Avoidable Deaths

Louis Appleby, Jenny Shaw, Nav Kapal, et al

  • Safety is at the heart of good health care. In mental health services safety is particularly important but it is also an issue that raises sensitive questions. Where should the balance lie between patient protection and patient autonomy? How great is the risk to the public from mental illness? How many deaths could services prevent?

Report of the independent inquiry into the care and treatment of John Barrett

Robert Robinson, Jane Fenwick, Simon Wood, (NHS London)

  • This Homicide Inquiry was conducted following the murder of Denis Finnegan, a 50-year-old former banker, on 2nd September 2004: he was stabbed to death in a random attack as he cycled through Richmond Park. The perpetrator of this crime was John Barrett, who had suffered from paranoid schizophrenia for many years. As a voluntary patient in a medium secure unit, he had been given unescorted leave the day before he committed this offence. The inquiry found that the agencies involved in his care appeared to have made a number of mistakes, including a severe lack of communication. This high-profile case led to renewed calls for community treatment orders for high-risk mentally disordered patients.

Abusive help - helping abuse: the psychodynamic impact of severe personality disorder on caring institutions

Hinshelwood RD

  • Personality-disordered patients have invariably suffered abuse at the hands of carers when young, and they tend to repeat an abusive relationship when they encounter care in later life. The provision of care in psychiatric, forensic, penal and other institutions may degenerate into a form of unconscious abuse perpetrated against those in care. This is almost always unrecognized and the experience of carers is often to mismanage their own frustrated inability to understand what is happening to them, their charges and the institution.

Splitting in hospital treatment

Gabbard GO

  • Splitting is a concept that is used in a variety of ways to describe several different phenomena commonly seen in hospital treatment. As defined in this paper, it should be reserved for situations in which intrapsychic and interpersonal splitting occur simultaneously, recreating the patient's internal object world in the milieu. Through projective identification, staff members unconsciously identify with projected aspects of the patient and behave accordingly. A clearer conceptual understanding of splitting in the hospital allows for its differentiation from common variants of splitting and for the development of strategies to manage splitting.

The Mask of Sanity

Hervey Cleckley, M.D, Emily, S. Cleckley

  • The Mask of Sanity was written by a physician called Hervey Cleckley, and was first published in 1941. It is a classic text describing Cleckley’s clinical observations from interviews he undertook with prison inmates who were considered to be psychopaths. The “mask” he refers to in the title is the semblance of normality, even charm, he believed these individuals were able to assume, despite their fundamental lack of inner emotions.

Report of the independent inquiry into the care and treatment of Michael Stone

Robert Francis QC, Dr James Higgins, Mr Emlyn Cassam

  • This inquiry followed the murder of a mother and one of her daughters, Lin and Megan Russell, as they walked down a country lane; Lin’s second daughter, though seriously wounded in the attack, survived. This crime led the then Home Secretary, Jack Straw, to attempt to extend the Mental Health Act to enable “dangerous psychopaths” to be detained indefinitely. Despite the media coverage of the report largely highlighting mistakes by mental health professionals and the prison service – of which there were a few – it actually concluded that Michael Stone's care had been of a high standard: "We are satisfied that the agencies and professionals involved here all did what they perceived at the time to be for the best. We doubt that much more would have been attempted anywhere else in the country." And they went on to say: "the inquiry has found no evidence that they [Stone's crimes] would have been prevented if failings in provision of treatment, care, supervision or other services to Stone had not occurred." These events were the catalyst for the UK’s “Dangerous and Severe Personality Disorder” programme.

Identification and its vicissitudes as observed in the perversions.

