and the oscillation between these two positions is a reflection of fragile mentalising. The transition between non-mentalising to mentalising comes with painful awareness of the desperation inherent in the murderous act. This awareness can lead to defensive displacement and projected rationalisation in the live narrative, where the victim becomes the focus: Perhaps you did him [the victim] a favour! He was suffering/bad/disabled, this is bad karma…perhaps he deserved it! – you might have released him from a life he didn’t like?

Here the speaker’s desperation and suicidal need for ‘release’ from suffering is projected into the victim; its persistence into the here-andnow of the group was shocking to hear. As mentalisation improved, group members also gained more awareness of how others might see them. This speaker imagined how he might talk to a woman that he wanted to get to know: ‘I am a killer, a schizophrenic – would you like to come home with me?’ His tone was ironic but also conveyed a sadness at the irreversible impact of his offence on his social and relational identity. He found it almost impossible to reconcile the person he had been before the offence (employed, mentally well, prosocial) with the identity he now had in the hospital. The group

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was able to help him to use the power of telling and retelling in the group to accept that he might have to accept the new identity, and yet still be able to recover some aspect of the old identity.

CONCLUSION Both studies demonstrate that absence or lapses of mentalising capacity seem to be important in relation to how people ‘own’ antisocial violence that leads to social exclusion and isolation. Lapses in mentalising for young American males helped maintain a type of narrative identity which keeps disturbing affects out of consciousness and shores up a strong antisocial identity. The opportunity to change narratives of identity and agency seems to be a crucial objective for these young offenders. Group interventions might offer a way for them to become less restricted in their view of themselves and more open to alternative ‘stories’ of their lives and minds. For the homicide group members, absence of mentalising can keep painfully suicidal feelings at bay and perpetuates ‘pretend mode’ that allows for the preservation of some sense of self from the past who is not an offender. We also note a parallel process between the homicide offence and group therapy in terms of loss of mentalising in response to distress and fear. The material also suggests that at the time of the killing mentalisation processes were deactivated, possibly in response to high levels of affect and arousal. Homicide perpetrators seemed to lose mentalising function when they experienced high levels of shame or perceived others to be dismissing or attacking them. It is likely that this process may reflect damage to affect regulation secondary to abuse and trauma in childhood and adolescence; many, if not all, of these violence perpetrators have experienced serious childhood adversity in the form of neglect, abuse, abandonment and humiliation. Such childhood adversity is known to increase the risk of violence commission in adulthood (Reavis et al. 2013; Baglivio et al. 2014). The mechanism of this association is unknown; one risk factor may be that the experience of chronic fear and trauma prevents the normal development of agency and identity, and leaves the child with unmetabolised fear and distress, which persists in the adult mind as a kind of complex PTSD (Herman 1992). The difficulty of the mentalising task may arise from the fact that early traumatic events are stored as sensory memories, and not conscious verbal narratives

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(van der Kolk 2006); and then unconsciously re-enacted in the fatal violence. Over time, group members have been able to acknowledge that trauma in childhood was recalled and re-enacted in transference to their abuser, so that their victim became for them either the whole or parthated object. The development of mentalising capacity can be a painful process to witness, especially when accompanied by immense guilt and suicidal states of mind. The group process does seem to allow members to develop a greater capacity to mentalise, which then enables and articulates a sense of agency over the choices they make for the future. The realisation that ‘The person I killed wasn’t the person I was angry with’ is a significant marker of better mentalisation, but also offers an opportunity to think more deeply about who might be the proper focus of the anger, and what unresolved conversation is yet unspeakable. Engaging these violence perpetrators in some sort of prosocial activity (like a therapy group) can offer a way out of social exclus­ ion and the perpetuation of an essentially antisocial offender identity. Yalom and Leszcz’s (2005) classic therapeutic factors in group work seem relevant here – especially the universality of experience, as evidenced by this quote: But we can learn from each other because we all have the experience of shame in our life because of the index offence.

ACKNOWLEDGEMENTS We are grateful to the participants in Dr Berko’s study, and the men of Groups A and B for their trust and generosity in granting consent for their material to be used anonymously for educational purposes. We also acknowledge the help and support of Mr Peter Aylward, who supervised both groups, and Dr Estelle Moore, who made the groups possible.

REFERENCES Adshead, G. (2011) ‘The life sentence: using a narrative approach in group psychotherapy with offenders.’ Group Analysis 44, 2, 175–195. Adshead, G., Ferrito, M. and Bose, S. (2015) ‘Recovery after homicide: narrative shifts in therapy with homicide perpetrators.’ Criminal Justice and Behavior 42, 1, 70–81.

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Allen, J.G. (2003) ‘Mentalizing.’ Bulletin of the Menninger Clinic 67, 2 (Special Issue), 91–112. Allen, J.G. (2012) Restoring Mentalizing in Attachment Relationships: Treating Trauma with Plain Old Therapy. Washington, DC: American Psychiatric Publishing. Anderson, E. (1999) Code of the Street: Decency, Violence and the Moral Life of the Inner City. New York: Norton Press. Baglivio, M.T., Epps, N., Swartz, K., Huq, M.S., Sheer, A. and Hardt, N.S. (2014) ‘The prevalence of adverse childhood experiences (ACE) in the lives of juvenile offenders.’ Journal of Juvenile Justice 3, 2, 1. Bateman, A. and Fonagy, P. (2006) Mentalization-Based Treatment for Borderline Personality Disorder: A Practical Guide. Oxford: Oxford University Press. Bateman, A., Bolton, R. and Fonagy, P. (2013) ‘Antisocial personality disorder: a mentalizing framework.’ Focus 11, 2, 178–186. Berko, Z.A. (2015) Street Code Adherence, Callous-Unemotional Traits and the Capacity of Violent Offending versus Non-Offending Urban Youth to Mentalize About Disrespect Murder. Unpublished doctoral dissertation, CUNY Graduate Center. Bracher, M. (2000) ‘Adolescent violence and identity vulnerability.’ Psychoanalysis, Culture and Society 5, 189–211. Drennan, G. and Alred, D. (eds) (2013) Secure Recovery: Approaches to Recovery in Forensic Mental Health Settings. London: Routledge. Fagan, J. and Wilkinson, D. (1998) ‘Social Contexts and Functions of Adolescent Violence.’ In D.S. Elliot, B. Hamburg and K.R. Williams (eds) Violence in American Schools: A New Perspective. Cambridge: Cambridge University Press. Ferrito, M., Vetere, A., Adshead, G. and Moore, E. (2012) ‘Life after homicide: accounts of recovery and redemption of offender patients in a high security hospital – a qualitative study.’ Journal of Forensic Psychiatry and Psychology 23, 3, 327–344. Fonagy, P. (2003) ‘Towards a developmental understanding of violence.’ British Journal of Psychiatry 183, 90–192. Fonagy, P., Target, M., Steele, H. and Steele, M. (1998) Reflective-Functioning Manual, Version 5.0, for Application to Adult Attachment Interviews. London: University College London. Gilligan, J. (2000) Violence: Reflections on Our Deadliest Epidemic. London: Jessica Kingsley Publishers. Goffman, E. (1955) ‘On face-work: an analysis of ritual elements in social interaction.’ Psychiatry 18, 3, 213–231. Herman, J.L. (1992) ‘Complex PTSD: a syndrome in survivors of prolonged and repeated trauma.’ Journal of Traumatic Stress 5, 3, 377–391. Maruna, S. (2001) Making Good: How Ex-Convicts Reform and Rebuild Their Lives. Washington, DC: American Psychological Association. Maruna, S. and Copes, H. (2005) ‘Excuses, excuses: what have we learned from five decades of neutralisation research?’ Crime and Justice: A Review of the Research 32, 221–320. McAdams, D.P. (1993) The Stories We Live By: Personal Myths and the Making of the Self. New York: William Morrow and Company. McAdams, D.P., Reynolds, J., Lewis, M., Patten, A.H. and Bowman, P.J. (2001) ‘When bad things turn good and good things turn bad: sequences of redemption and contamination in life narrative and their relation to psychosocial adaptation in midlife adults and in students.’ Personality and Social Psychology Bulletin 27, 4, 474–485.

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O’Connor, P. (1995) ‘Speaking of crime: I don’t know what made me do it.’ Discourse and Society 6, 3, 429–456. O’Connor, P. (2000) Speaking of Crime: Narratives of Prisoners. Lincoln: University of Nebraska Press. Parker, T. (1969) The Twisting Lane: Some Sex Offenders. London: Hutchinson. Parker, T. (1990) Life after Life: Interviews with Twelve Murderers. London: Secker & Warburg. Pearson, J. and Peltz, J. (2014) ‘Teen crews linked to 40 percent of NYC shootings.’ Associated Press. 1 May 2014. Presser, L. (2004) ‘Violent offenders, moral selves: constructing identities and accounts in the research interview.’ Social Problems 51, 82–102. Presser, L. (2009) ‘The narratives of offenders.’ Theoretical Criminology 13, 2, 177–200. Reavis, J.A., Looman, J., Franco, K.A. and Rojas, B. (2013) ‘Adverse childhood experiences and adult criminality: how long must we live before we possess our own lives?’ The Permanente Journal 17, 2, 44. Sykes, G. and Matza, D. (1957) ‘Techniques of neutralisation: a theory of delinquency.’ American Sociological Review 22, 6, 664–670. Toch, H. (1993) ‘Good Violence and Bad Violence: Self-Presentations of Aggressors through Accounts and War Stories.’ In R. Felson and J.T. Tedeschi (eds) Aggression and Violence. Washington, DC: American Psychological Association. Twemlow, S.W., Fonagy, P. and Sacco, F.C. (2005) ‘A developmental approach to mentalizing communities I: a model for social change.’ Bulletin of the Menninger Clinic 69, 4, 265–281. Ugelvik, T. (2012) ‘Prisoners and their victims: techniques of neutralization, techniques of the self.’ Ethnography 13, 3, 259–277. van der Kolk, B.A. (2006) ‘Clinical implications of neuroscience research in PTSD.’ Annals of the New York Academy of Sciences 1071, 1, 277–293. Yalom, I.D. and Leszcz, M. (2005) Theory and Practice of Group Psychotherapy. New York: Basic Books. Youngs, D. and Canter, D.V. (2012) ‘Narrative roles in criminal action: an integrative framework for differentiating offenders.’ Legal and Criminological Psychology 17, 2, 233–249.

Chapter 5

FOREVER HUNGRY FOR HER EYES The Pain of Maternal Absence ANNA MOTZ

I unswear words, and undo deeds. Naked things know me. I am first and last to be felt of the living. I am Hunger. Laurence Binyon, ‘Hunger’ (1922, p.102)

Maternal absence can be construed as a toxic presence. Neglect has a powerful and destructive impact on the developing infant. Neglect in childhood is one of the most significant predictors of disturbance in later life, distorting and damaging the pathways of development and rendering the sense of self both elusive and incoherent. In this chapter I focus on the impact of childhood neglect and trauma on women, and describe how earlier feelings of rage and hunger can lead to violent states of mind when these women become mothers, particularly in the context of social and economic deprivation. I refer to hunger metaphorically, to mean emotional starvation, but also literally, as the request for food by a child, and the mother’s attempt to respond to this, can become the trigger for a violent, destructive interaction (see also Chapter 6, Volume 2). My focus on hunger as an acute physical and psychological trigger for maternal violence and abuse is informed by the powerful and disturbing research of Kruger

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and Lourens (2016) on ‘the madness of hunger’. This study, significantly, takes place in the violent state of post-apartheid South Africa. The neglect that begins early in life often continues throughout adolescence as these girls are at increased risk of being sexually and physically abused in the context of un-protective parenting. The wish for care and nurturance can be converted into a desperate desire to become a mother, as though the infant will provide the young girl herself with an experience of being cared for and loved (Pines 1997). The task unconsciously assigned to the infant is to soothe the mother, in a reversal of what is required for ordinary development. In this way a cycle of unmet need can be created, though this is far from the young woman’s conscious awareness or wishes (Welldon 1988; Pines 1997). When such an emotionally deprived mother is forced into awareness of her infant’s needs and demands on her for care, she can feel tormented. Not only is the baby not providing for her, soothing her, as she hoped for, but it is making a demand on her, and expressing rage, distress and need; this can sometimes lead to serious, even fatal, violence. The hunger and need which the infant expresses is felt to be unbearable, and is experienced both as a persecutory demand and shaming reproach. The child’s request for food, comfort or contact unconsciously triggers the mother’s memory of her own deprivation and starvation, whether actual or emotional. I suggest that this memory is primarily a somatic one, stored in her body, and experienced as anger. These violent states of mind and body are both powerful and destructive, and can be manifested as an assault on another person or on the self through self-injury. Both anger and hunger can be felt in the guts as wrenching, churning pain; this physical state is felt to demand a physical release. This is an important feature of its primitive potency that can bypass reason or thought. A child, who is consistently faced with an angry, withholding or traumatised mother in response to expressing her needs for food, comfort or protection, takes this in, incorporating it into herself (Byrne 2016). She associates this maternal response with the expression of her need – so what is taken in is not food but hatred, fear, helplessness. The baby introjects her mother’s toxic feelings, so that what is withheld becomes not an absence but a potent, malignant presence. The origin of object relations lies in the first year of life, and most, although not all, psychoanalysts have viewed the infant’s

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initial relationship with his mother as being essentially oral in nature (Ainsworth 1969). In order to investigate the consequences of neglect, I will consider what may happen in the infant’s mind when the maternal object is absent, and how this can create not just a void, but the presence of a malevolent object in its place; or, alternatively, a perverse relationship with an illusory object that will obscure the painful reality of maternal absence (Bergmann 2000). I will outline both the impact of maternal absences, whether actual or psychological, on children and the development of ‘the alien self ’ in the face of an absence of parental reflective functioning. Bateman and Fonagy (2004) understand the incongruence between painful somatic and mental experiences and the responses of the caregivers as key to the development of ‘the alien self ’, an experience of one’s own painful or destructive feelings as unacceptable and overwhelming. That is, the infant’s own experience of her anger, pain or need is felt as alien: it is not met with a contingent response by another, and so a fundamental sense of incongruence is established. The need is not matched with a containing response, so that its intensity diminishes, nor is it articulated by another in language in a way that can help the raging infant to gain a sense of her own mind, and embodied state. The infant’s relationship to the object persists both in its absence and in its presence, and when it cannot be retained in the mind as a sustaining absent object, it becomes instead a malevolent object (O’Shaughnessy 1964). This resonates with how many patients in hospital feel when their carers turn away from them or cannot respond to their needs. Frustration and neglect can become intolerable and this can create a symbiotic and violent relationship between mother and child, particularly when longings and unmet needs are painfully, mutually, reawakened by one another. I will illustrate how the trajectory of damage develops, using both fiction and clinical case material, ending with the story of the feminist and lesbian African-American poet Audre Lorde, who describes the pain of emotional hunger in the context of social deprivation, racial discrimination and poverty. Here interpersonal harm reflects the greater violence wrought by social inequity.

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THE ABSENT OBJECT In her paper ‘The Absent Object’ (1964/2014), O’Shaughnessy describes both the function of the toleration of frustration and the tremendous anxieties that must be overcome in order for this to be achieved: Further, since the original situation of hunger in which the object is absent means starvation and death to the young infant, it is really this threatening extinction which is projected out, and which the reinternalized object will be felt to contain. The internal object is then felt to die from within, and the absent object, by projection, in its turn becomes a dead object. Furthermore, at an immature stage of development, any processes which make for improvement depend very greatly on the presence of the external object, so that in its continuing absence the child is given over to increasing fear and despair… (1964/2014, p.26)

In order to survive the pain of hunger and the fear of being left alone, unfed and unheld, the infant needs frequent and reliable reunions with a breast or maternal object, whose nurturance can be experienced as benign. When mothers are unable to offer this to their children, both the present and the absent breast, the fantasised object in absence and the actual object become imbued with fearful toxic elements. The infant then begins to function as a poison container (deMause 1990) for the mother, who experiences her as a receptacle for her unacceptable feelings – the embodiment of her shame and inadequacy. This reconfiguration of the needy infant into the powerful and persecutory bad object accords not only with the psychic reality of the mother’s mind, but also with that of the infant, who, in the absence of a containing presence, experiences herself as bad, destructive, devouring. She is simply left in the grip of the bad, violent feelings of unmet need, being greedy, empty, angry, bereft and scared. The image of the absent mother has also now been introjected or internalised as a bad and powerful force, a toxic part of herself, so that all she has left to feed on is the sense of rage, hate and need. Without the secure figure who can mirror back to the infant an image of her mind, to contain and soothe the primitive impulses and the devastating pain of hunger, loneliness and fear, the infant does not have the opportunity to learn that she can contain desperate feelings. She is left with an internal representation of badness and toxicity. She finds herself in the presence of a malevolent force that is taken in and becomes an aspect of the self. The developing child suffers a profound

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disconnection between her different and painful mental states; she acquires little sense of an integrated self in which these discordant states inhere. These states need to be identified, reflected back and held in the mind of another, often first through bodily containment, in order to be returned to the infant in detoxified form, and taken in. The malignancy of the absent object is a potent and toxic presence in the mind and body of the neglected infant.

HUNGER OF THE BODY AND HUNGER OF THE MIND The absence of food leads to interacting psychological and physical states of deprivation that create a toxic relationship between mother and child. A mother’s experience of her own hunger, through poverty, limited food supplies, self-inflicted starvation or religious fasting, can also contribute significantly to her inability to contain and nurture a distressed and hungry creature in need. I explore the links between deprivation, hunger and violence in the following anonymised clinical material.

CASE ILLUSTRATION: SOFIA Sofia was a recent immigrant from a middle-Eastern country who found her husband’s absence and the care of two small children, the youngest of whom was born in the UK, increasingly unbearable. They were living in a small apartment; she was unemployed, although had a professional role in her country of origin. She was in her early thirties and felt increasingly alienated; her unhappiness eventually erupted into violence. Desperate to please her neighbours and act as the ‘perfect mother’, she hid her post-natal depression and sense of profound alienation in her new country, and relatively new role. She had recently undergone the bereavement of two siblings and her aunt, to whom she was close, leaving her feeling unstable and vulnerable, desperate for nurturance and care in her own right. Sofia began wearing a gold cross on a necklace following the deaths of her family members. Far from home and alone with only her children, she felt guilty, isolated and desperate. Following a temporary separation from her husband, she was tasked with sole care of the children, aged two and five, both of whom were unsettled by the changes in their household.

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As they became increasingly disturbed, so too did Sofia, and she found herself unable to sleep and concentrate as she normally would. She did not notice that she was increasingly neglecting her children’s needs as she withdrew and increasingly turned to the bible for comfort. She later described this as an attempt to bring her closer to God, but, in hindsight, saw that this was an attempt to find solace for her deep unhappiness. As her mood declined she started to hate her appearance, feeling she needed to diet to become a better shape, a more acceptable form of woman, partly to attract her husband back home. She ate less and less; food preparation became increasingly burdensome. After a few weeks of dieting she felt weak, depleted and sick but triumphant in her defeat of her body’s incessant demands for feeding. Her children continued to clamour for food; on the night of the offence she found their cries unbearable. Additionally she had spoken to her grieving mother on the telephone and felt unable to soothe her and had attempted to speak to her estranged husband, but found him unreceptive. She was preparing soup for the children when they started to cry and wail, then argue with one another. Sofia said she ‘snapped’ and took the stirring spoon she had been using when she entered their shared bedroom to sort out their difficulties. She then took each of their arms in her hands and placed the hot spoon on them, causing burns. She was subsequently arrested and charged with child cruelty and assault, to which she pleaded guilty. Sofia received a prison sentence, an outcome that horrified her. Once her crime was known within the prison she was bullied and intimidated, considered a monstrous inhumane mother, echoing something of how the local authority had viewed her, despite her admission of guilt. Her statements were devoid of emotion as she tried hard to keep control over her feelings and saw depression as a sign of weakness. To the professionals, and to the judge, Sofia appeared to be solely a perpetrator, outsider and alien, whose anger could not be understood or thought about other than as the mark of her ‘badness’ and thus justification for further removal – to prison, where she could remain away, apart and Other. However, a fuller picture of her emerged in the prison, and she was able to engage well in art therapy, where she felt accepted and understood. Upon her release she re-engaged with therapeutic services, reentering a parenting programme she had been forced to abandon when she went into custody. It had helped to maintain a relationship with her through our visiting her in prison, and she expressed gratitude

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for this. She had made considerable progress in terms of exploring her own mind, and beginning to be curious about her children’s, despite the painful awareness she was developing about the impact of her actions on them. Eventually we were able to recommend that she reunite with her children for extended contacts, though she was not yet considered a suitable carer for them. Her ex-partner was granted custody and she was allowed frequent, regular contact meetings; this was closely supervised and conditional upon her full apology to them and assurance that she would never harm them again. Her guilt and shame about her actions remained intense, and therapy focused on her attempts to understand the ‘alien self’ that had overtaken her on the night of the offence. During therapy her own early experiences of maternal neglect and inconsistent, fragmented care were gradually uncovered and her parenting strengths were supported. She was able to be warm, loving and attentive to her children, within the context of a holding therapeutic environment, and to explore the meaning and harm of her violence against them, although she found this aspect of the work painful and disturbing.

THE IMPACT OF CHILDREN’S HUNGER ON MOTHERS: VIOLENCE AND FAILURE TO PROVIDE Sofia’s violent state of mind reflects the impossibility of caring for others when feeling so deprived herself; she enacted her sense of rage and injustice with the very tools of domesticity, subverting the expected role of carer and food provider. She inflicted injury on herself through starvation and hurt the children with the stirring spoon, a symbol of maternal care usually associated with an idealised image of motherhood. Her hunger of the body and of the mind led to savage acting out and a cruel misuse of power. While she described this as an impulsive loss of control, the children’s statements indicated that she returned at least once to the pot to heat the weapon, suggesting a more calculated and sadistic form of punishment and expression of rage. The tools of food preparation are significant, and this act of injury using fire can be seen to express an elemental, primitive rage. Sofia subverted the very act of maternal care and nurturance, waging rebellion on the idealised notion of sacred motherhood. She burned the children who wanted her warm food and care; the marks on their

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skin were evidence of her own burning rage. This act of desperation and fury drew attention to her dangerous state of mind and led to protection for the children, but the underlying meaning of the burning, and its communication of distress, desperation and grief, were not understood. She was configured solely as perpetrator, rather than perpetratorvictim, a woman who both inflicted harm and suffered in her own right. As a perpetrator she was condemned and exiled to a prison, repeating something of her previous experience of migration from her home. Although we had recommended therapeutic assistance in place of custody, she was not afforded this ‘luxury’ and was instead imprisoned, albeit for a relatively short period of time. Mothers who assault their children may have experienced emotional starvation throughout their lives, but it is also crucial to acknowledge the impact of social and economic deprivation. Faced with needs that simply cannot be met, they may respond with violent states of mind that can, under extreme pressure, result in violent action, designed to stop the unbearable demands. The feeding situation, so clearly one of the most idealised and primitive expressions of maternal love, exemplifies the act of self-sacrificial giving and gives rise to hope of limitless nurturance. In reality, those mothers who simply cannot find the food to feed them can perceive their children’s hunger as a shameful and persecutory reflection on their own maternal capacity, limited both externally and internally. Kruger and Lourens (2016) poignantly describe how poor women of colour in South Africa experience their children’s hunger. They focus on the shame and rage of being met with children’s hunger and the assumption that they can satiate the demand – ‘everyone asks me for a piece of bread’. The authors focus on how these mothers cope with the pain of not being able to provide for their children’s needs and how intolerable this is. It can lead to violence in an attempt to rid themselves of uncontained feelings of being fed from, demanded of and unable to provide. As was the case with Sofia too, their inability to meet their children’s needs and the violent reactions this triggers then serve as evidence of their inabilities and imperfections, as though the societal context is irrelevant: ‘A vicious cycle of hunger, sadness and anxiety, shame, anger and anomie, aggression and withdrawal, negative judgement, and more shame, are thus maintained. As such, the unbearable rebukes of hungry children can be thought of as evoking a kind of “madness” in low-income mothers’ (2016, p.125). The widely held fantasy of infinite

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nurturance is that it comes from within, and that limited resources without are irrelevant. This is an idealisation of maternal capacity that can rapidly turn to vilification. It is essential to acknowledge the economic realities that may drive maternal violence. Kruger and Lourens offer the following example: Sterretjie: He makes coffee all the time and this stresses me, because it’s sugar and such stuff is EXPENSIVE. And now his friends also sit there and he makes [coffee] for them. I then just hit him with a stick – in front of his friends. And I take the coffee and I pour it down the sink. See, everything is frustrations that comes inside of me…I just TAKE the things. I will take the bread, then I just throw it for the dog… He, he already ate. Don’t take again and eat, ask me… And he eats…that child eats continuously! I must lock everything. (2016, p.133)

In this example, what becomes clear is how the mother’s rage grows when her son makes his friends coffee, as she appears to see this as his taunting her, or perhaps as an example of his wastefulness. She retaliates by humiliating him, hitting him in front of his friends, then wasting the coffee by pouring it away. As the authors note, hearing these descriptions of uncontained rage by mothers, directed towards their children, is distressing, but this response too has to be interrogated in terms of gender constructions about maternal care and aggression. Throwing the bread to the dog offers a further example of this mother’s wish to punish and perhaps frighten her son, who presumably is already scared, humiliated and shamed by her frightening outbursts. She has projected her own unacceptable and unbearable feelings into him. She experiences his eating, and giving coffee to others, as unbearable; one has the sense that she feels he has devoured her, attacked her ravenously with his insatiable need and wastefulness. We can understand the violence that takes place between mother and child as an expression of the mother’s own harsh treatment, in terms of social and economic hardship, and also in relation to her impoverished and punitive view of herself. These mothers are deprived of essential resources, in a social system within which they are devalued, mistreated and neglected. In this sense the mothers are victims of systemic violence who then turn their rage onto their children, whose needs they cannot meet, and whom they consider insatiable. They then take on the shameful role of perpetrator.

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The anomie of impoverished mothers with hungry children is prominent in our findings. While at times this anomie left us as researchers frustrated and helpless, it does serve to highlight the neoliberal economic system’s failure to provide for the poor, ‘and makes explicit the violence of a system that can suck anyone dry’ (Nouvet 2014, p.90). This is an apt metaphor when considering the cruelty and reciprocal violence of a mother being sucked dry, and a child who is left to starve.

ZAMI: MATERNAL AND SOCIETAL NEGLECT AND CRUELTY In her autobiography, or ‘biomythography’, Zami: A New Spelling of My Name (1982), Audre Lorde describes her early childhood in terms of constant yearning for maternal care and understanding, and the neglect she faced, alongside beatings and verbal chastisement. She describes her painful, unmet needs for her mother’s comfort, but also how, despite her brutality, her mother offers her lyrical words, snippets of songs and phrases from her birthplace of Carriacou, that feed her imagination. Lorde shows how the socio-economic context within which maternal care takes place cannot be ignored; that the mother struggling to raise her children in situations of limited resource and a hostile environment may herself feel too depleted and pressurised to offer her children the emotional as well as physical care they long for. Her own situation as a woman of colour, away from her country of origin and ripped from home, raising a young family in a segregated and discriminatory New York City, leaves Lorde’s mother with intense and buried rage and a terror of letting her guard down. She too is in a place where care is absent, where home and mother are no longer available to her. She is brutal in her treatment of her daughters, especially when they don’t conform to expectations and threaten to bring shame on the family. In this way the daughters, especially the inquisitive and imaginative youngest child, Lorde herself, are effectively silenced, if not fully hidden. Despite her severely impaired vision and the distortions it has created in her perceptions of the world, Lorde sees the pain of others with intensity and sensitivity. She vividly describes how her friend, Gennie, sexually abused by her father and desperate for escape, was not protected by her own mother, or offered refuge by Lorde herself, who was scared that her mother would refuse her sanctuary. Gennie has no alternative

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but to return to her father’s abusive ‘care’. On her sixteenth birthday she kills herself, leaving Lorde with enduring grief; this grief and her love for Gennie are recurrent motifs in her poetry. She describes here the violence of neglect: I lost my sister, Gennie, to my silence and her pain and despair, to both our angers and to a world’s cruelty that destroys its own young in passing – not even as a rebel gesture or sacrifice or hope for another living of the spirit, but out of not noticing or caring about the destruction. I have never been able to blind myself to that cruelty… (p.282)

Lorde’s rage against this blindness speaks to an early environment in which her emotional states could not be named or reflected back to her, both because of her mother’s refusal to allow her to express pain and because of the racism and censorship of wider society, that overlooked them both. Many imprisoned women could tell a similar story today; their lives of pain and trauma have to be borne and suffered in silence, communicated through encoded expressions of pain, sometimes written on their own flesh. Their rage and trauma remain largely invisible, disguised and hidden.

ANGER, ABSENCE AND HUNGER Lorde describes how society cannot tolerate female anger and forbids its expression. Silencing the voices of women can be experienced as a repeated violation and act as incendiary to actual violence. She shows how for her, as for so many women with childhood trauma who face racial and cultural oppression, anger becomes a potent but hidden force, whose open expression is prohibited. She describes her own hunger to be seen and heard. It is considered unacceptable for women to express anger, particularly if these women are mothers, because of deeply held gender stereotypes and cultural norms relating to the sanctity of motherhood (Welldon 1988). Women who have experienced early neglect and abuse, and who face current hardship, can feel overwhelmed by feelings of rage, frustration and desperation. It is not surprising, then, that when anger’s expression is forbidden it goes temporarily underground, only to erupt explosively against those closest and most helpless to withstand assault: their children. At such times, these children become sources of persecution. Their mothers

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see them as witnesses to their inability to provide: insatiable monsters who insistently demand to be offered that which cannot be given, such as food and comfort (Kruger and Lourens 2016). Both food and love may be deliberately withheld, as the mother seeks revenge on the child, whose demands feel unbearable. The mother’s inability to respond to their relentless request for feeding and care leads to profound shame. They may then act in the grip of retaliatory urges to blind: to cast out the offending eye that sees their disgrace and to silence the hungry cries of their infants. These cries re-awaken their own, creating an intolerable situation. Their sense of shame triggers their violence (Gilligan 1997).

CONCLUSION In this chapter I have explored the consequences of early experiences of maternal neglect in the context of social deprivation. I have shown how, in the absence of the containing and sustaining object, the infant is left with a malevolent absent object. Such infants are at risk of developing an alien self, a sense of profound disconnection from their own aggressive and hungry states of mind and body. When they become mothers, the needs of their own children can feel impossible to meet and can trigger their own experiences of a painful absent object, leading to intense anger and longing. The unmet needs of their children place impossible demands on these women who are themselves deprived of essential emotional, psychic and material resources. This shared privation is a significant trigger to maternal violence – the unleashing of the alien self – and reveals maternal abuse as both a social and an intra-psychic problem, with far-reaching consequences for children. I have highlighted the central role of hunger, as both a psychic and a physical state, and I have stressed the need to understand its role in triggering violence in the mother–child relationship. Like the internal representation of a malevolent absent mother, the pain of hunger is savage and frightening. Women faced with this malignant presence are not only at increased risk of unleashing feelings of rage on their children and themselves, but can also find themselves searching all their lives for the sense of care and experience of being properly seen, understood and wanted. In her prose and poetry, Lorde describes the intensity of this unmet need for her mother’s love and nurture, as seen in the lines below, from her poem

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‘From the House of Yemanjá’. They evoke the pain of not being the perfect (white) daughter her mother had wanted, and her ongoing quest for her to see her in her blackness, in the image of the black mother goddess Yemanjá. My mother had two faces and a broken pot where she hid out a perfect daughter who was not me I am the sun and moon and forever hungry for her eyes. (Lorde 1973, p.235)

The metaphors of cooking pots and hunger are clear here. Lorde has been ‘cooked up’ by her mother into someone who remains forever searching: hungry, angry and unseen.

REFERENCES Ainsworth, M.D. (1969) ‘Object relations: dependency and attachment. A theoretical review of the infant–mother relationship.’ Child Development 40, 969–1025. Bateman, A.W. and Fonagy, P. (2004) ‘Mentalization-based treatment of BPD.’ Journal of Personality Disorders 18, 36–51. Bergmann, M.A. (2000) ‘A world of illusion: the creation of a perverse solution as a reaction to parental emotional absence.’ Canadian Journal of Psychoanalysis 8, 1, 41–67. Binyon, L. (1922) The Selected Poems of Laurence Binyon. New York: Macmillan. Byrne, G. (2016) Personal communication. deMause, L. (1990) ‘The history of child assault.’ Journal of Psychohistory 18, 1, 1–29. Gilligan, J. (1997) Violence: Reflections on a National Epidemic. New York: Vintage. Kruger, L. and Lourens, M. (2016) ‘Motherhood and the “madness of hunger”: “…want almal vra vir my vir ’n stukkie brood” (“…because everyone asks me for a little piece of bread”).’ Journal of Culture, Medicine, and Psychiatry 40, 124–143. Lorde, A. (1973) ‘From the House of Yemanjá.’ In The Collected Poems of Audre Lorde. New York: W.W. Norton and Company (2002). Lorde, A. (1982) Zami: A New Spelling of My Name. Berkeley: Crossing Press. Nouvet, E. (2014) ‘Some carry on, some stay in bed: (in)convenient affects and agency in neo-liberal Nicaragua.’ Cultural Anthropology 29, 80–102. O’Shaughnessy, E. (2014) ‘The Absent Object.’ Reprinted in Inquiries in Psychoanalysis: Collected Papers of Edna O’Shaughnessy. Hove: Routledge. (Original work published in 1964.) Pines, D. (1997) A Woman’s Unconscious Use of Her Body. London: Virago. Welldon, E. (1988) Mother, Madonna, Whore: The Idealisation and Denigration of Motherhood. London: Free Association Press.

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Chapter 6

VIOLENT STATES IN FEEDING DISTRESS The Antigone Paradigm and the Creative Possibilities of Collective Re-Imagining JOHN ADLAM

I will not eat the food that you offer, but if you didn’t offer it I would feel desperately alone, unnoticed, uncared for. I want and need you to offer it to me, SO that I can refuse it. How else could I tell you that the care is not enough, is not right, not sufficient, not there at the right time, might be taken away when I have not yet grown out of the need for it…? The offering is important, even if I refuse it. Beth, from ‘Persona Non Grata’ (2017, p.32)

…when the ‘matter in hand’ becomes substantial, in the most literal sense of the word, an actual giving and receiving of food, ready cooperation may come far less easily. For the sufferer of an eating disorder, the notion of actively engaging in the restoration of their health can be fraught with ambivalent feelings about compliance and recovery. The body becomes a battleground. Anonymous expert by experience (Conference poster presentation, 2014)

A hospital ward. The institutional clocks have ticked out the rhythms of mo(u)rning. They perpetually disagree, as to the precise hour, but their findings nonetheless sketch a broad consensus: by custom and decree, it is to be lunchtime. A communal meal is to be served: accurately, con­ siderately, punctually – or otherwise. It may be received or it may  be 81

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refused or it may be more or less covertly redistributed – or it may be replaced (whereupon, the agonised dance will resume) with a liquid supplement or a bolus feed. The stage is set for a fraught encounter. The cast is either gathered or scattered, according to temperament and role, habit and pattern. I am one of two members of staff who will be sharing (supervising?) the meal. I hover by the dining room door. The clocks have tricked me: it is too early to sit down to table, too late to wander back down the corridor again. Those colleagues who must perform the presenting of the food are gathered in the kitchen, assembling dinner trays, calculating portions. They busy themselves in the masking of their anxiety; much is riding on their endeavour. Myriad are the potential slips, in this contested ground, ’twixt cup and lip. Some of the patients have been gravitating towards the scene of the impending meal for 15 or 20 minutes, sometimes more. Others have gone to ground: in their rooms; in the bathrooms; in discreet angles of the ageing, fading corridors (the building used to provide accommodation for nurses: lines of sight were not a design consideration). One or two patients hover at the kitchen door, for an offer of food is anticipated and vigilance must be exercised accordingly. The offer must be scrutinised: for it must be just so, it cannot be otherwise. Or perhaps it cannot really be entertained on any terms – but nonetheless, if only because habit and pattern demand, the offerers must be cajoled, implored, assuaged; rebuked, diverted or dismissed. A powerful list of words, perhaps: for the patients may also know what it is like to be the objects or recipients of all these various moves and practices… These prolonged preliminaries thus consummated, an event now unfolds that bears the semblance, the shape or the structure of a communal meal. I sit at the head of one of the two main tables. I know clearly that I am not feeling comfortable – I sense myself cast in the role of some Victorian patriarch, as if with a stern eye to table manners and a solid conviction that the children should be seen and not heard. But I am the only member of staff at this table, and the patients, whom it is at least part of my given role to ‘over-see’, have strong ideas about the seating plan (but are we not all of us creatures of habit?). They do not suffer any of us lightly to come into their midst. Rarely have they any very strong sense of their ‘place in the world’, or so it seems to me: however, they have identified which seat they will each occupy – which insecure housing they will take up – the better (the safer?) from which to address the food

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that is offered, each according to their own individual and unique style of responding to that offer.1 One may hasten; another may dawdle. One may take in a mouthful in a measured enough manner; but if my eyes drop down to my own plate for a few seconds, she will be as quick as lightning to deposit, in her trouser pocket or some other fold of clothing adapted for the purpose, some quantity of the unacceptable offering. Another’s cheeks are suddenly swilled with the regurgitated food I believed her to have swallowed a few moments before. I catch her eye. I hope that my own eye is versatile enough in its communicative powers to perform the various tasks I now urgently need of it: that I may signal respect and concern; that she may know I have perceived her, while not feeling that my gaze has been too intrusive; that she may somehow not mis-read the thoughts I am trying to signal; that I would wish she could keep down the foodstuffs that have thus been covertly recycled – but not from any moralising grounds; that I am worried her fellow patients will be aware, but I am also worried for her own well-being; finally, that I perceive something of the state of mind out of which this unintended, reflexive practice of hers has emerged – but that I will keep these thoughts of mine close to my own heart and not try to press upon her, like so many further unwelcome kilocalories, my own sense of what it is like for her… ✳✳✳ Because such men live in violent circumstances, their language too, almost like the Furies, will speak in a more violent configuration. (Friedrich Hölderlin, from ‘Notes on the Oedipus’, 1802/2009, p.323)

To paraphrase Dostoevsky’s comment concerning prisons (1862): the degree of civilisation in a society might be judged by entering its eating disorder units. Right up to the turn of the century, patients were confined to their beds with a commode and force-fed up to low-normal body 1

A twist in this tale is that at one point we staff got into the way of thinking that it was indeed our role to organise the seating plan for the patients and to lay out personalised place mats accordingly. The patients in turn became understandably resentful of this intrusion. The dynamic had to be renegotiated in the forum of the daily community meetings. There is a cautionary tale here about the giving and the (habitual?) claiming of power alongside the offering of food.

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weight and no questions asked (or, at any rate, no questions answered). I can’t say that nobody’s life was saved by this violent ‘surgery’; but I can testify that the iatrogenically traumatised older adult selves of quite a few such sufferers still pace the corridors of places like the one I work in, unable quite to shake off the horror of those experiences – perpetually finding themselves back at the ‘scene of the crime’. There does seem to be something about the experience, on the part of the offerer, of food being spoiled or declined by the sufferer, that stirs powerful retaliatory urges. The encounter and exchange between the offerer and the receiver of food – or between withholder and hungerer – is one fraught with furies and ‘full of sorrow and leaden-eyed despairs’ (Keats 1819/1986). A violent state, interpersonally and psychosocially situated, may be said to obtain: between the would-be feeders and the won’t-be fed; also between the would-be fed and the won’t-be (or can’tbe) feeders. This violent state is almost nowhere addressed in the ‘clinical’ literature – perhaps because the clinical literature remains largely unconscious of its own violence (but see e.g. Treasure et al. 2011). (I do not propose here to argue against coercive interventions in the field of ‘eating disorder’ – it is the violent state within and from which coercion is often pursued that I seek to problematise.) The very term ‘eating disorder’ – like its conceptual cousin, ‘personality disorder’ – carries with it a pejorative attribution and a distorted/distorting focus on the behaviour of the constructed other (my title for this present chapter offers a new suggestion on terminology). The contested term ‘personality disorder’ is critiqued by a vast literature that there is not space to review here. It may suffice to note David Jones’ clear and detailed psychosocial history of the emergence of the term out of the explicitly violent attribution of ‘moral insanity’ (Jones 2016). My colleague Chris Scanlon and I have in the past proposed the term ‘interpersonality disorder’, at least to signal that the proper focus might be upon the disturbance that occurs between people, rather than to locate the disturbance solely in the feared or hated other person (Scanlon and Adlam 2006). Berkshire (2011) explicitly constructs ‘eating disorders’ as a violent field of thought. She imagines the difficulty ‘of attempting a clinical critique that does not mean to offend practitioners, but instead, works to lament the violent thought they are asked to practice with’ (2011, pp.335–6). She finds evidence for a violent state in ‘taxonomic thoughts, including all diagnostic statements about the client, which foreclose on

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avenues of thinking (including her authority to speak to her intentions) that might otherwise offer an embrace of the client’s being (just as she is)’ (p.336): thus raising an important challenge to the very claim of psychiatry to have anything to say about these practices. My principal focus in this chapter is upon violent states that obtain between offerer and refuser and societally in relation to the offering and withholding of food. I offer the conceptualisation that the violent state of mind of the sufferer herself – the intrapsychic state – is one in which agonised and agonising deliberations and circular loops of thought (‘antithought’, perhaps?), consequent upon the intensities of dread and longing that spiral outwards from the idea that food may be offered, generate surges of anxiety and distress. This state of mind is teleological (see e.g. Skårderud 2007, p.330): the imperative that something must be done may very rapidly dominate, flooding her consciousness. Violent deeds – vomiting, selfstarvation, self-exhaustion and other practices of self-harming – may often appear to be the product of these states of mind. These violent states and the refusal which appears to be at their centre are phenomena which may often be mis-recognised. In fact, since I began writing about food refusal and trying to find language in my clinical practice for my thoughts about this phenomenon, more than one sufferer has challenged my use of the term ‘refusal’. They have pointed out that I am thereby attributing intent, conscious or unconscious, even as I try to caution against that particular kind of violence being perpetrated. Here therefore, in relation to the concept of ‘refusal’, I am taking care to specify the perception of the offerer – the violent state of mind in the offerer that may emerge in response to his experience that his food is being refused. ✳✳✳ There is no health; Physitians say that wee, At best, enjoy but a neutralitie. And can there bee worse sicknesse, than to know That we are never well, nor can be so? We are born ruinous: poore mothers cry, That children come not right, nor orderly; Except they headlong come… John Donne, from ‘The First Anniversarie’ (1611) (Donne 1983)

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Robert Hinshelwood (1999) observed that the ‘difficult patient’ is a construct born of our difficulty with the patient. It is assuredly difficult for the sufferer to be suffering; it is likewise difficult for the offerer to behold this suffering; but the sufferer is not ‘being difficult’. This is no practice of difficult-ness; she is simply standing in the only place she feels she can. She may come ‘not right, nor orderly’, yet still she has absolutely the right to be received. In any case, as Berkshire argues, ‘[the sufferer] should inform our practice – not the other way around’ (2011, p.338). We (in the societal in-group) do not like to think in terms of Donne’s ‘neutralitie’ – we define ourselves as ‘well’ and we do so in opposition to ideas and constructs of sickness – and it is here that the ‘violent state’ forms. The notion that it is not ‘their’ difficulty in ‘being a patient’ that besets us, but our own frustrations and other feelings stirred as we address their suffering, is particularly rigidly defended against in the field of eating disorders. Beth (2017) asks the question of us directly: ‘How can you keep offering, in the face of such hollow-eyed and relentless refusal of all the good that you would seek to instil? How do you not, sometimes, feel the rejection of the food to be a symbolic refusal of your best attempts to care, support, deliver what you were able…’ (p.28). The answer must be that ‘we’ do certainly feel it thus. This may be because ‘we’ as clinicians (and carers) so strongly identify with the ‘provider’ role (Scanlon and Adlam 2012): we need our patients to accept and enjoy our ‘food’, be it calories or medication or nursing care or psychotherapies. How can we be feeders, if no one gets fed by our feeding? We need to know that we have ‘good stuff ’ on offer; perhaps we seek reassurance, in this knowing, that we are making rational food choices ourselves (that these selfsame food choices are not laying waste to our planetary environment, for example). We, the offerers, may consequently feel undermined, in our very sense of personal and professional self and citizenship, if our ‘good food’ seems to us to be refused or spoiled or purged, as if it were swill or poison. We may also even be feeling a little uneasy about the psychiatric frame within which we work: it must be ‘their’ difficulty in ‘being a patient’ and not ‘our’ difficulty in establishing a plausible taxonomy from which to authorise our interventions. We therefore tend – almost, we feel impelled – to see ‘the problem’ in terms of the refusal, not in terms of that which is offered or of the way in which it is offered. It is then but a small step to seeing the sufferer’s refusal

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as a kind of ‘lifestyle choice’ that could be given up, if only the sufferer would ‘see sense’ and ‘just eat up’. Severe eating disorder then takes its place alongside other psychosocial constructs such as ‘intentional homelessness’ or ‘deliberate self-harm’ or ‘fecklessness’, in which sufferers are (mis-)construed as needlessly suffering through their own ‘wrongthinking’ choices (see Chapter 2, Volume 1). This brings me to the figure of Antigone (Adlam 2015).2 At the climax of Sophocles’ tragedy, the Chorus tells Antigone that ‘You are the victim of your own self-will’ (Sophocles 1947, p.149). More than two thousand years later, Jean Anouilh’s Creon, in his complaint to the Chorus, exemplifies this violent state of mind of the self-styled spurned helper, caught up in a furious attribution of intent: ‘It was her choice. She wanted to die! None of us was strong enough to persuade her to live… All that mattered to her was to refuse everything and to die’ (Anouilh 1944/2000, pp.49–50). To Antigone and her paradigmatic, violent encounter with secular (medico-legal?) authority (and tyranny) in the person of Creon, I now turn. ✳✳✳ The tradition of all past generations weighs like an alp upon the brain of the living. (Karl Marx, The Eighteenth Brumaire of Louis Bonaparte, 1852, p.1)

Interventions on the part of the societal in-group, the system of care, directed towards the suffering and excluded out-group of the ‘patient population’, in the contested field of ‘eating disorders’, gravitate towards a stand-off that is both rigid and volatile. In my earlier paper (Adlam 2015) I explored the dynamics of a particular kind of fraught encounter in which the ‘irresistible force’ of medico-legal technologies (the Mental Health Act, naso-gastric feeding, restraint and sedation) meets the ‘immovable object’ of the individual patient’s refusal (as perceived by the familial or clinical grouping in question) to accept food and treatment on the terms offered. 2

There is not space to rehearse the story of Antigone here in detail. The reader is referred to the original (Sophocles 1947). The vast secondary literature is brilliantly reviewed by Steiner (1986). My previous paper (Adlam 2015) summarises the story and picks out those aspects that may particularly pertain to the theme of the present work.

