New Horizons in Disability Psychotherapy:
The Contributions of Valerie Sinason
†Graeme Galton, [email protected]†
The work of Valerie Sinason, a child psychotherapist and adult psychoanalyst, has been of major importance in† the field of learning disability. Sinasonís clinical and theoretical contributions to psychotherapy in this area of† extreme psychopathology are examined in detail and an assessment is made of the extent to which these† contributions represent major advances in the understanding and treatment of mentally handicapped patients. A detailed examination of the clinical and theoretical insights that emerged from her work with learning disabled patients shows the major impact she has had in promoting the use of psychoanalytic psychotherapy with such patients.
During the last twenty years one rather extraordinary mental health professional has made an enormous contribution to the study of extreme psychopathology. She is Valerie Sinason, a child psychotherapist and adult psychoanalyst, whose work in the fields of learning disability, ritual abuse, and dissociative identity disorder has been of major importance and has earned her an international reputation. This paper will focus on the pivotal role Sinason has played in pioneering and developing the use of psychoanalytic psychotherapy to treat learning disabled patients.
Sinasonís early work showed that a patient does not need cognitive intelligence in order to benefit from psychotherapy and that a learning disabled patient is likely to make considerable improvements in linguistic and emotional functioning following treatment with psychoanalytic psychotherapy. In addition, Sinason was one of the first clinicians to recognize the particular vulnerability of mentally handicapped patients to sexual abuse, the prevalence of such abuse, and the ways in which psychotherapy can be used to treat its debilitating effects. These ideas are now widely accepted but were viewed with disbelief and hostility when Sinason first presented them in the 1980s. Much of that change in attitude is the result of Sinason work. It is time to document and survey this body of work, so that it may become more widely known and more widely available, and to provide a critical appreciation so that we can see what these fields look like now and where the work needs to be taken.
All of Sinason's work is in fields which attract enormous amounts of painful and unwanted associations and consequently the terminology changes frequently. As Sinason (1992a) points out, when a term becomes contaminated by association with impulses society wishes to disown, it is replaced by a new as yet uncontaminated term. The phrase 'learning disability' has replaced the term 'mental handicap' in many sections of society in the United Kingdom. In the USA the term 'mental retardation' is used by professionals working in this area, while some workers in the United Kingdom are now referring to 'intellectual disability'. One of Sinason's patients told her, 'Iíve got four handicaps. Iíve got Down's Syndrome, special needs, learning disability and a mental handicap' (Sinason, 1992a). In the context of this ever-changing lexicon, in this paper the terms 'learning disability' and 'mental handicap' are used interchange- ably to improve the readability of the text.
Sinason achieved a long-held ambition in January 2000 with the establishment of the Institute of Psychotherapy and Disability (Kahr, 2000a,b; Sinason, 2002). Sinason made a singular contribution to this historic step and through the Institute she hopes to bring about further improvements in the treatment of mentally handicapped patients. The establishment of the Institute marks another milestone in twenty years of progress in disability psychotherapy.
Through its Training Committee, the Institute is setting standards for specialist training and accreditation in psychotherapy and disability. To achieve this the Institute has set about gaining accreditation as a training body for the United Kingdom Council for Psychotherapy and is working towards the establishment of a four-year training programme in disability psychotherapy. The training programme will be an expansion and elaboration of courses Sinason created at the Tavistock Clinic. Grandparenting procedures have also been established in order to admit to membership practitioners already experienced in the disability field (Kahr, 2000b). In this way the Institute proposes:
... The inauguration of a new variety of psychotherapy: namely disability psychotherapy, which will sit alongside child psychotherapy, family therapy, forensic psychotherapy, group psychotherapy, marital psychotherapy, and other such identities ... (Kahr, 2000a, p. 194)
The idea of disability psychotherapy as a specialized field would have been beyond imagination. when Sinason joined the newly created Subnormality Workshop at the Tavistock Clinic m 1979, while still training as a child psychotherapist. The Workshop, run by Neville Symington, met each week and was treating two mildly learning disabled adult patients when she joined. Sinason had had considerable contact with learning disabled children and adults while she was growing up, because her father, Stanley Segal, was a leading educator and political campaigner in the field of learning disability. She was interested in how psychotherapy might be used to help mentally handicapped patients.
Sinason began working with a very violent and almost silent seven-year-old boy with cerebral palsy who was severely multiply disabled. This was the patient whom she later called 'Barry' when she began writing about her work with mentally handicapped patients (Sinason, 1986). She saw Barry for once weekly psychotherapy for six years. Another of Sinason's early learning disabled patients was a mentally handicapped boy whom she saw in a special school for emotionally and behaviourally disturbed children and to whom she later referred as 'Ali' (Sinason, 1986, 1988a). Both boys had an IQ of 45 and at the time it was very unusual to treat such patients with psychoanalytic psychotherapy, because it was believed they did not have the cognitive ability to benefit from it. The view expressed by Reid (1982, p. 34) was typical when he writes, 'For the handicapped child or adult himself, the scope for individual psychotherapy is limited. Such patients do not have the intellectual resources to benefit from in-depth psychotherapy...'.
Although, at this stage, no-one else in the Workshop was treating such severely learning disabled patients, Sinason found the Workshop a warm and supportive forum in which to formulate an understanding of Barry, Ali and the other patients she began treating. Workshop members found there was very little published material available on psychotherapy with mentally handicapped patients and most clinicians who had entered the field had not continued the work for long. The existing literature was usually about patients with mild learning disability or physical disability and was not particularly helpful. The only detailed account of the treatment of a mentally handicapped patient from a psychoanalytic perspective, that they knew of, was by Clark (1933), written nearly fifty years previously.