Glasser M

  • This paper aims to contribute to the clarification of the different meanings of the concept of identification and the different processes involved in the making of an identification, by considering the perversions as disorders of internalization. The different forms of internalization are regarded as lying along a continuum of which identification is at one extreme and involves the incorporation of (part of) the object-representation into the self-representation. The pervert is shown to be unable to carry out the process of identification because he is fixated at an early developmental phase which I refer to as the 'core complex': instead of identification he has to make use of 'stimulation' in which the subject unconsciously models himself on (parts of) the object. The crucial role the body plays in these dynamics is considered. Exploration of these issues highlights how, in order for identification to take place, the issues of the core complex need to be adequately resolved in the course of normal development.

The difficult patient

Hinshelwood RD

  • In this paper, Hinshelwood (Professor of Psychoanalysis at the Centre for Psycho-analytic Studies, University of Essex) argues that staff dealing with “difficult patients” retreat from their inevitable but uncomfortable emotional responses into an objectified stance that can mask their significance. He explores how, in fact, these feelings can provide important information about such patients, if we can face up to thinking about them.

The Ailment

T. F. Main

  • This classic paper was written by Tom Main in 1957. Main, who worked at the Cassell Hospital in Richmond, South West London, for 30 years, set up a twice-weekly work discussion group after a number of staff began to show signs of stress. Its purpose was to make a retrospective study of those patients whose treatment could be considered a serious failure. What emerged was that each of these individuals had managed to form a “special” relationship with a member of staff. Over time, the group came to recognise how this had happened, and to understand better the evasions and distortions in their team working that had led to this situation developing.

The Response Aroused by the Psychopath

Neville Symington

  • What do we mean by 'psychopath'? We need to know this before we can understand the response which he arouses. The term 'psychopath' or 'psychopathic' covers a wide range of observable phenomena but there is one common denominator: the overriding determination to attain certain goals, and these by flouting the values which the society holds sacred. This was a point made succinctly by Edward Glover (1960): 'Moral obliquity is in fact the hallmark of the psychopaths who engage the attention of the courts.'

Psychiatric staff as attachment figures

G Adshead

  • In this paper, Dr. Gwen Adshead looks at the importance of attachment relationships between patients, their care-givers and even the institution. These are of particular importance in forensic settings, where patients can be detained for many years. In the paper, she describes how some difficult responses – such as self-harm or violence – can be understood as attachment behaviours, and how this has implications for treatment.

Group Therapy for Victims and Perpetrators of Incest

Estela Welldon

  • Abuse is an inter-generational problem. Abusers have been damaged in childhood by abusive action perpetrated on them, usually by their parents but sometimes by other significant adults. At times, in becoming adults, the early emotional damage can manifest into psychopathological features, including perversions or paraphilias and perpetration of abuse against children.

    People suffering from perversions present great difficulties for psychiatrists, one of which is based on these individuals' inability to intersperse a thought process before they commit the perverse action. Treatment has often been considered at best unrewarding, at worst impossible. Many sufferers encounter forensic psychiatrists in the course of brushes with the law, and many spend much of their lives in prison. When such people present a threat to the community, custodial care may be the only realistic option. However, punishment and incarceration are unlikely to have any effect upon the perversion.

Blurring the Boundaries

Max Rutherford

  • This Sainsbury Centre report details the increasing convergence between mental health and criminal justice, while exposing the differences that do and should exist between the two. It also recognises that too often the way services respond to offenders with mental health problems is inconsistent and disjointed. Too many people are either left to flounder in the gaps between services, or are caught in a “revolving door”. Too frequently, it is only due to the hard work of enthusiastic pioneers that improvements have been made in local areas.

Playing with Dynamite: A Personal Approach to the Psychoanalytic Understanding of Perversions, Violence, and Criminality.

Estela Welldon

  • Estela Welldon brings together a generous selection derived from her many literary gems, in which she illustrates her groundbreaking-and sometimes explosive-studies of female sexuality and perversions, perverse transference, malignant bonding, perverse motherhood, and the impact upon children of viewing domestic violence. Along with these are vivid descriptions of group analytic psychotherapy with forensic patients and, uniquely, of the joint group treatment of incest survivors and perpetrators. She also outlines the development of forensic psychotherapy as a new field of clinical and academic endeavour and her involvement in this. In a series of interviews with Brett Kahr she describes her professional journey, from being trained by Horacio Etchegoyen in her native Argentina, followed by an eye-opening period at the Menninger Clinic, then eventually to London and a distinguished career at the Portman Clinic.