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Alongside a group of anonymous experts by experience, I offered the concept of the ‘Antigone paradigm’ to conceptualise the nature and the field of conflict of this violent encounter between in-group and out-group, which is represented in Sophocles’ ancient tragedy by the figures of Creon, the tyrant of Thebes, and Antigone, Creon’s niece and the daughter (and sister) of Oedipus (Sophocles 1947; Steiner 1986; Butler 2000; Honig 2013). As Hölderlin (1802/2009) suggests, in relation to Antigone and Creon, in this version of the patient–psychiatrist encounter the parties are ‘equally balanced against one another’ in antiformal reaction and formal counter-reaction (Hölderlin 1802/2009, p.329). The dialectic, endlessly played out on eating disorder units, is between Antigonean ‘anti-formal’ food refusal inherent in her practices of self-abnegation and self-abjegation and the ‘Creonian’ deployment of medico-legal technologies in ‘formal’, coercive pursuit of and insistence upon what Lacan (1992) identifies as the excess of a ‘rule for all’. The Sophoclean tragedy can be taken as a ‘case history’ to illustrate a violent state obtaining between, on the one hand, generations of ‘Antigones’ who have not felt able to take up their place in the domain of the living and, on the other hand, generations of ‘Creons’ whose moral and ethical authority to govern they have challenged in their different ways of being. The Chorus in the play spells out the fate of she who would raise such a challenge and stand in proud defiant opposition to the Law – she shall be deemed ‘apolis’, stateless, beyond the pale: ‘banned from the hearth’ (Steiner 2011, p.207). She shall be subjected to the ‘civic death’ of the Code Napoléon – here is the paradigm for Agamben’s ‘states of exception’ (Agamben 2003/2005). Here is articulated the paradigmatic social exclusion of the alienated and oppressed outsider, and I trace back to the figure of Antigone, via the Romantics and anorexia mirabilis (Bell 1987; Vandereycken and Van Deth 2001; Adlam 2015; see also Chapter 7, Volume 2), the long history of an aesthetic of refusal in Western literature and civilisation. Levi-Strauss’ anthropological study of hostile responses towards the difference of the other (Levi-Strauss 1955) illuminates the reflexively violent state obtaining between the system of care and the treatmentrefusing sufferer in terms of the alternating dominance of impulses which he termed ‘anthropophagic’ (cannibalistic) and ‘anthropoemic’ (a coinage meaning literally ‘emetic of humankind’). In both these violent states, consciousness of the problematic difference is destroyed.

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In ‘anthropophagic’ responses, problematised difference is abolished through being coercively incorporated, swallowed up, consumed. There is no difference ‘left’, for now ‘we’ are all the same. In ‘anthropoemic’ responses, on the other hand, difference is abolished by being vomited out, evacuated, expelled. There is no difference left to trouble us, for the different other has been expelled from consciousness. In Genet’s play ‘The Maids’ (1947), Claire, channelling Madame, expresses the ‘anthropoemic’ position with vicious clarity: ‘Je hais les domestiques… [elles] n’appartiennent pas à l’humanité… Moi, je vous vomis’ (‘I loathe the servant classes…they are no part of the human race… Me: I puke you out’ (my translation)) (Genet 1947/2012, p.65). If the presenting syndrome around complex ‘eating disorders’ has indeed become more severe over time (see e.g. Adlam 2014a), then it is important to note that some of our Antigones lately in treatment were also in inpatient treatment 10 or 15 years ago, when inpatient units could ‘cherry-pick’ on criteria of motivation, psychological-mindedness and ‘willingness to abide by the spirit of the programme’. When the (we?) Creons of those days discharged them for not giving up all their ‘behaviours’, or for failing to ‘work in alliance’ or ‘in the spirit of the programme’, perhaps the anthropoemic dynamic was dominant. It might equally be important to note how those anthropophagically normative selection criteria included only ‘people like us’ (‘psychologically minded’?) – well, maybe…and that Antigone, if she presented truthfully, as Antigone herself feels bound to do, would not have been able to access treatment. I do not concretely suggest that Sophocles’ Antigone was anorexic; although Anouilh’s twentieth-century, wartime, adolescent Antigone explicitly is. Neither do I offer Antigone as representative of all sufferers engaged with or avoidant of eating disorder services (although I believe there will always be points of reference to the history of that aesthetic I have already mentioned). However, there is a group of contemporary Antigones whose difficulties are severe and who, manifestly, do not plausibly fall within existing structures for the diagnosis of ‘eating disorders’. They are often parentified children; they are traumatised; their very selves have been invalidated and negated. There may not be explicitly an incestuous tangle in their history, of the extreme kind that Antigone had to endure; but transgenerational transmission of some kind of familial trauma is frequently manifest: ‘weighing like an alp’ upon these

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sufferers is Kierkegaard’s ‘inherited guilt’ (1843/1992). Feeding distress – the violent state that obtains between the offerer and the ‘refuser’ – is the field in which contemporary Creons and Antigones play out their fraught and doomed collisions. ✳✳✳ This has been a truly collaborative process (rather than the normal ‘tokenistic’ nod to Service User involvement). This is reparative and ‘bridging’ – reaching across the chasm between Creon(s) and Antigone(s). I have felt seen, heard and respected (the antithesis, I feel, of my inpatient treatment). In this sense the author has/is practising the ‘hope’ driving this project and creating the beginnings of the collaborative reimagining he is advocating. (Anonymous expert by experience, from Adlam 2014b)

In October 1821, Shelley wrote to fellow poet John Gisborne: ‘You are right about Antigone – how sublime a picture of woman!… Some of us have in a prior existence been in love with an Antigone, and that makes us find no full content in any mortal tie’ (Shelley 1840). Hölderlin writes of Antigone’s ‘sublime mockery’ and of her ‘sacred madness’ as ‘the loftiest human phenomenon’; in her person he finds ‘the superlative of human spirit and of heroic virtuosity’ (2009, p.327). Antigone’s abilities and resources; her integrity and her vision; her love for her brothers and sisters; and her loyalty, courage and resilience are justly celebrated. Is it only in the service of her honouring of and identification with the lamented dead that these qualities manifest themselves? Violent states pervade Antigone’s life, her personal and familial history, her politics and her legacy. This is a reflexive violence (see Chapter 2, Volume 1); in uneasy identification with Creon, we, the in-group, cause her to have to wrestle with antinomial claims upon her allegiance. Steiner writes that Sophocles’ Antigone ‘goes freely into the blackness of absolute extinction, an abyss made the more terrifying by the possibility that her stance has been erroneous’ (2011, p.101). But is violence the only lens through which to view the practice of Hegel’s ‘Divine Antigone’, ‘that noblest of figures that ever appeared on earth’ (Steiner 2011, p.101)? As Honig points out, Antigone is not ‘only death-identified. She also acts in ways which promote life, though this facet of her is rarely noticed’ (2013, p.30).

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Sophocles’ Antigone is the first individual character in literature to whom the hitherto solely political concept of ‘autonomy’, of ‘selfgovernance’, is applied (McNeill 2011). This is of critical importance, partly because many of the contemporary sufferers I have in mind may be understood to be caught up in paradoxical practices of the pursuit of autonomy through starvation; partly because in the figure of Antigone is thus located the interplay between individual and societal violent states (as Hölderlin emphasises (2009, pp.331–2)). If Thebes is both violent (city-)state and violent state of mind, then it is one founded upon and riven by hubris, shame, betrayal, incest, parricide, fratricidal civil war, sacrilege and vendetta. Murder, suicide and self-mutilation course through its life-blood, define its neural pathways. And yet: one cannot pass a few minutes as a visitor to the hospital ward where I work (a place which I think of as populated, in part, by the inheritors of the political and aesthetic tradition of Antigone and Ismene and all their sisters-in-arms) without seeing evidence – even upon the walls of that dining room where this chapter opens – of great and enduring creativity in the contributions of the sufferers to the ward’s environment and culture, without sensing what Honig calls a ‘dissident quest for sovereignty or sororal solidarity’ (Honig 2013, p.19). I am moved therefore urgently to ask: what are we missing here? Clinically, culturally, collectively? There is something in the praxis of Antigone and her sisters that demands ‘radical refiguring’ (Butler 2000, p.33) on Creon’s part – on our part. How might we understand the nature and genesis of creative states in such places? What is the nature of the fine line between violent states and creative states – whether states of mind or states of familial or societal groupings – in the field of feeding distress? How might we start to imagine (see e.g. Martin 2017) a dynamic phenomenology of both creative and violent states of mind in this contested field? The more rigidly a violent state obtains – the more we ‘do unto’ Antigone and her sisters, and the less able we are to re-imagine being alongside, living with them – the less they are able to re-imagine living with us.

ACKNOWLEDGEMENTS To the necessarily anonymous experts by experience who have shared their creativity with me during the drafting of this chapter and its precursors, I am absolutely indebted. I am also very grateful to Anna Motz

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and to Helen Hewitt, who both very kindly read through an early draft of this chapter. Any lingering ventriloquisms or other misattributions are entirely my own.

REFERENCES Adlam, J. (2014a) ‘Meeting together; eating together.’ Journal of Psychosocial Studies 8, 1, 217–226. Adlam, J. (2014b) ‘“Project Antigone”: a psychosocial exploration of the dynamics of food refusal and force feeding.’ Conference paper, Association for Psychosocial Studies, 1st Annual Conference. Adlam, J. (2015) ‘Refusal and coercion in the treatment of severe anorexia nervosa: the Antigone paradigm.’ Psychodynamic Practice 21, 1, 19–35. Adlam, J. with an anonymous group of experts by experience (2014) ‘Refusal and coercion in the inpatient treatment of anorexia nervosa: Antigone and Creon in search of an equilibrium.’ Poster presentation, Eating Disorders International Conference: London, March 2014. DOI: 10.13140/2.1.4545.8885 Agamben, G. (2005) State of Exception. Chicago: University of Chicago Press. (Original work published in 2003.) Anouilh, J. (2000) Antigone. London: Methuen. (Original work published in 1944.) Bell, R. (1987) Holy Anorexia. Chicago: University of Chicago. Berkshire, E. (2011) ‘Violent field of thought: “eating disorders”.’ Psychodynamic Practice 17, 3, 335–340. Beth (2017) ‘Persona Non Grata.’ In J. Adlam and K. Turner (eds) Offering Food ‹-› Receiving Food. Special Edition of the Journal of Psychosocial Studies 10, 2, 23–34. Butler, J. (2000) Antigone’s Claim: Kinship Between Life and Death. New York: Columbia University Press. Donne, J. (1983) Selected Poems. London: Penguin. Dostoyevsky, F. (1862) The House of the Dead. London: Penguin Classics. Genet, J. (2012) Les Bonnes. Paris: Gallimard. (Original work published in 1947.) Hinshelwood, R.D. (1999) ‘The difficult patient.’ British Journal of Psychiatry 174, 187–190. Hölderlin, F. (2009) Essays and Letters. London: Penguin Classics. Honig, B. (2013) Antigone Interrupted. Cambridge: Cambridge University Press. Jones, D. (2016) Disordered Personalities and Crime. London: Routledge. Keats, J. (1986) ‘Ode to a Nightingale.’ In D. Wright (ed.) English Romantic Verse. London: Penguin Classics. (Poem composed in 1819.) Kierkegaard, S. (1992) ‘Ancient Tragedy’s Reflection in the Modern.’ In Either/Or. London: Penguin Classics. (Original work published in 1843.) Lacan, J. (1992) The Ethics of Psychoanalysis. London: Routledge Classics. Levi-Strauss, C. (1955) Tristes Tropiques. London: Penguin Classics. Martin, W. (2017) ‘Human Rights and Human Experience in Eating Disorders.’ In J. Adlam and K. Turner (eds) Offering Food ‹-› Receiving Food. Special Edition of the Journal of Psychosocial Studies 10, 2, 112–122. Marx, K. (1852) The Eighteenth Brumaire of Louis Bonaparte. Amazon edition.

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McNeill, D. (2011) ‘Antigone’s autonomy.’ Inquiry: An Interdisciplinary Journal of Philosophy 54, 5, 411–441. Scanlon, C. and Adlam, J. (2006) ‘Housing “unhoused minds” – inter-personality disorder in the organisation?’ Housing, Care and Support 9, 3, 9–14. Scanlon, C. and Adlam, J. (2012) ‘Disorganised Responses to Refusal and Spoiling in Traumatised Organisations.’ In E. Hopper (ed.) Trauma and Organizations. London: Karnac. Shelley, P. (1840) Journal of a Six Weeks’ Tour. Letters from Geneva. Journal at Geneva: Ghost Stories. Journal: Return to England. Letters from Italy. London: Lea and Blanchard. Downloaded 3 May 2016 from https://books.google.co.uk/ books?id=YEdbAAAAMAAJ&dq=shelley+antigone+gisborne&source=gbs_ navlinks_s Skårderud, F. (2007) ‘Eating one’s words. Part III. Mentalisation-based psychotherapy for anorexia nervosa. An outline for a treatment and training manual.’ European Eating Disorders Review 15, 323–339. Sophocles (1947) Antigone. In The Theban Plays. London: Penguin Classics. Steiner, G. (1986) Antigones: The Antigone Myth in Western Literature, Art and Thought. Oxford: Oxford University Press. Steiner, G. (2011) The Poetry of Thought. New York: New Directions. Treasure, J., Crane, A., McKnight, R., Buchanan, E. and Wolfe, M. (2011) ‘First do no harm: iatrogenic maintaining factors in anorexia nervosa.’ European Eating Disorders Review 19, 4, 296–302. Vandereycken, W. and Van Deth, R. (2001) From Fasting Saints to Anorexic Girls: The History of Self-Starvation. London: Bloomsbury.

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Chapter 7

ANOREXIA MIRABILIS Voluntary Self Starvation and the Role of Spirituality as a Legitimate Response to Sexual Violence1 ROBYN TIMOCLEA

…but from the fruit of the tree which is in the middle of the garden, God has said, ‘You shall not eat from it or touch it, or you will die.’ The serpent said to the woman, ‘You surely will not die! For God knows that in the day you eat from it your eyes will be opened, and you will be like God, knowing good and evil.’ Genesis 3: 3–5 (NASB 1971)

INTRODUCTION This chapter will explore the experience of voluntary self starvation (VSS) from a historical, spiritual, and personal perspective. VSS is choosing not to eat. The phenomenon of VSS has a long history spanning across multiple faiths and cultures (Bemporad 1996; McCarthy-Jones 2012; Bell 2014). From ancient Palestinian mystics to early Catholic reformers, rigid self denial (or asceticism) has been used for centuries as a legitimate way to liberate oneself from egocentricity in order to ‘purify the body and soul’ and achieve temporal influence (Bruch 1974, p.11; Meehan 1993, p.59; see also Chapter 6, Volume 2). Bynum (1988) argues that women, in particular, have historically engaged in VSS and asceticism as 1

This chapter was first published in October 2017 under the same title, as an article in the online Journal of Psychosocial Studies 10, 2, pp.99–104 (Special Issue: Offering Food ‹-› Receiving Food, guest-edited by John Adlam and Kati Turner).

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a way of exerting control over their bodies, enhancing or transcending their social position and challenging dominant patriarchal expectations (Davis and Nguyen 2014). In juxtaposition with this historical perspective, the current psychiatric paradigm forces us to view extreme VSS (with the exception of protest self starvation) firmly within a pathological, medicalized framework (World Health Organization 1992). However, in contrast to ‘anorexia nervosa’, ‘anorexia mirabilis’ or spiritual anorexia can be seen as a distinct phenomenon whereby VSS is used as a means to obtain radical holiness and to express devotion to a higher purpose or being (Brumberg 1988; Bynum 1988; Garrett 1998). Although there is some evidence that shows an association between divine struggles, body image distortion, and eating difficulties (Exline, Homolka and Harriott 2016), there is usually an absence of body distortion in spiritual anorexia and weight loss is not usually cited as a primary goal. ‘Anorexia mirabilis’ has historically been accompanied by voice hearing, unusual sensory perceptions, and belief systems that appear to deviate from the norm (Banks 1992; Huline-Dickens 2000; Bradford 2011; de Leede-Smith and Barkus 2013). Voice hearing is now supported by a vast amount of evidence as a non-pathological and relatively common experience (Posey and Losch 1983; Longden, Madill and Waterman 2012; Draaisma 2016; Baumeister et al. 2017). Unfortunately, however, both ‘anorexia mirabilis’ and voice hearing are frequently medicalized and misunderstood experiences within the current UK mental health system. Drawing on personal artwork completed whilst in treatment at a therapeutic community (TC), I will examine the role that VSS, spirituality, and voice hearing can play in the refusal of nourishment. I will describe how ascetic ideals helped me to cope with profound trauma and how I eventually managed to reconnect with other people and my body. Having been raised as a charismatic, born-again Christian, it was not uncommon within my spiritual framework to fast for periods of time in order to find solutions for both internal and external problems. Within this frame of reference, the ‘giving up’ of earthly nourishment preceded the receiving of spiritual nourishment in the form of guidance or healing. Hearing from God was also a common occurrence and was not seen as pathological. At the age of 12 I became the victim of multiple perpetrator rape and spent the next ten years making use of my spiritual framework and ascetic ideals to try to make sense of my traumatic experience. I entered the mental health system at the age of 17 after a voice instructed me to attempt

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suicide. However, it wasn’t until the age of 21, when I entered a TC, that I began to talk about my spiritual framework and intra-psychic conflict. It has been argued that spirituality and religious beliefs are important supportive factors for people who use mental health services (Swinton 2001; Clarke 2017). It is also well known that sexual violence is a frequent antecedent to mental distress (Oppenheimer et al. 2013; Garcia-Moreno, Zimmerman and Watts 2017). Sexual violence is known to be highly associated with higher rates of relapse, chronicity, and morbidity in ‘anorexia nervosa’ (Carter et al. 2006; Vrabel et al. 2010; Molendijk et al. 2017). Nevertheless both spirituality and sexual violence remained taboo subjects in my experience within mainstream mental health services. I was never asked to speak about them, despite both of these factors occupying major roles in sustaining a cycle of misery for me. Having access to a TC meant that there was finally space for other people to understand my own frame of reference and to work alongside me in my distress. This enabled others and myself to contextualize my behaviour and responses. For the first time I began to feel connected to others as well as remaining in control of my own narrative.

Figure 7.1: ‘Outside In’

The first picture (Figure 7.1) was completed early on in my therapy. The intrusive imagery and violent colours reflect the way in which I

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experienced the world at the time. The skull has no boundary, reflecting my difficulties with differentiating between internal and external phenomena. This experience has been well documented and is often labelled as psychosis (Frith and Done 1989; Bentall, Baker and Havers 1991; Mishara 2004; David 2010; Carhart-Harris et al. 2012). The rope and pills towards the bottom of the image reveal my perception that medication and psychiatry felt like a death sentence. I saw my madness as a process, something to journey through rather than something to be medicated away or labelled and redefined. I was extremely grateful for the TC’s policy of zero medication.

Figure 7.2: ‘This is My Body, Broken for You’

In the second image (Figure 7.2) there is some similarity to the medieval ascetic women whose non-consuming bodies were subjected to constant spectacle and interpretation. Their acts of food refusal and subsequent emaciation were a symbolic re-enactment of Christ offering his life so that we could receive forgiveness and eternal life. The body in the image is strung up like meat, ready for consumption, piously dead. It has similarities to the emaciated icons of Jesus during crucifixion. The belief that my body was a shell, a mere vessel, enabled me to give meaning to my experience of sexual violence and focus on maintaining the unblemished innocence and purity of consciousness that was me, dissociated from the shell.

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Multiple screens in the background represent the constant audience of therapy staff and fellow residents who were also at the TC. The screens express the voyeuristic devouring of a display of bodily sacrifice. In contrast to medieval female ascetics, whose audience responded with admiration and reverence, within a pre-modern culture, rationaliza­ tion and fear dominated the growing narrative around my body’s dis/appearance. Instead of generating spiritual discussion and salvation (the goal of all Christians), my appearance generated hostility and further pathologization. I began to realize that instead of communicating some deeper truth, I was becoming harder to hear, and I had to find new ways to communicate. The confrontation and critical challenges I experienced from my peers during my time at the TC enabled me to begin to question my spiritual framework. As others began to point out, the act of food refusal had in itself become pleasurable to me and therefore contradicted the ideology behind my fasting behaviour. This was a crucial turning point in my therapy.

Figure 7.3: ‘The Revelation of Evil’ and ‘Holy Surrender’

The pictures in Figure 7.3 are an amalgamation of two separate drawings embodying this turning point and the confusion and cognitive dissonance I experienced. The first picture shown here depicts the serpent

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that instructed Eve to consume the fruit in the garden of Eden to gain knowledge of both good and evil. The facial expression on the woman is one of questioning. The lampshade behind the woman represents the ‘light bulb’ moment in which I came to the painful realization that my attempts to preserve my innocence and purity through asceticism were futile and that essentially I had already received the knowledge of evil through my experience of sexual violence. My innocence was gone. The apple was picked. The snake here is almost a Freudian symbol of that knowledge already embroiled into a part of the woman’s body. In contrast to other images I drew of Christ earlier on in my therapy, the second picture in Figure 7.3 portrays Christ as a dark and foreboding shadow, a figure to represent the new distortion of my ascetic ideals. The woman in front is a depiction of the surrender of innocence and purity. It was around this time that the truth of what had happened to me became clear and I was no longer dissociated from my body. Rather than refusing food and nourishment, I began to turn my will towards refusing the life-draining ascetic ideals that had previously kept me in a state somewhere between life and death. I reconnected with feelings of pain, anger, loss, and shame. It was at this point the community fed me both physically and emotionally. As a collective force they helped to contain the weeks of purging emotion that followed.

Figure 7.4: ‘The Holy Matriarchy’

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Towards the end of my therapy I incorporated a more psychological framework for my ongoing distress around my victimization as a child. I came to the supposition that my traumatic experience had led to the formation of different parts and aspects of myself which were then ‘split off ’ from one another. The above image (Figure 7.4) reveals the relationship between these perceived parts. Moving from a position of being overwhelmed by emotion and surrender, the figure on the right portrays a new identity as a defiant protector. She is strong, shielding, and defensive. The expression in her eyes tests the viewer’s resolve. She is sizing you up. The removed razor blade sits carefully guarded on her lap. She is like a mother removing and guarding a dangerous object from her child. To her left, contained behind a translucent panel, is the observing starver, Ana, who remained a constant presence requesting the removal of nourishment. She is a controlling and dangerous part that needs to be kept away from the others. The woman to the left of the image characterizes the new connection with a part of myself that was warm, body conscious, and sexually empowered. In her hands, she is holding and containing the damaged and victimized 12-year-old child, frozen forever in a frame. Her eyes are closed in a compassionate, empathic response to the child’s traumatized state. The image conveyed all parts of my renewed sense of self and replaced the body-hating, cyclical, and conflictual way in which I had previously used VSS to bring meaning to my life. Instead of withholding nourishment for fear of corruption, I was able to give nourishment to parts of myself that had been starving for years. I was able to feel sadness for the loss of my childhood and innocence. This then enabled me to defend the hurt parts of myself in ways I had been unable to do previously. The punitive response I had incorporated into my way of relating to my traumatized self began to be contained within a safe religious context that could be drawn on appropriately when needed. I internalized the TC’s messages of care, and these finally gave me an alternative internal dialogue to draw upon at times of distress and retraumatization.

CONCLUSION I have taken you through an illustrated narrative of how I understood my difficulties across a spiritual and religious construct. I have also

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explained that the mainstream psychiatric system failed to accommodate this construct or to make space for me to talk about my experience of sexual violence. It was only when I entered a TC that others asked how I understood my distress and began to help me to unpick the threads of thinking that had assembled themselves into a kind of existential cat’s cradle. I have used some of my artwork to show how I initially felt that I had to sacrifice my body in order to find redemption and bring others to Christ. The artwork also reflects how, through a combination of challenge and compassion, the community helped me to adopt a more psychological approach to understanding my distress without relinquishing or compromising my spiritual integrity. I realise that spirituality, like any tool for coping, can be used to extremes and could therefore be harmful if its use is not moderated by a community. Self blame and criticism are a common response to sexual assault (Ullman 1996; Kelly 2013; Peter-Hagene and Ullman 2016). Sadly, a wider societal process of victim blaming often supports it (Grubb and Turner 2012; Hayes, Lorenz and Bell 2013; Salter 2017). It is clear to me now that the spiritual reframing of my victimization was inevitable given the complete lack of support from my immediate community, including my family. I had no other narrative from which to draw meaning. Extreme penance forms a practical and ongoing solution to self blame and, for a time, it kept me alive and functioning. The response to my distress from mainstream psychiatric services was poor. This could be due to the disparity between the lack of religiosity and spirituality within psychiatric staff as a population as opposed to the people whom they treat (Cook 2011). There was no sense of enquiry into either my spiritual beliefs or my experience of sexual violence. Whilst I am grateful to have found myself being treated in a TC, I am acutely aware that, along with many others across the UK, this community has now closed. This is not a recovery narrative. Recovery suggests that one has returned to a former state of health after a detour into some kind of sickness. However, my narrative is not a medical one. I regard my decision to stop VSS as a process of discovering and uncovering. I no longer hear distressing voices, and I attribute this to the fact that the meaning I once made of my voices has entirely changed. Many people will argue that extreme VSS is unacceptably harmful and that people require protection from such acts. I disagree with this to some extent. For myself, VSS provided an outlet for the energy that

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comes from suppressing extremely traumatic events. I also believe that, like any madness, it is a process, something to be travelled through, not stopped, paused, or avoided. It is my understanding, based on my own experiences, that problems arise when people get stuck in their journeys. This stalling can happen through over-medication, reframing into a disempowering medicalized narrative, being turned into battles for control, numbing, or simply being left to navigate one’s journey alone. People who use mental health services repeatedly highlight the importance of including their spiritual frameworks within their care (Clarke 2001; Levin 2001; Wong, Rew and Slaikeu 2006; Lilly 2010). It is also clear that many young people rely on spirituality or religious frameworks in order to make sense of experiences such as voice hearing (Steenhuis et al. 2016). The simple process of enquiring about spiritual beliefs in people who use services can provide therapeutic benefit (Murphy 2000), and there is evidence to suggest that strong religious and spiritual identity serves as a protective factor against the difficulties associated with disordered eating (Akrawi et al. 2015; Latzer et al. 2015). It is my concern that we will continue to be complicit agents in the medicalization of existential distress and the various creative and sometimes destructive ways in which we attempt to manage this distress as humans. This one-dimensional approach to caring for one another appears to exacerbate and prolong some people’s mental turmoil. It is also problematic to repeatedly label women’s responses to sexual violence as ‘disordered’. A disease model provides only one possible way to make sense of voluntary food refusal and voice hearing. It is my hope that in the future a more holistic and trauma-informed approach to understanding these phenomena will be pursued.

REFERENCES Akrawi, D., Bartrop, R., Potter, U. and Touyz, S. (2015) ‘Religiosity, spirituality in relation to disordered eating and body image concerns: a systematic review.’ Journal of Eating Disorders 3, 1, 1–24. Banks, C.G. (1992) ‘“Culture” in culture-bound syndromes: the case of anorexia nervosa.’ Social Science and Medicine 34, 867–884. Baumeister, D., Sedgwick, O., Howes, O. and Peters, E. (2017) ‘Auditory verbal hallucinations and continuum models of psychosis: a systematic review of the healthy voice-hearer literature.’ Clinical Psychology Review 51, 125–141. Bell, R.M. (2014) Holy Anorexia. Chicago: University of Chicago Press.

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Bemporad, J.R. (1996) ‘Self-starvation through the ages: reflections on the pre-history of anorexia nervosa.’ International Journal of Eating Disorders 19, 3, 217–237. Bentall, R.P., Baker, G.A. and Havers, S. (1991) ‘Reality monitoring and psychotic hallucinations.’ British Journal of Clinical Psychology 30, 213–222. Bradford, D.T. (2011) ‘Brain and psyche in early Christian asceticism.’ Psychological Reports 109, 2, 461–520. Bruch, H. (1974) ‘Perils of behavior modification in treatment of anorexia nervosa.’ JAMA 230, 10, 1419–1422. Brumberg, J.J. (1988) Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease. Harvard: Harvard University Press. Bynum, C.W. (1988) Holy Feast and Holy Fast: The Religious Significance of Food to Medieval Women (Vol. 1). California: University of California Press. Carhart-Harris, R.L., Leech, R., Erritzoe, D., Williams, T.M. et al. (2012) ‘Functional connectivity measures after psilocybin inform a novel hypothesis of early psychosis.’ Schizophrenia Bulletin 39, 6, 1343–1351. Carter, J.C., Bewell, C., Blackmore, E. and Woodside, D.B. (2006) ‘The impact of childhood sexual abuse in anorexia nervosa.’ Child Abuse and Neglect 30, 3, 257– 269. Clarke, I. (2001) Psychosis and Spirituality: Exploring the New Frontier. London: Whurr Publishers. Clarke, I. (2017) ‘Mystery, power and danger.’ Self and Society 45, 1, 87–97. Cook, C. (2011) ‘The faith of the psychiatrist.’ Mental Health, Religion and Culture 14, 1, 9–17. David, A.S. (2010) ‘Why we need more debate on whether psychotic symptoms lie on a continuum with normality.’ Psychological Medicine 40, 12, 1935–1942. Davis, A.A. and Nguyen, M. (2014) ‘A case study of anorexia nervosa driven by religious sacrifice.’ Case Reports in Psychiatry 2014, 512764. http://doi. org/10.1155/2014/512764 de Leede-Smith, S. and Barkus, E. (2013) ‘A comprehensive review of auditory verbal hallucinations: lifetime prevalence, correlates and mechanisms in healthy and clinical individuals.’ Current Perspectives on the Mechanisms of Auditory Hallucinations in Clinical and Non-Clinical Populations 62, 7, 367. Draaisma, D. (2016) ‘Neuroscience: listening in on yourself.’ Nature 532, 7597, 32–33. Exline, J.J., Homolka, S.J. and Harriott, V.A. (2016) ‘Divine struggles: links with body image concerns, binging, and compensatory behaviours around eating.’ Mental Health, Religion and Culture 19, 1, 8–22. Frith, C. and Done, D. (1989) ‘Experiences of alien control in schizophrenia reflect a disorder in the central monitoring of action.’ Psychological Medicine 19, 359–363. Garcia-Moreno, C., Zimmerman, C. and Watts, C. (2017) ‘Calling for action on violence against women: is anyone listening?’ The Lancet 389, 10068, 486–488. Garrett, C. (1998) Beyond Anorexia: Narrative, Spirituality and Recovery. Cambridge: Cambridge University Press. Grubb, A. and Turner, E. (2012) ‘Attribution of blame in rape cases: a review of the impact of rape myth acceptance, gender role conformity and substance use on victim blaming.’ Aggression and Violent Behavior 17, 5, 443–452. Hayes, R.M., Lorenz, K. and Bell, K.A. (2013) ‘Victim blaming others: rape myth acceptance and the just world belief.’ Feminist Criminology 8, 3, 202–220.

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Huline-Dickens, S. (2000) ‘Anorexia nervosa: some connections with the religious attitude.’ British Journal of Medical Psychology 73, 1, 67–76. Kelly, L. (2013) Surviving Sexual Violence. Chichester: John Wiley & Sons. Latzer, Y., Weinberger-Litman, S.L., Gerson, B., Rosch, A. et al. (2015) ‘Negative religious coping predicts disordered eating pathology among Orthodox Jewish adolescent girls.’ Journal of Religion and Health 54, 5, 1760–1771. Levin, J. (2001) God, Faith, and Health: Exploring the Spirituality–Healing Connection. Chichester: John Wiley & Sons. Lilly, R. (2010) ‘The Holy Spirit – Healer, Advocate, Guide and Friend.’ In T. Basset and T. Stickley (eds) Voices of Experience: Narratives of Mental Health Survivors. Chichester: John Wiley & Sons. Longden, E., Madill, A. and Waterman, M.G. (2012) ‘Dissociation, trauma, and the role of lived experience: toward a new conceptualization of voice hearing.’ Psychological Bulletin 138, 1, 28. McCarthy-Jones, S. (2012) Hearing Voices: The Histories, Causes and Meanings of Auditory Verbal Hallucinations. Cambridge: Cambridge University Press. Meehan, B. (1993) Holy Women of Russia: The Lives of Five Orthodox Women Offer Spiritual Guidance for Today. San Francisco: Harper. Mishara, A.L. (2004) ‘Disconnection of external and internal in the conscious experience of schizophrenia: phenomenological, literary and neuroanatomical archaeologies of self.’ Philosophica 73, 87–126. Molendijk, M.L., Hoek, H.W., Brewerton, T.D. and Elzinga, B.M. (2017) ‘Childhood maltreatment and eating disorder pathology: a systematic review and doseresponse meta-analysis.’ Psychological Medicine 19, 1–15. Murphy, M. (2000) ‘Coping with the spiritual meaning of psychosis.’ Psychiatric Rehabilitation Journal 24, 2, 164–179. NASB (1971) New American Standard Bible. La Habra, CA: Foundation Publications, for the Lockman Foundation. Oppenheimer, R., Howells, K., Palmer, R.L. and Chaloner, D.A. (2013) ‘Adverse sexual experience in childhood and clinical eating disorders: a preliminary description.’ Anorexia Nervosa and Bulimic Disorders: Current Perspectives 19, 357. Peter-Hagene, L.C. and Ullman, S.E. (2016) ‘Longitudinal effects of sexual assault victims’ drinking and self-blame on posttraumatic stress disorder.’ Journal of Interpersonal Violence 26, 10, 1934–1962. Posey, T.B. and Losch, M.E. (1983) ‘Auditory hallucinations of hearing voices in 375 normal subjects.’ Imagination, Cognition and Personality 3, 2, 99–113. Salter, L. (2017) ‘From victimhood to sisterhood part II – exploring the possibilities of transformation and solidarity in qualitative research.’ European Journal of Psychotherapy and Counselling 19, 1, 73–86. Steenhuis, L.A., Bartels-Velthuis, A.A., Jenner, J.A., Aleman, A. et al. (2016) ‘Religiosity in young adolescents with auditory vocal hallucinations.’ Psychiatry Research 236, 158–164. Swinton, J. (2001) Spirituality and Mental Health Care: Rediscovering a Forgotten Dimension. London: Jessica Kingsley Publishers. Ullman, S.E. (1996) ‘Social reactions, coping strategies, and self-blame attributions in adjustment to sexual assault.’ Psychology of Women Quarterly 20, 4, 505–526.

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Vrabel, K.R., Hoffart, A., Rø, Ø., Martinsen, E.W. and Rosenvinge, J.H. (2010) ‘Cooccurrence of avoidant personality disorder and child sexual abuse predicts poor outcome in long-standing eating disorder.’ Journal of Abnormal Psychology 119, 3, 623. Wong, Y.J., Rew, L. and Slaikeu, K.D. (2006) ‘A systematic review of recent research on adolescent religiosity/spirituality and mental health.’ Issues in Mental Health Nursing 27, 2, 161–183. World Health Organization (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization.

Chapter 8

VIOLENCE, RAGE AND CREATIVITY1 DEBORAH J. COHAN

This chapter examines connections between emotions and social structure and specifically the positive functions and outcomes offered by rage. I explore rage as a violent state of mind that can assist in the meaningmaking of the creative process. I examine how expressions of rage can become a gendered process; to do this, I use the phenomenon of male violence against women and explore how abusers and survivors rely on, make meaning from, negotiate and manipulate a discourse on rage to understand their behaviours. Drawing on my previous clinical work with batterers, I critique the standard construction of rage as an artefact of patriarchy related to hegemonic notions of masculinity that sustain violence. I evaluate how and why anger and rage serve in the healing and recovery process of survivors as they navigate through making meaning out of their experiences. Generally regarded as an impediment to growth, rage is evaluated here instead as having potential for cultivating a creative state of mind and helping to construct an authentic voice for navigating oppressive societal structures and discourses.

GENDERED RAGE Women’s relationship to rage is fraught; they are not taken seriously when expressing it, and rage is seen as taboo and an outgrowth of excessive emotionality. Stripped of its sociopolitical context, women’s rage is 1

Written permission was obtained to cite the perspectives and voices of perpetrators and victims in this chapter.

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individualized and medicalized, or dismissed as ‘that time of the month’, essentially relegating it to the private domain. Much self-denial is woven into the texture of womanhood in a routinized way, and when women pay attention to their emotional interior and express outrage, they are relegated to the lunatic fringe. Labelled man-haters, ballbusters, lesbians, dykes, feminists, Feminazis, scheming, shrill, abrasive, psycho, PMSing and uppity bitches, women are told the solution is sexual relations with a man. Frye (1983) expands on cultural stereotypes: It is a tiresome truth of women’s experience that our anger is not well received. Men (and sometimes women) ignore it, see it as our being ‘upset’ or ‘hysterical’, or see it as craziness. Attention is turned not to what we are angry about but to the project of calming us down and to the topic of our ‘mental stability’… (pp.84–85)

Women’s anger must fit into a cultural mandate to negotiate one’s sense of self around others’ needs. In a context of male domination and pervasive objectification, the subjectivity involved in taking women’s anger seriously is diminished. According to Frye (1983): ‘To get angry is to claim implicitly that one is a certain sort of being, a being which can… stand in a certain relation and position à propos the being one is angry at. One claims that one is in certain ways and dimensions respectable…’ (p.90). Frye argues that women’s anger is only taken seriously when in domains already understood to be associated with women, for example childrearing, and when it is articulated on behalf of families and moral causes. This happens because women’s identity and ways of being and knowing are culturally constructed as relational, confined to nurturance and caretaking (Belenky et al. 1986). Even in the context of violence, survivors are more likely to express anger about what other survivors experienced than about what they endured or about the perpetrator. In her memoir of healing from rape, Brison (2002) states: Rape survivors, who typically have difficulty getting angry with their assailants, find that in group therapy they are able to get angry on their own behalf by first getting angry on behalf of others. (p.63)

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INWARDLY DIRECTED RAGE Women’s rage directed on the self can be, and often is, self-mutilating; in this way, it is ‘privatized and disabling’ (Cloward and Piven 1979, p.652). ‘[A]n individual woman may go on choosing angry men because they express the anger that she holds in’ (Steinem 1992, p.277). There are a variety of ways in which women hurt themselves that are responses to structured gender inequality, including eating disorders, cutting and hair-pulling (see e.g. Chapters 5 and 6, Volume 2). When women’s rage is regarded as illegitimate and arenas are absent for the safe release of it, it is often turned in reflexively upon the self (see Chapter 2, Volume 1). In short, there are few approved public, social outlets for women to express rage, and when it is expressed it is not taken seriously and is minimized or denied because it is not seen as legitimate. This makes positive aspects and outcomes of rage more elusive for women to access. For men, sports and military involvement are arenas in which there is a formal structuring of rage to successfully perform a set of controlled functions. Michael Kaufman (1995) points to the ‘surplus aggressiveness’ in masculinity. Men are socialized to reject the feminine. Women are socialized into femininity yet simultaneously taught to realize its secondclass status; thus, the repression of the feminine is evident in the lives of both men and women. Slater (1996) describes her work with a patient diagnosed with antisocial personality disorder and draws an artful parallel between his sexual addictions and her drive to control her body: The culture that makes us afraid of the fat, the floppy, the soft and sapsweet, is the culture that kills us. And the recovering anorexic is not only in a particularly good position to articulate these truths, she is also, ironically, in a particularly good position, via therapy, to treat the misogynist male. She understands perhaps better than anyone the urge to whip and dominate, to discipline and even delete the female form. (p.51)

It is this fear of the feminine that Slater sees leading to rage that gets channelled as inward, hidden protests for women and as outward, stylized expressions of rageful dominance for men (see Welldon 1988).

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ACCOMPLISHING MASCULINIZED RAGE Men’s anger is understood as a straightforward assertion of grievances, and an expression of standing up for oneself. Boys and men are socialized into two dominant emotional strategies: to ‘suck it up’ and suppress feelings or to be angry. In some forms of male-on-male violence, a woman represents what is being fought over, as part of a fantasy of exchange or transaction in which the person of the woman is objectified as property of the dominant male. Many male abusers of women describe their desire to dominate other men, particularly when they have discovered another man’s involvement with their partners and ex-partners: ‘If I can’t have you, no one will.’ One insidious aspect of this sort of male violence against men is that the crime against women remains relatively invisible. This notion of a transaction exemplifies the colonization of women’s bodies and psyches and reveals the extent to which women’s bodies are contested terrain. The construction of a terroristic and militarized masculinity drives men’s tendency to use violence to get their needs met in intimate relationships. As Kaufman (1995) explains: The act of violence is many things at once. At the same instant it is the individual man acting out relations of sexual power; it is the violence of a society – a hierarchical, authoritarian, sexist, class-divided, militarist, racist, impersonal, crazy society – being focused through an individual man onto an individual woman…violence by men against women is only one corner of a triad of men’s violence. (p.13)

Rage, criminality and masculinity are interconnected in a complex prism related to patriarchal control, male entitlement, perceptions and experiences or fears of not being man enough, and socialization towards domination. Crime, then, can provide a resource for doing masculinity in specific social settings as well as contributing to a gendered line of action in which future accountability may be at risk…crime by men is a form of social practice invoked as a resource, when other resources are unavailable, for accomplishing masculinity. (Messerschmidt 1993, p.85)

Male abusers of women often look to something external to rationalize physical violence, such as: ‘a loss of control’; ‘something came over me’; ‘a lifelong bad temper’; ‘my rage took over’; ‘a monster inside of me came

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out’; ‘I never knew I was capable of something like that’; and so on. In this complex web of excuse-making, batterers blame others, claim victim provocation and blame a lifelong legacy of anger and rage, passed down by family members as well as by a culture that regards anger as part of how men claim power. Abusers thus tend to think of themselves as the victims and (rationalizing after the fact) convey the extent to which they perceive the use of violence to be the only way out of a situation that felt too uncomfortable, frustrating or painful to negotiate otherwise. There is an ideological paradox operating, since men who batter closely fit the stereotypical image of the ‘out of control’ ballistic, emotional woman, while the expectations surrounding battered women is that they should fit the masculine cultural stereotype of the ‘in control’, rational and logical man. bell hooks (1989) elaborates on this paradox: People within patriarchal society imagine that women are hit because we are hysterical, because we are beyond reason. It is most often the person who is hitting that is beyond reason, who is hysterical, who has lost complete control over responses and actions… (p.85)

While abusers may label other men’s violence as problematic, they less frequently see their own on the same continuum, serving as a distancing mechanism. Another recurring theme is the extent to which abusers believe they are being punished, so they use coercion to retaliate and punish their families and physically and psychologically infantilize and trap their partners. One man explains: …she said, ‘I’m not driving you.’ And I said, ‘Okay, I’m not going to let you have the car’ because I felt I was going to be late to school. She said, ‘You can’t have the car, it’s my car.’ I got so upset that I opened the hood and pulled one of the wires. ‘If I can’t have the car, then you can’t.’

