The Psychology of Female Violence: Crimes Against the Body

The Psychology of Female Violence, second edition What are the causes of violence in women? What can be done to help these women and their victims? Why does society deny the fact of female violence? This book explores the nature and causes of female violence from the perspectives of psychodynamic theory and forensic psychology. This fully updated and expanded second edition explores developments in research and services for violent women. Recent high profile cases of female violence are discussed alongside clinical material and theory. New topics include: the Victoria Climbié Inquiry, the controversy related to the diagnosis of Munchausen’s syndrome by proxy, dangerous and severe personality disorder in women, and the impact of pro-anorexia and pro-bulimia websites. New chapters address central clinical issues of working with women who kill and designing therapeutic services for women in secure mental health settings. Other major topics include: • women who sexually and physically abuse children • infanticide • fabricated and induced illness • self-harm The Psychology of Female Violence will be valuable to trainees and practitioners working in the fields of clinical and forensic psychology, women’s studies, sociology, psychiatric nursing, social work, probation, counselling, psychoanalysis, the criminal justice system and criminology. Anna Motz is a Consultant Clinical and Forensic Psychologist with the Thames Valley Forensic Mental Health Services. She has extensive clinical experience with women as perpetrators and victims of violence and with the staff teams who work with them. She has written widely on this topic and is the immediate Past President of the International Association for Forensic Psychotherapy.

Reviews of the first edition ‘…an intellectually substantial and highly readable contribution to our clinical knowledge of the complex roots of female violence.’ Estela Welldon, in her Foreword ‘…In The Psychology of Female Violence, Anna Motz offers a clear, well-supported, comprehensible, and theoretically sophisticated examination of three types of violence by women: violence against children, violence against the self, and battered women who kill their batterers. Although this book will be valuable to clinical practitioners, psychologists, sociologists, and researchers of violence, it is also clearly written and accessible to newcomers to the subject…. Because of the breadth and depth of the information in this book, it is a highly valuable addition to the literature on violence by and against women, applicable for both practitioners and academics. It is well written and well organized, and Motz offers extensive support for her contentions and conclusions, giving many references to other theorists, practitioners, and researchers.’ Danielle Currier, Psychology and Feminism ‘…For to be confronted with Motz’s dedication to those women who break the ultimate code brings us to consider the harsh reality of the female perpetrator…What is valuable is that Motz, as a chartered forensic psychologist, speaks from the cutting edge of experience drawing from her day to day work from the last ten years …it is important to recognise that Motz has studied these disorders in depth. Not only does she offer a comparative analysis of the psychodynamic and cognitive-behavioural models of treatment of these well-represented disorders, but her analysis of categories of harming behaviour is both illuminating and useful…Finally it is important to emphasise the wealth of practical, legal and professional information contained in this productive publication…. Motz has provided not only an outline of the complexity of each aspect of female violence, but also a full explanation of the means by which each of the professional agencies combine to ascertain diagnosis.’ Tessa Adams, British Journal of Psychotherapy ‘…Anna Motz clears up many of the mysteries surrounding the interpersonal damage that characterizes the offending behaviour of perverse and violent women. Learning about this material rather than simply feeling the emotional impact of it is one of the factors that will make this book essential reading for anybody who comes into contact with violent women.’ Anne Aiyegbusi, Criminal Behaviour and Mental Health Thoughtful conceptualisations of female violence are put forward by Motz in a book written primarily from a psychodynamic perspective. Motz describes how women, unlike men, tend to display violence towards themselves or to those who represents extensions of their selves (i.e. their children). Motz takes into account the influence of wider society in understanding such violence and our reactions to it by highlighting how society holds

an idealised view of women that may interfere with the detection of any violence perpetrated by them and the treatment given to them.’ Jane Ireland, Bulletin of the International Society for Research on Aggression ‘…This book offers a fascinating, albeit uncomfortable, read and demonstrates some of the difficulties of working with violent women…. the text is an important contribution to the literature on female offending.’ Emma Wincup, Probation Journal

The Psychology of Female Violence, second edition Crimes Against the Body

Anna Motz

LONDON AND NEW YORK

First published 2008 by Routledge 27 Church Road, Hove, East Sussex BN3 2FA Simultaneously published in the USA and Canada by Routledge 270 Madison Avenue, New York, NY 10016 Routledge is an imprint of the Taylor & Francis Group, an Informa business This edition published in the Taylor & Francis e-Library, 2007. “To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.ebookstore.tandf.co.uk.” © 2008 Anna Motz Paperback cover design by Lisa Dynan All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Motz, Anna, 1964– The psychology of female violence : crimes against the body/Anna Motz. —2nd ed. p. cm. Includes bibliographical references and index. ISBN 978-0-415-40386-3 (hardback)—ISBN 978-0-415-40387-0 (pbk.) 1. Female offenders—Psychology. 2. Violence in women. 3. Abusive mothers. 4. Self-destructive behavior. 5. Female offenders—Mental health services. I. Title. HV6046.M64 2008 616.890082—dc22 2007027295 ISBN 0-203-93091-6 Master e-book ISBN

ISBN 978-0-415-40386-3 (hbk) ISBN 978-0-415-40387-0 (pbk)

To the memory of Hans and Lotte Motz

Contents Foreword to first edition by Dr Estela Welldon Foreword by Baroness Helena Kennedy QC Acknowledgements

Introduction PART I Violence against children

x xiii xv

1 13

1 The development of maternal abuse: female perversion

15

2 Female sexual abuse of children

27

3 Maternal physical abuse

52

4 Fabricated or induced illness

80

5 Infanticide PART II Violence against the self

110 137

6 Deliberate self-harm

139

7 Anorexia nervosa

171

PART III Violence against others 8 Battered women who kill PART IV Clinical applications 9 Working with women who kill

193

195 225

227

10 Hiding and being lost: the case for women-only secure units

236

Conclusion

248

Bibliography

254

Index

268

Foreword to first edition I have to declare a special interest in this book as I met Anna Motz when she joined one of the first Diploma Courses in Forensic Psychotherapy which I inaugurated at the Portman Clinic. One always has high hopes for all one’s students, and almost all of them go on to do difficult and demanding work with courage and integrity, but relatively few produce books that make a significant advance in our understanding of our chosen field. Anna Motz is one of those few. As a clinician of genuine brilliance and courage, Motz provides us, her colleagues, with much that is valuable and new in our work with violent women. In her view, women who fail to express feelings of frustration and anger use their bodies ‘as their most powerful means of communication and their greatest weapon’ and she adds a new insight in her assertion: ‘Self-harm is a defence against intimacy, binding a woman to her own body to the exclusion of others.’ The case histories offered in this book are of women who have either been assessed or who are in treatment for crimes of violence against their own bodies, or their children or their partners. Motz’s description of the forensic settings and working relationships of the staff involved in those institutions is a key part of the contribution that she makes to our understanding of this most painful area of forensic psychotherapy. In purely numerical terms, there are only a few hundred documented examples of perverse motherhood. But the impact of perverse mothers is enormously powerful: on their innocent and helpless victims, on the growing numbers of families and communities corrupted and demoralised, on whole societies in shock, disbelief and bewilderment. These are not just clinical concerns. They are social, moral, cultural, penal, legal and bureaucratic, and as such touch almost everyone in society. As a professional colleague, I am grateful for the way that Motz describes the psychodynamics of the battered wife who becomes a husband-killer and how both partners re-enact their own unconscious wishes to swap roles. The long-term emotional and behavioural consequences of the children being witnesses and victims of parental abuse and the vulnerability of the abuser herself are delineated in a fine, delicate way. Motz provides us, her fellow clinicians, with case studies, theoretical discussions and professional insights that are all excellent. But her concerns and conclusions go beyond those of our profession. Counterpointing the calm professional voice is an angry and urgent call for attention from the clinicians with whom we have to work. We have now begun to understand that female violence has been with us in many different forms throughout human history. But it is only in the past 20 years or so that it has found a place on the psychological, social and political agenda. Even now, the whole topic is surrounded by extreme confusion and not only for tabloid journalists and the general public. Motz shows that, all too often, the professionals who make the decisions about the future of perverse mothers and their child victims, are driven by their own unconscious expectations, prejudices, political imperatives and professional inadequacies.

For these reasons, I wish I could give a copy of this book to every MP, social worker, tabloid editor, local councillor, caring professional, lawyer and police-person. Obviously, a book that is intended mainly for clinicians cannot begin adequately to deal with the issues that Motz so eloquently and sensitively documents. But by placing the case histories in the context of inter- and intra-agency decision-taking, she opens up the field of forensic psychotherapy in a new and important way. As forensic psychotherapists, we are required to provide professionally objective clinical assessments of the risks that perverse mothers present to their children, to themselves and to society at large. And, like many of us, Anna Motz is keenly aware of her own femaleness, her own body, her own emotional response to the perpetrators and their tragic victims. Thus, the future lives of severely abused and damaged children are at the centre of her concern, and it is to her credit that she allows us to share in her dismay and anger at the inadequacy of the thinking of the decision-takers, and of the strategies that are available for the care and protection of these tragic innocents. The case studies show that these violent and perverse mothers have themselves been severely sexually and/or physically abused. Without exception, these are women whose perverse violence results from their own early experiences of deprivation and abuse. Hence, the importance of designing and implementing comprehensive and sensitive treatment programmes for such women is incontestable. Existing treatment programmes tend to fail because they are fraught with the consequences of the prejudices derived from the difference in our attitudes towards victims and perpetrators. Lip service is generally paid to the inevitable cycle of violence and abuse applicable to both genders, but the victims are still thought to be women, and the perpetrators men. This book breaks new ground by providing us with new and brave insights into the suffering of small children inflicted by many generations of women who were themselves early victims of abuse, deprivation and despair. Apart from the inadequacy of the available treatment programmes for perpetrators, there is the question of the failure of existing programmes of care and protection for the victims who, without proper and comprehensive understanding, may easily become victimisers. When social workers and psychiatrists so often have no choice but to perpetuate, or even intensify, the pattern of abuse and deprivation, the dilemmas of the clinicians and decision-makers are indeed horrendous. They may have no choice but to consign a ten year old, who has been severely abused by her own mother, to a local authority’s care and protection system, But how do they cope with the knowledge that it is in that very system that the perverse mother has herself been abused and perverted? That is why she points us finally towards the need for ‘the system’, of which we are all a part, to ‘learn’ how to respond to the tragic dilemmas with which we are all confronted. In that context, all of us should have a part to play in deciding and implementing the strategies that our society develops to respond to this very new issue on its agenda. It is a challenge to all of us in the clinical and caring professions, and, especially, to those with responsibility for determining our society’s attitudes towards and strategies for dealing with these rare but appalling perversions. In conclusion, we, her colleagues in forensic psychotherapy, have cause to be grateful to Anna Motz for making such an intellectually substantial and highly readable contribution to our clinical knowledge of the complex roots of female violence.

But she has done much more than her professional duty. She has highlighted the systemic dilemmas that perverse mothers, in particular, reveal in our clinical, social, penal and caring programmes. In so doing, she has done a substantial service to society as a whole. Estela V.Welldon, MD, DSc (Hon), FRCPsych Consultant Psychiatrist in Psychotherapy, Portman Clinic Honorary Senior Lecturer in Forensic Psychotherapy at University College London

Foreword The interface between law and psychiatry is a fascinating territory and one of the most interesting areas of the legal advance. Until 20 years ago it was still very hard to persuade an English court that psychiatric medicine or the psychological sciences had anything to offer the courtroom processes. Unless people were mad according to what were known as the M’Naughten Rules or they suffered an abnormality of mind, which diminished their responsibility for murder, the courts were unwilling to give too much credence to psychiatrists. However, all that has changed. I have worked within the criminal justice system for over 30 years and many of my cases have involved women who have perpetrated acts of violence. As a result I have had close associations with many psychiatrists, who have helped me understand the motivations and underlying psychological processes at play. Through the work of committed professionals like Anna Motz, a revolution in understanding has taken place. Most of the women who come through the courts charged with criminal offences of a violent nature face a double set of prejudices. Violence invariably draws down a retributive response against both men and women but women on trial face the additional stigma of failing society’s expectations of good womanhood. To kill a baby, assault a child or anyone else for that matter is an affront to what we expect of women. The courts are often particularly punitive to violent women. For a long time, securing justice for women who killed their partners, even when there was a long history of domestic violence, was fraught with difficulty. Yet almost invariably these women themselves have been the victims of violence in childhood or some form of abuse. For lawyers, our own clients’ pain called out for a dramatic shift. Miscarriages of justice pointed up the law’s failures and showed that the vulnerable could confess to crimes they never committed; wrongful convictions showed that law’s exculpatory rules were too often created with men in mind. Provocation as a defence often failed women because they did not act immediately in the face of the provocative act but experienced a slow burning reaction. Women who killed their babies were overwhelmed with guilt and denial about failing to live up to the feminine ideal. After some serious cases of law’s failure, there was a greater willingness to recognise that the courts might benefit from the assistance of those who had greater understanding of the human condition and the workings of the mind. In consequence, lawyers like myself have been able to work collaboratively with psychiatrists, psychotherapists and others to raise awareness in the courts about why women commit violent offences. As a result we have been able to effect better outcomes for them. Over the years I have written frequently on the pressures which lead women to kill— either their children or their partners. Recently I led the Intercollegiate Inquiry for the Royal Colleges of Pathology and Paediatrics into Sudden Infant Death after a series of

women were convicted of murdering their babies on unsatisfactory evidence. Society’s expectations of women remain very different from those experienced by men and the behaviours women display are deeply affected by their development and place in power structures. Unravelling those intricacies with the help of professionals is the best way to secure justice for all concerned, including those who are the victims of such offending. This scholarly work by Anna Motz is a vital resource for all professionals dealing with violent women. It is a wonderful book and I am proud to be associated with it. Baroness Helena Kennedy QC

Acknowledgements My desire to write this book comes from my clinical work with the many women who have allowed me, over the course of the past eighteen years of clinical work, to hear about their experiences, both as victims and perpetrators of violence. I am indebted to these women, whose candour, resilience and eloquence inspired me to try to understand this violence. I was assisted in this understanding by the forensic psychotherapy course at the Portman Clinic and particularly by Estela Welldon, Donald Campbell, Robert Hale, Marianne Parsons and Anne Zachary. The work of Helena Kennedy has also been inspirational in its clear critique of the criminal justice system in relation to female criminals. I am most grateful to her for this pioneering work. I owe thanks to clinical psychologists Helen Liebling, Jaqui Saradjian and Caroline Lovelock, whose sensitive understanding of female violence has been illuminating. For their close reading and thoughtful comments I want to thank Tina Baker, Joanna Burrell, Ted Coleman, Jackie Craissati, Paul van Heeswyk, Brett Kahr, Pamela Kleinot, Kate Iwe, Sally Lane, Isabel Menzies Lyth, Paul Montgomery, Sheila Redfern, Jackie Short, Maya Turcan, Jane Ussher, Elyse Weiner and Estela Welldon. I am very grateful to my mother, the late Lotte Motz, whose interest in my work and perceptive, intelligent and honest comments on the early chapters were invaluable; her involvement and interest in this research have been greatly missed. I am highly indebted to my husband, Nigel Warburton, for his support, enthusiasm and the many insightful comments that have helped me greatly at all stages of writing. I also owe much to my uncle, Herbert Edlis, for his support and interest throughout this project. I want to thank Paul Valentine, Medical Librarian, West London Mental Health NHS Trust, for his great help in obtaining numerous journal articles for this research and Charlotte Couldrey for her help with this in Oxford. I also thank the following people for their moral support and intellectual participation in this project: Jean Burrell, Richard Beckett, Gavin and Margaret Cartledge, Denise Cullington, Sarah Du Feu, Susan Edlis, Maggie Fishman, Elizabeth Grocutt, Tirril Harris, the late Kate Hill, Patsy Holly, David Kirkby, David McMahon, Harriet Montgomery, Mrs Mills Burton, Ian Ochiltree, Lisa Robinson, Ben Ross, Philip Roys, David Shelton, Julie Tartakover, Kate Thompson, Sue Thorp, Marian Wassner, Phylis Weiner and Saskia van der Zee. I am grateful to Sean Hand for his insights into the link between violence and sentimentality. I owe special thanks to Hannah and Joshua Warburton for their love, patience and humour. I have been greatly stimulated and encouraged in the field of forensic work by the International Association of Forensic Psychotherapy and owe a great deal to valued friends and colleagues on the Executive Council, especially Anne Aiyegbusi, John Adlam, Tilman Kluttig, Gill McGauley, Carine Minne, Gwen Adshead, Reinmar duBois

and Michael Günter amongst the many others. More recently the stimulating discussions with my fellow trainees, supervisors and tutors on the Interdisciplinary Training Course in Psychoanalytic Psychotherapy at the Tavistock Clinic have helped me to deepen my understanding of analytic ideas, re-formulate my thoughts and return to the second edition with renewed insight and energy. I am grateful to the Taylor and Francis editorial team, particularly Penelope Allport whose great efficiency, sensitivity and care in editing the second edition was much appreciated; and also to Imogen Burch, Alison Dixon, Joanne Forshaw Sarah Gibson, Dawn Harris, Kate Hawes, Frank Pert and Vivien Ward. I also thank Michael Solomons for compiling the index for the second edition. I owe thanks to Karnac Books for allowing me to reprint the chapter on ‘Working with Women who Kill’, and am particularly grateful to Brett Kahr and Oliver Rathbone for their help. I am thankful to Jessica Kingsley Publishers for permission to reproduce the chapter on ‘Hiding and Being Lost’, and to the author for permission to reproduce her poem ‘Mirrored Images’. I am particularly grateful for the tremendous strength and encouragement of Estela Welldon, whose illuminating work, indomitable spirit and personal support have been invaluable in this, as in other projects. She remains a shining light in this field. I remain deeply indebted to my late parents, Lotte and Hans Motz, both of whom were inspirational and passionate scholars.

Permissions

The chapter on ‘Working with Women who Kill’ is reproduced by the kind permission of Karnac Books. The chapter first appeared in Ronald Doctor’s edited book Murder: A Psychotherapeutic Investigation, published in London by Karnac Books in 2008. The chapter on ‘Hiding and Being Lost’ is reproduced by the kind permission of Jessica Kingsley Publishers. A portion of this chapter first appeared in Nikki Jeffcote’s and Tessa Watson’s edited book Working Therapeutically with Women in Secure Settings, published in London by Jessica Kingsley Publishers in 2004, © Jessica Kingsley Publishers. The poem ‘Mirrored Images’ is reproduced by the kind permission of the author.

Introduction Some of us use the body to convey the things for which we cannot find words. (Hornbacher 1998:125)

In this book I explore the psychology of violent women, outlining the link between childhood experience and adult behaviour. I highlight the psychological and social functions and meanings of violence and provide a psychodynamic perspective on female violence, using case material throughout to illustrate theory. I describe acts of violence committed by women and identify those features which are unique to women. The pioneering work on female perversion by Estela Welldon in Mother, Madonna, Whore: The Idealisation and Denigration of Motherhood, first published in 1988, is central to this task as it provides a conceptual framework for understanding how female development and biology affect the evolution of perverse and violent behaviour. I present a psychological model for understanding female violence, emphasising its function and the meaning of the violent act, and, where appropriate, the implications for treatment. The unique situation of women demands that their experiences be considered separately, with emphasis on the perversions and crimes that women typically commit. A woman uses her body as her most powerful means of communication and her greatest weapon. In a sense she writes on her body in a gesture of protest and in order to elicit help, to communicate her sense of crisis. This book is intended to be an introduction to this largely unexplored area and to the model of forensic psychotherapy which provides a theoretical and clinical approach to understanding the dynamics of violence and criminality.

Defining violence It is important to understand what is meant by violence. Violence can be seen ‘as a loss of control of aggressive impulse leading to action’ (Shengold 1999:xii). Central to the definition of violence is the act of causing physical harm. In this book I focus on violence directed against individuals, not against objects. The roots of violence have been linked to a developmental failure to conceptualise one’s own and other people’s states of mind. What is too painful to be thought about may be enacted. It has been suggested that this difficulty is created by the mother’s hostility towards the infant which makes it difficult for the infant to think about her mother’s state of mind, and how the mother views her (Fonagy and Target 1999). This is clearly linked to violence:

The psychology of female violence

2

Violence, aggression directed against the body, may be closely linked to failures of mentalisation, as the lack of capacity to think about mental states may force individuals to manage thoughts, beliefs, and desires in the physical domain, primarily in the realm of body states and processes. (Fonagy and Target 1999:53) I am particularly interested in exploring the inner unconscious conflicts which may be reflected in the outward manifestation of violence: my main focus is on the inner world of the violent woman. Throughout the book I distinguish between offending and non-criminal acts of violence. I use the word ‘crimes’ both literally and metaphorically.

Clinical context I am a clinical and forensic psychologist working within the forensic psychiatry and psychology services, based at a regional secure unit. I assess and treat inpatients and outpatients. The women with whom I have clinical contact have been referred from both criminal and civil courts, social services, and the probation or psychiatric services. The group of women described may reflect extremes: as female violence is largely unexplored, however, it is valuable to study extreme examples of violent behaviour to shed light on the phenomenon in general. Although many of the women I see have come through the criminal justice system, not all are offenders, and some may have committed crimes for which they have never been convicted. Rather than focusing on criminal women specifically, I have addressed the general area of female violence, with reference to violent crimes which women typically commit. Not all types of violence discussed in this book are against the law, e.g. self-harm and anorexia nervosa, but I consider these to be metaphorically crimes against the body, acts of violence against the self. Confidentiality and anonymity I have illustrated theory with disguised and anonymised case material throughout. I consider this to be an invaluable source of instruction about female violence. This material is drawn from my clinical contact with women, both as inpatients and outpatients of the psychological and psychiatric services. Unless referring to high profile cases already reported in the public realm, I have changed clients’ details throughout in order to preserve their confidentiality and anonymity. In addition to working within the National Health Service, I work independently and see women for assessment in child care proceedings and criminal cases who may have no previous contact with psychological or psychiatric services. I have included anonymised material drawn from these contacts in the case discussions. The case material is therefore derived from a wide range of assessments and treatment of women seen over an eighteen-year period; some of the cases are composites of two or more different cases, informed by clinical situations I have encountered. Although I have disguised the individual women and aspects of their circumstances that could identify them, I have attempted to retain the essential features that most clearly illustrate the nature of female violence.

Introduction

3

The nature of the treatment I offer is short term compared to the traditional length of psychoanalytic psychotherapy: the maximum treatment undertaken is generally no more than two to three years and consists of once weekly therapy. Although my work is informed by psychoanalytic ideas, I do not intend to suggest to the reader that the clinical work described here is analytical psychotherapy in the traditional sense. I use the tools of forensic psychotherapy, as developed at the Portman Clinic, in which a psychodynamic understanding of the internal world of the offender guides clinical practice. While my background is in clinical psychology, I am informed by concepts including containment, transference, countertransference, part-object, and the psychological defences like projection, projective identification and identification with the aggressor, to which I will refer in this text. For anyone unfamiliar with the terminology, Laplanche and Pontalis’s A Dictionary of Psychoanalysis (1988) provides clear definitions and explanations of psychoanalytic terms.

Central aim of the book: challenge to the denial of female violence Although this book focuses on the violence committed by women, it is also essential to recognise the violence that is done to them through the denial of their capacity for aggression, and the refusal to acknowledge their moral agency. It is possible that the envy which this idealisation by others creates is also responsible for the denigration of women, particularly mothers, when they do not fulfil the expectations created by sentimentalised notions of motherhood and femininity. Two important reasons for ignoring female violence are, on the one hand, the widespread denial of female aggression and, on the other, the idealisation of motherhood. A further reason is the secretive or personal nature of much female violence, perversity or deviance. ‘Most violence is perpetrated by men, whether directed at men or women’ (Mayhew et al. 1992) but when women do commit acts of violence they are likely to do so in the private sphere, in the home, against themselves or their children. These may be considered hidden crimes and will not necessarily show up in the criminal statistics. Female violence is often committed in the private, domestic arena as opposed to the traditionally male arena of public life, highlighting important issues about the demarcation of spheres of power in society. When women do enter the public domain as criminals, they are often vilified with a venom that men escape. Baroness Helena Kennedy’s seminal work Eve Was Framed, first published in 1992, with a new edition in 2005, describes the treatment of women in the criminal justice system. She demonstrates that significant failures of understanding by the courts result in unfair sentencing practices for women. She has brought this crucial issue into the public domain in important ways. Social stereotypes of female behaviour are revealed in the courtroom as elsewhere and the female offender is treated in stark contrast to the male. Welldon’s (1991, 1992, 1993, 1994, 1996) work on female violence and perversion has outlined the psychodynamic processes which shape this behaviour, and the intergenerational transmission of perverse and abusive mothering. Dinora Pines (1993) describes the ways in which unconscious conflicts are expressed through pregnancy, childbirth and sexuality in women. These processes are evident in the women with whom

The psychology of female violence

4

I have clinical contact, many of whom are psychologically disturbed, and manifested in the violence that they inflict on their own bodies and those of their children. There are many expressions of female violence which demand careful analysis and exploration. In this text I have chosen to discuss those manifestations of female violence with which I have had most clinical contact, and this is in the areas of maternal abuse, self-harm, and the experience of women who have been the victims of male violence, some of whom have eventually retaliated. Because of the depths of disturbance and deprivation of the women I describe here, it is possible that the case material will appear dramatic and shocking. I must emphasise that I see a highly selective group of patients, some of whom have been convicted of serious crimes and sentenced to hospital treatment. I have also included material drawn from my assessments of women for use in care proceedings cases. I have almost always been asked to assess these women because of known or suspected abuse of their children, and the concerns of the local authorities that these mothers either pose an actual risk to their children or have serious difficulties in protecting them from abuse inflicted by violent partners. It is undeniable that I see highly disturbed women in the inpatient population, and only assess those mothers about whom concern has been expressed, and who may have been known to social services even before they became mothers. There is therefore an important sense in which I describe women in this book whose violence and deprivation are on the extreme end of a continuum; nonetheless, these women dramatically illustrate processes and experiences shared by other, non-offending women. I am aware that there are important manifestations of violence in women, including arson, lesbian partner violence, gang violence and serial murder, which I have not addressed here. This study should not be considered a comprehensive account of the vast and neglected area of female violence but rather an introduction to it.

The model of female perversion: conceptual foundations The notion of perversion as sexualised aggression is relevant to understanding female aggression. I consider many varieties of selfharm, including anorexia, to be female perversions, that is, the sexualised expression of aggression which serves to defend the person against depression or even psychosis, and in the case of women is not directed towards an objectified other but towards their own or their children’s bodies. The notion that there is a special, unique category of female perversion was developed by Welldon who argues that eating disorders, self-cutting and maternal incest can all be conceptualised as such. She states: The reproductive functions and organs are used by both sexes to express perversion. Perverse men use their penises to attack and show hatred towards symbolic sources of humiliation, usually represented by partobjects. If perversion in the man is focused through his penis, in the woman it will similarly be expressed through her reproductive organs and the mental representations of motherhood. (Welldon 1991:85)

Introduction

5

Unlike Freud’s definition of perversion, this conceptualisation need not be used in an exclusively sexual context. Throughout the book I have described female perversion: I hope it is clear to the reader that the term ‘perversion’ is used descriptively rather than pejoratively or morally, though many of the acts described are at the extreme of morality.

The language of the body I consider the acts of violence typically committed by women, against their own bodies and against their children, to be essential tools of communication. The work of McDougall (1989) addressing the psychoanalysis of psychosomatic disorder is relevant to an understanding of how the body can manifest conflicts and traumas which cannot be accessed or articulated consciously. While acknowledging the privileged position accorded to language in structuring the psyche and therapy in traditional psychoanalysis, she stresses the importance of paying attention to the complaints and disorders of the body. She argues that such psychosomatic illnesses reflect significant psychological distress and are both meaningful and potentially analysable, with some hope that these conditions can become articulated, and verbalised, gradually diminishing in lethal force. She states: Not all communications use language. In attempting to attack any awareness of certain thoughts, fantasies or conflictual situations apt to stir up strong feelings of either a painful or overexciting nature, a patient may for example produce a somatic explosion instead of a thought, a fantasy, or a dream. (McDougall 1989:11) I see a woman’s unconscious use of her body in pregnancy, and its symbolic use in selfharm, anorexia and its engagement in acts of violence against children as analogous to psychosomatic illnesses. These acts of violence serve a psychic function for the woman who perpetrates them just as the symptoms of psychosomatic illness ‘are childlike attempts at self-care and were created as a solution to unbearable mental pain’ (McDougall 1989:8). She relates the development of these disorders to early infancy, where the psychic structures are pre-linguistic and the earliest representations of the self are related to bodily experiences, and where the body is the primary medium for communication. I consider the most plausible model for understanding female violence to be one in which the violent act is conceptualised as a solution to a psychological difficulty and a bodily expression or communication of distress and anger, analogous to the psychosomatic complaint described by McDougall. The link between violence and perversion, as a defence against underlying psychological distress, is an essential one, which underpins the model of female violence proposed in this book.

The psychology of female violence

6

Alternative models of female violence There are alternative models of understanding female violence. These include a feminist understanding of female violence as a response to oppression and social conditioning, the biological model which places emphasis on the role of hormonal factors related to reproduction, a cognitive behavioural model of understanding the development and maintenance of psychological disturbance, and attachment theory, which offers a paradigm for understanding how patterns of parenting and early relations can lead to difficulties in psychological and social functioning in later life. Attachment theory is closely related to the psychodynamic model and developed both within ethology and within psychoanalytic paradigms. In this book I focus on a psychodynamic understanding of female violence, which I believe is the most powerful model for understanding its genesis and manifestation. Although I draw on feminist research, particularly in relation to self-harm and domestic violence, I do not use this model exclusively, favouring a psychological model in which psychodynamic processes are elucidated. My main aim is to understand the communicative function of the acts of violence discussed, and the psychological motivation which generates them. I view the acts of violence and offences as symbols and expressions of earlier conflicts, many of which can be traced to very early experiences in relation to the violent women’s own experience of mothering. Other models leave important aspects of female violence unexplained. Attachment theory offers insights into the intergenerational transmission of abuse. I accept the significant insight offered by Fonagy and Target (1999) relating to disturbed early attachment patterns and the resulting failure of infants to develop the capacity to mentalise: this difficulty appears to be manifested in some of the women I describe, whose bodies are used unconsciously as their main tools of communication. De Zulueta’s (1993) work has contributed significantly to the understanding of how disturbed attachment systems and traumatic events can lay the foundations for later perversions, which develop as a defence against psychic pain. She has made explicit the link between attachment theory, trauma and the development of pathological defences in the perverse or violent individual.

Structure of the second edition The second edition has been expanded to include updated data and developments in the field. I have revised all the original chapters and incorporated landmark cases into the discussions, where possible. The majority of changes can be found in Part I Violence Against Children, where recent legal and clinical developments have been significant. I discuss new clinical material in Chapter 3 on maternal physical abuse and explore the Victoria Climbié Inquiry and its relevance to the dynamics of severe child abuse, and the denial of female violence. I have addressed the controversy related to expert testimony in fabricated or induced illness cases, formerly known as Munchausen’s syndrome by proxy.

Introduction

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The book is divided into four parts: violence against children, violence against the self, violence against others and, finally, clinical applications. I have also added an introductory chapter that describes the development of disturbed parenting, tracing it from childhood through to pregnancy and childbirth. I have ordered these types of violence according to a conceptual progression, from the most hidden to the most public forms of violence. I consider maternal violence, both sexual and physical, the most hidden crime, often occurring in the private realm of the home. There may be no obvious physical signs on the victims as bruises are hidden and the fact of sexual abuse concealed; the traces are most often psychological. These acts of violence may become public when the child is brought to hospital with non-accidental injuries or the symptoms of illnesses that sometimes turn out to have been either fabricated or induced by the parent, usually the mother. At this point the public arena is entered and the intervention of the social services and the courts may become necessary. Maternal abuse can be hidden because of the power mothers have in relation to their children, whom they care for within the private realm of the home. Violence against the self may also reflect a private crime which can be perpetrated in secret, away from public view, but its effects are more readily seen in the scars of self-mutilation or the emaciated bodies of anorectic women than the hidden scars of emotional or sexual abuse in children. I link the aims of violence in self-harm and maternal abuse, using the notion of female perversion, with its emphasis on attacking the body, and the bodies of children. In the third part of the book I explore the phenomenon of women who kill their violent partners. It is in this chapter that violence is most clearly seen in the context of wider social issues related to power imbalances between men and women; the legal defences of these women are analysed in some detail. Part I Violence Against Children This is a major part of the book and discusses the development of maternal abuse, and the often hidden crimes of child sexual and physical abuse, fabricated or induced illness (formerly known as Munchausen’s syndrome by proxy) and the tragic crime of infanticide. I explore the idealisation of motherhood, the myth of The Great Mother’, a universal mother goddess (Motz 1997), and the pathological process in which unconscious conflicts are resolved through pregnancies and abusive parenting. The symbolic function of the child is also explored. In Chapter 1 I describe Welldon’s model of perverse mothering and Dinora Pines’s description of how a woman unconsciously uses her body in pregnancy and motherhood. I outline the theoretical basis for the model of female violence and the roots of disturbed mothering. For some disturbed young women with impoverished experiences of being mothered themselves, their children are narcissistic extensions of themselves. The baby can be seen as the good object which the ‘bad’ woman desperately needs as a receptacle for her projections. In her mother’s fantasy the unborn infant is the embodiment of a loving creature who confirms the mother’s regenerative power and the existence of some good in her. This idealisation can lead to disappointment and depression when the infant is actually born, awakening rage in the mother. Pines’s (1993) analysis of the experiences

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of pregnancy and mothering, and their disturbances, and Welldon’s (1992) work on perverse mothering, underpin this thesis. I outline intergenerational patterns of deprivation and abuse which may predispose some women to repeat abusive behaviour with their children. This model draws upon early experience of mothering as well as later social stresses and traces the path from abused girl to partnership with an abuser, the intensification of loss of control, learned helplessness and eventually a repetition of the abuse cycle. I provide examples of ‘pathological pregnancies’ as well as violence towards children to illustrate how women may direct their aggression on to their own bodies or those of their children to provide ‘solutions’ to psychological problems. This is related to early experiences of abuse, deprivation or neglect and mirrors the earlier trauma. In Chapter 2 I explore female sexual abuse of children, a taboo subject which has only relatively recently become the subject of media and professional interest. It is crucially important to recognise the phenomenon of female sexual abuse of children and to offer assessment and treatment to female perpetrators of sexual abuse against children, many of whom will also have been victims of intrafamilial abuse themselves. The denial of female sexuality, and the idealisation of motherhood, are evident in the refusal to ‘think the unthinkable’—to recognise the existence of maternal perversion. The notion of perverse mothering elucidates the causes, manifestations and psychic functions of maternal sexual abuse. Chapter 3 addresses physical abuse of children by their mothers. Physical abuse of a child can reflect the tremendous social stresses and personal losses that many young mothers face, as well as stemming from the reactivation of their own experiences of abuse or neglect. The symbolic significance of care proceedings in cases of child abuse is discussed. In care proceedings private violence becomes a public issue. Chapter 4 outlines how physical and emotional abuse of children can be manifested in fabricated or induced illness (FII), previously known as Munchausen’s syndrome by proxy (MSBP). In this chapter I consider the physical and emotional abuse manifested in mothers who fabricate or induce illness in children. Although a rare occurrence, it graphically illustrates how women may use their children perversely, continuing the theme of female perversion. I provide a case illustration and theoretical discussion of this dangerous and complex form of maltreatment. In this hidden form of abuse mothers may induce or fabricate symptoms in their children, sometimes with fatal consequences. This appears perverse and unbelievable to those who encounter it, and is sometimes only detected through the use of covert video surveillance, raising ethical difficulties (Cordess 1998). I explore the controversy related to the diagnosis of Munchausen’s syndrome, the General Medical Council’s ruling in relation to Roy Meadow, who was one of the key proponents of MSBP and its replacement with the term fabricated or induced illness. I also discuss recent legislation relating to child protection in this area and provide updated research in relation to the identification and treatment of FII. In Chapter 5 I discuss infanticide, one of the most shocking expressions of maternal violence. Again the mother uses her own body, as represented in the body of her child, to carry out an act of irrevocable violence. The remorse and grief experienced by women who kill their children is understandably profound. I discuss the association of infanticide with hysterical denial of pregnancy, so often associated with neonaticide. I examine recent literature in relation to infanticide prevention and the legal consequences of not

Introduction

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having an Infanticide Act in the USA. The shocking case of Andrea Yates, the clearly psychotic mother who killed her five children and is now serving life sentence for murder in the state of Texas, is used to focus debate on the utility and validity of the Infanticide Act. Part II Violence Against the Self Female violence is often directed against the self in depression, self-mutilation or voluntary starvation. Although these manifestations may reflect unconscious violence, directed against the self, they are not commonly considered to be crimes, and are certainly not prohibited legally. Because these manifestations of female violence are directed against women’s own bodies, or the bodies of their children, they are often hidden from the public. The book’s subtitle, ‘Crimes Against the Body’ refers to the selfdirected nature of much female violence; the term ‘crimes’ is used metaphorically. The women I describe here appear to identify themselves strongly with their bodies, reflecting not only their own inner psychic difficulties, but also the tremendous cultural emphasis placed on women’s bodies and their reproductive capacities. Their notion of selfhood is interwoven with their physical bodies: attacking their own bodies has a multiplicity of meanings which require articulation. These women attack themselves and, in fantasy, the body of their own mothers, through self-injury, using the concrete experience of pain to express psychological anguish and communicate unconscious conflicts. This part has two chapters, one on self-harm and the other on anorexia nervosa. Each is illustrated with case material to complement the theoretical understanding of violence against the self. My aim is to provide some understanding of the complexity and development of the behaviour, the underlying distress it signifies, its symbolic meaning and its impact on those working with these women. Chapter 6 focuses on deliberate self-harm, emphasising its communicative function and elucidating the model of female perversion developed by Welldon. Women harm themselves primarily to express their distress and anger in the hope, often unconscious, that others will respond to this. Likewise, the violence which women inflict on their children’s bodies often reflects a communicative need, and may be seen as a symptom of other conflicts. They choose to manage the intense internal pain they feel by directing it on to themselves, to externalise it in an attack on the body. The violence of self-injury is often minimised and it is viewed by others as simply annoying or manipulative rather than as a powerful communication. The majority of those who self-harm are not actually dangerous to others, although a minority are, particularly those who have themselves experienced very severe sexual, physical and emotional abuse. I have updated the chapter with reference to the evidence-based treatment, mentalization-based therapy for people with borderline personality disorder, that has been developed by Bateman and Fonagy (2004). In Chapter 7 I discuss anorexia nervosa. Self-injury, including anorexia, appears to offer a means of obtaining control, albeit temporarily, over the self through the body. Anorexia nervosa is a life-threatening condition in which the body is deliberately starved, expressing tremendous aggression turned against the self. A proportion of anorectics binge and then purge, engaging in a cycle of indulgence and self-punishment in which the abuse of their own bodies is evident. The act of purging can be viewed as a symbolic

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defence against retaining painful thoughts and memories, and can also be manifested in therapy as the inability to take in and digest the material. Issues for therapists in working with anorexic women are explored, with reference to the psychoanalytic work of Williams (1997) and Birksted-Breen (1997). While anorexia nervosa and bulimia nervosa are two distinct clinical conditions, anorectic women can sometimes use the purging methods that characterise bulimia. The chapter focuses on anorexia nervosa, but I provide some discussion of bulimia nervosa, particularly in relation to the psychic meaning of purging. This chapter has been updated and revised to reflect new literature and includes a discussion of the ‘pro-ana’ and ‘pro-mia’ websites that have proliferated in recent years. I discuss the debate about whether or not these websites should be shut down and the conflict between those who advocate for freedom of speech and others who believe that these sites have the potential to cause great harm to vulnerable young people. Part III Violence Against Others This part is devoted to the exploration of battered women who kill, as discussed in Chapter 8. I have expanded this chapter to include updated figures on female homicide. Women who are subjected to sustained physical abuse can become psychologically damaged, sometimes to the point of extreme passivity, a process which has been termed ‘learned helplessness’ (Seligman 1975; Browne 1987) and features in the ‘battered woman syndrome’ (Walker 1984). I describe what happens to women during periods of sustained abuse by their violent partners and the process which can lead such women to kill their abusive partners. Case illustrations are provided, one of which demonstrates the impact of sustained violence on a young mother, the other describing how the experience of domestic violence led a woman to kill her abusive partner. I discuss the psychological processes using psychodynamic terms, and evaluate the validity of the legal defence of ‘battered woman syndrome’, arguing for extended application of the provocation plea in relation to women who kill their violent partners. Part IV Clinical Applications In this section I provide more personal discussions of the clinical situations I encounter as a forensic psychologist working with women in secure settings. I describe a clinical encounter in Chapter 9, Working with Women who Kill, and discuss transference issues in relation to the pregnant therapist when the client is a woman who has killed her own child. In Chapter 10 I discuss service issues in relation to the development of single sex secure provision-women-only services, as recommended by the Department of Health documents Into the Mainstream (2003) and Mainstreaming Women’s Mental Health (2004). I provide an illustration of the difficulties faced by women in mixed-sex secure wards, and show how lost their needs can be in this environment. I address the question of whether dangerous and severe personality disorder is an applicable or helpful term for women offenders, and finally I provide an overview of the most helpful and sophisticated models of care for women-only secure units, developed along attachment principles. Readers familiar with the first edition will notice the many changes throughout this book. The expansion and revision are designed to reflect recent developments in clinical research and public policy and to consider any significant changes in criminal statistics.

Introduction

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The use of clinical situations that have been in the public eye can assist in the understanding of these crimes rather than simply condemning them and help the reader to appreciate the relevance of the model of forensic psychotherapy to the wider public.

Conclusion The conclusion ties together the themes of the preceding chapters and points the way forward for future research. It describes the role of forensic psychotherapy in understanding female violence and offering a treatment model in which the meaning of the violent act can be explored, with the hope that such understanding can lead to reflection, and render the violence obsolete. The ultimate goal of such therapy is to enable the violent woman to find another voice and to be less confined to using the language of the body, painful as this achievement may be.

Part I Violence against children

Chapter 1 The development of maternal abuse Female perversion Mothering, whether in the home or on the hospital floor, is a much more common route to power for psychopathic women than is commerce or sex. (Pearson 1998:107)

Introduction At the centre of female perversion is the perversion of motherhood. (Mitchell, Foreword to Welldon 1992)

The site of female perversion is the whole body and, by extension, the bodies of children. When women attack their own bodies, through self-mutilation, self-starvation or bingeing, they are symbolically wreaking revenge on their own internalised, often cruel and perverse, mothers. They identify their own body with the body of the mother. Likewise when they attack their children, they express violence towards a narcissistic extension of themselves: The main difference between male and female perverse action lies in the aim. Whereas in men the act is aimed at an external part-object, in women it is against themselves: either against their bodies or against objects of their own creation—that is, their babies. (Welldon 1992:72) These mothers have typically been used as extensions of their own mothers, who have treated them narcissistically: they repeat this pattern in the way they relate to their own babies. Early experience of maternal abuse or neglect increases the likelihood that in adulthood these women will be exposed to other situations of risk, including relationships with sexually and physically abusive men, leading to further distortions in their selfimage, and psychological functioning; this can, in turn, adversely affect their own capacity to mother. In this chapter I explore disturbances of pregnancy and mothering. I present case material which demonstrates the psychic processes manifested in a highly disturbed pregnancy, in which a young mother displayed violence towards her own pregnant body, and later towards her infant. These cases illustrate Welldon’s model of female perversion.

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In order to understand the phenomenon of sexual abuse of children it is essential to consider the nature of female perversion, and its roots in disturbed parenting. I begin this chapter with a discussion of female perversion, and psychological disturbances in pregnancy and mothering in general, before moving on to explore sexual abuse of children in particular.

The nature of female perversion Estela Welldon’s radical thesis challenged the assumption that perversion was related to the phallus, and thus the province of men, as Freud had established. In her Foreword to the 1992 edition of Welldon’s book, Mother, Madonna, Whore: The Idealisation and Denigration of Motherhood, Juliet Mitchell writes: Men are perverse; women neurotic; Estela Welldon was one of the first— perhaps in her field, the first—to question the status of this psychosocial truism…women could not be seen to be perverse because the model for perversion was male…. Welldon sets out her argument that female psychophysiology gives a completely different pattern to perversion. The source of both male and female perversion may lie in a disturbed infant/mother relationship but the aims of subsequent adult perversion in the two sexes differ. Both attack the mother who abused, neglected or deprived them but women will attack this mother as she is internalised in her own female body or found within her own mothering. The hated one is identified and lies thus within or in the baby who extends the self as once the perverse woman was her own mother’s extension. Consequently the typical perversions of women entail self-mutilation or child abuse…Perversion of motherhood is the end product of serial abuse or chronic infantile neglect. The reproduction of mothering is also the reproduction of perverse mothering. (Mitchell 1992:iv) Welldon argues that female perversion has generally been overlooked by psychoanalytic authors who have identified perversion with male sexuality and the castration complex which results from Oedipal longings. Freud essentially neglected the study of female sexuality and the possible perversions of women’s maternal desires, attributing to women strong feelings of inferiority about being female and a compensatory craving to be impregnated with sons. For Freud the penis is symbolically equated with babies; girls resolve their Oedipus complex by transferring the object of sexual desire from mother to father, and then changing the wish for a penis to a wish to be impregnated by their fathers. Having babies fulfils a woman’s needs, related to her penis envy and the compensatory craving for babies by the father. There was no indication by Freud that pregnancy or childhood could afford disturbed women opportunities for perversion and that motherhood itself might provide such a rich source of perverse and destructive power.

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Welldon was the first to describe explicitly how, for women, perversion is not simply located in the genitals. The whole functioning female body, and the babies which it produces, provide the focus for the manifestation of female perversion: I believe the term ‘body’ in the definition of perversion has been mistakenly identified exclusively with the male anatomy and physiology, specifically with the penis and genital orgasm. How could we otherwise have overlooked the fact that women’s bodies are completely taken over in the course of their inherent functioning by procreative drives, sometimes accompanied with the most perverse fantasies whose outcome materialises in their bodies? (Welldon 1992:7) Perversion as the erotic form of hatred Perverse behaviour enables women to project their own experience of childhood victimisation on to someone else, namely a child or children entrusted to their care. Such re-enactments may not take place at a conscious level and have important psychological functions. In the psychoanalytic sense perversion is a term used not pejoratively but descriptively, referring to a particular kind of erotic activity which does not have as its aim genital sexuality, thereby avoiding the intimacy that full sexual intercourse involves. Analysts differ in their understanding of the defining characteristics of perversion. Stoller (1975) describes it thus: Perversion, the erotic form of hatred, is a fantasy, usually acted out but occasionally restricted to a daydream (either selfproduced or packaged by others, that is, pornography). It is a habitual, preferred aberration necessary for one’s full satisfaction, primarily motivated by hostility. By ‘hostility’ I mean a state in which one wishes to harm an object; that differentiates it from ‘aggression’, which often implies only forcefulness. This hostility in perversions takes form in a fantasy of revenge hidden in the actions that make up the perversion and serves to convert childhood trauma to adult triumph. To create the greatest excitement, the perversion must also portray itself as an act of risk taking. While these definitions remove former incongruities, they impose on us the new burden of learning from a person what motivates him. But we are freed from a process of designation that does not take the subject’s personality and motivation into account. We no longer need to define a perversion according to the anatomy used, the object chosen, the society’s stated morality, or the number of people who do it. (Stoller 1975:4) Key characteristics of perversion include risk-taking, deceit, objectification of the victim, secrecy and ritualised behaviour. Perversions also appear psychically to engulf the person who enacts them, providing the central meaning to their existence. They offer tremendous gratification. Stoller’s notion of the ‘hidden fantasy of revenge’ is central to

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understanding the symbolic meaning of the perversion, and the sense in which it is a repetition of an earlier trauma, ‘converted to adult triumph’ as the victim now becomes the perpetrator. Women who present clinically with sexual perversions often appear wholly preoccupied by them, as though there were nothing else of meaning or value in their lives. This indicates the extent to which perversions can mask an underlying emptiness and sense of flatness, or depression. For some, keeping the perverse behaviour secret, and employing elaborate strategies to preserve its existence becomes a governing principle of life. Even when not enacted, fantasies may be the main source of comfort and control for such women. When women have themselves been subjected to sexual abuse in childhood, they can similarly feel preoccupied with memories of their own trauma and it is only through replacing their earlier persecution with their adult ‘triumph’ of offending that they feel temporary relief from their own memories of victimisation. This dynamic applies not only to sexual abuse, but also to physical and emotional abuse. For mothers, presenting the facade of ordinary, devoted maternal care provides an invaluable subterfuge for abuse. This will be explored in detail throughout the next four chapters.

The roots of disturbed mothering The ideas of Dinora Pines and Estela Welldon in relation to women’s unconscious use of their bodies are complementary, providing a sophisticated and comprehensive understanding of female experience. The psychoanalyst Dinora Pines eloquently describes how women’s bodies, in particular their reproductive systems, can become the vehicles for the expression of unconscious conflicts. She explores the many ways in which unconscious conflicts may be expressed through pregnancy, miscarriage, childbirth and sexuality. Her work differs from Welldon’s in that she does not focus on perverse or criminal women, although the processes that she describes can also be seen in extreme forms in these women. Through her pregnancies and the babies which she produces, the perverse mother is able to re-create the destructive patterns of her own birth and childhood, inhabiting a domain within which she has power, where she can wreak vengeance and gain compensation for her own abuse and deprivation. While these motivations may be unconscious, their conscious expression can be manifested in a woman’s apparently benign but overwhelmingly powerful desires to have a baby inside her body, and to produce a child who will finally give her unconditional love and affirmation of her own vitality and power. The baby may, in reality, become a receptacle for her own unacceptable feelings of helplessness and deprivation. Pines explores the interplay between a young woman’s relationship to her body, herself, her own mother as an object, and her own experience of being mothered, in relation to her experience of pregnancy and, later, to the baby. She identifies the process whereby the little girl who has not felt satisfied by her mother at the preOedipal stage, where she can introject feelings of bodily satisfaction, is left with a sense of being incomplete, empty. This contributes to a feeling of deprivation in adulthood where the woman longs for and seeks an experience that provides this sense of satisfaction. This

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deprived state, in which the adult woman is left feeling incomplete, can result in deep-seated problems with separation and individuation, as the achievement of an adult identity requires the prior internalisation of a sense of being mothered. Such a woman may ‘never make up for this basic loss of a primary stable sense of wellbeing in her body and with her body image…Narcissistic injury, giving rise to narcissistic rage, envy of the mother and lack of self esteem, may be painful and add to the difficulties of separation’ (Pines 1993:101). This is an extension of the Kleinian notion of the basis of the feeling of integration and security which is the consequence of the introjection of, or taking in, an object who is loving and protective of the self and who is, in turn, loved and protected by the self (Klein 1932). This is the introjected object, the internalised mother. Introjection has strong links with the first feeding experience, in which something is taken inside the infant, from the mother. Without this successful introjection, the process of separation in relation to the mother may become highly disturbed and create tremendous psychological difficulties. These difficulties may be repeated in the woman’s relationship with her baby, where separation and individuation become particularly problematic. Her own psychic state is vulnerable to becoming overwhelmed when memories and feelings related to her own deprivation are reawakened. The notion of the separateness of the baby is difficult for such mothers to conceptualise. Their understanding of the needs of the children for welfare and protection is limited, as their main concern is their own need to feel cherished and loved. They may describe feeling ‘empty’ inside and wanting a baby to make them feel ‘filled up’ and whole. This emptiness can mirror an earlier experience of emotional deprivation and depletion: the absence of an internalised good object. The birth of children for these women is often a tremendous disappointment, as the demands of the infants reawaken their awareness of their own unmet needs, making the situation persecutory and, at times, unbearable: ‘Mature object love, in which the needs of self and object are mutually understood and fulfilled, cannot be achieved, and the birth of a real baby might be a calamity’ (Pines 1993:103). Pines (1993) identifies an essential distinction between the experiences of pregnancy and motherhood; this differentiation is crucial in both practical and psychodynamic terms. The disappointment that women may feel when the pregnancy ends and the baby is born, the baby who not only fails to compensate them for their deprivation but also stirs up memories of frustrated needs and infantile rage, can lead to renewed feelings of anger, abandonment and isolation. The unbearable nature of the reactivated pain can lead to violent or perverse assaults on the baby. In the following case illustration I describe the psychic processes which give rise to violent assaults on an infant, both in the womb and following her birth. These attacks are not sexual ones, but stem from the disturbed constellation of experiences that may equally give rise to maternal incest. Both physical and sexual assault on children can be considered manifestations of female perversion. I have described this young woman, Kate, in order to illustrate the discussion of unconscious fantasies and terrors in pregnancy and their link with maternal abuse. She graphically illustrates Welldon’s notion of women’s ‘perverse fantasies whose outcome materialises in their bodies’ (1992:7).

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Case illustration

Pregnancy and unconscious fantasies Kate, an 18-year-old woman, was seen for assessment of her capacity to care for and protect her seven month-old daughter, Alana. She had been placed in foster care and was the subject of care proceedings following serious concerns about physical abuse by Kate, who had admitted to assaulting her on two occasions. The local authority was exploring the possibility of placing Alana for adoption rather than returning her to Kate’s care. I was asked to see her to explore her own history and her potential to engage in therapy that might help her to mother this child. There could be no offer of confidentiality as I would be preparing a report for the courts in relation to her general presentation, particularly in terms of her aggression, her mothering and her capacity to engage in relevant psychological work. Kate presented as a vulnerable young woman with difficulty in understanding the nature and purpose of the assessment and an overall sense of confusion and distractedness. She was slight and dishevelled, wearing ill-fitting and dirty clothes. She chose to keep her heavy jacket on throughout the initial interview, despite the warmth of the room, conveying a sense that she needed the protection of her clothing, and was not fully aware of how to take care of herself or how to respond to her environment. Her unwashed and unkempt appearance and red-rimmed eyes evoked the image of a neglected child, or an adolescent runaway sleeping on the streets. She was 12 weeks pregnant with her second child when I met her and had recently separated from her violent partner, the father of her first child. She was unsure who the father of her second baby was, having had casual sexual relationships with several men over the past year. Kate looked several years younger than her actual age, appearing ill at ease and awkward. Her face and voice were almost expressionless, aside from the occasion when she burst into tears as she described the extreme violence to which her mother, father and later her stepfather had subjected her throughout her early life. None of the adults in her life had protected her from this violence, instead she been berated and blamed. She felt worthless and unwanted at home. At age 12 she had come to the attention of social services because of bruising to her face and arms and disturbed behaviour at school. Her parents had separated the previous year and her mother had formed a new relationship with a man who had been charged with, but not eventually convicted for, sexual offences against children two years before he had met Kate’s mother. Kate referred to this man as her ‘stepfather’ and disclosed that she had been ‘terrified of him’. She had eventually been removed from her mother’s care and placed in a children’s home when she was 13. She had two younger brothers, who still lived at home with her mother. Kate’s own mother had been classified as having learning disabilities and had suffered with depression since her early twenties. Her first depressive episode had occurred when Kate was three weeks old. Kate said she ‘could not remember’ if she had been subject to sexual violence in early childhood but she had been seriously indecently assaulted by a stranger when she was 14. She had been willing to give evidence against her assailant but he had died before the case came to court.

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Kate gave the impression of being traumatised, intellectually and emotionally; she had been emotionally, physically and sexually damaged to the extent that she did not believe anything good or alive could survive inside of her. In conflict with her fear of what was inside of her was her overwhelming desire to continue with her pregnancy and become a mother, although she did not appear to have a real sense of what either experience involved. Kate vividly described her sense of confusion and fear during her first pregnancy. ‘I didn’t know what was inside of me,’ she explained, and went on to relate how she had used coathangers and other sharp instruments to try to dislodge the unborn baby from 18 weeks on, eventually giving birth at 36 weeks to a girl. She had presented at casualty frequently during her first pregnancy and the medical reports gave a graphic picture of her: ‘the patient presented as a young woman screaming to have the baby taken out of her.’ She experienced her pregnancy as filled with horror, describing a powerful sense of invasion. She had vivid images throughout her pregnancy of a monstrous creature growing inside her. She had wondered whether the baby was fully human and felt desperate for it to be born so that she could find out whether it was, in fact, a human baby. Once her daughter had been born, following Kate’s repeated unsuccessful and violent attempts to induce labour, she had found it increasingly difficult to cope with her demands. When the baby was nine days old Kate had shaken and thrown her, finding it unbearable to hear her crying, which she could not stop, and which powerfully reawakened her own memories of deprivation. Her assault on the baby brought her to the attention of the social services once again, this time as a mother; she had only recently been discharged from a care order herself. When care proceedings were instigated on her newborn child Kate reported a sense of relief, because she was aware that she was not able to cope with motherhood. In this sense the relief and her desire to protect the baby from suffering as she had in her childhood, reflected a healthy and protective aspect of her maternal capacity. Although she had an intellectual awareness, at times, about her potential to damage the baby, at another level she was able to deny her own murderousness and felt bereft and furious about having to lose care of her. She revealed how desperately she had wanted someone to love her, hoping that the baby would meet this need. Following the assault, the baby had been removed from Kate’s care and she soon became pregnant with her second child, having conceived approximately five months after the first was born. She appeared wholly unaware of the fact that she was considered to be a severe risk to a child in her care and thought she was seeing me to get ‘some ideas about how to look after two babies’. Although I had clearly and repeatedly explained my actual function, which was to prepare an assessment report for the court, she did not seem to understand this; she related to me with a degree of trust and hope that was both moving and distressing. Assessment revealed that that she did not seem to have the capacity to understand or meet the needs of her children, and also had a significant degree of learning difficulty, demonstrated by formal cognitive assessment carried out by my colleague. The risk that she could pose to a child of neglect or physical injury was significant and it appeared that the only hope for rehabilitation of her daughter to her care would be if the two were jointly fostered, with an experienced foster mother who might also be able to provide Kate with an experience of being cared for and contained. This had, in fact, been

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attempted when the baby was three weeks old but the placement had broken down because of Kate’s extreme envy about the foster mother’s attention to the baby, which she had found intolerable. Sadly she craved this maternal care for herself. Her low sense of self-esteem left her feeling devastated by criticism, to the extent that even minor suggestions about how to improve her sensitivity to her baby’s needs enraged her. I referred Kate to the local learning disability team and recommended that she receive supportive psychotherapy or counselling to help her cope with the trauma of her recent loss of her daughter, and to enable her to discuss how to manage her overwhelming feelings of distress and rage, which she had directed both at herself and her child. It appeared unlikely that she would be able to cope with the demands of her second baby unless she were placed in a highly supportive and structured environment with the baby on a long-term basis, and it was possible that she would also have this child removed from her care. This would be another significant loss for her, not least because she would lose the fantasy of being loved and cared for. Both pregnancy and motherhood had proved to be deeply disturbing and persecutory experiences which stirred up unbearable memories and feelings for this vulnerable and violent woman. Her sense of alienation from her own body that the pregnancy created seemed to be a graphic illustration of how her impoverished experience of being mothered had left her without a secure sense of her own female body. She perceived her pregnant body as an unreliable and frightening object, mirroring her experience in infancy of her own mother’s depression and emotional unavailability. There was a sense in which she unconsciously identified with the murderous and inhuman infant, whose desires for her mother had been unmet. Kate seemed tortured by an almost psychotic sense of unreality and fear about what was happening to her body during pregnancy. For this woman, who had so few inner resources and little sense of an internalised mother, the experience of pregnancy was one of unbearable violation and persecution.

Discussion Unconscious fantasies in pregnancy In pregnancy a woman narcissistically identifies with the foetus inside her and this revives infantile fantasies about herself as the baby in her mother’s body. This can result in the reactivation of intense ambivalent feelings towards her own mother, her internalised representation of her own mother and herself as a baby. If the hostility inherent in these ambivalent feelings is too great, she may not feel able to allow the actual baby inside her to live. Alternatively, she may not feel able to allow this baby a separate psychic life, viewing it as a narcissistic extension of herself. The notion of perverse motherhood described by Welldon is clearly consistent with Pines’s delineation of the psychic processes by which a young woman with an impoverished or disturbed experience of parenting can find the tasks of motherhood difficult, if not impossible. For women who have not experienced ‘good enough’ mothering in their own childhood, with the experience of internalised and integrated bodily experiences, the inevitable regressions involved in pregnancy can be deeply threatening, and the ‘infantile wish to merge with the mother and the opposing fear of it which occasioned a partial

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failure of self/object differentiation may be revived’ (Pines 1993:99). The child’s separation-individuation is also influenced by her mother’s relationship with the father, and her capacity to enjoy her own adult sexual body. Pregnancy offers the woman a form of biological identification with her own mother, which may be extremely frightening for her, depending on her own experience of being mothered and social circumstances. The developmental tasks faced by pregnant young women and adolescent girls require changing their relationship to their own prepubertal bodies and identifying with their own mother. This can reawaken earlier difficulties and produce symptoms as a defence against psychic pain, particularly where separation from the mother at earlier developmental phases has not been achieved. Laufer (1993) relates this difficulty to the Oedipus complex and the requirement that it must be resolved in order for the little girl to identify with her mother, and to view herself as having a body without a penis. This further requires her to give up the fantasy of possessing and fulfilling her mother as a man could; she must relinquish the fantasy of being able to give her mother sexual fulfilment. The loss of this omnipotent fantasy can generate serious anxieties in the child: What has impressed me most has been the capacity of some women to deny the reality of the changes taking place in their compelling need physically to attack their own bodies, or later that of their babies during these critical developmental periods. (Laufer 1993:69) This was clearly the case with Kate, who described her pregnancy as ‘terrifying’, saying, ‘I just didn’t know what was inside me.’ This revealed her fear about her unconscious murderous feelings towards her mother, her baby and herself. Throughout her pregnancy she had made violent attacks on her body in order to force the infant out, because she found the terrors of pregnancy unbearable. She was tormented by fears, both conscious and unconscious, about what kind of toxic creature was growing inside her. It seemed likely too that her earlier experience of sexual violence had made her highly sensitive to perceived intrusion and violation of her internal space: the unborn baby became a persecutory and terrifying object. Her violence could be understood as a response to her own sexual and violent traumatisation in childhood, underpinned by an inadequate attachment to her own mother, which led to perverse defences, such as the reliance on physical violence and powerful identification with a murderous infant (De Zulueta 1993). The combination of bodily and emotional states of first pregnancy powerfully reactivates earlier experiences, as Pines describes: The young woman may become aware of primitive, previously repressed fantasies and conflicts, arising from childhood sexual theories about her own conception, intrauterine life, and birth. It follows that positive and negative aspects of the self and of the object may be projected onto the unseen foetus as if it were an extension of them. (Pines 1993:100) The reactivation of earlier experiences can be persecutory, leading to powerful feelings of anger and fear about the development of the baby. These fears may be expressed as

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preoccupations about giving birth to deformed or damaged babies, illustrating the extent to which guilt about the murderous and destructive impulses towards the baby shapes fantasies. These fears can coexist with fantasies of narcissistic fulfilment, that the unborn baby will offer the mother unconditional love and nurturance. This hope was clearly expressed by Kate, who said she wanted to have a baby so that she could have ‘something of my own…someone who loves me’. While pregnancy might fuel a woman’s fantasies of wholeness and creativity or, alternatively, terrify her with thoughts of invasion, contamination and murder from within, the experience of being responsible for another person, a helpless and demanding infant, involves a completely different set of fantasies and experiences. This was clearly illustrated in Kate’s disturbances both in her pregnancy and in mothering, resulting in her violent assaults on the baby, both during and after the pregnancy—inside and outside her own body. At times this distinction seemed lost to her as if she and her baby were fused into one. Promiscuity and pregnancy Promiscuous sexual intercourse, with the unconscious aim of establishing pregnancies, may reflect a young woman’s desperate and unmet need for mothering, for the sense of fulfilment and ‘wholeness’ of which she feels deprived. A young woman’s physiologically mature and sexually alive body establishes adult status but also enables her to split off and deny painful emotional states by substituting bodily sensations. In this way, feelings of love or hate towards the self or towards the object can be concretely expressed, depression avoided and self-esteem raised. It follows that a sexual act, which, to the outside world, appears to be an act of adult, genital sexuality, may unconsciously become a means of satisfying unfulfilled pregenital longings for the mother and for being mothered. The mother is to her child the symbol both of the maturational environment and of motherliness itself. Her physical presence and emotional attitudes towards her child and its body are integrated with the child’s experience and her conscious and unconscious fantasies. The representation of an internal mother created in this way is a lifelong model for her daughter to identify with and also to differentiate herself from. (Pines 1993:102) Pines, unlike Freud, does not believe that pregnancy and birth gratify every woman’s basic wish to receive compensation for the deprivation of a penis. She states: There is a marked distinction between the wish to become pregnant and the wish to bring a live child into the world and become a mother. For primitive anxieties and conflicts arising from a woman’s lifelong task of separation-individuation from her own mother may be unexpectedly revealed by the emotional experience of first pregnancy and motherhood. (Pines 1993:98)

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The importance of her work is in tracing the development of disturbed mothering, through a woman’s fantasies during her pregnancy, to her own identifications with the internal representation of her own mother, that is ‘bodily reinforced’ in pregnancy. For perverse mothers this internalised mother will also be a perverse object.

Transmission of disturbed attachment patterns Important empirical research about the intergenerational transmission of disturbed parenting has come from attachment theory, based on the seminal work of John Bowlby. The experience of a disturbed early environment and particular styles of parenting, which are not attuned to the infant’s needs and desires, has been associated with difficulty in later social functioning. Disturbances in attachment in childhood may lead to problems in forming trusting and stable relationships with partners and in parenting children in a way which fosters secure attachment (Fonagy 1991; Fonagy et al. 1995). The lack of trust and security in early life may have long-term consequences for attachment patterns in later life. Insecure early attachment is associated with personality disorders in adulthood and has been studied in adulthood using the Adult Attachment Interview (AAI), a semistructured psychodynamic interview schedule which provides rich qualitative data about the nature of parenting in childhood, from which particular parenting styles can be identified. Participants are asked to describe their early attachments, their feelings about their parents, and significant losses or traumatic experiences in childhood. They are then classified into four different attachment categories, largely based on their style in describing their early attachments: ‘free to evaluate attachment’, ‘dismissing of attachment’, ‘enmeshed in attitude towards attachment’ and ‘unresolved/disorganised/ disorientated’ (Holmes 1993). Classification of these types of attachment in adults based on the AAI has been shown to predict particular styles of parenting relating to their own children, as demonstrated by observing the children’s response to temporary separations from their mothers or caregivers using the Ainsworth ‘strange situation’ experiment (Ainsworth et al. 1978). When pregnant mothers were given the AAI, it predicted the attachment status of their infants at one year with 70 per cent accuracy (Fonagy et al. 1991). Such empirical work provides evidence for the intergenerational transmission of disturbed parenting, and outlines possible mechanisms responsible for the psychic harm. For example, the child whose mother cannot attend to her needs consistently develops an insecure attachment in which she wants her mother to be with her at all times, as she has no internal sense of her. This absence of an internalised sense of a reliable mother leads to clingy behaviour, attempts to stay with her and feelings of acute abandonment and fear when left alone, as though the mother will never return. In psychoanalytic terms the child’s object relations are distorted, and she may well present with an adhesive quality in therapy, making desperate attempts to cling to the therapist and fearing that she will not be kept in mind unless actually physically present. Separations may feel unbearable. Recent work by Bateman and Fonagy (2004) explores the development of difficulties for individuals with early attachment difficulties in mentalising their own and others’ emotional states; instead they enact difficult feelings through impulsive behaviour including violence towards the self or others. There is a growing evidence base for

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psychotherapy informed by the underlying model of disturbed attachments in these individuals, aimed at addressing the difficulties in mentalising certain states of mind. Failures in early mirroring and reflective processes by carers create later difficulties in reflective functioning for the individual herself. This work is highly informed by the kinds of processes already described in this chapter in relation to the intergenerational transmission of disturbed parenting, and the developmental roots of such difficulties. The following chapters describe in detail how these difficulties are manifested in various acts of violence against children, the self and partners, making reference to the model of female violence described here.

Chapter 2 Female sexual abuse of children Ruth rose up and out of her guileless inefficiency to claim her bit of balm right after the preparation of dinner and just before the return of her husband from his office. It was one of her two secret indulgences—the one that involved her son—and part of the pleasure it gave her came from the room in which she did it… She sat in the room holding her son on her lap, staring at his closed eyelids and listening to the sound of his sucking. Staring not so much from maternal joy as from a wish to avoid seeing his legs dangling almost to the floor… In the late afternoon, before her husband closed his office and came home, she called her son to her. When he came into the little room she unbuttoned her blouse and smiled. He was too young to be dazzled by her nipples, but he was old enough to be bored by the flat taste of mother’s milk, so he came reluctantly as to a chore, and lay as he had at least once each day of his life in his mother’s arms, and tried to pull the thin, faintly sweet milk from her flesh without hurting her with his teeth. She felt him. His restraint, his courtesy, his indifference, all of which pushed her into fantasy. She had the distinct impression that his lips were pulling from her a thread of light. It was as though she were a cauldron issuing spinning gold. Like the miller’s daughter—the one who sat at night in a straw-filled room, thrilled with the secret power Rumpelstiltskin had given her: to see golden thread stream from her very own shuttle. And that was the other part of her pleasure, a pleasure she hated to give up. (Song of Solomon, Morrison 1998)

Female sexual abuse of children: the ultimate taboo The fact that women can and do sexually abuse children is deeply threatening to social stereotypes of motherhood and femininity. While the criminal statistics consistently reveal that women commit 1 per cent of sexual offences (Home Office 1993, 1998, 2003, 2006), there is evidence from other measures including self-report by victims of sexual abuse that this figure is not representative of the true rate of female abuse. In a recent retrospective study, based on self-report in the USA, Dube et al. (2005) found that men

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reported female perpetration of CSA nearly 40 per cent of the time, and women reported female perpetration of CSA 6 per cent of the time. Ford (2006) cites ChildLine figures from the year 2004–2005 that indicate that 3 per cent of girls calling reported abuse by a female, and 2 per cent by their mothers, while for boys 25 per cent reported abuse by a female, and 16 per cent abuse by their mothers. Clearly the official statistics relating to criminal convictions tell a different story. Female sexual abuse appears to be a vastly underreported crime (Saradjian 1996; Ford 2006). It is likely that female sexual abuse of children is vastly underreported by victims, for various reasons, including the greater sense of shame associated with abuse by a mother or other females, the dominant conception of male perpetrators and female victims, the complex and intense emotional attachment of children to their mothers or carers, and the fear, in many cases justified, that they will not be believed. The notion that some mothers, or women of child-bearing age, abuse children sexually is an unacceptable one which powerfully challenges idealised constructions of motherhood and femininity. The difficulty in accepting the existence of maternal sexual abuse appears greater than that of acknowledging maternal physical abuse, notwithstanding that when ‘battered baby syndrome’ was first identified there was a sense of outrage and disbelief. The failure to recognise the possibility of female sexual abuse reflects a general tendency to deny female sexuality in general, and female perversion in particular. The taboo of maternal incest remains strikingly powerful, making it difficult for female sexual abuse to be conceptualised: ‘secrecy and denial about sexual abuse are still common, particularly when the perpetrator of that abuse is a woman’ (Saradjian 1996:xiii). The easy access that women have to children as mothers, childminders, nannies, nursery nurses and au pairs and the intimate nature of their ordinary contact, i.e. bathing, dressing, feeding, changing nappies, applying creams and lotions, may make it particularly easy to abuse children in their care, and also allow the abuse to be concealed, affording many opportunities for perverse handling of children. The abuser herself often confuses sexual contact with children with genuine affection for them, mirroring her own experiences in childhood. The early experience of sexual abuse may predispose a woman to later sexual offending against children. Criminal statistics reveal that in 1995 in England and Wales 4600 men and 100 women were sentenced for indictable sexual offences against children and a further 2500 cautioned (Home Office 1995). When these were further analysed to cases where the victims of sexual abuse were under 16, there were 1350 cautions, of which 34 were against female offenders, 3284 prosecutions, of which 30 were female offenders, and 2554 convictions, of which 19 were against female offenders. In 1997 Criminal Statistics, documenting recorded crime in England and Wales in 1997, indicated that of 6500 offenders found guilty at all courts of sexual offences, only 100 were females, again pointing to the great discrepancy between the recorded crime rates of male and female sexual offenders. Grubin’s (1998) study for the Home Office on sex offending against children notes that the recorded offence for child sexual abuse by women is relatively uncommon. According to Criminal Statistics (Home Office 1998), less than 1 per cent of sexual offences are committed by women, although offender samples cite higher figures: Craissati and McClurg (1996) reported that 7 per cent of the sexual abuse reported by adult male sex offenders was perpetrated by females, and in the USA 22 per cent of male

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adolescent offenders with a history of sexual abuse claimed that their abuser was female (Ryan et al. 1996). The lower figure found in Criminal Statistics, which is drawn from recorded crimes, may, as the author acknowledges, be an artefact of the difficulty in defining and detecting child sexual abuse in relation to women offenders: The issue of women as perpetrators of child sexual abuse has been taken seriously only over the past 15 years and the actual extent of the problem is even more difficult to determine than it is for male offenders. Part of the difficulty, of course, is in the definition of sexual abuse, as in western societies women are permitted greater freedom than men in their physical interactions with children. In addition, overt sexual activity between an adult female and a boy may not be conceptualised by the boy as ‘sexual abuse’ even if he is emotionally unprepared for it and psychologically destabilised as a result (Johnson and Shreier 1987). Indeed, in spite of his confusion the child may be encouraged to view the event as proof of his virility. (Grubin 1998:28) This suggests another reason for the low rate of reporting maternal sexual abuse, which is the degree of ambiguity in the nature of the act, as illustrated in the passage from Morrison’s Song of Solomon, which opened the chapter. As the passage illustrates, there can be a powerful narcissistic element to breastfeeding, which may become an intoxicating experience for a mother to the extent that she continues to suckle her child for her own gratification. Morrison beautifully describes the secrecy of this breastfeeding mother, in search of a ‘balm’ against the drudgery of her daily life. She so loves the power of her own lactation and the sensual pleasure of the experience that she tries to avoid recognition of her child’s age so as not to spoil her fantasy or inhibit her behaviour. Is this sexual abuse or simply a retreat to a maternal fantasy of feeding an infant, in defiance of the reality that the child is over four years old? The mother appears aware that there is something wrong in her treatment of her son, but cannot bear to give up her ‘secret indulgence’. The ambiguity of this passage in its sympathy coupled with its hints of maternal perversion, exemplifies the complexity of conceptualising maternal sexual abuse. Defining sexual abuse of children Clinical definitions of sexual abuse of children tend to centre on three dimensions: an age difference of five years or more between perpetrator and child; specific sexual behaviours such as digital penetration, oral sex, penetration of the vagina or anus using the penis or objects, exhibitionism, pornographic photography, kissing, fondling the genitalia or breasts, and coercing the child to masturbate or touch the adult (Craissati 1998). There are grey areas, relating to issues like the extent of nudity in the family, at what age, if any, parents and children become modest about nudity, sleeping naked in bed with children and exposing children to sexual affection between adults: There is little consistent agreement on the way in which familial and cultural norms can influence the decision to define behaviour as abuse’ (Craissati 1998:3).

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The ambiguities in conceptualising female sexual abuse, other than in relatively clearcut cases of indecent assault and incest, seems to contribute to difficulties in thinking about, identifying and investigating this form of offending. Another description of levels of sexual abuse by females is provided by Kasl (1990) cited by Ford (2006). Kasl divides behaviour according to the following hierarchy, conceived of by a colleague, Carlson: 1 Chargeable offences like oral sex, masturbation and intercourse. 2 Offences like voyeurism, exposure, seductive touching, sexualised hugging or kissing, extended nursing or flirting. 3 Invasions of privacy including enemas, bathing together beyond a certain age, excessive bathing of foreskin, asking intrusive questions about bodily functions. 4 Inappropriate relationships created by the adult including substituting the child for an absent partner, using them for emotional support, sleeping with the child, using them as a confidante. It is the last category that most clearly reveals the ambiguity and complexity of conceptualising sexual abuse by mothers. However, even in the higher levels there are ambiguities including ‘flirting’ or ‘sexualised hugging’ and it must be noted that these behaviours are not offences in law. In the least severe forms of abuse it is clear that cultural and familial norms can vary enormously in defining acceptable behaviour like sleeping with a child or confiding in them for emotional support. In the fourth level the behaviour described appears more characteristic of emotional rather than sexual abuse and the artificial distinction between these categories becomes apparent. Physical abuse, emotional abuse and sexual abuse are not necessarily mutually exclusive, and unfortunately all three may coexist. Indeed, it is difficult to imagine that emotional abuse does not occur in every case of physical or sexual abuse of a child. Interestingly, Kasl considers ‘extended nursing’ to be a manifestation of abuse that she classifies as offences, although there is clearly no criminal offence related to this. Again, social norms vary enormously in terms of guidelines for breastfeeding and there may be instances of extended breastfeeding in certain cultures for reasons to do with norms, beliefs, necessity and tradition, and not to do with maternal sexual abuse. In other situations for particular women this quintessentially maternal nurturing act may have other functions. As illustrated in the opening passage by Toni Morrison, the narcissistic gratification for the mother who breastfeeds her son until he is older than four years old reveals the sense in which she uses him as an object, to meet her needs, with little regard for his development or subjectivity.

