Psychopathology: Theory and Practice

This presentations suggests that a key assumption, central to forensic psychotherapy, is that the offence has a meaning to the offender and can be understood in the context of their internal world, developmental history and relationships. The offence is considered as a symptom. Once it has been committed a line has been crossed where psychic reality has been acted out in external reality. Just as with physical diseases, the offence often has a prodromal period – a time when the disease process has begun but is not yet clinically manifested. If the underlying symptoms and mechanisms are not recognised and understood by the patient then the risk of similar offending remains. In this presentation Professor Gill McGauley theoretically explores how forensic psychotherapy can help us recognise and understand more about this prodrome to murderous attacks. She presents qualitative and quantitative data to illustrate how the patient’s representation of their index offence, their offence narratives and capacity to mentalise can help us predict and treat the unfolding of both aggressive and prosocial behaviour.

Video lecture with captions and slides – 30 mins

In this presentation, Remy Aquarone, director of the Pottergate Centre, Norwich, UK, explains the value of the Structured Clinical Interview (SCID-D). This assessment instrument was created for the diagnosis of DSM-IV Axis 1 disorders, a list that includes Dissociative Disorders. Remy Aquarone takes us through the criteria for the assessment and diagnosis of dissociation disorders, giving detailed explanation of key symptoms. These include the five dissociative disorders outlined in DSM-IV: Dissociative amnesia, dissociative fugue, depersonalisation disorder, dissociative disorders (not otherwise specified) and dissociative identity disorders (DID).

Video lecture with captions – 1 hr 3 mins

This talk offers an understanding of anxiety disorders that rests on research into the emotional systems that we share with all other mammals. Beginning with a brief discussion of Panksepp’s emotional taxonomy, with special emphasis on the GRIEF, FEAR & SEEKING SYSTEMS, Lucy Biven will explain how one type of anxiety is generated by issues in the FEAR system, while another separate pattern of anxiety is generated by GRIEF. The emotional, behavioural and biochemical aspects of each will be explained. The merits of both psychotherapeutic and psychotropic interventions will be discussed, including the interesting evidence that anxiety rooted in the FEAR system responds to tricyclite antidepressants, while GRIEF-based anxiety is addressed by benzodiazepines.

Video lecture with captions – 25 mins

In these talks Dr David Celani outlines Fairbairn’s pioneering model which describes how object relations influence personality development. He has found this particularly useful in the treatment of borderline patients who are generally considered difficult and unrewarding to work with.

Fairbairn’s Ideas
Video lecture with slides – 35 mins

Fairbairn’s Structural Model and Examples
Video lecture with slides – 45 mins

Treating the Hysteric, Obsessive and Narcissist
Video lecture with slides – 45 mins

Case Study: Clumsy Guy
Video lecture – 10 mins

Childhood maltreatment has been associated with profound deficits in the sense of self frequently leading the traumatized individual to become isolated and estranged in the secrecy of their trauma. Both intimate and non-intimate relationships frequently either become a way of re-enacting the past or appear unreachable. How do mind, brain, and body prevent traumatized individuals from engaging in social interactions, and how does this affect the therapeutic process? This lecture will describe the neurobiological underpinnings of social cognition, including theory of mind and eye gaze in chronically traumatized individuals and relate these findings to clinical case examples. An integrated approach to treatment of brain, mind, and body, including interventions geared to prevent the intergenerational transmission of trauma will be described.

Video lecture with captions and slides – 55 mins

Neuroscientifically-based effective therapeutic interventions for patients displaying altered states of consciousness following trauma

Four dimensions of consciousness, including time, thought, body, and emotion often become drastically altered as a result of traumatic experience. Even though such alterations in consciousness can be adaptive during the encounter of traumatic events, they can frequently lead to tremendous hardship in the aftermath of the trauma. How do we recognize such alterations in consciousness? Is there a dissociative versus a non-dissociative presentation of each dimension of consciousness? What predicts the occurrence of altered states of consciousness? How can we intervene effectively to overcome such altered states and how are those changes represented in mind, brain, and body? This lecture will describe a four dimensional model (4-D Model) outlining a dissociative and a non-dissociative dimension of each of these four dimensions of consciousness. Furthermore, the neurobiological underpinnings and a detailed approach to treatment of each dimension of consciousness will be described.

Video lecture with captions and slides – 57 mins

Dr. Mizen presents her theory of a neurobiological and developmental pathway for symbolisation and its failures in those with borderline presentations.

