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Introduction
We believe both that people are capable of helping each other, in forensic services, at a deeper level than the existing social order currently envisions and that this is in our self interest. We think co-productive relationships are one means to achieve this outcome.
Co-productive relationships are different because they prioritise equal mutual beneficial transformation. They also involve novel equal experiences, transparency, risks and discomfort. This paper is the story of how we came to develop these relationships in forensic environments over ten years. This time with a better psychological map, the benefit of hindsight and the illustrations of Jorge and Yousef.
We begin in the silo with backs to each other but the silo leaks, fighting in the silo, the food runs out, boredom sets in.
Patients and/or their families can now access biographical, topical, and other information via social media, personal websites and press reports. So whereas Ferenczi, et al, (1995) & Yalom (2003) argued that self-disclosure is an important therapeutic reparative force, similarly Jung (2014) suggested that you can exert no influence if you are not susceptible to influence. Now both more of that disclosure, and how we are influenced, is uncontrolled.
I have heard about you. Who actually are you? What are you? Wow, urgh, argh - being partially known.
One of forensic mental health services positive responses to cultural change was to change professional roles. Multiple professional key workers for each patient, embedded multidisciplinary practitioners and shared multidisciplinary, security and therapeutic responsibilities. However anxiety increased as confidence, the luxury of the habitual voyeur, reduced. This as we know may be temporarily resolved by seduction or objectification, both paranoid positions.
Is that all you are? Alternatively you are everything! Then feelings of betrayal. We have hit a brick wall, I don't see anyway around it.
What were our options? Not changing at all and something magical happens? It didn’t. It hurt but there were still more obstacles to the relationships developing. This included denying the relationships we were in already. Excessive narcissism as a defence against our shared vulnerabilities. In other words our attachment problems.
Ok, you can hurt me and I can hurt you. But you're not changing me so back off “I prefer the tumult of liberty to the quiet of servitude." Thomas Jefferson.
We learnt to view masochism and sadism as the same interpersonal action and not ethical. So at times we cared too much and at others cared too little. Instead we learnt to stand up to, and stand up for, each other.
In forensic systems the freedom to choose who we associate with is less. So we are stuck together and at risk from each other. That’s not comfortable either. So what's ok?
Using the existing scaffold
First we learnt to fit in. Getting the security procedures right. The rituals of tea, sitting still, shutting up, the talent of being present and not intrusive. Ok now talking. What can we talk about? Does it matter? In our experience no. We found permeable barriers between parts of the the system. This reduced the need to talk about 'the problem'. Instead, in our experience, the dilemmas and joys of experience were represented whatever we talked about. We also thought about linguistic ideas where the behaviours associated with speech have social system significance too. The multiple parallel processes of open systems theory in other words. However it was important we did talk. Without dialogue regression to earlier destructive means of relating (e.g. fighting and/or sex) became more likely. Both of these are not ok in a forensic environment. We learnt to invite each other to play, not fiddle without consent. So how did we make talking more likely?
A new scaffold number one - the ward talking group - the difference that makes the difference.
A ward talking group was a place for conversation. A simple analogy from popular culture would be a group of colleagues meeting over lunch where spontaneous interactions occur within a commonly understood framework. In this way we scaffolded novel interactions with ecological validity and containment. The talking group was not a psycho dynamic group. It was neither designed to examine unconscious processes nor induce people to regress. Therefore the ward talking group also worked by recognising these potential dangers in less structured groups (McLeod & Kettner-Polley, 2004). It also worked by being mindful of the evidence around the negative effect of expressed emotion (Butzlaff & Hooley, 1998). We learnt to proceed gently and with consent, the room door stayed open, deliberately reducing group cohesion (for a qualitative evaluation of this specific intervention see Geddes, 2015).
Can you really help me? Can I really help you? - A different discomfort
We found we were both the wrong and the right person to help. The task was to find out how. Thus practically demonstrating our responsibility to and dependence on each other. At its most successful, we had relationships analogous to Ferenczi's (1995) two terrified children who compare their experiences and because of their common fate understand each other completely. As such “no longer is he [she] the superior wise man [woman], judge, and counselor; he [she] is a fellow participant in the dialectical process just as deeply as the so-called patient" - CJ Jung (2014). So as per the proverb ‘Iron sharpens iron, one man sharpens another' we explicitly learnt how to help and be helped.
What’s equal? How equal? Does It matter?
For forty years some evolutionary psychologists and biologists have suggested that 'selfish genes' hardwire cooperation in animals and humans (Dawkins, 1976). Latterly Amy Banks (2015) detailed the current neuro psychological understanding of human cooperation. Suggesting universal developable capacities for co-operative relationships. Broader psychological research suggests there is an unexpected systematic bias to co-operative behaviour despite seeming 'irrational' to behavioural models e.g. the prisoner's’ dilemma. Another consistent finding is the willingness of people to give things up for what they consider a fair outcome (Fehr, & Fischbacher, 2003).
Culture interacts with these scientific findings to support the desirability of co-productive relationships. The Magna Carta principles make individuals equal before the law. This idea is present in law via equal opportunities and human rights. Also the legitimacy of social structures is often judged by the equality of opportunity or outcome it provides. In summary both culture and psychological research suggest we have predispositions towards co-productive relationships.