Symington (1981) was the first member of the Workshop to write about his work with a learning disabled patient. His article, about an adult patient with an IQ of 59, was very much the product of group thinking in the Workshop and introduced a number of concepts which Sinason would later develop. The article challenged the assumption that such patients did not have the cognitive ability to benefit from psychotherapy and Symington (1981, p. 191) said of the patient,'... it was quite clear that he was taking the interpretations and that they were becoming integrated in his personality'. In the same article, Symington also introduced the idea that a learning disabled person might exaggerate his or her handicap as a defence against the pain of the original handicap.
Members of the Workshop found that a patient did not need cognitive intelligence to benefit from psychoanalytic psychotherapy and they focused instead on working with their patients' emotional intelligence, a term coined jointly by Sinason and Jon Stokes (Stokes & Sinason, 1992). Sinason found that with psychotherapy, although a learning disabled patients IQ did not go up much, his or her language ability and emotional relating could certainly improve.
Sinason received a lot of referrals and found it difficult to say, 'No'. As a result, she was soon seeing a large number of patients, most of them without charge. By 1984 she was treating children and adolescents in three clinical settings and had become increasingly aware that a significant number of her patients, including some who were learning disabled, were unable to play with the standard set of toys in her consulting room. She provided new toys which included large and ordinary sized dolls and teddy bears. Sinason (1988c, p. 349) writes, 'The effect was devastating. Within the first session of their use nine children in three settings disclosed physical and sexual abuse'. Only after she had worked through her feelings of nausea and disbelief was Sinason able to realize that she had, up until then, been avoiding knowledge of the abuse because she was unable to tolerate the possibility of its occurring, a process which had been identified by Bowlby (1988).
When Symington left the Tavistock Clinic in 1985 only two of the original members of the Subnormality Workshop were left, Sinason and Jon Stokes. It was looking as if the pattern of clinicians entering the field and then soon leaving it was being repeated. However, both Stokes and Sinason had increased their clinical commitment to mentally handicapped patients and continued to convene the Workshop, which was renamed the Mental Handicap Workshop. They developed the links established by Symington with the Psychiatry of Disability Department at St George's Hospital Medical School, University of London. The psychodynamic work at St George's Hospital, led by Joan Bicknell and later by Sheila Hollins, was developing in parallel with the work at the Tavistock Clinic. Other clinicians, such as Judith Trowell and Arnon Bentovim, at the Tavistock Clinic and the Hospital for Sick Children, Great Ormond Street, were including some handicapped patients in the work they were doing with children who had been abused.
Sinason was working with a patient group who were not usually treated with psychotherapy and this enabled her to feel free from an internal orthodoxy. She felt able to use whatever psychoanalytic technique worked, without knowing why it worked, and then conceptualize afterwards. Gradually, the theoretical underpinning of her clinical work took shape. Between 1986 and 1988 Sinason published four key papers about her work with learning disabled patients (Sinason, 1986, 1988a,b,c). In addition to introducing a number of important new concepts, the papers are full of compassion. and understanding for her patients and contain a large amount of clinical detail. Sinason followed them with a large and continuous output of published work on the understanding and treatment of mentally handicapped patients. In 1992 she published Mental Handicap and the Human Condition: New Approaches from the Tavistock (Sinason, 1992a), a landmark publication in the history of psychotherapy publishing.
Symington (1981) had found that his patients level of handicap would vary, even from one moment to the next, suggesting that not all of the handicap was organic. Sinason (1986) expands and develops this concept and describes a number of defence mechanisms frequently employed by mentally handicapped individuals to protect him or her from the awfulness of realizing they are different. These defence mechanisms are defences against meaning and constitute secondary handicaps, additions to the original organic handicap, by attacking and denying otherwise intact skills and intelligence. They can also represent a revengeful attack on what is healthy in the patient and others to assuage some of the pain of the original handicap (Sinason, 1999b).
By exaggerating a speech defect, or lack of language knowledge, or handicapped walk, the learning disabled person is able to feel they have some control over their handicap. Also, they achieve a narcissistic victory over non-handicapped people by fooling them into believing the exaggerated speech or walk is their real voice or real walk. Frequently, the defence mechanism takes the form of an appeasing, handicapped smile to create a false, happy self and keep the outer world happy with them. These concepts do not use any new theoretical ideas, they are a version of Freud's secondary gain (Freud, 1901) and Winnicotís false self (Winnicott, 1960). These are familiar ideas showing themselves in a different way with this patient group.
Secondary handicap can also take the form of severe personality mal-development which is linked to, and added to, the original handicap. Mental handicap depletes a person's inner resources and excites and attracts emotional difficulty and disturbance (Sinason, 1988b; Stokes and Sinason, 1992). The resulting secondary handicap may be an exaggeration of the organic handicap as defence against dangerous impulses, such as sexual or violent feelings (Stokes and Sinason, 1992) and may include a hatred of the parents who made them, a hatred of the sexuality involved, a hatred of normality and an inability to mourn the patientís lost healthy self (Sinason, 1986). This personality mal-development exacerbates the original loss of normality, as with one lonely adolescent patient who desperately wanted a sexual relationship (Sinason, 1988b). He had such a deep fear of needing help or being humiliated that he aggressively avoided any possibility of meeting or learning to care about someone.
