BJPsych Advances (2018), vol. 24, 83–92 doi: 10.1192/bja.2017.23

Psychodynamic approaches to ARTICLE violence† Jessica Yakeley

violent crime are themselves at increased risk of Jessica Yakeley is a consultant SUMMARY psychiatrist in forensic psychother- developing physical and mental ill health. The assessment and management of violent apy, Director of the Portman Clinic, behaviour in mentally disordered patients are no Personality disorder, most commonly antisocial per- and Director of Medical Education at longer the sole domain of forensic psychiatrists, sonality disorder (ASPD), is overrepresented in the Tavistock and Portman National offending populations (Alwin 2006), particularly Health Service Foundation Trust, but are increasingly part of the day-to-day work London. She is also Editor of of all psychiatrists and mental health professionals. among individuals with convictions for violent Psychoanalytic Psychotherapy and a Violence risk assessment has become a huge offences (McMurran 2009). ASPD is associated Fellow of the British Psychoanalytical industry, and although the importance of dynamic, with high levels of comorbid psychiatric illness, sub- Society. as well as actuarial, risk factors is now recognised, stance misuse, poor physical health and early death Correspondence Dr Jessica Yakeley, Portman Clinic, 8 Fitzjohns a more systematic approach exploring the psycho- from suicide or reckless behaviour (Martin 1985; dynamics in the aetiology, assessment and treat- Avenue, London NW3 5NA, UK. Black 1996; Odgers 2007; Piquero 2011). Violent Email: [email protected] ment of violent behaviour is often lacking. In this acts may lead to post-traumatic stress disorder in article I revisit some of the key psychodynamic perpetrators as well as victims (Minne 2008). Copyright and usage principles and concepts relevant to an understand- © The Royal College of Psychiatrists ing of violence, summarising the historical contri- Improving offender health has been designated by 2018 butions of key psychoanalytic writers on violence the Department of Health as a priority area and aggression, and exploring the ideas of more (Health Inequalities National Support Team 2011). contemporary writers working in the field of foren- Most professionals in any field of mental health †In the previous issue of Advances, sic psychotherapy. A psychodynamic framework will be exposed to violence at some point in their Jessica Yakeley & William for working with violent patients is introduced, working life. For those who work in forensic settings, Burbridge-James explored psycho- focusing on the setting and containment, specific dynamic approaches to suicide and the assessment and management of risk of violence self-harm. therapeutic interventions and monitoring counter- are, of course, their bread and butter, and some transference reactions. may also be involved in applying specific therapeutic LEARNING OBJECTIVES interventions and programmes aimed at reducing violent behaviour. However, professionals in all • Understand historical and contemporary psy- choanalytic theories of the aetiology of mental health settings are at increased risk of aggression and violence being direct victims of violence from patients, and • Utilise a psychodynamic framework for working some work in institutions in which pathological with violent patients and offenders organisational dynamics contribute to an environ- • Understand the use of countertransference in ment of violence and fear. the risk assessment and treatment of violence Although psychoanalysts have contributed to a vast literature on aggression since Freud first wrote DECLARATION OF INTEREST about the subject, psychoanalytic practice is not None. usually associated with violent behaviour, which is seen by most as a contraindication for therapy. However, a psychoanalytic or psychodynamic Violence is recognised by the World Health approacha may complement and enhance, although a. The terms psychoanalytic and Organization as a major public health priority not replace, predominant theories of violence from psychodynamic are often used inter- changeably. However, the term psy- (World Health Organization 2002). Violence contri- other disciplines such as criminology, sociology chodynamic is a broader relational butes to lifelong ill health and early death from heart and forensic psychiatry (Yakeley 2010). concept encompassing the interper- disease, stroke, cancer and other illnesses when In this article I will highlight some of the key prin- sonal, intersubjective and embodied victims of violence adopt behaviours such as ciples underpinning a psychodynamic framework in experience of both the social world and the internal world. smoking, alcohol and drug misuse to cope with its which to understand the aetiology and psychological psychological impact. Violent crime is also asso- development of violent and antisocial behaviour, ciated with negative impacts on health and criminal and to assist in their management in a multidiscip- justice systems, social and welfare services and the linary setting. Psychoanalytic concepts such as wider economy (World Health Organization 2014). acting out, containment, transference and counter- The negative health impact of violent behaviour is transference will be explored in relation to under- not confined to its victims. Those that commit standing the causes and consequences of violence