The psychological impact of maternal sexual abuse The emotional impact of sexual abuse on children is profound, and the experience confusing. In sexual abuse a child’s needs for physical attention and handling are met in a sexualised way, intricately connecting their experiences of care and sexual arousal. This makes it impossible for them to differentiate between Oedipal fantasy and reality, as their unconscious sexual desires for their mother or father have actually been fulfilled. As well as being physically intrusive, female sexual abuse may also be emotionally damaging to

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the child. The invitation to get inside mother’s body is a frightening and alarming perversion of a wish, and offers the child a degree of power and responsibility that he or she cannot manage. It may be damaging and confusing precisely because it is a perverse enactment of a wish, or a repetition of an infantile activity, e.g. suckling at mother’s breasts. The child cannot feel certain that there is a strong barrier separating fantasy and reality. It is clear that the infant’s unconscious longings for mother, for example, to be back inside her, to suckle at her breasts or to have her all to himself and to kill off the father, are fantasies which need to be resisted in order for the child to feel that she or he is not omnipotent. The child requires the reality of non-sexual relationships with its mother and the realisation that it cannot destroy either the father or the parental couple in order to transcend these pre-Oedipal and Oedipal longings. This is a necessary stage of psychic development. Being encouraged or forced to enact these fantasies wreaks considerable psychological damage on the child who can internalise this confused and perverse model of care. The fact that, at some level, there may have been a wish for exclusive sexual contact only intensifies the resulting damage and conflict because it leaves the child with the sense of guilt so often described by victims of childhood sexual abuse. Kirsta (1994) describes both the widespread difficulty in accepting the fact of female perversion and its consequences for victims: One of the enduring myths surrounding female sexual abuse is that because of women’s essentially caring, gentle natures—as well as their physical and sexual characteristics—the word ‘abuse’ must be a misnomer, a contradiction in terms, and what we are really talking about are loving expressions of intimacy and caring that may border on the erotic or be mistaken by the child as sexual behaviour or abuse, such as mothers caressing and fondling their children in ways that inadvertently include genital contact with the capacity to arouse. This is one misconception of which we must rid ourselves entirely if the full horror of certain types of abuse is ever to be acknowledged and victims genuinely helped to recover from their trauma. (Kirsta 1994:281) A child’s body as well as her mind are violated through sexual involvement with an adult. This is experienced as highly intrusive, sometimes physically painful and, if coupled with her own sexual arousal, highly confusing, particularly when the child becomes old enough to appreciate the significance of the abusive behaviour. In maternal sexual abuse of children the most basic relationship, in which trust and containment are paramount, has become subverted into an intrusive, frightening and demanding seduction and/ or rape. Where the victims of child sexual abuse are male, there may often be a belief that the boys must have enjoyed the interaction and did not feel used or violated by it. This construction of abuse as wanted, desired or enjoyed misses the point that sexual abuse of children is not defined by reference to whether or not the child felt that he or she was exploited and abused, but by reference to the behaviour of the adult with the child. Children are not capable of giving informed consent to sexual relations in the sense that adults are.

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Female sexual abuse of adolescent boys may be represented as ‘seduction’ or ‘initiation’ rather than exploitation or harmful activity by an adult with a minor. Cases where the victim of female sexual abuse is an adolescent boy who is not related to the perpetrator are often constructed in ways that minimise the damaging effects on the boys: the case of Mary Kay Letourneau, a teacher who had sexual intercourse with her 13-yearold pupil, is one such example (Fualaau 1998). It was initially very difficult for those around her, including her husband, to recognise that she was having a sexual relationship with her teenage victim. The trivialising response of tabloid journalists and photographers, who appeared titillated by the idea of an attractive woman ‘seducing’ her student, illustrates this type of prejudice about the sexually voracious nature of adolescent boys and the power of the seduction myth—i.e. that an adolescent male would necessarily find it emotionally rewarding and sexually fulfilling to have sexual relations with an older woman. In the Panorama television special ‘investigating’ this case, it is striking that the only person who explicitly describes Letourneau as a sex offender is a female police officer, who identifies the ‘grooming’ techniques used by Letourneau, including granting her student the privilege of starting her car, singling him out as special, and using her powerful position to her advantage. She used techniques such as those favoured by male perpetrators of child sexual abuse that involve singling out a particular child and gradually creating a special, often secret, relationship with them. For some women, their own histories of neglect, deprivation and sexual abuse are risk factors that contribute to their sexual abuse of their own children. Having considered the roots of disturbed attachment and the model of female perversion in the previous chapter, it is now possible to apply this understanding to female sexual abuse of children. A central function of sexual abuse of children is to ward off depression and temporarily rid the self of unbearable feelings of helplessness. The abusers may genuinely confuse sexual pleasure and affection, related to the confusion of their own sexual victimisation in childhood: this is re-created with their children. There may also be a psychic pressure to repeat the abuse. The defence of identification with the aggressor is a powerful method for dealing with intolerable feelings, allowing former victims of abuse to project their own experiences of helplessness and humiliation on to children. There is also a powerful attraction to children and an association of sexual relations with children with sexual arousal and pleasure that can coexist with conscious awareness that such behaviour is exploitative and wrong. Recent research indicates that women who sexually abuse children have the same degree of cognitive distortions about children as male abusers, according to their performance on various risk measures (Beckett 2007). Nonetheless there are important questions about the transferability of models of risk from male to female abusers as this may not be at all straightforward. Women’s relationships to their own and other people’s children and to their own sexuality have unique complexities and dimensions: It is currently difficult to allocate female offenders to a level of service or intervention based on their risk and needs as not only are programmes in limited supply but transferring male needs/risk models to females may not be appropriate. A fundamental question that remains to be answered is whether the differences between male and female offenders create

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differences in the relative importance of currently identified static and dynamic risk factors. (Ford 2006:125) Female sexual abuse is explored in the following case illustration, which draws upon notions of female perversion and the transmission of disturbed parenting.

Case illustration

Laura: child sexual abuse with a male accomplice Laura was referred to the forensic clinical psychology service for assessment of her capacity to protect and care for her six-year-old daughter, Elizabeth, following her 18-month period of incarceration in custody for a conviction of two counts of indecent assault on a seven-year-old boy and a ten-year-old girl who were not her own children. They had both been made to manually masturbate Laura’s husband in her presence and she had taken part in coercing the children into posing for pornographic pictures, in which they were touching his genitals. She had been released from custody three months before seeing me. Once she had been convicted for criminal offences against children, Elizabeth had been placed on the Child Protection Register under the category of ‘at risk of sexual harm’. Her daughter’s social worker had requested an assessment of Laura’s risk to her and asked for an opinion about her suitability for psychological treatment addressing her sexual offending. Laura presented at the clinical interview as an obese, affable, middle-aged woman with no obvious symptoms of major mental illness, or learning difficulties. She expressed great apprehension about attending an outpatient clinic attached to a notorious psychiatric hospital, and asked whether I had been asked to see if she were ‘bonkers’. She wore a voluminous dress and slippers, with bare legs displaying extensive varicose veins. She walked very slowly and appeared breathless when she entered the consulting room. Her manner was almost aggressively jocular, and her laughter at frequent points throughout the interview was incongruous with the disturbing and distressing events that she described. She frequently impersonated her former husband in the interview, making graphic sexual statements in imitation of his voice. It appeared as though her jocular manner was a form of bravado, a defence against her underlying anxiety and discomfort. Indeed, Laura cancelled the following two assessment appointments saying that she had found the first meeting too upsetting. She eventually attended the final assessment appointment offered to her. Laura described her childhood as ‘ordinary’ but presented a picture of a controlling, rejecting mother and distant, emotionally unavailable father. He was often away from the family home for weeks at a time, working as a long-distance lorry driver. During his long absences from home Laura’s mother would have sexual relationships with several male friends, all of whom the children regarded as ‘uncles’. Her own mother had herself experienced periods of depression during Laura’s childhood and had identified Laura as ‘a bad one’, treating her with a degree of contempt and showing her little affection or concern.

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Laura was the eldest of five children and had spent much of her childhood acting as surrogate mother to her younger siblings. Between the ages of 8 and 14 Laura had been sexually abused by a friend of her mother’s, a man in his fifties whom she had always considered her ‘uncle’. One aspect of the abuse involved his taking photographs of her naked, which involved elaborate planning and great secrecy. He would also ask Laura to stimulate and masturbate him and would stroke her hair and face during this. He would masturbate her manually and she had occasionally experienced orgasm. Laura had tried to tell her mother about the abuse to which her mother responded that she was not to ‘make up stories’. In retrospect she herself described this abuse as ‘lovely’ and had viewed it as a form of affection and avuncular interest. She felt she had wanted and enjoyed this interest in her. She had felt unwanted by her parents and it appeared that the sexual interference was the only form of attention that she had received from adults which she could construe as ‘affectionate and caring’. She had felt that her abuser had genuinely liked and cared for her, complimenting her and generally paying her attention. She had been very hurt when he lost contact with her family and her, feeling that he had ‘dropped’ her, but did not view this as evidence that his interest in her had been primarily exploitative and abusive. Laura had attended mainstream schooling and had left education at age 16 with three GCSEs, going on to work in a food packaging factory until she married her first husband at age 19. He had been physically abusive to her for many years; the violence had started when she was pregnant with their first child at age 20. She had three children by this husband, a daughter now aged 21, a son aged 19 and another son aged 17. She had separated from this man when she was 41 and become involved with the man who was to become her second husband, and who had been her co-defendant in the criminal proceedings. Her daughter, Elizabeth, was the product of this marriage. At the time of the assessment Laura’s second husband was completing his prison sentence for the indecent assaults. Her eldest three children had been interviewed by social services and had denied that they had ever been subject to sexual abuse, expressing shock at their mother’s criminal conviction for sexual offences and attributing blame to her second husband. Observations It was striking that Laura only described the sexual offences that she had committed by speaking in her husband’s voice, as though she was unable to bear ownership of her own role in the offence, and denied her own excitement and gratification. She was unable to describe the victims’ experience with any real sense of empathy or compassion, finding it difficult to imagine how they had felt during and after the abuse. She perceived herself as the victim of her husband’s bullying, viewing herself as without any independent agency or volition, recalling the contemptuous names that she had been called by her husband, and how his constant belittling of her had reduced any sense of autonomy or pride. She remembered how he had publicly insulted her, calling her ‘the fat cunt’, and invited others to engage in denigration of her. She thought that he had an excessive interest in masturbation and reported that he would treat her sadistically, forcing her to masturbate him and hitting her brutally if she failed to give him satisfaction. Her imitations of him were chilling and highly detailed, as though she were wholly ‘in role’.

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Laura blamed her sexual offending on her ex-husband’s coercion and bullying; she denied having instigated the abuse or deriving any gratification from it. She had encouraged the seven- and ten-year-old victims to accompany her husband and herself on a camping holiday, where she had taken indecent photographs of the two children while they were masturbating her husband. She acknowledged, in retrospect, that this had been wrong, but repeatedly asserted that she had not herself been ‘turned on’ by taking the pictures. She claimed that these pictures had remained in the possession of her husband who had used them when he masturbated. She acknowledged that the children had looked ‘beautiful’ but denied that she had found them sexually stimulating. She minimised the extent to which the children had been coerced into masturbating her husband and expressed little awareness that they might have felt afraid, confused and unhappy. Her cognitive distortions in describing her own abuse as warranted, and her sense of the children as inviting and enjoying the attention of being photographed, revealed the extent to which she could not identify appropriate boundaries between adults and children, and saw them as consenting partners. Laura seemed to have almost no sense of herself, suffering from low self-esteem, a significant degree of emotional dependency, and a highly distorted conception of childhood sexual abuse, to which her own experience of sexual victimisation in the context of an emotionally barren childhood had significantly contributed. Her role in sexually abusing young children indicated both her emotional dependence on her husband, who appeared to have instigated the abuse, and her own unmet needs for comfort and control, which seemed to have been satisfied through this offence. She viewed the sexual activities with the children as non-abusive. This reflected her identification with the abused child who had actually enjoyed sexual relations with an adult, and illustrated the extent of her denial of her own exploitation of the children’s trust in her. She had little empathy for the confusion and vulnerability of young children. Her descriptions of her husband’s sexual preoccupations were so vivid and passionately delivered that I was left with the strong impression that she herself was excited by the behaviour but could only experience this pleasure vicariously. The power and control that she exerted over the children were aspects of the pleasure that she derived from the perverse activity. The element of deceit involved, in that both parents and children were ‘tricked’ into agreeing to a camping trip, was an important aspect of the abuse, and revealed the extent to which Laura was quite consciously and deliberately involved in criminal behaviour and saw the children as objects to be manipulated for the pleasure of adults. Laura’s description of her marriage revealed strong elements of a sadomasochistic relationship in which issues of power, control, subjugation and humiliation were central. At times, others, the children, would be brought into this relationship and she and her husband would join forces, becoming joint aggressors. Within this partnership Laura would take on the seductive and protective role, encouraging children to come away with the couple, assuring both the children and parents that her role as mother would ensure the children’s safety. Her strong maternal presence and heavy, middle-aged, unglamorous appearance served as apparent safeguards that any activities with children would be innocent. In this way a massive deception was facilitated and two young children were abused. Her social worker expressed serious concerns that Laura’s daughter Elizabeth had also been abused by her parents in sexual activities. She demonstrated sexualised

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behaviour at school and suffered from headaches, stomach aches, thrush infections and bedwetting. Laura remained able to deceive herself about the extent of her own role as offender, presenting herself clearly as victim rather than aggressor and projecting her sexual perversions and desires on to her husband, then identifying him as perverse and voracious in his sexual appetites. Her animated impersonations of him, and the sense in which she ‘became him’ in these imitations, indicated the power of the projective identification with him. Her animation in these impersonations contrasted dramatically with her general apathy and self-deprecation, mirroring something of the function of perversion in temporarily defeating an overwhelming sense of flatness, emptiness and depression. I considered her to be a risk to children in her care and felt that she should be engaged in treatment addressing her sexual offending. She was highly ambivalent about such treatment despite having asked for help herself, deciding that she could not face continued attendance at the outpatient clinic after beginning therapy. She clearly found therapy destabilising and became increasingly depressed, appearing unwilling or psychically unable to attend her appointments. It was therefore not possible to engage her in treatment, and we agreed to terminate our meetings. Although her daughter, Elizabeth, had made allegations that her father had sexually abused her, neither criminal nor civil proceedings were instigated against him and Laura remained sole carer for the child; her status as a Schedule One offender did not affect the decision made by the family court. It appeared difficult, if not impossible, for the professionals to bear in mind the possibility that Laura herself, independently of her violent and sexually abusive partner, could pose a risk of sexual, emotional or physical abuse to children. She was conceptualised as passive victim of a coercive partner, devoid of sexual interest herself.

Discussion Perversion as a defence against depression Various psychological defence mechanisms can be identified in female sexual offenders including identification with the aggressor, i.e. their own sexual abuser, identification with the child victim, by, for example, choosing a victim the same age as they were when they were abused, identification with their non-protective mothers and denial and projection, in that female abusers may attribute sexual motivations or seductiveness to their child victims and deny their own sexual arousal and aggression. They abdicate responsibility for their sexual offending in this perception of children as sexually willing, consensual and experienced. Other unconscious defences include splitting and projective identification in that they may split off unacceptable feelings in themselves such as sexual excitement and aggression, locate them in children and then identify in the children the feelings they do not permit themselves to own. The abusers’ perception of children in these terms can then be used both to justify their abuse and temporarily free themselves from such feelings. For many female sexual offenders, sexual abuse of children represents a powerful solution to a psychic problem.

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In the case described, the sexual offences appeared to ward off Laura’s underlying sense of inadequacy, powerlessness and depression and clearly expressed her perverse sexuality. Laura’s behaviour could be considered a perversion, as defined by Welldon, demonstrating the characteristics of dehumanisation, repetition and an element of compulsion, and the fact that the aim of her perversion was not simply genital stimulation or orgasm. She achieved sexual gratification through the reduction of object to partobject. The child was not seen as wholly human, as a subject, but was reduced to being a conduit of sexual pleasure for the adult, whose gratification came partially from the degree of control and manipulation which the abuse afforded (Green and Kaplan 1994:958). Laura appeared to be able to ward off a considerable degree of depression through her perversion. For Laura, the child or children she abused also represented her own child-self, who had ‘enjoyed’ the experience of sexual abuse or, at least, the aspect of the abuse which she construed as expressing attention and affection. It seemed as though Laura’s sense of herself was wholly sexualised and relational, in that she existed only insofar as she was desired or desirous. Interacting sexually with children was a way of asserting her existence and engaging with others, devoid though it was of genuine intimacy with a consensual partner. She identified both with the victims, the children, whom she thought had been deprived of other forms of affection or attention, as she had been, and with the perpetrator, becoming the powerful authority figure in control of her victims. Glasser’s (1979) notion of the core complex of perversion is relevant to an understanding of female as well as male sexual abuse of children, in its emphasis on the fear of annihilation and the terrors of actual intimacy. The roots of these fears inhere in early maternal deprivation and neglect; the manifestation of the psychopathology in adulthood is the constant struggle between closeness and distance with others and the narcissistic complex which precludes genuine intimacy with others. It is this lack of intimacy and the failure of genital sexuality that characterises perversion. Laura’s difficulties seemed to reflect what Glasser termed the ‘core complex’ of perversion, in which a fear of intimacy results in keeping the object of sexual desire at bay, and treating it sadistically. There is a fundamental narcissism in the core complex and a central fear of being either engulfed or annihilated by another, as the result of early experience with a mother perceived to be potentially overwhelming and destructive. Aggression becomes sexualised and the object of sexual desire is kept under strict control, allowing the subject to obtain a sense of mastery. The roots of Laura’s maternal perversion could be traced to her own emotionally deprived and sexually abusive childhood. Her current situation, in which she felt humiliated, contributed to her desire to gain power and control over others. Her distorted view of appropriate boundaries between children and adults reflected not only her participation in sexual behaviour with an adult in her own childhood but also her mother’s use of her as a surrogate parent to her younger siblings and her mother’s failure to acknowledge and respond to Laura’s needs. Her mother appeared to have herself been depressed and isolated and she sought comfort through sexual liaisons with various partners, one of whom had abused her own daughter. Her neglect of Laura and lack of concern about her safety and her emotional development had clearly contributed to her daughter’s sense of being unwanted, worthless and without any sense of identity.

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In Laura’s case her mother had been elusive and rejecting, an object that she wanted to ‘get hold of’ and possess, who had powerfully resisted these attempts. She had a strong desire to fuse with a maternal object, to become part of an idealised union, but this longing was very threatening to her fragile sense of herself and she feared that she might completely lose her identity through such a fusion without any possibility of recovery. Glasser describes the major component in the ‘core complex’ as ‘a deep-seated and pervasive longing for an intense and most intimate closeness to another person, amounting to a “merging”, a “state of oneness”, a “blissful union”’ (Glasser 1979:278). It seemed that her underlying sense of emptiness, deadness and depression was temporarily alleviated through voyeuristic sexual activity. Her fear of being wholly lost in, psychically annihilated by, someone else meant that only perverse sexuality was safe for her. She needed to keep the objects at bay and control the sexual interaction: child sexual abuse allowed her this control. She described hating sexual intercourse with her husband and ‘going through with it’ simply in order to be touched and cuddled. She had never had orgasms from sexual intercourse. It is significant that Laura had eaten compulsively ever since she was a young child in what seemed a desperate attempt to comfort and provide nurturance for herself. She had developed what could be classified as an eating disorder and was very obese, which in turn contributed to her negative self-image and her vulnerability to abusive, sadistic men, whom she seemed to attract and who taunted and humiliated her. She wanted to be filled up with something good and it appeared likely that food, which she ate compulsively, served this function symbolically, although this bingeing could never actually fulfil her craving for emotional sustenance. She was both victim and victimiser, using children sexually to rid herself, temporarily, of intolerable feelings of self-loathing and depression. She had herself been the abused child whose emotional deprivation made her ripe to be targeted by an adult sex offender and had internalised this wholly distorted model of sexual behaviour. She abused children as she abused her own body: both were acts of violence as well as expressions of unmet need. In abusing children Laura was able to escape from a sense of torment and subdue what Glasser calls ‘annihilation anxiety’. According to her own description, Laura used her abuse of children to feel less awful about herself and was able to avoid intimacy with the objects of her desire. She was essentially a grotesque parody of a mother who could comfort children with her enormous breasts and welcoming lap: instead of offering this protection to the children she became an abuser who, at some level, was sexually aroused by stimulation and manipulation of them. She eventually acknowledged that she had been aroused by the pictures of the children, but only indirectly, in that her husband had used the pictures to ‘excite himself and had then encouraged her to masturbate as well. She admitted to experiencing sexual pleasure during these activities and had also enjoyed the occasions of ‘relaxing’ the children and encouraging them to pose for the camera, although she did not consider that this constituted sexual abuse of them. She had little or no empathy for the children and her understanding of them was distorted, in that she attributed a high degree of sexual awareness and knowledge to them and saw them as consenting to the activities she involved them in. This characterises the type of ‘cognitive distortion’ referred to earlier. It is the conscious manifestation of a process of justifying abuse, despite some sense that it is wrong. In Laura’s case this way of viewing children enabled her to re-enact her own experience of sexual relations between adults and

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children without allowing herself awareness of the children’s states of mind. It seemed that Laura’s maternal status, her appearance of being an ordinary, middle-aged mother, seemed contradictory and confusing to those who knew that she had been convicted of sexual assaults of children. This was clearly a case of thinking the unthinkable. Ironically, Laura’s sexual abuse of children was seen as antithetical to motherhood, rather than an expression of perverse motherhood (and her own perverse mothering). This made it difficult for professionals to see her as a risk to children. The frightening result was that the outcome of the care proceedings relating to her daughter was to allow her to continue to care for her daughter without any shared care with the local authority and without any requirement that Laura engage in therapeutic work addressing her offending. It was impossible for the system to accept the notion of perverse motherhood and respond with an appropriate degree of protection for the child in this case. Once again, a dangerous and highly disturbed woman and mother was refigured as a victim of male aggression and tyranny. Her female sexuality and its perversion were overlooked and her degree of agency and choice were denied. Her sexual offending was ascribed to association with a violent and sexually avaricious man. This splitting enabled the professionals to locate ‘evil’ safely outside of the woman who had greatest access to children, and whose activities with them afforded the easiest and least visible avenues to child abuse. Relevance of this case to empirical research on female sex offenders The reluctance to address the fact of maternal sexual abuse has been reflected in the relative paucity of literature related to female offenders until very recently. Saradjian’s study of women who sexually abuse children is a significant attempt to describe and classify women who have been convicted of sexual offences against children. According to the classificatory system used by Saradjian in her 1996 study, women who sexually abuse children can be divided into three groups: • women who initially target young children • women who initially target adolescent children • women who were initially coerced into sexually abusing by men. Laura could best be classified as falling into the last group, although the degree to which she had been coerced is unclear, as she appeared to have derived considerable gratification from the sexual activities with children, and demonstrated little evidence of concern for them, or awareness of the harm that she was inflicting on them. Saradjian makes the following observations about the characteristics of women who sexually abuse children, based on her own study: – Women of any age, social class group, intellectual ability, type of employment and marital status can sexually abuse children. – The children they target are most likely to be children to whom they are in a maternal role. – When they abuse very young children, the sex of the child does not appear to be crucial in the choice of target child.

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– When adolescents are abused, the gender of the child appears to be an important aspect of the decision as to which child is targeted. – Women tend to use similar tactics to men in grooming the child for compliance and disclosure; threat, coercion, care-giving, attribution of responsibility onto the child, fear of abandonment, etc. – Women are likely to sexually abuse children in all the ways that a man does, except they have to penetrate the child with digits or objects instead of a penis. Women are capable of obtaining sexual satisfaction from sexual sadism with children. [my italics.] – Women of any age can and do sexually abuse children. It is proposed that age difference is not the key issue but that some aspects of the woman offender are developmentally fixated, leading to emotional congruence with the child. – Women tend to sexually abuse children over a long period of time particularly if the target children are their biological children. This may be because of the increased dependency of children on the women who sexually abuse them and/or because the children have less conviction that they will be believed if they say that their abuser was a woman, and therefore are less likely to disclose abuse. (Saradjian 1996:38) According to a somewhat different classificatory scheme proposed by Green and Kaplan (1994), Laura could be identified as someone who committed a ‘non-contact offence’ in which women coerce children into sexual activity with an adult, usually a male accomplice, or allow the co-defendant to molest the child in their presence. Their research demonstrated that incarcerated female child molesters had both greater psychiatric impairment and more intrafamilial physical and sexual abuse than a comparison group of incarcerated women who had not committed sexual offences (Green and Kaplan 1994). This was evident in Laura’s case, in that she had herself experienced intrafamilial physical abuse, although her sexual victimisation had occurred through her contact with her mother’s boyfriend. She believed that her mother had been aware of the abuse but failed to stop it, just as she herself had allowed and encouraged the children to be sexually abused both through involvement in pornography and through genital contact with her husband. Laura had taken an active part in enticing children to leave their homes and participate in sexually abusive activities. Additionally, her own childhood experiences and consequent construction of sexual activity between children and adults as affection, comfort and excitement had created her own desire to engage in sexual relations with children. She identified strongly with children and displayed a high level of emotional congruence, i.e. she felt that she could empathise with and relate to children better than to adults, with whom she felt inadequate and clumsy. Her voyeurism was evident when she encouraged the children to pose for pornographic pictures. She disavowed her own excitement by allowing her husband to express desire for her, enabling her to remain in

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control of potentially overwhelming feelings of sexual excitement and to abnegate responsibility for it. Mothers who abuse their children treat them as narcissistic extensions of themselves and inflict violence on them in a perverse attempt to rid themselves of underlying feelings of inadequacy, guilt and depression. The sexual interaction provides a temporary release from these feelings, an escape from their self-loathing and unhappiness, but after an initial euphoria the depression and guilt return and a vicious cycle is established. The guilt reinforces the depression, which in turn creates a greater need to escape from powerful negative feelings. Sexual fantasies provide a means of release and comfort. The desire to act on the fantasies gradually increases and, once acted on, the crucial boundary between thought and action has been crossed: the mother has become an active agent, perpetrating sexual violence against her child. Welldon gives an account of this cycle in her description of the female abuser: Clinically, the female abuser demonstrates a perversion of the ‘maternal instinct’ in which she, at times of stress, experiences strong and powerful physical sensations including sexual attraction towards children; her own and/or others. She tries to stop herself from acting out the thought, since she knows it is wrong, but the urge physically and/or sexually to attack the object of her desire/hate proves irresistible, and hence she succumbs. When committing the action there is a sense of elation and release of sexual excitement, but these feelings are immediately superseded by shame, self-disgust, and depression. (Welldon 1996:178) In understanding the roots of perverse mothering it is crucial to explore the mother’s own experience of childhood, of being mothered. The intergenerational transmission of abusive patterns of parenting is a phenomenon of great significance, as described in Chapter 1. It is, however, important to note that it is by no means inevitable that those who have been abused will go on to abuse others, and attention must be paid to breaking the cycle. Nonetheless the repetition of such patterns can be identified clearly in the histories of women who present at the forensic outpatients’ clinic, either under accusation of committing acts of sexual or physical abuse against children or because they did not protect their children from such abuse. These women may form relationships with sexually and physically violent men and become part of incestuous and chaotic families in which boundaries between children and adults are absent or dramatically perverted. Sexual abuse of their own children, echoing their own experiences of abuse in childhood, can become the norm within these unsafe families. This is illustrated in the following clinical material. Case illustration

Monica: maternal abuse by a 62-year-old woman Monica was referred for assessment to evaluate the risk she posed to her granddaughter, who was the first child of Monica’s youngest daughter. Monica had

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sexually abused her daughter in the context of severe sexual abuse, including incest, within the entire family; all of the ten children had been involved in sexual activities, with each other, with their parents, and with two middle-aged lodgers. Monica had been charged with two counts of indecent assault on the two youngest girls, whom she had penetrated digitally and whose breasts she had fondled. She had also been charged with indecent assault on her youngest son, whose penis she had touched in an attempt to masturbate him. In interview she was timid, with a marked speech impediment and a cleft palate. She wept when discussing the possibility that she might lose contact with her granddaughter, but seemed unconcerned about having no relations whatsoever with any of her other children. All of the children seemed to have disowned her following their disclosure of the widespread and deeply perverse abuse in the family, which had included exposure of the children to hard core pornography. My first contact with this family had been through one of the older sons, who had been beaten and sodomised by his eldest three stepbrothers and by a lodger from the age of seven. He had subsequently gone on to assault a three-year-old girl when he was aged 15 and had been active in abusing his younger sisters by having sexual intercourse with them: the youngest girl was six when the abuse started. He came to me for assessment when he was 19 following his release from custody and his partner of 18 months was expecting their first child. He had served a custodial sentence for the indecent assault and had made several serious suicide attempts in prison. He engaged in treatment related to his sexual offending and I saw him for approximately nine months, during which time he related details of his own childhood, including the degree to which his mother had interfered with him sexually. She would come into his bedroom at night and fondle his penis, until it became erect, and would sometimes masturbate him until he had an orgasm. He also had vivid memories of the violence and sadism with which his stepbrothers would have anal sex with him, often in front of his parents and other siblings. He and his younger brothers would both be buggered by the older boys and then encouraged to have sexual intercourse with their younger sisters. All the abuse was common knowledge within the family and would generally take place in communal places. Hard core pornographic material was often used in the household, including child pornography involving animals, and videos showing adults and children having group sex. This family was one of the most abusive, sadistic and disturbed families I had ever encountered, and the extent of the abuse and cruelty was difficult to bear. Perhaps most distressing was the clear illustration of the transmission of abuse seen as brothers raped sisters, under the instruction of their parents and elder siblings. The abuse often involved sadism, including violent assaults on the victims. An example of the nature of the sadism and humiliation was that the stepbrothers would make the younger children drink their own urine. The mother whom I was asked to assess had not only been aware of this extreme, almost unbelievable abuse, but had actively participated in it, appearing to derive both emotional and sexual gratification from the control and power that she exerted over these desperately damaged children. Monica’s youngest daughter, then aged ten, described her experience of maternal abuse in her police statement. A lesser form of abuse involved washing her mother in the bath, and being made to wash her breasts. This would follow the apparently ordinary

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activity of being bathed by Monica. In a perversion of the usual role of mothering Monica ordered the girls to wash her breasts, and then asked them to put talcum powder on them. This had an infantile and desperate quality, as though Monica was asking her young daughters to provide her with the kind of physical contact of which she had been deprived in her own infancy. At the same time as revealing this deprivation and pathos it demonstrated a complete disregard for the feelings of the girls, who were used as objects for her gratification. She forbade the girls to tell visiting social workers about any aspect of the sexual abuse they were subjected to on a daily basis, by brothers, sisters and Monica herself. Another daughter, then aged 12, the other main victim of the abuse, corroborated the description of her involvement in being made to bathe and fondle her mother’s breasts, going on to describe how Monica would rub her and her sisters’ genitals. She described how Monica would come into their shared bedroom and ask if their vaginas were sore, indicating her full awareness of the extent of the girls’ sexual victimisation by members of the family. This question also appears to be a perverse parody of ordinary maternal concern. If the girls said yes, because they quite often were, she would insert her finger into their vaginas in a rough way, before removing her finger and rubbing talcum powder into their genitals. This child described this behaviour as ‘rude’ and said it had ‘hurt’. Her statement is painful to read, particularly when she says, ‘When mum had done this she would say not to tell anyone or she would put me away.’ The threats, pain, confusion and fear that were part of the experience of sexual abuse were vividly described in the children’s statements. Unfortunately, many of the criminal proceedings against the siblings were discontinued owing to difficulties in gathering evidence from some of the other children involved in the abuse. It was therefore important that findings of fact in relation to sexual abuse were made in the civil court. In the care proceedings case regarding five of the children, the judge stated in his summing up: ‘So much of this is almost incredible that I repeatedly warn myself to be on guard and to be cautious but, however frequently I give myself that warning, I am driven to conclude not just on a balance of probabilities but with a quite saddening, frightening certainty that the children of the family have been sexually abused…. They have been sexually abused by the members of the family on a scale and over a length of time that even those who did not actively participate in that abuse must have known of it and must have failed to protect the younger children who were members of their own family.’ Although it was initially surprising that there should even be a question about Monica’s risk to children, the request for an assessment revealed the extent to which her participation in the sexual abuse of her own children could not easily be borne in mind by the professionals involved. It could not fully be understood or thought about. Her elderly, infirm appearance, her own psychological vulnerabilities, and the fact that she was the grandmother of an infant seemed to obscure the fact that she was a convicted Schedule One offender. In my report to the court I repeated the central facts of the case and the allegations which had been made about her systematic sexual abuse of her children, strongly emphasising the risk that she posed to any child with whom she had contact. The local authority care plan, which did not allow her contact with the child, was eventually accepted. The fact that the baby’s mother, the girl who had been aged 12 in her original statements to the police, and who had been one of the worst victims of abuse within the

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family, might also pose a risk of sexual abuse to her child, was also an important consideration that needed to be brought to the attention of the social workers involved in this distressing case. The extent of the traumatic sexualisation and violence within this family created a significant risk that the abuse would continue to be transmitted from one generation to the next. Kaplan (1991) describes the link between the strategies of the perverse woman and the social constructions which govern how her behaviour will be understood: ‘Since deception is so crucial to perversion, unless we lay bare the lies that are hidden there we will be deceived at once’ (Kaplan 1991:9). The issue of deceit, including self-deception, is a crucial one, which powerfully interferes with offenders acknowledging their responsibility for sexually abusing a child, and reduces the chances of engagement in treatment. The problem of denial in male sex offenders, for whom well-researched treatment programmes exist, has been well described by clinicians and applies equally to female sex offenders (Beckett 1994). The following case illustration describes both the difficulty of confronting denial in the female offender, particularly in the context of care proceedings where the future placement of the child hangs in the balance, and the powerful countertransference feelings that can interfere with the therapist’s capacity to engage the client. The greater shame of child abuse by mothers is a burden both to victims of maternal sexual abuse and to women themselves, as this is the crime which is probably thought most perverse and unacceptable to others, in its direct challenge to cherished notions about motherhood. The possible attraction of mothers to their children, even their adolescent sons, is still a highly taboo subject, and the potential for sexual contact can usually only be acknowledged if, like Jocasta, the woman is unaware that she is actually committing incest. Case illustration

Allison: maternal sexual abuse and deception Allison was a 39-year-old woman who was referred to the out-patients department for assessment of her suitability for psychological treatment related to her feelings of depression. She had recently lost custody of her baby daughter Samantha following a court hearing. The local authority had won their appeal for a care order to be granted on Samantha and the care plan they had submitted had identified adoption as the aim for her. Five years earlier Allison had voluntarily placed her six-year-old daughter Jennifer into local authority care because she had felt unable to cope with her. This child had made extensive allegations that Allison had abused her sexually, which had resulted in her eventually being placed in long-term care under a full care order. Allison denied the allegations of sexual abuse but admitted that she had rejected her daughter and neglected her needs. At the time of the assessment Allison lived alone with her 13-year-old son Luke, who was not subject to a childcare order. Allison was an anxious woman in her thirties who was apprehensive about attending the outpatient clinic, having had unhappy experiences with psychologists, one of whom had assessed her for the previous care proceedings, relating to Jennifer, and had concluded that she was a risk to children. She had found this hurtful and deeply unfair,

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expressing anger about this conclusion and pointing out apparent factual inaccuracies in the report that had been presented to the court. The documentation related to the case revealed, however, that Allison habitually changed factual details for no obvious reasons, leading to inconsistent and contradictory statements about such apparently straightforward facts as birth date and address. She admitted that she sometimes forgot things and found her situation confusing and overwhelming, not always being sure of ‘what was going on’. Her distracted and nervous manner conveyed her overwhelmingly chaotic life and disorganised personality, revealing her unstable sense of herself and her environment. She strongly disagreed with the observations of the child psychologists who had comprehensively assessed Jennifer and concluded it was highly probable that she had been abused by her mother. The child psychologists had found her allegations highly plausible in the light of her many consistent statements and the degree of disturbance that she displayed. Jennifer had made suicide attempts and graphically described the maternal abuse that she had experienced. Jennifer’s descriptions of her sexual abuse by her mother were consistent, detailed and clear; she described highly perverse behaviour. She reported that Allison had painted her own genital and nipple area prior to the abuse. She was alleged to have forced Jennifer to perform oral sex on her and to have vaginally penetrated her using her fingers and other objects. Jennifer reported that this abuse occurred frequently, sometimes up to three or four times a week and that her mother also used physical violence against her. Jennifer’s brother, Luke, had told a social worker that his mother ‘did rude things’ to his sister, but asked her not to tell his mother that he had said so. Jennifer displayed unusually disturbed and sexualised behaviour at school and was eventually brought into local authority care by her mother who found her ‘impossible’ to cope with. She consistently demonstrated sexualised behaviour with other children, including Luke, with whom she was seen kissing and cuddling in an intimate ‘adult’ way, saying that she was just ‘snogging him’. During her first placement with foster carers Jennifer first disclosed the serious allegations of sexual abuse. Jennifer had presented great difficulties for her foster carers because of her sexually disinhibited and aggressive behaviour, particularly in relation to her younger foster sister. Allison attributed these allegations to Jennifer’s anger at being rejected by her. Shortly after being taken into foster care Jennifer had stood in the middle of the road, pulled her skirt up, her underpants down, and said that she was ‘waiting for a car to come’. This appeared to be a highly sexualised suicide attempt, indicating the extent to which the child felt objectified, worthless and totally desperate. Allison thought this showed how rejected Jennifer had felt when she had been placed in care, asking why she would have placed her in care if she had wanted to abuse her, and becoming furious when I suggested that sometimes parents recognise that their children may be at risk at home. Allison disclosed that she herself had been sexually abused by her elder sister. She became highly distressed and angry when I suggested that she might have wanted to protect Jennifer from going through the same abuse that she had experienced herself, and that a healthy part of her wanted to ensure that the child was placed out of harm’s way. It was evident that Allison found it far easier to discuss her experiences of sexual victimisation than her own sexually abusive fantasies and activities. She tended to attribute blame for Jennifer’s disturbed behaviour, which included stealing and fighting, to the child herself, describing her as ‘canny’, ‘manipulative’, ‘a wind-up merchant’ and ‘attention-seeking’.

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It was difficult to take a clear history of Allison’s life to date, and to glean a coherent picture of recent events. She had lived in numerous places, moving frequently and impulsively following the break-up of sexual relationships with men. She was unclear about times and dates of moves, and gave a confusing account of her current residence, indicating that she had moved, but providing me with her previous address, only then to accuse me of getting her address wrong when I cited this address in my report to the court. She reported that she had not used drugs in recent years, but had in the past been a regular cannabis user, with occasional use of harder drugs including ecstasy and cocaine. She described general feelings of depression, victimisation, hopelessness and a profound sense of injustice, particularly in relation to being considered a sexual risk to her infant daughter. She did not appear to mind being apart from Jennifer and did not express concern about her, focusing instead on her own sense of injustice and her need to be with her youngest child. It emerged during the first interview that Allison disclosed the sexual abuse by her sister, Rachel, when she was a child. She had been six years old and her sister 11 when her sister had begun to force her to perform oral sex on her, and had also penetrated her digitally; she used physical force, sometimes tying her to the bed. Allison was the youngest of three girls. Her natural father had left her mother before she was born and she had never known him. When she was eight her mother had remarried, after having a series of brief relationships with other men, one of whom had sexually interfered with Allison on one occasion. Her mother had herself been a depressed woman with a violent temper who frequently assaulted her children with any available weapons, including, on one particularly frightening occasion, a fire poker. She had also failed to provide adequate protection of Allison, with the consequence that Allison’s sexual abuse by her sister went on for several years, until she was ten, apparently unnoticed and unreported. Allison clearly remembered the sexual violence and the ‘treats’ which she would be given after the sexual activity took place. She became visibly distressed as she related these details to me. Although Allison stated that she now hated her older sister, she had repeatedly left Jennifer in Rachel’s care, with no concern about the possibility that she would also be abused by her. When asked about this possibility in interview she expressed little emotion and no regret about this decision. She had some contact with her sister in adult life but did not see her parents or middle sister, whom she described as a ‘waste of space’. It appeared easier for Allison to view her son, Luke, as a separate person than it was for her to disentangle herself psychically from her daughter. It was possible for her to differentiate herself from him, perhaps because giving birth to him and bringing him up had not evoked her own feelings and memories about her own relationship with her mother and sister as powerfully. He was allowed some kind of individuation, although I bore in mind the possibility that Allison was sexually provocative and confusing with him, even if she did not actually engage him in incestuous activity. She spoke about Luke in terms of his capacity to care for and protect her, reflecting her wholly distorted boundaries and indicating the depths of her own dependence and egocentricity. Significantly, he was not considered to be at risk by the child protection professionals, despite his disturbed and sexualised behaviour at school and some indication that he may have been involved in the sexual abuse of Jennifer. It was as though it was inconceivable

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that a (now adolescent) boy could be at risk of sexual abuse by his mother, even though his sister had made such clear allegations of serious sexual, physical and emotional abuse. Although there had been no criminal proceedings regarding the sexual abuse allegations, the judge in the civil case concerning Jennifer had made findings of fact regarding them and had determined that the sexual abuse had been perpetrated by Allison on her daughter. This was based, in part, on the evidence of several childcare professionals who had assessed Jennifer, and on the evidence of the forensic clinical psychologist who had assessed Allison and produced a report for the court. The judge had found Allison to be a woman who posed a risk to children in her care, with little regard for their emotional and physical welfare, describing her sexual abuse and rejection of Jennifer as showing ‘callous disregard for her interests’. Allison attended the three assessment appointments offered to her but declined the opportunity to engage in psychological treatment because of my links with the forensic services, saying that she was not a criminal, she was simply depressed because she had lost two children, and had been a victim of childhood sexual abuse by her sister. She felt that she was ‘the accused’ and that everyone was ‘against’ her. The fact that seeing me would have involved exploration of her relationship with Jennifer and the sexual aspects of her mothering, her deep identification with her daughter, and her difficulty in establishing clear boundaries between children and adults, made the task far too threatening for her. She complained that I had ‘not really been listening’ and felt she was left completely isolated and helpless. There was an adamant refusal to acknowledge the hatred that she had felt towards her daughter and the hostility with which she had treated her. She eventually lost care of the baby, who was made the subject of a care order and placed for adoption. Once again, she had lost care of a daughter, and was left feeling furious and bereft and no further forward in terms of acknowledging her own sexual disturbances and abusiveness. My intense countertransference feelings made it difficult to retain a therapeutically neutral stance in relation to Allison because of the depths of her denial and her cruelty towards her daughter. I understood the cruelty to reflect her own murderous impulses towards herself and her own unprotective mother. I wondered whether Allison might lie compulsively about seemingly insignificant details in order to create a separate sense of identity and to convince herself that she had an internal, private space into which others could not easily enter. Through lying about apparently trivial events and facts she could create a distance between herself and others and preserve a sense of separateness, as though the boundaries of her personal identity were so fragile that she needed to defend herself against anyone knowing anything about her, or getting too close. Despite understanding her fear, I was left with a sense of being tricked or deceived by the many contradictions in Allison’s narratives; I felt quite persecutory towards her at points, wanting to challenge her about these inconsistencies. When I did ask about the discrepancies in her statements I was met with hostile denial of any such differences, and was accused instead of ‘not listening’ and ‘getting things wrong’. This led to my confusion and I found myself questioning my own understanding of the interviews and the accuracy of my notes. I was put in the role of being an unreliable witness, a position which alerted me to the significance of Allison’s own experience of deception and abuse. The person who listened and tried to make sense of her experience became persecutory

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and unreliable, just as Allison had experienced her mother as being an unprotective, negligent figure who had both allowed sexual abuse to occur and had herself inflicted physical violence on her. It seemed to mirror her experience in childhood of being lied to and made to feel that her perceptions were inaccurate, that she was mad. In addition, Allison felt furious that her own Victimhood’ was not being addressed, identifying herself as victim not perpetrator and feeling confused and desperate when her role as victimiser was explored. She could not manage to hold both these aspects of herself in mind, and found it intolerable when I attempted to do so. The intensity of my countertransference feelings seemed to relate to the cruelty of Allison’s own impulses towards herself, as expressed in her sexual abuse of her daughter. Through sexually abusing Jennifer, Allison was unconsciously enacting her own experiences, attacking the body of the little girl as her own had been attacked. Bearing her own experiences of humiliation and abuse in mind allowed me to feel some compassion for the girl she had been, and the woman she had become. She had made a serious suicide attempt during the time of the final hearing regarding Jennifer, which she described as motivated by guilt about having placed the child in foster care. In her mind Jennifer stood for her, and was the repository of her self-hatred and the target for her murderous impulses. The sexual sadism she directed towards her also represented a kind of psychic murder: The sexual abuse of children amounts to no less than the enactment of a symbolic form of murder, since the only way to kill someone, in the psychic sense, yet not literally take their life, is to penetrate their body via its orifices. (Kirsta 1994:289) By refusing to enter therapy Allison was also killing me off. She could trust me only insofar as I could nurture her and respond sympathetically to her as a victim of sexual abuse by a woman, and physical and emotional abuse by both her mother and stepfather. She could not bear me to acknowledge the sense in which she was also an aggressor and a victimiser of children. Her unhappiness and desperation appeared genuine and her defensive attitude seemed to relate to her shame and her underlying sense of her own worthlessness. The fact that I was aware of the allegations which Jennifer had made, that her son had corroborated, indicated to her that I would ultimately reject and condemn her. She was also left without a receptacle into which to pour her toxic feelings and without this container was faced with her own aggression and despair. Allison had defended against intolerable psychic pain by splitting off her aggressive impulses, projecting them on to her daughter through her sexual manipulation of her. She appeared to have an emotionally, if not sexually, overinvolved relationship with her son, whom she described as the ‘man in my life’. She had little capacity to recognise her own aggression, projected it on to others, saw it reflected back at her in the rest of the world, and therefore inhabited a paranoid world where she was repeatedly rejected, humiliated and, ultimately, abandoned. Her sexual abuse of Jennifer had temporarily afforded her an avenue of escape from her depression and fear, without which she felt desperate.

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The origins of Allison’s anger seemed to lie in her experiences in infancy and childhood, that had left her with a sense of abject self-loathing and undiluted, infantile fury towards her own depriving, unprotective and violent mother and her sexually exploitative sister. She had not had the experience of integrating her angry unacceptable feelings in childhood, and had developed no safe repository for them, either externally or in her internal world. For Allison her mother had been a barren, cruel object, unable to respond to her needs or her attempts to engage with her. Becoming the sexual aggressor against her own daughter enabled Allison to rid herself of the profound feelings of helplessness and victimisation that she had experienced by projecting them. She had internalised and identified with both her sister and her mother as aggressors and could recreate this dynamic with her own female child.

Conclusion These perversions of motherhood reflect the overwhelming sense of powerlessness and low self-esteem which create such difficulties for these women during pregnancy and motherhood. Motherhood may become an avenue for compensation and a forum for revenge, a sphere of authority, power and control. ‘Female sexual abuse, particularly maternal incest, represents the most tragically grotesque misuse and abuse of that power’ (Kirsta 1994:295). In these offences there is a re-enactment by the mothers of earlier trauma in which they identify both with the child-victims and with the aggressor: these defences and those of denial, minimisation and emotional detachment from the child enable such mothers to be freed, temporarily, from the psychic pain of remembering their own abusive histories. They are acting out, through their children’s bodies, experiences which are too difficult to think about. What cannot be borne mentally becomes enacted through this sexualised violence. As well as becoming more receptive to the possibility of maternal sexual abuse in child protection cases, clinicians have a responsibility to identify and classify the types of sexual abuse which have been perpetrated, and to heighten awareness of risk factors in women’s backgrounds which may predispose them to sexually offend against children. Additionally, assessment measures and treatment programmes specifically for the female sex offender need to be devised. There has been growing attention to this area; Beckett and colleagues have been conducting research to modify assessment measures for female offenders and establish relevant norms for this population with interesting results that indicate that similar types of cognitive distortions can be found in both male and female sex offenders against children (Beckett 2007). This is a developing area of research, whose results will be extremely valuable in terms of informing evidence-based practice, both in terms of adequate child protection assessments and in relation to the unmet therapeutic needs of the female sex offender. An important new body of research on female sexual abusers relating to the findings of three US studies on female sex offenders has been published (Davin et al. 1999). This literature represents a serious attempt to begin to recognise, explore and treat this problem. It is crucially important it is identified and that attempts are made to develop treatment programmes whose success can be evaluated.

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While it has been argued that there are intrinsic as well as culturally determined characteristics of women which might disincline them to abuse children sexually, such as their tendency not to sexualise relationships to the extent that men do, their preference for more powerful sexual partners, stronger bonding with children and disinclination to initiate sexual contact, it is clear that these factors may not operate in women with serious histories of childhood victimisation experiences within their own families and current life stressors (Finkelhor 1984). To cope with the trauma of this victimisation the women have developed certain pathological defences which make sexual abuse of children possible, and even likely. Furthermore, their own experience of sexualised behaviour by their family members may have desensitised them to the potentially traumatic effects of sexual abuse, distorting their understanding of children’s behaviour, and the importance of clear boundaries between children and adults. The experience of a neglectful or abusive mother may create a perverse ‘blueprint’ for abusive behaviour, which these women re-enact with their own or other people’s children. Further research into female sexual abuse of children must be based on a comprehensive model of analysis, and a sensitive understanding of the complexity of the problem. It is essential for good practice that sensitive supervision is provided for clinicians working in this disturbing area, since they are likely to experience strongly negative countertransference feelings to female sex offenders. Understanding the female sex offender requires the capacity to suspend stereotypes about ‘maternal instincts’ and the ability to hear, from the offender herself, the story of her own mothering: this will enable clinicians to gain a clear picture of the development of the psychopathology and to feel less shocked by and punitive towards the perverse mother, allowing them to address the crucial task of child protection.

Chapter 3 Maternal physical abuse A young single mother holds her screaming child in her arms; sensing her own distress, she realises that there is no one to hold her, to make her feel better. Her baby has unwittingly become the source of her old pain, once again revived. She needs to stop the pain. This pain is her child screaming but she can no longer feel it to be her child: this mother is back in the nightmare of her own childhood. The baby has become her tormentor, the one who hurts, whose screaming needs make the young woman feel she is bad and useless. She can no longer see her baby, for it has become the ‘monster’ she once was, that had to be controlled, to be beaten into shape. She becomes her own mother, her own terrifying parent with whom she has identified, as so many victims do. In her raging pain this woman smashes the baby’s head until the crying stops. In the silence that follows, a mother may discover herself to be a murderer…The child she wanted to love seems dead. At this point her mind comes to the rescue. She ‘forgets’. She ‘splits off’ the memory of her past and the memory of what she has just done to her little girl, a child she probably wants to love and protect. It may be that this time, and possibly the next, her child survives her destructive assaults. (De Zulueta 1993:4–5, my italics)

To deny female violence is to deny female agency. In the passage cited above, De Zulueta describes how the reactivation of traumatic memories can lead to violence towards an infant, and how dissociation, as a psychological defence against pain, can protect the violent mother from fully recognising her actions. This passage illustrates the nature of reactivated pain and demonstrates how mothers who were themselves neglected or abused in childhood can re-enact destructive patterns with their own children. The context in which this occurs is one in which the mother is young and single. De Zulueta is referring to a social environment of isolation, and possible economic hardship. Although I do not specifically explore social factors in the genesis of maternal depression and physical abuse of children in this chapter, I am aware of its impact. The social environment clearly plays a significant role in contributing to the sense of despair and abandonment in mothers that can lead to physical abuse and neglect of children.

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There is a wealth of significant literature and empirical research examining social factors in the development of depression (for example, Brown and Harris 1978; Brown et al. 1996; Harris and Brown 1996). The intergenerational transmission of neglect, which emphasises the interaction between early experiences of disturbed attachment experiences and later vulnerability to depression, has also been much studied (see, for example, Harris and Bifulco 1991; Bifulco and Moran 1998). Despite my awareness of the social context of maternal depression and physical abuse of children, my main interest in this chapter is in the inner world of the mother who abuses: I explore the dynamics of maternal physical abuse. Clearly emotional abuse and neglect of children can be interwoven with physical abuse. In this chapter I focus my discussion on actual acts of violence, on the premise that such violence often reflects an emotionally disturbed and abusive relationship with the child, who becomes the receptacle of unwanted feelings. I provide a case example of maternal violence against an infant by an isolated and depressed young mother, echoing De Zulueta’s description of maternal violence. I also discuss two further cases of extreme physical abuse, one based on a clinical situation and the other the case of eight-year-old Victoria Climbié, whose death at the hands of her great aunt and her partner provoked a review of children’s services in the UK. Discussion of this case elucidates some of the difficulties created by the denial of female abuse. In Chapter 2 I explored the nature of maternal sexual abuse. In this chapter I focus on the expression of violence through direct physical abuse, caused by shaking, hitting, punching, kicking, twisting, beating with weapons or other instruments, or burning. The physical abuse of children by their mothers may bring their private violence into the public arena, particularly when social services’ involvement generates formal legal proceedings. Physical abuse is often hidden from view, occurring in the privacy of the home. As in the case of sexual abuse, the victims may be too frightened or ashamed to let anyone know about the abuse. They may also have come to accept physical abuse and cruelty as normal, or even believe that they deserve to be treated violently. Exposure to abuse often creates a state of confusion and conflict in relation to the parent, or parental figure, to whom the child typically remains loyal. The nature of physical abuse varies greatly from woman to woman; it ranges from habitual, often premeditated and sadistic violence to a ‘one-off event where the mother, for a variety of reasons, loses control. The violence can take the form of systematic physical punishment for misbehaviour or be an uncharacteristic explosion of anger and frustration which is born out of depression, social isolation and a sense of complete helplessness. Maternal physical abuse sometimes reflects the collusion of a dependent woman with an abusive partner, who insists on the parental right, and even duty, to administer severe physical punishment to a child. She may mete this out to placate her violent partner even if she does not herself agree with the use of harsh punishment. It can also coexist with failure to protect her children from physical abuse by her partner for fear of the consequences of challenging him, or because of her difficulty in recognising the emotional and physical consequences of such abuse. Such passivity can result in children suffering serious neglect and cruelty and may mirror the mother’s own state of helplessness and intimidation, within the context of domestic violence in the relationship. In cases where the male partner is violent to his partner the risk of physical, sexual and

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emotional abuse to children is also significantly increased (Hiller and Goddard 1990; Farmer and Owen 1995; Ross 1996). In some cases the mother has herself experienced serious physical and/or emotional abuse in childhood and finds it difficult to comfort her child or provide containment for its demands and rages. This difficulty can be rooted in memories and experiences to which the mother does not have conscious access. The passage introducing this chapter describes how the mother’s identification with the inconsolable infant reactivates her own intolerable experiences in childhood, producing violence as an attempt to annihilate the source of reactivated pain; after she lashes out the mother’s ‘mind comes to the rescue’ in that the psychic defence of dissociation protects her against ‘the memory of her past and the memory of what she has just done to her little girl, a child she probably wants to love and protect’, as De Zulueta eloquently describes. The mother’s strong identification with her child, and the failure of psychic differentiation between them, play a major role in the genesis of her own violence, as does her identification with her own ‘terrifying parent’ whom she then becomes. That is, she sees herself in the crying, helpless child, cannot bear to be reminded of earlier pain, and then seeks refuge in an alternative identification, this time with her own aggressive/abusive parent. In this powerful passage De Zulueta portrays some of the most important dynamics in and conditions of maternal physical abuse, including the conscious wish to protect the child, in conflict with the unconscious wish to hurt her, and thereby escape the identification with the abused object, the child, in favour of an identification with the aggressor. In a recent study in Germany the role of these projective factors is further described, with reference to disturbances in empathic understanding and attachment. The authors describe how, for one mother, perception of her infant was distorted to the extent that the mother was re-experiencing encounters with her own intrusive and traumatizing mother in the face of her screaming child. She also perceived the infant’s motor impulses as physical attacks on herself and expressed intense anxieties about her daughter’s future aggressive potential. The infant was viewed by her mother as extraordinarily and dangerously greedy. Even neutral infantile vocalizations were perceived as manipulating and sadistic. She tried to ward off these anxieties by employing a rigid scheme of rules and obsessively controlling the father’s and grandmother’s interaction with the child. The mother feared being overwhelmed by the infant’s needs if she were to yield to them in flexible way. (Mohler et al. 2001:257)

Classifications of maternal abuse Kennedy (1997) distinguishes between three major and overlapping categories of female abuser:

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the ‘active abuser’, who is the main instigator and perpetrator; the ‘complicit abuser’, or ‘inciter’, who takes part in the attack but does not instigate it directly, and instead incites the partner to abuse; and the ‘denier’, who does not want to believe that their partner has abused their child or children. The denier, as with the others, may also be intimidated by the partner. But with the really difficult cases, intimidation is often fairly mutual…But, in the end, it is likely that these distinctions do not have that much explanatory value; furthermore, they might also give a false impression that being an active abuser is somehow much worse than, say, giving your child to someone else to abuse. There is not much to choose in terms of horror between different ways of torturing a child. (Kennedy 1997:109–10) Reviews of the perpetrators of abuse against children conducted in the USA have found that mothers or ‘mother substitutes’ were found to be responsible for 47.6 per cent of the physical abuse cases studied while 39.2 per cent of the incidents involved fathers or father substitutes (Gil 1970). This is consistent with more recent research that found females to be more likely to use physical violence against children than males (Gelles 1980). Other studies have supported the evidence for approximately a 50/50 split between mothers and fathers as perpetrators of physical abuse of children (e.g. Anderson et al. 1983). Ninety per cent of abuse incidents take place in the child’s own home (Garbarino 1976). The most interesting finding of these studies is not that they indicate that women assault children as much as or even more than men do, but that when women are violent, the aims or targets of their violence are far more likely to be members of their family, including their children. That is, women are far less likely to be violent than men towards general members of the population, but when they are violent they target their own bodies and those of their children. It is a shocking statistic that so much violence is directed at children by the people into whose care they are entrusted, in good faith. These findings of maternal abuse must challenge the myth of the all-nurturing, protective mother.

Sadistic mothers Enjoyment of cruelty It is important to consider those extreme cases in which mothers or mother substitutes appear to enjoy inflicting suffering on a child. In these cases violence is not simply the expression of uncontrollable release of a build-up of tension and distress. The mother treats her child as a part-object, as a thing to be manipulated and used for her own gratification. Mothers or mother figures may be able to use their powerful positions over children to meet their own needs for control, comfort and cruelty.

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Case illustration

Marian, a 41-year-old woman referred for psychological assessment, had for over four years been enforcing a harsh and strict regime on her two eldest daughters, making them clean the house and do chores to a high standard, as well as relinquishing all parenting responsibilities for her youngest child, a boy, to her eldest daughter. She was a wellpresented, intelligent and articulate woman and her home was immaculate; she had recently taken on a part-time job in an estate agency. She was estranged from her own family and well known to local services, where she frequently presented with a range of physical and psychological problems, complying well with physical treatments, but dropping out of any psychological treatment offered to her. Following a recent disclosure by the eldest child, it transpired that Marian had for years, unbeknown to the school or her neighbours, been chastising the younger girl, Agnes, with severe physical punishment when she did not meet her high standards in the household and when she found her irritating. She also punished her harshly with a belt for her frequent urinary incontinence. Agnes, now eight, was the middle of three children, by different fathers. She had maintained some contact with her eldest daughter’s father but did not see the father of her youngest child after he had left her for another woman. Agnes’s father had been a drug addict who had left Marian shortly after she gave birth and maintained little contact. Marian had found it hard to bond with Agnes from birth and seemed to have identified her with this unreliable and disappointing figure. Marian seemed to single out Agnes as a target for her rage and eventually her older sister, who often tried to protect her by standing between her mother and her, reported to a friend what had been happening at home. The friend reported these details to the school, who informed social services as a matter of urgency. The full details of the brutality were hard to bear. Gradually the story unfolded of how Marian had frequently kept her daughter off school for several days until her bruises faded, how she had kicked and beaten Agnes and, on a daily basis, berated and emotionally abused her. Agnes broke down when telling social workers about her mother’s treatment of her and was duly removed from Marian’s care, along with the other siblings and placed in foster care under an interim care order. The youngest child, the boy, seemed to have been the favoured child, though he too had been neglected by his mother, and less frequently chastised physically by her. The eldest daughter reported some occasions of physical abuse but had been able to ‘escape’ the family home and spend time with her father, which she felt had protected her. The rejection and abuse had sent Agnes into a profoundly dissociated and depressed state, from which she was gradually recovering in her foster placement, with her protective and overly responsible older sister. She still craved her mother’s love, concern and admission of wrong-doing. It is possible to understand the psychology of such emotional and physical abuse in terms of the mother’s attempt to get rid of deeply unacceptable feelings through mistreating another. This may be a reenactment of what was done to her in her own childhood, that she described as emotionally impoverished and neglectful, in which her young brother was a much preferred child, while she felt clumsy and stupid, ‘an accident’, as opposed to a wanted and cherished child.

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These frequent episodes of verbal and physical abuse of Agnes appeared at some level exciting and intoxicating to Marian, in that they allowed her to vent her frustration and rage and exert a sense of power and control over a helpless and vulnerable child. Agnes had been chosen, at an unconscious level, not just because she was less confident, assertive and attractive in her mother’s eyes than the other two, but also because, on account of these vulnerabilities, she saw herself in her. She was faced with an image of her younger self, and found this identification unbearable, seeing her as ‘useless’, as she had herself been labelled by her parents, in contrast to her highly successful brother. In order to get rid of this terrible sense of worthlessness in herself she located it externally in the child and then felt hateful towards her, physically and verbally attacking her, with little sense of remorse. When she saw evidence of Agnes’s fear and apprehension of her this further enraged and excited her and she inflicted yet more physical and emotional abuse on her. Agnes clearly served the function of ‘poison container’ (deMause 1990) effectively for this mother, illustrating the power of projective mechanisms as an underlying dynamic in severe child abuse. Throughout her severe and sadistic abuse of Agnes, Marian continued to view herself as victim and the child as persecutor, for reasons De Zulueta has clarified—she felt that this daughter caused her to be put in touch with unbearable pain. The only psychic release available to her was violence. Child abuse occurs in the form of a vicious cycle, like other acts of violence and perversion. The violent blow or emotional tirade against the child relieves the adult of an underlying sense of helplessness, depression and emptiness, providing temporary escape from these unbearable states of mind. Soon, however, the sense of guilt and distress returns, now intensified by the awareness of what the perpetrator has done to another person. This sense of guilt is quickly buried, as it is too difficult to face, and the act of violence now justified as an understandable response to the impossible behaviour of the ‘bad’ child. Once the child has been treated violently and the ‘body barrier’ overstepped, it becomes easier and more tempting to repeat the behaviour in the future. The child becomes, for the mother, the embodiment of her own toxic feelings and is viewed as a persecutor rather than a victim. This kind of objectification allows prolonged periods of torture in many situations, including war, and also characterises severe child abuse. Agnes was seen as the poisonous creature into whom her mother could evacuate her rage. Agnes’s response became increasingly fearful and desperate and in projective identification with her mother’s sense of her as hateful and despicable, she came to expect a violent response and to find it impossible to please her. The potential for longterm damage and disruption on the abused child’s development is clear and, as in so many cases of insecure attachment, a child treated harshly, even brutally, becomes ever more desperate for love and approval and accepts, as deserved, the cruelty with which they are treated. Marian, over time became increasingly indifferent to Agnes’s expressions of pain and distress; she distanced herself emotionally from her, not seeing her as a suffering individual, but using her as an object into whom to project her own frustration and anger. She nonetheless needed this child to be the projective container for her toxic feelings. The sense of power provided temporary escape from her internal sense of emptiness, offering an exciting, albeit shortlived release. She herself acknowledged that she felt relieved and pleased after punishing Agnes, and that seeing her want her mother’s

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affection after such an incident gave her ‘a buzz’. Because her level of awareness was so limited, and the pain of accepting the truth of her children’s allegations against her so great, she chose instead to separate herself from them, viewing them all as betraying and deceitful. Again she located unacceptable feelings in them rather than herself, exonerating herself from blame and once again reconfiguring herself as victim, abandoned by those she had trusted.

The role of the expert witness In the context of a complex legal framework in the UK, forensic and child clinical psychologists, psychiatrists, social workers and other medical and childcare professionals are often asked to act as independent experts, offering clinical opinions and recommendations to the courts. The role of the expert witness in childcare proceedings cases is fraught with ethical, professional and personal factors. Adshead (2005) notes that ‘distress and anxiety about child maltreatment influences all the players in the justice process and may interfere with the process of justice’. In his defence of Roy Meadow, who was struck off the Register of the General Medical Council (GMC) in 2005, before winning his appeal to be reinstated, Richard Horton, editor of The Lancet describes the nature of the problems facing expert witnesses who testify that abuse is likely to have occurred: In the 2003 report into the death of Victoria Climbié, Lord Laming wrote of evidence that showed maltreatment ‘to be the single biggest cause of morbidity in children’. He went on: ‘It seems clear that when considering the issue of deliberate harm to children, one must keep in mind that one is dealing not simply with the extreme cases which occasionally prompt public inquiries such as this one, but an enormous number of instances in which the health and development of children is impaired by maltreatment…I have no difficulty in accepting the proposition that the scale of this problem is greater than that of what are generally recognised as common health problems in children, such as diabetes or asthma.’ The logic of Laming’s report is straightforward but deeply troubling for society. It is a logic apparently so disturbing to confront that it remains largely undiscussed in our society today. For if children are to be considered as equally deserving of our protection as adults, and if children are to be safeguarded from the harm that those same adults can sometimes cause them, parents will inevitably come under suspicion of abuse. Suspicion means that difficult questions will be asked, evidence collected, and professional judgments offered in good faith. Inevitably, there will be cases where early suspicions are found to be wrong. But if children truly are protected by the same laws as adults, society has to accept the uncomfortable fact that there will be instances where parents are investigated and occasionally accused, incorrectly, of harming their child.

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Paediatricians need to be able to raise fears about a child’s safety without worrying that they themselves will be the subject of investigation and counter-accusation before the GMC. (Horton 2005:277) The psychological or psychiatric expert witness is often asked to assess the parents’ suitability for treatment and this question, posed in the context of care proceedings, carries an urgency that can interfere with the usual clinical considerations regarding suitability for psychotherapeutic intervention. Parents attend these interviews with the expectation that the nature of this expert opinion will shape decisions about their children’s future, and, indeed, the ‘expert’ can also feel that he or she has been placed in this omniscient position. As Horton describes, although expert opinion is often sought, and generally respected, recent controversies about the basis for expert opinion, as in the case of Munchausen’s syndrome by proxy, have raised questions of a false sense of omniscience by experts and an over-reliance on expert testimony in the courts. Discrediting the experts is further discussed in Chapter 4 and relevant to all cases of civil and criminal proceedings. The ultimate fate of the child entering the care system is uncertain, and this places enormous pressure on the mental health professionals to assess the degree of risk the child faces at home as carefully and accurately as possible, while remaining aware that separation from loved, if abusive or negligent, parents will almost always be traumatic for children. Parents may agree to treatment in order to facilitate rehabilitation of their children. Therapists offering treatment may be requested to address progress in reports prepared for court proceedings, illustrating the tension between confidentiality and the duty to protect children that such work creates. There is also a powerful coercive element when parents agree to engage in treatment in the context of childcare proceedings. This will inevitably play some role in the transference and the progress of therapy. This description of the role of expert testimony in childcare proceedings cases illustrates how intellectually complex and emotionally loaded the task of producing assessments for the court can be. A forensic psychotherapist may find herself requested to take the role of either advocate for or adversary of the parents, and struggling to retain professional neutrality. Omnipotent rescue fantasies of saving either abused children or victimised parents may interfere with the objective and independent clinical judgements that are urgently required. In any psychological assessment of parents for the court, the psychologist must remain aware that the paramount consideration of the court is the welfare of the child. This can itself create a somewhat adversarial situation, in which one is asked to consider the client in relation to someone else and focus on the notion of risk to others. The fact that there is always a third party to be considered, as well as evaluation of the client’s own needs and difficulties, creates a certain tension in the interview, as does the limited nature of confidentiality when preparing a report for the court. The mother, who has either perpetrated serious non-accidental injuries on a child or has not been able to protect the child from injuries perpetrated by her violent partner, may be assessed separately from her partner. The central issues which the psychologist or other mental health professional is asked to address generally include the risk posed to the child or children of remaining in the care of this mother, given the history of

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non-accidental injuries, her psychological characteristics, suitability and motivation for psychological treatment, and the possible effects of separation on the children. The evaluation focuses on the mother’s ability to protect her child, understanding of the child’s needs for safety and welfare, level of impulse control, capacity to place the child’s needs above her own, and insight into the need for change. The intersection between the private domain of female power and the public arena of legal intervention and control can be seen clearly in those cases in which the future of a family, and the continuation of contact between mother and child, are decided by the courts. The emotional impact on mothers who are considered unfit to care for children, and the psychological damage to children who are allowed to stay in the custody of abusive mothers compared to the emotional effects of separation from them, are sensitive and complex areas. The backdrop to this discussion is the pervasive myth of the idealised mother against whom all others are to be compared (Motz 1997). It should be noted, however, that a large number of child abuse cases are not dealt with through the courts, and many abusing parents will never be detected. The self-report of our clients testifies to the fact of severe physical and emotional abuse going undetected in the lives of many, some of whom have gone on to repeat these patterns with their own children.

When the system of care fails: child fatalities The existence of cases of serious sexual, physical and emotional abuse of children in local authority or foster care is a tragic indication that simply removing vulnerable children from environments in which there are known risks, to situations where risks are unknown, does not guarantee their safety and welfare. In a recent much publicised case of ongoing sadism and abuse the victims did not die, and eventually came to prosecute their foster mother, illustrating the fact of hidden abuse in a state registered and approved carer. The hidden nature of the abuse and difficulty believing it had occurred, as well as the tendency to blame welfare professionals for their apparent negligence, are common features of such crimes. I quote from the case below: Sadistic foster mother sentenced to 14 years in jail Three children suffered physical and mental abuse Judge criticises inaction by welfare professionals A sadistic foster mother who subjected three children in her care to horrifying physical and mental abuse over two decades was jailed for 14 years yesterday. Judge Simon Darwall-Smith told Eunice Spry, 62, that it was the worst case he had come across in his career. The judge said: ‘Frankly, it’s difficult for anyone to understand how any human being could have even contemplated what you did, let alone with the regularity and premeditation you employed.’ Bristol crown court heard that Spry beat the children, two girls and a boy, with sticks and metal bars, scrubbed their skin with sandpaper, and forced them to eat lard, bleach, vomit and even their own faeces. (Morris 2007, Society Guardian, 20 April 2007)

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Likewise, the tragedy of children being killed within their own homes and by members of their families, in cases where they were known to the statutory agencies, raises crucial questions about the need to acknowledge the possibility of lethal violence within families. Failure to take protective action can lead to fatal child abuse and the almost inevitable blaming of child protection agencies and families, as Reder and his colleagues have concluded in their analysis of 35 major inquiries into cases of deaths of children within their families (Reder et al. 1993). The complexities of denial rarely figure in these inquiries, as though psychological factors were secondary to procedural ones. Physical abuse always carries the risk of escalation to fatal or highly serious violence and injury and as such requires urgent attention. The reasons for child fatalities are varied and causes of death can range from the accidental and highly negligent—two infant boys under the age of two burned in a fire because they could not escape from their rooms as their alcoholic and learning disabled parents had tied their bedroom doors together; or non-intentional—a violent assault through shaking of an infant that resulted in brain haemorrhage and death; or murderous assaults not completed—a suffocation of a 12-week-old baby that led to her blindness and cerebral palsy. The picture can be complicated by the presence of violent partners, disinhibition due to drugs or excessive use of alcohol, and the intervening variables of mental illness and learning disability. In all these cases, however, women as well as men can be perpetrators of severe injury and even directly responsible for the deaths of children in their care.

The Victoria Climbié Inquiry Report The recent inquiry into the tragic death of eight-year-old Victoria Climbié, killed by her aunt and her aunt’s boyfriend after being systematically tortured by them in 2000, produced a 400-page report by Lord Laming (2003). Victoria had come from the Ivory Coast with her great aunt, Marie Therese Kouao, who, ironically, had offered Victoria’s parents a better life for their daughter; she and her boyfriend, Carl John Manning, were convicted for her murder. This Inquiry Report was the catalyst for reviews of child protection systems and new legislation and policies, consolidated in the most recent Children Act 2004 (Department of Health 2004). This revision of the 1989 Children Act highlights the urgent need for inter-agency working in relation to suspected child abuse. The document Working Together to Safeguard Children (Department of Health 2006), updated from 1999, underlines the urgent need for interagency communication and responsibility to prevent the recurrence of such tragedies, and to tackle the serious problems of neglect and lack of co-ordination on the part of child protection agencies. One of the many failings that Lord Laming identified in the case of Victoria Climbié was the lack of communication between professionals, including one member of medical staff who suspected abuse (though overruled by his senior who attributed Victoria’s strange marks to scabies) and the social workers involved in the case. He lamented the fact that no one had seemed to know or listen to the child herself. I suggest an additional fact that made it hard for those who came into contact with Kouao to think clearly was that she presented herself as Victoria’s mother. Her apparently maternal relationship to

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Victoria made it even more difficult for professionals to imagine that she would perpetrate sadistic abuse on this defenceless little girl. This tragic case is a clear illustration of society’s inability to recognise the range, complexity and secrecy of female violence and cruelty, and demonstrates its typical expression in the domestic arena. The presence of an apparently strong maternal figure and the conceptual difficulty and emotional pain of attributing acts of systematic cruelty to her were evident in this case. Victoria was not followed up on several occasions, despite injuries that included scalding to her face, nor was Kouao recognised as a sadistic abuser. Nonetheless various people expressed concern in their notes about bruises on the child and her apparent fearfulness in Kouao’s presence, to the point that on one occasion she wet herself while ‘standing to attention’ while being apparently told off by her (Laming 2003:40). Despite the obvious warning signs of abuse, the conclusions could not be drawn. The truth was too much to bear. It seemed that this couple wanted to keep Victoria with them, as she had become an object to be tortured, for their gratification. She was completely deprived of her humanity: Given that her hands were kept bound with masking tape, she was forced to eat by pushing her face towards the food, like a dog. As well as being forced to spend much of her time in inhuman conditions, Victoria was also beaten on a regular basis by both Kouao and Manning. According to Manning, Kouao used to strike Victoria on a daily basis, sometimes using a variety of weapons. These included a shoe, a hammer, a coathanger and a wooden cooking spoon…. It is unclear what Kouao’s intentions were at this stage. During the course of Ms Arthurworrey’s home visit on 28 October 1999, they discussed the option of returning to France. However, despite the two visits to Paris, Kouao seems to have had little inclination to return permanently. Manning was under the impression that Kouao’s intention was to send Victoria back to her parents in the Ivory Coast, but despite his obvious distaste for Victoria, he said he did not push the issue. (Laming 2003:35) This situation was perhaps even more complicated by complex cultural issues and professionals’ possibly unspoken fear of appearing racist if they expressed their suspicions of Kouao; it is also possible to speculate that she might have been attended to more carefully had she been a white British child. It is not possible to know how much these factors played a role, but what is clear is that her grave and dangerous situation was not properly thought about nor attended to. It is possible on a practical level that her ‘unknown’ status contributed to the overall negligence of her welfare and also helped Kouao to ‘lose’ various local authorities who had seen Victoria. She was not enrolled in a school, for example, and so lost this potential monitoring agency. The role that Victoria’s racial identity played in the tragic events is not clear, but her situation appears even more frightening and desperate because she was utterly dependent on the carer with whom she came to two strange countries and her own status as ‘stranger’ or outsider in the UK. This case reflects not only the dynamics of abuse, but also the degree to which it cannot be thought about because of the painful emotions it evokes in others.

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The Inquiry Report informs its readers that in the last few weeks of her life Victoria was kept ‘living and sleeping in a bath in an unheated bathroom, bound hand and foot inside a binbag, lying in her own urine and faeces’ (Laming 2003:1). Here deMause’s notion of children as ‘poison containers’ for their parents’ murderous, toxic feelings is graphically and horrifically embodied. As in so many cases of severe child abuse, the child’s fear response of incontinence, either urinary or faecal, can further enrage parents or carers, who then mete out even harsher punishment, which in turn exacerbates the situation further. In this case the violence escalated to an almost unimaginable degree, in that Victoria was kept inside a binbag, tied up in an attempt to contain and confine her emotional and bodily outpourings. The Report describes the horror of the evidence of the abuse, only revealed in full after the child’s death: At the end, Victoria’s lungs, heart and kidneys all failed. Dr Nathaniel Carey, a Home Office pathologist with many years’ experience, carried out the post-mortem examination. What stood out from Dr Carey’s evidence was the extent of Victoria’s injuries and the deliberate way they were inflicted on her. He said: ‘All non-accidental injuries to children are awful and difficult for everybody to deal with, but in terms of the nature and extent of the injury, and the almost systematic nature of the inflicted injury, I certainly regard this as the worst I have ever dealt with, and it is just about the worst I have ever heard of.’ At the post-mortem examination, Dr Carey recorded evidence of no fewer than 128 separate injuries to Victoria’s body, saying, There really is not anywhere that is spared– there is scarring all over the body.’ (Laming 2003:12) Victoria herself may also have been terrified to expose the danger she faced, much as the professionals who suspected abuse could also have felt too frightened to uncover it, as Cooper and Lousada (2005) suggest. The parallels between the deceived, confused and frightened workers and the terrified child operate on many levels. It is both remarkable and unsurprising that upon hearing of Victoria’s death Kouao is reported to have said, This is terrible; I have lost my child’ (Laming 2003:37); this illustrates the sense in which Victoria had become hers, an object to be used and abused, and reveals Kouao’s own internal denial of the extreme danger in which she had repeatedly placed her. It is not however clear that she intended to secure a child for the purpose of torture and it may be that the entire situation escalated out of all control, particularly with the introduction of Manning, and the advice given by two different pastors that Victoria was possessed by spirits. Manning’s diary entry describes how he was going to go home ‘and release Satan from her bag’, conveying the almost psychotic quality of the belief that this distressed and traumatised child was in fact demonic. In reading the chronology of events detailed in the Inquiry Report it is also possible to see how the abuse intensified after Manning became involved with Kouao, and how Victoria may have become increasingly tormented as she ‘intruded’ on the adults’ relationship. On one occasion documented in the Inquiry Report, Kouao arrived at their home with Victoria and begged her previous childminders, the Camerons, to take her

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permanently because of the problems she caused her and Manning. It may be that this also, at some level was an unconscious attempt to ‘save’ the child, as well as herself, from an increasingly intolerable situation. Unfortunately, the childminders were not able to ‘take’ the child, despite their concerns for her, and yet another opportunity to rescue Victoria was lost. The repeated failure of medical and social services staff to identify Victoria’s risk and remove her from the ‘care’ of those who tortured her was all too evident. She is a haunting reminder of the horror of child abuse and the collective responsibility of us all to ensure that children are protected from harm, insofar as we are able to see it, and believe what we see. This task is not as straightforward as it might seem. Rustin (2005) describes how such emotionally painful, frightening situations act as attacks on thinking, preventing professional workers and others from grasping the obvious, despite their awareness that something is quite wrong. Rustin (2005) examines the issue of ‘not seeing’ what is unbearable, or rather seeing and not seeing, in her exploration of the events and failures of key professionals to protect Victoria. Cooper and Lousada (2005) identify crucial features in the resulting Report that fail to address issues of depth in such cases. The underlying difficulties of confronting denial in childcare professionals, parents and children alike, as well as bearing unbearable knowledge, raise ‘questions of seeing and knowing in child protection work’ (Cooper and Lousada 2005). That is, information can be intellectually known but not acted upon, because of emotional difficulties in processing difficult material and making links between what is and what is not known, so that an accurate understanding of a child’s safety can be achieved. They discuss the sense in which this most comprehensive report nonetheless does not address the emotional connections between the various failings in the system of child protection, nor the difficulties that operate at a deep level in individual consciousness, namely ‘the continual and perfectly understandable wish on the part of workers to believe that what they are being presented with is not a case of child abuse…It is in fact only human not to want to be obliged to enter this territory’ (Cooper and Lousada 2005:160). The photographic image of Victoria’s smiling face as she was when she first arrived in the UK was frequently reproduced in the newspapers and television coverage after her death, in conjunction with reports of her death and her scarred and emaciated body. Her ordinary childish hopefulness and vulnerability were painfully apparent in this portrait. As Lord Laming describes in the Inquiry Report, Victoria Climbié, and the hope she represented, was murdered: ‘In the end she died a slow, lonely death—abandoned, unheard and unnoticed’ (Laming 2003:12). Victoria Climbié’s death prompts us to examine the difficulties that mental health, medical and childcare professionals have in overcoming their own stereotypes, prejudices and fears related to the cruelty that women, as well as men, are capable of inflicting on those most vulnerable in our society.