Secondary handicap can also serve as a psychotic defence against trauma (Sinason 1986, 1988a). Behaviour which is often explained as part of the original organic handicap can be reframed as a version of unrecognized post-traumatic stress disorder. This form of secondary handicap protects against the unbearable memory of trauma, either the trauma of the original organic handicap or the trauma of subsequent sexual or physical abuse. Headbanging can be understood as an attempt to rid the mind of bad thoughts. Violent and aggressive behaviour, such as kicking, biting, and head-butting, can be understood as a psychotic attempt to manage the helplessness inherent in trauma and to omnipotently compensate for the handicap. If there has been sexual abuse, violent and sexualized behaviour can be understood as a way of repeating the trauma in an attempt to assimilate it and as a defence against further attack. Eye-poking, cutting, and other forms of self-injury can be understood as attacks on the patientís despised body for being unable to prevent the abuse.
Secondary handicap, as a psychotic defence against trauma, is also evident in the aggressive cuddling by Down's Syndrome children through which they enjoy the violence of abusive physical contact whilst showing ostensible affection (Sinason, 1986; Stokes and Sinason, 1992). In another patient, compulsive and aggressive masturbation is a way for him to revenge himself on his parents for the attack he fantasises they made on him at birth (Sinason, 1995b).
Sinason (1986, 1990c, 1995a) identifies the therapistís initial task as elimination of the aspects of secondary handicap, which include an exaggerated handicapped physical appearance, handicapped smile, posture or speech. The therapist must acknowledge to the patient that there is a better functioning self underneath his or her twisted movements and guttural sounds. The therapist needs to acknowledge the angry, hurt, and painful feelings that lie behind the handicapped smile. There follows an opportunity to treat the more pathological kind of secondary handicap represented by the disturbed, envious, and destructive aspects of the personality. The therapist becomes an auxiliary brain, helping thinking and filling in missing words or sentences, being careful not to continue this when the patient is capable of managing without it (Hollins, Sinason & Thompson, 1994). This is likely to be a period of crying, rage, grief, and depression as the patient mourns their lost healthy self, their limitations, their dependency and their terrible feeling of aloneness (Sinason, 1995a). The trauma can be remembered, acknowledged and healed, in a safe setting with the therapist as protector (Sinason, 1986).
If treatment can be maintained there is usually an improvement in internal and external functioning by this point. If there is an accompanying psychosis, the likelihood of which increases with the severity of the handicap (Sinason, 1990c), this may now be treated. Sinason has found that a relatively small input of psychotherapeutic resources can make a big difference to a mentally handicapped patientís functioning, which can improve dramatically, although not to normal levels. The improvement in functioning may not be constant and is likely to fluctuate (Sinason, 1989c; Stokes and Sinason, 1992; Hollins, Sinason & Thompson, 1994). Improvement is especially likely to fluctuate if a patient has been sexually abused.
Sinason is particularly concerned with the high proportion of her mentally handicapped patients who have been sexually abused. In these cases the traumatic experience of the original handicap is compounded by the further trauma of abuse. Over a two-year period, out of two hundred referrals of emotionally disturbed children and adults with a mental handicap, Sinason found that one hundred and forty had been sexually abused (Sinason 1994b).
Learning disabled children and adults are particularly vulnerable to sexual abuse for a number of reasons (Sinason 1988b, 1989c, 1992a, 1993b, 1994b, 1995b). Their lack of sexual knowledge and assertiveness may make it very difficult for them to say 'No' to the perpetrator. They may be physically dependent on those abusing them. Their guilt and shame at being disabled and the fear that comes from knowing some people wish they were dead, makes them feel they do not have the right to say, 'No'.
When abuse has occurred the mentally handicapped victim is likely to find it harder to communicate about the abuse, so it is more likely to continue. Diagnosis is particularly difficult if the victim is nonverbal. He or she is more likely to be disbelieved because of the widespread belief that sexual attractiveness plays a part in abuse. The psychological symptoms and the disclosure of the abuse are often wrongly diagnosed as psychotic fantasies arising from the original organic handicap and convictions are extremely difficult to achieve (Cooke & Sinason, 1998). Likely symptoms will include self-injury, excessive masturbation, and, in children, highly sexualized play (Sinason,1988a,1992a, 1994b).
Sexual abuse is more likely to lead to psychological disturbance in a learning disabled victim than a cognitively normal victim (Sinason, 1989c, 1993c, 1996b; Cooke & Sinason, 1998). A mentally handicapped victim is more likely to have pre- existing psychological and social problems and possibly past psychiatric illness. Past victimization experiences, low self- esteem, and the lack of a supportive social network combine to exacerbate the impact of the trauma. The disbelief of others increases the likelihood of psychosis in this group (Sinason, 1990b, 1993c, 1994b).
These victims often lack a cognitive process to aid healing and enable the painful aspects of the abuse to be processed and symbolized (Sinason, 1997d; Cooke & Sinason, 1998). Self-injury, such as cutting and poking, the most common reason for referral of the sexually abused learning disabled patient (Sinason, 1993c), is an attack on the patientís own despised body as the hated helpless victim who was not strong enough (Sinason, 1996a). The patient may even have experienced an involuntary orgasm or sexual awakening as the body's survival mechanism to accommodate the intrusion (Sinason, 1996a), in which case the body is even more despised. Sinason has found that the effects of sexual abuse on a learning disabled victim can be so severe that in some cases it can even become the primary cause of mental handicap (Sinason, 1989c). Handicap becomes a defence against the memory of sexual abuse because, as Sinason (1988a, p. 104) writes, 'To throw out the knowledge of an abusing trusted adult means throwing out other learning ...'.
Sinason has found that when mentally handicapped patients are able to disclose abuse they often reveal their intelligence. She notes some patients show a dramatically improved level of language and other functioning after they have remembered and disclosed the abuse in the safe presence of a psychotherapist able to bear the knowledge of the abuse (Sinason, 1986, 1988a, 1989c, 1992a). However, she notes that, in the long-term, a patientís improvement will fluctuate and that none of her patients has regained their potential for more than part of each day (Sinason, 1989c).
