Working with Violent and Sexually Harmful Children and Adolescents

This book is so new that it bears, on my copy, a copyright date of 2022 even though I have had it in my hands since late August 2021. (One might reflect that perhaps this confusion over dates reflects a rush to get into print a book that, alas, has not been copy-edited very well: I've found several typos and solecisms, which is not a thing one typically expects or encounters in Routledge books.)

In any event, it is a rich collection of articles from numerous clinicians in England associated there with the prestigious Portman and Tavistock clinics: A. Nathanson et al., eds., From Trauma to Harming Others: Therapeutic Work with Delinquent, Violent, and Sexually Harmful Children and Young People (Routledge), xxiii+172pp. In what follows, I simply put together some insights pulled from several (but not all) chapters. I do so in part because about half my current clinical work is with adolescents court-ordered into individual and group psychotherapy for various sexual offenses. This is not work I ever expected to find myself doing at this stage of my life. It was, to be frank, work I was faintly horrified by when I first learned of it. But now that I have been immersed in it for nearly a year, I have come very much to enjoy it in that Winnicottian sense I wrote about here. 

The introduction takes us into some of the theoretical underpinnings of the essays in the collection, and explicitly makes mention of someone whom I was introduced to through reading Adam Phillips: the late American psychiatrist and psychoanalyst Robert Stoller. His book Perversion: the Erotic Form of Hatred gets cited by the editors as a useful text, which I have also found it to be. Stoller has argued--in my view correctly--that often what is sought in sadomasochistic fantasies and enactments as an adolescent or adult is a triumph over childhood traumas. The authors and editors in this new book would also seem to share that view.

The other author they cite, unfamiliar to me, is Ismond Rosen, editor of a collection of articles, published by Oxford UP in its third edition (original: 1979) in 1995 as Sexual Deviation. 

The editors go on to be clear about things that in the popular imagination are often obscure, noting that "only a minority of adolescents who sexually harm others turn into habitual sex offenders" (xiv). This is confirmed in some of the case studies later in the book of adolescents who sexually harmed children not because of an attraction per se to children as such, but because in each case the child represented something the offender hated and sought to strike at to hurt someone else--chiefly a parent. 

The editors in the introduction, and many of the other authors in this collection, acknowledge that what has changed in their work over the years with this population is the Internet and the widespread and rampant access to pornography (and the related problem of other images on social media). 

Mariane Parsons has a brief chapter, "Key Concepts Developed at the Portman Clinic," whose conclusion is simply stated but, in my view, absolutely crucial for this kind of work: "to foster...and enhance the youngster's self-esteem and capacity to be curious about himself it is of vital importance to help him to feel seen by the therapist as a whole person with strengths that can be valued (as well as weaknesses that need help). This offers hope to the patient and is essential for a move towards a healthier future" (p.7). I have written at length elsewhere (in press) about trying to do exactly this and why it is so vital for clinician and patient alike, so I will say no more about that here. (The last chapter in the book, "The History of the Portman Clinic," brings us back to the introduction, but with more particular detail and less clinical material.)

Anne Alvarez, in her chapter "Motiveless Malignity," notes bluntly that clinicians, when working with patients of psychotic and psychopathic tendencies, must "look evil straight in the eye" but then also look at whatever good qualities may be starting to emerge in a patient as well. Sometimes these qualities will be very minimal and must not be overplayed or exaggerated. In some particularly damaged individuals the most we might ever see are "faint beginnings...of trust and faith" which may be remarked upon unsentimentally. Such patients also generally cannot handle symbolic interpretations ("in attacking me you are seeking to strike at your mother") so these must be used with great caution.

Donald Campbell's chapter, "Considering Perversion from a Portman Clinic Perspective," engages with Stoller and other recent clinicians after returning to Freud's 1905 Three Essays on the Theory of Sexuality. Campbell's chapter inspired me to return to that 1905 work also, and find in it some refreshingly blunt and straightforward claims, including that "sadism is the most common and the most significant of all the perversions." 

Campbell agrees with this, and notes that none of us should recoil from this because "all of us in one way or another are neurotic and have entertained perverse fantasies" (22). Much of the rest of the chapter is taken up with case studies and other clinical material. 

