Jonathan Shedler’s workshop “Treating Personality Patterns and Disorders: Clinical Case Formulation as a Roadmap to Treatment”
Following my last blog Trauma – Psychotherapy and a ‘Healing Canopy’ I had some afterthoughts triggered by the rapidly unfolding, or exploding, Jimmy Savile scandal. Like many of my colleagues I struggle to comprehend how, considering the several hundred individuals that have come forward with allegations, this could have been kept quiet for so many decades. This whole unfolding of events does indeed feel like one huge collective afterthought.
Many are quick to react with cynicism that everyone is complaining now that the man is dead and can’t defend himself anymore, ‘jumping on the bandwagon’. Whilst I think that it is important to hold on to ‘innocent until proven guilty’, especially considering how the British media are already doing ‘their thing’, I think it is just as important to not become part of the dynamics of abuse. As mentioned in my previous blog – siding with the perpetrator is easy, since they only ask us one thing: to do nothing. The recent BBC Panorama programme gives reason to think that this is what happened when rumours and suspicions had started circulating around the third and fourth floor of BBC. Allegations were laughed off, by Savile, those around him, and BBC senior staff. Or they were simply not believed or generally ignored. In fact, Liz Dux, solicitor of the victims, states that many coming forward recently say that they did report incidents and that no action was taken.
Siding with the victims, on the other hand, poses many very difficult challenges, and what abused individuals frequently face after a traumatic experience is a response of disbelief, ridicule and even blame by others. Savile’s alleged abusive behaviour during BBC employment would have started in the mid1960s, which means one has to take into consideration that the victims, children or teenagers at the time, were living in a society that had radically different attitudes towards rape and sexual abuse compared those tentatively developing in Western society today. Not only would they not have had a ‘healing canopy’ which would have provided support and a shared reality, it increasingly appears as if they were also dealing with a societal and institutional ‘silencing blanket’. The Panorama programme starts by stating that ‘The NHS, the Home Office, and local authorities may all face legal actions for failing to protect Savile’s many young victims.’ And the BBC specifically is being accused of having turned a blind eye for decades, and especially in recent months, with the controversy surrounding the shelving of the Newsnight programme exposing Savile’s behaviour and the BBC’s conduct. Renowned BBC journalist John Simpson calls it ‘the worst crisis that I can remember in my nearly 50 years at the BBC.’
In a Culture, Media and Sport Select Committee hearing, BBC Director-General George Enthwistle, admitted that ‘There is no question that what Jimmy Savile did and the way the BBC behaved in the years that the culture and practice of the BBC seems to allow Jimy Savile to do what he did, will raise questions of trust and reputation for us, and one can only look back with horror that his activities went on as long as they did undetected. This is a gravely serious matter. […] I am determined to get to the bottom of this and to put it right.’ There will be two separate reviews, one conducted by Dame Janet Smith looking at BBC culture, and Entwistle states that ‘there are great many people we need to talk to to find out whether anybody did know what was going on.’ The second investigation is led by Nick Pollard and will focus on the Newsnight controversy.
Karen Ward, interviewed in said Newsnight programme and the first to speak on camera about being abused by Savile, explains that when she heard that the programme was shelved she felt very hurt. Her statement exemplifies the fear and risk of humiliation an abuse victim might experience when considering speaking out about such a crime: ‘To me it just meant that yet again I hadn’t been believed. But I’ve spent my whole life not being believed. It was hurtful and it was difficult because I had been pushed so hard to do it when I didn’t want to. […] In the end I said ok. That’s what made me angry, the fact that I had gone through all that stress when I really had to concentrate on getting well and then they never used it, because someone higher up didn’t believe me.’
Some of the responses shown in BBC’s Panorama programme exemplify typical responses to abuse. Martin Young, reporter of BBC Nationwide, worked with Savile and says ‘I thought he was a pervert.’ When asked if he ever thought of reporting anything he replies ‘No, never even crossed my mind. And I take my share of the blame for that.’ Bob Langley, also of BBC Nationwide, remembers seeing some girls coming out of Savile's motor home: ‘They would have been 12 or 13, maybe 14, but certainly not 15. When they had left he indicated to me in a nudge nudge wink wink sort of way that he had just had sex with them. I didn’t believe him! Supposing I had gone to the police or the BBC what would have happened? The answer is nothing would have happened - he would have said it was a joke.’
BBC Radio DJ Paul Gambaccini states: ‘This horror was going on while the whole of society was watching. But because it was off the scale of everybody’s belief system, they didn’t really come to terms with it.’ When he was asked why he didn’t report his suspicions he replied: 'So what, I, a junior DJ am supposed to get up there and say my senior is a perve? They're going to laugh at me.’