Some victims of abuse go on to become abusers themselves, whether learning disabled or not. Evidence indicates that approximately one victim out of every fourteen is likely to do so (Sinason, 1996a) in response to a need to transmit the same complex sequence of pain followed by pleasure, as they experienced themselves in the original trauma. These abusers are responsible for the largest number of sexual offences and male patients are more likely than female patients to repeat the abuse cycle (Sinason, 1994b). Such a cycle of repetition was noted by Klein (1932) and others as victims find that: '... the only way to deal with an intolerable experience, the memory of which cannot be borne, is to expel it by making someone else experience it instead' (Sinason, 1990b, pp. 550-551). Sinason notes that learning disabled offenders, whether committing sexual or other crimes, are less likely to be taken seriously as offenders by professionals (Sinason, 1997e). Such lack of acknowledgement of their crimes can actually increase the offender's sense of guilt and level of disturbance and cause further sexually disturbed behaviour (Sinason, 1997d,e).
Whether a patientís cognitive deficit is the result of chromosomal abnormality, organic illness, birth injury, violence, sexual abuse, lack of attachment, poor schooling, malnutrition or a combination of factors (Sinason, 1997d), the level of emotional disturbance increases with the severity of the handicap (Sinason, 1992b, 1999c). Moreover, the emotional distress is often not recognized and the symptoms are ascribed to the disability, rather than to the emotional state of the individual (Hollins, Sinason & Thompson, 1994). At a World Congress for the Scientific Study of Mental Deficiency in 1989, out of five hundred papers, only ten were concerned with emotional disturbance (Sinason, 1990c). In 1987, in the United Kingdom, a study of five hundred and ninety six self-injuring learning disabled adults and children showed that only twelve were receiving any psychological treatment, of which only one, with Sinason herself, was psychoanalytical (Sinason, 1990c). This was despite Sinason's evidence that even severely and profoundly mentally handicapped patients can show a reduction in symptoms when treated with psychoanalytic psychotherapy.
There are significant challenges for the psychotherapist treating a learning disabled patient, because of the particular demands of this group. The therapist has first to come to terms with his or her own guilt about not being handicapped (Sinason, 1988b) and fears of not understanding the patientís speech (McCormack & Sinason, 1996; Sinason, 2000). The therapist must also accept the limitations of what can be achieved, because the emotional disturbance might be treatable, but the actual organic handicap is not. Differences of technique are required as visual contact is needed by the patient, so it is not possible for them to lie on the couch (Hollins, Sinason & Thompson, 1994). More affective colouring is required in the therapistís speech (Sinason, 1999c) and negative transference interpretations require a facilitating tone of voice or they will be understood as direct complaints from the therapist (Hollins, Sinason & Thompson, 1994). At times there is a need for a straightforward educational comment (Sinason, 1997c). The therapist must also be prepared to be part of a larger care and treatment team (Sinason, 1999c). Crucially, the therapist must be able to accept the possibility that sexual abuse has occurred (Sinason, 1989c).
The most challenging aspect of working with mentally handicapped patients is the therapistís need to withstand and interpret the patients' extremely powerful projections (Sinason, 1997b). Sinason's remarkable ability to sustain and expand her work in the learning disability field is evidence of her enormous capacity to do this. Sinason uses her countertransference as a key diagnostic and therapeutic tool and maintains that this is particularly essential when working with these patients, because of the combined effect of their impaired cognitive ability and their communication difficulties (Sinason, 2002). In 1984, when so many of her child patients abruptly disclosed their abuse, Sinason, in her countertransference, had been feeling that she was not providing what was needed emotionally and had concretized that feeling by providing dolls and teddies which then allowed her patients to show her the abuse (Sinason, 2002).††††††††
In her case studies Sinason describes the powerful feelings projected into her by her patients as they, on occasions, make her feel completely helpless, stupid, disgusted or nauseous. In the consulting room she has had incontinent patients urinate or defecate, then smear their faeces or throw their used sanitary pads onto the floor, then sometimes roll their wheelchairs over it so the smell and mess is spread (Sinason, 1992a, 1997b). On other occasions patients have poked their fingers or other objects into their anus or vagina and then sometimes licked the object (Sinason, 1988a). Sinason (1992a, 1997b) describes how her primitive response oŪ' disgust when made witness to these actions made her unable to think properly. She describes the effort she had to make to understand these actions and interpret them back to the patient as expressions of powerful feelings of stupidity, self-disgust, and self-loathing and as attempts to project into the therapist the same stupefaction, disgust and loathing.†††††††††
Sinason also recognizes the powerful feelings that mentally handicapped people evoke in those who live or work with them. As with projections into the therapist, 'feelings in learning-disabled clients of being, for example, stupid, useless, uncomprehending, powerless, unattractive, socially denigrated and unwanted are projected into the workers' (Sinason, 1997b, p. 105). Sinason raises concerns that workers with the mentally handicapped are often not adequately trained or supported (Sinason, 1988b), allowing these negative projections to be internalized and to grow into hatred for those in their care (Sinason, 1993b). There is denial of these negative feelings out of guilt for not being handicapped themselves (Sinason, 1988b, 1993b).†††††††††
For the learning disabled patient this hostility forms part of a general death wish, which is felt about them by society in general, unconsciously or otherwise. He or she usually understands very well the purpose and meaning of amniocentesis (Sinason, 1992a, 1995b, 1997c) and society's wish that they had not been born. The ubiquitous handicapped smile and outward friendliness of mentally handicapped patients is a defence against this accurately perceived societal death wish (Sinason, 1986). Sinason's understanding of the handicapped smile as a defence against pain is perhaps, of all her work, the aspect which has taken off the most and lost its connection with her (Sinason, 2002). Society's guilt about not being handicapped leads to collusion and the creation of defensive myths about mentally handicapped children being friendly, even when there is clear evidence that they are not (Sinason, 1986, 1993b, 1999c).
