Author: Jessica Yakeley, Director, Portman Clinic

Building on its history, the Portman Clinic continues to maintain its core psychoanalytic identity based on its clinical work, which informs the many other activities it is involved in, whilst developing new opportunities in the context of a changing landscape.

The Portman Clinic today is an out-patient NHS forensic psychotherapy clinic that offers psychoanalytic psychotherapy assessments and treatment to adults, adolescents and children presenting with violence, problematic sexual behaviours, delinquency, and antisocial behaviour. It also carries out a range of other activities, including consultation, teaching, training and supervision to forensic institutions.

The Clinic’s clinical staff come from a variety of disciplines including psychiatry, psychology, nursing and social work, and most have further qualifications as psychoanalysts or British Psychoanalytic Council (BPC) -accredited psychoanalytic psychotherapists or child psychotherapists. It has a national remit in that its specialist clinical service is commissioned by NHS England so that referrals can be accepted from anywhere in England, with 75-80% of referrals from within Greater London. Most referrals come from GPs or secondary mental health services, as well as referrals from probation, social services, youth offending services, local authority education services, and the private sector, and importantly, the Clinic accepts self-referrals. The Clinic receives around 250 patients a year.

Most patients who are referred have had several interventions by local services but need the specialist provision offered by the Portman Clinic. A recent audit showed that 67 % present with paraphilic disorders and other problematic sexual behaviours (e.g. paedophilia, use of child internet pornography, fetishism, exhibitionism, and addiction to adult pornography), 19% with violence (antisocial behaviour, domestic violence/ interpersonal violence, physical assault, sexual assault, rape, murder); 4%  with  gender identity issues; and 10%  with a combination of sexual and violent behaviours.  85%-90% of patients referred are male, partly because women are often seen as ‘less dangerous’ to the community as they tend to enact this type of disturbance by harming themselves, their children and sometimes their partners. The audit showed that the average age at referral is 35, the youngest patient referred was age 4, and the oldest age 80.

At any one time there are about 170 patients in treatment, roughly half in individual therapy and half in group therapy, and a few receiving couple therapy. Treatment sessions are usually weekly and, given the disturbances and failures in these patients’ developmental histories, often resulting in a mistrust of and difficulty in using professional care provision, treatment tends to be more long term. For many patients, approximately 3 years tends to be what is required for the establishment of some degree of stability in the reduction of antisocial behaviours, but a few patients are seen for longer.

The child psychotherapy team sees children, adolescents and young adults for psychotherapeutic assessment and treatment, actively working with their families, carers and the wider network. The team also carry out risk assessments of young persons referred by social services, forensic health services, childrens’ homes and other agencies.

A number of challenges have impacted on the work of the Clinic in recent years. In the past decade the Portman Clinic, like every other service in the NHS and public sector in the UK, has suffered from financial cuts imposed by successive governments’ politic-economic policies of austerity. Additionally, many longstanding psychoanalytic psychotherapy services in the NHS have been decommissioned due to a perceived lack of evidence for their efficacy, despite a robust and growing evidence base. Moreover, commissioned psychological treatments are increasingly time-limited, being rarely more than one year in length, and most less than six months in duration. The changing profile of patients presenting to secondary and tertiary mental health services is also a challenge: patients present with more complex psychopathology and co-morbidity, and with new problematic behaviours enacted on-line, resulting in a significant increase in the past decade in patients referred to the Portman Clinic with offences for downloading illegal images of children, as well as those with antisocial personality disorder.

Seeing more complex patients has also meant that more risky patients are being seen, and risk to self and others is continually assessed and monitored throughout treatment. One of the factors that helps mitigate such risk is the containment – not only emotional containment that is provided by clinicians in providing a safe psychological space within therapy for the patient to begin to explore his thoughts and feelings, but also the physical containment afforded by the physical containment of the building – a shabby, Victorian building a bit like a dilapidated family home, and its familiar waiting room and friendly receptionist, – what the psychoanalyst, Henri Rey, used to call the ‘brick mother’.

Despite this difficult environment, the Portman Clinic has succeeded in maintaining its core model of psychoanalytic psychotherapy, as well as developing important new initiatives in the areas of consultation, training, research and service development.