Maternal depression and physical abuse of children The link between depression in women and physical abuse of children has been elucidated by Bifulco et al. (2002) as discussed in relation to intergenerational transmission of vulnerability to depression and other disorders. It is important to note that

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intergenerational transmission is a complex picture, and there are many intervening variables and protective factors. In Bifulco et al.’s (2002) study of the offspring of mothers vulnerable to depression, they found that depression alone was not linked with adversity in the children, but was mediated through physical abuse or neglect: Offspring of vulnerable mothers had a fourfold higher rate of yearly disorder than those in the comparison series (43% vs. 11%, p<:001). They were twice as likely as those in the comparison series to have experienced childhood adversity comprising either severe neglect, physical or sexual abuse before age 17. Physical abuse, in particular, perpetrated either by mother or father/surrogate father was significantly raised in the vulnerable group. Analysis of the combined series showed that maternal vulnerability and neglect/abuse of offspring provided the best model for offspring disorder. Maternal history of depression had no direct effect on offspring disorder; its effects were entirely mediated by offspring neglect/abuse. (Bifulco et al 2002) Mills (1997) and Cox (1988) focus on physical abuse in depressed mothers and report that nearly half of inner-city, under-resourced mothers in the UK, at home with young children, are suffering from clinical depression. Mills suggests that the women who have experienced depressed or rejecting mothers in their childhoods may have substituted an idealised internal mother. Their desire to have a child of their own may reflect a wish to please their internal objects, with the consequence that ‘the child they produce is of course nothing like the ideal child whom they would like to offer to their internal mothers as a gift and thus is often rejected’ (Mills 1997:186). This rejection can take the form of physical aggression towards the child. Mills (1997) describes the work of Shanti, an all-female psychotherapy centre in which such depressed and abusing mothers can receive brief psychodynamic psychotherapy. She argues that by offering women the safety of an all-female environment they can escape from the experience of powerlessness and alienation which pervades the ‘phallocentric discourses of their everyday world, where they exist without much access to economic independence, with only limited outlets for their creative talents and with little experience of an unmenaced physical autonomy’ (Mills 1997:187). This form of psychotherapy was found to have lasting benefits in terms of the women’s psychological well-being two years after therapy ended (Reader 1993). Clearly, there are many factors and motivations which produce female violence towards children, some of which are also found in male child abuse and some of which reflect the particularly intense relationship between mother and child, and the limited spheres of influence and control available to many women. A crucial factor is the link between the demands of the babies and children and the reactivation for the woman of her own experiences of abuse and neglect, echoing the sentiments expressed by De Zulueta in the opening passage of this chapter: Whenever they are put into the position of being a mother, having to look after a dependent child, particularly when there is the possibility of feeling vulnerable, they blank off their maternal feelings. To be a mother, for

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these women means having to identify with their own neglectful mother, the one who allowed abuse to happen. (Kennedy 1997:111) Women who have alcohol or substance abuse problems may become physically abusive or neglectful to their children when they are disinhibited by these substances and lose control of their behaviour; others may use their children to express sadistic impulses or to provide themselves with a sense of mastery and control. Mills argues that women who have themselves been subject to deprivation in childhood find it difficult to provide their children with clear boundaries, to say ‘no’, because of a profound identification with the child who is refused or deprived of something. The children who have never had limits set for them may become out of control and disturbed and the mothers, who have effectively relinquished the adult role of boundary setting only take back the authority at the moment where the behaviour becomes unmanageable and they respond through violence. There is no internalised voice or authority or capacity for containment in the mothers themselves. They alternate between identifying with the deprived children and overindulging them and suddenly ‘flipping’ and administering harsh physical punishment. As previously stated, violence can occur in conjunction with emotional and sexual abuse, cruelty and neglect. For women who have themselves been abused physically, their own violence towards children can reflect the psychological process of identification with the aggressor, in which the mother gives to the child the experience that she herself suffered as helpless victim. She turns her passive role of victim into the active one in which she is in control, as the aggressor. When there is a violent or abusive partner present in the household the child’s risk is further increased.

Loss and physical abuse The following case study illustrates how a physical assault on a child can be an echo of earlier experiences for a mother, expressing her need for help and to discharge her anger. There is a sense in which the mother’s assault on her child reflects the reactivation of her own memories of abuse and an intensification of her feelings of helplessness and murderous rage towards her own internalised mother, whom she had idealised. The birth of her own child shatters this idealisation: ‘Back come emotions in memory, feelings and specific images, many of which do not accord with the idyllic and satisfying treatment that was fantasised as part of a life-long defence against disillusion and object loss’ (Mills 1997:178).

Case illustration

Melissa: distress and isolation in a physically abusive mother Melissa was referred for evaluation of her capacity to care for her 18-month-old son, Ethan, in care proceedings, in the light of her history of physically abusing him. There

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were also concerns about her ability to mother her second child, with whom she was seven months pregnant at the time of the assessment. The father of this child was not Ethan’s father Clifford, as this relationship had broken down following the intervention of the local authority and her disclosure of his violence towards her. Melissa was late for her first appointment and presented as a softly spoken and nervous young woman. She was delicate and attractive, with a fragile and youthful appearance: she seemed slight and doll-like although she was heavily pregnant. She reminded me of a timid child. She came to the initial assessment interview with her new boyfriend, Joshua. At first she appeared to find it difficult to speak and was somewhat reticent and unforthcoming; she nodded when her boyfriend spoke, as though she were mute. This indicated how hard it was for her to have a voice, or express her own needs, a hypothesis that was later supported by analysis of her offence. Despite her initial reticence and shyness Melissa grew increasingly confident and articulate as the assessment period progressed. She expressed some insight into her difficulties with assertiveness and communication when seen on her own at the second interview. She was open and descriptive in her account of the non-accidental injuries of Ethan, the nature of her relationship with Clifford and her history of difficulty trusting social workers. She was living with her partner Joshua, whose child she was expecting. The two had met initially when they were 17. Joshua had moved to Spain for two years and had recently returned to resume the relationship. Neither Melissa nor Joshua was employed at the time of the assessment, but he was hoping to start his own business eventually and Melissa said that she would be pleased to obtain parttime work of the kind she had held before, working in a factory. Joshua presented as a competent, realistic and assertive man who was fully aware of the complications facing the couple in their application to be reconsidered as potential carers for Ethan. Melissa was the only child of parents who had separated when she was just under two years old. When she was ten her mother told her that her father had sexually abused her when she was a baby and that he had later served several prison sentences for sexual offences against two other children. She could not recollect anything about her father, had no memories of the abuse and had not felt able to ask her mother for further details. She had been aware that her father was in custody for much of her childhood and knew that her mother did not want her to make contact with him. He had not attempted to contact her at any point. When Melissa was eight years old her mother married again, to a 39 year old plumber went on to physically abuse them both. He was an alcoholic who became violent when inebriated, and often accused Melissa of ‘winding him up’ and trying to ‘get in the way’ of his relationship with her mother. When she was 12 years old Melissa had been sexually assaulted by two local boys and feared that she had become pregnant. Her early experience of sexual abuse appeared to have left her vulnerable to repeat victimisation and she blamed herself for failure to protect herself during this encounter. She had been out on her own later than the other girls she occasionally socialised with and had agreed to go to the park with two older adolescent boys who had subsequently raped her. Because of her feeling that she had somehow deserved this assault she had not told her mother about this experience until she became afraid that she was pregnant, She

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described feeling powerless in the face of male aggression and becoming almost entirely mute during the sexual assault. Fortunately, she was not pregnant. Melissa first became known to social services at age 15 when her name was placed on the At Risk Register for physical abuse of which her stepfather was the perpetrator. She believed that her mother had been too intimidated by her stepfather to protect her adequately, and stated that it was only following her mother’s relatively recent separation from her husband that they had been able to build a satisfactory relationship with each other. Melissa’s mother had herself suffered from periods of depression and had few sources of social or family support; the few friends she had once had were estranged from her because of her husband’s possessiveness and jealousy. At the time of assessment Melissa had regular contact with her mother, whom she described as considerate and supportive and against whom she expressed no anger. Much of Melissa’s time in secondary school was marred by bullying at the hands of other schoolgirls. She described herself as Very shy’ and ‘backwards socially’ and reported that other girls would call her names and physically assault her. She had enjoyed the academic side of school but had received little encouragement at home and had eventually left school at 16. She would have liked to stay on at school but left because her stepfather had insisted that she earn money; her mother had not intervened. Melissa then worked on a youth training scheme as a nursery assistant which she said she ‘loved’. She recalled the sense of comfort derived from being in a safe environment, filled with toys. Later she had worked in a factory where she found the routine of work and the companionship of the others rewarding. Her first serious relationship had been with Clifford who was six years older than her and whom she described as violent, intimidating and a heavy user of alcohol. She had met him shortly after finishing her placement on the youth training scheme and had agreed to go out with him mainly because of a sense of loneliness, and because he initially appeared to be caring and protective. He soon discouraged her from continuing with her training as a nursery nurse, to which she subsequently agreed. She gradually began to perceive him as domineering and frightening. She described them as having frequent arguments about his drinking and his use of their shared income for buying alcohol. Six months into the relationship, Melissa, who had moved in with Clifford, became pregnant with Ethan. This pregnancy was unplanned and Melissa felt isolated, helpless and unsupported. At that time she had little contact with her mother and her stepfather, who had encouraged her to move in with Clifford. She had no close friends from school. Following Ethan’s birth, Melissa became even more isolated and distressed, finding it difficult to manage the conflicting demands of her small baby and her partner, who had become violent to her during the course of her pregnancy. She felt that she had no means of communicating her distress or exerting any influence over Clifford who would often leave her with the baby for hours at a time without letting her know where he was going. On several occasions he stayed out all night, which Melissa found frightening and upsetting as she had become anxious about being alone with Ethan, whose needs she found difficult to fathom. She would frequently question Clifford about where he had been and was regularly assaulted by him in response to what he perceived as ‘interfering’. She did not report these assaults to the police, believing that she had provoked and somehow deserved this treatment and also out of fear that without Clifford

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she would be on her own with sole responsibility for a child; she considered this a frightening and unmanageable prospect. Social services first became involved after Melissa shook Ethan hard when he was eight weeks old and suffering from colic. Clifford had reported this shaking incident to the health visitor who in turn informed social services. Following this, there was a second occasion in which Melissa presented Ethan, aged 15 weeks, at the accident and emergency department of her local hospital saying she was worried about her child’s welfare, showing the medical personnel that he appeared to have a fractured arm which she later stated had most likely been caused by Clifford’s rough handling of him. She also reported that she had herself been violently assaulted by Clifford, to whom she had attributed Ethan’s injuries. Ethan was then removed from the home and placed with foster carers at Melissa’s request. She had disclosed that she had herself also repeatedly hit him on the side of the head with his plastic milk bottle in complete frustration and despair. She later confessed that she had actually broken Ethan’s arm by twisting it as hard as she could. An interim care order was granted in relation to Ethan as neither Melissa nor Clifford was considered to be a suitable carer for him at the time. The couple remained together for several months following Ethan’s removal until Clifford left Melissa and started an affair with someone else, saying that he found her depression ‘too much of a downer’. After Clifford left, Melissa asked to be considered as a sole carer for Ethan and undertook a residential assessment with him. They both flourished within this environment and Ethan was eventually returned to her care, only to be removed again when it became known that Clifford was visiting the family and Melissa was again subject to violence. At this point the environment was considered unsafe for Ethan because of Melissa’s vulnerability to violence, her past inability to protect him and her unreliability in terms of reporting contact with Clifford. Her vulnerability to being abused violently by men was considered to increase the risk that she might not be able to protect Ethan from witnessing violence or being injured by a violent partner. Although Melissa had confessed to causing Ethan’s injuries, it was still thought likely by social workers that she might be covering up for Clifford’s violence and she was repeatedly questioned along these lines. She remained clear that she was confessing because she felt guilty about what she had done. She later regretted her decision to have Ethan accommodated by social services and attended contact visits reliably, continuing to assert her desire to have her son returned to her care. After she and Clifford separated, he attended contact visits only sporadically. It seemed that, at some level, she had been aware of her potential and actual danger to the infant and had taken the only responsible action that she could have in her situation, by relinquishing custody of her son. Her mixed feelings towards him were clearly in evidence in her actions. Her relationship with Joshua appeared quite different in kind. The couple had been together for one year before Melissa became pregnant again; this pregnancy was also unplanned but the consequences of the birth and the financial implications had been thought through carefully and discussed. There was no violence in the relationship and Joshua had no history of drug or alcohol dependence. The couple felt persecuted by Melissa’s former partner and unsure as to why they were no longer being assessed as potential carers for Ethan. Melissa had been silent in the case conference when asked about whether she would like to continue the assessment. She later disclosed that this

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silence resulted from her long-standing difficulty in speaking when she felt intimidated. She was aware that this was misinterpreted as hostility or lack of co-operation and hoped to have help so that she would no longer ‘clam up’. She was adamant that she wanted the assessment to continue. Melissa had asked to have Ethan accommodated in care at a point in her life when she felt heavily criticised by social services and abused by her partner. Her request may also have expressed her ambivalence towards her child, and her recognition of the potential danger of these feelings. She appeared to have made this decision out of a sudden fear about the extent of her own rage and uncontrollable feelings of frustration. She felt that she had not known how to keep him safe and had lost faith in her own degree of self-control and maternal competence. This appeared to have been triggered, in part, by relatively trivial criticisms of her childcare which the health visitor had made, in relation to warming the milk bottles and sterilisation techniques for the bottles. Her request for help in the form of respite care could be understood as protective action that had, unfortunately, not been recognised as such, but seen as confirmation of her inability to cope. Melissa’s degree of vulnerability to perceived bullying made it likely that she would magnify any criticism or suggestion that she was incompetent, and then become overwhelmed with feelings of worthlessness and helplessness as a result. She also, at some level, recognised how overwhelming her anger towards the baby was, and how it resonated for her with her own unmet needs for protection and care. She found his crying intolerable when on her own with him. It was striking that when she herself felt contained, when she was in a residential assessment unit, or when Ethan was placed with foster carers who treated Melissa like another of their charges, she could interact well with Ethan. The mother and baby unit had been positive about her capacities, saying ‘overall two-way bonding between mother and child was observed’ and ‘it was evident from the beginning that she found caring for Ethan enjoyable and used advice and guidance well’. Melissa was reported to have gained confidence, ‘her own personality’ and an understanding of Ethan’s needs. At this point social services were seriously considering rehabilitation of Ethan to Melissa’s care but this plan was suspended as a result of information coming to light about a reconciliation between Melissa and Clifford, calling into question her reliability and her capacity to place the needs of her child above her need to be in a relationship with a man. That this reconciliation followed a successful assessment by the mother and baby unit appeared to make little sense to social services, who had perceived Melissa to be a vulnerable woman in need of protection and assistance. They considered her decision to resume a relationship with an abusive partner, about whom concerns were still held in relation to his role in the physical abuse of Ethan, to reflect impulsiveness, immaturity and lack of understanding of the needs of her child. Social workers were also concerned by what appeared to be Melissa’s wilful deceit about her relationship with Clifford; for example, she denied that she had maintained contact with him while at the mother and baby unit, which he later contradicted. She appeared to have been confused about the permanence of her relationship with Clifford and reported to social services that she had fully separated from him, and wanted protection from him. Social workers began to view her as deceitful, selfish and manipulative, rather than as an innocent victim who could be rescued, as she had previously been perceived. It appeared that this sense of having been

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deceived created a residual anger towards Melissa and confirmed fears about her as an incompetent mother, in stark contradiction to her evaluation at the residential unit. The outcome of the court case was that Ethan would remain in long-term foster care under a full care order and would eventually be placed for adoption. The outcome for him, with his highly disturbed attachment and experience of physical abuse in infancy, remains unclear. Joshua and Melissa would be allowed to care together for the new baby, who would be placed under a full care order at birth, and closely monitored; shared parental responsibility would mean that this baby could be removed into local authority care at any point, should there be sufficient grounds for concern. It was clear that Melissa was both perpetrator and victim of child abuse, and the court considered her unsafe to be a carer for her second child. Her history of abuse in her own childhood and her physical abuse of her infant son were considered risk factors that could not be overcome, despite her resolve to undertake treatment and parenting education. There were also serious worries about her reliability in relation to the local authority who, understandably, she viewed with some suspicion. Although Melissa had to give up the chance of caring for her baby, due to the court decision, she could still be offered the chance to make some sense of her experiences, and be helped to cope with this enormous loss of both her children. I referred her to the local department of clinical psychology. Although she initially attended the appointments offered to her, she found it physically difficult to attend in late pregnancy and decided that she did not want to continue treatment after the first four sessions. She described the sessions as helpful and said that she would be re-referring herself to the department following the birth of her child. The female psychologist who had offered her therapy interpreted Melissa’s withdrawal from treatment as a reflection of how painful it was for her to address issues of relating to her own experience of abuse. Avoidance of confronting distressing aspects of her past appeared to Melissa to be the safest option available to her.

Discussion It seemed that because of the intensity of her traumatic experiences Melissa found it easier to enact her distress rather than to address it verbally. She was too frightened to engage in therapeutic work and also felt suspicious about the degree to which social services might be involved in the psychological work, feeling that she was being coerced into undertaking painful and intrusive treatment. It was evident that the process of making explicit her memories of traumatic experiences would be a threatening task, which Melissa did not feel ready to take on. In a sense, she found her silence comforting, and did not want to give it up. I hoped that she would, one day, feel ready to confront her fearful memories, and defuse their destructiveness. Given Melissa’s history of traumatic abuse, her difficulty in self-expression and her reliance on dissociation as a protective mechanism are not surprising. The sense of helplessness, that is perceived difficulty in effecting change in her environment and asserting herself, seemed clearly to express the impact of her traumatisation, both in childhood and in her recent violent relationship.

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Unfortunately, Melissa was caught up in a violent relationship with Ethan’s father, and found herself adhesively drawn to him, and then increasingly unable to leave him. Her failure to leave him was seen as evidence of her ‘failure to protect’ and her collusion with violence, rather than an almost inevitable consequence of her early traumatisation, and unconscious choice of a partner similar to her mother’s. There appeared little recognition on the part of her social workers that women who have been victims of domestic violence often find it hard to leave the situation and have no confidence in their own abilities or that independent living is a threatening prospect, which is attempted unsuccessfully, before the women are coerced back into the abusive partnership. I understood Melissa’s act of inflicting injuries on her son and bringing him to hospital to reflect the extent of her sense of distress, victimisation and helplessness. It also revealed her difficulty in viewing him as a separate and vulnerable being, and raised child protection issues. In an important sense she viewed him as an object, on to whom to vent her despair. Her feelings were rooted in early experience and reactivated both by her violent relationship with a partner, where she felt helpless and dependent, and also by the experience of motherhood itself, that powerfully reawakened memories of her own neglect and deprivation. She expressed regret and remorse about the injuries that she had inflicted on her son, describing them as reactions to extreme stress. The fact that she brought Ethan to the hospital suggested that she was aware of his need for medical attention and wanted witnesses to the damage she had inflicted on him. Her behaviour could also be understood as her inability to request help in her own right, because of her lack of self-confidence and repeated abuse, and her attempt to highlight the situation through the presentation of her son’s injuries. This has parallels with mothers presenting their children with fabricated or induced illnesses, as a means of attracting care and concern for themselves. This was her way of letting the caring agencies know that there was a domestic situation in which neither she nor her child was safe. Rather than request help in her own voice, Melissa attended the accident and emergency department with Ethan, stating that he had been injured by his father, but later confessing that she had inflicted injuries herself, in despair. Her communication difficulties reflected the depths of her sense of inadequacy and her fears of not being understood. It appeared that she would gain confidence sufficiently to develop her capacity to articulate her unhappiness and sense of isolation only gradually, and after working through the impact of her own sense of abandonment and victimisation in childhood. There were some hopeful signs that she could be helped to develop her parenting; when she felt safe and protected herself, for example, she had demonstrated a capacity to protect Ethan and care for him within the supportive environment of the mother and baby unit. There was real concern about whether she could survive outside the containment of a structured, parental environment. Melissa had deeply ambivalent feelings towards Ethan and her relationship with him had strong echoes of the experience of her own mother as an unreliable object, who could not maintain a safe environment. This relates to her degree of disturbed attachment, her own sense of maternal deprivation, and her impoverished understanding of her own mental states. She was left with a high level of emotional dependency on others and an inability to tolerate intense emotional states in herself or others. She appeared not to have internalised a containing and reliable maternal object, who could manage her rage and distress. These difficulties were exacerbated and reactivated when she was faced with the

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task of coping, unsupported, with her helpless and demanding infant. She was a frightened young woman whose own experiences of victimisation had profoundly interfered with her capacity to care for her first son. The description of physical abuse that introduced this chapter fitted Melissa: De Zulueta (1993) writes of victims of childhood abuse who become parents themselves: They want to be really good parents. But for some, these childhood terrors and torments have not been allowed to disappear. Though apparently forgotten, the experiences of their parents’ cruelty or indifference have been ‘internalised’ in the form of mental representations which will persist in their minds, albeit in an unconscious state. It is often in the midst of their own children’s screams and tears that those traumatic experiences are reactivated, even if they continue to remain unconscious. (De Zulueta 1993:4) General considerations that emerge from this clinical illustration include Melissa’s identification with the aggressor as her psychic defence against overwhelming feelings of vulnerability, her history of victimisation, and her transition from being a child on the At Risk Register to a young mother who placed her own child at risk. The symbolic significance of social services’ ‘care’ for Melissa, who had not received adequate protection during her own childhood, was a relevant factor as she felt persecuted by her social workers, and condemned to fail in the assessments that they conducted. She may have felt envious of the care that Ethan was offered, in contrast to the neglect she herself had experienced. Likewise, the information which was available to the social services department about Melissa’s background placed her in the category of women who might pose a risk to their own children; this was based on maternal neglect in her background and a history of sexual and physical abuse. In this context it became difficult for either professional or parent to approach the child protection problems with a wholly objective perspective and inevitably they became polarised. Through her violence Melissa had surrendered her own role as a mother to the local authority, perhaps requesting unconsciously that her son would be protected from the abuse that she had suffered, and which she had not been able to work through. It may therefore have reflected her unconscious fear of re-enacting this abuse through physical or sexual violence towards her baby. She had already found herself physically expressing frustration and anger towards the baby, and this had clearly frightened her. It appeared, at first glance, that the perception of Melissa as a victim of domestic violence was at odds with the discovery that she had lashed out at her child. It seemed hard for the professionals to recognise, unacceptable as it was, that Melissa’s aggression towards Ethan was one of her only ways of communicating her own sense of desperation and isolation, and re-enacting with him what had been done to her. When she was seen as colluding with her violent partner (rather than being wholly intimidated by him) and betraying the trust of the local authority, she was treated as a ‘hopeless case’ incapable of change, and she felt cast out. She then lost the chance to show that she had developed parenting skills and a capacity for protectiveness.

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Sympathy for Melissa as victim seemed to turn into anger at her for contact with her violent partner, failing in her maternal duties, and expressing her aggressive feelings. Although she had, by her own admission, directed violence towards her son, she had later taken full responsibility for this, expressed appreciation of its harmful effects, and what seemed to be genuine statements of remorse. She had made use of the support subsequently offered to her but despite these hopeful signs had lost the trust of social workers involved in protecting her child. The perception of her shifted dramatically and she went from being seen as vulnerable and in need of help herself, to dangerous and deceptive. This polarisation and splitting seemed to stem from the painful emotional issues that such situations evoke for professionals involved. Additionally, Melissa was ultimately viewed as without agency in her own right, mirroring her own fears about herself. As long as she was associated with Clifford she could not be trusted with a child, but her new partner was seen as solid and supportive, enabling her to be ‘given a chance’ to parent her new baby. Her potential to effect change could somehow not be thought about. Bearing victim and perpetrator in mind Melissa, like many perpetrators of violence, male and female, was both victim and abuser, which created a tension for those working with her. This dual status as perpetrator and victim is common in forensic work and clinicians must attempt to address both sides of their patients. The temptation is to address one or other aspect, because to try to acknowledge both is far more confusing and complex, for patients and therapists alike. One illustration of the difficulty of this dual status is found when women who are already known to social services because of abuse in their own childhoods become mothers themselves, sometimes with violent partners. These women may feel that they have suddenly lost the protection and support that they needed and craved for themselves as abused children, and are now treated as abusers, or as unfit and unprotective mothers. The perception may indeed be accurate. Although the dynamics in the relationship between childcare workers and mothers are not necessarily conscious to the participants, it is striking how often the same battles are played out, and makes co-operation between mother and social workers problematic. There can be a strong sense of mutual suspicion and hopelessness about the future for the child in the care of the other party. While both parties accept that the welfare of the child is paramount, they may not be able to agree on how best to proceed. The mother may feel that everything she has that is good is being taken from her; the social worker may feel that the mother’s needs make it impossible for her to parent her child effectively. This is related to the complexity and difficulty for mothers of overcoming the psychic consequences of abuse and neglect experienced in childhood in order to cope with the demands and needs of their own children. There is a clear need for childcare agencies to offer work to ‘parent the parents’, i.e. to empower parents who were themselves abused or neglected to care for their own children. The highly emotive nature of childcare proceedings cases also seems to reflect how the vulnerability of children ‘in care’, with no certainty about their future, evokes painful, sometimes unbearable, feelings for all those involved in the proceedings. The trauma that these children experience seems to be projected into the whole network of individuals

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involved and may reactivate tremendous anxieties and painful memories for the parents and professionals alike, as we have seen in the discussion of Victoria Climbié. For children who have been abused and then become parents themselves, the loss of their own children can reactivate a tremendous sense of deprivation and injustice, leading to anger and great difficulty in engaging with the child protection team. These feelings must be recognised and respected before an allegiance can be forged. There is a real danger of mothers and social workers becoming polarised. It is important for psychologists to emphasise positive aspects of the maternal functioning, as well as areas of difficulty, and to highlight the possibility of offering psychological therapy to break the intergenerational cycle of abuse and neglect. I also attempt to provide the courts with an understanding of how aggression and even violence may arise in the context of otherwise good mothering, at times of acute stress or crisis. It is possible that mothers who have been violent to their children are offered therapy, to help to understand and manage their anger, if genuinely motivated to do so. This process requires confronting the depression, isolation and traumatisation that often underlies the aggression. In order to protect their own children, or manage their own feelings of deprivation and anger, mothers need to be to able to work through their own experiences of abuse in childhood and to learn to protect themselves. It is also important that a woman whose children are subject to care proceedings, and who is faced with the possibility of losing them, has the experience of being understood and supported. If she loses her children in care proceedings she will face profound and ongoing grief, for which she may need help. This can be suggested and discussed with her solicitor and a referral can be made to the appropriate agency. Likewise, referrals can be made to child and family psychiatry and psychology services to help mothers in need to understand and manage their children’s behaviour and develop some understanding of how to set boundaries for them through parenting groups (Redfern 1999). It is essential to raise awareness of how unconscious expectations of female behaviour affect professionals’ judgements about maternal competence. The capacity to understand the complexity of maternal behaviour, rather than simply reacting with horror when women display aggression, can inform decisions about how best to meet the child’s needs. Rather than denying female violence and then demonising violent women, understanding the causes of such violence and identifying the potential for change is crucial. Women who display aggression towards others, particularly their children, may be perceived to be extraordinarily unmaternal creatures, rather than people who may have been treated with violence themselves, who require help and understanding in order to care adequately for their children. Support and treatment are often in the best interests of the child and may prevent a painful separation or break-up of the family. The difficulty for women in leaving a violent partner should also not be underestimated by child protection agencies: the fact that women may stay in, or even return to, violent situations is not evidence that they have put their own needs above those of their children. They may be considering their children’s needs when making this decision, or when finding it impossible to do otherwise than to stay. The degree of pressure placed on women to leave violent partners or risk losing their children through care proceedings does not take into account the emotional and practical difficulty such a

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move may involve, or necessarily provide alternative means of support. This forced choice may encourage women to lie, as Melissa did, about the extent of involvement with a partner. This deception will then be used as evidence of the unreliability of the mother and her ‘failure to protect’ herself or her children. They need to be sure that they will receive practical and emotional support if they attempt to leave the violent relationship and establish an independent lifestyle. In the context of social and religious pressures on women to ‘make the most’ of their relationships and the prejudice against single mothers, it is unsurprising that leaving a violent partner may be fraught with difficulty and ambivalence (see Chapter 8).

Intergenerational transmission of abuse and its prevention The experience of intergenerational transmission of attachment patterns is also evident in the case of women whose children are subject to care proceedings in the civil courts, just as they were. For some the experience reawakens memories of their own childhood, and their own placement into local authority care. Aside from the painful reactivation of memories of parental cruelty or neglect, these women may also have been sexually, physically or emotionally abused while in care, by foster parents or residential staff in children’s homes. This raises particular difficulties for them and makes the process of undertaking care proceedings even more poignant and painful. As young children or adolescents these mothers tried to understand and cope with their own removal from their parents’ care and being placed in strange and uncertain fostering or institutional settings. As they grew up they would have been unlikely to have received psychological help in coping with their new situations and may only have come to the attention of the psychological or psychiatric services once they became pregnant. As mothers these women may unfortunately, by virtue of already being known to social services, become identified as potential abusers rather than victims of abuse and feel stigmatised by their own history of being in local authority care. They may be ambivalent about becoming a mother and may sometimes even feel relieved when their own potential to repeat abusive parenting is recognised. At times these women express the feeling that social services have been involved with them for their entire lives, that they have no experience of being part of a normal family either as children or parents. If the women were abused but had no protection from social services in their childhood they may feel additionally deprived and envious, asking why their children are receiving the care and attention that they missed out on. They may strongly identify with the child at risk and hope that they too will receive help and protection from the professionals involved. On a more positive note, this hope can be a stepping stone in engaging the women in therapeutic work. Efforts made to ‘parent’ these women may include fostering the mother and child together, encouraging them to attend local authority run family centres and nurseries where basic education in child management and parenting skills can be taught and practised within a supportive environment, and engaging them in ‘parenting groups’ or other forms of family therapy at child and family psychiatry clinics, including centres

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of excellence like the Tavistock Clinic, Great Ormond Street Hospital and the Cassel Hospital, amongst other NHS facilities where families can engage in specialist treatment programmes.

Conclusion This chapter has considered some of the psychological motivations for maternal abuse, and traced patterns of intergenerational transmission of disturbed parenting. Attachment models clearly elucidate these processes, and complement psychodynamic concepts that are central for understanding the psychic functions of child abuse for the abusing parent. These include the projection of unbearable feelings of worthlessness into children, and an attempt to annihilate these feelings in themselves through attacking these children. The cycles of child abuse also testify to the power of learned behaviour, and the difficulty in drawing back from violence and aggression once it has been enacted. The complex interaction between the increasingly vulnerable and desperate child, the focus for murderous projections, and the abusing mother, with her profound and hateful identification with this child, may take on a compulsive and addictive quality. In all the cases discussed in this chapter the abuse took place in secret, in the home, but was eventually uncovered. In the case of Victoria Climbié and Melissa’s son Ethan, the children were presented with injuries at hospital. In Marian’s case her daughter was kept entirely at home when injured and the whole family took part in covering up the abuse her mother inflicted on her. Melissa’s violence did not reveal sadism, seeming to be an uncontained impulse arising from her own depression and isolation; she presented her baby’s injuries to communicate her own mute despair and rage. The UK Department of Health is currently commissioning major reviews of the efficacy of a variety of interventions for physical abuse towards children, and the results of these reviews should provide a clear framework for the practice of evidence-based therapies, including psychotherapy and cognitive behavioural approaches, to address these difficulties in managing feelings of anger and frustration, rather than expressing them through physical abuse. As a member of the Advisory Board for this study I am able to emphasise the need to identify therapeutic approaches for mothers whose own needs for care and help may be expressed through physical abuse of the children. For some women, individual psychotherapy to address their own experiences of trauma or neglect may play a key role in enabling them to parent their own children safely. Recognition of the dual status of these women, as survivors and as perpetrators of abuse, requires an understanding of the intergenerational transmission of abuse and how to break the cycle. When possible, psychotherapeutic support should be attempted to help the mothers manage their frightening feelings of destructiveness, rage and desperation. Being allowed to articulate these unacceptable impulses and encouraged to trace their origin and modify their toxicity can be a powerful relief for these mothers, This may be the first, and most important step in enabling them to separate their own experience of neglect, abandonment and violence in relation to their parents from their current relationship with their own children. The overwhelming identification which these mothers may have with their vulnerable and demanding children, and the consequent reactivation of

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uncontrollable anger, can potentially be thought about and managed through therapy, rather than repeatedly and destructively enacted. This therapeutic work can be an essential factor that significantly affects whether or not mothers repeat patterns of their own abuse with their children, in order to ‘convert childhood trauma into adult triumph’ and project into their children their own unresolved feelings of deprivation, vulnerability and rage. Therapy, whether psychodynamic, in a traditional transference focused framework, mentalization-based, with its proven efficacy in women with borderline personality disorder (Bateman and Fonagy 2004) with a cognitive behavioural focus on achieving impulse control in conjunction with parenting education and support, can be highly effective. Parenting education and individual therapy can provide women with the space to think about their behaviour and their children’s needs, and to identify aspects of their own histories that make apparently basic, ordinary parenting tasks difficult and painful to manage. Recent research by Spinelli and Endicott (2003) found that interpersonal psychotherapy was effective in reducing depression in pregnant women, to a greater extent than parenting education programmes, with implications for the women’s mental stability in the postnatal period. They note the significant correlation between depression in the antenatal and postnatal period and the impact of maternal mood on the quality of parent-child interactions. The impact of social and personal factors including marital dysfunction, and a history of child abuse, and chronic stressors, financial and housing problems, negative life events, and inadequate social support were all linked to high depressive symptom profiles during pregnancy. Therapeutic interventions can help women to recover from the traumatic consequences of their own abusive experiences in childhood and enable them to begin to manage their own feelings and memories, in turn, allowing them to manage their children’s needs for containment and protection. The opportunity to consider the impact of one’s own early parenting experience on development, to begin to gain understanding and control of violent and desperate impulses and to appreciate the baby as other, not as an extension of the self, is the starting point of a necessary psychic separation between mother and child. In this way mothers at risk of maltreating children can gain a real sense of them as existing in their own right, rather than as mirror images of themselves or receptacles of their own needs and desires. While it is clearly of central importance for government to legislate and enforce shared responsibility between health authorities, local authorities, educational officers and the police in relation to children’s welfare and protection, this alone cannot prevent tragic failures from occurring, for reasons that may be unconscious, to do with individuals defending themselves against emotional pain. Questioning the belief that women, particularly those in maternal roles, are fundamentally nurturing and protective may be one such painful but necessary task. The urgent need for reliable and sensitive supervision and training for childcare professionals cannot be overestimated. Without such resources the emotional processing and thought required to manage such cases will be impossible, even if the most elaborate and well-articulated multi-agency procedures are firmly in place.

Chapter 4 Fabricated or induced illness In each case, it is worth noting that not just detection, but a realisation of what was happening, took months because those in charge would not think the unthinkable, and even when they started to think it wouldn’t believe it, a nurse killing a patient and particularly babies. (Hunt and Goldring 1997:190; my italics)

Introduction Fabricated or induced illness (FII), or as it was formerly known, Munchausen’s syndrome by proxy (MSBP), provides one of the most disturbing and dramatic examples of a female perversion, in which women use the ostensibly caring role of mother, nurse or nanny to inflict harm on children.1 The quote above from the barristers involved in the case against Beverley Allitt, a nurse in the UK who killed four children, including babies in her care, describes the central difficulty in identification of this type of abuse. Positions of nurse and nanny are symbolic maternal roles that are idealised in such a way as to mask the opportunity for cruelty and perversion which they afford. The injured body of the child reveals the inner damage of the perpetrator’s mind. In this chapter I discuss the controversy surrounding the diagnosis of Munchausen’s syndrome by proxy, and its replacement with the term fabricated or induced illness. I explore theoretical literature relating to this relatively rare but highly dangerous condition and discuss recent developments in the high profile cases of two of the leading proponents of Munchausen’s syndrome by proxy and subsequent rulings by the General Medical Council (GMC). Child abuse, expressed through fabricated illness or actual suffocation or poisoning of an infant, reveals murderousness and powerful identifications on the part of the parent or carer, that I explore and illustrate. I also provide a case illustration of the difficulties inherent in the identification of FII and the complexity of its manifestation. The difficulty in understanding and detecting FII relates to professionals’ blind spots in recognising female violence, particularly when it involves maternal abuse. A literature review of FII referred to in the Report by the Royal College of Paediatrics and Child Health (2002) was conducted by Postlethwaite and Eminson who identified 605 cases of FII. This consisted of 313 cases in single case reports and small case series and 292 in

1 The term Munchausen’s Syndrome by Proxy (MSBP) has largely been replaced in recent research in the UK with the term Fabricated or Induced Illness (FII). For the purposes of this chapter I have, at times, retained the term MSBP when it was used in previous research.

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more extended case series. According to the results of this review, the perpetrator of abuse was female in 92 per cent of all cases; she was the child’s mother in 89 per cent of these cases and a mother substitute in 3 per cent. The perpetrator was male in only 5 per cent of cases in this review, although it should be noted that the majority of the men engaged in the more intrusive forms of physical abuse, while mothers committed acts of illness induction and fabrication all along the spectrum. While acknowledging the recent controversy over the use of Munchausen’s syndrome by proxy as a diagnostic category, it is nonetheless illuminating to look at the literature relating to it. One of the largest epidemiological studies conducted indicated that in 85 per cent of 128 cases considered representative of MSBP, nonaccidental poisoning and non-accidental suffocation, the perpetrator was the child’s mother (McClure et al. 1996). The reluctance to recognise this syndrome reflects the strength of idealisations of motherhood and the denial of its potential danger. The predominance of female over male perpetrators is a finding replicated in more recent epidemiological studies of FII. Clinical evidence indicates that fabricated or induced illness is usually carried out by a female carer, usually the child’s mother (DH 2001; RCPCH 2002). The emotional and intellectual difficulty in recognising MSBP as a type of child abuse is well described in the accounts of the trial of Beverley Allitt provided by Hunt and Goldring, barristers for the defence and for the Crown Prosecution Service in the case (1997). Ms Allitt, though vilified, was ultimately sentenced to psychiatric treatment in a special hospital under section 37/41 of the Mental Health Act. James Hunt QC, leading Counsel for the Defendant, described the difficulty of the case: We were presented with a defendant who insisted that she had done nothing to harm anyone and continued to do so after she was sentenced. She was a nurse, she was a member of a profession dedicated to caring and saving life. On the face of it, an unlikely candidate…. From our research into the defendant’s background we also knew of the diagnosis, or, at least to begin with, a possible diagnosis of Munchausen’s syndrome, both simpliciter and by proxy…we knew that many of those diagnosed as Munchausen’s by proxy cases were nurses, 20 per cent, most being the mothers of the children they abused. (Hunt and Goldring 1997:189) In the cases of Beverley Allitt, Susan Nellis and Janey Jones, the combination of being a woman in the caring professions, particularly a nurse, and the victims being babies, made accurate understanding of what had happened ‘unthinkable’. It appeared that this constellation of factors rendered understanding of the problem impossible. Too many taboos and idealisations were challenged simultaneously, resulting in a paralysis in the system and an inability to think about or recognise what was happening. This attack on thinking interfered with the capacity of the organisation, i.e. the hospital in which Beverley Allitt worked, to take protective action even after acknowledging her dangerousness. She remained in post. The failure to see the obvious, and the resulting tragedy of further deaths, then had a profound backlash in terms of the vilification of Ms Allitt and the outrage and horror that greeted her crime. She is now considered a notorious serial killer, whose early

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manifestation of Munchausen’s syndrome later turned to Munchausen’s syndrome by proxy. While she was no doubt highly disturbed and dangerous, the degree to which her offences were treated with disbelief and moral panic also reflected the extent to which she, as a nurse caring for children, had shattered the images of womanhood held most sacred by the general public. Little was understood about the link between her need for destructive power and her attraction to the role of nurse, to be seen as an ‘angel of mercy’ when she leapt to the aid of the injured or ill child. only later to be reconfigured as ‘an angel of death’. There were risk factors in her background indicating her instability, including eating disorders and self-harm, but these had not been considered relevant when she applied for a position of nurse. Most seriously, failure to consider her potential for harm earlier contributed to the institutional failure to protect vulnerable children in her care In my view this lethal failure of imagination reflects a sentimental and blinkered view of women that is socially constructed and reinforced. Until the fact of female violence can be recognised and understood, children will continue to be put at risk. These same factors operate to hinder identification of cases of FII.

The current status of the MSBP diagnosis The diagnosis of MSBP places emphasis on the disturbance of mind of the perpetrator rather than highlighting the fact of child abuse; and has therefore been criticised as an unhelpful construction with little substance as a psychiatric entity. It has been replaced in the UK by the term fabricated or induced illness, and emphasis now placed not so much on diagnosis of the perpetrator’s mental state, but on identification of induced or fabricated illness in a child. Such identification is a crucial aspect of effective child protection, but the question remains of whether this can be ascertained without reference to the presentation and motivation of the mother or carer. The recent report by the Royal College of Paediatrics and Child Health, (2002) presents a fascinating and comprehensive account of the arguments for replacing the term ‘Munchausen’s syndrome by proxy’ with ‘fabricated or induced illness’, the forms of presentation of this, and the role of professionals across disciplines in working together to combat this potentially lethal form of child abuse. It addresses issues of aetiology, identification, treatment and prognosis. Rather than identifying a particular form of child abuse as part of a diagnostic picture of a mother or carer, this new term emphasises the nature of the abuse itself. The injury to the child became the focus of concern and identification, rather than the motivations of the parent, although the latter are clearly part of the picture—for a case of illness to be fabricated or induced there must be an active agent inducing and/or fabricating illness. In the report by the Royal College of Paediatrics and Child Health, the working party decided that the term MSBP was no longer appropriate or useful, because of its implications that there was a unitary motivation on the part of the perpetrator, and that there was a discrete mental category or classification that this referred to. The report Fabricated or Induced Illness by Carers accepts the criteria first proposed by Meadow for MSBP that:

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1 The illness is fabricated by the parent or carer. 2 The child is presented to doctors, usually persistently. 3 The perpetrator (initially) denies causing the child’s illness. 4 The illness clears up when the child is separated from the perpetrator. (Meadow 1977) However, the authors also note that the third and fourth criteria are true for any form of child abuse, and therefore do not discriminate FII (or MSBP) from other forms of child abuse. The authors conclude, in relation to nomenclature that: The condition known as Munchausen Syndrome by Proxy or other variations does not satisfy criteria for acceptance as a discrete medical syndrome because of the wide variation’ (Royal College or Paediatrics and Child Health 2002:8). The authors also note that in strict semantic terms the diagnosis of MSBP could only properly have been applied to those individuals who had suffered from Munchausen’s syndrome themselves, and then manifested the disorder through the bodies of their children. It could also be argued that the term is used more metaphorically than this, that the children serve the ‘by proxy’ function for their mothers, even if the mothers themselves have not suffered from Munchausen’s syndrome in earlier life. In recent years, the diagnosis of Munchausen’s syndrome has itself been replaced with somatoform or somatising disorder. Morley (1995) had also argued that the diagnostic criteria suggested by Meadow were non-specific and could lead to false diagnoses of MSBP as well as detracting medical attention from the nature of the injuries sustained by the child or children. He notes that for each diagnostic criterion or ‘pointer’ there are situations in which the presence of such a factor does not necessarily point to MSBP and can create unnecessary suspicion in relation to concerned and/or anxious parents who may appear to ‘fabricate’ symptoms when they are actually exaggerating certain aspects of their child’s physical presentation, either because of their genuine ignorance of medical matters or their high level of anxiety in relation to their child’s health. Some of the indicators that the presenting symptoms may be fabricated are similarly non-specific, and hence open to misinterpretation. The factors which have been identified as signs of fabrication include the following: • inconsistent histories taken from different observers • symptoms and signs that are unusual or bizarre and inconsistent with known pathophysiology • observations and investigations inconsistent with parental reports or the condition of the child • treatments which are ineffective or poorly tolerated • symptoms or signs which begin only in the presence of one parent or carer. These indicators are not conclusive evidence of fabrication. It is clear that the interpretation of inconsistency in medical histories depends on the perspective of the doctor taking the history as well as on how the history was obtained, i.e. what questions

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were asked and which areas were highlighted. The determination of ‘unusual signs or symptoms’ also depends, in part, on the judgement of the doctor as well as on the observational accuracy of the parent or carer. Similarly, there can be a benign explanation for the fact that symptoms began in the presence of one parent or carer, in that many concerned mothers are with their ill child all the time (Morley 1995). Morley’s caution in relation to practical concerns about the MSBP diagnosis highlighted the need for medical professionals to focus on the child’s injuries and illness rather than the mother’s mental state and to bear in mind the likelihood that most mothers who bring children to the surgery when they believe them to be ill are acting out of ordinary concern and appealing in a trusting way to a medical authority. It is nonetheless significant that in a small minority of cases of presentations of ill children the illnesses will either have been fabricated or actually induced by a parent, and in the vast majority of cases this parent is the child’s mother. It is essential that those involved in child protection are able to acknowledge this possibility and bear it in mind when considering cases of childhood illness that appear to defy medical explanation, despite the apparent concern and dedication of the mothers. Education about the presentation of these mothers, and sometimes fathers, and the dynamics that they can create within staff teams could help in accurate detection of this potentially lethal disorder. A central concern is that the diagnosis of MSBP gives no indication about what happened to the child. Instead of the nature of the abuse being elaborated upon, i.e. suffocation, poisoning, putting blood in the urine, false reporting of fits or other difficulties, the mother’s state of mind becomes the central focus of investigation. The abuser becomes identified as a patient who is ‘suffering from MSBP’ rather than a perpetrator of particular physical and emotional abuse on a child, who is the real victim. This subtle reframing of the situation facilitates the process described by Busfield (1996) in which the ‘madness’ of women locates them outside the realm of aggression and delinquency, shifting the emphasis in sentencing from punishment to treatment. The term MSBP abuse was a helpful step towards emphasising the destructive aspects of MSBP for child victims, rather than simply identifying the parents as patients.

Background to the MSBP diagnosis In his original paper coining the phrase ‘Munchausen’s syndrome by proxy’, Meadow (1977) described the great similarity between Munchausen’s syndrome proper and MSBP. He argued that in MSBP mothers use their children to generate the attention and care which they crave for themselves, whereas in Munchausen’s syndrome itself people present themselves for medical attention for fabricated injuries and illnesses, even to the extent of undergoing unnecessary operations and other medical interventions. They might have been presented by their own parents, and unconsciously equate medical with maternal care. Munchausen’s syndrome proper can be understood as a form of self-harm, which both creates a situation of self-injury and, in a sense, victimises the medical professionals, who are tricked into being active agents of this self-mutilation. In Munchausen’s syndrome by proxy the mother uses her child’s body rather than her own to achieve this end. Approximately 20 per cent of people diagnosed with MSBP have also displayed signs of

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Munchausen’s syndrome (Adshead 1997) and 10–25 per cent of the MSBP perpetrators produce or feign illness in themselves (Rosenberg 1987). Of great interest in considering the phenomenon of female violence is the finding that while sufferers of Munchausen’s syndrome are equally divided between men and women (Hyler and Sussman 1981) it has been estimated that up to 98 per cent of MSBP perpetrators are female (Rosenberg 1987). The victims, however, are equally divided between male and female children (Rosenberg 1987). Additionally, some mothers continue to exhibit signs of Munchausen’s syndrome preceding their MSBP and following discovery of their abuse and removal of their children (Parnell 1998). There are significant actual differences in terms of the nature of FII abuse compared to the self-injury and deception of Munchausen’s syndrome or somatising disorder, and there are dramatically different legal consequences between injuring a child and harming oneself. Parnell suggests: There seems to be a fundamental difference between the psychopathology of an individual who is willing to make herself suffer and that of one who is willing not only to watch but to create suffering in another human being, particularly her own helpless child. (Parnell 1998:19) I argue, in contrast to this view, that, for perverse mothers, the motivation is in fact closely linked. In psychodynamic terms, there is clear identification for the mother between her child and herself, the two become fused for her and her own somatisation is extended to include her child, viewed as part of herself. It has been further demonstrated that in cases of active induction of injury mothers use the portals created by medical intervention as means of abuse (conduits for toxins, etc.) and this illustrates the powerful link between maternal and medical intrusiveness, where both have become dangerous and destructive.

Previous classifications of MSBP MSPB, as it was originally known, was not viewed as a unitary diagnostic category and its subcategories map on to common features of FII. Libow and Schreier (1986) attempted to refine the concept of MSBP and distinguish between its presentations through providing the following categories of MSBP, which fit conceptually with presentations of FII. Help seekers The production of symptoms in the child is seen infrequently, usually as a result of stresses in the mother such as depression or anxiety. She presents the child as an expression of her own distress when her maternal competence is overwhelmed as a result of these stresses

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Doctor addicts These mothers seem genuinely convinced that the child is ill, to the extent that this belief approaches delusional intensity. Such mothers may also hold paranoid, suspicious beliefs and may have personality disorders. The desperate need for help for themselves is masked through their presentation of their apparently ill child, and the intervention which is sought may be some kind of reality affirmation. This seems to mirror the classification of Verbal fabrication’ of illness in the contemporary classificatory scheme, although it appears that the mothers are themselves unaware of the difference between reality and fantasy, i.e. they may not have knowingly fabricated the illnesses for conscious reasons. Active inducers It is this last category of women who commit dramatic and often highly complex and secretive physical assaults on their children, and who also demonstrate extreme denial, projection and affective dissociation in their presentation. They frequently injure their children and/or fabricate mysterious symptoms. They are most characteristic of MSBP perpetrators (cited by Barker and Howell 1994). This category of MSBP mothers clearly maps on to the category of parents in the FII classifications who use active physical induction of illnesses in their children. In this classificatory scheme parents are placed on a continuum from verbal fabrication to the most intrusive form of physical intervention. The last two categories describe those individuals most clearly representative of FII, who would formerly have received the diagnosis of the disorder of MSBP. These two groups appear to be motivated more by unconscious than conscious needs and secondary gain. In the second category, the doctor addicts, the mother is one step removed from actually abusing the child directly but brings her child to medical professionals under false pretexts, with the intention that they will proceed with intervention. In such a case the mother has fabricated symptoms that require medical intervention. In other cases, those of the active inducers, the mother herself harms the child, in order to induce apparent symptoms of illness which require medical treatment; for example, subjecting her child to laxative poisoning which causes severe diarrhoea, for which no obvious organic cause is detected, leading to high levels of concern and further investigation. Just as it can be difficult to distinguish between exaggeration of symptoms and fabrication, it can also be extremely complicated to disentangle symptoms of FII in cases where it coexists with an underlying organic illness. In such cases the complex interplay between actual and induced symptoms, deception and truth and the psychological needs of mothers affecting and damaging the physical bodies of children is evident, and makes the detection of fabrication and induction of illness symptoms even more difficult. The complexity of the psychosomatic matrix and the enmeshed relationship of mother and child make detection and treatment of FII in these cases highly problematic. Although the illnesses of children who have been subject to FII abuse often involve respiratory, neurological, infectious, gastrointestinal and haematological difficulties, there are more than 100 symptoms which have been associated with this syndrome (Schreier and Libow 1993; Parnell and Day 1998). The most common factitious symptoms associated with it are seizures, bleeding, apnoea, diarrhoea, vomiting, fever, rash (Rosenberg 1987) and lethargy (Schreier and Libow 1993). It has been noted that such mothers can be creative and deceptive, falsifying symptoms in ways which a

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physician might find it difficult to imagine. Attempting to cross-reference the current presentation of a child with their previous medical records can provide important clues about the nature of the apparently inexplicable illness, pointing to an extensive history of medical consultation and even evidence of fabrication and induction of symptoms in the past: The written medical records may contain evidence of false medical history of the child or family, exaggeration of the child’s medical condition, exaggeration of physician statements regarding the child’s medical condition, reports of symptoms that never occurred, faked or simulated symptoms, and actual induction of symptoms. The distinction between exaggeration and fabrication is difficult to make, as is a determination of simulation versus induction, through consideration of the symptom presentation or report alone. Induced symptoms are generally much more difficult to detect, especially because induction tends to create actual physiological conditions. (Parnell and Day 1998:7) The risk for professionals of failing to take seriously the mother’s presentation of an apparently ill child is great: a sick child might be left untreated and suffer serious harm. The professional has a duty to take action. In those instances where the mother fabricates symptoms, leading to unnecessary and intrusive medical intervention, she entices neutral professionals into a destructive game where medical knowledge, the tools of treatment become the weapons that injure vulnerable children. This has clear parallels with the type of self-harm evident in Munchausen’s syndrome, where the patient deceives medical professionals into conducting painful interventions, sometimes including surgical procedures. The patient is passive in terms of directly injuring themselves but manipulates a third party into doing so. This third party is often the person to whom the Royal College Report refers as ‘the duped doctor’, who becomes a central part of the process. In making a formulation of the unconscious motivations for generating a fabricated or induced illness, I will also consider the symbolic significance of the ‘duped’, deceived and castrated doctor, who is rendered unable to perform his or her essential role.

Understanding the dynamics of fabricated or induced illness A formulation for outlining the psychodynamics of FII can be offered, in which it is situated on the continuum of other forms of maternal abuse and illustrates the use of the child as part-object. It often reflects an enmeshed, fused relationship between mother and child. The perpetrator, usually the mother, has often experienced instability of environment in her own early life; this is particularly common for those women who engage in the more physically intrusive forms of illness induction (Royal College of Paediatrics and Child Health 2002). She may have constructed her sense of identity not in terms of an inner core of stability, a continuous sense of self, borne out of a satisfactory early relationship with a mother who could mirror her moods and help her gain a

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coherent sense of self, but instead feels fragmented, and tends to focus on the concrete aspects of her own body as the constant that remained throughout this instability. When she has her own child a similar difficulty in ‘mentalising’ the mind of the child and capacity to relate to another human being as a subjective creature with desires and feelings quite separate from hers may also become evident. Her own mothering mirrors her difficulties with separation and individuation and reflects an overemphasis on the body and on bodily communications. Just as she is likely to have used her own body as a tool of self-expression, possibly through self-harm, eating disorders and even somatising disorders, so too is she likely view her child, a narcissistic extension of herself, as another body to be manipulated. These factors and early attachment disorders have been found to be prevalent in the backgrounds of mothers who present to medical practitioners with children who have FII. Other significant background features include the following: • Existing mental health difficulties have been reported. These include Somatising and Somatoform Disorder (formerly Munchausen Syndrome), Personality Disorders, Eating Disorders, self-harm, alcohol and drug abuse. • Previous contact with mental health agencies is reported in 30%. This needs to be compared with controls for parents attending general outpatients which are almost as high. Fabricators often have a history of somatisation disorder or other episodes of fabrication. • Personal histories of fabricators also include reports of physical or sexual abuse as a child (25%), being in local authority care during childhood (children’s homes or foster care), and childhood mental health difficulties history of many kinds often associated with concurrent abuse. • Various patterns of family relationships have included reports of a distant, passive or absent father. (Royal College of Paediatrics and Child Health 2002:31) The role of the ‘duped doctor’, the person to whom mother turns with her injured or apparently ill child, is also of great significance in conceptualising these dynamics. This doctor may represent the ‘third term’, that is, the absent father who was not available to stand between mother and child, to facilitate healthy separation between them and to reduce the risk that the child would grow up to become a mother with an equally fused, confused and entangled relationship with her own children. The ‘duped doctor’ is the father rendered impotent, unable to perform his much needed function of protecting mother and child from some kind of incestuous, boundaryless and ultimately toxic relationship that can engulf them both. Deceiving the doctor can be viewed as an act of vengeance against the absent father, and also re-enacts the profound deception and distortion that the perpetrating mother may herself have experienced in her own childhood, only this time it is the doctor whose trust is betrayed, not the mother herself; some of these women may have themselves been used as objects in whom illness was fabricated or induced by their own mothers, with the doctors becoming active, though unwitting, agents of injury against them.

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It is possible to consider the hospital too as the healthy body, the functioning organisation or ‘family’ that needs to be attacked and corrupted. Such elements of revenge, deception and cruelty are not necessarily available to the mother’s conscious mind but are important aspects of the script that is being followed. For women who have been abused and lied to in childhood, reenactments in adulthood of such maltreatment and deceit can provide a temporary escape from the pain of their own experiences. The sense of power created both by the damage done to the child, within the guise of caring, and to the body of the medical institution may be exhilarating, particularly for people who have felt so powerless themselves. Furthermore there may be an unconscious wish to be caught and stopped from continuing this abuse. Like so many other forms of criminal acting out, the perpetrator can be driven by an unconscious sense of guilt and have buried in consciousness the notion of an authority that will ultimately detect the crime, and stop and punish the perpetrator, protecting the victim. Evidence for this hypothesis can be found in the description given in the Royal College Report that several parents described a great sense of relief when the FII was detected: Parents have particularly appreciated those paediatricians who have been non-accusatory and nonjudgemental in their approach to them, and by corollary found it exceptionally hard when subjected to the paediatrician’s anger. Quite a number of parents describe feeling considerable relief when the paediatrician revealed they had unravelled the fabrication. For many parents though, their initial response was indignant denial, anger, or even apparent incredulity, yet they had been able to appreciate the paediatrician’s concern later, once they had been in some form of therapeutic work, or where they had had time to reflect further. (Royal College of Paediatrics and Child Health 2002:64) While FII is potentially a fatal form of child abuse that evokes strong emotional responses against the perpetrators, it is still crucial to understand and delineate the functions it can serve for women who feel without a voice or legitimate claim for help, respect and attention in their own right. By presenting their children for help and appearing in the medical setting as devoted carers, these women may be accorded great respect and approval. They disavow their aggressive impulses and become agents of care and mercy. In a fascinating paper exploring the cross-cultural expressions of Munchausen’s by proxy, Nancy Scheper-Hughes describes such behaviour as the ‘weapon of the weak’ and views it as a disorder on the continuum of disturbance in women whose whole social status and sense of identity comes from their roles as mother: Just as mothers sometimes project onto their babies their own frustrated wishes and needs, so do medical professionals and other caregivers project onto women their fantasized and naturalised images of ‘motherhood’ and ‘mother love’, which make it difficult to see harmful behaviours that are occurring right before their eyes. A commitment to the ideological formation of ‘maternal bonding’ and mother love obscures the real dangers that mothers can pose to their own children…Behaviours

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conforming to the symptoms of Munchausen’s by Proxy exist along a continuum of maternal behaviours, from normative to deviant. Munchausen’s by Proxy syndrome is rooted in conventional roles that isolate women, make them overly responsible for the physical care of vulnerable family members, and thereby prone to the social uses and abuses of somatization and the sick role, and especially to the drama and pageantry of fictive illness and heroic (though false) medical rescue. (Scheper-Hughes 2002:171) It is interesting to note that it is not only the mothers who, prior to detection as perpetrators of FII are configured as angelic carers, but the doctors themselves who are imbued with great powers of healing and trust. This idealisation is also seen in those cases where the expert witnesses themselves become ‘detectives’ who find evidence of abuse in cases of apparently natural illnesses. And when those expert witnesses, like the mothers themselves, fall from grace, a similar backlash of horror and hatred can greet them.

Background to recent General Medical Council ruling in relation to Regina v Clark The decisions of the UK General Medical Council in relation to suspending paediatricians Roy Meadow and David Southall have highlighted the controversy surrounding the diagnosis of Munchausen’s syndrome by proxy, and the difficulties for expert witnesses testifying in cases of child abuse. Critics of the decisions by the GMC have described its ruling to strike off one of its medical practitioners (Professor Meadow) and restrict the practice of the other as unfair and ungrounded, warning that such decisions could have serious and detrimental consequences for other professionals working in the field of child abuse. The ruling following Sally Clark’s successful appeal against her conviction for murder of her two sons, and the fact that evidence given by both Roy Meadow in that case Regina v Clark, and David Southall’s testimony during the trial was considered flawed. Meadow’s evidence included the statistical proposition that the chances of two infant deaths in the same family were one in 73,000,000 based on squaring the likelihood of one such death, an erroneous and highly misleading statistical finding. It was on this basis that Meadow was found to be guilty of serious professional misconduct by the GMC, despite the other evidence before the court that the infants had suffered injuries not consistent with sudden infant death syndrome. In fact it was not Meadow’s evidence that determined Ms Clark’s conviction to be overturned, but the fact that the pathologist had not disclosed crucial information about a possible cause of death. There was evidence of staphylococcus aureaus infection in Mrs Clark’s son, Harry, the second baby to die. The reason that the case was overturned was therefore not on grounds of Meadow’s erroneous statistical evidence, although the appeal judge noted the questionable use of statistics, the judge in the original trial had actually warned the jury not to rely on them. In his defence of Roy Meadow, prior to the GMC ruling, Dr Horton writes in The Lancet: ‘Meadow is presently an understandable lightning rod of blame for the wrongful conviction of Sally

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Clark. But this misconceived pursuit of one man is wrong and threatens the effective delivery of child protection services in Britain’ (Horton 2005:3). The role of the expert witness became highly vulnerable following this decision to suspend Meadow, despite the stated intention of the GMC to restore confidence in expert witnesses through this chastisement of Meadow. In a further twist on this tragic case, Sally Clark was found dead at home in March 2007; the coroner reported no evidence that she had intended suicide and concluded that she had died of acute alcohol intoxication. Her death was conceptualised as an example of her failure to recover from her wrongful conviction and once again Meadow was portrayed as villain throughout the press coverage. Mrs Clark was depicted as the deeply wronged victim of a miscarriage of justice. It was Professor Meadow’s erroneous statistic that became the focus for the tremendous backlash against Mrs Clark’s conviction. The error of this statistical evidence is undeniable, but there was a sense in which it was used to call into serious question the role not only of the expert witness himself, but the validity of the condition that he had identified. The turning away from Meadow’s findings and credibility had a powerful effect on the confidence of the courts in relying on this diagnosis, and in the public eye expert witnesses like him were portrayed as somehow corrupt, perverting the truth and condemning innocent parents. The process of denigration of the expert witness can also be understood as a backlash against those who do see and name something fundamentally unbearable to deeply held and cherished beliefs about motherhood. Silencing Roy Meadow, and by proxy other expert witnesses, may be analogous to the silent suffocation of children, whose voices then will not be heard. Indeed, while expert witnesses may be accused of blinding themselves through their own blinkers, seeing only what they want to, it is nonetheless the case that careful observation and evaluation by impartial experts is often crucial in cases of child protection.

Background features of women with children in whom FII is identified Women with somatic disorders were found to represent a high proportion of MSBP mothers: this has been described as ‘maternal somatisation disorder’ (Livingston 1987) based on clinical interviews and examination of available medical records. Livingston linked the complex medical histories of MSBP mothers with multiple unexplained symptoms and repeated hospitalisations and surgical procedures without evidence that their own symptoms had been voluntarily produced and noted that these medical histories were consistent with diagnosis of somatisation disorder as described in the Diagnostic Statistical Manual, third edition (DSM-III, APA 1980), which is retained in the fourth edition of DSM. The description of these mothers as suffering from somatisation disorder rather than factitious illness such as Munchausen’s syndrome was first described in the literature by Livingston (1987). Background features in women diagnosed with MSBP include delinquency and criminal convictions in adolescence, eating disorders, self-harm, parental abuse or neglect, including sexual abuse, and a history of self-harm (Adshead 1997). For women who have undergone experiences of abuse, their conception of the value and use of their

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own bodies may be heavily distorted and they can use their bodies to express their pain and despair, as well as their anger at the parents whom they feel have let them down and betrayed them. Their sense of identity may reside in their bodies, as their early experiences have not allowed them the opportunity to develop a clear sense of themselves as separate from their bodies, which have been treated as objects to be punished or sexually exploited by adults. The domain of control and of the sense of self are located firmly in the body, which therefore assumes a central importance and expressive function for these women. There are significant commonalities in women who self-harm and women who perpetrate injuries upon and/or fabricate illnesses in their children. The development of these forms of violence can be understood in the context of both social and individual factors. There are important communicative functions of self-harm and FII. Both are clear expressions of a distorted and damaged sense of self, often related to a history of abuse. Women with FII may also have eating disorders and histories of depression, as well as self-harm. In these manifestations of female violence, aggression is turned against the self or against children, the central domains of power and control. The body of the woman herself, or, by extension, her child’s body, is the focus of female violence (Welldon 1992). It has been suggested that risk of fabricating or inducing illness in children may have its roots in women’s own attachments in childhood and in their relationship to the world, in their excessive susceptibility to taking on socially prescribed roles of mother or caretaker: The ultimate role of caretaker is that of the mother figure. Women are expected to be the primary nurturing figures for their children and to attach to them protectively. However, MSBP mother-perpetrators clearly display a disorder of empathy and attachment with their children. They harm their children without feeling the children’s pain. The children become objects used horribly by the mother-perpetrators in order to have their own needs met. The reasons attachment fails to develop are diverse, but they grow from disturbed object relationships beginning in childhood with experiences of physical, sexual, and emotional abuse. (Day and Parnell 1998:163)

Case illustration

Grace, a 24-year-old woman suspected of FII Harriet, a ten-month-old baby, was presented at her general practitioner’s (GP’s) surgery with breathing difficulties by her mother, Grace, a 24-year-old woman who had worked as a nursing assistant in a surgical ward three years earlier, for approximately 15 months. She appeared highly distressed by the baby’s condition and was well informed about the possible implications of the difficulties, such as asthma or bronchiolitis. The GP found no clear organic cause of the baby’s difficulties, nor did he observe any signs of chest congestion or wheezing in the infant. He was initially impressed by the mother’s

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intelligence, concern and apparent medical awareness, but noted that he could not detect any physical signs in the infant to corroborate her observations. A few weeks later Harriet was again presented at the surgery by her mother who expressed concern about bruising around the baby’s eyes. This bruising was not easily explained. At this point the GP developed some concern about the welfare of the child as such bruising can be associated with suffocation or strangulation attempts, but did not feel that he had sufficient evidence to contact social services to alert them to the possibility of child abuse. Although Grace had requested that a referral be made to a specialist breathing unit, this referral had not been made. She was insistent that the bruising around the eyes be investigated thoroughly by a specialist but the GP offered her an appointment at the surgery the following week to check on the baby’s condition. At this appointment Grace, appearing calm and composed but adamant and assertive in her views, complained that Harriet had been vomiting, that the rash around the eyes was persisting and that she continued to have fits in which she found it difficult to breathe. She expressed the fear that Harriet suffered from asthma, which she insisted must be diagnosed and treated as a matter of urgency. The GP felt alarmed by what he considered to be an overinsistent approach by Grace and he was disturbed by the extent of Harriet’s crying and irritability of mood. He examined Harriet thoroughly at this third appointment and found swelling and tenderness of her arm. He had her referred immediately for X-rays which demonstrated that she had a spiral fracture of her left arm as well as other bruises indicative of earlier injuries. He now strongly suspected that the injuries were non-accidental and contacted social services who placed Harriet’s name on the Child Protection Register in the category of at risk of physical abuse. Grace denied that she had played any role in perpetrating the injuries, or that her husband could have caused them as he had been away on business several days a week for the past few months, and had not been at home at the time the spiral fracture was believed to have occurred. There was still no evidence or direct observation of Harriet’s breathing difficulties or vomiting, despite Grace’s assertion that these had occurred on an almost daily basis when she was at home with her. Grace and her husband, Mick, were subsequently assessed by social services and by the consultant psychiatrist based at the child and family psychiatry services. The psychiatrist concluded that Grace had low self-esteem and difficulty in asserting herself but detected no evidence of mental illness. She evaluated Mick as being less articulate and intelligent than Grace but perceived that he had a strong need to assert his control over his wife. Grace had reported that he had physically assaulted her on one occasion, after she had gone out with friends, and that he tended to be jealous and possessive of her, encouraging her to stay at home and have minimal contact with friends and family. Although the consultant child psychiatrist did not report the extent of her grave concerns about the mother’s deceptiveness and the dangerous family dynamics in her report, as some of her views were matters of speculation, she stated that the spiral fracture was an almost classic case of battered baby syndrome. In an informal discussion with me she expressed her opinion that Grace had several risk factors indicative of maternal abuse and that she retained serious concerns about the welfare of a child in her care. She considered it highly likely that Grace was suffering from MSBP, but said that she did not feel that she could make this diagnosis in a report for the court.

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I was requested to assess the risk which Grace posed to Harriet in the light of the occurrence of non-accidental injuries for which both parents denied responsibility. I was aware that the psychiatric opinion was that the injuries were highly likely to have been perpetrated by the mother and that her presentation was of a woman with long-standing psychological difficulties in self-esteem and self-expression. The psychiatrist had also concluded that there was no evidence of formal mental illness or personality disorder in the husband. The parents’ understanding of child development appeared relatively sophisticated and Grace had been described by her husband as ‘an ideal mother’. There was a history of sexual difficulties in the marital relationship, dating back to Grace’s pregnancy with Harriet, who was their first child. Her husband said that he had been ‘delighted’ to learn that Grace was expecting a girl, as he came from a family of three boys; Grace had said she didn’t mind what the baby’s sex was. Harriet had been born four weeks early and her delivery, by Caesarean section, had not been easy. Grace had been looking forward to a natural birth but was diagnosed with placenta praevia at 36 weeks. Harriet had weighed 5 Ibs 1 oz when she was born and had developed jaundice, which had required photo therapy. Grace described the sense of loss and worry that Harriet’s removal from her care to be placed under lights had generated, and her fear that the jaundice reflected a serious liver condition rather than simply a common and easily treated complication of preterm birth. Harriet was slow to gain weight and Grace said that she had also worried about this, particularly as she felt upset that she was not breastfeeding her. She talked knowledgeably about Harriet’s ‘failure to thrive’ and how this had changed when solid food was introduced into her diet at four months. For the first few weeks of Harriet’s life Grace had been low in mood, describing a sense of failure because she had not had a natural birth. She had experienced intense anxiety about Harriet’s survival. She had also not been able to breastfeed her which had been a source of some disappointment to her, particularly as her best friend, who had recently given birth, had described the sense of fulfilment that she had derived through successfully breastfeeding her son. Grace had not been breastfed herself and had found her own mother unsympathetic to her difficulties in feeding Harriet. Despite her acknowledgement of the anxiety and disappointment surrounding Harriet’s birth Grace was adamant that her relationship with her baby was good and that Harriet was a ‘good baby’ who rarely cried. This was contradicted by her husband who described his difficulty in functioning at work because of the baby’s frequent waking and prolonged crying fits, particularly when she was aged around eight weeks and he had taken on a challenging project at work. He was an insurance broker and had recently been promoted to a senior position at his firm. He reported that although Grace had ‘not been herself’ for the first three months of Harriet’s life she had ‘taken to motherhood’ and been ‘brilliant with her’ ever since. At ten months Harriet had just begun to crawl; Grace described how she had no conception of danger and would put wire flexes into her mouth. She appeared somewhat nervous about the increased mobility of her child and the sense that she might not be able to prevent Harriet from coming to harm. As medical examination progressed it became evident both that the fractures were non-accidental in origin and that the child had suffered multiple injuries over the past few weeks, as revealed through the X-rays. Although the rash around the eyes was not fully explicable, it was possible that the infant had developed this as the result of strangulation

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attempts. This would also explain her reported breathing difficulties, which had not been observed on medical examination, nor had an organic basis which could be identified. The unanimous medical opinion of four different paediatric specialists was that the injuries were perpetrated by an adult and were nonaccidental. The breathing difficulties could not clearly be diagnosed or explained and there was some suggestion that either the symptoms had been fabricated altogether or that the difficulties were the result of strangulation attempts by one of Harriet’s adult carers. The balance of probability pointed to the mother as the likely perpetrator; the father was away at the time that Harriet had been brought to the surgery with the bruising to the eyes and reported breathing problems. The child psychiatrist, the paediatrician and I were aware that in cases of MSBP or FII the perpetrator is almost always the mother. We considered it important to bear this hypothesis in mind. Although a police surgeon examined Harriet and considered the injuries to be non-accidental, the police did not consider there to be sufficient evidence for charges to be made against either Grace or her husband for assault or cruelty. I assessed Grace in order to determine the extent of the long-standing psychological difficulties alluded to by the psychiatrist who had examined her, and to evaluate risk factors in her parenting capacity. She presented as an articulate, attractive and intelligent woman who spoke in a soft, flat voice as she described her unresolved worries about the health of her child and her sense of confusion about how she could have come to sustain serious injuries. She stated that Harriet must have twisted her arm while rolling over in her cot, and that the other injuries could have been sustained when she caught her leg in the cot bar. She was aware that these explanations had been considered improbable and were inconsistent with the medical evidence, but did not appear to be troubled about this discrepancy, repeating that she had never harmed the child. There was a bruise to Harriet’s face which appeared to be a cut, scratch or abrasion. The police surgeon had suggested that this could have been caused by either a hard smack on the face or a gag which had been tied around the baby’s mouth and had cut into her skin. Grace rejected these explanations and maintained that any facial bruises had been caused by Harriet banging her head into the cot bars accidentally. She stated that she herself had pointed out the bruises to the examining physician because of her concern. Although her self-reported behaviour suggested that she was vigilant and concerned about the health and welfare of her daughter, she had only limited recognition of the serious worries about her own psychological vulnerabilities and wholly denied the possibility, as expressed by medical experts, that she had perpetrated the injuries herself. She appeared rather calm and distant and did not seem to have engaged fully with the professionals involved, including myself. She was pleasant and co-operative but described her apprehension and unhappiness about undergoing a psychological assessment. Although she seemed candid in her description of the tensions within her marital relationship and her sense of abandonment when her husband left for business trips, there was no acknowledgement that she required help herself in order to cope with her feelings of inadequacy and distress. When I offered a referral for psychological counselling she rejected this suggestion outright, saying that she had no difficulties other than her worries about her ill child, who she felt was not receiving appropriate medical attention. She repeatedly asked for explanations regarding the organic cause of Harriet’s breathing difficulties. Grace frequently flushed during the interviews and she conveyed

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an impression of being an injured party, who herself felt assaulted by the intrusive nature of the care proceedings assessments. Grace had experienced great difficulty in separating from her own parents, having been a clingy child who had found it hard to socialise with her own peer group. It seemed to be that profound difficulties arising from separation were reactivated in her relationship with her daughter. Grace had left home at 16 to live with her first boyfriend, Mick, whom she had later married. Her descriptions of herself and her daughter suggested that she saw Harriet as being very like herself, and had an inadequate sense of differentiation from her. The enforced separation when Harriet was only two days old and needed to be placed under lights to treat her jaundice, the failure to breastfeed and the removal of the baby from her womb under Caesarean section were all events which appeared highly disturbing to Grace, who had viewed her baby as an extension of herself rather than a separate and ultimately autonomous individual. She had been pleased after all to have a girl, whom she described as ‘just like me’. The early separations and difficulty in breastfeeding were distressing experiences for her, which she acknowledged, but she was unable to see any relevance in terms of the immediate consequences for her relationship with Harriet, or to discuss the features in her own background which had affected the development of her sense of identity. Grace indicated that there had been strict physical punishment in her own childhood but felt that she wanted to ‘put it behind her’ and focus on the future. Her own mother had been a strict woman who had brought up all five of the children on her own, as the father had left the family when the youngest child was eight months old. Grace described herself as having been a sickly child who had received little attention at home except during her periods of acute illness when she would enjoy the comfort and care of her usually busy and preoccupied mother. She described these occasions as the times when she felt most cared for and loved, and said that she had sometimes even exaggerated her symptoms in order to prolong her special status in the sick role. Investigation of her medical history revealed that her own mother had presented her to hospital on at least six occasions during her childhood, requesting urgent medical investigation for acute stomach pains and, on one occasion, breathing difficulties. Despite repeated investigation no medical explanation or diagnoses for Grace’s conditions had been forthcoming. The professionals had doubts about how to establish the cause of the injuries and considered the option of covert video surveillance in order to determine whether Grace was harming Harriet directly. It was decided not to pursue this option at the present time but to bear it in mind for the future, in the event that Harriet remained in Grace’s care and received further injury. The child psychiatrist, the paediatrician and I remained of the opinion that Grace had harmed Harriet. Throughout the duration of care proceedings, Grace and Mick had continued to deny responsibility for the injuries to Harriet who was placed with a paternal aunt under a full care order. She was, however, eventually returned to her parents’ care, despite serious concerns expressed by the medical experts and myself. The social worker and guardian ad litem in the case did not consider Grace to pose a risk to her daughter and felt that rehabilitation was the most desirable option, fulfilling certain conditions specified in the Children Act in that Harriet would be cared for by her natural parents. The care plan prepared by the local authority outlined conditions to be met by the parents to ensure Harriet’s safety: these included attendance at a marital guidance clinic, regular meetings

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with the social worker, Harriet to attend a local authority nursery full time, and attendance at regular reviews at the nursery in which their parenting skills could be assessed. Mick had also changed jobs to enable him to be at home more and help Grace with the childcare. One year after the care proceedings case had been closed Mick reported to his GP that he had, on one occasion before Harriet’s removal from the household, seen Grace place her hands around Harriet’s neck in what appeared to be a strangulation attempt but he had screamed at her to stop and she had. He had not disclosed this at the time because he had not wanted to prevent his beloved daughter from returning home, but had internally vowed to supervise the situation closely, and had felt guilty about his deception. He had presented to his GP with insomnia and it became clear that his anxiety about the significance of what he had witnessed played an important part in his sleep disturbance. Although the GP alerted the social services about this disclosure and requested a re-examination of Grace, the case was not reopened as Harriet did not present with evidence of any further injuries or difficulties. Grace denied that this incident had occurred and thought that Mick had been under stress, which resulted in his imagination playing tricks on him. This appeared to be an attempt to undermine him, but his statement, though less eloquent than hers, rang true in the light of the suspicions of the childcare professionals about her culpability.