The isolation and loneliness of mentally handicapped patients is painful and devastating and, having internalized the hostile stares of strangers, they feel they are aliens (Sinason, 1997c,d). They feel like outsiders, even in their own families, and usually have an acute awareness that they look more like other handicapped people than like their own parents or siblings (Sinason, 1988b, 1992a). They sometimes blame themselves for their learning disability and imagine they have somehow caused it (Sinason, 1999b). They internalize a primitive fantasy that disability is caused by a damaging parental intercourse or poisoned sexuality in which something went wrong (Sinason, 1988b, 1992a, 1997c; Cooke & Sinason, 1998). They sometimes seek to return to a foetal, pre-birth stage in order to undo the damage they imagine was caused at birth (Clark, 1933; Symington, 1981; Sinason, 1986).
For most parents the birth of a learning disabled child is an enormous disappointment (Sinason, 1992a, 1993b) and a blow to the parents as procreating beings (Stokes & Sinason, 1992). Sinason (1992b, 1999b,c) suggests the baby will see in his or her mother's eyes that they are not wanted and, as Winnicott (1967) observed, the absence of a positive maternal mirror will prevent. healthy ego development. Sinason (1993b, 2000) notes Ferenczi's observation that unwanted children in a family make a conscious choice to die (Ferenczi, 1929). In the consulting room, the internalized parental death wishes can lead to a fear that the therapist will want to kill the patient like '... the annihilating pre-oedipal mother who will destroy' (Sinason, 1997c, p. 274).
Unconscious parental death wishes and hatred are often disowned and a manic cheerfulness is adopted in denial of the disability (Sinason, 1993b). One expression of this denial is the restricted language used by parents and carers, with the result that everything is described as 'nice' (Sinason, 1992b, 1993b, 1994b). Learning disabled individuals are not permitted to use the negative words with which they might explore their anger. Sinason (1994b) has noted her patients using an increased vocabulary of painful and negative words when they are allowed to show their illegitimate knowledge of all they have seen and felt.
The parents of a handicapped child must learn to share the child with a range of professionals (Sinason, 1993b, 1999c) and sometimes the parents are fiercely possessive of their child (Sinason, 1990a; Stokes & Sinason, 1992). The divorce rate for such parents is three times the average (Sinason, 1988b). Parents also worry what will happen to their child if the child outlives them and the death wish takes the form of a hope that the child will die first.
The learning disabled adolescent and adult is often infantilized by his or her parents and by others, with girls dressed in drab pleated skirts and short white socks. Sinason (1992a, 1997a) notes how frequently the learning disabled adult is infantilized by being introduced by their first name only and by being described as 'naughty'. Sinason identifies a collusion between parent and child. For the parent this represents an attempt to manage the painful knowledge that the child is never going to leave home and live independently (Sinason, 1992a). For parents and others it also seeks to maintain the child as an asexual being who will not repeat the damaging intercourse of their parents (Sinason, 1997a). Sinason came later to realize that, just as the mentally handicapped patientís sexuality is threatening to those around them and is therefore denied, so do mentally handicapped individuals themselves seek to deny their adulthood, not only to appease their parents, but in order to avoid facing the pain of exclusion from normal adult activities (Sinason, 2000).
The transition from childhood to adolescence and then to adulthood is particularly difficult for the learning disabled individual to negotiate, because they are marked out as noticeably different and feel themselves as ugly and sexually distasteful (Sinason, 1988b, 1999b). What Sinason terms the 'hierarchy of attractiveness' is difficult and painful for any adolescent to accept but particularly so for the individual who knows they are at the bottom of that hierarchy. The handicapped male projects his disgust at his handicap into the female, who is then rejected (Sinason, 1988b), while the handicapped female projects her disgust into her own body via self-injury (Sinason, 1997c).
Sinason sometimes uses myth, fairy tale or literature to understand and interpret the psychopathology of a learning disabled patient. This not only aids understanding, but renders the material less dangerous, a function that was to prove essential when she began her work on ritual abuse. She uses Richard III and Hephaestus to understand male difficulties with a wounded body image and uses Echo to understand aspects of female handicap (Sinason, 1988b, 1999b). On another occasion she makes use of Dylan Thomas's 'Hunchback in the Parkí, as well as Cinderella and Pygmalion (Sinason, 1997c). Tourneurís play The Revenger's Tragedy is used to understand how trauma is translated into revenge as a response to loss and hate (Sinason, 1995b). Elsewhere, Sinason uses Coleridgeís poem The Rime of the Ancient Mariner to demonstrate the need felt by a victim of trauma to pass on to others what he has witnessed in order to share the pain and the knowledge (Sinason, 1997b).
In addition to writing in specialist journals and contributing chapters to psychotherapy books, Sinason also wrote several picture books in a series aimed at earning disabled people and their carers. These important publications became known as the Books Beyond Words series (Hollins, Sinason & Webb, 1992, 1993; Hollins, Sinason, Boniface &Webb, 1994- Hollins, Horrocks, Sinason & Kopper, 1998, Hollins Sinason & Brighton, 2001) and deal with issues which confront mentally handicapped people who have been abused such as disclosing the abuse and giving evidence in court. The first of these books has a few words of text opposite each picture. However to avoid excluding learning disabled readers, the later books are written with pictures only, with a separate explanatory text for parents and carers at the back.
