The Risk Factor : In Denial of Abuse

By Tamsin Cottis and Richard Curen, Community Care, Vol. 6-12th May 2004

CLIENT: Ashley Woodhouse is 19 and has moderate learning difficulties. His speech is sometimes difficult to understand.

CASE HISTORY: For the past two years Ashley has been living in a residential care home some distance from his family home. Ashley spent all his childhood at home with his parents and younger sister, Donna, 10, who also has a mild learning disability. He admitted that he had had sexually abused Donna. This caused his father great anger and their relationship is now poor. Nonetheless, family contact has been extremely important to Ashley although this hasn't happened with the regularity he hoped for. Subsequently, care staff have become concerned that Ashley's sexual behaviour could pose a risk to others. Despite being constantly supervised outside the home and closely supervised within it he has, for example, managed on at least three occasions to lock himself in the bathroom with other residents and followed another resident into their bedroom.

DILEMMA: Ashley has the ability to take part in the community but refuses to acknowledge that his behaviour is inappropriate.

RISK FACTOR: If unsupervised, Ashley's impulsive sexual behaviour can put vulnerable adults and children at risk.

OUTCOME: Work continues with Ashley. It is hoped that psycho-dynamic therapy will help him come to terms with his behaviours.

If you are to resolve any personal or social difficulty, the initial step is to acknowledge and recognise that you have the problem in the first place. It's the basic requirement in dealing with, for example, drug and alcohol abuse. But it is just as true for people who have sexually inappropriate behaviours. People like Ashley Woodhouse.

Ashley, 19, has learning difficulties and was moved two years ago into a residential care home following his inappropriate touching of his younger sister, Donna, and Donna's friends. The home, which provides high staffing levels, cares for people with more severe disabilities than Ashley's. Although he is closely supervised at the home he has on three occasions been caught locked in the bathroom with other residents. Because of their inability to communicate, it is not known for sure what, if anything, happened.

In an attempt to better understand Ashley's behaviours and to plan more long-term, Ashley was referred for a risk assessment to Respond, a service for people with learning disabilities who are victims or perpetrators (or both) of sexual abuse. Through a regular 12-week assessment process, the assessor will, amongst other things, aim to assess the root causes of any sexually reactive behaviour. Tamsin Cottis conducted the risk assessment and met with Ashley for twelve sessions, each lasting just under an hour. The risk assessment process is not a psychotherapeutic piece of work but is informed predominantly by psychodynamic thinking. It is Respond's experience that clients hurting others through sexual aggression will rarely be found to be a behaviour that does not have its roots in earlier trauma.

"Since Ashley was about 10 there have been concerns about the sexualised nature of some of his behaviour," says Respond psychotherapist, Tamsin Cottis. "The cause of the behaviour is uncertain but there are some concerns that Ashley may have been sexually abused at this time."

"Although it was the sexual risk he posed to Donna, in particular, which led to Ashley being removed from the family home, more recently he has been seen watching children at play very intently and there are strong concerns that he is also a sexual risk to children," adds Richard Curen, director of Respond, who managed the case.

"Although Ashley agreed that he has sexual feelings towards Donna, I think he was too anxious to face up to these as he clearly identifies them as the source of his difficulties. He knows that his abuse of his sister led to him leaving his family and is seeking instead to deny it," says Cottis.

Ashley's family is very important to him. "He talks about them a lot and has spent many hours working on and then looking at his family tree. He is also envious of Donna's greater intellectual ability and feels some resentment towards him. I think this is probably fuelled by the fact that Donna continues to live at home while Ashley cannot," says Cottis.

Respond believes Ashley's family attachment experiences are a good indication for the success of any further therapy. "The main block to him forming good relationships at present is his difficulty in acknowledging his past and present dangerous behaviour. His levels of denial are very high and this increases the risk he poses as he is unwilling to accept that he has done anything which may cause hurt," says Curen.

Ashley, who has also been physically aggressive towards staff, kept calm in the sessions. "He was controlled, polite and friendly, which suggest that at times he is able to control his impulses."

However, says Curen, although it is encouraging that "Ashley is capable of controlling his behaviour, while he continues to deny his dangerousness it is hard for his carers to build picture of when it is safe for him to be unaccompanied."

Respond believes that Ashley should live somewhere closer to home, which might make family contact more positive. This should be somewhere with maximum opportunity for safe community involvement which will help bolster his self-esteem. Also that Ashley's carers should be aware of his possible experiences as a victim of sexual abuse and the enduring and damaging affects of this abuse, including his vulnerability to sexually abusing others.

"I think that with long-term therapy Ashley would be able to face up to his denial and to look at what he does at a deeper and more profound level," says Cottis.

" We intend to return to this case later in the year to check on progress.

ARGUMENTS FOR RISK

" Therapy will give Ashley a chance to explore his childhood experiences and link them with his present day life. Challenging therapy will also address his dangerous behaviour and seek to help him acknowledge it and understand its causes and triggers.

" Although Ashley may well continue to pose a risk to his sister, he derives a considerable sense of identity and belonging from his family and this should not be denied - making a move nearer home will help this. It may be necessary to give more focussed support to his family as they seek to cope with Ashley's enduring dangerousness and its possible causes.

" There is currently a discrepancy between the amount of control exercised over Ashley and his wish for more independence and freedom. A guardianship order should be considered with a residential requirement. The appointment of an advocate for Ashley will also help Ashley to put forward his own views about his care.

ARGUMENTS AGAINST RISK

" He does not deny that he hurt his sister but seemingly does not accept responsibility for this. With his high level of denial and his limited capacity for empathy, the risk of Ashley continuing to be a danger to others is high."

" There are many external controls in place at the moment but even with these in place it is not possible to guarantee the safety of other residents."

" Staff have reported that he can be physically aggressive towards them, particularly when denied his wishes."

" Ashley's current offending behaviour appears to opportunistic and compulsive. He takes a chance when it is available to be alone with other residents. Because of the high levels of supervision, he has few opportunities. However, he makes the most of those he does have."

" If contact with family does diminish this will undoubtedly cause great distress to Ashley and he will need considerable support to deal with his feelings of loss and abandonment."