Author: Stanley Ruszczynski, Portman Clinic, first published in the Journal of Child Psychotherapy 2016
The Portman Clinic is an NHS outpatient psychotherapy clinic, part of the Tavistock and Portman NHS Foundation Trust, London. It offers assessment and psychotherapeutic treatment to children, adolescents (and their parents/carers) and adults who are disturbed by their delinquency, criminality or violence, or whose sexual behaviour is disturbing or damaging to themselves or others. On the basis of this clinical experience, the Portman offers teaching and training, and clinical and organisational consultancy to clinicians, their supervisors and managers, working with similar patients/clients in mental health, social care and criminal justice settings.
In 1960, when writing about the beginnings of the Portman Clinic, one of its founders, psychoanalyst Edward Glover, stressed that in relation to its patients,
The first concern of the [Portman Clinic] was to make a thorough examination [of their situation, circumstances and presenting problem] … and the second to arrive at a provisional diagnosis. The diagnosis should be sound enough to permit of a satisfactory recommendation of disposal; the examination should be comprehensive enough not only to exclude diagnostic error but to permit of subsequent … research.(Glover, 1960: 48)
From its very inception, the Portman Clinic has had as its purpose assessment, treatment and research. In addition, it now offers a range of teaching and training programmes, contributes to service development and offers clinical and institutional consultancy to colleagues, their supervisors and managers working with similar patients and clients.
The Portman Clinic at 8 Portman Street, 1938
Glover also wrote that because delinquency and crime are social phenomena, they appropriately attract the attention of a variety of disciplines including social workers, probation officers, youth offender workers, psychologists, psychiatrists and sometimes lawmakers. However, in his view, ‘the most fundamental approach to crime, pathological or otherwise, is that of psycho-analysis’ (Glover, 1960: xii). He goes on to say,
… so long as the existence and power of unconscious motives is disregarded, we cannot learn any more about crime than an apparent common sense dictates … However speculative and uncontrolled some psychoanalytic views on crime may be, they do at least promise to uncover the fundamental flight from reality that leads to pathological and possibly all forms of criminal conduct.(Glover, 1960: xiii)
Although the Portman Clinic now treats patients with a greater range of disturbance than criminality, this perspective remains central to its work. The understanding that a disavowal of reality is often at the heart of much perverse, violent and delinquent behaviour sustains much contemporary clinical practice in the Portman Clinic.
The beginnings of the Portman Clinic go back to 1933 when it was established as the clinical arm of the Institute for the Study and Treatment of Delinquency (ISTD), initially established in 1931 as the Institute for the Scientific Treatment of Delinquency. The Institute was founded by a small group of people including psychoanalysts Edward Glover and Kate Friedlander, both motivated, in part, by the work of Dr. Grace Pailthorpe, a fellow psychiatrist and psychoanalyst, who, after the First World War, worked in Birmingham and Holloway Prisons. There, Pailthorpe became interested in the personality of women prisoners and in 1932 published Studies in the Psychology of Delinquency.
‘Studies in the Psychology of Delinquency‘ by Grace Pailthorpe
In 1948, on the creation of the National Health Service, the Portman Clinic formally separated from the ISTD and became part of the NHS. In 1970, it moved to its current premises next to the Tavistock Clinic and both the two clinics were managed by the Hampstead Health Authority. Finally in 1994, the two clinics joined together to become an NHS Trust and then a Foundation Trust in 2006. (For fuller descriptions of the history and development of the Portman Clinic, see Fishman and Ruszczynski (2007), Saville and Rumney (1992) and Shapira (2016)).
The Portman Clinic, 8 Fitzjohn’s Avenue
At the time of the beginning of the Portman Clinic, a few psychoanalysts, including Glover in particular, had begun to develop psychoanalytic thinking and its adaptation and application to the field of criminality and delinquency. Freud had already written ‘Criminals from a sense of guilt’ (1916), Klein wrote ‘Criminal tendencies in normal children’ (1927) and ‘On criminality’ (1934), and later Winnicott wrote ‘The antisocial tendency’ (1956).
Inside the Portman Clinic, 1938
Glover’s book, The Roots of Crime (1960) in which he wrote about alcoholism, drug addiction, paraphilias, prostitution, sado-masochism, perversion and aggression, stemmed from his association with the Portman Clinic. He had been centrally involved with the London Clinic of Psychoanalysis, and his clinical interests led to the creation of the Portman Clinic.
Portman Clinic medical exam, 1938
The psychoanalytic orientation of the Portman Clinic therefore, goes back to its origins and over the years has evolved to include not only the original Freudian orientation but also theory and practice stemming from Klein and her followers and from the Independent school. In many ways, although a theoretical development and understanding of Portman patients is, of course, essential, the focus of the clinic’s work tends to be on the clinician’s affective experience of being with patients who, by definition, enact their conflicts and impulses, and as a result create disturbed and disturbing states of mind in those around them, including their clinicians.
Psychological testing at the Portman Clinic in 1938
Through projective processes, the mind of the clinician becomes the receptacle for the patients’ unprocessed psychic states, but in so doing becomes, through processes of identification, the vehicle for the beginning of the patient developing a capacity to process and contain these states.
