Joel, you make good points about who can be seen in private practice. Although, I think one never really knows for sure. I have a patient in my practice who also has a delusion that people, including me, are raping him, changing his body into that of a woman, exchanging parts of his body, etc. He has been crack-addicted and homeless. He has come a long way in that he is no longer abusing drugs, has been able to secure a nice apartment, does not have the states of pronounced terror, is less symptomatic, etc. Despite decades of medication and my psychotherapy of 6-7 years with him, he still remains locked into a persecutory delusional world. I saw him five times a week with longer session length (Medicare reimbursement)-now only two times a week.

At one point, in the throes of his delusions and voices, he got up from the couch (he sits up--I do not ask any of my patients to recline on the couch--if they want to they can--I do not see this as essential, or even helpful for many people) and started towards me to attack. I immediately grabbed for the phone (knowing that I did not really have time to call) and said I would call the police and then in a firm voice I said "sit down!! Luckily, he did and then we tried, over time, to process this. I think we can never really know the course and outcome of our work.

Many patients deemed, perhaps somewhat hastily, to be only suitable for clinic settings, in my experience can be seen privately. If I feel very uncomfortable (e.g., with the background information) with a new patient, I may ask for family to attend the first meeting or so. Recently, I started with a very delusional and hallucinating young man who was threatening his neighbor and had written notes to burn down his building (on an unconscious level I believe he felt he was on fire and trapped within persecutory others--they hated him and wanted him dead). I met with him, his sister and father after we began treatment--I believe this was stormy for him (and myself) but very helpful to the treatment. He is much less delusional and hallucinative.

I remember one time when a severely obsessional (psychotic anxiety) woman, in a rage, impulsively hurled a large Tibetan bell (it was sitting on a piece of furniture near her) towards me. I held up my hands to block it from hitting me in the head. Fortunately, she must have exerted some control as she hurled it because it hit to my side. I stood up saying I was calling the police. She immediately ran out of the office. She continued to call my phone answering machine on an almost, literally, continuous basis. I felt my phone became a torture machine (as she was and as she felt others, including me, were towards her). The calling would not stop and was very disruptive to my practice and my state of mind. I had to finally enlist the help of the local detectives in the West Village who told me she is known for doing this to therapists. A firm threat of imprisonment stopped her constant calls.

So, there are patients who I do not feel at all capable of working with in a private practice setting. But my experience has led me to believe that it usually works. If it does not, I first refer to a trusted collegue, Dr. Jessica Arenella, in hope that the dynamics will be different. I am truly grateful to have the support of someone like Dr. Arenella as well as free consultation from my wife, Julie Kipp, and the support of the local NY Branch of ISPS-US.

I am not sure working within the structure of a clinical institution may provide more security (although it does to some degree)-it may be somewhat of an illusion. I have many memories on inpatient wards of staff retreating when a patient became violent. Like Joe, I had been suddenly attacked as I walked out of my office on the ward by a patient I was not even working with. Another time I was being verbally threatened (two inches from my face) by a very hostile patient in the state hospital--staff were about twenty feet away and turned a blind eye to it (perhaps to act out their aggression towards me vicariously or they were relieved it was not happening to them). For the years I worked in the dismal confines of a state hospital (patients had no A/C in summer, bars on the windows, dorm-like bedrooms, impersonal, sterile, etc.), I did not feel particularly safe nor did I feel I could always rely on staff to help me out of a jam. The staff, who were not trained or supported by the administration, were often very primitive and I saw many experiences of exploitation of patients. I also saw staff aggression against patients that was totally uncalled for. I learned of sexual abuse of patients, etc. A nightmare.

In regard to the medication issue: Of course there are symbolic and proto-symbolic phantasies about ingesting meds (whatever the true nature of them are). Some people experience psychotropics as invasive, controlling, colonizing (when someone has a very porous boundary these fears are even more pronounced), humiliating and shaming, almost like poison. Some people I work with feel all of the above, while some experience them as transitional objects mitigating separation anxiety.

Some patients who mistrust, for whatever reason, closeness with and dependence on others, prefer to rely on medications and not other persons to help them out of their hell. Some are in such despair and feel so helpless, that they believe only strong medicines can control their emotions and fears. Some have no faith in themselves or others. My experience is that it does not have to be just the threat of medications to induce the threat of annihilation and shameful control. People with very permeable ego boundaries (which in some situations of low adversity may confer a social advantage due to the person's sensitivity to social experience) can feel threatened with closeness. Paranoid persons can feel taken over, subjugated, colonized and persecuted also when they feel the need for others. Separation from (absence) and indifference of others can feel persecutory--they can feel hated when they are in need. I have a paranoid male patient who feels extremely threatened by effeminate men--as if they were going to turn him into a woman which unconsciously in his mind really is about humiliation and an attempt to beat him into submission (kill-or-be-killed emotional atmosphere). Themes of dominating power, powerlessness, weakness, and vulnerability are significant in his mental universe.

In order to really help people who suffer from these vulnerabilities, we must be able to contain and confront their omnipotence and destructive narcissism within a firm, strong, quiet psychotherapeutic relationship. For potentially violent and arrogant patients I have found the work of Harold Searles, Herbert Rosenfeld and Arthur Hyatt-Williams to be very helpful. PostKleinian psychiatrist Hyatt-Williams' (1998) "Cruelty, Violence, and Murder: Understanding the Criminal Mind" is a gem of a book, as is Rosenfeld's (1987)"Impasse and Interpretation." Searles has an excellent chapter on working with murderous individuals in his 1979 bookon countertransference.

The murder of Wayne Fenton is a tragedy for Wayne and his family, as it is for the young man who murdered him. There by the grace of God go most of us.

Brian Koehler