In forensic setting we also note the work of Jenkins (2009, p xiii)
"perhaps the most significant consolidation in invitational theory is the notion of a parallel journey for workers. This concept refers to understanding of the political nature of the intervention and the belief that our journeys as workers must mirror the journeys of our clients....Becoming ethical in our own parallel journeys shifts us away from an us and them attitude.." .
What are you two doing in there? A third person looked in
According to some people, these scaffolds and relationships still created significant cultural change. By identifying which were highly co-productive relationships we also threw light on those, we and others had, which were less so. In hindsight building new relationships was more successful than formulating and/or intervening in present or past ones. Instead a narrative of development was helpful in focusing on where we were going than where we had come from.
Different mental health practitioners had different views and practices with regard to the changed cultural context. There was disagreement as to the best way forward with regard to the how of clinical practice. Whilst goals seem to be largely shared, differing views on the significance of parallel process existed. This meant that the disputed importance of the methods by which we attempt to achieve our shared goals have on the final outcomes. To one side, as in Audrey Lordes’s (1984 cited 2012) feminist essay, 'the master’s tools will never dismantle the master’s house' to the other, a utilitarian perspective, where the ends, eventually, justify the means. These two positions suggested quite different designs of mental health practice in forensic services. This disagreement was not resolved.
New scaffold number 2 the social music groups. You are not yourself today, to what do I owe this pleasure?
Patients got to know staff better through music. In turn they allowed staff to get to know them better through music. Taking turns in being vulnerable by trying new things. The novelty helped us connect. We enjoyed making musical mistakes with pace, pitch, timing, and or volume. In these ways intimacy was safely practised. Playing as children under the supervision of our adult selves. In this way as Searles (1975) suggested we experienced a therapeutic symbiosis comparable to normal infancy.
I am concerned if we embrace change this one time, change will get the wrong idea and take it as a long term commitment.
The end of the relationship. Thanks for the memories As William Wallace's uncle in Dunipace said, Freedom is the best of all things, never live in {or impose] slavery my son'. Who else can I relate to?
We know all experience is temporary. The ending of these kind of relationships was neither at some set time nor always of our choosing. The endings were differently uncomfortable but did not come as a complete surprise. Anyone who works in forensic systems should not get too upset at being rejected. There is an ethical necessity of choice in forensic systems.
What just happened? We think it's all good but some of it is better.
We know negotiating for mutual transformation, via equality, in relationships starts in infancy. The learned responsiveness in relating found in a secure attachment. Failure to attach securely is theoretically and empirically associated with mental health problems (Bowlby, 2005). Consequently cognitive analytic therapy (CAT) aims to transform mutually destructive reciprocal roles into different, constructive reciprocal roles (Norcross,& Goldfried, 2005). However the latest systematic review of CAT suggests the empirical evidence to support CAT as an intervention is limited at present (Calvert & Kellett, 2014). Therefore, along with a predisposition, an absence of co-productive relationships may worsen mental health. However was prioritising co-productive relationships a reasonable means to address mental health problems? The following psychotherapeutic approaches suggest that sometimes is the case.
Schema therapy shifted cognitive behavioural therapies approach towards more ‘authentic’ co-productive relationships. (Young, et al, 2003). The efficacy of schema therapy based interventions has been demonstrated by systematic review (Taylor, Bee, & Haddock, 2016). Thirdly the theory behind motivational interviewing interventions considers 'relatedness' a universal need. Specifically to interact, be connected to, and experience caring for others (Deci & Ryan, 2011). The same therapeutic reciprocity described in a co-productive relationship. Motivational interviewing has a strong empirical evidence base across a variety of settings (Rubak, et al, 2005). Finally Yalom’s existential psychotherapy (2002) advocates equal exchanges in psychotherapy. For example where the therapist disclosure enables client disclosure. This form of intervention has also attracted a positive meta analysis of its outcomes (Vos, Craig, & Cooper, 2015). In summary there is theory, evidence and a culture that humans are predisposed toward co-productive relationships, can suffer mental health problems through a lack of them and be improved in mental health by having them.
We know a good enough practitioner promotes effective clinical and non clinical relationships. In our view co-productive relationships are a successful model to do just that in contemporary forensic services. It developed from the psychoanalytic, and other, fields, where there is a long established therapeutic rationale for equal co-productive mutual transformation of the therapist and the client (Schamess,2012).
Critique and failure
It does indeed seem harder to be a stand-alone scientist practitioner, in any profession, ministering to the unscientific. We recognised that this old model of mental health practice is became harder to fit with the culture within which we now operated. We also apologise to those whose feelings were hurt in learning these hard lessons.
Conclusion
Co-producing reciprocal outcomes, making your dependence on other people an asset. Accepting invitations to come alongside other people, to spend time with them, be influenced by their world, to talk and to play music. That shared power gives us an insight into another person’s world, equalising the experience, the meaning of the relationship, the level of commitment, openness to new experiences, risk, and respect. It feels like we are doing something new together. In this way both parties allow themselves to be transformed ethically by someone else. A ‘co-productive relationship.
Co-productive relationships are rooted in culture, psychological theory, research, and practice. From these perspectives they seem reasonable approach for health professionals. Their ethical properties appear to be dependent on the skills, capabilities and contexts of those entering into them. In some circumstances they appear to have different ethical properties than other forms of helping relationships (Perry 2019.)
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n.b. I have also collated a list of other free resources on forensic psychology and psychiatry. You can access them here : CLICK HERE