Working with Violence

In the last two decades the mental health field has spawned a proliferation of publications and books about the risk of violence: how to assess and manage such risk, the links between mental illness and violence and the debate as to whether mental health workers should be involved in risk prediction at all. But while much has been written about the prediction and prevention of violence, less attention has been paid to the treatment of violent behaviour. Furthermore, much of the literature is written from a medical perspective, focusing on the small proportion of individuals whose violence is associated with mental illness and can be treated with medication or short-term behavioural treatments. Yet many mental health workers in forensic and non-forensic settings, as well as professionals from other disciplines such as probation, police and social services, work closely with violent individuals who may not be formally mentally ill, but clearly in need of help.

Although psychoanalysis has been preoccupied with the nature of aggression and destructiveness since Freud, until recently very little has been written about the psychoanalytic understanding of actual violence. Similarly, although most psychoanalysts and psychotherapists are familiar with the murderousness and violent fantasies in the patients they see in their clinical practice, few will see patients who act on their fantasies to become violent. In the last two decades, however, there has been increased interest in the psychoanalytic understanding and treatment of violent and delinquent patients, patients with a history of criminality and those who enact sexual violence and other perversions in which violence is inherent. This parallels the increasing interest in psychoanalytically informed treatments for people with severe character pathology, such as those patients diagnosed with borderline or antisocial personality disorders who constitute an increasing proportion of the patient population referred to psychiatrists and therapists for help.

Mr B, a white British mini-cab driver, had a highly disrupted childhood during which he was physically abused by his mother, and in and out of foster care. Father was a distant figure, an alcoholic and promiscuous ‘businessman’ known as ‘Jack the lad’. Mr B was disruptive at school, and as a teenager became involved in delinquent activities such as stealing cars, and misusing illicit drugs. In his 20s Mr B became closer to his mother, but had a series of relationships in which he was domestically violent to his partners. After being arrested following a drink driving offence, he was held in custody, where he accused the prison guards of poisoning his tea. On his release, he committed a robbery with a knife, and then approached a woman and killed her with multiple stab wounds.

The psychopathic criminal is a familiar and enduring figure used by authors, filmmakers and journalists to frighten and seduce their audiences — the cold, calculating serial killer, the mafia gangster, the ruthless business magnate or the Nazi SS officer. The psychopath’s superficial charm, ruthlessness, pathological lying, disregard of emotional attachments, lack of remorse and shame and capacity for extreme and sadistic violence have intrigued both lay people and professionals in the world of mental health for the past two centuries. This has culminated in a new risk-obsessed millennium in which the detection of psychopathic traits in convicted prisoners and psychiatric patients has been refined and enshrined in risk assessment tools that are marketed to predict which individuals are most likely to be violent.

Aggression plays an integral part in all sexual activity. Although one might think of sexual intimacy as being the expression of loving feelings and the wish to be truly close to the other, aggressive impulses are necessarily involved to facilitate separation and to manage anxieties about being both overwhelmed by and losing the other person. Adult sexual relations and sexuality involve a complex interplay of conflicting feelings of love and hate, wishes to merge with the other versus wishes for independence and creative versus destructive impulses, all of which represent the culmination of a complex developmental trajectory from unconscious infantile and oedipal wishes, phantasies and conflicts, through adolescent revivals and crises, to adult modes of relating.

The vast majority of violent crimes are committed by men. This statistic has been robust over time and in different populations. Around four-fifths of all violent incidents in the UK are committed by males (Home Office, 2004), and this pattern is very similar in France and Germany (Heidensohn, 1991), as well as in the United States, where recent statistics showed that 81.8 per cent of persons arrested for violent crime were male (US Department of Justice, 2007). The ratio of male to female homicide in England and Wales has remained stable at about 10:1 in recent years (Home Office, 2006). However, recent statistics suggest that overall numbers of male and female perpetrators of violent crimes against another person are increasing compared to other offences (Ministry of Justice, 2008), and more specifically, the proportion of recorded domestic violence incidents in which the offender is female has increased significantly in recent years (Home Office, 2004). As will be discussed in this chapter, the relationships between offender and victim show marked differences according to the gender of the offender — most victims of male violent perpetrators are not known to the offender, whereas the victims of violent women are most often close family members — their partners or children.

So far, we have considered violence from the perspective of the individual person, and the influences that lead to his or her aggression becoming manifest. However, history shows us that the most frightening and uncontained violence is perpetuated by groups of people, and we are currently witnessing how the unprecedented social violence of the twentieth century’s wars and genocides continues to evolve into new forms of terrorist and urban violence in the twenty-first century. This chapter will give a brief overview of group and social violence, and from a psychoanalytic perspective examine some of the underlying processes that contribute to human beings becoming more violent when they come together — from the small group violence of playground bullies, juvenile gangs and the football crowd, to violence of a much larger scale in military actions and warfare, and how socially sanctioned mass violence can be perverted to become sadistic violence intentionally aimed at non-combatant civilians in acts of genocide and terrorism. There is of course a multitude of important political, socio-economic and ideological influences that combine to produce socially violent events to which I cannot do justice, but I will touch upon issues of race and ethnicity which underscore many acts of violence, again looking at this from a psychoanalytic viewpoint.

