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Case notes

Practitioner: Tamsin Cottis, psychotherapist, and Richard Curen, director of Respond.  

Field: Learning difficulties. 

Location: Greater London. 

Client: Ashley Woodhouse is 19 and has moderate learning difficulties. His speech is sometimes difficult to understand. 

Case history: For the past two years Ashley has been living in a residential care home some distance from his family home. Ashley spent all his childhood at home with his parents and younger sister, Donna, 10, who also has mild learning difficulties. He admitted that he had sexually abused Donna. This caused his father great anger and their relationship is now poor. Nonetheless, family contact has been extremely important to Ashley although this hasn't happened with the regularity he hoped for. Subsequently, care staff have become concerned that Ashley's sexual behaviour could pose a risk to others. Despite being constantly supervised outside the home and closely supervised within it he has, for example, managed on at least three occasions to lock himself in the bathroom with other residents and followed another resident into their bedroom.  

Dilemma: Ashley has the ability to take part in the community but refuses to acknowledge that his behaviour is inappropriate. 

Risk factor: If unsupervised, Ashley's impulsive sexual behaviour can put vulnerable adults and children at risk. 

Outcome: Work continues with Ashley. It is hoped that psychodynamic therapy will help him come to terms with his behaviour.

If you are to resolve any personal or social difficulty, the first step is to acknowledge you have the problem. It's the basic requirement in dealing with, for example, drug and alcohol abuse. But it is just as true for people who have sexually inappropriate behaviours. People like Ashley Woodhouse.

Ashley, 19, has learning difficulties and was moved into a residential care home following his inappropriate touching of his younger sister, Donna, and her friends. The home cares for people with more severe disabilities than Ashley's. Although he is closely supervised at the home he has on three occasions been caught locked in the bathroom with other residents. Because of their inability to communicate, it is not known for sure what happened, if anything.

In an attempt to better understand Ashley's behaviours and to plan more long-term, Ashley was referred for a risk assessment to Respond, a service for people with learning difficulties who are victims or perpetrators (or both) of sexual abuse.

The 12-week risk assessment, among other things, aimed to evaluate the root causes of Ashley's sexually reactive behaviour. Although this process is not a psychotherapeutic piece of work, it is informed by psychodynamic thinking, which takes as its starting point the importance of thoughts and feelings drawn out from both client and therapist during therapy. Respond's experience is that clients who hurt others through sexual aggression almost always have this behaviour rooted in an earlier trauma.

"Since Ashley was about 10 there have been concerns about the sexualised nature of some of his behaviour," says Respond psychotherapist, Tamsin Cottis who met with Ashley for 12 one-hour sessions. "The cause of the behaviour is uncertain but there are some concerns that Ashley may have been sexually abused."

Richard Curen, director of Respond, who managed the case, adds: "Although it was the sexual risk he posed to Donna, in particular, which led to Ashley being removed from the family home, more recently he has been seen watching children at play very intently and there are strong concerns that he is also a sexual risk to children."

"Although Ashley agreed that he has sexual feelings towards Donna, I think he was too anxious to face up to these as he clearly identifies them as the source of his difficulties. He knows that his abuse of his sister led to him leaving his family and is seeking instead to deny it," says Cottis.

Ashley's family is very important to him. "He talks about them a lot and has spent many hours working on and then looking at his family tree. He is also envious of Donna's greater intellectual ability and feels some resentment towards her. I think this is probably fuelled by the fact that Donna continues to live at home while Ashley cannot," says Cottis.

Respond believes Ashley's family attachment experiences are a good indication for the success of any further therapy. "The main block to him forming good relationships at present is his difficulty in acknowledging his past and present dangerous behaviour. His levels of denial are very high and this increases the risk he poses as he is unwilling to accept that he has done anything which may cause hurt," says Curen.

Cottis continues: "I think, with more time, and a safe therapeutic environment, Ashley may be able to talk more about whether or not he has been abused. If so then the sexual nature of his attacks will need to be seen as a response to this."

Ashley, who has also been physically aggressive towards staff, kept calm in the sessions with Cottis. "He was controlled, polite and friendly, which suggest that at times he is able to control his impulses," she says.

However, adds Curen, although it is encouraging that "Ashley is capable of controlling his behaviour, while he continues to deny his dangerousness it is hard for his carers to build a picture of when it is safe for him to be unaccompanied."

Respond believes that Ashley should live somewhere closer to home, which might make family contact more positive. This should be somewhere with maximum opportunity for safe community involvement which will help bolster his self-esteem.

"I think that with long-term therapy Ashley would be able to face up to his denial and to look at what he does at a deeper and more profound level," says Cottis.

- We intend to return to this case later in the year to check on progress.

Arguments for risk

• Therapy will give Ashley a chance to explore his childhood experiences and link them with his present day life. Challenging therapy will also address his dangerous behaviour and seek to help him acknowledge it and understand its causes and triggers.  
• Although Ashley may well continue to pose a risk to his sister, he derives a considerable sense of identity and belonging from his family and this should not be denied - making a move nearer home will help this. It may be necessary to give more focused support to  his family as they seek to cope with Ashley's enduring threat to others and its possible causes.  
• There is currently a discrepancy between the amount of control exercised over Ashley and his wish for more independence and freedom. A guardianship order should be considered with a residential requirement. The appointment of an advocate for Ashley will also help Ashley to put forward his own views about his care.   

Arguments against risk 

• He does not deny that he hurt his sister but seemingly does not accept responsibility for this. With his high level of denial and his limited capacity for empathy, the risk of Ashley continuing to be a danger to others is high. 
• There are many external controls in place at the moment but even with these in place it is not possible to guarantee the safety of other residents. 
• Staff have reported that he can be physically aggressive towards them, particularly when denied his wishes.  
• Ashley's current offending behaviour appears opportunistic and compulsive. He takes a chance when he can to be alone with other residents. Because of the high levels of supervision he has few opportunities. However, he makes the most of those he does have. 
• If contact with family does diminish this will undoubtedly cause great distress to Ashley and he will need considerable support to deal with his feelings of loss and abandonment.

Independent comment     

At Voice UK we know many people with learning difficulties, like Ashley, who are desperate for the opportunity to have skilled, experienced help like that provided by Respond, writes Kathryn Stone. 

Sadly, many local authorities and others responsible for funding such care don't see the real worth of such support.  

In Ashley's case, it is very positive to see his funders trying to understand his behaviour and "to plan long term". Our experience is mostly seeing short-term measures that don't really address the root of the difficulties, which can leave them, and others, vulnerable to further abuse or abusive behaviours. 

People with learning difficulties can, like everyone else, be abusers. Providing timely intervention is likely to reduce the incidences of this and reduce the number of future victims of abuse. Respond's intensive and meaningful therapeutic support to Ashley not only forms a unique assessment of his needs, but also offers insights into what steps should be taken to protect others from Ashley's inappropriate behaviour. 

Respond is a well-respected organisation which has enabled people with learning difficulties to have an insight into their emotional worlds. Therapy has helped them to become the people they wanted to be, instead of the people that trauma and abuse had made them.  

Kathryn Stone is director of Voice UK, a  charity supporting people with learning difficulties who have been abused.