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Security and the social mind: attachment
and therapeutic communities
Gwen Adshead
Dr Gwen Adshead is
Consultant Forensic
Psychiatrist at the Forensic
Psychiatry Department,
Southern Health Foundation
Trust, Fareham, UK.
Abstract
Purpose –The purpose of this paper is to describe some of the basic features of attachment theory, and explore
how they relate to the development of the “social mind”and the work of therapeutic communities (TC).
Design/methodology/approach –The author describes the essentials of attachment theory in humans;
and the development of both secure and insecure states of mind. The author will set out how insecure
attachment systems are associated with deficits in mentalising processes which are fundamental to the
activity of the social mind.
Findings –The author suggests how attachment to a TC can promote mentalising processes. The author
draws on the work of other speakers in the conclusions about how to “grow”secure minds and societies.
Research limitations/implications –This paper is a brief over view only and does not address attachment
process to TC in any depth.
Practical implications –Attachment theory could help both service users and therapists who work in TCs
understand some of the difficulties people have in engaging at the start. Attachment theory also gives a guide
to what a “good enough”experience in a TC might look like.
Originality/value –There is little existing discussion of the application of attachment theory to TCs.
Keywords Security, Therapeutic communities, Psychoanalytic techniques, Groups, Attachment, Social mind
Paper type Viewpoint
Introduction
It is truly a privilege to have contributed to the annual Windsor Conference in September 2014;
and then to be able to offer some written reflections, enriched by reading those of others. I am a
group therapist by training, and my experience so far has repeatedly confirmed for me that my
best work is always a group effort. So too here, this paper should be seen very much as the
product of a group process: fed by the thinking of others, and the experience of being in all kinds
of groups, both social and therapeutic.
Like Rex, my training began with an encounter with the therapeutic community (TC) movement,
which occurred completely by chance. It was the summer after a year of house-jobs, and I was a
hapless houseman sitting in the doctor’s mess, reading the paper (an experience that must now
seem Elysian to current foundation year doctors who do not have rooms to sit in where you can
talk to peers or just “be”). I noticed an advertisement for a Richmond Fellowship Conference
with a programme of speakers that included Thomas Szasz, Antony Clare, R.D. Laing and
Metropolitan Anthony of Sourouzh. Even in my completely uneducated state, I knew this was
a line-up that no would-be psychiatrist should miss, so I booked myself in.
The conference was amazing and I was spell bound. R.D. Laing was difficult to follow, however;
and I was struggling to make sense of what he was saying when a deep pleasant voice rumbled
in my ear, saying “Do you think Ronnie is drunk?”. I had nothing to offer in response to this; but
my neighbour continued to engage me in interesting conversation and invited me to join him and
The author is grateful to Dr Steve
Pearce for his editorial assistance.
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his wife for a drink and supper. He introduced himself as Maxwell Jones, and over dinner, I had a
crash course in TC theory and methodology, and the social psychiatry challenge to mainstream
psychiatry. I had no idea what he was talking about, but the democratic ideal sounded just right to
me, and I was moved and impressed. I was even impressed when Max, pursuing the spirit of
openness, honesty and transparency, rang me up at one o’clock in the morning to ask me how
many lovers I had had.
I took this spirit of openness, honesty and transparency with me into my first psychiatric job, and
I have tried to nurture it ever since. My early exposure to TC thinking and process acted as an
essential corrective to the psychiatric training, which (then as now) encouraged junior
psychiatrists to categorise distressed people into diagnostic categories and to try to medicate
their distress away. I was not lucky enough to do the junior psychiatry job at the Henderson,
but I had lots of exposure to people who did; and to the luminaries who worked there, like Estela
Welldon, Stuart Whiteley and Kingsley Norton, who supervised and taught me well, despite my
general ineptitude and resistance.
1. Attachment theory
I came across attachment theory first when I was working at the Trauma Clinic at the Maudsley, in
the context of trying to understand why different people responded differently to traumatic
events. The epidemiology was very clear; not everyone got PTSD after a trauma, and some (very
odd) people had no distress at all (Kessler et al., 1995). Further, some people seemed to be able
to make good use of the therapies we were offering (then a mixture of CBT and more supportive,
reflective work) and some seemed to get much worse. I was greatly helped by reading Scott
Henderson’s paper on abnormal care eliciting behaviours (Henderson, 1974) and by reading
Bowlby; or more accurately, Jeremy Holmes’excellent biography of Bowlby (Holmes, 1993).