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within this framework (Box 1). A psychodynamic and Heinz Hartmann and ego psychologists in the approach to aggression and violence may help to USA (Fig. 1), and those who saw it as reactive to inform risk assessment and therapeutic interven- environmental traumas and deprivations, such as tions for violent individuals. Donald Winnicott and Ronald Fairbairn (Fig. 2). Klein furthered Freud’s concept of the death Early psychoanalytic theories of aggression instinct by emphasising the instinctual origins of aggression. She believed that envy and destructive- Psychoanalysts have had a lot to say on the nature of ness were manifestations of the death instinct and aggression since Freud first posited the existence of predominated in early life, giving rise to persecutory the death instinct (thanatos), an innate destructive anxieties and primitive defences, unconscious fanta- force that operates insidiously in opposition to the sies and an archaic superego, all of which formed the life instinct (eros) (Freud 1920). The death instinct, ‘paranoid schizoid’ position (Klein 1946). This however, represented the last of his partial theories, gradually develops into the more mature ‘depressive which were never completed, on the fate of aggres- position’ with the tolerance of loss and ambivalence sive instincts in the individual; prior to this he had (Klein 1935). Winnicott (1971), by contrast, saw located aggression first as a component of the aggression as a creative influence necessary for sexual instinct used in the service of mastery normal psychological growth, enabling individu- (Freud 1905) and then within the self-preservative ation and separation; pathological aggression and instincts, where aggression was a response to both violence arose in response to traumatic and internal and external threats, such as loss (Freud adverse experiences. 1915, 1917). Subsequent early analytic writers on This polarisation of constitutional or instinctual aggression tended to elaborate particular aspects of versus environmental or reactive theories of aggres- Freud’s thinking at the expense of building a coher- sion has been mirrored in more recent debates ent and comprehensive theory. They may be divided regarding the relative strength of genetic versus into those who viewed aggression as an instinct, psychosocial factors in the genesis of pathological such as Melanie Klein and Wilfred Bion in the UK violence. Within contemporary psychoanalytic thought, a more balanced approach has emerged embracing both biology and psychology, recognis- BOX 1 Psychoanalytic concepts ing that although the capacity for aggression is innate and universal, aggressive behaviour occurs Acting out Expressing an unconscious wish about their relationships with significant in response to threats that the self perceives in rela- or fantasy through impulsive action as a way caregivers becoming incorporated in the mind tion to internal or external objects. Furthermore, of avoiding experiencing painful affects. at an early stage of development to become there may be different types of aggression, which Countertransference Feelings and emo- prototypical mental constructs which influ- ’ are exhibited in different forms of violence. tional reactions of the therapist towards the ence the individual s mode of relating to patient resulting from both unresolved con- others in adulthood. flicts in the therapist and the projections of Projection Primitive defence mechanism in A typology of violence the patient. which unacceptable aspects of the self are Violence is distinguished from aggression by being a Introjection The process of internalising the expelled and attributed to someone or qualities of an object. Introjection is essential something else. behaviour that involves the body. Glasser (1998) fi to normal early development, but can also be Projective identification Projection (as de ned violence as an actual assault on the body a primitive defence mechanism in which the above), but a more powerful unconscious of one person by another, involving penetration of distinction between subject and object is defence in which the person who has been the body barrier, ‘the intended infliction of bodily blurred. invested with the individual’s unwanted harm on another person’. Violence is also an inter- Mentalisation A focus on mental states in aspects may unconsciously identify with what personal phenomenon, involving bodies and oneself and others, recognising desires, has been projected into them and may feel minds. De Zulueta (1994)defined violence as a needs, feelings, beliefs and reasons, espe- unconsciously pressurised to act in some form of interpersonal human behaviour in which a cially in explanations of behaviour. Normal way. thinking ‘subject’ is doing something destructive to mentalisation develops in the first few years Splitting Primitive defence mechanism in an ‘other’ human. A psychoanalytic approach of life in the context of safe and secure which incompatible and polarised experi- focuses on exploring the mind of the violent attachment relationships. ences of self and other are kept apart to person, who communicates via bodily action moti- prevent conflict. Object Significant person in the individual’s vated by internal and external object relationships. environment, the first significant object usu- Superego Structure in the mind formed by It is widely recognised that there are at least ’ ally being the mother. the child s internalisation of parental stan- two different forms of human violence, underpinned dards and goals to establish the individual’s Object relationship The individual’s mode by different neurophysiological pathways (Meloy moral conscience. of relation to the world, determined by the 1992). Affective violence is an immediate defensive ’ child s experience, perceptions and fantasies reaction in which the person mounts a ‘fight or flight’ response to a perceived threat, and it involves

