Dangerous Patients

A Psychodynamic Approach to Risk Assessment and Management

Ronald Doctor

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367105303
• eBook ISBN: 9780429912511
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This thought-provoking new collection - the fourth volume in the Forensic Psychotherapy Monograph Series - investigates the inherent difficulties in risk assessment. We have all read the lurid headlines when things go wrong but what is it like for the professional who has to make such vital decisions? Ronald Doctor has assembled an impressive group of clinicians who specialise in various aspects of forensic psychiatry and psychotherapy to present their experiences and theories on this formidable subject. The book begins with a general overview of current psychodynamic approaches and covers various mental health settings, including medium- and high-security units, general medical hospitals and psychiatric wards. This collection will prove to be an indispensable guide to any healthcare professional and a fascinating insight for all into this highly-pressured environment.

CHAPTER ONE

Pathways of risk: the past, the present, and the unconscious

Daniel Antebi

Implicit within any construct of risk is the fact that it can be only partially predictive. This means that sometimes, no matter how thorough the risk-assessment and risk-management process, events will occur either because they were unpredictable or because the risk-assessment process produces a false negative result. Moreover, the more sophisticated and accurate the predictive abilities of risk assessment become, the rarer and, therefore, the more catastrophic will any incident appear to those who are not directly involved.

Much of the work and research around risk assessment focuses on trying to conceptualize risk, profiling the typical perpetrator of violence, or on managing risk factors in the acutely disturbed patient (Duggan, 1997). For general psychiatrists, assessing and dealing with the potential risk of violence to themselves or to others is a daily anxiety-provoking experience. Each new patient who enters the consulting-room brings with him the unknown, and this stress may be experienced by the clinician several times a day. The idea of risk is one with which practitioners have an highly ambivalent relationship, as it raises fundamental conflicts and anxieties. There is the moral and social conflict between one’s role as a crime prevention officer and the way in which that role may or may not conflict with the role of psychiatrist and confidante. There are the anxieties associated with the possible overt and direct risks to oneself, one’s family, and other members of staff. Lastly, there is the potential of a serious incident to cause damage not only to one’s sense of self, but also to one’s sense of judgement and, ultimately, to one’s reputation. All this means that the practitioner will inevitably bring some internal dissonance both to the conceptualization of risk and to the consultation with the patient. The clinician must therefore have the personal ability and the appropriate environment in which to try to contain such conflict and anxiety, as inability to do so will inevitably be perceived by the patient, and the risks inherent in the consultation will increase.

In this chapter I should like to review some of the factors that are commonly accepted to have some predictive value in violent acts, many of which are well rehearsed in the literature, and to understand them in the context of the patient’s history and the clinical presentation, through both conscious and unconscious communication. From the point of view of the general psychiatrist, this requires the ability to consider simultaneously both actuarial and clinical information, and to assess their relative importance in each individual case.

Risk is often described in terms of an event outcome, such as the likelihood of a violent act, but there are numerous risk-influencing decisions that need to be taken by the clinician before this end point—for example, managing the risk of disengagement or clarifying the options if treatment fails. Such factors all have an impact on the process of risk assessment as the patient moves through a pathway of care. I also explore, therefore, risk pathways and how seemingly trivial decisions along these pathways contribute to the overall risk outcome. Numerous enquiries report a string of minor systematic mistakes or failures culminating in a catastrophic event.

Finally, I address the issue of containment, both for individual clinicians and for organizations. Risk can only be managed safely if the containment of clinician anxieties is seen as a priority, both by the clinicians themselves and by the organization. The creation of such an environment enables more freedom and flexibility in risk taking and in itself reduces risk and produces a safer clinical or analytic space within which to work.

There are two main conceptual approaches to the consideration of risk assessment—the actuarial or mathematical and the clinical (Buchanan, 1999). The actuarial involves the collection of facts about the patient, including demographic data, history (specifically previous episodes of violence), and current presentation. These facts are then weighted according to some formula and a figure is arrived at, which apparently gives a predictive value to the likelihood of a future act of violence. The problem with such an approach is that many of the “facts” that should be part of this process are not really facts but actually individual clinical judgements. For instance, how does one grade or rate the presence, severity, and content of a delusion? Does it make a difference whether such a delusion is part of a systematized set of delusional beliefs? How systematized does it have to be? It is unlikely that such psychopathology is quantifiable except in very crude terms.