To emphasise the point, the lack of an internal psychic space within which the patient can process and contain their emotional and somatic experiences, results in the patient – via various dynamic processes, including identification with the aggressor, identification with neglect, processes of splitting, projection and projective identification – turning to their body or to the body of others or to the external environment more broadly, to create the theatre within which to act out their toxic states. The disturbing unprocessed mental states become located in the other, in their body and in their mind. In addition, just as the mind of the victim is impacted and disturbed by the violent act, so is the mind of the perpetrator who now has the experience of having been perverse or destructive towards another.
This has clear technical implications for clinical practice. If we understand that the patient’s disturbed and disturbing behaviour is their only way of dealing with unprocessed internal states, then clinicians will inevitably become actors in this dynamic and be recipients of the toxicity of the patient’s minds. It is often said that with patients who excessively use projective identification as a way of expressing themselves, the clinician is obliged to carefully monitor and survive the often disturbing countertransference experience. This is especially difficult when the patients’ way of functioning, inevitably present in the clinical encounter, involves a somatic component. Clinicians working with patients who express themselves using or attacking their own bodies or the bodies of others will to some degree have their own somatic sense disturbed, for example by feelings of disgust, fear, excitement, arousal or vengefulness. As Freud said the first ego ‘is first and foremost a bodily ego’ (Freud, 1923: 26) and hence both the ‘forensic’ patient and their clinician have to process not only disturbed and disturbing psychic states but often disturbing psycho-somatic states.
The reference to a lack of an internal space in the patient clearly suggests early developmental failure with regard to the necessary containing parental object which contributes to the infant and child developing an internal containing object. This failure results in a pathological relationship to both the somatic and psychological self. Constitutional vulnerabilities are also likely to be present and so the forensic patient can be thought to have bio-psycho-social disorder. It is essential that clinically we look for the abused and violated child in the abusing and violent adult or, to put it in another way, that we look for the victim in the perpetrator.
For this reason it is especially appropriate for the Portman Clinic to offer assessment and psychotherapeutic treatment to children and adolescents and to adults, with child and adolescent psychotherapists working alongside adult psychotherapists, sharing clinical discussions and sometimes sharing clinical work, with the former working clinically with the child/adolescent and the latter working with the parent/carer. The adult therapists can hear about childhood disturbances which are likely to be the psychic roots of their adult patients, and the child therapists can hear about the crystallisation of developmental difficulties in the psychopathology of adult patients.
Thinking about this introduction to this edition of the Journal, I came across the following passage from Glover’s writings, ‘It is a general rule that in cases of pathological outbursts of violence it can be established that disordered acts of the same kind have occurred in early childhood’. He continues,
If sufficient trouble were taken, pathological cases liable to commit murder could be detected during early childhood; in other words pathological murder is potentially preventable, or, at least, the tendency can be detected at a time when measures of prevention can be taken.(Glover, 1960: 348)
He goes on to suggest that such people are often amenable to treatment if taken young enough and if the treatment is continued long enough. He suggests that all those who are convicted of violence should be offered assessment for treatment.
This view may be an example of a degree of idealism present in some of the early writings about the beginnings of the Portman Clinic – that treatment can always supersede punishment. Or perhaps is it a view that actually makes common sense and needs to inform thinking within youth offending and criminal justice settings. Can this perspective, appropriately modified by realistic expectations and goals, and taking proper account of risk, inform contemporary political thinking with regard to how best to try to understand and develop services for people considered as potentially dangerous to others as well as to themselves? Can this understanding also take seriously the fact that offending behaviour and actions are often, inevitably, very disturbing to the clinicians and services who work with them, and that this has to be taken account of in service design? How do we balance our awareness of such offenders’ risk and dangerousness and the need to protect society, whilst at the same time assess for the possible offer of a professional psychotherapeutic treatment, provided by staff supported to manage the disturbing nature of much of what they will deal with?
The history and work of the Portman Clinic shows an organisation that is tasked to do exactly that.
FISHMAN, C. and RUSZCZYNSKI, S. (2007) ‘The Portman Clinic: an historical sketch’. In MORGAN, D. and RUSZCZYNSKI, S. (eds) Lectures on Violence, Perversion and Delinquency. London: Karnac.
FREUD, S. (1916) ‘Criminals from a sense of guilt’. SE 14: 332–3.
FREUD, S. (1923) ‘The ego and the id’. SE 19: 12–66.
GLOVER, E. (1960) The Roots of Crime: Selected Papers on Psychoanalysis. London: Imago.
KLEIN, M. (1927) ‘Criminal tendencies in normal children’. In The Writings of Melanie Klein, Vol. 1. London: Hogarth, 1975.
KLEIN, M. (1934) ‘On criminality’. In The Writings of Melanie Klein, Vol. 1. London: Hogarth, 1975.
PAILTHORPE, G. (1932) Studies in the Psychology of Delinquency. London: Medical Research Council.
SAVILLE, E. and RUMNEY, D. (1992) Let Justice Be Done: The History of the ISTD – A Study of Crime and Delinquency from 1931 to 1992. London: ISTD.
SHAPIRA, M. (2016) ‘Psychoanalytic criminology, childhood and the democratic self’. In FFYTCHE, M. and PICK, D. (eds) Psychoanalysis in the Age of Totalitarianism. London: Routledge.
WINNICOTT, D.W. (1956) ‘The antisocial tendency’. In Collected Papers: Through Paediatrics to Psycho-Analysis. London: Hogarth, 1958.