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activation of the autonomic nervous system, result- Instinctual theories of aggression ing in a state of high arousal and anxiety. By con- trast, instrumental or predatory violence lacks Freud (1920) • Aggression is instinct in its own right – death instinct • Excess of death instinct leads to harsh superego, emotional involvement: it is purposeful and calculat- unconscious guilt and repetition compulsion ing and characterised by a lack of empathy for the Klein (1935, 1946) and • victim. Such violence is more common in people Death instinct manifests in innate envy, destructive- post-Kleinians ness, unconscious persecutory fantasies, primitive with prominent psychopathic traits. A bimodal dis- anxieties and defence mechanisms, and early punitive tribution of violence has been supported empirically superego – this is paranoid schizoid position • Later tolerance of ambivalence and loss, concern and by physiological (Stanford 2003), psychopharmaco- guilt for the object, and mourning lead to depressive logical (Barratt 1997) and neuroimaging (Raine position 1998) studies. Bion (1959) • Baby’s instinctual destructive and envious attacks are From a psychoanalytic perspective, Glasser (1998) evacuated by projective identification into mother, proposed a similar typology in distinguishing what he who ‘contains’ them and feeds them back in modified called ‘self-preservative’ violence from ‘sadomaso- form, enabling healthy development chistic’ violence. Self-preservative violence corre- Hartmann and • Aggression is instinctual, but does not constitute sponds to affective violence, and is a primitive ego psychologists (1949) death drive • Aggressive drive is neutralised by ego: response triggered by any perceived threat to the • if ego is strong, healthy aggression ensues, physical or psychological self. Such threats might be facilitating physical and psychological development external, such as attacks on the person’sself-esteem, • if is ego weak, destructive and murderous tendencies emerge frustration, or feeling humiliated or insulted. The person can also feel threatened by internal sources, FIG 1 Instinctual theories of aggression. such as feelings of disintegration and internal confu- sion that might occur in psychosis. The violent response is immediate and aimed at eliminating the care or other traumatic childhood experiences. source of danger. Sadomasochistic violence is How may we understand from a psychodynamic similar to predatory or instrumental violence. perspective how these early adversities and dis- Glasser proposed that sadomasochistic violence is rupted relationships contribute to the development derived from self-preservative violence via an uncon- of pathological aggression and violence? scious process of sexualisation. Many psychoanalytic writers on aggression The main difference between these two forms of and violence locate the origins of violence in a violence involves their relationship to the object pathological early relationship between mother and (i.e. the person towards whom the violence is infant, where the mother is more concerned with directed). In self-preservative violence, the object is her own needs than those of her child. The mother perceived as being of immediate danger and must may be experienced as neglectful, or overwhelming be eliminated, but holds no other personal signifi- and intrusive, but in either case the child is prevented cance for the perpetrator. By contrast, in sadomaso- from developing a sense of separate identity and uses chistic violence the object and its responses are of great interest to the perpetrator. The object must be made to suffer, but must be kept alive in order Reactive theories of aggression

to achieve this. Sadomasochistic violence also Freud (1950) • Aggression is part of sexual instinct – healthy involves sadistic pleasure, which is not a component aggression helps mastery, but unhealthy leads to of self-preservative violence, where anxiety is always sadism present (Table 1). Freud (1915) • Aggression part of self-preservative instinct: The difference between the two types of violence aggression may be a reaction to internal as well as external threats, e.g. loss may be illustrated on the one hand by the soldier who kills the enemy in a battle to prevent himself Fairbairn (1952) • Aggression arises from frustration and loss • Ego and object split from being killed (self-preservative violence), and • Child attempts to control bad objects through on the other hand by the soldier who captures the internalisation enemy and tortures him to make him suffer (sado- • Child’s outward expression of aggression is curtailed, so that relationship with real mother survives, but masochistic violence). at the expense of the child’s internal aggression attacking the needs of his developing self The role of the object, the interpersonal Winnicott (1971) • Aggression is a creative force necessary for normal psychological growth by enabling individuation and world and the core complex separation • Pathological aggression arises in response to Many individuals with violent and antisocial behav- traumatic and adverse environmental experiences iour report histories of neglect, rejection and abuse, dysfunctional family relationships, time spent in FIG 2 Reactive theories of aggression.