The clinical approach, on the other hand, is seen as informal and not amenable to quantitative assessment, and it leaves the power with the clinicians. Taking a clinical approach results in an assessment that is very difficult to quantify because of the absence of any external validation. Consequently, employing organizations such as health trusts or social-work agencies are unable to manage risk in a coherent and auditable manner and therefore cannot take meaningful medico-legal responsibility for the actions of their clinicians. For this reason, a model for risk assessment and management must take into account the reality that each clinical situation is unique. Alongside this is the need for a formal structure that is understandable and repeatable.

The past

Pattern recognition forms the essence of good and containing clinical practice. It is the basis for the assessment, the diagnosis, and the treatment of all patients, whatever mind/brain model is employed by the clinician. The biologist will understand psychopathology in terms of structural abnormalities in the brain or neurotransmitter dysfunction. It is assumed that these abnormalities are persistent or recurrent and will therefore present in repeatable symptom clusters the detail of which will be patient-specific. The recurrence of these particular symptom clusters and their material relationships within the brain provide the basis for a biological model. The cognitive behaviourist will recognize patterns in terms of antecedents or stimuli, behaviour and consequences, or as repeated cognitive distortions. Again analyses of sequences of behaviours or thoughts are identified by their repeatable patterns. The social theorist will argue that given a particular social or political environment, there will be an understandable and inevitable psychological reaction from those who are subject to it. The psychoanalyst comes to recognize repeated patterns of unconscious behaviour and their relationship to the patient’s conscious world. This will be understood in terms of defences such as projection and splitting. All these models are underpinned by the fact that there are recognizable patterns to people’s behaviour, and this gives us the possibility of making some predictions about future behaviour. The truism “the best predictor of the future is the past” clearly has some basis in clinical reality. It also has a strong basis in a formal or informal actuarial approach. The fact that it is fundamentally a statistical model means that it gives an indication of who is the high-risk patient or which is the high-risk situation.

This historical pattern can, however, only form a context in which the present can be understood and contained. The model takes particular events and predicts that, because a particular event happened once in a particular context, this event is more likely to happen again. If it happens more than once, it is very likely to happen again. In terms of predicting actual human behaviours, however, it fails, because it can never predict a particular act at a particular time. The ability to make more detailed predictions about the timing of an act depends on being able to listen to and understand the conscious and unconscious communication of the patient in the present. The importance of the historical context is that it helps to make sense of the present.

Certain factors and patterns in the patient’s history are important when considering risk. Clearly a past history of violence of any sort must be taken seriously, especially when the patient minimizes the importance of that violence. One must also explore the meaning, quality, and consequences of the violent act. The ability of the patient to offer an understanding (whether psychotic or otherwise) gives the clinician an indication as to whether there was some degree of psychological containment in his actions or whether the act was an impulse with little or no cognitive correlate. The quality may be sadistic or frenzied and will give an indication of the mental state of the perpetrator at the time of the attack. For instance, an attack resulting in are multiple stab wounds is more likely to happen where the relationship between perpetrator and victim is close. The behaviour after the event gives an indication of the degree of remorse on the part of the patient.

From a phenomenological perspective, a history of psychosis and, more particularly, congruity between the delusional beliefs or hallucinations and the act are always significant. For some patients whose psyche may be very fragmented, behaviour can be unpredictable and unconnected to expressed internal experience. On the other hand, a patient with a paranoid psychosis can sanely murder his mother in order to inherit her money. Particular attention should always be paid to a history of command hallucinations (Junginger, 1995). Direct instructions to the patient, particularly if they have been violent in content, may precede acts of violence. Diagnostically, patients who have multiple diagnoses or co-morbidity and who are perceived as “difficult to engage” often suffer from psychotic illness, have chaotic lifestyles, and frequently misuse alcohol and drugs. This combination—particularly the effects and sequelae of intoxication with drugs or alcohol—is highly unpredictable and for many patients violence can be intoxication-dependent. A particular psychotic disorder that is relevant is morbid jealousy or Othello syndrome (Shepherd, 1961) in which one party is convinced that their partner is having an affair. This belief is based on delusional thinking—that is, the evidence for coming to such a belief is based on a misinterpretation of events and therefore does not preclude the partner actually having an affair. A history of morbid jealousy must always be identified with an high risk of violence and may ultimately involve such measures as the breaking of confidence on the part of the clinician.