Discussion Despite the clear parallels between Grace’s childhood experience of emotional deprivation, presentation at hospital for urgent medical interventions, the attention her mother had given her when she was ill, and what appeared to be her fabrication of symptoms and the production of injuries in her own daughter, with whom she strongly identified, these links were not consciously accessible to her. She acted out her psychological difficulties, with little capacity to verbalise her distress, and had only limited understanding of the physical and emotional needs of her daughter. She appeared to be presenting her daughter at the surgery to elicit the help and attention of the medical professionals, seeming to mirror the only form of maternal attention that she had experienced in her own childhood. Her method of coping with and defending against psychological distress was to split off her good and bad feelings. This was clearly reflected in her dual role as aggressor towards her child and apparent protector of her, the caring mother who brought her to the attention of the emergency services. The attention on her child satisfied a need in her to be cared for and responded to. It was possible that this frustrated and confined woman, whose husband placed harsh restrictions on her freedom, enjoyed the involvement with the team of medical experts, who would consult her about the aetiology and manifestation of the symptoms. In this setting she could be important and involved. Grace’s flight from the possibility of treatment and consistent denial of her involvement in the creation and fabrication of Harriet’s injuries reflected the difficulty of engaging her in psychological work which directly addressed her own problems. It appeared that she relied on an indirect means of getting help for herself and could not articulate her concerns in her own voice. It was possible that she could not actually

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distinguish her infant’s needs from her own because of her distorted perception of herself and her baby, and that she so identified with the helpless and damaged child that she could not recognise the cruelty of her actions or the extent of culpability in endangering Harriet’s life. Her behaviour was undoubtedly dangerous and violent but neither her disturbance nor her fabrication of illness was identified. She had powerfully projected her internal splitting into the team of childcare professionals, who were polarised into those who saw Grace as a danger, and those who viewed her as a competent mother, victimised by the overprotectiveness of the local authority. Eventually the guardian ad litem and the health visitor, who championed the parents, convinced the social worker to draw up a care plan that would result in rehabilitation of Harriet to her parents’ care. The parents readily accepted this care plan. I strongly opposed the plan but was at least able to refer the family to the child and family psychologist who agreed to see them; the child psychiatrist had refused to see them until there was an admission of culpability for the injuries. Clinical interview indicated that Grace had convinced herself that she had not actually produced Harriet’s symptoms through physical injury and through fabrication of symptoms that were never seen by others, as though the power of her need to create this situation also produced a form of dissociation in her. In this emotionally distanced state she seemed to believe that her child was genuinely ill and that she was the concerned and vigilant mother requesting help; the knowledge of her own role in producing symptoms could be denied, allowing her to engage in the drama that she had created. She clearly fitted the typical pattern of behaviour and psychological presentation of a mother who fabricates illness in her child. Grace did not seem aware of the pretence and fantasy of this scenario and had fully entered into the drama. At some level she must have been aware of the lie upon which the medical crisis rested but her powers of dissociation were such that she could keep this knowledge at bay. Grace’s difficulty in linking her past and present behaviour, and her denial of her own role in creating illness in her child, appeared to have different psychological origins. As previously suggested, it appeared to reflect a profound dissociation and capacity to split off the aggressive part of herself. It was also possible that her current role as protective parent, despite the murderousness that she had directed towards the infant, mirrored her own experience of being deceived and mistreated by her own mother whose care had been inconsistent but who had essentially acted the part of the caring mother when Grace was ill, perhaps genuinely believing herself to be one. Grace had herself been subject to a deeply confusing experience of apparent care but actual neglect, within the context of frequently being presented for care at medical settings. Grace may have perceived her mother’s vigilance towards her when ill to be deceptive, in that her concern was only short-lived, in front of a medical audience and directed only towards overt injury and illness. It was not clear whether Grace’s own mother had actively induced symptoms in her or had simply exaggerated her symptoms, possibly using her to express her own somatisation disorder. It was clear that she had been emotionally distant and rather neglectful of Grace except when she was ill, when she would rally to her bedside and take on the role of a devoted mother.

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Relevance of this case to FII in general Close consideration of features of Grace’s background and psychological functioning can help to provide a general understanding of the development of FII. Her own experience of physical abuse in the form of harsh chastisement in childhood, her failure to develop a sense of her own separate identity, and her impoverished relationship with her mother were important factors in the development of her capacity to understand and relate to her own daughter as a separate entity. Research which identifies the importance of attachment difficulties for later personality disorders highlights the centrality of early bonding and the development of essential psychological capacities, such as a sense of self (Fonagy and Target 1999). The intergenerational transmission of such difficulties has also been well described in relation to early disorders of attachment. Jones et al. (2000) also identify attachment disturbances between parent and child as one of the key factors in the development of what they term ‘MSBP abuse’, citing other factors including illness or illness behaviour in the fabricator’s childhood, somatisation in her adolescence, capacity for dissociation, personality disorders, self-harm, somatisation to self, foetal MSBP abuse and postnatal depression as other important aspects of the development of this disorder. Grace was split off from the part of herself that could function as a caring and protective mother and seemed to have projected this caring and thinking part of herself into others, specifically into the parental figures of the medical professionals. Having distanced herself from this good object she then had to gain access to it, which she achieved through generating and fabricating physical ailments in her child, with whom she strongly identified. She could then present her child and herself to the medical services and would alternately identify with the injured and deprived baby, whose needs must be taken seriously, and with the competent adults who could diagnose and treat these injuries. Although part of her wanted to be like the adults who could meet the needs of the child, another part of her wanted to be distant from them, to retain secret knowledge that made their efforts ridiculous. Her hostility was born out of unmet dependency needs. There was an element of aggression in what appeared to be Grace’s deceit in relation to the injuries. Meadow (1977) and Adshead (1997) describe the thrill FII mothers derive from tricking the professionals. Grace’s motivations appeared more complex and ambivalent than this; she appeared to have convinced herself that there was an organic cause of Harriet’s illness. Her psychological manoeuvres, as she operated both as vigilant semi-professional and as destructive saboteur, seemed to occur at an unconscious level and to meet profound psychic needs, involving a great deal of self and other deception. The elements of splitting, dissociation, somatisation, lack of differentiation between herself and her child and failure to distinguish between fantasy and reality were evident in Grace’s complex presentation. Her intelligence, motivated by her underlying disturbance, enabled her to engineer situations in which she could appear as saviour, although in fact she was the perpetrator of injury. At an unconscious level Grace was requesting recognition of the reality of her own despair and deprivation.

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Clinical response: denial of female violence A psychodynamic formulation of Grace’s behaviour highlights her unconscious request to be caught and ‘found out’, to escape from the compulsive cycle of her perverse behaviour. The response of the professionals included the splitting of the experts into those who considered the mother to be a risk to her daughter and those who refused to accept or recognise the extent of her violence. Grace’s apparent competence and the commonly held belief in the natural tendency of women to be caring mothers, with protective maternal instincts, were two crucial factors which prevented the truth from being seen in this case. That an articulate, attractive and apparently co-operative woman could also be someone who systematically abused her child to fabricate and induce illness was too threatening and unfamiliar a notion to be easily understood and accepted. Only the medical and psychological professionals who had seen the mother for a limited number of assessment sessions could hold this possibility in mind, while those who had more direct and long-term contact with her became much more fixed in their views about which one or other of these aspects of the same woman was her ‘true self’. It became impossible for those involved with Grace to retain a sense of her ambivalence towards her daughter and her powerful internal conflict. She seemed to polarise the professionals, reflecting her internal, psychic splits. There was no real possibility of an integrated team view of her, at least initially, because Grace’s intrapsychic split was dramati-cally mirrored in the attitudes and beliefs of the professionals involved in the case. Despite the overwhelming medical evidence stating that the injuries were likely to have been non-accidental and perpetrated by the mother and the opinion that she had fabricated some of the baby’s symptoms, particularly in relation to breathing difficulties, the local authority was determined to rehabilitate the child to her parents’ care. Neither the father nor the mother admitted any responsibility for the injuries and both remained adamant that Grace was an exceptionally competent mother. My recommendation was that rehabilitation should begin only once an acceptable explanation for the injuries and alleged breathing difficulties had been forthcoming: this was ignored. The clear voice of the psychological and medical experts was silenced, evoking the image of the gagged baby whose cries were unheard because she was not even allowed the freedom to cry. This silencing in the face of apparent child abuse reflected both the seductive and convincing power of this dissociated, split-off and disturbed mother and a profound denial by other involved professionals of female violence in general, and particularly in the case of an articulate and attractive young woman in an apparently stable marriage. In understanding how to identify and treat mothers who fabricate and induce illness in children it is important to be aware of the intense countertransference responses which such women evoke in those involved in the case. There is a powerful dynamic in operation in which the professionals may be silenced so that all potentially vigilant carers become like the helpless child whose cries will not be responded to. In this sense the professionals become impotent and negligent. In this complex abuse, the mother is able to rid herself of the experience of being let down and lied to by setting up a situation where her infant (part of herself) is brought for help but where the true source of danger is disguised and the apparent protector is actually the persecutor. Those who might actually be able to help, the medical professionals, are sabotaged in their attempts and so

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share the experience of being useless, humiliated and impotent. This powerfully illustrates the psychic defence of projective identification. The single source of hope in this disturbing and confusing situation is that through the presentation of the damaged infant at the surgery the mothers are effectively bringing into the public domain the evidence of private abuse and betrayal which often characterises their own backgrounds. They are alerting professionals that they are in danger of continuing this pattern by reenacting it. In this sense FII creates a situation in which an individual adult’s distress and abuse is made public through the presentation of an apparently ill or damaged child for medical attention. The use of a child’s body as a medium of communication is clearly perverse. Maternal perversion: failure of differentiation In the case described it was significant that the onset of the injuries coincided with Harriet’s increased mobility, expressing in concrete terms her increasing independence from her mother. Grace’s difficulty in differentiating between herself and her child, and in finding separation so threatening and potentially unmanageable, became particularly intense as her baby began to crawl. Abusive mothers characteristically experience serious difficulties in separation and individuation, both in terms of their own relationships with their mothers and with their daughters. Grace found it intolerable that her infant could now, physically at least, move away from her. The earlier experiences of unexpected separation from Harriet, and disrupted bonding with her, may have been painfully evoked by this development. Indeed, the act of injuring the child directly, or fabricating symptoms of her illness, which appeared to be the case in terms of the inexplicable breathing difficulties, may have been Grace’s attempt to assert her authority over her child and make a bid for her body. It expressed hostility towards her daughter’s physical and emotional separateness and an attempt to merge the boundaries between herself and her child, whom she considered to be part of herself. When the female child is targeted in cases of FII there is a clear illustration of the underlying psychological process of identification between mother and child, and a failure to recognise and negotiate the fact of separation and differentiation. The calling in of the third party, the medical professionals, to protect the child may be an unconscious recognition of the need for intervention and a symbolic attempt to enlist the help and protection of the absent father. Despite the danger and despair evident in FII it nonetheless represents a solution, though maladaptive and destructive, to a problem: the mother does not know how to relate to or protect her infant from her own murderous fantasies about her. This formulation does not deny the mother’s capacity for violence against her child, who, like herself, is viewed as the appropriate target for injury and revenge, and one of the only provinces of power and control for her. Nonetheless, there is ambivalence in the enactment of these murderous fantasies and an unconscious request for containment, understanding and control. The element of secrecy takes its excitement and power from the fear of discovery as well as the unconscious desire for such discovery, and the possibility of recognition and understanding. This may be masked even to the abusive mother herself, who, when confronted with reality, may deny her role in creating and fabricating symptoms in her child. Her massive self-deception serves to protect her from recognising the violence of her own actions.

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Criteria for distinguishing FII The differential diagnosis A central difficulty for professionals involved in child protection cases or working with suspected perpetrators of physical injury towards children is the complicated clinical picture which FII presents, and the complexity of its identification, with reference both to the child’s medical conditions and the mother’s presentation. There is a sense in which this is analogous to the finding that sexual abuse has occurred in a child in that the child’s injuries, both psychological and physical, are subject to scrutiny, and on occasion the mind of the alleged perpetrator may also be examined for evidence of paedophilic tendencies. FII has the advantage over MSBP of creating a ‘stand-alone’ status for symptoms of FII, without necessarily referring to the mind of the perpetrator. This enables the injuries to the child to be seen for what they are, independently of scrutiny of the mother’s profile, although later this may become an important focus for investigation. Consideration of the clinical presentation of the mother requires the involvement of professionals skilled in the evaluation of psychological difficulties in adults. The medical evidence may subtly shift from attention to the abuse suffered by the child to the psychological ‘illness’ experienced by the mother, which may reflect a tendency to pathologise and excuse female violence and to view maternal abuse as a product of illness rather than as aggression. By shifting from diagnosis of MSBP to identification of FII there is some movement away from psychiatric pathology towards criminal and moral agency on the part of the mother. However, the psychological disturbance of mothers who perpetrate FII can be profound, and requires understanding, prevention and treatment rather than punishment. There are many difficulties inherent in identifying a case of FII, and the need for corroborative and independent evidence is of paramount importance. At a practical level the detection of FII is notoriously difficult and the risk of false diagnosis and overlooking a ‘genuine’ or organic illness in the child is great. There is an additional problem in that the secrecy of the maternal abuse means that covert techniques may need to be used to uncover it, which generates ethical as well as technical difficulties for practitioners. A full understanding of the perverse and destructive dynamics inherent in FII may lead to enforced separation of mother and child, which, although apparently cruel, may actually be essential in ensuring the child’s physical and psychic survival. At one level the mother, aware of her own limitations, may symbolically be asking for the care of the child to be taken from her, to protect the child from her own murderous impulses. Meadow poignantly describes a case of MSBP in which a mother had given her child toxic doses of salt, resulting in the child’s death. A necropsy revealed mild gastric erosions indicating chemical ingestion. The mother learned of the results of this investigation, wrote to the doctors, thanked them for their care and then attempted suicide (Meadow 1977). The link between her homicidal and suicidal urges was explicit. She had first made murderous attacks on her child and then turned this rage on to herself, attempting suicide. The confusion in the mother’s mind between herself and her child is clear in the sequence of events. An alternative explanation for her behaviour would be that the mother had not really intended that the child should die, but hoped that she would stay alive, allowing the deceptive game to continue. When the child died the pretence

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could not continue and the psychic functions that it had served for the mother were removed; at this point she became seriously depressed, finding her own life unbearable. The death of the child may also have forced her to confront the reality of her own aggressive impulses. The subsequent guilt might have triggered her desire to kill herself in an act of remorse, coupled with grief. It is also possible that the mother became suicidal because she was ‘discovered’, i.e. her poisoning of her child was revealed in the post-mortem. This case illustrates the strong link between suicidal and homicidal urges in mothers who fabricate or induce illness in their children.

Management of FII The identification of this disorder should alert the physician to contact the appropriate agencies so that child protection measures can be put in place. These can include the removal of the child from the parent’s home and possible long-term provision for care, psychiatric assessment of and treatment for the child, and consolidation of the child’s medical care with one medical centre, which should be fully aware of the history of the medical presentation. The somatising mother often ‘doctor shops’ until medical intervention is obtained for the child, and the fact that this disorder is often associated with fatal maltreatment must be borne in mind by the relevant agencies. It is for this reason that attempts should be made to confine the child’s medical care to one agency or centre, which is fully aware of the nature of the maternal disturbance and the possible implications for the child of her disorder. The practical problems of detection, treatment and prognosis of MSBP are addressed in Munchausen Syndrome by Proxy Abuse (Eminson and Postlethwaite 2000), a comprehensive guide which goes into considerable detail in these areas. The legal and therapeutic aspects of these cases are dealt with sensitively and clearly, outlining those issues most relevant to practitioners and clinicians attempting to engage victims and perpetrators of FII. This important text outlines the developmental pathways leading to FII abuse, although it should be noted that there is not a unitary pathway towards this form of abuse.

Treatment considerations and prognosis for FII victims and perpetrators Is there any point in recommending psychological treatment for someone who has fabricated or induced illness in their child in the face of denial of responsibility for injuries? If treatment is considered, should it be individual, family based or treatment of the couple? What theoretical perspective is most effective in the treatment of perpetrators of FII? Can a mother who has fabricated or induced illness in her child be helped to relate to her daughter as a separate entity? One of the dimensions considered to be prognostic for treatment in the report by the Royal College of Paediatrics and Child Health (2002) is the capacity of mother to distinguish her child’s need from her own. These are crucial questions for child protection specialists to address. The Department of Health (2001) document,

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Safeguarding Children in Whom Illness has been Induced or Fabricated, highlights the need for multi-agency working and describes the long-term effects on children who have been abused in this way: Fabrication of illness may not necessarily result in the child experiencing physical harm. Where children have not suffered physical harm, there may still be concern about them suffering emotional harm…Children may also suffer emotional harm as a result of an abnormal relationship with their mother (if she is responsible for the abuse) and their disturbed family relationships. (DH 2001:15) The authors note that although the father may not have been the active perpetrator of abuse, their awareness of what mothers were doing to the children places them in a culpable position too, and reveals the extent of disturbance in the family system. Furthermore, children who are abused in this way can sometimes develop severe health anxieties or forms of self-harm, continuing to display strong attachment to the mothers who abused them, as well as considerable confusion, in that the abuse began when they were too young to understand it and was concealed from the outside world; they were falsely viewed as well-loved, if ill, children. This confusion, characteristic of children who have been abused by trusted carers, can leave them feeling angry and betrayed by medical and other health professionals in adulthood. Outcome for children in whom illness has been fabricated or induced A follow-up study of 54 children who were known to have had illness induced or fabricated (Bools et al. 1994) found a range of emotional and behavioural disorders, and school-related problems including difficulties in attention and concentration and non-attendance. These difficulties were present both in children who were living with their abusing parent and those who had been placed with alternative carers, suggesting the need for treatment regimes which specifically address the child’s ongoing needs throughout childhood. McGuire and Feldman (1989) also reported a range of disorders in children known to have had illness fabricated or induced, depending on the age of the child; feeding disorders in infants, withdrawal and hyperactivity in preschool children and direct fabrication or exaggeration of physical symptoms by older children and adolescents. One of the most important factors in the accurate and early detection of FII is the recognition by professionals that maternal violence exists and that it can occur even where there is apparent maternal competence. In conducting accurate risk assessment it is essential that involved professionals gather as much information as possible in order to generate a comprehensive understanding of the factors which led to the mother abusing her child in a particular way. This task may be more difficult in cases of FII in that some women will never admit that they have deliberately produced or fabricated symptoms in their children; hence the justification for the use of covert video surveillance techniques (Cordess 1998). It is important that professionals retain an objective view about the

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probable cause of the injuries and do not allow sentimental and idealised views of motherhood to affect their judgement and allow a child to continue to be at serious risk. Some childcare experts argue that rehabilitation of a child to the home in which abuse has occurred can only be instituted in cases where acceptable explanations for non-accidental injuries have been given (Weiner 1998). Others argue that only through engaging the family in treatment can denial be challenged and shifted and that to disrupt the bonds between a child and her family is to do harm to the entire family. Denial has been recognised as a major obstacle to therapeutic change in families where abuse has occurred. Trowell (1997) suggests that if greater levels of confidentiality existed in relation to child abuse, the problem of denial could be reduced and more families successfully engaged in treatment; such therapeutic alliance could potentially reduce the risk of re-abuse and enable families to stay together. This risk assessment can be undertaken when the child has been removed from the abusive situation, according to procedures determined by a child protection conference, which would be convened to bring together the relevant professional groups required to conduct such an evaluation, and ultimately construct a childcare plan in which risk of future harm was minimised. Berg and Jones (1999) were able to follow up a small number of families in which FII was identified. Ten of the 13 families for whom treatment had been possible were reunited following the child and family intervention. They found: Overall, the children had done well in terms of their development, growth and psychological adjustment…Berg and Jones (1999) cautiously conclude that family reunification is feasible for a subgroup of these cases, but only where there can be long-term follow-up involving continuing health monitoring, social casework, and psychological treatment. (Jones et al 2000:293) Whether or not treatment and rehabilitation are indicated in the face of consistent denial of abuse is a complex issue. Individual factors in the case, including the nature of the abuse inflicted and the demonstrated level of co-operation by the parents, appear to be the key elements in determining outcomes for abused children. In cases of maternal abuse the threshold for removing children from their mother’s care is higher than in cases where a male has been the perpetrator of abuse. The role of the mother as nurturing and caring appears to be so entrenched in social perceptions and expectations that it persists even in the face of stark evidence that she can be deceptive, violent and dangerous to her own offspring. Livingston (1987) describes the problems in treating abusing parents if they have somatisation disorder and therefore require regular supervision and management by a primary care physician and notes that individuals who have been identified as MSBP mothers, with or without somatisation disorder, are likely to be resistant to psychotherapy. Important factors to consider when determining treatment include the duration and medical severity of the abuse, ‘whether acknowledged or denied by the parent, and the extent to which features of sociopathy are present’ (Livingston 1987:214). He argues that a psychodynamic formulation of the basis of the abuse is also potentially helpful; such possible formulations as cited in the literature include respite from

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parenting responsibilities, vicarious receipt of caregiving and ‘symbolic re-creation of a previous loss’. It is clear in such cases that the mother’s sense of identity may be fragile and the boundaries between her and her child blurred. Livingston notes: ‘In any case, the first priority in treatment should be protection of the child’ (1987:214).

Psychotherapy with mothers who have fabricated or induced illness The work of the Cassel Hospital, a therapeutic community in Richmond, Surrey, provides a unique opportunity to engage violent and sexually abusive families in psychotherapy over an extended period of time, and to assess the capacity of these families to care for children and respond to treatment. Coombe (1995) describes successful treatment of a mother with FII to the point where her child remained in her care following discharge from the Cassel Hospital. Kennedy describes the history of the work at the Cassel Hospital with mothers with postnatal depression in the 1950s and the development of treatment of families in which children were identified with FII: At times, the children were seen as objects to be used by the others for mere comfort for themselves. The mothers who completed the treatment programme revealed powerful and primitive aggressive fantasies, centred around both their own bodies and their children, possibly related to their own childhood experiences of being abused. At times they were close to collapse and disintegration, and needed considerable amounts of help and support of the kind which seems able to be provided only in an in-patient setting…Treatment was prolonged in two of these [three cases] requiring nearly two years before the families were considered safe enough to return to their communities…Crucial to change was the capacity of the parents, particularly the mothers, both to face their own destructive feelings and to experience feelings of dependency, towards both staff and other people, without collapsing. (Kennedy 1997:126) Forensic psychotherapy, as well as the individual and family therapy approaches used at the Cassel Hospital, offers a framework for understanding FII and a treatment approach for the mother to help her recognise her underlying difficulties. A psychodynamic treatment of the mother can address the aggressive and deprived child within; facilitating recognition of this neglected and destructive aspect can help her to function in a maternal capacity and gain a sense of her child as a separate entity.

Conclusion The concept of MSBP retains some utility, although its diagnostic validity remains questionable. It is still an important description of a form of maternal behaviour in which the needs of a mother are met through her use, and abuse, of her child. The term ‘diagnosis’ is less helpful than the concept of a type of harmful behaviour on a continuum

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of other disturbed ways of relating to and abusing children. The essence of this form of child abuse and its association with various motivations in the mind of the perpetrator has been preserved in the term ‘fabricated or induced illness’. Nonetheless there may be some clinical utility in retaining the notion of a particular disturbance of mind in the mother while discarding its jurisdictional use in court. Even when the terms have been redefined, the close interconnection between the child’s body and the mother’s internal damage remains a central feature of this type of abuse. Psychological understanding of maternal motivation should be comprehensive and recognise aggressive impulses in mothers towards their own children. It has been objected that such an understanding may actually be abused to distort the truth, to exonerate the abuser by minimising her aggression and portraying her as a victim. This accusation rests, to some extent, on the false dichotomy in which victims and abusers are seen as mutually exclusive. This objection does raise an important issue about the possibility that an overemphasis on a mother’s or carer’s psychological vulnerability can shift attention away from her aggression and potential dangerousness. A psychological model that emphasises the link between aggression and victimisation will make these connections explicit and explain how it is that damaged and depressed women can pose a risk to children, moving from victim to victimiser. This model may well meet with resistance, in part because of the strength of idealisations of motherhood. The denial of female violence is evident in the ready acceptance of psychological disturbance in women to the point where their culpability and aggression are overlooked. It is essential to bear in mind that the mother is a perpetrator of abuse who, because of her own psychological disturbance or unmet needs, has either fabricated the symptoms or perpetrated injuries to induce illness according to her own internal script. Attempts should be made to uncover the nature of this internal narrative in order to protect the child and help the mother, if there is to be a possibility of the child remaining in her mother’s care. In order for child protection to be effective it is essential to recognise the possibility of female abuse. As Welldon notes: ‘It has been extremely difficult for society to acknowledge that women can sexually or otherwise abuse their children, and this has left children unprotected’ (1996:177); this denial and ‘conspiracy of silence’ also spreads to professionals. There is a dramatic element to the FII scenario in which the mother becomes a highly significant and valued person on the ward, where her concerns and the health of her child are taken seriously. The ward becomes the theatre where her own unresolved emotional dramas are played out and her child, in this situation, becomes a means to an end. FII has strong parallels with self-harm, in which psychic conflicts are literally embodied and fought out on the flesh. In FII the child’s body is used as the mother’s own, and her violence is directed against herself as well as her child. Her thinking is concrete and just as she somatises her own psychological pain she also projects this on to her child, either in fantasy (fabricating symptoms) or through physical violence, overstepping the body barrier and inducing illness in her child. In order to understand this and other forms of child abuse it is necessary to consider and elaborate the symbolic function of these acts and the meaning of this performance for the mother. The communicative function of maternal physical abuse can sometimes be elucidated by reflecting on the institutional response to suspected abuse. The mother’s psychic conflicts may be mirrored in the divisions within the team, who may fail to

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recognise opposing aspects of her personality. When even the possibility of abuse cannot be entertained by child protection specialists and other professionals, a dangerous situation may be allowed to continue. At times, only the existence of video evidence can bring to light this perverse and dangerous abuse; I suggest that the invasion of privacy produced by the use of covert surveillance, while undoubtedly fraught with ethical considerations, is a lesser evil than potentially fatal maltreatment of a child. The guidelines provided in Safeguarding Children in Whom Illness is Fabricated or Induced (DH 2001) are clear about the use of covert surveillance with reference to the Regulation of Investigatory Powers Act 2000, to ensure that investigatory powers are used in accordance with human rights. These powers include the use of covert surveillance such as video surveillance, in the course of specific operations. In FII there should already be strong suspicion about the possibility of abuse before such a move is undertaken because of the ethical concerns. Ultimately, however, the capacity to suspend idealised notions of motherhood and femininity and think the unthinkable is far more important than the use of such technology to obtain evidence.

Chapter 5 Infanticide What is required is not to look away, but to communicate with and learn from these mothers. The great promise of understanding them better will play out in an incalculable number of saved lives. (Spinelli 2004:1555)

Violating those taboos held most sacred, infanticide is a crime that bewilders and appals both the general public and mental health professionals. The attributes conventionally assigned to motherhood are grotesquely distorted in this crime. The twin taboos of child killing and female violence are irrevocably interwoven in this offence. The public imagination feeds on tales of infanticide, devouring the details with disbelief and fascination. Infanticide is a crime which can only be committed by women, as the law does not recognise paternal killing of a child under the age of one as an instance of infanticide. Infanticide is a rare crime according to the recorded crime statistics. One possible reason for this is that crimes of neonaticide (killing a newborn within the first 24 hours of life) are often undetected. In such cases an infant is killed by young women whom people may not even have known were pregnant (Meyer and Oberman 2001). There were two recorded cases of infanticide in the UK in 2001 and eight in 1999, of whom seven were subsequently found guilty of infanticide (Home Office 2003, 2004). In the period between 1983 and 1993 the greatest number of convictions was in 1988, when eight women were found guilty of infanticide, of whom seven received a probation order (Home Office 1998). Analysis of criminal statistics suggests that most cases of maternal killing of infants under a year old in the UK are dealt with under the Infanticide Act and that the perpetrators usually have their charges dropped from murder to manslaughter on grounds of diminished responsibility (Bluglass 1990). While a proportion of such crimes is committed by women suffering from severe mental illness, many are committed by women who have not received psychiatric diagnoses and who have different reasons for killing their children, including fear of social shame, and in some cases did not intend to kill their child at all. Indeed, a proportion of the cases of maternal infanticide are the result of negligence or child battering, as discussed in Chapter 3 on physical abuse, where mothers did not consciously intend to kill their babies. Women who kill their own children may be afforded some sympathy if it is clear that they have themselves suffered through their behaviour, but less so if there is an element of revenge or retribution. Women who kill other people’s children are generally perceived to be evil. Even when women are clearly mentally ill, as in the recent case of Andrea Yates in Texas, who killed all five of her children, the taboo of maternal killing may prevent understanding. Yates is now serving a life sentence for what was without

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question the act of a profoundly mentally ill person (Spinelli 2004) because of the failure of the law in the USA to recognise the crime of infanticide. Spinelli, a forensic psychiatrist, describes the public response to such crimes: Maternal infanticide, or the murder of a child in the first year of life by its mother, is a subject both compelling and repulsive. The killing of an innocent elicits sorrow, anger and horror. It is a crime. It demands retribution. That is the law. Yet the perpetrator of this act is often a victim too, and that recognition makes for a more paradoxical response. On the one hand is the image of a defenceless infant, killed by the person he or she depended on for survival. On the other hand is the image of a mother, insane and imprisoned for a crime unthinkable to many. (Spinelli 2004:1548) Ironically, in the tragic case of Yates v Texas there were several key risk factors that, if attended to, might well have prevented the multiple filicides that followed. This includes the fact of Yates’s previous history of psychiatric illness, her childbearing history and the fact that she had experienced mental illness in the form of depression, suicidality and psychosis after the birth of each child. For example, after the last two pregnancies she had been admitted to psychiatric hospital on four occasions. Additionally, she had a family history of psychiatric illness and was not offered follow-up and support after her discharge home where she was main carer for her five children, aged between six months and seven years old and her ill elderly father. Throughout this time, Yates was known to the psychiatric services and had experienced her first psychotic episode after the birth of her first child, Noah. She had been living in a converted Greyhound bus and expressing fixed religious beliefs that had a psychotic quality, including the belief that she felt Satan’s presence in her home. At the time of the offence she believed herself to be Satan, yet, because she alerted the police to her actions after the killings she was considered capable of knowing ‘right from wrong’ under the M’Naughten rules and therefore culpable for her actions in the Texan Court of Law. In her excellent analysis of this tragedy, Spinelli (2004) describes the difficulty in identification, treatment and prevention of postpartum illness and infanticidal tendencies in a psychiatric system where post-partum illness is not recognised in a discrete DSM-IV category (APA 1994) and infanticide not conceptualised as a particular kind of crime borne of this illness. I further argue that the conceptual underpinning of this failure to recognise infanticide and post-puerperal illness as a serious risk to children’s health rests in a refusal to believe the destructiveness that mothers are capable of. Sentimental notions of motherhood fuel this dangerous level of denial. In this chapter I address the questions of how women who kill children can be understood and treated. I discuss recent studies relevant to understanding, classifying and preventing infanticide and reviews of the impact of post-partum depressive and psychotic illness on killing The model of understanding female violence described in previous chapters provides a meaningful conceptual framework for understanding how women come to kill their own babies. According to this model, first proposed by Welldon in 1988:

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The main difference between a male and a female perverse action lies in the aim. Whereas in men the act is aimed at an outside part-object, in women it is usually against themselves, either against their own bodies or against objects which they see as their own creations; that is, their babies. In both cases, bodies and babies are treated as part-objects. (Welldon 1994:477)

Perversions of motherhood and the link between homicidal and suicidal feelings ‘Odd though it may sound, motherhood provides an excellent vehicle for some women to exercise perverse and perverting attitudes towards their offspring, and to retaliate against their own mothers’ (Welldon 1992:63). Instead of turning the force of destructive rage on herself, she turns that murderous impulse towards her child, her narcissistic extension. The function of child killing thus mirrors, in fantasy, the function of a suicide. By killing off the bad part of herself, as projected into the child, the mother has relieved herself, temporarily, of the unacceptable aspects of herself which she cannot integrate. She has identified with the helplessness of the child, and found her inability to meet the infant’s needs intolerable. The identification is so unbearable that the situation cannot be allowed to continue. This child murder therefore functions unconsciously as a form of suicide in a situation where a mother feels persecuted by the child. In certain situations that I explore in this chapter the threat occurs not just at a psychic level but has profound social implications for young women. These are often adolescent girls, who fear family and social rejection and harsh censure if their pregnancies are not hidden from view. They then kill the babies resulting from these concealed pregnancies, rather than risk the shame of discovery. For other women the inability to tolerate the baby’s tremendous dependence on her, and demands for her and the memory of her own inability to have her needs met by her mother generate a life or death struggle between mother and child. The infant’s needs are perceived as life-threatening attacks that must be defended against. In the case of ongoing child abuse the object is kept alive to be tortured, in the case of murder it has literally been killed off. The role of hate in fatal child abuse is also highly significant (Brockington 2004) and some acts of infanticide can be motivated by a feeling of uncontrollable hatred towards the baby. Valerie Sinason poignantly describes the hatred and death wishes felt by some mothers towards their learning disabled babies (Sinason 2007). Infanticide presupposes the intent to kill whereas other forms of filicide do not. Death may have been an unintended consequence of abuse, either long-term and sadistic, as in the case of Victoria Climbié discussed in Chapter 3, or a one-off loss of control. An example of the latter would be the death of a baby following an incident of violent shaking, when the mother’s intention was to silence temporarily the screaming infant rather than to kill it. This episode of rage may have been uncharacteristic and borne out of accumulated anger that ultimately could not be tolerated.

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The shock that faced the notion ‘battered baby syndrome’ when it was first discovered by Kempe in the 1960s still has echoes today, and testifies to powerful social resistance to the fact of maternal rage and violence and the potential consequences for children. At some level such recognition may threaten our own sense of safety and faith in the care we received as children, yet, as Bloch (1978) identifies, the fear of infanticide is a universal one that can be uncovered in children’s play and nightmares. Recognising the parental wish for infanticide is even more taboo than accepting children’s fear of being killed. The idea that children universally fear that their parents may kill them is a startling one; yet I have found that it is far more acceptable than the possibility that parents may actually have such a wish’ (Bloch 1978:7). This taboo persists in the face of the harsh reality of family violence. There is evidence that homicide victims under 16 years of age are more likely to be killed by their own parents than strangers: ‘In 2002/03, there was a total of 99 victims under 16 years of age, an increase of 55 per cent on the previous year. Fifty-five of these victims (and 56 per cent of the total) were killed by their parents’ (Home Office 2004). One of the most troubling statistics that can be found in the UK Home Office publication, Crime in England and Wales 2002/2003, is that, as in previous years, those children under one year old were most at risk of homicide at 58 per million population (Home Office 2004). It is clear that infanticide is not just confined to the realm of unconscious wishes.

The nature of female homicide In contrast to other homicide patterns, in which male perpetrators dominate (approximately 88 per cent in the USA), filicide patterns in the USA show equal numbers of mothers and fathers who kill their children (Bureau of Justice Statistics 2001; Lewis and Bunce 2003), demonstrating the characteristic targeting of female violence on to their own children. Children under the age of one have the highest rate of maternal filicide in the USA (Finkelhor and Ormrod 2001). Women who kill are most likely to attack members of their own families, including their partners. About 80 per cent of victims of female homicide are family members; 40–45 per cent kill their children and about one-third kill their spouse or lover (D’Orban 1990). According to a study of homicidal parents by Bourget and Bradford (1990), the sex distribution was as follows: male 30.8 per cent and female 69.2 per cent in a sample of 13 homicidal parents, and in 48 cases of non-parental homicides 81.3 per cent were male and 18.7 per cent female. These data, albeit based on a small sample, suggest that women are more likely to be homicidal parents while men are more likely to be perpetrators of extra-familial murder. The rates of female homicide are much lower than those of male homicide: in 1997 eight women were convicted of murder, compared to 153 men; eight women were convicted of section 2 manslaughter, compared to 32 men; and 19 women were convicted of other manslaughter, compared to 120 men (Home Office 1998). In 2003, 3900 women were found guilty of crimes of violence against the person offences in UK courts, compared to 38,000 men (Home Office 2003).

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Causes of infanticide: the biological argument The notion of biological causes of female madness is perhaps most clearly demonstrated in the theoretical approaches to understanding infanticide. Both psychodynamic and psychiatric models emphasise the ‘disorders of mind’ brought about by childbirth and the resulting chaos and irrationality that ensue. According to the biological model the mother is a vestige into which uncontrollable hormonal forces flow, compelling her to act upon them. There is a tradition of considering that the suppression of the menses gives rise to acts of uncontrollable violence, for which the woman has no responsibility. However, in the case of infanticide by mothers there is strong evidence for the existence of serious post-partum depression and psychosis in some cases, that should be of great assistance in not only identifying mothers at risk of violence towards their children, but also in informing treatment and management that could be crucial in reducing infant fatalities (Spinelli 2004). As there is no Infanticide Act in the USA, women who have killed their children while in post-partum depressions or in psychotic states cannot testify under this defence. This means they may be sentenced to life imprisonment rather than receive the psychiatric treatment they desperately need, as in the case of Andrea Yates. Neonaticide, or the killing of an infant within the first 24 hours of life, is far less associated with mental illness in mothers and more clearly linked to circumstantial and social factors in young girls living at home with parents; it is also linked to hysterical denial of the pregnancy in vulnerable and immature young girls. Psychiatric assessments of women who have committed neonaticide have found links between dissociative states in pregnancy and early childhood abuse and family lives in chaos (Spinelli 2001). Infanticide has been associated with post-partum psychosis, which may be connected to pineal gland activity (Sandyk 1992). This is one possible biological explanation for the ‘disturbance of mind’ required for the charge of infanticide to be levied. Sandyk concedes that the pathophysiology of post-partum depression and psychosis is poorly understood but suggests that the substantial hormonal fluctuations play a significant role. While some evidence exists for the association between the decline in progesterone plasma levels and post-partum depression (Dalton 1971), other studies found no correlation between postpartum depression and levels of luteinising hormone, oestrogen or progesterone (Nott et al. 1976). Recent studies failed to demonstrate associations between post-partum psychosis and thyroid function tests in 30 women hospitalised for post-partum depression (Stewart et al. 1988). Sandyk claims that drastic changes in pineal melatonin secretion during the post-partum period have been observed and concludes that since there is an association between pineal melatonin function and psychotic behaviour, alterations in the activity of the pineal gland are causally related to the genesis of post-partum psychosis. One implication for this hypothesis is that melatonin secretion should be increased in therapeutic management of post-partum psychosis. This would include such measures as exposure to bright light or the administration of oral melatonin. While this biological model has some intuitive appeal, stronger evidence is required for the causal association between falling melatonin levels and the onset of post-partum depression and psychosis. Even if these two factors are correlated, one cannot conclude that one causes the other. Furthermore, psychotic depression is not a precondition for infanticide, particularly in the case of neonaticide. It has been well documented that nonpsychotic depression may give rise to both suicidal and homicidal urges (Campbell and Hale 1991). It is important to recognise women’s vulnerability to hormonal fluctuations

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and the possibility that such biological factors, coupled with other stresses, may for some women result in the onset of severe mental illnesses including post-partum depression and psychosis; post-partum illness can, in turn, increase the risk of infanticide (Spinelli 2004). The role of hormonal factors can be integrated into a formulation that also addresses the meaning and significance of this act for the mother concerned, her social context and the immediate stressors in her life at the time of the offence. The choice of therapeutic intervention appropriate for a particular woman will much depend on close and careful analysis of her psychological and social circumstances at the time of the offence and her current situation. For example, those mothers who were most likely to cause death through prolonged child abuse or a single case of explosive violence against a child are more likely to be personality disordered rather than mentally ill, and may require psychotherapeutic treatment and social support without psychotropic medication, while women suffering from serious mental illness would clearly require both. In the following case illustration, I describe the motivations and treatment of a mentally ill mother who was convicted of infanticide. The links between her suicidal and homicidal urges are evident and the killing of her 11-month-old son can be seen as a symbolic act of suicide. I outline this mother’s own traumatic experiences in childhood and her presentation within the secure unit. Close analysis of this tragic case highlights dynamic processes involved in infanticide and the dual status of the mother as both perpetrator and victim. Case illustration

Dawn, a 28-year-old mother convicted of infanticide Dawn was 28 years old when she was admitted to a regional secure unit following her conviction for infanticide of her 11-month-old son, Gabriel. He had been taken from her care shortly after his birth following Dawn’s frequent admissions to psychiatric hospital for depression since the time of her separation from her husband, when she was four months pregnant and on previous occasions. Dawn had a long history of psychiatric admissions for severe depression and suicide attempts, but had not previously been charged with a violent offence. She had suffocated and strangled Gabriel after making a special request to spend the night with him at his foster parents, after a contact visit which was supposed to have lasted only three hours. She had called the police on the evening of the offence and informed them of her intention to kill Gabriel, saying that she felt certain she would go through with it unless they could find her, but she had telephoned from a pay phone, without leaving her name or any other information about her whereabouts. I saw Dawn for a short period of focused psychotherapy during her time as an inpatient at a regional secure unit. This therapy ended after six months at her request. She had been referred by the consultant psychiatrist; he had serious concerns about whether an understanding of her offence had been achieved in the 18 months since she had been admitted to the unit. Dawn was the only child of a mother who had been diagnosed with psychotic depression, and who had spent long periods of Dawn’s childhood in a psychiatric hospital. She had never known her father. Dawn had been in numerous children’s homes

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throughout her childhood and had vivid memories of waiting anxiously for her mother to visit and reclaim her. In two of these children’s homes she had been sexually abused by other residents and in one of these homes a member of staff had also abused her. She had a history of self-harm and depression. Dawn had planned the offence only on the day it occurred when she had worked out how she would get to spend time with Gabriel on his own. Prior to this visit she had only short periods of unsupervised access to him, but had established a good relationship with the foster parent whom she saw as maternal and warm towards her. The foster mother was later to say that she had been persuaded to allow Dawn the contact with Gabriel because of her insistence that she had missed him terribly over the past three weeks and would find it comforting to sleep in bed with him. The foster mother had pitied her, she said, and had found the image of Dawn returning late at night to a lonely bedsit unbearable. She had, it seemed, become confused about whose needs to protect, and had inadvertently placed Gabriel in mortal danger out of sympathy for Dawn. This response to Dawn’s pathos, which blinkered the foster mother to her violence, was one which characterised Dawn’s relationships, particularly with mother figures. The foster mother had been unaware that Dawn’s estranged husband, Gabriel’s father, had recently petitioned Dawn for a divorce. Dawn described herself as having felt ‘devastated’ and had been furious with him; she reported that the overwhelming sense she had of rejection and abandonment made her feel that she would lose her mind. She felt that this played a central role in the killing and had been aware at some level that she was in terrible danger of doing something awful to get rid of this feeling. She saw Gabriel as intricately connected to his father, and to herself, and became convinced that he should not be allowed to live. She felt that her own life had been destroyed by her husband leaving her, Gabriel being taken into care and, finally, being asked to give her husband a divorce, she felt that she too should die. On the night of the offence she decided that unless the police could find her and provide her with the requisite help she asked for she would kill him. She phoned the police and threatened to kill her son unless they found her and took her for help. In her desperate state of mind she failed to let the police know where she was and then waited for them to arrive, watching her son sleep. When help was not forthcoming she carried through her plan, killing her sleeping son by suffocating him as he lay next to her. She had then informed the foster mother of Gabriel’s death and the police were called. She was reported to be calm and dispassionate during the police interview but to speak of him in the present tense, as though unaware he was actually dead. She appeared dissociated. I tried to focus my work with Dawn on the offence which she found impossible to address. She presented as child-like and dissociated, speaking in the quiet and polite tones of a well brought up little girl, which was in stark contrast to the violence of her offence. Her voice had an unreal, other-worldly quality and her breathy, high-pitched tones, almost whispers, were suggestive of strangulation. She spoke so softly that I strained to hear her and leaned forward to her. This seemed to be an unconscious attempt on her part to bring her carers closer to her, and she appeared to crave some form of physical proximity and contact. Dawn had always felt that she was different and that she didn’t belong. This had been reinforced while growing up. Through her early years of abuse and traumatisation at a strict children’s home, in which she was further taunted because of her peculiar,

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whispering speech, Dawn said that she had learned to stifle her anger, for fear of being ‘told off’. The cheerful and compliant ‘false self personality’ (Winnicott 1964) that she had developed in infancy, to enliven her emotionally withdrawn mother, covered up her feelings of sadness and despair which lay dormant, ready to emerge in a moment of absolute rage and despair. Her pregnancy with Gabriel had been fraught with difficulty. She had found it impossible to visualise the baby inside her as he grew. She suffered similar fears to those of Kate, of being invaded by an alien, as described in Chapter 1. Dawn had found it difficult to separate herself from her own mother psychologically, and could not conceive of herself as capable of mothering. Although she was able to relate the facts of the offence, she could not convey the emotional flavour of the event, or portray her son with any sense that he had a separate identity to her. She seemed to have little capacity for symbolic thinking, illustrating the phenomenon described by Fonagy (1991), Fonagy et al. (1993), Fonagy and Target (1999) as ‘a failure to mentalise’. ‘Both self harm and mindless assaults on others may reflect inadequate capacity to mentalise’ (Fonagy and Target 1999). They trace the development of this failure to a stage in selfdevelopment when the child would be looking for a representation or mirror of her own mental states in her mother or other primary caregiver. When this does not occur the child fails to build up a picture of her own, and hence other people’s, mental states. This failure in the development of symbolic thought relates to reliance on the violent act as ‘an attempt to obliterate intolerable psychic experience’ (Perelberg 1999:5). Dawn could not bear to think about the pain of abandonment; she seemed to have converted this mental despair into bodily action, through a murderous assault on her son, a representative of herself. Her strong identification with Gabriel also seemed to be reflected in her voice, which echoed the voice of the strangled infant whose mother did not allow her to develop a separate existence. Her violent strangulation of Gabriel seemed essentially a concrete reenactment of Dawn’s own infantile experience of murderous rage: she had been symbolically strangled. Her inability to speak clearly, loudly or with any force, coupled with the few occasions of dramatic violence in which she set fire to her room, revealed the essentially split nature of her personality. She disavowed her aggression even to the extent that she repressed any anger or force in her speaking voice. She was aware of the peculiar effect that her little girl’s voice had on others and of the anger that it evoked in staff, who thought she was pretending and ‘manipulative’. In some ways she invited this punitive attitude from them and her behaviour was often provocative. She appeared to be emotionally detached from her offence, presenting herself as a victim of violence and rejection rather than as an aggressor herself. At the moment of the killing Dawn had become enraged by her own abandonment, by her husband, son, and at a deeper level, her own mother. In fantasy she became the abandoned infant whose depressed mother had neglected and rejected her. She projected these feelings on to Gabriel, who became the embodiment of the unwanted, demanding and helpless child. She also saw him as only her possession. She was later able to recollect this thought precisely and dispassionately during the course of therapy. Although she had been diagnosed as psychotic, Dawn was also considered to have clear features of borderline personality disorder.

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For women like Dawn, violence is a powerful means of communication. One motivation for Dawn in killing her child was her anger about being denied help from the emergency services. She had requested such help for herself prior to the offence, phoning the police to report that if she were not apprehended she would kill her son. Unfortunately, she could not be located in time to avert the killing. She created a situation in which she became the indirect victim of the failure by the police to take effective protective action in time, transforming herself from active killer to the passive victim who is deprived of the requisite help, which further fuelled her murderousness. At one level, her telephone call to the police—which placed significant responsibility on to them for potentially saving Gabriel’s life—was a highly sadistic act that placed the police in the role of incompetent witnesses to a murder, which she had led them to believe could have been prevented. The offence served several functions for Dawn: first, through the temporary annihilation of the hated aspects of herself; second, through the fantasised revenge on her mother and actual revenge on her husband; third, to draw her own alienation and despair to the attention of the paternalistic psychiatric and custodial services. It also communicated her symbolic ownership and control of Gabriel. Her request for containment and a ‘place of safety’ was expressed through the infanticide, and tragically it was only through this act that her needs for psychiatric treatment were eventually met. She did not feel able to ask for help in her own strangled voice and needed to gain some sense of power through her capacity for destruction. In the past she had used threats about her own suicidal intentions to gain entry to the psychiatric services. At no time did she express a sense of Gabriel as a separate person from her, and she much related to him as a part object, to be used for her own ends. She experienced being separated from him as an attack on her.

Discussion One of my first thoughts about this tragic case was how difficult it was to get a clear sense of Dawn’s state of mind at the time of the offence, as she appeared both rational and dissociated at the same time. A thorough assessment and formulation identifying key factors in the index offence were necessary to inform the clinical management of Dawn’s care and reduce the risk of future violence and self-harm. In Dawn’s case a significant trigger for her offence was her perception of abandonment. At points in her stay in the regional secure unit, where she felt similarly abandoned, she retaliated against the organisation as a whole, and against particular significant individuals. An example of this occurred when her psychiatrist failed to keep two appointments. Dawn felt rejected by this. On the second occasion she vented her rage against him by attacking her own room, which she set alight. Through this act of arson Dawn was clearly endangering the lives of nursing staff and residents. By identifying the threat of abandonment as a significant trigger for Dawn’s past violence, the analogue situation of abandonment or perceived rejection on the ward could also be identified as a time when the risk of violence would increase. The link between the consultant and other significant abandoning figures in Dawn’s life, such as her mother and her estranged husband, was relevant to anticipating that disappointment in her

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psychiatric treatment could reawaken earlier feelings of murderous anger. Those most significant to Dawn were most at risk of provoking her anger as she invested them with fantastic power. Such figures were inevitably going to disappoint Dawn, confirming her fears about herself which centred around being rejected and hurt by seductive but unreliable people. It was possible that I too became such an object for Dawn, and she ultimately chose to leave me rather than risk being abandoned by me. She had an underlying terror of dependency. Dawn set fire to her room after we had agreed to end, leaving four more sessions. She had started the fire by burning a diary in which she had written about the offence, an entry which she had said that she wanted to read to me in the following session. It was possible that the horror of her offence would be reawakened if she were to continue in the work with me and disclose details of the killing. She seemed to feel that everything she had ever had that was good had been lost and I wondered if she felt that if she were to discuss Gabriel with me she would lose her memory of him, and her sense that he was hers alone. There was a self-protective aspect to Dawn’s resistance to engaging in psychotherapeutic work, in that to do so would be to take the risk of becoming overwhelmed by feelings of grief, despair and guilt. At times she expressed nihilistic feelings, including a sense of suicidal despair. In one sense her homicide was, symbolically, a suicide. She remained at risk of self-harm and often endangered her health and safety, wandering around the grounds with little clothing, becoming a target for sexually predatory male patients and setting fire to her room when she was in it. This expressed both her homicidal and suicidal feelings. It was significant that she burned her own belongings, including her diary, in which she had recounted the offence, illustrating the unbearable nature of the crime that she had committed and her desire to obliterate all evidence of it, both psychologically and physically. The consultant psychiatrist was pessimistic about Dawn’s capacity to survive outside a secure setting and she remained an inpatient, with no real prospect of rehabilitation into the community because there was no evidence of therapeutic change or insight. She never expressed a sense of remorse for her offence to me, or spoke of Gabriel as a real child, with a separate existence; he had served as a receptacle for her murderous projections, and she had annihilated him in a similar way to her assaults on my capacity to think. It was almost as though she couldn’t bear to have any hope, and had to destroy anything that could be hopeful. She seemed disengaged and vacant, adopting the part of an obedient, timid little girl in a way that starkly contrasted with the violence of her behaviour. It was this eerie contrast that made sessions with her particularly uneasy and disconcerting, overshadowed as they were with the implicit threat of her violence. Transference and countertransference issues In the context of Dawn’s capacity for violence, which surfaced with catastrophic intensity and consequences, it was essential for all members of the multidisciplinary team to have clear and fixed boundaries and to communicate a consistent message to Dawn. This would minimise the possibility of generating disappointment and retaliatory attacks. The quality of deprivation inherent in her presentation and interactions with staff generated strong maternal and protective feelings. Some members of the team were tempted to try

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to compensate her for the lack of care she had received in early life. Dawn had been seen weekly for approximately three years by an occupational therapist who had undertaken a counselling course. While ostensibly working with her supportively, the occupational therapist was, in fact, heavily drawn into colluding with Dawn’s fantasies about an idealised relationship with an omnipotent mother. She took her for long walks and gave her Christmas presents, displaying compassion and humanity but little awareness of Dawn’s need for clear boundaries and roles. While these countertransference feelings were understandable reflections of the degree of Dawn’s traumatisation, the occupational therapist had not used her feelings to inform her work but had acted on them without reflection. Her behaviour only set up false hope in Dawn and led to confusion about the nature of their relationship. Breaking professional boundaries and acting as a surrogate mother meant that the occupational therapist was doomed to fail and disappoint Dawn, who was not after all her daughter and who could not ultimately be brought home and cherished. At some level this special care, though apparently welcome, was familiar and disturbing to Dawn, echoing previous abusive relationships. Indeed, the OT may have been unconsciously using Dawn to meet her own needs to rescue, protect and feel special. Another illustration of the depths of Dawn’s emotional deprivation and the strong responses that she evoked was provided by her primary nurse. She reported that she brought Dawn winter clothes to stop her from wandering around the hospital grounds in winter wearing only a thin dress and jumper. No other patient had elicited this response from the nurse who then found herself ‘targeted’ by Dawn for individual attention and asked many intrusive and personal questions, particularly about whether she had children. There was a point when Dawn became angry and threatening towards this nurse, out of frustration that the relationship did not progress. Because the boundaries had already been broken through the special act of dressing Dawn, acting out the maternal transference, the nurse found herself ‘targeted’ and her own boundaries challenged. She found this distressing, particularly because of the feelings of guilt and helplessness that Dawn awakened in her. This was especially difficult because of her particular responsibility for Dawn’s ward-based programme. Eventually this nurse was able to use supervision to discuss the degree of her overinvolvement with Dawn and to re-establish clear limits. She salvaged the relationship before the confusion overwhelmed either her or Dawn. Eventually Dawn’s anger towards her subsided; although she wanted the attention of a special relationship it also appeared to be reassuring to her to have clear limits reestablished. She was also able to recognise that her curiosity about the nurse’s personal life was something that she had to manage and control. Other staff found Dawn’s crime so unbearable that they avoided working with her. This was particularly true of staff who had just given birth or who had difficulty in conceiving. The feelings evoked in staff by women who have killed their babies are powerful and workers need close supervision to reflect on these. If unchecked, staff can adopt a punitive approach to these clients, which is a destructive form of overinvolvement to be guarded against. Dawn had never reported the experience of clearly psychotic symptoms that would have enabled staff to view her as ‘mad’ rather than ‘bad’ and this undoubtedly contributed to the punitive feelings she awakened. Women with personality disorder project their unwanted impulses and internal conflicts on to those around them: staff groups often mirror their psychic splitting (Aiyegbusi 2004). In Dawn’s case some staff members wanted to mother and nurture her,

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in response to her deprivation and childlike dependence, while others wanted to punish and humiliate her, in response to the aggressive, narcissistic aspect of her personality. Few felt indifferent to her or were able to adopt a stance of ‘therapeutic neutrality’. It was for this reason that individual psychotherapy needed to be undertaken by someone who was not directly involved in her daily care. Those supportive aspects of individual nursing care, involving individual meetings, required close supervision to prevent boundary confusion. Dawn’s despair and anger were powerfully projected, making it difficult for professionals to think about her care and respond effectively to her needs. Her psychic disorganisation made it impossible for her to think about her own mental states and also attacked the thinking of those around her, who, like Dawn herself, found themselves acting rather than reflecting. The power of the anxieties that she projected seemed to create this compulsion to act, and this action seemed to be a manic defence against actually understanding and thinking about her early and recent experiences of trauma, abuse and loss. This conversion of thought to action was mirrored in the offence itself, which seemed to be an attempt to annihilate a source of unbearable pain and longing. Although I had attempted to forge a therapeutic alliance with her, Dawn found the perceived focus of work with me, on the offence, bereavement, guilt and her future, unbearable to think about. She avoided real engagement in the work and constantly attempted to draw me into a more friendly discussion in which I was invited to share information about my own life with her; and invariably disappointed her by refusing to do so. Her resistance to working therapeutically was evident and, given the degree of trauma which she had experienced and the horror of her offence, understandable. The difficulties of therapeutic work with women who have killed are further explored in Chapter 9. In the end, little exploratory work was actually achieved but Dawn had at least had an experience of boundaried and clear meetings with me for some time, until she chose to stop. I found her rather evasive and frustrating in therapy, and she gave me the feeling that there was something difficult to get hold of in her. It was possible that by symbolically killing me off as a therapist, preventing us from addressing significant areas of her life, she protected me from the murderous feelings towards me that would emerge if she were actually to engage in work with me and allow herself to become dependent on me. The depths of her murderous rage made it feel unsafe to her to become involved with another person, and she seemed desperate to retain a polite but distant relationship with me, and one in which her status as an infanticidal patient in a secure unit was denied. Despite this her ‘dangerousness’ gave her the inner security of knowing that she was housed in this safe environment for the foreseeable future, keeping her terror of abandonment at bay. Infants as ‘poison containers’ In his powerful work on infanticide, deMause (1990) argues that child assault has been prevalent in different societies throughout history. He is committed to ending this destructive practice and analyses its roots in unfulfilled psychological needs of the perpetrators for love and protection, related to their own impoverished early experiences.

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His perspective is that of psychohistory, ‘the science of historical motivation’ which combines the approaches of psychodynamic psychotherapy and the social sciences: The history of humanity is founded upon child assault. All families once practiced infanticide. All states trace their origin to child sacrifice. All religions began with the mutilation and murder of children. All nations sanction the killing, maiming and starving of children in wars and depressions. Child assault is, in fact, humanity’s most powerful and successful historical group-fantasy. Using children as scapegoats to relieve personal internal conflict has proved an extremely effective way to maintain our collective psychological homeostasis. (deMause 1990:1–2) Infanticide, he argues, is universal and found more in humans (in relation to their offspring) than in any other species. DeMause insightfully describes the psychodynamic processes involved in infanticide, in terms of treating children as receptacles of unacceptable impulses, ‘poison containers’, who can then be manipulated, tortured or killed: The main psychological mechanism that operates in infanticide is the same as is present in all cases of child assault—physical, sexual, or psychological. It involves using the child as what I have termed a ‘poison container’, a receptacle into which one can project disowned parts of one’s psyche, so that one can manipulate and control these feelings in another body without danger to one’s self. (deMause 1990:4) Dawn’s killing of Gabriel reflects this psychic process. In some cases of women who kill their children there is a conflict between the desire to have babies who will compensate them for love they never had and their fear of motherhood, which may reflect a complex relationship between them and their own mothers, in which feelings of rivalry, envy, anger and deprivation may be evident. The mother who cannot bear to hear her infant scream may be rejecting, or assaulting, it because she wanted the baby to contain her despair, and feels unable to perform that maternal function herself. Again, this may relate to abuse, neglect and trauma in her own experiences in childhood, which dramatically interfere with her own relationship with her children (Bifulco and Moran 1998). DeMause (1990) suggests that infanticidal mothers have had highly inadequate child-rearing experiences and have harsh, punitive superegos that demand punishment of their strongest wishes, including their wish to be a mother.

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Theoretical approaches Filicide and maternal depression There is strong evidence to suggest that depression is the diagnosis most often associated with filicide, although it must be remembered that the occurrence of child murder following childbirth is still much rarer than the occurrence of severe depression in puerperal women (Brockington 1996). The most common type of crime found in depressed assailants (West 1965) was maternal homicide of small children. The data on filicide are, however, somewhat contradictory in relation to incidence of child murder in general (Bourget and Bradford 1987). For example, some authors, such as Gibson (1975), reported that 81 per cent of murdered children in England and Wales under age 16 were killed by their parents while Jason (1983) found that parental homicide is only a minority of the cases of child homicide and constitutes 29 per cent for all victims over age three. The studies of Jason (1983) and Bourget and Bradford (1990) provided support for the research findings of previous literature in identifying the greater incidence of maternal rather than paternal perpetrators in cases of filicide, indicating that a higher proportion of these crimes are committed by mothers. In some cases of homicide of children the act is followed by suicide; the role of major affective disorder is clearly significant in these crimes. West (1965) found that this pattern occurs in more than 50 per cent of the murders committed by women. The suicide attempts are often serious and successful. Herjanic et al. (1977) reported that female offenders suffering from affective disorders were charged with more serious crimes than schizophrenics or those with a personality disorder. This indicates the potential dangerousness of depressed sufferers with their tendency towards self-harm and nihilistic outlook on life. Although Bourget and Bradford (1987) suggest the possibility of a genetic predisposition for homicide in individuals who may be at higher risk of developing major affective disorders, they emphasise the multifaceted aspects of the crime and the significance of psychosocial factors in the aetiology of severe depression.

The impact of psychosis on maternal filicide In a recent retrospective study of the clinical data of 55 filicidal mothers, spanning a 22-year period, Lewis and Bunce (2003) found that 52.7 per cent had psychotic symptoms at the time of the offence. Compared to the mothers without psychosis these women were more likely to have a history of substance abuse, to have past and present psychiatric treatment, to be older, unemployed, more educated and divorced or separated. They more often confessed, made suicide attempts themselves, used weapons, killed multiple children and expressed homicidal thoughts and feelings to their families prior to the offence.

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Major depression with psychotic features is the most common diagnosis in maternal offenders. Since the most critical period has been described as the first six months of life, this corresponds with the risk of maternal post-partum psychoses and depression. Another significant diagnostic category associated with filicide is schizophrenia. Altruistic filicide is often associated with an underlying depressive illness and characterised by the desire to kill the child ‘to relieve real or imagined suffering’ (Bourget and Bradford 1987:224). Extended suicide-homicide is significantly associated with altruistic motives. Psychological identification with a child may contribute to the conversion of suicide to filicide. Sullivan (1924) suggests that child murder in psychotic mothers is primarily an expression of suicidal tendencies. West (1965) concludes that murder-suicide in the course of depressive illness occurs at periods when the suicidal risk is at its greatest. Bourget and Bradford (1990) add further support to the research pointing to parental filicide as being predominantly a female activity. In their study 69.2 per cent of the perpetrators were females. They note that in accidental filicide such as a fatal battered child syndrome the homicidal intent is lacking. In such cases the abusive parents are under intense and unusual stress at the time that the battering occurs, have been abused in childhood, and the victims are likely to be young and unwanted. They identified accidental filicide as occurring twice as often as pathological filicide which might be psychotically driven and have altruistic motives; it is likely that psychosocial factors play an important role in such cases. In contrast, in their later study Bourget and Bradford (1990) found that a diagnosis of borderline personality was slightly more prevalent than diagnoses of major depression in mothers who kill accidentally, i.e. through fatal battering or neglect. This suggests that the link between hormonal imbalance post-partum, depression and killing may be weaker than previously assumed. They attribute this somewhat unexpected finding to the high proportion of ‘battered child syndrome’ cases in their sample, noting the similarity between battering parents and borderline personality disorder patients in terms of background characteristics. The authors highlight the significance of psychosocial stressors in filicide offences. Exposure to a variety of psychosocial stressors appeared to have been a major factor in most cases of filicide. In their study 61.5 per cent of cases had experienced severe psychosocial stress prior to committing the filicide. Possible stressors included financial hardship, moving house and relationship breakdown. There is a new body of research addressing maternal and paternal filicide that attempts to identify similarities as well as differences in these crimes. In their review of paternal and maternal filicides Bourget et al. (2007) describe the following similarities between men and women who commit filicide: first, the presence of significant life stressors; second, social isolation and lack of support; third, a history of abuse in childhood. Difference between the genders centres on the following: first, fathers rarely commit neonaticide; second, filicidal fathers are usually older; third, filicidal fathers are more likely to have a history of violence towards their children; fourth, filicidal fathers are more likely to commit suicide. When fathers are perpetrators of filicide they are generally in the ‘fatal abuse filicide’ category, and rarely have psychotic and depressive disorders, although in cases of filicide followed by suicide there was a higher proportion of mental illness identified in fathers (30 per cent of these fathers had depressive disorders and 52 per cent were found to have psychotic disorders in a study by Bourget and Gagne 2005).

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Classifications of filicide Parental killing has been classified into two main types: 1 Neonaticide—the killing of a newborn child within the first few hours of life. 2 Filicide—the killing of a child who is more than one day old. Infanticide refers to the killing by a mother of an infant who is less than 12 months old. Research has attempted to identify the types of child killing according to various classificatory systems, one of which is based on parental motive (Resnick 1969, 1970) while another is based on the source of the impulse to kill (Scott 1973). Scott (1973) further classified the following categories of parents who kill, based on their motivations during the killing: 1 Parents who kill an unwanted child. 2 Mercy killing. 3 Aggression attributable to gross mental pathology. 4 Stimulus arising outside the victim (displacement of anger, avoidance of censure, loss of status or loss of love object). 5 Stimulus arising from the victim (the battering parent who responds to the perceived provocation of an infant who will not stop crying). D’Orban (1979) added a sixth category to this list: 6 Neonaticide, as defined by Resnick (1970), in view of its special characteristics and medico-legal interest from the point of view of the Infanticide Act. Yet another classificatory system was provided by D’Orban: 1 Battering mothers (36 subjects). In these cases the killing occurred as a sudden impulsive act characterised by loss of temper; immediate stimulus to aggression arose from the victim. 2 Mentally ill mothers (24 subjects). These mothers were severely mentally disturbed at the time of the killing and had been diagnosed with either psychotic illnesses, reactive depressions associated with suicide attempts, or personality disorders with depressive symptoms of sufficient severity to require hospital admission. 3 Neonaticide (11 subjects). These mothers attempted to kill their children within 24 hours of giving birth. 4 Retaliating women (nine subjects). For these mothers aggression towards the spouse was displaced on to the child, fitting the pattern of ‘the Medea situation’ described by Stern (1948). This category would correspond to Scott’s categorisation of retaliatory killings and Resnick’s ‘spouse revenge filicides’. 5 Unwanted children (eight subjects). Women killed unwanted children by passive neglect or active aggression.

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6 Mercy killing (one subject). A genuine degree of caring for the victim and absence of secondary gain for the mother. This could arise, for example, in the case of a terminally ill child. The notion of stimuli arising outside the victim in Scott’s classificatory system refers to the kinds of major disturbances in psychological functioning found in mentally ill women and other mothers suffering depressive reactions as a result of real or perceived changes in their relationships, situation or status. Such women, who may not be considered to be severely disturbed prior to pregnancy and childbirth, are likely to have felt highly ambivalent about the pregnancy and the consequent changes in personal appearance. As outlined in Chapter 1, Dinora Pines (1993) discusses with great sensitivity the unconscious conflicts that pregnancy and childbirth may awaken. Spouse revenge filicides are perhaps the most difficult group of women for courts and professionals to understand and empathise with. Resnick (1969) and D’Orban (1979) describe these ‘retaliating women’ as a highly unstable and disturbed group with a high combined score on measures of stress. They were characterised by severe personality disorders, aggressive or impulsive behaviour, and suicide attempts leading to previous psychiatric hospital admission. They had chaotic and hostile marital relationships and were considered to have used their children to manipulate their spouses. Bluglass (1990) found them to have immature, child-like and histrionic personalities which, when followed up for extended periods following the initial acute episode, would often be misdiagnosed as psychotic. This appears consistent with a diagnosis of personality disorder rather than depression. Meyer and Oberman (2001) report that little recent evidence exists for the category of ‘spouse revenge filicides’. Neonaticide appears to have the most accessible social explanation, as it occurred with greater frequency in earlier times when contraception was primitive, social conditions such as overcrowding common, and women easily exploited. Many unwanted babies were produced and disposed of. Bluglass claims, in terms that may appear somewhat pejorative rather than purely descriptive, that: Such deaths still occur from time to time, often to young, immature, dull mothers who are often ignorant and naive. In a number of cases the mother has denied the reality of her pregnancy, or frankly claims that she was totally unaware of it, in convincing terms. The babies are sometimes born in hotel rooms and death is by drowning in the toilet. Others are strangled, suffocated, or other methods are used. (Bluglass 1990:527) The most common reason (80 per cent; Faulk 1988) for neonaticide is psychosocial in that the mothers want to be rid of the baby immediately after its birth: The majority of the offenders are young women who have become pregnant and wish to get rid of the unwanted child because of shame or fear’ (Faulk 1988:253). There is some evidence for a correlation between infanticide and the prohibition of abortions (Meyer and Oberman 2001) further illustrating the social and cultural aspects of unwanted pregnancy. The other cases of filicide, originally considered a small minority, have been classified as follows (Resnick 1970):

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1 An acute psychosis with delusional motivation. 2 Altruistic killing. 3 Child battering. Resnick (1970) states that filicide is committed twice as frequently by mothers as by fathers; this is not supported by recent evidence by Bourget et al. (2007) that identifies similar rates of filicide by both. He also states that when the mother is responsible she is frequently assessed as mentally disturbed. He discusses acutely psychotic women with delusional motivation and women who kill their deformed or damaged babies altruistically as mercy killing, but clearly the state of research has progressed significantly and the tremendous impact of social and contextual factors in filicides is now being recognised. The classification of killing or ‘elimination of an unwanted child’ can be further subdivided into those mothers who kill their children violently and those whose children die as the result of neglect. This may be referred to as the act/neglect distinction. It is important to recognise that neglect itself contains aggression. It would be useful to distinguish between levels of awareness of the consequences of actions; the woman who deliberately starves her child or deprives him or her of comfort may in fact be more consistently aggressive and abusive than the woman who unthinkingly lashes out at her child in a moment of loss of control. In Bluglass’s (1990) review, the mothers in the ‘neglect’ category were younger than those in the second group and historically accounted for large numbers of child deaths, through neglect or starvation and denial of the pregnancy. Denial of the pregnancy, despite weight gain and amenorrhoea, was a common feature. In such mothers no psychiatric diagnosis is usually found or ‘there is evidence of abnormal personality with neurotic features and an early personal history of family discord and maltreatment. Neglect of the child may reflect the mother’s own pathology, for example death by malnutrition in a child whose mother suffers from anorexia nervosa’ (Bluglass 1990:525). The mother’s lethal overidentification with the infant in these cases is evident.

New classifications: integration of social and psychological factors The classifications presented thus far fail to mention those mothers who were themselves subject to physical violence at the hands of partners and were unable to protect children adequately; they may have been subsequently charged with killing their child, or being an accomplice to this crime. The classificatory schemes outlined tend to emphasise individual psychopathology at the expense of understanding the social context, or the degree to which the woman could have been acting out of fear of a violent partner, or in the context of being heavily influenced by a man. There is little emphasis on the tremendous cultural pressures which may contribute to the woman’s actions, and her sense of isolation and despair in relation to caring for an infant. Although Bourget and Bradford (1990) highlight the role of psychosocial stressors in filicide offences they do not incorporate this into their system of classification.

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The notion of altruistic killing reflects a certain naivety in its assumption that the killing could occur without an aggressive or narcissistic component; it reflects a somewhat sentimental notion without reference to the difficulties for the mother of managing possible feelings of fear, failure and hatred towards a disabled child. The term ‘altruistic’ is used to describe motivation to prevent distress and suffering, but this avoids the issue of the impact of the existence of disability on the mother, and the particular threats to her identity that a disabled child poses for a narcissistically driven mother. Indeed, Resnick (1970) describes such ‘altruistic’ killings as delusional on occasion, and sees them as sometimes part of an extended suicide. It appears that such an ‘altruistic’ killing always reflects a significant element of suicidal motivation, in terms both of an ‘elimination fantasy’ (Campbell and Hale 1991) and in relation to the mother’s narcissistic identification with her damaged baby. The notion of elimination of unacceptable parts of the self through murder (or suicide) is congruent with the idea of children as poison containers (deMause 1990). Findings of a strong association between depression and maternal killing have been used to highlight the role of individual psychopathology decontextualised from the social factors which lead to and exacerbate depression, leaving depressed mothers socially isolated and without emotional or practical support. It could be argued that the intervening variable of major affective disorder is genetically loaded but that its expression in a violent or non-violent form is multiply determined. There is a powerful link between homicidal and suicidal urges. Like psychosis, depression is the precipitant which can lead to the enactment of either or both impulses. The assessment of depression and other aspects of mental illness plays an important role in determining the risk that a woman poses in terms of harm to herself or others. In a recent more sophisticated and comprehensive typology of mothers who kill (Meyer and Oberman 2001) the emphasis is not solely on a medical model of infanticide, but also incorporates social and psychological factors, taking into account the heterogeneity of this group. Theirs is the largest study of contemporary accounts of infanticide in the USA, drawing from media and legal databases. They described five broad categories, based on social, cultural and economic variables, rather than on the basis of motive. They describe these as follows: neonaticide, associated with young women who deny their unwanted pregnancies and have early experiences of abuse and chaotic family lives; the second category is women who kill their children in conjunction with violent, abusive male partners; a third is infants who die because of neglect, as a result of mothers’ distraction or preoccupation, which could relate to other problems including a violent relationship, social stressors or drug and alcohol abuse; a fourth category relates to women whose discipline attempts go wrong, leading to their child’s death, often associated with previous abuse of the child; a final category is purposeful infanticide which may be due to mental illness, i.e. schizophrenia, post-partum depression or post-partum psychosis. For women with poor education about parenting, coupled with other difficulties, for example, substance abuse or learning difficulties, death of their children may occur as a result of profound neglect or failure to understand the consequences of their actions, as in the case of ‘shaken baby syndrome’ that results in death. As Meyer and Oberman (2001) argue, deaths of children have multiple causes and their prevention requires a sensitive and individual typology of mothers at risk that integrates social factors.

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A psychological evaluation of a mother who kills, or is at risk of killing, should always take into account her social circumstances. The quality of social, practical, emotional and psychological support available to a depressed and/or psychotic, substance abusing or learning disabled mother is crucial in risk assessment. If the mother requires psychiatric treatment of depression or other mental health issue, early recognition of this can reduce the risk that she poses to herself and her baby. Likewise other risk factors in her social situation, including a history of violence towards the child, will also enhance risk of other forms of child death, including accidental filicide or death by neglect. Domestic violence can also impact on a mother’s own mental health, and indicates the presence of a violent partner who may inflict harm on the mother and her children; this will also affect her capacity to protect her children’s welfare and safety, and clearly plays an important role as risk factor in such evaluations.

Legal issues Is infanticide a special case? The classification of infanticide is contingent upon the mental state and intentions of the mother at the time of the child’s death. An important question to consider is whether there are good conceptual and/or ethical grounds for the existence of a separate crime called infanticide, which refers to maternal killing of an infant who is less than one year old. The separate recording and classification of this crime has significant implications for the legal disposal of offenders and is premised on a particular, biological understanding of maternal ‘disorders of mind’. Does this clarify this complex and tragic crime or is it an unnecessary and inaccurate notion?

Sentencing practice The law has special provisions for the crime of infanticide in the UK but not in the USA. It is punishable like manslaughter which gives judges complete discretion over the sentence. Since 1976 the outcome for the charge of infanticide has always been a hospital order, probation order, conditional or absolute discharge (Bluglass 1990). If murder, and not infanticide, is charged the woman may be allowed to plead guilty to infanticide, thereby avoiding a trial or medical evidence. This has the clear advantage of allowing the mother, who is already in a highly distressed state, to avoid the trauma of a public criminal trial. Spinelli (2004) effectively argues that the absence of such a US law creates a tragic state of incarceration for women who have killed their children in postpuerperal states of psychosis and depression, and that neither the law nor DSM-IV (APA 1994) recognise the particular characteristics of post-partum illness and the consequent behaviour. This reflects a failure of the medical body to create research-based evidence for the existence of the disorder in such a way as to allow informed decisions to be taken in the criminal court. She further notes that incarceration and punishment rather than treatment of infanticide are ineffective in terms of deterring infanticide, in that rates of infanticide are the same in countries like the UK where the Infanticide Act influences

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sentencing, and Scotland, where it does not. That is, infanticide is not a crime whose punishment will deter potential perpetrators—it is produced by mental illness and intrapsychic disturbances of such magnitude that the prospect of incarceration will not prevent it, but effective identification of risk factors and adequate psychological and psychiatric treatment is crucial. A historical approach: the Infanticde Act in the UK The Infanticide Act has written into it the notion of instability of mind owing to childbirth and, if ‘the presence of disturbance of mind’ at the time of the killing can be demonstrated, the mother will often receive a lighter sentence than she would if the infanticide plea were disallowed, or if, for instance, she had not succeeded in killing her child and was charged with grievous bodily harm or attempted murder. Under the 1803 Act the prosecution had to establish that the child had been born alive, with ‘a separate existence’. In the UK the Offences Against the Person Act 1803 reformed the statute of 1623 and established infanticide as a crime, no different from murder. The mother was presumed innocent unless proved guilty; if a murder charge failed the jury could return a verdict of ‘concealment of birth’, with a maximum penalty of two years’ imprisonment. Trials for concealment increased threefold between the 1830s and the 1860s. The Offences Against the Person Act 1828 made it clear that the separate existence rule did not apply to cases of concealment of birth (of a stillborn child, for instance). The Offences Against the Person Act 1861 allowed the prosecution to bring an independent charge of concealment of birth and provided that this could be an alternative to a murder charge. Judges were unhappy with the law as they had to pass the death sentence on convicted women, knowing that, because of an increasingly sympathetic attitude to mothers, the sentence would not be carried out. Because of the harshness of the penalty, judges were increasingly reluctant to convict. The Infanticide Act 1922 reduced the offence of child murder to manslaughter: ‘where a woman caused the death of her newly born child by any wilful act or omission but at the time of the act or omission she had not fully recovered from the effect of giving birth to such child, by reason thereof the balance of her mind was disturbed’ (cited by Bluglass 1990:524).

The Infanticide Act 1938 The Infanticide Act was the result of a Bill introduced by a doctor and clarified anomalies in the 1922 Act but widened the psychological and physiological reasons for reducing the offence of child killing from murder to one of infanticide; Section 1(1) of the Infanticide Act states that a woman who has wilfully caused the death of her child under the age of 12 months will be punished as if she were guilty not of murder but of manslaughter, if ‘at the time of the act or omission the balance of her mind was disturbed by reason of her not having fully recovered from the effect of giving birth to the child, or by reason of the effect of lactation consequent upon the birth of the child’. This Act required only that there be a disturbance in the balance of mind at the time of the killing.