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TABLE 1 Two types of violence aggression towards the mother to preserve the self. Glasser proposed that this was the origin of self-pre- Self-preservative Sadomasochistic servative violence. Sadomasochistic violence may Aim to negate danger/nullify Aim to preserve the object emerge at a later stage in development by converting the object (victim) (victim) and make it suffer self-preservative aggression into sadism. This Object relationship absent Object relationship present resolves the vicious circle of the core complex, as Absence of pleasure Presence of pleasure the mother/object is not destroyed but survives to Presence of anxiety Absence of anxiety be manipulated and controlled by the child. Primitive ego function and Ego functioning present Distinguishing between these two types of vio- defence mechanisms lence, and the underlying associated anxieties of the Absent superego functioning Superego functioning present but perverted core complex, may be important in risk assessment. Self-preservative violence is more likely to be trig- gered by persecutory feelings of being engulfed and aggression as a desperate measure to create space intruded upon, whereas sadomasochistic violence between self and m/other. The inner world of the is triggered by fears of being abandoned by the child is populated with primitive unconscious fanta- object. These conflicting anxieties, which provoke sies of a maternal object that is engulfing and obliter- the defensive reactions of the core complex, may be ating, and violence is seen as an unconscious heightened by interpersonal situations of intimacy, fantasised attack on the mother’s body (Fonagy which may then become potent triggers for violence. 1995; Perelberg 1995; Bateman 1999; Campbell 1999). ‘ ’ Glasser (1996) also considered the relationship to The role of the father, the third object and the mother to be fundamental in the genesis of the superego aggression and violence in his concept of the ‘core Many of the above-mentioned psychoanalytic theor- complex’. This refers to a particular unconscious ists have focused on role of the mother in the genesis constellation of interrelated feelings, ideas and atti- of violence. What influence does the father have in tudes, a major component of which is a deep- this model? In normal development, the father or seated and pervasive longing for an intense and father substitute (who may be any third person sig- intimate closeness to another person. Such longings nificant for the child) may be thought of as having occur in all of us, but where there has been an early an essential role in creating a space to facilitate the relationship to a narcissistic mother, who prioritises child in gradually separating from the mother and her own needs over her child’s, they persist as primi- assuming an identity of his (or her) own. The pater- tive unconscious persecutory anxieties unmodified nal relationship is internalised by the child to form by later stages of development. The person wishes an intrapsychic paternal or ‘third object’ that acts to merge and achieve a ‘state of oneness’ or a ‘blissful as an intermediary object by preventing pathological union’ with a significant other, but these wishes symbiosis and fusion between the self and primary/ develop into fears of a permanent loss of self, an maternal object. Many violent individuals, however, annihilation of existence, an engulfment by the have histories of absent or emotionally unavailable object. To defend against this annihilatory anxiety, fathers, or abusive fathers who did not provide any the person retreats to a ‘safe distance’ from the source of love or care that the child could trust. In object. But this provokes painful feelings of emo- such individuals there is a lack of an adequate pater- tional isolation, rejection and abandonment, which nal identification and the person feels trapped in a prompt the desire for contact and union with the dyadic relationship with the mother where there is object again, so that the person is caught up in a no possibility of another/third perspective. vicious circle in which no satisfactory emotional This failure of internalisation of a secure paternal contact can be sustained. function has been linked to impairments in the con- One ‘solution’ that the child may resort to is to stitution of the superego or conscience. Freud (1923) mount an aggressive response to the unconscious introduced the concept of the superego as an intrap- fantasies of annihilation and experience of being sychic structure that, in a boy, results from the iden- overwhelmed by the object – usually the mother at tification with the father to avert castration anxiety this very early developmental stage – who must be and, in a girl, results from identification with the destroyed so that the infant survives. But this mother to avoid loss of her love. The superego is would lead to the loss of any security, love and today broadly understood as the internalisation of warmth that she offers. At this point the infant has parental values, goals and restrictions to form an two options – to withdraw into a narcissistic state internal structure in the mind that represents the to protect the mother, but at the expense of the devel- person’s conscience, which can be experienced as opment of the infant’s nascent self, or to resort to supportive, punitive or absent. Deficits in superego

