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A recent paper suggests that violence must be approached multidimensionally. How can violence be conceptualized in a way that allows us to improve the lives of patients?

In the paper, Dr. Jessica Yakeley and J. Reid Meloy, Ph.D., argue that we should try to avoid using a single framework to explain why people kill, hurt others, or undermine the integrity of other human beings--and I think they're right. For many of us, it is easier to choose a conceptual framework, and view all violence and aggression through a single lens. But this would be a mistake.

The authors attempt to be comprehensive in their analysis of the origins of aggressive and violent behavior. For example, they discuss attachment theory as a major underlying factor in the expression of violence. And in fact, it is. The role of the mother in the preoedipal development of the child who becomes a killer or a predator is important. The mother who is unable to love her child and create a rich bond leaves the child vulnerable, and he or she becomes aggressive as a teenager or young adult. They never learn empathy.

Having been loved is an essential for someone to be able to empathize with another human being and to feel what the other person feels. I have taught and expressed the idea that trying to understand the violent person requires knowledge of their growing up, childhood experiences, and that hatred of parents who mistreat, undermine, and teach them to feel worthless is an important factor in the development of a violent person.

But as Dr. Yakeley and Dr. Meloy point out, the person's relationship with the father also might have a role in the development of violence. "Many violent individuals ... have histories of absent, abusive, or emotionally unavailable fathers, and the resulting lack of an adequate paternal introject, or at best a positive identification, renders the person perpetually trapped in a dyadic relationship with the mother where there is no possibility of another/third perspective" (Aggress. Violent Behav. 2012;17:229-39).

We know from the work of Dr. Vincent J. Felitti and his colleagues in the adverse childhood experiences or ACEs study that these experiences contribute greatly to the development of an aggressive child. In particular, witnessing domestic violence and cruel punishments are all factors in the kinds of fantasies that push a child in the direction of aggression.

When it comes to terrorists, the authors argue, "the homicidal superego demands are often manifest in several accelerating and evolving mental states." They go on to quote Dr. Meloy, who elaborated on this idea in an article he wrote a few years ago on the "violent true believer": "Within this identification arose a totalitarian state of mind in which omnipotence was idealized, intolerance of difference was magnified, hatred was exemplified, paranoia was rampant, and the entitlement to kill those who do not believe was embraced" (J. Pers. Assess. 2004;82:138-46).

The authors argue that within psychoanalytic theory and among practitioners, an appreciation for the heterogeneity of violent acts has been largely missing. "Most salient is the absence of an understanding that certain violent acts are neither anxiety- nor affect-based, but usually related to specific character pathologies, have relatively distinctive neurobiological underpinnings, and deserve psychoanalytic understanding."

They go on to discuss the different types of violence--for example, predatory and affective. When violence among children and adolescents is studied, these constructs are relabeled proactive and reactive.

"Children and adolescents who engage in proactive violence are typically less anxious, more callous, and more severely conduct disordered when diagnosed utilizing DSM criteria," they wrote. Affective violence, on the other hand, is survival against an imminent threat. Inherent in this discussion is the submission-dominance gradient that occurs in all assaults and violent acts. I have discussed this in other essays related to bullying. All of these acts occur in the absence of reciprocal affective ties. Some delinquent adolescents see their gang as their family. And in cases in which a kid who gets into trouble has no backup (affectional tie) from his fellow gang members--despite their promises to the contrary--we get a huge negative reaction.

Freud made extensive theoretical contributions to the subject of aggression, but a practical conceptualization of his was the notion of "criminals from a sense of guilt." This idea is played out hundreds pf times by people who commit crimes to assuage a sense of unconscious guilt.

I had a case in which a 15-year-old boy would steal his father's car and get caught by the police, and when brought home to his father, would be punished severely. The boy would steal the car after participating in homosexual acts and felt guilty about it. He sought the father's punishment to assuage this guilt--not for stealing the car--but for engaging in his "unacceptable" homosexual acts. The superego plays a big role in the perpetration of aggression and violence.

Psychiatrists need to understand why violent outbursts sometimes occur in people who have been let down. In some cases, they have experienced a narcissistic injury and when the person has such an experience, it is accompanied by shame and humiliation. The street language for this is feeling "disrespected."

In my work with young offenders, I have found that they often talk about their need to be respected. Likewise, when a father punishes a teenager by beating him severely, that young person is terribly humiliated. One of the important goals of adolescence, after all, is for the young person to achieve autonomy. And this kind of beating undermines the young person's integrity and autonomy--which, in turn, leads him to feel disrespected.

Treating these patients psychotherapeutically is always challenging. As Dr. Yakeley and Dr. Meloy point out, "many of these individuals cannot tolerate psychoanalysis or individual psychoanalytic therapy, where the intensity of the relationship with the therapist may feel overwhelming." This is one of the main reasons that treatment in group settings might prove more beneficial.

Rarely do we ask the right questions to help us understand the individual criminal mind and behavior. The paper that led to this column gave me many ideas on how to think about perpetrators and what factors might have led to their actions.

BY PAUL J. FINK, M.D.

DR. FINK is a consultant and psychiatrist in Philadelphia, and professor of psychiatry at Temple University. He can be reached at cpnews@elsevier.com.
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Title Annotation:FINK! STILL AT LARGE
Author:Fink, Paul J.
Publication:Clinical Psychiatry News
Date:Nov 1, 2012
Words:1036
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