Psychoanalytically Informed Interventions in Violence: Four Case Studies1

When I was asked to speak at a meeting about violence, I expressed quite a bit of initial hesitation. In part it was because I automatically assumed that I had to speak about how one ought to work with violent patients. “Who am I,” I asked myself, “even to speak about working with violent patients, let alone to suggest a model treatment approach?” After all, like most full-time private-practice psychoanalysts, my contact with physically violent patients has been rather limited compared, for example, with that of a staff therapist at Rikers Island or at the lock-up ward at Bellevue. But I didn't say no right away and I soon found myself thinking about the differences between aggression and violence in clinical work. I was thinking about how they could both be pretty scary. The primitive rage of a frustrated narcissist or the depth of aggression in certain borderline patients can often be very difficult to tolerate, but the way it is frightening for the therapist differs considerably from the kind of anxiety we feel in the presence of an actively violent patient. What got me thinking about this was remembering a consultation I once had with a man who, quite convincingly, told me that he murdered a girlfriend—a murder that he was never held to account for—while in the midst of an acute paranoid psychosis. From the story he told, I believed him. Whether or not this was a sign of gullibility on my part is certainly open to question, but the fact of the matter was that I did believe him. The reason he scheduled a consultation with me was that he feared he was decompensating and about to once again become actively psychotic. As best I could tell he was correctly assessing his situation, and the last thing in the world I wanted, at a time like that, was to become an important transference figure in his turbulent emotional life! So I told him about all the reasons why I was not the best choice of therapists for him, and got him out of the office as soon as I could. He really