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functioning may explain the lack of empathy and mechanisms that may be normal in a young child, remorse in psychopaths; by contrast, an overly but are pathological if they predominate in adult- harsh superego may lead to internal persecutory hood. The person may experience affects primarily feelings of intolerable shame and guilt that lead to concerned with the self, such as anxiety, excitement, the eruption of self-preservative violence. envy and shame, but may find it more difficult to have more mature feelings that involve appreciation Attachment and mentalisation of others, such as guilt, remorse, empathy and sadness. Similarly, more mature defence mechan- Integrating some of these psychoanalytic ideas with isms, such as repression or sublimation, which those from attachment theory, writers such as de would prevent aggressive impulses from erupting Zulueta (1994) and Meloy (1992) emphasise the into violence, are lacking; instead the person is deleterious effects of poor attachment experiences reliant on more primitive defences such as projec- between the infant and its primary care givers. tion, splitting, projective identification and acting Early experiences of trauma, neglect and loss have out. Emotions associated with vulnerability are par- an impact on the attachment process by interfering ticularly difficult for the person to process and hold with the normal development of affect recognition within the mind, and instead are disowned and either and expression, empathy and impulse control. In projected into others in fantasy or acted out by these circumstances, the child resorts to violence as actual violence. Shame and humiliation are particu- an angry protest; but, in the face of rejection, aggres- larly difficult emotions for all of us to tolerate, but for sion is turned against the self or develops into more people with such a fragile sense of identity and pathological destructive aggression. Violence can agency, these affects are felt to have the power to vio- therefore be understood as being rooted in a failure lently disrupt the person’s state of mind and there- in adequate caregiving or ‘faulty attachments’ (de fore have to be expelled via violent action towards Zulueta 1994). others. Fonagy and colleagues extend these ideas by In his work with inmates in high security prisons proposing that early trauma and disrupted attach- in the USA, Gilligan (1996) discovered that almost ments involving physical and emotional abuse may all of them justified their violent offences by believ- lead to aggression and violence by interfering with ing that they had been ‘disrespected’ by the victim the development of mentalisation (Fonagy 1995). (s). This had evoked intolerable feelings of shame In normal psychological development the child and humiliation that were rooted in much earlier becomes increasingly aware of his own mind and experiences of being rejected, abused or made to its contents through his growing awareness of his feel that they did not exist. This had predisposed mother’s mind by her capacity to demonstrate to them as adults to being particularly sensitive to him that she thinks of him as a separate person feeling ostracised, insulted, criticised or ignored. with intentions, beliefs, feelings and desires that Gilligan proposes that shame and humiliation are distinct from hers. However, if the mother is underlie all forms of violence, and that words alone abusive or neglectful to the child, this prevents him may constitute trauma and trigger violence. from developing a capacity to feel safe about what others think of him. In such children, aggression therefore arises as a defence for the fragile emerging A psychodynamic framework for working self against the assumed hostility of the object. If the with violence abuse or neglect is ongoing, aggression and self- How may some of these psychoanalytic ideas expression become fused in the mind of the child, regarding the origins of violence inform the as- impairing his capacity for reflection and mentalisa- sessment, management and treatment of violent tion of his own and others’ minds, and leading to patients and offenders? A psychodynamic frame- adult relationships to self and others that are work (Box 2) acts to organise and ground some of mediated against a background of aggression and these psychoanalytic concepts in the context of violence. working with violence in mental health and forensic settings. The framework involves consideration of Shame and humiliation several overlapping constructs. These include: the Where psychological development and the capacity setting in which the person is managed, in which for mentalisation have been impeded, the indivi- issues of containment, risk, boundaries and disclos- dual’s sense of self remains precarious because ure of information are paramount; assessment for it is based on more primitive modes of thinking risk and treatability; engaging the offender in a and subjective experience. Psychodynamically, the therapeutic process; specific therapeutic inter- mind of the violent person may be conceptualised ventions; and recognition and analysis of the power- as being formed by immature affects and defence ful countertransference reactions that violent