Masculinity is sustained through structures of domination in society: ‘the violence of social regulation’ (Butler 1997, p.184). Masculinized violence is also sustained through the process by which men who batter connect themselves to, or disconnect themselves from, structures of domination such that they best serve to reinforce violent behaviour. Men actively interact with the messages they receive about their behaviour and attach themselves to or detach themselves from the communicators of these messages. Essentially, we need to be more attuned to what I call ‘dis/connections of domination’ as much as we are attuned to structures of domination.

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One abuser commented on how he disconnected from what he learned from his mother growing up about how to treat women and connected to ideology that supported male bullying and dominance. He states: ‘We’re all bullies; that’s all we are. We hit women. We hit our wives; we hit our girlfriends. We hurt them all. We did exactly what our mothers told us not to do when we were young.’ This man normalizes and rationalizes his rage and bullying strategy and reveals both to be core pieces of how he has both constructed and managed masculinity. Though he articulates this in a way as to suggest some self-disgust, it is worth understanding that he admitted to spending hours every day using pornography, insisted on oral and anal sex when his wife asked him to clean the house and help with the children, and admitted to throwing lit matches at his wife while she held their small child, injuring them both. Eisikovits and Winstock (2001) use metaphors of bank accounts and credit lines to show how batterers manipulate a ‘memory archive’ containing a storehouse of memories of interactions, some of which the authors describe as ‘raw’ and others as ‘molded’: the latter used more readily in the process of the escalation of abuse. The authors build a theoretical model out of this metaphorical framework to explain that a batterer manages the memory archive as a credit line for himself and his partner, with a more fixed credit line for her and a more elastic, flexible one for himself: By explicitly warning her (e.g., ‘Beware’) he signals to her that she needs to be aware of the situation she is in… Covertly, he feels she went too far, and he does not like her statements. Overtly, he hears and sees her actions. The validity of his claims is high because both his overt and covert criteria point to the woman’s overstepping of limits. From this point onward, once the woman has reached her credit limit, there are two possible scenarios: one is to back off her statements; the other is to be beaten. If she backs off in a manner that satisfies the man, she renews her credit line. If not, the man overdraws his credit line by using violence. They are now both in the same situation. Their respective overdrafts nullify each other and they can develop an illusion of a fresh start. (pp.14–15)

The memory archive becomes a cumulative database of information which batterers then utilize, as their violence escalates, as evidence for their own perceptions of injustice, however distorted some of these

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claims may be. Their sense of rage is often heightened by their belief that they are the victims, that they were treated unfairly, by their families of origin, peers, partners; by a legal system (which they believe favours women) holding them accountable for their behaviour. Rage, shame and blame form a complex nexus of relationships when viewed in connection to violence and masculinity – in terms of actions and also in terms of narratives and states of mind underlying such actions. According to Gilligan (1996): I have yet to see a serious act of violence that was not provoked by the experience of feeling shamed and humiliated, disrespected and ridiculed, and that did not represent the attempt to prevent or undo this ‘loss of face’ – no matter how severe the punishment, even if it includes death. For we misunderstand these men, at our peril, if we do not realize they mean it literally when they say they would rather kill or mutilate others, be killed or mutilated themselves, than live without pride, dignity and self-respect. They literally prefer death to dishonor… The emotion of shame is the primary or ultimate cause of all violence, whether towards others or toward the self. (p.110)

DOMINANT RAGE The legitimacy of the expression of rage needs to be up for questioning if it emanates from the person or group that historically and culturally is in the more strategically powerful position. When a man who has been abusive to his female partner shows a rageful response, it should be understood that that rage emerges from a different context than the rage of a battered woman fighting back. The rage of the abuser may be a response to felt injustice, related to something inside or outside of the relationship. Whether or not his grievance is in any sense legitimate, his rage is still linked to, precedes or emerges from abuse that, in and of itself, is so related to domination that the feeling and action state of rage exists in a dominant form. There are abusive men who may not be dominant in other domains and societal relationships. However, their abusive behaviour identifies them as members of a group that wields domination. Jones (1994) writes about the differential impact in the expression of dominant and survivor rage:

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…one woman I interviewed told me that when she persuaded her abusive, alcoholic husband to seek help… ‘His therapist said he needed to get his anger out,’ she reported, ‘so he was supposed to shout whenever he felt like it. But every time he started shouting, what he shouted was abuse – and the more he shouted the more vicious it got. When he got tired of shouting, he’d have a few more drinks and go to sleep; and I’d sit up all night shaking.’ He felt relieved, she felt terrified. He felt liberated, she felt oppressed. He felt free of anger, she felt furious. ‘If I’d ever shouted about how mad it made me to have to listen to that,’ she said, ‘he’d have broken my jaw…’ (pp.112–113)

Profound inequality exists between the rage of an abusive person and the rage of the person who experiences these actions. It is crucial to examine the different motives and outcomes of dominant rage and survivor rage. Abusers do not abuse those accorded more power and resources (Bograd 1988; Jones 1994): ‘how a man deals with stress, or feelings, or conflict depends upon whom he’s dealing with, and particularly upon the sex and status of that other person’ (Adams, cited in Jones 1994, p.89). Potential abusers are alert to the extent to which violence is tolerated or not and the ways in which institutions simultaneously support and obscure male domination, such that women’s endangerment is rendered invisible. Abusers draw upon the structuring of emotion, specifically rage, as it plays out in discourses of domination, in order to legitimate control. This ruling ideology of dominance, as established, for instance, in domestic violence laws, sets public standards of ‘tolerance’ that entitle men to what is regarded as privatized violence, when in fact this violence is not a private matter. Batterers learn to exploit the artificial bifurcation imposed between the private and public spheres which reinforces women as property. As one violent man claims: I think you have anger and sometimes you’re in control and out of control, and then out in the public or whatever you have a different set of ideas of it; it’s not acceptable and you can’t do it. When you get home in your relationships you feel free to be out of control… There’s different faces you have – one of them is when you get up, then you walk out the door and stick on another face before you get to work so you’re a different person, so there’s a different standard that you live by when you’re at work with other people and when you’re in your own home with your wife. There’s some things that you do at home that you would never do out in public.

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He shows how proud he is of the public face that he has been able to maintain, an image rooted in rigid gender socialization that rewards men for being stoic, tough and as ‘manly’ as possible. His impression management (Goffman 1959) assists him, because if people view him as a calm and level-headed mediator, they are not likely to believe that he would be capable of being out of control at home. He consciously chooses when to be out of control; when it counts in public, he conforms.

SURVIVOR RAGE: THE INTERSECTIONS OF TRAUMA AND RAGE In the case of male-on-female violence within relationships, power differentials mean that the female victim’s anger has rarely, if ever, been adequately heard, legitimated and contextualized: ‘[t]he terror, rage and hatred of the traumatic moment live on in the dialectic of trauma’ (Herman 1992, p.50). Survivor rage is built out of the darkest, most painful aspects of negative rage, but when accessed as a way to forge a new sense of self, survivor rage can be a creative state with positive indications for recovery, intertwining a healing rage with resistance and courage. Survivor rage responds to and negotiates the rough edges and corners of dominant rage. As Brison (2002) writes, ‘[t]he “no” of resistance is not the “no” of denial. It is the “no” of acknowledgement of what happened and refusal to let it happen again’ (p.64). Survivor rage stands at the intersections of trauma, memory and healing and emerges through the unique vantage point that only a survivor has. Gilfus (1999) turns traditional trauma theory on its head and claims that, rather than conceptualize trauma as wholly disruptive, survival should be seen as something which gives life to a visionary, albeit painful, perspective: Survivor knowledge is still usually considered an illegitimate source of knowledge… The knowledge of no safe place in the world – at home, in one’s body, in the streets, in the academy and the professions, and to a certain degree within the self – may forge a unique epistemological stance… I question the assumption that survivors’ ways of seeing the world are inherently abnormal or pathological… The victim sees the hypocrisy of those adults who are either harming her or standing by while she is being harmed, and at the same time expect her to

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behave more honorably and with greater loyalty than they expect of themselves… A survivor-centered stance involves first and foremost the acknowledgement of the survivor as a complete human being, with a cultural and historical context, capable of expert knowledge, who is subject in her or his own right, to be viewed through a lens of loving perception. (pp.1248, 1250–1253)

Rage figures prominently in the recovery process for survivors as they navigate processes of meaning-making. According to Ferraro and Johnson (1983), survivors experience what they call an emotional career of victimization involving the power of anger: Unless the expression of anger is encouraged in a supportive environment, such women may suppress anger and feel only depression (Ball and Wyman 1978). When anger is expressed, it often leads to feelings of strength and exhilaration. Freedom from threats of violence, the possibility of a new life, and the unburdening of anger create feelings of joy. (p.209)

Herman’s conceptualization of ‘the survivor mission’ underlines the potential for creative states to emerge out of trauma: While there is no way to compensate for an atrocity, there is a way to transcend it, by making it a gift to others. The trauma is redeemed only when it becomes the source of a survivor mission. Social action offers the survivor a source of power that draws upon her own initiative, energy and resourcefulness but that magnifies these qualities far beyond her own capacities. It offers her an alliance with others based on cooperation and shared purpose. Participation in organized, demanding social efforts calls upon the survivor’s most mature and adaptive coping strategies of patience, anticipation, altruism and humor. It brings out the best in her… (1992, p.207)

Just as the survivor mission provides a context for developing shared meaning and transformation, so too does survivor rage and healing rage. We can see that survivor rage and healing rage, as cornerstones of creative states, deliver the promise of re-connection to one’s own core values and sense of self and also sustaining, life-affirming connections with other people. As Riggs (2010) comments: ‘The space in which creativity takes place can help victims reconnect links disconnected through trauma such as finding a sense of meaning, identity and place’ (p.23).

Violence, Rage and Creativity

CONCLUSION: CONCEPTUALIZING HEALING RAGE AS A CREATIVE STATE The experience of trauma challenges the meaning-making process that is central to a creative state. However, as Hall (2002, p.276) proposes, ‘rage transformed is also voice’. Meaning and creativity are forged through imagination and memory. As van der Kolk states: Imagination is absolutely critical to the quality of our lives… Imagination gives us the opportunity to envision new possibilities – it is an essential launchpad for making our hopes come true. It fires our creativity, relieves our boredom, alleviates our pain, enhances our pleasure, and enriches our most intimate relationships. (2014, p.97)

Although not always easy to access, rage is a legitimate response to entrapment, fear, threats and humiliation. Survivors have different attitudes about rage; some regard it as an obstacle to a smoother, more spacious life. Francisco (1999) writes, ‘As if I’ve gotten a piece of splintered glass in my eye, I view the world through the narrow lens of rage. I see reflections of the rapist’s hatred and disregard everywhere’ (p.115). Brison (2002) suggests that the empowering quality that rage offers is more nuanced and figures more or less prominently depending on one’s stage of recovery. Evaluating rage as an ultimately liberating tool for release from oppressive circumstances and post-traumatic events like sexual violence, Brison states: I, like other rape victims I came to know, found it almost impossible to get angry with my assailant. I think the terror I still felt precluded the appropriate angry response. It may be that experiencing anger toward an attacker requires imagining oneself in proximity to him, a prospect too frightening for a victim in the early stages of recovery to conjure up… my anger spread, giving me painful shooting signs that I was coming back to life. (p.13)

Anger became a powerful barometer for Brison’s sense of self-resurrection. That some sufferers at some moments view rage as deadening, while others see it as having properties that re-awaken and affirm life, is evidence of the contested terrain of rage. Interpretations of perpetrator rage can figure prominently in survi­ vors’ reflections upon victimization. Raine (1998) writes, ‘I experienced

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his rage as if it were a separate entity, a shadow self to his physical being. I understood that this entity was hungry and that it was feasting on something from me – my terror…’ (p.13). Heart (1991) speaks of the torment and shame of incestuous silence and ‘the profound meeting of rage and ecstasy’: …don’t ever give up the capacity to rage rage is the source of daily passions the energy to begin and sustain the readiness to become angry in a moment could save your life in a late night garage… I begin to dance in the rage …pure spark joy filled again. (p.157) Incest sometimes leaves survivors feeling homeless in their bodies. Home and the self can be excavated and re-made through a visionary process taking trauma stored deep in the body and releasing it in music, writing, therapy, art, dance, etc., and these vehicles become creative ways of breaking secrecy and silence. Artistic, therapeutic, mindful, transformative rage lights pathways toward creativity. Lamott (1994) writes: ‘Your anger and damage and grief are the way to tell the truth’ (p.201), underscoring that delving into darker emotional undercurrents forges development of voice; this requires value clarification, self-reflection and understanding one’s place in the social landscape. ‘Moving from silence into speech is for the oppressed, the colonized, the exploited’ (hooks 1989, p.5). Rage can be pivotal in salvaging and re-birthing the self, creatively transforming the painful, fragmentary quality of violence and moving toward survival, clarity and wholeness.

REFERENCES Ball, P.G. and Wyman, E. (1978) ‘Battered wives and powerlessness: what can counselors do?’ Victimology 2, 3–4, 545–552. Belenky, M., McVicker, B., Goldberger, N.R. and Mattuck Tarule, J.M. (1986) Women’s Ways of Knowing: The Development of Self, Voice, and Mind. New York: HarperCollins.

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Bograd, M. (1988) ‘Feminist Perspectives on Wife Abuse: An Introduction.’ In K. Yllö and M. Bograd (eds) Feminist Perspectives on Wife Abuse. Newbury Park, CA: Sage Publications. Brison, S.J. (2002) Aftermath: Violence and the Re-Making of a Self. Princeton, NJ: Princeton University Press. Butler, J. (1997) The Psychic Life of Power: Theories in Subjection. Stanford: Stanford University Press. Cloward, R. and Piven, F.F. (1979) ‘Hidden protests: the channeling of female innovation and resistance.’ Signs 4, 1, 651–669. Eisikovits, Z. and Winstock, Z. (2001) ‘Overdrawing and balancing accounts: the contribution of past events to the escalation process from the batterer’s perspective.’ Violence Against Women: An International and Interdisciplinary Journal 7, 5–21. Ferraro, K.J. and Johnson, J.M. (1983) ‘How women experience battering: the process of victimization.’ Social Problems 30, 61–74. Francisco, P.W. (1999) Telling: A Memoir of Rape and Recovery. New York: Cliff Street Books. Frye, M. (1983) The Politics of Reality: Essays in Feminist Theory. Freedom, CA: The Crossing Press. Gilfus, M.E. (1999) ‘The price of the ticket: a survivor-centered appraisal of trauma theory.’ Violence Against Women: An International and Interdisciplinary Journal 5, 1238–1257. Gilligan, J. (1996) Violence: Reflections on Our Deadliest Epidemic. New York: Vintage Books. Goffman, E. (1959) The Presentation of Self in Everyday Life. New York: Doubleday Anchor. Hall, S. (2002) Drawn to the Rhythm: A Passionate Life Reclaimed. New York: Norton. Heart, K.F.H. (1991) ‘Womon Throwing Off Rage.’ In L. Wisechild (ed.) She Who Was Lost Is Remembered: Healing From Incest through Creativity. Seattle, WA: Seal Press. Herman, J. (1992) Trauma and Recovery. New York: HarperCollins. hooks, b. (1989) Talking Back: Thinking Feminist, Thinking Black. Boston, MA: South End Press. Jones, A. (1994) Next Time, She’ll Be Dead: Battering and How to Stop It. Boston, MA: Beacon Press. Kaufman, M. (1995) ‘The Construction of Masculinity and the Triad of Male Violence.’ In M. Kimmel and M. Messner (eds) Men’s Lives, Second Edition. Boston: Allyn & Bacon. Lamott, A. (1994) Bird by Bird: Some Instructions on Writing and on Life. New York: Anchor Books. Messerschmidt, J.W. (1993) Masculinities and Crime: Critique and Reconceptualization of Theory. Lanham, MD: Rowman & Littlefield Publishers. Raine, N.V. (1998) After Silence: Rape and My Journey Back. New York: Three Rivers Press. Riggs, A. (2010) The Creative Space: Art and Wellbeing in the Shadow of Trauma, Grief and Loss. Doctoral dissertation, Victoria University. Slater, L. (1996) Welcome to My Country: A Therapist’s Memoir of Madness. New York: Doubleday.

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Steinem, G. (1992) Revolution from Within: A Book of Self-Esteem. Boston: Little, Brown, and Company. van der Kolk, B. (2014) The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York: Viking. Welldon, E.V. (1988) Mother, Madonna, Whore: The Idealisation and Denigration of Motherhood. London: Karnac.

PART III

TERROR IN THE PRIVATE SPHERE …all the time, as his father read and turned one after another of those little pages, James kept dreading the moment when he would look up and speak sharply to him… And if he does, James thought, then I shall take a knife and strike him to the heart. He had always kept this old symbol of taking a knife and striking his father to the heart. Only now, as he grew older, and sat staring at his father in an impotent rage, it was not him, that old man reading, whom he wanted to kill, but it was the thing that descended upon him – without his knowing it perhaps: that fierce sudden black-winged harpy, with its talons and its beak all cold and hard, that struck at you (he could feel the beak on his bare legs, when it had struck when he was a child) and then made off, and there he was again, an old man, very sad, reading his book. That he would kill, that he would strike to the heart. Virginia Woolf, To the Lighthouse (1927)

…cruel are the times when we are traitors And do not know ourselves; when we hold rumour From what we fear, yet know not what we fear, But float upon a wild and violent sea Each way and none. Shakespeare, Macbeth: Act 4, Scene 2, lines 18–22

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BREAKING INTO A SACRED, BLOODIER SPEECH The Healing Role of Monsters in Child Development, Trauma Play, and the Cultural Imagination CLAUDE BARBRE AND JILL BARBRE

INTRODUCTION In his essay ‘Poetry, Personality and Death’, the poet Galway Kinnell (1971) wrote, ‘The death of the self I seek, in poetry and out of poetry, is not a drying up or withering. It is a death, yes, but a death of which one might hope to be reborn more giving, more alive, more open, more related to the natural life’ (Kinnell 1971, p.235). In a poem entitled ‘Ruins under the Stars’, Kinnell described the death of the self and rebirth experience when listening to the ‘lonely yelping’ of the south-bound Canadian geese until he arrives to a point ‘of breaking into a sacred, bloodier speech’ (Kinnell 1964a, p.39). As the poet says of this death and birth phenomenon in creativity, ‘I know I live half alive in the world’, while at the same time ‘I know half my life belongs to the wild darkness’ (Kinnell, ‘Middle of the Way’, 1964b, p.38). When children who have experienced deaths, violence, trauma, or toxic caregiving move ‘in play and out of play’, they often create monsters in their therapy narratives and action – they role-play monsters, set up monster scenarios and death-dealing scripts, and draw and paint in their own unique idioms the creatures of their hurt and distress. It is the very creation of a personally constructed monster that signals a child’s capacity and wish for life and health, as a means for containing and expressing intolerable states that might otherwise be acted upon destructively. 123

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In this chapter we explore the many meanings of the monster form and figure: as a familiar image in child development; in the role monsters serve in child therapy as regards trauma play and recovery; and in the importance of the monster in the cultural imagination. We examine what the monster means for children – both as a cultural construct handed down by children to each other and by adults to children via play, oral lore, and children’s literature, and as suffused with the child’s unique personal and developmental issues around fear and aggression. We explore how the monster concept functions as a container, creating a containing space that provides opportunities for the mastery of trauma through play. Finally, we suggest that the monster concept should be used therapeutically according to the developmental capacities of the  child. Keeping in mind Winnicott’s emphasis on ‘the sacredness of the occasion’ in play (Winnicott 1989, p.320), we examine how and why the ‘wild darkness’ of the child’s ‘sacred, bloodier speech’ can unfold into a healing potential as she confronts trauma and violence through the transformative form and figure of the monster creation.

WHERE DO MONSTERS COME FROM? Let us consider the origins of the monster concept for the child. Concepts of mummy, daddy, sister, brother, or others with social roles pertinent to the child’s life, such as teacher or storekeeper, come from the child’s direct experience. Cultural figures, such as prince, princess, king, queen, good guy, bad guy, and astronaut, can be more abstract to a child, but still recognizable as human and chosen by a child for play and identification, usually after they have been exposed to them in stories, children’s books, or other media, or by other children. Animals and dinosaurs are also recognizable, and they too provide vehicles for identification and expressions of children’s affective and relational experience – for example, the fierce, aggressive dinosaur, or the scared, vulnerable kitten. Even more negative figures such as witches and vampires are typically given specific characteristics. Although the monster is ubiquitous in children’s play and lore, we are led to wonder who introduces this concept to children. How is it introduced? What does it mean to share this concept with a child? The contemporary monster concept, as experienced and used by children, is often introduced with no realistic or even fixed visual form, and is often never actually given any visual form at all in children’s play,

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even though it is still every bit as real to a child as those figures who are. For example, the monster is often quite solidly installed under a child’s bed, without being at all visualized in detail. The monster’s very lack of form makes it an ideal container for fears of every kind, for aggressive wishes, and for violent potentials. For example, who and what is the ‘Boogie Man’? In some cultures the Boogie Man’s features are prescribed through stories, but even then the child does not exactly know what he or she is, and in his or her unknowing the child creates a space for all manner of otherwise intolerable feelings. In short, someone must at some point tell the child that a monster exists, must label what in the child’s existence was previously without words but needed identifying, in order to give what is frightening a form that can be tolerated and integrated into meaning-making and creative discovery. In sharing this concept with a child, a liminal cultural inheritance about certain kinds of feelings and fears is being communicated. The first time that a young child startles at a sound from an unseen source and another child or a grownup says ‘It’s a monster!’, with marked affect signalling a playful attitude, the child is given a cultural label to attach to the experience and the fear. When the Boogie Man is invoked as a way of keeping the child in line, the monster concept is being used to instil fear  but also becomes a way for the child to process their experience of fear about the consequences of wished-for transgressions. The monster may be introduced at a moment of heightened fear, or to instil fear, but the child’s subsequent creation and re-creation of the monster in play renders it into a manageable form. A concept of the ‘monster’ has actually been present in human culture since the beginnings of mythmaking. Research by d’Huy (2016), who used computer-aided phylogenetic analysis for the comparative analysis of myths, reveals that the Monster in the Cave, or ‘Polyphemus myth’, is one of the basic families of myth which share recurring themes and plot elements, and that it has been present since Palaeolithic times. D’Huy states that, as its original public most likely heard it, the myth of Polythemus involves a hunter, facing one or many monsters that possess a herd of wild animals. He enters the place where the monster keeps the animals and finds his way out blocked by a large obstacle. The monster tries to kill him. The hero manages to escape by clinging to the underbelly of one of the animals. (d’Huy 2016, p.25)

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These cultural myths and stories allowed early peoples to put their collective fears and desires into a metabolized, structured form, one that could be used and reused as well through being handed down in oral histories. The monster is thus one of our earliest and longest-lasting psychological inheritances, a symbol offering inoculation for human fears throughout millennia. In continuing to support and provide for monster play and fantasy for children, as well as in other cultural forms for adults, we continue to offer this psychological inoculation to succeeding generations. One such descendant of the monster myths, exemplifying the ubiquitous nature of the monster across more recent cultures, can be found in Briggs’ description of the evil spirit play of an Inuit child and her family (Briggs 1998). A three-year-old girl named Chubby Maata is visited by a three-year-old boy, Saali, who is wary and shy, but pushed by his mother to move out from behind the safety of her legs and go play. Saali begins to join Chubby Maata in running around, turning some of his earlier anxiety into a dysregulated frenzy. Saali’s mother intervenes with an idea that ‘will at once elevate and “civilize” the fun by giving form to the idiosyncratic wildness of the two running children. “Play that you are an evil spirit (tunraq),” she suggests to Saali’ (Briggs 1998, pp.100–101). As in monster play across many other cultures, tunraq play consists of one person being the monster, with contorted face and voice and strange movements, who chases the others, who then run squealing with delight, and hide. The one who plays the tunraq has the pleasure of acting out aggressive feelings and wishes safely; but Briggs importantly notes that ‘it is the fear of real tunrait [the plural form of tunraq] that gives spice to these performances, and that fear is a much heavier matter’ (Briggs 1998, p.101). The monster concept is so compelling to children because real fear is attached to it: fear that is always either on the verge of spilling out of the story or play, or actually doing so. The experience of dread forms a large part of the enjoyment of monster play – ‘Oh no, here it comes!’; ‘Where is it?’ – and in the excited, heightened experience of dread, monster play becomes a means for mastery of this aspect of human experience as well. Freud (1918), exploring how fear is given cultural form and containment (or not), notes that, in German, uncanny is translated as ‘unheimlich’ (un-home-like) or the opposite of ‘heimlich’, which means ‘homely’ and familiar. For young children, the tension between what feels homely, comforting, predictable, and familiar and what is unknown and fear-inducing, including their own affect storms, is acute. Their need

The Healing Role of Monsters

for forms of containment is imperative. They typically take readily to the monster concept, creating their own containing versions out of their personal psychologies. However, all too often children are denied free use of the monster concept because of adult misunderstandings and feelings of anxiety and threat about its meanings – anxieties which can lead adults to attempt to limit or quash the monster play expression, in families and other settings where cultural transmission and regulation takes place, such as preschools. This takes away a vital psychological function for the child, giving the message that certain mental contents are not safe. In communities where violence and trauma compromise the child’s ability to distinguish what is real from unreal, and extra support from adults is also needed, a monster form provides a safer container for play than, for example, pretend guns, because the monster always has a kind of unreality that a gun cannot. It is the affect that needs to be monitored and regulated when children become overexcited or overwhelmed, not the actual content of their play. When the two are conflated, the child’s ability to make use of symbolic content is compromised. Luckily for most children, there are still spaces under the radar of adult attention, where monster play lurks freely, or even if noticed by adults is not given much import, despite the crucial psychological work that children are actually doing.

HOW VIOLENT STATES ARE TRANSFORMED INTO MONSTERS When rageful and murderous states of emotional death and rebirth are enacted in the therapeutic crucible, monster figures can enable trauma enactments to be symbolized and confronted. The therapist has to survive being the monster or being attacked by the monster, as play dramas create a middle space where the child can find a new beginning. Once he or she ‘survives’ the ‘monster’, the patient – invariably astonished as the object survives destruction and thus becomes real and, hence, encountered and communicated – can begin to know about the usefulness of being able to love; can learn to love with ambivalence; can allow for hatred of the object, all of which may remain unsayable, but ‘spoken’ in the play space (see Winnicott 1971). The development of symbolic function has been a central feature of psychoanalytic theory. Two lines of thought regarding this aspect of development particularly pertain to the symbolic use of the monster

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concept. The first is Winnicott’s idea of the transitional object and transitional space (Winnicott 1971). Winnicott traces the developmental trajectory of symbolic functioning as beginning with the child’s initial use of a ‘transitional’ object which the child chooses as a stand-in for the mother. This ability to use a stand-in for the primary object/mother/ caregiver means that the child has begun to be both cognitively and emotionally capable of using one thing to represent another; this marks the beginning of symbol use. The transitional object is both ‘me’ and ‘not-me’ (mother) at the same time. Language also develops in this transitional space, as the child learns that words/symbols must increasingly be used to connect with the mother/ caregiver to signal desires and intentions. This is also the space that the monster begins to inhabit in the child; the use of transitional space allows the child to create a ‘me’ and ‘not-me’ experience relating to the monster concept, to imbue the monster with personal meanings and affects, and thus install it as a container. As Alford notes, the ‘forming and reforming’ of cultural symbols by the child is an ‘active, unconscious process, in which the cultural symbol is used as the child uses a transitional object, investing it with the power of self and other, and creating meaning out of things’ (Alford 1999, p.45). In line with Winnicott’s thinking, we want to underline the importance for the child of making use of cultural symbols such as the monster in their own way, and not being ‘instructed’ in their use by prescribed books, movies, toys, or games. It is the child’s unique feelings, experiences, and meanings that inform their use of transitional space and not that which is imposed from without, which may have the effect of collapsing, impinging, and even negating that space. Although important parts of the process of developing a symbolic function thus start very early on, it takes time to complete, as well as the support of a caregiving adult who possesses this capacity to symbolize and ‘mentalize’. In the second line of thought useful to our exploration of the development of the monster concept, Fonagy and Target (1996) trace the importance of the ‘mentalizing other’ for the development of symbol use in children. They observe that young children around three years of age are normally in a state of ‘psychic equivalence’ (Fonagy and Target 1996, p.218) in which they regard their psychological states as equivalent to objective or physical reality, rather than as being intentional or belonging to them. They are like Freud’s neurotic patients who ‘react

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just as seriously to thoughts as normal people do to realities’ (Freud 1913, p.159). They do not yet have the capacity to appreciate the ‘merely representational’ nature of ideas and feelings: they are very concrete in their thinking. As they engage in play, developing their capacity to recognize that what is pretend is not real, they can use pretend ideas that come from their mind; only sustaining this ‘pretend mode’ as long as the pretend quality is marked and exaggerated, so that it does not seem to correspond with reality. When pretend mode collapses, their fears become real, and so what they are afraid of is real – even when it is a monster that they have never seen. Creating protected time for children to be in pretend mode allows them to continue to develop the capacities that play instils. In Fonagy and Target’s thinking, this protected space allows for the next development in the capacity to symbolize, in which the child’s and the other’s behaviour makes sense in terms of mental states and in which mental states are representations that may change because they are based on a range of possible perspectives. Psychic reality and pretend mode are thus ‘integrated’ in the sense that the child sees that psychic reality is not reality, but relative and dependent on one’s point of view. For this development to take place, say Fonagy and Target, three things are necessary: the child’s ‘current feelings and thoughts, these mental states represented (thought about) in the object’s mind, and the frame represented by the adult’s normally reality oriented perspective’ (Fonagy and Target 1996, p.221). The child needs an adult or older child who will help them to move from their internal experience to their expression of that experience; to mark play as play, ‘licensed and supported’ and ‘without consequence’; to help the child to feel safe to reflect on her mental contents and thus metabolize them. Being alone with her thoughts and fantasies can lead the child to be stuck in worries about those fantasies having psychic equivalence: A father sits down during a mock battle, only to be told ‘You are the monster – you have to stand up so that I can kill you!’ If the father dutifully stands up, he is helping his child to metabolize and work through the murderous phantasy. If he stays sitting down (or especially if he responds to the phantasy with disapproval, anger, sadness, fear, reinforcing the child’s sense that it might become too real), the murderous thoughts remain unmetabolized. (Fonagy and Target 1996, p.228)

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Fonagy and Target also note that thoughts that cannot be metabolized by the parent are typically passed on for the child to cope with, as in intergenerational transmission of trauma. Provision of the monster as a concept for play can provide inoculation against the felt fear and violence of trauma transmission, through the engagement of the child’s mentalization and creativity to cope with it. In Briggs’ description of the Inuit children’s play, she notes that the mother is both escalating the children’s behaviour and providing a shape and meaning to it, and in this way ‘probably enjoying both the impropriety of the game and its propriety, its antisocialness and its socialness’ (Briggs 1998, p.101). She adds: ‘Unwittingly, [the child] may be showing the adults their own monsters – their own aggressive feelings and their own fears.’ This is an excellent example of the investment that the adult can have in the child’s monster play, and points to the need on the adult’s part to communicate intergenerational experiences through cultural symbols and forms to their children, perhaps as a form of connection to the intergenerational legacy, and as a way of unburdening themselves from the affects surrounding it. If the child is allowed to participate and make use of the monster as a cultural symbol, they can join in the inheritance. When the child’s capacity to make use of the monster as a symbol is compromised through an excess of fear and trauma transmission, however, the play could elicit tears and frozen silence rather than squeals of laughter and delight, and that can give the child a different, unhelpful message about how play with cultural symbols can be used.

TRAUMA AND THE FAILURE OF SYMBOLIZATION TO CONTAIN VIOLENT STATES Alford (1999) discusses the failure of symbolization in those who perpetrate violence, using interviews of inmates and free individuals that asked them, via open-ended questions, to identify their concepts of evil. Most in each group referred to an experience of dread – interesting to note, as we have earlier stated that dread is one of the features of monster play and the monster concept. Alford observes that the inmate population seemed unable to use symbolic thinking, and notes that their strategy for managing an experience of dread seemed to be to evacuate it from themselves by putting it into the bodies of their victims: ‘Putting our dread into the other by terrorizing and victimizing him, we give our

The Healing Role of Monsters

dread form’ (Alford 1999, p.39). In psychic equivalence, the symbol is literal, becomes the body itself, and evil thoughts are equivalent to evil deeds. Most of the inmates Alford interviewed, when asked ‘Is it evil to think evil?’, replied that it was. Most free informants said no, suggesting that their capacity to recognize a thought and to symbolize with language and image – to mentalize – has allowed them to manage evil at a more abstract level than those inmates who are ‘trapped in their bodies’ and ‘have difficulty using language to capture and reflect their  feelings’ (Alford 1999, p.44). In children and adults who have experienced maltreatment and interpersonal trauma, mentalization and the ability to reflect on the self and emotional states has been compromised. Ensink et al. (2015) point to research which shows that abuse and neglect are associated with poor discrimination of all emotions, and also with delays in self-recognition in the mirror between 18 and 30 months – typically also the age where the development of language and symbol formation and use begins to take off. They further state that parents who maltreat may be ‘unable or unwilling to imagine the child’s internal experience, may discourage coherent discourse about mental states, and undermine the development of mentalization in children to avoid engaging with the psychological impact and suffering they inflict’. ‘Children,’ the authors note, ‘may be terrified to think of the minds of caregivers who sometimes harbor malevolent intentions or have distorted representations of them and may avoid thinking of this in order to preserve their attachment relationships’ (Ensink et al. 2015, p.205). Parents who may have had these experiences in their own childhood may either have general difficulty in mentalizing their children’s experience, because they did not have help to do that themselves, or have islands of unmentalized emotional content or difficulty acknowledging what a child brings to them around specific areas, such as sexuality, aggression, or dependence. For the child in this situation, as for the child who has experienced trauma directly, monster play may remain too frightening to contemplate; or the child may become dysregulated in their attempts to engage in it if the environment fails to provide a frame of physical safety and emotional holding. With the support of another child they may be able to participate in it usefully, often away from the parent’s radar, and begin to use the monster as a container for their trauma, but their play may become stuck, repetitive, and joyless.

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Cultural symbols are useful to the child only insofar as they are helped to make use of them through a facilitating environment. In traumatic play, the child does not have the necessary emotional freedom, or the ability to engage in trial action or thought, because he is caught in a traumatic space of psychic equivalence dominated by flashbacks that hold him in violent and fearful states of mind. The child therapist is typically quite familiar with the monster, frequently bidden to be its target or to take on its role, but the therapist often may consider the monster a symbol of the child’s conflicts and negative feelings that need to be worked through so as to rid the child of the need for it, rather than as a vehicle not only for healing but for cultural participation in itself through its free expression in play. This is not to say that a therapist should introduce the monster concept to a struggling or traumatized child, but should recognize its importance so as to facilitate its expression as it emerges from the child’s play initiatives and subjectivities. Having cultural symbols and forms available to the child, and to the adult, is vitally important, but it is even more important that the child has the opportunity to use these in her own way. That being said, having a basket of monster figurines available in one’s office both invites this kind of play and, in some children’s avoidance of it, provides helpful diagnostic clues. O’Loughlin (2010) underlines the importance of having cultural lore available to children, particularly when it comes from sources that have been repressed by a dominant culture. He notes the Aboriginal therapist Judy Atkinson’s idea of a crisis of lorelessness (Atkinson 2002), ‘in which absence or severance of the kinds of social linkages or narrative continuities’ needed for psychic health can actually ‘create a basis for future psychosis or some other equally traumatic solution’ (O’Loughlin and Merchant 2012). It can certainly be observed that a lack of connection to cultural meanings underlies much anomy and emptiness in our current age, but it must also be noted that the ability to make personal use of the cultural meanings that are available, as the child must make use of the monster, is what makes possible the use of lore.

The Healing Role of Monsters

CONCLUSION: THE DEVELOPMENTAL AND THERAPEUTIC IMPORTANCE OF THE MONSTER CONCEPT A knowledge of the developmental processes by which children begin to make use of symbols and symbolic thinking, with the help of a facilitating other, can usefully inform the child therapist’s understanding of and interaction with the monster concept in the child’s play. Expectations of the adult need to be kept in line with the child’s developmental capacities, which in some children may not be in line with chronological age but more connected with emotional functioning and/or cognitive capacities. The multiplicity of roles and story lines in monster play allow the child the benefit of increasing their capacity for mentalization and imagination, as well as solidifying the child’s ability to cope with affects such as fear and dread through their containment in play. It is through the medium of play that an act of recognition can take place – discontinuous self-states previously disavowed can become noticed in play, become elaborated, articulated, explored, and enacted more openly. Disavowed aspects of oneself become symbolized through their enactment. Thus, through playing, these states become realized, integrated, and accepted into the child’s experience of him or herself (Frankel 1998). Chazan’s (2002) work on the meaning of the play state and how to observe a particular child’s ability to be in and move in and out of the play state is helpful in facilitating the therapeutic process of monster play. Watching the child’s affective expression for signs of being in a play state, and for when they move out of the play state because of fear, is particularly important in encounters with the monster so that the child therapist can know when he should expressively ‘mark’ monster play as play in order to help the child stay with it and elaborate on it, and when the child may be showing that the monster is too real to them to maintain a play state and she needs to stop and have those feelings of fear acknowledged and contained. The therapist’s marking of monsters as safe and as play gives the message to the child that violent mental states can be given a safe form from which to tolerate them and also to explore them and move towards essential meaning-making. Emotional freedom can then release the child from violent and fearful states, infuse their play with energy, and bring them to a place, to revisit the Kinnell quote we began with, ‘of which one might hope to be reborn more giving, more alive, more open, more related to the natural life’.

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As Alford writes: ‘T.S. Eliot said we do not inherit a tradition. We obtain it at great labor. Most of which, it should be added, remains invisible to us, an unconscious cycle of projection, cultural containment, and reintrojection of re-formed experience’ (Alford 1999, p.45). With the therapist’s support, the child’s ability to remain in a play state and utilize the symbolic properties of the monster concept can give the child a space for both working through his or her particular struggles, and for increasing his or her capacity to make creative use of a cultural legacy.

REFERENCES Alford, C.F. (1999) ‘A psychoanalytic study of evil.’ American Imago 56, 27–52. Atkinson, J. (2002) Trauma Trails. Recreating Song Lines: The Transgenerational Effects of Trauma in Indigenous Australia. North Melbourne, Australia: Spinifex Press. Briggs, J.L. (1998) Inuit Morality Play: The Emotional Education of a Three-Year-Old. New Haven: Yale University Press. Chazan, S. (2002) Profiles of Play: Assessing and Observing Structure and Process in Play Therapy. London and Philadelphia: Jessica Kingsley Publishers. d’Huy, J. (2016) ‘Scientists trace society’s myths to primordial origins.’ Scientific American 315, 6, 29 September 2016. Accessed on 6/12/2017 at www.scientificamerican.com/ article/scientists-trace-society-s-myths-to-primordial-origins Ensink, K., Normandin, L., Target, M., Fonagy, P., Sabourin, S. and Berthelot, N. (2015) ‘Mentalization in children and mothers in the context of trauma: an initial study of the validity of the Child Reflective Functioning Scale.’ British Journal of Developmental Psychology 33, 203–217. Fonagy, P. and Target, M. (1996) ‘Playing with reality: I. Theory of mind and the normal development of psychic reality.’ International Journal of Psychoanalysis 77, 217–233. Frankel, J. (1998) ‘The play’s the thing: how the essential processes of therapy are seen most clearly in child therapy.’ Psychoanalytic Dialogues 8, 149–182. Freud, S. (1913) ‘Totem and Taboo.’ In J. Strachey (1955) The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XIII (1913–1914): Totem and Taboo and Other Works. London: The Hogarth Press and the Institute of Psycho-analysis. Freud, S. (1918) ‘The “Uncanny”. In J. Strachey (1955) The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XVII (1917–1919): An Infantile Neurosis and Other Works. London: The Hogarth Press and the Institute of Psycho-analysis. Kinnell, G. (1964a) ‘Ruins under the Stars.’ In Flower Herding on Mount Monadnock. Boston, MA: Houghton Mifflin. Kinnell, G. (1964b) ‘Middle of the Way.’ In Flower Herding on Mount Monadnock. Boston, MA: Houghton Mifflin. Kinnell, G. (1971) ‘Poetry, Personality and Death.’ In D. Hall (ed.) (1982) Claims for Poetry. Ann Arbor: The University of Michigan Press.

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O’Loughlin, M. (2010) ‘Ghostly Presences in Children’s Lives: Toward a Psychoanalysis of the Social.’ In M. O’Loughlin and R. Johnson (eds) Imagining Children Otherwise: Theoretical and Critical Perspectives on Childhood Subjectivity. New York: Peter Lang Publishing, Inc. O’Loughlin, M. and Merchant, A. (2012) ‘Working obliquely with children.’ Journal of Infant, Child and Adolescent Psychotherapy 11, 149–159. Winnicott, D.W. (1971) Playing and Reality. London: Tavistock Publications. Winnicott, D.W. (1989) ‘The Value of Therapeutic Consultation.’ In C. Winnicott, R. Shepherd and M. Davis (eds) Psycho-Analytic Explorations. Cambridge, MA: Harvard University Press.

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Chapter 10

‘YOU BE THE MURDERER NOW’ TAMSIN COTTIS

We were in the midst of a game in a therapy session when 13-year-old Paula said to me, ‘You be the murderer now.’ Initiated by Paula, and retold and developed between us over many months, the game involved an intruder coming into a house to attack and strangle a young woman while she lay sleeping in bed. Paula1 had Down’s Syndrome and severe learning disabilities. As a very young child she suffered repeated experiences of life-threatening violence, including in utero. At age three she had been removed from her home, forcibly, by police. After a number of foster placements, Paula was found a permanent home aged 11 and was referred for psychotherapy. Because the traumatic events happened in the context of chaotic family life while Paula was pre-verbal, the precise details of the abuse suffered were unclear to me and to her. This was work which had no distinct and detailed chronological narrative and was unlikely ever to have one. However, it was clear at the time of referral that her interactions with others were intensely sexualised and predatory. This made her both vulnerable and a threat. Paula’s main carers had been objects of fear. This had led to a disorganised attachment (Main and Solomon 1986). This deeply split way of relating leads love and hate to become horribly confused: loving feelings imply potential annihilation and this leads to a terror of intimacy. Where a child has, like Paula, been sexually abused by her carers, there 1

Permission to use clinical material has been granted. Details have been changed to preserve confidentiality of identity.

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is a further confusion of eroticisation and terror. This resonated with my experience of Paula, especially in the early sessions, and made establishing a positive therapeutic relationship with her extremely challenging. In this chapter I will explore violent states of mind in children and young people who have learning disabilities and who have experienced significant trauma and abuse in early childhood. My child patients also often pose a sexual risk to others. Their violent state of mind is always at the edge of needing to be evacuated into a (part-)object. Repeated early experiences of trauma have disrupted their capacity for selfregulation of emotion, and their powerful feelings can easily overwhelm cognitive processes which have also been partly compromised by organic intellectual disabilities (Fonagy 2004; Sobsey 1994; van der Kolk 2005). I discuss ways in which long-term forensically informed Integrative Arts Child Psychotherapy (IACP), which has creativity and play at its heart, can be a helpful response and intervention for these very troubled and disabled patients. This therapeutic approach allows for a violent state of mind to be met and understood in the context of a relationship in which play and creativity are viewed not only as important means for the expression and externalising of traumatic feelings and experiences, but also as a critical developmental opportunity: one which can facilitate the integration of a range of feelings, such as fear, shame, sadness and vulnerability, which may hitherto have become disavowed and dissociated from, or projected into others in violent ways. In IACP, powerful expressions of hate and aggression, including sexual aggression, in the therapy – usually made through play and metaphor but sometimes more directly – can be worked with creatively to bring about change. Such an approach allows for concentrated work in the negative transference and, underpinned by an understanding of Winnicottian object relations (Winnicott 1945), attachment theory (Bowlby 1953) and trauma theory (van der Kolk 2005), can support a patient with learning disabilities to develop safer and more positive ways of relating to self and others. Children who represent a threat to others must, of course, be cared for in ways which minimise their risk, and therapy must take place in a safeguarding context. Effective communication between all those involved in care is a critical aspect of this kind of therapy with vulnerable children and adults (Blackman and Cottis 2013). In IACP the behaviour is addressed indirectly through play and metaphor against and through the

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backdrop of the developing relationship between therapist and patient. IACP can play a part in enabling patients to maximise their potential for a life which is as self-determined and independent as possible.

