The 90-year-old clinic working to break generational cycles of abuse

Violent and sexual crimes are on the rise. As is domestic violence. As the criminal justice system struggles to make transformative change that goes beyond punitive measures, they’re turning more to organisations offering alternative approaches. One such place is the Portman Clinic, a treatment, research, and teaching clinic, deeply interested in why people behave the way they do – a fundamental part of the Clinic’s attempt to break generational cycles of violence and abuse. As the Clinic marks its 90^th birthday, it faces rising demand for its highly specialist services, to help patients who often find it hard to access help elsewhere.

The Portman Clinic, which is part of the Tavistock and Portman NHS Foundation Trust, was founded in 1933 and is an NHS out-patient clinic specialising in the psychoanalytic assessment and treatment of criminal and troubling sexual behavioural problems in children and adults –sexual offences, anti-social behaviour, and violence, as well as behaviours that may not be illegal but cause severe distress to the individual, like adult pornography addiction. Some of the patients that are referred to the Portman are hard to reach, difficult to engage, high risk, and those who can most benefit from a free highly specialist service commissioned by the NHS.

It’s a very niche and highly complex area to work in, so there aren’t many services like these about. In the UK, the Portman Clinic is the only national service that specialises in treating problematic sexual and paraphilic disorders. In Europe there are maybe a handful of clinics offering some of what they do. This makes the knowledge and expertise of the clinicians who work there highly prized. It’s no surprise that outside of their clinical services treating patients, organisations often turn to them for professional consultations to help them understand their most complex and challenging problems.

“We’re constantly in demand,” says Dr Jessica Yakeley, the consultant psychiatrist who leads the clinic. “We don’t have enough staff and the need for our service is ever greater. Youth organisations, charities, a lot of the criminal justice system, prisons and probation services – they come to us for help.”

The Portman perspective

The help requested can take many forms.

Sometimes it might be reflective practice meetings, where Jessica and her fellow clinicians meet with other professionals and teams to help them make sense of their work, with what some clients refer to as the ‘Portman perspective.’

“We offer consultations and reflective practice for other institutions. For example: we go into prisons and get the staff together – prison officers, probation officers, health staff and psychologists working in prisons. In a safe space we help them think about the emotions that are evoked in them by working with clients with complex needs and challenging behaviours or helping them think about the difficult organisational dynamics that can happen in these institutions,” says Jessica.

Feedback from a recent audit shows that organisations value these sessions with the Portman Clinic as distinct from other forums where they discuss their work.

“I very much appreciate the Portman perspective in the safe space created by the facilitator,” said one client.

Another said: “there is something particularly healing about the collective response so beautifully held in mind by the facilitator.”

Tackling domestic violence

In one of their latest projects, a local police force asked the Clinic for help to treat perpetrators of domestic violence, after realising that many of the offenders have a history of maltreatment themselves.

“This local police force has been running a comprehensive programme for those perpetrators of domestic violence known to them. It was CBT-based, and included drug and alcohol support for the victims, and contacting support services. But it was not successful, and they wanted a different approach, so they came to us,” explains Jessica.

“We see a lot of patients who have perpetrated domestic violence, but we don’t have a specific programme for it, and this has been an area of growing interest in the last few years.”

Last year, police recorded 1.5 million domestic abuse-related incidents and crimes in England and Wales alone. That’s a phone call to police every 30 seconds, and a 7.7 percent increase from the previous year.  If these numbers sound high, remember that experts say domestic abuse is a largely “hidden crime” which goes unreported to the police. The reported numbers may be conservative, but the economic cost of domestic violence is set around a staggering £66 billion a year, for the NHS, criminal justice system and victims/survivors.

In response to the call for help, the Portman Clinic crafted a tailored psychodynamic programme, which they will deliver together with what the local police are offering once a week, in the community.

They are repeat offenders, who have perpetrated serious violence. They need to come voluntarily; we can’t force them to come.