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expelled from the mind through violent action or BOX 2 Psychodynamic framework for working projected into other people’s minds, including the with violent offenders professionals they are in contact with. Moreover, owing to the original failures in care that they suf- • A containing therapeutic environment/setting fered in childhood, these individuals have been • Careful assessment unable to internalise parental values or societal • Engaging the patient standards and they mistrust authority figures, so • Specific therapeutic interventions and modalities are likely to break any boundaries or rules • Monitoring countertransference imposed on them. This may elicit unconscious • Working with other professionals involved with the retaliatory responses in clinical and managerial patient staff to impose even stricter and more punitive regimes. The pathological culture of many forensic institu- tions and prisons mirrors the pathology of the individuals provoke in those involved in their care. patients and offenders housed in them. The primi- Understanding how the offender’s unconscious com- tive intrapsychic anxieties and defensive constella- munications and utilisation of immature defence tions of individuals become unconsciously reflected mechanisms affect the teams and institutions in the structure and function of the organisation. looking after them can be used to refine therapeutic The offenders’ early relationships, defined by interventions and the assessment and management aggression and violence, are recreated in their rela- of risk. This psychodynamic framework may be tionships with professionals, triggering internecine helpful in organising the various facets of managing conflicts between offenders and staff members, and and caring for violent offenders whatever the discip- within the staff group itself, and causing splitting line of the professional and their prevailing model of and fragmentation of the institution. Working in understanding. such toxic environments often leads to high levels of staff turnover, sick leave and burn out. A containing environment is achieved not only by Containment ensuring that robust physical and procedural secur- Containment has a specific meaning within psycho- ity measures are in place, but also by attending to the analytic theory, referring to the holding of emotions unconscious communications between patients and and feelings within the mind. ‘Containment’ is a staff and between different members of the multidis- term introduced by Bion (1959, 1962) in describing ciplinary team or institution. Understanding the the function of unconscious projective processes that intense pressures and projective forces that they occur between therapist and patient in the analytic are exposed to, acknowledging the anxieties pro- situation as paralleling the way the baby projects voked within them, and recognising how the psycho- its unbearable distress into the mother, who ‘con- pathology of the patient may be re-enacted in the tains’ it and responds by modifying the baby’s anx- institution are vital in maintaining healthy interper- ieties. This is similar to Winnicott’s(1954) notion of sonal relationships and mutual care and respect. the ‘holding’ function of the analyst and of the ana- These often intense, unconscious countertransfer- lytic situation, providing an atmosphere in which the ence responses can be elucidated and understood patient can feel safe and contained even when severe via multidisciplinary work discussion, staff support regression has occurred. or reflective function groups so as to mitigate the Although these authors were not describing destructive dynamics that paralyse therapeutic forensic patients, their concepts of containment functioning. and holding are highly relevant to forensic settings. For violent offenders and patients, the provision of a safe and containing therapeutic environment is The uses and misuses of essential for risk management and treatment to be countertransference in risk assessment effective. Risk can only be managed safely if the The role of clinical intuition in violence risk assess- anxieties of patients, individual staff and the insti- ment has been recognised as a valuable addition to tutions in which they work are adequately con- the application of traditional validated structured tained. But, as described above, many violent risk assessment tools in forensic practice (Carroll individuals lack the mature and robust internal 2012). Intuition involves the use of emotions as a mental structures that are needed to tolerate anxie- source of data; in psychodynamic terms this involves ties aroused by strong and conflicting emotions, the countertransference. Countertransference refers particularly those associated with vulnerability, to the emotional responses that the therapist or clin- shame and humiliation. Such feelings have to be ician has towards the patient. It reflects a dynamic in

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which the patient’s unconscious communications for example ‘liking’ or feeling frightened of the interact via reciprocal processes of projection and patient. introjection with the therapist’s own conflicts and The clinician’s unrecognised subjectivity may personal history to produce affective states and result in errors, often in overestimating risk. bodily responses that may feel alien to the clinician. Feelings of anger, fear or disgust in response to a Countertransference is by definition unconscious patient’s violence may elicit conscious or uncon- and therefore conscious feelings about a patient, scious punitive or sadistic responses in the clinician, such as boredom, may be misleading and disguise such as unnecessary restraint or prolonged incarcer- more unconscious unacceptable feelings, such as ation. This in itself may increase the risk posed by disgust or hatred. the offender, in provoking anger and resentment so Countertransference reactions to violent and anti- that he is likely to behave more dangerously. Some social patients are often disturbing (Box 3). These patients present themselves as victims of mistreat- may range from therapeutic nihilism – the belief ment and misunderstanding, eliciting sympathy in that the patient is