LEARNING DISABILITY AND THE VIOLENCE OF SOCIAL EXCLUSION The boundary between environment, disability and developmental disturbance caused by trauma is a porous one. If Paula saw a photo of herself she would declare, ‘Look at my stupid idiot ugly face.’ Like many children with learning disabilities, Paula’s sense of herself as disabled and ‘other’ had impacted on her sense of self. She looked different; she was in a special school. The ‘ordinary’ development of a child with identified learning disabilities can also be arrested by what Hollins (2000), with reference to Money-Kyrle’s (1971) ‘facts of life’, has called the impact of the ‘three secrets’: sex, dependency and death. Hollins explores how all of us have to come to a place of integration and ‘peace’ with these facts of life. The presence of a disability sometimes engenders unconscious feelings of a life less valuable, of being created by ‘bad sex’. Complex and compromised patterns of dependence upon and individuation from an attachment figure can make such developmental processes much more difficult for the individual. Sobsey’s (1994) ecological model of abuse illustrates how these individual developmental experiences are in a dynamic interaction with, and horribly exacerbated by, the presence and expressions of disability hatred in contemporary British society. A valued place in society can be very hard to attain, and this is made harder if you have not felt yourself valued within your own family (Cottis 2009; Sinason 2012). People with learning disabilities are subject to very high levels of hate crimes and discrimination (Mencap 2010) and are often socially isolated and lacking in support. This extreme vulnerability is made more acute by the current climate of austerity in Britain, which has had a disproportionate impact on disabled people (Mencap 2012a). People with learning disabilities also have unequal access to health care (Mencap 2012b) and experience neglect and abuse in institutions which are ostensibly places of care and support for them (The Guardian 2015). It is important to acknowledge the impact of such systemic discrimination and of fears and hatred expressed through the social unconscious (Corbett and Cottis 2016).

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Corbett (2014) concludes that ‘the profoundly low levels of self-esteem, agency and psychic integrity felt by people with intellectual disabilities stem more from all that is projected into them from birth (and beyond) than from the actual fact of their low IQ’ (p.8). Gilligan (2011) identifies how internalised shame at needy and dependent feelings in the self may be projected into others in violent ways. He argues that times of economic inequality heighten shame in those who are doing least well materially. It could be argued that a person with an enduring need for care and a seriously compromised capacity for economic self-sufficiency would speak to us the loudest and connect us most deeply with our fear and shame about such states. Certainly, notable examples of brutal hate crime perpetrated within communities (e.g. Hampshire Safeguarding Adults Board 2009) would suggest this. We know from the work of Schore (1994) and others that brain development and positive attachment is optimised through non-shaming attuned attachment relationships. Shame leads to withdrawing and retreat from relationships and as such is antithetical to relational psychotherapy. People with learning disabilities find themselves on the receiving end of hatred and hostility which can represent an ongoing psychic challenge to their notion of humanity as benign and nurturing. The very capacity to trust in help to be helpful can thus be damaged. Furthermore, the sexuality of people with learning disabilities may be experienced as frightening and disgusting. There may be fears of uncontrollable sexual feelings being expressed, and fears that any pregnancy resulting from sexual intercourse between people with learning disabilities would result in a continuation of the disability. Such feelings fed past eugenics movements and may still be present in superficially more palatable forms today: ante-natal screening for potentially disabling genetic conditions, especially Down’s Syndrome, has become increasingly sophisticated and widespread. In a recent survey in the United States, termination rates following a diagnosis of Down’s were assessed at 67 per cent in 2012 (Natoli et al. 2012). The equal value or even ‘allowability’ of learningdisabled life is very far from assured. These feelings may be held in the social unconscious, pervasive and hard to access. However, they can and should be admitted to the therapeutic process, and a therapist in this field needs to work with this knowledge as an integral part of their practice.

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TRAUMA, TRANSITION AND PLAY Youell (2009) highlights how early experiences of play and playfulness are central to children’s development and how trauma impedes a child’s capacity for play. At the beginning of my work with Paula, the overwhelming feeling was one of chaos. She grabbed at toys, then cowered in a corner, by the door. She would pick up the toy animals and inspect, prod and claw at their genital areas. Dolls had their clothes ripped off and scattered about the room. She brought with her a great confusion of fear and need, along with physical restlessness and mess-making. Paula said repeatedly that she was going to take off her top and show me her breasts. If she heard a siren outside on the street, she would flinch and cower. She seemed to have no idea how to be with another person – protesting her love one minute and shouting at me to be quiet the next. She was hypervigilant, recognising my footsteps from far down the corridor and, at first, never taking her eyes off me in sessions. She was never calm or relaxed. She picked at her skin, causing deep wounds which she could not let heal. Youell stresses the relational aspects of play and of working creatively with children to help build the capacity for play. This involves the therapist in being committedly and whole-heartedly ‘in the play’ but also with one foot outside the game, in order to stay able to think about, contain and process the powerful emotions which are being expressed. Patients with learning disabilities often need to play out their traumatic experiences repeatedly, just as a more cognitively able or articulate person may need to retell the story of a traumatic experience over and over again in therapy. In our game of ‘Murder’, I didn’t know how the action linked with Paula’s actual lived experiences, but I understood that I was being asked to bring her overwhelming fears of catastrophe or annihilation alive in the room and that she needed me to be in the role of perpetrator of a horror. Like many games created by children as they play them, our game unfolded unpredictably. Play which is co-created and evolving is an inherently risky business, analogous, as Winnicott says (1951), to the creative output of an artist and therefore open to all that a human may feel. The game took place with Paula lying underneath a blanket and on large soft cushions at the base of a large cupboard, with me sitting just outside the (slightly ajar) door. No physical contact took place between us, but I was required by Paula, in effect, to recreate with feeling the sound effects of the murder. She played out her consequent fear and terror equally expressively.

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Another game that Paula loved was for me to pretend to be a cackling, caricature wicked witch and then, at her direct instruction, revert to being ‘Kind Tamsin’. She would order me into the ‘witch’ state and then immediately back again. It is possible to see how this repetitive play (familiar to parents of very young children) would help create the close connection and dyadic mutual understanding that allows for development of a good object. Fraiberg, Adelson and Shapiro (1975) suggest that an affectless narrative memory keeps the abusing person in the place of identification with the aggressor. By becoming more comfortable with feelings of fear and aggression – experienced pre-verbally by Paula and now locked in the body, unavailable to her conscious memory – they could become detoxified and begin to be integrated. I see Paula’s games as ‘object games’. That is to say, they are games created by the child, played repeatedly and liable to further development, the details of which are mutually understood and shared by therapist and child. They function in a similar way to transitional objects (Winnicott 1951). They create relational space for the creativity and imagination of the child to take a lead. They also offer a chance to play out a sense of mastery over the bad object and to externalise it. Paula’s aggression and witch-like evil was projected into me through play and I could hold it for her. This illustrates the critical nature of hate in the therapeutic relationship. If I cannot bear my patients’ hate or to feel hate towards them, albeit hate contained in part by the boundaries of a game we have created, we would not be able also to experience the feelings of warmth and love which, Winnicott (1947) suggests, derive from the same impulse. Winnicott suggests that the potential for aggression may become activated by feelings of persecution, and it is likely that a disorganisedly attached child, such as Paula, who has experienced life-threatening danger and carries internalised hatred from the social unconscious because of her disability, may feel readily persecuted. The child comes to welcome persecution, as it fits in with expectations and the defensive false self-functioning to which the child is psychically accustomed. Playing out games of violence in therapy offers a rich source of metaphor and relating to try to untangle some of this disturbance. I can respond in play by speaking clear and feeling-full words: ‘How terrifying! The murderer is coming and there is no one to keep you safe’; or ‘You thought I would look after you but now I am going to kill you!’ I do not need to come out of metaphor, and in the play I have expressed, witnessed and named the affective experience of Paula being afraid for her life.

‘You be the murderer now’

Fraiberg et al. (1975) write of having to recover the ‘affect’ of a split-off experience in a traumatised child who has hurt others, in order to move forwards. The child has to ‘feel’ what they felt at the time of trauma, in the presence of a therapist. This ties in with Alvarez’s (2012) idea of different levels of work: a developmentally delayed, traumatised or disabled child may require work at the ‘vitalising’ level, in which the child may not know that there are such things as feelings, and also at a descriptive or amplifying level, in which ‘severely neglected or traumatised children might require not the offering of alternative and additional meanings but the elucidation and enlargement of single meanings, one at a time’ (p.4). Van der Kolk (2005) has identified a potentially new diagnosable child psychiatric disorder – Developmental Trauma Disorder (DTD). He argues that children often present with multiple psychiatric diagnoses, none of which capture or name the impact of repeated traumatic experience in early childhood. DTD captures the way that such experiences affect child development across all domains: physical, relational, cognitive and educational. Research on the chemistry of the developing brain (Schore 2003) shows that too much stress and fear in infancy can affect the hard-wiring of the brain. Excess cortisol triggered by life-threatening situations which demand fast fight/flight/fright/ freeze reactions may actually shrink the hippocampus and make higherlevel functioning more difficult. The trauma may thereby be seen, in some cases, to have caused the learning disability.2

Lukas In another long-term treatment, it was the use of puppets which enabled a child to access hitherto disavowed feelings of aggression, hate and vulnerability. Eight-year-old Lukas, who had been sexually abused, neglected and tortured within his family until age three, was referred following an incident in which his foster carer had found him digitally penetrating the vagina of his three-year-old sister. Lukas flatly denied his sexually violent behaviour and presented as a calm and well-mannered 2

I am mindful that, in this context, the therapeutic environment is potentially fraught with the possibility of retraumatisation. Van der Kolk (1996) suggests that a ‘re-experiencing of trauma lights up only the right hemisphere of the brain – i.e. that most involved in emotional arousal – and not the left where the child can make experience known as language’ (p.4). Alvarez (1992) says abuse experience needs to be absorbed in tiny pieces, as children will have a fragmented sense of self and be unaware of their whole experience.

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child. In one session, which took place about halfway through his 18-month treatment, Lukas put a spider glove puppet in his hand. He’d named this puppet ‘Steve’. He started to throw some flexible plastic discs, about 30cm in diameter, which we often used for a game. He threw them at me, increasingly fast and hard, and in larger numbers, Frisbee-style. It was impossible for me to get them and I was doomed to fail. I said, with feeling, ‘Ouch! That was tough!’ and ‘There was no way I could catch them.’ Lukas seemed pleased and blamed the puppet, attributing to Steve his angry and aggressive behaviour. I could gently talk about this, feeding it back to him in manageable pieces, naming the feelings I saw in him. He then excitedly took out the play tunnel. He stretched it to its full extent. We looked at each other from opposite ends of the tunnel. His face lit up and so did mine. He wanted us to pass balls to each other. We had fun and I said so. Lukas then wriggled into the tunnel and I met him as he emerged from the other end. This play felt very early – like a baby of 18 months, perhaps. The game set up a chance for us to meet each other and for me to animatedly show my pleasure at seeing him. He was also adventurous and curious about the tunnel. I felt the tunnel also served as a communication about birth and carried some maternal transference. Lukas then decided he wanted to make a den for himself in the corner of the room, access to which would be through the tunnel (I couldn’t fit in the tunnel). He wanted cushions and a blanket and Steve Spider, along with some other puppets who had names and identities acquired over months of play. He slowly made his way in. At that point I felt completely shut off, stranded and abandoned. He said he was a baby and began to speak in a high-pitched, squeaky and completely incomprehensible tone. The noises were distressed and distressing. In the transference, I felt bereft and terribly alone. I got out another puppet – a dog – and I dialogued with this puppet about how left out I felt and how upset the baby seemed to be. Lukas began to throw random toys at me, saying they were bad food that he didn’t like. I reflected these negative feelings and amplified them with much affect in my voice. Lukas, as the baby, expressed more aggression and hurt. He threw the toys harder and wailed louder. It seemed to go on a long time and then he stopped. Still in his house, Lukas invited me to join him. I climbed round to where he was and he flung his arms around me in a

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too-tight hug. This felt dysregulated and uncomfortable for me. It was as though Lukas felt great confusion about what middle ground might lie between outright rejection and an invasive hug and was perhaps beginning to explore this.

Discussion By engaging in a relationship underpinned by play, it is possible to see how these co-created object games can allow for a transition from a violent state of mind to one which is more creative, carrying within it the potential for change and previously unimagined possibilities. Transitional objects help to build a sense of self: each new aspect of a game, like a name given to a puppet or an attachment formed to a sand tray object, is a sign of the child’s own mind at work. It can be grown and expanded over time: the roles and characters can become more complex, and have more interesting things happen to them. The objects, actions and characters are found and created by the child and they act as builders of secure attachment as well as of the mind and its imaginative powers. This vignette helps to illustrate how play in therapy allows also for an experience of shared pleasure and mutual enjoyment – which is at the heart of playfulness. This, and the fact that so much imaginative play involves seeing things from the perspective of another person or character in the play, means that this is a therapeutic approach which can also help to develop empathy. As Fonagy (2004) says, violence and the threat of violence interferes with mentalisation. For violence to occur there has to be – however fleetingly – an absence of empathy and a failure to recognise or engage with the mental state of another. The process in which I notice, share and remember children’s ideas for games and play helps to co-create a narrative – a language of our own. A child feels understood and special. I am providing an affective experience of empathy and a healthy intimacy can develop. Crucially, the relationship is dyadic, and the child derives a sense that they are being authentically enjoyed by an attachment figure. Alvarez (2012) writes of how children with disabilities very often do not have the opportunity to feel that they can be bringers of pleasure. To see love and appreciation reflected in the gaze of their attuned carer is also key to optimal brain development as shared enjoyment stimulates the pleasure hormones of oxytocin, which seem to be so crucial to the healthy development of

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neural pathways and help strengthen the neuro-cognitive capacity for mentalisation (Fonagy 2004, p.45).

SEXUALITY AND AGGRESSION Many of the children I see have been prematurely sexualised through sexual abuse within their families. Disturbed expressions of sexuality are a feature of this work even in so-called latency-age children. As O’Brien (2004) says of her child patient Bella, ‘it is hard to watch a small child behaving in a sexually alluring way. Anxiety is evoked in the therapist that the abuse is being continued in therapy… [The abuse of Bella] was held as a behavioural memory that she enacted frequently’ (p.10). This can make the work behind the closed door of the consulting room very risky. The possibility of allegations being made against one has to be integrated into the work and mitigated against wherever possible through good safeguarding practice, supervision and accurate record keeping. Children with experiences of sexual abuse and exploitation have complex sexualities, and feelings of loss and attachment can be easily sexualised. Seduction may have been a way to get attachment needs met. Children and adolescents with learning disabilities may be met with fear and disgust when they actively express their sexuality: they have an even more complicated path to tread (Alvarez 2012; Corbett 2014; Cottis 2009; Lloyd 2009). Winnicott’s view (1950) is that aggression in a child is connected to motility and to a life force. In order to develop, the child has to move, and in moving towards something it encounters resistance and it is this which facilitates growth. However, where there has been too much resistance or adverse experience, which he calls ‘impingements’, then there is a lack of integration of aggression and a ‘false-self functioning’ arises (p.213). Winnicott sees the fusion of erotic and aggressive factors as a developmental task and, if there are multiple impingements, the child’s relationship to a therapist can be aggressive and erotic in turn: loving warm feelings, which are an ordinary part of the positive transference in a less disturbed child, cannot safely find a place inside the child’s object relations worlds and become eroticised because of earlier experience of premature sexualisation. This connects with Glasser’s (1996) description of the ‘Core Complex’, in which the forensic patient fears annihilation from the intimacy he craves.

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CONCLUSION Children with learning disabilities who have experienced terrible trauma are often, in my experience, unable to link a current behaviour to a past experience in words. Their capacity for mentalisation is also likely to be impaired in the long term. However, therapy provides an opportunity for the repeated playing out of trauma, using creative interventions which can play a part in developing the individual’s mind and imagination. It can offer chances to safely express aggression, violence, sexual disturbance, hate, shame and vulnerability, as well as enjoyment and love. This takes place in the context of an attuned, empathic and containing relationship. Paula and Lukas had responded to the violence perpetrated against them with violent behaviour acted out towards self and others. Both also had conscious and unconscious experiences of the violence and hate of a society which could be extremely hostile to their very existence and deeply resistant to the fact of their enduring and complex needs for support. A recognition of these experiences, and the way in which they had been in interplay with experiences of life-threatening trauma to bring about, or exacerbate, learning disabilities, helped inform my understanding of the meaning of their play in therapy. In long and challenging treatments it felt possible to develop and draw upon the resource of creative states experienced in relationship, to help the children develop a greater capacity for self-regulation and a sense of themselves as people of value and interest who could begin to become better acquainted with their own minds and to be more able to think into the mind of another.

REFERENCES Alvarez, A. (1992) Live Company. London: Routledge. Alvarez, A. (2012) The Thinking Heart. London: Routledge. Blackman, N. and Cottis, T. (2013) Psychotherapy at Respond: The Relational and Attachment-Based Systems Model (unpublished paper). Bowlby, J. (1953) Child Care and the Growth of Love. Harmondsworth: Penguin. Corbett, A. (2014) Disabling Perversions. London: Karnac. Corbett, A. and Cottis, T. (2016) ‘The Irish Social Unconscious in Relation to Disability.’ In E. Hopper and H. Weinberg (eds) The Social Unconscious in Persons, Groups and Societies. Vol 2: Mainly Foundation Matrices. London: Karnac. Cottis, T. (2009) ‘Love Hurts: The Emotional Impact of Intellectual Disability and Sexual Abuse on a Family.’ In T. Cottis (ed.) Intellectual Disability, Trauma and Psychotherapy. London: Routledge.

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Fonagy, P. (2004) ‘Early Life Trauma and the Psychogenesis and Prevention of Violence.’ In R. Campher (ed.) (2008) Violence in Children: Understanding and Helping Those Who Harm. London: Karnac. Fraiberg, S., Adelson, E. and Shapiro, V. (1975) ‘Ghosts in the nursery: a psychoanalytic approach to the problems of impaired infant–mother relationships.’ Journal of the American Academy of Child Psychiatry 14, 3, 387–421. Gilligan, J. (2011) Why Some Politicians are More Dangerous than Others. Cambridge, UK: Polity Press. Glasser, M. (1996) ‘Aggression and Sadism in the Perversions.’ In I. Rosen (ed.) Sexual Deviation, 3rd Edition. Oxford: Oxford University Press. The Guardian (2015) ‘NHS trust “failed to properly investigate deaths of more than 1,000 patients”.’ 9 December 2015. Accessed on 5/12/2017 at www.theguardian. com/society/2015/dec/09/southern-health-nhs-trust-failed-investigate-patientdeaths-inquiry Hampshire Safeguarding Adults Board (2009) Learning from Experience Database – Serious Case Reviews: Fiona Pilkington (Leicestershire). Accessed on 5/12/2017 at www.hampshiresab.org.uk/learning-from-experience-database/serious-casereviews/fiona-pilkington-leicestershire Hollins, S. (2000) ‘Developmental psychiatry – insights from learning disability.’ British Journal of Psychiatry 177, 3, 201–206. Lloyd, E. (2009) ‘Speaking Through the Skin: The Significance of Shame.’ In T. Cottis (ed.) Intellectual Disability, Trauma and Psychotherapy. London: Routledge. Main, M. and Solomon, J. (1986) ‘Discovery of an Insecure-Disorganized/Disoriented Attachment Pattern.’ In T. Berry Brazelton and M.W. Yogman (eds) Affective Development in Infancy. Westport, CT: Ablex Publishing. Mencap (2010) Don’t Stand By. Accessed on 14/3/2018 at www.mencap.org.uk/sites/ default/files/2016-08/Don%27t%20stand%20by-research-report%20%281%29. pdf Mencap (2012a) Stuck at Home. Accessed on 16/9/2016 at www.mencap.org.uk/sites/ default/files/2016-08/Stuck_at_home.pdf Mencap (2012b) Death by Indifference: 74 Deaths and Counting. Accessed on 16/9/2016 at www.mencap.org.uk/sites/default/files/2016-08/Death%20by%20 Indifference%20-%2074%20deaths%20and%20counting.pdf Money-Kyrle, R. (1971) ‘The aim of psychoanalysis.’ International Journal of Psychoanalysis 52, 103–106. Natoli, J.L., Ackerman, D.L., McDermott, S. and Edwards, J.G. (2012) ‘Prenatal diagnosis of Down Syndrome: a systematic review of termination rates (1995– 2011).’ Prenatal Diagnosis 32, 2, 142–153. O’Brien, F. (2004) ‘The making of mess in art therapy: attachment, trauma and the brain.’ Inscape 9, 1, 2–13. Schore, A. (1994) Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development. New Jersey: Lawrence Erlbaum Associates. Schore, A.N. (2003) ‘The Human Unconscious: The Development of the Right Brain and its Role in Early Emotional Life.’ In V. Green (ed.) Emotional Development in Psychoanalysis, Attachment Theory, and Neuroscience: Creating Connections. Hove: Brunner-Routledge.

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Sinason, V. (2012) Mental Handicap and the Human Condition. London: Free Association Books. Sobsey, D. (1994) Violence and Abuse in the Lives of People with Disabilities: The End of Silent Acceptance? Baltimore: Paul Brookes Publishing. van der Kolk, B. (1996) ‘Dissociation and Information Processing in Posttraumatic Stress Disorder.’ In B.A. van der Kolk, A.C. MacFarlane and L. Weisath (eds) Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society. New York and London: Guilford Press. van der Kolk, B. (2005) ‘Developmental Trauma Disorder: toward a rational diagnosis for children with complex trauma histories.’ Psychiatric Annals 35, 5, 401–408. Winnicott, D.W. (1945) ‘Primitive Emotional Development.’ In Through Paediatrics to Psychoanalysis (1984). London: Karnac. Winnicott, D.W. (1947) ‘Hate in the Countertransference.’ In Through Paediatrics to Psychoanalysis (1984). London: Karnac. Winnicott, D.W. (1950) ‘Aggression in Relation to Emotional Development.’ In Through Paediatrics to Psychoanalysis (1984). London: Karnac. Winnicott, D.W. (1951) ‘Transitional Objects and Transitional Phenomena.’ In Through Paediatrics to Psychoanalysis (1984). London: Karnac. Youell, B. (2009) ‘The Importance of Play and Playfulness.’ In R. House and D. Loewenthal (eds) Childhood, Well-Being and a Therapeutic Ethos. London: Karnac.

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Chapter 11

INTO THE LABYRINTH Working with Bizarre, Unspeakable and Extreme Violence SARITA BOSE, MARTHA FERRITO, ALEX MAGUIRE, MARTINA MINDANG AND ANDREW WARE

INTRODUCTION What you’ve got to understand is that here you’re dealing with the high security patient – we will go that extra inch. (Anonymous service user)

Historically, the three High Secure (Special) Hospitals in the United Kingdom were all built upon land isolated from so-called civilised society; public transport to such hospitals still remains sparse. They have multiple high fences and walls that serve both to protect society from those individuals detained within, and to protect those individuals within from society. Symbolically they are places where even the idea of these individuals can be safely deposited. Our own ongoing audits in one High Secure Service (HSS) suggest that approximately one third of the patients detained in such settings have an index offence of homicide. Within this third there is a further sub-group for which ‘the homicide itself…involves bizarre methodology of killing and behaviour after the offence; or comes “out of the blue” from a person of previously good character’ (Adshead, Bose and Helliwell 2012, p.39). It is this particular sub-group, who have perpetrated bizarre and unspeakable acts indicative of extremely violent states of mind – those that will go that ‘extra inch’ – that are the focus of this chapter. The terms ‘bizarre’, ‘extremely violent’ and ‘unspeakable’ mean different things in different contexts. We are here referring to one 151

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or a combination of seven acts: multiple/serial killing; necrophilia; cannibalism; decapitation; dismemberment; disembowelment; and torture of the victim. Such actions elicit amplified media coverage and public fascination; they become well-documented ‘high profile’ cases (Williams 2001). Psychopathy and paranoid schizophrenia featuring command hallucinations are much more prevalent in this sub-group; the diagnoses, in themselves, are correlated with higher levels of risk of violence (Fullam and Dolan 2006, p.1591). These patients are detained in a HSS for treatment rather than punishment. The focus on punishment entails the risk that ‘once we have labelled someone as “evil” there are often no limits to the degree of cruelty and violence we can feel justified in imposing on him or her’ (Gilligan 1996, p.14), as mental health professionals have violent states of mind of their own to keep at bay. The no man’s land of the HSS, where it can be said ‘normal’ laws no longer hold sway, bears metaphorical similarities to the hidden maze of the Minotaur of Greek mythology. The myth of the Minotaur of Crete tells of an uncivilised creature, half man and half bull, born of an illicit relationship with Queen Pasiphae. His hideous violence and his appetite for consuming the innocent was both feared but also fed by society, to keep at bay both the horror it represented (the product of King Minos’ betrayal and the ill-fated Queen Pasiphae’s lust – and therefore also representing the depths of untrammelled lust and desire deep in the human heart) and the real physical danger that the Minotaur posed. The Minotaur was pacified by the sacrificing of ‘tributes’, innocent youths who entered the underground labyrinth where the Minotaur lived. The labyrinth was an unfathomable place with many passages and the tributes could never find a way out and so surely died and were eventually consumed by the Monster. Their deaths brought grief but also relief – until the next demand came for more young lives and the cycle of violence was resumed. The hero of this myth is Theseus, who was determined to free Cretan society from the oppression and terror of this violent state. Before entering the Minotaur’s domain Theseus was given a gift by Princess Ariadne: a ball of golden thread, that he might unspool as he progressed, thus providing himself with a route out of the labyrinth. Theseus both killed the Minotaur and successfully resurfaced to a civilisation no longer under threat.

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The myth is, of course, intertwined with frivolous interference from the gods and ill-fated human error, but essentially it is a tale of good overcoming evil, assisted by the most simple of gifts, invested with hope for the future and given in love. It has inspired many poets and artists; in Dante’s topographical model of the Inferno, the Minotaur is used as a representation of violence in general, and artists such as Matisse, Ernst and de Chirico have all worked with the myth. Perhaps the most famous pictorial image of the Minotaur is to be found in Picasso’s Guernica of 1937, where the half man, half bull figure represents the unthinking violence of the bombardment of that city. The Minotaur retains its power as a metaphor for the disavowed parts of the psyche, both collective and personal, which are banished to the labyrinth of the mind. The Minotaur contained within represents the extremely violent states of mind that are the focus of this chapter.

THE PSYCHOPATHOLOGY OF EXTREMELY VIOLENT STATES OF MIND The patients described in this chapter are members of a widely heterogeneous group, and their behaviours are varied and complex. Besides being condemned by society, these individuals can also experience intense self-loathing and disgust. Many describe feelings of emptiness, numbness and a lack of physical sensations or emotions, such as love and remorse, before they began being violent to others (Gilligan 2003). They talk of feeling a profound disconnection from the human race, experienced from a young age. Their internal worlds are complex, characterised by pain, anger and separation. The pain of the knowledge of what has been done and the separation from this and other feelings threaten to overwhelm and annihilate the ego (Jones 2006). Historically these men have experienced unusually high levels of childhood trauma, including sexual abuse, brutal beatings and neglect (Gilligan 2003). Burgess and colleagues (1986) noted that a predilection to multiple homicide, for example, lies in the failure of the empathic bond of attachment between child and carer. Bowlby (1944) also described violence and crime as disorders of attachment and disruption in the care-giving system. Fonagy (2003) reported that violence is the result of failures in the developmental processes that lead to a lack of

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understanding of the ‘other’ as a psychological entity. Thus the mental structures required for psychotherapeutic work are already damaged or less integrated. Humiliation and embarrassment are also common experiences, which may cause a sense of shame and shattered self-worth (Hale 1993). Violence in this context can be a tool to regain lost power (Katz 1988). The victims of serial killers are often vulnerable and easy to control, and include a majority of women, particularly prostitutes, and children (Morton and McNamara 2005). In the act of violence the internal and external cues of the original humiliation are generalised and often used to justify the righting of a perceived wrong. However, since the victim is usually deceased and thus unable to bear witness to the killer ‘righting this wrong’, the killer has failed to remove the original target of their humiliation, and the violence is bound to continue (Hale 1993). Unsurprisingly, psychosis can also precipitate extreme violence; in a review of patient records at the three HSS in England, 75 per cent of patients with psychosis were recorded as being driven to offend by their delusions (Taylor et al. 1998). Those committing repeated acts of violence have delusional remnants awaiting reanimation at an acute phase of illness (Junginger 2006). These delusions are likely to be intertwined with thriving and self-maintaining beliefs that legitimise and normalise the use of violence and sadism (Gresswell and Hollin 1994). Johnson and Becker (1997) suggest that fantasy plays an important role in the relationship between humiliation and violence. Many ‘normal’ people experience violent and deviant fantasies (Crepault and Couture 1980), and these short-term experiences of intense feelings of power and control may be sufficient to manage shameful memories internally (Gresswell and Hollin 1994). However, in the case of serial killers, it is believed that even before a violent act is committed, the offence has already been committed in fantasy in the perpetrator’s mind (Dietz, Hazelwood and Warren 1990). In 13 of 16 sexually sadistic killings, for example, the perpetrators had fantasised about each offence prior to its actuality, and in a sample of 43 single and multiple murderers, 86 per cent of multiple killers disclosed a history of violent fantasy, compared to 23 per cent of single killers (MacCulloch et al. 1983; Prentky et al. 1989). Therefore, those with more extreme fantasies, such as those that include sexual sadism and end in death, may be most at risk of acting out these violent states of mind.

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TREATMENT DILEMMAS IN THE LABYRINTH Vicarious traumatisation When hearing accounts of extremely violent acts, clinicians unavoidably take in unprocessed moments of horror saturated with persecutory anxiety. They can also be subject to the toxic effects of the shame and hatred of the perpetrator. It is unsurprising, therefore, that a high percentage of clinicians working with violent traumatised individuals experience Post Traumatic Stress Disorder (PTSD) themselves, irrespective of clinical experience (Weaks 1999). This type of ‘vicarious traumatisation is an inevitable occupational hazard. It is not something our patients are doing to us or we are doing to ourselves. It is a process, not an event. It includes our feelings and our defences against those feelings. It comes with connection to and empathetic understanding of those traumatised’ (Phillips 2004, p.216). However, this can culminate in compassion fatigue and burnout (Salston and Figley 2003).

Between a rock and a hard place Knoll (2009) argues that this extreme sub-group of ‘morally objectionable’ patients are treatable but that the clinician inevitably treads a narrow path between ‘therapeutic nihilism’ and ‘malignant pseudo-identification’. Whilst therapeutic nihilism perhaps represents the view of the tabloid press – that such individuals are immune to and unworthy of treatment – malignant pseudo-identification describes the therapist’s false identification with the patient, who, consciously or unconsciously, may stimulate the therapist’s own narcissistic characteristics. Threading a steady path between the ‘rock’ of ‘feelings of patients being unworthy of treatment’ or the ‘hard place’ of their being ‘responsive to the treatment only I can provide’ is a constant dialectic we navigate.

Disconnection and dislocation in violent states of mind Our experience tells us that, contrary to the popular media image of such patients being axe-wielding crazed monsters, ‘even the most violent people are not violent most of the time’ (Gilligan 2001, p.36). For nursing staff tasked with the care and management of such patients, they  are mostly polite and courteous in their day-to-day interactions. They tend

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not to have ‘incidents’ of a degree nor nature that would warrant formal incident reporting, unlike many of the other patients for whom, when in a violent state of mind, there are specific techniques to address and contain actual risk of harm to others. So rather than working with ‘active’ violent states of mind, ironically it is the patient in the wake of bizarre, extreme and unspeakable behaviour that we engage with and treat. It is this complete lack of connection to the violence that can give the work a bizarre quality and causes anxiety in the therapist. It also leads us to question in supervision, even years after we started work with these patients, the point of this work, given the seeming lack of apparent ‘symptoms’, behaviour or distress. Of course, the Minotaur is still in the labyrinth, and although the beast is sleeping, his latent violent state is ever-present and is perceptible in the surreal atmosphere of dislocation which persists in these interactions. The therapist is at risk of assuming that the violence has abated. This can either increase anticipatory anxieties or induce complacency, neglect and a lack of connection with the aspects of the mind that need to change. For example, a patient commented that ‘it is getting so you cannot act on your own thoughts any more’. It is only when considering the extreme violence in his history that the comment takes on a disturbing quality – for this man, his very thoughts were murderous.

CASE VIGNETTE 1: COLLISION OF DREAMS AND REALITY One co-author, having worked at the hospital for 20 years, recalled a dream about a patient: Waking up in a sweat and recalling the nightmare, I remembered being trapped in the serial killer’s lair. The room was sound-proofed, the instruments of torture were set out very neatly and classical music was playing quietly in the background. The killer smiled at me. I knew I was going to die and…I knew that it was going to be a prolonged, painful death… Later that day, upon entering my ward, a patient calmly approached me and, smiling warmly, greeted me. I became instantly frozen to the spot as I recognised the patient as the man from my earlier nightmare who had been planning to bind, torture and kill me. This degree of disturbance was experienced in part because the man who warmly smiled was in reality a serial killer and the details of

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his offences were known. There had been a collision of my personal and professional worlds and it took a moment for me to reassure myself that I was both awake and safe.

Later exploration of this in a reflective practice session helped the therapist regain a sense of equilibrium. The image of his face (from the dream), in the active phase of his extremely violent state of mind – that look of pleasure, power, menace, freedom and cruelty – remains in their memory to this day, although the affective component is now ameliorated by time.

CASE VIGNETTE 2: FEELING LIKE PREY In a session in which two of the usual co-therapists were on leave, the third co-therapist (one of the co-authors) (naively, in retrospect) arranged to facilitate the session with a student nurse keen on gaining some group work experience. In hindsight, this vulnerability was fully exploited, as in this session the physical action of a murder being dramatically role-played was demonstrated. This rendered the facilitator speechless, paralysed and horrified. She felt this disturbance throughout her whole body. The additional disturbance came from the anxiety that she perceived that all other patients and the student nurse were all looking at her for guidance and to see her response, as we were all rendered speechless. In the moment she could not speak, and after a pause another patient spoke about what items he had ordered from the shop – a ‘safe’ subject. She did recover herself enough in session and was able to find a link to return to make a comment on the roleplaying patient’s actions in the group, to which he instantly dismissed her by informing her, with a triumphant smile, that it was only a joke. In that moment the therapist was left feeling like she was the one with the problem, not him, and that she was making a big deal out of nothing much. She decided to refrain from further engagement about what he did to the group as she felt the attacks to her capacity to think would keep on coming, blow after blow, acutely feeling a sense that she was no match for him. She felt like prey. It was enough just to survive the session.

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COUNTERTRANSFERENCE PHENOMENA The established psychoanalytic technique, of using the counter­ transference to inform our understanding of our patients’ unconscious internal conflicts, desires and impulses (Heimann 1950; Hinshelwood 1999; Gordon et al. 2016), is complicated, when working therapeutically with these patients, by needing to spend a significant amount of time working out if what we are feeling belongs to the patient or ourselves. Feelings can be generated from a range of sources: • patients’ unconscious projective identification communications • conscious or unconscious resonance with the therapist’s own personal history • conscious and unconscious anxieties of the organisation, public and media press • conscious empathic and/or disturbing reactions to hearing the details of others’ victim and perpetrator experiences. When working with these patients we have found that additionally our own psychological and physiological responses to fear are a significant consideration. Am I frightened by my own conscious imagination (the potential risk), a real risk or threat of harm (an actual risk), or am I feeling frightened due to an unconscious projective identification communication, or a combination of these? This takes time to work through in supervision, and consequently it takes considerably longer to find the courage to draw attention to sensitive material and to challenge and enforce seemingly normal therapeutic boundaries. We have noticed over the years a reduction in our own fear of this group of patients. This could be worrying, akin to complacency setting in, or our overuse of a defence mechanism such as denial to manage the inherent ongoing risk. We attribute this fear reduction to a type of habituation to the fear and anxiety generated when thinking of the actual and potential risks we face when in close proximity with this group of men. Spending the time to get to ‘know’ them in the ordinary ways of psychodynamic group therapy has reduced the fear of threat of harm but has not reduced our fear of the unknown, that is, what lurks in the minds of such men. ‘The oldest and strongest emotion of mankind is fear, and the oldest and strongest kind of fear is fear of the unknown’

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(Lovecraft 1927/1973, p.12). This is an experience all humans grapple with to different intensities and degrees. Our quest to ‘know’ about the world we live in, and in the therapists’ case, to know the minds of violent people, helps us reduce this innate anxiety and enables us to feel our experiences as more manageable, predictable and less frightening. We support each other when we wobble and struggle with our own internal monologues, questioning our curious engagement with the minds of such extreme mentally disordered offenders. Being in the company of those who have committed bizarre and extremely violent acts triggers within us a natural survival instinct to flee from perceived threat and danger. This complicates basic therapeutic engagement skills such as interaction and conversation. It is understandable that clinicians have to learn to suppress a wish to avoid the perilous. However, after several years of intensive therapy, patients can shift significantly in their presentation. They evoke more compassion and sadness in us following their increased ability to put the unspeakable acts perpetrated upon them into words, and this is when the abused child frame of reference comes into view. The men are increasingly able to talk with other clinicians and patients about the details of the act committed, allowing the ‘murderous psychopath’ and the ‘abused child’ to be more clearly defined and understood. The unknown becomes known and reduces the clinicians’ anxieties over time. Lucas (2013) has written that ‘the clinician’s countertransference feelings will mirror the patient’s state of mind. If they have projected feelings that they have experienced as totally unbearable and have murderously attacked, then the clinician’s mind will be affected so that he or she feels deskilled, unable to think or have constructive associations’ (p.182). Applying Lucas’ suggestion to therapy with these patients, the anticipatory anxiety that we find ourselves feeling is experienced to an extreme degree. Having to contain, make some sense of and interpret these feelings takes not only practice, but also requires much more support from colleagues. Thinking and linking during the session is the most challenging aspect of this work due to the frequency of attacks on thinking experienced in any therapy hour. There is an exponential compound effect of multiple attacks on thinking exhibited through myriad behaviours, comments, non-verbal communications and unconscious projective identification communications, in addition to external ward and organisational intrusions.

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TRYING TO MAKE SENSE OF OUR EXPERIENCES We frequently explore in supervision the possibility that these acts of killing, dismembering, torturing, decapitation and disembowelling were in themselves a cataclysmic release of years of pent-up internal conflict and torment. If this were the case, the ongoing threat of reoccurrence would appear reduced. However, feelings engendered in the therapists suggest that for some patients the violence has not gone away but could be repeated if the conditions leading to historical violence were somehow matched in the present. Where does the disturbance go? Has the act of violence been perversely cathartic or can it be located in others now? At times, losing track of the current or shifting location of the violence can contribute to the feeling of losing one’s bearings on what is ‘normal’ and is further compounded when taken up by the patient too. The effort to resist this strongly felt retaliatory response can often be taxing and, in the moment, paralysing, so that the capacity to actively think is ‘killed off ’ in the therapist. The therapeutic reflective endeavour is replaced by a preoccupation with emotion regulation in the therapist. For the group to be reflective of the whole-person experience, the therapists necessarily make themselves available in this setting to conscious and unconscious threats. There have been many therapeutic disclosures wherein patients provided unbidden visceral descriptions of their offences, including the experience of having delivered an excessive number of stab wounds or ‘I killed with just my thumbs!’ with the accompanying affect of pride and/or excitement in the retelling. The telling, bearing and reflecting of the offender patient narrative and the beginnings of empathic interaction form an important part of the metabolising of shame (Mollon 2002).

CONCLUSION – ARIADNE’S THREAD The world of science has adopted the concept of ‘Ariadne’s thread’ to describe backtracking, reversing earlier decisions and trying alternatives whilst maintaining a trail at all times. We suggest that it is a useful concept when considering the psychotherapeutic endeavour in HSS, with its uncertain territory and labyrinthine paths fraught with threats to the well-being of both staff and patients. Clinical supervision in this setting, where ‘trial and error’ is never a safe option, is at its most useful

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when it adopts or allows for this process. There is a need for regular clinical supervision which can take into account the ‘signature’ of an offender and the extreme feelings evoked by their offences. The ripples from dyadic relationships into the group dynamic of the ward, and from the ward into the organisation and out into the larger societal group, need special attention. The clinical supervisor also has to engage with the anxiety, fear and potential mental disturbance that is activated in the therapists by engaging with the violence that is represented in the mind of such disturbed persons, and to resist the flight or shutting-down responses that may offer temporary relief. If the Minotaur represents our primal fear of entering the dark, the myth may also be seen as a metaphor for death and the death anxiety which is present in our work. Whether it is explicitly or implicitly addressed in therapy, the fact of a homicide always exists. The Minotaur may be understood as but one image arising from and personifying the nothingness of not knowing. To confront the Minotaur in the darkness of the labyrinth is to confront oneself: our fears, our ferocious bestial nature, our rage, aggression, sexuality, mortality, and the demonic. This self-confrontation is eased by proceeding along one’s own Ariadnean thread. We extend the analogy to include the vital role played by clinical supervision. Some life-violating acts are akin to the all-consuming monstrous traits of the Minotaur – the basic struggle between the natural and unnatural – and lend themselves to the discussion about what keeps us safe as we encounter such disturbance in our clients. Certainly without adequate supervision there is a risk of raised levels of staff sickness, burnout and even suicide in this staff group. Regular specialised supervision has enabled us to identify ‘normal’ responses, therapeutic responses and inappropriate responses when working with what is for most of society the stuff of fiction. Questions such as why we specialise in this area of work can be processed in supervision, and phantasies of exorcising the world (and self) of such demons can be robustly challenged. Why would anyone choose to go into the labyrinth? The patients in this setting have limited choice over where their mental disturbance takes them. When the therapists struggle with  the material in therapy, not only with patients, but sometimes also with an organisational system which can disavow the severity and bizarreness of the offending, this question of ‘why’ is a very relevant one.

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In this setting we are wrestling with a tension different from that aimed for in many models of therapy in which you ‘get alongside’ the patient. Here, to travel with the patient and go where the patient might take you may well be a journey during which every fibre of your being is urging you to ‘stop and get out’ before you enter a psychological labyrinth from which there may be no return; one is regularly privy to knowledge that one cannot unknow. However, just the ordinary act of regularly meeting and sitting with is to make civil or pro-social the Minotaur. Brought into the light, the Minotaur becomes less frightening. Our experience informs us that, like Ariadne’s gift, supervision and institutional support for this therapeutic work need to be ongoing, unbroken, long and constant. It may be too much to hope that this support will be given with love, but just as a ball of thread is so simple a structure, so the model of supervision is structured to be safe, not sensationalist. Holding on to the thread and then losing our way, grasping at ideas that become difficult to hold on to, feeling ashamed by wanting to write about this material and finding it difficult to articulate unspeakable acts and then to make them palatable for the reader, have all been experienced in the authorship group and in the process of developing this chapter. Individuals who offend in these ways are a part of the whole of our society, and whilst they are of necessity split off and placed apart from society, in a labyrinth of society’s making, a failure to acknowledge the existence of this Minotaur serves to encourage a paranoid-schizoid position, rather than one of integration. In the absence of both heroes and the death penalty, it is our task to keep our patients’ personal Minotaurs in mind; to use Ariadne’s thread in order to acknowledge our own fears and to keep our own Minotaurs in check.

REFERENCES Adshead, G., Bose, S. and Helliwell, S. (2012) ‘Index Offence Work for Homicide: Reflective Therapy Groups for Men who have Killed.’ In R. Worthington and E. Glorney (eds) Forensic Update 105. The British Psychological Society, Division of Forensic Psychology. Bowlby, J. (1944) ‘Forty-four juvenile thieves: their characters and home life.’ International Journal of Psycho-analysis 25, 19–52. Burgess, A.W., Hartman, C.R., Ressler, R.K., Douglas, J.E. and McCormack, A. (1986) ‘Sexual homicide: a motivational model.’ Journal of Interpersonal Violence 1, 251–272.