A Practical Guide to Forensic Psychotherapy

Estela Welldon & Cleo Van Velsen (eds)

  • Forensic Psychiatry has expanded exponentially in the last twenty years with a dramatic increase in forensic psychiatry posts and medium secure unit beds. More recently there has been increased concern with the treatment and management of mentally ill offenders which has led to more interest in understanding. Treatment is seen by many people to be of great importance, hence the formation of the International Association for Forensic Psychotherapy, and the founding of the first diploma in forensic psychotherapy at the Portman Clinic, London. This practical text book is written for all professionals involved with people who break the law.

Ideas in Psychoanalysis: Sadomasochism

Estela Welldon

  • Estela Welldon contests the view that sadomasochism is an isolated ‘perversion’. Using numerous examples from literature, film, opera and other media, she undertakes an exploration of the psychodynamic aspects of sadomasochism that carries us from the writings of de Sade and von Sacher-Masoch to the contemporary underground S&M club scene. Challenging our expectations that S&M is concerned only with ‘bizarre’ activities, Welldon illuminates the dynamics of power and control in everyday family life and sexual relationships. Her investigation deepens to include the downward spiral of domestic violence and child abuse, and the ‘malignant bonding’ between couples in cases such as Ian Brady and Myra Hindley and Fred and Rose West. Is sadomasochism invariably present in the victim-perpetrator cycle? Is it learned or innate? Are sadism and masochism complete opposites, or do they complement one another? Are they specifically related to the genders? Welldon asks these questions and many more in a fluent, thought-provoking essay.

Mother, Madonna, Whore:?The Idealization and Denigration of Motherhood

Estela Welldon

  • Welldon explores why the quality of their bodies is fundamental to women's psychology; how this may lead to self-mutilation; and how such perverse behavior may also be aimed at objects which women see as their own creations, specifically, their babies. The potential causes and consequences of these conditions, including maternal and paternal incest and its frequent aftermath, prostitution, are also discussed.

Forensic Group Psychotherapy: The Portman Clinic Approach

John Woods and Andrew Williams (eds.)

  • Forensic Group Psychotherapy: The Portman Clinic Approach is part of the Portman Paper Series and New International Library of Group Analysis series. 

Respond and Forensic Psychotherapy

Richard Curen

  • Frontline Volume 91 - Forensic Issues and Disability, July 1st 2013

Laying the ghosts to rest: a therapeutic approach to the treatment of a sexually abused man with a learning disability

Richard Curen

  • Richard Curen explains how accompanying 'Gary' on a journey through three phases of psychotherapeutic treatment facilitated some kind of resolution.

    In The Psychotherapist magazine of the UK Council for Psychotherapy (UKCP), February 1st 2013.

Understanding self-injury: Psychoanalytical approaches to understanding self-injury

Richard Curen and Pauline Heslop

  • This chapter by Richard Curen and Pauline Heslop on psychoanalytical approaches to understanding self-injury can be found in the book: Understanding and Working with People with Learning Disabilities Who Self-injure edited by Pauline Heslop and Andrew Lovell. Adopting a predominantly psychological approach, the book provides carers with up-to-date information and resources to provide appropriately individualised care to people with learning disabilities who self-injure.

Psychoanalytical approaches in practice

Curen, R. and Blackman, N.

  • This chapter by Curen and Blackman on Psychoanalytical approaches in practice is found in the book Understanding and working with people with learning disabilities who self-injure.

    Adopting a predominantly psychological approach, this book provides carers with up-to-date information and resources to provide appropriately individualised care to people with learning disabilities who self-injure.