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It has been argued that the courts are generally sympathetic to this group of offenders and, in practice, the degree of disturbance acceptable to the court seems much less than would have been required if the defence had been one of diminished responsibility (Faulk 1988). The sentences given are usually a probation order with or without psychiatric supervision. Infanticide applies only in the case of a mother killing her child as, presumably, the father could never be considered to be subjected to the hormonal imbalances produced by pregnancy and childbirth.

Critique of the Infanticide Act The notion of female hysteria is woven into the fabric of the Infanticide Act. Women who have given birth are considered to be likely candidates for ‘disturbance of mind’ and, indeed, the supposed ‘effects of lactation’ are presumed to contribute to this mental disorder, in which state killing is justifiable. Far from considering the decision by a young woman, facing social censure, isolation and emotional upheaval for at least the next 15 years of her life, to kill her child to be a rational if highly unethical decision, it is more palatable to justify this behaviour on the grounds of mental instability. The task of proving that her decision arose from disturbance of mind owing to raging hormones, to which she was victim, appeared to be relatively easy, given the preconceptions of the judges and the general public at the time the Act was framed. It would be hard to imagine a case where a neonaticide was not committed in the context of considerable despair. The social reality of shame, isolation and hardship should not be equated with the biological condition of postnatal instability. It is relatively easy to make a case for infanticide: This offence is ubiquitous in that the law requires only an association in time between the existence of a ‘disturbance of mind’ and the death of the child. There is no requirement for a causal connection. It is this that allows courts and experts considerable flexibility in each case. (Bluglass 1990:527) Despite suggestions that judges and public sentiment are sympathetic to women who kill their children, I would argue, on the contrary, that the presuppositions implicit in the Infanticide Act relate to deep-seated fears of women’s procreative capacities. The fear of menstrual women and the mystique of childbirth are taboos which have held tremendous influence cross-culturally for centuries. Evidence from folklore and anthropology suggests that these taboos have shaped behaviour and attitudes towards women for centuries and led to their segregation. The implication is that woman is wholly ruled by biological forces. Lotte Motz (1997) disputes the Jungian notion of The Great Mother’ who was universally revered and respected, arguing instead that: When we regard the beliefs of modern hunting and herding peoples of northern Eurasia we note that their attitude toward the ‘mystery of the fertile womb’ is far from reverent. The climate of emotion is, in these regions, so deeply affected by a fear of women’s biological functions,

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menstruation, pregnancy and parturition that numerous rules and prohibitions were created to counteract the potential danger. (Motz 1997:6) These prohibitions included various rules regarding the demarcation of special ‘women’s places’ in which the unclean women, menstruating, pregnant or following childbirth, are confined. Indeed, modern religions retain vestiges of these beliefs concerning the unclean nature of menstruating women, as is evident in the Orthodox Jewish tradition of the mikvah, in which women must immerse themselves in a pool of water, under strict supervision of a female attendant, after childbirth and several days after the cessation of a menstrual period. The tradition of fearing women and the mysterious biological forces which are seen to govern them is evident in the creation of the Infanticide Act. Though apparently sympathetic to women, it can actually deprive them of moral agency and feed into the notion of woman as intrinsically hysterical and untrustworthy, literally a product of the unpredictable and terrifying womb which she houses. The scientific premises of the Act, with its inclusion of ‘the effects of lactation’ as a factor which contributes to mental derangement, are themselves open to dispute on scientific grounds. The supposed correlation between premenstrual syndrome and criminality in general is used to support the notion of hormonal causes of criminality. However, it is undeniable that there are some cases when postpartum illness is responsible for the type of thinking that leads to killing a child or children. As Spinelli argues, in such cases it is invaluable to have a recognised set of psychiatric symptoms that typify this illness, and are well researched and understood. In these cases juries need to be guided by psychiatric and psychological expertise rather than succumb to desires for retribution without understanding the nature of the crime. The crime of neonaticide is generally not associated with postpuerperal distress, and there is some evidence that the women who commit neonaticide are in situations of acute social shame and fear. It is not the case that they are mentally ill, though clearly understanding of their plight, and of the association between such crimes and poor social support and education needs to be provided. In their comprehensive typology of women who kill their children Meyer and Oberman (2001) argue persuasively for the need to appreciate the heterogeneity of these mothers and to examine the different motives commonly found, as well as the complex interaction with social factors. A balanced, measured and individual analysis of each case with reference to the interplay of social, interpersonal and mental health issues may be far more useful than a blanket assumption of a woman deranged by a mysterious and overwhelming influx of hormones that renders her senseless. These authors further extend the existing typologies to include reference to situations of privilege and power, and to situate infanticide in a complex social context in which various inequities, individual and societal, may combine to contribute to this tragic act. Similarly, the woman who commits a crime as devastating as killing while distressed and dissociated following childbirth cannot simply be assumed to be a hapless and passive subject of her hormones; she also displays a complex, and even rational, set of motivations and considerations within a particular social context. While her hormonal changes may have contributed to her behaviour and can be presented as a mitigating

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factor in consideration of her offence, to assign them the degree of primacy outlined in the Infanticide Act is not necessarily accurate. It also minimises the role of cultural and social pressures that may have tremendous influence on the decisions of young mothers faced with unwanted babies. In some cultures neonaticide of girl babies is not uncommon because of the open disregard for the value of female as opposed to male life, yet this practice could hardly be attributed simply to hormonal imbalances. However, despite a warning against the need to simplify or reduce this complex and tragic crime, it is important to recognise the evidence of post-partum disorder, whose risk can be identified by physicians and midwives in a variety of ways. Risk factors include previous psychiatric history, previous episodes of depression and/or psychosis following childbirth, lack of adequate intervention, support and evidence of relapse including psychotic ideation, all of which could be identified in the case of Andrea Yates. Neonaticide: a closer look Neonaticide is a tragic act of violence, which can result from a tremendous fear of social stigma, feelings of total helplessness in relation to an unplanned baby, or a range of complex psychological factors, which result in a psychotic panic, in which killing seems the only solution, particularly when the baby is newborn and has not yet been recognised by the mother as a separate human being, The threat of social stigma, coupled with profound psychic threat, may contribute to the mother’s desperation to be free of the baby. In dynamic terms, infanticide can be seen as an expression of suicidal feelings projected on to an aspect of the self, the baby, who becomes a ‘poison container’ (deMause 1990) that must ultimately be destroyed. In cases of neonaticide the risk factors are quite different, and the mothers have usually not given birth before. Indeed, one of the difficulties is the problem of concealment or denial of pregnancy and the impaired communication with their families. Such young women are clearly harder for medical professionals to identify and help than women who are at risk of infanticide due to postpartum illness. These women are typically younger, unmarried, often deny or conceal their pregnancies, do not receive antenatal care and have not planned how to care for the child once it is born (Bourget et al. 2007). In terms of motivation to kill, the main one seems to be the undesirability of the child. These women show less evidence of depression, psychotic illness or suicidal attempts than women who have killed an older child, and are less likely to be hospitalised than those who commit filicide. Because they are often adolescents who remain hidden from the view of midwives and other professionals, and keep pregnancies concealed from immediate families, this is a group who may be harder to help and whose crimes are more difficult to prevent. A case of hysterical denial of pregnancy and neonaticide is described by Green and Manohar (1990); they report the case of a young woman who killed her newborn baby by drowning her in the lavatory bowl in which she was born. The mother and her dead infant were later discovered by her boyfriend and police investigations brought a charge of second degree murder, later reduced to infanticide. Following her admission to hospital the mother was adamant that she had not known she was pregnant, despite a positive pregnancy test conducted at four months following her presentation at her general practitioner’s consulting rooms for nonspecific malaise. Confirmation of the pregnancy had also involved an ultrasound examination. The young mother had repressed all

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memories of these events and maintained that she had had no idea that she was pregnant and had not realised that she was in labour until the baby was born and she had collapsed in shock. There was no evidence of psychosis or of an intention to kill. The authors link the patient’s initial denial of her pregnancy diagnosis with her experiences of deceit in childhood and argue that the denial has an hysterical aetiology. The features of the case illustrate many of the characteristics of neonaticide as described by Resnick (1970), including the patient being an immature girl giving birth to an illegitimate child and feeling oppressed by strong parental influences. The manner of the infant’s birth and death by drowning in the lavatory bowl is also a common feature of neonaticide. Meyer and Oberman (2001) described 47 cases of neonaticide and identify the lack of partner as a relevant factor; in only one case was there another person present at the birth and the neonaticidal mothers did not have stable relationships with the babies’ fathers. Denial of pregnancy was a common feature of these mothers; the authors suggest that such denial has an impact on the mothers’ capacity to bond with the unborn foetus, and how the absence of such a relationship can cause dissociation when the baby is actually born. The relationship is devoid of emotional connectedness and this, in turn, may play a role in the baby’s disposal through death.

Conclusion The lack of data about the best treatment for depressed mothers, and mothers at risk of killing their children for other reasons, including complex mental health difficulties, social isolation and stigma, family situations of violence and criminality, profound social deprivation and poor understanding of reproduction, birth control and childbirth, has hindered the development of informed practice. As recently as 2004 Spinelli wrote of the paucity of research related to infanticide, its relation to post-partum mental illness and its accurate assessment. Although there are specialist settings for mentally ill mothers and babies to be kept together while the mother is treated and observed, there is a paucity of data comparing these units with others where mother and baby are separated. Kumar et al. (1994) note the difficulty of making informed decisions in the light of the absence of comparative data. Kumar and Hipwell (1996) have developed a clinical rating scale, the Bethlem Mother-Infant Interaction Scale, designed to assess mother-infant interaction within the clinical setting in an attempt to evaluate the degree of risk which a mother may pose to her infant. It remains to be seen whether such a scale will have predictive validity in enabling clinicians to evaluate a mother’s capacities to provide safe parenting for her child. Identifying and treating depression in the antenatal and postnatal periods is of vital importance. Oates (1994) describes the practice of inpatient psychiatric treatment for mothers and babies, such as that offered at the Queen’s Medical Centre, Nottingham. Such specialist treatment is not, however, usually available for women who are already mentally ill, or known to the psychiatric services when they give birth. Other such resources include the Cassel Hospital, Richmond which offers a therapeutic community approach to treatment of mothers and babies and provides ongoing risk assessments. More recently Spinelli and Endicott (2003) conducted research into the superior efficacy of interpersonal psychotherapy compared to educational interventions for depressed

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pregnant women. This kind of research is invaluable in creating an evidence base for treatment for this vulnerable population, and may have a positive impact on the quality of care these mothers will provide for their babies. The limited resources available for mentally ill mothers and their babies may reflect a social resistance to acknowledging the fact of maternal violence and depression. This denial results in a failure to provide appropriate facilities. Some women who go on to kill their children have previously subjected them to other forms of physical abuse and may already be known to child protection and psychiatric services. The risk of accidental death, on top of the existing risk of physical, emotional and psychological harm, needs to be assessed in such cases, even when the mother does not express an explicit wish to kill. There is profound resistance to acknowledging maternal violence. The tragic cases of infanticide and other maternal killings tend to be viewed solely as evidence of extreme disturbances of mind, as reflected in the Infanticide Act. It is essential to recognise the possibility of female violence, and its manifestation in violence against children in women who are not mentally ill, as well as in those who are. Analysis of the dynamics of female violence and repeated abusive patterns of mothering is crucial. Empirical evidence for the intergenerational transmission of abusive patterns of parenting is vitally important and has contributed to our understanding of the impact of early experience on parenting and the need for interventions, such as individual psychotherapy and parenting groups, to help to break the cycle of child abuse. Clearly, social conditions which contribute to maternal depression, parental discord and stress will impact adversely on childrearing. In a society where young single mothers are treated with contempt and hostility the offences of neonaticide and infanticide will continue to occur, as acts of desperation. There is a powerful need to recognise the complexity of filicide and the particular perils of motherhood, including the possibility of serious mental illness following childbirth and the impact of social isolation on mothers with particular vulnerabilities. A sensitive understanding of the conscious and unconscious realities that face an individual mother and her relationship with her children can inform a broader awareness of infanticide in its social contexts, and its multiple motivations and meanings. While infanticide is associated in a significant proportion of cases with postpartum illness, neonaticide is not. It has been established that there is no one cause or motive for infanticide (Meyer and Oberman 2001; Spinelli 2004); its meaning and precipitating causes for an individual mother need to be seen against the background of her social and personal situation. The causes, treatment and prevention of infanticide are multifactorial. There is an urgent need to integrate the psychiatric, social and psychodynamic models of understanding this tragic act. Failure to understand the risk of violence by mothers feeds directly into a denial of infanticide and neonaticide, preventing rather than assisting the essential task of identifying mothers and children at risk and offering the treatment, education and support that could save lives.

Part II Violence against the self

Chapter 6 Deliberate self-harm Introduction ‘Deliberate self-harm is a symptom of internal distress, which has both a private and a public message’ (Adshead 1997:111). Like other manifestations of female violence, selfharm is viewed with horror and incomprehension by many and its origins and purpose are ignored. I consider it to reflect the typically female expression of anger, which is to turn it against the self. While men tend to cope with anger by directing it outwards, viewing themselves as the victims of injustice in a harsh and punitive world, women blame themselves, and take responsibility for wrong done to them. When memories of abuse or feelings of anger threaten to overwhelm them, and destroy their conciliatory stance in relation to aggressors, they turn the anger inwards and, rather than damaging the other person, inflict injury on themselves. For self-harmers the scars caused by cutting symbolise their psychic pain to the outside world. Self-harm makes public this private pain and expresses that which cannot be thought about. The action of self-harm replaces and prevents thinking. In this chapter I discuss two central models for understanding deliberate self-harm, the psychodynamic and the psychiatric, and consider treatment approaches from the perspectives of psychodynamic psychotherapy, feminist theory and dialectical behavioural therapy. I provide a critique of the psychiatric model of self-harm that stresses its link with borderline personality disorder (BPD). In my extended case illustration I explore the various functions that deliberate self-harm can serve. Self-harm occurs in the general population, in individuals who have no contact with psychiatric or psychology services. The clients whom I see may have difficulties that are on the extreme end of the continuum but their underlying experiences and mode of expression relate to female experience in general, and female violence in particular. To pathologise these women is to ignore the existence of female violence and its manifestation in aggression against the self. Self-injury is not necessarily a suicide attempt or simply manipulative behaviour. It is a complex set of behaviours, with different meanings in different contexts. Its significance for a particular individual can be gleaned only through sensitive analysis. Any attempt at treatment of this behaviour must be based on a thorough and sophisticated understanding of the thoughts and desires that gave rise to it, and its psychological functions. Understanding the reasons why a woman self-harms is the first stage in enabling her to find other less violent ways to articulate her distress and alleviate her pain.

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Defining the parameters of deliberate self-harm The term ‘self-harm’ has sometimes been used to include apparent suicide attempts, but it has been argued that there is a distinction between lethally motivated suicide attempts and what has been termed the self-harm syndrome (Pattison and Kahan 1983). The latter is marked by late onset in adolescence, multiple episodes over many years and harm that is directly inflicted upon the body (Sabo et al. 1995). Suicidal motivation is not a feature of deliberate self-harm as defined by Pattison and Kahan (1983). This contrasts with the model of self-harm described by Campbell and Hale (1991) who identify unconscious suicidal motivations in self-harm, including a fantasy of ‘elimination’, in which bad bits of the self can be evacuated through attacks on the body. In their study of deliberate self-harm in women in Ashworth Hospital, Liverpool, a high secure hospital for patients considered to require both maximum security and psychiatric care, Liebling and Chipchase (1992) found that the most frequent types of self-harming behaviour were cutting, attempted suicide and self-strangulation. They used a broad definition of self-harm that included suicide and suicide attempts, endorsing the notion that self-harm expresses a suicidal fantasy. The term ‘deliberate self-harm’ in the specific sense is generally confined to cutting, strangulation, head-banging, burning and insertion into the body of sharp or painful objects. Although burning and/or cutting oneself may appear to be highly unusual and bizarre activities, they are not, in fact, uncommon in certain populations, for example, among adolescent girls who have been sexually abused. These acts of violence, while directed against the self, also have indirect victims, such as parents and medical professionals who witness these acts of self-mutilation and the scars that are produced. The failure to protect the young woman from her own destructiveness can induce strong guilt feelings in these carers when they are faced with these indelible images of distress. Deliberate self-harm is a powerful bodily enactment of psychic pain which women demonstrate much more frequently than men. In the UK one in seven women prisoners will self-harm and self-mutilate, while the comparable figure for male prisoners is one in 33 (Lloyd 1995:178). The gender difference in self-harming rates appears to reflect social conditioning, requiring women not to express anger, and to value their appearance and social acceptability above all else. Attacking themselves is not only one of the legitimate channels allowed women to express their anger, it is also a defiant protest against the idealised, sentimentalised image of them that others hold. It is an attempt to use the body to point to an underlying, psychic damage and, as such, is eloquent. It reflects the way that women communicate their experiences and assert control over their private spheres of influence, their own bodies. It can also be understood symbolically as an attack on the body of the mother, as symbolised by the woman’s own body. Women typically locate their sense of identity in their bodies; this reflects the tremendous cultural emphasis placed on women’s bodies and their reproductive capacities. They express anger, contempt and shame through injuring their bodies, symbolising psychological pain in this concrete experience.

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Deliberate self-harm and the model of female perversion Self-injury has a compulsive aspect that parallels the strength of a perversion: selfharming temporarily affords a fantastic, but shortlived, sense of release from depression. The model of perversion described by Welldon (1992) can be applied to self-injury, which she views as a typically female act of violence in which the crime is committed against the body. In female perversion it is the woman’s whole body that is the instrument of sexualised aggression whereas in the male it is the phallus. Although there are cases of female flashers, this is a much rarer perversion than self-harm, which involves the whole body, not just the genitals. The aggressive impulse is turned inwards on to their own bodies for self-harmers. This may have a sexual component, creating a release from tension similar to that achieved through orgasm. For Welldon, the origin of this self-harm is the woman’s early object relations, that is, her experience of being mothered in infancy: During adolescence, if she hates her mother’s sexual body and is unable to identify with her and her body, the adolescent girl will use her hand to attack her own body in a compulsive way by, for example, cutting her arms or wrists…In doing such harm to their bodies they are expressing tremendous dissatisfaction, not only with themselves but also with their mothers, who provided them with the bodies they are now fighting. (Welldon 1992:40) In their study of the link between self-mutilation, anorexia and dysmenorrhoea in obsessive compulsive disorder, Yaryura-Tobias et al. (1995) define self-mutilation as ‘a volitional act to harm one’s own body without intention to cause death’ and argue that there are four distinct populations in which self-mutilation is found: in mental retardation and other organic conditions; in psychoses; in personality disorders, particularly borderline personality disorders; and in inmates. The latter appear to be responding to their incarceration. The authors state that ‘these acts were compulsive, ritualistic, usually painless, and capable of relieving tension’ and noted that the frightening content of the obsessions that led to self-mutilation often involved the fear of harming others’ (YaryuraTobias et al. 1995:35). This finding highlights the profound link between homicidal and suicidal actions, i.e. aggression directed towards others and towards the self. Self-harm can function as a ‘safe’ alternative to murderous assaults on others. It is also possible that the ‘fear of harming others’ actually disguises a wish to harm others and a desire to enact revenge.

The functions of deliberate self-harm The function, as well as the definition, of self-harm has been variously identified. The reasons why women self-harm include depression, to regain control and to reduce feelings of anxiety and tension (Cookson 1977; Sellars and Liebling 1988; Burrow 1992). The communicative function of self-harm is central: women harm themselves primarily to express their distress and anger, in the hope that others will respond to this

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communication. They manage the intense internal pain that they feel by directing it on to themselves, and externalising it in an attack on the self. For these women self-harm serves two central psychological functions: to temporarily alleviate mental pain and to channel their anger. The desire to self-harm can be so powerful that it can mirror a compulsion, an overriding urge to action, taking precedence over other considerations and desires. It is overwhelming and once it has occurred in thought there is a tremendous pressure to act. The avoidance of painful thinking, through its behavioural enactment, is one of the central functions of deliberate self-harm. Self-harm often coexists with other difficulties. Williams’s (1989) study of selfinjurious behaviour of women in the community associated self-injury with social anxiety and found that women who self-injured were unhappy with their bodies and felt that their lives were out of control. Self-injury appeared to offer them a means of obtaining control, however temporary.

A psychodynamic model of self-harm Self-harm and early trauma: attacks on thinking Adshead stresses that ‘a psychodynamic formulation needs to complement a psychiatric diagnosis and behavioural description of deliberate self-harm’ rather than presenting a mutually exclusive alternative (1997:111). Self-harm can be understood as a cruel attack on the body representing an attempt to kill off the self (Campbell and Hale 1991). These assaults are the expressions of previous traumatic experiences and are expressed through and on the body; the scars left by self-mutilation are literally the embodiment of the traumas which they reflect. Adshead (1997) argues that a central reason for the expression of these traumas through violence on the body is the attack on thinking that the traumatic experience produces, with the result that the experience is somatised, that is, expressed through the body. It is as if a memory of terrible overwhelming pain is imprinted on the body through its own actions. The self-mutilating woman may not be able to process the experience at a symbolic or intellectual level because of the power of the traumatic experience, or because she has been traumatised at an early developmental stage. The trauma can safely be enacted through her own body that is symbolically linked to her mother’s body. Campbell and Hale (1991) suggest that the suicidal fantasy itself expresses a symbolic attack on the mother’s body. The link between childhood sexual abuse and deliberate self-harm The experience of childhood sexual abuse or incest can contribute to the emergence of suicidal behaviour, as expressed through self-harm. Campbell and Hale (1991) emphasise the aggression inherent in self-harm and the underlying fantasies that motivate such behaviour, seen as a type of acting out, in which the action serves as: the substitute for remembering a traumatic childhood experience, and unconsciously aims to reverse that early trauma. The patient is spared the painful memory of the trauma, and via [his] action masters in the present

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the early experience he originally suffered passively…the internal drama passes directly from unconscious impulse to action, short-cutting both conscious thought and feeling. (Campbell and Hale 1991:280) Self-harm occurs as the result of an ‘elimination fantasy’ in which the body is experienced as a potential destroyer that threatens to kill the self. For an incest survivor the guilt of having enacted Oedipal fantasies of sexual relations with the opposite sex parent is profound, generating a perceived need for punishment. The difficulty of integrating ‘bad’ desires within the self is evident in the need to split off these impulses and then, having located them in the split-off body, the subsequent attempt to kill them off. For an abuse survivor, the split-off body is the object upon which she projects her murderous impulses in order for her ‘real’ self to survive; that is, the violence is fundamentally self-preservative. She is attempting to eliminate the ‘bad’ self who had sexual relations with her father or other adults. During the experience of being sexually abused, the child or adolescent might find it protective for the body to be split off to preserve some sense of a good object; that is, the mind could float above the violence that was being inflicted on her body, and thus survive. The sense of her body as a source of badness will be particularly intense for an abuse victim whose adjustment to her sexually maturing body, with its confusing and overwhelming infantile wishes, was grossly disturbed by parental abuse. Her conception of her body as ‘other’ and as a receptacle for violent impulses makes it possible for the survivor of sexual abuse to inflict violence against her body. Her sense of guilt for the sexual abuse, and the false belief that she may have invited the abuse, can also contribute to a need for punishment; this punishment can be self-inflicted. In their psychoanalytic discussion of depersonalisation and self-mutilation, Miller and Bashkin (1974:647) write of a patient that ‘he preserved in the flesh, in a dramatic and conspicuous manner, the history of events he could not integrate into the fabric of his personality’. This description powerfully evokes the experience of women who have been sexually, physically or emotionally abused in childhood and who express their traumatisation through their bodies. There is also a sense in which the childhood events that could not be talked about or processed were preserved through their inscription in the flesh. The difficulty in integrating or assimilating these early experiences is revealed through literally splitting off the anger and focusing it on to the body. Deliberate selfharm can thus be seen as an attempt to preserve the good bits of the self that were not corrupted by abuse, and which are located in the mind or ‘soul’ of the survivor, by identifying the damage clearly in the body and, in a sense, confining it to that realm. The common association between deliberate self-injury and a history of childhood sexual abuse has been widely documented; some studies have found that over 50 per cent of patients who displayed deliberate self-harm had been sexually abused by one of their primary caretakers (Briere and Zaidi 1989; van der Kolk et al. 1991). Both phenomena coexist in disturbed women as well as in women who do not suffer from major psychiatric disorders. The diagnosis of borderline personality disorder is itself associated with serious sexual and emotional abuse in childhood and may reflect the extent to which distressing and traumatic experience interferes with personality development. The

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resulting personality organisation can rely on early or primitive psychic defences and the world is perceived to be a frightening place, as indeed it was in early life. The defences of splitting and projective identification are used to ward off feelings of unhappiness threatening to overwhelm and engulf the woman. Self-harm can be seen as one type of projection and one manifestation of profound difficulty in managing anger and unhappiness. Because these women have not had the experience of a parent who is able to contain these feelings, they have not internalised this containing capacity, and they strive instead to get rid of these feelings by enacting them. Therapy can demonstrate that apparently intolerable psychic pain can be borne and thought about, that memories and feelings of despair do not necessarily require urgent action. The therapist can offer the woman an experience of containment, and can show her that she can bear to think about her history. The capacity to manage these impulses and to mentalise states of feeling rather than enact them is central to the work of Bateman and Fonagy (2004). The link between sexual abuse, in which essential boundaries and taboos have been violated, and the pain of self-injury is evident in the way that the self-mutilator violates the boundary between thought and action, internal and external, psychological and physical pain, in an apparent attempt to locate and circumscribe the damage. The taboos of not cutting one’s own flesh or piercing oneself internally are also broken and the scars on the body can be considered to be symbolic ‘battle scars’. Self-injury demonstrates the historical damage that has been done and bears witness to crimes which have already been committed against the body. As Miller and Bashkin describe in their account of a man who could not experience his life as continuous, and who had no sense of stable and enduring personal identity, ‘F’s self-inflicted wounds with all their visibleness became for him constant and concrete reminders that he, in fact, had lived and suffered in time’ (Miller and Bashkin 1974:647). Once self-harm has occurred and the body barrier has been broken it is increasingly easy to enact violence against the self. Because self-harm offers only short-lived relief there is a compulsion to repeat the action whenever anxiety reaches unacceptable levels. The function of therapy will be to articulate these thoughts, reducing the need for splitting off good and bad feelings and acting out. Women who have suffered rejection, abandonment or neglect by their mother may express anger and disappointment through vicious attacks on their own bodies, and through direct assault on their sexual organs. Women who insert objects into their vagina that cut or harm may symbolically be attacking their mother’s body. The self-harming woman ‘internalised the source of her original trauma, and acts sadistically towards her own body’ (Adshead 1997:41). They may also be attacking their own identity as mothers or potential mothers symbolising the dangers inherent in sexual relations. To attack the body in this way may still have a selfpreservative function in that the ‘bad’ part of the self, the body, can be damaged in order that the rest of the self can survive; the danger is located in a particular place and then annihilated. Self-harm as primitive defence mechanism: splitting An important component in the development of self-injurious behaviour is the primitive defence mechanism of splitting, in which good and bad aspects of an experience are kept separate in order to protect the person against unbearable feelings of loss or anxiety. The

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self-harmer tries to annihilate her mental pain by inflicting physical pain on herself. She also indirectly attacks those around her, who have failed to protect her or help her to manage unbearable memories and feelings, so that she feels forced to enact them on to her own body. This aggression may be fuelled by the anger that she feels towards her once idealised carers, and may also be an attempt to protect them from this rage by turning it on herself.

The psychiatric model Self-harm and borderline personality disorder Self-harm has been found to be strongly associated with the diagnosis of borderline personality disorder and, to a lesser extent, with antisocial personality disorder. One diagnostic feature of borderline personality disorder is the presence of intermittent psychosis, that can be associated with deliberate self-harm in two ways: first, women may say they self-harm in response to voices; second, psychosis creates a divorce from reality and altered state of consciousness, or dissociation, in which action can take place without the usual emotional affect, physical perceptions or cognitive awareness. This may explain the sense of release from tension and absence of pain self-harmers typically experience (Adshead 1997). In their study of female prisoners who self-harm, Wilkins and Coid (1991) found that self-mutilation, ‘as a single variable, identified a subgroup of female prisoners with severe personality disorder and multiple impulse disorders’ (Wilkins and Coid 1991:247). This subgroup (7.5 per cent of women with a history of self-mutilation received into a London prison) were also characterised by disruption and deprivation in their early family environment, and greater experience of physical and sexual abuse than controls. Their criminal histories also differed from those of offenders who did not self-mutilate and were characterised by an early onset of persistent, serious and wide-ranging patterns of offending. The authors found that the women who self-mutilated demonstrated abnormal psychosexual development and ‘polymorphous perversity’. Despite their severe psychopathology and repeated and frequent psychiatric contact, these women were subject to long periods of custody, with psychiatric hospitals being ‘unwilling or unable to cope with their behaviour’. Self-harm as a symptom-reduction strategy There is evidence that the function of self-mutilation for women with borderline personality disorder is to obtain relief from the affective components of the disorder, i.e. their mood, and that the deficit in impulse control is associated with other disorders of impulse control (Wilkins and Coid 1991). They conclude that the underlying disorder is the intensity of the depressed and anxious feelings, rather than a behavioural disorder. They suggest that the most important factor in generating and maintaining self-injurious behaviour is the release of tension, anxiety and depression that the women report, and consider this to be of greater significance than environmental factors. Wilkins and Coid (1991) find support for the hypothesis that a history of self-mutilation in women

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prisoners indicates severe and extensive psychiatric pathology and does not merely reflect the institutional environment alone. Their study involved screening all women remanded in custody by nursing staff for a history of self-mutilation and also included checking for evidence of scarring during the routine physical examination. Controls were 62 women selected at random from the remaining pool of prisoners. In a later study Coid et al. (1992) used cluster analysis of phenomenological variables and the associated symptom profile of self-mutilation in 74 women remanded in custody. They identified a subgroup of women who injured themselves in order to relieve the symptoms of their underlying severe mood disorder; this subgroup of women also received a diagnosis of borderline personality disorder. There were distinct differences between this subgroup of self-injuring women and those who self-injured reactively, i.e. not as a result of a disorder of mood but as a reaction to life events, psychotic illness or as a suicide attempt. For the women diagnosed with borderline personality disorder, the central function of self-mutilation was relief from mounting feelings of tension, depression, anxiety and anger, that built up as the day progressed and for which no particular external triggers could be identified by the women themselves. These women described the lack of physical pain accompanying selfmutilation and the successful reduction of symptoms of affective disorder. They also found that self-harm caused the cessation of experiences such as depersonalisation and derealisation; that is, the use of self-injury resulted in release from distressing psychological experiences and facilitated the return of ‘feeling real’. Reactive self-harm The women who self-mutilated in response to underlying feelings of tension, anxiety and depression were in stark contrast to another group of women, who could clearly identify triggers in the external world preceding the decision to self-harm, and who were not diagnosed with borderline personality disorder. This group was identified as self-injuring in reaction to external events rather than because of ‘internal’ disorders of mood and the resulting symptomatology, and was found to have a different pattern of self-injury. They did not self-mutilate more in the evening and at night, unlike the women diagnosed with borderline personality disorder, who appeared to be responding to an accumulation of symptoms; their motivation for self-injury was different. They did not rely on selfmutilation as a symptom-reduction strategy, and indeed appeared to be free of the symptoms found in the borderline personality disorder group. The groups were clearly differentiated by the phenomenology of their self-injury, their psychiatric history and their criminal histories. The women with borderline personality disorder diagnoses were also found to have much more extensive psychiatric and criminal histories than the other group of women who appeared to be using self-harm as an intelligible and discrete response to particular environmental stressors. The role of the disturbed early environment was identified as a significant factor in differentiating between these groups of women who self-harm.

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Self-harm and a deficit in impulse control The studies cited above differ from previous research in terms of highlighting the positive function of self-mutilation in women with severely disturbed personality organisation. Coid and colleagues (1992) emphasise the role of underlying mood disturbance rather than lack of impulse control or a primary disturbance in behaviour, as stressed by Pattison and Kahan (1983), and emphasise the need for therapeutic intervention, rather than the ‘therapeutic nihilism’ often associated with the diagnosis of personality disorder. Lacey and Evans (1986) identified a group of patients with multiple disorders of impulse control, poor prognosis for treatment, and frequent presentation at the psychiatric services, and suggest that this is evidence for a ‘multi-impulsive personality disorder’. The types of impulse disorder that can coexist with self-injurious behaviour include compulsive sexuality, kleptomania, eating disorders and anger-control difficulties. Coid et al. (1992) also suggest that different forms of destructive behaviour can replace selfmutilation and that in the personality disordered group of women in their study the presence of other ‘impulse disorders’ was usual; the non-personality disordered group of women did not usually manifest these impulse disorders but self-harmed in reaction to external events. Coid et al. do not view a deficit in impulse control as a sufficient cause for the self-harm behaviour, in the absence of underlying depression or anxiety, viewing these ‘affective disorders’ as an integral part of the self-harm syndrome: Lacey and Evans contrast with us in emphasising the primary problem as a deficit in impulse control closely related to difficulty in coping with depressive emotions and anxiety rather than the severity of these symptoms themselves. We would argue that this deficit in impulse control is combined with a severe underlying affective disorder…the disastrous combi-nation of the two has led to their inclusion in a prison sample and the poor prognosis. (Coid et al 1992:11) It is worth noting that the effects of incarceration can result in high rates of self-harm, and may reflect an institutional dynamic, in which self-harm is accepted as the currency of communication within an organisation. The high rates of self-harm among women in prisons, special hospitals and psychiatric units point to the possibility that incarceration can itself predispose women to self-harm. The research conducted by Coid and colleagues is important in its elucidation of the complex multifaceted nature of self-harm, and the need to identify the particular function that it serves for an individual in terms of her particular constellation of psychological difficulties, and her social context. It highlights the significance of underlying psychological distress for particularly disturbed women, and indicates the powerful role of self-injury as an effective strategy for symptom relief. The study of self-injury within a custodial population, and the comparisons between the groups of women in terms of their patterns of injury and factors in their own current psychological presentation and background history, provide a useful starting point for further research, identifying and distinguishing between types and functions of self-injurious behaviour.

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The psychiatric debate centres on whether self-harm is predominantly a function of an ‘impulse deficit’ or symptom relief from an ‘affective disorder’. There are strong links between borderline personality disorder and self-harm and it is suggested that the subgroups of women who are diagnosed with borderline personality disorder and who self-harm do so as a result of the intensity of their underlying ‘symptoms’ rather than in reaction to particular external events or ‘triggers’. Critique of the psychiatric model There are certain methodological limitations of the studies discussed; one is that they place emphasis on self-injury as an expression of severe psychopathology, placing it on the far end of the continuum of ‘normal’ distress, and therefore situating it at some remove from the ordinary experience of women. It is a medical model that emphasises individual psychopathology over social factors and the effects of confinement. Coid et al. (1992) apply a traditional distinction between endogenous and reactive affective disorders to the onset of self-injury and consider the institutional context to be secondary to severe psychopathology of the individual. This emphasis somewhat minimises the profound effects of incarceration and largely ignores the communicative function of self-harm. Additionally, Coid et al.’s study highlights the central role of psychopathology rather than elucidating the ‘common pathway’ that may lead both to personality disorder and to self-mutilation. The authors make a distinction about endogenous versus reactive selfmutilation based on the women’s difficulties in identifying current triggers for self-harm. It may be the case, however, that such triggers exist but that the more emotionally abused and traumatised women feel unable to make these links explicit. Early traumatisation can impair verbal articulation and symbolisation. Incarceration in a custodial setting may itself act as a trigger for recurrent self-harm in its evocation of earlier experiences of being humiliated and powerless. The feelings of depression, anxiety, tension and depersonalisation can be a response to the situation of being incarcerated, and resonate with painful memories. The whole custodial situation may act as an unconscious trigger for the woman, in releasing painful and overwhelming feelings, that she attempts to manage through self-harm. In other words, the failure to identify a particular external trigger for self-mutilation is not strong evidence of an underlying, endogenous mood disorder. The feelings described as ‘symptoms’ can be understood as intelligible responses to situations of degradation and humiliation, evoking painful memories of similar experiences in early life. This model of conceptualising self-harm seems to reflect the language of psychopathology and the medical model of understanding the behaviour as indicative of personality disorder, and as such is an impoverished and, I suggest, ultimately limited approach. It tends to focus on the pathology rather than the meaning of behaviour, and to locate the reasons and motivations of the self-harming women in the psychiatric classification that best fits them. This creates a constricted and dehumanising model of understanding the symbolic, as well as the immediate, function of self-harm. It is a retreat to the realm of female madness and itself reflects the process of splitting: according to this model self-harm can be located in ‘mad’ women rather than recognised as an intelligible response to intolerable situations.

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Case illustration

Patricia: deliberate self-harm in an incest survivor Patricia was 23 when she was arrested and charged with assault occasioning grievous bodily harm, to which she pleaded guilty, after her initial charge of wounding with intent to kill had been reduced in the plea-bargaining process. She had stabbed her boyfriend in the chest with a knife, following what appeared to be a trivial disagreement between them. She had narrowly missed his lungs and disclosed that she had, at the moment of stabbing him, felt like killing him. Her motivation for this had not been clear to her at the time and she had not planned to kill him before the meeting, or brought along a weapon with the intention of stabbing him. She had carried a knife with her at all times to make her ‘feel safe’. She had not used it against anyone other than herself before this occasion; she revealed that she had used it to cut herself, inflicting tiny wounds in places that no one else could see, like her inner thighs, her breasts and the soles of her feet. She had been remanded to a secure unit for the preparation of psychiatric reports following an episode of serious depression in prison, where she had initially been held for two months before being transferred to hospital. Her serious self-harm attempts in custody had alerted the prison authorities to her vulnerability and she had been transferred to the hospital wing of the prison prior to her admission to a regional secure unit. She was eventually sentenced to a hospital treatment order at the regional secure unit under section 37 of the Mental Health Act and a restriction order, section 41 of the Mental Health Act, imposed in the interests of public safety. At initial presentation on the admission ward she appeared withdrawn, thin and childlike, and had difficulty making eye contact. She complained of difficulty sleeping, saying that she had nightmares. but was unable to describe their content. She was nervous in the presence of male staff and other patients, particularly men, and seemed to find it hard to trust anyone. On one occasion when she reported having a nightmare, a male nurse put his arm around her shoulder in a gesture of comfort; he was startled when this triggered an angry and frightened outburst from Patricia, who accused him of ‘rape’. After several weeks on the ward Patricia and a female nurse had formed a close relationship and she frequently asked to speak privately to this nurse, to whom she disclosed secrets. The psychiatric assessment at the prison had been thorough and Patricia had disclosed that she had been sexually abused in her early adolescence by her father and had a history of drug abuse, anorexia, running away from home and deliberate self-harm. Patricia had four older brothers, the eldest one was six years her senior while the youngest was only 18 months older than she was. As the only girl, and the youngest child, Patricia had enjoyed special privileges. She described herself as a ‘Daddy’s girl’. Her father had spent time alone with her in her childhood, taking her out to visit relations in other cities and helping her with her homework. She described her mother as a ‘weak’ woman who had worked long hours in a cleaning job and was not readily available to spend time with the children. Throughout Patricia’s childhood her mother had suffered from asthma and chronic fatigue, often being confined to bed for several days at a time. Although she had never received psychiatric treatment it appeared that she had also suffered from depression. Patricia remembered the distress and anxiety it had caused her to see her mother so weak and frail. She had held a secret conviction that her mother had a form of

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cancer that would eventually kill her, leaving Patricia totally responsible for the household and forced into the role of surrogate wife to her father. She was attached to her maternal grandparents who lived next door. Her father had repeatedly sexually abused Patricia from the age of 11 and she vividly recalled how he had followed her into her room after school one afternoon, when no one else was in the house, watching her as she changed out of her school uniform, and then raped her. After the first occasion of sexual abuse Patricia cut herself, in secret, on the soles of her feet. She later began to cut her inner thighs, and on a few occasions had also made tiny cuts on her genitals. She described this as being a sign to herself that something awful and damaging had happened to her; she believed that she had somehow provoked her father’s sexual interest because he had first abused her shortly after she began wearing a bra and started her periods. He had accused her of ‘showing off’ to him, and she had accepted this criticism as a reason for his continuing to have violent sexual intercourse with her several times a week. When I first saw her on the ward, at the urgent request of the nursing staff, my impression of her was that she seemed like a little girl. Patricia had difficulty making eye contact but would occasionally look up and smile at me; this was unexpected and engaging. She presented like a child who had been dressed quickly by a distracted mother, and wore ill-fitting and torn clothing; her messy black hair was held back in a ponytail. She was slight with a thin, flat-chested body and walked with a boyish swagger. Her face was bony and drawn with deep hollows under her eyes. Prior to meeting with me Patricia had begun to work with a female clinical psychologist to address issues relating to her childhood sexual abuse. This therapist had left the secure unit after ten months of working with her. She had been available to see her in emergencies and on several occasions Patricia had been found almost unconscious with a ligature tied around her neck; after having the ligature removed and regaining strength she would be asking to speak to the psychologist. The nursing staff would always contact the female therapist immediately, even at nights or at weekends. She lived near the hospital grounds and had offered Patricia time for discussion outside of the allocated 30-minute sessions that they had scheduled for twice a week. When I began to see her for regular appointments I made it clear that I would not be available to offer emergency meetings because I would not see Patricia outside of our allocated weekly session. I felt that this was necessary to preserve the strict boundaries of the psychotherapeutic work and also because twice-weekly meetings could cultivate a strong transference in Patricia that I felt could be overwhelming for her. I did not want to encourage a deep dependence on me at the expense of her developing a sense of autonomy, nor play the part of rescuing angel, difficult as it was to resist. The urgency of the referral appeared to be related both to Patricia’s perceived need to have individual psychological treatment and the nurses’ feelings of helplessness and abandonment following the previous psychologist’s departure. Patricia had been in the unit for 19 months when I met her and her self-harm had, if anything, escalated during this time. Patricia self-injured regularly using bits of material that she had in her room; these could be torn from clothing or her bedclothes. The pieces of material were used as ligatures by Patricia in attempts to strangle herself. She secreted these bits of material in her room although she would occasionally hand one in to staff, saying that if they did not confiscate it she would use it. She said that she always let go before she asphyxiated and

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that she never intended to die. She would generally let staff know that she had tied a ligature around her neck and would tell them that she had felt unable to resist the urge. On a few occasions she had been discovered in her room, weak and faint with a ligature still tied around her neck. As a result of the self-strangulation she developed bruises on her neck and the areas around her eyes were often the sallow colour of bruising. Partly because she looked like a helpless, battered child it was difficult for both nursing staff and me to remember that she was actually an adult woman. Her self-strangulation and child-like demeanour evoked feelings of protective outrage in some staff who felt that she must be observed one to one constantly for days to prevent further ‘incidents’. Others felt furious with her for demanding so much time and attention when other less demonstrative patients were overlooked despite their severe mental illnesses. Patricia explicitly linked her self-strangulation and her history of self-cutting, that had started after the first occasion of incest. Her confinement in the secure unit had deprived her of the opportunity to cut herself. Cutting her feet signified her sense of violation and was her attempt at self-punishment and a way of marking, in secret, the fact that the abuse had taken place. She described cutting herself in secret, in places on her body no one else would see, except possibly her father, who would be too aroused to look carefully at his frightened daughter and the injuries that she had inflicted on herself. She was, however, physically unable to cut herself in the secure unit because of the careful supervision of her and the restriction of access to sharp weapons. She had decided that she would tie herself with a ligature at times when she felt like cutting herself, e.g. when she would be flooded with memories of her sexual abuse or when she felt particularly disgusted with herself. She reported that while cutting relieved tension, suffocation blocked out sensation altogether; this offered a great release from anxiety and torment. Progress of therapy In the first three months of therapy the focus of the sessions was Patricia’s sense of loss in relation to the previous psychologist leaving and how hard it would be to ‘start all over again’. She had told the other therapist things about herself that she had not previously disclosed and had developed trust in her. I was treated with a degree of suspicion and it appeared likely that the anger she had felt about being left by the other psychologist was directed at me; she had not expressed anger towards this previous therapist. She acknowledged these aggressive feelings towards me and let me know that, while I could never replace the other therapist, I might be allowed to help her understand herself and control her self-destructive behaviour. The mourning period for the previous therapist had been cut short by my arrival on the unit and because of the anxiety of the staff, who did not want Patricia to be left without support for more than a few weeks. Additionally, the psychologist had only given Patricia relatively short notice (six weeks) prior to leaving, for fear of destabilising her. I did not agree with this decision and felt that Patricia needed a longer time to address the process of separation, and anticipatory mourning for the loss of this valued relationship. Despite my awareness that Patricia needed a longer break between the other psychologist leaving and my beginning to work with her, I was also drawn into the powerful fear of destabilising her, and did not feel able to refuse this referral; to do so would have been perceived as cruel and irresponsible. I found it impossible to resist the compulsion to help.

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In the first few months Patricia often ended the sessions early, finding it difficult to concentrate for more than half an hour. She sometimes stared vacantly around the room, as though she were trying to locate her thoughts in the external environment, or identify where she was. She used my first name frequently, checking to see that I was still listening to her, sometimes demanding reassurance that she was understood through her repeated question, ‘Do you know what I mean?’ I thought that underlying this was the more alarming and hopeless question, ‘Can you ever know what I mean, or what I feel?’ She considered her experience of incest highly unusual, beyond what could be thought about or understood and felt that she was a ‘freak’. Despite her sense of isolation, it became easier to talk to her about feeling alone and her difficulty believing that her experiences were communicable in words. Her fear of the destructive impact of her feelings emerged. As therapy with Patricia progressed she began to discuss in detail the feelings and thoughts preceding her deliberate self-injury. She had recurrent images of her father undressing before having sex with her, and a specific memory of the expression on his face the first time that he raped her. She reported that this memory would often intrude upon her thoughts and affect her peace of mind. She would begin to feel afraid and disturbed, as though he were still in the next room to hers and could enter her bedroom at any moment. Certain noises, like the sound of a light being switched on, could set off these memories, as she associated these sounds with her father approaching her bedroom door. Although she would begin to feel anger towards her father when these images and memories occurred, she had learned to empty all the feelings out of her mind because she was afraid that they might overwhelm her. Her anger at her boyfriend at the time of the index offence had followed her refusal to have sex with him; he had become insistent and aggressive in his demands that she have intercourse with him. The experience of coercion had, she said, brought back feelings of blind panic and rage, that she related to her earlier experience of incest. Her sense of confusion was evident as she described how her father, whom she had loved and trusted, began to terrorise her systematically with his sexual demands. She reported feeling guilty about becoming angry with him, and felt that she should not be talking about the abuse, that she must have invited it, encouraged and deserved it. At the same time she knew that her father had been wrong and had somehow changed from being loving to being predatory and frightening, like an animal. The physical sensations that she remembered left her feeling totally overwhelmed and terrified, literally trapped. She felt guilty, suffocated and scared at the same time. She had a clear recollection of being afraid that she would not be able to breathe because of her father’s weight on her. She also remembered his heavy, quick breathing and her desperate wish for her mother to somehow protect her from the abuse mixed with her hope that her mother would never find out about it. Patricia had developed a variety of techniques to cope with these memories and defuse the aggressive impulses that she felt she might enact. One of these strategies was to make herself go numb, and simply observe the images/memories as though she had not been a participant. She had become accomplished at reaching this state of emotional numbness but was aware of a negative consequence—that it made her feel similarly disconnected from events and interactions in her present life. She would be left feeling depersonalised and ‘unreal’, as though she was an observer in her own life. After some time in this calm

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but estranged state she would need to ‘get back to normal’ and found that tying a ligature around her neck, or cutting herself if she had the means, would bring her back, allowing her to ‘feel real’ again. She had an elaborate ritual for self-injuring and believed that methodically and carefully going through this ritual also allowed time for the intrusive and disturbing memories to fade, so that their destructive power would be reduced when she once again engaged with the world. As she became aware of the times when she would be most likely to self-injure she developed a clear idea of its functions. She understood her self-strangulation to have five main functions: first, to allow her to feel ‘real’ again once she had numbed herself in response to unwanted thoughts and feelings; second, to distract her from the pain of intrusive memories of childhood sexual abuse; third, to alert staff members to the danger that she felt she was in, and her need for support and understanding; fourth, to express anger and outrage; five, to gain control at times when memories and current events made her feel powerless. Taking each function in turn she was able to outline strategies other than self-harm that could achieve the same end. Although it initially appeared to be a weak alternative, Patricia developed the capacity for mental imagery and relaxation that she used to distract herself from the memories of abuse and to reduce tension and anxiety. Eleven months into the therapy Patricia informed me that she was starting to keep a diary about her memories, and the thoughts and feelings leading to her self-harming. She appeared to want to transform her mental anguish into something tangible and she could, in a sense, redirect her need to physically attack herself to doing something else with the feelings, writing them down. This seemed to be a highly significant move; she had shifted from writing on her body to writing about her body. Writing gave her an alternative method of distancing herself from the memories and also enabled her to identify patterns in her self-harm. She did not always wish to show me everything that she had written, showing how exposed she felt in relation to me, conflicting with her desire to unburden herself to me. She slowly began to allow herself to express anger at her father, and the rest of the family, whom she blamed for not protecting her from serious sexual abuse. This shift from blaming only herself for the abuse developed slowly. As this emerged she recognised that she did not need to remain emotionally numb; that it was possible to allow herself some strong feelings about her abuse, and her role in her family. Therapy continued for almost 18 months but Patricia still felt alienated, dissociated and desperate at times throughout this period. She described these experiences as similar to the feelings that she had cultivated at the time when the abuse was going on. She recognised that the ability to ‘go dead’ and become alienated had been necessary for her as a young incest victim, but also that it no longer served a useful function for her, and actually blocked the expression of her current feelings. She wanted to find other ways to let staff know when she felt pressured or ignored, and was aware that her self-injurious behaviour curtailed her degree of freedom on the ward, re-creating a situation in which she was controlled and infantilised. Although at some level this met her need for protection and concern, at another level she craved greater freedom and a degree of autonomy. Although she often felt depressed about the past she retained some hope for change. She had increasing insight into how she unconsciously re-created abusive situations, for example, through allowing sexual activity to take place with exploitative men on the

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ward, and through indiscriminate disclosure of intimate details. She felt that through her sessions with me she was increasingly able to contain her communicative needs and ‘save’ them for the sessions rather than alerting the entire ward staff to her situation. In the past she had related details of the incest to various nurses and junior doctors, eventually experiencing this as another abusive situation. Revealing painful material to several people left her feeling anxious and exposed. It also blurred the boundaries between staff members and me, her therapist, leaving Patricia confused about who could be relied on to know about and contain the anxiety and horror evoked by her experiences. There was also a seductive element in her choosing to confide in ‘special’ people. Transference issues and breaks in therapy I was aware of the danger that Patricia would enact her distress and anger about the breaks in therapy through self-harm. I emphasised the need for her to articulate her anger and disappointment in me. It was, at times, difficult to understand which significant figure in her past I became in the transference, and what kind of object I was for her. At times, particularly when there were breaks in therapy owing to holidays, I seemed to become an unprotective and abandoning mother or a confusing father who, on the one hand, offered love and interest and, on the other, appeared violent and uncaring. Patricia often praised and flattered me, revealing a highly idealised picture of me. At other times she expressed great disappointment and anger, believing that I would not keep seeing her, that I would leave her to her own devices because she was not ‘doing well enough’. I appeared at times to become a persecutory, demanding and unreliable object. In some ways even the privacy of therapy mirrored the abusive experience in its intimacy and removal from the other members of the ward. It was therefore essential to allow Patricia to discuss this and to clarify to her that the individual psychotherapy sessions were not secret, that is, that they formed part of her treatment programme on the ward and that the progress, though not the intimate details, of this work would be communicated to others involved in her care. The limited nature of confidentiality and the role of the psychologist in relation to the rest of the multidisciplinary team was made clear to her all along. It was essential that therapy was private but not secret and that I resisted Patricia’s attempt to turn me into a special person for her whom she could seduce and be seduced by. This allowed Patricia the opportunity to have an intimate therapeutic relationship that would be non-abusive but where I would not be compelled to silence. At times Patricia relied on me to communicate for her to others and it was clear that protecting her physical and mental health meant being able to tell other members of the team how she was feeling. My countertransference feelings for her were primarily protective but she also occasioned disappointment and anger when she self-harmed. I felt at those times that I had let her down and that she was actually attacking me for this perceived failure. In the transference I had become the unprotective mother who could not prevent Patricia’s body from injury and, in a sense, I was being attacked; Patricia psychically split off her body from herself, identified her female body with mine, the symbolic maternal body, and then attacked it through her self-strangulation. My sense of being attacked was a powerful communication about the motivations for Patricia’s self-harm. I interpreted this in therapy as Patricia being angry with a weak mother who could not and did not stop the sexual abuse, just as I was not always available and able to stop her self-harm. By

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telling me about her self-harm she was both punishing me for my impotence and, more hopefully, letting me know that she was at risk, so that I could help her. Outcome of therapy Patricia did not stop self-harming altogether during the course of psychotherapy but there were fewer instances recorded during the time when she was engaged in therapy and over the course of the first year after ending therapy. She developed the confidence to let staff know when she was distressed or anxious, and to say when she did not want to go into details about her memories and experiences. She began to take more care of her physical appearance, washing her hair regularly and gaining some weight, although she still went through periods of ‘forgetting’ to eat. She was significantly more assertive in her interactions with staff and patients. She made direct eye contact with others and her speech sounded more distinct and adult, less like that of a self-conscious young girl. She was eventually discharged from the secure unit to live in a hostel. It was reported by hostel staff that she still self-harmed at times of crisis but the frequency of these occasions was much less than when she had first been admitted to the secure unit. Although we had continued to meet during her preparation for leaving, over a period of a further six months, Patricia chose to see me only infrequently once she had left the unit, feeling that to return for regular outpatient appointments would stigmatise her and tie her to secure services. She did not seem aware of the unconscious meaning of her choice of words, and I wondered whether ligatures had represented a form of connection to the unit, and to a sense of being cared about. It seemed significant that she chose ordinary material, particularly torn from sheets, with which to self-harm, as though alerting the ward staff to the sense of danger she perceived in the bedroom, and how the provisions she was given could be harmful. At follow-up she continued to maintain progress although she had not entirely given up self-strangulation at times of acute stress. For Patricia to relinquish her self-strangulation completely would have meant sacrificing one of her most powerful forms of expression. It appeared that while she could reduce her reliance on self-harm she could not altogether abandon it. Such acting out might be viewed as a contraindication for treatment in traditional psychoanalytically informed therapies; in the context of the containing environment of the regional secure unit I did not take this view and attempted to work with her to understand the meaning and function of her behaviour, and to develop other ways of coping with and expressing anger and despair. The intensity of the feelings of depression and anxiety giving rise to self-harm abated considerably during the course of therapy as Patricia was able to work through her experience of childhood sexual abuse. I was informed by a psychodynamic model of understanding her unconscious communications and their effect on me and the multidisciplinary team. Her self-harm seemed powerfully linked to her experience of incest, expressing her sense of guilt, anger, helplessness and depersonalisation.

Discussion Feeling real: an attack on depersonalisation Miller and Bashkin (1974) describe this function of self-harm in an account of depersonalisation in patient F: ‘F mutilated himself to rapidly terminate states of acute

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depersonalisation characterised by feelings of unreality, deadness and depression, of being outside himself and not in full control of his actions’ (Miller and Bashkin 1974:641). One of the central functions of self-harm is to regain a feeling of ‘being real’ in people who feel that they are no longer engaged in the world, and who have lost the sense that they are experiencing sensations and emotions. They feel numb and detached from others, describing the return of sensation as being one of the most important aspects of their self-harm. Psychic withdrawal from the world can be defeated through the physical engagement that self-harm provides. In a sense, the act of self-harming is a hopeful one, indicating a desire to return to the world and to restore the capacity to feel, not least by finding a symbolic method of communicating distress. It has been suggested that for some self-harmers the sensation of pain during the act is greatly reduced or negated altogether; this has been corroborated by women’s own descriptions of self-harming. For others, the experience of sensation, even if painful, is an attempt to restore their sense of feeling and reaffirm their own existence. For those who have been traumatised in childhood, depersonalisation, the experience of feeling not real, not inhabiting one’s own body, has served the essential function of affording escape from potentially intolerable situations. At times of stress and unhappiness in their current lives this defence may be reawakened, with the resulting feelings of being unreal and unable to engage with others. This defence may be useful for a short period of time but may become deadening, and seem inescapable. It is at this point that self-harm may serve to effectively bring the person back to life. The function of self-harm, and its communicative validity, should not be overlooked in the attempt to prevent it. The behaviour cannot simply be dismissed as a pathological example of an inability to cope, or a masochistic perversion. Patricia often described feeling unreal and confused, sometimes wondering if she was still a little girl or a fully grown woman. She had feelings of being ill at ease in, and uncomfortable with, her body and this sense of a split between her mental and her physical state was unpleasant and disturbing for her. Self-harm allowed her to feel that her mind and body were connected. As a child she had relied on this capacity to split off mentally from what was happening to her body and to ‘float away’ to other places, to dissociate herself from the intrusion, distress and pain of her father’s sexual assaults on her. As an adult she employed the capacity to separate herself mentally from her environment in order to cope with stressful situations, but then found this psychological distance frightening and confusing, intensifying her sense of isolation and alienation. The strategy that had been crucial for survival in childhood had become confusing and frightening in adulthood. Selfstrangulation was her chosen antidote, enabling her to feel that she could reengage in the world and that her body was under her control. Distraction Patricia found the planning and execution of self-injury helpful in distracting her from emotional pain. It also helped her to unify body and mind. By focusing on her physical pain she felt relieved of mental pain and reassured that her body was hers and could be controlled and manipulated by her mind and that it could experience sensation. At times when she felt most depressed and anxious she became tempted to self-harm. She focused on the images of the act. The ideas of going to her room, ripping some material, tying the

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ligature and gradually increasing the pressure became powerful preoccupations; at times of intense anxiety she said she thought of little else, imagining precisely how she would harm herself. Acting on this fantasy brought mental relief and physical sensation together, allowing her to feel that she was ‘normal’ and real, that she existed. It would also bring a tremendous sense of relief from the tension, anxiety and depression she frequently experienced, particularly when images of the sexual abuse intruded on her. The long periods spent alone on the ward were times when the memories became particularly oppressive and frightening. Communication The communicative function of Patricia’s self-injury was clear; she was informing staff that her current feelings of anxiety and unhappiness endangered her. She was also communicating her experience of pain, related to the memories of the incest; she was inscribing her suffering on her body, using the language of violence and mutilation. Susan Bordo describes the gesture of protest that such violence constitutes: ‘a steady motif in the feminist literature on female disorder is that of pathology as embodied protest—unconscious, inchoate and counterproductive protest without an effective language, voice or politics but protest nonetheless’ (Bordo 1993:97). Patricia’s self-harm was, in part, an expression of anger at the staff and those close to her who betrayed, disappointed and hurt her. This anger was too dangerous to be expressed to them directly and she displaced it instead on to herself, thus finding an indirect mode of communication. When she tied ligatures around her neck or cut herself she was making a public statement. In the past her father had hurt her in secret, making it impossible for her to let anyone know what was going on. She was making public her private experience and showing that she was, literally, a damaged object who needed care and help. The nursing staff response to her self-harm provided important information about the nature of Patricia’s communication, as expressed through self-harm. This will be discussed further in the section entitled ‘Countertransference issues’ (see pp. 222–6). Self-injury as expression of anger: displacement Patricia’s self-injury expressed the anger that she harboured towards her father who had abused her, psychologically, physically and sexually, and towards those family members who had failed to notice her abuse or protect her from it. The significant figures in her current life who had failed her also generated considerable feelings of anger, to which she rarely gave voice. Her frequent self-harm attempts reflected her degree of self-blame and anger at herself for allowing the abuse to take place and, she believed, for being the kind of person who had attracted this sexual activity and interest. She accepted her father’s distorted reasoning that she was responsible for the abuse. She often blamed herself for the incest, reproaching herself for wearing nice clothes, scent and pretty underwear. She called herself a ‘dirty slut, a whore’, as her father had done while abusing her. She described these statements as critical intrusive thoughts that preoccupied her. Deliberate self-harm followed apparently trivial disappointments and perceived rejections. She selfinjured at times when the intrusive and negative thoughts became intense and persecutory. This allowed her to punish herself for being a ‘dirty slut’ as well as

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channelling the anger that she felt towards others, so that her father, mother and brothers could survive. Self-injury attempts also followed disagreements with ward staff that evoked fears in Patricia of what her anger could do to people on whom she relied. On occasions when she felt let down and hurt, her anger was so intense that she found it necessary to deflect it on to herself, on to her own body that she felt had already been defiled and violated. Her self-harm could be viewed as manifesting the defence of identification with the aggressor. In order to alleviate the pain of victimisation Patricia identified with her father, using her own body as an object to be treated with contempt and violence, as he had. Patricia’s use of violence against herself did not preclude the use of violence against another person, as illustrated in her index offence; this had been triggered by her boyfriend becoming aggressive and making sexual demands. Although she mainly turned anger against herself she had stabbed this sexual partner, in an apparent displacement of the rage that she felt at her father, and in the context of her own alcohol abuse. That she stabbed her boyfriend, penetrating him with a knife, has obvious symbolic significance. It reflected her profound difficulties in sexual relationships and her confusion of her boyfriend with her father: she associated her sexuality with deviance and shame. There was also a homicidal aspect to her destructiveness; the homicidal urge that underlies suicidal behaviour was manifest in her index offence. Her feelings of guilt and self-blame for the abuse still plagued her. She worried about how her disclosure might destabilise the family to the extent that she still did not want her mother to know that incest had taken place, seeking to preserve the illusion of a happy family. Her placement in a secure psychiatric unit, however, stigmatised the family and raised questions about its functioning, drawing attention to the fact that something awful had happened within this apparently happy family. Assertion of control In some ways Patricia felt that through self-harm she was branding herself, and asserting the fact that her body, if not her mind, was her domain, over which she could exert control. It was an attempt to reclaim ownership and control over her body and to assert that she, not anyone else, had the right and power to touch it. She displayed her bruising with a degree of pride that conveyed this, and did not believe that her self-injuring was out of her control or a suicidal gesture. She felt that it literally tied her to reality and also brought tremendous and necessary relief from the psychological pressure that she faced. Her anger, she felt, was justified and needed to be demonstrated. Interestingly, this particular expression of anger was a potent symbol for the whole staff team, who became preoccupied with preventing her from self-harming, while finding it difficult to think about what it symbolised for her. Countertransference issues The nature of the institutional response to Patricia’s self-harming, like the nature of the communication, was not primarily verbal but found its expression through behaviour and through the emotional quality of the interactions with Patricia. She became a central

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figure, who would require much discussion in ward rounds and staff handovers, generating heated debates about how best to manage her self-injurious behaviour. Her self-harming behaviour, coupled with her vulnerability and dependence, contributed to a powerful re-creation on the ward of her earlier experience of abuse. Her behaviour and her psychological functioning had a powerful effect: the nursing staff responded by taking on roles in relation to her that mirrored her earlier experiences. The nurses, Patricia’s main carers, became either the punitive aggressors, who could not see her pain, or, if they could, blamed her for it, or the unprotective mothers who could be vigilant only after their child was hurt. The nursing staff who wanted to be with Patricia and observe her every action were behaving like the guilty mother who has failed to see what is happening to her child and whose protectiveness comes too late. The constant presence of nurses was also intrusive, reminiscent of the father who had not allowed her any privacy. The male staff felt uncomfortable with Patricia, alternating between feeling overprotective of her or becoming drawn into a flirtatious relationship with her. The defence mechanism of projective identification was illustrated in the way that the nursing staff were not only receptacles for Patricia’s powerful projections, but also integrated these projections into themselves and behaved accordingly, becoming the persecutory figures who inhabited Patricia’s internal world. The staff members may have had benign and helpful motives in relation to her, but without the necessary opportunity to reflect on their responses they reinforced Patricia’s disturbance, mirroring earlier experiences, without helping her to gain insight into it. The pull of her distress was simply too great to resist. She successfully evacuated her anxiety into staff, as she evacuated her mental distress into and on to her body. In an important sense her self-harm contained a significant degree of aggression towards those who were required to manage it, and who were reminded of their inability to do so whenever she self-harmed. The staff group was dramatically split in their understanding of and attitude towards Patricia. An example of this was found in the ongoing disagreement between the consultant psychiatrist and the registrar attached to his team about how best to manage her self-harm attempts. The consultant was in favour of ensuring that one-to-one observation continued for 24 hours a day, for an indefinite period of time, while the registrar believed that this was unhelpful and infantilising; she felt that Patricia should be referred for specialist psychoanalytic psychotherapy outside the unit. Decisions were often postponed while staff at all levels argued about appropriate policies in relation to managing her self-harm and ensuring her safety. Protection and control were concerns that could not easily be reconciled with Patricia’s need for privacy and increasing levels of freedom. It became difficult for staff to feel confident enough to test out whether she had gained sufficient control of her behaviour and mood to make it possible to consider her progress through the unit. For weeks no specific policy or decision would be made as the debates continued. The splits in nursing and professional staff can be read as clues about the patient’s disturbance and seen as the externalisation of the fragmentation of her own internal world. Patricia rendered the ward staff impotent because she was able to re-create the family dynamics in that sexual abuse of a child can occur, where the secrecy and silence surrounding the activity render those who could help paralysed and ignorant. Patricia was symbolically asking the staff member whom she had told about her self-injury to take notice of her pain and help her to manage it. She was not simply reproaching the staff but

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warning them to be aware of her fragility and difficulty in managing her fear and anger. She was also giving them an opportunity to repair her psychic damage. If they could be vigilant enough to see when she was distressed and speak to her instead of ignoring her, they could help her to articulate her despair rather than enact it through self-injury. In this sense the act of self-injury in the context of the secure unit was a hopeful gesture, inviting staff to help her to understand and contain unhappiness and anger. Patricia did not always disclose that she had hurt herself immediately but on those occasions when she did she was symbolically violating the secrecy of the incest situation. The function of her self-harm was that she could re-create the relationship between her childhood self and her father in the current relationship between her body and herself, only now she could become the aggressor. Once she had self-harmed she was able to show other people evidence that she had been harmed, in the hope that they might help her and protect her from further pain. She was mastering her earlier trauma, playing an active rather than a passive role in relation to her body. She was, literally and figuratively, writing on and with her body. Patricia’s compulsion to self-harm was multiply determined. She responded to boredom, frustration and conflict in her environment and also to feelings of unhappiness and anxiety generated by her thoughts. It reflected her need to re-create the abusive situation in order to master it in adulthood; self-harm provided a means by which staff could be transformed into significant figures from her childhood. By simply listening without attempting to punish or protect her, the nursing and medical staff could help Patricia to come to terms with what had happened to her. This perspective was difficult for staff to maintain when confronted with their feelings of inadequacy and distress about not preventing her self-harm. It was easier for staff to respond actively to the behaviour than to reflect on it, because of the degree of anxiety that her self-mutilation evoked. This type of task-orientated response to anxiety has been powerfully described by Menzies Lyth (1959) in her exploration of social norms in nursing as a defence against the anxiety of getting too close to the patient’s painful experiences. Some nursing staff also perceived triumph and hostility in Patricia’s disclosures that she had self-harmed in secret and they had been powerless to prevent it. This seemed to them to be a sadistic reproach, an accusation that they had failed her. Staff response was either to become angry and punitive towards her or to become overprotective and anxious, checking on her every move, therefore infantilising her. The split in the staff group mirrored the split within Patricia and the difficulty that she had integrating the aggressive and dependent aspects of her personality. The difficulty that both Patricia and the medical and nursing staff had in understanding the contradictory aspects of her personality reflected the psychological consequences of her sexual abuse in childhood. In some ways Patricia seemed to be developmentally fixed at age 11, as though the trauma of sexual abuse had interfered with the emergence of an adult personality. On the ward she behaved and was treated like a vulnerable child or adolescent rather than an angry and powerful adult woman. Being infantilised created a situation in which she could not acknowledge her feelings of rage against her father. She continued to turn this anger against herself and used herself, specifically her body, as the receptacle for her violent impulses and only very gradually gained insight and control into the reasons for her self-harm. She could then develop another voice, becoming able to articulate her thoughts and memories rather than enacting them.

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The effect of deliberate self-harm on nursing staff The countertransference feelings towards women who self-harm are powerful and it is essential that supervision is provided in which the clinician can address this. The urge to protect self-harmers and, alternatively, punitive feelings towards them, are to be expected in undertaking treatment with this client group. The impact of a self-injurious action on nursing staff can be profound. A central question for any staff team is how to deal with and appropriately manage self-injury. The crucial importance of the relationship with healthcare professionals relates to the needs of the patient for ideal care and protection that were not available in her early life, and which are invariably disappointed. The carer is idealised and then denigrated, particularly if she responds to the patient’s vulnerability by colluding with and maintaining a ‘special’ relationship in which boundaries are overstepped (Adshead 1997). Staff working with women who self-harm can alternate between feeling drawn towards them in a protective capacity or horrified and repulsed by them. They often feel helpless, anxious and incompetent as a result of the patients’ projections. Those members of the nursing staff who have to stitch a patient’s wounds, or find her in a nearly strangled state, will often feel physically affected themselves. To some extent the staff can also be viewed as victims in the self-harm attempt; they are assaulted with the horror and pain that patients who self-harm are not able to contain themselves and have projected on to and into the staff who treat them. Such patients can also create situations in which they are themselves treated sadistically, often because of the strong feelings that self-harm creates in those around them. In this case they become victims of their own and others’ sadistic impulses and re-create the situation of their original trauma. This can be understood as the compulsion to repeat, demonstrating that an underlying conflict has not yet been resolved or, more benignly, as an attempt to master the trauma through recreating the original situation but hoping for some resolution of the conflict. Therapists and all members of the multidisciplinary team need to resist the force of these projections in order to understand them and help the self-harming woman to understand herself, and manage her destructive impulses. In her excellent analysis of the difficulties for nurses of working with severely traumatised women in secure settings, Anne Aiyegbusi writes: Women receiving care and treatment in secure environments present with a complex range of needs that are hard to meet. For nurses this is made especially challenging both by the nature of the nursing role and by the fact that their main therapeutic tool is the nurse-patient relationship. Anxiety based on early trauma with the caregivers is stirred up in the patients. The only means patients have of communicating their distress is to make the nurses who care for them suffer emotionally. However, if nurses can learn to contain the patients’ projections, therapeutically meaningful work can take place. (Aiyegbusi 2004:119)

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Summary of treatment models A psychological model of self-harm should highlight the significance of the development, function and maintenance of self-harm for a particular woman, within a particular context. I have provided an extended case study to show the complexity and overdetermination of such cases, and to highlight indirectly how different kinds of violence can coexist. Patricia had suffered from anorexia in adolescence, regaining weight led to the onset of her self-mutilation; she went on to stab her boyfriend, and became dependent on self-strangulation when an inpatient in a medium secure unit. The scars she had from cutting into her skin might serve as memories that she needed to record and inscribe. The secondary gains achieved through self-harm, and the absence of alternative modes of self-expression, can be important in maintaining the behaviour. Selfharm is multifactorial and can occur as a response to intrusive and frightening thoughts or memories or even in response to command hallucinations in psychotic illness. Patricia’s self-harm seemed to be a symbolic request for containment of her aggressive impulses through external care and control because of her lack of faith in her own capacity for internal containment. Cognitive behavioural therapy and dialectical behaviour therapy A psychological model has been proposed that stresses the significance of obsessive thoughts in the generation of self-harm and applies cognitive behavioural techniques to the treatment of self-injurious behaviour and dissociative symptoms. This model emphasises the cognitive processes leading to self-harming and advocates the woman’s own identification of the thoughts leading to such behaviour, helping her to identify alternative methods for coping with stressful intrusive thoughts. Kennerley (1996) outlines this approach, describing the treatment of self-mutilation and dissociation through cognitive behavioural therapy. Linehan (1993) has developed a cognitive behavioural treatment approach, dialectical behaviour therapy (DBT), designed for use with self-injuring women; this has proven efficacy in treating individuals with borderline personality disorders. Linehan’s approach challenges the therapeutic nihilism surrounding the diagnosis of borderline personality that so often accompanies self-injurious behaviour. This nihilism is further challenged in the Department of Health document Personality Disorder: No Longer a Diagnosis of Exclusion (2004). Linehan argues that the diagnosis of borderline personality disorder is one that does not preclude the possibility of making changes in the behaviour of those individuals, challenging the critique made of the notion of borderline personality as pathologising women who have experienced trauma, and who express these effects in their behaviour. The strong link between childhood sexual abuse and the diagnosis of BPD has led critics of the diagnostic term to suggest that another diagnosis is given, which emphasises the association of the traumatic experience and the development of behaviour such as self-injury and severe disturbances in interpersonal relationships with difficulty in retaining a stable sense of identity. Such a diagnosis might be ‘posttraumatic syndrome’. Linehan notes an important overlap between self-injury and the diagnosis of BPD: ‘most individuals who engage in non-fatal self injurious behaviour and most individuals who meet criteria for BPD are women’ (Linehan 1993:4).