Later in the Panorama programme it is reported that in 1973 BBC Radio controller Douglas Muggeridge ordered his press officer Rodney Collins to investigate if any of the rumours about Savile having sex with minors were true. Derek Chinnery was asked to confront Savile about the rumours, which he did, and Savile denied everything. Chinnery states ‘if the man’s denied it you don’t then go and hound him. There was no reason to do so at the time.’ This is another example of it being easier to side with the abuser rather than with the victim. It also shows how frequently, in sexual abuse cases, there seems to be more pressure on the victim to prove the abuse rather than on the perpetrator to prove his innocence.
There are also accusations that Savile chose especially vulnerable victims, and this again would tap into the dynamics that frequently occur after abuse – reportedly he ‘targeted’ girls from Home Office approved Duncroft School. It is stated that ‘all the girls at Duncroft were deemed emotionally disturbed’. The former Duncroft pupils who were interviewed for Panorama state that they knew very well at the time that even if they had had the courage to speak out about what they had to go through, because of their history and the stigma already attached to girls at that institution, they would not have been believed or even properly listened to.
Yesterday Savile’s family made a statement of how shocked they are by recent events, and that they are struggling with imagining that the Jimmy Savile they knew could ever have done such terrible things. This reminded me of another difficulty the BBC and people involved or in the know might have been faced with – Jimmy Savile represented something to the British people to the extreme: goodness. As Jim in Jim’ll Fix It he was the one who would make children’s dreams come true; as a Radio 1 DJ and as Top of the Pops presenter he enjoyed almost rock star celebrity status; and his charity work itself seems to have almost catapulted him to sainthood. If that hasn’t then the Catholic Church made sure he was catapulted close to it, when, in 1990, the same year as having been knighted by the Queen, Pope John Paul II honoured him with a papal knighthood, making him a Knight Commander of the Order of Saint Gregory the Great (KCSG). Which, given the Roman Catholic Church’s own troubled history with its dealings with sexual abuse by their own clergy is highly controversial in itself.
What seems to have occurred hand in hand is that the media and Savile co-created his image and persona, whilst the British public increasingly projected their hopes and fantasies of goodness on to his persona too. Both processes were probably increasing and enabling each other. This was something that quite possibly, consciously or unconsciously, played into the considerations of anyone who was thinking of reporting any of Savile’s questionable behaviour they might have seen or suspected. It wasn’t just one person’s life they were confronting, it would be a whole nation’s hopes, and people’s sense of their own goodness in a way too. This, of course, is by no means an excuse, but an attempt at understanding and explaining the situation.
The other issue that hasn’t really been addressed is that there seems to be an inherent conflict of interest in the BBC running a programme that essentially is a damning report of BBC procedure and conduct. It kind of makes sense that it was ITV who eventually ran the story.
When emotions run high things tend to get seen in extreme, quite split ways. The British media and the British public’s idealisation of Savile left little room for criticism. A figure of such perfection has to be kept perfect at all times, at all costs. Doubts were brushed off very quickly. This might explain why, as allegations finally started being publically voiced after the ITV programme, the situation switched rapidly into the other extreme – completely demonising him and judging him without waiting for the outcome of official enquiries and reports. All of a sudden people make statements such as ‘It’s obvious’, ‘I’ve known it all along’, and ‘He looks like a pervert anyway’. On one hand it seems implausible that this story has not exploded into the public sphere much earlier; on the other hand there are many possible explanations why, for so many decades this hasn’t surfaced. A tragic large-scale example of the dynamics of abuse? Let’s wait for the evidence.
Like so many psychological processes, the effect of trauma is characterised by dialectic tensions, of wanting to kill the pain with silence and denial, and of attempting to kill it by shouting it out from the top of one’s lungs and giving it a name. The attempt to make it go away by ignoring and burying it is rarely, if ever, successful - trauma usually finds its way out as a symptom, prolonging and repeating the horror in disguised form. Letting the unbearable unthinkable pain, shame, hopelessness and rage out can come at the cost of disintegration and retraumatisation. This dialectic tension emphasises the need for a combination of an empathic response as well as putting emotions into words, and Klein (1987) emphasises the latter, putting the ‘talk’ back into talking therapies.
The nature of the psychosomatic symptom in a sense follows the pattern in which we try to deal with traumatic experiences – it screams for the pain to be recognised, trying to drag attention to the story and memory of an atrocity, while at the same time distracting from it, silencing its real origin and nature, and deflecting attention from that unspeakable experience. This leads to an oscillating between feeling numb and having traumatic and retraumatising flashbacks and dissociation. Memories and feelings about the traumatic event often are fragmented, incoherent or absent from consciousness altogether, being the result of defensive mechanisms humans can use to help them survive events that are overwhelmingly atrocious, physically and/or emotionally.