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Crepault, E. and Couture, M. (1980) ‘Men’s erotic fantasies.’ Archives of Sexual Behaviour 9, 565–581. Dietz, P.E., Hazelwood, R. and Warren, J. (1990) ‘The sexually sadistic criminal and his offences.’ Bulletin of the American Academy of Psychiatry and Law 18, 163–178. Fonagy, P. (2003) ‘Towards a developmental understanding of violence.’ The British Journal of Psychiatry 183, 3, 190–192. Fullam, R. and Dolan, M. (2006) ‘The criminal and personality profile of patients with schizophrenia and comorbid psychopathic traits.’ Personality and Individual Differences 40, 8, 1591–1602. Gilligan, J. (1996) Violence: Reflections on Our Deadliest Epidemic. London: Jessica Kingsley Publishers. Gilligan, J. (2001) Preventing Violence. New York: Thames & Hudson. Gilligan, J. (2003) ‘Shame, guilt and violence.’ Social Research 70, 3, 1149–1180. Gordon, J., Harding, S., Miller, C. and Xenitidis, K. (2016) ‘X-treme group analysis: on the countertransference edge in inpatient work with forensic patients.’ Group Analysis 38, 3, 409–426. Gresswell, D.M. and Hollin, C.R. (1994) ‘Multiple murder: a review.’ British Journal of Criminology 34, 1, 1–14. Hale, R.L. (1993) ‘The application of learning theory to serial murderers: “You too can learn to be a serial killer”.’ American Journal of Criminal Justice 17, 2, 37–45. Heimann, P. (1950) ‘On counter-transference.’ International Journal of Psycho-analysis 31, 81–84. Hinshelwood, R.D. (1999) ‘Countertransference.’ International Journal of Psychoanalysis 80, 4, 797. Johnson, B.R. and Becker, J.V. (1997) ‘Natural born killers? The development of the sexually sadistic serial killer.’ Journal of the American Academy of Psychiatry and the Law 25, 335–348. Jones, D. (2006) ‘The malign transference: dealing with the unbearable in the internal world of the murderer.’ Group Analysis 39, 1, 51–58. Junginger, J. (2006) ‘“Stereotypic” delusional offending.’ Behavioural Sciences and the Law 24, 3, 295–311. Katz, J. (1988) Seductions of Crime. New York: Basic Books. Knoll, J.L. (2009) ‘Treating the morally objectionable patient: countertransference reactions.’ Psychiatric Times 26, 4, 45. Lovecraft, H.P. (1973) Supernatural Horror in Literature. New York: Dover Publications. (Original work published in 1927.) Lucas, R. (2013) The Psychotic Wavelength: A Psychoanalytic Perspective for Psychiatry. Hove: Routledge. MacCulloch, M.J., Snowden, P.R., Wood, P.J.W. and Mills, H.E. (1983) ‘Sadistic fantasy, sadistic behaviour and offending.’ British Journal of Psychiatry 143, 20–29. Mollon, P. (2002) Shame and Jealousy: The Hidden Turmoils. London: Karnac Books. Morton, R.J. and McNamara, J.J. (2005) Serial Murder: Encyclopaedia of Forensic and Legal Medicine. New York: Elsevier. Phillips, S.B. (2004) Group Interventions for Treatment of Psychological Trauma. Module 7, Countertransference: Effects on the Group Therapist Working with Trauma. New  York: American Group Psychotherapy Association. Accessed on 25/6/2016 at www.agpa.org/docs/default-source/practice-resources/countertransference-effects-on-the-group-therapist-working-with-trauma.pdf?sfvrsn=2

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Prentky, R.A., Burgess, A.W., Rokous, F., Lee, A. et al. (1989) ‘The presumptive role of fantasy in serial sexual homicide.’ American Journal of Psychiatry 146, 887–891. Salston, M.D. and Figley, C.R. (2003) ‘Secondary traumatic stress effects of working with survivors of criminal victimisation.’ Journal of Traumatic Stress 16, 167–174. Taylor, P., Lesse, M., Williams, D., Butwell, M., Daly, R. and Larkin, E. (1998) ‘Mental disorder and violence: a special (high security) hospital study.’ British Journal of Psychiatry 172, 218–226. Weaks, K.A. (1999) Effects of Treating Trauma Survivors: Vicarious Trauma and Style of Coping. Unpublished doctoral dissertation, Texas Woman’s University. Williams, K.S. (2001) Textbook on Criminology. New York: Oxford University Press.

Chapter 12

TREAT ME NICE Music Therapy and Extreme Violence ALEX MAGUIRE

INTRODUCTION Many and varied are the functions of music in our lives; indeed, we are accompanied through our lives by lullabies, nursery rhymes, fanfares, marches, nocturnes, laments, and all stops in between. From ‘Rock-abye Baby’ to ‘Rock of Ages’ and from Handel to Leonard Cohen, music seems to be our go-to medium for consolation, confirmation, relaxing and reaffirming. It can ground us and lift us, and while it can provide a glimpse of the divine, they say that the Devil can still lay claim to the best tunes. What follows are the thoughts of a man detained in high-security psychiatric care for over 30 years, a place whose concrete walls reinforce the damaged internal structures of its inhabitants (see Chapter 11, Volume 2). Initially imprisoned after an episode involving physical violence and life-threatening arson, he has continued his violence in prison and hospital; short spells in medium-security have all resulted in returns to highly secure services where he remains. His perception of the institution is that it is ‘suppressive, oppressive and repressive; it persecutes, it kills, it abuses human rights’. It is, in sum, a violent institution. One of the aims of this chapter, aside from allowing the mind in a violent state a voice, is to suggest that creativity, in this case clinically focused and enacted in music therapy, may ameliorate the violence of the institution and the individual, affording respite to both, and laying the foundations of authentic recovery. Bill (not his real name) has never engaged with any psychological treatment, but agreed to meet with the music therapist for weekly sessions 165

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where we play, record and talk about music and the part it plays in his life. Bill claims to be the incarnation of (among others) Elvis Presley. We have now been meeting for four years. In this case, it’s unclear what ‘progress’ would look like – marvellously constructed alternative realities keep life bearable for Bill. There is, however, a feeling (not uncommon in such patients) that he has never been really listened to, that his authentic voice has not been heard amidst the static interference of his psychosis – a term he himself would dispute – and that we are failing to ‘get’ him. Music seems to offer Bill a place where he can communicate emotionally, and allow his more authentic self time-out from the demands of coping with a fierce and unremitting illness. Music’s dual aspect – being simultaneously concrete (the lyrics, the instruments, the recording, etc.) and symbolic (with its audible representation of inner desires, conflicts and needs) – affords a space in which inner feelings can be expounded and explored, and where derivatives of the unconscious may be discerned in subtle shifts of interactive tension, spontaneous flights of imagination, and gradations of tone (Sloboda 1997, p.122). Paying attention to the actual musical and lyrical content, and its interaction with the evolving dance of interpersonal dynamics, allows not just for understanding, but sets the stage for transformation in real time. What follows are edited transcripts of a series of interviews in which we imitated the popular BBC Radio 4 programme Desert Island Discs, wherein an invited guest chooses a selection of music that he or she would take with them to an enforced exile, discussing along the way their reasons for their choices and the part the music has played in their lives. Bill says that he wants to ‘paint a canvas in music, a universe of the mind encompassing different souls’. The interviews were carried out over a three-month period and involved Bill also singing the tunes accompanied by the music therapist at the keyboard.

INSTRUCTIONS FOR USE Whilst there are a number of patient accounts of illness and therapy (notably Schreber 1903/2000; Yalom and Elkin 1974; and Barnes 1978), the printed words of this chapter only present half of the story – our sessions are filled with live music – and, to enhance these, it is recommended that the reader takes a little time to compile a playlist of

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the tunes referred to on their computer or preferred listening device. They are all available via such websites as YouTube or Spotify. These should then be played as they appear in the text, and will go some way towards recreating the feeling in the room, and the relationship between Bill, the music and ‘the violent mind’. The full lyrics for each song are similarly widely available on the internet.

PLAYLIST 1. Treat Me Nice – composed by Jerry Lieber and Mike Stoller, performed by Elvis Presley 2. Indescribably Blue – composed by Darrel Glenn, performed by Elvis Presley 3. Man of Peace – composed and performed by Bob Dylan 4. Memories – composed by Mac Davis and Billy Strange, performed by Elvis Presley

TREAT ME NICE A One of the records that you’ve chosen is Treat Me Nice. B Treat Me Nice, such a beautiful record, it’s a spontaneous record, and it’s also a spontaneous kind of love. And that’s one of the reasons I love the song, the main reason why I love the song. It’s about love being shown. (sings) When I walk through that door, baby be polite, you’re gonna make me sore, if you don’t greet me right, don’t you ever kiss me once, kiss me twice, treat me nice. A beautiful song. A You choose a lot of tender ballads and love songs, but your history is one of violence. How do you connect that with Treat Me Nice? Do you want people to treat you nice? B Well, you say my history is one of violence, but your history is your history; you can’t say it’s one of violence, or one of romance or one of love – it’s all integrated, all in together. I don’t think you can partition or say that this part of his life was violence and this part of his life was romance. Maybe romance and violence went together – you see what I mean?

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A But if you’re singing a song like Love Me Tender, or Treat Me Nice, which is one of your favourites… B Yeah. (sings) When I walk through that door, baby be polite. You want to make me sore, you don’t greet me right. Don’t you ever kiss me once, kiss me twice… Treat me nice. Make me feel at home…a beautiful song…it’s spontaneous…it’s asking for spontaneous love, right, maybe there’s no such thing that is not spontaneous love anyway, if you see what I’m saying. A That all love is spontaneous? B All love is spontaneous, yeah, yeah. The only violence I’ve committed in this lifetime – it’s quite a bit of violence to tell the truth – has been quite extreme like, you know. But I just want to point this out – when I’ve committed violence, it’s – cause I’m in mental hospital, right – it’s not some kind of fucking mental defect; to use a bad word, I’m not a bleeding fucking lunatic, who goes around cutting people up for no reason. I went through this all for a good reason. Jesus says he hates war, he despises war, he detests war, he has nothing but contempt for war – that is why he makes war on war. And he is master of war, Jesus – I tell you that. A I’m wondering about the song – Treat Me Nice – it sounds as if you want somebody to be kind to you. B Well um I do like fighting, right, I do like fighting. But violence, what can I say about violence? Sometimes it’s not the answer, but sometimes the only answer is violence, you know. Sometimes the only answer is violence. A Do you think, on the occasions you used violence, that there might have been a better way? B No I don’t think so. A It was a last resort? B Yes. Let’s talk about mental illness. A psychiatrist, right, analyses from his own point of view, right? You’ve got a pervert like Freud analysing you, he’s going to come to his own perverse fucking reasons for you doing things which he sees as perverse like the violence that I do. ‘Maybe it goes back to my childhood when my mother beat me’; my mother didn’t beat me, I’m just giving that as an example. You see what I’m saying? That’s how pathetic that Freud is. A What, then, would be the roots of your violence?

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B My mother didn’t beat me, right? It might be what a pervert like Freud would say. What I’m saying is that a psychiatrist…let’s say if the first analyst is wrong, right, then the next psychiatrist bases his analysis on the first one, right, so their analysis is wrong, and then further along the line distortion and lies and deceit…and discrepancies and…what do you call it…

Comment 1 From the outset, Bill presents his two major themes: the indivisibility of the human psyche and the unavoidable use of violence in certain circumstances. The disconnect between the song’s plaintive lyrics and Bill’s habitual use of violence mirrors the circumstances of the original recording; in September 1957, where, to get Elvis in the mood for what was intended to be a Christmas disc, Colonel Parker had a Christmas tree complete with wrapped presents set up in the studio. The lyrics have a rather threatening tone, as if to suggest that if the singer isn’t greeted and ‘treated nice’, violence may be ‘the only solution’; there’s no doubting Bill’s pride in his violent behaviour; when we first discussed the possibility of co-writing something about it, he assured me that his violence was ‘second to none’. His dismissive critique of ‘that pervert’ Freud may be seen as a defence against acknowledging any role that the unconscious may have. After all, control is all important to this man – Bill is already plagued by concerns about ‘the Chinese’, communists, all-seeing cameras and all-hearing microphones – and the idea that he may be at the mercy of unconscious fears and desires is anathema to him. However, the topics of psychiatry, analysis, mental illness and violence are readily introduced by Bill and he seems keen to share his views.

INDESCRIBABLY BLUE B It’s a beautiful song. It’s like Krishnamurti said, right? I’ve told you about the I and the Me, the Me and the non-Me. The I and the Me. This is mental illness, right. The only form of mental illness it’s possible to have; if you get depression, that’s not mental illness. I’ve never been depressed. But what Freud said – and this is the one thing Freud was right about, the one thing – the id, the ego and the superego. Now what Krishnamurti

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A B

A B

A B

called it, which was much more clear and concise, is the I and the Me (the id and the ego) and the Me and the non-Me (the observer and the observed). For me to observe you, there’s distance between us there of a few feet. Now for me to observe you, between you and me, that’s an analogy for the mind, there’s a distance, right, and that’s the distance between the I and the Me, you follow, the id and the superego. In the distance between the id and the superego, the I and the Me, is a fragmentation, a duality of the personality, the id’s saying one thing and the ego’s saying another; there’s a fragmentation, a duality of the personality. If the I and the Me become one (the ego and the id become one) then you are whole. Perhaps that is probably the only form of mental illness you can have; the fragmentation of the I and the Me, the duality of the personality. In the past you’ve said that mental illness doesn’t exist… It doesn’t exist, except in that way. There are other forms of illness, depression and so on, but all this comes from Satan – depression, thoughts of suicide – I don’t have anything like that, but that’s all Satan, like. I’m wondering who owns the memory of the violence you committed in prison? I do, I do. I did do the violence pretty badly, like. When I have fought in here – I did gouge someone’s eyes out in here. I have a very violent temper – I did gouge someone’s eyes out, but I tell you this, when I do gouge someone’s eyes out, I could do a lot worse than that. I’m not boasting, but I could take on 20 people, easily. Every fight is different. Maybe, just maybe, this is a possibility, I say I can take on 20 people, someone bangs me on the chin, right, from the side, and knocks me out or whatever. I’ve never been knocked out, but someone bangs you on the side of the chin… When I was Chinese, right, I remember saying this – it’s hard enough to take out five people, let alone 20, right? That is true to a certain extent, but if you take out the first two so really fucking violently, ruthlessly, you injure them so badly, the others are very, very fucking scared that when they do try to come and get you, they will be inadequate, because they’ll be so scared of what you’re going to do to them. Why attack the eyes? If you injure the eyes, then your opponent can’t hurt you. My favourite three or four targets are the eyes, maybe the nose – just smash the nose

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into the brain, or the abdomen, the throat, just on the Adam’s Apple, kick the knees, break the side of the knees, break the leg. That’s the favourite. A But I wonder if there’s something about stopping somebody seeing anything? B My teacher said to me ‘what do you think on facing an opponent?’, and I replied there is no opponent. He asked why is that, and I said because the word ‘I’ does not exist. Now, I’ve told you why the word ‘I’ doesn’t exist; Krishnamurti’s philosophy, which is my philosophy. The ‘I’ exists as a way to talk about myself, the ‘me’ does not. A Listening to you sing, you would never think – this is a violent guy. B But putting a piece of a person there, and saying that’s violence, and this is how the romance goes with the violence, death is nothing to someone who knew how to live. That’s true, isn’t it – death is nothing to someone who knew how to live. A What’s your first memory of Indescribably Blue? B Well actually, my first memory of Indescribably Blue comes from my Mike incarnation… A So that’s very early? B It wasn’t of singing it on stage or anything like that. A So your first memory would have been of hearing it? B That’s right, not of singing it, but of hearing it, and that was as ‘the previous owner of this body’. A And what did he think of it? B He loved it; he was with his girlfriend, right, and er, er, well she left him. A So he was heartbroken? B Not heartbroken, but like sad, you know? Sad; if that’s heartbroken, then it’s heartbroken, right? It’s such a beautiful song…er… (sings) And now you’ve left me indescribably blue. Beautiful song, man. A So the song reminded him of the relationship… B Yeah… A …and what he’d lost? B Yeah, yeah, yeah. A It’s a very sad song isn’t it? B Yeah, yeah. A You were talking about a woman in your life…of course, the first woman in anyone’s life is their mother. B Yeah.

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A I wonder what memories you have of her? B Just good memories, good memories… (sings, waveringly and rather faintly, as if from afar) Our friends all ask me, the last time I (hesitates) I saw you. I smile and tell them, it’s been a day or two. There’s no way to explain it, the way I miss you; oh my love, you have left me indescribably blue.

Comment 2 The Elvis Presley recording of ‘Indescribably Blue’, made in Nashville in June 1966, also has an enigmatic history in that it was recorded without Elvis himself – who refused to leave his hotel room for reasons that remain unclear – only adding his own vocals some days later. In this second record choice, Bill develops his leitmotif of the unity of the human spirit, and now acknowledges the Freudian topological model, although preferring Krishnamurti’s eastern adaptation. Although Bill’s exposition of this is perhaps a little unclear, the crux of it seems to be that unity or equivalence of the conscious and unconscious is the route to health and wholeness, and that fragmentation and ‘duality of the personality’ lead to mental illness, indeed are its only causes besides the influence of Satan, which is discussed later. Bill’s attacks on the eyes of his victims, rendering them unable to see and him unseeable, is undoubtedly significant, linking both to Krishnamurti’s ‘The Seer’ and ‘The Seen’ and to more familiar thinking about shame and guilt, although these links are denied by Bill himself. Bill introduces ‘Mike’ (again a pseudonym), the ‘original owner of this body’, that is the teenage offender who has so blighted Bill’s life and resulted in his subsequent years in high security. Bill’s mother – the victim of his index offence – makes a fleeting appearance, and his singing, faltering and hesitant, is suffused with a feeling of nostalgia. This is clearly a difficult and emotive subject and all references to her are brief and vague. The song is replete with the potential for sentimental excess, but in Bill’s hands – his voice quavering and cracking – becomes a vehicle for the heartfelt and poignant expression of loss.

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MAN OF PEACE B Dylan sings about violence, right, but he’s a man of peace. A Man of Peace? Dylan singing that the devil can come disguised as a man of peace? B Yeah. A Might you also be a man of peace…because there’s a side to you which is very tender…and perhaps one can see it when you sing these songs… but there’s also a side to you which is merciless… B Well, when you say that, when you say ‘there’s a side to you…’ you’re making a sort of division within the personality, like. When you make a division in the personality, you’re certainly having difficulties analysing those divisions separately; you can’t separate the unconscious from the conscious mind. A Then perhaps your violence comes from the unconscious mind? B Well, why should it? Why should it? What I mean is, if someone’s insulting you, with me, right? I can take insults, but when people lie about me, and they’re insults, that man is very fucking hard to take, very hard to take. A You’ve said that sometimes the only way to let people know… B …that they can’t fuck with you is to do them in. What I mean is, I’m not being true to myself; when all these insults come at me from people on here, I haven’t been true to myself, because if I had been true to myself, they’d be in a bloody mess, like. A In the past you’ve said that mental illness doesn’t exist… B It doesn’t exist, except for that. There are other forms of illness, depression and so on, but all this comes from Satan, like. Satan – depression – thoughts of suicide – I don’t have anything like that, but it’s all Satan, like.

Comment 3 ‘Man of Peace’ is from Bob Dylan’s 1983 album Infidels – Dylan is another of Bill’s ‘incarnations’ – and seems to refer to the idea of the Devil adopting a disguise so as to deceive humankind. Satan looms large in Bill’s theology, and we have frequently had to abandon recordings as Satan has ‘interfered’ with his voice and started putting ideas into his head while we are working together. As noted above, for Bill, Satan is a major cause of psychological disturbance, and he has often described his own plight as that of ‘a struggle between good and evil’.

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Bill’s heightened sense of vigilance against the influence of evil can render him acutely sensitive to perceived insults or humiliation, something he finds ‘very hard to take’, and this often leads to violent confrontation. The links between humiliation, shame and violence are not readily accepted by Bill; besides its protective function, the adoption of ‘incarnations’ seems to serve also as a way of stopping and restarting time. Time as a concept is flexible for Bill – ‘incarnations’ may be living or dead, and whilst he can describe the process of incarnation in some detail for some, others are much more mysterious; they all share the qualities of being mavericks, outsiders to some extent, solo operators rather than team players. Invariably they are strong, driven, powerful individuals, people on a mission.

MEMORIES B Talking about the violent mind, my teacher came along and said ‘are you meditating, like?’ and I said yeah… I’m not necessarily looking for peace and harmony, or music, I’m just looking for the best way to kick someone’s fucking head in, right? Contemplating violent mind, right, you must think of it like this – can a violent mind contemplate its own violence, like? Without perpetrating it, like? Or complying with its own thoughts. Like I told you that er, the er…violent mind…a violent mind…or sociopathic mind or whatever, like, it all functions in perfect harmony, like, it’s all got order in it, even the neuroses, or schizophrenia, psychopaths, it all functions perfectly. A Obviously a peaceful, harmonious mind is better for the world in general… B Better for the world in general? Well, there can be ecstasy or euphoria in violence. A Would that be a reason for being violent? To get a kind of high? (Long pause) B (sings) Memories, pressed between the pages of my mind; memories, sweetened through the ages just like wine. Quiet thoughts come floating down and settle softly to the ground, like golden autumn leaves around my feet. I touched them and they burst apart with sweet memories, sweet memories…of holding hands and red bouquets and twilight trimmed in purple haze, laughing eyes and simple ways and quiet nights and gentle

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A B

A

B

A B

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days with you. Memories… When I sing that record I…from my Elvis incarnation, I see the crowd in front of me… Memories…locked away in your mind. Well I don’t know if they’re locked away in your mind, like. They’re in your mind, but does the mind ever lock anything away? Like locking a door? What about if one was involved in some traumatic event…I wonder if the mind might then bury that because it’s too painful or difficult to deal with, and would make living very difficult. I told you, Alex, that the mind can only function in perfect order, whether that order’s one of distress or whatever…even in distress (or anything like that) it still functions in perfect order, like. So…neurosis and psychosis and things like that, psychopathy, it all functions in per­ fect order, like. The only thing that makes the mind function in not perfect order is Satan, you know. That’s the only thing…even then the mind is functioning in order, like, but Satan interrupts the mind if you see what I mean. I’m not sure what you mean by ‘functioning in order’. Does that mean it’s functioning at its best? Functioning in order! With clarity, understanding what it’s saying. Like Jesus said to the priest in the temple, like, ‘Destroy this temple and I will raise again three days.’ The priest said something and then Jesus said, ‘You have spoken, you have misunderstood.’ That happens in mental illness, believe it or not. That people speak and they aren’t understood? Do you think it often happens in mental illness? There’s no such thing as mental illness, Alex! Listen, I’ve got some memories of spying, right? Now if you’re going to put someone away, right, in America or Britain or France or Germany, or any of the democracies, right, if you want to put someone away for a long time, and no one can let them out, you nut them off, know what I mean? And if they say they’re a spy, like, you know what I mean, you just nut them off. So anything they say is not taken seriously. You’ve often complained of Satan influencing your voice, and your thoughts and talking to you. Sometimes, you hear Satan’s voice instead of your own thoughts. If the possession is extreme, you will only hear your own thoughts rarely – this is important. If I’m waiting for you, Satan will say, ‘Alex isn’t coming’,

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A B A B

A B A B A B

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then God says, ‘Yes, Alex is coming,’ and then Satan says, ‘No, Alex isn’t coming.’ Satan’s like a dog on a lead, pulling against the lead all the time. So what is the task – to make that dog obedient? (laughing) Kick it a couple of times, ha ha! Use violence against it? Well…I told you about when Satan – he still does it now sometimes – makes me walk fucked-up, like. You’ve seen the film Downfall, haven’t you? Well that’s not particularly true, Hitler’s physical characteristics, in the bunker, like. His walking was really fucked up, like. And er his left foot stamped down when he walked like that (demonstrates by stamping on the floor), due to the physical effects, right, of what Satan had put in his body. So Hitler was battling Satan too? Hitler was battling Satan too. So what can you do about the dog? Apart from giving him a couple of kicks? Kill him! Kill him! Do you remember when you first had contact with Satan? Um…it’s hard to say, like. You see, Satan is very subtle. The previous owner of this body didn’t hear his own thoughts at all, only Satan’s thoughts. If you don’t believe in God, you can’t have regard for er a person’s spiritual welfare. In the same way that brotherhood can’t be practised, or love can’t be practised, cannot be talked about – Krishnamurti said that. They’re just ideas? They’re not just ideas, they’re facts. You can write a book about love, but that isn’t actually love.

Comment 4 ‘Memories’ was introduced into the Elvis canon in 1968, the year in which female audience members at live shows started throwing their underwear onto the stage; in response, Elvis started ‘accidentally’ splitting his trousers on stage. At one performance he sang the song from behind the curtain while he changed trousers. It’s one of Bill’s favourite songs, and spurs him to elaborate further on his philosophy; he wonders aloud whether it is possible to think about violence without perpetrating it – is violence simply a state one may inhabit, or is it a visceral reaction unmediated by thought? He admits that violence can be ecstatic, leading

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to a feeling of euphoria, and certainly Bill is known for the ferocity of his attacks, as he mentions earlier. The idea of being ‘nutted off ’, locked away in response to the threat of spreading subversive or seditious ideas, is a pervasive theme for Bill, and indeed he has spent more than 30 years incarcerated. As mentioned in the introduction, he feels, with some justification, that he is not being listened to, that at best his wisdom is falling on stony ground, and at worst he has been forgotten. Amidst this, he continues to battle with Satan pulling like a dog on a lead, trying to maintain balance and not be pulled over. His final remark calls to mind Magritte’s 1929 painting The Treachery of Images (‘Ceçi n’est pas une pipe’).

CONCLUSION If listening to the recordings of the songs whilst reading the above text is a strange experience, playing them whilst Bill sings verges on the bizarre. He is a man who, driven by powerful paranoid ideas, has consistently responded to these intrusions with sustained and ruthless violence, often inflicting permanent damage on his victims. The music, mawkish and sentimental, is the vehicle by which he can communicate the feelings of loss, regret, tenderness and love. For all Bill’s talk of integration and the indivisibility of the psyche, his own mind is firmly segregated, with Elvis, Bob or Hitler being called upon to deal with different confrontations as they arise. Just as ‘the camera never lies’, so it is difficult to disguise genuine emotion in music, and whilst Bill’s singing is bound up with the ‘incarnated’ Elvis, it is also his emotional tool and belies the intellectualism of Krishnamurti and others. It is in the music that Bill’s authentic self can be glimpsed, a fragile, lonely self, struggling with misunderstanding and searching for connectedness. In Bill’s words, ‘Perception is reality, not ideas, belief or conviction’, suggesting that Bill is also hypervigilant, ever ready to respond to threats. Christopher Bollas, urging restraint in the use of the therapist’s countertransference, notes that there is a reason that our patients communicate to us in the way they do (Bollas 2012), and the clinically directed use of music (i.e. music therapy), with its emphasis on listening and responding, and its dual concrete and symbolic functions, can serve as the transformative medium of a creative solution to interpersonal violence.

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Music is the multi-layered map of Bill’s emotional landscape. Each castaway on the radio programme is allowed a book and a luxury they can take with them. Bill’s luxury was orange juice; his two books were Adolf Hitler’s Mein Kampf (1925/2007) and Krishnamurti’s The Awakening of Intelligence (1997).

REFERENCES Barnes, M. (1978) Mary Barnes: Two Accounts of a Journey Through Madness. New York: Ballantine Books. Bollas, C. (2012) The Freudian Moment. London: Karnac Books. Hitler, A. (1925/2007) Mein Kampf. Mumbai: Jaico Publishing House. Krishnamurti, J. (1997) The Awakening of Intelligence. San Francisco: Harper. Schreber, D. (1903/2000) Memoirs of My Nervous Illness. New York: The New York Review of Books. Sloboda, A. (1997) ‘Music Therapy and Psychotic Violence.’ In E.V. Welldon and C. Van Velsen (eds) A Practical Guide to Forensic Psychotherapy. London: Jessica Kingsley Publishers. Yalom, I. and Elkin, G. (1974) Every Day Gets a Little Closer: A Twice-Told Therapy. New York: Basic Books.

SOURCE MATERIAL Guralnick, P. (1994) Last Train to Memphis: The Rise of Elvis Presley. London: Abacus. Guralnick, P. (1999) Careless Love: The Unmaking of Elvis Presley. London: Abacus.

PART IV

CREATIVE APPROACHES From the Global to the Individual

True art, which is not content to play variations on ready-made models but rather insists on expressing the inner needs of man and mankind in its time – true art is unable not to be revolutionary, not to aspire to a complete and radical reconstruction of society. This it must do, were it only to deliver intellectual creation from the chains which bind it… André Breton and Leon Trotsky, Manifesto: Towards a Free Revolutionary Art (1938)

No man is an Iland, intire of itselfe; every man is a peece of the Continent, a part of the maine; if a Clod bee washed away by the Sea, Europe is the lesse, as well as if a Promontorie were, as well as if a Manor of thy friends or of thine owne were; any mans death diminishes me, because I am involved in Mankinde John Donne, Meditation XVII: Devotions upon Emergent Occasions (1624)

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RESTORATIVE JUSTICE APPLICATIONS IN MENTAL HEALTH SETTINGS Pathways to Recovery and Restitution GERARD DRENNAN

In this chapter I will introduce two unlikely bedfellows – mental health recovery and restorative justice. It is not an easy union. Conflicts arise when considering them together. Even so, their combination has the potential to bring about creative transformations in the rehabilitation of people with long-term mental health difficulties and a history of offending behaviour. I will start with an outline of the development of restorative justice practices. I will go on to consider the meaning of mental health recovery for those who also have a history of offending and describe restorative justice interventions in such settings. Finally, a preliminary definition of a mode of recovery that accommodates the recognition of harm will be attempted.

THE RESTORATIVE JUSTICE ENCOUNTER The genealogy of modern restorative justice practice within criminal justice settings has been traced back to the First Nation peoples of Canada, New Zealand, and elsewhere. This refers to practices within socalled tribal societies with which to repair ruptures in the community caused by offending behaviour, without the expulsion of the wrong-doer. It stands to reason that a relatively small grouping of people, trying to 181

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survive in what might be a hostile and isolated territory, cannot afford to simply banish the young men who violate laws or rules. To do so would weaken the collective and quite likely strengthen a neighbouring competitor. It becomes imperative to find a solution that addresses the needs of three parties. The harmed party must have their harm acknowledged, but instead of punishment, this acknowledgement is focused on restitution. Simply punishing the wrong-doer will not bring back whatever has been lost, but some form of restitution might restore the harmed in some way. There is something else that simply punishing the wrong-doer will not achieve – moral development and motivation to not re-offend. A wrongdoer who is dehumanised in punishment may simply become embittered and resentful, and will perhaps harbour wishes for revenge. Finally, the rupture in the wider community needs to be repaired. The family of the harmed party need to see that the wrong-doer has acknowledged the damage caused to one of their number, and the family of the wrong-doer need to not be stigmatised and excluded by association. The risk of escalation into factional conflicts needs to be avoided and a cohesive collaborative restored. Braithwaite (1989) has theorised that the process by which these complex, multi-faceted tasks are achieved is ‘reintegrative shaming’. Rossner (2013) has highlighted the transformative emotional power of the ritual elements of restorative justice processes. An upsurge in interest in restorative justice has seen the emergence of a range of psychological models at the early stages of their development (Gavrielides 2015; Hopkins 2016; Kelly and Thorsborne 2014). Re-integrative shaming can occur when a wrong-doer comes to a community gathering, typically with elders presiding, in a state of shame. Through a process of detailing the harm caused, more layers of harm than they may have conceived of emerge. Harm to the party they wronged, but also harm to their own family through their shame and the damage to the family’s reputation. This significantly increases the wrongdoer’s shame and creates the impact that is necessary to bring about the emotion of remorse. What differentiates this from what Braithwaite (1989) refers to as ‘stigmatic shame’ is that the wrong-doer is given a choice. The slate will be wiped clean if a form of restitution is paid. Restorative justice interventions may be unique in providing this three-sided benefit in a single action. To be effective, the theory would suggest, this requires the powerful and emotionally violent act

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of deepening shame in a wrong-doer. This power is transformative as opposed to destructive, in so far as it is driven by an expression of hope – hope that the harmed can be healed or soothed; that the wrong-doer can be reformed and re-integrated; and finally that the cohesion of the collective can be restored with justice seen, and felt, to be done. This is not without risk. Go too far and the wrong-doer is simply wounded. Go not far enough and the harmed is re-victimised. These are finely balanced and high-stakes encounters. They require the powerful exercise of authority, engaged in an act of creativity, in which community is refashioned each time. This dynamic tension is the crux and essence of this chapter. It is only through engaging with psychic pain that the alchemical process of human transformation can be achieved. To be a catalyst of this transformative process, the people who mediate between people in pain must themselves be able to tolerate the violence of creative states. Bion wrote of transformation in psychoanalysis: ‘The change is violent change and the new phase is one in which violent feelings are violently expressed’ (1965, p.9). The re-integrative practices described above have been revived in the social practices of some First Nation peoples, through, for example, youth courts and family group conferences in New Zealand (MacRae and Zehr 2004). Family group conferences in a somewhat altered format have now also become widespread in the UK as a response to family breakdown and social services involvement (NSPCC 2009). In justice circles, victim– offender mediation (VOM) developed in a number of local authorities in the 1990s in the UK (Liebmann 2015). This has developed into what is known as ‘script-based’ restorative justice conferencing (Restorative Justice Council 2011). There are other models and vehicles for restorative justice processes, many involving some form of ‘circles’; however, I will focus here on so-called ‘conferencing’. Restorative justice conferencing is intended to be ‘victim-led’. In other words, it can only proceed if the harmed person agrees. In fact, proponents of restorative justice argue that victims often feel excluded  from conventional ‘retributive justice’. This is partly because they want answers to specific and personal questions, partly because they want to express their feelings and, very importantly, many do not want the punishment meted out through retributive justice. With the agreement of the harmed person and then the agreement, however partial, of the

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wrong-doer, there is a carefully facilitated, structured meeting. Not just between the two parties directly involved, but also a ‘supporter’ for the wrong-doer, a ‘supporter’ for the harmed and, on occasion, a third party. As much as there is a structure to the meeting, as implied in ‘scriptbased’, what happens within the structure should be free and spontaneous. There is an axiom of skilled facilitation of a conference – which is ‘don’t steal the conflict’. Feelings can and should run high. A single event can only have transformative power if it is impactful, emotional, and challenging. This is no place for complacency. But this can only happen responsibly if there has been a great deal of preparation. Another axiom of conference facilitation is that 90 per cent of the work happens before the conference itself. This is because the facilitator will have met with the harmed person, assessed their resilience, informed them of the process, and given them space to think about what outcomes they would like to see. This can be done in a single meeting, but in more serious cases, preparation can take months. Similarly, the wrong-doer also has preparatory meetings, to assess their suitability for the intervention, to assess the risk of re-traumatisation of the victim, and to prepare them for the format of the meeting. This process is repeated for all main parties. So it can be a misnomer to refer to ‘conferencing’ as a single event. It is more likely the culmination of a process.

MENTAL ILLNESS AS A DISQUALIFICATION FROM RESTORATIVE JUSTICE PROCEDURES Until recently, people with significant mental health difficulties have typically been excluded from access to restorative justice procedures. Sometimes this is because of explicit policy exclusion. Liebmann’s (2007) definitive text on what works in restorative justice contains one reference to a case in which someone with a mental illness could not participate due to a lack of capacity. This is a notable exception in the literature where the place of mental illness is largely elided. This may have arisen because restorative justice practitioners have not typically had mental health training and fear acting outside of their competence. Cases in which a wrong-doer has a mental illness are by definition ‘complex and sensitive’ in the terms of the Restorative Justice Council’s handbook for practitioners (2011). However, people who have fallen victim to acts perpetrated by people with mental illnesses are also deprived of restorative

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justice outcomes, and victims of offences who have mental illnesses are excluded from benefiting from restorative processes themselves.

THE MULTI-FACETED NATURE OF RECOVERY FOR THE OFFENDER PATIENT Patricia Deegan (1988) is credited with having initiated a profound shift in how recovery for those suffering from severe and chronic conditions is understood. Deegan, a clinical psychologist with a diagnosis of schizophrenia, described a highly individual and personal journey of coming to terms with the presence of clinical symptoms and yet living a full and meaningful life. This distinction between clinical recovery and living well with impairment has come to be known as personal recovery (Slade 2009). Personal recovery emphasises the importance of a positive sense of self, a meaningful life, hope for the future, and, crucially, personal responsibility. Anthony’s (1993) landmark paper describing recovery as a vision for the 1990s provides a definition of recovery: a deeply personal process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing way of life even with limitations caused by the illness/ offending. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness. (Anthony 1993, p.15)

This concept of recovery is transformative of mental health services when scaled up. Jacobson’s (2004) anthropological account of the implementation of recovery identified that recovery can imply a system reform, a service model, and a social movement. Davidson, Rakfeldt and Strauss (2010) describe recovery as fundamentally a civil rights movement. Policy makers around the world have directed clinicians to recognise the implications of honouring a commitment to personal recovery for each service user at the level of system-wide provision of services. Davidson et al. (2010) quote the US Surgeon General’s Report from as far back as 1999 exhorting the service delivery community to recognise that ‘the goal of services must not be limited to symptom reduction but should strive for the restoration of a meaningful and productive life’ (p.455). They highlight that typical phrases used to describe the recovery movement are ‘revolutionary’; ‘a new paradigm’;

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‘transformative implications’; and ‘truly a new era’. To many clinicians these phrases appear to be hysterical hyperbole. As a ‘revolution’ or a ‘new era’ the recovery movement could be seen to be passing by many clinicians. In UK forensic mental health settings the primary drivers for the pragmatic implementation of recovery-oriented care have been commissioner contract targets. It is curious that clinicians have not been in the vanguard of taking up both the challenge and the opportunity of the recovery movement. Some have argued that this can be accounted for by vested interests in the status quo or a lack of resources. Others view the recovery movement as a form of denial of illness (see Evans 2016); that recovery is simply new jargon to justify the withdrawal of services; or that recovery initiatives should replace the oppressive and stigmatising services already in place. My own view is that while there is an element of validity in all of the above perspectives there is an additional factor. This is prefigured in Anthony’s (1993) vision for the future when he suggests that ‘Recoveryoriented health systems must structure their settings so that recovery “triggers” are present… The mental health system must help sow and nurture the seeds of recovery through creative programming… Helpers must have a better understanding of the recovery concept in order for this recovery-facilitating environment to occur’ (p.21). ‘Helpers’ struggle to understand the recovery concept, not least because many believe that there is nothing new that needs to be understood, but also because the imperative to practise evidence-based medicine inhibits ‘creative programming’. Mental health systems have lacked a vision or a language with which to ‘structure their settings’ in an open-ended way that does not ‘prescribe’ recovery but which creates a palate that can be ‘used’, in the Winnicottian sense of the creative use of object, to invent a unique and personal outcome. It can be seen as a waste of public funds to direct resources towards an initiative with no proven evidence base. A ‘lean’ culture of rationing resources cannot easily tolerate the importance of providing a recovery-enabling environment in which superfluity of opportunity is present. However, if there is a single change in the delivery of services that is enabled by the recovery movement, it is introduction of peer worker roles. The leavening of the introduction of peer workers could provide a transformative ingredient without the prior evidence base of outcomes to justify such a step.

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IS RECOVERY IN FORENSIC SERVICES ANY DIFFERENT? Drennan and Alred (2012) and Drennan et al. (2014) have taken up the challenge of implementing a recovery vision in forensic mental health settings with one key adjustment. They challenged the prevailing wisdom that there was no difference between recovery for the forensic patient and a non-forensic patient (Royal College of Psychiatrists 2004). These authors argue that the reality of the offence constitutes a fundamental difference and that this difference permeates all facets of the recovery journey with an additional layer of complexity. The offence can shape clinical recovery, the social inclusion of recovery, and the meaning of personal recovery. It is often the case that recovering a meaningful life with a positive sense of self and hope for the future is more difficult to achieve in the face of a grievous offence than it is in the face of an enduring illness. In order to identify this difference in additional tasks, Drennan and Alred (2012) coined the term ‘offender recovery’. Dorkins and Adshead (2011) and Adshead, Ferrito and Bose (2015) refer to the challenges of ‘offender identity’. The parallel nature of these recovery tasks can be seen in the following quotes – one from Anthony’s paper regarding mental health, and one from Ward and Maruna (2007) writing about the Good Lives Model of mainstream offender rehabilitation: There is the possibility that efforts to affect the impact of severe mental illness positively can do more than leave the person less impaired, less dysfunctional, less disabled, and less disadvantaged. These interventions can leave a person not only with ‘less’ but with ‘more’ – more meaning, more purpose, more success and more satisfaction with one’s life. (Anthony 1993, p.16) What is required at the clinical level is some attention to helping offenders to build a better life (not just a less harmful one) in ways that are personally meaningful and satisfying and socially acceptable. (Ward and Maruna 2007, p.83)

Building on Anthony’s definition of recovery to incorporate the offencerelated tasks, one could re-work his definition to accommodate the additional facet of offending behaviour in the following way: a deeply personal process of changing one’s (offending) attitudes, values, feelings,

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goals, skills, and/or roles. It is a way of living a (safe), satisfying, hopeful, and contributing way of life even with limitations caused by the illness/ offending. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness/offending. The descriptions of personal recovery above emphasise the importance of people taking personal responsibility for their illness. However, there is an important distinction to be drawn here. Taking responsibility for illness cannot generally be taken to mean that the person must take responsibility for developing an illness. They do need to take responsibility for their recovery after the fact, but they cannot generally be held ‘to blame’ for falling ill. Drennan et al. (2014) make the point that it would not make sense to ask of someone suffering from a mental illness ‘what motivated you to become ill?’, but for the offender patient motivation is a central question to be posed in their recovery. Taking responsibility for recovery for the offender patient has implicit within it that the patient takes responsibility for their offending behaviour. Buckley et al. (2014) put it thus: ‘The change must be in health certainly, but also in ownership of behaviour’ (p.585). My proposal here is that restorative justice practices are a uniquely powerful vehicle for advancing this aspect of recovery and that this could be deployed as part of ‘creative programming’ in forensic mental settings. This claim is based on the extent to which the organising principle of restorative justice is the focus on the harm that has resulted from actions. For the offender patient, restorative justice practices promote a focus on the harm that has brought him or her to this place. At the same time, these practices create a place for ‘the harmed’ to participate. I will expand on this below in order to suggest that, just as peer worker roles present a unique opportunity for recovery processes, creating roles for those who have been harmed could similarly provide a source of ‘creative programming’ to enable interventions with their three-sided benefits.

RESTORATIVE JUSTICE INTERVENTIONS IN FORENSIC MENTAL HEALTH SETTINGS Cook, Drennan and Callanan (2015) describe one initiative to formally introduce restorative justice processes into forensic mental health settings in the UK. Since that time a small number of forensic mental

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health services have trained staff in restorative justice conferencing skills and have begun to implement this approach. It is encouraging that these services have ranged from high security to services for patients with intellectual or learning difficulties.1 Cook et al.’s (2014) evaluation did not include conferencing between an external, stranger victim and a forensic patient. At that stage the project had progressed to the point of applying restorative justice structures to intra-familial violence or infractions based in the institution, where patient-on-staff or patienton-patient incidents were addressed through restorative processes. The authors describe processes where patient assaults on staff members were dealt with in this way, and they highlight that it required courage on the part of the staff members, who were obliged, as part of the process, to make themselves more vulnerable, through higher levels of personal disclosure about their experience of harm than they would normally engage in with a patient. However, there were early indications that the wrong-doer’s capacity to recognise harm was enhanced by the immediacy of the presence of their victim in the room in active dialogue with them, structured as a restorative justice process. Another approach to introducing victim awareness in forensic mental health has been through the introduction of the Sycamore Tree Programme (STP) (Wood et al. in preparation). The STP is an accredited victim awareness and restorative justice intervention offered by Prison Fellowship in prisons across the UK and in other countries. However, it has never before, to our knowledge, been delivered in a forensic mental health setting. In session three of the six-session programme, victim representatives attend the group and, over the course of the session, they recount their experience of victimisation – how it affected their lives, what they and their families went through, and how, eventually, they began to move past whatever happened, even if it will never really be behind them. In the second session of the first cohort, when the possibility of repair and restoration was put forward by the Programme Tutor, one group member challenged him by saying words to the effect of ‘How can you repair when someone has been killed?’ In this group, that was a 1 The Mesdag Clinic and the van der Hoeven Clinic in the Netherlands have published Guidelines for Implementing Restorative Justice in Forensic Mental Health: https:// files.enflow.nl/fd9938a8-0039-4987-aee4-d3773cabfd43/c3fe5633-659c-46d0-b62470920d1cd024/projecten/call-2013-13-richtlijn-definitief.pdf

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profoundly serious question. It was highly impactful for the entire group when, one week later, the victim representatives arrived and began to describe the circumstances in which their eldest son was killed by three young men in the street one Friday evening. Everyone participating in the group, the learners and the staff team, were deeply moved by this experience. The reality of the shock, the disbelief, the horror, the anger, the pain, the self-recrimination, the ‘if only’ questioning, the autopsy, the trial, the encounters with the accused in the court, the encounters with the accused’s family members – themselves deeply shamed and grieving too – the sentencing, and the trying-to-get-on-with-your-life: these are layers upon layers of reality that most minds cannot conceive of unless it is recounted with the immediacy of a first-person narrative. It is difficult to predict how a group of offenders will respond to such a story when they are in the presence of the people who have lived through, and continue to live with, what they are describing. Some fall silent and become introspective, some have spontaneously stood up to embrace the victims, and others appear chastened and unsure of themselves. In our initial cohort of 18 patients, one chose not to attend the third session of the group, when the victim representatives attended. In this sense, that person was, technically, a dropout. The reality was something different. The very idea of meeting victims under these circumstances was more than he could bear. He had been challenged as much as he could tolerate already. The impact of this appeared to destabilise the ‘dropout’ for a number of weeks, only to recover a significantly improved level of engagement in the weeks and months that followed. Following STP group sessions, patients spoke about being ‘moved’ by the encounter with the victim representatives – their story and the way in which they related to the men on the programme. A small number of patients in the initial cohort were ‘moved’ to the extent that their mental state was somewhat destabilised. They needed additional support and opportunities to work through what they had heard and the way in which this challenged them. The STP Course Tutor used a memorable phrase for the way in which the men are invited to be open to the conflict that this might stir up in them – he would invite the learners to ‘lean into the discomfort’.2 In a corollary to this, programme facilitators of this and other offender interventions also need to find the courage to 2

Finlay Wood, Sycamore Tree Programme Tutor.

