Rosamund
Rosamund is a practitioner working on the Forensic Therapies HoST programme at HMP Holloway. Here she describes the challenge of working with the dynamics of Borderline Personality Disorder and how her own theoretical model enables her to support the dialectical approach used in this specialist service.
I am one of a group of seven honorary counsellors and psychotherapists, six of whom were recruited specifically for the HoST project whilst the seventh was already an established counsellor within the generic Forensic Therapies service in Holloway prison. Our role is to provide the weekly individual counselling or psychotherapy session which complements the skills groups attended by the women in the programme, although, in keeping with DBT principles of marrying group and individual work, two of us are also involved with delivery of the skills groups in addition to our work with individuals – an opportunity that will be available to all honorary colleagues, as the project proceeds. So it is from my current dual perspective of individual and group therapist that I offer the following thoughts.
Honorary practitioner posts are unpaid and many organisations depend upon the services of such volunteers, particularly when offering therapeutic services to client groups that have a plethora of needs. Despite the lack of salary, however, honorary posts are much sought after with no shortage of high calibre and experienced applicants. So why do we do it? Why do we all clear a day in our busy week to work with what is acknowledged to be one of the most difficult client groups, in one of the most challenging settings? It is perhaps noteworthy that all of us have varied work histories, both therapeutic and non-therapeutic, with marginalised and excluded client groups. We have already made a commitment to working with some of the most vulnerable members of society, in the awareness that they, conversely, can make society feel most vulnerable and, in reality of course, pose a risk to society.
I am a psychoanalytic psychotherapist with a background of working in therapeutic communities and reduced cost therapy services with clients who have enduring mental health issues. I was attracted to the project by the prospect of widening my skill base both in terms of working in a prison setting and with a programme addressing the very particular treatment needs of people with Borderline Personality Disorder. But it was also more than that. I think that there is something about the decision to train as a psychotherapist that acknowledges a wish to work with possibility – the possibility of understanding, of change, of choice – and, for my own part, an earnest desire to keep hope alive. I know, of course, that words like possibility, change, choice and, perhaps especially, hope, are not to be used lightly and need to be tempered by the word ‘responsibility’. Forensic Therapies, last annual report was entitled ‘Invitations to Responsibility’ and from my reading of it I understood this to be an expectation on clients, practitioners and the organisation itself; particularly as the gap between these therapeutic ideals of understanding, change and hope and the minute by minute progress of a psychotherapy session can be immense! The work is rewarding, but along the way it can also be painful, taxing, infuriating – and lonely. In applying to join the HoST project I wanted to work for an innovative service but I also wanted to be part of a team.
Much of the work of ‘mainstream’ therapy happens in a privileged space, between two individuals. The client brings what they choose of their world to the therapist, to be explored in a defined time and a given, reliable setting. This is not so in prison. Apart from anything else, you enter the world of your client in an absolutely concrete way. And it’s a reality that they know better than you. A great deal has been written about the essential tension between the aims and practice of psychotherapy and the realities of prison life. I had read about this, thought about it and discussed it at interview. But nothing quite prepares you for the moment when you find yourself fumbling with recently issued keys, escorting your new client back to her wing, on a route through the prison that you had to get in early to practise (well, I did that anyway) so that you look vaguely as though you know what you’re doing. It might have been quite overwhelming if it were not for the fact that we had been preparing for the start of the client work for six months.
I have worked on other pilot projects where we hit the ground running, delivering a service before even meeting properly as a team, fire-fighting for the first few weeks. That’s the way it can be, of course, but with this particular client group and setting it would certainly not be ‘responsible’ and possibly self defeating and dangerous – for all concerned. DBT works on a founding principle of team delivery and, therefore, whether we work with individuals or with the skills groups we have all met together regularly over the last six months for training, supervision and the exchange of information that ensures the coherence of approach that is essential for our particular client group. Holding these meetings in HMP Holloway for three months prior to beginning to see clients proved essential. Working in a prison, especially for the first time, provokes anxiety and so I have been grateful to experience the counterbalance of a climate of respect in which courtesy and helpfulness are the norm.
One of the unexpected impacts of working with the HoST project has been the wider application to my work in other settings, most particularly in my private practice. In a recent edition of the British Journal of Psychotherapy, Abraham Brafman (BJP 24:2: p199) observes that most practitioners work within the ‘parameters’ of the training they received, in terms of length and frequency of sessions, mode of greeting and parting at the start and finish of a session, use of the couch, arrangements for holidays and fee paying. He questions whether this meets the needs of the client and suggests that it is perhaps more for the ‘comfort’ of the therapist, expressing the hope that practitioners can, instead, develop a pattern of working that is the result of ‘conscious, deliberate self-scrutiny and experimentation’. Working in a prison setting ensures that you have to make decisions about how to retain the integrity of your work – from ‘parameter’ stage onwards – with clients who sometimes cannot stay in a room, unless locked in, for more than ten minutes at a time, who have no notion of boundaries and a history of non-engagement and where you, as the therapist, are subject to the primacy of the institutional need for security. The therapeutic parameters, although they might seem quite insignificant, actually set the scene and underpin the main task of engaging with the client in thinking about meaning. As I commented earlier, working in a prison means entering the physical world of your client in a way that just doesn’t happen in private practice and it is easy to be seduced into thinking about ‘concrete reality’ and ignoring the significance of internal reality. The only way to keep to the therapeutic tasks of creating an alliance and engaging in symbolic thinking with the client is to remain alert to interferences from the setting, the client and oneself to this process. The opportunity and necessity of such ‘self-scrutiny’, along with the team input offered by being part of the HoST project, is invaluable and I look forward to a long association with it.