Shame and violence in ‘Starred Up’

Shame plays a powerful role in triggering violence, sometimes with fatal consequences. It is fundamentally important to understand and treat the roots of this aggression and its links to an internal sense of shame. In this paper, I will discuss the contribution of forensic psychotherapy to this project and link it to the excellent depiction of violence, shame and the development of insight and impulse control through psychotherapeutic work in the powerful film, ‘Starred Up’, written by Jonathan Asser and directed by David Mackenzie. At the 2015 Birkbeck summer conference, I was asked to speak to the themes of the film and relate them to my work with violent male offenders and their psychotherapeutic treatment. As a clinical and forensic psychologist and forensic psychotherapist, I have been heavily involved in assessing and treating men and women with violent histories in prisons, mental health services and community settings over the past 25 years. I see the film through the lens of forensic psychotherapy, filtered by my own clinical encounters. I discuss its main themes in relation to the challenges and possibilities of the therapists who work with men with entrenched violence and the underlying issues at stake for the men themselves.     

The idea of a moral psychology: The impact of psychoanalysis on philosophy in Britain1

In this paper the author addresses the question of the significance of psychoanalysis for moral psychology via a more specific question: the impact of psychoanalysis on British philosophy in the twentieth century. He argues that there has been no influence of any real significance, and offers intellectual reasons why not. However, he also argues that there has recently emerged the possibility for a future engagement between psychoanalysis and philosophy, and he offers a history of the emergence of this possibility. In particular, the author discusses how the emerging interest within philosophy to work out a satisfying approach to naturalist moral psychology leads it to a concern with internal mental structure and, most importantly, to transformations of intrapsychic structures. He believes that this will lead philosophy to take a greater interest in psychoanalysis.     

Narcissistic configurations: Violence and its absence in treatment

'On narcissism: An introduction' constitutes a turning point in psychoanalysis. Although narcissism is a concept which has not been explicitly referred to by many important thinkers for decades, it could be said that there is no paper written in psychoanalysis since Freud that does not implicitly take into account the modifi cations in thinking that the work brought about. In this paper, the author contrasts two types of narcissistic confi gurations: in the fi rst, the intolerance of the other is dealt with by expulsion and violence; in the second, by withdrawal. The author contrasts patients who express manifest violent behaviour with patients for whom the violent behaviour is absent but who, nevertheless, present similar background histories, which might have led to a prediction of violence. They are also profoundly different in terms of what they provoke in the countertransference. In addition, this paper argues that the treatment of narcissistic personalities has allowed in recent years the understanding of a modality of depression. Following Green, the author argues that, instead of a fruitless debate that involves evolutionary issues around the concept of narcissism, it is necessary to distinguish the narcissistic aspect in any analytic relationship, to identify the narcissistic transference in different types of psychopathologies.     

Reinforcement sensitivity of sex offenders and non‐offenders: An experimental and psychometric study of reinforcement sensitivity theory

This study tested predictions of Gray's Reinforcement Sensitivity Theory (RST) in subgroups of sex offenders and male non‐offenders using an experimental choice task consisting of a reward and a non‐reward phase. In addition, RST‐related psychometric measures were used. Both experimental and psychometric data were of interest to determine whether sex offenders could be reliably differentiated from non‐offenders. Paraphilic (N=50) and impulse control‐disordered (N=48) sex offenders showed greater sensitivity to continuous reward than male non‐offenders (N=51). Impulse control‐disordered sex offenders showed less behavioural adaptation under non‐reward than both paraphilic sex offenders and male non‐offenders. In addition, reward sensitivity, rash‐spontaneous impulsivity, and anxiety measures discriminated sex offenders from male non‐offenders. The results suggest that reinforcement sensitivity is a promising personality trait for differentiating subgroups of sex offenders from non‐offenders. The experimental and psychometric results illustrate that predictive accuracy in forensic settings could be improved by combining several types of data.     

Psychoanalytic application and psychoanalytic integrity

In this article, the author offers an analysis of psychoanalytic application, defined as the breaking of new conceptual ground in some field of knowledge whereby the new idea is conceived, and later articulated, with the aid of reference to analogous phenomena in psychoanalysis. It requires apt analogy based on competent understanding of the applied field and of psychoanalysis. Only when the relevant differences between the applied and psychoanalytic fields are grasped can the extent of certain parallels emerge. The thinking by analogy that comprises psychoanalytic application may be intuitive and implicit, but should be susceptible of explicit theoretical elaboration that specifies, precisely, the point(s) of correspondence between psychoanalysis and the applied field in relation to a precise specification of their relevant differences. Applied psychotherapy at the interface of the internal and external worlds (historically rooted in casework) is employed as a model. By analogy with Donnet's concept of the analytic site, the author proposes the concept of the psychodynamic (case)work site, and elaborates it for that applied field in order to elucidate the proposed principles of psychoanalytic application.     