untreatable – to excitement and the clinician, who may then underestimate their fascination, often imbued with erotic feelings, which risk. If the patient reoffends and inadequate risk are rarely admitted to by the clinician (Yakeley assessment is exposed, this may lead to unhelpful 2012; Meloy 2013). Patients with severe psycho- defensive practices. pathic traits may invoke feelings of disgust (Hale 2008) or atavistic fear that, even in the absence of threatening behaviour, the therapist experiences Psychodynamic interventions for the viscerally as autonomic arousal (Meloy 2002). treatment of violence Countertransference is a tool through which the Violence has always been considered one of the more patient’s internal world may be accessed, and it is serious contraindications for psychoanalytic treat- a cornerstone of the technique of psychoanalytic ment. It was thought that violent patients had psychotherapy used to inform therapeutic interven- weak ego strength and primitive defences and were tions. However, if unacknowledged or unexplored, therefore unlikely to be able to use psychoanalytic the clinician’s emotional responses to the patient therapy, which is aimed at exploring the uncon- can contribute to subjective judgements that inter- scious fantasies of the internal world, and that fere with accurate evaluations of risk. Blumenthal such treatment might increase the risk of the et al (2010) investigated the relative contribution patient acting violently. However, a few early psy- of actuarial and emotive information in determining choanalysts, such as Karl Menninger (1968) in the how experienced forensic mental health profes- USA and Edward Glover in the UK (Glover 1933), sionals, who were well-trained in structured were interested in expanding the boundaries by and actuarial risk tools such as the Historical treating violent patients. Glover worked at the Clinical Risk Management-20 (Douglas 2013) and Portman Clinicb in London, founded in 1931 to b. The Portman Clinic, now part of the Psychopathy Checklist-Revised (Hare 2003) rated offer psychoanalytically informed treatments for Tavistock and Portman NHS Foundation Trust in London, is a the risk of violence. They showed that these pro- violent, delinquent and ‘perverse’ patients, and specialist psychoanalytically oriented fessionals were unaware how they often minimised employing many prominent psychoanalysts. These forensic psychotherapy out-patient the importance of well-known actuarial factors in pioneering analysts laid the foundations for the dis- clinic offering assessment, treatment risk assessment, and that their judgement was cipline of forensic psychotherapy – the application of and consultation services for adults, children and adolescents who are disproportionately influenced by emotive factors, psychoanalytic expertise to the treatment of men- troubled by problems of criminality, tally disordered offenders. violence, sexual deviance or anti- The work of forensic psychotherapists over the social personality disorder. BOX 3 Common countertransference reactions past 25 years has challenged the widely held belief to a violent patient (Meloy & Yakeley that psychoanalytic therapy is ineffective, if not 2013) harmful, for patients who act out in violent ways. Traditional psychoanalytic techniques have been • Therapeutic nihilism adapted and refined for patients with a limited cap- • Illusory treatment alliance acity for reflection, unstable affect regulation and fi • Fear of assault or harm impulsivity. Modi cations of technique include • Denial and self-deception actively fostering a positive therapeutic alliance, avoiding the use of free association or long periods • Helplessness and guilt of silence, limiting transference interpretations, • Devaluation and loss of professional identity and using supportive techniques to build ego • Hatred and the wish to destroy strength such as identifying and distinguishing the • Fascination, excitement or sexual attraction different affects associated with violence (e.g. anger, excitement and anxiety). Although a

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psychodynamic understanding of violent patients antisocial personality disorder and is increasingly assumes that unconscious determinants play a being delivered in forensic settings (Adshead 2013; major role in their behaviour, interpretations of Bateman 2016: pp. 377–413). unconscious thoughts, fantasies, affects and motiva- Although most treatment programmes for redu- tions are used with caution, as these may be misun- cing violent behaviour in the criminal justice derstood as referring to concrete realities, which may system today are based on a cognitive–behavioural disturb and destabilise the patient. The therapist is model, psychodynamic treatments, particularly also alert to the patient’s lack of trust and sensitivity aimed at offenders with personality disorder, are to feeling criticised or slighted, which may be trig- becoming increasingly available. Following the gers for violence, and so will actively cultivate a con- decommissioning of the Dangerous and Severe Per- taining and therapeutic stance in relation to the sonality Disorder (DSPD) programme (Department patient. Therapy aims to foster the development of of Health and Home Office 1999), the Offender Per- a psychic function in the patient’s mind that can sonality Disorder (OPD) programme was initiated in begin to experience and tolerate loss, remorse, 2011 for managing high-risk personality disordered concern and empathy, and to learn to insert feeling offenders; it is based on a ‘whole systems pathway’ and thought between impulse and action. across the criminal