Her ‘Relational Affective Hypothesis’ describes how neurobiological mechanisms promote mother infant interaction launching a developmental process through which the ability to symbolise emerges. Triangulation, which is key to developing the capacity to symbolise, may fail through relational or the psychodynamic defence mechanism of projective identification leading to a concrete emotional world and a disordered sense of physical and psychological identity.

The result is the emergence of two conflicted states of mind and patterns of interpersonal relating which give rise to the affective instability and impulsiveness of people with a diagnosis of borderline personality disorder and a disordered sense of what belongs to whom.

Video lecture with slides – 45 mins

Pathological narcissism can be interpreted as a defence against the terror of fragmentation, a fear Kohut referred to as, ‘the deepest anxiety a man can experience.’ Drawing on ideas from Lacan, Bollas, Kohut and Buddhist philosophy, Dr Phil Mollon suggests that we all bound to make identities from the culture we are all born into, the images others have of us in their minds.

However, pathological narcissism develops because there is no negotiation at all between the infant’s own nascent grandiosity and his mother’s idea of her perfect baby. This causes the infant to split off his own grandiosity and a personality develops that swings between self-regard and self-denigration in an ongoing effort to avoid the psychotic outbreak of a still fragmented underlying psychic structure.

Audio lecture – 45 mins

In this talk Anna Motz describes the unique manifestations of female perversion and violence, with illustrative clinical material. She draws on Welldon’s (1988) model of female personality and consider in particular whether the concept of psychopathy has any relevance to women, or if it is a misappropriation of a construction related to men. She will also describe societal responses to crimes perpetrated by women, and how details of the potential for female violence and perversion only serves to perpetuate unhelpful stereotypes and vilify those women. Finally, she will outline therapeutic approaches for working with violent and sadistic women.

Video lecture with captions and slides – 23 mins

Clara Mucci asserts, “We don’t just get a patient. We get someone who is the last part of a chain of family heritage.” This presentation examines the paths that intergenerational trauma takes as it transmits from one generation to the next. Within a framework of psychoanalytic and attachment theory, Clara Mucci elaborates how early relational trauma in the form of disorganised attachment is the most damaging means via which trauma from one generation passes to the next. This is explained by the primary care-giver’s incapacity to offer the emotional regulation that is necessary for healthy development. Furthermore, a parent who has adopted the defence of dissociation is likely to have a dissociating child. She proposes that secure attachment mediates against future traumatic effects, by enabling one to negotiate loss and process future traumas. Therapy for intergenerational trauma, she suggests, occurs in the form of enactment, where the trauma of past generations may become expressed. Clinical and theoretic material is drawn upon from her own practice and also from such authors as Giovanni Liotti, Dori Laub, Ilany Kogan, Philip Bromberg and Allan Schore.

Video lecture with slides – 44 mins

Past generations, trauma, loss and moving beyond the victim-persecutor dyad

This presentation builds on Clara Mucci’s theoretical discussion in Part I, and considers psychoanalytic treatment approaches for the effects of the traumatic experiences in the lives of parents, grandparents and ancestors. One clinical challenge is the decreasing clarity, symbolisation, narrative formulation of the original trauma as it passes from generation to generation. Somatic awareness or even psychosis may be the only way that it is expressed. Equally striking is a tendency towards victim-persecutor relational dynamics. We will look at the possibility of raising these effects to consciousness, easing symptoms and ultimately going beyond these dynamics into greater psychic freedom.

Video lecture with slides – 50 mins

The seminar covers the key diagnostic issues in identifying traumatic experiences that are rooted in childhood and differentiating these from traumas experienced by otherwise healthy adults that may result in PTSD and a disruption in their self-reflective functioning. The seminar considers implications for planning an appropriate treatment strategy and is illustrated with case material.

Video lecture with captions (part 1) – 47 mins

Treatment approaches for complex PTSD and simple PTSD in the otherwise healthy adult – PART 2

This lecture considers implications and differences in planning an appropriate treatment strategy for people with single incident PTSD and complex PTSD. Illustrated with case material.