Some of the processes involved in dealing with trauma are denial, repression, and dissociation. These operate at the social as well as at the individual level, and the ways in which we experience, frame and tackle trauma is always closely linked to the social context. In Germany, for example, during and after the Holocaust the traumatic reality of the atrocities was frequently denied and repressed, and only after years and decades did the working through and rediscovery of ‘Forgotten History’ (Herman 1992) take place. In German the term for this kind of process is ‘Aufarbeiten’, which literally translates as ‘working up’ – thinking, feeling, remembering, in order to push the repressed traumatic material, memory and emotional fragments up from the scary depths up into consciousness. Implied in the literal English translation is that one gets ‘worked up’ in such a process, which brings me back to the dialectical tension – psychotherapy, especially working with trauma, is often experienced as an opening of a can of worms.
Without ‘Aufarbeitung’, however, developing a coherent narrative facilitating healing is not possible. Similarly to ‘good enough’ psychotherapy, the German school system provided a safe place in which pupils were taught about the Holocaust and encouraged to face the facts, with all their emotional impact, and process it together, under the pastoral guidance of a teacher. This frequently involved facilitating a re-experiencing of events by remembering, reading accounts and watching films, which frequently was retraumatising. It brought the events that collectively had been repressed into the depths of the German unconscious back to the surface, where for the first time atrocities to an incomprehensible scale could start to be processed. For that generation of Germans this involved experiences that have not been actively experienced but have been passed down as vague and diffuse secondary experience, which probably has a similar nature to primary traumatic experiences that have been distorted by dissociation and fragmentation.
There is a distinction between trauma caused by natural disasters or accidents, and trauma caused by human design. The former is easily met with sympathy and empathy, but in the latter the outsider is caught in the conflict between victim and perpetrator, and has to choose sides. Herman (1992) points out that it might seem easy to side with the perpetrator, who only asks us one thing: to do nothing. In contrast to this, the victim asks us to feel their pain, to act, engage, take sides, protect, remember, and risk becoming subject to attack, ridicule and shame as well.
The perpetrator does all he or she can to promote forgetting, by silencing, ridiculing, denying, rationalising, manipulating, attacking one’s credibility, and arguably worst of all, attacking one’s trust in oneself and one’s perception of, and relationship with, reality. An additional danger is that the perpetrator’s account in isolation from the wider community can seem very convincing and bullet-proof to a bystander. The victim’s account and experience become both invalid and invalidated, and unspeakable. To speak about it makes one vulnerable to even more stigma, shame, disbelief and ridicule.
To hold traumatic events in consciousness requires the weaving of what I call a ‘healing canopy’, (similar to Peter Berger’s (1967) concept of the ‘sacred canopy’), a social context and community that affirms and protects the victim coherently, and that weaves together the victim, witness and bystander in a common alliance, co-creating a coherent and shared sense of reality. It is so immensely important for recovery that the victim, witnesses, friends and family together knit what I call a ‘post-traumatic narrative’, eventually leading to a ‘healing canopy’, which provides respite and a secure base from which to gradually start engaging with life, the world and people again.
Going back to the history of psychoanalysis, Charcot laid the groundwork in the 19th century, and by 1890 Janet, Freud and Breuer agreed that the so-called hysterical symptoms they observed were the result of psychological trauma which has caused an alteration of consciousness, a state of dissociation. They discovered that psychosomatic symptoms disappeared when traumatic events were called back into consciousness, together with the accompanying intense feelings, in what they called a process of ‘abreaction’ or ‘catharsis’, and what Freud later termed psychoanalysis, (also termed ‘the talking cure’ by Breuer’s client Anna O), by following back ‘the thread of memory’.
Interestingly, there seems to be a typo on page 13 in Herman (1992) ‘Trauma and Recovery’, spelling ‘thread’ with a ‘t’ in the end, which says it all - a parapraxis symbolising the paradoxical tension between wanting to remember and to speak about it, but also wanting to employ all sorts of defenses to cut off the thread/threat of memory, because it is so intolerably threatening, frightening and painful. Freud followed the thread of memory back to sexuality as possible origin of hysterical symptoms, and frequently more specifically childhood sexual abuse.