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The cognitive behavioural treatment programme she has developed for individuals with borderline personality, DBT, is primarily directed at women who display selfinjurious behaviour, using a wide range of cognitive and behavioural strategies to address the problems of BPD, including self-injurious behaviour. Techniques such as problem solving, exposure techniques, cognitive modification, skills training and contingency management form the core procedures in treatment, that has the advantage over other therapeutic endeavours of being empirically evaluated: it was found that there were significant gains over one year, many of these were maintained at follow-up, but Linehan is herself cautious about the strength of these findings, based only on a sample of 72 women: Our data do not support a claim that one year of treatment is sufficient for these patients. Our subjects were still scoring in the clinical range on almost all measures. Second, one study is a very slim basis for deciding a treatment is effective…much more research is needed. Third, there are few or no data to indicate that other treatments are not effective…no other treatments have ever been evaluated in a controlled clinical trial. (Linehan 1993:24) The techniques of DBT have been outlined in training manuals, and Linehan and her colleagues offer workshops to clinicians who are interested in attempting to work therapeutically with those diagnosed with BPD. While the therapeutic optimism of the approach, and its openness to empirical testing and evaluation, are valuable aspects of this approach, it remains open to the criticism that it situates self-injury within the psychopathology of BPD, locating it within a particular psychiatric paradigm and ignoring its traumatic roots. To locate it thus is to miss the complexity and symbolic quality of this form of self-expression. The psychiatric model The psychiatric model emphasises the role of personality disorder that develops in response to particular developmental difficulties and a disturbed early environment. The competing hypotheses of self-harm as a symptom reduction strategy and as the manifestation of poor impulse control are offered, and it has been suggested that there are distinct population groups for whom self-harm serves different functions. For the group diagnosed with BPD self-harm occurs primarily in response to internal problems, i.e. symptoms of anxiety or depression, while in another less disturbed group, self-harm occurs in response to external triggers. The main criticism of this model is that it emphasises individual psychopathology at the expense of recognising the profound meaning and communicative function of self-harm and its cultural context. Psychodynamic psychotherapy and mentalization-based treatment More recently Bateman and Fonagy (2004) have developed an approach to working with women with diagnosis of personality disorder, often with histories of self-harm, using the model of treatment they have developed, that integrates an attachment perspective and

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psychodynamic principles. There is already some evidence that this approach is effective in reducing impulsivity and enabling women to contain their impulses to enact violence, towards themselves and others. Most significantly this work is operationalised and there are ongoing training workshops on the technique held at the Anna Freud Centre, London, enabling staff teams to gain an informed understanding of the development of such difficulties from the perspective of disturbed early attachments, and to learn how to approach treatment of these women with sensitivity to the role of trauma. The aim is for the women themselves to develop the capacity to mentalise their emotional states rather than enact them. The work is also subject to ongoing evaluation and provides a hopeful example of evidence-based practice that incorporates psychodynamic perspectives. Over the next few years increasing numbers of women who have histories of self-harm will be in units that are informed by attachment modes of care, and it will become possible to evaluate the efficacy of mentalization based treatment further. This a positive move against what was the therapeutic nihilism surrounding the notion of personality disorder. Psychodynamic perspectives highlight the elements of secrecy, risk taking, guilt and ritual which are powerful factors in deliberate self-harm and in other perversions. Selfharm is a defence against intimacy, binding a woman to her own body to the exclusion of others. These aspects of ritual, excitement and secrecy, as well as the short-lived but powerful sense of well-being immediately following an episode of self-harm, serve as important and intoxicating ingredients that perpetuate the cycle. This model also emphasises the role of early experience in the development of later disorder, and the symbolic meaning of self-harm; its role as the embodiment of trauma is seen as central. In psychodynamic psychotherapy conflicts relating to early experiences can be articulated, understood and resolved. The psychodynamic treatment of self-harm in a ward setting Interventions intended to increase therapeutic engagement with patients and cause a reduction in their self-harm behaviour are described by Cremin et al. (1995) who used a psychodynamic treatment perspective to address self-harm in a unit specialising in the treatment of people with personality disorders. This unit was intended to address the needs of people aged 17 to 30 with an entrenched pattern of impulsive and self-destructive behaviour. The authors noted that self-harm escalated following admission and that nursing attempts to increase surveillance and curtail freedom simply resulted in ‘a hostile stalemate. It was as if the patients’ sole ambition was to defeat the staff by dangerous gestures approaching a final act of freedom, the threat of suicide’ (Cremin et al. 1995:237). Instead of persisting with this approach to treatment, with which patients were dissatisfied and staff frustrated, a new programme was introduced. A psychoanalytic perspective on self-harm, viewing it as a compulsion to repeat, was chosen as the theoretical foundation on which to base a treatment intervention. This intervention involved a preliminary pre-admission assessment in that the admitting team would, under the supervision of a psychotherapist, arrive at a psychodynamic formulation of the self-harming behaviour. This formulation was used to inform the meaning of further acts of self-harm and to anticipate the probable effects on and reactions of the staff, primary nurse and team. This approach identified various functions of self-harm for the patient

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and anticipated the roles that the nursing staff would be tempted to enact, fulfilling the patient’s unconscious needs and repeating aspects of her history. By identifying these prior to admission, the patient’s attempt to re-enact or repeat aspects of her early life could be thwarted and alternative solutions to the patient’s difficulties presented. This treatment intervention was based on a recognition of the psychological make-up of people with BPD and the effect that such people can have on the organisation in which they are placed. The defences employed to defend against psychic pain, including splitting of the ego (Freud 1940) and projective identification (Klein 1946; Bion 1959) are described and the effects of this on the nursing system anticipated. The authors describe how these individuals create powerful and destructive relationships with others: The means by which a person may defend him or herself from feelings of rage, helplessness and betrayal can lead to sadomasochistic relationships with significant others, including nurses. Such relationships tend to be highly addictive as the person employing these defences becomes excited and triumphant, but also unconsciously frightened of the consequences of their actions and therefore cannot give them up. So, for example, relentless, escalating, cruel attacks on the nurses’ concerned attempts to offer help and care not unnaturally drive nurses to despair and to hate the patient (Winnicott 1949). Thus, defences, initially intended to protect the patient from psychic pain, can give rise to dangerous situations spiralling out of control. (Cremin et al. 1995:238) The transference relationships created by the unconscious needs of these patients, rather than being seen as obstacles to treatment, were used to develop an understanding of the patients’ internal world. Even splits in the nursing staff that may be created by the task of caring for patients who employ these primitive defences can contribute to an understanding of the patients’ psychological functioning. In Cremin et al.’s study the nursing staff were given intensive training and education in understanding the genesis and function of self-harm, using a psychoanalytic model, and were guided in developing a comprehensive picture of the various roles they were invited to play. This is a valuable example of a sensitive and informed treatment approach. A feminist approach: understanding the reasons for self-harm Deliberate self-injury often requires an immediate medical or nursing intervention but the staff team may fear that responding too readily to self-injury may actually reinforce the behaviour and escalate the self-harm. This fear can be alleviated through a sensitive understanding of the motivations behind and functions of self-harm for a particular individual. Significant feminist research has been undertaken in high secure hospitals by Liebling and Chipchase (1992) and Liebling et al. (1994) who have examined the reasons why women say that they self-harm and staff perceptions of self-injury and its function. They state that while the problem of self-injurious behaviour in women has been well documented, ‘the understanding of this behaviour is minimal and effective treatment and management programmes are lacking’ (Liebling and Chipchase 1992:19). Such

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behaviour is often dismissed as ‘attention seeking’ and ‘manipulative’ and therefore not requiring serious psychotherapeutic treatment. Self-injurious behaviour by female patients is a frequent problem in special hospitals in general (Burrow 1992). Liebling and Chipchase (1992) had provided invaluable data about the prevalence, assessment and treatment of self-harm in female patients in Ashworth Special Hospital. Sellars and Liebling (1988) compared male and female patients in Broadmoor Hospital, all detained under section 3 of the Mental Health Act. This study revealed that 88 per cent of the women compared with 15 per cent of the men had exhibited some form of self-injurious behaviour during their stay at Broadmoor. This raised questions about whether the difference in self-injury rates reflected a difference in levels of depression or clinical disturbance in men and women, or whether there were other factors at play, such as gender differences in the expression of distress. Cookson (1977) studied female prisoners and identified a number of factors as possible risk factors for self-injury. She argued that for some ‘intro-punitive’ women, self-injury generates a punitive social response that would in turn encourage further selfinjuries. This social response was seen as positive. Self-injury both distracted the individual from profound psychological distress and provoked a response from her environment. This allowed women to gain a sense of control that reduced their feelings of helplessness and depersonalisation. The pilot study conducted by Liebling and Chipchase (1992) showed that staff perceptions of the motivations and functions of self-injury largely correlated with those cited by the self-harming patients themselves. Their research into the backgrounds of female self-harmers in special hospitals revealed the extent of the abuse, both sexual and physical, in the backgrounds of these women, highlighting the link between childhood abuse, particularly childhood sexual abuse, and self-harm. They describe the various losses that these patients had experienced since being admitted to the special hospitals, including their removal from social support networks, families of origin, relationships, and, often, the removal of their children from their custody because of concerns about possible risks to the children posed by these women. In the context of tremendous losses and helplessness, self-harm may be the only means by which some degree of control can be reclaimed by the women, and some ownership of their own lives asserted. The authors emphasise the importance of working with staff groups to educate them about the causes of self-injury and to offer support when dealing with emotionally distressing and physically abhorrent injuries. In terms of treatment options for the selfharmers, the model of a supportive psychotherapy group is favoured and the emphasis is on enabling the women to discuss why they self-injure and helping them to develop alternative ways of coping with unmanageable feelings. Liebling and Chipchase (1996) outline the significance of supportive interventions and reflective spaces with the staff who work with women who self-harm, providing them with opportunities to discuss their feelings, and helping them to understand the motivations for self-injury. The therapeutic approach to working with self-harm should address the underlying problems that lead to the self-harm behaviour, rather than simply focusing on the self-harm itself. A thorough assessment of the problem is a prerequisite, as is the importance of staff remaining non-judgemental and accepting of self-harm behaviours. Focusing on the distress underlying self-harm allows staff to keep moral judgements in check. Self-harm should be viewed as a meaningful communication about psychological distress and therefore it serves a valuable function. This view is not always

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easy to accept, particularly for staff who treat the results of self-injury, and it can be the first step towards helping the woman to deal with underlying unhappiness and distress in other ways. This mirrors Aiyegbusi’s (2004) notion of containing patients’ projections. Liebling et al. (1997a, 1997b) stress that treatment for self-injury should be based on understanding why women self-harm and what factors maintain this behaviour. They have drawn up a semistructured questionnaire that can be used as a guide in drawing up care plans and identifying treatment aims. They ask the women the following kinds of question: 1 When did you start self-harming? What was happening in your life at that time? 2 How did self-harm help you to cope with your life at that time? How does self-harm help you to cope now? 3 What situations currently lead you to feel like self-harming? 4 How do you feel before you self-harm? What thoughts run through your mind at these times? 5 How do you feel after self-harming? 6 What helps you to cope with feelings of wanting to self-harm? (Liebling 1995) Underlying these questions is an acceptance of self-harm as a way of coping and a desire to enable women to identify alternative ways of communicating feelings. Liebling and her colleagues found that the therapeutic needs of women who self-harm were not being adequately met. They identified nurse training as an important area to focus on in the development of comprehensive and sensitive therapeutic programmes for women in special hospital settings (Liebling et al. 1997b). Liebling et al. evaluated group therapy for women who self-harm, expressing the view that this type of treatment, based on qualitative information about the development and function of self-harm for individuals, was helpful for women in special hospitals.

Conclusion The need for a psychological treatment model A psychodynamic understanding of the meaning and origins of self-harm will enhance a psychological formulation of the problem by drawing attention to a woman’s underlying distress rather than simply focusing on preventing the behaviour. It is essential to view self-harm, including anorexia, as a solution to a particular psychological conflict or crisis. Therapy can assist the woman who relied on this solution to develop other less destructive ways of resolving her crises and articulating her distress. Therapy should be informed by a sensitive, non-judgemental attitude to the behaviour, regardless of the theoretical orientation of the therapist. The feminist research provides an invaluable guide

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to understanding the meaning of self-harm, avoiding the discourse of psychiatric pathologising. Any thorough psychological formulation must identify factors in the background and current situation of the woman who self-harms in order to understand the function of self-harm in the present and the historical antecedents that gave rise to the underlying thoughts and feelings. Psychological treatment, whether along psychotherapeutic, attachment based or cognitive behavioural lines, requires a comprehensive understanding of the particular occasions that give rise to self-harm, and how it is manifested. The feelings producing self-harm are explored and the woman who self-mutilates will be encouraged to express her feelings verbally and to identify underlying thoughts about deserving to be punished, or needing to keep her suffering silent and secret. There is a vital role to be played by organisations such as the Bristol Crisis Service for Women, who provide a telephone crisis line to support self-harming women in the community and information for their friends and relatives. It is clear that therapists, nurses, social workers, probation officers, youth workers, psychiatrists and general practitioners would also benefit from informed, compassionate training programmes to enable them to identify and treat self-harm, both in the general population and in prisons and psychiatric hospitals. The NICE (2004) guidelines on management of treatment for those who self-harm recommended further qualitative research to evaluate service users’ experiences of mental health therapies and provision. Current research with women in secure units who have been able to stop self-harming reveals that the development of a stable, trusting relationship with a therapist, nurse, or other patient, plays a central role in this (Grocutt 2007). Clinical psychologists and psychotherapists have an important role to play in psychiatric units, where they can offer multidisciplinary staff training, assistance and supervision in understanding self-harm, assessing the aetiology of the problem for particular individuals, and designing and evaluating treatment programmes and ward policies for dealing with self-injurious behaviour. The woman’s use of her body, her secret weapon, can eventually be talked about explicitly in therapy. The opportunity to discuss her feelings can be helpful in reducing her need to show her pain and relieve her anxiety and tension through self-mutilation. She can be helped to find other ways of articulating her distress and other methods of relieving anxiety, depression and anger. The therapist should also take into account the environment in which the woman finds herself, and the particular function that self-harm serves within this setting. The issue of control within an oppressive institution can be explored within a psychological model of self-harm. Countertransference responses to the self-harming or anorexic patient will be powerful as therapists working alone, or a ward-based team, become witnesses to the violence that women inflict on themselves. Close supervision and proper training of nursing staff are essential when working with self-harming women, who generate both powerful protective and punitive feelings in therapists, which threaten their capacity to think clearly about how best to approach them. If the communicative function of self-harm is to show what cannot be spoken about, this must be recognised and responded to. In order to build a therapeutic relationship with the patient it is crucial to convey to her that her pain is recognised and can be understood.

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This can be the first step towards the woman being able to articulate her feelings as it generates faith in the possibility of communication. Women who were sexually abused and had to bear the burden of secrecy may have lost hope that their experiences can be spoken about to others. They may feel unable to think or speak about their histories of abuse and instead enact them. Women locate their sense of identity in their bodies, which can be their most powerful tools of self-expression. For many women, painful experiences are literally inscribed on their bodies. When their histories of abuse, neglect and trauma are written on their bodies these narratives must be decoded and understood.

Chapter 7 Anorexia nervosa One of the cruellest forms of attacking the body is to starve it, depriving it of the nutrition that it requires for life. It expresses violence towards the self. The object of hostility in this case is the woman’s own body, representing the mother’s body. As Welldon states: In female perversion not only the whole body but also its mental representations are used to express sadism and hostility. Women express their perverse attitudes not only through but also towards their bodies, very often in a self-destructive way. If we look at the psychopathologies most frequently associated with women, we find syndromes of self-injury associated with biological or hormonal disorders affecting the reproductive functioning. Such is the case with anorexia nervosa, bulimia, and forms of self-mutilation, where the menses, their absence or their presence, may act as indicators of the pathological condition. These women experience a feeling of elation from the manipulation of their bodies when they are starving, and which disappears when they start to eat again. They experience a sense of power through being in control of the shapes and forms their bodies assume as a result of the physical injuries and abuse they inflict on themselves. (Welldon 1992:34) Like other manifestations of self-harm, anorexia nervosa can be viewed as a communicative attempt, and as a solution, no matter how potentially dangerous maladaptive, to a central conflict or difficulty. For those women who are required to be very thin because of their professions or aspirations, for example, modelling, ballet or athletics, anorexia may develop out of the need strictly to restrict eating. The sense of control that this provides can become an end in itself. Anorexia nervosa is generally considered to be multifactorial in aetiology. It is a selfperpetuationg disorder, in that factors which were not central at the outset eventually assume a significance which contributes to its maintenance, such as the powerful sense of mastery afforded by ‘successful’ starvation and weight loss. Initially, at least, social admiration for this successful transformation of the self may also fuel the drive. The shared nature of the compulsion, particularly amongst adolescent girls can be a powerful factor in perpetuating the disease to which the recent popularity of anorexia websites and chatrooms testifies. Being an anorectic has its own identity and provides a clear and potent focus to life during the turbulence, insecurity and self-questioning of adolescence. In this chapter I focus on the understanding of anorexia as an expression of female violence against the self. Eating disorders in general are found far more frequently in women than in men, and the average age of onset of anorexia nervosa has been found to

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be 18 (Crisp 1995:22). It is a disorder which often begins in adolescence, occurring much more commonly in females than males, and has been conceptualised as a response to the changes in body shape and weight which occur in puberty. Its description in the Diagnostic Statistical Manual-IV (APA 1994) specifies that the absence of menstrual periods is one of the essential criteria for diagnosis of the disorder, as is the refusal to maintain body weight within the normal range. I will also discuss the cognitive behavioural approach and its treatment implications as well as considering systemic and feminist understandings of anorexia nervosa. Treatment of anorexia nervosa is known to be difficult, as the anorectic will often not recognise weight loss as a problem and will resist treatment of the disorder. I will briefly describe the main psychotherapeutic models of treatment, namely individual psychotherapy, cognitive behavioural therapy and family therapy, as well as drawing attention to particular difficulties faced by therapists who work with anorectic women.

DSM-IV classification of anorexia nervosa Anorexia nervosa is a recognised syndrome which has been classified in the DSM-IV according to the following criteria: (a) Refusal to maintain body weight at or above a minimally normal body weight for age and height (e.g. weight loss leading to maintenance of body weight less than 85% of that expected: or failure to make expected weight gain during period of growth leading to body weight less than 85% of that expected). (b) Intense fear of gaining weight or becoming fat even though underweight. (c) Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on selfevaluation, or denial of the seriousness of the current low body weight. (d) In post-menarcheal females, amenorrhoea, i.e. the absence of at least three consecutive menstrual cycles (a woman is considered to have amenorrhoea if her periods occur only following hormone, e.g. oestrogen, administration). Specified type: restricting type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge eating or purging behaviour (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas). binge eating/purging type: During the current episode of anorexia nervosa the person has regularly engaged in binge eating or purging behaviour (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas). (APA 1994:544–5)

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Anorexia and female violence against the self Anorexia is an act of violence against adult female sexuality in its creation of an amenorrhoeic state: it is a denial of women’s reproductive capacity and a refusal to relinquish the comparative androgyny of childhood. It reflects an attempt to defy the natural processes of ageing which psychoanalysts have linked to a disturbance in the process of separation from the mother: I would say that anorexia nervosa is more than a disorder in the psychological meaning of body weight or a disorder in relation to food. It is an attempt to annihilate the very nature of human existence—inequality, progression through the life cycle, death…one component of this state of affairs lies in a disturbance in the areas of symbolisation connected with a lack of a ‘transitional space’ with the primary object. (Birksted-Breen 1997:118) Women can carve their bodies into objects of desire and trophies testifying to their selfcontrol and self-sacrifice through anorexia. The target of this act of destructive selfcontrol is the body; the weapon is her mental control over her appetite. This control offers the anorectic woman a sense of power and mastery within the private sphere of her own body. It often develops at a point in the life cycle when teenage females are struggling to individuate themselves from their mothers, in families in which their bodies are actually not considered to belong to them, in enmeshed family systems where boundaries between parents and children, and between siblings, are blurred. It can be a powerful weapon and means of control within this family. Anorexia appears to express internalised rage and is a form of assault on the self; it is a clear illustration of the model of female violence proposed by Welldon (1992). The virtual addiction of some women to self-starvation demonstrates the compulsive quality of this form of activity. Lawrence (1984) describes the anorexic woman’s use of her body as a form of communication with a text and a subtext. While the apparent text may read that the woman is powerful and in control of herself, the subtext reveals a different message about feeling powerless: ‘I am weightless/worthless; I am empty/nobody. That is what my behaviour is all about…I am doing this because I feel so helpless that not even my own body belongs to me’ (Lawrence 1984:24). The anorectic women themselves initially only recognise the apparent text, but after the euphoria fades and the reality of the disorder dawns on consciousness they start to be aware of this subtext, and of underlying motivations in starvation. The link between anorexia and aggression has been well described. Anorexia nervosa is potentially a life-threatening condition. Hughes warns: Patients with anorexia nervosa show real and alarming behaviour to the point of self murder, and it is important that both the impulse to damage the self and to sabotage the therapy are addressed. These are not idle worries: one in six anorectics dies either from illness resulting from starvation or by committing suicide…this patient’s therapy is a life and death matter. (Hughes 1995:48)

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Anorexia and the model of female perversion I must stress that the notion of perversion is not a moral one, nor a condemnation, but is descriptive of a mode of functioning which essentially precludes the possibility of intimacy with another person. The body is used as a means to an end, and treated with a degree of sadism; in this sense it is a vehicle for perversion. The powerful functions of anorexia and its communicative value are evident. The cycle of perversion described by Welldon (1992) takes as its starting point a woman’s low self-esteem and sense of guilt which engender feelings of worthlessness, depression and and a pervasive sense of emptiness. These feelings are managed partly through a retreat to a fantasy world of imaginary activities. When the depressive feelings threaten to overwhelm her, a woman may act out these fantasies, which temporarily provides an exhilarating escape from distress and emptiness. These are essentially forbidden activities, prohibited by the ego and by social norms, which may have been internalised in the superego, or conscience; there is a sense of a compulsion to act despite some awareness that to do so will be dangerous. The activities are performed secretly, which itself creates thrill and excitement. Eating in front of others is fraught with difficulties. The hostility of the eating disorder is directed towards the self, towards the mother, as she is symbolically embodied in the woman’s own body. It is also directed towards others, who are kept at a distance by the woman’s narcissistic immersion in anorexia. Underlying this aggression is the fear of being submerged or engulfed in an intimate relationship. The perversion is essentially narcissistic, in that the woman is immersed in her own fantasies, and activities, to the exclusion of anyone else. It has been suggested that this escape from intimacy is one of the main functions of perversions (Glasser 1979), and that anorexia nervosa enables its sufferer to retreat from the terrors of sexual relationships and anaesthetise the self against painful emotions (Malan 1997). The object of a perversion is tortured and kept at a distance: in the case of anorexia this object can be identified as the appetites of the body itself, symbolically represented through food. The anorectic can engage in a complex deception in which she either pretends to eat, when watched or actually eats, but later, in secret, purges, literally emptying herself of the food. Purging does not necessarily accompany anorexia, but as the DSM-IV description makes clear, it is a feature of one type of anorexia: it has been suggested that diagnosis of anorexia nervosa without this type of dietary restriction is increasingly rare. The anorectic may occasionally binge eat and then purge. She may also hoard food, without actually eating it, surrounding herself with forbidden objects (Crisp 1995).

Distinction between bulimia nervosa and anorexia nervosa In bulimia nervosa the distortion of body image, severe restriction of food intake and amenorrhoea that characterise anorexia nervosa are absent. Bulimia nervosa is characterised by an excessive intake of food followed by purging, through vomiting and/or laxative abuse. Bruch (1985) suggested that bulimia nervosa should not necessarily be considered a clinical entity in its own right: ‘I have grave doubts that bulimia is a clinical entity. Compulsive overeating may occur in different conditions and with different severity’ (Bruch 1985:12). This approach has shifted dramatically and

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bulimia nervosa is now recognised as a separate clinical entity. As the DSM-IV classification of anorexia nervosa makes clear, purging can also be part of the anorexic syndrome. Bulimia nervosa can exist as a separate disorder, in which the body image distortion is absent. Like anorexia it is characterised by an overvaluation of weight and shape, and an engagement in dietary restriction, which in the case of bulimia is an alternation of binge eating and purging. Wilson describes bulimia as a loss of control over eating and the expression of ‘chaotic dietary habits…with binge eating and compensatory purging’ (Wilson 1999:582). Bulimia nervosa is further distinguished from binge eating disorder, which is characterised by recurrent episodes of binge eating without the extreme attempts at dietary restriction seen in anorexia and bulimia nervosa. Generally, bulimia nervosa is not considered to be as dangerous a disorder as anorexia nervosa, which is associated with mortality and, as such, is a potentially fatal condition. In one sense, anorexia nervosa can be construed as an attempt to annihilate or kill off the body, through denial of its needs, as expressed through hunger. Bulimia nervosa can be seen as an ongoing abuse of the body, a kind of sadistic alternation of gratification and deprivation of the body, in which food is rammed into the body in a frenzy and then violently removed, through a purge. The guilt of eating is expiated through the purging, which may occur in secret, so that the bulimic may give the appearance of enjoying food and eating ‘normally’. Bulimia can therefore be understood in relation to the model of female perversion, with its characteristic secrecy, deceit and violence towards the self. In bulimia and binge eating food is gorged and frantically crammed into the body, without a sense of internal limits, and little awareness of the feeling of being full; this can be likened to a sexual frenzy, in which the climax is indefinitely postponed. Bingeing has often been rehearsed in fantasy before it takes place, it is an example of acting out perverse fantasies that appear to offer an escape from depression and feelings of emptiness. Although the excitement of enacting the perversion offers short-lived euphoria, this soon subsides and gradually the sense of depression returns, with an intensified sense of guilt and self-loathing as a result of having enacted the fantasy. The starting point of the circle is again reached and the perverse cycle is reinforced. At the moment of frenzied eating there is an absence of symbolic thinking. The inner sense of emptiness is concretely managed through bingeing, rather than being understood as something psychological, to do with states of mind. Anorexia as a disorder of adolescence Anorexia nervosa often begins in adolescence, and is much more common in girls than boys, reflecting the adolescent girl’s struggle to retain her childlike state and to assert control over her body and, indirectly, over those around her, who become witness to her self-starvation. The cultural ambivalence towards women’s bodies and their procreative capacities, which are both idealised and denigrated, is a significant reason for female anxiety about weight and size (Maguire 1995:186). Laufer and Laufer (1984) identify adolescence as a time when hormonal changes create an excited longing for sexual and physical intimacy; this is overwhelming for vulnerable young women who perceive their bodies as being out of their control. Their deep fear is that these strong desires become ‘indistinguishable from a desperate longing

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for regressive intimacy with the parent, in an idealised fusion with the parent, which is both desired and dreaded’ (Hughes 1995:48). The attempt to starve herself is a young woman’s attempt to kill off the longings of the pubertal body, and return to the comparative safety of the child’s body. The force of her longing for sexual intimacy comes from her infantile wishes for her mother’s body, and her murderous feelings towards the mother who frustrates these desires. Anorexia can stem from guilt feelings about violent fantasies relating to the mother. Adolescence is a time when biological, hormonal changes create an intense need for physical contact, reawakening infantile needs for intimate contact with the parent. It has been referred to as the second phase of individuation, in that, once again, the child must negotiate the task of separation from the parent (Blos 1967). Separation difficulties frequently occur in women with eating disorders including anorexia. Contemporary object relations analysts link somatising pain to the dilemma of the young woman who must differentiate herself psychically from the mother with whose body she identifies. This process of psychic separation is lifelong and unresolved conflicts in relation to the mother will resurface and intensify at crucial points of the life cycle, that is, puberty, pregnancy and the menopause (Pines 1993). This has been outlined in Chapter 1. Birksted-Breen describes the central conflict for the anorectic woman: The anorexic’s wish for, and fear of, fusion with her mother… anorexia can be seen as a girl’s attempt to have a body separate from her mother’s body, and a sense of self separate from her mother, the pathological nature of this attempt arising from the very lack of achievement of such separateness prior to adolescence. (Birksted-Breen 1997:105) A young woman’s abuse of her body therefore expresses her ambivalence about identifying with her mother’s body: starving herself is a symbolic assault on the mother’s body. Williams describes anorexia as the young woman’s refusal to allow a foreign object into her body and links this, in some cases, to an earlier experience of being used to contain a parent’s anxieties (Williams 1997). Anorexia is described as having a ‘no-entry’ quality. Rather than the parent containing and making manageable the difficult psychic experiences of the child, the child has been used to perform this function for the parent. Because of her developmental stage, and the fragility of her own psychic apparatus, she is unable actually to contain these projections: she does not yet have the capacity for containment. The child was used as a dumping ground for her parent’s anxieties: A pervasive symptomatology with a ‘no-entry’ quality can represent a defensive system developed by a child who has perceived himself/herself (early in infancy) to have been invaded by projections. These projections are likely to have been experienced by him or her as persecutory foreign bodies. The ‘no-entry’ syndrome performs the defensive function of blocking access to any input experienced as potentially intrusive and persecutory. (Williams 1997:121)

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Malan (1997) describes the repression of sexual drives through the rigid control of appetite; in this sense, sexual feelings are represented by hunger, and successful mastery of uncontrollable appetites is attempted through anorexia nervosa. Additionally, anorexia reflects a retreat from the frightening world of relationships and provides an escape from intimacy, albeit into the claustrophobia of obsession. Malan identifies the possible sources of the self-destructive impulses associated with anorexia in terms of id, ego and superego aspects. He suggests that self-destruction is not the primary aim of anorexia nervosa, which, in fact, provides a solution for psychic difficulties, although one that will ultimately fail. He outlines certain psychodynamic aspects of anorexia, including the threatening quality of intense needs for physical closeness and satisfaction from others and the use of eating as a substitute for intimate relationships. One of the most significant functions of self-starvation is to anaesthetise the anorectic against the turmoil of emotions, which threaten her psychic equilibrium: Hunger as an emotional anaesthetic. Its aim is to defend against the hope of having these needs fulfilled, in order to avoid the disappointment and despair consequent upon their being left unfulfilled. In other words, hunger functions as a defence against all aspects of close relationships. (Malan 1997:95) Malan describes how anorexia originally develops as a solution to a psychic problem but can become highly destructive, through the force of obsessional rituals and starvation. This destructive deprivation enables the anorectic to express guilt as self-punishment for sexual and aggressive impulses as well as serving as ‘the expression of self-directed rage about disappointment in the past’ (Malan 1997:95). He does not consider the desire to kill oneself to be the primary motivation in anorexia, viewing suicide as an unintended consequence of this condition.

Pro anorexia (pro-ana) and pro bulima (pro-mia) websites The thesis of this book is that the main target of female aggressive impulses is the woman’s own body, and that such self-directed violence serves important psychological functions for the women who engage in it. It is clear that women with anorexia, binge eating and bulimia fit into this pattern and that their behaviour expresses rebellious protest as well as a desperate attempt to exert power and self-control. In the past few years there has been a proliferation of adolescent-developed websites, visited mainly by young women, portraying anorexia and bulimia as forms of underground protest or a lifestyle choice. Pro-eating disorder (pro-eds) websites are communities of individuals who engage in disordered eating and use the internet to discuss their activities. Prorecovery sites are less numerous and express a recovery-oriented perspective. These websites create strong links between anorectic or bulimic women and appear to have a compulsive power of their own. The safety of these websites is highly controversial as they appear to encourage young women to be part of a community that shares and promotes disturbed beliefs about weight, eating patterns and health (Norris et al. 2006). Although the home pages of the

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sites claim to be supportive to eating disordered sufferers rather than to cause and encourage anorexia or bulimia, this has been disputed by critics outlining the harmful effects of a forum in which eating disordered behaviour is normalised and becomes the currency of communication. The chatrooms are filled with conversations about how to continue to avoid eating, lose weight and escape detection of eating disorders. It is argued that these sites glamorise thinness and entice vulnerable women into a false sense of ‘community’ that supports the illness, rather than encouraging the women to seek help outside. Research warns that anorexia, binge eating and bulimia are conceptualised and promoted as lifestyle choices on some of these websites, rather than as illnesses with potentially fatal consequences, and there is some evidence that adolescents who visit the sites spend less time doing schoolwork than those who don’t visit the sites and are sick for longer, Until we know more about the usage patterns and health outcomes in patients who use pro-ED sites, we will not be able to assess whether true harm results from their use or which patients may be particularly vulnerable to the content displayed in these Web sites. However, these results suggest that both pro-ED and pro-recovery Web sites are frequented by adolescents with EDs, with their parents often unaware, and that their use may lead some youth to adopt unhealthful dieting practices. Future prospective studies that more objectively measure health outcomes and Internet use in these potentially vulnerable populations are indicated. (Wilson et al. 2006:1642) Some experts in eating disorders find the pro-eating-disorder sites unethical and destructive. ‘lt’s one of the few times in history that someone has come out and said that a very dangerous illness is a good idea, and here’s how to do it,’ says Christopher Athas, vice president of the National Association of Anorexia Nervosa and Associated Disorders (cited in Springen 2006). The attraction of these websites appears to come from the secrecy, the invitation to be part of something radical and the sense of security and concern they seem to offer. The names ‘pro-mia’ and ‘pro-ana’ evoke exotic female names, rather than illnesses, and can offer an isolated young girl who visits the site the hope of meeting interesting friends. The sites present the woman with an idealised image, thin and ethereal, of herself. The names of the sites reveal the obsessive drive for thinness and include ‘Thinspiration’, ‘Dying to be Thin’, and ‘Wasting away on the Web’. The ‘thinspiration’ images are photos of extremely thin, even emaciated, women whose images are intended to inspire further weight loss. Photographs of celebrities who have lost vast amounts of weight and are suspected of suffering from eating disorders are posted on various pro-ana sites. These sites often have angel, dragonfly and butterfly motifs, evoking an image of an idealised state of prepubescent innocence and an other worldly quality. One site chillingly has an image of a spider’s web with the slogan ‘Tell me it’s not worth dying for’. The romantic ideal of absolute thinness seems a denial of the corporeal and establishes the drive against hunger and weight gain as a form of spiritual quest. The recurring image of wings evokes angels, moths, butterflies and birds: fragile airborne creatures with very little substance.

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Many of the pro-ana and pro-mia sites appear, at first glance, to offer practical support and warn against the dangers of these disorders. Nonetheless there have been protests against these sites, arguments for greater regulations and claims that they never assist recovery, and in fact cause serious harm. Parents are urged to be aware not only of the existence of such sites, and whether their daughters are using them, but also to become informed about their content. Although the sites vary in viewpoint and content, it is clear that many promote anorexia and bulimia rather than recovery. The isolation that develops from eating disorders may exacerbate the fears of intimacy, making this virtual contact seductive. The nature and impact of the message given by the websites is under debate, and some proponents of free speech argue that it would be more harmful to close down these sites and force them to go underground than to allow them to continue under strict regulation. Brotsky and Giles (2007) conducted research using a participant observer to enter various websites as a supposed anorexic to investigate the nature of the psychological support offered. The result was that support for recovery was provided by some on the various websites while others were more hostile; they came to the conclusion: These starkly different responses challenge the notion of a broad “pro-ana” philosophy, suggesting that the sites are best understood as local cliques offering temporary relief from offline hostility, but it is doubtful whether they can be said to possess any therapeutic value beyond the immediate online context’ (Brotsky and Giles 2007). The websites appear to reflect the underground nature of the activity and the sense of rebelling against the desires of others who insist on ‘healthy’ weight and eating patterns. The women who write to the sites seem to identify themselves as heroines, who risk death to achieve physical perfection, and find elaborate ways to defeat hunger. The body becomes the forum for self-expression, control and punishment. Users of the websites argue that they obtain support from sharing experiences with other sufferers, but there is some evidence that adolescents who use these websites remain ill for longer than those who do not, making them less likely to seek help elsewhere. The Stanford study by Wilson et al. (2006) found that users of [pro-eating disorder] sites were sick longer and that 96% of them reported learning new tips for weight loss or purging, and 69% said had they used them. Although there will continue to be those who argue that closing down the sites will not help people with anorexia or bulimia to recover, it seems clear that these websites can perpetuate distorted and self-destructive beliefs about weight loss, serving to maintain rather than reduce dangerous behaviour. The apparent intimacy offered by fellow sufferers through these sites is mainly derived from sharing obsessive fears about eating, weight gain, and other people’s perceptions of ‘normal weight’ and swapping methods for maintaining weight loss, even when this may involve disguise and deception—hiding the activites of purging or starvation from others who would interfere. This type of ‘intimacy’ may actually serve to ward off actual physical engagement and contact with others, preserving a sense of illusory closeness in this virtual community.

Anorexia nervosa and offending behaviour In an important sense, eating disorders can be understood symbolically as crimes against the body. In addition, some women also commit offences against others or against

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property that express their aggressive feelings, and desire for compensation and punishment. The meaning of these actual crimes is complex and individual but often reveals underlying unconscious conflicts and unacceptable feelings. There are times when the public offence has a direct link to the private act of violence found in eating disorders. In the forensic population, anorexia nervosa, or a history of anorexia, is often found in women who commit relatively minor offences, such as shoplifting and theft, and also in women who commit acts of violence against others and inflict harm on themselves (Crisp 1995; Maden 1996). It can feature as part of the complex set of behaviours which are found in those women classified as ‘personality disordered’ and also occurs in the general population of young girls and women who are desperately striving to achieve an ideal state of thinness. It can coexist with other forms of self-harm, and dramatically illustrates a refusal to allow anything good or fulfilling to enter into the woman’s internal world, behaviourally enacting the psychic state in which rejection and defence are the main strategies for survival. Crisp (1995) discusses the link between hoarding and anorexia nervosa; there appears to be an important association between the act of stealing and the self-starvation of anorexia. Both stealing and punishment seeking can be associated with anorexia nervosa, as though eating itself is considered to be bad and greedy, whereas deprivation of the self is seen as good; it demonstrates strength and control. The anorectic can create a state of tension between fulfilment and deprivation of desire. At an unconscious level the anorectic shoplifter’s act of theft may serve to guarantee punishment for the crime of greed. This punishment will temporarily alleviate the guilt an anorectic feels when she eats, or otherwise desires. Stealing food has clear symbolic significance revealing eating as a forbidden activity, a transgressive act. There are symbolic links between the satisfaction of hunger and other bodily appetites, particularly sexual ones, so eating itself becomes taboo. Food must be ‘stolen’ rather than freely enjoyed. The link between shoplifting, a form of theft, and self-deprivation through anorexia is illustrated in the following case material.

Case illustration

Ruth: shoplifting and anorexia in a 32-year-old woman Ruth was referred to me for assessment of her suitability for psychotherapeutic treatment following her conviction for three charges of theft. She was a slim, anxiouslooking woman of Central European parents, who spent much of the first session in tears as she described her sense of loneliness and failure and her guilt about stealing. Although in her early thirties she dressed more like an adolescent, in trainers, leggings and a baggy tee shirt. She mainly stole food from shops and, even more significantly, only stole bags of sweets, which she would then devour on her own. She had been caught shoplifting on at least half a dozen occasions and came to me for assessment following a referral by her probation officer, whom she was seeing regularly as part of her probation order. She had never received a custodial sentence for her offences.

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It became apparent by the end of the assessment period that Ruth was suffering from an unresolved grief reaction following her father’s sudden death when she was 16. She felt guilty about having left home shortly before his death and for beginning to have sexual relationships in the few months before he died. She felt guilty much of the time and described a sense of relief when she was caught for her shoplifting, explaining that this seemed to make her feel, temporarily, less guilty. Three months after her father’s death she had developed anorexic symptoms, which had resulted in serious illnesses on three occasions. Over the past two years her weight had been stable at just below seven stone and was regularly monitored by a nurse at her general practitioner’s surgery. Her shoplifting had increased just as her weight had begun to stabilise. Although her weight had not reached dangerously low levels in the past three years, she continued to starve herself for at least two days out of every week, but would then make sure that she took in just enough not to lose too much weight. She exerted punitive control over her appetite, depriving herself of ‘luxury items’ like sweets and occasionally chocolate, but never stole anything other than this. Ruth had a younger brother with whom she had a long history of conflict and antagonism, exacerbated by her envy of his emotional detachment from his mother and his apparent enjoyment of his independent life and his own family. Ruth felt that she had been left to care for her mother while her brother was allowed the freedom to become an adult, with his own independent interests and new allegiances. Her perception was that sons were allowed to leave home while daughters were obligated to act as carers and companions for their parents, and were subject to strict control by them. She felt that she had never been allowed to leave home, and had developed few friends, interests or hobbies. Anorexia gave her a way of expressing her anger at being so harshly restricted and confined. Despite her rigorously restricted social life Ruth was fulfilled in her work as a medical secretary and formed deep attachments to the doctors in the surgery, one of whom had encouraged her to seek help for both her compulsive shoplifting of food and her selfdestructive dieting. She took great pride in her work and was extremely conscientious about it, conveying the extent to which she was capable of a high level of functioning, and the degree to which her behaviour was shaped by a fear of losing control or getting things wrong. Just as she cleaned her house several times daily, for fear of germs and contamination, she also checked through reports and letters written for the doctors repeatedly, sometimes staying in the office for hours after the practice had closed to check through her work. At the conclusion of my three-session assessment of her suitability for psychotherapy I prepared a report for the court in which I emphasised the underlying meaning of Ruth’s shoplifting (to receive punishment for her unconscious guilt) and its compulsive nature. After meeting with her I prepared a psychological report for the court, in relation to the three counts of theft for stealing confectionery and also a few cheap bracelets on one occasion. Her probation officer recommended that she receive a probation order; her crimes appeared fairly minor but she was a repeat offender. I recommended that she engage in therapeutic work addressing her underlying difficulties, and the function of shoplifting in enabling her to be punished for her forbidden impulses. It was my opinion that the best method for reducing the risk of reoffending and alleviating her psychological distress would be for her to be engaged in individual therapy addressing these issues, and

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allowing her to make links between her bereavement, her frustration about being stuck in an enmeshed relationship with her mother, and her desire to punish herself through selfstarvation and stealing. Ruth was sentenced to a two-year probation order without the condition to attend for therapy, as I had indicated that the work would be more effective if she attended out of her own volition. It was clear that to subject Ruth to a condition of treatment would be, once again, to recreate a situation of restrictiveness and render her submissive. Ruth attended therapy with my colleague reliably for over two years and did not reoffend during this time, although she continued to starve herself at times of stress and during the therapeutic breaks. She found it hard to attend for more than three sessions consecutively and would miss the following session, as though therapy, like food, was something that she needed to control and of which she would deprive herself. She used the therapy to explore her sense of anger, abandonment, guilt and confusion following her father’s sudden and devastating death. It appeared that her attack on her own body was, in part, an attack on this unreliable internal object, as well as an attempt to keep him alive, through a painful process of mourning in which healing could not occur and the loved lost object would not need to be relinquished. This process has been described by Freud in ‘Mourning and Melancholia’, in which he explores how, in suicidal patients, aggression towards the lost object is turned inwards, on to a hated part of the self: ‘the shadow of the object fell upon the ego’ (Freud 1917:258). Ruth felt that allowing herself peace of mind and bodily health would mean she would have to relinquish her father’s presence, which she experienced most powerfully when she was in a state of intense pain and anxiety. She described him as having been ‘strict but loving’ and missed him most when she was alone. Crying seemed to heighten her experience of loss and made her father seem a closer presence and his absence more deeply felt. Her anorexia meant that she was often fatigued and exhausted, which resulted in frequent bouts of crying; this gave her a sense of being connected with her father that she craved, painful as it was. During the two years of therapy Ruth did not reoffend, nor did she fall below a critical weight. She remained at home with her mother but described her attendance at the clinic as very important, saying that she looked forward to sessions and felt that they gave her something for herself. She retained, however, a firm belief that she was still heavy in spite of her obvious thinness and eating remained a preoccupation for her. She continued to feel guilty after she ate anything, despite her growing awareness that this stemmed from sources other than her relentless need for food. She did not enter a sexual relationship during this time but did form a close female friendship and began to acknowledge her sexual attraction to several male colleagues.

Discussion Understanding Ruth’s anorexia Ruth obsessively focused on her own body, treating it with a cruel degree of control. Paradoxically, she had chosen to work in an area where the ill body was the focus of attention and concern. She herself wondered whether her fascination with starving

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herself, to see what would happen, and her interest in her job, with the morbid details of illness and death readily at hand, were an attempt to understand and defeat the processes of mortality. She also wanted to find out what had happened to her father in his illness, and had a wish to gain control over inexorable processes of illness and deterioration. Although anorexia can be seen as a specific attempt to attack adult sexuality and preserve childhood, it can also be seen as a struggle to defeat the terrifying process of ageing in general, not just the reproductive development of an adult woman’s body. Like other hysterical disorders Ruth’s anorexia was an attempt to manage frightening sexual and destructive impulses through carefully constructed defences and rituals. Ruth felt that to allow the expression of her hunger would be dangerous; awareness of her body awakened her sexual feelings and stirred up underlying anger about her mother’s suffocating control over her. Her unconscious sense of guilt about these feelings could be managed through indulging and then punishing herself with food. She could only allow herself to have food that she craved, sweets, with their high calorie content, in situations where she would be punished. In this sense, her anorexia related to her fear about her own underlying impulses. She refused to take food into her body in normal amounts and became highly distressed when she felt that she had eaten too much; her self-starvation could be understood as a reflection of her fear that what was taken in would become an internal persecutor. Her appetite was related to other uncontrollable and unacceptable urges and impulses, i.e. to sexual and aggressive feelings. Sweets represented indulgence, greed and childish treats, all of which Ruth felt that she must resist. Her shoplifting resulted from an irresistible impulse to take a forbidden, pleasurable food, the kind of food used as a treat for children. Her stealing put me in mind of a small child, who feels deprived, stealing a special treat which she wanted, but she did not deserve. When she was caught, she felt like a naughty child who would be taken away and kept out of harm’s way, as though she were being sent to her room. A part of her craved this infantilising experience, in which she could feel that her own impulses would be kept under external control, and that her dangerous desires would not lead her into trouble. She was freed from responsibility and could be temporarily cocooned in an enclosed space, without the temptation to behave like an adult. Eating sweets was, like sex, a forbidden pleasure: Ruth could only allow herself tiny tastes of this and had to create a situation where fulfilling her desires would result in punishment, maintaining this constant tension between wanting and denying. She did not allow herself to have sexual relationships, finding it very difficult to forget what she considered the catastrophic consequence of her adolescent sexual relationship—her father’s death. Underlying her self-denial was a desperate sense of deprivation and a longing to escape the claustrophobia of her relationship with her mother. Using her own body as an object to be tortured, denied food, and then teased with forbidden indulgences was her only way of asserting this autonomy, and reminding both herself and her mother that her life was, in fact, her own. Relation of Ruth’s anorexia nervosa to her shoplifting It seemed that Ruth’s shoplifting represented a conscious but compulsive act over which she had little control. Both shoplifting and self-starvation appeared to be motivated by an

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unconscious need for punishment and related to her entangled relationship with her mother, which had interfered with her capacity to separate from her and establish an adult identity. Ruth’s anorexia expressed her need to control her body, to enact violence against herself, particularly her sexuality, which she felt had led her astray, away from her parents. She retained an omnipotent fantasy that her attempts to separate from her parents had somehow caused her father’s death and that he could not survive without her. She had unexpressed rage against her mother which she enacted on herself. She inflicted the violence of starvation on herself with relentless cruelty, becoming wholly absorbed in the fight to restrict her food intake. She perceived hunger as a tormentor, against which she had to guard. Her anorexia, guilt, sexuality and shoplifting were intimately connected, representing her conflicting drives and impulses. Her ongoing concerns were with staying thin at any cost and with pleasing her remaining parent, her mother, with whom she had a very enmeshed relationship. The process of separation from her mother had been abruptly and irrevocably interrupted by her father’s death and in a powerful sense Ruth still behaved like an adolescent daughter, a ‘good girl’ who stayed at home with her mother rather than pursuing her own social life. Her sphere of autonomy and control was her own emaciated and deprived body. Significance of stealing Shoplifting can itself be understood as a symptom of underlying distress, reflecting the dissatisfaction and rebellion of apparently very compliant and respectable women, waging a private war against the hypocrisy and constraints of their circumstances. It has been described as an unconscious protest against the ‘sociological false self’ demanded of women: This facade is about being sweet natured, kind, quiet, considerate and nurturing to others. With women shoplifters this facade seems taken to an extreme and adopted unknowingly, unconsciously. Whilst most women knowingly adopt and play these roles, suffering guilt about their hypocrisy in doing so but being trapped by social expectation to continue, women shoplifters seem unconscious that their roles are merely a false sociological self. (Knowles 1997:211) Stealing is fundamentally the act of taking something that one doesn’t have a claim to; it is clear that for women like Ruth the appetites, for food, sex or life itself, are disavowed and can only be satisfied indirectly and surreptitiously, through theft.

A personal account of anorexia nervosa Sufferers of anorexia nervosa and bulimia nervosa often describe how they feel possessed by these disorders, which become the governing principle of daily life. In her moving

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autobiography Marya Hornbacher vividly describes her immersion in both activities and compares the murderous nature of her anorexia with the less dangerous violence of her bulimia: What I am about to say is tricky, and it is a statement about my own relationship with bulimia and anorexia. Bulimia is linked, in my life, to periods of intense passion, passion of all kinds, but most specifically emotional passion. Bulimia acknowledges the body explicitly, violently. It attacks the body, but it does not deny. It is an act of disgust and of need. This disgust and this need are about both the body and the emotions. The bulimic finds herself in excess, too emotional, too passionate. This sense of excess is pinned to the body…the bulimic impulse is more realistic than the anorexic because, for all its horrible nihilism, it understands that the body is inescapable…The anorectic operates under the astounding illusion that she can escape the flesh, and, by association, the realm of emotions. (Hornbacher 1998:93) Throughout her memoir Hornbacher explores the complex and deeply absorbing nature of her eating disorders, describing her total immersion in both anorexic and bulimic behaviour and the power of the obsession that she developed with food and her own body, specifically the cruelty with which she inflicted starvation upon herself. She describes her awareness of her violent impulses towards herself, her risk taking and impulsive sexual promiscuity with great clarity and insight. She acknowledges the violence and the deceptive quality of eating disorders, and how their danger can be denied: I had a clear, haunting knowledge that my eating disorder was cruelty. We forget this. We think of bulimia and anorexia as either a bizarre psychosis, or a quirky little habit, a phase, or as a thing that women just do. We forget that it is a violent act, that it bespeaks a profound level of anger toward and fear of the self. (Hornbacher 1998:123)

Models of anorexia nervosa Family dynamics and anorexia nervosa: link with sexual abuse There is empirical evidence that unwanted sexual experiences are associated with eating disorders. It must be borne in mind that these associations may be correlational rather than causal, i.e. both may occur with a high degree of frequency in the female population (Calam and Slade 1987). Calam and Slade suggest that the link between the development of an anorexic eating disorder and unwanted sexual experience within the family might be a form of punishment directed towards either the abusing or the nonprotective parent. They propose a linear model of the causal direction of the anorexic symptomatology:

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Unwanted sexual experience Ļ Dissatisfaction with self, body Ļ Desire to alter body Ļ Dieting Ļ Eating disorder According to this model a change in eating behaviour can have an important function within the family system in that a degree of control is thus exerted by the abused young woman, who becomes the focus of concern. The anger about her victimisation is expressed indirectly at those who had enabled her abuse to take place: her own body becomes the conduit for the expression of anger, and in a sense she reclaims it as her own. A cognitive behavioural formulation of anorexia nervosa Although a psychoanalyst, Hilde Bruch, has been credited with laying the foundations for cognitive behavioural accounts of anorexia nervosa through her clinical observations which emphasised the importance of these patients’ thinking style: she identified the ‘paralysing sense of ineffectiveness, which pervades all thinking and activities of anorexic patients’ (Bruch 1973:254). The emphasis on the thinking patterns of the anorexic and the possibility of applying the principles of cognitive theory and cognitive therapy, as proposed by Beck et al. (1979), were further developed by Garner and Bemis (1982, 1985) and laid the foundations for current cognitive behavioural approaches to the understanding and treatment of anorexia nervosa. Anorexia is conceptualised by cognitive behavioural theorists as an expression of ‘an extreme need to control eating’ which is maintained by the rewards of self-control, so that it becomes a self-reinforcing activity, in which the physiological effects of starvation and the social rewards of thinness also contribute to the maintenance of the disorder (Fairburn et al. 1999). Fairburn et al. (1999) propose a cognitive behavioural formulation of anorexia nervosa which highlights the significance of anorexia as a means of gaining a sense of selfcontrol, placing emphasis on this aspect of the disorder over other features, previously identified as key factors to be modified through treatment. This new emphasis on anorexia nervosa and self-control informs the treatment: Features which need to be addressed (in typical Western cases) are the use of eating, shape and weight as indices of self-control and self-worth, the disturbed eating itself and the associated extreme weight-control behaviour, the body checking and, of course, the low body weight. In contrast, we suggest that low self-esteem, difficulty recognising and expressing emotions, interpersonal problems and family difficulties, all of which are targets of the leading cognitive behavioural approach…do not need to be tackled unless they prevent change. (Fairburn et al. 1999:10)

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Cognitive behavioural treatment emphasises change in behaviour and thoughts about the need to control eating and weight loss; it focuses attention on the conscious function which anorexia serves for the individual, that is, the need to assert control through relentless dietary restriction. The underlying premise is that anorexia nervosa is characterised by an extreme need to control eating, and that the feeling of self-control afforded by self-starvation is itself reinforcing. Abnormal concerns with shape and weight are not given as central a role as earlier conceptualisations of the disorder such as that proposed by Garner and Bemis (1982, 1985). This new conceptualisation would account for the prevalence of anorexia disorder in some non-western societies in which shape and weight concerns are not part of the disorder, highlighting that the social concerns with appearance are not the only causes of the disorder. The cognitive behavioural conceptualisation of anorexia nervosa proposed by Fairburn and colleagues provides an interesting model of the maintenance of the disorder. This conceptualisation informs treatment of those patients who do not present with other disturbances and personality difficulties, and who would be likely to benefit from this approach. It is worth noting that the developmental aspects of the disorder are not given primacy in this model, and the reasons for the choice of the body as the forum for the expression of self-control are not explored. Furthermore, the success of cognitive behavioural approaches in treating anorexia nervosa has not yet been determined and as such ‘its efficacy remains in question’ (Wilson 1999:79). The as yet unproven efficacy of cognitive behavioural treatment of anorexia nervosa is in contrast to cognitive behavioural treatment of bulimia nervosa which has long been the treatment of choice and has proven efficacy (Wilson and Fairburn 1998; Wilson 1999). Cognitive behavioural treatment of bulimia nervosa has been demonstrated to be more effective in the short term than psychotherapies to which it has been compared. Earlier studies on the efficacy of behavioural modification (without the cognitive therapy component) in treating anorexia nervosa have demonstrated that while it can result in weight gain during the hospitalisation of patients, upon discharge from hospital they lose weight and relapse, leading to the conclusion by Garfinkel et al. (1977) that ‘patients gain weight rapidly with this treatment and that, although not proving harmful, there is little evidence to suggest that it is superior to other conventional therapies. Not all patients with anorexia nervosa require or benefit from behavioural modification’ (Garfinkel et al. 1977:327). In general, treatments for anorexia are required to be longer term than treatments for bulimia nervosa and cases with early onset and short duration have the best prognosis (Fairburn et al. 1999). The low prevalence of anorexia nervosa, less than 1 per cent, makes it difficult to recruit participants for controlled studies and this has contributed to the absence of research relating to the comparative efficacy of various treatments of the disorder. When anorexia nervosa occurs in conjunction with other manifestations of severe disturbance, such as other forms of self-harm, psychotic episodes or antisocial behaviour such as arson, it is one aspect of a constellation of difficulties, all of which require articulation, understanding and, ultimately, treatment. Isolating the anorexia nervosa or introducing a behavioural modification programme may be perceived as persecutory by the anorexic woman herself, and engender feelings of helplessness and loss of control in her only sphere of influence. Treating the anorexia nervosa works against the woman’s

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conscious desire to remain thin at all costs, and conflicts with her needs. The treatment model proposed by Fairburn and colleagues aims to address this by focusing on the anorexic patient’s sense of self-control and her thoughts about her need for extreme control over eating. The cognitive behavioural model of anorexia nervosa proposed by Fairburn and colleagues has implications for treatment of the disorder. While respecting the value of this approach for certain individuals, I suggest that there are complex and symbolic uses of anorexia nervosa which cannot always be addressed or articulated through a cognitive behavioural approach. For patients who present with a constellation of difficulties, and for whom anorexia may be one among many forms of self-expression and acts of violence, a psychotherapeutic approach, in which earlier difficulties with containment and symbolic thinking can be uncovered, may be preferred. Clearly, empirical research exploring treatment efficacy and differentiating between those for whom cognitive behavioural treatment may be indicated, and those for whom psychotherapy is the preferred treatment option, would be invaluable. Socio-cultural factors It is important to acknowledge the great significance of the social context in which eating disorders develop, predominantly in women, in a culture which emphasises the aesthetic ideal of slimness and youth in women, to an unrealistic and unhealthy extent. While cultural factors have an important part to play in the development of eating disorders, they are clearly not the sole determinants of these disorders: The clinical as well as epidemiological findings that eating disorders are over-represented in women have been held as the most convincing support for the view that socio-cultural factors contribute to the expression of anorexia and bulimia nervosa…Since not all women are suffering from an eating disorder it would be naive to assume that cultural factors alone can ‘cause’ the development of anorexia or bulimia nervosa. (Weeda-Mannak 1994:19) Nonetheless, the central role of the tendency to evaluate self-worth in terms of shape and weight, particularly in western cultures, is considered to be one of the distinguishing features of this disorder (Vitousek 1996; Fairburn et al. 1999). A feminist model A feminist perspective on eating disorders and the social construction of beauty suggests that all women in western societies are vulnerable to developing some degree of eating disordered behaviour, such is the emphasis on the cult of youth, slimness and beauty. While I have described extremes of behaviour, the women whose anorexia has taken over their lives and threatened their very existence, it is important to acknowledge that such disturbed behaviour can be conceptualised as a continuum upon which we, as women, all lie:

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For Orbach, anorexia represents one extreme on a continuum on which all women today find themselves, insofar as they are vulnerable, to one degree or another, to the cultural constructions of femininity…the anorectic embodies, in an extreme and painfully debilitating way, a psychological struggle characteristic of the contemporary situation of women…in which a constellation of social, economic and psychological factors have combined to produce a generation of women who feel deeply flawed, ashamed of their needs and not entitled to exist unless they transform themselves into worthy new selves. (Read: without need, without want, without body.) (Bordo 1993:47) For women who present with anorexic symptomatology, in the absence of other disorders, cognitive behavioural therapy may be effective. This therapy would challenge the woman’s accepted social constructions of beauty, and could replace these overvalued ideas with an emphasis on health and the strength, versatility and power of the mature female body. Similarly, a psychodynamic approach which helped the anorectic woman to explore the symbolic significance of her need to restrict her eating could help her to articulate her fears and accept her underlying impulses, enabling her to express in words the actions of her body. It is important to recognise that both therapeutic approaches would be in conflict with the powerful social message that equates extreme thinness with female beauty. Clearly, the more pervasive problem of oppressive social constructions of female worth, and its identification with slimness, requires powerful cultural re-evaluation. As Bordo states: ‘whether externally bound or internally managed, no body can escape either the imprint of culture or its gendered meanings’ (1993:212). This pressure is inescapable and contributes to the obsession with the appearance of the female body, for both men and women, which in turn makes self-starvation, and other forms of self-harm, expressive forms of protest. Unfortunately, the cultural celebration of weight loss tends to disguise the extreme cruelty and violence of the anorexic condition. Therapeutic possibilities What kind of therapeutic relationship can be established with an anorectic woman in the light of her intense and exclusive preoccupation with her own body, which precludes the possibility of intimacy with another? Hughes argues that the anorectic may exert a powerful effect on those around her, including her own family, and warns of the danger that the therapist will repeat these patterns, and be invited to engage in a strongly protective relationship in the countertransference: The anorectic is perhaps unique, however, in the way in which her flirting with death by starvation is both a prolonged and public act, and one in which family, friends and therapist are inexorably required to be witnesses to the self-destruction. This scenario is commonly complicated by the anorectic’s lack of concern or even euphoria about her emaciation, and apparent indifference to the prospect of her possible premature death. (Hughes 1995:49)

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Psychotherapy with an anorexic woman can be fraught with difficulties as a powerful attempt will be made to kill off the therapist symbolically, through keeping her at a distance. This will conflict with dependence on the therapist and a desire for intimacy with her. This conflict is likely to mirror the central dilemma for the anorexic woman which is the desire to be fused with the mother and the terror of this fusion, and its feared annihilation of individuality. As well as being an assault on the actual body, anorexia is also an attack on bodily representations; in this case, the representation of the adult female body of the mother. It can coexist with purging, which may symbolise the inability, literally or symbolically, to digest experiences, out of an internal feeling of emptiness and the tendency to perceive anything which comes into internal or psychic space as an intrusion, to be defended against. The therapist working with anorectics will face the difficult task of attempting to retain neutrality. She will struggle to avoid being drawn into the attempt to rescue the patient, and must not allow the therapy to be sabotaged by the anorectic’s refusal to take anything into her internal world, even the help and understanding offered by therapist. The starving patient may also engender feelings of hopelessness, fear and impotent rage in the therapist, who is faced with the prospect of the patient’s possible death, and is made witness to her ongoing self-torture. She is made to witness suffering which she is unable to prevent, and is therefore an indirect victim of the violence of anorexia. The nurturance offered by therapy can be experienced by the anorectic as a violation, an unwanted intrusion, as something good which she cannot take in. It is this ‘no-entry’ quality which the therapist must address with perseverance, sensitivity and respect, in the hope that eventually the anorexic woman will allow herself to engage in the therapy, and relinquish her relentless assaults on her own body.

Conclusion Anorexia nervosa can be conceptualised as a woman’s assault on her own body, particularly against her adult female sexuality, with its reproductive capacities. It can be viewed as a dramatic expression of violence against the self, and against the mother, with whose body the woman identifies. It reflects unconscious murderous feelings both towards the mother and towards the self. I consider the model of female perversion illuminating in its exploration of the dynamics of anorexia: it emphasises the symbolic and unconscious meaning of the behaviour as an assault on the body of the mother as represented through the self. Anorexia may also symbolise the hope of the adolescent girl for immortality, as she attacks her reproductive capacity to defy ageing and death. The narcissistic immersion in the self, in the body as the source of all meaning, is an essential aspect of the perversion evident in anorexia: The sickness occupies your every thought, breathes like a lover at your ear; the sickness stands at your shoulder in the mirror, absorbed with your body, each inch of skin and flesh, and you let it work you over, touch you

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with rough hands that thrill… Nothing will ever be so close to you again. You will never find a lover so careful, so attentive, so unconditionally present and concerned only with you. (Hornbacher 1998:125) Like other forms of self-harm, the meaning of anorexia or bulimia for a particular woman needs to be understood: in its extreme form it signifies much more than simply the desire to conform to an accepted notion of beauty and desirability. It expresses a private and symbolic violence.

Part III Violence against others

Chapter 8 Battered women who kill The idea of woman as killer challenges popular beliefs about femininity. Women kill infrequently but the rarity of the occurrence often fuels the repugnance. There is still shock value in women, the begetters of life, taking a life. (Kennedy 2005:196)

Introduction The notion of woman as killer is abhorrent to cherished beliefs about femininity, as Helena Kennedy so clearly expresses above. The fact that women are more likely to kill within the family than a stranger contributes to the horror and bewilderment that surrounds female homicides. In considering women who kill, psychodynamic questions emerge. These include the question of what is actually being split off and killed off through the murder, in terms of the killer’s fantasy. Addressing unconscious issues in killing requires an understanding of how it can be an enactment of a primitive defence mechanism whereby an aspect of the self, threatened with annihilation, retaliates through murder. The act of killing can be experienced as a temporary escape from this danger and may appear to ensure psychic survival. This apparent solution is short-lived, however, and the internal dangers return; the initial euphoria recedes and depression threatens. Women who have disturbed early experiences are more likely to enact violence than others (Browne 1987; Fonagy and Target 1999) because of the difficulties which they have experienced in integrating their murderous feelings: first, their aggression is projected into others, their violent partners, and when this becomes unbearable they retaliate through violent action themselves. There are important social and psychological factors to consider in exploring the circumstances of domestic violence and revenge. A central question of this chapter is why women, when they do kill, are more likely than men to kill intimate acquaintances and spouses or family members than strangers; this is in stark contrast to the male pattern of murder (Home Office 1998, 2003). I address the psychological motivations and social situations of battered women who kill their abusive partners and their subsequent disposal by the courts. In these cases I argue that the plea of self-defence on the grounds of provocation could offer a satisfactory alternative to the pleas of murder, or manslaughter on the grounds of diminished responsibility; the UK courts do not yet readily accept this, for reasons that Kennedy links to stereotypical notions of victims and perpetrators: ‘all the same stereotypes blight the justice system’ (Kennedy 2005:196). This is yet another unhappy manifestation of the denial of female violence and the oscillation between idealising and demonising women. In this chapter I do not provide an exhaustive account of female homicide, but focus on

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those cases where the former victim of violence, the battered woman, becomes the perpetrator of violence in an act of fatal retaliation. This chapter looks at the prevalence of the crime and psychological models for understanding it, using illustrative case studies. In order to understand what leads battered women to kill, it is necessary to understand the dynamics of abusive relationships; a case study illustrates the difficulties of a woman abused by multiple violent partners and the psychological consequences of repeated abuse. A further case illustration describes a battered woman who killed her violent partner.

Prevalence Statistical figures reveal that women are still much more likely than their male partners to be victims of fatal assault within the family (Home Office 1993, 1998). When they are victims of homicide women are far more likely than men to be killed by their former partners and lovers. The homicide figures from 2005–2006 show: Fifty-four per cent of female victims knew the main or only suspect at the time of the offence. Of these female victims acquainted with the suspect, 61 per cent were killed by their partner, ex partner or lover. By comparison, 38 per cent of male victims knew the main or only suspect, and of these male victims 12 per cent were killed by their partner, ex-partner or lover. In 2005/06, 219 men (44% of all male victims) and 83 women (33% of all female victims) were known to have been killed by strangers. The proportion of female victims killed by strangers in 2005/06 is higher than in previous years because of the effect of the 7 July London bombings. (Home Office 2007:9) The finding that over half (61 per cent) of female victims were killed by current or former partners compared to only 12 per cent of men demonstrates the greatly increased risk for women that they will killed by intimate acquaintances and accords with previous figures: In 1997, just over half of male victims (54 per cent) and nearly four-fifths of female ones (79 per cent) knew the main or only suspect before the offence took place. While only eight per cent of men were killed by former partners or lovers, the figure was considerably higher for women (47 per cent). (Home Office 1998:70) Men were much more likely than women to be killed by strangers: 31 per cent of men were killed by strangers in contrast to only 12 per cent of women in 1997; over the five-year period between 2001–2006 43 per cent of males compared to 27 per cent of female victims were killed by strangers (Home Office 2006).

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Analysis of the criminal statistics reveals that although children are more likely to be killed by men than by women, and that women are more likely to be killed by men than men are by women, but that when women do kill they are far more likely to kill their spouse, an intimate acquaintance or family member than a stranger. It is worth bearing in mind that the major proportion of violent crimes, including homicide, are perpetrated by men and that men are more likely to be convicted by a court than women. In 1997 in cases of domestic homicide, 167 women were charged and 74 per cent were convicted, in contrast to 521 men who were charged with domestic homicide, of which 91 per cent were convicted. From 1991 to 1997 the courts in England and Wales dealt with male and female suspects differently: Males are more likely to be convicted than females, and the conviction is more likely to be for murder than for manslaughter. Furthermore males are more likely than females to be sentenced to immediate custody for manslaughter (immediate custody is mandatory for a murder conviction), and to be sentenced to a longer term. (Home Office 1998:71) The figures in 2005–6, insofar as the cases were completed by the time of publication of the statistical records, supported the earlier disposal patterns: almost twice as many males as females indicted of homicide were convicted of murder. For those suspects where proceedings had concluded, 230 were male and 14 female. Over half (53 per cent) of males indicted of homicide were convicted of murder, 28 per cent were convicted of manslaughter and 16 per cent were acquitted. For females indicted, 29 per cent were convicted of murder, 43 per cent of manslaughter and 14 per cent were acquitted (Home Office 2006). The group most at risk of being killed were children under the age of one year. There were 38 infants per million under the age of one who were victims of homicide in 2005–6 and 58 per million in 2002–3. (Home Office 2004, 2006) The most vulnerable group is males under the age of 1 where the figure rose to 43 per million. D’Orban (1990) reviewed the incidence, characteristics and patterns of female homicide, with special reference to England and Wales. He found that the male:female ratio for homicide offences was similar to the ratio for other offences of violence, but that murder was almost exclusively committed by men. In the 1980s the annual average of female murder convictions was only 6.5 per cent of the total of murder convictions per annum. Wykes (1995) found that females committed relatively more homicide offences related to mental disorder (i.e. diminished responsibility, manslaughter and infanticide) than men, that they had a better chance of acquittal of murder, and that they were more likely to be dealt with by a probation order than by imprisonment. About 80 per cent of the victims of female homicide are family members; 40–45 per cent kill their children and about one-third kill their spouse or lover (Wykes 1995).

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The trap of violent relationships To what extent can it be said that a woman who ‘chooses’ a violent partner is aware of her actions and to what degree does she contribute to the violence? Does she have the option to leave earlier in the relationship or is she making a conscious choice to stay in a high-risk relationship? Is she implicitly condoning the violence through her apparent decision to stay? These questions relate to the extent to which women in violent relationships lose their capacity to make real choices or exercise their autonomy. There are psychological, social and economic factors that are highly relevant to the continued dependence of some women on partners who may be violent and emotionally abusive.

Learned helplessness and depression A clear understanding of how victims develop particular responses to unpredictable aggressors over time, and how distorted their thinking may become about the options available to them, is relevant to the current debate concerning legal defences for killing an abusive partner. The development of learned helplessness and depression has been identified in the psychological literature relating to battered women who remain in abusive situations (Walker 1984; Browne 1987). The women who enter into relationships that are already violent, or which become abusive over time, often have certain vulnerability factors in their own backgrounds that, in combination with certain social stressors, make it more likely that they will have an unplanned pregnancy in adolescence and develop depression in adulthood (Harris et al. 1987). One highly significant vulnerability factor for depression identified by Brown and Harris (1978) in their seminal work on the social origins of depression was the experience of early maternal loss. Women who have been subject to parental violence often leave home early in an effort to escape the stressful situation. In the context of this need to escape from unhappiness their choice of partner may be somewhat indiscriminate. The person who appeared to offer sanctuary turns out to be an abusive or violent partner. Once involved in a relationship these women find it difficult to leave, even in the face of physical or emotional abuse, because of their lack of self-esteem, scarce financial resources, fear of letting others know about the abuse, worries about the future of their children, and dependence on their partner. Women who are repeatedly exposed to painful events over which they have no control and who have no obvious means of escape may develop the classic symptoms of learned helplessness as first identified by Seligman (1975) in experiments using laboratory animals: they become passive, lose their motivation to respond, and come to accept that they cannot take action which would allow them to escape from the painful stimuli, even when situations are introduced in which action could be taken by them to avoid them. This situation is analogous to that of women who initially attempt strategies to avoid their partner’s aggression but learn that, whatever they do, violence will result. Eventually, they lose faith in their own selfefficacy and become increasingly unable to take action, even when it could be effective. The experience of being mistreated further reinforces their low sense of self-esteem and the belief that they are powerless to alter their situation or take effective action.

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This state of ‘learned helplessness’ describes the powerful effects of prolonged exposure to uncontrollable aversive and painful stimuli and has cognitive consequences too; this sense of passivity and despair may be reflected in the way battered women appraise their situation and evaluate the avenues of escape available. Their perceptions of events become mainly negative and their sense of their own power impoverished; this attributional style is associated with depression. The abused partner ceases to take action even in situations over which she may be able to exert an influence and becomes ever more dependent and unhappy. Her victimisation results in a pattern of behaviour in which she is increasingly unable to defend herself against future abuse and a vicious cycle is established. Her attempts to alter the situation through reasoning with her partner are often ineffective and it may take third-party intervention, a serious crisis or intensive counselling to enable her to leave the situation. Sometimes the relationship will end only after the violent partner leaves or is incarcerated. Leaving will not necessarily guarantee safety. Many women who leave are stalked and hounded by their former partners until they are so intimidated that they return. Additionally, the socioeconomic and psychological vulnerabilities, including attachment disturbances and early trauma, that consciously and unconsciously drew them to this partner in the first place will be unchanged. Even if they leave one violent partner, they soon meet another, feeling unable to manage without a relationship for any significant length of time. Unfortunately the pattern of victimisation may well be repeated.

The dynamics of abuse The violent partner expresses his dominance and asserts his identity through attempting to control and master every aspect of his partner’s life. He uses patterns of coercive and violent behaviour to establish control and power over his partner (Dobash and Dobash 1979). Through creating an illusion of omnipotence his own feelings of inadequacy and helplessness are temporarily alleviated. The psychological process of projective identification is a powerful means of attempting to rid oneself of unacceptable impulses through denying them in oneself and identifying them in another. The concomitant is that, having seen these projections in another, one is then able to despise and condemn them. Klein (1946) described projective identification as an interactive process in which patients have a fantasy of evacuating unwanted parts of themselves on to the therapist, and this fantasy may be accompanied by behaviour intended to evoke feelings in the therapist corresponding to the fantasy, so that the other person begins to take on those characteristics. This dynamic not only occurs between therapist and patient but between partners in intimate relationships; it is not consciously chosen. Projective identification serves an important function, particularly in those people who are unable to bear the fact that good and bad aspects of the self can coexist in the same person. An interesting feature of projective identification is the relation of the person on to whom badness has been projected to the person who has temporarily freed himself from unacceptable impulses; he is, in a sense, impelled to behave according to the projections that he receives. The person on to whom weakness has been projected may

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find herself feeling helpless, vulnerable, weak and useless. She relinquishes any feelings of self-esteem or control, feeding into her persecutor’s distorted perceptions. This dynamic is clearly evident in the battered woman who becomes the sponge for her partner’s feelings of inadequacy and self-contempt. She absorbs these feelings, becoming increasingly depressed, while he in turn loses touch with his own feelings of vulnerability, finding his aggressive and sadistic feelings more acceptable and less frightening to acknowledge. The moment where the victim becomes aggressor, where the battered woman becomes the killer, can be seen as the moment of rebellion, of challenging the polarised and distorted roles that have been created. Just as the aggressive partner has denied his feelings of vulnerability through the battering, cruelty and intimidation, the abused partner has been allowed to deny her own feelings of murderous rage: this rage has been suppressed and her partner has enacted the feelings for her, until this explosive moment. The fear of these intense emotional states, either of murderous rage or complete vulnerability and abandonment, are actually shared by both. The polarisation within the relationship has enabled each partner to deny an important and feared aspect of the self. The relationship between abuser and victim is one in which both play an active part. The relationship is not the creation of only one person alone and it is the complex interaction between the two parties, and the participation of the victim in the relationship, which is the most complex and sensitive issue for theorists to address. There is a fear that to explore the role of the victim or her participation in an abusive relationship is to blame her for the abuse that she has suffered. But to ignore her role in the relationship is to denigrate her and to assign her to a kind of incidental role in which she is wholly passive. I have attempted to explain the interaction between victim and abuser through the discussion of psychological defences like projective identification, and will now turn my attention to the sense in which the abuser perceives himself to be, and is actually, dependent on his victim. He needs to see himself through her eyes because his sense of potency and worth is derived from her devotion to and fear of him. Browne (1987) makes the important point that the backgrounds of abusive men who become victims of homicides, and their own disrupted and traumatic experiences, put them at significant risk of entering into destructive relationships. The backgrounds of both abused and abuser can share features of trauma and violence. The victim is undoubtedly a significant person for her partner and she is aware of this. Initially, her partner may have been highly solicitous towards her, making statements of great love and dependence. Following the first violent incident he expresses profound feelings of remorse and regret, offering to do anything to make up for this behaviour and promising to change. These protestations of love and short-lived determination to change may be genuine, although difficult if not impossible to enact. The victim is aware that her partner, at least in part, feels repentant and has other aspects to his character that are deeply at odds with this destructive and frightening side. She has projected her violent feelings on to him as he has projected his feelings of vulnerability and helplessness into her. The victim may represent a desired but unreliable mother figure to the violent partner; any hint that she has her own mind or desire awakens his fear that she could abandon him at any moment. It is as though the victim’s sensitive understanding that her partner’s violence stems from his own deprivation, and that he confuses her with other significant

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and withholding women in his life, further prevents her from leaving him. The defence of identification is important here because those women who can identify with this deprivation may find it hardest to ‘disappoint their partners’ as to do so would be to recreate their own experiences of abandonment and rejection. It can be easier to forgive and understand than to acknowledge the extent to which they are being controlled and manipulated, as an object to be kept. The notion of unconscious representations of people, e.g. where a wife is seen as the mirror image of mother, is highly relevant to understanding how early experiences tend to be re-created in later life; the power of these associations is enormous. The abuser may be furious when faced with possible loss or abandonment because of his earlier experience of deprivation or betrayal. He may then displace his intense anger on his partner. He projects this blueprint of uncaring and rejecting women on to his partner and is hypersensitive to any perceived rejection or abandonment; he is looking for evidence that he is unlovable, often finding it impossible to accept it if he is shown love and loyalty. He has often had an early experience of witnessing parental violence and has learned that fathers beat mothers and often children, and that anger, shame and need are normally expressed through violence. He may perceive himself to be helpless and humiliated in relation to his partner, whom he views as virtually omnipotent, responsible for most things that bother or frustrate him. The compulsive aspect of abusive relationships relates to this unconscious fit, where deep-seated emotional needs are met and familiar destructive patterns are enacted. There is a shared dependence and a shared fear of abandonment, though not one that is necessarily articulated. The abusive relationship thus has strongly entrenched destructive dynamics, involving mutual need, making it difficult to escape from.

Violence and sadism in abusive relationships In violent relationships the abuser needs his victim to stay alive. The aggressive impulse is not to destroy her but to preserve her in order to control and hurt her, to make sure that she does not leave. It is a key feature of sadomasochistic relationships that the object needs to be kept alive to be tortured (Welldon 2002). The abuser needs his victim to be a living recipient of his torture, an available object into which to pour his self-contempt and feelings of helplessness, although at times of extreme rage he is capable of killing her. The violent man will often describe his partner as the ‘ideal woman’ whom he ‘worships’ but whom he is terrified of losing, predicting that she will ultimately abandon him. The use of sustained physical and emotional abuse and intimidation enables him to feel that he is in control of her and helps to enhance his sense of self-esteem, giving him a shortlived sense of efficacy and power.

Difficulties in leaving violent relationships Browne (1987) points out that ‘the question, “why don’t battered women leave?”’ is based on the assumption that leaving will end the violence. Her study consisted of 42 female homicides and a comparison group of 200 victims of domestic abuse who did not

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kill. Fifty-three per cent of women in the group who did not go on to kill their violent partner had left the partner by the time of interview. She points out that these women will not easily be identified as battered women because they have left after the first or second violent incident and often will not have discussed their experiences with anyone, out of shame, guilt or self-blame. In the homicide group a significant proportion of women had left their violent partners in the past, and some had even been separated or divorced for several years before the fatal incident. Browne (1987) outlines three important reasons why women do not, or cannot, leave their violent partners: 1 Practical difficulties in effecting separation. 2 Fear of retaliation. 3 The effects of severe abuse on the victim. The practical difficulties of leaving a violent partner include the fact that most friends and relations are well known to the violent partner and this makes escape tricky. The woman cannot simply vanish without cutting herself off from friends and family just at the point when she needs their support most. The violent partner is often highly intrusive, jealous and possessive and he may be well aware of the possible refuges that she would seek in a crisis. While shelters for battered women and their families do exist, they are often oversubscribed and cannot offer protection for all women who seek it. Additionally, residence in a refuge or shelter carries a degree of stigma and insecurity that may be particularly burdensome for children to bear. Arrangements for childcare and major disruptions to children’s daily routines are also important considerations for any responsible and caring mother. The battered woman may be particularly vulnerable to feelings of guilt, shame and self-reproach and feel that by leaving her partner and subjecting their children to disruption, instability and the loss of their father she is acting irresponsibly and selfishly. At the same time the desire to protect the children from violence can be the catalyst for her decision to leave. Practical difficulties When a woman has left her partner and entered a refuge or temporary accommodation with her children, she also runs the risk of a custody battle in which her husband will use the fact of her leaving as evidence of her unstable mental state, lack of compliance with social norms and disregard for the well-being of her children. He may charge her with desertion. In a custody battle these are grave allegations and could well jeopardise the woman’s future care of her children: ‘In many cases the abuser fights the woman for custody of the children, and sometimes wins’ (Browne 1987:111). This is more likely if there is no evidence of the partner’s violence against the children. The abused spouse must rely on women’s refuges or social services to house and support her. Once social services are aware that a woman and her children are at risk of physical abuse they may refer the mother for psychological assessment which may conclude that, at the time of the evaluation, she is not able to offer adequate care and protection for her children. Once again the people to whom she turned for support betray and abandon her and she may face losing custody of her children. She may be afraid that her environmental instability and psychological distress following the separation will reduce

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her chances of retaining care of the children. Social services have a statutory duty to protect the children. In cases of risk assessment, child protection is the priority and the needs of the mother are secondary. The 1989 Children Act explicitly states that the needs of the children for welfare and protection are the paramount consideration of the court and highlights the importance of keeping children within their biological families wherever possible. In cases where severe neglect or abuse of children has occurred it may be difficult for the professionals involved to avoid feeling punitive towards the parents, and they may become overly pessimistic about helping the family to stay together. Rehabilitation may be the ideal but its success is not necessarily easy to envisage, particularly if the mother or primary caregiver has been guilty of serious neglect or abuse. There is a danger of polarisation between parents and childcare professionals. It may not always be possible to bear in mind that to help the mother psychologically and practically is to help the children. There is a risk that childcare professionals occasionally operate on the basis of a false dichotomy, i.e. only two options may be identified—helping the mother or helping the children—and these two are mutually exclusive. Where possible, attempts to ‘parent the parents’ should be made. In fact, there are many options available and care plans drawn up by the local authority can reflect this, identifying strategies for helping the mother to gain the necessary insight, skills and support so that rehabilitation of her children becomes possible. Psychological treatment may be recommended as a precondition for rehabilitation, or as an option to be undertaken once rehabilitation has occurred. One obvious difficulty with this is that psychotherapy then becomes a coercive activity, a means to achieving a goal, rather than something freely chosen. Much of forensic psychotherapy has this tension within it and there is an important sense in which this is viewed not as an obstacle to the work but as an acknowledged aspect of the therapeutic relationship. It is recognised that psychological change is sought, in part, to bring about an external change; in this case, to ensure that children are returned to a safe environment (see Chapter 3 ‘Maternal Physical Abuse’). The emotive nature of child protection work can create situations in which parents and social workers are polarised and a custody battle is fought out in the courtroom in a way that is antithetical to the spirit of the 1989 and 2004 Children Acts. Parents can be split against each other or one parent may face fighting the local authority for custody of the children. The fear of losing her children, through their abduction or death or through a legal battle, can deter an abused woman from leaving an apparently unbearable situation. Her partner may have threatened to ensure that she will lose the children if she leaves him. She also knows that if she leaves she may be harshly judged by others, as a bad wife and callous mother, or told that she must have created the situation herself through provocation of her partner. Having children in the household increases the risk of intimate partner violence towards women and clearly complicates the situation of leaving: Also it may be that the form of intimate violence changes as the relationship changes, and women or men who leave a violent relationship may then experience stalking by the expartner. Previous research has indicated that having children in the household (among women) may be

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related to higher risk of intimate violence because women who experience partner abuse are reluctant to break up the family. (Walby and Allen 2004, cited in Home Office 2006:62) Fear of retaliation This is a significant factor in preventing battered women from leaving violent relationships. Their partners have threatened to kill them and their children if they leave. Sometimes the violent man, who is genuinely desperate at the prospect of his own abandonment, threatens to commit suicide if his partner leaves him. This emotional blackmail taps into the woman’s sense of overriding responsibility for her partner’s mental state and frightens her. The fear of escalating violence following separation is grounded in fact and there is evidence that the most dangerous time for an abused woman follows attempted separation or its discussion (Glass 1995). If a woman has left, taking her children with her, and she is found by her partner, she believes that they will all be at greater risk of harm than previously; this thought terrifies her. Her partner has convinced her of his omnipotent control, that he will track her down wherever she tries to go and that she simply cannot escape from him. In Browne’s study 98 per cent of the homicide group and 90 per cent of the comparison group believed that their abuser could and would kill them, and were convinced that leaving would not prevent this. Fears of being killed increase when the possibility of leaving is discussed with an abusive partner who may become homicidal, suicidal or deeply depressed; ‘the point of, or even discussion of, separation is one of the most dangerous times in an abusive relationship’ (Browne 1987:115). The psychological effects of severe abuse The main effect of severe abuse is to heighten the victim’s level of perceived helplessness. The vulnerability factors of some of the women who formed relationships with men who became abusive will still be present when those relationships become worse. Their vulnerability in terms of their background or lack of family and social support does not cause them to be abused but it can play a role in increasing the likelihood that they will be victimised and also makes it more likely that they will be disadvantaged in terms of escape routes. If anything, their lack of self-esteem and feelings of helplessness will have been increased by the experience of violence in a relationship and they will feel even less able than previously to take effective action to leave. For those women who had strong social and family support the experience of trying to placate and subdue a jealous and possessive partner will often have meant weakening those links, becoming socially isolated and estranged from family, resulting in a loss of confidence and increasing dependence on the violent partner, who demands that he is the main, if not the sole, recipient of devotion and attention. The dynamics of abuse create a vicious cycle in which the victim becomes increasingly more passive and frightened and the abuser more able to control and terrorise; the more she gives up her external sources of support, the easier it becomes for the abuser to dominate her.

