From Moral Insanity to Psychopathy

Psychopathy is currently a condition that arouses great interest among psychiatrists because of its significant involvement in the forensic field. The authors illustrate the course over time of the concept of psychopathy, starting from the definition of “moral insanity” of Prichard. The historical journey allows to illustrate the different positions that the various European schools of psychiatry have had toward psychopathy, until modern nosographic classification systems such as Diagnostic and Statistical Manual of Mental Disorders (DSM). Special attention is paid to the “core” of psychopathy: the alteration of the moral sense, and through the illustration of moral development is provided a reading of morality in the psychopath and the reasons for its impairment. A clinical and critical examination of psychopathy assessment scales is proposed, with the aim to broaden the horizons of assessment, also to individuals who do not show violent behavior, but with compromised moral sense. Lastly, authors propose an interpretation of the social aspects of psychopathy that goes beyond the assessment of the psychopath confined in jails, with several highlighted aspects of psychopathy that contribute to social success in work, relationships, and career and that can contribute to the success of the psychopath

Colloquio psichiatrico e capro espiatorio nelle istituzioni penitenziarie

The psychiatric interview in jail, between mental health professionals (psychiatrist, criminologist, psychologist, social worker, ecc.) and patients often shows the tendency to identify the responsibility for his deprivation of freedom, or physical and psychological sufferings, with other people or groups. These people are called enemy by patient, and can be the objective of physical violence, as a scapegoat. In these enemies or scapegoats we can put also mental health professionals. The subject matter of the present article is to describe six dynamics that allow to study in detail the creation of the enemy made by patients in penitentiary institutes: 1) The acute creation of a real enemy for a real fact; 2) The progressive and self-serving creation of an enemy; 3) An aggressive manner to control an environment seen as violent and unrestrainable; 4) An opportunity to assault the symbols of the establishment; 5) The fulfilement of the possibility to judge or punish the others in spite of being punished or judged by them; 6) The attempt to thwart the inner aggressiveness of the group. The purpose of this study is to better the mental health operators professional skills through the knowledge of their emotions when they are seen as enemies, to avoid iatrogenic injures caused by unsuited emotional responses, to understand how to use the patient’s creation of an enemy as a way to make diagnosis in a deeper way, and to better the therapeutic intervention on the patient.Il colloquio in istituzione penitenziaria fra operatore della salute mentale (psichiatra, criminologo, psicologo, assistente sociale, ecc.) e paziente, mette spesso in luce la tendenza di quest’ultimo ad identificare, in altre persone od altri gruppi, la responsabilità per la sua privazione di libertà e per le sue sofferenze psichiche e fisiche. Queste persone sono qualificate dal paziente come nemiche e nei loro confronti, come un capro espiatorio, possono essere messe in atto anche delle violenze fisiche. Tra questi nemici o capri espiatori vi possono anche essere gli operatori della salute mentale. Oggetto del presente studio è la illustrazione di sei dinamiche che permettono di approfondire la conoscenza della creazione del nemico da parte del paziente nei colloqui con gli operatori della salute mentale in istituzione penitenziaria: 1) La creazione acuta di un nemico reale per un fatto reale; 2) La creazione progressiva e pretestuosa di un nemico; 3) Una modalità aggressiva per controllare un ambiente ritenuto aggressivo e incontrollabile; 4) L’opportunità per aggredire i simboli di ciò che si odia; 5) La gratificazione di poter giudicare e punire gli altri, invece di essere giudicato e punito dagli altri; 6) Il tentativo di neutralizzare l’aggressività intragruppale. Lo scopo del presente studio è quello di migliorare la formazione professionale degli operatori della salute mentale in carcere attraverso la consapevolezza delle loro emozioni, allorquando sono considerati nemici, evitare errori iatrogeni legati a reazioni emotive inadeguate, e saper utilizzare la creazione di un nemico da parte del paziente come un mezzo per approfondire la diagnosi e migliorare l’intervento terapeutico sul paziente

La Traslazione del paziente, con disturbo mentale e comportamento violento, verso il terapeuta

We described eleven typical clinical cases of patients’ translational typology with mental disorder and violent behaviour towards the therapist. The clinical cases described exhibit neurotic and psychotic translation linked to translation linked to mental disorder and translation linked to the aetiology and to the dynamics of violent behaviour. The objective of this clinical study is to enrich the psychiatric diagnosis and therapeutic pathways of patients with mental disorder and violent behaviour and to avoid iatrogenic error by using the concept of translation in its widest understanding

La Controtraslazione del terapeuta verso il paziente con disturbo mentale e comportamento violento

We described thirteen typologies of the therapist countertransference toward the patient with mental disorder and violent behavior. The purpose of this study is to improve: a) the ability of the therapist to mentalize emotions without any passing to the act; b) the recognition of the patient transference; c) the recognition of the countertransference related to mental disorder and violent behavior

Reattività inadeguata del terapeuta nei confronti del paziente a rischio suicidario = Therapist’s reactions on the treatment of suicidal patients