We live in a risk-obsessed culture. Children are no longer allowed to play freely because of the risk of being run over or being abducted by paedophiles, teenagers in our inner cities are afraid of being stabbed by each other and we are all at risk of being killed by the insane, or so the media would have us believe. Society’s increasing aversion to any form of risk, and the resultant ‘blame culture’, has had a disproportionately powerful impact on the field of mental health. Mental illness is often negatively portrayed in the media, and its association with violent behaviour exaggerated. Many view people with psychosis as dangerous, despite the fact that rates of homicide by the mentally ill have remained stable for years and constitute only a small proportion of the total numbers of homicide.

The most dangerous members of our society reside in locked institutions, forcibly removed from public life and mostly forgotten by that society, except for the courageous, or perhaps foolhardy, few who work in these institutions. A visitor to a secure forensic hospital or prison, once through the many security checks, thick walls and locked doors, may be pleasantly surprised by the apparent calm and orderliness within, the prison inmates quiet in their cells or the hospital patients settled on the wards, and wonder where the danger and anxiety has gone. This chapter will attempt to open a window into these secure forensic settings to observe and explore the experiences of those who live and work within, and to locate their anxieties, that have not disappeared, but have been re-distributed among the different parts of the institution to silently and insidiously corrode and distort its functioning. In describing these forensic settings, I will focus on the secure forensic hospital, but will finish by touching on some of the particular problems encountered in the environment of the prison.

Violence has always been considered to be one of the more serious contraindications for psychoanalytic treatment. Conventional psychoanalytic wisdom regarding suitability for psychoanalysis teaches that a patient who has a history of violence towards self or others indicates weak ego strength and primitive defences, and so is unlikely to be able to utilise psychoanalytic therapy, which in itself may increase the risk of the patient acting violently. However, the nature of human aggression is one of the most essential themes that has interested psychoanalysis since its inception, and in its investigation, eminent psychoanalysts on both sides of the Atlantic have treated violent patients. As we have seen in the preceding chapters, violence in itself has only achieved prominence in the psychoanalytic literature within the last few decades. However, earlier generations of analysts produced creative clinicians interested in expanding the boundaries of classical psychoanalysis, such as Menninger (1938, 1942, 1963, 1968) in the United States, who saw many very serious violent cases for treatment. In the UK, the Portman Clinic in London was founded in 1931 as the Psychopathic Clinic, the clinical arm of the then Institute for the Scientific Treatment of Delinquency, by Dr Grace Pailthorpe, a psychoanalyst and psychiatrist, who enlisted the interest and support of prominent psychoanalysts such as Edward Glover and Kate Friedlander. The Clinic’s first formal patient seen in 1933 was ‘a woman, 47 years of age, noted as having a violent temper, charged with assault on her woman employer’ (Saville and Rumney, 1992).

For many individuals with a history of violent behaviour, group psychotherapy may be the treatment of choice. In a group setting, the violent person may feel safer and more contained than in individual therapy where the intensity of the relationship with the therapist may feel overwhelming. The triggers to potential violent behaviour may also be more easily recognised and confronted than in an individual treatment. Violent individuals may prove to be valuable group members, particularly in facilitating other members of the group in acknowledging their own anger and potential aggression, which may be an unrecognised but important component of their pathology. Many people who resort to violence have grown up in dysfunctional families in which anger and violence characterised the communication between family members. Such individuals inevitably have difficulty in forming intimate adult relationships based on mutual respect and trust. The group can act as a socio-familial microcosm in which the violent person’s interactions with other group members can be understood as reflecting the pathological dynamics of their original familial experiences. The group experience may offer the opportunity of learning more healthy and mature ways of relating to others.

Violent individuals, by the nature of their antisocial behaviour, are more likely to come into contact with other institutions within our society than those concerned with health, most obviously the criminal justice agencies (police, probation and the courts), but also services such as housing, social services and education. The concerns over risk and public safety, broadcast by the media and resulting in an era of public protection policies and legislation, have influenced the way society deals with offenders by prioritising punishment and public protection, rather than focusing on the welfare of the offender. Where each professional agency locates itself on this spectrum will determine its attitude towards management of the violent person, but all agencies risk being pushed, by the overt pressure of government policies, and the more insidious influence of public opinion, towards undermining the rights of the individual offender in favour of the protection of society as a whole.