The nature of disorders and symptoms is closely connected with the social context in which they appear – for example the oppression of women and hysteria, war and shell-shock/PTSD and ‘the combat neurosis of sex war’ (Herman 1992), in which women’s reality and existence in the private sphere was denied, which made them vulnerable to all sorts of sexual and domestic abuse, and simultaneously robbed them of the opportunity to speak out about it without shame and facing disbelief. There was no concept or terminology for the abuse they often were subject to, which left them unable to name and identify the wrong-doings in the first place. Neither was there a social framework which would have enabled the moral calibration of their experiences.
American feminist Betty Friedan called a woman’s situation ‘the problem without a name’ – I believe that one of the most damaging things after a traumatic event has occurred is the fact that abuse robs a woman (or any victim) of a voice, making him or her literally and metaphorically suffer in silence. The feminist movement created therapeutic self-help groups practicing ‘consciousness-raising’, which again reminds of the term ‘Aufarbeitung’. Their codes are similar to psychotherapeutic relationships, based on intimacy, confidentiality and honesty. This enabled women to overcome barriers of denial, secrecy, shame, guilt, denied experience, denied feelings and denied reality, (which had prevented them from naming their injuries), and enabled them, often for the first time in their lives and maybe even history as a whole, to find and use a voice. In these groups, frequently in contrast to the consulting rooms of their time, women were surrounded by supportive women who believed them when they were talking about being raped, often sharing that very experience. The existence of these groups also led to consciousness raising at the social level, and gradually also towards a change in legislation, as well as a change in attitudes within the mental health profession. In 1975, as a direct result of feminist pressure, a centre for the research of rape was established within the National Institute of Mental Health in the USA. For the first time women were seen as informants, not just subjects; their emotional experiences were honoured and validated. The results confirmed what Freud had initially established but then repudiated (maybe itself as an act of defensive denial of traumatic reality): sexual assaults against women and children were pervasive and endemic, at least in Western culture.
For the first time this allowed women to define sex against their will as rape and atrocity, and maybe for the first time allowed them to realise the traumatic impact these experiences have had on them. This led to the discovery that men might have been ‘using their genitalia as weapons’ (Herman 1992), whether they were suffering from ‘combat syndrome’ or not, and that the different kinds of trauma, including the newly termed ‘rape trauma syndrome’ and ‘battered woman syndrome’, were all closely intertwined, in a destructive, dirty ‘abusive canopy’, passed down from generation to generation. This canopy has also become soiled by the abuse and silent pain that has been swept under the carpet. It is the difficult and delicate task of the therapist to help the traumatised client unpick the fabric of this old, dirty and fragmented canopy or carpet with holes, following back both the thread and the threat of the trauma, and together weaving a ‘narrative canopy’ to facilitate healing.
Berger, P. (1967) The Sacred Canopy: Elements of a Sociological Theory of Religion, Open Road Media
Berger, P., Luckmann, T. (1966) The Social Construction of Reality: A Treatise in the Sociology of Knowledge, London: Penguin Books
Herman, J. L. (1992) Trauma and Recovery: From Domestic Abuse to Political Terror, London: Pandora
Klein, J. (1987) Our Need for Others and its Roots in Infancy, London: Tavistock Publications
The findings of the The Centre for Economic Performance’s Mental Health Policy Group are shocking but don't come as a surprise to many in the profession - there is a 'massive inequality within the NHS' in the way it treats mental illness compared to physical illness. Facts from the report first, my experience as an NHS Honorary Therapist and and Attachment-Based Psychotherapist in Training later.
According to the report, which was written by distinguished economists, psychologists, doctors and NHS managers, almost half of the health problems of under 65s in the UK are mental illness (mainly depression, anxiety disorders and child disorders). Despite mental illness often being more debilitating than physical illness, the NHS only offers treatment to 25% of mental health issues, compared to the fact that (arguably) most physical illnesses being treated. One of the reasons given is that NHS commissioners have failed to adequately commission the health services that NICE recommend.
The report emphasises that the need for changes in policy is urgent, but that currently the NHS is cutting mental health services rather than expanding them, which would cost the NHS nothing. Mental health problems can make physical symptoms worse and can even cause them in the first place. Frequently, patients with 'medically unexplained symptoms' get referred from one specialist to the next, without any improvement. Treating physical symptoms caused by mental illness currently cost the NHS £10 billion, which according to the Mental Health Policy Group would be better spent on psychological therapies, where the cost is low and the recovery rates are high. They found that about half of those suffering from anxiety disorders and depression respectively recover after an average of only ten hours of CBT, permanently.
This report exposes the extent of which NHS policies focus on short-sighted, often inadequate treatments of symptoms, rather than tackling their real causes. It is not rocket science to figure out that that is not an economical way of going about it, and not a very healthy one either. I know of GPs refusing blood tests to patients complaining of tiredness, but instead wanting to prescribe them anti-depressants, having spent only five minutes with a patient they have never met before. (Interestingly, the use of anti-depressantsand other types of medication are not addressed in this report.)