Non-psychotic indicators of violence occurring in the context of relationship difficulties are associated with patterns of enmeshment, jealousy, or separations. These are important, as such dynamics are likely to be repeated in the transference and to create potential risk to the clinician. Other diagnoses associated with increased likelihood of violence are psychopathy and the disinhibition associated with head injury. The use of particular prescribed drugs such as benzodiazepines can also lead to violent disinhibition. Gathering such detailed information lends itself to hypothesizing the nature of the patient’s internal world and patterns of behaviour. Such hypotheses can be monitored, tested, and modified as the relationship with the patient develops. One should also bear in mind that the only approach an enquiry panel can take after an incident is to assess and evaluate the history as taken to consider whether enough attention was paid to particular facts and whether the information was recorded and passed to the relevant people. The stuff of serious incident enquiries is often about previous episodes not being taken sufficiently seriously, warnings not being heeded or information not being shared appropriately (Reed, 1997).

Having collated the above information, it is therefore crucial that it is recorded and organized in an understandable format. There are, however, clinical dangers in having well-documented notes and a formal risk-assessment process within an organization. It means that an environment is created wherein both the organization and the individual clinician, having labelled a patient as “high risk”, can abrogate responsibility and avoid anxiety. With the future enquiry at the back of our minds, we want to claim that we did all we could and went through the accepted procedure. The patient is split off as bad, and we may cease the struggle to understand and to help. We can avoid the risk and danger to ourselves, our reputations, and our own internal worlds by being the good crime prevention officer. The outcome is a patient who is damned both in the clinicians' own mind and in the minds of the agencies trying to manage him. The hope we should bring to each clinical situation is lost and that will inevitably be experienced by the patient. The consequence of this is an increase in dangerousness. This is not to say that all adverse events are preventable but we must be careful to use historical risk assessment not as a tool of persecution but, rather, as an aid to achievable containment.

The present

Using the above historical information as a background, the presentation of the patient at each consultation can be understood within that context. The presenting risk can be assessed along two axes: (1) the content of the communication and presenting symptoms, and (2) the diagnostic formulation. The overt content of the communication is relatively straightforward. Direct and specific threats against an individual, either rationally or psychotically driven, are always significant. One should enquire about the extent of prior planning to the act—for instance, has a weapon been acquired? What efforts are to be made to avoid detection? Often if homicide is contemplated, there is the intention to commit suicide afterwards. Patients may make vague and non-specific threats about what they may do to a third party. Such threats must be fully explored and assessed with a knowledge of whether the patient has previously committed acts of violence and in the context of some understanding of the personality, including the ability to control impulse. Increasingly violent or sexual fantasies should also be considered as possible precursors to an act of violence, including sexual violence. Again, such symptoms must be carefully and fully explored. The importance of the presence of paranoid delusions and command hallucinations, as discussed above, should alert the clinician to further exploration of violent fantasies. Areas that the patient hints at or avoids discussing may also be relevant. That which is not said is often more important than that which is. After the first assessment, an initial diagnostic formulation is made. In terms of risk, this should contain an assessment of personality with some emphasis placed on impulse control, misuse of psychoactive substances, and the presence of delusional thinking.

The unconscious

Assessment of unconscious processes that may alert the clinician to risk requires some overall understanding of the patient’s psychodynamics and personality structure. It is often suggested that the clinical hunch is unscientific as it is unquantifiable and often beyond description. However, such experiences should be acknowledged as important by clinicians. “Hairs on the back of the neck” or “gut feelings” may be somatic projections that are communications emerging from within the patient’s unconscious. The fact that they are somatic suggests that the patient has no contact with them as they are very primitive experiences. On a slightly more sophisticated level, being with the patient may induce an intense feeling of fear that is not reflected in the conscious communication. This lack of congruence between the conscious and unconscious suggests a splitting off of the experience of fear leaving the patient with a sense of omnipotence. This clearly has the potential to be a source of risk.

