The name of the service user has been changedTherapy helped Ashley explore his childhood experiences and link them with his present day life. It addressed his dangerous behaviour and sought successfully to help him acknowledge and understand it. Importantly, the therapist, albeit only an hour a week, has been there for Ashley. "This has meant he has been able to model back to Ashley qualities of being dependable and sensitive," says Curen. "They built up a relationship that fed back on itself." By becoming a positive attachment figure the therapist helped Ashley gain insight. "Having internalised this, Ashley is now able to think about the therapist at times when he feels vulnerable or feels like acting out: now there is this figure who is saying to him, 'don't do this' or 'think about this'," explains Curen. He has transformed from being a shy and nervous person to a more outgoing one. His language and ability to communicate has improved significantly.
PRACTITIONER: Richard Curen, director of Respond, a national charity working with people with learning difficulties who are the victims or perpetrators of abuse.
FIELD: Learning difficulties.
LOCATION: Greater London.
CLIENT: Ashley Woodhouse is 21 and has moderate learning difficulties. His speech is sometimes difficult to understand.
CASE HISTORY: About three years ago Ashley admitted that he had sexually abused his younger sister, Donna, then 10, who also has mild learning difficulties. He was placed in a residential unit away from his hometown. Although not a secure unit, Ashley did have one-to-one supervision as his sexual behaviour posed a risk to the other residents who were all less able and more vulnerable than him. Despite close supervision he managed to lock himself in the bathroom with other residents on at least three occasions and also followed another resident into their bedroom. In an attempt to better understand his behaviour and to plan more long-term, Ashley was referred to Respond and first became a client in September 2003.
DILEMMA: Ashley has the ability to take part in the community but refused to acknowledge that his behaviour was inappropriate.
RISK FACTOR: If unsupervised, Ashley's impulsive sexual behaviour can put vulnerable adults and children at risk.
OUTCOME: Following two years of psychodynamic therapy Ashley has at last recognised his behaviour and has learned to understand and control it. He has also moved to a residential unit back in his home town.
Although there are many different types of psychotherapy, the one thing they all have in common is that they are "talking treatments" based on a therapist and client talking to each other and sometimes doing things together.
Psychodynamic psychotherapy, for example, focuses on the feelings we have about other people, especially our family and those to whom we are close. Treatment involves discussing past experiences and how these may have led to our present situation and also how these past experiences may be affecting our life now. The understanding gained frees the person to make choices about what happens in the future.
This is the favoured approach of Respond, a national charity working with people with learning difficulties who are the victims or perpetrators of abuse. And the one they applied in their work with Ashley Woodhouse, who was moved out of the family home he had always known into a residential care home following his sexual behaviour towards his younger sister.
"The home he moved into originally was far from ideal," says Richard Curen, director of Respond, who managed the case. "Ashley was the most able person there and there wasn't much known about his risk to other people at that point either."
Although closely supervised at the home Ashley did manage to get himself alone on at least four occasions with other residents. Following assessment he became a client at Respond, which has long been influenced by the work of Valerie Sinason, a child psychotherapist and adult psychoanalyst well known for her pioneering work with people with learning difficulties.
"One of her theories is that being born with learning difficulties, for the person and their family is a traumatic experience in itself," says Curen, "and that their futures and expectations will be irreparably changed not least because of external stereotyping and societal attitudes. If a person with learning difficulties was a victim of sexual abuse that would also be traumatic - but would be seen by us as a secondary trauma to the initial trauma of being born with a learning difficulty."
Once referred as having been sexually abused or having bereavement issues or, as with Ashley, being a sexual offender, Respond is usually presented with a series of facts about their life.
"What we're interested in is going back to their birth and their early attachment history," says Curen. "In our experience clients who hurt others through sexual aggression almost always have this behaviour rooted in an earlier trauma, which can often be sexual abuse." He continues: "And it is often in their history that any reparative work has to take place. But that can take a long time to be carried out. People are mostly with us for 18 months to three years." Indeed, after just over two years Ashley's sessions came to a close. "The main block to him forming good relationships had been firmly rooted in his difficulty in acknowledging his past dangerous behaviour. His levels of denial were very high and this increased the risk he posed as he was unwilling to accept that he had done anything which had caused hurt," says Curen.
However, that has changed and, as a result, so has his behaviour. Curen continues: "There have been times when he has been physically aggressive but there's been no sexual acting out of which we are aware."
It also seems that a move last summer to a unit closer to his family home has had a huge therapeutic effect. "He was very isolated in the previous home," says Curen. "He was, like a lot of people, very attached to his hometown and really identified with his place of birth where he had lived all his life. So to be moved away from that area was a significant trauma. Staff in the new unit have commented that he has settled well, interacts with staff and service users and has built up a therapeutic relationship with staff, which is great."
Curen believes that therapy has helped Ashley begin to manage some of his thoughts and to understand what his frustrations were about: "He seems much better able to think, talk and be understood. A degree of empathy seems to be emerging for the first time. He is more thoughtful. However, on the downside this thoughtfulness might lead to him being more calculated in terms of acting out sexually. This has not happened yet but professionals need to remain vigilant."
Arguments for risk
Arguments against risk
That Ashley was able to admit he hurt his sister but was seemingly unable to accept responsibility for this was worrying. With such a high level of denial and limited capacity for empathy, the risk of Ashley continuing to be a danger to others remains high. Given the current circumstances it cannot be possible to guarantee the safety of others. In Ashley's previous residential unit, despite being monitored and supervised 24 hours a day, he still got himself into situations where he was alone with others vulnerable to abuse. There may have been no known attempts to follow up on this behaviour or examples of him acting out sexually, but there may be have been occasions when this happened without staff knowledge. With a move closer to home, this will inevitably include visits back to the family home - the scene of previous abuse. This may challenge Ashley's current behavioural management and may trigger his more opportunistic and compulsive behaviour.
The effectiveness of the psychodynamic therapeutic approach as a treatment option for people with learning difficulties continues to be researched and there are some positive outcomes, writes Sue Rhead.
However, in the case of dangerous sexual behaviour this could only ever be one component in a total treatment package based on a full understanding of a person's developmental needs and including intensive behavioural and educational input.
First, it is necessary to assess the individual and their circumstances in order to come to a view about the causes of their behaviour. Only then can an suitable intervention be planned. If a service is overly influenced by a single therapeutic approach you run the risk of fitting the person into your treatment rather than fit the treatment around the person.
This case also underscores the need to use terminology consistently. Ashley's behaviour is described variously as inappropriate touching, sexual aggression, sexual abuse and sexual offending.
But if Ashley's behaviour was inappropriate touching and there was no police or legal involvement, then removing him from his home to a residential unit far away will have undoubtedly created some of the problems Curen feels the treatment resolved.
Nonetheless, this is an exceptionally difficult field and we should encourage all well-researched efforts to develop effective interventions.
Sue Rhead is a chartered clinical psychologist for an NHS Trust in Derbyshire