LOVING THEM TO DEATH: THE ANOREXIC AND HER OBJECTS

The author suggests that eating disorders function to reinforce phantasies of control of the internal parents, a feature of Klein's view of the manic defence. Using this hypothesis, she attempts to differentiate between anorexia and bulimia. It is argued that in anorexia objects are felt to be permanently in thrall, suspended or frozen, whereas in bulimia they are attacked in a frenzied and intermittent way. Using case material from three seriously ill patients, the author draws attention to some important differences between them. Two of the patients were treated in psychoanalysis, while the third was seen for an extended consultation and once-weekly treatment thereafter. It is suggested that the nature and degree of the murderous attack on the internal couple may determine the severity of the illness as well as the patient's capacity to benefit from treatment. The conclusions drawn are discussed in relation to some contemporary views on eating disorders as well as writings on the difficulties of working through the Oedipus complex more generally. The author suggests that eating disorders may represent a special case of oedipal illusions.     

PSYCHOANALYSIS AS APPLIED AESTHETICS

The question of how to place psychoanalysis in relation to science has been debated since the beginning of psychoanalysis and continues to this day. The author argues that psychoanalysis is best viewed as a form of applied art (also termed applied aesthetics) in parallel to medicine as applied science. This postulate draws on a functional definition of modernity as involving the differentiation of the value spheres of science, art, and religion. The validity criteria for each of the value spheres are discussed. Freud is examined, drawing on Habermas, and seen to have erred by claiming that the psychoanalytic method is a form of science. Implications for clinical and metapsychological issues in psychoanalysis are discussed.     

A theoretically informed meta-analysis of the risk for general and violent recidivism for mentally disordered offenders

Mentally disordered offenders (MDOs) pose a significant challenge for forensic and correctional staff charged with managing them in a safe and humane manner. As with non-disordered offenders, it is important to identify the factors that are predictive of recidivism and can serve as treatment targets for MDOs. The present meta-analysis evaluated the relative predictive validity of the risk/need domains from the General Personality and Cognitive Social Learning (GPCSL) perspective and variables taken from the clinical perspective. The search yielded a total of 126 studies reporting on 96 unique samples (N = 23,900). Results indicated that all risk/need domains under the GPCSL perspective were significantly related to both general and violent recidivism. In contrast, the majority of clinical variables (with the exception of antisocial personality/psychopathy) were not predictive of either outcome. These findings emphasize the importance of identifying appropriate risk factors for MDOs.     

Out of the consulting room and into the world: hermeneutic dialogue, phronesis, and psychoanalytic theory as practice

One of the relics of positivism has been an underappreciation of the moral and ethical dimensions of psychoanalytic theory and practice. In a positivist metapsychology, cure and therapeutic gain were often defined instrumentally, with relatively little consideration given to aspects of human experience (e.g., moral, cultural, spiritual) that did not fit within a positivist framework. Conceptual and paradigmatic shifts in psychoanalysis have occurred, in part, because of the inability of the classical model to provide a language that adequately captures deeply felt human values and beliefs. Aided by hermeneutic and postmodern influences, many contemporary psychoanalytic theories are beginning to focus greater attention on the notion that analytic therapy is empowered by a set of ethical convictions, beliefs, and commitments, which are tied to a certain understanding of the good life. Along these lines, the author argues that developing a fresh understanding of the moral and ethical dimensions of psychoanalysis requires elaborating a new ontology of human subjectivity and social life. The author offers a sketch of how this gargantuan task might be started by integrating psychoanalysis within a hermeneutic perspective on dialogue, by suggesting that it would be helpful to view psychoanalysis as promoting Aristotelian practical wisdom or phronesis, and by rethinking psychoanalytic theory and interpretation as a form of practice.     