In the present study, we describe fourteen therapists’ reactions (Avoidance, Rejection, Suicidal collusion, Overinvolvement, Overprotection, Loss of patients’ responsibilities, Loss of therapists’ responsibilities, Reaction to the feeling of being exploited, Creation of dependency, Manipolatory acting out, Feeling of undergoing an iniquity, Patients psychopathology inflation, Therapists’ psychopathology inflation, Suicidal Burnout Syndrome), based on emotions, behaviors and cognitivity, toward patients with suicidal risk. These responses can interfere with a correct assessment and management of suicidal risk in psychiatric patients. The purpose of the present clinical study was to improve therapist’s professional skills through the recognizement and management of his own responses to suicidal patients

Il Colloquio con il detenuto: aspetti antropologici

During the clinical interview – both criminological and psychiatric – between the prisoner and who works in the mental health (psychiatrist, criminologist, psychologist, etc.) in the context of a prison, a lot of features can make this therapeutical relation very difficult: first of all, the suspiciousness and the prejudices of people who works in the mental health against the prisoners and vice versa. Then, for a better understanding, it is useful to consider the prisoner, deprived of his freedom and forced to long imprisonment, connected to his behaviours, values, rules and choices, tightly related to a “subculture of prison” and so different from “life out of the prison”. The clinical interview is the way how who works in a mental health context makes the first therapeutical intervention and it has got very specific features. Some of the elements will be examinated, particularly by an anthropological and cultural point of view (psychological processes, cultural context, etc.), in order to go deeper into the understanding of the clinical interview with the prisoner, but also in order to aid a specific therapeutical intervention

La Valutazione clinica del paziente con disturbo mentale e comportamento violento sulle persone = Clinical assessment of patients with mental disorders and violent behavior directed towards others

Objective The management of patients with mental disorder and violent behavior has become one of the most important issues among psychiatrists, due to repercussions related to professional liability. The aim of this study is to identify an assesment methodology of patients with mental disorder and violent behaviors oriented to manage the risk of violent behavior in clinical practice, particularly focusing on both stimulating and protective factors. Methods This study is a personal contribution based on clinical experience among specific institutions specialized in the evaluation and treatment of psychiatric patients, who committed violent crimes. The presented methodology is based on contributions of clinical reports and the most recent literature. Results and conclusions Authors present a methodology of assessment of patients with a mental disorder and violent behaviors including categorical psychiatric diagnosis, dimensional psychiatric diagnosis, dynamic psychiatric diagnosis, etiologic evaluation of violent behavior, the assesment of transference, countertransference and resistance of the patient. The treatment trend that emerges includes a sequence of operative indications that concern the treatment of both mental disorder and violent behavior, beyond the adoption of protective measures. It is also specified that the evaluation of the risk have to focus on the specific patient. We ought to, at least, emphasize the importance to document in case histories, the evaluation of the violent behavior risk carried-out, as a concrete proof of good clinical practice

[Guidelines in psychiatry: clinical and forensic issues]

Treatment guidelines (GL) in psychiatry represent a useful and functional tool to be explored and enhanced in terms of the contribution of patient care and the promotion of scientific improvement. However, they show some limitations, both clinical and forensic. The objective of this paper is to examine the objectives, the clinical limitations and the applicability of the GL on professional liability (forensic aspects). From a clinical point of view, the GL have objectives that are functional to the promotion of physical and mental health, among which the constitutional observance of the right to health, the improvement of public health, the implementation of best clinical practices, the promotion of scientific research, the professional training of operators in the field of physical and mental health. However, GL cannot replace a contextualized clinical judgment. GL must be applied, in the single clinical case, in light of their multiple criticalities, including the limits of the methodology used for their formulation, the differences between the GL' recommendations, the difficulty of their application in daily clinical practice, the lack of specific treatment interventions. From a forensic psychiatric point of view, GL, as currently conceived, cannot be used in terms of professional liability without their interpretation on a legal basis with forensic psychiatric methodology, similarly to any other clinical and scientific information, with its qualifications and criticalities

[The psychiatrization and unpredictability of interpersonal violent behavior]

The relationship between mental illness and violent behavior is a complex phenomenon. Scientific literature indicates that the presence of a mental disorder, even severe, is not sufficient, alone, to predict or motivate violent behavior, which seems to be more associated with other intermediate variables. The phenomenon of psychiatrization of violent behavior can be defined, from a psychiatric-forensic point of view, as the prejudicial and erroneous attribution to mental illness as a causal factor in relation to violent behavior. This phenomenon has consequences in psychiatric clinical practice, but also at the level of social stigmatization, management of organizational and economic resources, and the judicial system. In this paper, clinical criticalities related to the psychiatrization of violent behavior will be analyzed, including the need to differentiate clinical etiology and legal causality, predictability and avoidability, protective clinical factors and clinical risk factors, the limits of categorical psychiatric diagnosis, the need for specific victimological information, the criticalities of pharmacotherapy. Some forensic criticalities will also be analyzed, including errors in clinical and forensic methodology (psychiatrization of the symptom, prejudicial contamination, diagnostic overshadowing, legal causalization of protective and risk factors, the use of categorical diagnosis in the forensic field, the psychiatrization of non-pathological human experiences, the criminalization of the subject with mental disorder). In conclusion, it is highlighted that an individual can have a psychic disorder, even severe, but this disorder is not necessarily in a causal relationship with violent behavior. The lack of a causal relationship makes predictability of violent behavior difficult, even impossible depending on the case, both in the general population and in individuals with psychiatric disorders