It is vital that these issues are brought to public awareness emphasising the urgent need for change, especially since such change would be self-funding. It does, however, come from a rather medical perspective, and many psychodynamic psychotherapists have concerns about the bias towards Cognitive Behaviour Therapy (CBT) in new NHS guidelines. Recently, over 6,000 practitioners have signed a petition against NICE guidelines in the IAPT programme. Psychodynamic psychotherapies tend to be open-ended and unstructured, making them much less attractive for the NHS, not because they aren't proven to be highly effective, but simply because their 'success rates' are much more difficult to statistically quantify compared to CBT, and because they tend to have a longer duration. Psychotherapists' criticism of this bias is indeed justified, but it has to be put into perspective: A course of CBT is usually the first treatment offered by the NHS, but in a way it is only a starting point. Yes, it is unlikely that 12 sessions of CBT will cure every mental illness. The facts are that it has varying success rates for different illnesses. But to say that CBT is generally unhelpful is also inaccurate, since it does reduce or alleviate many patients' symptoms, and often permanently. For the 50% who do not recover after a course of CBT, and especially if a patient is persistent enough, the NHS has fantastic things on offer, and I was unaware of this before my time as an NHS Honorary Therapist: GPs, psychiatrists and community health teams further evaluate and can offer patients up to one year of psychoanalytic psychotherapy, various group therapies, as well as 18 months of Mentalisation Based Therapy (MBT). Amazing resources are available within the NHS, but the fact that they are not frequently mentioned is symptomatic of the inequality mentioned by the report.
It is also pointed out that, unbelievably, and despite the IAPT programme, mental health services are still being cut rather than expanded. The personality disorders service I am working at have been subject to these cuts, losing around half of their staff over the last year, and as a result having to reduce the amount of patients they are able to treat. Waiting lists and waiting times are long. The criteria of admission to the service has been changed from moderate to severe personality disorders, which means only individuals who currently self-harm are taken on. As a result many individuals continue to suffer from their personality disorders, as well as those around them. The cost to society (and other NHS services, e.g. A+E) will also be increasing as a direct result of these cuts, since many personality disorders come with drug addiction, suicide attempts, unemployment, self-harm, crime, anti-social behaviour and violence. These changes now lead to a situation where individuals with mild or moderate PDs go through lengthy assessment procedures, only to be told that they can't benefit from that particular service, after which they are transferred back to the general psychotherapy service. Often they fall through the occurring cracks of the current system.
This leads straight to some of the advantages of psychotherapy services outside of the NHS. Psychotherapists in private practice are independent (apart from their regulating bodies' ethical guidelines) and don't have to follow frequently changing government policies. This enables them to offer a more consistent treatment and to fine tune the therapy according to the client's needs rather than being driven by having to meet targets and fulfilling quotas. Attendance, motivation and results tend to be better if the clients / patients actually pay for their sessions. Navigating through the NHS system trying to get help often means being on long waiting lists, going through assessments, being denied certain therapies, being referred back and forth and having to deal with a great deal of uncertainty and additional anxiety along the way. It can be experienced as feeling forgotten, feeling like a burden, and feeling rejected. In a sense only those able to be persistent and proactive enough to 'work the system' are likely to get treatment, leaving it inaccessible to those who need it the most. Trying to get NHS treatment for mental health issues frequently inflames the very vulnerabilities and difficulties that a patient is seeking help for. Ambivalent attachment at its best. This should really be avoided. Private practitioners try to offer a sense of stability and security from the beginning.
Psychodynamic psychotherapy circles tend to be rather critical of the NHS's mental health services, and especially CBT. The problems in the private sector of this profession is that often those most in need of intervention are unable to afford the rates that we need to charge in order to make a living. The training organisations make sure that their trainees offer long-term therapy at minimum wage for unwaged training clients, and registered therapist often still offer low-cost therapy, but, since training costs and running costs are high, and this is our income, the average of £60 or £70 a session will be the bulk of a private practitioner's work. Whilst making a valid point, some of the criticism might be coming from anxieties about professional survival in difficult economic times. Most importantly, the main focus should be to get those suffering from mental illness access to efficient treatment, and that means the NHS having to offer more psychotherapeutic treatments, including longer term psychodynamic ones, not just CBT.
The report 'How Mental Illness Loses Out in the NHS' by The Centre for Economic Performance’s Mental Health Policy Group can be downloaded for free at
Silke Steidinger 1/9/2012
Silke Steidinger - Psychotherapist writing about developments in psychotherapy