Sinason has always emphasized that learning disabled people need appropriate understanding and support from all those responsible for their care, not just psychotherapists. She has always believed that even complex psychoanalytic ideas can be communicated m dear and accessible language. In Understanding Your Handicapped Child (Sinason, 1993a) she presents a psychotherapeutic perspective on the emotional difficulties of learning and physically disabled children, in a very clear and practical manner, which is aimed at parents. The book seeks to increase the understanding by parents and carers of the needs ot their handicapped child. The book also addresses the conflicts, disappointments, and primitive feelings associated with having a handicapped child in a way that supports and educates parents.
Sinason believes strongly that for many learning disabled patients group-analytic treatment can be especially helpful (Sinason, 1994b, 1997c,d, 1998, 2002; Hollins, Sinason & Thompson, 1994; McCormack & Sinason, 1996; Hollins & Sinason, 2000). At the Tavistock Clinic and St George's Hospital she has run treatment groups for mentally handicapped children, adolescents, adults, victims of abuse, and for perpetrators of abuse.
Sinason (2002) has found she tends to start a group because she has not got enough space to treat patients individually and is then amazed at how quickly the group members' functioning improves, sometimes even more quickly than in individual treatment. The experience of thinking, sharing, and understanding as a member of a group offers particular benefits for the mentally handicapped patient. These patients are more likely to have experienced social exclusion and are therefore particularly likely to find it difficult to relate to others. The sense of solidarity that is built up in the group would not be possible in individual work (Hollins, Sinason & Thompson, 1994). Members learn to value each other's contributions, to wait their turn and to share the available time and attention. The group situation is thus able to compensate to some extent for deficits in ego controls (McCormack & Sinason, 1996).
All the typical features of the group process of cognitively normal groups are found in learning disability groups. The differences lie in the timing, duration, degree, and prominence of these features, reflecting the distinctive psychopathology of the mentally handicapped group member. As with individual treatment, the aims of group treatment for these patients are to assist emotional maturation and prevent secondary handicaps. Group patients usually develop an im- proved ability to relate to others and to become more reflective.
The members of a learning disability group are able to pool their intelligence to increase the group's thinking capacity so, in addition to the therapist functioning as an auxiliary brain, the group can undertake this function too (McCormack & Sinason, 1996). As well as the cognitive effort, the emotional load can be shared. In a group, the mentally handicapped† patients defences are less threatened, because he or she can be† quiet while someone else is talking. They can hear someone else† voice things they would never have dared to voice in individual† therapy (Sinason, 2002). Sinason (1997c) has described a group† of learning disabled women. who were discussing family planning† and abortion. This is a particularly frightening subject for these patients because of their acute awareness of society's death† wishes for them. One member said, 'Amnio-', and stopped, then† another member finished the word, '-centesis'. Sinason (1997c, p. 276) comments, 'The killing word needed two people to carry ití.†††††††††
Sinason has found the only significant contra-indications for learning disability group treatment are psychosis and† aggressive acting-out behaviour (Hollins, Sinason & Thompson,† 1994). However, the composition of the group may require special consideration. Some learning disabled patients have a serious speech impediment or are mute, either electively or through organic impairment. McCormack & Sinason (1996) suggest that while one silent group member may be effective for the group's functioning, a whole group full of silent members would not.†††††††††
The issues which typically preoccupy learning disability groups include group members' handicaps, their dependence on others, their sexuality, and their mortality (Hollins, Sinason & Thompson, 1994). Sometimes a mutually supportive defensiveness will emerge and members will collude to avoid mentioning these topics, especially in the early stages of the group.†††††††††
Confidentiality can be a difficult area for patients who are accustomed to their parents or carers knowing all the intimate details of their lives. This can also make it very difficult for parents and carers to respect the confidentiality of the group and to tolerate not knowing what goes on in the group (Hollins, Sinason. & Thompson, 1994).†††††††††
Members of any learning disability group will have experienced an extraordinary degree of loss in their lives and will experience any disruption to the group as a further crushing loss. They, therefore, need even more notice than usual of any changes to the group, such as new group members, a change of therapist, upcoming breaks or termination of the group (McCormack & Sinason, 1996). Sinason (1997c) has described one open group of learning disabled women who were very wary of a new member, because they feared she might drop out and make the group feel aborted.
††NEW HORIZONS IN DISABILITY PSYCHOTHERAPY 599
It is usually appropriate for two therapists to run a group for learning disabled patients because of the high degree of disturbance and the intensity of grief and anger likely to emerge (McCormack & Sinason, 1996). There are practical reasons for having at least two therapists, such as the potential for violence, or the fear of violence, in such a group. Also, there may be a need to accompany members who need to be taken to the toilet during the session. In addition, there are sound psychodynamic reasons for having co-therapists. Members are able to develop a negative transference to one of the therapists while maintaining a positive attachment to the other.
A learning disability group is likely to take longer to move through the stages of group development than a cognitively normal group (McCormack & Sinason, 1996). The usual issues of starting a group can be accentuated by the members' lack of cognitive ability, plus a degree of defensive use of secondary handicap, whereby members are deliberately slow to understand the meaning of what is being said. Initially, members tend to relate only to the therapists, which results in a series of unconnected monologues directed to the therapists. It can take several months to develop a linked juxtaposed series of monologues, reflecting the extended period necessary for the build up of empathy with the group (Sinason, 1997c). At first, therapists have to be more active in the group by making connections and ensuring understanding. Additionally, a learning disability group is likely to need a great deal of reassurance (Hollins, Sinason & Thompson, 1994).