Toward the end he offers a welcome note of caution which it seems to me those running CBT-type treatments for sexual offenders might need to take deeper note of: whether in individual or group treatment, authoritarian and "macho" tendencies must be avoided in leaders who must also avoid focusing "exclusively on behavioral change without understanding the individual's internal conflicts and anxieties." Merely focusing on externals overlooks "the abuser's capacity to adopt language, concepts, and whatever is suggested as normative behavior," offering "simulated attitudes and behaviour" and a mere appearance of change (33). 

Graham Music and Heather Wood author the next chapter, which focuses on porn on the 'net. They begin by quoting a 2017 UK study to the effect that 65% of adolescent boys had not just seen porn on-line but "thought such images were realistic." Those who are emotionally fragile may gravitate towards porn and become fixated on it in part because of a pre-existing lack of connection to their own "bodily experiences and desires" (38). Continued use of it may be a defense mechanism against "core complex anxieties." One way to combat this, they aver later in the chapter, may come through developing greater capacity to mentalize, here drawing on Peter Fonagy's well-known work in this regard. 

The authors are commendably straightforward about what is offered by life in comparison to the endless fantasies of porn: compared to those images, reality must seem "very grey and dull" and it requires a perhaps unlovely "acceptance of ambivalence and imperfection" (39). Here I am put in mind of Adam Phillips again and his rather bald assertion that "reality matters because it is the only thing that can satisfy us." 

The ending of this chapter leads into the next, for both talk about porn in Winnicottian terms: as an object over-invested with meaning for some; as an object that attempts to replace human and fleshly contact because of past trauma; as an object to which one relates precisely to escape from the problem of relating to flesh-and-blood human beings. Thus do we come to John Woods' chapter on porn, "Seeing and Being Seen," which draws on Winnicott at length.  

Woods begins by commendably acknowledging the "contradictory messages from adult society" that children and adolescents get around sex and porn. On the one hand, we live in a libertarian world where "freedom of expression" is strongly encouraged and the right to sex, to sexual and gender identity, and to explorations of the same are all held up as goods that rights-bearing autonomous citizens have and which must not be impeded by censorious governments or others. But on the other hand, those of us who are working with adolescents and children, especially those court-ordered into treatment, operate with an inescapable and relatively clear moral imperative: certain forms of sexual exploration and expression are totally prohibited by the law, which punishes those who disobey, and our adolescent patients must be brought into compliance with this. 

Woods introduces another element here between competing moral and legal philosophies: the question of development. He believes that "unrestricted access to internet pornography undermines normal development" (56) and can contribute to the problem of voyeurism. On this topic, he draws on Winnicott's erstwhile analysand, the problematic Masud Khan (himself guilty of sexual boundary violations--inter alia--with patients), who notes that the intensity of pornographic arousal may be closely tied to how much of a need for "object relating" it provides. Additionally, the power of voyeurism may come from the fact that one believes one to be able to see anything and everything without consent.

Later in the chapter, Woods returns again to the moral problem of pornography, and is refreshingly candid in asking why "we are turning a blind eye to the very damaging effects of internet pornography in our society" (60) which he says should be regarded as a "Public Health issue" (61). He says clinicians should give support to parents who are fighting to maintain some control over what their children are exposed to, and that "the ideal of free expression and no censorship has to be questioned." Based on my own clinical experience watching how badly distorted some adolescents' views of sex are based on exposure to porn, and how many problems it has created in their life, I am firmly in agreement with Woods in all this.

Ariel Nathanson's chapter "Working with Mental Hackers and Backroom Thinkers" introduces the useful concept of having a mental backroom "as both a hiding place and a control centre" from which to exercise one's wishes for "omnipotence" (67). This chapter could have withstood some further development and elaboration, not least by drawing on what seems to me an obviously relevant body of literature: that of schizoid personality theory from Fairbairn, Guntrip, Winnicott, and most recently Nancy McWilliams. 

She reports confronting one patient with the rather colourful question: "are you making direct in-the-moment contact with me or do you use the sessions as a takeaway service, store my comments, and feed yourself elsewhere?" (76). If progress is made with such patients, then they may come to realize how much of life they are missing out from and thus they may come to leave their backroom, regarding it no longer as a "glorified control centre" but instead a "bleak addict's den" (77). 

In his chapter "Angels and Devils: Sadism and Violence in Children," Graham Music echoes several themes noted earlier about sadomasochism supplying unmet needs, or being a way to triumph over earlier traumas as well as various forms of "anxiety, stress," or "feelings of inadequacy" (86). Sometimes, however, the intensity of sadistic fantasies or enactments is precisely due to the patient having an internal world that is "empty and flat" with much deadening of feeling.