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supportively challenge the learners on their programmes. However, few group facilitators have the moral authority to challenge complacency in the way a genuine and sincere victim of a serious offence can. Just as peer workers can carry a narrative of belief in the possibility of self-change and taking responsibility for recovery in a very different way from the professional worker, so too can surviving victims carry a narrative of repair and restitution in uniquely affecting ways. The STP is also not the only programme that brings victims and offenders into direct contact. The Forgiveness Project programme Restore (Adler and Mir 2012) and the Khulisa programme Silence the Violence (Worth et al. 2015) do similar things. My contention here is that there is a real possibility that the presence of the ‘victim in the room’ engages with the ‘victim in the mind’ of the offender in ways that are more powerful and more visceral than the abstract idea of a victim. We are only at the beginning of being able to theorise the impact of this way of working. Nevertheless, there are encouraging signs that for a sizable number of people with severe mental health difficulties and histories of offending, the introduction of actual victims of crime into treatment programmes induces a state of mind in which transformation becomes possible.

RECOVERY FROM HARM – TOWARDS A DEFINITION How then does someone who has committed a serious offence while in a state of diminished responsibility ‘take responsibility’ for their offence? There is no one answer to this question as there are many pathways to committing an offence. No single generalisation will suffice. However, the language of victim awareness and restorative justice can create a notion of ‘harm’, which in turn opens doors to engaging with reparation in ways that the brute facts of what happened cannot. The perpetrator cannot meaningfully ‘take responsibility’ for acting on a delusional belief. The wrong-doer can take responsibility by acknowledging the hurt, harm, or impact of the event on the person who suffered as a result of their actions. The statement ‘I recognise what happened to you and I am profoundly sorry’ is a powerful version of taking responsibility. Recognition is transformative – this rehumanises both parties. This work has given rise to a form of ‘episteme’ or ‘ground for thought’ (Foucault 1970) in which it has become possible to conceive of

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a description of the facet of recovery that is in operation for the forensic patient. Based on the above preface, I can propose the following as a definition of the processes involved in recovery for anyone who has caused harm: Recovery from Harm – the processes by which a person who has caused harm, directly or indirectly, recognises and accepts the harmful impact of their actions, is willing to take steps to prevent future harm, and is engaged in coming to terms with what this will mean for their own future.

It is my contention that a thorough-going focus on the fact of harm caused, and the ramifications of this through restorative justice processes, has the potential to make a unique and powerful contribution to the transformation of the violent states found in the mind of the forensic patient. Through the range of ‘three-sided’ interventions that are made possible by this focus, the creative states necessary for personal recovery for all of the people caught up in acts of violence may be given a space in which to emerge.

ACKNOWLEDGEMENTS With thanks to Fiona Wood, Finlay Wood, Joel Harvey, Heather Reynolds, and Penny Parker for their partnership in delivering and evaluating the STP and for their comments on earlier drafts of this chapter. And to Ray and Vi Donovan for sharing their recovery from loss and their consent to its inclusion here.

REFERENCES Adler, J.R. and Mir, M. (2012) Evaluation of The Forgiveness Project within Prisons. Available from Middlesex University’s Research Repository. Accessed on 6/12/2017 at http://eprints.mdx.ac.uk Adshead, G., Ferrito, M. and Bose, S. (2015) ‘Recovery after homicide: narrative shifts in therapy with homicide perpetrators.’ Criminal Justice and Behaviour 42, 70–81. Anthony, W.A. (1993) ‘Recovery from mental illness: the guiding vision of the mental health service system in the 1990s.’ Psychosocial Rehabilitation Journal 16, 11–23. Bion, W.R. (1965) Transformations. London: Heinemann. Braithwaite, J. (1989) Crime, Shame and Reintegration. Cambridge: Cambridge University Press.

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Buckley, P.F., McGauley, G., Clarke, J., Moore, E. et al. (2014) ‘Principles of Treatment for the Mentally Disordered Offender.’ In J. Gunn and P.J. Taylor (eds) Forensic Psychiatry: Clinical, Legal and Ethical Issues (2nd Ed). Boca Raton: CRC Press. Cook, A., Drennan, G. and Callanan, M.M. (2015) ‘A qualitative exploration of the experience of restorative approaches in a forensic mental health setting.’ Journal of Forensic Psychiatry and Psychology 26, 4, 510–531. Davidson, L., Rakfeldt, J. and Strauss, J. (2010) The Roots of the Recovery Movement in Psychiatry: Lessons Learned. Chichester: Wiley-Blackwell. Deegan, P. (1988) ‘Recovery: the lived experience of rehabilitation.’ Psychosocial Rehabilitation Journal 11, 4, 11–19. Dorkins, E. and Adshead, G. (2011) ‘Working with offenders: challenges to the recovery agenda.’ Advances in Psychiatric Treatment 17, 178–187. Drennan, G. and Alred, D. (eds) (2012) Secure Recovery: Approaches to Recovery in Forensic Mental Health Settings. London: Routledge. Drennan, G., Wooldridge, J., Aiyegbusi, A., Alred, D. et al. (2014) Making Recovery a Reality in Forensic Settings. London: Centre for Mental Health. Accessed on 2/1/2017 at https://imroc.org/resources/10-making-recovery-reality-forensicsettings Evans, M. (2016) Making Room for Madness. London: Karnac. Foucault, M. (1970) The Order of Things: An Archaeology of the Human Sciences. New York: Vintage Books. Gavrielides, T. (ed.) (2015) The Psychology of Restorative Justice. Farnham: Ashgate Publishing. Hopkins, B. (ed.) (2016) Restorative Theory in Practice: Insights into What Works and Why. London: Jessica Kingsley Publishers. Jacobson, N. (2004) In Recovery: The Making of Mental Health Policy. Nashville: Vanderbilt University Press. Kelly, V.C. and Thorsborne, M. (2014) The Psychology of Emotion in Restorative Practice. London: Jessica Kingsley Publishers. Liebmann, M. (2007) Restorative Justice: How it Works. London: Jessica Kingsley Publishers. Liebmann, M. (2015) Building the Restorative City. Accessed on 1/11/2016 at www. voiceandinfluence.org.uk/sites/voiceandinfluence.org.uk/files/Restorative%20 City%20chap%207%2015.pdf MacRae, A. and Zehr, H. (2004) The Little Book of Family Group Conferences: New Zealand Style. Auckland: Good Books. NSPCC (2009) Family Group Conferences in Child Protection: An NSPCC Factsheet. London: NSPCC. Restorative Justice Council (2011) Best Practice Guidance for Restorative Practice. London: Restorable Justice Council. Rossner, M. (2013) Just Emotions: Rituals of Restorative Justice. Oxford: Oxford University Press. Royal College of Psychiatrists (2004) Rehabilitation and Recovery Now. Council Report (CR121). London: Royal College of Psychiatrists. Slade, M. (2009) Personal Recovery and Mental Illness. London: King’s College. Ward, T. and Maruna, S. (2007) Rehabilitation: Beyond the Risk-Paradigm. London: Routledge.

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Wood, F.A., Harvey, J., Wood, F. and Drennan, G. (in preparation) The Sycamore Tree Programme in an In-Patient Secure Forensic Mental Health Setting. Worth, P., Gavrielides, T., Smith, M., Ntiadoma, A. and Gouseti, I. (2015) ‘The Psychology of Restorative Justice: Creating the Inner and Outer Space for Change – An Observation of Restorative Justice Meetings.’ In T. Gavrielides (ed.) The Psychology of Restorative Justice. Farnham: Ashgate Publishing.

Chapter 14

VIOLENT ACTS AND CREATIVE RESPONSES Resilience Building Through Art Psychotherapy KATE ROTHWELL AND SIMON HACKETT

RESILIENCE Resilience is a complex and multi-layered construct which includes the notion that people can increase their capacity to adapt well in the face of adversity. Some definitions of resilience emphasise the development of a capacity to manage strong feelings and impulses as an important feature (American Psychological Association 2014). A primary factor in enabling resilient responses to adverse life events for individuals is having the experience of or access to caring and supportive relationships (Southwick et al. 2014). Also, embedded within the concept of resilience is the idea of personal growth in response to trauma or loss through finding opportunities for self-discovery. Resilience…would involve a reintegration of self that includes a conscious effort to move forward in an insightful integrated positive manner as a result of lessons learned from an adverse experience. (Southwick et al. 2014)

In this chapter we will explore what resilience might mean for violent offenders who have inflicted violent, adverse, and traumatising events on others and are serving sentences in prison. We will present accounts of violent offenders who have engaged in creative arts practice within group art psychotherapy in a prison in the UK. The participating members of the group reported here have given their permission and consent for 195

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descriptions of their work and words to be written about and all names and identifiable details have been anonymised. Case vignettes illustrate processes involved in art psychotherapy group sessions. Events taking place in the group are described in detail with additional explanations about group members discovering ways of reintegrating aspects of self through personal creativity. Notions of what resilience building might mean for people who have severely damaged or destroyed relationships by their extreme violent acts and failure to manage strong feelings and impulses will be considered. In conclusion, we identify the contributory factors in the art psychotherapy group that appeared to support resilience building.

ART THERAPY/PSYCHOTHERAPY ‘Art psychotherapist’ is a title used in health, social care, and secure therapeutic settings in the UK by qualified therapists registered with the Health and Care Professions Council. Art psychotherapy emphasises the process of making art safely within the context of a therapeutic relationship in pursuit of beneficial psychological, social, and rehabilitative goals for its participants. In practice, art therapy involves both the process and products of image making (from crude scribbling to sophisticated forms of symbolic expression) and the provision of a therapeutic relationship. It is within  the supportive environment fostered by the therapist–client relationship that it becomes possible for individuals to create images and objects with the explicit aim of exploring and sharing the meaning these may have for them. It is by these means that the client may gain a better understanding of themselves and the nature of their difficulties or distress. This, in turn, may lead to positive and enduring change in the client’s sense of self, their current relationships, and in the overall quality of their lives (Edwards 2004, p.4). ✳✳✳ It’s 2 o’clock in the afternoon and the room is prepared and waiting for the group to arrive. The men wander in slightly early to bring the art materials out of the cupboard into the open space and then sit in a circle, poised and full of anticipation. The uncertainty weighs heavy, and there’s

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an expectation that something will happen, though no one knows what. It’s a well-rehearsed, familiar structure performed week in and week out, and yet the outcome remains unknown. Art will be made, thoughts and feelings shared, issues discussed, and something will change in each exchange. This is known. The men have come to trust that if they use the art materials and create an image, something will be made available to them to explore with the group and that it will be meaningful in a new way. The risk comes with what they choose to expose about themselves and how this will be received. Once the marks are made, the paint applied to paper, and the shapes formed, there is no going back. It’s out there for all to see, not least for themselves. It now exists in a new form, outside of their heads and in the minds of everyone else as witnesses to a scene, a moment in time, an experience, a belief that has become visual. It’s a process over time that succeeds in becoming present and available. It has to be owned by the creator and the audience and cannot be silenced or hidden any more.

THE PRISONERS – A CAPACITY FOR VIOLENCE The act of art making has become a visual testimony to the act of the offence as the artists (prisoners) are all violent offenders who have committed serious crimes culminating in their receiving life sentences for murder, sexual offences, substance abuse, grievous bodily harm, robbery, fire arms, and the list goes on. The victims are family, loved ones, friends, associates, and strangers. People. The legacy of their offences is devastation, traumatisation, and ultimately the destruction of human life and well-being.

PRISON – ‘THE EASY OPTION’ The art psychotherapy group is part of a core programme of psychodynamic group psychotherapies, run within a Therapeutic Community in a Category B prison, facilitated by prison officers and clinicians. The inmates have chosen to spend part of their sentence in one of the six communities held within the prison to work on their criminal behaviours. This is a long-term undertaking, often seen initially by inmates as the ‘easy option’ in serving their sentence, until they realise the gravity of the choice they’ve made leads them to an internal world

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they never knew existed. And herein lies the paradox of art psychotherapy, also seen by some as childish, something they did at school, who missed the opportunity to view art or to appreciate the importance of art making as a form of communication or self-expression. To appreciate art as an agent of change comes with the experience. In theory it sounds odd, that the simple use of art materials can lead to a revelation of something unknown made known, yet the men in the art psychotherapy group would say differently, having taken the uncompromising risk of finding out what lives deep within their unconscious. What starts as a meandering and faltering journey into the unknown becomes a creative force leading to the potential of preventing further violence.

THE ARTISTS – A CAPACITY TO DESTROY AND TO CREATE The act of creativity may be violent in itself and can be felt, seen, heard, moving, still, close, distant, confusing, challenging, reliving, relieving, an escape, a change of view, ambivalent, but never irrelevant. Ultimately the outcome of the experience of sitting in a room with others, all using art materials, creating something in a space and time devoted to art making in the presence of an art psychotherapist, is to enable the development of resilience.

CASE VIGNETTE 1: STANLEY Stanley’s time in the art psychotherapy group was a process of learning how to handle anger and to use it constructively. He identified a fiercely angry part of himself through others’ work in the group but deliberated whether to allow this experience to impact him, thereby allowing something in that would have an emotional effect. Stanley admitted to not ever knowing how he was feeling and described himself as an ‘ice cube’ protecting himself against vulnerability, which he saw as weakness. For the first time, Stanley was able to reflect on his need to look at the feelings he had hidden away. He thought about his avoidance of feelings and what support he’d need on release. He also recognised his tentative steps to bring more work from an unconscious place and less pre-planned material into the group: beginning to take risks to trust the group.

Resilience Building Through Art Psychotherapy

Later in the work, Stanley made an image of a haunted house precariously held up by two spindly brackets on the edge of a cliff, with him hanging on under the house as it crumbles away above him. Stanley explained that the house is unsafe and collapsing: the ghosts inside are from his past and he hopes, if he lets go, there will be a soft landing not far below, proving he had nothing to fear in the first place. The analogy for Stanley indicated a fear as to whether he can make a blind leap of faith to trust and rely on others. This was further represented in an image of a flight of stairs against which several ladders leant, and a black hole at the bottom of the stairs in which he sat unseen, waiting for a ladder to be positioned so he can climb out from the hole. This he linked to his release and his acknowledgement of his need to be able to rely on others’ support. An image of a frozen male penguin clutching his egg between his feet for protection, and yet cracked, was a most profoundly moving image for Stanley. He spoke of how penguins huddle to keep each other warm. This penguin was alone in a blizzard of words about death, dying, and relationships getting killed off. This sad image helped Stanley to think more about the impact of trauma as a frozen state and the process of defrosting that needs to be slow and gradual in building up his resilience against loss. In an image of ‘numbskulls’ Stanley reasoned that the numbskulls in his head have a job to edit his humorous defences and that he can choose whether to pretend to care or to not care: both sounded equally dangerous. Stanley’s emotions were held in his images and enabled him to identify with others’ emotions of feeling helpless, vulnerable, and humiliated. Through art making he explored feeling fearful of the world outside, and challenged his own practices of remaining hidden or running away from his problems rather than seeking alternative solutions.

CASE VIGNETTE 2: ARNOLD The theme of boxes has been a useful metaphor for Arnold in describing his use of compartmentalisation as a defence since childhood. Over time, his gradual unveiling of past information from the box has afforded him protection until he felt able to trust he would not be rejected, at which point the box became a transparent object exposing the emotional wounds inflicted on him over the years. This transparency enabled Arnold

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to recognise his vexatious feelings, spurred by feelings of rejection and abandonment, which led him to hold deviant fantasies. The ultimate box for Arnold was his self-imposed duration in prison. Arnold was able to reflect on his need to deconstruct in art psychotherapy and to look at the feelings he was hiding away, having never looked at them before, to protect himself from anxiety. However, Arnold received help from the group by sharing their observations, which enabled him to see elements surfacing from an unconscious place less in his control. This interested him on a cerebral level but seemed to connect less on an emotional level. Arnold experienced himself as a socially inadequate person with low self-esteem. He described himself as someone who prefers his own company. In thinking about the ongoing support he needed, Arnold visually described doubt, fear, and selfishness as emotions that burdened him. He viewed ‘hope’ just out of reach. Any attempt to help Arnold consider his emotional impact on others was met with dismissal. Arnold’s hope was to get rid of negative emotions, rather than assimilate the feelings in a more manageable size. It became observable that Arnold gradually worked in more depth, using the containment of the group and image-making process. He identified his own struggle to self-regulate his emotions but developed resources to explore darker emotions without fear of rejection. Once this fear was processed, his resilience began emerging. Having described ‘the old me’ as boxed in, bottling up feelings and self-loathing as a defence against intimacy or taking responsibility, Arnold described ‘the new me’ as the opposite of this. The formulaic appearance in his work was replicated in his seemingly predictable behaviour, assumed as if he were hoping to ensnare a victim, as he had in his offence. This behaviour is not dissimilar to that of children who have never been shown how to express their feelings and therefore attempt to devise a sociable and responsive albeit unauthentic appearance. Arnold applied this stance from age seven onwards when he was ignored and neglected. To this end, Arnold was more able to identify his intimate relationships where he felt he was paid attention and taken seriously. Through art making Arnold was able to depict powerful and articulate representations of his need for impenetrable defences for protection. The group’s willingness to work with his difficult issues and tolerate the material he needed to bring enabled him to counter his need for

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denial as a defence. The risks Arnold presented were elusive, but with the group members’ supportive and challenging enquiry, Arnold took a more enquiring stance. This showed his progression in being able to express his emotions openly through the gentler approach of art making. Through imagery, it was possible to see how Arnold’s feelings of impotence and infantilisation had fed into his deviant fantasies as a means of correcting a perceived imbalance and to assert authority over those he deemed to be undermining his role in the family.

CASE VIGNETTE 3: ADE During an incident that compromised the therapy space in making symbolic representational objects deemed a risk to security, there was an effect on the group that could have potentially ruptured the containing structure. This caused a rise in organisational anxiety, but fortunately the group was able to continue working, having learnt lessons from this experience. Ade, though angered by what was misinterpreted as an attack on security boundaries, was able to retain some reflexion on the matter and questioned why he was seen as such a threat. This is an important question and an area that needed more work to be understood. In the aftermath of the incident, it was evident that Ade could cause feelings of incompetence and disempowerment in others. This helped form a better understanding of Ade’s susceptibility to betrayal anxiety, most likely to have been formed through early experiences of deceit by authority figures in his life. This was discussed at length when reporting on the incidents that led him to his feeling betrayed and undermined and how crime enabled him to maintain hierarchical authority over others. It was important for Ade to recognise his need to invest value in his therapeutic work and to support him to work in a transparent, non-collusive way that afforded him a secure base to which he could attach. This helped him exercise honesty in himself and towards others, and to process his fear of betrayal and need to overpower others to retain control. On many occasions the image enables the artist to speak in more depth about trauma and ultimately show the disintegration and devastation behind the primary need for dependency, whilst maintaining strength to symbolically return to the place that changed the person’s life forever. Having found the resilience to return to a very dark chapter in

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their lives, artists also find a balance with good memories that remind them of many elements that have gone into making them strong. This polarity was reflected in an image of a ‘lowly’ crow walking along unbothered by the aggression of a fist punching violently and suddenly through a wall behind it. The small crow aspired to be unfazed by emotional turmoil and appeared to carry on its way regardless of the explosion. The lowly crow became a symbol of ordinariness for the group, who recognised a neglected part of themselves that they all wanted to find.

THE ARTISTS – A CAPACITY TO DISCOVER CASE VIGNETTE 4: RAY In a 3D paper skeleton sculpture Ray explained his feeling that therapy is enabling him to go ‘back to the bone’ and become exposed in a positive way. For Ray, the sculpture resonated most with his vulnerability as if having no buffer or filter in the form of flesh and skin to enable him to filter his anger, therefore allowing potent emotions to reach straight to  his core with no external protection. The skeleton is the size of a two-year-old with bones that can be easily damaged. This resonated for Ray, who shared stories of childhood brutality at the hands of his step­ father and gave more meaningful expression to his difficulty regulating his emotions.

Figure 14.1: Skeleton

Resilience Building Through Art Psychotherapy

Having become aware of the effects of never having his needs met throughout his childhood, Ray acknowledged his needs in his adult life, though this connected him again to vulnerable and messy feelings. From his work in art psychotherapy, Ray found feelings of being cared for and caring about others distressing, given his multiple losses. Having visually depicted his childhood experience of asking for but never receiving help, Ray had a tendency to return to his default position, ingrained from childhood. Ray’s capacity to express his emotions with powerful affect through art making enabled him to expose a softer, highly creative and charismatic side, which he expressed through well-crafted paper sculptures. However, Ray also used his talents to break what he makes. Suddenly Ray leapt up and punched a paper figure of himself, breaking his knuckle joints on the concrete floor. Shockingly Ray did not inform staff or his group, his response being that it didn’t matter. It was pointed out that not only had he smashed himself symbolically but also literally, giving cause for concern that Ray was self-harming in the group and not reporting it so as to receive the care and support he needed.

Figure 14.2: Smashing myself up

This implied his learnt capacity for destructive responses to manage his emotions was an area that needed more work but enabled Ray to recognise the hurt he had caused people throughout his life and to explore these emotions, rather than avoid the pain by obliterating them

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with drugs and alcohol. Ray went on to moderate his emotions through art making, using the process symbolically to resist making dramatic responses that have literally caused him and others harm.

THE ARTISTS – A CAPACITY TO CONNECT WITH SELF AND OTHERS CASE VIGNETTE 5: BENJI By repeatedly bringing feelings of not being trusted or being put under suspicion, misunderstood, targeted, and discriminated against, Benji was enabled to develop a theme that threaded through much of his work. In an early image portraying a police officer in a playful monster stance that creates a demon-like shadow scaring two smaller figures (one being Benji), a concealed part of himself contained in the shadow was gradually emerging. This represented for Benji a feeling of being a shadow of his former self as the person with a promising future, unaware that he presented as someone untrustworthy. This was evident in his depiction of an image of the self in a suit looking at himself in a hoody, surrounded by blackness with the words ‘fuck knows’. He spoke of these two distinct parts with genuine intrigue, which helped him identify a feeling of wanting to be powerful in both his professional world and his street life. This was a defining image in recognising different parts of himself, though neither recognised the other. It could be said that, here in the image, they met each other for the first time. Benji saw the pleasant person as the real him, but realised there was a thuggish, overprotective person that he felt he was expected to be, and which he described as a ‘product’ of his life. Benji succinctly depicted his anxieties that were promoted when he felt ‘in the dark’ and uncertain of his future. He identified this as a familiar feeling from childhood when he had no guidance and was left confused and alone having to work things out for himself. This suggested a developing maturity in recognising the impact of his emotions in more depth and the impact Benji had on others. Since being in prison, Benji has learnt how loved he is and how much he loves those close to him. He became more connected to his capacity for violence and aggression through his art making than he did verbally and was able to explore different aspects of himself with

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genuine curiosity. The trust Benji built in the group and the therapist enabled him to express annoyance and exasperation at his own actions that caused him to be imprisoned. Benji’s paintings came to represent different parts of himself as he became emotionally aware whilst finding ways of reaching new insights in understanding where his capacity for violence and dangerous behaviour stems from and what he was prepared to do in order to protect himself and his family. He learnt what alternative resources he has in expressing his emotions that won’t put others at risk and became aware of what little respect he had for human life. Using the words ‘Alone, I believe in me, never give up, life is a struggle’ and then ‘rejection, isolation, abandoned, and accepted’ in artwork, to show the feelings he has always had since childhood, has shown Benji his capacity for resilience and growth. This has allowed him to take stock of the support he received in a facilitating environment and accept the nurturing boundaries he lacked as a child but can now allow himself to rely on.

THE ARTISTS – A CAPACITY FOR SEEING THE SELF AS IS Benji and his peers used art psychotherapy to look at their capacity for violence. They also appeared to explore and include examples of resilience building through creativity. By visually expressing their contrasting parts that oscillate between isolation and depression, liveliness and aggression, pain and vulnerability, therein surfaced the split-off self-preserving and omnipotent parts, giving the impression of being more in control than they actually were. It would seem the men became very good at protecting themselves from their own fears through aggression. By resorting to protect others from the truth they appeared to have kidded themselves in the process. The gradual unveiling of reality through art making provided the artists with visual representations of their intense, and at times insurmountable, need for objects they could depend on to expose their raw, innermost pain that ultimately led them to perform their most destructive acts, which brought them into prison and into the art psychotherapy group.

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DISCUSSION – A CAPACITY FOR RESILIENCE Whilst this chapter is largely descriptive, we believe that it raises important insights into the processes within art psychotherapy groups for violent offenders and how this can contribute to the development of personal resilience. One important aspect of this work is the shift in focus from exploring personal deficits towards enabling a personally creative discovery of strengths. Processes that appear to be important for violent offenders include the development of a capacity for a more accurate representation of self and the bringing about of an insightful integration of previously unacknowledged parts of the self. The metaphors inherent in the personally generated art making by the men in the group appeared to offer them opportunities to articulate a more ‘authentic’ self and have this acknowledged or, at the very least, witnessed by others. More broadly, participation in creating art is valued. Organisations such as The Koestler Trust encourage ex-offenders to change their lives through taking part in the arts. In the UK they receive as many as 8000 submissions to their annual competition from prisoners and patients in secure care and they stage exhibitions nationwide. One exhibiting artist said: In an environment, which alternates between clinical brightness and a dreadful darkness, Koestler brings permission for colour, texture and light. Every prisoner should be given a brush and told to make a mark – perhaps then less would return. (The Koestler Trust 2017)

It has been reported by art psychotherapists that the personally created artwork made by offenders often allows the exploration of aspects of self from a ‘safe distance’ (Meekums and Daniel 2011). This idea has also been specifically related to people exploring their anger and aggression through art therapy (Smeijsters and Cleven 2006). In work in prisons in the US, art therapy was observed to engender positive responses and encourage inmates to express themselves through artwork in an environment where there was an inherent distrust of verbal disclosure (Gussak 2004, 2006). Also evident in art psychotherapy work is the importance of having opportunities for sharing and looking at artwork together with a therapist and in a group. This process indicates the ‘conscious effort’ being made to acknowledge the personal thoughts and feelings of self and of others that can be associated with artwork that has been personally and individually created (Hackett 2016; Rothwell 2016).

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However, the stark image of self can also evoke destructive responses. This experience was quite literal for Ray as he attacked the image he had made of himself when he was faced with a realisation of the hurt he had inflicted on others. This is an illustration of the high expressed emotions and the hard lessons that can be learned from coming face to face with a more accurate representation of self. Ray then went on to learn to moderate his emotions through making art in the group. The tool of creative art making can often provide seemingly indirect personal material that can help some offenders to come to realisations that help them to ‘learn lessons’ and enable resilience building. The importance of resilience building is underscored by the child psychotherapy literature. Music (2016) states that ‘Resilience is not just about positivity but marked by a capacity to bear and manage difficulty. It’s about finding hope in difficulty’ (p.243). This is vital for the men participating in the art therapy group, who need to feel they are investing in an activity that will support their progression. He also reports that ‘Resilient people tend to look forward to good things and maintain an appetite for life. To deal with stress successfully we need functioning seeing and affiliation systems. High stress and trauma can turn [these] psychological and biological systems off ’ (Music 2016, p.243). Cicchetti and Rogosch (2014) maintain that the ability to bounce back from adversity evidences a capacity for resilience. We have seen observations of group members learning to use a new emotional vocabulary and humour to face their destructive selves and their losses. In the group there has been an increase in their emotional self-regulation in the face of a more representative and authentic image of themselves that includes a greater recognition of the impact their violent actions have had on others.

CONCLUSION Resilience building has been observed to take place for violent offenders through offering them creative tools and through giving them permission to explore images of self through generating personal metaphors at a ‘safe distance’ within the boundaries of a therapeutic setting. Within the art psychotherapy group there was a focus on making a ‘conscious effort’ to look forward in an insightful and integrated manner that enabled group members to ‘learn lessons’ from their own adverse experiences and their

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destructive acts towards others. It is through these creative rather than violent responses that we see violent offenders allow their vulnerabilities and strengths to be witnessed and explored by themselves and others through visual forms of their own making.

REFERENCES American Psychological Association (2014) The Road to Resilience. Washington, DC: American Psychological Association. Accessed on 6/12/2017 at www.apa.org/ helpcenter/road-resilience.aspx Cicchetti, D. and Rogosch, F.A. (2014) ‘Genetic moderation of child maltreatment effects on depression and internalizing symptoms by serotonin transporter linked polymorphic region (5-HITTLPR), brain-derived neurotropic factor (BDNF), norepinephrine transporter (NET), and corticotrophin releasing hormone receptor 1 (CRHR1) genes in African American children.’ Development and Psychopathology 26, 4, 1219–1239. Edwards, D. (2004) Art Psychotherapy. London: Sage. Gussak, D. (2004) ‘Art therapy with prison inmates: a pilot study.’ The Arts in Psychotherapy 31, 4, 245–259. Gussak, D. (2006) ‘Effects of art therapy with prison inmates: a follow-up study.’ The Arts in Psychotherapy 33, 3, 188–198. Hackett, S. (2016) ‘Art Psychotherapy with an Adult with Autistic Spectrum Disorder and Sexually Deviant Dreams: A Single-Case Study Including the Client’s Responses to Treatment.’ In K. Rothwell (ed.) Forensic Arts Therapies: Anthology of Practice and Research. London: Free Association Books. The Koestler Trust (2017) About Us. Accessed on 6/12/2017 at www.koestlertrust.org. uk/about-us Meekums, B. and Daniel, J. (2011) ‘Arts with offenders: a literature synthesis.’ The Arts in Psychotherapy 30, 4, 229–238. Music, G. (2016) ‘Resilience and Good Feelings.’ In G. Music (ed.) Nurturing Natures: Attachment and Children’s Emotional, Sociocultural and Brain Development. Oxon and New York: Routledge. Rothwell, K. (ed.) (2016) Forensic Arts Therapies: Anthology of Practice and Research. London: Free Association Books. Smeijsters, H. and Cleven, G. (2006) ‘The treatment of aggression using arts therapies in forensic psychiatry: results of a qualitative inquiry.’ The Arts in Psychotherapy 33, 37–58. Southwick, S.M., Bonanno, G.A., Masten, A.F., Panter-Brick, C. and Yehuda, R. (2014) ‘Resilience definitions, theory, and challenges: interdisciplinary perspectives.’ European Journal of Psychotraumatology 5, 1. Accessed on 28/2/2018 at http:// dx.doi.org/10.3402/ejpt.v5.25338

Chapter 15

SPIRITUAL MOVEMENTS AS CREATIVE FORMS OF RESPONSE TO STRUCTURAL VIOLENCE JAMES S. VRETTOS

INTRODUCTION: ON UNDERSTANDING MOVEMENTS AS CREATIVE FORMS OF RESPONSE We are people of this generation, bred in at least modest comfort, housed now in universities, looking uncomfortably to the world we inherit…we began to see complicated and disturbing paradoxes in our surrounding America. Although mankind desperately needs revolutionary leadership, America rests in national stalemate, its goals ambiguous and tradition-bound instead of informed and clear, its democracy system apathetic and manipulated rather than of, by, and for the people… Our work is guided by the sense that we may be the last generation in the experiment with living. Port Huron Statement of the Students for a Democratic Society (1962)

These words, written collectively by social and political activist Tom Hayden and a small group of student activists at the University of Michigan in 1962, became a powerful manifesto of movement build­ ing for a more just society half a century ago. It could easily be mistaken for a call to action by student activists on many American university campuses today. Many of the same concerns of that era still exist and have been manifested in new wars, environmental abuse, racism, genocide, 209

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patriarchy, and a generally violent, ‘fear-based’ worldview today that continues to bedevil the human condition. The Port Huron Statement presciently grappled, in part, with what academics later came to define as the problem of structural violence in one of the most paradoxical advanced nations: America (Galtung 1969; Gilligan 1997; Lee 2016). This chapter continues a dialogue that has been part of a debate from the earliest days of the American experience in its attempt to counter that violence. It will discuss a specific, social scientific paradigm that is rooted in a focused moral view of what a public intellectual’s role might be and the specific moral movement that could follow from it. As the Port Huron group understood, America is an ongoing living experiment and experience of complex paradoxes and contradictions. It has tended to be an optimistic culture – at times, naive and crude, and at other times, soaring and liberating. It can be an inspiration as well as a cautionary tale for other cultures. At their best, American progressives are optimistic and they largely agree with Marx that progress is something objectively definable. But they also tend to disagree with those Marxists who regard the historical process as a deterministic, progressive movement of emancipation that will necessarily take place in a series of epochs in an economic formation characterized by discontinuity, disharmony, and more or less abrupt leaps from one type of society to another, accomplished through class conflict. Public intellectuals, activists, academics, and spiritual leaders can have important moral roles to play in the analysis and struggle against structural violence, moral bankruptcy, and ecological and human misery that have become the lot of the countless, faceless many who continue to be the casualties of violent structures. The real transformation will have to be a creative one – a response by ordinary Americans and people around the world involved not at the level of Marxian conflict, but through the ‘praxis’ and experience of healing, radical love, and tikkun olam, or repair of the world. It’s toward this goal that this chapter and dialogue are dedicated.

Spiritual Movements as response to structural violence

REASONS AND NEEDS FOR NEW FORMS OF SPIRITUAL POLITICAL MOVEMENTS It would be difficult for those anxious to extend progressive change today to dispute the need for a viable transformative world built around humane values and the social, economic, and political policies and practices that nurture them. Far from being a utopian ideal, we have come to a point where these values and policies are essential for humanity’s sustenance and survival; the question should rather remain on how and what ‘form’ the change should take – how it will collectively manifest itself. The chorus of conflicting views could include: ‘alt-right tea parties’ verging on fascism, ‘re-entrenchment’ of disaster capitalism, expansion of corporate mercantilism, worker and consumer resistance, cultural polarization and war among the populace, the neo-liberal consensus politics of Barack Obama or Hillary Clinton, libertarian socialism, or any among a seemingly endless list of other possible social reactions or combinations. In a sense, the presidency of Donald Trump, with his brand of what intellectual activist Cornel West has called an ‘American version of neofascism’ (Democracy Now 2016, p.4), has brought us into what many believe is ‘never before’, uncharted territory. However, the concerns and issues he has raised have been those that humanity around the world have reacted to in a variety of ways from time immemorial. Sometimes these responses can take the form of principled civil disobedience or an insurgent protest plea for political and economic justice. The American progressive populist experience is rooted in a tradition that is both political and spiritual and has at times attempted to transcend ‘parties’, gender, age, class, race, ethnicity, religion, or geographical and community affiliation. A movement is envisioned here that would not be an explicitly ‘religious’ one, but one that expresses an inclusive spiritual vision that has been the common wisdom of humanity for much of recorded history.

SOCIAL SCIENTIFIC INSIGHTS INTO SOCIAL MOVEMENTS AND DEVIANT BEHAVIOUR From its beginnings as an empirical, scientific discipline, sociology sought to explain a specific form of violence within a general theory of deviant behaviour. Durkheim’s Le Suicide (1897/1951) popularized

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the ‘anomie’ tradition that evolved through at least three major phases of development to become a dominant paradigm in contemporary sociology trying to explain deviant behaviour. At the same time, these early social scientists and the newly emerging field debated vigorously the normative, political, and ethical role public intellectuals should play in the public’s responses to their research efforts. This analysis and paradigm began to offer important, embryonic insights into possible policy and social movement responses as well. Finding an answer to the question of why people deviate into violence would be the overriding concern. Once found, academic analyses would apply the prescriptions for programmes and policies that politicians, policy makers, and the general public would see as rational and agreed upon by the strength of databased evidence. The problems of violence, crime, and deviance would be solved. Critiques of the system itself and questions about radical social change would be unnecessary as this paradigm focused on finding a particular stress, strain, or weakened control state that would explain all deviance and crime; issues of spiritual concern such as morality, ethics, ideology, and belief systems would be likewise subordinated to that effort. As Durkheim (1897/1951) put it, a human’s ‘capacity for feeling is in itself an insatiable and bottomless abyss’ (p.247) – the external collective order must be capable of regulating social desires, unlimited aspirations, and limiting them; these intense feelings of anomie, normlessness, or rootlessness can cause suicide rates to increase. Nowhere else is an attempt at a master theory to explain all deviant behaviour stronger than in Robert Merton’s essay ‘Social Structure and Anomie’ ([1938]1968). Here anomie is defined as a breakdown in the cultural structure, occurring particularly when there is an acute disjunction between cultural goals and socially structured opportunity. Merton identifies four major forms of possible culturally deviant adaptations – innovative, ritualist, retreatist, and rebellious – but doesn’t explain what form of deviance might be adopted versus another – for example, why suicide vs. political rebellion or gang delinquency, why mental illness vs. drug addiction, etc. To put it another way – how does one account for different ‘forms’ of deviance, given the same anomic stress or strain state? Merton’s protégé Richard Cloward (1959) discussed differentials in the accessibility of both legitimate and illegitimate opportunity as a basis for nonconformity and to help answer the question of why people deviate in

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different ways. This observation has had profound implications for the formation of social and political movements. Cloward and Ohlin (1960) argued that ‘delinquency is not, in their final analysis, a property of individuals or even of subcultures; it is a property of the social system in which these individuals and groups are enmeshed’ (p.211). The target for preventive action, then, should be defined, not as the individual or group that exhibits the delinquent pattern, but as the social setting that gives rise to delinquency. It also meant that the poor should have a major say in their ‘salvation’. These social scientists argued that a much more fruitful approach would entail less concentration on the so-called ‘why’ question and more attention directed at the possible form that violent behaviour and social change might take. Their work had the important effect of helping to reawaken moral debate as to the role activist scholars might play in the struggle for justice.

CONTRIBUTIONS OF STRUCTURAL VIOLENCE THEORISTS By the end of the 1960s, formalizing what Hayden and his group had described earlier in the Port Huron Statement, Johan Galtung’s article ‘Violence, peace, and peace research’ (1969) introduced structural violence as an academic term and new field of study. Galtung expanded the scientific debate by stressing the need to analyse forms of violence wherein some social structures or social institutions may harm people by preventing them from meeting their basic human needs. Institutionalized adultism, ageism, classism, elitism, ethnocentrism, nationalism, speciesism, racism, and sexism were proposed as some examples for study. Structural violence was unnecessary and avoidable since it could be corrected by social science research and policy decisions. Gilligan (1997) and Lee (2016) further refine the debate by bringing their model of preventive medicine to the study of structural violence. Gilligan defines structural violence as the ‘increased rates of death and disability suffered by those who occupy the bottom rungs of society, as contrasted with the relatively lower death rates experienced by those who are above them’ (1997, p.192). These excess deaths are ‘non-natural’ and he attributes them to the shame, stress, disrespect, and humiliation that result from the negative stigmatization and degradation ceremonies more powerful groups typically wield over those of lower status.

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Lee refers to ‘the avoidable limitations society places on groups of people that constrain them from achieving the quality of life that would have otherwise been possible. These limitations could be political, economic, religious, cultural, or legal in nature and usually originate in institutions that have authority over particular subjects.’ This ‘directly illustrates a power system wherein social structures or institutions cause harm to people in a way that results in mal-development or deprivation’ (2016, p.9). In using language such as harm, shame, stress, humiliation, maldevelopment, deprivation, and non-natural death, Gilligan and Lee are introducing not only medical terminologies but equally important psychological, political, moral, and spiritual dimensions to the field. Their work has had the effect of facilitating moral debate as to the role activist social scientists and public intellectuals might play on campus and in the larger society to bring about moral and spiritually based social movements in response to the misery of much of humankind.

THE NEED FOR A CRITICAL, NONCYNICAL INTELLIGENTSIA Chomsky (1969) describes a rich tradition highly critical of the role American intellectuals have played in designing and implementing public policy, interpreting historical events and formulating an ideology of social change that Chomsky argues falsifies, restricts, and subverts the possibility of true progressive change. Originally, ‘mandarins’ was a term that referred to bureaucratic and pedantic officials in the Chinese Empire who were persons of position and influence – elders, traditionalists, and reactionary members in circles of power. Today, they are the intellectuals and activists who are challenged to meet their responsibilities in the face of a new generation of contemporary military–industrial power. Chomsky puts it succinctly: political and economic elites do not take the actions of ‘ordinary people’ seriously, and it becomes easier to mobilize negative and punitive actions against them while at the same time creating enough fear to control other like-minded groups who might dare to join in the rebellion. To understand the possibility of progressive social movement in a more desired form, one must first understand that ordinary people in

Spiritual Movements as response to structural violence

their everyday struggle to cope with the injustices of their everyday lives break rules that regulate that behaviour. This breaking of rules can and does vary widely. In this chapter we are primarily interested in understanding when and why the breaking of the rules takes the form of a collective insurgency that emphasizes social justice, a redressing of grievances, and building a world based on the spiritual values of love and caring for one another.

THE STRUCTURING VARIABLES AND THE FORM SOCIAL MOVEMENTS MIGHT TAKE Although it is highly unlikely that we will be able to predict with any great statistical certainty the connections between a need state and the consequent development of a social movement, Cloward and Piven (1990) have identified four categories of intervening or structuring variables needed in any analytic scheme designed to develop an integrated approach to explain the form that social movements might take. These four categories are social ideas, social resources, social norms, and societal reactions and are presented here in briefly defined terms. They are crucial analytic tools to begin our understanding of the complex linkages that exist between deviant behaviour and possible expressions of protest, righteous indignation, and social movement responses to the various injustices that otherwise regulate people’s behaviour. According to Cloward and Piven, social ideas are the ideas through which people perceive their world – its cause, its legitimacy, its potential mutability by one form of human action or another – and interpret their own situations. They help to explain their actions and are part of a social context that influences behaviour, and explain why people sometimes challenge political authority. Social resources could be thought of as the means, institutions, organizations, and mechanisms through which people express the multitude of ideas and emotions that they are experiencing – including those resources that enable people to ask questions and act against the validity of authority structures and hierarchies. Human behaviour and action are constrained by intricate sets of social rules or norms. When people commit rule violations, they do so in ways that remain largely consistent with social norms. When people act against rules, agencies of social control may respond in a multitude

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of ways. Occupiers of lower social positions are more vulnerable to invidious societal reactions and severe sanctions. While these structuring variables operate in complex and fluid ways, playing off on one another in constantly changing patterns, reactions to them can also encourage people to persist in challenging existing political and moral arrangements. ‘Deviant behaviour’ is seen as social behaviour that is capable of principled protest and movements of righteous indignation.

CREATIVE CHALLENGES FOR A NEW MOVEMENT – A TRANSFORMATIVE FACE, MIND, AND SOUL Movements need to be systematically integrated before they can effect the change that can bring about a survival and sustenance of the planet and its inhabitants. The Port Huron Statement (1962) made it clear that a first task for any social movement is to convince people that the search for orienting theories and the creation of human values is complex but worthwhile: ‘…we must analyze the concrete conditions of social order. But to direct such an analysis we must use the guideposts of basic principles. Our own social values involve conceptions of human beings, human relationships, and social systems’ (p.4). In the next sentence Port Huron harks back to the Declaration of Independence (1776) and a spiritual progressive tradition: ‘We regard men as infinitely precious and possessing of unfulfilled capacities for reason, freedom and love.’ The challenge lies in our capability to be creatively open to complicated and disturbing paradoxes and to continue, through radical love, to critique, prod, energize, empower; to mobilize, organize, and agitate.