I tried to think about how attachment theory might be useful to the jobbing clinician; and
especially how it might help us understand those people with the fruitless label of personality
disorder (Adshead, 1998). I am very grateful to those patients with that label whom I met as junior
trainee in forensic psychiatry; the learning process was scary but what I learnt was invaluable.
In his excellent Quintessence paper (this issue) Rex Haigh comments that attachment is not a
cuddly process. He insightfully reminds us that attachment processes are closely related to
containment of emotions, which in turn involve the exercise of boundaries and rules in the
creation and maintenance of relationships. I will now try to distil some key features of attachment
theory from the vast literature on this subject that I think are particularly important for TC practice.
I start from the assumption that what Rex has memorably called “The -TC-in-the head”is closely
related to what Robin Dunbar calls the “social mind”( Dunbar, 2003). Attachment theory had its
roots in ethology of social bonds in non-human primates; first in the work of Harry Harlow, and
continued by Stephen Suomi. Like our non-human primate neighbours, with whom we share so
much genetic material, we are group animals, whose survival depends on attachment to, and
membership of, groups: so much so that prolonged human social isolation is associated with
early death, typically by violence or suicide (Wilkinson and Marmot, 2003). Dunbar’s work (1993,
1995; Aiello and Dunbar, 1993) suggests that the expanded volume of the human neocortex
developed in proportion to the size of the groups that humans could be members of; and
relatedly to the use of language, which makes social relationships and group membership
possible across distance and time.
Humans need to attach to something or someone; the social self is grounded in relationships with
others. Important aspects of identity are relational and constructed in relationships: especially
roles involved in caring such as parent, health care professional or therapist. Attachment to a
group facilitates a creative engagement between the individual and the group, and regulates both
cooperation and competition between individuals. One could argue that attachment to a group is
the essence of the pro-social experience; it balances the hierarchical tendency and fear based
impulses to hostile competition with affiliation and cooperative behaviours.
The first research on attachment bonds was carried out in Harlow’s primate laboratory; and
found that early disruptions to the development of social bonds in monkeys had profound social
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effects when those monkeys grew up. Monkeys who were either raised in social isolation, or who
had peer not maternal rearing, showed very abnormal behaviours with other monkeys when they
were adults: specifically, they struggled to make sexual pair bonds, attacked their offspring if they
had any, and mounted suicidal attacks on senior monkeys who were higher in the hierarchy.
These behaviours in monkeys were depressingly similar to the behaviours that got people
referred to the forensic clinics that I knew best. Reading his work, I noted a tragically ironic
comment by Harlow in which he comments that the dreadful social isolation to which he exposed
baby monkeys could never happen to human children. I had already worked out that most of my
forensic patients, especially those with personality disorder, had as children suffered similar types
of social isolation and much, much worse.
2. The clinical aspect of attachment theory: a brief overview
It may be helpful to think of attachment systems operating in both mind and brain: as
neurobiological and psychobiological systems that develop in childhood and influence care
eliciting and care giving behaviours across the life span and the regulation of the feelings that
arises when people seek care or give care to others. These systems are activated when we
experience illness, fear, anxiety and any other situation where we feel vulnerable and/or perceive a
discrepancy between our power and someone else’s. Attachment systems are relational, and
rely on both conscious and unconscious processes of “reading”other people’s intentions
towards us: one aspect of the term “mentalising”. Without mentalising, there would be no social
mind because mentalising entails awareness and reflection on the existence of others’minds as
being as real as our own (Allen, 2006; Frith, 2007).
Mary Ainsworth et al.’s (2014) research drew on attachment theory and ethology, and set out to
study how small children (18-36 months) react to a relational stressor; namely being left alone in a
strange place, and also being left with a stranger. This research established a number of crucial
facts: first, that children could be reliably divided into different groups on the basis of their
behaviour in this “strange situation”; and second, that some children showed odd and disturbing
behaviours when reunited with their mothers. The majority of children (60 per cent) showed a
“secure”pattern of behaviour when stressed; they protested, they cried, and they clung to their
attachment figure on reunion. In contrast, the “insecure”group (40 per cent) either seemed not to
notice when mother left or reappeared; or seemed ambivalent in their response; or displayed very
odd behaviours: “freezing”, aggression and apparent “spacing out”. These insecure groups were
categorised as avoidant, ambivalent and disorganised, respectively.