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The emphasis on asking why women leave or stay in violent relationships also reveals the extent to which such action is framed in terms of individual choice and agency rather than as a product of social forces and the unequal distribution of power. The problem is framed in simplistic and individual terms. Mahoney (1994) discusses the notion of female victimisation and agency within violent relationships: Women live under conditions of unequal personal and systemic power. Violence at the hands of intimate partners, a relatively common event for women, is experienced in this context of love and responsibility…Social stereotypes and cultural expectations about the behaviour of battered women help to hide women’s acts of resistance and struggle. Both law and popular culture tend to equate agency in battered women with separation from the relationship…‘Staying’ is a socially suspect choice while ‘leaving’ is often unsafe. In fact, women often assert themselves by attempting to work out relationships without battering. Separation assault, the violent, sometimes lethal attack on a woman’s attempt to leave the relationship, proves that the power and control quest of the batterer often continues after the woman’s decision to leave. The prevalent social focus on leaving conceals the nature of domestic violence as a struggle for control, pretends away the extreme dangers of separation, and hides the interaction of social structures that oppress women. (Mahoney 1994:60) In the context of the practical problems of leaving, the fears of reprisal, the certainty that leaving will not necessarily mean safety, the paucity of alternative shelters, and sometimes the fact of previous failed attempts to leave, it is not surprising that battered women do not leave abusive relationships, and even when they do that they are not necessarily free from danger. The more profound question might be why the abusive partner is not requested to leave, or at least to seek help, by any agencies of social control. The dynamic in which the woman is held responsible for her partner’s mental state, mood, social success, and blamed for any failure or distress is actually mirrored in the pervasive attitude which places responsibility for her own abuse on the victim herself, i.e. ‘she should have left…she must have wanted it’. This is a classic example of victim-blaming which can be explained by ‘cognitive dissonance theory’. According to this theory, the belief that the world is just is so cherished that events which suggest otherwise are reinterpreted so as to fit in with the ‘just world hypothesis’. Rather than accept that a woman was severely abused emotionally, physically and even sexually, because of violence in her partner, it is more comfortable to identify characteristics in her that justify the abuse; in its crudest form this is expressed as ‘she was asking for it’. If she can be held responsible for her own abuse, this makes it less likely that an ‘innocent’ person would also be victimised in the same way. This is known in social psychology as ‘derogation of the victim’. While it is undeniable that violence is the product of an interaction, it does not follow that the victim has caused her abuse, or that she bears responsibility for its beginning or end. The best predictive factors for violence are found in the backgrounds of the perpetrators, not the backgrounds of the victims. Although violence in childhood was a factor found in the

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majority of the partners of violent men, this factor was not nearly as significant in predicting future violence as the exposure of the abusers to parental violence in their own childhoods (Browne 1987). This elucidates the way that a violent upbringing may enhance the likelihood of future violence. The following study of a woman who was repeatedly involved in abusive relationships illustrates some of the reasons why battered women do not leave. Case illustration

Jasmine: multiple victimisation in a 22-year-old woman Jasmine was referred to the forensic psychology services for assessment of her parenting skills. Her eldest four children, aged seven, five, four and three years old, had been placed in long-term care under full care orders and were subject to adoption proceedings. They had three different fathers and all four had been severely physically abused by Jasmine’s most recent partner. The two girls, aged seven and four, had been found to have been seriously sexually abused and there were suspicions that they had also been victims of physical violence. The boys had been found to have cigarette burns and bruises on their bodies indicative of severe and sadistic physical abuse. All four children had been thin, pale and frail when the local authority first investigated the situation, owing to concerns about the children being abused and neglected. The children described the cruelty with which they had been treated by their mother’s current partner; he had frequently threatened to kill them and their mother, and repeatedly assaulted her in front of them. Jasmine had recently given birth to a fifth child, whose father was the man who had sexually, emotionally and physically abused her other children. This child was the subject of the current care proceedings and Jasmine was applying for custody of him. He was seven months old at the time of the assessment and living in foster care. Jasmine had daily contact with him at a family centre, where she was taking part in cooking, budgeting and childcare groups. Her relationship with her most recent partner had ended and she was living on her own. She was extremely tearful throughout the interviews, expressing feelings of guilt and regret about having failed to protect her four eldest children from the serious abuse which they had suffered. She missed them badly and was frightened that her baby would also be placed for long-term fostering with a view to adoption. She had herself been the victim of violence by her previous partners. The central question of the assessment was the extent to which this vulnerable woman could protect a young baby in her care. The related issue of her capacity to protect herself from this kind of relationship was also crucial in this assessment. There were factors in Jasmine’s background that appeared to contribute significantly to her parenting difficulties. These included her own experience of serious violence by her half-brother towards her mother; the lack of protection offered to her by her mother in childhood, having been the victim of a sexually abusive relationship with an older, exploitative man; the disruption and discord that she suffered through parental separation when she was 12; and the general lack of supervision and guidance throughout her childhood. Jasmine described her home life as difficult and unhappy after her parents’ separation. She had run away from home at age 13, in an apparent effort to escape from a

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tense and fraught environment. Her mother seemed to have been unable to provide her with adequate support and supervision or to protect Jasmine or herself from physical abuse. At age 15 Jasmine’s father died; he had been a source of some comfort and support to her and his death brought a profound sense of loss. At age 14 Jasmine had been held hostage and repeatedly raped over a three-day period by her boyfriend at the time, to whom she had run to escape from an unhappy home situation. This violent and prolonged sexual assault had traumatised her. When I met her, eight years later, she still displayed symptoms of post-traumatic stress disorder including flashbacks to the rape and physical violence, nightmares about the experiences, intrusive thoughts about the sexual violation and violence, fears of being on her own with men, and a sense that the trauma was still taking place. Jasmine had been involved in sexual relationships with at least eight partners in the past seven years, all of whom had been physically abusive towards her. Her longest relationship had lasted just over one year. The pattern of these relationships was that the man would appear to offer Jasmine an escape from a difficult and violent relationship or an unhappy situation at home. She had little self-confidence and would only leave an abusive situation with his help. This new partner would then become violent himself, leaving her feeling trapped and helpless until yet another new partner would appear on the scene, apparently offering protection and a means of escape. Her desperation to leave a dangerous situation would affect the rationality of her judgements about the new partner and the decision to form a new relationship would be made in the context of anxiety and despair, without the necessary regard to potential risk to herself. Her children were with her throughout but their needs were, unfortunately, neglected. These decisions were not in the best long-term interests of the children in her care but appeared at the time to offer short-term solutions to the threat of immediate danger. Jasmine’s early experiences affected her sense of self-esteem and contribute to her impoverished internal model of parenting. Her mother was a depressed woman who found it difficult to attend to her needs and Jasmine, already vulnerable because of her experience of violence and her own difficulties at school, where she was considered ‘backward’, was left to find attention and affection where she could. She had tended to seek out adults whom she felt could protect her and was unaware of the exploitative nature of their attention, which was often sexual. She had few good objects in her internal world and a confused notion of comfort and care. Her main feeling throughout her early years was of being alone and unlovable and she hoped that through having babies she could finally ‘have something for myself, someone that really loves me’, reflecting both her sense of deprivation and her narcissistic conception of children. Her descriptions of violent encounters with men illustrate her sense of resignation, powerlessness and fear. Her mother, to whom she turned, was unable to offer real protection or refuge. Jasmine described the physical violence inflicted on her by her previous partner: ‘I can remember one incident when he became violent towards me. It was over money…he reckoned that I had spent some of his wages when he was away. What he did to me then was try to strangle me. He got angry and put his hands round my throat. When he did this he would be under the influence of drink. He drank quite a bit but later in our relationship it got worse. He got me pinned to the floor and said, “I’m going to have to batter you, what you going to do to stop it?” He stopped, that time, but I don’t know why…I stayed at my Mum’s after he had tried to strangle me. He constantly

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tried to ring my Mum’s that night and the phone had to be unplugged. In the morning I was frightened to return to the house and I asked for the police to come with me. I wanted to go back to collect some of the kids’ clothes…When I entered the house my lightbulbs in the front room and the kitchen were smashed, two windows were completely smashed. There was glass all round the front room from bottles of beer which he had smashed into the wall. I did not make a complaint on that occasion because he had already been arrested and I thought I wouldn’t bother.’ She vividly described her sense of helplessness and her tacit acceptance that her evidence would be discounted and her maltreatment minimised if she were to make a further complaint against her violent partner. She had learned not to bother. This illustrates the psychological state of’ learned helplessness’ (Seligman 1975). She believed, perhaps realistically, that there was nothing she could do to avoid this terrorising and dehumanising treatment although she had taken the significant step of leaving her partner. The frightening consequences of having left him and the constant fear of his retaliation are demonstrated by Jasmine’s experience of returning home to find a scene of devastation and destruction. Outcome Following my recommendations and those of the guardian ad litem for the baby, and the workers conducting the assessment at the family centre which Jasmine was attending regularly, it was agreed at a social services case conference that the local authority care plan would be to support gradual rehabilitation of the baby to Jasmine under a full care order. This would enable the local authority to retain shared parental responsibility with Jasmine and to remove the child and place him with foster parents should there be evidence that he was injured or that neglect had occurred. Jasmine was to be supported by the family centre, a family aide and the allocated social workers. She was also engaged in weekly counselling which enabled her to talk about her own experiences of sexual abuse, and her profound difficulties in asserting herself. There was a positive outcome in this case in that one year after the care proceedings had been settled, Jasmine still had custody of her youngest child and was coping well with the demands of childcare. She was also more assertive and confident in her own right, and seemed to feel contained by her individual counselling and the supportive system relating to the baby. He appeared to be thriving and there were no concerns about her handling of him. The social worker had, however, frequently voiced concerns about her association with various male ‘friends’ but Jasmine maintained that she had not established a serious sexual relationship since the final hearing of the care proceedings case. Despite concerns about the nature of her involvement with these men, there was no evidence that either Jasmine or her baby were being physically, sexually or emotionally abused. She appeared to be supported by the help and attention of the local authority and, in particular, by the staff at the family centre, who took a maternal interest in her. The problems of her social isolation and poor self-confidence appeared to have been alleviated, in part, by the structure and support of the family centre. Additionally, her own mother was increasingly involved in her daily routine, which Jasmine greatly valued, feeling that her mother was finally making an effort to help her, through helping her with her son. She still found the loss of her older children and her awareness of the abuse which they had suffered, distressing, and this sense of profound loss remained with her.

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Discussion Intergenerational transmission of disturbed attachments Violence and discord are often found in the backgrounds of adults who have failed to give their children adequate protection, or who have themselves abused them. This intergenerational transmission of abuse is partly explained by a social learning theory model which highlights the importance of early parental modelling on later parenting (Browne 1987). Recent research from attachment theorists also provides empirical support for the intergenerational transmission of disturbed parenting and the development of individual psychopathology, such as borderline personality disorder (Fonagy 1991; Fonagy et al. 1995; see Chapter 1 for further discussion of attachment theory). As described in previous chapters, an early experience of a mother who cannot provide the containment of the infant’s projections, and cannot allow the infant to develop the capacity to mentalise, can result in a failure to think symbolically. This failure to mentalise predisposes an individual to violence; as painful mental states cannot be thought about and managed, they are externalised through behaviour. Disturbances in early attachment can lead to difficulty in developing the necessary confidence and sense of security which enable people to recognise and leave abusive situations or to lead an independent life. Jasmine appeared to have been deprived of stability and parental protectiveness in early life and seemed to be seeking compensation for this through her sexual relationships. The death of her father seemed to have deepened her need to have male sources of comfort and had left her with a fragile sense of confidence. Like many victims of childhood traumas she repeatedly found herself in abusive situations where her apparent protector became her persecutor. One explanation for this is that she was trying to overcome the original trauma through re-entering the situation as an older and more competent person; this is known as ‘mastery of trauma’. Another explanation is that this experience affected her so adversely that she was not able to distinguish between trustworthy and abusive partners or to pick up early warning signs of danger. The damage done to her self-esteem and confidence was so great as to make her needs for security and comfort override rational considerations about who would be able to protect and care for her children. She seemed to have been intellectually damaged by her traumatic experiences, which had left her with little capacity to plan for the future or to understand cause and effect. The effects of early traumatisation on mental development have been powerfully described by Sinason (1986) and are relevant to Jasmine’s situation. The description of mental handicap as a consequence of trauma given by Sinason (1986) suggests that cognitive deadening can follow emotional and sexual trauma as a defence mechanism for avoiding psychic pain. Thinking is attacked as a defence against remembering trauma. In Jasmine’s case she appeared to have emotionally and intellectually shut down. It was as though the only world that she could bear to inhabit was one in which confusion and chaos distracted her from recognising her own unhappiness and helplessness. Through blurring the harsh outlines of her world she achieved some kind of psychic survival. This unconscious defence had developed early in her life and remained her strategy for survival in adulthood but left her with profound difficulties in protecting either her older children or herself from sexual abuse and serious

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violence. Her own parenting of these children at times reflected her own needs for comfort and protection rather than theirs; her capacity to think about them was dramatically impaired.

Battered women who kill One of the most common victims of women who kill is their husband or partner. In a significant number of cases this partner has been violent to the woman over many years. A substantial percentage of women who commit homicide of intimate partners have a history of being abused by them (Barnard et al. 1982; Daniel and Harris 1982; Kirkpatrick and Humphrey 1986; Foster et al. 1989). For women living under these conditions the possibility of killing their abuser becomes real. But not all women who are abused (and a conservative estimate of US spouse abuse estimates that 1.6 million women are beaten by their partners each year; Strauss and Gelles 1986) go on to kill. The reasons why some women do, and their psychological motivations, demand exploration. Studies indicate that the presence of certain factors in the situations of battered women who killed distinguished them from those who did not go on to kill. These included the abuser’s threats to kill, the abuser’s alcohol abuse, the presence of a firearm or weapon in the house, and the woman’s perception of experiencing severe psychological abuse. These seemed to be more important factors than the escalation and severity of violent incidents. This lends support to the notion that what is most important in determining what makes women kill their abusive partners is their own perception of the situation and their subjective experience of humiliation, degradation, isolation and terror imposed on them by their partners. In her study Browne (1987) found that the factors which best predicted which women would kill their abusive partners were the severity of the woman’s injuries, the man’s alcohol or drug use, the frequency with which abusive incidents occurred, the man’s threats to kill and the woman’s suicide threats. Campbell (1986) administered the Danger Assessment to 79 battered women in order to determine their risk of becoming either a victim or a perpetrator of homicide. The factors included in the assessment tool were threats to kill, a gun present in the home, drug or alcohol abuse by the batterer, sexual abuse, suicide threats or attempts by the woman, and the degree of control of the woman’s life by the abuser. In a descriptive study of factors present when battered women kill, Foster et al. (1989) interviewed 12 women imprisoned for killing their abusive male partners and found that threats to kill made by the abuser, daily alcohol use by him and the presence of a firearm in the home existed in most of these relationships. The women perceived the psychological abuse that they had experienced in the form of enforced isolation, humiliation and degradation to be more devastating than the physical abuse. Other factors present that the women themselves perceived as less important reasons for taking lethal action included an escalation in the severity and frequency of violence, the occurrence of sexual abuse and their own suicidal feelings. Foster et al (1989), Browne (1987) and Campbell (1986) therefore cited the presence of a firearm in the home as an important factor. The problems of substance and alcohol addiction may further contribute to the development of violence and other types of offending. There is evidence that alcohol abuse is a significant factor in the cases of

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women who kill their violent partners and alcohol dependence has also been found to be significantly associated with violence in a sample of female prisoners (Maden 1996). Criminal statistics cite the use of alcohol as a prevalent factor in households where violence occurs (Home Office 2004). It is important to explore why the women’s suicidal feelings should be an important factor in those women who went on to kill their partners. The link between suicidal and homicidal feelings has been well documented, particularly in the psychoanalytical literature (Zachary 1997; Hyatt-Williams 1998): the act of killing another person can be seen as a projection of murderous feelings which are actually directed against an internal object, a part of the self. For women whose sense of self has been deeply disturbed, by their early experiences and by the traumatisation of living with a violent partner, the intensification of feelings of self-loathing, fear, helplessness and worthlessness is almost inevitable. The reliance on primitive defence mechanisms like projection and projective identification becomes greater as the psychic and physical threats increase, and killing can be seen as the expression of these basic defence mechanisms. A central explanation for why battered women kill is found in the notion of the ‘battered woman syndrome’ which has been used in courts to plead for the charge of murder to be reduced to one of manslaughter on the grounds of diminished responsibility. Can this be upheld in a court of law as a self-defence plea (self-defence on grounds of provocation) rather than an attempt to argue for diminished responsibility? A related question is whether it is psychologically valid and socially useful as a legal defence. Does the attempt to explain why the victims of abuse kill their abusers vindicate their action, or does it simply burden them with social stigma and pathologise a simple act of selfpreservation?

The failure of previous attempts to leave a violent relationship Why is extreme violence perceived to be the solution to the problem that a battered woman faces? It is ironic that the attempt to combat violence may produce in the ‘victim’ the motivation and commitment to kill in a moment of profound identification with the aggressor in order to defeat him. Why are other methods of escape or change unsuccessful? It is on this point that the notion of learned helplessness is particularly powerful as it describes how depression and the expectation of loss of control results in failure to act and severe cognitive distortions in the appraisal of one’s situation. This does not mean that the killing of a life-denying partner is necessarily irrational but it does clearly demonstrate how this may have seemed to be the only possible solution to a lifethreatening problem. Understanding the practical and emotional difficulties faced by women who try to leave violent partners, described earlier in this chapter, illuminates this question and dispels the myth that the women chose to remain in these relationships This answers judges’ queries about why other means of escape were not successfully attempted or even contemplated before the woman finally ‘snapped’ and killed her partner. There appears to be some suspicion that women who kill could actually have taken effective protective action earlier, that they could not be both helpless victims and cold-blooded killers. The confusion about how a victim can become an aggressor, finding no rational alternative other than killing, could be clarified if the effect of depression on

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thinking were better understood. The issue of reactivated trauma is also relevant; sustained emotional and physical abuse erodes a sense of stability and safety, reawakening earlier experiences of trauma and potentiating the impact of later events. In fact women who killed often did take protective measures first, but these were revealed in time to be useless, feeding into the cycle of learned helplessness, and into the cycle of abuse and forgiveness which defined their relationships. In a sense these ‘protective measures’ could be viewed as the devalued currency of violent partnerships, the only means of communicating fear and anger by the victim, through the enlisting of third parties and the legal system. Only too often, however, these third parties could not provide requisite protection and the victim was left even more desperate than before, with her partner more eager to assert his claim over her. He increases his efforts to restrict her movements and is more vigilant about thwarting attempts to establish any form of independence.

Case illustration

Eve, a battered woman who killed Eve, a 34-year-old mother of three, was admitted to a secure unit for psychiatric and psychological evaluation after killing her partner. She had been transferred from prison where she had been considered to be a suicide risk, following an attempted overdose, and had been diagnosed with psychotic depression. She had spent three weeks in the hospital wing of the women’s prison before being transferred. She was pleading guilty to manslaughter with diminished responsibility. Although she had been acutely depressed immediately after her arrest, at the time I met her, one month after her admission, she demonstrated no signs of mental illness. She still wept copiously when describing her feelings about being separated from her children and her fears about their future. She was anxious about the impending trial and unsure whether the Crown Prosecution Service would accept the reduced charge of manslaughter. Although she appeared to be going through the stages of grief which would be expected in any case of a recently bereaved person, she did not seem to link this grief with feelings of guilt about killing her partner. She remained adamant that she had acted in a moment of intense fear about her partner’s threats towards her and had been justified in killing him to protect herself and her children. She felt that the action reflected a moment of temporary insanity in that she would never normally behave in a violent way towards anyone, but that this impulsive and ‘crazy’ act had been brought about by years of sustained violence towards her, even while she had been pregnant with her youngest child, Kathy, aged 14 months at the time of the offence. The argument following which Eve had seized a knife and stabbed her husband was no different from the usual arguments in content, consisting largely of his accusations about her sexual infidelity. However, it followed a significant and potentially destabilising change in the relationship. She had recently taken on part-time work at a local pub and had been enjoying the freedom from home that it had given her. Eve was defending herself against her partner’s accusation that she had been having an affair with a co-worker at the pub. She had not worked at any point during the 12-year relationship

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but had decided that, as Kathy was her last child, it would be important for her to rebuild a life outside the home. Eve had gained an insight into the possibility of another type of existence and some confidence that she could have an identity outside the home. The threat of losing the slight independence that she had gained, with which her partner had threatened her, along with the escalation in violence towards her eldest son, appeared to her to be intolerable. It became a question of life and death. In her own history her mother had been kept a virtual prisoner in the house at the insistence of her alcoholic husband. The threat of repeating this pattern had been in her mind over the past few years and had become increasingly distressing to her as she saw a mirror image of her mother’s life in her own. Her mother had died of cancer the previous year and this had caused frequent arguments between Eve and her partner who was even jealous of her visits to her mother, whom he perceived to be a threat to their relationship and an intrusion into their lives. Until recently she might have allowed the argument to proceed; however, on this occasion she felt that she could not stand the threats and abuse and was terrified that he might really kill her. She still suffered from deep feelings of grief related to her mother’s death and had a strong sense of being alone in the world as she had no contact with her father. Her partner threatened her with taking the children away while she was at work and accused her of ‘whoring’ behind the bar with her boss. He went up to the children’s room and shouted to them that their mother was a ‘slag’ and a ‘bitch’. They screamed at him to ‘shut up’ and Eve remembered her oldest child, her son Gerry aged 9, trying to hit and kick his father, resulting in him being pushed away with a blow to his chest. She saw how terrified her children had been and how they feared that he would kill them all. Her partner came back downstairs and punched Eve in the face and then the stomach, choosing, as he tended to, those parts of her body which were most vulnerable. He had first assaulted her during her pregnancy with Gerry; he had seemed to perceive her pregnant stomach as a provocation. After he had punched her hard approximately seven or eight times in succession he pushed her on to the floor, leaving her to bleed and cry while he continued to accuse her of deceitful and untrustworthy behaviour. When he eventually finished his tirade, he slumped in front of the television set and returned to drinking straight whisky, having already consumed approximately two-thirds of a bottle in the course of the evening. Eve went up to check her children and found them crying in their shared bedroom and trying to comfort one another. Although she had gone to see the children with the intention of comforting them, when she saw how distressed they were she felt unable to say anything helpful, feeling too tearful and shaky herself. She later said that her despair and horror were vividly reflected in theirs and that this realisation triggered the thought that the situation was completely unbearable—that she had to do something to stop it immediately. She remembered how terrified she had been that her father would kill her mother, and that she had often returned home from school with a sense of dread about what she might find when she entered the home. She was reminded of her tremendous sense of relief when her father had eventually left her mother for someone else, when she was 13. On the way downstairs she had seen herself in the hall mirror, something she had learned to avoid doing following arguments, and she saw that her face was puffy and distorted, that her make-up had run all down her face making her look grotesque and

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mad. Her blouse, which had been washed and ironed for work that night, was covered with blood and foundation and several buttons had come off. She looked, she said, ‘completely mad, like a crazy, slovenly woman’ and her earlier confidence had been completely eroded. She felt full of resolve and rage. On entering the living room she saw that her partner had fallen into what seemed like a heavy sleep, a halffinished drink spilled on his lap and the glass on the floor by his feet. She felt a flash of elation when she saw him lying there, no longer capable of assaulting her. Her only thought had been to stop the misery and terror to which she and her family had been subjected and in order to do this she had to kill her partner, then, without hesitation, while he slept. The hysteria and fear had left her and she felt calm, determined and composed. She fetched a knife from the kitchen and stabbed her sleeping partner three times in the chest, puncturing his lungs and killing him almost instantly. She had then phoned the police saying that she was sure she had killed her husband and asking them to come at once. When they arrived she was shaking, repeating phrases over and over again and moving in a robotic manner. She manifested signs of posttraumatic stress disorder, in particular displaying emotional numbness and shock. Over the course of the next 18 months she had flashbacks to the argument and the moment when the knife entered the body, finding herself shaking, sweating with a racing heart and rapid, shallow breathing, She was initially arrested and charged with murder. The charge was later dropped to manslaughter on the grounds of diminished responsibility, to which she pleaded guilty. In her defence psychiatric reports were produced which emphasised the role of depression that had developed after the birth of her youngest child and had never been treated, intensifying in the days leading up to the offence. The killing, it was argued, reflected the actions of a deeply depressed woman, who had not had full awareness of the consequences of her behaviour, and who had not been able to make a fully rational decision because of the debilitating effects of her alleged depression. This account, although at odds with Eve’s own recollection of events, had intuitive appeal to the court and appeared to offer a satisfactory account of her assault on her husband. The positive action of taking on a job while in the throes of supposed depression was ignored and the possible justifications, grounded in rationality, for her killing this violent and abusive man were wholly overlooked. Eve had, in fact, consulted her general practitioner following the birth of her third child, explaining that she had fears about the baby’s development. While this had been attributed to ‘postnatal depression’ Eve had not been able to say that her fears about the baby were grounded in the fact of her husband’s assaults on her during her pregnancy. She had, quite reasonably, worried that her baby might be developmentally delayed as a result of blows inflicted upon her during the third trimester. She had also described some feelings of anxiety and depression, explaining that she had difficulty concentrating on even quite simple tasks, had no appetite and suffered from insomnia. The reasons for killing A central issue emerging from consideration of this case is the difficulty for the public in general, and the legal establishment in particular, of understanding that there can be a rational basis for killing. The gendered construction of killing makes it almost impossible to view Eve’s action, in one sense a logical consequence of her experience of constant

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battering and abuse, as anything other than either mad or evil. The sympathy given to men who kill their unfaithful or ‘nagging’ wives is not extended to female killers (Kennedy 1992). Although Eve’s understanding of her possible options was distorted by her abuse, her decision, in the context of her situation, had a rational basis. It appeared to her to be the only viable solution to an intractable and life-threatening problem. In order for such subversive behaviour to be explicable it had to be read as ‘mad’ rather than an act of selfpreservation. It was therefore important to gather evidence testifying to her instability rather than lend credibility to her actions through attempting to enter into and understand her situation. While her consultation with a general practitioner for ‘depression’ was used as evidence for her mental instability during her trial, the rationality of her fears then, and the logic of her decision making when she killed her husband, were not issues addressed in this trial, as if the possibility that a woman could kill her violent partner as a rational act of selfdefence did not exist. Eve was advised not to use the self-defence plea because the argument had ended by the time that she stabbed her husband. Although his assault on her had not endangered her life on this particular occasion, he had on others. On one occasion, when she had been heavily pregnant with their third child, he had kicked her down the stairs and she narrowly missed the edge of a radiator at the bottom of the staircase. This assault could have caused her to miscarry, or seriously endanger the unborn child. In the days leading up to the offence her husband’s violence had intensified and was directed against their oldest child, who had tried to protect her. She had not contacted social services to inform them about his violence towards her or the eldest child out of fear that the children would be removed from home. This was a case in which the notion of ‘psychological selfdefence’ could readily be applied, and indeed where physical selfdefence was still a major consideration. Eve’s rationale for the killing was that she could end the severe beatings which she had suffered on a regular basis (at least once every two weeks, sometimes more often) over the previous ten years, since her first pregnancy. Despite her resourcefulness and intelligence she had not found access to other ways of escape and had ended up killing the person who she feared would ultimately kill or destroy her. The reservations surrounding the use of a battered woman’s plea of self-defence in a case of domestic killing, compared with the familiarity and acceptance of a plea of ‘diminished responsibility’, demonstrate how much easier it is to locate murderous feelings outside, in the ‘mad’, rather than acknowledge that such rage is the likely consequence of systematic, degrading and debasing humiliation. It serves to distance the ordinary individual from those women who succumb to ‘insane’ impulses apparently at random. It takes all responsibility away from the abuser despite his central role as the long-term aggressor in such cases. It also acts as a defence against recognising that everyone has the potential capacity to kill, and that to do so may, at times, reflect a decision which has a coherent internal logic. Accepting that possibility is not equivalent to excusing or condoning killing but is a crucial step in understanding that a battered woman could kill in self-defence, even though her immediate safety was apparently not in jeopardy. In order for the plea of manslaughter on grounds of diminished responsibility to be acceptable, it is important that defence solicitors and psychiatrists emphasise the

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momentary and unpredictable nature of the madness at the time of the offence: that is, any suggestion that the behaviour is explicable in the light of the individual’s background or situation will make it less likely that the plea of diminished responsibility will be accepted. This means that the legal objective, to enable a client to be found guilty of a lesser charge if she was ‘out of her mind’ at the time of the offence, is directly antithetical to the psychological and psychoanalytical task. The task of the psychologist or psychiatrist is to understand how the offence fits in with the person’s history and current situation, how it can reflect her response to traumatic experiences rather than simply revealing aberrations in her usual mental processes. This case has parallels with that of Sara Thornton, a battered woman who was released from prison in 1996, following her appeal against her murder conviction for killing her violent husband and her subsequent retrial. Sara Thornton had initially been refused the option of pleading manslaughter on grounds of diminished responsibility by the Crown Prosecution Service and had then been found guilty of murder (Wykes 1995). At her retrial in 1996 she was found guilty of manslaughter on the grounds of diminished responsibility, related to an ‘abnormality of mind’ and her murder conviction was quashed (O’Hanlon 1996). It is essential to recognise the threat to psychic life that an assault, or its threat, constitutes in the context of sustained and severe abuse. Psychological understanding of learned helplessness and other long-term effects of physical and emotional abuse can illuminate the processes by which a non life-threatening assault can be interpreted and defended against as though it were. There is evidence that a significant proportion of intimate homicides occur in the context of an argument, or loss of temper: ‘A quarrel, revenge or loss of temper reportedly accounted for 30 per cent of homicides in 2002/03 (35 per cent excluding the Shipman cases). Where the suspect (or suspects) was known to the victim, around half the homicides resulted from a quarrel, an act of revenge or a loss of temper’ (Home Office 2004:6).

Defences in the courtroom: legal issues At present the charge of murder carries with it a mandatory life sentence. The battered woman who kills will receive a life sentence if she pleads guilty to murder. She may choose to plead self-defence or that she is guilty of the reduced charge of manslaughter, either on the grounds of provocation or of diminished responsibility. Currently, the only plea which has met with some success in reducing the murder charge to a lesser one of manslaughter is diminished responsibility, which can be founded on the basis of the ‘battered woman syndrome’. The complete defence of self-defence, which would allow a killer to go free if accepted, has not been successfully used by battered women who have killed. The use of this defence rests on the notion of what force a ‘reasonable man’ could be expected to use in situations when his life was at serious risk. These actions have not been found to include those steps taken by women who believe their own lives to be severely threatened by their abusers.

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Self-defence and provocation A central legal question in the area of female homicide is the acceptability of the plea of self-defence or manslaughter on the grounds of provocation for a battered woman who kills her abusive partner rather than the currently accepted plea of manslaughter with diminished responsibility. The use of the provocation defence in cases of the battered woman syndrome has been accepted in the USA but has not been widely recognised in the UK. In her seminal work on female offenders and the law, Eve was Framed, now in its second edition, Helena Kennedy powerfully demonstrates that women are not treated justly by the courts. Unlike men, women’s previous behaviour is considered relevant to their disposal in cases of murder or manslaughter and women must present themselves as ‘good victims’ in order to be treated well. She presents a strong case for the abolition of the mandatory life sentence for murder and for increased acceptance of the provocation plea: Provocation is a defence to murder and only to murder. In any other case, such as assault, it can only provide mitigation. If a defence of provocation is successful in a murder trial and reduces the charge to one of manslaughter, the court still has to pass an appropriate sentence. Women invoke self-defence or provocation defences infrequently, and the reason is that the legal standards were constructed from a male perspective and with men in mind, and women have a problem fulfilling the criteria…The immediacy principle makes no sense when the provocation takes the form of long term abuse. (Kennedy 2005:209) Women who kill have often been severely physically beaten and/or sexually abused over long periods of time by their male victims, whereas men who kill generally claim to have been provoked by nagging or promiscuity. Men regularly plead provocation on these grounds, claiming to have acted in the heat of the moment while women killers may have to seek a weapon or wait for abusers to be asleep or drunk, signifying premeditation. (Wykes 1995:54) Whether or not the provocation plea can be applied to women who kill violent partners is contingent on the definition of ‘provocation’; it is currently described in law to be an immediate threat on the defendant. In cases of female homicide of an abusive partner, the killing does not necessarily occur at the moment of greatest threat, mainly because women are generally not physically strong enough to overcome male assailants. The killing may occur minutes later when the woman has recovered from the immediate attack enough to equip herself defensively with a weapon. It can even take place weeks or months later, in the face of a less serious assault or argument that triggers the fatal attack. It has been argued in courts of law that the composure and degree of self-control required for the woman to equip herself with a weapon, at the point when the immediate threat to her own safety appears to be reduced, suggests a degree of intent, in a situation where she

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does not face a threat to her own life; this invalidates her plea of self-defence in response to provocation. Proponents of the self-defence plea argue, in my view quite accurately, that the battered woman’s perception of what constitutes a threat to her own life has been shaped by her experiences in the past, and that she responds to cues of impending violence with a degree of fear which is entirely reasonable in the light of this. Her relationship to her partner is entirely relevant to her motivation for killing him. This is a valid and important argument, in which the psychological sequelae of systematic physical and emotional abuse are acknowledged without the victim herself being pathologised. The type of reasoning and psychological defences that victims develop are perfectly explicable and could reasonably be expected to inform their actions. The need to recognise the severity and horror of the psychological damage created by years of sustained abuse is essential. For the courts to decide whether or not an abused woman can be said to have acted in self-defence, they need to understand clearly the long-term psychological effects of abuse and to retain a notion of how systematic abuse, sustained over years, can indeed be considered provoking factors in triggering a violent assault. The notion that only an immediate fight or threat can serve as a trigger to take selfpreservative action rests on a simplistic and inaccurate understanding of psychological motivation, and on the consequences of repeated victimisation. The important work of leading human rights barristers, notably Helena Kennedy, has done much to challenge these notions and raise awareness in the courts of the dynamics of abuse. Psychological self-defence The notion of ‘psychological self-defence’ as valid grounds for killing is proposed by an American author, Charles Ewing (1990), who argues that, in the case of battered women who kill, their very identity has been systematically eroded; at the point when they kill they are struggling to retain psychic survival. The profound and sustained attack on their identity represents a psychological, if not physical, life or death struggle. Their perceived need to kill the aggressor can be justified by reference to the notion of psychological selfdefence. Ewing bases his argument on the battered woman syndrome as defined by Walker (1984) and states that ‘battered women who kill have invariably been both physically and psychologically abused by the men they killed. Many if not most of them have also been raped and/or sexually abused by their batterers’ (Ewing 1990:583). This argument has great relevance to battered women who kill in the UK, and who are also highly unlikely to plead self-defence on the grounds of provocation. In what sense does the notion of psychological self-defence improve on the justification for homicide as the product of battered woman syndrome? Ewing argues that the battered woman syndrome helps to explain why, despite the claimed abuse, the woman did not leave her batterer before killing him but generally offers little evidence for the reasonableness of the woman’s ultimate homicidal act. His aim is therefore to provide a rational basis for the decision to kill, arguing that what was under attack was the woman’s psychological, if not actually her physical, survival at the moment of killing. He defines psychological self-defence as justifying the use of deadly force:

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where such force appeared reasonably necessary to prevent the infliction of extremely serious psychological injury. Extremely serious psychological injury would be defined as gross and enduring impairment of one’s psychological functioning that significantly limits the meaning and value of one’s physical existence. (Ewing 1990:587) Ewing considers that the battered woman syndrome explanation offers a partial understanding of why women can predict the likelihood of future violence by their partners, but states that this only really applies to those women who kill during a battering episode: the syndrome can be considered as a legitimate self-defence plea in those cases. In the majority of cases, however, where women kill their batterer while he is asleep or after an incident, the claim that their physical survival was at risk is not immediately relevant, therefore the self-defence plea is not acceptable. For the battered woman syndrome and the killing of a violent partner in self-defence to be acceptable, the notion of threat would need to be extended beyond the period of time of the actual violence, to explain why a woman killed not at the time of the injury but later or when the assault had abated, or, as Ewing argues, extended to encompass the notion of psychological self-defence. Critique of the notion of ‘psychological self-defence’ The notion of ‘psychological self-defence’ has been attacked, in particular by Morse (1990), on the grounds that it is the product of ‘soft psychology’ and represents bad law in which killing can be justified on subjective and flimsy grounds. The main argument against the acceptance by the courts of such a defence appears to be the ‘slippery slope’ argument that, once one such case is accepted, there will be others which also fit the concept and that eventually everyone who kills will be able to offer legally valid grounds for murder. There seems no acknowledgement of the difference between understanding the motivations for fatal violence and excusing or justifying it. Ewing’s argument is that severe victimisation results in the loss of the capacity to function as an autonomous and integrated person to the extent that physical existence or life ‘loses much of its meaning and value’. The notion of extinction of self is vague and can even be considered inaccurate if a careful analysis of the dynamics of interpersonal violence is conducted. Ewing’s account is somewhat simplistic and would benefit from psychological elaboration and theoretical precision. The role of the victim cannot be ignored; she changes in response to her aggressor’s assaults and his emotional control over her. I would argue that battery does not erode the self but, in fact, creates a distorted, damaged and depressed self through the continued use of intimidation, threat and abuse. The underlying process through which the batterer attempts to rid himself of weakness, fear and self-contempt, by identifying them in the victim and then seeking to annihilate or destroy her (albeit temporarily), involves the psychological defence of projective identification described earlier and the victim herself takes on these characteristics. She is, in a sense, compelled to become weak, frightened, unable to placate or calm her partner within this highly circumscribed relationship. Ewing (1990) does not take into account the complexities of this process and the destructive interdependence between

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victim and aggressor that is established, and which perpetuates the cycle of battering, forgiveness, reconciliation, estrangement and battering. While he is right to highlight the fact that sustained violence results in psychological damage to the ‘self’, he ignores the nature of the self which is created, that can be viewed as exaggerations of certain aspects of the self and the neglect of others in a polarised dyad. That is, the victim takes on the despised parts of her aggressor and he loses, for an illusory moment, his weakness. It can be argued that the theory of learned helplessness itself ignores the complexity of individual interpretations of events, i.e. the cognitive processes that mediate between the occurrence of painful stimuli and the individual’s response to them. The ‘battered woman syndrome’ adopts this model and incorporates it into a description of a ‘typical’ response to sustained abuse in which the woman is perceived as passive and victimised, losing her grasp on reason. The ‘battered woman syndrome’ ignores the active aspect of the female partner in a violent relationship and the significance of her unconscious and conscious choice to participate in the abusive relationship. Ewing (1990) has accepted these doctrines wholeheartedly and builds on them in an attempt to provide a sophisticated legal defence for battered women who kill. Despite the intuitive appeal of his notion and its sympathetic description of psychic infiltration and defeat, it is ultimately untenable either as a legal defence or as a psychological analysis. Like ‘premenstrual syndrome’ as a legal defence in court the notion of ‘psychological self-defence’ is in danger of being patronising to women and pathologising their responses to extreme, systematic abuse. Careful analysis of individual situations should make the adoption of such theories, predicated on the notions of women’s vulnerability and ‘special’ status, unnecessary. A legal defence that relies on the existence of a ‘syndrome’ is one in which pathology is central. The construction of a syndrome may have more utility as a legal defence in court than an empirically validated clinical entity; this is discussed in Chapter 4 in relation to the diagnosis of Munchausen’s syndrome by proxy. There is a danger that labelling a response to systematic abuse ‘battered woman syndrome’ without adequate reference to the social, cultural and political circumstances that allow this abuse to continue will contribute to stereotypes about women’s inherent madness. Self-defence has been reconceptualised as hysteria. Widening acceptance of the provocation plea would, in any case, make the notion of ‘psychological self defence’ unnecessary. The claustrophobic, trapping nature of domestic violence produces a restricted set of stratagems in which violence is the only solution; it has become the common currency of communication in a situation where all other means of assertion or negotiation have been rendered obsolete. For the former victim to take power and revenge on her partner she is compelled to use his methods of domination. Psychically, and even practically, violence becomes the only option.

Transference and countertransference issues in treatment One of the most disturbing consequences of having killed is that the killer cannot trust herself to differentiate between fantasy and reality. The ultimate and crucial barrier between thought and action has been broken and it becomes unsafe to acknowledge feelings of murderous rage in case they are re-enacted. In working therapeutically with

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killers, one is struck by the degree of fear which they experience as they project their own destructive and murderous feelings on to others, creating a persecutory and predatory external world. A central task for the therapist is to allow reintegration of this anger into the self and the gradual reconstruction of the capacity to distinguish between fantasy and reality, to acknowledge impulses without enacting them. In analytic terms this can be likened to the development of symbolic thinking. There may be deep-seated issues of grief related to the offence of killing, e.g. feelings of loss related to the victim and the associated guilt, anger, despair and shock that accompany any bereavement. The guilt in the case of a killer may be much more profound than in an ordinary bereavement and may provoke a complicated grief reaction, which makes recovery slow and difficult. The female killer will be incarcerated, whether in prison or in a psychiatric secure unit, and will be faced with separation from her children and other family members. This may feel intolerable and produce a profound depression. The stigma of having killed and the continuing feelings of anger towards the victim may pose intractable problems for the killer, who is unable to face up to what she has done and retreats instead into a remote world where she denies what has happened. The relationship with the victim will often be characterised by ambivalent feelings that contribute to a complicated grief reaction. The realisation that the apparent solution to abuse and threats of her partner’s death has also created her own separation from her family can leave her in a state of profound depression. (See Chapter 9). On an unconscious level the powerful defence of projective identification that killing involves, in which all bad is located in another person who is then annihilated, only evacuates these feelings temporarily, and is ultimately destined to fail. Although an initial feeling of euphoria and exhilaration follows the killing, this is only transient and the killer will become depressed when unacceptable feelings are once again acknowledged in herself. She will see that her attempt to rid herself of these feelings through splitting them off, locating them in someone else and then killing him off, has failed, and that she must face the task of reintegrating them into herself. This exactly parallels the experience of the abuser, who used battering as a way of ridding himself of unacceptable feelings by projecting them into his partner and then attacking her. His defence against unwanted feelings is also destined to fail, offering only temporary relief from self-loathing, guilt and fear of abandonment; once these feelings return, so too does the need to batter again. The therapist can evoke a powerful transference in the patient where she becomes the object of murderous rage or the highly idealised good object. It is essential that therapists receive adequate training and ongoing supervision to avoid acting out these projections and becoming either a victim, like the client was, or a persecutor, like the abuser, or an idealised object to whom no anger can be expressed because of the fears about the destructive power of anger. The person who has killed has relied on splitting as a defence mechanism and has been inextricably enmeshed in a heavily polarised relationship with her abuser. In order to enable this client to take anger, sadness, fear and helplessness back into herself, it is essential to avoid re-enacting the abusive relationship. It is also tempting to see the client as passive victim and to ignore the complexity of her relationship with her partner and the unconscious needs that it may have met for her, including the disavowal of aggression. Ignoring these needs will collude with the client’s denial of

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anger rather than helping her to integrate and manage it, tracing its origins. Forensic psychotherapy offers a sensitive model of working with people who have killed. One way of avoiding moral censure for those involved with killers is to deny their aggression, viewing them solely as victims. This view is both psychologically inaccurate and therapeutically unhelpful. It is a product of denial on the part of the helper and requires exploration through supervision; paying attention to unconscious processes will generate a more balanced and sophisticated understanding. It can be even more powerful when there are strong external similarities between therapist and client, for instance, age, gender and ethnicity, that enable an identification to be made easily. There may be strong reasons for a female therapist to work with a woman who has killed but these should be examined carefully in each individual case.

Conclusion Female homicide and the denial of female violence As in so many cases of female violence, acceptance of the fact of female homicide requires a suspension of commonly held beliefs about violence and femininity, creating massive resistance to the notion that women can kill and may, in some cases, have valid reasons for doing so. In the cases where battered women kill an abusive partner their previous role of victim makes such violence appear even more extreme and abhorrent. The incongruity of a beaten, submissive partner taking violent action in an attempt to annihilate her aggressor contributes to the difficulty that others have in making sense of her action, or reconciling the image of victim with that of killer. The fact of her rationality is perhaps even more difficult to bear and she is thus perceived as a mad or evil woman who could have found other ways out of her situation if she had only tried. The evidence of such rationality in the planning of a killing, which may take place in the case of a battered woman who kills, suggests to the courts that the action could not have been one of self-defence; the woman had time to plot and plan and therefore was not, at the moment of killing, under threat to her life. To see the woman as a calculating killer, who has killed gratuitously in that she was not in immediate danger, is to deny the abuser’s history of violence, intimidation and cruelty towards her and her children. What is also denied is the threat to her psychological survival and the desperation with which she responds to this psychic danger. The struggle is one of psychic as well as physical life or death as Ewing’s notion of ‘psychological extinction’ attempts to highlight. The wider context Domestic violence is such an emotive and distressing phenomenon that it is tempting to simplify its dynamics, disregarding its complex nature and the role of each partner in maintaining the destructive interaction. To view the woman as only a passive victim is to deny female agency, but to ignore the social forces that create restricted choices for her is dangerous. The refusal to recognise psychic conflict and ambivalence in both the male abuser and the woman who kills him is striking. Until the complexity of the individual, interpersonal and social dynamics that maintain violent relationships is recognised, the

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motivations of women who kill their violent partners will continue to be simplified and misunderstood. The woman who kills will either be vilified or glorified. In either case she will be removed from the realm of the ordinary and seen as extraordinary, which unfortunately overlooks the fact that she inhabits a world shared by many female victims of domestic violence, most of whom do not go on to kill. While it is undoubtedly important to identify those factors distinguishing between battered women who kill their violent partners and those who do not, it is equally important to identify and address those factors, both internal and external, contributing to the situation of many more women who are subjected to domestic violence for years. Psychological intervention can and should take place within a context of social support and an understanding of the wider concerns of oppression, sexism and injustice.

Part IV Clinical applications

Chapter 9 Working with women who kill* We are all guilty of the wish to murder, all subject to thoughts of killing and all capable of extreme violence in fantasy. But to translate such feelings into action requires some other, qualitative shift from ordinary fantasy to extraordinary behaviour. What happens when murderous wishes, either unconscious or indeed conscious, are actualised? Why can’t thoughts be kept in the mind rather than acted out? In this chapter I will address the specific dynamics of mothers who kill, at moments of disastrous identification both with their infants and with their own depriving/killing mothers. The question I pose is how best to understand, from an analytic perspective, women who move from murderous thoughts to murderous behaviour. I will illustrate the discussion with the clinical case of a woman who killed her four-year-old daughter. In this case reason is clouded by the fact of psychosis. Nonetheless the murderous rage which underpins the act is neither rational nor irrational, it is more primitive, an expression of unconscious phantasy. For those women who have experienced cruelty in their own childhood, becoming a mother, while apparently providing an opportunity for reparation, may unconsciously offer darker possibilities for enacting revenge. The multiple identifications which operate in such cases are enacted in these tragic situations where mothers inflict cruelty on their own children. These events unfortunately often represent the exact opposite of the stated desire ‘never to repeat what was done to me’. Estela Welldon (1992) was the first contemporary analyst to draw attention to the sense in which women can use the opportunities afforded by motherhood for perverse and cruel purposes, challenging the sentimental and idealised notion of mothers that shaped social stereotypes. Her views were radical, frightening and unacceptable when first published 17 years ago, but increasingly they have been borne out by new information about women who hurt, kill and sexually abuse their children. Although still shocking there seems to be an increasing capacity to challenge this most deeply held taboo—that mothers can use their privileged position to wreak revenge. It is still difficult to accept that mothers can kill, as the recent outcry against the notion of Munchausen’s Syndrome by Proxy reveals. When they do, as in the case of Rosemary West and Myra Hindley, or even when they are associated with child killers, as Maxine Carr was, they are demonised and targeted in a kind of contemporary witchhunt—they can no longer be considered women in the sense of obeying ‘maternal instinct’. As Warner notes:

* This chapter is reproduced by the kind permission of Karnac Books. The chapter first appeared in Ronald Doctor’s edited book Murderers, published in London by Karnac Books 2007.

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The new demons of crimes against children still act as biological women, but they have disqualified themselves from the rank of mother, and the category of women altogether. A woman like Myra Hindley is seen to embody a violent sexuality that is more appropriate to the male than the female. (Warner 1998)

Murderous phantasies in pregnancy Unconscious rage and murderousness can be stirred up in pregnancy, with its concrete as well as symbolic invocation of the woman’s own attachment to another. Welldon located the source of female perversion in the woman’s own reproductive capacities, in contrast to the male who uses his phallus for perverse purposes. In pregnancy the woman is able to turn her hatred of mother, as symbolised in her own procreative body, towards herself and her own unborn baby. Unconscious forces may shape the desperate desire for pregnancy, particularly acute in young women without an internalised sense of mother or good internal object, as she strives to feel filled up with something good and nourishing. This fantasy of pregnancy as offering wholeness may consume her as she seeks urgently to have a baby, to have someone who loves her, as she feels so unloved, unloveable and unwanted. As Welldon so powerfully argues, the narcissistic pleasure of pregnancy, of the woman’s fantastic power can become totally removed from any genuine concern for or awareness of the separate and dependent creature within. While the fantasy of pregnancy offers the dream of being filled up with a loving object who can provide the maternal care of which they were deprived, its reality can create a sense of persecution, and ultimate disappointment. In pregnancy the body of the woman is invaded, intruded upon, fought within and fundamentally altered, in order to enable another life to take shape. The sense of wholeness and completeness that has been wished for may actually become a sense of almost psychotic and paranoid engulfment. Women with difficulties in their own earlier relationships with mothers in terms of separation and individuation are likely to find this situation rather disturbingly different from their conscious fantasy of pregnancy. The distortions in their own bodily boundaries and shape and accompanying sense of helplessness may be unbearable for women who have complex feelings about their own bodies and the integrity of their personal boundaries, or those for whom hatred against their mother’s bodies is now turned against themselves and their children. Their own adult body can become the symbolic representation of their mother’s and can then become subject to attack through self-harm or eating disorders. Interestingly anorexia can be viewed as an attempt to prevent the young girl’s body from becoming mature, as she keeps herself childlike through self-starvation: this may differentiate her from her mother and be an attack on her own reproductive capacities. Pregnancy may afford opportunities for extreme disappointment and childbirth a forum for expression of violent impulses. The experience of giving birth to an actual child, with its hungers and demands may feel even more disappointing and persecutory. Rather than realising a wish for love and completeness, childbirth reawakens earlier horrors of deprivation, neglect and starvation. Pines notes ‘Mature object love, in which the needs of self and object are mutually

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understood and fulfilled, cannot be achieved, and the birth of a real baby might be a calamity’ (1993:103). The bodies of children, Welldon argues, are not seen as independent subjects in their own right, but extensions of the mother: if she has harmed herself she may well extend this damage to the child who represents her. One striking feature of these disturbances in women, who turn their violence against their own bodies and those of their children, is the location of identity in their physical bodies and the sense in which thoughts inevitably lead to action. There is profound difficulty in what might be considered a form of abstract or symbolic thinking, and a dramatic need to express feeling through physical action and release. Women who selfharm typically describe how they convert psychic to physical pain in an attempt to confine emotional pain to their bodies, hurting themselves to release tension that has tormented them. Self-harm serves as a physical expression of emotional pain and a powerful release from unbearable and unthinkable distress. It is of course, a violent act, symbolically attacking the body of the mother whose representation lies in the woman’s own body. Fonagy and Target (1999) explore the nature of the compulsion to enact violence with specific reference to the ‘failure to mentalise’ that characterises perpetrators of violence. Rather than concretely following a ‘cycle of violence’ model in which former victims of physical violence enact this on others, in an attempt to rid themselves of their own experiences of passivity and helplessness, through identification with the aggressor, violent adults often follow a more complicated and subtle route to violence. Their early experiences of caregiving have not provided a central mirroring function in which their own mental states, feelings and intentions have been reflected back to them; a central developmental step towards symbolisation, bearing awful thoughts, has been bypassed. They are not able to hold painful mental states in their minds, nor find satisfaction through others’ responses, and so have a tremendous need to act on these feelings and thoughts and expel them through bodily acts of violence. For women, the violence is typically directed on to their own bodies, representative of the body of the mother; for men such violence is directed outwards on to others. Welldon (1988) stresses that symbolically the bodies of babies are also extensions of the self for women with these early experiences of deprivation, neglect and cruelty, and therefore also become objects to be used as receptacles for violent impulses. De Mause’s notion of children as poison containers is highly relevant here in his conceptualisation of infants as universal receptacles of unwanted impulses, as the carriers of toxic human feeling. I will illustrate these complex dynamics with the following (disguised) clinical material that contains distressing and disturbing details about a mother who killed her child.

Case illustration

Dolores The Offence Dolores, a single mother of Eastern European origin in her late twenties had been living alone with her two young daughters, one aged four (Angel) and one seven, when she had attempted to kill both of them and herself. She had become convinced that the

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girls were in danger of abduction by a paedophile gang who would use them in ‘snuff movies’—that is pornographic films in which an actual murder is filmed. She had planned her homicides and own suicide in some detail but the decision to kill them all seemed to have been made on the day of the offence. She had taken the children to school as usual and then prepared the materials for their deaths, hanging three nooses in her home, as well as mashing barbiturates into their pudding; she had hoped that this would sedate them so that she could gently suffocate them, before hanging them and then herself. She was convinced that the house was being observed by the ringleaders of the paedophile gang and that the people she encountered on the walk on the way home were spies for this gang, using their mobile phones to alert one another about her movements. She had attacked Angel’s head with an ice pick prior to drowning her. During this time of what was a frenzied and violent attack, one that she said she had never intended to be painful for the child, her older daughter escaped, although she had also suffered head injuries. This older child ran for help, but by the time the police arrived and managed to gain entry into the house they found the younger girl dead in the bath and Dolores in a frenzied state searching for her older daughter, claiming she needed to ‘save’ her, as she had ‘saved’ Angel. Mental state Dolores was transferred very shortly after being imprisoned and subsequently sectioned under 37/41 of the Mental Health Act (1989), having pleaded guilty to manslaughter by virtue of diminished responsibility. She was considered to be suffering from a psychotic disorder at the time of the offence and was to receive treatment at a medium secure unit. I saw her for weekly psychotherapy from the time of her admission into hospital until after her discharge into the community: a total of four years. Despite the horror of her own history in childhood and recently as the killer of an apparently beloved child, Dolores managed to present a superficial veneer of calmness, rationality and charm. As a kind of ‘false self’ personality she was always polite and friendly to me, beautifully dressed with make-up, fashionable clothes and freshly washed and styled hair. Her sense of herself as located in her physical body was highly evident, and she seemed to attempt to control inner chaos through rigid control over her appearance and a mask-like, made-up face. She appeared in many ways like a doll, with a steady impermeable gaze and artificial but delicate and precise gestures. When I asked about her feelings of guilt at our first meeting, she replied that she felt terribly guilty, not because she had killed the youngest child but because she had not succeeded in ‘saving’, i.e. killing, the surviving child. She revealed an underlying and pervasive belief in the delusion that had guided her—that she needed to kill to save. Often she would begin sessions by relating details about her wardrobe, or plans to return to her previous employment as a beautician. While this revealed something about how she had covered up her illness and hidden the facts of abuse in her own life from her adoptive parents, disguising the fact of her paranoid delusions from those around her including her daughters’ father, it also conveyed the quality of distant communication and avoidance in our sessions. Everything bad or frightening, violent or destructive was covered up and made safe. Dolores was fascinated by fakeness and delighted in her false nails, which struck me as symbolic of weapons that could not actually harm, as well as providing her with a sense of glamour and grooming.

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Background Dolores’s mother already had three older daughters before she had been conceived as a result of a relationship with a foreign sailor. She decided to give Dolores up for adoption at ten days old. Dolores was four when she learned she had been adopted (the same age as her murdered child). She had felt totally devastated and betrayed by this revelation and saw its disclosure as an act of cruelty by her mother. Her adoptive father had lavished attention on her, but she felt that her mother resented this and had told her she was not really ‘theirs’ as punishment. She had been sexually abused in childhood and felt her mother had always disliked her, treating her with a degree of distance and harsh discipline, just falling short of physical abuse. She had a history of anorexia/bulimia, shoplifting and self-harm, displaying what may be considered to be a typical constellation of female expressions of disturbance, and violence, largely directed towards the self. In adolescence she became promiscuous and formed many short-term sexual relationships with men. An attractive and vivacious girl, she had tended to prefer the company of men to women, but remained very close to one older woman. At age 17 she had become desperate to meet her natural mother and had traced her, only to discover that she had moved to Central Europe with her third husband. She had travelled to meet her and described feeling a strong bond with her and with her sisters, denying feelings of envy or rejection. Progress in therapy At initial presentation Dolores was clearly psychotic, believing the hospital was a factory for experimentation and that various patients had special connections with the CIA and other secret groups. She attributed special significance to simple statements, ascribing meaning to commonplace phrases that indicated she was in a unique and privileged relationship to the speaker. Her florid delusions abated within the first six weeks and nursing staff became concerned that with her increasing insight into the horror of her actions a strong suicidal tendency would emerge. It was at this point that she was referred to me for ‘supportive psychotherapy’ and psychodynamic evaluation. During her time in hospital she had formed two significant relationships with violent male patients and, despite the close supervision of these relationships by the medical and nursing staff, she had become pregnant. This was a wished for event, which she had often related to me in sessions, describing a wish to replace loss, a desire to forget what she had done and as, she put it, ‘lead a normal life’. She had initially resisted this impulse, in the light of reality and the knowledge that she would be unlikely to be allowed to bring up another child because of the risks that she would kill again. After much discussion with the multidisciplinary team and the realisation that pregnancy would require her to come off psychotropic medication, only to have to give up the baby for adoption after birth, and that this would also prolong the time she would be likely to spend in hospital, Dolores decided to undertake a termination. This termination, at 12 weeks, recapitulated her murder of her daughter and sent her into a deep state of depression, requiring the relinquishment of her fantasies of bringing another ‘perfect’ replacement baby girl into the world. Her hope of reparation was actually destroyed as she again found herself in the position of killing; additionally her physical solution to unbearable loss was obliterated. As her memories and dreams progressed, Dolores sometimes recalled vivid details about the actual killing. These again centred on physical sensations—feelings in her body and physical environment at the time, akin to the attention to detail found in post-

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traumatic stress disorder, but with another quality too, as though her understanding was located in her physical body. The memory seemed inscribed in central physical sensations that threatened to destablise her, and she sometimes seemed to dissociate in the session itself. She described feeling unable to bathe, as it triggered the visceral memory of the wound in the little girl’s head, which she said she could feel when water touched her own head. She could only take showers as these were less vividly associated with that day, and with her last memory of her child. The horror of the unintended physical violence, the pain, disfigurement and mess seemed to be possible for her to focus on while thinking about the loss seemed impossible. Again this illustrated the tremendous need to locate emotion in the body and the difficulty in conceptualising the minds of the children she harmed, or indeed what went on in her own mind at the time. The unbearable irony of her killing to save Angel from imagined suffering and eventual murder was also too much for Dolores even to contemplate. It was equally impossible for her to consider the sense in which she, in identification with a cruel mother, envious of a loved child, might wish to inflict suffering on another. At some level she was in touch with a sense of real guilt, and never fully accepted that responsibility lay in her loss of the distinction between fantasy and reality and the power of her delusional beliefs. It is possible that this guilt seemed somehow misplaced, as she had so clearly been psychotic at the time. I wondered if her guilt feelings stemmed from awareness of actual neglect or some inklings of her unconscious hostility, as she seemed to have discounted the fact of her apparently psychotic breakdown, seeing herself as wholly responsible for Angel’s death. In this case the therapeutic task involved helping her to relinquish a sense of guilt, whereas in so many cases in forensic work the aim is precisely the opposite, to encourage guilt and remorse. Through getting to know Dolores, hearing about her tremendous rage at the adoptive mother who betrayed her, and her natural mother who gave her up, I formed a hypothesis about the meaning of her offence. I would suggest that in an important sense this murder had been directed at someone else, at the mothers who had abandoned her; this homicidal motivation can also be seen in her own attempted suicide, she herself was a mother who failed. Although danger apparently lay in the nameless, faceless ‘gang of men’ who lived to torture her and her children and to immortalise their pain and humiliation in film, this gang could be understood as the family unit of the strangers who had raised her and exposed her to abuse. Her deceptive adoptive mother and abandoning natural mother could be seen as the unconscious targets of her murderous rage, who were out of reach. Symbolically the murder also stood for suicide, as Angel also represented Dolores herself, the four-year-old child who had learned that her apparent mother was a fraud, that she had been given away, killed off. From very early on Dolores had felt she could trust no one. Welldon has shown how women who kill or harm their children behave towards them as narcissistic extensions of themselves, treating them as they themselves were treated by their own mothers. Linking this notion with the deep tie between homicidal and suicidal urges it becomes possible to understand something of the dynamics of murder in the case of this profoundly damaged young woman. She could not see her daughters as separate from her, imagining them to be extensions of herself, vulnerable to the same neglect, abuse, deception and ultimate abandonment she had suffered. She had externalised her

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own violent urges towards her daughters, or envy of them for being brought up by her, their natural mother, seeing all danger as located outside herself. Despite her denial of abuse or neglect to them prior to the offence, statements by other family members revealed that she had been neglectful and, at times, cruel. On occasion she had used physical violence towards them and she displayed her older daughter’s soiled underwear, which had been hidden, and laughed about it with friends in front of her. She had organised a fourth birthday party for Angel but had not allowed her friends to come, going through the macabre motions of hosting a silent, friendless children’s birthday party. This seemed a symbolic re-creation of the emptiness and falsehood of her own early life. Dolores was adamant that she loved the girls though she hated herself. Her suicidal impulses were converted into homicidal urges towards them. She had planned to kill herself after killing them, as the three nooses she had hung demonstrated; at the time she was apprehended she had also stockpiled a large supply of antidepressant medication that she had planned to take just before hanging herself. This violence, directed on to the woman’s own body, or its narcissistic extension, her children, is a symbolic attack on the mother’s body. For Dolores, her mother’s body had been a betraying and abandoning object, and her adoptive mother inadequate, deceitful and ultimately cruel; she had allowed Dolores to be sexually exploited by men, treating her with contempt and envy. The symbolic meaning of Dolores’s violence in relation to her fears of sexual exploitation and murder of her children for the gratification of adults was a recapitulation of her own earlier ‘soul murder’. She enacted on her children’s bodies the violence to which she felt she had already been subjected in her own childhood, and the suffering she imagined would return to torture them. Her narcissism, evident in her failure to view the children as separate from her, even before her psychotic breakdown, was also apparent in her behaviour and demeanour after the offence. Her narcissistic personality structure, though clearly destructive in the extent to which it contributed to her fatal assault on her daughter, in another sense proved to be protective in her recovery; without this defence against overwhelming depression and guilt it would not be possible to imagine her survival. Dolores continued to plan for her future and to focus on immediate sources of gratification like new clothes, losing weight, finding a boyfriend and experimenting with different hairstyles. She also hoped to prove herself well enough to have contact with her surviving daughter when the girl felt able to visit her, or her estranged ex-partner allowed such contact. Yet again she focused on the shape and outward appearance of her physical body, believing she needed to be slim and pretty to prove her health to her surviving daughter. The ugliness and deformity in her mind seemed invisible to her. A central feature of the ending of therapy was that I had become pregnant, to which Dolores reacted with surprise, concern and apparent generosity. It seemed to me that the fact that I was leaving in order to go on maternity leave evoked unbearably strong fears in her and removed the opportunity for richer understanding of her own desires to give birth, and to kill. Dolores was discharged from hospital after approximately three and a half years. She retained ties with both her adoptive and natural mothers and began a parttime job, continuing to attend regular outpatient appointments with the consultant psychiatrist. She had attended our last few sessions as an outpatient, living under a new name in the community. She chose not to re-enter into psychotherapy with a different

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person, saying she felt she had ‘come to terms’ with what she had done. I was left feeling that she had never fully explored the extent of her unconscious hatred for herself, her mother and her daughters. She expressed the fear that this level of analysis would destabilise her to the extent that she would not feel able to leave the containment of the secure unit. I believe she was also trying to protect me from murderous rage towards me that could have emerged so powerfully in the transference, with consequences she might have felt unable to control or predict. Dolores’s identification with her own tortured, abandoned and deceived child was evident as she described the deep similarities between herself as a child and her youngest daughter. The guilt she felt about her murderousness seemed to have become projected into me when I was pregnant and at times I felt that I could not subject her to such a cruel situation. The similarities between us, as women of similar ages, became as undeniable as the differences once my pregnancy was obvious and I informed her that I would be going on maternity leave. She reacted with extreme concern and solicitude.

Transference and countertransference issues The transference issues that arise in working with women who have killed are complex and powerful, as the therapist may alternate between hiding behind the false protectiveness of the patient’s idealisations of her and exposure to her murderous rage. The primitive defences of splitting have been dramatically and irrevocably enacted when women have killed, and the atmosphere in the consulting room reflects this. At times there is an almost unbearable deadening of all feeling and thought between therapist and patient, as though the danger of acknowledging feelings must be kept at bay through a kind of suffocation, and at other times there is an exciting sense of danger, which seems to be manifested in great curiosity about the awful unthinkable event. This fascination may come across to the patient as a kind of intrusive voyeurism in which they are implored to revisit traumatic scenes and relate them in intimate detail. Case presentations by clinicians can indicate the level of prurient interest or excitement found in working with people who enact these universal fantasies. The feelings of depression, dread and fear, which underlie the violence, may resurface in therapy, threatening to engulf both therapist and patient in an overwhelming sense of helplessness. Perhaps the most insidious attack on thinking is the invitation to collude with the denial of what has happened. The passive voice takes over in sessions, as the patient describes their offence with distance and conveys their sense that something outside of themselves has ‘happened’, as it were, to them. Indeed, it may be difficult for a therapist to keep in mind the fact of explosive violence, when faced with a calm depressed woman, who may present herself as victimised. Perhaps it is only at times of great vulnerability in the therapist when such memories or thoughts become vivid and appear in the transference as immediate threats to psychic or physical safety. These issues are particularly relevant when the therapist is female and of child-bearing age, and are even more intense when the therapist is herself actually and visibly pregnant. A personal example of this in relation to the clinical material just presented comes from my own pregnancy when I became convinced in a session with Dolores that my unborn baby had actually died inside me. I felt as if paralysed with fear and could hardly

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think, let alone respond to the patient. I became somewhat suspicious, wondering whether this patient had willed this apparent death. I became so focused on this fear that it developed a quasidelusional quality and it was almost impossible to retain an awareness of the patient as she sat with me in this state. There are, of course, various hypotheses about why my fear should have reached such intensity during this session, probably related to an unconscious communication of her tremendous envy and hostility. I wondered if through projective identification I had become the murderous mother, or even the dead object that I imagined I was holding. I considered it most likely that Dolores had projected into me her own envy and murderousness, and her desire to attack the living creature whose growth I could sustain, in stark contrast to her. Perhaps through surviving this unconscious attack I was able to help her to understand that sometimes her destructive fantasies could be managed and defused. Pregnancy in the therapist is a direct challenge to the neutrality and anonymity usually associated with the transferential situation, as there is concrete and undeniable evidence not only of sexual intimacy but also physical interconnection with another living creature, the unborn baby. The mind as well as the body of the therapist may become an unreliable, untrustworthy and otherwise occupied object. There may be a sense of triumph in the therapist as she faces her bereft or barren patient with the fullness of her own successful intercourse, or a sense of shame as she becomes known in some basic, human and very vulnerable sense. How can a therapeutic alliance be preserved without direct acknowledgement of the tremendous changes that the presence of this third party brings to the therapy situation? It is essential that the therapist can allow such thoughts to be developed, articulated and addressed, but the fears of filling the room with anger or envy may still make direct communication difficult. Working with women who have killed their babies creates situations of great complexity and sensitivity, as well as the possibility of an enhanced intimacy and depth in the therapy, as issues that may have been left unexplored like the therapist’s sexuality are thrust into the consulting room. Complex transference and countertransference issues between female therapists and women who kill are inevitable and require specialist supervision that attends to them. Starting in pregnancy we can use Welldon’s shocking insights to see how women’s bodies, particularly their reproductive capacities can become the vehicles for expression of unconscious conflict, and the sites for re-enactment of earlier trauma. Such conflicts are potently and often destructively expressed in pregnancy and childbirth. Women who have felt deprived and neglected in their own childhoods may seek to fill this inner emptiness through pregnancy, as a fantasised act of reparation, but in fact it become a forum for reactivation of earlier deprivation. Motherhood can then offer opportunities for revenge and re-creation of earlier cruelty. The complexity of the relations between the murderous woman and her children, her relation to her own mother and her relationship with her therapist require careful and close analysis in each case, with the hope of enhancing awareness of how and when such tragedies occur. Such insight can inform preventive actions to reduce the risk of these destructive re-enactments.

Chapter 10 Hiding and being lost* The case for women-only secure units Looking around the daily community meeting one morning I was struck by the fact that of the seven women on this long-term, mixed low secure ward, six of them were, or seemed to be, hiding. One remained in her room altogether, escaping the tension, drama and conflict offered by this meeting. Three others had placed themselves in corners of the room. One crouched down, close to the ground. Another stood, arms folded, against the door and the last sat in a chair, behind the circle of chairs, making herself virtually invisible, although she was still nominally present in the room. Only one sat in the circle, but she avoided eye contact altogether and spoke only when addressed directly. I was put in mind of the children’s games of peek-a-boo, where the child delights in losing and finding again the mother’s face, and of hide-and-seek. The latter game allows the hiders the experience of fleeing, exciting and fearful, and hiding, safe in the expectation of being found. The seekers have the lonelier and more persecutory task of hunting down the hiders. I resisted my strong urge, both maternal and predatory, to draw those hiding female patients from their secret places, to collect them up and place them in the circle, to be seen. In this chapter I will look at the experience of female patients on a mixed ward, as mirrored in the feelings of the professionals who work with them. I will point out the sense in which the hide-and-seek motif characterises the interactions between the women and the workers, and illustrates the central conflict for women with a severe personality disorder—that is, the desire for intimacy and to be known, understood and helped, in constant battle with the wish to defend oneself against this contact and remain isolated and at war. How are staff members to work with this paradox? And how to begin to address the reflected split in this staff group as they struggle with the desires to help, contain and comfort, conflicting with the equally strong urges, at times, to abandon, disappoint and retaliate against these women? I will conclude with a description of the current move to develop women-only secure services, to allow women a greater sense of protection and freedom of expression. One of the central features of women diagnosed with severe personality disorders is their conflicted, ambivalent and frightened relationship with others and with themselves. The fear of being seen, literally because of shame and fear of sexual assault and figuratively as a metaphor for being known, is reflected in their hiding, curling up and making themselves invisible. I think this relates to a central conflict between the wish for privacy, to be left alone, and the fear of total isolation and abandonment. The desire for closeness is in powerful conflict with the fear of intimacy. Difficulty in maintaining close relationships is a central feature of severe personality disorder. I will first to look at the ways in which these women hide themselves, and aspects of themselves away. * This chapter is reproduced by kind permission of Jessica Kingsley Publishers. A portion of this chapter first appeared in Nikki Jeffcote’s and Tessa Watson’s edited book Working Therapeutically with Women in Secure Settings, published in London by Jessica Kingsley Publishers in 2004, © Jessica Kingsley Publishers.

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Hiding and shame For many women in this setting their feminine body is lost, covered, hidden under baggy clothing, layers of flesh, scars, hair falling in the face, sometimes militant masks, piercings, tattoos. The sexual body has often been the site of abuse and violation, and so an attempt is made to cover it up, disguise and transform it. It may also become the site of embodied trauma and protest, as I will discuss when I look more closely at the phenomenon of self-harm. The naked body is often covered up completely and the most obviously recognisable feminine aspect can be that of the girl, in childish jewellery, kittens on tee shirts, socks and slippers. This may be encouraged by staff, whose maternal feelings become activated by their awareness of deprivation in these patients’ early lives. There may also be a paternalistic and infantilising culture of care for women with severe personality disorders. I have often been struck by the sense in which the barren and severe aspect of special hospitals, with their high walls and secure fences, are softened internally by the abundance of stuffed animals, which are scattered throughout the rooms of female patients. It could be suggested that this type of infantilising is a defence by the staff against recognition of the violence and adult sexuality of such patients. Instead of attributing adult levels of functioning to these women, they are stripped of their competence and the staff’s own vulnerable, childlike and needy feelings are projected into them. This type of splitting and projection is an example of a defence against the overwhelming anxiety of working closely with women in so much pain, with such profound levels of disturbance. The pain of their adult life is often lost (consciously or not) in the environment which attempts to disguise the pain through forgetting their histories, particularly the most traumatic aspects. This kind of ‘losing’ the memories of abuse and trauma that the women have experienced also seems to reflect an unconscious defence against overwhelming anxiety. This process again leaves the patients hidden. The environment seems to be designed to block out and cover up the psychic reality these women face now and have borne in their past. These defences, engaged in by staff of all disciplines, but particularly those who are in closest contact with the patients, that is the nurses, are codified in the culture of these institutions, which often provide no thinking spaces where practice can be analysed and understood. At times the women can be seen but not heard. They are not only hidden but also silenced. In the mixed ward the male patients choose to play loud music much of the time, drowning out conversation in the communal areas. I am struck by the loud, often romantic and sentimental music that plays in the unit, its lyrics jarringly at odds with the scene in which they are played: for example, to a group of isolated, dishevelled women with no sense of being attractive or loveable: ‘You’re gorgeous, I would do anything for you’. As the title of this chapter suggests, the situation of the women on this mixed ward is that they are not only lost within the system, sometimes out of a kind of wilful forgetting, but they also hide themselves away. There is an important sense in which these women have chosen to hide, perhaps out of a desire for privacy, safety and some kind of dignity. Another powerful motivation is their profound sense of shame about the events that have shaped their lives, their current situations, their involvement in shameful activities; and

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the rage, which they would love to discharge. This shame results in the need to avoid being seen, as James Gilligan (1997) suggests in his study of violence. The look of the ‘other’ is crucial to the concept of shame. It is as if by hiding they cannot be seen, a type of magical thinking. Another form of magical thinking may also be at work as the women avoid our gaze, like infants who think that if they close their eyes they are invisible to us—they may hold the unconscious belief that if they look away or hide their eyes they cannot be seen. They can be invisible, unseen, unchallenged and left alone, their shame not exposed.

What has been lost? What is hidden? If shame is the motivation for hiding it becomes essential for us, staff working with these women, to gain some understanding of what it is that creates this sense of shame and loss. These women have lost their sense of identity, within their families, peer groups and wider society. Crucially, they may feel bereft of their cultural identity, which seems particularly difficult to preserve in the ward environment. There is a loss of particular racial identity and a sense of blending into a homogeneous group of ‘patients’ who are without individual features. For many black women this type of merging into white culture may feel profoundly uncomfortable and evoke a deep sense of betrayal and loss. For many of these women the ordinary experiences of womanhood have been destroyed or perverted. Their hidden losses may include miscarriages, stillborn children, adopted children or even murdered children. Their sense of themselves as part of the community of women, as mothers, has been destroyed, as has their sense of reproductive capacity and mothering possibilities. In the unit I work in, with only one exception, the losses and burdensome secrets include the early traumatic loss of sexual innocence, through incest or extra-familial abuse.

Envy and curiousity: the impact on staff The women often comment on us, female staff—what we look like, whether we have children—with a kind of resigned admiration that may well disguise envy, but in any case highlights the sense of shared gender but totally different experience of femininity. This can create strong feelings in all staff, particularly feeding into narcissistic needs for gratification or, alternatively, into our fears about being found, or even found out. That is, the idealisations and desire to know about us may be both flattering and frightening, making us want to hide away. The potential for identification with these women can itself be a threatening prospect, inviting us to imagine what it might be like to be in their situation. I believe that this dynamic is particularly powerful for women working as therapists and nurses with women with severe personality disorders. Confronting our own fears of going mad, of losing children and a sense of self-worth, as well as having major restrictions placed on our freedom—sexual, physical, psychic—is a truly frightening prospect. Defending against such an identification requires strategies for distancing oneself, which may

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include an angry withdrawal or a disavowal of affinity, that is an attempt to split off unacceptable fears or impulses and locate them in the women patients, perceived largely as ‘other’.