FORWARD TOGETHER IN A MORAL MOVEMENT: RADICAL LOVE, HEALING, REDEMPTION, AND JUSTICE The Rev Dr William Barber, pastor at Greenleaf Christian Church in Goldsboro, North Carolina, refers in his sermons to ‘standing at the gap and speaking a truth that has a moral focus – not merely a democratic version, a republican, or a liberal version, but a moral focus of what our government ought to be’. As he puts it: ‘We ought to pull from our

Spiritual Movements as response to structural violence

deepest moral and faith traditions and our Constitution. It is time for people of faith to come out of the sanctuary and preach in the public square’ (Barber 2014). He has been organizing for a New Poor People’s campaign in 2017– 2018 that takes Rev Dr Martin Luther King’s call for a time to break the silence about the injustices in society seriously, declaring that it is time to move beyond left and right, liberal and conservative, and uphold higherground moral values, preaching as King did, in his famous Riverside Church Vietnam sermon, that ‘we as a nation must undergo a radical revolution of values’ (King 1967). Barber’s message of fusion coalition politics, representing all people in any place, throughout this globalized world, could push a moral agenda over and against the interests of the powerful. We need to reclaim the possibility of democracy – even in the face of a corporate-financed, extreme force. Only such a diverse fusion movement that unites black, white, and brown; rich and poor; employed and unemployed; gay and straight; documented and undocumented; and religious and secular can heal a society’s wounds and produce public policy that is morally defensible, constitutionally consistent, and economically sane. A populist progressive politics is unlikely to succeed without simultaneously presenting a spiritual agenda that speaks to the needs and deepest aspirations of a community that cares about something beyond money and self-interest. It should be noted that Barber’s leadership in these moral movements today have much in common with past and present efforts of liberation theologians in Latin America during the 1950s and 1960s (Cardenal 2010; Gutierrez 1988) as well as that of Bernard Henri Levy, perhaps the most prominent progressive intellectual in France today (see e.g. Levy 2008). Alexander, author of The New Jim Crow: Mass Incarceration in the Age of Colorblindness (2012), works to spread awareness about the crisis of mass incarceration of Americans into a full-scale movement that embraces the possibility of redemption and forgiveness – one that does not ignore people who are labelled ‘criminal’. People of faith have a particular role in changing ‘hearts and minds’ to end mass incarceration. ‘We’re going to have to inspire people to care about the “least of these”, there’s no way around it’ (Alexander 2013). Rabbi Michael Lerner (2006), editor of Tikkun magazine and founder of the Network for Spiritual Progressives, calls for a ‘new bottom line’

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in which economic, political, and social institutions should be judged rational and productive not only to the extent that they maximize money and power but also to the extent that they maximize love and caring, kindness and generosity, and environmental sustainability. This would enhance our capacity to see human beings, our planet Earth, and the larger universe with awe and wonder and as embodiments of the sacred rather than through the more typical instrumental or utilitarian frame of reference. Cornel West for decades has been involved in putting forward practical and programmatic dimensions of a revolutionary Christian perspective and praxis anchored in the prophetic Christian tradition of the Afro-American experience. …until change comes about let us not forget that Jesus Christ proclaimed: The Spirit of the Lord is upon me, because he has anointed me to preach good news to the poor. He has sent me to proclaim release to the captives and recovering of sight to the blind, to set at liberty those who are oppressed (Luke 4:18). And therefore let us forever remember the plight of the downtrodden in the spirit of resistance and hope. (West 2002, p.146)

Gilligan puts it this way: The attempt to understand and prevent the major threats to life that are presented by the human predisposition to engage in violence (from behavioral violence to structural violence to the ecological violence that could yet kill us all) needs to be directed at evidence based social science and as a problem of public health. Just as importantly, we need to expand our conception and notion of love from eros (impersonal lust) and philia (interpersonal love) to agape (transpersonal, universal concern) with care and respect for all humans…none of whom are good but all of whom are sacred (including the worst criminals)… Religion, then, can be understood to occupy the space that is left in mystery even after all questions that are possible for science to address have been given an always tentative, provisional, temporary, hypothetical answer… It’s the religion Einstein understood when he said there is no such thing as a miracle…actually, everything is a miracle. Or Tolstoy when he said love life, for God is life, and to love life is to love God. (Gilligan in press, p.8)

Spiritual Movements as response to structural violence

It’s represented in the writings and work of Rev Dr Liz Theoharis, cofounder of Kairos – the Center for Religions, Rights, and Social Justice at Union Theological Seminary. Theoharis (2017) documents Jesus’ teachings and actions around poverty, wealth, and power, especially in Matthew’s Gospel in the Sermon on the Mount, which show him to be a ‘New Moses’ – a social movement leader with a revolutionary economic programme who brings new instruction and a new understanding of law and justice to a people in need of dignity and freedom. Chomsky’s ethical analysis, based on what he calls ‘the principle of universality’, is a secular humanist representation on the same theme: that at the very least we should apply to ourselves the same standards that we apply to others. This is both a moral and an intellectual imperative. What Barber, Alexander, Lerner, Theoharis, Gilligan, Chomsky, and West are referring to is the profound need for radical love in the world. It needs to be a major part of any progressive movement’s creative response to the suffering and violence of the world. West describes it with prophetic fire: ‘Never forget that justice is what love looks like in public’ (2015).

CONCLUSION – TRANSFORMING PROGRESSIVES AND THE WORLD: LET THE HEALING BEGIN The traditional progressive movement has never incorporated a systematic and integrated ‘spiritual’ worldview in its attempt to bring about political and economic justice, although there have been numerous attempts to articulate such concerns and longings (apart from institutionalized religious dogma). As such, it has oftentimes disguised and distorted strategies, and has failed to build a mass-based insurgent movement that addresses the broader needs of ‘physical and spiritual’ humanity – a complex ‘plan’ and agenda that would match the complexity of human interaction and human existence. As a result, the liberal left and its reform-minded paradigm often has not operated in a significantly different way than the hardline, fear-based militaristic model of the right. It is a mindset that often proposes to act out of the best of intentions and even under the control of well-meaning, decent activist professionals and ‘crusaders’. Often it has resulted in a set of social ideas that sees no other alternatives to endless cycles of violence, wars on ‘evil’, crime, drugs, and terror and with no realistic

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hope of radical change that can bring about a more peaceful and less violent world. The world was what it was and nothing could be done to radically alter or even imagine possibilities of what that world might be or become. There are no real alternatives to the cycle of violence, pain, mistrust, and suffering. Any viable alternative needs to challenge and confront this intellectual paradigm and its consequences (Lee 2017). Since America has more violence than any other democracy on earth and incarcerates more people (mainly poor men of colour) and keeps them there longer (creating a further layer of dysfunctional dependency) than any other developed, industrial country, this reveals that we as a culture do less for our own citizens than any other democracy – less health care, child care, housing, support to families, etc. If we wish to reduce or prevent violence, we not only need political and economic reform but a spiritual awakening to take better care of each other, especially the neediest and most vulnerable – including the incarcerated and particularly beginning in childhood, when the needs for love and care are most intense. Much can be understood about the nature and character of dominant powers in the way they politically and spiritually treat the most vulnerable and degraded among us. The promise of what form might lead to a more unified and mature political and spiritually progressive movement has been the central concern of this chapter. The enormous differences between societies around the world in their rates of both individual and collective violence constitute repeated empirical demonstrations that a fear-based mindset and recourse to violence can be prevented or structured differently. For a new progressive movement to finally succeed in America and abroad, it must be equipped to deal with and confront a political, economic, and spiritual foundation of a fear-based worldview. For that ‘success’ and healing to have a chance of occurring, it must be prepared to look at the human condition in a systematic way that includes a social scientific paradigm that understands the incredible complexity of human society and interaction; be aware and not be afraid to acknowledge that spiritual (as opposed to institutional religious) values have been and continue to be central to human life and social survival for the vast majority of humanity from whatever cultural, religious, political, humanist, atheist, or agnostic tradition; and finally, it is necessary that academic activists and public intellectuals have the moral courage, commitment, and intellectual honesty to take these spiritual values seriously.

Spiritual Movements as response to structural violence

The sooner social progressives more clearly understand and act on the need to systematically transform themselves and become a truly scientific, intellectual, political, and spiritually moral force, the sooner they can help repair and heal future history, the world as it is, and ourselves. There are no absolute blueprints to guide these movements. But for these movements to emerge and flourish, organizers and leaders should proceed creatively and with as much radical love as possible. To quote West (2001): I cannot be an optimist but I am a prisoner of hope. In these downbeat times, we need as much hope and courage as we do vision and analysis; we must accent the best of each other even as we point out the vicious effects of our racial divide and pernicious consequences of our maldistribution of wealth and power… None of us alone can save the nation or world. But each of us can make a positive difference if we commit ourselves to do so. (p.159)

AUTHOR’S NOTE For audience clarity and transparency, the author wishes to acknowledge his life-long academic and intellectual interest in social change and social movements that has involved him in a life-long activism and participation in many movements as well. In this chapter in particular, he draws attention to his intellectual and activist participation in Rev Barber’s New Poor People’s Movement and the Stop Stop and Frisk Movement. He wants to deeply thank his mentor Richard Cloward and his friend and colleague Dr James Gilligan for demonstrating and showing how true scholarship and an activist life of moral integrity can in fact co-exist and indeed flourish, leading to a more complete understanding of the complexity of human behaviour.

REFERENCES Alexander, M. (2012) The New Jim Crow: Mass Incarceration in the Age of Colorblindness. New York: The New Press. Alexander, M. (2013) ‘Michelle Alexander: Mass Incarceration, Believing the Possibility of Redemption and Forgiveness.’ 5 March, Yale Divinity School All School Conference. Accessed on 6/12/2017 at https://divinity.yale.edu/news/michellealexander-mass-incarceration-believing-possibility-redemption-and-forgiveness

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Barber, W.J. Jr (2014) ‘A Moral Movement for the Nation.’ 30 September, sermon preached at Judson Memorial Church in New York City. Cardenal, G. (2010) The Gospel of Solentiname. New York: Orbis. Chomsky, N. (1969) American Power and the New Mandarins. New York: The New Press. Cloward, R.A. (1959) ‘Illegitimate means, anomie, and deviant behavior.’ American Sociological Review 24, 164–176. Cloward, R.A. and Ohlin, L. (1960) Delinquency and Opportunity. New York: The Free Press. Cloward, R.A. and Piven, F.F. (1990) ‘Why People Deviate in Different Ways.’ In School of Justice Studies, Arizona State University (ed.) New Directions in the Study of Justice, Law and Social Control – Critical Issues in Social Justice. New York: Plenum Publishing. Declaration of Independence (1776) The United States National Archives and Records Administration. Democracy Now (2016) ‘Cornel West on Donald Trump: this is what neo-fascism looks like.’ 1 December, p.4. Durkheim, E. (1951) Suicide: A Study in Sociology. New York: The Free Press. (Original work published in 1897.) Galtung, J. (1969) ‘Violence, peace, and peace research.’ Journal of Peace Research 6, 3, 167–191. Gilligan, J. (1997) Violence: Reflections on a National Epidemic. New York: Vintage Books. Gilligan, J. (in press) ‘Morality, Violence and Religion.’ Union Theological Seminary, Course Proposal. Gutierrez, G. (1988) A Theology of Liberation. New York: Orbis. King, M.L. Jr (1967) ‘Beyond Vietnam: A Time to Break Silence.’ 4 April, sermon preached at Riverside Church in New York City. Lee, B.X. (2016) ‘Causes and cures VII: structural violence.’ Aggression and Violent Behavior 28, 3, 109–114. Lee, B.X. (2017) ‘Causes and cures XV: syntheses and integration.’ Aggression and Violent Behavior 35, 91–96. Lerner, M. (2006) The Left Hand of God. New York: HarperCollins. Levy, B.-H. (2008) Left in Dark Times. New York: Random House. Merton, R.K. (1959) ‘Social conformity, deviation, and opportunity-structures: a comment on the contributions of Dubin and Cloward.’ American Sociological Review 24, 177–189. Merton, R.K. (1968) Social Theory and Social Structure. New York: The Free Press. Port Huron Statement of the Students for a Democratic Society (1962) Courtesy of Office of Senator Tom Hayden, Students for a Democratic Society. Theoharis, L. (2017) Always With Us? What Jesus Really Said about the Poor. Michigan: Wm. B. Erdmans Publishing Co. West, C. (2001) Race Matters. New York: Vintage Books. West, C. (2002) Prophecy Deliverance! Westminster, Kentucky: John Knox Press. West, C. (2015) ‘Radical Love – Living Justice Out Loud and in Public in Times of Crisis.’ Union Theological Seminary, Course on Radical Love.

Chapter 16

VIOLENT STATES AND EXISTENTIAL-THERAPEUTIC WORK IN MEXICAN EX VOTO PAINTING WAYNE MARTIN

In a striking 1940 self-portrait, Frida Kahlo portrays herself seated alone in a room, wearing a man’s suit that is far too large for her slight figure. In place of Kahlo’s familiar long hair we see her hair cut short, in a masculine style. The haircut is evidently recent, with long strands of just-cut hair strewn chaotically around the room. It is also self-administered: in her right hand, Kahlo holds the scissors with which it has been effected. Kahlo’s Self-Portrait with Cropped Hair (1940) is gripping, with work, sitter and painter each in their way demanding the viewer’s attention. It is also disturbing in its latent, symbolic and threatened violence. The severity of the haircut might itself be described as violent, and the positioning of the cut hair throughout the room seems to indicate that it has been violently hurled away, lock by lock, as the barber proceeded with her work. Its position on the floor is suggestive of corpses, as if the room represents the scene of a massacre, itself the product of a violent state of mind. The scissors (the ‘weapon’ used in that massacre) are still in the sitter’s hand, slightly open and palpably sharp, threatening further violence yet to come. The position of the scissors, immediately between the legs clad in male attire, are suggestive both of the male sexual organ and of an act or a threat of castration – a suggestion strongly reinforced by the thick braid lying near the chair on the floor. 223

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A few biographical details make the work all the more compelling. In 1940, Kahlo had recently divorced her husband Diego Rivera, the celebrated Mexican muralist. Rivera was 20 years her senior; the marriage (her first and his third) had lasted 11 years. Kahlo had been a young art student when they first married; Rivera was already a towering figure on the Mexican art scene. The relationship was notoriously tumultuous; both partners had affairs, culminating in Rivera’s affair with Kahlo’s younger sister, Cristina. The 1940 self-portrait is unmistakably undertaken in response to these traumatic events in Kahlo’s life. The suit worn by the sitter is clearly Diego’s. The motto of the painting, inscribed as the lyric on a musical score at the top margin of the canvas, is taken from a folk song whose theme is broken love: ‘Mira que si te quise, fué por el pelo. Ahora que estás pelona, ya no te quiero.’1

Figure 16.1: Self-Portrait with Cropped Hair, 1940 Frida Kahlo (1907–1954) Oil on canvas Museum of Modern Art, New York

1

‘Look, if I loved you it was because of your hair. Now that you are without hair, I don’t love you any more.’

EXISTENTIAL-THERAPEUTIC WORK IN MEXICAN EX VOTO PAINTING

In probing the significance both of Kahlo’s self-portrait and of the violent states that it explores, I propose to take my orientation from an earlier artistic tradition with which Kahlo herself was intensely concerned. An ex voto retablo (or simply, ex voto) is a distinctively Mexican form of religious folk art. An ex voto is small (roughly the size of an A4 sheet of paper), made of readily available materials (characteristically oil on tin), often painted in a ‘naive’ style, and inexpensive. It is a form of art associated specifically with shrines and sites of miracles. The term ex voto is a truncation of ex voto suscepto – from the vow made. The term captures a crucial element of the practice, that it is a work of art produced in fulfilment of an earlier promise made – specifically a promise made to a saint.2 A typical ex voto includes an inscription in which the vow is recounted, together with one or more images representing either the moment of trauma when the vow was undertaken, or the subsequent veneration in which the victim of the trauma expresses gratitude for a miraculous intervention – or both. Violence (whether feared or actual) is a common theme in ex voto paintings, which portray (inter alia) executions, lynchings and assaults. The form has recently been used to explore criminal violence associated with Mexican drug trafficking.3 In his famous reflections on van Gogh’s painting of a pair of peasant shoes, Martin Heidegger invites us to consider not what the painting shows, but rather what work it does. Heidegger: ‘What is happening here? What is at work in the work?’ (Heidegger 1950/2002, p.16). These questions have an important application when reflecting on paintings in the ex voto tradition. If we are to understand their significance, and their bearing on Kahlo’s art, we cannot confine our attention to their formal or aesthetic qualities, nor to their representational content alone. We must also consider what role these artworks play in the broader set of human practices in which they are embedded. What is the work of these distinctive works of art? The answer to this question is complex (Graziano 2016). The work of these particular artworks is in part theological and religious, playing a role both in the private devotional lives of the individuals depicted 2 3

Here and throughout I use the term ‘saint’ broadly, so as to include the Virgin Mary (Santa Maria). A number of examples can be found on the website associated with the 2011–12 Wellcome Trust exhibition Infinitas Gracias: Mexican Miracle Paintings: https://wellcomecollection. org/whats-on/exhibitions/infinitas-gracias (accessed on 6/9/2016).

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in them and in the public life of the religious shrines in which they are characteristically displayed. They have also played a complex economic role, in sustaining a cadre of almost entirely anonymous ex voto painters who made their living in and around the famous shrines, producing art for pilgrims – art which in turn is displayed at the shrine, embellishing the reputation of the saint, which in turn brings more business to the painters. Here, however, I propose to focus on yet another way in which ex voto paintings carry out their distinctive work; let’s call it existentialtherapeutic work. In bringing this third form of work into view, we can start from the moment of commissioning. For while there is an important autobiographical element intrinsic to the ex voto form (as signalled, for example, by the frequent use of the word ‘I’ in the mottos), the painting themselves are frequently not produced by the person who originally made the vow to the saint. The work is rather commissioned, typically in conjunction with a pilgrimage undertaken to the shrine of the saint. Arriving there, the pilgrim commissions the ex voto from one of the local painters, a transaction that inevitably involves the telling of the often intensely personal and traumatic story that is to be represented. There is thus what I will refer to as a confessional moment built in to the production of the work – a moment in which the pilgrim articulates and externalises their trauma-narrative.4 This confessional moment is only one aspect of what I am calling the existential-therapeutic work. There is a further element, intrinsic to the structure of the artwork itself, which reverberates in the work to which it is put. To bring this out, it helps to consider that subgenre of the ex voto form in which the tin panel is divided into three fields. In this form, the bottom margin of the panel is given to the motto, in which the traumanarrative is recounted, usually together with an account of the vow made to the saint and the act (materialised in the work itself) of fulfilling that promise in the present act of dedication. The top portion of the work is then vertically divided into two panels: the left panel portrays the past

4

Here and in other work, I use the term ‘confession’ in a broad sense, indebted to Rousseau and Foucault, in which an act of confession may but need not involve any confession specifically of guilt. I shall not hazard a definition here, but the core phenomenon that I have in mind is a form of externalising self-narration in the service of self-understanding and judgement.

EXISTENTIAL-THERAPEUTIC WORK IN MEXICAN EX VOTO PAINTING

trauma; the right portrays the present act of veneration.5 Once the work is complete, both of these discrete times have become past – although the work itself plays a role in the present by prompting an imitative reenactment of the veneration that it represents.

Figure 16.2: Ex-voto del milagro realizado a señor Elías Chavarría, 1904 Unknown artist, 20th century Oil on tin Museo Nacional de las Intervenciones, Mexico City

With this formal analysis in hand, we can begin to articulate the distinctive structure of the existential-therapeutic work projected by the ex voto. It will be useful to distinguish three interrelated dimensions of that work: temporal, hermeneutic and mereological. It should now be clear, first of all, that what I have called the confessional moment in the ex voto has quite a complex temporal structure. It involves a form of self-narration that not only recounts the past traumatic episode, but also binds that past together with the subsequent acts of commissioning the work and venerating the saint, all through the temporally complex mechanism of the recollection and representation of a past vow which itself points forward towards a future 5

Not every ex voto painting explicitly makes use of this tripartite form. All include a motto, but some visually represent either the trauma or the veneration rather than both. But there is an important sense in which the tripartite format is the fullest articulation of a structure that is essential to the whole genre, given that every ex voto essentially makes reference both to the traumatic episode at which the vow was made and to the episode of veneration in which it is fulfilled.

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and now-completed fulfilment. The form of unification of these discrete temporal moments is not merely that of time-ordering; the deeper form of unification is hermeneutic and mereological. That is, it both isolates the past trauma as a discrete past episode in its own discrete space in the visual field and exhibits that trauma as a meaningful part of a greater whole which is affirmed. The existential-therapeutic work reaches its completion when the traumatised individual is able to take up a stance of gratitude in the face of the totality, even if not towards each part considered in isolation. In short, the composition is closely linked to the creative work of the ex voto as a way of linking together past trauma and present circumstance into a hermeneutic whole – a whole that makes sense as a whole and projects forward towards a meaningful future. ✳✳✳ Kahlo herself was fascinated by ex votos. She and Rivera reportedly had a collection that numbered in the hundreds, many of which were displayed in their home. She also produced several works of her own that were composed in variations on the ex voto form (Castro-Sethness 2004–5).6 For our purposes, Kahlo’s most important exploration of the ex voto form comes in connection with her fateful accident, at age 18, in a bus that was struck by a tram. The tram shattered the bus and pinned it against a wall, crushing and killing a number of passengers. Kahlo herself was very severely injured; Alejandro Gómez Arias, travelling with her at the time, later reported that he thought she would surely die. A hand rail from the tram punctured her uterus, shattered her spine and exited her body through the vagina. Her right foot was also crushed in the accident. Kahlo suffered from the consequences (including chronic pain, impaired mobility and infertility) for the rest of her life (Herrera 1983, p.49). It was during her long convalescence from this accident that Kahlo produced her first important variation on the ex voto form, a pencil drawing on paper. The drawing is divided into three horizontal bands. In the top band, occupying the top half of the sheet, we see the horrific scene of the accident: the tram has collided with the bus; bodies are strewn across the ground. In one tiny vignette a man seems to be providing 6

For an example of Kahlo’s mature ex votos, see Kahlo (1932a), painted in small format on tin in the year of Kahlo’s miscarriage in Detroit.

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aid to one victim; a man prays over another; other figures can be seen trying to escape through the bus windows; still others are bloodied corpses beneath the tram’s wheels. In the middle band of the sheet we see Kahlo herself. She is readily identifiable by the setting: the Kahlo family house (the so-called Casa Azul – ‘the blue house’) is in the background; the figure is drawn with the pronounced arching eyebrows that Kahlo adopted as her ‘attribute’. The bottom band of the drawing is an inscription: 19th of September, 1926. Frida Kahlo (Accidente). The date in the inscription is significant. The accident in which Kahlo was injured was on 19 September 1925. So the date here is the first anniversary of the trauma. To mark the occasion, it seems, Kahlo is remembering and representing the trauma that had befallen her. The dating of the inscription brings the pencil drawing into alignment with elements of the spatiotemporal form of the traditional ex voto. The drawing presents us with the events of the earlier traumatic accident; the inscription fixes the drawing in a discrete time and space, from which the individual is able to reflect back – reimagining and reconstructing the trauma from an external perspective that was unavailable to her at the time.

Figure 16.3: Accident, 1926 Frida Kahlo (1907–1954) Pencil on paper Private collection

The connection between Kahlo’s 1926 pencil drawing and the ex voto tradition is brought out more fully by a curious subsequent episode.

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Some time after 1926, Kahlo herself came into possession of a distinctive ex voto retablo. The image on the ex voto shows a collision between a tram and a bus, and a solitary female figure trapped beneath the wheels of the tram. A figure of a saint looks down over the scene from the upper left corner, her heart pierced by a sword. The represented accident is not the accident in which Kahlo was involved, and the ex voto was commissioned and composed quite independently of Kahlo’s involvement. But the similarity is certainly striking, and Kahlo herself was struck by it. Having acquired the artwork, she proceeded to modify it, making three additions to the image itself. First, she painted the name ‘Coyoacán’ on the side of the bus. This is the name of Kahlo’s borough in Mexico City, and had been the destination of the bus involved in the collision. She added a similar destination sign to the tram. And she modified the eyebrows on the figure of the injured woman. Kahlo also changed the inscription at the bottom margin of the work: Mr and Mrs Guillermo Kahlo and Matilde C. de Kahlo give thanks to our Lady of Sorrows for saving their daughter from the accident in 1925, at the corner of Cuahutemozin and Calzada de Tlalpan.

These modifications to the ex voto in effect serve as an act of appropriation (not to say: theft) by Kahlo, as she transforms someone else’s highly personal votive offering into a reflection upon her own, eerily similar trauma. ✳✳✳ As a very young girl, Kahlo contracted polio. The disease was painful and disabling, resulting in significant and permanent damage to one leg and foot. In a diary entry composed much later in life, Kahlo recounts a practice that she developed in the aftermath of this debilitating and isolating trauma. In her room there was a glass door; at the age of six, Kahlo would stand before the glass and breathe onto it, fogging one of the panes with her breath. With her finger she would then draw a door on the glass, through which she would ‘fly’ out of the room, and across the landscape, to a dairy. There she would fly through a second portal and meet a second little girl, an ‘imaginary friend’, ‘joyful and weightless’, who ‘knew all about

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my affairs’ and ‘to whom I told my secret problems while she danced’.7 In the vocabulary of psychiatry, we could describe these childhood experiences as a form of dissociation. Six-year-old Frida responds to a trauma with an experience in which her identity is sundered into an ego and an alter-ego (dissociative depersonalisation). She invents or discovers or at any rate encounters an alternate reality in which this alter-ego exists and in which the two can interact (dissociative derealisation). These early experiences of the very young Kahlo help to illuminate an important element in the pencil drawing that Kahlo produced on the first anniversary of her accident on the bus. For in the middle band of the pencil drawing we find not one image of Kahlo but two. In one self-portrait she lies, wrapped in body bandages, on a stretcher marked Cruz Roja – Red Cross. Her eyes are closed. In the second self-portrait we see only her neck and head, eyes open, hovering in an indeterminable space, gazing down on the figure on the stretcher. The striking self-duplication provides a powerful illustration of dissociative depersonalisation (here in the form of an out-of-body experience) and derealisation (as the boundaries of the real and the imagined become indistinct). It also provides an important further clue about Kahlo’s distinctive form of existential-therapeutic work. In the face of her violent and debilitating trauma following the accident, Kahlo finds herself drawn into a distinctive form of creative work that had been effective for her before. A crucial part of her response involves a kind of self-sundering in a constructed imaginary space that helps her work through a painful and isolating experience. Six-year-old Kahlo had used the fogged glass and her finger as the medium for this work; as a convalescent young woman, she turns to paper and pencil. As a child she projected a version of herself who both understood her struggles and was at the same time joyful and able to dance. It was at once a form of escapism and the projection of an ideal to be accomplished. Subsequently, despite dire predictions from her doctors, Kahlo was reportedly always determined to dance, and did dance (Herrera 1983, p.419), even after her accident and the later amputation, uniting the two versions of herself that had undergone this sundering division. What we can see in the later pencil drawing are the traces of similar work. Here again is a form of self-sundering, and the projection of a version 7

Kahlo’s diary forms part of the collection of the Diego Rivera and Frida Kahlo Museums, Mexico City. For a reproduction, see Fuentes (1995). The relevant entry carries the title ‘Origen De Las Dos Fridas: Recuerdo’ [Origin of the Two Fridas: Memory].

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of herself who is not bound by the bandages and traction devices in which Kahlo was confined during the first year after the accident. The second Kahlo projected in the pencil drawing floats free of all such encumbrances, while also occupying a space and taking up a stance of meditative reflection on the tragedy that has befallen her. In both cases we see her engaged in a form of aesthetic play in response to the trauma and to the radically new situation in which she finds herself as a result. In Kahlo’s distinctively aesthetic form of existential-therapeutic work we should recognise a deep resonance with the ex voto tradition. As we have seen, an ex voto is itself a medium for recollecting and re-presenting a trauma. It is also a tool for the distinctive hermeneutic work involved in making sense of that trauma. And in its fully elaborated, tripartite form, it involves a form of self-duplication: the subject of the ex voto literally appears twice, once in the midst of trauma, and once occupying an external perspective which creates space for contemplation and reflection. When the existential-therapeutic work of an ex voto is completed it facilitates a certain kind of healing – not in the medical sense, but in the temporal-hermeneutic-mereological sense that we delineated above. The person who has undergone the trauma works through the task of finding (or forging!) a meaningful whole out of the discrete and violently fragmented parts of her past, present and future life. The young Kahlo seems to have hit upon a variant of this existential-therapeutic strategy quite of her own accord. She later discovered that her secret psychic experience had a material correlate in a folk-art tradition of her native Mexico. We should not be surprised that that same strategy and tradition came to occupy a central place in her mature work as an artist. ✳✳✳ We are now in a position to return to the self-portrait from 1940. SelfPortrait with Cropped Hair is not itself an ex voto. But we can see in it a mature and original appropriation of some of the structures – both aesthetic and existential – that we have identified from the ex voto tradition. What the painting presents overwhelmingly is a vision of what I propose to call self-possession in response to trauma. In the wake of Rivera’s betrayal, Kahlo presents herself as angry, to be sure, but also as supremely strong and self-confident, prepared for a new form of

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aesthetic action that the viewer can see already realised in the painting itself. The lyric of the song places the woman in the role of a victim, cast aside and abandoned by her beloved. But her comportment presents us with someone who has taken possession of the situation as protagonist, using both symbolic, self-directed violence (the cutting of the hair) and the threat of other-directed violence in taking control of a traumatic situation. Of course the painting also presents us with an act of theft. Kahlo has here stolen Diego’s clothing, and along with it his male identity – even as she publically repudiates both his principles and his preferences regarding the attire of Mexican women.8 The virtuosity of the painting and the defiance of the self-portrait seem also designed to stake a claim on his greatness as an artist. Taken as a whole, then, the painting shows us a powerful woman who has faced down, reclaimed and incorporated a traumatic experience – and stands stronger than ever as a result. The natural question to ask next is: How did she manage to do that? By what alchemy does one transform a disorienting trauma into this kind of oriented and determined projection into future possibility? These are not questions that admit of simple answers, but we can begin to address them by recognising the use that is being made here of the ex voto tradition, and of the existential-therapeutic work associated with it. Consider first the motto. The inscription has here moved from its traditional place at the bottom margin of an ex voto to the top of Kahlo’s self-portrait, and has been artfully incorporated in the form of a lyric from a popular song. As in the traditional form, it plays a role in narrating the past trauma that occasioned the present work. But even here, Kahlo has effected a subtle but powerful appropriating twist. The voice associated with the lyric is unmistakably that of the male partner in the broken relationship. So it is, in effect, Diego speaking, placing Kahlo in the position of the addressee, insulted and cast aside. But in the context of the painting it is Kahlo who has chosen these particular words, placing them in Diego’s mouth, thereby taking control of his verbal agency. Furthermore, the loss of hair which the male voice uses as 8

See for example Rivera’s notorious later remarks reported by an unnamed correspondent from Time magazine: ‘The classic Mexican dress has been created by people for people. The Mexican women who do not wear it do not belong to the people, but are mentally and emotionally dependent on a foreign class to which they wish to belong, i.e., the great American and French bureaucracy’ (Anonymous 1948, p.22). In the same article he is quoted as saying that Kahlo ‘has worn nothing but Mexican clothes for 22 years’.

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the occasion and excuse for his rejection has here been carried out by the woman herself. The effect is to lift Kahlo out of the role of passive victim of the trauma and to re-establish herself as an agent in the upheavals. A second key to understanding the complex work of the self-portrait is to recognise the forms of self-doubling with which it plays. As we have seen, implicit and explicit self-doubling is intrinsic to the ex voto form and to the existential-therapeutic work we find at work there. Selfdoubling is certainly not an explicit feature of Self-Portrait with Cropped Hair. After all, the painting shows a single woman, alone in an otherwise empty room. But when we reflect on the existential dynamics of the selfportrait, we can see that there are at least two forms of self-doubling at work there. Both are essential to understanding its place in Kahlo’s complex appropriation of her trauma. The first form of self-doubling pertains to the interplay with Rivera. Recall that in her early childhood experience, young Frida had projected her joyful dancing alter-ego, with whom she was then able to interact in finding a route out of her isolating trauma. The resolution was completed when she was able to reunify her sundered self, culminating in her ability to dance even with her damaged leg and foot. The ‘two Fridas’ divide and then reunite as a stronger whole. In the 1940 self-portrait, Kahlo presents us with a mature variant on this sophisticated childhood play. The alter-ego in this instance is Diego, her ‘other half ’ – someone who ‘knew all about my affairs’ and was able to dance (paint). What Kahlo projects here is a narrative, now at its point of culmination, in which Diego’s attributes, which she had originally encountered as embodied in another, are here being incorporated within her own person and body, now reunified as a single whole. The outcome is a figure who is at once both male and female, both Rivera and Kahlo, taking on the attributes and abilities and ambitious projects of both. The second form of self-doubling is far more intimate. To bring it into view we have to see through the paint to the process of painting that produced it. Place yourself in Kahlo’s position, upon discovery of Diego’s affair with Cristina, with all the extreme and violent emotions that must have come in its wake. In response, what do you do? Kahlo’s response (or at least one part of it) was to withdraw to her studio – or to whatever new space she created as an ad hoc studio. And what did she take with her? A canvas, an easel, a palette, paints and brushes, a pair of scissors…

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and a mirror. It is with this equipment of her craft that Kahlo confronts the new situation. Concretely, what this means is that she spends many hours, sitting in front of the mirror, cutting her hair and producing the portrait. In this specific configuration of space and materials, Kahlo once again reproduces a variant on her early childhood experience. She gazes into a pane of glass and there she encounters an image of herself. And as the work progresses she is faced with not one but two such images: one in the mirror and one on the canvas. In this way she creates exactly the kind of complex space in which the requisite form of existentialtherapeutic work can be carried out.9 ✳✳✳ One further issue must at least be raised here, although it is far too large to be addressed properly, much less resolved, in the space that remains. In our reflections on the ex voto form, on the existential-therapeutic work associated with it, and on Kahlo’s variations thereon, we have so far neglected one prominent visual theme. A defining constant in every traditional ex voto is its representation of a saint. Kahlo’s variations, by contrast, characteristically omit the saint. One exception is the ex voto that she appropriated and modified, in which ‘our Lady of Sorrows’ (painted by someone else, and for someone else) is allowed to remain.10 The omission of the saint is particularly striking in the pencil drawing from 1927. For there Kahlo marks out one of the places (upper left corner) where a saint would traditionally appear. Instead of the saint, what she places there is an image of the sun, in what must be seen as explicit naturalising of the traditional supernatural form. Kahlo’s secularisation of the traditional ex voto correlates with the secular analysis I have proposed of its distinctive work. For while we have identified economic, temporal, hermeneutic, mereological, existential and therapeutic dimensions in that work, we have so far said nothing about its specifically theological aspect. It will not be possible to take up here the legion of important issues that emerge once this lacuna in our analysis is brought into view. What exactly is a saint, theologically speaking, in the tradition(s) in which the ex voto 9 I discuss self-doubling self-portraiture in an earlier artistic tradition in Martin (2006). 10 For another important exception, see Kahlo (1932b), which incorporates a portrait of a weeping Virgin of Sorrows. For a discussion of Kahlo’s uncharacteristic inclusion of a saint in this work, see Ades (1989, p.227).

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finds its place? And what is the social significance of saints in the forms of life around the Mexican shrines and in the broader Mexican cultural situation in which ex votos appear? For us, however, the most important questions are neither theological nor sociological but specifically phenomenological. First, what is the structure of the experience of saints for the person who commissions an ex voto? Second, what role does the manifestation of the saint play in its existential-therapeutic work? And third (to sharpen the second question into a disjunction), should we see the experience of saintly intervention as essential or incidental to the therapeutic work in which the ex voto plays its distinctive part? Both Kahlo and Rivera were themselves committed Marxists, and of course atheism is a central commitment of Marxist ideology. But at the same time Kahlo herself extensively incorporates an eclectic range of religious forms and motifs in her art – some recognisably Christian and others not. So we also confront here a range of political, biographical and art historical questions about the place of religion(s) in her life and art, as well as about the possible divergence between her own commitment to Marxism and that of her contemporaries and peers – particularly Rivera and Trotsky, both of whom were her interlocutors, domestic partners and lovers. For now it must suffice to enumerate these questions, and to mark them for further reflection and future research. As a down payment on that further work, I conclude with two final observations about the 1940 portrait – one philosophical and one art historical. First, there is no saint in Self-Portrait with Cropped Hair, and Kahlo presents herself (whether truthfully or not) as responding to her trauma alone, in an autonomous act of what I have called self-possession. Even as a young child, Kahlo’s existential-therapeutic work was in an important sense solipsistic. The phenomenological structure of the traditional ex voto could not be more different: it serves first and foremost as an acknowledgement that the distinctive work we carry out in recovering our orientation after trauma is not something that we manage alone. Viewed from an art historical perspective, however, this philosophical observation requires qualification. For while there is no traditional saint in Kahlo’s self-portrait, there is an unconventional one. Or perhaps there are two. The first is Kahlo herself, who here, as in much of her work, seems to be setting herself up as a modern-day secular saint, complete with icons and attributes, to whom others (other women, in particular) might look in navigating their own experiences of trauma, violence and

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abuse. The second saint is at most referenced, albeit unmistakeably, in the yellow chair upon which Kahlo is seated. For a self-proclaimed modern artist of the twentieth century, that chair is not just any chair; it is van Gogh’s chair (van Gogh 1888). It is, in particular, one of two chairs that van Gogh had painted at Arles, at the height of his own violent personal trauma and self-harm, and in the context of his own bitter rivalry with a great painter with whom he had shared his domestic life.11 So the second non-traditional saint here is a specifically painterly saint whom Kahlo calls to her aid: St Vincent! The presence of van Gogh’s chair in Kahlo’s painting brings with it extraordinary complexities when trying to understand the existentialtherapeutic work of which it forms a part. The mapping of that work that I have proposed here must therefore be seen as radically incomplete. We would next need to consider not only Kahlo’s relationship with van Gogh, but also the provocative use she makes of the chair. Here it is worth noting its cruciform structure, and the way in which it is displayed in the painting, draped and tangled with mutilated remains of Kahlo’s broken body. It is perhaps too much to say that with these allusions Kahlo is identifying herself not only with van Gogh but with the crucified Christ. But it certainly does force us to confront a set of troubling and difficult questions about the role of specifically sacrificial violence, not only in religion and the history of art, but in existential-therapeutic work undertaken in response to trauma. Further exploration of these themes and issues must await another occasion. But even having come this far, we can recognise in Kahlo’s selfportrait the material traces of a distinctive form of existential-therapeutic work. In response to trauma, Kahlo draws resources both from her own youthful experiences and from her cultural tradition. In retreating to her studio she quite literally conjures an image of the self that she sets out to become – a reunified whole person who has not denied or disowned or repressed her trauma, but has incorporated it into a larger living whole. That conjured self may or may not have corresponded to the person Kahlo saw reflected in her mirror in 1940. But the creation of that image of self-possession marks out both a pathway and a substantive step in

11 For a provocative interpretation of van Gogh’s two chairs, see Blum (1956).

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moving beyond a traumatising present while at the same time carrying it forward into a future that she projects as her own.12

REFERENCES Ades, D. (1989) Art in Latin America: The Modern Era, 1820–1980. New Haven: Yale University Press. Anonymous (1948) ‘Mexico: fashion notes [interview with Diego Rivera].’ Time 51 (3 May 1948), 21–22. Blum, H. (1956) ‘Van Gogh’s chairs.’ American Imago: A Psychoanalytic Journal for the Arts and Sciences 13, 3, 307–318. Castro-Sethness, M. (2004–5) ‘Frida Kahlo’s spiritual world: the influence of Mexican Retablo and ex voto paintings on her art.’ Woman’s Art Journal 25, 2, 21–24. Fuentes, C. (ed.) (1995) The Diary of Frida Kahlo: An Intimate Self-Portrait. New York: Abrams. Graziano, F. (2016) Miraculous Images and Votive Offerings in Mexico. Oxford: Oxford University Press. Heidegger, M. (2002) ‘The Origin of the Work of Art.’ (Translated by Young and Haynes.) In Martin Heidegger: Off the Beaten Path. Cambridge: Cambridge University Press. (German text first published in 1950.) Herrera, H. (1983) Frida: A Biography of Frida Kahlo. New York: Harper and Row. Kahlo, F. (1932a) Henry Ford Hospital (oil on metal panel; 30.5 x 35 cm). Collection Dolores Olmedo, Mexico City. Kahlo, F. (1932b) My Birth (oil on metal panel; 30.5 x 35 cm). Private Collection of Madonna. Kahlo, F. (1940) Self-Portrait with Cropped Hair (oil on canvas; 40 x 27.9 cm). New York: Museum of Modern Art. Martin, W. (2006) ‘Bubbles and Skulls: The Phenomenological Structure of SelfConsciousness in 17th Century Dutch Still Life Painting.’ In H. Dreyfus and M. Wrathall (eds) A Companion to Phenomenology and Existentialism. Oxford: Blackwell. Reprinted in T. Staehler (ed.) (2012) Existentialism. New York: Routledge. Volume 3, 113–137. van Gogh, V. (1888) Van Gogh’s Chair (oil on canvas; 91.8 x 73 cm). London: National Gallery. 12 Earlier versions of this chapter were presented to audiences at a 2015 University of Sussex conference on ‘The Work of Phenomenology and the Work of Art’, at the 2016 meeting of the American Society for Existential Phenomenology (Franklin Marshall College), and at the University of Essex. I am grateful to Joanne Harwood, curator of ESCALA, the Essex Collection of Art from Latin America. Harwood first introduced me to Kahlo’s 1940 selfportrait, and drew my attention to the relevance of the ex voto tradition for understanding it. This chapter would never have been written without her generous assistance. I have profited from comments and insights from many others, including John Adlam, Laurie Bussis, Fabian Freyenhagen, Irene McMullin, Stephen Hubbard, Mark Wrathall, Geneviève Dreyfus, Beatrice Han-Pile, Dan Watts, David Batho, Ian Dudley and Cristóbal Garibay. I am grateful to Ana Bilbao and Rosie Worsdale for their support in securing permissions for use of images.

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IMAGE CREDITS Figure 16.1: The Museum of Modern Art 2018 ©Photo SCALA, Florence / © Banco de Mexico Diego Rivera Frida Kahlo Museums Trust, Mexico, D.F. / DACS 2018. Kahlo, Frida (1907–1954): Self-Portrait with Cropped Hair, 1940. Digitale (1)(A) New York, Museum of Modern Art (MoMA). Oil on canvas, 15 3/4 x 11’ (40 x 27.9 cm). Gift of Edgar Kaufmann, Jr. Acc. n.: 3.1943.© 2018. Digital image, The Museum of Modern Art, New York/Scala, Florence Figure 16.2: Reproducción Autorizada por el Instituto Nacional de Antropología e Historia. Figure 16.3: © Banco de Mexico Diego Rivera Frida Kahlo Museums Trust, Mexico, D.F. / DACS 2018.