Such projections must be explored either internally by the therapist or, if possible, with the patient, and thought through in the context of the patient’s personality. If being with a patient whom you know to have strong borderline elements to their personality and who has poor impulse control engenders a feeling of intense anxiety or fear, it is essential that each communication is carefully considered and that the clinician makes adequate personal preparations for the next meeting. Projections inevitably stimulate a countertransference response in the assessor. Time taken to distinguish between and reflect on these inner experiences will provide some containment in the assessment and some objectivity to the real risks.

Other projections that may alert the clinician are the feeling of being toyed with by the patient, which may suggest a sadistic element to the personality or that the patient experiences some triumph in making the clinician or services fail. This suggests the possibility of a destructive impulse as a part of the personality or defensive structure. There are particular experiences—namely coldness or emptiness—that clinicians should note. When these are experienced in the clinical situation, it may suggest that patients may not have, or be aware of, any inner emotional life themselves and therefore do not see it in others. They can therefore cause pain without guilt. More importantly, they may catch glimpses of integration and emotional aliveness in others, and this can arouse very powerful feelings of envy, which will inevitably be associated with destructive impulses (Joseph, 1986). Exploring the unconscious phantasies the patient may have in relation to the therapist may be helpful in indicating the presence of underlying envy. The way a patient reacts to a trial interpretation will give an indication of their ability to integrate their inner experience. Obviously such an interpretation must be carefully judged to be at a depth that is tolerable for the patient. Too deep an interpretation may produce a puzzled response or may alienate the patient completely; too superficial an interpretation will not test the strength of the personality. In other words, does the patient have the capacity to move from a paranoid-schizoid position to a depressive position through interpretation and understanding? If he is unable to do so, the interpretation will be perceived as threatening to the psyche and will result in a negative therapeutic reaction. Patients who survive by maintaining a borderline position or pathological organization (Steiner, 1987) are unable to tolerate any challenge to their delicate psychic equilibrium and may respond to interpretation and intimacy with psychic fragmentation and projection, the results of which are unpredictable.

Thus the details of the minute-to-minute dynamic changes and interventions will give an indication of how patients tolerate intimacy and psychic challenge and how they may defend themselves against linking and understanding. Assessment through the use of the trial interpretation must be done sensitively, as this produces anxiety, to which a small number of patients will react with anger.

Thus, in the clinical situation, an exploration of the personality structure, psychodynamics, defensive responses, and unconscious phantasy gives a picture of the potential for violence and the interpersonal triggers to such acts. Safety dictates that such an assessment must be done with at least some previous knowledge of the patient’s history. The clinician’s unconscious attitude is also important. He will bring a set of anxieties as well as his own personality structure, defences, and prejudices. An inappropriate countertransference reaction to a particular patient’s projection or attitude can cause anything from negative therapeutic reaction to the arousal of rage. This does not mean that all clinicians should have an analysis, but it does make supervision and time for reflection essential.

Pathways of risk

The common view of risk is that it represents the likelihood of an event occurring in a given set of circumstances and that, given those circumstances, there is some predictability of that event reoccurring. However, thi...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Series Foreword
• Editors and Contributors
• Foreword by Pamela Taylor
• Introduction
• 1 Pathways of risk: the past, the present, and the unconscious
• 2 Assessment of violence in medium-secure units
• 3 Risk assessment in general psychiatry: a psychoanalytic perspective
• 4 The psychodynamic assessment of violence in the general medical hospital, or, taking the “non-body” seriously
• 5 Psychoanalytic aspects to the risk containment of dangerous patients treated in high-security hospital
• 6 Containment and countertransference issues in a violent borderline patient
• 7 Risk-taking in the assessment of maternal abilities
• 8 The role of violence in perverse psychopathology
• 9 Envy and violence in confused sexuality
• References and Bibliography
• Index