Boundary matters in a forensic learning disability service

Richard Curen

  • Richard Curen's chapter on Boundary matters in a forensic learning disability service is found within Anne Aiyegbusi and Gillian Kelly's book on Professional and Therapeutic Boundaries in Forensic Mental Health Practice.

Forensic Psychotherapy and Paedophilia in Intellectual Disabilities

Richard Curen

  • Richard Curen's chapter on Forensic Psychotherapy and Paedophilia in Intellectual Disabilities appears in the book 'Contemporary Issues in Intellectual Disabilities' edited by V. P. Prasher.

Violence, abuse and disabled people: learning-disabled adults and children

Richard Curen and Valerie Sinason

  • Richard Curen and Valerie Sinason's chapter on Violence, abuse and disabled people: learning-disabled adults and children appears in 'Domestic and Sexual Violence and Abuse: Tackling the health and mental health effects' edited by Catherine Itzen, Ann Taket and Sarah Barter-Godfrey.

Can they see in the door: Assessment and treatment of learning disabled sex offenders

Richard Curen

  • Richard Curen's chapter on assessment and treatment of learning disabled sex offenders is found in 'Intellectual disability, trauma and disability edited by Tamsin Cottis.

Map of Medicine: Schizophrenia

Bradley Hillier

  • Published in September 2013 by International as part of the map of medicine health guides. 

Foreign National Mentally Disordered Offenders' pathway through secure services

Spencer, S., Gilluley, P. & Hillier, B.

  • Over recent years UK immigration legislation and procedures have changed significantly. Although these developments affect many foreign national mentally disordered offenders, the professionals caring for them are often unaware of the implications of these changes and the possible alternative care pathways. In this article the authors explore the amendments and the options available for this patient group, and highlight the ethical difficulties that professionals can face.

Open letter to President Obama on hunger strikers in Guantanamo

Arnold, F., Iacopino, V., Allen, S., Reyes, H., Chalmers, I., et al.

Delusions arising in virtual reality

Hillier, B. & Sethi, F.

  • The role of the internet is increasingly pertinent in the daily lives of both clinicians and patients. The authors present two case reports, concerning patients recently presented to their service, involving beliefs concerning the social media website, Facebook. 

Mapping offender-patient pathways in the different jurisdictions of the European Union

Hillier, B., Lambourne, C. and Larsen, T. G.

  • Published in Criminal Behaviour and Mental Health, the article shows how process mapping was used as a tool to describe, clarify and contrast the pathways for Mentally Disordered Offenders in different jurisdictions of the European Union.

    It is necessary to subscribe to the online library in order to read the full article.

Royal College Examination Fees surplus

Lee, W., Thomson, A., Acosta, C., Ashraph, M. et al.

The Future of Quality in Healthcare Provision and the role of the Peer ReviewProcess: Quality Networks

Gilluley, P., Tucker, S., & Hillier, B.

  • In this paper the authors discuss the history, motivation and policy development behind the quality agenda in healthcare, and summarise the challenges and current work on developing quality standards and indicators. They review the development of the principle of peer review of services and finally, they use the example of the Quality Network for Forensic Mental Health Services to explain how the Quality Network concept can be used to benchmark quality on a national level and lead to improvements in services.

Use of the HoNOS-LD in identifying domains of change

Hillier, B., Wright, L. & Hassiotis, A.


    The aim of the work was to analyse clinical outcome indicator data from the Health of the Nation Outcome Scales for People with Learning Disabilities (HoNOS-LD) in adults with intellectual disability admitted to mental health wards during a 19-month period; and to identify clinically relevant domains of change associated with in-patient admission. 

Ana Attia's Story - failed by her keepers

Bradley Hillier

  • Letter to The Independent newspaper on Sunday 29th August 2010.

Violence to body and mind: treating patients who have killed

Carine Minne

  • This is a chapter in Agression: From Fantasy to Action edited by Paul Williams.