From Ainsworth’s work has grown a vast research enterprise; either looking at what happens in
the long term to insecurely attached children, and the difference between them and securely
attached children; or studying the neurobiological nature of attachment bonds, both secure and
insecure. Research from the latter perspective have demonstrated that the attachment system is
a neurobiological one, involving specific neural circuits connecting the neocortex to the amygdala,
and other parts of the brain that regulate negative feelings.
In terms of the former work, it is clear that irrespective of temperament, relationships determine
relationships. Early attachment sets a pattern for future adult relationships (school, peers,
romance), especially those relationships that involve care giving or care eliciting. Attachment
security status is not immutable: securely attached children can become insecure if exposed to
trauma and adversity, and some insecure children can “earn”security if they have positive
experiences of care in later childhood or adulthood (Weinfield et al., 2000). Ainsworth’s research
has been replicated in many studies in different countries and cultures, and the normative data
base is impressive: a review of data from 10,000 people confirms that a substantial sub-group
(40 per cent) of the general community have insecure attachment systems, and this proportion
greatly increases in clinical populations (Bakermans-Kranenburg and van Ijzendoorn, 2009).
3. Security of attachment: regulation of relational stress and distress
Why should insecurity of attachment be a risk factor for psychological and psychiatric morbidity?
The explanation lies in the role of attachment systems in regulating emotions and feelings,
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especially negative feelings that are activated by relational stress. Attachment systems are
activated across the life-cycle, whenever we seek care or provide it to others with whom we
are in caring relationships. A secure attachment system allows the individual to enjoy a healthy
mature dependency on others when vulnerable. Attachment relationships act as “hidden
regulators”of distress responses at times of crisis and loss: distress responses that are
physiological, psychological, and sociological. The attachment system is both psychological and
embodied; as Antonio Damasio has suggested, we experience emotions in our bodies, and these
emotions are converted into psychological feelings and representations of relational experience
(Damasio et al., 1996).
A child with a secure attachment system learns first that they can reliably access good enough care
from a carer when they are frightened and distressed; that they can safely approach and get close to
their carer when they are vulnerable. Years of good enough-care allow the child to build up a
psychological representation of how to get care when vulnerable, and how to give care; and how to
“read”the mind of a carer and experience their own mind being “read”. By the age of five, a securely
attached child can name and articulate distress; seek care effectively, and even soothe themselves to
some degree ( which make school possible as well as the development of social bonds outside the
family). A secure child can construct a self-narrative of their experience of distress, which generally
becomes more reflective and includes other people’s perspectives as they get older. A securely
attached child is well placed to manage the pubertal challenge to identity and experience, as bodies
and “selves”become sexed, gendered and autonomous in very definite and social ways.
Attachment security is vulnerable in adolescence because of the massive neurophysiological and
psychological changes over this period. However, most securely attached adolescents negotiate
this period to become secure young adults; ready for their roles as care givers to themselves and
others, and ready to attach to their own social group. Most importantly, they can manage normal
distress, and know how to get help if they are struggling.
The capacity to manage relational stress and distress is essential for life long success. Bluntly,
fear and distress are not optional in a long happy mammalian life; managing response to fear,
personal threat and loss is part of life in relationships. For humans, loss of attachment figures is a
potent threat, as evidenced by the huge psychological and psychiatric costs of bereavement:
often rather dismissed but significant. A 2014 study of the long-term effects of bereavement
found that 30 per cent of people suffered real psychiatric morbidity in the year after the loss of a
loved one; including new severe mental illness such as psychotic breakdown (Kaplow and Layne,
2014). My point here is not to medicalise bereavement especially but to note that attachment
disruptions can seriously disorganise your mind, often for quite long periods. Simply put, your
mental security rests on the stability of your relationships with others: your mind is social.