Group-analytic work with cognitively normal children is still comparatively rare, and it is rarer still to work with mentally handicapped children in a group setting. However, Sinason has run successfully a number of groups for mentally handicapped children (Sinason, 1994b, 1998; McCormack & Sinason, 1996). In one group, which lasted two years, the children had all been abused and were initially extremely quiet and withdrawn (Sinason, 1994b). After some time in the group their vocabulary had not only expanded to include longer and more complex words, but moved from exclusively positive- sounding words to include negative and angry language which expressed their hatred, fury and hurt. In another group of learning disabled children who had been abused, and themselves behaved violently and abusively:†
... the benefit of the group was that hopeful feelings of ending abusive behaviour could be located in one person and sadistic wishes to perpetuate the abuse could be located in another. In individual therapy, the children would not have had the same freedom to share their unbearable experiences. (McCormack & Sinason, 1996, pp. 237-238)
Sinason has run several learning disability groups for adult female victims of abuse, both at the Tavistock Clinic and St George's Hospital. She has found the group setting helps patients avoid the feelings of shame and guilt for their experiences of abuse, because they know other group members have been through a similar experience. In one group of mildly to severely learning disabled women gender issues were very powerful (Sinason, 1997c). Only after the group had been running for nearly a year were members able to talk about pregnancy, amniocentesis, marriage, and cervical smears. Sinason. explains the gradual understanding that emerged in the group:
We were able to slowly understand that since having a baby was the ultimate taboo it was easier for them to transform all sexual ideas of intercourse into something painful so that they could disguise their procreative wishes. (1997c, p. 276)
At St, George's Hospital, Sinason ran a forensic group for mentally handicapped men who were child abusers and wished to stop their offending behaviour (Sinason, 1997d, 2002; Hollins & Sinason, 2000). Without exception these men were abused themselves as children and were now perpetuating that, abuse and found group treatment helped them avoid the shame of the abuse and their offending behaviour. Sinason (1997d, p. 60) describes how the men gradually understood the sequence of events that led them to commit a crime, '... the male offenders had become movingly aware that their desires to offend, in both the build up of masturbatory fantasies and in action, followed loss or humiliation'. Slowly, members of the group were able to use this understanding to make choices. In one session a man told the group of a recent experience when a painful humiliation by a male nurse drove him very close to committing a sex offence against a child in a park. However, before offending the man was able to think about the anger he felt towards the nurse who humiliated him, chose not to commit the crime and instead reported the nurse to the police. 'The group applauded him. They all recognized the power of that different option' (Sinason, 1997d, p. 61). Sinason (2002) has found that offender patients change more quickly in group treatment than in individual treatment. However, she has not yet tested this observation formally and has not written about it.
Many of the insights and techniques which are applied in the group-analytic treatment of mentally handicapped patients can be used to inform work outside a formal group setting (McCormack & Sinason, 1996; Sinason, 1998). Many patients with learning disabilities are involved in some sort of group activity and, even outside of a treatment group, group-analytic interpretations by a teacher or coordinator can be of enormous benefit to the learning disabled person. For example, the teacher of a class of mentally handicapped children can have a major beneficial impact with an appropriate group-analytic interpretation (McCormack & Sinason, 1996).
Carers and teachers, working with mentally handicapped children and adults, need their own reflection space to consider their responses to those in their care. At the Tavistock Clinic Day Unit, which treated emotionally disturbed children, Sinason ran a mothers' group with a social worker. In the group meetings it was revealed that without exception these mothers shared a bed with their mentally handicapped sons (Sinason, 1998). The group gave these women a space to begin to think about the meaning of this emotional abuse of their sons. In the same setting there was a weekly community meeting for all the children and adults (Sinason, 1998). At the meeting Sinason used to make psychoanalytic interpretations of the discussion and behaviour in the room and encourage others to do the same so that they could think together about the meaning of what was happening.
It was many years before Sinason realized the importance of testing and measuring the improvement in her patients' functioning in a formal way. Only as she began work on her doctoral thesis did she fully appreciate the need for evaluative outcome research if her findings were to achieve credibility in the wider professional fields of medicine and psychology.
The only published study which tested Sinason's clinical findings was done at the Tavistock Clinic from 1989 to 1993 (Bichard, Sinason & Usiskin, 1996). Sinason collaborated with Sheila Bichard, a psychologist, who. used the Draw-a-Person (DAP) test to assess changes in patients' functioning following psychoanalytic psychotherapy. The study looked at patients with IQs ranging from 30 to 69, some of whom received psychotherapy and some of whom received no treatment and served as the contrast group. Patients were also assessed with other projective tests, including House-Tree-Person, Kinetic Family Drawing, TAT and Rorschach, as well as cognitive testing.††††††††
The study confirmed what Sinason already knew and shows that over a two-year period the great majority of the treatment group, regardless of IQ, had improved cognitive and emotional functioning as measured by increased DAP scores. In the contrast group all except one patient showed a deterioration in functioning over the period of the study. Bichard, Sinason & Usiskin (1996) conclude that an increase in emotional functioning leads to an increase in cognitive functioning, but not necessarily to an increase in IQ. The study also shows that it is difficult to predict, at the outset, an individuals potential for improvement or likely rate of improvement.†††††††††
Sinason is keen to make up for the lack of outcome research studies and hopes to accumulate a body of formal evidence to back her pioneering clinical findings. The results of a number of unpublished research studies are presented in her recently submitted doctoral thesis. In one study she measured changes in patients' language structure following psychoanalytic psychotherapy (Sinason, 2002). The study examined mean length utterance of matched pairs of those patients who were in treatment and those in a contrast group which was matched for gender, age, symptom, and IQ. The study shows that language structure improves for those in treatment but remains the same in the contrast group, proving what Sinason has known for a long time. Sinason concludes that before treatment there is† a defensive gap between patients' expressive vocabulary (e.g., nice, good, clean) and their large receptive vocabulary of insults† (e.g., disgusting, revolting, devastating). After a year in therapy the negative vocabulary to which they have been exposed is able to emerge.†††††††††
Other significant unpublished research includes a study† which Sinason is conducting with Sheila Hollins at St George's Hospital Medical School (Sinason, 2002). The study uses two psychoanalytic tests, the Defence Mechanism Test and Perceptual Object Relations Test, which were originally developed at the Tavistock Clinic, but had fallen out of use in the United Kingdom. These tests are widely used in Sweden and the study links St George's Hospital with five other treatment centres abroad, including one in Lund, Sweden. The tests are being used to assess the effect of psychotherapy on patients in two of Sinasonís psychoanalytic groups at St George's Hospital. In one group the patients ai-e all female victims of abuse, while the other group consists of male sex offenders. By early 2002 the study was well advanced with the treatment group, but a contrast group had not yet been chosen.