Video lecture with captions (part 2) – 45 mins

Dissociative Identity Disorder (DID) (American Psychiatric Association 2013) is examined in this presentation from the perspective of its relevance to the criminologist. As this psychiatric condition is linked to severe and prolonged childhood abuse, accounts of DID patients inevitably involve reports of serious crimes, in which the person was the victim, perpetrator or witness. These reports can thus contain crucial information for criminal investigations by the police or for court proceedings. However, due to the person’s dissociative states, such reports are often very confusing, hard to follow or believe and difficult to obtain. Through the analysis of clinical examples, Dr Adah Sachs explores how decisions are made by a person with DID, the notions of choice and’competent reasoning’, and the practical and ethical ways for interviewing a person with DID who has witnessed or participated in a crime.
(A version of this presentation was published (2015) at the International Journal for Crime, Justice and Social Democracy)

Audio presentation with captions and slides – 30 mins

Borderline Personality Disorder (BPD) is a severe disturbance of personality-functioning. It is characterised by affect and impulse-control disturbances associated with deficits in emotion regulation, as well as a pervasive pattern in self-image and persistent difficulties in interpersonal relationships. Current models of the aetiology and adaptive dysfunction of BPD are now converging as an attachment disorder that formed in the first years of life. These patients commonly experienced abusive and neglectful developmental backgrounds, a growth-inhibiting relational environment not only for social-emotional development but for early brain maturation.

Models of developmental psychopathology suggest that borderline attachment histories alter the development of regulatory cortical-sub-cortical limbic-autonomic circuits of the early developing right brain. In line with these models, a number of recent neurobiological studies now show right brain and orbitofrontal deficits in BPD patients. The clinical relevance of this documented maturational failure for diagnosis and treatment is discussed in the light of research.

Audio lecture with slides – 1 hr 40 mins

Recent research into the brain mechanisms of emotion has identified the primitive ‘natural kinds’ of mammalian emotion. This research reveals some surprising findings about the emotional circuitry of the human brain, which radically change our classifications of the basic emotions, and which have substantial implications for our understanding of psychopathology. This talk will summarise the relevant findings and will discuss the clinical implications, in relation to, for example, addiction, mood disorders, anxiety disorders and thought disorders, and more generally for theories of human sexuality and aggression.

Video with captions and slides – 1 hr 13 mins

Brain mechanisms of emotional consciousness: implications for clinical technique

Most forms of psychoanalytical psychotherapy conceptualise therapeutic change as a process whereby the unconscious parts of the mind are rendered conscious. Classically this involves a clinical technique which endeavours to attach words to preverbal and nonverbal mental processes. This is the essence of the ‘talking cure’. In this presentation, new findings regarding the brain mechanisms of consciousness will be reported which require us to turn the classical conceptualisation of talking therapy on its head. The parts of the brain that generate ‘instinctual’ ways of thinking and behaving are the same parts of the brain that generate all consciousness. The parts of the brain that are associated with verbal cognition, by contrast, are intrinsically unconscious and are only capable of generating conscious thinking to the extent that they are activated by the more primitive, instinctual-emotional parts of the brain. Some implications of these findings for psychotherapeutic technique will be discussed.

Video with captions and slides – 51 mins

Working with people with antisocial or psychopathic personality disturbance can have a profound impact on clinicians. Many of the offences committed by these individuals are of a highly sadistic kind and therefore traumatic to hear about and process, leading to angry and punitive responses. On the other side of the coin, some staff identify strongly with the victim within the offender, since childhood histories of appalling abuse and disrupted attachments are common. Team splitting and conflict frequently ensue, thus undermining the best efforts at treatment. This talk will consider the dynamics impacting on teams’ ability to function together in this work, and what measures can be taken to mitigate these effects.

Video lecture with captions and slides – 47 mins

This presentation describes some concepts underpinning forensic psychotherapy, including a theory of a triangular dynamic between patient, psychotherapist and society that was developed by Dr Estela Welldon. The talk explores the countertransference in relation to personality disorder, and how challenging this can be for the clinician, arousing such responses as collusion, disbelief and condemnation and also stirring our own sadism via projective identification. He considers how even the most apparently insane violence has meaning inside the mind of the person who commits it. This is explored in relation to two cases in which the violence erupted through a fragile narcissistic structure that had been attempting to hold the self together. This concept of a narcissistic organisation of the mind, which arises when there is a failure of containment in infancy, is discussed as a means of understanding this fracturing of psychic defenses.

Video lecture with captions – 28 mins

The History of Murder – and the Murder of History

In this detailed theoretical and case-based presentation, Dr Ronald Doctor considers the many-faceted but mostly concealed psychological states and experiences underlying the act of murder. In most cases, killing occurs concretely only after it has been committed many times previously in dreams, nightmares and unconscious fantasies that have never become conscious. Before the deed, conscious efforts – sometimes unconscious too – are designed and devoted to keeping the impulse to murder encapsulated to prevent action. Commonly a sudden reversal takes place internally that breaks the murderousness loose from its cordoned-off status. Ronald Doctor proposes that there is always an underlying psychically traumatic and indigestible experience of loss and death. Using clinical material from two patients who suffered severe loss he explains how they sought refuge: the first in psychosis, and the second in a sado-masochistic retreat.