Forgiveness, acceptance and the matter of expectation

In this paper, the author argues for a dynamic conceptualization of forgiveness during psychoanalysis. The trauma of failed expectations in intimate relationships is narcissistically dislodging. When legitimate expectations in relationships are not met, forgiveness becomes a challenge for ego to restore the lost narcissistic balance through the resumption of a significant internal bond. The author argues that the ending of any successful analysis is marked by three possibilities regarding the patient's relationship to significant others and his traumas: in cases where the relationship was marked by minimal expectations, one simply learns to accept the wrongdoer without ever feeling the need for forgiveness; in cases where a relationship was marked by high expectations, the patient can learn to accept the trauma without the will or need to forgive its perpetrator. However, even with the painful frustration of high expectations in an intimate relationship, the patient can come to forgive his wrongdoer if there remains enough of a positive internal bond to be salvaged. The developmental roots of such forgiveness, as well as the addictive characteristics of 'nursing a grudge' and the conversion of the qualitative mode of seeking fulfillment into a quantitative one, are further investigated.     

Examining the Use of Sex to Cope in a Forensic Sample

The authors examined differences between sexual and mentally disordered offenders on the Coping Using Sex Inventory. Sexual offenders were more likely to use sex to cope with negative life events but did not use all forms of deviant sexual activity.     

COLLABORATING WITH THE UNCONSCIOUS OTHER

The analysand's capacity for making use of psychoanalytic treatment has been a subject of importance since the beginning of psychoanalysis. The author addresses an aspect of the difficulty encountered by analysands in achieving a psychic state that allows the creative use of free association, dreams, parapraxes and other spontaneous phenomena occurring during the course of treatment. He suggests that a very specific state of mind is essential to both the psychoanalytic process and the creative process. Using theoretical concepts derived from Freud, Klein and Bion, he develops the idea of an internal object relationship, 'the collaboration with the unconscious other', which forms the basis for both creative thinking and the psychoanalytic function of the personality. Creative thinking is distinguished from artistic endeavour and discussed as a universal potential, on which growth in psychoanalysis depends. The term 'unconscious other' is meant to signify the subjective experience of a foreign presence within oneself from which both spontaneous creative inspiration and involuntary psychic phenomena are felt to emanate. The author presents clinical material to suggest that paranoid-schizoid and depressive anxieties form obstacles to collaborating with the unconscious other, and must be worked through in order to achieve an analytic process.     

Sexual sadism and sadistic personality disorder in sexual homicide

Controversies exist about the diagnostic validity of sexual sadism and its relation to sadistic personality disorder in sex offenders. The aim of this study was to investigate which diagnostic, developmental, and criminal characteristics differentiate sexual sadistic from non-sadistic sexual homicide perpetrators. Psychiatric court reports on 166 men who had committed a sexual homicide were evaluated regarding psychiatric, sexual and criminal history. Sixty-one offenders (36.7%) with sexual sadism (SeSd) were compared with 105 (63.3%) offenders without this diagnosis (NSeSd). Besides the sexual sadistic symptoms, there were seven factors that discriminated best between the two groups (sexual masochism, sadistic personality disorder, isolation in childhood, multiple sexual homicide, previous rape, previous tendencies for similar behavior, and long duration of the homicidal act). Sexual sadism is connected with circumscribed other characteristics and has to be considered in risk assessment and treatment of sex offenders.     

Dangerous and severe personality disorders: a new personality concept from the United Kingdom

In 1998, we in England were shocked by the apparently motiveless murders of a mother and two of her children when they were traveling home from school in a rural area. Subsequently a patient with personality disorder, being monitored by the forensic psychiatric services, was convicted of their murders. The government was determined to prevent this type of offense from recurring and in 1999 introduced a new concept, dangerous and severe personality disorder (DSPD). This subsequently became a treatment and assessment program for individuals who satisfy three requirements: (1) have a severe disorder of personality, (2) present a significant risk of causing serious physical or psychological harm from which the victim would find it difficult or impossible to recover, and (3) the risk of offending should be functionally linked to the personality disorder. The implications of this program are discussed with regard to international systems of classification and service provision. We also attempt to place DSPD in the wider context of psychiatric participation in the management of personality disordered offenders.     

Discomfort in the community. The place of psyche: Between zōē and bios

In this paper, the author considers the treatment of people diagnosed with a psychosis or borderline personality disorder in therapeutic communities from a psychoanalytic perspective, with a particular focus on the work of Jacques Lacan and of André Green. He discusses two key questions. First, how are these patients to recover life? – not just in the biological sense but in terms of subjectivity. Secondly, is it ever really possible to build relationships with them? In relation to this second question, the author emphasizes the importance of the training and supervision of practitioners, as well as their own analysis. Therapeutic communities, above all, he argues, can provide structure and security in a society which is increasingly fragmented and unstable.     

