I would like to do an update on a recent posting of a situation in which a person I am seeing in long-term intensive psychotherapy threatened to murder me (and described the gruesome details of how it would be done) and delusionally accused me of raping him and murdering his father (which he feels he has done). The sessions have been very tense, difficult to endure, and highly anxiety provoking. The person's psychopharmcologist thought I should try to hospitalize him. I did not see this as a viable option. I felt it would set the patient and the work back by years. We have come so far in the progression of his trust in me, that to do so would have been a form of betrayal. I would have strongly considered it had I thought I or someone else was at risk. The fact that he was showing up for all of his weekly sessions reassured me. I thought the need was, as pointed out so cogently by DW Winnicott, for the analyst's survival. Winnicott spoke of the value of containing the stage of maximum destructiveness in order to help the patient establish externality, i.e., the capacity to place the other outside of his/her zone of omnipotence-to be able to "use" (this has a positive valence for Winnicott) the other to 'feed' the self-otherwise, the other remains a projected part of the patient (a bundle of mental projections under the person's omnipotent control-but of no real use in nurturing the self). Recently, the sessions have more of a sense of what Searles and Benedetti have called a "therapeutic symbiosis." There is a deep feeling of emotional connection-my fear and hatred of the patient has been replaced, to a large degree, at least temporarily, by feelings of warm connection. I feel that we have 'weathered the storm.'

I am including some material on psychotic violence which I have previously posted to our listserv.

In the public mind and in the popular press there is often an association between violence and psychosis, e.g., Andrew Goldstein, David Berkowitz - "Son of Sam"-, Herbert Mullin, John Hinkley Jr. etc. The facts are that in the Epidemiological Catchment Area Study (ECA) only 3% of the total violence reported was perpetrated by individuals with schizophrenia. Most crime in the US is committed by persons not diagnosed with mental illness and most people with mental illness are not violent. In fact, often other factors, e.g., education and gender, seem to have a greater association with violence than mental illness per se. There is not a convincing body of literature of evidence linking command hallucinations with dangerous behavior.

If one studies the background of some individuals who have engaged in psychotic violence, one could see an association between events triggering fragmentation of the self (e.g. with ‘Son of Sam,’ he lost his adoptive mother in high school when she died of breast cancer and his adoptive father eventually remarried and moved from the Bronx to Florida) and decompensation into a paranoid delusional world in which the individual experiences this self- fragmentation as being perpetrated on him by others, animals, etc. (see Hyatt-Williams, A. (1998). Cruelty, Violence, and Murder. Northvale, NJ: Jason Aronson for an excellent dynamic understanding of this paranoid reaction).

For an excellent discussion of the associations between violence and psychosis (psychological and biological factors, the criminalization of the mentally ill in our society, etc), I recommend: Mark Serper and Andrea Bergman (2003) Psychotic Violence: Methods, Motives, Madness, published by Psychosocial Press.

Brian Koehler
New York University