Video presentation with captions – 52 mins

Mary Haley is the lead psychotherapist on a Category B prison wing of 35 prisoners. In this video she describes the task of rehabilitating these men, who have invariably suffered extreme neglect or abuse in childhood. The therapeutic approach consists of living within a democratic therapeutic community, in which the residents learn how to tolerate themselves and each other in close quarters by sharing responsibilities for the community. They have small group, in-depth psychotherapy 3 times each week in which they challenge and support each other in facing both their crimes and the childhood experiences that predisposed them to acts of violence. Bearing what is often extreme past shame and humiliation, facing their demons and accepting personal responsibility takes great courage and Mary Daley movingly illustrates how the longer term residents often show great tenderness and compassion towards new prisoners. She illustrates the combination of attachment theory, object relations that forms the integrative therapeutic approach underlying the work. She also explores the value or otherwise of such terminology as Borderline Personality Disorder, and the therapeutic use of the International Personal Disorder Examination (IPDE).

Video talk to camera – 42 mins

In this audio presentation, Dr Onno van der Hart explains dissociative disorders as an acute disintegration of the personality into sub-systems that become a fixed ‘structural dissociation’ of the personality, as a result of severe child abuse. This system of self-protection is fully explained, and a phase-oriented treatment approach detailed.

Audio with captions and diagrams – 38 mins

In this talk Professor Jeremy Holmes surveys the great analytic and literary thinkers on narcissism, providing a sense of the condition’s unconscious origins, it’s pathological development in childhood and giving examples of its appearance in life, the therapy room and in stories from Eastern and Western Culture. Following Kohut’s notion of the parental task being to offer ‘optimal frustration’ to the child, Professor Holmes concludes that the therapeutic challenge in repairing narcissistic wounding is to ‘walk the line’ offering a deep empathy that is nevertheless tempered by challenging the patient’s isolating self-centredness and illusion of self-sufficiency.

Audio lecture – 50 mins

Fortunately, most people who attend for psychotherapy have never perpetrated acts of criminality and do not suffer from an overtly diagnosable mental illness. A small cohort of non-forensic patients will, however, commit a variety of offences, none of which constitute a breach of the law of the land but which, nevertheless, cause significant suffering to themselves and to others. In this presentation, we shall explore the psychodynamics of the sub-clinical “non-forensic” patient, concentrating on how and why such individuals function in this quasi-forensic fashion and what impact their unconscious “criminality” might have. We will question whether the definition of forensic psychotherapy might need to be expanded in recognition of the broader range of unconscious sadism that we often encounter in our work.

Video lecture with captions and slides – 35 mins

Dr Jean Knox suggests that mirror neuron research offers valuable scientific insights into the mind-body dichotomy. She proposes that it challenges the model that privileges mind and thought over bodily enactment as the essence of what makes us human. She suggests that intersubjectivity is increasingly recognised as the embodied relational matrix out of which each individual emerges. The mirror neuron mechanism automatically prompts the observer to resonate with the emotional state of another individual, with the observer copying the motor, autonomic and somatic responses. Dr Knox sees this is the basis for both empathy and emotional contagion, ‘concordant countertransference’ (Racker) and introjection. The therapist often has to relate to states of mind activated by mirror neurons that are unbearable. This may lead the therapist to retreat from embodied inter-subjectivity into defensive positions such as intellectually-based, theoretical stances to the detriment of the therapy, while an understanding of the mirror-neuron mechanism may help therapists to tolerate embodied emotional discomfort.

Video lecture with captions and slides – 32 mins

Dr Estela Welldon suggests the principle cause of violent crime is the need to express rage, helplessness and humiliation rooted in unconscious childhood memories of abusive experiences and domestic violence. When these experiences have been extreme, and there has been a lack of loving containment by an attachment figure, something powerful is held inside the psyche until it is released in adulthood through loss of control, often triggered by a repeated trauma. Although the violent act may appear irrational, in the context of the patient’s past experiences it may be very meaningful. The violent act, furthermore, provides a sense of agency, of being seen and experienced by others. The key to forensic psychotherapy is for the patient and therapist to uncover the unconscious meanings of the act, through language. Hopefully this will be aired before the ‘splash’ – the moment when the crime is committed – if that person has access to therapeutic help. By gaining an understanding of their own past experiences of rage, impotence and humiliation the patient may resolve the unconscious impulses underlying the crime. We see that in effective psychotherapy, talking and thinking replace the acting-out.

Video talk to camera – 26 mins