The Clinic’s consultation and training activities include running reflective practice groups with staff in prisons and Young Offender Institutes in London and in other parts of the country, and to professionals from a variety of backgrounds within criminal justice, health, social care and voluntary sector settings. In 2018, a working party was established with the British Psychoanalytic Council to promote the application of psychoanalytic and relational approaches within prisons and more widely in the criminal justice system at both the strategic and operational level.

5 years ago, the Portman Clinic started a BPC accredited forensic psychotherapy training, D59F, for therapists from non-medical disciplines, as until then the only formal training in forensic psychotherapy was in psychiatry. D59F is a two-year training, involving taking on 2 patients for psychotherapy under supervision, as well as attending lectures and seminars, which lead to a qualification as a forensic psychodynamic psychotherapist.

The Clinic also offers a number of CPD courses, including ‘Introducing psychoanalytic ideas on violence, delinquency and sexual deviation’; ‘Foundations in psychodynamic approaches to risk and complexity’; and ‘Assessing risk: a relational approach’.

Another key development is the continuation and expansion of the Clinic’s research activities and endeavours. One of the previous directors of the Clinic, Mervyn Glasser, formed a research violence workshop which met during the 1980s and 90s and formulated many of the ideas that are still very useful today.  Since then, there have been several significant research projects, which include a study at Ashworth High Secure Hospital in which weekly consultation to the staff increased the number of personal engagements between staff and patients; research on risk assessment in which it was shown how emotive factors, which we could conceptualise as the countertransference, contributed disproportionately to risk assessment even in experienced forensic practitioners; a study interviewing patients to ascertain their experiences of psychotherapy at the Portman Clinic and their views on what changed and how; research at HMP Grendon Prison Therapeutic Community on the Implicit Association Test, in which an implicit association between violence and enjoyment (sadism) was identified and found to be associated with offenders who are more antisocial, advancing our understanding of risk; and the Portman Clinic’s involvement in a large multi-site randomised controlled trial led by University College London, evaluating the efficacy of mentalization-based treatment (MBT) for violent men with antisocial personality disorder under the supervision of the National Probation Service. For the latter study, the Portman Clinic was commissioned by NHS England and the Ministry of Justice to develop, implement and deliver the MBT services, which were being evaluated by the trial, within the National Probation Service nationally across 14 sites as part of the government’s Offender Personality Disorder Pathway. These services were shortlisted for the prestigious Health Service Journal award in 2018.

The aim is to develop the Portman into an actively functioning psychoanalytic research clinic and build an evidence base for the efficacy of its treatments in an under researched population, particularly in regards to patients accessing illegal images of children, and those with paraphilic disorders. A research programme was initiated in 2017 evaluating the efficacy, quality, safety and patient experience of therapy, in which every consenting patient accepted for treatment receives a battery of measures and qualitative interviews assessing their symptoms and behaviours, risk, experience of treatment, quality of life, and how these change during treatment.  Despite the challenges in conducting this research alongside the patient’s therapy without interfering with the psychoanalytic frame, this initiative has been widely welcomed in its endeavour to provide a wealth of information and evidence not only regarding the question ‘does therapy work?’ but addressing ‘how does it work?’ in identifying conscious and unconscious mechanisms of change.

In relation to service development, in 2018 the Portman Clinic was successful in being awarded the contract for designing, developing and delivering a forensic child and adolescent mental health service (FCAMHS) for North Central and North East London, part of the national rollout of similar services commissioned by NHS England. This is primarily a consultation and liaison service helping all the disparate agencies – social services, local CAMHS, youth offending services, third sector organisations, the criminal justice system – which are involved with children and young people with high risk behaviours, complex needs and psychopathology liaise with each other, provide formulations and help them manage and contain the young person in the community. This work builds on the longstanding liaison, consultation and risk assessment expertise and work of the Clinic’s child and adolescent psychotherapists, which is based on psychoanalytic and attachment theory.  FCAMHS consists of a multi-disciplinary team of psychiatrists, psychologists, mental health nurses, child psychotherapists and a team administrator, and its work to date has received much positive feedback from both referrers and commissioners.

Finally, as with all NHS services, the Covid pandemic has presented further significant challenges, including a shift to staff working from home and adjusting to delivering its clinical, consultation and training activities remotely, enabling the Portman Clinic to continue to work in these difficult times.