Intriguingly, our closest attachments nearly always involve ambivalence and negative feelings
towards our attachment figures, so that managing hostile feelings towards those we care for is
part of the security of the attachment system. Other people can be experienced as a form of
threat; sometimes just because we depend on them, and are vulnerable with them. Winnicott
(1949) described this in his famous paper about hate in the counter-transference; it may also
make more sense to understand Klein’s account of infantile envy as really a fearful response to an
awareness of neediness and power disparities. However, conceptualised, in our social
relationships, others can be experienced as both a source of support and threat; and a secure
attachment system makes this ambivalence and ambiguity easier to manage and bear.
4. Risky business: insecurity of attachment and clinical risk
Allen Schore (2002) has described how security of attachment helps infants develop a properly
regulated sympathetic and parasympathetic nervous system capability for stress responding. If
you have a secure attachment system, you can cope with distress, loss, life-threat by getting help
and being able to be present with your own distress. You do not become violent or psychotic or
somatise (very much). You eventually reorganise around your loss , and can symbolise what you
think and communicate it in words or images with others.
It follows from this that insecurity of attachment systems is a significant handicap to optimal
development of the social mind. Insecurely attached children have insecure neurophysiological
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responses to relational stress, as well as insecure psychological beliefs and cognitions about
how to access care. Insecure children tend to become insecure adolescents who become
insecure adults (Weinfield et al., 2000), who manage their distress in dysfunctional ways.
The dysfunction is manifest in disturbances of affect regulation and metacognition, especially in
relation to other minds.
Insecure avoidant individuals tend to dismiss distress ( their own and other people’s) and may
even be derogatory about their distress. They deactivate their attachment systems, and are
hypo-aroused to stress. They claim to be “fine”and may seem “fine”on the surface; they will often
be reluctant to seek help from others and avoid getting close or being vulnerable. In the general
population about 20 per cent of people show this attachment style: but this proportion is much
greater in clinical populations, especially offender populations (Pfafflin and Adshead, 2003). Their
self-narratives are often thin, sparse and contradictory; for example, when asked about their early
life, they may cheerfully claim to have no memories of childhood, while also saying that it was
perfect or excellent.
Insecure ambivalent individuals oscillate between getting close to others when they are
distressed and pulling away. Rapid swings between positive attachment and hostile withdrawal
characterise the ambivalent state of attachment; and these individuals frequently seek care and
closeness to others, only to reject it very soon afterwards. Attachment systems are hyper-
aroused and activated on a frequent basis, and metacognition is limited, with real problems in
distinguishing what “seems”from what “is”. Reality testing may be poor for both avoidant and
ambivalent individuals, but can be especially compromised in the ambivalent group as they
become emotionally hyper-aroused. In the general populations, ambivalent attachment is found
in about 16 per cent of the population; but again, this proportion is much higher in those seeking
medical, psychiatric or psychotherapeutic help: for obvious reasons. This group are also called
“preoccupied”because their self-narratives are preoccupied with their relationships with others;
sometimes in an angry way. Their attachment narratives often focus on how powerful other
people are, and others are failing or exploiting them, while they are helpless to act.
The disorganised attachment group are still not well studied in adulthood. The key feature of this
group is that they have highly disorganised and irregular responses to stress and distress; becoming
unpredictably hypo-aroused or hyper-aroused in unreliable and inconsistent ways. Their capacity to
self-soothe is poor, and disorganised children grow up to be adolescents who develop controlling
strategies for relating to others: either controlling care giving or controlling care eliciting. These
adolescents often describe dissociative experiences, suggesting that their regulation of conscious
awareness and reality testing may be compromised. This group are at risk for substance misuse, as
they struggle to manage bodily feelings of distress, which may be stimulated by what would seem to
others to be innocuous events or experiences. Their self-narratives are often highly incoherent, and
sometimes characterised by what have been called “Hostile-helpless”states of mind in relation to
others (Lyons-Ruth et al., 2007). Such states of mind are stimulated by care giving roles such as
parenting; or when receiving care from care givers.
These brief clinical descriptions of insecure states of mind may well be ringing clinical “bells”for
the reader, and rightly so. Insecure states of mind have been described in high proportions in
many clinical groups, especially people with personality disorder and psychosis. Many
commentators have suggested that personality disorder would be better renamed as adult
attachment disorder or relational disorders. There is also good evidence that attachment security
influences the presentation and treatment of people with psychotic illnesses and physical
disorders like diabetes (Berry et al., 2007; Read and Gumley, 2008; Maunder and Hunter, 2008).