An Unwelcome Guest: The Unconscious Mind in the Courtroom

Reena Kapoor and Andrew Williams

  • This article argues that psychodynamic principles and approaches should continue to be used in forensic psychiatric work within the legal system and outlines with case study examples how this can be done.

"Filled With Desperation": Psychotherapy With an Insanity Acquittee

Reena Kapoor

  • This case study appeared in the Journal of the American Academy of Psychiatry and the Law in December 2008. 

Commentary: Psychotherapy in a Forensic Hospital

Daniel J Papapietro

  • This article, appearing in the Journal of the American Academy of Psychiatry and the Law, is a commentary on Reena Kapoor's article "Filled with Desperation": Psychotherapy with an Insanity Acquittee from the same journal (and listed in publications on this website).

Commentary: On Walking and Talking

Gwen Adshead

  • This article, from the Journal of the American Academy of Psychiatry and the Law, is a commentary on Reena Kapoor's article "Filled with Desperation": Psychotherapy with an Insanity Acquittee, that appeared in the same journal (and is found listed in publications on this website).

Locks, Keys, and Security of Mind: Psychodynamic Approaches to Forensic Psychiatry

Jessica Yakeley & Gwen Adshead

  • In this article, the authors discuss psychological approaches to the understanding of acts of violence and, specifically, psychodynamic approaches to both formulation and treatment. 


Commentary: Forensic Psychotherapy

Victor A. Altshul

  • This article from the Journal of the American Academy of Psychiatry and the Law is a commentary on Yakeley and Adshead's article on Locks, Keys, and Security of Mind: Psychodynamic Approaches to Forensic Psychotherapy that appeared in the same journal (and is also listed on this website).

Disabling Perversions: Forensic Psychotherapy with People with Intellectual Disabilities

Alan Corbett

  • This book offers an overview of how to work with some of the most damaged members of society - children and adults with intellectual disabilities who abuse others.

Toxic Couples: The Psychology of Domestic Violence

Anna Motz

  • Domestic violence is a major public health concern, affecting millions worldwide. It is underreported, often devastating and sometimes ends in murder. In Toxic Couples: The Psychology of Domestic Violence, Anna Motz integrates psychological and criminological data with clinical illustrations and discussion of current high-profile cases.

Forensic Music Therapy: A Treatment for Men and Women in Secure Hospital Settings

Stella Compton Dickenson, Helen Odell-Miller & John Adlam (eds)

  • Forensic Music Therapy demonstrates diverse and innovative approaches, which include live, improvised and pre-composed music, from music therapy teams working in secure treatment settings. The book covers clinical development, research, supervision and discussion of institutional and multi-disciplinary team dynamics. 

The Therapeutic Milieu Under Fire: Security and Insecurity in Forensic Mental Health

John Adlam

  • This book offers fresh, original and stimulating approaches to engagement with individuals who have been multiply excluded from society and who present challenges to traditional psychiatric models of assessment and treatment. 

The Violent True Believer as a "Lone Wolf" - Psychoanalytic Perspectives on Terrorism

Meloy, J.R. & Yakeley, J.

  • The existing research on lone wolf terrorists and case experience are reviewed and interpreted through the lens of psychoanalytic theory.

Paraphilias and paraphilic disorders: diagnosis, assessment and management

Yakeley, J. & Wood, H.

  • In this article, the authors outline the difficulties in classifying paraphilias as mental disorder and summarise the changes to this diagnostic category in DSM-5. 

Antisocial personality disorder: new directions

Yakeley, J. & Williams, A.

  • Antisocial personality disorder is a complex condition carrying high rates of comorbidity and mortality for individuals as well as harmful consequences for their families and society. Despite the publication of National Institute for Health and Care Excellence (NICE) guidelines for the disorder, the evidence base and provision of effective treatments remain inadequate, and the belief that the condition is untreatable remains widespread among psychiatrists and other professionals. This article highlights current diagnostic controversies and summarises the evidence for conceptualising antisocial personality disorder as a disorder of attachment. 

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