From the beginning of Sinason's work with mentally handicapped patients at the Tavistock Clinic she received a very warm and enthusiastic response from outside agencies. In 1985, Vicky Turk, a psychologist working in Lewisham, suggested to Sinason that she run a short course for outside workers in order to share her understanding of working with learning disabled adults and children. Even without advertising, that first ten-week course was immediately very popular, so it was repeated and soon there were up to three such courses running at any one time. The ten- week course in psychotherapeutic approaches to working with people with mental handicap became part of the Tavistock Clinic's official training programme. The course presented a psychoanalytic perspective on learning disability, something no other course had ever done in this country.
Gradually, Sinason was joined in the teaching by other psychotherapists skilled in working with mentally handicapped patients, including Brett Kahr, Janet and Henri Bungener, Maria Pozzi, and Janine Sternberg. In 1990 the ten-week course was expanded into a one-year course. The popularity of the expanded training led to requests for a course that could form part of an MSc. Sinason tried at first to set this up at St George's Hospital with the University of London, but its stringent requirements for a substantial balance of written work to clinical work made it an unsuitable partner. The Tavistock Clinic already had strong links with the University of East London so it became the eventual partner for a Post-Graduate Certificate in Psycho- therapeutic Approaches to Working with People with Learning Disabilities which was set up after Sinason's connection with the training ended. When Sinason left the Tavistock Clinic in 1998 she knew that the subject was well established and would continue to be successful in her absence. The disability courses run by the Tavistock Clinic and the University of East London continue to ensure that psychoanalytic insights inform the work of many psychologists, social workers, and other professionals working with learning disability.†††††††††
Sinason has found that it can be helpful for the recovery of patients who have been abused if they see the perpetrators of the abuse brought to justice (Sinason, 1990b, 1993c, 1994b, 1996b, 1997b,e). Unfortunately, this is seldom possible and one reason for this is that learning disabled people are often not regarded as credible, reliable witnesses in court. Sinason is an active member of the organization VOICE UK, which campaigns on behalf of mentally handicapped people who have been abused and works to ensure an appropriate response from all agencies when a learning disabled person has suffered abuse. Sinason and other clinicians such as Arnon Bentovim, Eileen Vizard, and Judith Trowell have worked to bridge the gap between the legal system and psychotherapists, so that clinicians can more easily give expert testimony and learning disabled people can be accepted as viable witnesses.†††††††††
Sinason has returned to South Africa every year since her first visit in 1994 and in 1997 she was appointed Honorary Consultant Psychotherapist at the Cape Town Child Guidance Clinic in the Psychology Department of the University of Cape Town.. Sinason has become a key person in training psychologists in South Africa to use psychotherapy to deal with disability and abuse. She continues to spend three or four weeks every year lecturing and working, without payment, in the South African townships, giving supervision to clinicians and treating disturbed children, many of whom have seen members of their family tortured and killed.†††††††††
In Sweden, psychotherapists listened to Sinason and began applying what she had to say more quickly than in the United Kingdom. Her work is highly regarded in Sweden and she has been awarded life membership of Sveriges Handikappsykologers Forening, the Swedish organization for psychologists working in the field of disability. She is regularly invited to Sweden to give papers and run workshops.
Despite remarkable progress in disability psychotherapy, institutional responses are sometimes less than whole- hearted and the development of thinking is not always matched by the commitment of clinical resources. For instance, work with learning disabled patients at the Tavistock Clinic, although well established, has actually declined since the 1980s. In 1987 Sinason was seeing more mentally handicapped patients herself than the entire learning disability service at the Tavistock is now seeing in 2002 (Sinason, 2002).
Sinason hopes the newly created Institute of Psychotherapy and Disability will provide an institutional frame- work to carry the disability work forward in areas that she has not been able to develop as an individual. She is part of a formidable team guiding the Institutes work in these crucial beginning stages. The initial trustees were Sinason, Pat Frankish, Sheila Hollins, and Brett Kahr, soon joined by Nigel Beail as a further trustee, Ann Casement as vice president, and Joan Bicknell as patron. In addition to setting standards for specialist training and accreditation in psychotherapy and disability, the Institute plans to produce a specialist journal, something Sinason and her Institute colleagues have wanted to establish for a long time.
One of the central tenets of the Institute of Psychotherapy and Disability is that learning disabled people must be treated with overt respect (Kahr, 2000b). Sinason (2002) believes that adult psychotherapists sometimes blame the patient for their illness and are too often discourteous to their patients. This is unhelpful for any patient, but for mentally handicapped patients serves only to reinforce the societal hostility they face every day. Sinason hopes that, in the promotion of overt respect and courtesy for all patients, the Institute may have a wider impact than just in the disability field.
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