“These men are deemed ‘high-risk, high harm’ by police. They are repeat offenders, who have perpetrated serious violence. They need to come voluntarily; we can’t force them to come. They will be difficult to engage. They often don’t realise they have a problem – they minimise the violence or find it difficult to understand the impact on the victim. So we have to adapt our treatment. It’s a group-based programme, but we have to do a lot of individual work before it gets into a group.”

A pioneer in forensic psychotherapy

The Portman is well positioned on all fronts to deliver this specialist kind of work.

They practise forensic psychotherapy, which involves assessing criminal behaviour and helping people on the margins of society, who are often rejected by other services or who reject services themselves.

A long-time pioneer of robust research and groundbreaking work in these niche areas, the Portman Clinic and its associates have achieved many firsts and been closely tied to some of the best minds in psychoanalysis and literature, with former vice presidents including Sigmund Freud, Carl Jung and HG Wells.  

It lobbied for the end of the death penalty and the decriminalisation of homosexuality in the 1950s. The first study of female crime was published in 1932 by Grace Pailthorpe, whose research led to the Clinic’s establishment the following year. A little more than five decades later the first book on perversions in women was published by Estela Welldon, a pioneering Honorary Consultant Psychiatrist in Psychotherapy at the Tavistock and Portman NHS Foundation Trust, who later founded the International Association of Forensic Psychotherapy.

Reducing problem behaviours

While more organisations are asking for help with domestic violence, 70 percent of the Portman Clinic’s patients are referred in for problematic sexual behaviours, 20 percent are referred for violence, and 10 percent for a combination of the two.

“When I started working at the Clinic 20 years ago there were very few referrals for people downloading illegal internet pornography images. Over the past ten years, about 20 percent of patients we see in treatment have downloaded illegal images. It reflects the society we live in and it’s a good proportion of the patients we see. We do see quite a lot of people addicted to adult pornography as well. We have people who are doing legal things, but they are very distressed by them, for example, compulsive or risky sexual behaviours,” says Jessica.

They’ve also seen an increase in patients with antisocial personality disorder since establishing a dedicated unit for this at the Clinic.

Pretty much all our patients have had difficult childhoods, some more extreme than others. And their offending behaviour stems from there. Think about it as a maladaptive coping mechanism.

About 80 percent of patients show a reduction in the frequency of problem behaviours after six months of treatment at the Portman Clinic.

Therapy is usually long term, it may be one to one or in groups, and is psychoanalytically based, which aims to identify unconscious, as well as conscious conflicts and motivations underlying their behaviour and difficulties in relationships.

For the patients with antisocial personality disorder, they use a kind of therapy called Mentalization-based treatment (MBT) – a form of psychological treatment on how we understand other people by having an idea of what they are thinking and feeling, and the reasons for their behaviour. 

“Everyone needs to be able to mentalise, to be able to interact with other. It’s a normal process that develops as you grow older, but with people who have experienced neglect, abuse, adverse events in early childhood – particularly from their parents – their ability to mentalise has been compromised. They find it more difficult to interpret other people’s behaviour,” says Jessica.

While there’s no surefire way to measure whether any therapy is working, the Portman employs a comprehensive research programme, including a system of evaluating patient progress. It includes but isn’t limited to a range of evaluation tools, assessing personality traits and disorders, ability to be reflective, impulsivity, anxiety, and depression. They’re currently analysing years of data and hope to publish the results in future.

Jessica says: “We’re trying to properly evaluate whether patients get better in treatment and in recent years our researchers carry on contact with them after treatment. The problem is you still can’t tell, even where someone has improved, you can’t definitively say it’s due to this treatment. The only way you might be able to do that is through a randomised controlled trial, which would be very complicated to do given the people we see.”

Breaking generational cycles

This work isn’t for the faint of heart. All therapists at the Portman Clinic must have undergone therapy themselves and have regular reflective meetings with the team.