The obvious question is how insecurity of attachment develops in young children; and the answer
is a multifactorial one. It is likely that there is a genetic component, especially in relation to those
genes that affect the regulation of neuro-peptides like dopamine and oxytocin that are active
in processes of craving, desire and closeness: although the research findings are mixed
(Van Ijzendoorn and Bakermans-Kranenburg, 2006). What is absolutely clear is that childhood
adversity, and/or social isolation and deprivation in childhood is a potent risk factor for insecurity
of attachment. Children exposed to childhood maltreatment (especially physical abuse and
neglect) are at much greater risk of developing disorganised attachment in childhood; and
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growing up then to be disorganised adults. A study by Murphy et al. (2014) found a very strong
relationship between increasing childhood adversity and insecurity of attachment.
A key aspect of attachment insecurity is the inability to mentalise effectively, i.e to be able to “read”
and be aware of their own intentions as well as other people’s; to be able to reflect on them; to be
comfortable with ambiguity and uncertainty, and to be able to regulate thinking and feeling
together. Mentalising function is low in many insecure individuals (Levy et al., 2006), especially
those with disorganised attachment. This is important for two reasons: poor mentalising function
may make it difficult for people to relate effectively to care-givers (e.g. in therapy); and carers with
poor mentalising function are not likely to be able to give the good-enough care that will promote
the development of secure attachment in their off spring. Several studies have shown that women
with insecure attachment tend to have babies who have exactly the same insecure attachment
pattern as they do; and this is detectable from as early as six weeks.
It will now be obvious what people with insecure attachment systems will struggle with. They
struggle with the experience of distress, and their response to that distress. Adults with insecure
attachments cannot put negative feelings into words, but avoid trying to manage those feelings:
either by locating them in the body or by externalising them, and seeking an external solution to
an internal problem. Their self-narratives are incoherent and lack a sense of agency in relation to
others, or to their own distress. Linguistically, their narratives show many markers of incoherence
of thought and of self-experience; and lack meta-cognitive skills, such appearance –reality
distinction or acknowledging the possibility of change of view over time or context.
The good news is that it seems that it is possible to help people with insecure attachment improve
their mentalising function ( Levy et al., 2006). The bad news is that it probably takes longer than
the six weeks currently allocated to distressed people by most mental health services. The other
badish news is that the progress of therapy may be stormy and uncomfortable for all parties
involved as the therapeutic process itself activates the attachment system (Liotti, 2007; Fonagy
and Adshead, 2012). For the patient, there is a paradoxical agenda here for them to do the
opposite of what they have done for so long: avoidant people have to experience more affect
without running away, and ambivalent people have to stay with ambivalence and ambiguity in
relationships without running away. In this sense, avoidant and ambivalent attachment insecurity
can be understood as defensive ways of coping with a global dysregulation of the attachment
system, which are organised and complementary; whereas the disorganised attachment style is
evidence of a lack of any sort of defensive structure that will work to effectively reduce stress.
5. Attachment and TCs: mentalisation is the social mind in action
Mentalisation is a key psychological process for the activation and experience of a social mind.
Without mentalising skills, other people will not be “real”to you, and your own mind may also not
seem very “real”. Poor mentalising also affect the ways that we relate to our bodily experience,
especially when anxious. Those who mentalise poorly may act in ways that alienate others: just
when they need them most.
The attachment literature claims that the capacity to mentalise begins with attachment to a
person who can be a “secure base”for the child who has to “grow”a social mind. I would argue
that the TC (however, configured) can act as a secure base for insecure people to attach to, so
they can learn to develop a social mind. TCs already offer therapeutic approaches which are
associated with secure attachment: truthfulness, open communication and tolerance of
negativity and ambiguity. The TC offers itself as a regulator of all those who participate in it; while
recognising that the participants are co-regulating each other and generating a matrix of security.
If these people with insecure attachment can tolerate the anxiety of engagement ( which is
considerable), then there is ample evidence that they can learn to develop mentalising skills in
relation to themselves and others. Boundary setting and maintenance, group relating and
dialogue create a matrix of relating that enables mentalising skill to develop and grow. It is
noteworthy that mentalisation based therapy (MBT) is essentially group therapy with individual
support (which is a model that TCs are familiar with); what is important is the evidence that MBT is
effective in helping people manage their distress better. MBT has been tested on the same
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populations of people who use TCs; and I suspect that the proven effectiveness of TCs is partly
due to the improvement in mentalising that TCs enable.