As we move into the later chapters in the book, some of the clinical material becomes darker and we see more severe cases of violent sexual acting out. This leads one of the authors in this section, Tim Baker, to reflect on the connection between aggression and the counter-transference. This becomes especially tricky to manage if one is working with an adolescent offender who was also himself victimized at some point. Baker's chapter on self-harm in adolescents offers some helpful vignettes to those struggling to understand such things as adolescents exposing themselves on-line or in school settings, or in public places, or those who admit to, but never carry out, sexual attacks on siblings. Much of this is discussed under the heading of Winnicott's aphorism that "it is joy to be hidden, but disaster not to be found." 

Patricia Allan's chapter, "Securing the Disaster Zone," offers some useful ways to think about initial contact, early assessment, and decisions for treatment with adolescents. She worked with a badly traumatized 8-year-old boy whose clinical presentation was of very considerable complexity and difficulty.

Ariel Nathanson's chapter closes out the book. She begins by presenting a case of a young man who admitted to using sadomasochistic pornography (of violent cuckolding) to masturbate to as a way of handling fights with and rejection from his girlfriend. He explicitly felt that this was a better way of handling things than giving in to his aggression towards her. The problem with such an approach, Nathanson says (here drawing, as numerous authors before her have, on the work of M. Glasser in the Rosen volume, Sexual Deviation, noted above) is that it rapidly becomes "both perverse and highly addictive" (139).

Nathanson's chapter is an attempt to synthesize "common themes and dynamics" across her many years of work with adolescent and young adult males presenting with sexual difficulties and offenses. Most of them wound up in long-term psychotherapy. All of them presented as "suffering, highly addicted to their destructive activities and feeling at the mercy of those, unable to free themselves, as they would desperately like to do in order to lead a normal life" (140). 

Central to every story, she says, is a theme of descending into a dark world. For many, this is a comforting and familiar world, a world where they can feel alive, where they feel their "real self" may be discovered, where their "real attachment" and "first love" abide (140). Such a world elides the problem of abandonment. It creates and welcomes plenty of bad objects which become perversely salvific.

Nathanson talks of how all her patients come sooner or later to a moment of realizing how and when their "fuck-it" button functions in life--that rapid moment of transition from one self-state to another which has previously been so rapid for them and so out of control that they find themselves back in addictive behaviors before they realize it, let alone attempt to control them or resist them. As one increasingly recognizes the dynamics of this process, she reports that patients notice things slowing down. The fuck-it button might still get pressed, but this time with a little more room for noticing, and perhaps very briefly tolerating, the anxieties that precede it.  

As this increases, patients realize how much they have ritualized, via negative behaviors, unintegrated anxieties, memories, feelings. Over time much of this can actually decrease: enactments may still happen, but with less intensity and frequency, and with greater realization and control: this is what she calls "emerging potency" (148). One patient noted "how not enacting sexually made him feel more potent, creative, and able to use his aggression to assert himself at work." 

Central to success in this work is an increasing "integration between the physiological and psychological, often reconfiguring the relationship between their bodies and their minds after many years of addiction and abuse" (149). 

In her conclusion, Nathanson affirms a practice that is central to the program I work in with adolescent sexual offenders: not just building a general relationship with each patient, but having each patient narrate in close and concrete and unsparing details the nature of their enactments and abuse. These are then "looked at carefully, under a microscope." 

Each of my patients struggles to do this, but it is key to all future progress. Such enactments, she says--echoing, of course, Bion--constitute "attacks on linking." The moment when the fuck-it button is identified is the beginning of the end of attacks on linking, the beginning of the restoration, in fact, of the capacity to see, and gradually to accept and tolerate, linking (between, that is, maladaptive behavior in the present along with anxieties and feelings from a traumatic past, which are now noticed and increasingly tolerated before being changed). 

Finally, Nathanson notes that responses to enactments are often much more effectively delivered by group therapy than individual. In the latter, responses from the therapist to enactments can seem authoritarian and punitive, shutting down the process of exploration and reinforcing the very habits of flight one is working to heal. A group, by contrast, offers different ways of exploring these enactments that eventually lead to their extinguishment (or at least very dramatically reduced number and nature).

In sum, then, From Trauma to Harming Others is a rich compendium of clinical experience that all those of us working with adolescents and young men struggling with sexual addictions and crimes can profit from with gratitude.