Understanding violence: Does psychoanalytic thinking matter?

A coherent psychoanalytic theory of violence has been hindered by the very few psychoanalysts who have actually worked with violent patients, by political allegiance to certain psychoanalytic schools of thought, a naïve belief that all violence is typically not intentional, but rather a problem of impulse control, and the lack of understanding of recent neurobiological findings concerning aggression. Although intensive psychoanalytic treatment is usually not appropriate for violent individuals, the authors assert that a comprehensive understanding of violent behavior from a psychoanalytic perspective is of relevance for all mental health practitioners interested in the nature of human aggression. Actual violence is informed by bodily enactments and regressions to primitive subjective states; the effects of trauma on representation and symbolic functioning; the demarcation between affective and predatory violence; and understanding how all of our mental processes, including cognitions, wishes, memories, unconscious phantasies, ego-defenses, and object relations, are originally rooted in the body. The authors review the historical psychoanalytic literature on violence and critique contemporary psychoanalytic theorizing regarding the etiology of violent behavior in the light of some neurobiological research findings. They conclude with treatment recommendations for those clinicians whose patients have been violent toward others

Mentalization for Offending Adult Males (MOAM): study protocol for a randomized controlled trial to evaluate mentalization-based treatment for antisocial personality disorder in male offenders on community probation

Background Antisocial personality disorder (ASPD), although associated with very significant health and social burden, is an under-researched mental disorder for which clinically effective and cost-effective treatment methods are urgently needed. No intervention has been established for prevention or as the treatment of choice for this disorder. Mentalization-based treatment (MBT) is a psychotherapeutic treatment that has shown some promising preliminary results for reducing personality disorder symptomatology by specifically targeting the ability to recognize and understand the mental states of oneself and others, an ability that is compromised in people with ASPD. This paper describes the protocol of a multi-site RCT designed to test the effectiveness and cost-effectiveness of MBT for reducing aggression and alleviating the wider symptoms of ASPD in male offenders subject to probation supervision who fulfil diagnostic criteria for ASPD. Methods Three hundred and two participants recruited from a pool of offenders subject to statutory supervision by the National Probation Service at 13 sites across the UK will be randomized on a 1:1 basis to 12 months of probation plus MBT or standard probation as usual, with follow-up to 24 months post-randomization. The primary outcome is frequency of aggressive antisocial behaviour as assessed by the Overt Aggression Scale – Modified. Secondary outcomes include violence, offending rates, alcohol use, drug use, mental health status, quality of life, and total service use costs. Data will be gathered from police and criminal justice databases, NHS record linkage, and interviews and self-report measures administered to participants. Primary analysis will be on an intent-to-treat basis; per-protocol analysis will be undertaken as secondary analysis. The primary outcome will be analysed using hierarchical mixed-effects linear regression. Secondary outcomes will be analysed using mixed-effects linear regression, mixed-effects logistic regression, and mixed-effects Poisson models for secondary outcomes depending on whether the outcome is continuous, binary, or count data. A cost-effectiveness and cost-utility analysis will be undertaken. Discussion This definitive, national, multi-site trial is of sufficient size to evaluate MBT to inform policymakers, service commissioners, clinicians, and service users about its potential to treat offenders with ASPD and the likely impact on the population at risk

Why medical students choose psychiatry - a 20 country cross-sectional survey

BACKGROUND: Recruitment to psychiatry is insufficient to meet projected mental health service needs world-wide. We report on the career plans of final year medical students from 20 countries, investigating factors identified from the literature which influence psychiatric career choice. METHODS: Cross sectional electronic or paper survey. Subjects were final year medical students at 46 medical schools in participating countries. We assessed students' career intentions, motivations, medical school teaching and exposure to psychiatry. We assessed students' attitudes and personality factors. The main outcome measure was likelihood of specializing in psychiatry. Multilevel logistic regression was used to examine the joint effect of factors upon the main outcome. RESULTS: 2198 of 9135 (24%) of students responded (range 4 to 91%) across the countries. Internationally 4.5% of students definitely considered psychiatry as a career (range 1 to 12%). 19% of students (range 0 to 33%) were "quite likely", and 25% were "definitely not" considering psychiatry. Female gender, experience of mental/physical illness, media portrayal of doctors, and positive attitudes to psychiatry, but not personality factors, were associated with choosing psychiatry. Quality of psychiatric placement (correlation coefficient = 0.22, p < 0.001) and number of placements (correlation coefficient =0.21, p < 0.001) were associated with higher ATP scores. During medical school, experience of psychiatric enrichment activities (special studies modules and university psychiatry clubs), experience of acutely unwell patients and perceived clinical responsibility were all associated with choice of psychiatry.Multilevel logistic regression revealed six factors associated with students choosing psychiatry: importance of own vocation, odds ratio (OR) 3.01, 95% CI 1.61 to 5.91, p < 0.001); interest in psychiatry before medical school, OR 10.8 (5.38 to 21.8, p < 0.001); undertaking a psychiatry special study module, OR 1.45 (1.05 to 2.01, p = 0.03) or elective OR 4.28 (2.87- 6.38, p < 0.001); membership of a university psychiatry club, OR 3.25 (2.87 to 6.38, p < 0.001); and exposure to didactic teaching, OR 0.54 (0.40 to 0.72, p < 0.001). CONCLUSIONS: We report factors relevant to medical student selection and psychiatry teaching which affect career choice. Addressing these factors may improve recruitment to psychiatry internationally

Psychodynamic treatment of antisocial personality disorder

Many psychoanalytic clinicians and researchers experienced in working with severe personality disorders have concluded that patients with a diagnosis of antisocial personality disorder are not treatable with psychodynamic psychotherapy (Gabbard 2005; Kernberg 1984; Kernberg et al. 2008). This pessimism is based on the seeming impossibility of engaging with patients whose pervasive deception and emotional detachment forecloses any possibility of entering into a viable therapeutic relationship, while the focus of therapy is constantly being diverted from exploration of the patient's mind into managing his risky antisocial behaviors. Although there is a lack of systematic controlled empirical evidence to indicate that psychodynamic treatments are effective in these individuals, recent research into the psychopathic patient's abnormal cognitive deficits and emotional responses (Patrick 2006) and awareness that antisocial personality disorder is a disorder of attachment (Meloy 2002) are stimulating a renewed interest in psychodynamic approaches

Pinned against the ropes: Understanding anti-social personality-disordered patients through use of the counter-transference

This paper focuses on difficulties in the treatment and care of patients with a diagnosis of psychopathic, or anti-social personality disorder as it is usually referred to today. The current psychiatric diagnostic systems (ICD-10 and DSM-IV) are primarily categorical and theoretical. Diagnosis is arrived at by assessing the presence or absence of symptoms and behaviours. These diagnostic systems do not take any account of the individual's development or personality structure and consequently there is no dimension for describing links between different diagnoses. This means that these patients are often thought to be either suffering from paranoid schizophrenia or anti-social personality disorder or a dual diagnosis depending on the phase of their illness. The current diagnostic system does not recognize the underlying personality structures that link the diagnosis and cycles of the illness together. However DSM-V, which is coming out next year, will take a more dimensional approach, and as such will be more compatible with a psychoanalytic understanding of mental disorder. In this paper the author draws upon literature in this area and suggests that this dichotomy between the psychotic and the anti-social may be too simple and argues that if we can understand that psychotic processes may well also underlie the personality disorders, we may reach a better understanding of what takes place in these settings and how staff are affected by the patients. In order to function effectively, staff need regular, on-going supervision. These arguments will be illustrated with clinical examples taken from supervision groups and consultations in forensic and mental health settings