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Epilogue JAMES GILLIGAN

In the history of thought, beginning with our transition from hunting and gathering cultures to the invention of civilization some ten to twelve millennia ago, and continuing with our transition from agriculture-based economies to the scientific, industrial, and technological revolutions of the past four centuries, one of the most powerful innovations that has made possible virtually limitless cultural evolution was the division of labour into increasingly small areas of specialization. This has made possible a constantly increasing body of knowledge, resulting in a constant increase in the duration of the average human life-span and an enlargement of our capacity to sustain an ever-increasing human population whose size is limited only by the capacity of our small planet to withstand the stresses that such a large population places on it. However, there is no benefit that does not come with some costs, and the bill for our past successes has now come due. Up to now we have been able to live in a world in which more and more people know more and more about less and less, because of their specialization on tinier and tinier areas of knowledge. What had been an enormous benefit in the past is now threatening to blind us to the need for a larger perspective, a more holistic world-view in which we can ask questions about how we are going to protect not only our species as a whole but all life on earth from the dangers that our knowledge is currently exposing us to – from climate change to thermonuclear war. ‘Knowledge is power’, as Francis Bacon said, but power itself is morally neutral, as Lord Acton said: it can be used for good or evil purposes. Our task now is to accept the fact that we need to find ways to gain power over our power, rather than becoming the helpless victims of the destructive power that our own knowledge exposes us to. 241

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That destructive power has a name: violence. For it is human violence, in all its forms – behavioural, structural, and ecological – that poses an unprecedented threat to the continued survival of our species. Thus, nothing is more important at this stage in our evolutionary history than to learn how to understand the causes and prevention of violence. But violence comes in countless different varieties, all of which have in common only that they consist of human behaviours that cause death and disability. And these multiple different forms of violence have so many causes, resulting as they do from the interaction between biological, psychological, and social determinants, that we simply cannot understand the causes and prevention of violence until we have been able to synthesize these varied contributors to the lethal outcome. I am not saying we should renounce specialization, I am saying we need to transcend it. Of course it is true that no one can know everything about everything. But we have reached a point where we need to take off our disciplinary blinders and learn how to synthesize what we have learned so far about the biological, psychological, and social causes of violence, and its primary, secondary, and tertiary prevention (thus treating it as a problem in public health and preventive medicine). People from different specialities need to learn to talk with and understand each other, rather than remaining isolated in their own disciplinary echochambers. We need to take our cue here from one of the greatest physicians in history, the nineteenth-century German physician and statesman who was one of the founders of public health and preventive medicine (as well as of anthropology and pathology), Rudolf Virchow, who commented that ‘Medicine is a social science, and politics is merely medicine on a larger scale.’ For example, we cannot hope to prevent epidemics of violence (from increased rates of homicide and suicide, to war and genocide, to atmospheric apocalypse) without influencing and changing our political institutions and behaviour. Just as we hear more and more pleas for evidence-based medicine, we have now reached the point where we have even more need of evidence-based politics. This work is contributing precisely to that foundation. I am convinced that one of the most powerful sources of resistance to this is what we might call ‘disciplinary narcissism’, by which I mean the all-too-common practice we see in many of our colleges and universities to build walls around each academic ‘department’, as though any of these

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boundaries between the different areas of knowledge were truly built into the nature of reality. For example, when I was an undergraduate at Harvard in the 1950s, the psychology, sociology, and anthropology departments made the brilliant and laudable decision to combine into one department, which they called the Department of Social Relations. They recognized that there was no such thing as individuals who were not totally embedded in and shaped by their social and cultural environment, which they influenced and sometimes changed in turn. I am reminded here of the paediatrician and psychoanalyst D.W. Winnicott’s famous statement that there is no such thing as a baby. And of course he was right. You never find a baby who is not part of a duo (mother and child), who are themselves part of a family, a community, a culture, etc. In fact, we can extend Winnicott’s insight to the generalization that there is no such thing as a person. For you never find an individual who is not part of a family, a community, a culture, etc. That was the premise on which Harvard’s Department of Social Relations was based (until, alas, disciplinary narcissism, jealousies, and insecurities led them to regress to the previous pattern of individual disciplinary fiefdoms, each ensconced in its own feudal castle surrounded by an intellectual moat designed to keep out any intruders from alien, ‘competing’ disciplines). The same point was made by the anthropologist Clifford Geertz, who observed that ‘human nature’ is not something that exists independently of or even prior to culture. As he showed, we humans had not even completed evolving our current anatomical structure before we were influenced by cultural forces. His point is that it is our culture that socializes us (as it did our parents) and defines for us what it is to be a human being, so that it is a huge mistake to think that there could ever be such a thing as a ‘wolf child’ raised apart from one cultural environment or another who could function well enough to be viable. We are only able to become viable human beings by means of the socialization we receive from our culture. One complication of that is that different cultures define what it is to be human, and what one must do in order to be considered human, differently. That understandably gives rise to numerous possibilities for misunderstanding, disagreement, conflict, and ethnocentrism. For example, people may be taught that ‘only my culture is valid and legitimate, only people who belong to my culture are really humans’, etc. Erik Erikson (1968) has referred to this as ‘pseudo-speciation’, the belief

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that people who belong to cultures different from one’s own belong to a different species, which unfortunately lowers the bar to genocide. Even the notion that ‘human nature’ is defined by our genome, or that any given personality is defined by the person’s genome, has had to be substantially altered by our increasing knowledge of epigenetics – the degree to which gene expression is dependent on and altered by many biological, psychological, and social variables. For example, Terry Moffitt and her colleagues (Caspi et al. 2002) have identified a genetic mutation in infants that predicts violent behaviour when they reach adolescence or adulthood – but only if they were also subjected to severe child abuse. Absent that environmental determinant, individuals with the mutant gene were no more violent than those with a normal gene. In fact, they were slightly (though not significantly) less violent. Thus, it is not only our genes that determine who we are and how we behave. Our environment is an equally powerful determinant. Unfortunately, many professional training programmes do not teach our future psychotherapists, teachers, scholars, politicians, and others to think in those terms. For example, most clinical psychologists and psychiatrists are taught only how to engage in clinical treatment programmes with one individual at a time. While that is indeed worthwhile and necessary, it is not sufficient. For example, to limit physicians to the clinical approach may well enable them to understand what is making any one individual sick, and what therapy (if any) will restore him or her to health. But that does not help us in the least when we are trying to learn what is causing an epidemic of that illness at unprecedentedly high rates, among people who previously would not have become ill. It is true that, in any given epidemic, the most vulnerable individuals are likely to be the first to become sick, and then those who are slightly less vulnerable, and so on. Clinical medicine alone may help us to identify who the most vulnerable individuals are. But that alone will not enable us to learn what is causing the rates of illness to explode to epidemic proportions among larger and larger proportions of the population. For that we need to shift gears and transition from clinical medicine to the perspective of public health and preventive medicine – that is, the causes and prevention (or cessation) of epidemics of life-threatening pathologies throughout entire populations, whether those consist of physical illnesses, or of the various forms of lethal violence, from epidemics of individual homicides and suicides to the various forms of

Epilogue

collective violence, such as war and genocide (if not ‘humanicide’). And that is precisely what this work, with its multi-dimensional orientation, can help us to do. Finally, if our goal is to maximize our ability to enhance, protect, and sustain human life (and, just as importantly, all life, since we can only survive in an ecologically rich environment), then we will need to transcend a purely ‘therapeutic’ or ‘medical’ concept of what public health truly consists of. To illustrate what I mean by that, I will need to tell a story from my own years in medical school. On a visit home during one of our rare vacations, I was talking with a young woman who had been one of my high school classmates, who was a multi-talented poet, painter, and theatre director. During our conversation, I expressed the rather self-important opinion that medicine was the most important and worthwhile profession, since it consisted of making the difference between life and death for many people. My friend quickly reminded me how myopic my point of view was, when she commented: ‘Ah yes, but art is what makes life worth living.’ I believe this work can serve as a constant reminder of the truth in my friend’s statement. This is not meant to imply that art is the only thing that makes life worth living, but rather that life without the creativity that artistic imagination brings would be so impoverished as to be much less worth living. Not only that, many authors in this work demonstrate that it can powerfully enhance life as one of the best antidotes to violence. Indeed, it is hard to imagine how to survive some of life’s worst traumas without the richness that art adds to our lives. And for reminders of that truth, as well as for the many other insights in this work, we are indebted to the creativity of the editors and contributors for a job well done.

REFERENCES Caspi, A., McClay, J., Moffitt, T.E., Mill, J. et al. (2002) ‘Role of genotype in the cycle of violence in maltreated children.’ Science 297, 5582, 851–854. Erikson, E.H. (1968) Identity: Youth and Crisis. New York: Norton.

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List of Contributors John Adlam is Consultant Adult Forensic Psychotherapist at River House MSU, Bethlem Hospital, where he has particular responsibility for Reflective Practice Groups across the forensic pathway. He is also Principal Adult Psychotherapist and lead for inpatient psychological therapies with the SW London and St George’s Adult Eating Disorders Service. He was formerly Principal Adult Psychotherapist with the Henderson Hospital Democratic Therapeutic Community Outreach Service and Vice-President of the International Association for Forensic Psychotherapy. He is a founding member of the Association for Psychosocial Studies and an independent researcher who has published widely on the psychosocial dynamics of homelessness, dangerousness, disorder and social exclusion; on the phenomenology of eating distress and the psychodynamics of force-feeding; and on working in and with traumatised teams in traumatised organisations. He is co-editor of The Therapeutic Milieu Under Fire: Security and Insecurity in Forensic Mental Health and Forensic Music Therapy (both Jessica Kingsley Publishers, 2012). Gwen Adshead is a forensic psychiatrist and psychotherapist. She trained at St George’s Hospital, the Institute of Psychiatry and the Institute of Group Analysis. She worked as a consultant forensic psychotherapist at Broadmoor Hospital for over 15 years, where she ran psychotherapeutic groups for offenders, and worked with staff and organisational dynamics. Gwen also has a Master’s Degree in Medical Law and Ethics; and has a research interest in moral reasoning, and how this links with ‘bad’ behaviour. Gwen has published a number of books and over 100 papers, book chapters and commissioned articles on forensic psychotherapy, ethics in psychiatry, and attachment theory as applied to medicine and forensic psychiatry. She has appeared on Radio 4 on a number of different programmes and been involved with public lectures and presentations at the Wellcome Trust. She was a visiting professor at Yale in 2013 and is currently the Gresham Professor of Psychiatry. She works at a medium secure unit in Hampshire.

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Claude Barbre is Full Professor, Clinical Psychology Psy.D. Department, Chicago School of Professional Psychology. Dr Barbre is Course Lead Coordinator of the Psychodynamic Orientation at the Chicago School, and lead faculty in Child and Adolescent Studies. He has counselled children and families for over 30 years, and served for 12 years as Executive Director of the Harlem Family Institute, a New York City school-based, psychoanalytic training programme, working with children and families in high-needs neighbourhoods. Author of prize-winning articles, books and poetry, Dr Barbre is the recipient of the 2016–17 Ted Rubenstein Inspired Teaching Award (TCS), and a five-time recipient of the International Gradiva Award for his writings on art, psychoanalysis and the humanities. Dr Barbre is currently a Board member and training supervisor at the Chicago Center for Psychoanalysis (CCP), and is in private practice in Chicago. Jill Barbre is a psychoanalyst, licensed clinical social worker, and special educator specialising in early childhood development and mental health. She has a private practice in psychotherapy with children and adults, and is a programme supervisor at the Illinois Department of Children and Family Services/Erikson Institute Early Childhood Project in Chicago. Jill has taught and supervised in the areas of psychoanalytic theories of child development at the Institute for Clinical Social Work in Chicago, infant mental health assessment and practice at the Erikson Institute Infant Mental Health Certificate Program in Chicago, and psychoanalytic psychotherapy with children and families at the Harlem Family Institute in New York City. Jill is a mentor, supervisor and Board member at the Chicago Center for Psychoanalysis. Zoe Berko is an Associate Psychologist at Brookwood Secure Center, New York State Office of Children and Family Services, where she works with adolescents convicted of violent felonies. She is also an adjunct assistant professor in the Psychology Department at the John Jay College of Criminal Justice, City University of New York. She was formerly a clinician with the New York City Department of Juvenile Justice. Her clinical and research interests centre on the assessment and treatment of violent offenders; urban street culture and disrespect homicide; forensic psychotherapy; and Mentalization Based Treatment (MBT) for Anti-Social Personality Disorder. Sarita Bose has worked in Broadmoor High Secure Hospital for 21 years to date in a range of roles as a Registered Nurse (Mental Health), and is currently working in the role of Clinical Nurse Specialist. Over the last 16 years she has made a particular study of individual and group psychodynamic theory in forensic psychiatry. She has an MSc in Psychodynamics of Human Development, a Post

List of Contributors

Graduate Diploma in Forensic Psychotherapeutic Studies, and qualifying PG Diplomas in both CBT Psychotherapy and Reflective Organisational Practice. Her areas of experience and interest include homicide offender treatment, relational security enhancement in forensic mental health nursing, traumainformed care, the dynamics of therapeutic nurse–patient relationships in personality disorder services, and reflective practices in organisations. Deborah J. Cohan is Associate Professor of Sociology at the University of South Carolina-Beaufort, and her areas of specialisation include: gender-based violence, bodies and sexuality, race, creative nonfiction, and feminist pedagogy. She publishes widely, both in academic research and for a general audience. Her essay ‘The Gold Pen’, on caregiving, creativity and dementia, is featured in the anthology titled Letting Go: Feminist and Social Justice Insight and Activism (Vanderbilt University Press, 2015). Utne Reader selected ‘The Gold Pen’ for reprinting (April 2016). Deborah’s writing regularly appears online for Psychology Today. She has written for The San Francisco Chronicle and Inside Higher Ed, and she is often quoted in the media, in news outlets such as Vox, Vice News, The Christian Science Monitor, USA Today, The Atlanta JournalConstitution, and The Chronicle of Higher Education. For many years, Deborah worked as a counsellor and clinical supervisor with abusers and survivors of violence. Tamsin Cottis is a UKCP-registered integrative arts child psychotherapist. She is a co-founder and former Assistant Director of Respond, the UK’s leading provider of psychotherapy to children and adults with learning disabilities, including those with sexually harmful behaviour. More recently Consultant Clinical Supervisor at Respond and a teacher at the Bowlby Centre, she also works as a child psychotherapist and clinical supervisor in primary schools and in private practice. Tamsin is a founder member of the Institute of Psychotherapy and Disability and a member of the International Association for Forensic Psychotherapy. She has written widely for books and professional journals, particularly regarding psychotherapy and learning disability, and has presented a range of academic papers. Publications include Witnessing Nurturing and Protesting: Therapeutic Responses to Sexual Abuse and Learning Disability (coauthor) (David Fulton Publishers, 1996) and Intellectual Disability, Trauma and Psychotherapy (editor) (Routledge, 2009). Tamsin is also a prize-winning, published author of short stories. Gerard Drennan is a consultant clinical psychologist and Head of Psychology and Psychotherapy for the Behavioural and Developmental Psychiatry Clinical Academic Group of the South London and Maudsley NHS Foundation Trust.

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Gerard’s clinical work in the National Health Service has focused on forensic mental health settings for the past 18 years. He has written about collaborations with colleagues to develop recovery-oriented care with forensic mental health service users and has trained as a restorative justice conference facilitator. This has led to various initiatives to introduce restorative justice practices into forensic mental health. His commitment to social justice and social inclusion in mental health stems from his experience of working as a clinical psychologist in South Africa. He is training as a psychoanalytic psychotherapist. Reinmar du Bois is a child and adolescent psychiatrist and psychotherapist on the faculty of Tübingen University Medical School. Formerly he was Clinical Director of the Hospital for Child and Adolescent Psychiatry in Stuttgart and now divides his time between lecturing, supervisory and consultation work in adolescent psychotherapy units and adult secure hospitals, as well as psychiatric assessments in juvenile and family courts. He is the author of five monographs on early-onset schizophrenia, inpatient treatment milieus, childhood anxiety and aggression, and juvenile delinquency. He is responsible for the child and adolescent psychiatric content within the longest-established German textbook on psychiatry (Tölle/Windgassen) and principal author of a reader on inpatient adolescent psychotherapy (du Bois/Resch). In 1991 he was one of the founding members of the IAFP. After retiring from his post as medical director he founded an institution for the recruitment, training and supervision of psychological and psychiatric court experts (Gutachtenstelle Stuttgart GmbH), which is now his central work base. Martha Ferrito is a qualified cognitive-behavioural psychotherapist registered with the British Association for Behavioural and Cognitive Psychotherapists (BABCP). She is also trained in Eye Movement and Desensitisation Reprocessing (EMDR). She has experience working with people presenting with a range of psychological problems including severe mental health problems, for the past ten years. Her experience includes general practice in mental health care (NHS, private and charities) as well as experience in secure forensic hospital settings. Martha is committed and passionate about ongoing learning and she is currently working on her doctoral research at the University of Portsmouth which focuses on the process of meaning reconstruction and self-reconciliation for men who have committed homicide. Her research study complements her interests in people affected by significant psychological trauma and loss. James Gilligan is Clinical Professor of Psychiatry and Adjunct Professor of Law at New York University. He is a renowned violence studies expert and author of the influential Violence Our Deadly Epidemic and Its Causes (Jessica

List of Contributors

Kingsley Publishers, 1996), as well as Preventing Violence (Thames & Hudson, 2001)and Why Some Politicians Are More Dangerous than Others (Polity Press, 2016). He has served as Director of Mental Health Services for Massachusetts’ prisons and prison mental hospital, President of the International Association for Forensic Psychotherapy, and as a consultant to President Clinton, Tony Blair, Kofi Annan, the World Court, the World Health Organization and the World Economic Forum. Simon Hackett is Lead Arts Therapist for Northumberland, Tyne and Wear NHS Foundation Trust and Associate Clinical Researcher at the Institute of Health and Society, Newcastle University, UK. Simon is actively involved in National Institute for Health funded art therapy research with violent offenders being treated in secure care in the NHS in England. Simon is an associate editor for the International Journal of Art Therapy and a leader of a national art therapy clinical special interest group for the British Association of Art Therapists. Tilman Kluttig is Senior Clinical Psychologist in the Clinic for Forensic Psychotherapy and Psychiatry in the Reichenau Centre for Psychiatry, Germany. He trained in psychodrama, systemic therapy, cognitive-behavioural therapy and psychoanalytic psychotherapy for psychosis. After more than 30 years in clinical psychotherapy he is now part of the Reichenau research group in forensic psychotherapy and psychiatry and also of the Reichenau forensic outpatient services. He is an external supervisor for forensic and addiction services in Germany, Switzerland and Austria. He is a forensic expert in court and the prison and probational services in Germany. He has published on art therapy and theatre in forensic psychotherapy, on the forensic psychiatric system in Germany, on addiction and psychosis, on the psychotherapy of psychosis and on group psychotherapy in the forensic system. He has been for many years a Board member of the International Association for Forensic Psychotherapy and was formerly its President. Bandy X. Lee is on the faculty of the Law and Psychiatry Division of Yale School of Medicine. For 17 years, she served as Director of Research for the Center for the Study of Violence (Harvard, U. Penn., N.Y.U. and Yale). She co-founded Yale’s Violence and Health Study Group and leads an academic collaborators group for the WHO Violence Prevention Alliance (VPA). In addition to her research in Tanzania as a fellow of the US National Institute of Mental Health, she has helped to set up violence prevention programmes internationally, as well as to reform New York City’s Rikers Island. She teaches students representing asylum seekers and studying to be public defenders at Yale Law School, as well as a Global Health Studies course of her design, ‘Violence: Causes and Cures’.

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She has published more than 100 peer-reviewed articles and chapters, edited 11 academic books and authored the textbook Violence (Wiley-Blackwell, 2019). At the time of this publication, she has just released a compendium of mental health expertise for the public in The Dangerous Case of Donald Trump (Macmillan, 2017). Alex Maguire is Senior Music Therapist at Broadmoor High Security Hospital in the UK, specialising in working with high dependency and intensive care patients. He has presented his work at numerous conferences and contributed to the books Forensic Music Therapy (Jessica Kingsley Publishers, 2012), The Forensic Arts Therapies Anthology in Research and Practice (Free Association Books, 2016) and Working Across Modalities in the Arts Therapies: Creative Collaborations (Routledge, 2017). The hospital choir for both staff and patients, which he co-founded, has been commended in the Arts and Health Awards, and performs widely at hospital functions, as well as providing a Christmas visiting service to the intensive care wards. In a parallel life, Alex continues to perform, record and broadcast in a variety of jazz and improvised music contexts across Europe, the Americas and the Far East. Wayne Martin is Professor of Philosophy at the School of Philosophy and Art History at the University of Essex, where he also serves as Director of the Essex Autonomy Project – a multi-disciplinary research project investigating ideals of self-determination (autonomy) in care relationships (health care, elder care, psychiatric care, etc.). His recent work draws on phenomenological methods to investigate the experience of decision-making, particularly in psychiatric contexts. He has also written about German Idealism, the paintings of Lucas Cranach, and Dutch Still Life. His contribution to the present work is part of a longstanding project on the phenomenological structure of self-consciousness, particularly as it has been explored and represented in the history of painting. Maggie McAlister is a Jungian Analyst (Society of Analytic Psychology, London), psychoanalytic psychotherapist and arts psychotherapist, currently working in complex care within the National Health Service. She previously worked for many years as a forensic psychotherapist in inpatient NHS settings and has written and published widely on the subject of violence, homicide and psychosis, as well as being co-editor and author of two books on difficult team enactments and organisational dynamics in forensic mental health care systems. She taught for many years on the MSc in ‘Psychotherapeutic Approaches to Mental Health’ jointly run by West London Mental Health Trust and Bucks New University, and helped co-found the ‘Forensic Psychotherapy Society’, a member institution of the British Psychoanalytic Society. She has many

List of Contributors

years’ experience running staff ‘reflective practice’ groups for traumatised and traumatising populations. She has a private practice in North London. Martina Mindang is an art therapist. Since qualifying in 1996 she has worked within the NHS (UK) mental health services in adult community care, acute admission and high secure care services. Her special clinical interest is creative approaches to psychological recovery from violence, on which subject she has presented at local and international conferences and seminars, as well as contributing to the books Forensic Arts Therapies – Anthology of Practice and Research (Free Association Press, 2016) and Working Across Modalities in the Arts Therapies: Creative Collaborations (Routledge, 2017). Martina is a BAATregistered clinical supervisor, private practitioner and a lecturer on the MA Art Psychotherapy Programme at the University of Roehampton, London. Anna Motz is a Consultant Clinical and Forensic Psychologist at the Family Assessment and Safeguarding Service, Oxford Health NHS Foundation Trust, and a psychoanalytic psychotherapist in private practice. She has extensive experience of working with women as perpetrators and victims of violence, and has written extensively about maternal abuse and neglect, as well as violence directed towards the self. She is also a Consultant and Trainer for the Institute of Mental Health where she designs and delivers BSc and MSc Modules on Working with Women with Personality Disorder for staff working within mental health and criminal justice systems. Anna is also an MBT Supervisor for the Anna Freud Centre, Visiting Lecturer at the Tavistock Clinic and author of several books on psychoanalytic approaches to working with violence in individuals and between couples, uncovering invisible trauma and understanding selfharm. She was Past President of the International Association for Forensic Psychotherapy. Kate Rothwell is Head of Arts Therapies for the Forensic Directorate in the East London Foundation Trust, and senior clinician in the Specialist Learning Disability Forensic Service. Kate has worked as an art and small group psychotherapist in a prison wing of HMP Grendon Therapeutic Community since 2013. Having worked in forensic settings for over 30 years, she has convened the Forensic Arts Therapies Advisory Group since 2010. Supervising arts therapists across a range of services, Kate is also a published author, editor of the Forensic Arts Therapies Anthology of Practice and Research, and an associate researcher on the NIHR-funded art therapy research with violent offenders being treated in secure settings in the NHS in England.

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Robyn Timoclea is a survivor researcher with a specialist interest in emancipatory approaches. Previous work has included facilitating sexual violence and hearing voices groups in prisons. Her past research has explored the experiences and needs of traumatised women in forensic services. Robyn has also provided guidance to clinical commissioners about non-oppressive service-user co-production. Clinton van der Walt is a psychoanalytic psychotherapist working in private practice in Johannesburg, South Africa. He worked at the University of the Witwatersrand as a supervising psychologist, and as a consultant psychotherapist at the Ububele Educational and Psychotherapy Trust. He has published and researched on post-apartheid justice and reconciliation in South Africa. He was the lead researcher on the Tswelopele programme, which was developed to reintegrate traumatised ex-combatants into economic and social communities. He has also worked as the programme evaluator for the Young Voices Network in South Africa, Zimbabwe and Malawi. He is a musician and a poet. James S. Vrettos is a sociologist at the City University of New York – John Jay College of Criminal Justice. He is the co-author of the critically acclaimed The Elementary Forms of Statistical Reason (St Martin’s Press, 1996) and has written numerous articles on social movements, deviance and criminal justice for Tikkun Magazine. He was the facilitator for the Tikkun Group of Spiritual Progressives in New York City for ten years and taught sociology and criminal justice at Yeshiva University where he developed their criminal justice courses and supervised their criminal justice internship programme. He is presently the creator and host for the weekly cable television show The Radical Imagination on Manhattan Neighborhood Network and active with Rev William Barber and the New Poor People’s Campaign. In 2011–2012 he, along with other spiritual and political progressives, including the activist Cornel West, was involved in the first demonstration and trial in New York City protesting Stop and Frisk policies by the New York Police Department. Andrew Ware is a trainee clinical psychologist at the University of Surrey. He has published research on Mentalisation Based Therapy (MBT) and is interested in work with individuals diagnosed with a borderline personality disorder. Andrew was formerly an assistant clinical and research psychologist at Broadmoor Hospital where he worked within the Centralised Groupwork Service. He continues to work passionately with groups and wider systems in his clinical practice.

Subject Index adolescents 28–9 development of autonomy 12–15 juvenile offenders: mentalisation study 56–9 see also parent battering Adult Attachment Interview 28 affect regulation 10–11 play 127 thirdness 40, 42, 46 ‘affective violence’ 25 agency and identity 53–4 mentalisation studies 56–64 previous research 54–5 ‘alien self ’ 69 anger/rage see gender and rage anomie 76, 211–12 anorexia mirabilis definition of 96 therapeutic community (TC): spiritual framework 96–7 artwork and analysis 97–101 vs mainstream psychiatric approach 101–3 and voluntary self starvation (VSS) 95–6, 102–3 see also feeding distress anti-social personality disorder (ASPD) 24, 30–2 Antigone paradigm 87–91 Ariadne’s thread/Minotaur myth 152–3, 160–2

art psychotherapy 196–7 prisoners and prison setting 197– resilience 195, 206–8 vignettes 198–205 attachment attuned 27–8, 140, 145–6 distorted patterns 18–19, 28 and mentalisation 23–4, 27–9 and seduction 146 thirdness 39 autogenic third and narcissism (Mr A) 41–2, 44–7 autonomy development of 12–15 and eating disorders 91 battering see gender and rage; parent battering childhood aggression 12–15 childhood neglect/physical and sexual abuse 11–12, 33–4, 63–4, 131 psychopathology of extreme violence 153–4 see also anorexia mirabilis; learning disabilities; maternal absence as hunger clinical supervision 160–2 confessional moment 226–8 conflict vs deficit debate 24–7 containment 26–7, 126–7, 130–2 therapeutic setting 48 countertransference 158–9, 177 255

creative programming 186 cultural stereotypes see gender and rage cultural symbols see monsters death instinct 25–6 destructive and creative capacities 198–202 developmental thirdness 39–40, 41 Developmental Trauma Disorder (DTD) 143 deviance: social science perspective 211–13 disability creative responses to 230–2 see also learning disabilities disconnection and dislocation 155–6 discovery capacity 202–4 dominant rage 113–15 Down’s syndrome (Paula) 137–8, 139, 140, 141–2 eating disorders see anorexia mirabilis; feeding distress ecological model of abuse and learning disabilities 139–40 empathy 145–6 ex voto paintings 225–30, 235–6 existentialist-therapeutic work see Kahlo, Frida extreme violence psychopathology of 153–4 see also High Secure Service (HSS); music therapy

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fantasy 13–14, 154 feeding distress Antigone paradigm 87–91 contested construction of eating disorders 84–5, 87 hospital setting 81–4 refusal of food 85–7 see also anorexia mirabilis First Nations: restorative justice 181–3 forensic mental health settings 188–91 recovery concept and definition 185–6, 187–8, 191–2 Forgiveness Project programme 191 gender and rage healing rage as creative state 117–18 men construction of masculinity 110–13 dominance 113–15 women 107–8 inwardly directed rage 109 mothers 77–8 survivors 115–16 Good Lives Model of recovery 187–8 hate crimes 140 healing rage 117–18 High Secure Service (HSS) 151–2 clinical supervision 160–2 countertransference 158–9 Minotaur myth/Ariadne’s thread 152–3, 160–2 psychopathology of extremely violent states of mind 153–4 treatment dilemmas 155–7 homicide see agency and identity; serial killers humiliation 154 hunger metaphor see maternal absence as hunger incest 118 Indescribably Blue (music therapy) 169–72

infant irritability and excitation 10–12 infant mental states 25 Integrative Arts Child Psychotherapy (IACP) 138–9 intergenerational transmission of trauma 130 inwardly directed rage 109 juvenile offenders: mentalisation study 56–9 Kahlo, Frida: existentialisttherapeutic work accident 228–30 disability 230–2 ex voto paintings 225–30, 235–6 relationships 224, 236 Self-Portrait with Cropped Hair 223–4, 232–5, 236–8 ‘Kind Tasmin’ game 142 learning disabilities 137–8, 147 Integrative Arts Child Psychotherapy (IACP) 138–9 premature sexualisation 146 social exclusion 139–40 trauma, transition and play 141–6 lorelessness 132 malignant pseudoidentification 155 Man of Peace (music therapy) 173–4 masculinity, construction of 110–13 maternal absence as hunger 67–9 absent object 70–1 case illustration: Sofia 71–4 impact of 73–6, 77–9 Zami (autobiography) 76–7 meaning-making and play 133 recovery of male abuse survivors 116, 117–18

Memories (music therapy) 174–7 memory, somatic 68–9 memory archive 112–13 mentalisation and attachment 23–4, 27–9 identity and agency studies 56–64 learning disabilities 145–6, 147 parent experiences of own childhood 131 play 128–30, 133, 145–6 pre-mentalistic modes and risk of violence 29–33 thirdness 40–1 mentalisation-based therapy (MBT) groups 30–2, 59–63 Minotaur myth/Ariadne’s thread 152–3, 160–2 monsters concept of 124–7 development and therapeutic importance of 133–4 symbolic and transformative function 127–30 trauma and symbolization failure 130–2 moral movements 216–19 mother–child relationship see attachment; maternal absence; mentalisation; parent–child interaction ‘Murder’ game 137, 141 music therapy and extreme violence 165–7, 177–8 playlist and comments 167–77 narcissism and autogenic third (Mr A) 41–2, 44–7 nature-nurture debate 24–7 ‘object games’ 142 object relations 39, 68–9 absent object 70–1 transitional objects 128, 142 Oedipal thirdness 38–9 parent battering 15–16 general dynamics 16–17 regressive arousal states 17–18

Subject Index

social awkwardness 18–19 therapeutic interventions 19–20 parent–child interaction 9–10 childhood to adolescence 12–15 infant irritability and excitation 10–12 nature-nurture debate 24–7 see also attachment; maternal absence; mentalisation play 12, 13–14 and mentalisation 128–30, 133, 145–6 trauma and transition 141–6 see also monsters Post Traumtic Stress Disorder (PTSD) children 11–12 clinicians/therapists 155 homicide perpetrators 63–4 pre-mentalistic modes and risk of violence 29–33 ‘predatory violence’ 25 pretend mode 29, 33, 34, 41, 129 private and public spheres 114–15 prosthetic third and psychosis (Mr K) 41, 42–4, 47 psychic equivalence mode 29, 41, 128–30, 131, 132 psychosis 30, 33, 154 and prosthetic third (Mr K) 41, 42–4, 47 puppet play 143–5 race juvenile offenders: mentalisation study 56–9 maternal absence 71–4, 76–7 recovery in forensic mental health settings 185–6, 187–8, 191–2 and meaning-making 116, 117–18 ‘redemption narratives’ 55 regressive arousal states 17–18

relational thirdness 39–40, 48 religion ex voto paintings 225–30, 235–6 see also anorexia mirabilis; spiritual/social movements resilience 195, 206–8 respect/disrespect 58–9, 113 restorative justice conferencing 183–4, 188–9 First Nations 181–3 forensic mental health settings 188–91 recovery concept and definition 185–6, 187–8, 191–2 mental illness as disqualification from procedures 184–5 rough-and-tumble play 12 sado-masochism/sexual sadism 19, 20, 24–5, 154 self ‘alien self ’ 69 and other connection 204–5 reality of 205 Self-Portrait with Cropped Hair (Kahlo) 223–4, 232–5, 236–8 self-preservation violence 24, 25 serial killers 153–4 sexual violence/rape 108, 117, 154 see also anorexia mirabilis; childhood neglect/ physical and sexual abuse sexualisation, premature 146 shame 78, 113, 140, 154 shaming, re-integrative 182–3 Silence the Violence programme 191 social awkwardness 18–19 social exclusion 139–40 societal neglect 76–7 somatic memory and neglect 68–9 spiritual/social movements 209–10 creative challenges 216 intellectuals and ordinary people 214–15 moral movements 216–19

new progressive movement 219–21 political dimensions 211, 214, 217 social science insights 211–13 structural violence theories 213–14 structuring variables 215–16 street code adherence 56, 58–9 structural violence theories 213–14 supervision, clinical 160–2 Sycamore Tree Programme (STP) 189–91 symbolization see monsters taking responsibility 188, 191–2 ‘teleological mode’ 30 temper tantrums 12–13, 15 therapeutic community (TC) see under anorexia mirabilis therapeutic nihilism 155 therapeutic relationship play 145–6 thirdness 48–9 thirdness 37–8 narcissism and autogenic third (Mr A) 41–2, 44–7 pathological/‘pseudo-third’ 41–2, 47 psychosis and prosthetic third (Mr K) 42–4, 47 reality and violence 38–42 therapeutic relationship 48–9 ‘three secrets’ 139 thrill, concept of 14 transitional objects 128, 142 trauma theory 14 Treat Me Nice (music therapy) 167–9 vicarious traumatization 155 victim awareness: Sycamore Tree Programme (STP) 189–91 voice hearing 96–7, 102, 103 women see gender and rage Zami (autobiography) 76–7

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Author Index Adelson, E. 142 Adlam, J. 84, 86, 87, 88, 89, 90 Adler, J.R. 191 Adshead, G. 24, 27, 55, 59, 151, 187 Agamben, G. 88 Ainsworth, M.D. 69 Akrawi, D. 103 Aldice, O. 12 Alexander, M. 217, 219 Alford, C.F. 128, 130–1, 134 Allen, J.G. 55, 59 Alred, D. 55, 187 Alvarez, A. 143, 145, 146 American Psychological Association 195 Anderson, J.G. 56, 58 Anouilh, J. 87 Anthony, W.A. 185, 186, 187–8 Atkinson, J. 132 Baglivio, M.T. 63 Baker, G.A. 98 Balint, M. 14, 19 Ball, P.G. 116 Banks, C.G. 96 Barber, W.J. Jr. 216–17, 219, 221 Barkus, E. 96 Barnes, M. 166 Bateman, A. 24, 27, 30, 38, 53, 59, 69 Baumeister, D. 96 Becker, J.V. 154 Belenky, M. 108 Bell, K.A. 102 Bell, R. 88 Bell, R.M. 95 Bemporad, J.R. 95

Benjamin, J. 39, 40 Bentall, R.P. 98 Bergmann, M.A. 69 Berko, Z.A. 56 Berkshire, E. 84–5, 86 Beth 86 Binyon, L. 67 Bion, W.R. 26–7, 183 Blackman, N. 138 Bogaerts, S. 13 Bograd, M. 114 Bollas, C. 177 Bolton, R. 53 Bose, S. 55, 151, 187 Boulton, M. 12 Boulton, M.J. 12 Bowlby, J. 26, 27, 138, 153 Bracher, M. 56 Bradford, D.T. 96 Bradley Report 24 Braithwaite, J. 182 Braungart-Rieker, J.M. 11 Briggs, J.L. 126, 130 Brison, S.J. 108, 115, 117 Britton, R. 39, 40, 46 Bruch, H. 95 Brumberg, J.J. 96 Buckley, P.F. 188 Bufferd, S.J. 14 Burgess, A. 14 Burgess, A.W. 153 Butler, J. 88, 91, 111 Bynum, C.W. 95–6 Byrne, G. 68 Callanan, M.M. 188–9 Canter, D.V. 58 Cardenal, G. 217 Carhart-Harris, R.L. 98 Carter, J.C. 97 Cartwright, D. 29

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Caspi, A. 244 Castro-Sethness, M. 228 Charles, A.V. 15 Chartier, J.-P. 15 Chartier, L. 15 Chazan, S. 133 Chess, S. 10 Chomsky, N. 214, 219 Cicchetti, D. 207 Clarke, I. 97, 103 Clarkin, J.F. 41 Cleven, G. 206 Cloward, R. 109, 212–13, 213, 215, 221 Cook, A. 188–9 Cook, C. 102 Coombes, R.H. 15 Copes, H. 54 Corbett, A. 139, 140, 146 Cordess, C. 23 Cottis, T. 138, 139, 146 Couture, M. 154 Cox, M. 23 Crepault, E. 154 Cummings, E.M. 11 Daniel, J. 206 David, A.S. 98 Davidson, L. 185–6 Davis, A.A. 96 de Leede-Smith, S. 96 Declaration of Independence, US 216 Deegan, P. 185 deMause, L. 70 Democracy Now 211 d’Huy, J. 125 Dietz, P.E. 154 Dolan, M. 152 Done, D. 98 Donne, J. 85, 179

260

VIOLENT STATES AND CREATIVE STATES

Dorkins, E. 187 Dostoevsky, F. 7, 83 Douglas, M. 12 Draaisma, D. 96 Drennan, G. 55, 187, 188, 188–9 du Bois, R. 15 Durkheim, E. 211–12 Edwards, D. 196 Eisikovits, Z. 112 Elkin, G. 166 Ensink, K. 131 Epps, J. 14 Erikson, E.H. 243–4 Evans, M. 186 Exline, J.J. 96 Fagan, J. 56 Ferraro, K.J. 116 Ferrito, M. 55, 187 Figley, C.R. 155 Fischer, K.W. 13 Flanders, J.L. 13 Fonagy, P. 24, 27, 28–9, 30, 38, 39, 40, 41, 53, 57, 58, 59, 69, 128, 129–30, 138, 146, 153–4 Foucault, M. 191–2 Francisco, P.W. 117 Frankel, J. 133 Freud, S. 11, 25, 38–9, 126, 128–9 Friaberg, S. 142, 143 Frith, C. 98 Frye, M. 108 Fullam, R. 152 Gabbard, G.O. 41 Galtung, J. 210, 213 Garcia-Moreno, C. 97 Garrett, C. 96 Gavrielides, T. 182 Geetz, C. 243 Genet, J. 89 George, C. 28 Gerson, S. 38 Gilfus, M.E. 115–16 Gilligan, J. 28, 58, 78, 113, 140, 153, 155, 210, 213, 214, 218, 219, 221 Glasser, M. 23, 24, 30, 146 Gleason, M.M. 19 Goffman, E. 56, 115 Gordon, J. 158 Graziano, F. 225 Green, A. 37, 38

Greenberg, J. 39 Gresswell, D.M. 154 Grubb, A. 102 Guardian 139 Gussak, D. 206 Gutierrez, G. 217 Hackett, S. 206 Hale, R.L. 154 Halfon, O. 12 Hall, S. 117 Hampshire Safeguarding Adults Board 140 Hanly, C. 37, 38 Harbin, H. 15 Harriott, V.A. 96 Havers, S. 98 Hayes, R.M. 102 Hazelwood, R. 154 Heart, K.F.H. 118 Heidegger, M. 225 Heinmann, P. 158 Helliwell, S. 151 Herman, J. 115, 116 Herman, J.L. 63 Herrera, H. 228, 231 Hewes, J. 12 Hinshelwood, R.D. 33, 86, 158 Hitler, A. 178 Hölderlin, F. 83, 88, 91 Hollin, C.R. 154 Hollins, S. 139 Homolka, S.J. 96 Honig, B. 88, 90, 91 hooks, b. 111, 118 Hopkins, B. 182 Huline-Dickens, S. 96 Jacobson, N. 185 Johnson, B.R. 154 Johnson, J.M. 116 Jones, A. 113–14 Jones, D. 84, 153 Junginger, J. 154 Kaplan, N. 28 Katz, J. 154 Kaufman, M. 109, 110 Keats, J. 84 Keene, A.C. 14 Kelly, L. 102 Kelly, V.C. 182 Kierkegaard, S. 90 King, M.L. Jr. 217 Kinnell, G. 123 Klein, D.N. 14

Klein, M. 25, 39 Knoll, J.L. 155 Koestler Trust 206 Krishnamurti, J. 178 Kruger, L. 67–8, 74–5, 78 Lacan, J. 40, 88 Lamott, A. 118 Latzer, Y. 103 Lee, B.X. 210, 213, 214, 220 Lerner, M. 217–18, 219 Leszcz, M. 64 Levi-Strauss, C. 88–9 Levin, J. 103 Liebmann, M. 183, 184 Lilly, R. 103 Lloyd, E. 146 Long, C. 38, 41, 46 Longden, E. 96 Lorde, A. 76–7, 78–9 Lorenz, K. 102 Losch, M.E. 96 Lourens, M. 67–8, 74–5, 78 Lovecraft, H.P. 159 Lucas, R. 159 McAdams, D.P. 55 McCarthy-Jones 95 MacCulloch, M.J. 154 McGauley, G. 24, 28 McNamara, J.J. 154 McNeill, D. 91 MacRae, A. 183 Madden, D. 15 Madill, A. 96 Main, M. 28, 137 Martin, W. 91 Maruna, S. 54, 55, 57, 187 Marx, K. 87 Meehan, B. 95 Meekums, B. 206 Meloy, R. 25, 30 Mencap 139 Menzies Lyth, I. 33 Merchant, A. 132 Merton, R.K. 212 Messerschmidt, J.W. 110 Mir, M. 191 Mishara, A.L. 98 Mitchell, S. 39 Moffitt, T. 244 Molendijk, M.L. 97 Mollon 160 Money-Kyrles, R. 139 Morgan, D. 23 Morton, R.J. 154 Mouren, M. 12

Author Index

Murphy, M. 103 Music, G. 207 Narayan, A.J. 11, 14 Natoli, J.L. 140 Nguyen, M. 96 Nouvet, E. 76 NSPCC 183

Rothwell, K. 206 Royal College of Psychiatrists 187 Ruszczynski, S. 23

Palermo, M.T. 13 Parisette-Sparks, A. 14 Parker, T. 54 Paulton, M.F. 15 Pears, R.L. 16 Pearson, J. 58 Peltz, J. 58 Perelberg, R.J. 46 Perry, R. 11 Peter-Hagene, L.C. 102 Phillips, S.B. 155 Pines, D. 68 Piven, F.F. 109, 215 Planalp, E.M. 11 Port Huron Statement of the Students for a Democratic Society 209–10, 216 Posey, T.B. 96 Prentky, R.A. 154 Presser, L. 54, 58

Sacco, F.C. 58 St Augustine 7 Salston, M.D. 155 Salter, L. 102 Scanlon, C. 84, 86 Schore, A.N. 140, 143 Schreber, D. 166 Shakespeare, W. 121 Shapiro, V. 142 Shelley, P. 90 Shriver, L. 25 Sinason, V. 139 Skårderud, F. 85 Slade, M. 185 Slaikeu, K.D. 103 Slater, L. 109 Slobada, A. 166 Smeijsters, H. 206 Smith, C.E. 13 Smith, P.K. 12 Sobsey, D. 138, 139 Solomon, J. 137 Sontag, S. 38 Sophocles 87, 88, 90, 91 Southwick, S.M. 195 Sroufe, A. 19 Steenhuis, L.A. 103 Steinem, G. 109 Steiner, G. 88, 90 Steinmetz, S.K. 15 Stern, D. 39 Sullivan, R.M. 11 Swinton, J. 97

Raine, N.V. 117–18 Reavis, J.A. 63 Reebye, P. 9 Restorative Justice Council 183, 184 Rew, L. 103 Riggs, A. 116 Rogosch, F.A. 207 Rosenfeld, H. 46 Rossner, M. 182

Target, M. 29, 38, 128, 129–30 Taubner, S. 12, 15 Taylor, P. 154 Terr, L. 14 Theoharis, L. 219 Thomas, A. 10 Thorsborne, M. 182 Toch, H. 58 Treasure, J. 84

O’Brien, F. 146 O’Connor, P. 54–5 Ogden, T. 39 Ohlin, L. 213 O’Loughlin, M. 132 Oppenheimer, R. 97 O’Shaughnessy, E. 69, 70

Trotta, R. 16 Turner, E. 102 Twemlow, S.W. 58 Ugelvik, T. 54 Ullman, S.E. 102 van der Kolk, B. 19, 63–4, 117, 138, 143 van der Walt, C.M. 38, 41, 46 Van Deth, R. 88 van Gogh, V. 237 Vandereycken, W. 88 Virchow, R. 242 Vrabel, K.R. 97 Wakschlag, L.S. 13 Ward, T. 187 Warren, J. 154 Waterman, M.G. 96 Waters, E. 19 Watson, M.W. 13 Watts, C. 97 Weaks, K.A. 155 Welldon, E. 19, 68, 77, 109 West, C. 211, 218, 219, 221 Wilkinson, D. 56 Williams, A. 24, 30 Williams, K.S. 152 Winnicott, D.W. 10, 13, 26, 39, 127–8, 138, 141, 142, 243 Winstock, Z. 112 Wong, Y.J. 103 Wood, F.A. 189 World Health Organization 96 Worth, P. 191 Wyman, E. 116 Yakeley, J. 24, 30 Yalom, I. 166 Yalom, I.D. 64 Youell, B. 141 Youngs, D. 58 Zehr, H. 183 Zimmerman, C. 97 Zwiebel, R. 40

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