Who is who in dissociation?: A plea for psychodynamics in a time of trauma1

Contemporary theories of dissociation and trauma for the most part have evolved outside of psychoanalysis. Psychoanalytic writings have also been regarded as being in opposition to trauma‐based notions of human psychopathology. The specific psychoanalytic contribution—the emphasis on unconscious conflict and meaning—is for the most part excluded from the discourse on dissociation, often resulting in a mechanic conceptualisation of trauma. In this paper, based on clinical material, the author argues in favour of including conflict, unconscious intention and personal meaning in understanding the kind of dissociation we see in cases of multiple personality pathology. Textual analysis of letters written to the analyst illustrates how events of abuse are defensively elaborated. The author demonstrates that patterns of affect regulation and dominant object–relational strategies can be captured through analysis of the discourse structure. She focuses on how an organised character pattern, revealed mainly through narrative style and the analyst's countertransference, serves protective purposes as well as wishfulfillment. She argues that dissociation in the form of multiple personalities may imply an active, strategic agent.     

THE PSYCHOANALYTIC CONTRIBUTIONS OF MELITTA SCHMIDEBERG KLEIN. MORE THAN MELANIE KLEIN’S REBEL DAUGHTER

Compared to the impact of the work of Melanie Klein on the history of psychoanalysis, the contributions of her daughter, Melitta Schmideberg, passed almost unnoticed. At present, Schmideberg is solely remembered for having harshly attacked her mother at the start of the Controversial Discussions of the British Psycho-Analytical Society and for having coined the fitting expression “stable instability” in order to describe borderline and asocial personality disorders. However, the author discusses how the early groundbreaking discoveries of Klein with regards to primitive anxieties were the result of the joint work and thinking of Melanie and Melitta. Moreover, he argues that the conflict between the two, along with the subsequent polarization of their views, did not facilitate the development of psychoanalysis, neither did it help the analytic community to recognize the value of Melitta’s contributions to psychoanalysis.     

Psychoanalytic Controversies: The relationship between psychoanalysis and schizophrenia

In this article, the author considers psychoanalysts' current attitudes towards schizophrenia. After early optimism of a psychoanalytic approach, interest has waned, other than in the field of first-onset psychosis. This was because of poor outcome figures and regarding schizophrenia as now having a biological, rather than psychological, base. The author argues that there is a paradox, because only psychoanalysis offers a framework for relating to psychotic patients in a way that helps them to make sense of their experiences. A framework is described, with clinical examples, to illustrate the application of analytic thinking to patients with schizophrenia. Psychoanalysis needs to revitalise its attitude to psychosis, as it has a significant contribution to make within general psychiatry, not least in the training of the next generation of psychiatrists.     

Angstzustände bei Patienten mit schweren Persönlichkeitsstörungen

States of anxiety are very common problems in patients with severe personality disorders. All phenomena of anxiety can be observed. In this connection a continuum of the severity of impairment of structural personality organisation can be postulated. In many cases proper anxiety disorders exist as comorbid disorders. Anxiety is esteemed to be the central affective problem of borderline patients. In spite of these relations, states of anxiety in patients with personality disorders are often underdiagnosed or misdiagnosed. For the treatment of neurotic anxiety disorders (for example panic disorders), there exist disorder-specific therapy manuals that proceed from behavioural as well as psychodynamic perspectives. Nevertheless, for the treatment of anxiety states in personality disordered patients, the techniques that focus heavily on symptomatology appear often contraindicated. In our opinion, treatment of these typically severe anxieties must be contained within a therapeutic framework, which essentially takes into account the personality organisation of this group of patients. Such treatment makes special demands on the therapist for working with transference and countertransference processes. From a disorder-specific psychodynamic perspective recommendations are given for psychotherapy.     

Killing Me Softly

Abstract

“Forced termination” of psychoanalysis occurs when the analyst electively terminates the treatment for reasons of his own, independent of the clinical indications for termination. The author describes his own experience with the forced termination of his training analysis. The literature is reviewed, with an emphasis on the attitude of each author regarding the straggle around the decision. The author explores sources of general ethical knowledge, the ethical foundations of the analyst-analysand relation ship, and the application of these ideas to psychoanalysis. From these princi ples, the ethical problems of forced termination are derived and examined. The author proposes reforms to address these problems.