When things get challenging, they only need to remember why they do this work.  

“There are all these distressed people out there and they’re not getting any help. There aren’t the services to treat them. We want to help them change, but we also want to help stop that transgenerational cycle of abuse for some of our patients. Most of them have been victims themselves as children. They’ve been abused in childhood and then they become abusers. A lot of patients come in saying ‘I don’t want my children to have the same childhood that I did’, but they end up repeating some of it,” says Jessica.

They’re human beings. They’ve done some bad things. It doesn’t necessarily define them as bad people. Whatever horrible things they’ve done, you get to know them, and you care about them. When there is change, it’s incredibly moving to see.

Referrals come in from GPs, psychiatrists, other NHS mental services, probation officers, social services, and patients themselves. But patients must attend voluntarily.

“They can’t just be sent from the courts. If they are forced, they may not have the motivation to engage in the therapy. They might just be doing it to get the children back, for example.

“Our patients are motivated. They are often extremely grateful to be seen because there aren’t other services out there. A lot of them are extremely ashamed of what they’ve done. It’s quite common for them to be seen in secondary mental health services for depression, but they don’t dare mention why they’re so depressed, because they’re so ashamed of it.”

Strict confidentiality

For that reason, confidentiality is strict at the Portman. Patients wouldn’t come or engage if they worried about their identities being leaked.

Currently the Portman is seeing about 150 patients. 90 percent of them are men, with the average age of referral being around 35. Last year they received 189 referrals, of which they accepted 129.

Patient opinion from the most recent audit is mostly positive, with patients often citing confidentiality or appreciating access to specialist help:

“The service I have experienced is hard to value. It affords me the essential opportunity to explore difficult issues I have had for all my life in a safe, professional environment.”

“Confidential, relaxed and professional practitioners. Meetings skilfully overseen and of great value. Strong feeling of on-going therapy helping me to bring out problems.”

“[They] treated me with compassion and understanding. [They] raised important questions that felt very reliant and gave me confidence in seeing this was the correct place for therapy.”

Achievements

For the Portman Clinic, continuing research and sharing learning remain a fundamental part of its work and future.

The Clinic runs a British Psychoanalytic Council accredited course in Forensic Psychodynamic Psychotherapy, which allows participants to practice as forensic psychodynamic psychotherapists. 

Among its noteworthy research work, the Clinic is a key player in a major randomised controlled trial investigating whether MBT is an effective treatment for individuals with a diagnosis of antisocial personality disorder, under supervision in the community on the National Probation Service. Commissioned by the Ministry of Justice, the project is run together with partner organisations UCL and the Anna Freud Centre. It recruited over 300 participants and is analysing its data ahead of publication.

With so many impressive feats under its belt, the Portman Clinic has a lot to celebrate as it turns 90 in September. 

For Jessica though, the biggest achievement is not what you might expect.

“It’s difficult because I’m mentioning all these external projects but actually the work we do day in day out, it’s very difficult work. That’s the real major achievement. That’s why we’re all still here. A lot of clinicians tend to stay a really long time. We’re doing this really difficult work and we’re still surviving and being commissioned,” she says in a matter-of-fact way.

As she illustrates her point one gets a clear sense that the achievement she speaks of is the Portman Clinic making a change in people society believes cannot change or aren’t worth the effort.

“I co-run a weekly therapy group for men with antisocial personality disorder, and this is the highlight of our weeks. These are men who by definition hate other people. They’re antisocial, they do lots of bad violent things. These sessions are very difficult work, and you go away full of complicated emotions. But over time, the group members have got to know each other. They will say to us that this is the family they never had. They’ve created these bonds between them. Many professionals think that people with this diagnosis aren’t treatable, or they can’t form attachments. We’ve found actually they can. They’ve built up this trust between them and it’s so moving. You can see them caring for each other. It’s that sort of thing that keeps us interested and going.”