justice system and National Group therapy is often more effective than Health Service (Joseph 2012). This strategy is individual therapy for many violent individuals. informed by a developmental model of personality People whose aggression stems from intense core disorder and recognition of the centrality of attach- complex anxieties may find the perceived intimacy ment experiences in the early and current lives of of individual therapy too threatening and may feel offenders. It offers a variety of different psycho- more contained in a group where the multiple rela- logical interventions in prisons, probation and tionships with other patients offer more than one approved premises, including those based on target for their aggressive impulses and, paradoxic- psychodynamic principles such as therapeutic ally, attenuate them (Welldon 1996). Engaging in a communities, psychologically informed planned therapeutic group and seeing their own difficulties environments (PIPES) and MBT. Research and reflected in others can help to reduce antisocial evaluation of these initiatives is ongoing. behaviour and bring about therapeutic change. Group therapy also offers more opportunities to mentalise minds in relation to other minds. Future directions Moreover, the patient’s dysfunctional patterns of This article offers psychiatrists and other mental relationships will inevitably be repeated in their health professionals one approach to understanding relationships with other people in the group, some of the putative factors involved in the genesis of including the therapist. This can be helpful in iden- certain types of violent behaviour. In viewing the tifying the interpersonal triggers of violence and, if heterogeneity of violence through a psychoanalytic the consequent anxieties and conflicts can be toler- lens I have focused on the existence of two modes ated and understood, patients may learn that dis- of violence, self-preservative and sadomasochistic, agreements and misunderstandings do not always which present distinctive behavioural manifesta- have to be resolved by violent solutions. An import- tions and neurobiological underpinnings. I have ant therapeutic focus in group therapy is how the not explored the aetiology and manifestations of group negotiates its rules and boundaries, and other types of violence that occur in different circum- this is particularly important for individuals who stances, such as psychosis, groups, crowds and have experienced inappropriate boundaries from warfare, nor violence in relation to other important their original caregivers. The experience of a ther- variables such as gender and sexuality. I have apist modelling appropriate boundaries that are focused on how psychoanalysis offers theories that consistent yet flexible can help antisocial offenders explore how pathological violence arises from dis- to become more trustworthy of others and turbed early familial relationships, and how these prosocial. dynamics may be unconsciously repeated in the Some of the therapeutic techniques and modifica- individual’s adult relationships, casting profes- tions for the treatment of violent behaviour detailed sionals and others in the roles of their early care- above have been operationalised into specific psy- givers, which, if unrecognised, may result in chodynamic manualised therapies for people with unhelpful and inappropriate countertransferential personality disorders who exhibit violence towards responses. However, these psychodynamic explana- self and others. Perhaps the most prominent is men- tions must be viewed as partial theories, which may talisation-based treatment (MBT). Originally devel- complement and expand existing theories on violence oped for the treatment of borderline personality from other disciplines and methodologies. Further disorder, MBT has been adapted for people with efforts are needed to substantiate these concepts

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MCQs 3 The core complex: 5 Violence: Select the single best option for each question stem a only occurs in individuals predisposed to violence a is best treated in individual psychotherapy b stems from a pathological relationship to a b may arise from disorders of attachment 1 Sadomasochistic violence: paternal object or ‘third object’ c when triggered by shame and humiliation is more a is similar to instrumental violence c involves annihilatory wishes likely to result in sadomasochistic violence b involves negation of the object d underlies self-preservative but not sadomaso- d if treated by psychodynamic psychotherapy c is associated with anxiety and palpitations chistic violence requires that the therapy be adapted to avoid d is unrelated to self-preservative violence e may be activated in interpersonal situations of long silences and highlight interpretations of the e only occurs in domestic violence. intimacy. transference e is best treated by MBT. 2 Melanie Klein: 4 Countertransference: a emphasised the reactive origins of aggression a involves the clinician’s conscious experience of b focused on Freud’s self-preservative instincts affects and bodily reactions that feel alien c emphasised the defence mechanisms of repres- b reveals the clinician’s unconscious fantasies sion and sublimation in primitive aggression c is solely based on the patient’s unconscious d believed that excessive aggression resulted in an projections archaic superego d is always an unreliable tool in risk assessment e proposed that containment was important in e may aid understanding of institutional dynamics. mitigating destructive aggressive impulses.

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