Clinical example The events I am about to describe took place in the weekly women’s group on the ward, itself an attempt to create a safe and enclosed setting for the women on the unit. In one group there was an intimate discussion of the losses of children, and how devastating it would be for anyone outside the hospital to hear about these experiences, how impossible to accept and understand. The women in the group were clearly split in their relation to their losses. One had become mute with grief, and related like a child herself, rocking and smiling, offering us sweets. Several patients gave the impression of being children in foster care, being offered apparent kindness but feeling they had to pay their way, making sure we the staff were placated and ‘bought off’ with sweets and expressions of gratitude. Another woman, a fire-setter of longstanding, found the experience of being in a more intimate setting than the ward both distressing and welcome at the same time. She became so confused and angry that she mixed up her words as she attempted to describe her experience, remembering how she had been talked into the decision to let her son be adopted, saying how the nurses had ‘defused’ her. She went on to describe her overwhelming sense of ‘confusement’, which seemed like a composite concept of confusion, debasement and defusion, that is, being left with no potency or hope. This arsonist spoke of being ‘defused’ by staff, evoking an image of a bomb having its force, its dangerousness, removed. She viewed this as a kind of stripping of her power, a humiliating and painful process. Staff in turn described her as having ‘burned out the nurses’. This, to me, as in so many parallel cases, expressed clearly the dynamics of projective identification in which she had split off and projected her anger and despair so powerfully that it had been located in the nursing staff, who in turn had been ‘burned out’, destroyed by the experience of intense rage. She was no longer left with the anger, but had evacuated it into those around her, and was left, if anything, empty. Her experience of being defused may have been her attempt to describe this process, which I would argue had taken place at an unconscious level. The nurse’s unwitting understanding of how this rage had been projected into her, enacted in her angry attempts to control this patient, and then burned through her, was conveyed through her description—‘she burns us out’. Something of the relentlessness and force of the patient’s experience and psychopathology is conveyed through this description. A third woman, who had taken a baby some 15 years ago, for which she had spent 11 years in a special hospital, seemed to have adopted the role of articulating the pain of mourning, and she spoke about losses with candour and sadness. Losses of children, privacy, identity, hope and sexual dignity were common experiences. This discussion led to a sharing of feelings of vulnerability and violation, particularly in relation to the men on the unit, with their sexually predatory and disinhibited behaviour. Within the group setting the staff seemed able to relate to and contain these feelings, but on the ward there was little sense of understanding. The traumatic experiences are kept at a distance and the emotional impact is avoided. Sometimes the experience of the

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patients, who feel dehumanised and lost, are described in written rather than spoken form, as this poem by a woman in a locked ward illustrates:

Mirrored Images Once when I looked at myself In the mirror, I was afraid; Afraid at what I might see there, From time to time Afraid to communicate at the face staring back at me, In case I became something like what they called me Afraid to admit that I am alive In case they don’t want me, And cancel me out Sometimes I couldn’t speak My mouth was paralysed Like now When all I can do is write. (A 2005)

Losses and secrets: self-harm For so many of these women the rage at their deprivation is manifested against themselves as they mutilate themselves in private, further damaging the points of contact between their own and other people’s bodies. I have argued that women use their bodies to articulate what cannot be spoken or thought about—that their bodies become quite literally the sites of battles and the modes of communication. It follows, therefore, that the most hidden and shameful secrets, like sexual abuse as victim or perpetrator, are likely to surface in memory with no verbal expression. That is, to describe or discuss these events is a potentially traumatic experience and the woman with severe personality disorder is more likely to attempt to escape from or encode this memory through action. One such action is self-harm, offering a tremendous sense of relief and conversion of psychic to somatic pain. Self-harm is often revealed as a fait accompli with the scars festering, the blisters and blood evidence of the secret act. It is also a warding off of contact. It seems at some level to be the creation of a false skin, warped and other, keeping the woman apart from anyone who might try to touch her. The perverse aspect of self-harm, its narcissistic immersion, is also a powerful defence against intimacy. A concrete example of the hidden nature of self-harming is the discovery, in the x-rays of one of the women on the unit, after she had fallen and broken her arm, of some 45 needles she had inserted into her skin, completely undetected by

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staff. Her innocent, ‘feminine’ requests for the occupational therapist to help her develop skills in cross-stitch had this underlying motivation, with its deception, violence and perversion. Self-harm can have a profound effect on staff, who are asked to witness these acts of violence, and to some extent to take responsibility for them. The nurses in particular are asked to take on a maternal, protective role, tending to the self-inflicted wounds with kindness and concern. But these wounds are often shocking, repulsive and frightening to behold, conveying a sense of reproach -’you didn’t stop me from doing this—you allowed this to happen on your shift—look what I can make you do now’, and hostility. Staff responses can be angry, as a reaction to the unconscious communication of hostility by the self-harmer, and because of the sense of frustration, helplessness and despair that dealing with self-harm generates. It is a violent act and can meet with a violent response. When staff become unable to think about the self-harm because they are too hurt and confused by it, too assaulted, they may feel overwhelmed, out of control and have a strong (shameful) wish to retaliate. This is clearly a potentially destructive situation and one that demands reflection and working through. I have described how some of the particular challenges and provocations unconsciously created by women with severe personality disorders are bound to invite retaliatory behaviour and feelings by staff, particularly those staff who work most closely with them. This is a dynamic which is painful to describe and even more painful to be caught up in, challenging as it does the staff’s conceptions of themselves as carers—the feelings of wanting to care for and comfort that have been the conscious impetus for entering mental health care. Staff who choose to work in fields like psychiatric nursing may also have a powerful unconscious desire to be cared for themselves, and this can lead to envy of the patients who receive this care (Menzies Lyth 1959). These feelings are painful for staff to acknowledge and manage.

Social defences against anxiety What generates such powerful, hostile countertransference feelings in us? What makes us want to throw away the most intimate accounts these patients give us of their experiences? Or condemn personality-disordered patients as ‘abusive’, ‘irritable’, ‘confusing’, ‘demanding’, words that seem to be used in every handover involving such patients. Do staff confuse their irritation, sense of being victimised, envy of being cared for, and anger at receiving a demand, with the wilful aggression of the patients? Or is it just too painful to examine the need that underlies the so-called abuse, attention seeking or demand? Looking at staff defences against anxiety is an important starting point for understanding how it is that such extraordinary levels of pain are avoided through taskorientated activity. I have already alluded to examples of splitting and projection that are primitive defences against anxiety, and are called upon when primitive earlier anxieties are activated. In her seminal paper on social defences against anxiety, Menzies Lyth (1959) identified how nursing structures and practices were set up to facilitate a socially enforced defence against anxiety. The regressive state of the patients, their dependence and the pain of their suffering evoked early anxieties for nursing staff, who found ways to

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keep this anxiety at bay. These defences were then collusively agreed upon and codified within the culture and practice of nursing. Such defences include profound resistance to change, diffusion of responsibility and splitting among the staff group. Although this paper was written approximately half a century ago it is still of profound relevance, and illuminates a great deal of current practice. An example of retaliation: creativity and envious attacks by staff In this setting it is often hard for women to retain their talents and the modes of expression that were aspects of their lives before the institution took over and further eroded their fragile sense of identity. It often comes as something of a surprise when women on such a ward exhibit their strengths, in singing, art, writing or other skills. It is as though the women have become their damage and disturbance, and their healthy, vital or creative aspects are totally located outside them, in the talented staff who are able to attend to them. When talents are exhibited they are sometimes responded to with an envious attack, unconsciously enacted by the staff. An example of this is the case of the missing poems and letters, which a largely silent but highly intelligent woman had been presenting to the nursing staff as gifts, or so it seemed to me. Eventually it transpired that they had been thrown into the rubbish heap, not even filed in her notes without being read, but thrown away unread. Her communication was too painful and raw for the staff to bear. Somewhat more removed, I found her writing beautiful, perhaps also holding it at arm’s length in this way, and had gone looking for it. One letter began, written in red ink, ‘Please consider this as written in blue, because today there is no blue pen’. It went on as a love letter, personal and painful to read, about an early sexual encounter: ‘I was excited as I thought no man would have me as I was brown…’. She had discovered her work in the bin and confronted the housekeepers with this discovery. She then took to her bed for over a week, refusing to communicate in any way. This illustrates how her communication could not be recognised by staff; yet she powerfully received their hostile response—she was witness to the apparent indifference and rejection to which her letters had been subject. This example shows how this woman’s communication was collectively obliterated, to the great cost of her self-esteem and the possibility of therapeutic engagement.

Designing women-only services Do women require units for severe and dangerous personality disorder? The problems for women in mixed-sex secure settings have been recognised recently through governmental initiatives, described in the Department of Health documents, Women’s Mental Health: Into the Mainstream (2002a) and Mainstreaming Gender and Women’s Mental Health (2003). These documents cite research into the backgrounds and presenting problems of women in the mental health services, including forensic and secure services, and also draw on the thoughts expressed by female service users. Although many of the women in secure settings have been diagnosed with personality disorder, particularly borderline personality disorder, the concept of dangerous and severe

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personality disorder that has shaped mental health services for male offender patients has little applicability for female offenders and there are no plans to develop specific treatment units for women with so-called dangerous and severe personality disorder as only about 20 women in the UK would meet the criteria for the diagnosis (Maden 2004): The conclusion that the number of women meeting DSPD criteria is very small has been reached from first principles, simply by considering the well known facts about women’s offending; that they offend at a lower rate than men overall; that their rates of violent and particularly sexual offending are lower still; and that their victims tend to be those with whom they are in a close relationship. (Maden 2004:76) One of the governmental objectives for women’s secure provision is to minimise the level of external security so that many women who are now resident in high secure hospitals will move to units with lower levels of physical security, with emphasis placed on therapeutic interventions…The research has identified that the majority of women placed in secure therapeutic services do not need high secure environments, but clinical settings that reflect their needs for psychological security and enable them to overcome traumatic experiences, explore and gain some control over overwhelming feelings and form satisfactory relationships with others. It has been demonstrated that women in secure mental health facilities have different pathways into these services, and different psychological needs from men. Services should be designed to reflect these differences but historically women have simply slotted into existing systems desiged for men, with the result that many of their needs were unmet. Since the difficulties of mixed-sex provision were identified and the needs of female clients in secure settings outlined, single sex secure facilities have been created across the UK. Several of these units operate on attachment models of care, notably the Therapeutic Enhanced Service opening in West London in September 2007, and several of the smaller units attached to medium secure units. The principles enshrined in the philosophy of care of such settings are those of optimising choice for women within forensic mental health services, facilitating their psychological functioning in a safe environment with the lowest level of external security that is possible, while reducing the risk that these women pose to themselves and others. Matching security with women’s complex mental health needs The evidence that women enter into secure units primarily because of violence directed towards themselves rather than risk to others, or because of other co-morbid difficulties including substance and/ or alcohol abuse as well as mental illness or personality disorders, has led to the conclusion that women generally do not require the same levels of physical security that men do (Bartlett 2003, 2004). Their offences tend to be less violent towards others than those of the men, and the presenting problems relate mainly to self-harm, assault of staff and fire-setting. It is suggested that their needs are best served by low secure environments that are enhanced through the provision of a wide range of psychological therapies. Embedded within this concept of enhanced secure

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provision is the notion of ‘relational security’, namely the increased level of psychological security and containment that can be provided through secure and healthy attachments to others, including staff and patients. These relationships will eventually provide the sense of safety and containment that can enable stabilisation of mental states and reduce rates of disturbed behaviour in the least restrictive environment possible. It is hoped that through the creation of units that emphasise therapeutic rather than custodial principles, the complex mental health needs of the women themselves and the requirements for public protection can be met without compromising the rights of female patients for dignity, privacy and choice. Furthermore, the provision of gender specific services for women protects the safety of women who were previously placed in close proximity to male patients who frequently had histories of violence and sexual offending. This perverse situation was profoundly unhelpful, not only for the women in these settings, but also for the men, who were faced with risky situations in which they found themselves living with women whose earlier experience of sexual abuse may have left them vulnerable to repeated abuse, and difficulties in asserting sexual boundaries. The familiar, if destructive, pattern of relationship featuring sexual exploitation or violence could have a compulsive appeal for both men and women; the risk of traumatic re-enactments in this situation was high. Theoretical underpinning of the attachment model The model of attachment theory provides the conceptual foundation for the models of care for many of the new women-only secure units. This model emphasises the disturbed history of abusive, neglectful or inconsistent care that is known to characterise the lives of the majority of women in secure provision. Through placing attachment theory at the heart of the women’s service it becomes possible to gain a conceptual as well as clinical understanding of the role of insecure early relationships and their impact on later psychosocial development. One of the tenets of attachment theory is that adults who were insecurely attached in childhood are likely to display disturbed behaviour in later life, often experiencing instability in relationships, difficulty trusting others, problems in managing impulse control, a sense of needing others but difficulty in establishing intimacy. These difficulties are consistently identified in the histories of those women who are often diagnosed with borderline personality disorder. They find intimate relationships problematic yet struggle to feel secure on their own; this fear can be traced back to an insecure attachment with a primary carer, who failed to act as ‘a safe base from which to explore’. Recent theorists have linked such attachment difficulties with a fear of being abandoned and some major limitations in being able to understand and modify distressing states of mind (Bateman and Fonagy 2004) and emphasise the need for clinicians working with such individuals to be sensitive to the danger of reactivation of disturbed attachment systems that prevent thoughtfulness or self-reflection. Insecure styles of attachment are created by experiences of loss, separation, abandonment, or rejection in early life, and by being a victim of prolonged psychological trauma, such as childhood abuse. These disturbed attachment styles endure throughout a person’s life cycle and are manifested through patterns of behaviour and emotional experience within the context of intense intimate relationships. Relationships that activate

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attachment behaviour and concomitant emotional experience include those with professional carers when sick or dependent. Research has indicated that individuals with insecure attachment styles are more likely to have an offending history and experience significant mental health problems characterised by difficulty receiving care and treatment. This has obvious implications for the relationships that are likely to develop between nursing staff and patients on womenonly units. Women who have repeatedly experienced disruption and unreliability in their care are likely to expect that such experiences will recur, and will test out, threaten and reject the overtures made by nursing staff and other mental health professionals, finding it safer at times to reject such care for fear of being disappointed yet again. Additionally, there may be an apparent safety in returning to familiar styles of relating, even if these are ultimately doomed to failure, as the women with these disturbed early experiences are convinced of their own worthlessness and may find genuine care and concern almost impossible to manage. The primary task of nursing staff is to provide care, and to learn how to ‘nurse under fire’ (Aiyegbusi 2004) in order to withstand the psychological and even physical assaults that these women are likely to display. An understanding of the major disturbances in attachment styles, the anticipated rejection and unconscious attempts to re-create neglect and abuse, will be invaluable in enabling staff to withstand the assaults and provide consistent and reliable care for the female service users. Staff choosing to work in women-only services may have idealised them, as though all aggression was located in male patients and all vulnerability in the females. They may have been attracted to the work because of a desire to heal and rescue, but find themselves disappointed. This kind of idealisation and hope can lead to despair if it is not addressed. Women’s aggression towards one another as well as towards themselves, and the potential for destructive re-enactments with members of the staff, must be acknowledged when designing the services, and on an ongoing basis through regular training and supervision. A basic understanding of attachment models and the features of disturbed attachment styles can be helpful for nursing and other staff, who can then better understand the behavioural disturbances and relationship difficulties which the women typically display. The model informs nursing practice, including procedures relating to levels of observation and nursing response to self-harm. The notion of providing a safe base for women in distress can inform nursing practice. It is a useful model for understanding how the security of a relationship can help women to feel more able to explore their environment and gain confidence when moving away from the immediate proximity of the ward, or from a trusted member of staff. The model also provides an understanding of the importance of separations and breaks for patients and allows staff to recognise the central role their presence can play in creating a sense of safety and containment. Some specific nursing practices have been informed by this approach, including the practice of one-to-one observations of women in distress, who are considered to be in need of close supervision. It became possible to review this practice in the light of attachment theory and to recognise that far from offering a sense of security to woman in distress, close and constant scrutiny can be intrusive and highly arousing, reactivating a sense of fear and panic. Being near a comforting and containing figure, without being closely watched, can be far more helpful to women in distress than the traditional response of close observation.

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The one-to-one response is, in some of the new women-only units, replaced with another type of observation that involves being able to see the women from a distance; this is referred to as ‘zonal observation’, meaning that staff ensure that women can be seen in various parts of the ward to enhance their safety, rather than being shadowed at all times by a member of nursing staff. It may be that there is an underlying, unconscious sense of omniscience hidden in the traditional notion that simply watching a woman sleep, sit and read can somehow prevent her from doing harm to herself and others. The fantasy is to do with a wish for control and reveals the concrete equation of ‘seeing’ with ‘knowing’ or ‘seeing into’ as though watching someone closely will reveal their internal world. To return to the central motif of this chapter, for women placed on ‘one-to-one observations’ there may be nowhere for them to hide, in a physical sense, but they may nonetheless feel quite lost. The practice of one-to-one observation also fails to understand aggression as communication at a time when the individual does not feel attended to or contained. What may actually stop this woman from enacting her aggressive impulses is the sense she has of being in the presence of another who can bear and contain these unacceptable, aggressive thoughts and feelings. Once again Menzies Lyth’s work is highly relevant to formulating the close observation system as a form of defence against anxiety; in the face of anxiety and despair the traditional response of the social system is to become task focused and distant, so organising a rota of one-to-one observations and charting them temporarily reduces staff anxiety. In fact, emotional engagement and the creation of a containing ward in which the woman’s distress can be heard may be more effective in reducing the risk of harm. A central difficulty of establishing this kind of therapeutic environment is that it requires staff to surrender their traditional defences and engage with the emotional pain of the women’s experiences. Recently, Bateman and Fonagy (2004; 2006) have developed a therapeutic approach to women who repeatedly enact impulsive behaviour; their model of ‘mentalization-based treatment’ offers a framework for therapeutic interventions with this client group. In this form of therapy women with severe difficulties in impulse control are helped to think about rather than enact their mental states. This requires the attachment system to be ‘deactivated’, that is, in a state of low arousal. Familiarity with the consequences of disturbed early attachment on later adult functioning will greatly assist this understanding. Specific training in mentalization-based therapy should be undertaken by whole staff teams to create a shared understanding of the specific needs of this population and develop ways of enhancing reflectiveness and self control in this highly vulnerable group. Reflective space including group and individual supervision is essential to help staff teams process and understand their clients’ experiences and how they can be projected into them. Another important need of female units is the availability of talking therapies, including psychotherapy, and creative therapies. One of the central tasks for mental health professionals working with female offenders is to enable them to give voice to distress in other ways than attacks on themselves, through their own or their children’s bodies. This can occur symbolically through music, dance and art, as well as through words.

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Returning to the theme of hiding and being lost, the hide-and-seek game, which has been invoked throughout this chapter, has as its central aim the desire to be found. This is the central fact to bear in mind. The hider who is never found is like the runaway whose absence is not noticed. The unconscious hope of many women in secure settings is that they will and can be found by others, that they can make contact with us and that we will find a way to bear their communication. The women’s fear of and desire for closeness requires staff to encourage gradual steps towards therapeutic contact and remain receptive to the possibility of communication rather than a persecutory approach that is intrusive or condemns behaviour without understanding its meaning. Through sensitivity to the women’s paradoxical wishes for closeness and separateness and attention to the multiple meanings of her violence, genuine therapeutic engagement can be made.

Conclusion My aim in this book has been to present a range of cases of female violence and to offer a model for understanding these cases. Although primarily informed by a psychodynamic perspective I have also drawn from other models, including attachment theory and a feminist understanding of the causes and manifestations of female violence; the latter was especially relevant to the discussion of self-harm as a form of communication and to the understanding of abused women who kill their violent partners. Each act of violence that I have discussed has a particular meaning and can be read as a communication of psychic conflict and distress. The link between depression and violence should not be overlooked as many acts of violence, whether targeted against the self, others or children, are linked to severe depression. The strong connection between homicidal and suicidal urges is evident in the extreme acts of violence which occur within the context of depression. This is illustrated in Sylvia Plath’s semi-autobiographical work, The Bell Jar (1963), in which dying objects, images of death and killing are central motifs. She describes the torment of depression, and the subsequent violence which the central character inflicts on herself through various suicide attempts. Plath also explores the traditional medical response to attempted suicides, the manifestation of aggression, turned in on the self, and vividly describes the violence of this response, which itself mirrors the homicidal urges inherent in the suicidal acts. She presents a powerful account of the violence which psychiatric treatment in the form of shock therapy, known as electro-convulsive treatment, can inflict. This presents psychiatry at its worst, in what Plath perceives to be its brutal and objectifying treatment of depressed patients: Doctor Gordon was fitting two metal plates on either side of my head. He buckled them into place with a strap that dented my forehead, and gave me a wire to bite. I shut my eyes. There was a brief silence, like an indrawn breath. Then something bent down and took hold of me and shook me like the end of the world. Wheeee-ee-ee-ee, it shrilled, through an air crackling with blue light, and with each flash a great jolt rubbed me till I thought my bones would break and the sap fly out of me like a split plant… At least at Belsize I could forget about shock treatments. At Caplan a lot of the women had shock treatments. I could tell which ones they were, because they didn’t get their breakfast trays with the rest of us. They had their shock treatments while we breakfasted in our rooms, and then they came into the lounge, quiet and extinguished, led like children by the nurses and ate their breakfasts there. (Plath 1963:151, 217)

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This moving description of helplessness and fear serves as a powerful message for therapists to attend to their clients’ experience of treatment. The therapeutic task is surely to help women articulate and express unhappiness and anger, so that they can effect change in their lives, not to silence or extinguish them.

Therapeutic responses to female violence As a clinical psychologist I draw from a range of models, depending on the particular difficulties with which clients present. I offer psychotherapy, often in conjunction with psychotropic medication which is prescribed by psychiatric colleagues. While I recognise the need for psychotropic medication in the treatment of what can be considered major mental illnesses, medication alone cannot resolve underlying psychological difficulties, and women who have committed violent acts, whether or not they are diagnosed with major mental illnesses, must be given a voice and empowered to understand and articulate their experiences in order to exert control over their lives. I see forensic psychotherapy as a central tool in achieving this task. It is important to acknowledge that women often present at the forensic psychiatric and psychological services for multiple reasons, and enter these services with dual diagnoses; the existence of these diagnoses in female offender patients is described in the clinical audit conducted at the regional secure unit where I am based (Turcan and Bercu 1999). The existence of dual diagnosis points to the complexity of difficulties with which violent women present in the psychiatric services and underlines the need for clinicians to approach them with a range of therapeutic models for understanding and managing their violence. The psychiatric needs of women in prison have been well documented (Allen 1987; Carlen 1996, 1998; Maden 1996) and it is clear that these mental health needs are not best addressed within the custodial services. In the case of psychotic women who kill, their mental state at the time is a key consideration in judicial decisions. If such women are ‘sentenced to treatment’ rather than custody it is essential that their psychotherapeutic needs are not subsequently overlooked so that they are confined within a hospital rather than a prison. Specialist services must be designed to address the specific needs of women in the psychiatric system, including facilitating contact with their children, and protecting them against sexual abuse and harassment. Carlen (1998) recommends that ‘women-wise’ practices be developed in the criminal justice system, which applies equally to the psychiatric services.

Need for forensic psychotherapy with violent and perverse women In order for the violent client to be engaged in a model of psychological treatment informed by psychodynamic thinking, the ideal psychoanalytic model requires radical modification. It is generally not possible to treat patients in more than once-a-week therapy within the forensic services, and these patients may be incarcerated, or attending therapy as a condition of treatment attached to their probation order. The motivation of the patients to attend for psychological treatment may include the desire to avoid

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custodial sentence, the hope of retaining custody of their children in the face of care proceedings, or the fear of losing a significant relationship because of violence. The Portman Clinic model of psychoanalytic psychotherapy with offender patients (forensic psychotherapy) accepts these as valid reasons for wanting to understand and change behaviour. This approach makes it possible for violent individuals, some of whom may feel coerced into undertaking treatment, to become engaged in long-term therapeutic work in which the link between early experiences and current difficulties and between unconscious motivations and conscious behaviour can become explicit. Paul Verhaeghe, a Lacanian Professor of Psychoanalysis in Ghent, notes the limitations of contemporary psychiatric diagnostic categories and focuses on the transference situation as a highly important diagnostic tool. He emphasises the need to attend to the powerful countertransference feelings that arise and also to bear in mind the sense in which the violence, or perversion, is nonetheless a psychic solution to underlying issues that cannot simply be removed or stopped: The good news is that such a situation can be used as a diagnostic instrument. To the extent that one can start treatment, one must fully take into account that the perverse behaviour or scenario is itself a solution for the underlying problematic structure. Focussing exclusively on relapse prevention removes the perverse subject’s attempt at solution without addressing the underlying problem. To the extent that relapses stop, this must occur as a result of treatment, not as the primary goal. This is why one must focus on establishing an effective therapeutic working alliance. (Verhaeghe 2004:426) It is important to bear in mind that underlying these extreme disturbances there can be an experience of profound trauma or neglect; violence has developed as a psychic defence. The integration of therapeutic services is crucially important in the areas of child and family psychiatry and the forensic psychiatric services. In these areas working with victims and perpetrators of abuse is often highly polarised and communication between the two specialities can be fragmented and poor. This failure of integration in the systems can only be detrimental to the common aim of reducing the risk of violence to children. Many abusive parents were themselves neglected or maltreated children who find themselves reenacting their own traumatic experiences with their children, against their conscious wishes to protect and care for them. In the case of maternal violence this task may pose particular difficulties for professionals, who must question and eventually relinquish preconceptions about motherhood in order to engage and work with violent women. It is crucially important that insights into the development of violence and disturbance through early attachment disturbance are used to understand and help mothers, not to blame or condemn them. The intergenerational transmission of violence, which is described throughout, is one of my central concerns. In order to understand violence it is essential to trace its origins and development. Psychotherapy is an invaluable tool for addressing the development and manifestation of violent impulses, and aims to facilitate the violent woman’s understanding of her internal world and help her to manage the external expression of her distress and anger. By offering violent and abusive parents treatment aimed at addressing

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unresolved psychological issues, the risk of re-enactment of earlier trauma with their own children can be reduced. In order for this work to be effective, it is essential that the various mental health agencies co-ordinate their programmes and work together to help parents improve their understanding of child protection and child welfare, and to implement this. External sources of practical, educational and emotional support for mothers facing social isolation and stress are highly important and can sometimes be prerequisites for engaging in the therapeutic work.

Women in custody: the external reality In studying the area of female violence I have focused on the internal realities of the women whom I have seen in the context of psychological assessment and treatment. I have not included an extensive discussion of the external realities faced by violent women when they commit offences and enter the criminal justice system. The work of Carlen has been invaluable in providing a thorough exploration and critique of the treatment of female offenders. I refer the interested reader to her work, specifically to Sledgehammer: Women’s Imprisonment at the Millennium (1998), which is an extremely thorough, forceful and informative study of the treatment of female offenders and an argument for the abolition of imprisonment altogether. She presents criminal statistics relating to the high proportion of first-time female offenders who are incarcerated and whose children are therefore also punished through this enforced and unwanted separation. Maden’s (1996) book, Women, Prisons and Psychiatry: Mental Disorder Behind Bars also provides a fascinating account of his study of the psychiatric conditions of incarcerated women and an exploration of how, if at all, the custodial services can meet these needs. There is clearly a powerful interaction between social and psychological factors in the genesis of violence in women. It is evident that female violence is multiply determined and it would be wrong to minimise the importance of social factors, which can predispose individuals to criminality through the stresses of poverty, unemployment and racial and sexual discrimination. The available research demonstrates that it is not possible to provide a simple formulation in which the relative weights of the various contributory factors are quantified. Specific types of violence, such as deliberate self-harm, have been studied in female prisoner populations and have been found to be associated with particular psychological experiences, such as a history of being in care, of violent offending and alcohol dependence (Cookson 1977), and with arson, sexual abuse and violence within the home (Liebling 1992). While these findings are of great interest, it is important to remember that they are associations between particular experiences and behaviour, rather than proved causes of the behaviour. The social factors which influence rates of female violence are not necessarily fixed, in that attitudes about the acceptability of female aggression are changing, the social circumstances of women are also changing, and powerful role models for young girls have shifted. There has been an increasing rate of female violence since the 1970s, and in 1997 the number of violent crimes committed by women had doubled since the 1970s (Home Office 1998). While the number of violent crimes committed by women is still far

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behind the number perpetrated by men, e.g. 8600 compared to 49,600 in 1997, the increasing rate of female violence is still significant. The recent case of a 71-year-old widow who was murdered by two adolescent girls prompted media interest in the increase of female violence and in possible explanations for what has been dramatically termed ‘this horrifying new trend’ (The Independent on Sunday, 1 August 1999). Dr Sue Bailey, an adolescent forensic psychiatrist, suggested that girls are now less inclined to express their anger through self-mutilation but will lash out at others, taking an active part in violent activities rather than simply accompanying a violent male in luring victims. It could also be suggested that the rising recorded number of violent crimes by women is indicative of an increasing acceptance of the possibility of female violence, and a willingness to prosecute female offenders. It is worth noting too that the violence which is now considered to be a ‘horrifying new trend’ is the violence towards others, rather than self-directed violence, or violence towards children, which, as I have argued, has been largely overlooked, despite its potential danger. Nonetheless, the growing awareness of female violence, and particularly sexual violence, indicates that some aspects of the denial and taboo of female violence are gradually being challenged. The development of separate male and female mental health facilities, following the research and guidelines in the Department of Health documents Women’s Mental Health: Into The Mainstream (2002a) and Mainstreaming Gender and Women’s Mental Health (2003) testifies to an increased understanding of women’s unique needs and backgrounds. Services are being designed with women’s increased risk of trauma and need for relational security in mind. This attention to difference is a step towards the journey of understanding the development of female violence, but the question remains of whether women require secure provision at all. The idea of locking up women whose difficulties centre on their own destructive impulses against themselves remains problematic. Cherie Blair raised a similar issue in a speech (May 2007) against the increase in prison sentences for women, arguing that the hidden damage of these disposals was in the separation of the women from their children. The notion of punishment, rather than understanding and support seems to remain popular in our society, particularly where female criminals are concerned.

The dangers of sentimentality A central thesis of this text is that female violence is often ignored or denied, because to accept it, particularly in relation to maternal abuse, would be too threatening to traditional and idealised notions of motherhood and femininity. I consider this to be a fundamentally dangerous social attitude, which can lead to vilification of those women who do display violence to the extent that they are considered inhuman and ‘evil’, and, at the other extreme, a massive denial of risk to children who may remain under the unsupervised care of abusive mothers and carers. Ultimately, this denial of female violence, and specifically maternal abuse, results in the failure to recognise and design comprehensive and sensitive treatment programmes for women whose violence results from psychological difficulties, with roots in their own early experience of deprivation and abuse.

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Sentimentality can both engender and disguise violence. A sentimental attitude is one in which an abstracted conception of someone as part-object is maintained, such that a denial of imperfections must be preserved. This attitude requires a suspension of objectivity or recognition of the conflicting qualities within the idealised person. It is a feature of a sentimental relationship that it is an inauthentic one in which the flaws in the person are redescribed as benign or even desirable. Sentimentality requires idealisation, which can quickly lead to denigration. The cherished object can easily become an object of disappointment, engendering anger and contempt when it fails. The object may then need to be contemptuously dismissed or attacked, to rid the subject of its sense of anger and disappointment; the container of idealised projections now becomes the ‘poison container’ (deMause 1990). The move from idealisation to denigration can be seen in the sentimental regard with which women and children are held, and the rage which is evoked when their aggressive or sexual impulses appear to become out of control or dangerous. There is then a punitive backlash that has a ferocity alarming to those who attempt to understand aggressive behaviour. It can be seen in the public fury when mothers display aggressive or perverse behaviour, and appears to be a manifestation of rage and disappointment that these women have failed to conform to powerful stereotypes of them as nurturing and gentle creatures. The backlash against these women reflects the depths of the disappointment and anger that they do not conform to these sentimental notions and reveals the strength of the taboos relating to maternal incest and violence. This process has been vividly elucidated by Welldon in her exploration of the idealisation and denigration of motherhood, and further illustrated here. The sentimental attitude disguises the violence of objectification and dehumanisation—the treatment of young girls, and women, whether or not they are mothers, as partobjects—and must be redressed through a thoughtful and sensitive understanding of female violence.

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Index AAI see Adult Attachment Interview abandonment 34, 72, 100, 107; abusive relationships 279; attachment difficulties 341; fear of 330; infanticide case 162, 163, 164, 165–6, 170; post-pregnancy 25; self-harm 200 abuse: child protection 282; fabricated or induced illness 11, 127; fatal 156, 157; filicidal parents 174; insecure attachment 341; intergenerational transmission of 5, 8, 10, 55–6, 188–9, 290–1; ‘learned helplessness’ 14; unconscious attempts to recreate 342; women’s own experience of 19–20, 21, 23, 26–7, 31, 171, 352; see also domestic violence; emotional abuse; physical abuse; sexual abuse acting out 68, 198, 200, 217, 243, 245, 309; see also re-enactment adolescence: anorexia 240, 245–8, 266; neonaticide 186; self-harm 196; sexual abuse 53 adoption 321 Adshead, G. 79, 138–9, 193, 197, 200–1 Adult Attachment Interview (AAI) 33 affective disorders: homicide 172, 179; self-harm 203, 204, 205, 206 ageing 256, 266 agency 4, 71, 184, 284–5, 311 aggression 104, 271, 352; anorexia 242, 243, 248; as communication 343; denial of female capacity for 4; fabricated or induced illness 127, 138–9, 142, 149;

Index

269

female killers 309; filicide 175, 177; projection of 67; self-harm 194, 198, 201, 223, 227, 255; sexualised 6, 49, 50, 196; women’s secure provision 342 Ainsworth, M. 33 Aiyegbusi, Anne 226, 234 alcohol use: co-morbidity 340; domestic violence 289; fabricated or induced illness 122; infanticide 179; killing of abusive partners 292, 293; physical abuse 83, 90, 92–3, 94; self-harm 221, 350 alienation 89, 214, 219 Allitt, Beverley 111, 112–14 altruistic filicide 173, 177, 178–9 ambivalence: abusive relationships 311; fabricated or induced illness 142; pregnancy 29, 176 amenorrhoea 241, 244 anger 67, 97, 107, 171, 352; alternative ways of relieving 236; anorexia 248, 257, 260; domestic violence 279; killing of abusive partners 308–9; murderous 166, 170, 278, 323, 326; postpregnancy 25; projection of 169, 334; self-harm 193, 195, 197, 201, 203, 217, 220–2, 225 Anna Freud Centre 229 ‘annihilation anxiety’ 51 anorexia nervosa 3, 9, 13, 239–67, 317, 321; bulimia distinction 244–5; case illustration 252–8; cognitive behavioural formulation 260–3; countertransference 236; as disorder of adolescence 245–8; DSM-IV classification of 240–1; feminist model 264–5; filicide 178; offending behaviour 251–2; personal account of 258–9; perversion 6, 243–4, 266; ‘proana’ websites 13, 248–51; self-harm 196, 208, 227; sexual abuse 259–60; shoplifting 251, 252–3, 254, 256–7, 258; socio-cultural factors 263–4;

Index

270

symbolic use of the body 7; as violence against the self 241–2 antisocial personality disorder 201 anxiety: anorexia 245; fabricated or induced illness 118; incarceration 206; nurse-patient relationship 226; self-harm 197, 200, 202, 203, 217, 219, 224, 236; staff defences against 331, 336–7, 343 arson 166, 262, 340, 350 Ashworth Special Hospital 232 assessment 5, 28, 81–2; battered women 286–7, 289–90; female sex offenders 64, 68; see also risk assessment attachment: fabricated or induced illness 127, 128, 138; intergenerational transmission of disturbed parenting or abuse 8, 33–4, 290–2, 349; mentalization-based therapy 229, 230; physical abuse 106; women-only secure units 339, 340–4 Bailey, Sue 350 Bashkin, E.A. 199, 200, 218 Bateman, A. 13, 34, 200, 229, 343–4 ‘battered baby syndrome’ 36, 130, 157, 173 ‘battered woman syndrome’ 14, 294, 302, 305–6, 307 beauty 264–5, 267 Beck, A.T. 260 Beckett, R. 68 Bemis, K.M. 260, 261 Berg, B. 147 Bethlem Mother-Infant Interaction Scale 187–8 Bifulco, A. 88–9 binge eating 241, 244, 245, 248–9 biological factors 8; causes of infanticide 158–60; fear of women’s procreative capacities 183–4 Birksted-Breen, D. 241–2, 246 Blair, Cherie 351 Bloch, D. 157 Bluglass, K. 176, 177–8, 183 body 6–7, 9, 155–6; adolescence 245–6; alienation from 29; anorexia 13, 239, 242, 246, 256, 258, 265–6; assertion of control over 221–2; children’s 317–18; fabricated or induced illness 121–2, 127, 150; female perversion 21, 243;

Index

271

hiding 330; identity located in 127, 195, 237, 318; as mode of communication 335; pregnancy 29, 30–1, 317; self-harm 195–6, 197–8, 200–1, 216, 219, 221–2, 224, 236; split-off 198–9, 216; symbolic attack on mother’s body 318, 324; unconscious conflicts 23–4, 328; violence against the self 12, 19 body image distortion 241, 244 Bools, C. 145–6 borderline personality disorder (BPD): attachment difficulties 341; dialectical behavioural therapy 227–9; infanticide 164, 173; intergenerational transmission of disturbed parenting 291; mentalization-based therapy 13, 108; secure units 338; self-harm 193, 196, 201–2, 203–4, 205, 228, 229, 231; sexual abuse 199 Bordo, Susan 220, 264, 265 boundaries: professional 167–8, 169, 225; staff/therapist 215; therapeutic 209 Bourget, D. 158, 172, 173, 174, 177, 178 Bowlby, John 33 BPD see borderline personality disorder Bradford, J.M.W. 158, 172, 173, 178 breastfeeding 35, 38, 39–40, 130–1, 134 Bristol Crisis Service for Women 235 Broadmoor Hospital 232 Brotsky, S.R. 250 Brown, G.W. 275 Browne, A. 278, 280, 283, 284, 293 Bruch, H. 244, 260 bulimia nervosa 13, 239, 267, 321; anorexia distinction 244–5; cognitive behavioural treatment 262; personal account of 258–9; ‘pro-mia’ websites 13, 248–51; socio-cultural factors 263 Bunce, S.C. 172 burning 194, 195 Busfield, J. 117 Calam, R. 259–60 Campbell, D. 194, 198 Campbell, J.C. 293 care proceedings 25–6, 28–9;

Index

272

abusive relationships 286, 287, 289–90; assessment of parents 81–2; fabricated or induced illness 134–5, 136; maternal physical abuse 95–6, 98, 101, 103, 104, 105; sexual abuse cases 58–9, 60, 61, 65; see also child protection; social services Carlen, P. 347, 349 Carr, Maxine 316 case illustrations: abusive relationships 286–90, 291–2; anorexia 252–8; fabricated or induced illness 128–40, 141; filicide 319–26, 327; infanticide 160–71; killing of abusive partners 295–300; physical abuse 76–9, 91–8, 99–102; pregnancy and unconscious fantasies 25–9, 30–2; self-harm 207–17, 218–25, 227; sexual abuse 43–8, 49–52, 56–9, 60–7 Cassel Hospital 106, 148–9, 188 child protection 80, 81–2, 83, 101, 349; battered women 282; conflicts with parents 103; expert witnesses 126; fabricated or induced illness 114, 116, 144, 145, 146–7; failures of 109, 114; recognition of female abuse 150; sexual abuse 52, 68, 69; shared responsibility 108–9; Victoria Climbié Inquiry Report 84, 87, 88; see also care proceedings; social services childbirth 183–4, 185, 317 children 5, 9, 10–12; battered women 281–2, 297–8, 300; custody battles 281, 282–3; fabricated or induced illness 111–51; killing of 82–8, 153–89, 319–26, 327, 328; physical abuse of 71–109; ‘poison container’ concept 78, 86, 170–1, 179, 186, 318–19; removal into care 65, 81–2, 95–6, 98, 101, 103–5, 144; separation of women prisoners from 349, 351; sexual abuse of 35–69; see also child protection; filicide; infanticide Children Act (1989) 282 Children Act (2004) 84 Chipchase, H. 194, 232, 233 Clark, Sally 125–6 Climbié, Victoria 72, 79–80, 84–8, 107, 157

Index

273

cognitive behavioural approaches 8; anorexia 260–3, 264; bulimia 262; maternal violence 107, 108; self-harm 227–9 cognitive dissonance theory 285 cognitive distortion 43, 46, 52, 68, 294 Coid, J. 201–2, 204–6 communication 6–7, 100, 164; aggression as 343; anorexia 239; fabricated or induced illness 150; nurse-patient relationship 226; physical abuse 102; self-harm 13, 197, 219–20, 234, 236, 345; staff rejection of patient’s communication 338; therapeutic 328, 344 concealment of birth 181–2, 186 confidentiality 146, 215–16 containment 142, 165, 200; anorexia 246–7, 263; attachment disturbances 291; ‘relational security’ 340; women-only secure units 342 Cookson, H.M. 233 Coombe, P. 148 Cooper, A. 87, 88 counselling 28–9; abusive relationships 276, 290; fabricated or induced illness 133 countertransference 348; anorexia 265; fabricated or induced illness 140; infanticide 167, 168–9; self-harm 216, 222–5, 236; sexual abuse 60, 65, 66, 69 covert video surveillance 134, 146, 150–1 Cox, A. 89 Craissati, J. 37, 39 creativity 337 Cremin, D. 230, 231, 232 criminal justice system 2–3, 4–5, 349–51; expert witnesses 79–82; infanticide 180–2; killing of abusive partners 296, 299–300, 301, 302–8; sexual abuse 37; stereotypes 272; ‘women-wise’ practices 347; see also legal issues; legislation; offenders; prisoners

Index

274

criminality 349–51; anorexia 251–2; hormonal causes 184; see also offenders Crisp, A.H. 252 cruelty 318, 324, 328; anorexia 257, 259, 265; domestic violence 278; fabricated or induced illness 123; maternal passivity 73; physical abuse 75–9, 88; sexual abuse 57, 65, 66; Victoria Climbié Inquiry Report 84–5; women’s own experience of 315 cultural identity 332 cultural norms 39–40, 263–4, 265 custody battles 281, 282–3 cutting 194, 195, 210–11, 227; see also self-mutilation dangerous and severe personality disorder (DSPD) 338–9 Day, D.O. 120, 128 DBT see dialectical behavioural therapy De Zulueta, F. 8, 71, 72, 73–4, 78, 90, 101 deception 47, 59, 65, 105; anorexia 243; fabricated or induced illness 120, 122, 123, 137, 138–9, 142; pro-eating disorder websites 251 defences 8, 31; anorexia 256; cognitive deadening 292; killing as enactment of primitive defence mechanisms 271, 294; manic 169; self-harm 231, 232; sexual abuse 48–9, 68, 199; staff 331, 336–7, 343; see also projective identification; splitting degradation 293 deMause, L. 86, 170–1, 318–19 denial 4, 71, 149–50, 188, 272, 351; child protection 88; fabricated or induced illness 119, 136, 137, 139–41, 142, 146; female aggression 310; infanticide 12, 155, 189; killing of abusive partners 308–9, 310; physical abuse 75; of pregnancy 12, 177, 186–7; sexual abuse 11, 36, 59, 60, 65, 68; therapist’s collusion with 327

Index

275

Department of Health 14, 107, 145, 338, 351 dependency: abusive relationships 279; emotional 100; terror of 166; treatment of parents 148; unmet dependency needs 138 depersonalisation 199, 203, 206, 213, 217, 218–19, 233 depression 12, 26–7, 243; abusive relationships 275–6, 277, 294; bulimia 245; cognitive distortion 294, 295; fabricated or induced illness 127; incarceration 206; infanticide 155, 159–60, 161, 171–2, 179, 180, 181; interpersonal psychotherapy 108; killing of abusive partners 295–6, 299, 300, 309; maternal physical abuse 73, 78, 88–91; narcissism as defence against 325; perversion as defence against 48–52, 55; resurfacing during therapy 327; self-harm 196–7, 202, 203, 217, 219, 236; sexual abuse 42; social conditions 72, 189; violence link 345; see also post-partum illness deprivation 100, 317, 318, 352; abusive relationships 279; anorexia 257; core complex of perversion 50; fabricated or induced illness 135, 139; infanticide 171, 187; pregnancy 23, 24, 328 derealisation 203 ‘derogation of the victim’ 285–6 despair 163–4, 165, 171, 308; infanticide 183; projection of 169; self-harm 217, 336; sexual abuse 66 Diagnostic and Statistical Manual-IV (DSM-IV) 127, 155, 181, 240–1, 243–4 dialectical behavioural therapy (DBT) 227–9 diminished responsibility 154, 272, 274, 294, 295, 299, 301–2, 320 dissociation 71, 73, 77, 99; denial of pregnancy 187; fabricated or induced illness 119, 137, 138, 139; filicide 322; infanticide 162; neonaticide 159; psychosis 201; self-harm 214, 219

Index

276

distraction 219, 233 ‘disturbances of mind’ 181, 182, 183, 188 doctors 120–1, 122–3, 124, 128, 129, 135 domestic violence 14, 45, 73, 102, 104–5; case illustrations 94, 95, 99, 286–90, 291–2, 295–300; destructive interdependence 306–7; difficulty leaving relationships 280–6, 294–5; dynamics of abuse 277–9; fear of retaliation 283–4; infanticide 180; killing of abusive partners 271–2, 278, 292–311; learned helplessness 14, 275–7, 289, 294, 295, 302, 307; legal defences against homicide 302–8; number of abused women 292; psychological effects of 284–6, 304; sadism 280; trap of violent relationships 275; wider context 311; see also physical abuse D’Orban, P.T. 175, 176, 274 drug use: co-morbidity 340; fabricated or induced illness 122; infanticide 179, 180; killing of abusive partners 293; physical abuse 83, 90; self-harm 208 DSM-IV see Diagnostic and Statistical Manual-IV DSPD see dangerous and severe personality disorder dual diagnosis 347 Dube, S.R. 36 dysmenorrhoea 196 eating disorders 51, 113, 122, 243; fabricated or induced illness 127; pregnant women 317; pro-eating disorder websites 13, 248–51; sexual abuse 259–60; socio-cultural factors 263–4; see also anorexia nervosa; bulimia nervosa ego 243, 247 ‘elimination fantasy’ 178–9, 194, 198 Eminson, D.M. 112 emotional abuse: case illustration 77, 78; coexistence with physical/sexual abuse 39, 72, 91; undetected 82; women’s own experience of 23 emotional dependency 100 emotional numbness 213, 214, 218, 298

Index emotions 247, 261 emptiness 78, 79 Endicott, J. 108, 188 envy 4, 28, 171; of children 323, 324; of staff 332–3; staff envy of patients 336, 337–8; of therapist 327 Evans, C.D. 204 evidence-based practice 13, 68, 107, 230 Ewing, Charles 304–7, 311 expert witnesses 79–82, 124, 125–6 extended nursing 39–40 fabricated or induced illness (FII) 11, 100, 111–51; case illustration 128–40, 141; clinical response 139–41; diagnosis of MSBP 114–18; differential diagnosis 142–4; failure of differentiation 141–2; management of 144; previous classifications of MSBP 118–21; Regina v Clark case 125–6; treatment and prognosis 144–8; understanding the dynamics of 121–4; see also Munchausen’s syndrome by proxy Fairburn, C.G. 261, 263 ‘false self’ 163, 258, 320 family centres 106, 287, 289, 290 family psychiatry 348 fantasy: acting out 243; aggressive 148; bulimia 245; destructive 327; ‘elimination fantasy’ 178–9, 194, 198; fabricated or induced illness 119, 150; murderous 141–2, 316–19; Oedipal 40; omnipotent 257; perversion 22, 23, 25; projective identification 277; psychosomatic illnesses 7; self-harm 198; sexual 55; unconscious fantasies during pregnancy 29–32; working with killers 308, 326 father: doctor as father figure 122; fabricated or induced illness 141, 145;

277

Index

278

filicide 157–8, 174; see also partners Faulk, M. 177 Feldman, K.W. 146 femininity: cultural constructions of 264; female killers 271; idealisation of 151, 351; sentimentalised notions of 4; stereotypes of 36 feminist approaches 7–8, 345; anorexia 264–5; self-harm 220, 232–5 FII see fabricated or induced illness filicide 171–8, 180, 189, 315, 328; case illustration 319–26, 327; classifications of 174–8; maternal depression 171–2; psychosis impact on 172–4; transference and countertransference issues 326–8; see also infanticide; neonaticide firearms 292, 293 Fonagy, P. 2, 8, 13, 34, 163, 200, 229, 318, 343–4 Ford, H. 36, 43 forensic psychotherapy 4, 15, 347–9; battered women 282; dual diagnosis 346–7; fabricated or induced illness 148; female killers 309; see also psychotherapy foster care 28, 77, 82–3, 98, 161–2 Foster, L.A. 293 Freud, Sigmund 6, 20, 21, 255 Garfinkel, P.E. 262 Garner, D.M. 260, 261 General Medical Council (GMC) 11, 79, 111, 125–6 Gibson, E. 172 Giles, D. 250 Gilligan, James 332 Glasser, M. 50–1 GMC see General Medical Council Goldring, J. 111, 112 The Great Mother’ myth 10, 183 Great Ormond Street Hospital 106 Green, A.H. 54 Green, C.M. 186 grief 11–12, 252, 296, 297, 308 ‘grooming’ 42, 53 group therapy 233, 234–5

Index

279

Grubin, D. 37–8 guilt: anorexia 246, 248, 255, 256, 257; battered women 280, 281; bulimia 245; carers of self-harming women 195; fabricated or induced illness 123, 143; female perversion 243; grief reactions 308; killing of abusive partners 296, 309; killing of children 166, 320, 323, 326; maternal physical abuse 78; murderous fantasies towards unborn child 31; narcissism as defence against 325; psychodynamic approaches 230; self-harm 198, 199, 217; sexual abuse 41, 55, 198, 199, 221; shoplifting 252–3, 254, 258 Hale, R. 194, 198 Harris, T.O. 275 hatred 21–3, 156, 325–6 health professionals: ‘conspiracy of silence’ 150; fabricated or induced illness 120–1, 129–32, 134–5, 136–7, 139–41, 142, 145, 146–7, 150; preconceptions about motherhood 348–9; self-harm 225; working with female offenders 344; see also staff helplessness 97, 99, 346; abusive relationships 277, 279, 284, 289, 294, 309; anorexia 263; ‘cycle of violence’ model 318; infanticide 156; learned 14, 275–7, 289, 294, 295, 302, 307; neonaticide 185–6; nursing staff 225–6; physical abuse 73, 78, 91; pregnancy 23, 317; resurfacing during therapy 327; self-harm 217, 233, 336; sexual abuse 42, 67 Herjanic, M. 172 hiding 330–2, 344 Hindley, Myra 316 Hipwell, A.E. 187 homicide 9, 315–28; battered women 14, 271–2, 278, 292–311, 345; case illustrations 295–300, 319–26, 327; child victims of abuse 82–8; fabricated or induced illness 143–4;

Index

280

legal defences 302–8; male/female statistics 158, 272–4; nature of female 157–8; rational basis for 299–300, 305; suicide link 156, 160, 166, 172–4, 176, 179, 196, 221, 293–4, 345; transference and countertransference issues 326–8; treatment of female killers 308–10, 347; see also filicide; infanticide; murder charges hormones 159, 160, 182, 183, 185 Hornbacher, Marya 1, 258–9, 267 Horton, Richard 79–80, 125 hostility: attacks on the body 239; fabricated or induced illness 141; perversion 22; pregnancy 29; self-harm 336; unmet dependency needs 138 Hughes, P. 242, 265 human rights 151 humiliation 42, 293, 301 Hunt, J. 111, 112–13 hysteria 183, 184, 307 id 247 idealisation 4, 10, 11, 91, 124, 342, 352 identification: abusive relationships 279; with aggressor 42, 48, 67–8, 74, 91, 101, 221, 294; with child 48–9, 67–8, 73–4, 77, 90, 107, 138, 156, 173, 178, 315, 326; fabricated or induced illness 141; with mother 30, 32, 33, 49, 315, 323; sexual abuse 42, 48–9; staff identification with patients 333; with therapist 310 identity: battered women 304–5; cultural 332; fabricated or induced illness 127, 138, 147; located in women’s body 127, 195, 237, 318; role as mother 124; self-harm as attack on 200, 201 impulse control 256–7, 341; mentalization-based therapy 107, 343–4; self-harm 202, 204–5, 229 incest 25, 36, 39, 60, 67, 352; perversion 6; self-harm 198;

Index women in secure units 332; see also sexual abuse individuation 24, 30, 32; adolescence 246; difficulties with 121, 317 infanticide 11–12, 153–89; biological causes 158–60; case illustrations 160–71; classifications of filicide 174–8; infant as ‘poison container’ 170–1; legal issues 180–2, 183–5; maternal depression 171–2; nature of female homicide 157–8; perversions of motherhood 156–7; psychosis impact on 172–4; social and psychological factors 178–80; statistics 274; see also filicide; neonaticide Infanticide Act (1938) 154, 175, 181, 182–5, 188 infantilisation 223, 225, 256, 330–1 intergenerational transmission: abusive parenting patterns 10, 55–6, 188–9; attachment difficulties 8, 33–4, 138, 290–2; breaking the cycle of abuse 104; neglect 72; perverse mothering 5; physical abuse 105–6, 107; sexual abuse 55, 57–9; violence 349; vulnerability to depression 89 internal conflict 2, 169, 170; see also unconscious conflicts intimacy 50, 51, 243; adolescence 245, 246; anorexia as escape from 243, 247; attachment theory 341; desire for 330, 344; pro-eating disorder websites 250, 251; self-harm as defence against 230, 335; with therapist 265 introjection 24 isolation: abusive relationships 284, 290, 293; fear of 330; filicide 174; infanticide 183, 187, 189; physical abuse 72, 73, 100, 102, 104; post-pregnancy 25; self-harm 219; support for mothers 349

281

Index

282

Jason, J. 172 Jones, D.P.H. 138, 147 Jones, Janey 113 ‘just world hypothesis’ 285 Kahan, J. 194, 204 Kaplan, M.S. 54, 59 Kasl, C.D. 39 Kennedy, Helena 4–5, 74–5, 148, 271, 272, 303, 304 Kennerley, H. 227 killing see homicide Kirsta, A. 41, 66, 67 Klein, Melanie 24, 277 Knowles, J. 258 Kouao, Marie Therese 84–7 Kumar, R. 187 Lacey, J.H. 204 Laming, Lord 79–80, 84, 85, 86, 88 Laplanche, J. 4 Laufer, E. 245 Laufer, M.E. 30, 245 Lawrence, M. 242 learned helplessness 14, 275–7, 289, 294, 295, 302, 307 learning disability 26, 28, 83; hatred towards learning disabled babies 156, 178; infanticidal mothers 179, 180 legal issues: fabricated or induced illness 144; infanticide 180–2, 183–5; killing of abusive partners 302–8; see also criminal justice system legislation: Children Act (1989) 282; Children Act (2004) 84; Infanticide Act 175, 181, 182–5, 188; Mental Health Act 207; Regulation of Investigatory Powers Act 150–1 Letourneau, Mary Kay 42 Lewis, C.F. 172 Libow, J.A. 118 Liebling, H. 194, 232, 233–5 Linehan, M.M. 227–8 Livingston, R. 126–7, 147–8 loss 255, 275, 332 Lousada, J. 87, 88 Maden, A. 338–9, 349–50 Mahoney, M.R. 284–5

Index

283

Malan, D.H. 247, 248 Manning, Carl John 84–7 Manohar, S.V. 186 manslaughter 154, 272, 294, 299, 320; case illustration 295, 296; conviction statistics 274; legal defences 301, 302 marital guidance 135 maternal somatisation disorder 126–7, 137 maternal violence 9, 10–12, 71–109, 352; denial of 351; development of 19–34; killing of child 82–8, 153–89, 319–26, 327, 328; preconceptions about motherhood 348–9; see also infanticide; physical abuse; sexual abuse McClurg, G. 37 McDougall, J. 6–7 McGuire, T.L 146 Meadow, Roy 11, 79, 114–15, 117, 125–6, 138–9, 143 ‘Medea situation’ 175 medication 160, 346 melatonin 159 menstruation (menses): anorexia 239, 240, 241; fear of 183, 184; infanticide 158 Mental Health Act 207, 232, 320 mental illness: child fatalities through physical abuse 83; fabricated or induced illness 122; filicidal fathers 174; homicide 172; infanticide 154–5, 158–60, 175–6, 179–80, 181, 183, 187, 189; insecure attachment 341; limited resources to treat 188; medication 346; secure units 339–40; see also personality disorders; psychiatric services; psychosis mental imagery 213–14 mental retardation 196 mentalization 200; attachment difficulties 34; failures of 2, 8, 121, 163, 291, 318; mentalization-based therapy 13, 108, 229–30, 343–4; see also symbolic thinking Menzies Lyth, I. 224, 337, 343 mercy killings 174, 175 Meyer, C. 176, 179–80, 184–5, 187

Index

284

Miller, F. 199, 200, 218 Mills, M. 89–90, 91 Mitchell, Juliet 19, 20–1 mixed-sex secure units 14, 329, 330–1, 333–4, 339, 340 Mohler, E. 74 mood 204 Morley, C.J. 115 Morrison, T. 35, 38, 40 Morse, S.J. 306 mother: abusive relationships 279; adolescence 246; anorexia 246, 257, 265–6; attachment disturbances 291; caretaker role 127–8; fabricated or induced illness 112, 116, 118–20, 121–4, 126–51; failure of differentiation 141–2; homicidal motivation 323; hostility towards infant 2; identification with 30, 32, 33, 49, 315, 323; infanticide 153–89; intergenerational transmission of abusive mothering 5; internalised 24, 29, 34, 91, 316; maternal somatisation disorder 126–7, 137; own experience of abuse 19–20, 21, 23, 26–7, 31, 37, 42, 71, 73–4; pregnant woman’s body association with 317; roots of disturbed mothering 23–5, 33, 55; self-harm 195, 196, 198, 200–1; separation from 108, 246, 257–8; sexual abuse by 35, 36, 38, 40–1, 54, 55, 56–69; symbolic attack on mother’s body 324; therapist as surrogate 167–8; see also maternal violence motherhood 25, 67, 328; attachment theory 33–4; distortion of ideals 153; fear of 171; idealisation of 11, 82, 112, 124, 146, 149, 151, 316, 351–2; perverse mothering 10, 21, 30, 52, 156; preconceptions about 348–9; sentimentalised notions of 4, 60, 155; stereotypes of 36; see also pregnancy motivation: fabricated or induced illness 121, 149; filicide 174–5, 323; infanticide 185; killing of abusive partners 304, 306, 311; Munchausen’s syndrome by proxy 114–15, 118; self-harm 203, 216, 233–4; unconscious 348

Index

285

Motz, Lotte 183–4 mourning 255 MSBP see Munchausen’s syndrome by proxy multi-agency working 108–9, 145, 349 ‘multi-impulsive personality disorder’ 204 Munchausen’s syndrome 113, 115, 117, 118, 121, 122 Munchausen’s syndrome by proxy (MSBP) 11, 111–12, 124, 147, 149, 316; Allitt case 113; attachment difficulties 138; background features 126–8; detection, treatment and prognosis 144; diagnosis 114–18, 142; expert witnesses 80, 125; previous classifications of 118–21; see also fabricated or induced illness murder charges: infanticide distinction 181; legal defences 301, 302, 303; male/female statistics 158, 274; see also homicide narcissism 19, 31, 40, 288, 325; anorexia 243, 266; core complex of perversion 50; narcissistic injury 24; staff 333 neglect 83, 101, 107, 317, 318, 348; child protection 282; core complex of perversion 50; fabricated or induced illness 127, 137; filicide 177–8, 324; infanticide 179, 180; intergenerational transmission of 72; maternal passivity 73; mother’s own experience of 171; pregnancy 328; self-harm 200; social environment 72; unconscious attempts to recreate 342; vulnerability to depression 89 Nellis, Susan 113 neonaticide 153, 179, 183, 185–7, 189; causes of 159, 160, 176–7; classification of 174, 175; denial of pregnancy 12; social shame 184, 186; see also infanticide ‘no-entry’ syndrome 246–7, 266 Oates, M. 188 Oberman, M. 176, 179–80, 184–5, 187

Index

286

object love 25 object relations 34, 196, 246 obsessive compulsive disorder 196 occupational therapy 167–8 Oedipus complex 21, 30 offenders 349–51; female homicide 158; forensic psychotherapy 347–9; physical abuse 75; sexual abuse 37, 42, 43–8, 49–52, 56–67, 68; women-only secure units 338–44; see also criminality; prisoners one-to-one observation 342–3 Orbach, S. 264 pain: containment 200; defences against psychic pain 8, 231; ‘losing’ of traumatic memories 331; reactivated 71, 73; self-harm 13, 193, 195, 197, 201, 218, 219, 236, 318, 335; somatising 246 parenting skills 106, 108, 286–7 Parnell, T.F. 118, 120, 128 part-objects 49, 121, 155–6 partners: abusive 178, 271–2, 275–86, 287–9, 292–311; infanticide 162, 178, 179, 180; killing of 271–2, 278, 292–311, 345; physical abuse of children 73, 74–5, 83, 94–6, 97, 102, 104–5; retaliatory filicide 175, 176; sexual abuse of children 43, 45–6, 47, 48, 52 passivity: abusive relationships 73, 284; ‘cycle of violence’ model 318; learned helplessness 276 pathology: as embodied protest 220; filicide 175; infanticide 178, 179; legal defences against homicide 307; self-harm 202, 206; see also psychopathology Pattison, M.E. 194, 204 Pearson, P. 19 penis envy 21 persecutory object 31 personality disorders: anorexia 251; attachment difficulties 138;

Index

287

desire for intimacy 330; fabricated or induced illness 119, 122; filicide 176; identification with patient 333; infanticide 160; ‘multi-impulsive personality disorder’ 204; projection of internal conflicts 169; retaliatory behaviour by staff 336; self-harm 196, 206, 229; ‘therapeutic nihilism’ 204, 227, 230; women-only secure units 338–9; see also borderline personality disorder perversion 9, 19–23, 25, 30; anorexia 243–4, 266; attacks on the body 239; bulimia 245; core complex of 50–1; as defence against depression 48–52, 55; denial of 36; as erotic form of hatred 21–3; fabricated or induced illness 11, 111, 141–2; forensic psychotherapy 348; infanticide 156–7; model of 6; self-harm 12–13, 195–6, 202, 335; sexual abuse 11, 38, 40, 41, 48–52, 55; source of 316; violence link 7 physical abuse 9, 11, 36, 71–109; case illustrations 25–9, 76–9, 91–8, 99–102, 287; child fatalities 82–8; coexistence with sexual abuse 39, 91; depression 88–91; enjoyment of cruelty 75–9; expert witnesses 79–82; fabricated or induced illness 122, 129–30, 138, 150; female perversion 25; infanticide 154, 175, 178, 188; intergenerational transmission of 55–6, 105–6; victim/perpetrator dualism 102–5; Victoria Climbié Inquiry Report 84–8; women’s own experience of 23, 55–6, 73–4, 91, 92–3, 101, 103; see also domestic violence; sexual abuse pineal gland 159 Pines, Dinora 5, 10, 23–5, 30, 31, 32, 176, 317 Plath, Sylvia 345–6 ‘poison container’ 78, 86, 170–1, 179, 186, 318–19, 352 Pontalis, J.B. 4 pornography 54, 56, 57 Portman Clinic 4, 347

Index

288

post-partum illness (postnatal depression): fabricated or induced illness 138, 148; infanticide 155, 158–60, 173, 179, 181, 184–5, 186, 187–8, 189; killing of abusive partners 299 post-traumatic stress disorder 287, 298, 322 Postlethwaite, R.J. 112 power 9, 284, 285 pregnancy 7, 10, 20, 23–5, 163; ambivalence about 176; case illustration 25–9, 30–2; denial of 12, 177, 186–7; depression during 108; fear of women’s procreative capacities 184; murderous phantasies 316–19; promiscuity 32; shame of 156; therapist’s own pregnancy 325, 326, 327–8; unconscious fantasies during 29–32; unwanted 177, 179, 185–7, 275 premenstrual syndrome 184, 307 prisoners 349–51; psychiatric needs 347; self-harm 195, 196, 201–3, 205, 206, 207, 232–3; see also offenders; secure units ‘pro-ana’ websites 13, 248–51 projection 49, 67, 106; abusive relationships 279, 294; anorexia 246–7; fabricated or induced illness 119, 136, 138; infant as ‘poison container’ 171; internal conflicts 169; killers 308; self-harm 222–3, 226, 234 projective identification 48, 49, 78, 199–200, 334; abusive relationships 277, 294, 306; fabricated or induced illness 140; killing of abusive partners 309; self-harm 222–3, 231; staff 331, 337; during therapy 327 promiscuity 32 provocation plea 14, 272, 294, 302–4, 305, 307–8 psychiatric approaches: infanticide 158, 189; self-harm 193, 201–6, 229 psychiatric services 161, 165, 166; dual diagnosis 346–7; family psychiatry 348; postnatal depression 188; self-harm 236; see also secure units

Index

289

psychoanalysis 3, 347; female perversion 21, 22; psychosomatic disorder 6–7; self-harm 230–1, 232 psychodynamic approaches 4, 5, 8, 347; anorexia 264; fabricated or induced illness 139, 147, 148–9; infanticide 158, 170–1, 189; Munchausen’s syndrome by proxy 118; physical abuse 106; self-harm 193, 197–201, 229–32, 235; therapy 108 psychohistory 170 psychological abuse 292, 293 ‘psychological self-defence’ 300, 304–8 psychopathology: infanticide 179; intergenerational transmission of disturbed parenting 291; self-harm 202, 205, 206, 229; see also pathology psychosis: anorexia coexistence with 262; borderline personality disorder 201; filicide 172–4, 176, 177, 320, 323; infanticide 155, 164, 179, 181; neonaticide 186; post-partum 158, 159–60; psychiatric needs of women in prison 347; risk factors 185; self-harm 196 psychosocial stressors 173–4, 177, 178–80 psychosomatic disorder 6–7; see also somatising disorder psychotherapy 3–4, 107, 346, 347–9; anorexia 263, 265–6; battered women 282; depressed pregnant women 188; fabricated or induced illness 147, 148–9; infanticide 160, 164; resistance to 147, 166, 169; self-harm 229–30, 233; therapeutic neutrality 169; women-only secure units 344; see also forensic psychotherapy; therapy purging 13, 241, 243–4, 245, 266 Queen’s Medical Centre, Nottingham 188 race 85, 86, 332 rape 41, 93, 287;

Index

290

killing of abusive partners 305; self-harm after 208–9, 212; see also sexual abuse re-enactment 21–2, 67–8, 69, 328, 348, 349; abusive relationships 309; destructive 342; fabricated or induced illness 123, 141; fear of 101; mixed-sex secure units 340; physical abuse 71, 102; self-harm 231; see also acting out Reder, P. 83 refuges 281 Regina v Clark case 125–6 Regulation of Investigatory Powers Act (2000) 150–1 rehabilitation: battered women 282; infanticide 167 relapse prevention 348 ‘relational security’ 340, 351 remorse 11–12, 143, 167 research 236 Resnick, P.J. 175, 176, 177, 178, 187 retaliation: fear of abusive partners 283–4; filicide 175, 176; killing of abusive partners 271; by staff 336, 337–8 revenge 67, 272, 315, 316, 328; fabricated or induced illness 123; filicide 175, 176; infanticide 154, 165; killing of abusive partners 272, 302; perversion as hidden fantasy of 22; self-harm 196 risk assessment: Bethlem Mother-Infant Interaction Scale 187–8; child protection 282; fabricated or induced illness 130, 132, 146; infanticide 180, 189; physical abuse 81; sex offenders 43; see also assessment ritual 230, 247, 256 Royal College of Paediatrics and Child Health 112, 114, 115, 121, 123, 145 Rustin, M.E. 87–8 sadism: abusive relationships 277, 280; attacks on the body 239;

Index

291

body as vehicle for perversion 243; infanticide case 165; sexual abuse 53, 57, 66 Sandyk, R. 159 Saradjian, J. 36, 53 scars 200, 227 Scheper-Hughes, Nancy 124 schizophrenia 172, 173, 179 Schreier, H.A. 118 Scott, P.D. 174, 175 secrecy 4, 36, 142, 143, 243; bulimia 245; pro-eating disorder websites 249; psychodynamic approaches 230; self-harm 223, 224, 236; see also deception secure units: mixed-sex 14, 329, 330–1, 333–4, 339, 340; women-only 14, 330, 338–44, 351; see also prisoners seduction 41–2, 215, 216 self: abusive relationships 277, 278, 294, 306, 307; anorexia as violence against the 239, 241–2, 266; attachment difficulties 138; attack on the 197; ‘bad’ 198, 201; ‘false’ 163, 258, 320; ‘good’ 199; lack of coherent sense of 121; violence against the 3, 9, 12–13, 19, 255, 266 self-blame 221, 280, 281 self-contempt 277, 280, 306 self-control 242, 248, 260–1, 262, 263 self-defence 272, 300, 301, 302–4, 310; ‘battered woman syndrome’ 294; ‘psychological’ 300, 304–8; reconceptualised as hysteria 307 self-destruction 247, 265 self-esteem 32, 46, 67, 129, 130; abusive relationships 275, 276, 277, 280, 284, 288, 291; anorexia 261; female perversion 243; staff rejection of patient’s communication 338 self-harm 3, 12–13, 113, 193–237, 321, 335–6; affective disorders 172; anorexia coexistence with 251, 262; assertion of control 219, 221–2; attachment model 342; borderline personality disorder link 201–2; case illustrations 207–17, 218–25, 227;

Index

292

communication 219–20, 345; countertransference issues 222–5, 236; defining the parameters of 194–5; depersonalisation 218–19; displacement 220–1; as distraction 219, 233; embodied trauma 330; emotional pain 318; fabricated or induced illness 122, 127, 138, 145, 150; feminist approach 232–5; functions of 196–7, 205, 213; impact on nursing staff 225–6; impulse control 202, 204–5, 229; infanticide 161, 166; mentalization failures 163; Munchausen’s syndrome 117, 118, 121; perversion 6, 195–6; pregnant women 317; prison populations 350; psychiatric model 201–6, 229; psychodynamic approaches 197–201, 229–32, 235; reactive 203–4, 206; sexual abuse 198–201; symbolic use of the body 7; as symptom-reduction strategy 202–3, 205, 229; treatment 236; women’s secure provision 340 self-mutilation 9, 12, 195, 196, 227, 239; borderline personality disorder 201–3; case illustration 208; female perversion 20–1; psychodynamic model 197–8, 199; reactive self-harm 203, 206; therapy 236 self-strangulation 194, 209–11, 213, 216, 217, 219, 227 Seligman, M.E.P. 276 Sellars, C. 232 sentencing practice 180–1 sentimentality 352 separation 24, 30, 32, 257–8; abusive relationships 283, 284, 285; adolescence 246; anorexia 241; difficulties with 121, 133–4, 246, 317; fabricated or induced illness 141–2; insecure attachment 341 sexual abuse 9, 10–11, 35–69, 142, 332; anorexia 259–60; borderline personality disorder 228; in care 161; case illustrations 43–8, 49–52, 56–9, 60–7, 286–7, 290, 321;

Index

293

coexistence with physical abuse 39, 91; defining 37–40; fabricated or induced illness 122, 127; female perversion 20, 25; intergenerational transmission of 55–6, 57–9; killing of abusive partners 293, 305; mixed-sex secure units 340; non-verbal enactment of memory 236, 335; perversion as defence against depression 48–52; prisoners 350; psychiatric system 347; psychological impact of 40–3, 225; recognition of female abuse 150; research on female sex offenders 52–6, 68; self-harm 195, 198–201, 208–9, 212–14, 217, 219–21, 224, 233; women’s own experience of 23, 27, 31, 37, 42, 44–7, 50, 54–6, 62–3, 68–9; see also incest; rape sexual feelings 247, 255, 256, 257 sexual intercourse 32, 51 sexualised behaviour 47, 61, 62, 64, 69 sexuality 36, 52, 257, 266; failure of genital 50; infantilisation of women patients 331; perversion 22; therapist’s 328 ‘shaken baby syndrome’ 179 shame 66, 195, 330, 331–2; battered women 280, 281; domestic violence 279; infanticide 183; neonaticide 184; pregnant therapists 328; see also social stigma shock therapy 345–6 shoplifting 251, 252–3, 254, 256–7, 258, 321 silence 140, 150, 223 Sinason, Valerie 156, 291, 292 single mothers 189 Slade, P.D. 259–60 social environment: adverse impact on childrearing 189; anorexia 263–4; infanticide 173–4, 177, 178–80, 185, 189; maternal physical abuse 72; violent offenders 350–1 social learning theory 291 social services 5, 9; abusive relationships 289–90; assessment of parents 81–2, 289; battered women 281, 282, 300; Child Protection Register 129;

Index

294

fabricated or induced illness 134–5; maternal physical abuse 27, 77, 94–8, 101, 102, 103, 105–6; parents’ relationship with 103–4; sexual abuse 47, 59, 60; Victoria Climbié Inquiry Report 84–8; see also care proceedings; child protection social stigma 185, 186, 187, 294; see also shame social support 311, 349 somatisation 126–7, 137, 138, 139 somatising disorder 115, 118, 122, 126–7, 137, 147 Southall, David 125 Spinelli, M.G. 108, 153, 154, 155, 181, 184, 187, 188 split-off body 198–9,216 splitting 49, 52, 67, 199–200; fabricated or induced illness 136, 137, 139; female killers 309, 326; self-harm 200, 201, 231; staff 169, 331, 337 staff 168–9, 330, 332–3, 334; attachment model 341–2; defences against anxiety 331, 336–7, 343; infantilisation of patients 331; observation of women 342–3; retaliation by 336, 337–8; self-harm 210, 215, 216–17, 220, 222–6, 230–2, 233–4, 236, 336; see also health professionals stalking 283 stealing 252, 258 stereotypes 5, 36, 316, 352; battered women 272, 284–5, 307; ‘maternal instincts’ 69 Stern, E.S. 175 Stoller, R.J. 22 ‘strange situation’ experiment 33 stress 218 substance abuse: co-morbidity 340; fabricated or induced illness 122; infanticide 179, 180; killing of abusive partners 293; physical abuse 83, 90; self-harm 208 suicide: abusive relationships 283; altruistic killings 178; anorexia 242, 248; fabricated or induced illness 143–4; filicide 323; homicide link 156, 160, 166, 172–4, 176, 179, 196, 221, 293–4, 345; infanticide 155, 165, 186;

Index killing of abusive partners 293–4; self-harm distinction 194; sexual abuse 61, 62, 66; symbolic attack on mother’s body 198 Sullivan, W.C. 173 superego 171, 243, 247 supervision 344 symbolic thinking 163, 263, 291, 308, 318; see also mentalization taboos 183, 200, 351, 352 Target, M. 2, 8, 163, 318 Tavistock Clinic 106 therapeutic alliance 169, 328, 348 Therapeutic Enhanced Service 339 ‘therapeutic nihilism’ 204, 227, 230 therapeutic relationship: anorexia 265–6; professional boundaries 167–8; self-harm 236 therapy 3–4, 107–8, 346–7; abusive parents 81; anorexia 242, 254–5, 264, 265–6; avoidance of 48, 98, 99; breaking the cycle of abuse 104, 107, 189; breaks in 215; containment through 200; depressed mothers 89–90; disturbed attachments 34; fabricated or induced illness 148–9; family 106; female killers 308–10, 320, 321–2, 325–6; infanticide 160, 161, 164; mentalization-based 13, 108, 229–30, 343–4; projective identification 277; resistance to 147, 166, 169; self-harm 209, 211–17, 227–30, 234–5; sex offenders 60, 65; women’s secure provision 340; see also psychotherapy; treatment thinking style 260 Thornton, Sara 301 torture 78, 84–7 transference 167, 168, 209, 348; infanticide 169; killing of abusive partners 309; killing of children 326–8; self-harm 215–16, 231–2; see also countertransference

295

Index

296

transitional space 242 trauma 8, 107, 348; borderline personality disorder 228; embodied 330; impact on mental development 291–2; insecure attachment 341; ‘losing’ the memories of 331; ‘mastery of’ 291; mother’s own experience of 23, 171; re-enactment/reactivation of 67–8, 71, 101, 295, 328, 348, 349; self-harm 197–8, 206, 224, 226, 230 treatment 351–2; anorexia 261, 262–3, 264–6; battered women 282; fabricated or induced illness 144–8; family therapy 106; killing of abusive partners 308–10; nurse-patient relationship 226; prisoners 347; resistance to 98, 99, 147; self-harm 226–35, 236; see also therapy Trowell, J. 146 unconscious conflicts 2, 23, 328; see also internal conflict verbal abuse 77, 78 Verhaeghe, Paul 348 victim-blaming 285–6 victim/perpetrator dualism 102–5, 149, 160 victimisation 99, 100–1, 164; abusive relationships 276, 277, 284, 304, 306; anorexia 260; fabricated or induced illness 149; projection of 21; self-harm 221; sexual abuse 23, 42, 46–7, 58, 62, 64–6, 67, 68 violence: abusive men’s own experience of 278, 286; alternative models of 7–8; anorexia 259, 265, 266, 267; as communication 164; cycle of 318; defining 2; depression link 345; displacement of anger 221; intergenerational transmission of 349; perversion link 7; social factors 350–1; therapeutic responses to 346–7;

Index

297

see also domestic violence; homicide; maternal violence; physical abuse voyeurism 39, 51, 54 Walker, L.E. 305 Warner, M. 316 weapons 292, 293, 303, 304 websites 13, 248–51 Weeda-Mannak, W.L. 263–4 Welldon, Estela: anorexia 242; bodies of children 317–18; female perversion 1, 5, 6, 10, 13, 19–21, 23, 25, 30, 239, 243; idealisation of motherhood 316, 352; killing of children 324; part-objects 155–6; pregnancy 317, 328; recognition of female abuse 150; self-harm 195–6; sexual abuse 55 West, D.J. 172, 173 West, Rosemary 316 Wilkins, J. 201–2 Williams, G. 246, 247 Williams, K. 197 Wilson, G.T. 244, 249, 251 women-only secure units 14, 330, 338–44, 351 women’s refuges 281 Wykes, M. 274, 303 Yaryura-Tobias, J. 196 Yates, Andrea 12, 154–5, 159, 185 zonal observation 343