But as both Rex Haigh and Hanna Pickard (forthcoming) suggested in their papers, there is something
even more important about the process of belonging to a TC; more important than mentalising. It is the
process of becoming more agentic, more present and active in terms of engaging in social life. It entails
a reworking of the self-narrative from one that is highly passive ( in which things just keep happening to
you) to a narrative which acknowledges that there are choices to be made, and ownership of actions
that make up identity. This is not an easy process, and it is uncomfortable to do as an adult; I suspect
that for people with secure attachments, the move from a passive voice to an active voice in the
self-narrative happens organically as people age and develop. “When I was a child, I thought as a child,
I spoke as a child, but when I became a man, I put away childish things”: the difficulty for people with
insecure attachments is that their self-narratives are full of childish themes, of powerful adults who do
not care, of giants that oppress and terrorise, of helpless children threatened by nightmares and fears.
Their challenge in therapy is to gradually let go of the cover-story of their lives, and rebuild a new self-
narrative, a more adult one; which is co-constructed in dialogue with other people who have living out
similar challenges; where vulnerability and dependence are respected and supported; where sadness
and grief are accepted as events that shape identity but do not determine it.
As I have said, this is hard work: as more experienced TC residents and workers will attest. I am
mindful that it is possible; that people can and do change their narratives of themselves to become
both more of an author of their own lives and also connected to group identity. Work by Maruna
(2001), Adler et al. (2008) and Lysaker et al. (2007) suggest that people with considerable handicaps
and distress can and do change their narratives of themselves with therapeutic help. Lysaker’swork
with people with psychosis in particular resonates with Val Jackson’s description of the work of open
dialogue. My colleagues from Broadmoor and I have been privileged to observe how attachment to a
group can facilitate subtle but important changes of identity that are crucial for people who are both
victims and perpetrators of trauma (Adshead et al., 2015).
I also wonder if TCs offer people new opportunities to learn how both how to relate to care givers,
and how to give care to others. Insecure attachment disrupts both care giving and care eliciting
systems; learning how to give care to others is a crucial challenge to the delusional belief that
there are needy dependent people (called “patients”) and there are strong powerful people (called
“doctors”or “therapists”) and these groups have nothing in common and can never know each
other’s worlds. The recent market-based narratives of health care, so beautifully described in
Penny Campling’s paper, strongly suggest that the NHS is full of useless carers who have be
harassed into taking care of helpless patients who have simultaneously every choice and no
choice. “Disorganisation”of attachment is being mirrored in disorganisation of health care: which
we might expect, given that the NHS is a national attachment system for the regulation of care.
6. Conclusion
We all need a community to attach to. George Vaillant’s (2008) work on psychological defences
across the life span suggests that those who enjoy old age are those who belong to some sort of
group. TCs may be able to give people with insecure attachments a place to attach to, and create
new self-narratives. As we face a national election, and fears about international insecurity, we
may want to ask ourselves: what makes a secure group and community? What makes a secure
country and government? What I have taken away from my limited but valuable experience of TC
work is that the flattening of hierarchies is evidence of growing up; that there is a type of security
achieved when power is earned and shared; and that mature dependence entails respect and
support for vulnerability and power disparity. What we see at present, at the highest level of
government, is a contempt for vulnerability and need, and derogation of health care provision and
carers, which in turn suggests a type of mass insecurity at the political level. Perhaps it is always so.
I was struck that several of my co-presenters used horticultural metaphors to describe what
works in a TC, and the contrast between a horticultural model of mind and a mechanistic.
It reminded me of an image that was sent to me by a friend who found it on the internet,
unattributed and unsourced. Its message was simple, but profound: we come from the earth, we
return to the earth; and in between, we garden.
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About the author
Dr Gwen Adshead is a Forensic Psychiatrist and Psychotherapist. She is also a qualified member
of the Institute of Group Analysis. She worked at Broadmoor Hospital for nearly 20 years and now
works in a medium secure unit with men who have committed acts of violence when mentally
unwell. She has a long standing interest in attachment theory applied to offenders and violence
perpetrators. Dr Gwen Adshead can be contacted at: gwen@gwenadshead.org
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