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 83 Downloaded from https://www.cambridge.org/core. 28 Sep 2021 at 09:58:08, subject to the Cambridge Core terms of use. Yakeley 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